VP Orientation & Training

Faculty Development

Guiding questions:

Why is faculty development on the use of virtual patients (VPs) needed?
How to buy-in staff to participate in faculty development?
How to effectively train faculty in using VPs?

The reviewed literature is unanimous in the recommendation that faculty development is a crucial factor in a successful curricular implementation of VPs (e.g., [Berman 2009, Haag 2010, Kleinheksel 2017]). It is in general true that each curriculum renewal requires faculty development [Kulasegaram 2018], but we can also give more specific reasons to justify that for VP faculty training. Contemporary teachers have seen in their lives thousands of lectures, but just a handful of VPs (if any at all) [Posel 2012]. Sometimes these are not the technical skills that are lacking. For instance, Dafli et al. 2019 showed in her study that the majority of surveyed teachers (~80%) felt their IT skills were sufficient to author VPs [Dafli 2019]. The point is that the teachers should also know the learning activities around the VPs and how to assess and provide the students with feedback based on those activities. Teachers sometimes blame the new method for the educational failure, whereas the problem lies in their lack of proficiency in the application of the method [Nordquist 2012]. Lack of a sufficient number of adequately trained tutors makes many VP implementation scenarios infeasible [Hege 2007]. Therefore it is very important to support and prepare them for this challenge by providing instructions, necessary additional materials, contact details to a help desk, or a person responsible for technical support.

Teachers are often reluctant to participate in faculty development activities giving many reasons [Sudacka 2021]. The success depends on finding a good buy-in for the teachers’ participation [Kulasegaram 2018]. Top-down methods require that educators feel that their effort in developing their teaching skills will be acknowledged by their supervisors [Posel 2012]. This can be achieved for instance by awarding them with additional credit points or certificates recognized in their evaluation. Faculty can be also motivated by their students who expect their teachers to be familiar with the VPs integrated in the curriculum [Huwendiek 2013] and may express this in negative teacher evaluation. Academic teachers are often also researchers, so they expect to be presented with some evidence that the new method works [Nordquist 2012, Posel 2012]. Finally, it is motivational for teachers to participate in faculty development if the courses are tailored to their individual needs (“learner-centered” faculty development) [Kulasegaram 2018]. What emerges from our project’s pilots is that ideally this issue is solved on an institutional level. We can also share success stories from the students to motivate teachers. It is feasible to gather educators that are involved in a particular course where you want to implement VPs and during the introduction meeting give them a short training from the technical and pedagogical possibilities of the tool.

There is only limited research published so far on how to effectively train faculty in using VPs. Teachers are often highly experienced in their medical fields, but when it comes to the use of new educational methods like VPs, they shift from experts to novices which makes them feel insecure [Nordquist 2012]. Therefore, their clinical experience should be acknowledged in the training and it also helps when the facilitators who conduct faculty development courses are valued in the local setting [Gillham 2015]. Since teachers are often very busy and complain about lack of time for faculty development, it is recommended to offer them a spectrum of short courses that target particular skills from which they can select those that meet their particular task in the curriculum (e.g. case author, small-group facilitator, assessor). This will also give them the possibility to effectively refresh their skills when needed [Kulasegaram 2018]. Teachers also have their preferences regarding the faculty development method: e.g. some prefer face-to-face workshops close to their workplace, webinars in the evenings, or e-learning modules that need to be accommodated [Kulasegaram 2018]. An international collaboration of teachers from Scotland and Malawi demonstrated a successful curricular implementation of VPs with faculty development as the key enabling factor [Dewhurst 2009]. It consisted of a series of three closely supervised workshops in which faculty members first developed VPs in small groups. Next, they discussed how to implement those in their teaching. Less formal approaches to faculty development involve building communities of practice where the teachers can post messages when instant feedback is needed [Steinert 2021]. Our project partners also give the teachers a chance to get directly involved in VPs creation, which then makes them feel more confident about using these later on with their students.

We should always remember that the technology behind VPs is just one of many factors when implementing them in curriculum. The success of implementation often hinges on human factors. Teachers are the key stakeholders that need to be convinced on the utility of VPs and adequately prepared. Faculty development events are a good opportunity to do that.

Recommendations:
– Support and prepare teachers for use of VPs in their classes, especially when they are lacking technical proficiency by providing instructions, necessary additional materials, contact details to a help desk or person responsible for technical support.
– Provide teachers a good buy-in to actively participate in implementation of a new method.
– Consider extra credit points, certificates, other forms of recognition in their annual evaluation, or share the success stories from the students in order to motivate the tutors.
– Offer teachers a variety of training methods e.g., short face-to-face workshops close to their workplace, webinars in the evenings, or e-learning modules, that target particular skills from which they can select those that meet their needs.

Student training

Guiding question:

Is user training on the technology/pedagogy of VPs necessary and if so how should it be performed?

To successfully implement a new learning activity or a tool into the curriculum it is important to identify, discuss, and reflect on both students’ and faculty’s expectations and preconceived notions [Nordquist 2012]. Guiding students on the VPs prior to the encounter is necessary and may have a direct positive effect on perceived learning [Berman 2009, Nordquist 2012]. Moreover, as some students may struggle with the technology associated with VPs learning platforms, it is vital to guide them through those systems, to avoid distraction from the actual learning experience [Naumann 2016]. We also noticed in our iCoViP pilots that when students’ received prior training on the VPs they could focus better on the learning process, and not on technical issues.

Familiarization with the VP system and with the concept of VPs should take place upon the first exposure to the cases, for instance with use of an introductory presentation. During initial demonstration of the system, students can be given a patient monitoring form to aid the systematic collection and processing of information or tutor instructions [Dahri 2019, Hirumi 2016]. Orientation and training on VPs can also be done as near-peer teaching (i.e. postgraduate trainees) allowing active engagement of both parties [Kulasegaram 2018].

What also might be helpful during orientation process, is to use the student information system, online platforms or course handbooks, to post requirements, instructions (written or video tutorials) or send reminders about the due assignments [Hirumi 2016, Nasir 2017]. Students find it very important to know how the VPs were integrated in the curriculum and aligned with other educational activities. Hand-outs and/or an online timetable, with links to related VPs could be very helpful [Huwendiek 2013].

Recommendations:
– User training is crucial in order for students to focus on the learning process, rather than technical issues.
– Familiarization with the VP system and with the concept of VPs should take place upon the first exposure to the VPs

Phase of the curriculum	4th year of medical school
Goal in the curriculum	The iCoViP collection was implemented to practice selected VPs in the subject of Occupational Medicine (a voluntary subject in the University of Zaragoza in the 4th year of medical school).
Effective use of resources	The collection was used asynchronously so it was not necessary to have a computer infrastructure or a specific room and all students in Spain have laptops or access to the medical school computers. However, issue of updating content not yet solved.
VP alignment	The collection is used while students are doing their clinical placements having a teacher revising the responses and explaining to students most frequent mistakes.
Prioritization/relevance	For Occupational Medicine, the use of the iCoViP collection was a mandatory assignment needed to pass, but did not add points to the final grade.
Relation to other learning activities	None
Time allocation	One week was given to complete the assignment but more time was available for those who wanted to do the activity remote from home.
Group allocation	Students worked alone at home, when the educator discussed the solution of the VP, it was allocated in class (face-to-face or online).
Presence mode	Asynchronous
Technical Integration	It was integrated into Moodle.
VP use orientation/training	VPs were related to a specialty of medicine, but were randomly assigned to students regardless of where in the specialty they were rotating at the time.
Technical infrastructure	We used the technical infrastructure of the iCoViP project without any additions at the University of Zaragoza.
Learning activities around VPs	The teacher explained each VP and how to resolve them after getting the responses of all the students.
Assessment	Students had to complete the VPs, but there was no grade at the end. Only credit (pass/fail).
Quality assurance, maintenance, and sustainability	Frequent revision of the VPs by medical doctors.

Phase of the curriculum	Year 3 and 4 of medical school
Goal in the curriculum	Students learn basic steps of clinical reasoning including identifying relevant findings, developing differential diagnoses, deciding about a final diagnosis, ordering tests to rule out / confirm differentials, and suggesting treatment options.
Effective use of resources	Course tutors needed time to familiarize themselves with the VPs and time had to be planned during the synchronous meetings to discuss the VPs
VP alignment	VPs were part of the modules (e.g. Abdomen, cardiovascular system, pulmonary system, etc.) in year 3 and 4 of medical school and aligned with the objectives of these modules based on key symptoms. In addition a pool of 41 VPs was available for deliberate practice across key symptoms and diagnoses.
Time allocation	5 VPs / module
Group allocation	Students could choose whether to work in groups or individually.
Presence mode	Students could decide when and where to work on the VPs during the period of the module.
Technical Integration	VPs were integrated into the school's learning management system Moodle via a SingleSignOn interface.
VP use orientation/training	No specific familiarization, but general introduction at the beginning of year 3.
Learning activities around VPs	Depending on the modules other learning activities were embedded.
Assessment	The topics of the VPs were part of modules assessment.
Quality assurance, maintenance, and sustainability	We used the built-in feedback functionality to receive qualitative feedback from students and VPs were part of the regular evaluation activities of the medical school.

Phase of the curriculum	Year 1 and 2 of medical school
Goal in the curriculum	Students learn basic steps of clinical reasoning such as identifying & prioritizing findings and composing a summary statement. They also can follow the reasoning process of the VP author concerning differential diagnoses, ordered tests, and treatments.
Effective use of resources	Course tutors needed time to familiarize themselves with the VPs and time had to be planned during the synchronous meetings to discuss the VPs.
VP alignment	VPs were part of the longitudinal clinical course and aligned with the other modules in year 1 and 2 (In case of Augsburg this was Contact, Movement, and equilibrium). We aligned the key symptoms of the VPs with these modules, so that students worked in parallel on these VPs and the corresponding module.
Time allocation	15 VPs over two years / 5 VPs per module.
Group allocation	Students could choose whether to work in groups or individually.
Presence mode	Students could decide when and where to work on the VPs during the period of the module.
Technical Integration	VPs were integrated into the school's learning management system Moodle via a SingleSignOn interface.
VP use orientation/training	At the beginning of year 1 students were introduced into clinical reasoning and how they can train this ability with VPs.
Learning activities around VPs	Depending on the key symptoms during the longitudinal clinical course other learning activities were embedded.
Assessment	The topics of the VPs were part of the clinical longitudinal course assessment.
Quality assurance, maintenance, and sustainability	We used the built-in feedback functionality to receive qualitative feedback from students and VPs were part of the regular evaluation activities of the medical school.

Phase of the curriculum	Basic sciences/pre-clinical years: - At Jagiellonian University Medical College in Kraków we have integrated it in the “Introduction to Clinical Sciences” course in 2nd year of medicine. - At University of Porto in the “Propedeutics/Semiology” course in the 3rd year of medicine.
Goal in the curriculum	- To provide the students with an opportunity to challenge their knowledge at home in between classes with an interactive, clinical-oriented task. - To support learning by linking basic science knowledge with clinical reasoning. Students had the opportunity to practice on undiagnosed cases the skill of differentiating common symptoms, such as dyspnea, abdominal pain, headache.
Effective use of resources	Use of iCoViP VPs in native language of the students. No extra cost needed.
VP alignment	- In Kraków we have selected a few VPs (seven) with common diseases (e.g. pneumonia, pancreatitis, pulmonary embolism) with common symptoms. - In Porto, VPs are chosen according to the common symptoms to promote clinical reasoning.
Prioritization/relevance	- In Kraków the completion of all VPs is mandatory. - In Porto, VPs are introduced on a voluntary basis and are available on demand.
Relation to other learning activities	We used the time students had at home between seminars (Kraków: between on-campus based PBL sessions). VPs were spaced-activated (a new VP appeared biweekly synchronized with changing topics of the PBL seminars that focus on different leading symptoms).
Time allocation	Around 30 minutes biweekly, repeated 7 times in a semester.
Group allocation	Students worked alone at home to reflect but could consult the VPs with their peers or instructors in small groups of the face-to-face PBL seminars.
Presence mode	Students worked on the VPs asynchronously and self-directed at home to have time to reflect and consult textbooks.
Technical Integration	VPs were integrated with a course to which all students were enrolled on the official university learning management system Moodle using Learning Tools Interoperability (LTI) interface.
VP use orientation/training	Students were provided with an introductory email with instructions and had additionally the opportunity to technically practice using CASUS in a parallel “Telemedicine” (Medical informatics) course. Instructors received test-codes to practice the VPs at home.
Technical infrastructure	Students used their own computers from home. An email address was provided to a person responsible for technical support.
Learning activities around VPs	Students were asked to complete concept maps for all VPs they solve. Moreover, in Kraków students were provided with links to additional online articles to help them with topics difficult at this stage of education.
Assessment	Students were asked to complete the cases prior to the end of the term. They were not given grades for the activity - just credit. Their answers were randomly inspected to see common mistakes and provide general feedback to all students.
Quality assurance, maintenance, and sustainability	We checked the diagnostic accuracy of individual cases (and detected one case with imprecise diagnosis). Students evaluated the course using the iCoViP case collection evaluation questionnaire.