Goal in the curriculum

Guiding questions:

Why should I have VPs in the medical curriculum?
For what purpose should I be using VPs?
What are the pros and cons of integrating VP into the curriculum?

All medical schools should strive to have virtual patients (VPs) in their curriculum, as these are important tools for students on their way to become health professionals, offering them an authentic, comparable, interactive, patient-centered, and safe learning experience.

VPs are employed as a tool for curricular integration that requires the students to combine and apply knowledge from several disciplines in one activity. At the curricular level, VPs offer greater consistency and reliability in the delivery of learning experiences. In a blended learning curricular model, the virtual curriculum runs alongside the existing face-to-face curriculum, giving educators the flexibility in selecting methods to meet the learning objectives. [Tworek 2010].

The versatility of skills that can be taught with VPs encourages many educators to try to embed this teaching method into the medical education curriculum for several purposes. [Sobocan 2017]. Virtual patient panels are being used in health professions education to facilitate the development of clinical reasoning abilities, resource utilization, and longitudinal patient care, as well as knowledge acquisition, teamwork, and clinical skills training. [Hege 2016, Kononowicz 2015, Quail 2019]. Exposure to VPs also can help students to develop non-technical skills such as decision-making, teamwork, communication skills, but also self-awareness and self-confidence. It is especially common to see a recommendation to apply VPs in support of clinical reasoning training [Cook 2009, Plackett 2022], because VPs are giving the students an opportunity for deliberate practice of patient diagnostic and management skills. Using virtual patient panels, students compare and contrast similar clinical findings and have to weigh different options based on the relative probability of each diagnosis and the typicality of findings [Mayer 2022].

VPs also provide clinical and contextual diversity in collections [Bowden 2021]. The coverage of various subjects and possible situations that can appear in real-life medical activities is an important factor in the expected effect of VP training [Doloca 2016]. VPs allow efficient presentation of multiple patient visits, and in accelerated time-perspective how diseases change over time and interact with several factors including genetic background, psychosocial context and comorbidities [Smith 2007]. VPs unlike the textbooks or most lectures are interactive, in addition provide access to multimedia materials, possibility to check reference sources, reflect in the decision-making process and to make mistakes and learn from them [Botezatu 2010]. VPs allow students to safely apply obtained knowledge without putting at risk either themselves or patients [Edelbring 2011, Kulasegaram 2018].

VPs act as a link between students’ factual knowledge and the clinical environment [Ellaway 2015]. This provides students with an opportunity for productive struggle within the context of authentic clinical situations. VPs help students to discover new concepts, structure and then apply their knowledge in face of the ambiguity, complexity or uncertainty of medical practice [Kulasegaram 2018].

You should consider VPs as an opportunity for your students, if you are looking for a tool to increase their exposure to patient cases beyond what is possible in the clinic. VPs give the students the possibility to be confronted with a wide variety of diseases, symptoms, and clinical scenarios, permitting to

overcome limitations in exposure to real patients (e.g., lack of contact with rare diseases or presentations or differences across groups of students on the types of patients they meet) [Cederberg 2012, Posel 2012]
meet institutional or national curricular objectives [Hege 2016]
offer an authentic experience in early stages of the medical curriculum free of ethical concerns [Washburn 2020].

It is fair to say that VPs in the curriculum are not a silver bullet to solve all problems and they also have drawbacks when misused. VPs should not limit access to real patients as this is the gold standard in medical education. Consider for instance the limitation of VPs in terms of physical examination or history taking. Some types of VPs may deteriorate soft skills of students (e.g. showing empathy), when students focus too much on finding the right diagnosis and forget the human-aspects of patient care. Finally, it is tempting for some teachers to trust that VPs will replace them in the role of teachers in assessment or providing feedback and by that save their time. However, VPs, as many other educational technologies, are just tools to aid the educator, but without good support students will feel lost in their education or learn to game the system.

Recommendations:
– VPs are great for curricular integration, that requires the students to combine and apply knowledge from several disciplines in one activity.
– Versatility of skills can be taught with VPs, choose how you can utilize them.
– VPs act as a link between students’ factual knowledge and the clinical environment.
– Utilize VPs to address knowledge gaps, to ensure more
comprehensive learning experiences, to provide otherwise unavailable clinical experiences and to guarantee availability of standardized material.

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.