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Marmara Medical Journal 2015; 28: 63-69
DOI: 10.5472/MMJ ra.2802.01
REVIEW / DERLEME
63
The use of virtual patients in medical education
Tıp Eğitiminde sanal hasta kullanımı
Özlem Mıdık ( )
Department of Medical Education, School of Medicine, Ondokuz Mayıs
University, Samsun, Turkey
e-mail: dromidik@gmail.com
Mehtap Kartal
Department of Family Medicine, School of Medicine, Dokuz Eylül
University, Izmir, Turkey
Submitted/Gönderilme: 13.01.2015 Accepted/Kabul: 27.03.2015
Özlem MIDIK, Mehtap KARTAL
ABSTRACT
The use of simulations in medical education depends on the interest
of the academic institutions and the educators, on technological
developments, on infrastructure, on the resources of the medical
faculties and on the integration into medical curricula. Virtual
patient simulations involving high-techology, emerge as one of
today’s most popular topics in medical education.
In this review, a simulation, ”virtual patient’’, is studied
under the main headings concerning its description, essential
features, its use and its future in medical education.
Keywords: Virtual patient, Virtual systems, Medical education,
Computer based cases
ÖZET
Simülasyon uygulamalarının kullanımı, kurumun ve eğiticilerin
ilgisine, teknolojinin gelişimine, fakültelerin alt yapı ve
olanaklarına ve programın müfredata entegrasyonuna bağlı
olarak gelişir. İleri teknoloji içeren sanal hasta simülasyonları
ise günümüzün en popüler konularından biri olarak karşımıza
çıkmaktadır.
Bu derlemede bir simülasyon tipi olan ‘sanal hasta’ tanımı, temel
özellikleri, tıp eğitiminde kullanımı ve geleceği irdelenecektir.
Anahtar kelimeler: Sanal hasta, Sanal sistemler, Tıp eğitimi,
Bilgisayar tabanlı vakalar
Introduction
The purpose of medical education is to educate physicians
so that everyone can enjoy a healthy life [1]. In the light
of that aim the educated physician is expected to possess
a large number of skills. This expectation requires that
medical education be high-quality and scientific and also
constantly self-renewing.
Medical faculties today define themselves, not on
the basis of the systems, but of the educational strategies
they use, and adopt a pluralistic approach. The pluralistic
approach, which goes back to the philosophy of science of
Feyerabend [2], is reflected in medical education due to the
hypotheses set out below.
• No theory is by itself sufficient to explain learning and
teaching
• No behavior or cognitive affective attribute can be
taught through a single theory or method.
• Different means should be employed for each
individual to learn the same behavior or attribute.
• Different strategies, methods or reasoning procedures
must be used when the level or nature of behavior changes.
• Behaviors and learning are more permanent when
several activities are employed together [2,3].
The reflection of pluralism in medical education is seen
in curriculum planning and in the components of strategies,
methods, climates and testing in application and evaluation.
The educational method contains sufficient variety to
permit a multi-method to the curriculum. This includes
class teaching, problem based learning sessions, team work,
bedside training, training outpatient clinics and operating
rooms and skills training. The newest approach in terms
of education management is simulation-based training.
Simulation is defined as the imitation of tasks, relationships,
phenomena, equipment, behavior or some cognitive
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Virtual patients in medical education Marmara Medical Journal 2015; 28: 63-69
activities that are actually present in reality.
Various kinds of simulation tools are used in medical
education. One of the most popular subjects today is patient
simulation using high-tech methods.
This review examines the definition, basic features, use
in medical education and future of one type of simulation –
the ‘virtual patient’ (VP).
What is a virtual patient?
A virtual patient (VP) is defined as a special type of computer
program used in medical education or testing, that simulates
clinical scenarios in real life and in which learners emulate
health professionals in taking histories, performing physical
examinations and deciding on diagnosis and treatment [4].
In one sense, the VP is an online, interactive computer
simulation of an encounter with a patient [5].
How did the concept of the virtual patient appear?
The development and use of the a VP is nothing new.
Computer-based training simulations of patient encounters
were fırst developed in the 1960s [6]. These were described as
‘case-based learning systems, computer-assisted simulations,
interactive patients and patient simulations,’ and as ‘virtual
patients’ after 2005 [7]. For reasons such as high cost, a low
level of expertise, technical and design limitations, limited
evidence of effectiveness and, finally, for cultural reasons,
their spread has not been as rapid as was once expected [8].
The growth in their use in recent years has been attributed
to the lowering of costs and the fact they can be created,
redesigned and shared between institutions [9].
Why was there a need for virtual patients?
Complexity, uncertainty and inconsistencies in the field of
healthcare are increasing. The concept of hospitalization
has changed due to economic pressures, and lengths of
hospitalization have been shortened. This has led to a more
opportunistic educational environment in which the patient
profile is regarded as a constant variable. Today’s medical
training process reduces interaction between instructor,
patient and student, restricts experience-based learning and
does not allow for patient encounters [5]. Yet the minimum
skills required of newly graduated physicians are increasing
all the time in terms of numbers and levels.
Although diagnostic errors are frequently thought to be
associated with an inadequate collection for information,
such errors in fact derive from faulty interpretations and
deficiencies in synthesis and reasoning, in other words
from cognitive mistakes. This is attributed to students not
encountering sufficient cases and to their lack of experience
[4]. Although physicians’ medical knowledge grows,
uncertainty in taking medical decisions increases and
insufficient time is set aside for training. Different clinical
pathways are frequently required for the acquisition of
reliable and effective knowledge.
Research shows that clinical reasoning skills of students
develop most when meeting patients, encountering and
actively solving problems and, most importantly, through
adequate feedback [4]. Meeting the patient is important
for the acquision of core knowledge. Medical practice
is a field involving interventional techniques, the use of
which is increasing. However, students have increasingly
less opportunity to learn patient care and interventional
techniques. Physical simulation is not always available,
although simulated and/or standardized patients make this
partly possible [6]. One of the main problems in medical
education, despite the high expectations from graduate
physicians, is the lack of sufficient resources such as
materials, personnel and opportunities for meeting patients
during training. In particular, despite the rise in student
numbers, the low number of instructors in some countries
is striking. This is described as a manpower crisis in sub-
Saharan African countries such as Malawi [10].
Simulation is a potential solution that can partly ease the
problem(s) described above. Accreditation bodies explicitly
state that if no means are available in the clinical environment
then students need to receive simulated experiences [6].
How are virtual patients used in medical education?
VP procedures are used to develop four skills in learning-
teaching procedures and evaluations in the medical
education trilogy of pre-graduation, post-graduation and
ongoing professional development [11-15].
1. Clinical reasoning, problem-solving
Clinical reasoning is the integration and application
of knowledge acquired from various sources within a
diagnostic and therapeutic management plan. Although
clinical reasoning is regarded as a general skill, it is in fact
a case-dependent one. For example, reasoning regarding
headache cannot always be applied to abdominal pain.
Specialists frequently make use of patterns and disease
scripts in the clinical reasoning process. However, more
cases are required for new learners [16].
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Mıdık and Kartal
Virtual patients in medical education
Marmara Medical Journal 2015; 28: 63-69
A VP is a procedure that bestows experience by
offering various options through different cases [4]. A VP
provides an opportunity to acquire treatment management
skills through clinical reasoning and problem solving,
reduces the numbers and effects of medical errors and thus
contributes to patient safety [5]. VP procedures have been
shown to be the best means of acquiring these skills at a
superior level [8].
2. Core knowledge acquisition
Some VPs are designed for the purpose of improving
conceptual knowledge and illuminating the basic principles
underlying medical procedures. However, there are those
who maintain that VP use is not the best means of teaching
and facilitating core knowledge and who believe that dealing
with basic subjects through traditional educational methods
before using VPs will reduce the cognitive burden that may
arise during VP applications [4].
3. Skills acquisition
A VP can be used in teaching history taking, physical
examination, communication and procedural skills.
However, the technique may be inadequate when it comes
to understanding and expressing basic principles (such as
diagnosing a mitral stenosis murmur or asking questions
appropriate to a dyspneic subject), to the application of
effective skills (such as knowing when to perform cardiac
examination or performing appropriate auscultation) or
learning empathy-building skills. Simulated or standardized
patients are individuals who are selected and trained to
portray a patient accurately and consistently [17]. Simulated/
standardized patient use is thought to be more appropriate in
the acquisition of such skills [4].
4. Affective characteristic development
Although simulated/standardized patients are
recommended in the development of affective characteristics
such as student interest, motivation, attitude and academic
self-concept, some studies have shown that VP use is
beneficial in the acquisition of professional competence and
objectives concerning ethics and the law [12,14,18,19].
What are the features of the vitual patient system?
A VP differs from other form of simulation. The VP system
is one of the high fidelity simulation forms, and requires
special equipment [4].VPs are processed on the computer
screen by way of clinical scenarios. The computer provides
the patient responses and the requisite information. The
learner communicates with the patient (the computer) by
writing, selection or in some cases by speaking. During
this process, the learner has to develop a diagnostic and
management plan. There is considerable scope for variation
within this program. These variations have different effects
on learning and evaluation, but the case itself represents the
most important structure. Case selection and arrangement
may be more important than the technical case details.
Feedback is very important; it permits the development of
such cognitive attributes as recall, attention, reasoning and
problem solving [4].
Standard web and multimedia tools are used for VP.
These are frequently installed in special systems in which
both the writing process and the resulting VP applications
are revealed. These systems reflect the designers’ norms,
values and concepts together with any technology employed
[4].
There is no clear answer to the question of which
VP design is more effective for learning, and there is no
standard setting out which characteristics the VP should
possess. Strategies determined for VP applications include
encouraging clinical reasoning, developing teaching cases,
improving learning through simulation and designing
effective multimedia tools for cognitive learning. These
strategies certainly need to be present in VP applications,
although it is unclear how these affect student learning
[20].
Techniques recommended for effective VP designs
include:
• Asking open-ended questions,
• Providing single-sentence summaries of patient
problems,
• Asking questions to elicit characteristics for
differentiating or testing diagnostic hypotheses,
• Drawing early conclusions for a differential diagnosis,
• Prioritizing diagnoses,
• Encouraging the student to compare diagnostic
hypotheses based on genuine clinical data,
• Showing relatively diverse diagnostic possibilities and
• Showing typical presentations of different diagnostic
hypotheses.
Case characteristics should be relevant, realistic,
interconnected, demanding and instructive [21-23].
There are numerous variations including one or more
characteristics in VP applications. Characteristics and basic
questions for VP variations are shown in Table I.
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Virtual patients in medical education Marmara Medical Journal 2015; 28: 63-69
Table I: Characteristics and basic questions for VP variations
[4,20]
Interactivity–What kind of information is included in the case?
Requesting and providing clinical information – how do learners
elicit and interpret information? (in the form of text, sound or
images)
Case flow – does the case flow change? For example, does the case
flow change depending on the learner’s decisions or by chance?
Diagnostic information – Is the diagnosis known from the outset
or not?
Case organization - (diagnosis, difficulty, number) selected or
consecutive?
Feedback and instruction–how and when do these appear?
Instructional development – What kind of teaching strategies
such as listing differentiating characteristics, requesting tests or
differentiating different cases are involved?
Learner characteristics – what is the learner’s level and existing
clinical knowledge?
Learner collaboration – does the learner work alone or in a group?
Curriculum integration – Is it part of the compulsory curriculum
or an elective?
Evaluation – how and for what purpose is evaluation used?
Case development and maintenance – how were and are cases
developed?
VP typologies employing different systems are currently
in use. The majority of these have been developed on the
basis of international cooperation in the scope of projects.
One example of this is the-VIP Project [24] which is intended
to investigate standards in health and medical education,
comply with technical standards and make it possible to
share the VP content. Using four different systems and more
than 300 cases, e-VIP permits material exchange between
nine institutions (Great Britain Warwick, Coventry and St
George’s Hospital; Sweden’s Karolinska Institutet; Germany
Heidelberg, Witten/Herdecke and Ludwig-Maximilians; The
Netherlands Maastricht; Poland Jagiellonski and Romanian
universities) [7]. The computer programs include: CASUS
[25], Munich Ludwig-Maximilians University; CAMPUS
[26], HeilderbergUniversity OpenLabyrinth (27), Edinburgh
UniversityWeb-SP (28), Karolinska Institutet.
Other systems and approaches include Tufts, Pittsburg,
New York University, The International Virtual Medical
School and Decision Simulation [7,29,30].
What is the evidence regarding virtual patient?
Research into VP in medical education constitutes evidence
in the following three spheres:
1 Satisfaction with VP
VP is popular with students because of its independence,
compatibility with student programs, the contribution
it makes to the cognitive case library and its stress-free
environment. However, students also add that it cannot
replace real patients. They also appreciate its data collection
process, more/less demanding options, its provision of
developments that respond to the student’s actions and the
presence of feedback. Students report that authenticity, case
type and computer presentation (including video and with
realistic dialogues and fluent speech) also contribute to case
realism [31].
The VP system requires technological sufficiency and is
difficult for instructors. Some instructors suggest that these
applications make them ineffective [32].
2 The effect of VP on learning
• Evaluations based on post-test
Studies involving procedures without pre-tests have
assessed students’ knowledge acquisition, and evidence has
emerged that VP facilitates learning [33-35].
• Comparative evaluations
Many comparative evaluations have been performed
with simulated patient procedures. Studies have reported
that VP procedures facilitate the student’s learning and grasp
of the technical aspects of medical interviews. On the other
hand, simulated patient procedures have been found to be
more effective in terms of exhibition of affective skills [19].
One study comparing VP with written cases reported
that students prefer VP applications to written versions [36].
In a two-group comparative study of students on internal
diseases internships, Botezatu et al. reported that VP
provided better long-term memorization than traditional
learning methods [36].
3 VP designs
There is no guide to the design and application of VP,
although research into VP design and application has
increased in recent years.
• Studies comparing case formats
Studies by Friedman and Bearman may be regarded as
some of the earliest research. In 1991, Friedman compared
three case formats, pedagogic, problem solving and high-
fidelity. The pedagogic format achieved greater success in
post-test, but the other formats produced more hypotheses
directed toward reasoning. Bearman’s 2001 study reported
that a narrative approach, in which series of effects over
time were set out around a consistent main theme, was
more effective in students’ acquisition of communication
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Marmara Medical Journal 2015; 28: 63-69
skills than the problem solving approach involving a case
needing to be solved. Bearman’s 2003 study reported that
the problem solving format led to greater negative emotions,
such as anger, in students [32,37].
• Studies comparing menus
One study compared the CAMPUS classic and card-
based types in a problem solving format. The CAMPUS
classic type is a simulative mode of presentation containing
relatively free navigation and an authentic web-based
interface (in these an image of an examining room is shown
behind the patient and in which students’ movements are
shown in graphic form, so that those parts of the body that
are examined are being shown in color). This format is
predominantly characterized by long question menus. The
long menu lists consist of appropriate, likely related options
for students to choose between. The capacity of the lists is in
the region of 8000 items. Students can also access free text.
These questions permit automatic feedback. The CAMPUS
card-based type is a presentation model containing a short
menu of questions without graphic support with a previously
determined task flow and web-based interface. The study
results showed that students found the classic type with a
long menu mode more demanding but more motivating, and
much preferred it due to its revelation of gaps in knowledge
and its being intended to fill these [7].
Jäger et al. reported that brief VP cases, having a mean
case study time of 15 min and important take-home messages
in the design, were more effective on student outputs [38].
• Studies concerning the origin of virtual patient data
One study investigating the source of cases necessary
for VP applications revealed that electronic health records
are frequently taken from hospital computer systems and
that genuine patient data and the experiences of clinical
trainers are often employed together. Requirements of these
applications include that they should be easy to obtain, the
anonymity of data, and that they should reflect the current
reality, together with deficient information [39].
• Studies regarding its place in the curriculum
Studies have shown that designs that are associated
with seminars, courses and corresponding tests [40], that
are balanced [41] and appropriately integrated into the
curriculum [42] all motivate students. Edelbring emphasized
the importance of assessing VP-based activities not as
separate phenomena but as an integrated whole together
with other educational activities [42].
• Studies concerning individual or group applications
VP applications are suited to individualized learning
and assessment. However, students prefer group work in
terms of rectifying their deficiencies, increasing motivation
and observing different approaches. Kühne-Eversmann
submitted evidence that working with a partner activates
the student, increases knowledge levels, improves reasoning
abilities and elicits greater discussion about approaches to
patient management [31,38,43]. Jäger et al. revealed that
students with high levels of preliminary knowledge who
work with a partner are more successful and that short VP
cases are more effective [38].
The future of virtual patient applications
Trainers, clinicians and researchers emphasize the pedagogic
value and significant effects of VP. They report that while
VPs cannot replace real patients they can be employed as an
assistant tool for improving clinical reasoning and problem
solving skills in particular in medical education.
International information is the most important element
in helping to spread VP applications, in ease of accessibility
and in establishing norms for the field. It is predicted that
the time spent on VP design will gradually decrease and
that design will become easier. VP authoring systems will
be developed and branching designs in which the outcomes
of different decisions that can improve patient management
skills will emerge. VPs will become an indispensible part of
the curriculum, will be used together with other simulative
tools, and three-dimensional environments including digital
avatars will be seen [5,29].
Conclusion: The situation in Turkey and projections and
recommendations for the future
There is increasing research into simulation applications
in Turkey. Simulation is occupying ever greater space in
education programs, various simulation tools are being used
and skills appropriate to a spiral curriculum are becoming
the main element of education programs. Work is also
taking place on the opening of skills laboratories in faculties
as well as simulation facilities at the central level. National
and international symposia and congresses are being held
to increase interaction between simulation and relevant
professions. However, VP applications in Turkey are still at
the theoretical level.
Although VP applications are still regarded as a project
involving economic burdens on faculties, one of the most
important factors in the structuring and implementation
of VP applications is multiple professional interaction. In
particular, joint projects with computer engineering can
be arranged at the local level, and this will assist with the
emergence of more economical and applicable systems.
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Virtual patients in medical education Marmara Medical Journal 2015; 28: 63-69
The use of VP applications will assist faculty curricula
in terms of multiple methods. It must be regarded as a factor
that will enhance physicians’ skills and contribute to a high-
quality health field. It must not be forgotten that VP systems
make a great contribution to reasoning and decision-making
processes, and the educational impact on students with its
educational objectives, aims, means and interaction must be
borne in mind when including the method in the system.
It seems not unrealistic to predict that with the advantages
bestowed on multiple method use by educational programs
employing VP applications, these will be increasingly more
widely used in Turkey as well as in a rapidly changing world.
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