ArticlePDF Available


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
Marmara Medical Journal 2015; 28: 63-69
DOI: 10.5472/MMJ ra.2802.01
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
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
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
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
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
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
• 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
64 Mıdık and Kartal
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].
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
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
Techniques recommended for effective VP designs
• Asking open-ended questions,
• Providing single-sentence summaries of patient
• 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
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.
66 Mıdık and Kartal
Virtual patients in medical education Marmara Medical Journal 2015; 28: 63-69
Table I: Characteristics and basic questions for VP variations
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
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
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
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
Mıdık and Kartal
Virtual patients in medical education
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.
68 Mıdık and Kartal
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.
1. Sayek I, Kiper N, Odabasi O. Mezuniyet Öncesi Tıp Eğitimi
Raporu 2008. Ankara: Türk Tabipleri Birliği Yayınları, 2008.
2. Doğan MP. Feyerabend ve çoğulculuk. İlim Dünyası 2012;
4: 16-26.
3. Sönmez V. Gelecekteki olası Eğitim Sistemleri. Ankara: Anı
Yayıncılık, 2008.
4. Cook DA, Triola MM. Virtual patients: a critical literature
review and proposed next steps. Med Educ 2009; 43: 303-11.
doi: 10.1111/j.1365-2923.2008.03286.x.
5. Poulton T, Balasubramaniam C. Virtual patients: A
year of change. Med Teach 2011; 33: 933-7. doi:
6. Ellaway RH, Davies D. Design for learning: deconstructing
virtual patient activities. Med Teach 2011;33: 303-10. doi:
7. Huwendiek S, Reichert F, Bosse HM, et al. Design principles
for virtual patients: A focus group study among students. Med
Educ 2009: 43: 580-8.doi: 10.1111/j.1365-2923.2009.03369.x.
8. Huang G, Reynolds R, Candler C. Virtual patient simulation at
U.S. and Canadian medical schools. Acad Med 2007; 82;446-
9. Bateman J, Allen M, Samani D, Kidd J, Davies D. Virtual
patient design: exploring what works and why. A grounded
theory study. Med Educ 2013; 47: 595-606. doi: 10.1111/
10. Dewhurst D, Borgstein E, Grant M, Begg M. Online virtual
patients- A driver for change in medical and healthcare
Professional education in devoloping countries. Med Teach
2009; 31: 721-4.
11. Wood E, Tso S. The virtual continuity in learning programme:
results. Clin Teach 2012; 9:216-21. doi: 10.1111/j.1743-
12. McEvoy MM, Butler B, MacCarrick G, Nicholson AJ. Virtual
patients: an effective educational intervention to improve
paediatric basic specialist trainee education in the management
of suspected child abuse? Ir Med J 2011; 104:250-2.
13. Gunning WT, Fors UG. Virtual patients for assessment of
medical student ability to integrate clinical and laboratory data
to develop differential diagnoses: comparison of results of
exams with/without time constraints. Med Teach 2012;34:222-
8. doi: 10.3109/0142159X.2012.642830.
14. Hooper CR, Jivram T, Law S, Michell A, Somasunderam A.
Using virtual patients to teach medical ethics, medical law
and medical professionalism. Med Teach 2012; 34:674-5. doi:
15. Gormley GJ, McGlade, K, Thomson C, McGıll M, Sun JA.
Virtual surgery in general practice: Evaluation of a novel
undergraduate virtual patient learning package. Med Teach
2011; 33: 522-7. doi: 10.3109/0142159X.2011.599889.
16. Norman G. Research in clinical reasoning: past history and
current trends. Med Educ 2005; 39:418-27.
17. Lane JL, Slavin S, Ziv A. Simulation in medical education: A
review. Simul Gaming 2001;32: 297–314.
18. Kononowicz AA, Krawczyk P, Cebula G, et al. Effects of
introducing a voluntary virtual patient module to a basic
life support with an automated external defibrillator course:
a randomised trial. BMC Med Educ 2012; 12:41.doi:
19. Deladisma AM, Johnsen K, Raij A, et al. Medical student
satisfaction using a virtual patient system to learn history-
taking communication skills. Stud Health Technol Inform
2008; 132:101-5.
20. Huwendiek S, De Leng BA, Zary N, Fischer MR, Ruiz JG,
Ellaway R. Towards a typology of virtual patients. Med Teach
2009; 31: 743-8.
21. Bowen JL. Educational strategies to promote clinical
diagnostic reasoning. N Engl J Med 2006; 355: 2217-25.
22. Nendaz MR, Bordage G. Promoting diagnostic problem
representation. Med Educ 2002; 36: 760-6.
23. Bordage G. Why did I miss the diagnosis? Some cognitive
explanations and educational implications. Acad Med 1999;
74: 138-43.
24. eViP Electronic virtual patients. http://www.virtualpatients.
eu. Access on 27.10.2014
25. CASUS Online. Access on 07.11.2014
26. CAMPUS Online.
Access on 07.11.2014
27. OpenLabyrint.
Access on 07.11.2014
28. Web-SP. Access on 07.11.2014
29. Benedict N. Virtual patients and problem-based learning in
advanced therapeutics.Am J Pharm Educ 2010;74:143.
30. Conradi E, Kavia S, Burden D, et al. Virtual patients in a
virtual world: Training paramedic students for practice. Med
Teach 2009;31:713-20.
31. Cook DA, Erwin PJ, Triola MM. Computerized virtual patients
ın health professions education: A systematic review and
meta analysis. Acad Med 2010; 85: 1589-602. doi: 10.1097/
Mıdık and Kartal
Virtual patients in medical education
Marmara Medical Journal 2015; 28: 63-69
32. Bearman M. Is virtual the same as real? Medical students’
experiences of a virtual patient. Acad Med 2003;78: 538-45.
33. Kleinert HL, Fisher SB, Sanders CL, Boyd S. Improving
physician assistant students’ competencies in developmental
disabilities using virtual patient modules. J Physician Assistant
Educ 2007; 18:33-40.
34. Triola M, Feldman H, Kalet AL, et al. A randomized trial
of teaching clinical skills using virtual and live standardized
patients. J Gen Intern Med 2006; 21:424-9.
35. Sanders CL, Kleinert HL, Free T, Slusher I, Clevenger K,
Johnson S, Boyd SE.Caring for children with intellectual
and developmental disabilities: virtualpatient instruction
improves students’ knowledge and comfort level. J Pediatr
Nurs 2007;22:457-66.
36. Botezatu M, Hult H, Fors UG. Virtual patient simulation: what
do students make of it? A focus group study. BMC Med Educ
2010; 10: 91. doi: 10.1186/1472-6920-10-91
37. Bearman, M, Cesnik B, Liddell M. Random comparison of
‘virtual patient’models in the context of teaching clinical
communication skills. Med Educ 2001; 35: 824-32.
38. Jäger F, Riemer M, Abendroth M, Sehner S, Harendza S.
Virtual patients: the influence of case design and teamwork on
students’ perception and knowledge – a pilot study. BMC Med
Educ 2014;14: 137. doi: 10.1186/1472-6920-14-137
39. Bloice MD, Simonic KM, Holzinger A. On the usage of
health records for the design of Virtual Patients: a systematic
review. BMC Med Inform Decis Mak 2013;13: 103. doi:
40. Hege I, Ropp V, Adler M, et al. Experiences with different
integration strategies of case based e-learning. Med Teach
2007; 29: 791-7. doi: 10.1080/01421590701589193
41. Berman N, Fall LH, Smith S, et al. Integration strategies for
using virtual patients in clinical clerkships. Acad Med 2009;
84:942-9. doi: 10.1097/ACM.0b013e3181a8c668.
42. Edelbring S, Dastmalchi M, Hult H, Lundberg IE, Dahlgren
LO. Experiencing virtual patients in clinical learning: a
phenomenological study. Adv Health Sci Educ Theory Pract
2011;16:331-45. doi: 10.1007/s10459-010-9265-0
43. Kühne-Eversmann L, Eversmann T, Fischer MR. Team-
and case-based learning to activate participants and enhance
knowledge: An evaluation of seminars in Germany. J Contin
Educ Health Prof 2008; 28: 165-71. doi: 10.1002/chp.175
... An integrative review of authentic assessment studies also suggested that the education trends are changing through simulations that combine e-learning or mobile devices (Maude et al., 2021). These education methods have fostered learners' clinical and educational competencies, such as knowledge and clinical reasoning (Midik and Kartal, 2015;Ludwig et al., 2018). Clinical reasoning helps the learner to integrate and apply the acquired knowledge associated with patients within a therapeutic implementation plan (Ludwig et al., 2018). ...
... A virtual simulation provides opportunities to develop intervention skills through repeated cases (Kron et al., 2017). These experiences have reduced medical errors and improved patient safety (Midik and Kartal, 2015). It is necessary to consider developing virtual or computer-based simulations of patients with various health problems and to evaluate their effectiveness. ...
Background The increasing complexity of the clinical environment demands a higher level of clinical performance competency. New pedagogical authentic learning methods have been developed to meet this need by bridging the gap between knowledge and practice. Objective This systematic review aimed to examine authentic learning methods and their effects in healthcare education. Design Systematic review. Data sources Data were obtained from a literature search of Embase, PubMed, MEDLINE, CINAHL, PsycINFO, and Korean databases (e.g., KoreaMed) for studies published until May 2021. This review selected research papers documenting RCTs or quasi-experimental studies targeting undergraduate students training to become healthcare professionals. Review methods. This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline. The risk of bias assessment utilized the Joanna Briggs Institute (JBI) critical checklist. Results Of 20 selected studies, 12 studies were randomized controlled trials, while 8 had quasi-experimental designs with a control group. Simulation was identified as an effective educational method for authentic learning. Through authentic learning, undergraduate students cultivated their knowledge and learning motivation. However, divergent conclusions were shown for performance skills. Conclusions Authentic pedagogical methodologies effectively enhanced learners' competencies in the cognitive, psychomotor, and affective domains. Integrating technological applications, e.g., e-learning or web-based approaches, facilitated education across academic boundaries. Further studies on combining technology with authentic learning approaches should be conducted to construct realistic educational environments for learners. Trial registration CRD42021229350.
... Virtual patients can be used to improve knowledge and skills in clinical education like problem-solving and clinical reasoning that decrease the number of medical errors and consequently enhance patient safety. Also, they can be applied in learning history taking, clinical examination, medical communication, and practical skills (Mıdık and Kartal, 2015). The goal of this study is to speculate on the educational benefit of using virtual clinical patients teaching in the orthopedic field for the clinical teaching of medical students. ...
... VPs are computer-based simulations of authentic clinical cases that allow users to interact with the system for the purpose of health care or medical trainings, education, or assessments [17,18]. Current uses of VPs in medical education are primarily to develop students' clinical reasonings, problem-solving skills, core or conceptual knowledge acquisitions, skills acquisitions, and affective characteristic developments (eg, professional competence) [19]. Reviews evaluating the effectiveness of VPs in medical education [17,20] have reported VPs as a cost-effective tool and as successful in facilitating clinical reasonings, communication skills, and ethical reasonings among students when used as an alternative or supplementary tool to existing curricula. ...
Full-text available
Background: The ability of nursing undergraduates to communicate effectively with health care providers, patients, and their family members is crucial to their nursing professions as these can affect patient outcomes. However, the traditional use of didactic lectures for communication skills training is ineffective, and the use of standardized patients is not time- or cost-effective. Given the abilities of virtual patients (VPs) to simulate interactive and authentic clinical scenarios in secured environments with unlimited training attempts, a virtual counseling application is an ideal platform for nursing students to hone their communication skills before their clinical postings. Objective: The aim of this study was to develop and test the use of VPs to better prepare nursing undergraduates for communicating with real-life patients, their family members, and other health care professionals during their clinical postings. Methods: The stages of the creation of VPs included preparation, design, and development, followed by a testing phase before the official implementation. An initial voice chatbot was trained using a natural language processing engine, Google Cloud's Dialogflow, and was later visualized into a three-dimensional (3D) avatar form using Unity 3D. Results: The VPs included four case scenarios that were congruent with the nursing undergraduates' semesters' learning objectives: (1) assessing the pain experienced by a pregnant woman, (2) taking the history of a depressed patient, (3) escalating a bleeding episode of a postoperative patient to a physician, and (4) showing empathy to a stressed-out fellow final-year nursing student. Challenges arose in terms of content development, technological limitations, and expectations management, which can be resolved by contingency planning, open communication, constant program updates, refinement, and training. Conclusions: The creation of VPs to assist in nursing students' communication skills training may provide authentic learning environments that enhance students' perceived self-efficacy and confidence in effective communication skills. However, given the infancy stage of this project, further refinement and constant enhancements are needed to train the VPs to simulate real-life conversations before the official implementation.
... A review of the international literature shows that VPs are widely used in the field of health sciences, although the concept is relatively new in Turkey. The VP concept remains theoretical in Turkey and is yet to be used in training, although recommendations have been made for its development and use (Mıdık & Kartal, 2015). The authors of this study spent 4 months in the University of Florida, College of Medicine, where virtual training applications are in common and effective use in teaching, and had the opportunity to experience different virtual human applications. ...
Full-text available
Virtual patient (VP) is a concept used in the teaching of communication skills, and like physical examinations and other professional skills, must be taught with utmost care. In Turkey, as VPs are yet to be used in medical training, the usual practice when teaching such skills is to use standardised patients (individuals pretending to be patients). The main purpose of this study was to design, develop and evaluate a 3D VP application that can move, has speech-over lip sync, allows written communication and is supported by a strong scenario to improve the communication skills of students. The study was designed and carried out using developmental research methods. The implementation phase involved a pretest posttest quasi-experimental design. The participants in the study consisted of academics specialising in medicine, software experts, an education technology expert, an assessment and evaluation expert, and medical students. The study found that VP applications were accepted by students and were as effective as standardised patients for the teaching of communication skills. The students reported that the VP application developed was very successful in terms of visual and behavioural reality.
Full-text available
Dear Editor, One of the most modern and effective methods of computer-assisted learning is the use of virtual patient technology. This technology is defined as the interactive computer simulation of the actual conditions of clinical scenarios for health, treatment, education, and measurement purposes. The virtual patient technology has become one of the most common types of problem-based learning in medical education [1]. This concept incorporates the interactive computer simulators that are used in medical education and their main focus is on simulating the clinical steps; including patient history, physical examination, laboratory tests, diagnosis, treatment prescription, and feedback [2].
Full-text available
Background Virtual patient (VP) cases are an effective teaching method, although little is known about how to design and implement them for maximum effectiveness. The aim of this study was to explore the effect of case design and teamwork on students’ learning outcome. Methods One hundred forty-six undergraduate medical students participated in a mandatory medical computer science course consisting of five seminars. At the end of each seminar, they worked on one VP case, either in teams of two or individually. Each student filled out an introductory and a final survey and a feedback sheet after completing each case. Additionally, there was a surprise multiple choice (MC) test after the last seminar with three questions regarding each case. Results Students with more clinical experience and students who had worked in a team performed significantly better on MC questions. Students with less clinical experience more frequently used information which had been positioned less prominently on the case material. Certain aspects of case design were rated more positively by students who had an interest in e-learning. In general, students preferred to work on cases for less than 15 minutes. Conclusions Clinically more advanced students and students working with a partner seem to benefit most from short VP cases with prominently presented information.
Full-text available
The process of creating and designing Virtual Patients for teaching students of medicine is an expensive and time-consuming task. In order to explore potential methods of mitigating these costs, our group began exploring the possibility of creating Virtual Patients based on electronic health records. This review assesses the usage of electronic health records in the creation of interactive Virtual Patients for teaching clinical decision-making. The PubMed database was accessed programmatically to find papers relating to Virtual Patients. The returned citations were classified and the relevant full text articles were reviewed to find Virtual Patient systems that used electronic health records to create learning modalities. A total of n = 362 citations were found on PubMed and subsequently classified, of which n = 28 full-text articles were reviewed. Few articles used unformatted electronic health records other than patient CT or MRI scans. The use of patient data, extracted from electronic health records or otherwise, is widespread. The use of unformatted electronic health records in their raw form is less frequent. Patient data use is broad and spans several areas, such as teaching, training, 3D visualisation, and assessment. Virtual Patients that are based on real patient data are widespread, yet the use of unformatted electronic health records, abundant in hospital information systems, is reported less often. The majority of teaching systems use reformatted patient data gathered from electronic health records, and do not use these electronic health records directly. Furthermore, many systems were found that used patient data in the form of CT or MRI scans. Much potential research exists regarding the use of unformatted electronic health records for the creation of Virtual Patients.
Full-text available
Virtual patients (VPs) are online representations of clinical cases used in medical education. Widely adopted, they are well placed to teach clinical reasoning skills. International technology standards mean VPs can be created, shared and repurposed between institutions. A systematic review has highlighted the lack of evidence to support which of the numerous VP designs may be effective, and why. We set out to research the influence of VP design on medical undergraduates. This is a grounded theory study into the influence of VP design on undergraduate medical students. Following a review of the literature and publicly available VP cases, we identified important design properties. We integrated them into two substantial VPs produced for this research. Using purposeful iterative sampling, 46 medical undergraduates were recruited to participate in six focus groups. Participants completed both VPs, an evaluation and a 1-hour focus group discussion. These were digitally recorded, transcribed and analysed using grounded theory, supported by computer-assisted analysis. Following open, axial and selective coding, we produced a theoretical model describing how students learn from VPs. We identified a central core phenomenon designated 'learning from the VP'. This had four categories: VP Construction; External Preconditions; Student-VP Interaction, and Consequences. From these, we constructed a three-layer model describing the interactions of students with VPs. The inner layer consists of the student's cognitive and behavioural preconditions prior to sitting a case. The middle layer considers the VP as an 'encoded object', an e-learning artefact and as a 'constructed activity', with associated pedagogic and organisational elements. The outer layer describes cognitive and behavioural change. This is the first grounded theory study to explore VP design. This original research has produced a model which enhances understanding of how and why the delivery and design of VPs influence learning. The model may be of practical use to authors, institutions and researchers.
Full-text available
The implementation of the European Working Time Directive and specialty-driven care has resulted in the loss of continuity of patient care, and thus a loss of continuity in learning. We proposed a potential solution to this fragmentation of junior doctor workplace learning in the Virtual Continuity in Learning Programme (VCLP). The VCLP enables the doctor to follow the virtual patient journey (of an actual patient who is no longer under their care) using the Virtual Consulting Room (VcR), and to understand the rationale behind clinical decision making prior to completing their case-based discussion (CbD) work-based assessments. Fifty-seven out of 62 (92%) of foundation doctors (Homerton University Hospital, London, UK) consented to participate in the study. Web-tracking software was used. Fifty-three out of 57 (93%) doctors completed an initial questionnaire. Twenty-nine out of 57 (51%) doctors returned a follow-up questionnaire 6 months later. Eleven doctors were interviewed in three focus groups: the VcR user group; the VcR non-user group; and a mixed group. The data was analysed qualitatively. Tracking showed 33.3 per cent (19/57) of doctors used the VcR over a 6-month period. Interestingly doctors used the VcR in a range of situations, not solely as instructed. Results enabled us to understand how doctors learn and their perception of using the VCLP to support their learning and completion of work-based assessments. Foundation doctors use the educational resources available, including the VcR, to help structure their workplace learning. The majority of VcR users found it particularly useful for just-in-time learning. The VCLP offers support to junior doctors learning during their preparation for case-based discussion.
Full-text available
Simulation is used widely in medical education. The simulation methodologies used at the present time range from low technology to high technology. This article describes how role play, standardized patients, computer, videotape, and mannequin simulations are integrated into the educational curricula for medical students and physicians. Advantages and disadvantages of simulation and barriers to the use of simulation are discussed. Simulation is an integral part of today's undergraduate, postgraduate, and continu-ing medical education curricula. It has been recognized for some time that simulation is a valuable and necessary adjunct to the educational experience because opportuni-ties to learn essential clinical skills in the real clinical setting may be inadequate. To be competent, a medical student must master a basic skill set by the time of graduation, continue to master new skills during further training, and pursue lifelong learning skills once formal training is completed. Skills needed by physicians may be divided into three distinct areas: (a) patient-centered skills, (b) process-centered skills, and (c) environment-centered skills. Patient-centered skills are those related to the direct care of an individual patient and include data-gathering skills (history taking and physical examination), communica-tion skills, interpersonal skills, and technical skills. Implementation of these skills combined with a sound knowledge base and clinical reasoning ability generally results in successful diagnosis and management of a patient. Process-centered skills are those that allow physicians to practice successfully in their local environment and include information management skills, teamwork skills, patient advocacy skills, and self-directed learning skills. Environment-centered skills are those that enable the physician to be successful in the culture of medicine and the wider medical practice AUTHORS' NOTE: We would like to thank Sybil Fullard for her help with the preparation of the article and Ruth Gottlieb and Kenneth Green for their support and advice.
Full-text available
The concept of virtual patients (VPs) encompasses a great variety of predominantly case-based e-learning modules with different complexity and fidelity levels. Methods for effective placement of VPs in the process of medical education are sought. The aim of this study was to determine whether the introduction of a voluntary virtual patients module into a basic life support with an automated external defibrillator (BLS-AED) course improved the knowledge and skills of students taking the course. Half of the students were randomly assigned to an experimental group and given voluntary access to a virtual patient module consisting of six cases presenting BLS-AED knowledge and skills. Pre- and post-course knowledge tests and skills assessments were performed, as well as a survey of students' satisfaction with the VP usage. In addition, time spent using the virtual patient system, percentage of screen cards viewed and scores in the formative questions in the VP system throughout the course were traced and recorded. The study was conducted over a six week period and involved 226 first year medical students. The voluntary module was used by 61 (54%) of the 114 entitled study participants. The group that used VPs demonstrated better results in knowledge acquisition and in some key BLS-AED action skills than the group without access, or those students from the experimental group deliberately not using virtual patients. Most of the students rated the combination of VPs and corresponding teaching events positively. The overall positive reaction of students and encouraging results in knowledge and skills acquisition suggest that the usage of virtual patients in a BLS-AED course on a voluntary basis is feasible and should be further investigated.
Full-text available
We have evaluated medical student ability in a problem-based learning course using a virtual patient (VP)-based exam with variable parameters for assessment purposes. A class of 155 second year medical students was assessed using a VP exam with unlimited access during a 1-week period; 2 years later, the identical exam was administered to 175 students with a 3-h time limit. Students taking the exam without time constraints utilized approximately twice as much time than students with the time limit. Without the pressure of a time-limit, students utilized half as many inquiries of the patient history, physical, and lab/imaging tests than were used by students having a time constraint, indicating that the time limited students used a "shotgun approach" to try to collect as many "required" inquiries as possible. Most students (91%) taking the untimed exam were able to correctly diagnose the exam case but only 31% of the time limited students correctly diagnosed the VP exam case, despite their higher number of inquiries. Our results demonstrate that an identical VP exam, administered with variables to compare untimed versus time-limited conditions, resulted in an unraveling of student's ability to integrate the data discovered during the process of progressive disclosure.
: Two multimedia, virtual-patient modules that focused on patients with developmental disabilities were developed as clinical training tools for physician assistant (PA) students. Primary objectives of the modules included (a) improved knowledge and (b) reduced perception of difficulty in treating patients with developmental disabilities. The modules were developed using an iterative, collaborative process within a core development team that included medical professionals, multimedia specialists, parents of children with developmental disabilities, and an individual with a developmental disability. The modules included two virtual patient cases - a well-child visit for a young adolescent female with Down syndrome, and a routine office visit for an infant born significantly preterm. Within the context of the two cases, students were required to identify appropriate and effective clinician-patient interactions, in addition to relevant medical and developmental concerns for this population. An effectiveness study utilizing a sample of 42 PA students suggest that the modules are an effective tool for improving PA student knowledge and reducing their perception of difficulty in providing care to patients with developmental disabilities and their families.
Child abuse is a particularly difficult subject to teach at both undergraduate and postgraduate level. Most doctors are dissatisfied with their training in child abuse recognition and management. We developed an interactive video based Virtual Patient to provide formal training for paediatric Basic Specialist Trainees in the recognition of suspected child abuse. The Virtual Patient case revolves around the management of suspected physical abuse in a seven month old child, who initially presents to the Emergency Department with viral upper respiratory tract symptoms. This Virtual Patient was used to facilitate a case discussion with Basic Specialist Trainees. A questionnaire was developed to determine their perception of the value of the Virtual Patient as an educational tool. Twenty five Basic Specialist Trainees completed the questionnaire. Upon completion of the case, 23/25 (92%) participants reported greater self confidence in their ability to recognize cases of suspected child abuse and 24/25 (96%) of participants reported greater self confidence in their ability to report cases of suspected child abuse. Basic Specialist Trainees perceived the Virtual Patient to be a useful educational tool. Virtual Patients may have a role to play in enhancing postgraduate training in the recognition of suspected child abuse.