Conference Paper

Implementation of Process-Oriented Feedback in a Clinical Reasoning Tool for Virtual Patients

To read the full-text of this research, you can request a copy directly from the authors.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... 16 It was considered as limitations of this study the number of students who participated in the sample as well as the non-application of assessment tools that would allow to quantify and determine specific aspects of reasoning that were best achieved by these students, as well as if these aspects correspond to meaningful learning. 17,18 In conclusion, this study proposes the early incorporation teaching strategies that encourage systematic training to improve critical thinking skills through clinical problem solving and feedback discuss. In addition, it is recommended the use of this type of intervention no just as teaching-learning tool but also as a useful assessment format. ...
Full-text available
Introduction Students experience difficulties defining a sequential order and analyzing variables when solving a clinical problem on real-time. Learning in a virtual environment using PBL and e-learning promotes hypothesis-generating research and case study through clinical reasoning. Methods Twenty-two physical therapy students enrolled in a Clinical Reasoning course were asked to solve virtual clinical cases that included three different fields: orthopedic, cardiovascular/pulmonary and neurological. To evaluate the intervention, students’ perception as well as their lecture/lab academic performance, were considered. Results An increase in academic performance in both lecture and lab average grades in comparison to previous years (ANOVA test, *p < 0.05). Fifty-eight percent of students reported prior study, critical thinking and technical language were aspects improved by this resource. Half of the enquired subjects also reported not having enough time to solve cases and suggested be given more adequate feedback. Conclusions After this experience, teacher's role as a facilitator in the teaching learning process, putting the student in a leading role by using metacognitive strategies in tune with technology. Case-solving presents an advantage by improving the process of hypothesis-generation based on the information gathered from a case study problem. Early introduction of teaching strategies promote a systematic practice such as critical thinking through case study, and debate about the feedback needed for its achievement.
... While the learners proceed through a scenario, they may note their observations, hypotheses and plans, and show graphically how those relate. Learners' input into the tool, showing their reasoning process, can be then compared with an experts' answer for feedback (Hege, Kononowicz, Nowakowski, & Adler, 2017). This tool will be integrated in both reference VS systems of WAVES (OpenLabyrinth and CASUS) using a RESTful API. ...
Full-text available
European higher education (HE) systems have undergone extensive reforms over the last two decades to keep pace with globalization processes and increased competition. Some were initiated by national governments, whereas others were the result of joint European initiatives. Among the most prominent European policies is the Bologna Process. Launched in 1999, the Bologna Process aimed at establishing a European Higher Education Area (EHEA) by 2010. One of its core objectives was the adoption of a system of easily readable and comparable degrees. In this article, the intersection between European and national HE policies and processes is considered. The extent of Europeanization versus domestic pressures is examined, with a focus on degree structure reforms in the three Scandinavian countries: Denmark, Sweden, and Norway.
... The tool will also be used for further research studies about clinical reasoning in VPs aiming at answering open questions on the design of a VP to optimally foster the training of clinical reasoning. For example, we are currently implementing a study investigating differences on the reasoning process in undergraduate medical students comparing outcome-and process-oriented expert feedback [39]. ...
Full-text available
Background: Clinical reasoning is a fundamental process medical students have to learn during and after medical school. Virtual patients (VP) are a technology-enhanced learning method to teach clinical reasoning. However, VP systems do not exploit their full potential concerning the clinical reasoning process; for example, most systems focus on the outcome and less on the process of clinical reasoning. Objectives: Keeping our concept grounded in a former qualitative study, we aimed to design and implement a tool to enhance VPs with activities and feedback, which specifically foster the acquisition of clinical reasoning skills. Methods: We designed the tool by translating elements of a conceptual clinical reasoning learning framework into software requirements. The resulting clinical reasoning tool enables learners to build their patient's illness script as a concept map when they are working on a VP scenario. The student's map is compared with the experts' reasoning at each stage of the VP, which is technically enabled by using Medical Subject Headings, which is a comprehensive controlled vocabulary published by the US National Library of Medicine. The tool is implemented using Web technologies, has an open architecture that enables its integration into various systems through an open application program interface, and is available under a Massachusetts Institute of Technology license. Results: We conducted usability tests following a think-aloud protocol and a pilot field study with maps created by 64 medical students. The results show that learners interact with the tool but create less nodes and connections in the concept map than an expert. Further research and usability tests are required to analyze the reasons. Conclusions: The presented tool is a versatile, systematically developed software component that specifically supports the clinical reasoning skills acquisition. It can be plugged into VP systems or used as stand-alone software in other teaching scenarios. The modular design allows an extension with new feedback mechanisms and learning analytics algorithms.
Full-text available
Think about a clinical teaching session that you supervised recently. How much feedback did you provide? How useful do you think your feedback was?
Virtual patients are interactive tools commonly used by medical schools for teaching and learning, and as training tools for the development of clinical reasoning. The feedback delivered to students is a crucial feature in virtual patients. Personalised feedback, in particular, helps students to reflect on their mistakes and to organise their knowledge in order to use it appropriately in a clinical context. However, authoring personalised feedback in virtual patient systems can become a di�cult task, due to the large number of choices available to students and the complex implications of each choice. Additionally, the current technologies used for the design and exchange of virtual patients have limitations in terms of interoperability and data reusability. Semantic web technologies are designed to model complex knowledge in a flexible manner, allowing easy data sharing from multiple sources and automatic data processing. This thesis demonstrates the benefitts of Semantic Web technologies for the design of virtual patients, in particular for the automatic generation of personalised feedback. Seven important types of personalised feedback were identified from the literature, and a preliminary survey showed that students in year 3 to 5 consider two of these types of feedback to be particularly useful: feedback indicating actions that each student should have chosen but neglected, and feedback indicating the diagnoses that each student should have tested and rule out or confi�rmed, given the initial presentation of the patient. SemVP, a Semantic Web-based virtual patient system, was created and evaluated by medical students, using a quantitative survey and qualitative interviews. This study showed that SemVP can generate useful personalised feedback, without the need for a virtual case author to write feedback manually, using a semantic model representing both the virtual patient and each student's actions, and leveraging existing data sources available online.
Background: Virtual patients (VPs) are increasingly used to train clinical reasoning. So far, no validated evaluation instruments for VP design are available. Aims: We examined the validity of an instrument for assessing the perception of VP design by learners. Methods: Three sources of validity evidence were examined: (i) Content was examined based on theory of clinical reasoning and an international VP expert team. (ii) The response process was explored in think-aloud pilot studies with medical students and in content analyses of free text questions accompanying each item of the instrument. (iii) Internal structure was assessed by exploratory factor analysis (EFA) and inter-rater reliability by generalizability analysis. Results: Content analysis was reasonably supported by the theoretical foundation and the VP expert team. The think-aloud studies and analysis of free text comments supported the validity of the instrument. In the EFA, using 2547 student evaluations of a total of 78 VPs, a three-factor model showed a reasonable fit with the data. At least 200 student responses are needed to obtain a reliable evaluation of a VP on all three factors. Conclusion: The instrument has the potential to provide valid information about VP design, provided that many responses per VP are available.
This study aimed to examine what students perceive as the ideal features of virtual patient (VP) design in order to foster learning with a special focus on clinical reasoning. A total of 104 Year 5 medical students worked through at least eight VPs representing four different designs during their paediatric clerkship. The VPs were presented in two modes and differed in terms of the authenticity of the user interface (with or without graphics support), predominant question type (long- versus short-menu questions) and freedom of navigation (relatively free versus predetermined). Each mode was presented in a rich and a poor version with regard to the use of different media and questions and explanations explicitly directed at clinical reasoning. Five groups of between four and nine randomly selected students (n = 27) participated in focus group interviews facilitated by a moderator using a questioning route. The interviews were videotaped, transcribed and analysed. Summary reports were approved by the students. Ten principles of VP design emerged from the analysis. A VP should be relevant, of an appropriate level of difficulty, highly interactive, offer specific feedback, make optimal use of media, help students focus on relevant learning points, offer recapitulation of key learning points, provide an authentic web-based interface and student tasks, and contain questions and explanations tailored to the clinical reasoning process. Students perceived the design principles identified as being conducive to their learning. Many of these principles are supported by the results of other published studies. Future studies should address the effects of these principles using quantitative controlled designs.
MedBiquitous Virtual Patient Architecture
  • R Ellaway
  • C Candler
  • P Greene
  • V Smothers
Ellaway R, Candler C, Greene P, Smothers V. MedBiquitous Virtual Patient Architecture. 2006. Available from