Virtual patients: From pragmatic

implementation to educational research

and back
Martin Fischer, MD, MME (Berne)
Institute for Teaching and Educational Research in Health Sciences
Medical Faculty
Private University Witten/Herdecke
martin.fischer@uni-wh.de

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Circumstances matter
1989 until now

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http://rcpsc.medical.org/canmeds/index.php

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We have done it like
this for a long time…
Why change?

Show me the data.

What is the evidence?

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ICT and Learning: Instruction vs.
construction

Valcke & De Wever 2005

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 What is a virtual patient?

A virtual patient has been defined as "an

interactive computer simulation of real-life
clinical scenarios for the purpose of
healthcare and medical training, education
or assessment" (Ellaway, Candler et al.,
2006).

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Linear? Brached? Lost in
Hyperspace?

Huwendiek et al. 2009 submitted

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 JAMA 2009
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…in concluding that Internet-based learning is
educationally beneficial and can achieve results
similar to those of traditional instructional methods.
Cook et al. JAMA 2009
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 2193 studies identified…

Elucidating how to effectively implement

Internet-based instruction will be answered most
efficiently through research directly comparing
different Internet-based interventions.
Cook et al. JAMA 2009
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ICVP-Conference - Krakow June 5th, 2009 11
 Best Evidence Medical Education
(BEME)
A legitimate child of Evidence-based Medicine

„Best evidence medical education (BEME) is the

implementation, by teachers in their practice, of
methods and approaches to education based on
the best evidence available.

It involves a professional judgement by the

teacher about their teaching taking into account
a number of factors […]“

Harden 1999

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 BEME: Q U E S T S
A multi-dimensional approach

1. Quality: How good is the evidence?

2. Utility: To what extent can the method be transferred and

adopted without modification?

3. Extent What is the extent of the evidence?

4. Strength How strong is the evidence?

5. Target What is the target? What is being measured? How

valid is the evidence?
6. Setting? How close does the context or setting approximate
How relevant is the evidence?
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 Harden et al. Medical Teacher 1999
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 Medical Education
Research…

Those who can´t do teach.

Those who can´t teach
teach how to teach.
Those who can´t teach
how to teach do research
on teaching.
adapted from Bernhard Shaw
The doctor's Dilemma 1906

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 Who will be next?

Winner of the € 50.000 Karolinska Institutet

Award for Excellence in Research into Medical
Education.

H. Schmidt R. Harden G. Norman

Psychologist GP, Endocrinologist Epidemiologist & Statistician
Netherlands Scotland Canada

A VP-researcher from Europe?

More research needed...

 „Descriptive studies“ (What was

done?)

 „Justification studies“ (Did it work?)

 „Clarification studies“ (Why or how did

it work?)
H. Schmidt, AMEE 2005

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 And the distribution is…
 110 articles
 published in 2003 and 2004 in
 Acad Medicine

 Adv in Health Sciences Education

 American J of Surgery

 J of General Internal Medicine

 Medical Education

 Teaching and Learning in Medicine

 75 (72%) justification studies

 17 (16%) description studies
 13 (12%) clarification studies
Cook, Bordage & Schmidt; Med. Educ. 2008

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Example CASUS

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 Adding subtitles

Localization (medical documentation)

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Visisbility of student activities

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 Credits drives case use

Sessions Psychology, n=3009

350
Internal Med I, n=939
300
Tuesday Internal Med II, n=18
250

200

150

100

50

0
20.05.2004 27.05.2004 03.06.2004 10.06.2004 17.06.2004 24.06.2004

Hege et al. 2007

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 Learning by teaching: law Faculty
LMU

 Students create their own case in small

teams in a tutorial context with assistance of
a content expert
 Credits for completed case (after
presentation)
 Status quo: 33 cases (21 peer reviewed)
created by 45 students
 Promising acceptance, motivation and
success
 Integration of the cases into the curriculum
after review

Hege et al. 2007

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 Voluntary use and a case-based
exam

 200 students attend an integrated PBL course

(rheumatology, emergency med., orthopedics,
trauma
surgery).
 10 exam-related cases are provided as
voluntary learning tool.
 Exam case (paper/online)
 High acceptance

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 Assessment drives the case use
Sessions
400

350
Summerterm 03
Winterterm 02/03
300

250

200

150

100

50

0
25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0
Days prior to exam

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Combining VP´s…

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…with biomedical basics

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 Clinical skills online CAU &
LMU: Blended Learning
Case (1): Presentation & Case (2):
Theoretical
Introduction of Explanation Cont. &
basics
Patient of skills finish

Questions for formative self-assessment

Face-to-face: Course physical examination

Typical cases plus

Skills lab training
basics
Questions for formative self-assessment

Summative assessment - OSCE

Karsten et al. 2009

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 VP´s and beyond

high-fidelity
simulation

assessment lecture assessment

low-fidelity
simulation

Scholze, Jenderek et al. 2009 (submitted)

 High- versus Low-Fidelity

A B

Obstetrical skills CTG-interpretation

* *
12

20
10

8 15

6
10

5
2

high-fidelity low-fidelity high-fidelity low-fidelity

Scholze, Jenderek et al. 2009 (submitted)

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 High- versus Low-Fidelity

CTG

Obstetrical decision making

6
History 28 (1G/0P) 34.5 weeks of gestation. 
Estimated fetal weight on 10th percentile.
5 “lower UTI” ­ treated with 
Amocixillin (500mg, po, tid) since 24h

Maternal paramters •HR: 115 bpm

4 •NIBP: 105/60 mmHg
•RR: 25 bpm
•Temp.: 38.2oC
3
Pelvic examination •Dilatation: early effacement
•Presentation: Vertex; LOA
2 •Station: -4

Plan  Induction of fetal lung maturity and

1 delivery after 48 h
 Oxytocin i.v. to accelerate contractions
 Ventouse extraction
x Immediate delivery by cesarean

high-fidelity low-fidelity section
 CT-scan to exclude pulmonary embolism

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 Worked examples: learning from
errors
 Objective: fostering medical students` diagnostic knowledge:
 conceptual knowledge
 strategic knowledge
 conditional knowledge
 Worked examples with errors versus without errors

 Errors as learning opportunities (Oser, 2005), but: errors need

to be understood to foster learning

 Elaborated feedback versus knowledge of result (KOR-)

feedback

 Elaborated feedback facilitates understanding in complex

domains

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 Design & Instruments for
Assessing diagnostic knowledge

Feedback format

elaborated KOR

with errors n = 38 n = 38
Example format
without errors n = 39 n = 37

Conceptual knowledge
 Multiple-choice (MC) tests, 23 items
Strategic knowledge
 10 key-feature problems
Conditional knowledge
 3 problem-solving tasks
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 Results for Arterial hypertension

50

48
Score (points)

elaborated
46 Feedback
44 KOR

42
N = 153 medical students
40
with errors without errors
Main effect error: p < .05, Interaction effect: p < .01

 Findings replicated for hyperthyroidism

 Sustained effect in the field

34
Kopp et al. 2008
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From CASEPORT…

Session Manager Learning Systems

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 … to the eViP Project

 3-years project co-funded by the European

Union until Sept. 2010, 4 systems, 9 partners

 Aims
 Creating large international repository of
virtual patients
 Sharing/exchanging of virtual patients
 Repurposing of virtual patients
 Implementation of virtual patients into the
local medical curricula

http://www.virtualpatients.eu

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Item-banking and VP-systems

www.ims-m.de
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 Ingredients of success

1. Good research question.

2. Good research design.
3. Good working conditions.

Bordage 2002

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 Theory-grounded
vs.
pragmatic approaches?

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Quantitative
vs.
Qualitative?

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 Interprofessional
and
Inter-institutional?

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 Room for improvement

Finally, although our findings

regarding the quality of this
body of research are not
unique to research in
Internet-based instruction,the
relatively low scores for
methodological quality and
the observed reporting
deficiencies suggest room for
improvement.

Cook et al. 2009

http://www.gmc-uk.org/education/index.asp
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More challenges to do research on…

 e-Learning/virtual Patients
 Peer-assisted learning
 Communication
 Interprofessional learning
 Simulations
 Assessment
 Faculty development
 Professionalism
 Student selection
 Mentoring
 CME/CPD
 ….
 Perspectives

 More research on case-based

learning needed (from VP´s to real
patients and back)
 Integration of learning assessment
 Fostering interdisciplinary and
interinstistutional approaches

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Outcomes: Improving patient care!

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Many thanks!

martin.fischer@uni-wh.de
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