gms | German Medical Science

Virtual Patients (VPs) offer the possibility to interactively guide learners through diagnostics and treatment of a specific clinical case, imparting clinical patterns and diagnostic and therapeutic algorithms. In recent years, different designs and approaches have been described [1]. VPs are especially suited for promoting clinical reasoning skills [2]. Moreover, current educational research also focuses on the successful integration of e-learning activities in existing medical curricula and residency programs [3]. To achieve optimal benefit, “blended learning” approaches gain popularity which combine e-learning activities with conventional face-to-face teaching [4], [5], [6], [7], [8]. Despite a lot of positive experiences with VPs and blended learning in the training of medical students [9], [10], [11], [12], [13], [14][, possibilities offered for continuing medical education and residency training were noticed quite recently [15], [16].

The survey presented here evaluates the pilot use of VPs at a residency training course. Different aspects of the learning experience with VPs, the combination with a common lecture, and the general opinion about the use of VPs for residency training were evaluated.

The main question was whether and how VPs can be a reasonable complement to learning activities in residency programs. Underlying positive experiences in the training of medical students, the hypothesis was that VPs are suited well in this field, as also in continuing medical education. The use of VPs is flexible, timely and locally independent, and the possibility to customize their content might provide great benefits.

Twice a year, the German Society for Pediatrics and Adolescent Medicine (DGKJ) hosts a revision course offered particularly to pediatric residents. In 2009, this course was hosted at the Center for Pediatrics and Adolescent Medicine Heidelberg, Germany, and one of the authors (DC) was announced for the lecture on nephrotic and nephritic syndrome in children. Two existing VPs on these topics were adapted to the requirements of residency training with the help of experienced specialists and blended with the lecture. The VPs were designed in accordance with published design criteria [17] using CAMPUS software [18]. They were drafted as a wrap-up session of the lecture and were worked-up by around 200 participants in a separate session at the end of the revision course on personal mobile devices via Wi-Fi (see Figure 1 [Fig. 1]). In addition, the VPs were available on the internet for another eight weeks (via http://www.virtuellepatienten.de).

After the completion of the cases, the participants were asked to fill in an online survey. The survey was based on a shortened version of published evaluation instruments for the design of VPs and their curricular integration [19]. It comprised 10 items; six of them asked for agreement on a Likert scale from 1 (totally disagree) to 5 (totally agree), and four questions for multiple free text answers (see table 1 [Tab. 1]). For these open questions, all answers are presented that were mentioned more than once.

Unfortunately, the online survey was unavailable at the revision course due to a problem with the firewall of the Wi-Fi network used. Cases could be completed without any problem, but evaluation was not possible locally. These circumstances reduced the return rate because surveys could only be sent when working with the VPs from the hotel or back home. As the wrap-up session was placed at the event of the course, we were not able to switch to a paper and pencil version after the problem appeared.

A total of 42 survey forms was returned, with N=40 evaluable forms (approximately 21%). 62.5% of the participants were female; 36 residents, two specialists and two consultants participated in the survey. Results of the Likert scaled items are presented as mean ± standard deviation in Table 1 [Tab. 1]; the number of answers is shown in round brackets.

There were strong agreements with the statements that work-up of the cases prepares for diagnostics and medical care of real patients (4.4±0.5 and 4.2±0.8, respectively) and it was perceived as a worthwhile learning experience (4.5±0.7). The case presentation with symptoms, (differential) diagnostics and treatment (9 mentions) was mentioned being a specific strength of this kind of training, followed by interactivity (4) and easy access in a timely and locally independent manner (2). Sporadic criticism was mentioned for diagnostic or therapeutic steps (3), too much text-intensive parts (2), and missing comparison of the correct answer with the given one (2) – altogether criticism on the cases themselves or the software platform. On being asked about the use of VPs in the field of residency training in general, there was a strong agreement for VPs being very suitable (4.7±0.6) with the wish for more such offers (4.7±0.7). VPs should be provided via the internet (34), with secure access via central websites e.g. of the DGKJ (11), and free of charge (6). The blended learning approach, comprising a lecture and adapted VPs, was rated a worthwhile learning experience (4.4±0.7).

The pilot study presented here evaluated acceptance of a blended learning approach, combining virtual patients as a wrap-up of a pediatric lecture in the field of residency training. Participants felt better prepared for real patients with these clinical symptoms after completion of both parts, and perceived the work-up of the VPs as a worthwhile learning experience. Strengths of VPs were mentioned, e.g., the interactive case presentation, its diagnostics and treatment, as well as the timely and local independence of learning. VPs were considered an appropriate learning modality in the field of residency training and continuing medical education, with the wish for more such offers.

The existing offers concerning VPs – except for student education – are rare and often of a commercial nature [20]. Regarding relevant but infrequently occurring content, like e.g. resuscitation algorithms, VPs may fill gaps in continuing medical education curricula or residency training [21]. Flexible use combined with practical relevance of a concrete clinical case suit these target groups well. Content can be tailored individually to specific needs and learning goals, and learning is provided in a timely and locally independent manner allowing repetitive practice.

Blended learning approaches are more and more highlighted for residency curricula as they facilitate an intensive extra-occupational face-to-face training by a structured self-directed learning with interpersonal exchange and networking [16]. There is only little experience with the use of VPs in residency training and continuing medical education. One of the few examples is the inter-professional emergency course at the Center for Pediatrics and Adolescent Medicine Heidelberg, Germany, in which medical and nursing staff are trained to deal with emergency situations in teams after individual preparation with VPs [22]. This course concept was primarily implemented within the local skills laboratories for undergraduate training [14].

The pilot study presented here, for the use of VPs curricular blended with face-to-face teaching, is limited – given the sample size and the use of a non-validated survey instrument. The limitation of the sample size is mainly due to the fact that the survey form was only available to those who completed the cases at home or hotel, as the survey form was not available at the course because of the problem mentioned with the local Wi-Fi firewall. This might be a bias as it addresses mainly tech-savvy participants.

The combination of face-to-face lectures with VPs is innovative in the field of residency training as there is very little experience. It seems a reasonable approach for the application of knowledge learned from face-to-face teaching in virtual practice with feedback.

VPs may reasonably complement curricula in the fields of residency training and continuing medical education. Their practice orientation and flexible use seem to suit these target groups well. Because of the sample limitations, further studies are necessary to confirm these findings and to optimize this approach.

The authors declare that they have no competing interests.