gms | German Medical Science

Research in Medical Education – Chances and Challenges International Conference

20.05. - 22.05.2009, Heidelberg

Can virtual patients be used to promote reflective practice as part of pediatric trainees’ diagnostic reasoning strategies?

Meeting Abstract

Research in Medical Education - Chances and Challenges 2009. Heidelberg, 20.-22.05.2009. Düsseldorf: German Medical Science GMS Publishing House; 2009. Doc09rmeF1

doi: 10.3205/09rme30, urn:nbn:de:0183-09rme304

Published: May 5, 2009

© 2009 de Leng et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Question: Patient safety benefits from strategies to avoid cognitive errors when patients are being diagnosed [1]. Unfortunately, effective methods to teach residents to avoid cognitive errors during clinical reasoning are not readily available [2]. We developed a program in diagnostic reasoning for residents, focused on reducing cognitive errors. The program uses the strategy of ‘diagnostic time-outs’ [3] in a controlled educational setting, where the diagnostic team takes ‘time outs’ to reflect on working diagnoses.

We used virtual patients to bypass ethical, logistical and methodological problems that would arise when the ‘time outs’ were fitted into consultations in real clinical practice.

We wanted to test the feasibility and value of virtual patients together with the strategy of ‘time outs’ in small group sessions.

Methods: We used virtual patients to promote deliberate practice in groups of residents trying to solve standardized cases known to be susceptible to cognitive errors. The virtual patients were computerized problem-solving cases, allowing users to virtually explore and intervene in the cases. The cases were based on real cases where ‘premature closure’ had occurred, i.e. attending doctors failed to consider reasonable alternatives after reaching an initial diagnosis. The virtual patients were built in CAMPUS, a cross platform and web-based program developed at Heidelberg University, Germany.

Reflection, discussion and feedback on the data gathering and the synthesis of the information were promoted by punctuating the case workup with several ‘time outs’. After a preliminary diagnosis was made based on initial examinations, a procedure to stimulate reflective diagnostic reasoning [4] was conducted during a scheduled ‘time out’.

During this procedure, trainees were asked to revisit their initial inquiry and write down:

findings supporting their diagnosis,
findings contradicting their diagnosis, and
findings to be expected if their initial diagnosis was correct but that were not encountered.

Next, trainees were asked to generate alternative diagnoses and produce the same 3 types of findings for each of them. Finally, each trainee was asked to rank their diagnoses in order of likelihood, based on their personal analysis.

After each trainee had individually diagnosed the virtual patient, the logged differential diagnoses of all trainees were aggregated and fed back to the group by means of a specially developed feedback tool. The group discussed how the diagnoses were ranked and why, based on the trainees’ recorded findings.

In April 2009, the feasibility and the value of specially designed virtual patients, the feedback tool and the ‘time-outs’ will be piloted in Maxima Medical Centre, Veldhoven, Netherlands.

Results and conclusions: We will present the results of observations of a clinical reasoning session, the perceptions of the instructor and the trainees, and our preliminary conclusions.


Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499. DOI: 10.1001/archinte.165.13.1493. External link
Regehr G, Norman GR. Issues in cognitive psychology: Implications for professional education. Acad Med. 1996;71(9):988-1001. DOI: 10.1097/00001888-199609000-00015. External link
Trowbridge R. Twelve tips tor teaching avoidance of diagnostic errors. Med Teach. 2008;30(5):496-500. DOI: 10.1080/01421590801965137. External link
Mamede S, Schmidt HG, Penaforte JC. Effects of reflective practice on the accuracy of medical diagnoses. Med Educ. 2008;42(5):468-475. DOI: 10.1111/j.1365-2923.2008.03030.x. External link