Efficacy of virtual patients in medical education: A meta-analysis of randomized studies
Highlights
► Virtual patients (VPs) are computer-based simulations of clinical cases. ► VPs show a positive educational effect compared to more traditional methods. ► The effect is greater for clinical reasoning than for communication or ethical skills. ► A critical issue is the way in which VPs are integrated in the curriculum.
Introduction
Virtual patients (VPs) are computer-based simulations of clinical cases allowing the users to interact with the system and train their clinical reasoning skills. The term “virtual patient” has been referred to various educational tools and methods like simulated patients in the form of actors (Cleland, Abe, & Rethans, 2009), software-based physiological simulators (Holzinger, Kickmeier, Wassertheurer, & Hessinger, 2009), physical manikins and advanced technological simulators (Khan, Pattison, & Sherwood, 2011). A further new learning method near to the concept of Virtual patients is based on platforms to use real patient records to teach undergraduate students decision making and clinical reasoning (Bloice, Simonic, Kreuzthaler, & Holzinger, 2011).
There is however a general consensus in considering a VP an “interactive computer simulation of real-life clinical scenarios for the purpose of healthcare and medical training, education or assessment” (Ellaway, Poulton, Fors, McGee, & Albright, 2008).
VPs can provide a way to overcome the reduced student access to real patients, as well as a structured and safe environment for students to practice; they are therefore more and more extensively used in medical education but their efficacy is still a matter of debate (Poulton & Balasubramaniam, 2011). A recent review provided a critical evaluation of relevant literature but it could find mainly descriptive articles, many articles measuring students' satisfaction with VPs but few studies providing evidence about the efficacy of VPs (Cook & Triola, 2009). One of the issues raised by Cook in his review was the way in which VPs are integrated in the curriculum. VPs have been used in many different instructional designs and educational applications (Huwendiek et al., 2009) but not always the terminology used to describe the learning environment and VPs usage was uniform. At this proposal, in her recent paper (Ellaway & Davies, 2011), Rachel Ellaway proposes to apply activity theory to redefine Virtual patients “from a software artifact to an intrinsic part of an activity that mediates the ways that learners and their objectives interact. The same virtual patient artifact can be used in different learning activities and activity theory identifies each application as discrete and specific to the activity in hand.” This was an important theoretical contribution as a model to describe interventions that use VPs in a meaningful and consistent way. Ellaway and Davies (2011) and Huwendiek et al. (2009) work provided categories to identify in a clearer way context of use, objectives and type of interventions for VPs, allowing an easier comparison among different experiments.
This meta-analysis summarizes evidence from randomized studies comparing the effect of educational interventions in which VPs were used either as an alternative method or additive to usual curriculum versus interventions based on more traditional methods. We performed also an evaluation of the efficacy of VPs when used to achieve outcomes oriented to clinical reasoning or outcomes addressed to communication skills and ethical reasoning.
Section snippets
Methods
This meta-analysis was designed, conducted and reported according to QUORUM statement on quality of reporting of meta-analyses (Moher et al., 1999).
Results
Table 1 summarizes the characteristics of the 12 randomized and controlled studies selected for meta-analysis. The 22 articles excluded from meta-analysis (Table 2) were primarily survey on students' perception and satisfaction with VPs or pre-post, non-randomized studies, in some instances addressed to validate VPs as an instrument of assessment.
Table 3 reports the number of studies providing information considered to be quality indicators. All studies gave details about the educational
Discussion
Our analysis showed a clear positive pooled overall effect for VPs compared to other educational methods. A positive effect has been documented both when VPs have been used as an additive resource and when they have been compared as an alternative to a more traditional method.
Nevertheless, heterogeneity among studies was high as shown by the rather wide dispersion in the forest plots (Figs. 2and 3). This inconsistency was expected, due to the great difference in the selected studies as to
Conclusions
Although limited to a rather small number of cases, this meta-analysis summarizes the best available evidence at present. The main indication is that VPs are effective toward many different specific educational outcomes like clinical reasoning in selected topics, clinical data gathering and interpretation and – to a more limited extent – they are also useful in preparing students for further educational activities in the domain of communication skills and ethical reasoning. These last topics
References (59)
- et al.
Virtual patient training to improve reproductive health care for women with intellectual disabilities
Journal of Midwifery and Women's Health
(2008) - et al.
A pilot study to integrate an immersive virtual patient with a breast complaint and breast examination simulator into a surgery clerkship
American Journal of Surgery
(2009) - et al.
Learning performance with interactive simulations in medical education: lessons learned from results of learning complex physiological models with the HAEMOdynamics SIMulator
Computers & Education
(2009) - et al.
Interactive internet-based cases for undergraduate otolaryngology education
Otolaryngology and Head Neck Surgery
(2009) - et al.
Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of reporting of meta-analyses
Lancet
(1999) - et al.
Caring for children with intellectual and developmental disabilities: virtual patient instruction improves students' knowledge and comfort level
Journal of Pediatric Nursing
(2007) - et al.
The use of virtual patients to teach medical students history taking and communication skills
American Journal of Surgery
(2006) Assessing professional behavior: yesterday, today, tomorrow
Academic Medicine
(2002)- et al.
Trends in study methods used in undergraduate medical education research, 1969–2007
Journal of American Medical Association
(2007) Is virtual the same as real? Medical students' experiences of a virtual patient
Academic Medicine
(2003)
Random comparison of ‘virtual patient’ models in the context of teaching clinical communication skills
Medical Education
Integration strategies for using virtual patient in clinical clerkships
Academic Medicine
Development of an interactive application for learning medical procedures and clinical decision making
Springer Lecture Notes in Computer Science LNCS
Virtual patient simulation: knowledge gain or knowledge loss?
Medical Teacher
A systematic review of the reliability of objective structured clinical examination scores
Medical Education
The use of simulated patients in medical education: AMEE guide no 42
Medical Teacher
Time and learning efficiency in internet-based learning: a systematic review and meta-analysis
Advances in Health Sciences Education Theory and Practice
Method and reporting quality in health professions education research: a systematic review
Medical Education
Virtual patients: a critical literature review and proposed next steps
Medical Education
The use of a virtual patient case in an OSCE-based exam—a pilot study
Medical Teacher
Virtual patient and undergraduate anesthesia teaching
Medical Education
Medical student satisfaction using a virtual patient system to learn history-taking communication skills
Studies in Health Technology and Informatics
Do medical students respond empathetically to a virtual patient?
American Journal of Surgery
Is case-specificity content-specificity? An analysis of data from extended-matching questions
Advances in Health Sciences Education Theory and Practice
Design for learning: deconstructing virtual patient activities
Medical Teacher
Building a virtual patient commons
Medical Teacher
Virtual patients come of age
Medical Teacher
What every teacher needs to know about clinical reasoning
Medical Education
Cited by (129)
Effect of Non-Immersive Virtual Reality Simulation on Type 2 Diabetes Education for Nursing Students: A Randomised Controlled Trial
2022, Clinical Simulation in NursingDecision making at extreme prematurity: Innovation in clinician education
2022, Seminars in PerinatologyThe use of virtual patients for breaking bad news: A rapid review
2024, Clinical Teacher