Each year around 8-12 % of hospitalised patients suffer from adverse events, including errors in diagnosis, according to European Commission estimates on patient safety and quality of care. Improving clinical reasoning skills that medical students acquire during training could help reduce such errors. Clinical reasoning is usually taught face-to-face, at the patient bedside, during problem-based tutorials or during internships. But virtual patients are increasingly used in medical education providing a safe environment where students can learn from their mistakes. The EU-funded VirtualPatients project has devised an online learning tool specifically to impart such skills for group instruction or self-learning. “Medical students need to learn clinical reasoning and clinical decision-making. When they do that with real patients in the midst of many distractors and social factors, it may be too much for them in the early stages of their expertise development,” explains project coordinator Martin Fischer of the Institute for Medical Education, University Hospital of Ludwig Maximilian University of Munich (LMU). “Medicine is about making the best out of the information we have. And this can sometimes be very fuzzy,” Professor Fischer explains. Virtual patients – interactive computer-based programmes that simulate real-life clinical encounters – have existed for a long time, but the EU VirtualPatients project devised a new tool to support differential diagnostic thinking that, when combined with virtual patients, helps students improve their clinical reasoning skills. Real patients’ problems “VirtualPatients are samples of real patients’ problems that train this thinking process,” says Professor Fischer. Outpatients may be dealt with over several weeks or admitted to hospital. “Timeline-based limitations only allow us to teach students through a certain window of time while patients are available for clinical teaching,” Professor Fischer explains. Often patient information is scattered – on charts and case notes; on images or X-rays; or provided by the patients themselves, with all the challenges associated with communication, “VirtualPatients condenses all that,” he says. “It eliminates the time span and provides all the information in one place.” Dozens of virtual patients Within the project around 80 virtual patients have been designed based on symptoms. “The students start by meeting a patient with symptoms. From there they work through the process step by step when they are asked how they interpret the information from the patient, what their differential diagnostic thinking is at that point in time, and to provide answers to what should happen next,” says Inga Hege, associate professor for medical education at LMU Munich’s medical faculty, who devised the VirtualPatients project funded by a 2½ year Marie Skłodowska-Curie Global Fellowship in cooperation with LMU Munich, the Geisel School of Medicine at Dartmouth in the United States and the Munich-based eLearning company Instruct. “It makes the clinical reasoning process more explicit to the student, so they can really see [how it works],” she says. This is done with the help of an integrated support system or ‘scaffolding’ to guide the student. “The tool can also detect when errors happen, which is the big advantage – students can learn from the errors they make. It tells them what could be the reason for their errors and what they could do to improve,” she explains. The virtual patients can be designed for students at different levels of medical education, with experienced students needing less support. In its pilot phase the system was improved with feedback from students. It is currently used in medical schools in Germany, Poland and the United States. Around 150 hours of structured integration of virtual patient work is recommended for medical students, Professor Fischer says. But he notes that by law it cannot replace face-to-face interaction in clinical situations. “There is no danger of it taking over from bedside learning,” he says.
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