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Effective Clinical reasoning in Virtual Patients

Periodic Reporting for period 2 - VirtualPatients (Effective Clinical reasoning in Virtual Patients)

Reporting period: 2017-01-01 to 2017-12-31

The European Commission estimates in the report ""Patient Safety and Quality of Care"" (2014) that each year 8 - 12% of hospitalized patients suffer from adverse events, including errors in diagnosis. One reason for the occurrence of such errors is a lack of clinical reasoning skills, a core competency that healthcare students have to learn during their studies.
Clinical reasoning is often taught in face-to-face courses such as bedside-teaching, problem-based tutorials or during internships. Since the early nineties virtual patients (VPs) became more and more important in medical education to
teach clinical reasoning skills.
The knowledge gap this project addresses was raised by Cook et al. (2009, 2010) but, until know, remains unaddressed. He concluded that there is no evidence how VP design variations influence clinical reasoning acquisition and that it is not fully understood how VPs teach clinical reasoning and how this process could be improved.
Therefore, in this project research will be undertaken to develop and assess an effective clinical reasoning tool to be embedded into VPs, and create guidelines on how to implement the tool based on the outcomes of an interdisciplinary grounded theory approach.

The project has the following four main objectives:
1. Provide an overview of VP types and VP systems, clinical reasoning features and integration with face-to-face teaching
2. Develop a research-based concept for a clinical reasoning tool
3. Assess the effectiveness of the tool in a large-scale, cross-institutional study
4. Disseminate the results and integrate the tool into the availables standards
"Based on a broad interdisciplinary grounded theory analysis the topic of learning clinical reasoning and how it is implemented in virtual patients has been explored. The core category ""multifactorial nature of learning clinical reasoning"" is reflected in the following five main categories: Psychological Theories, Patient-centeredness, Context, Learner-centeredness, and Teaching/Assessment. Each category encompasses between four and six related concepts.
Based on the outcomes of grounded theory, the concept for a clinical reasoning tool and guidelines on how to embed it into VPs was developed.
This concept guided the development process which included a course concept, a technical specification, a prototype, the final software solution, and the integration into existing VP systems. Usability tests and a pilot study were implemented for quality assessment purposes. The developed clinical reasoning tool is based on a concept mapping approach and can be used as a stand-alone tool or in combination with virtual patients. Learners are asked to document relevant findings, differential diagnoses, necessary tests to rule out or confirm a diagnosis, and management options. All items can be connected with each other. Additionally, learners are pompted to compose a short summary statement about the patient. Feedback is provided based on the author's answer, peer answers and learning analytics.
Two courses have been developed consisting of virtual patients (81 in German, 63 in English) and seven short videos explaining the project, clinical reasoning as a process, cognitive errors, the purpose of a summary statement, and the handling of the software.
The researcher has implemented three studies based on the developed material:
Study 1: Analysis of the clinical reasoning process of medical students in two freely available courses from January until July 2017. Overall, the researcher analyzed 1393 completed datasets created by 317 learners. Three groups were identified: Correct final diagnosis on first try (59%), correct final diagnosis after 2-17 tried (13%), and correct diagnosis revealed by the system (28%). The clinical reasoning process differed significantly betweeh the two groups that diagnosed the virtual patient correctly (no matter how many tries) and the group that gave up. This finding has implication for the teaching and researching of clinical reasoning showing that it is more important to come to the correct diagnosis eventually than have it in the first try.
Study 2: How does the patient representation influence learners' clinical reasoning. Six virtual patients with three different patient representations (disruptive description of patient behaviour, friendly description of patient behaviour, and no patient story, just facts presented) were provided to 46 medical students in a rendomized controlled trial. The results showed that a disruptive description of a patient behaviour is more influential on the clinical reasoning process of medical students than the design variations. Telling the story of a patient increases extrinsic motivation, but does not significantly influence the clinical reasoning process. Further research is needed concerning the reliability of difficulty assessmentof virtual patients.
Study 3: A pilot study in cooperation with the Jaggelonian University in Krakow, Poland was implemented, exploring the influence of outcome- versus process-oriented feedback in virtual patients. 64 medical students at Jagellonian University, Kraków, Poland were provided with 16 virtual patients in a spaced way of four virtual patients / week. Overall, 873 clinical reasoning concept maps with 19.689 nodes and 641 connections were created. The results show no significant differences between the two feedback modalities concerning clinical reasoning process.

Overall, the project indentifed the need for a structured and longitudinal teaching of clinical reasoning for healthcare students and the implementation of a faculty development course for educators to be trained on the teaching of clinical reasoning.

The EC report from the commission to the council on patient safety (dated from 2012) identified the area of education and training as the least implemented among all areas envisaged to improve patient safety. The project addresses this issue by improving clinical reasoning training in medical students aiming to reduce medical errors in their future clinical practice. The projects results - including the clinical reasoning tool, the course material, and guidelines how to
integrate it - have been made publicly available for adoption by educators in Europe. The implemented tool ( and all dissemination material is publicly available under open source licenses. These resources can be used and adapted by educators and VP system developers and included into their VPs.
Overall, a Europe-wide provision of virtual patients - with effective clinical reasoning training for medical students - will improve students' diagnostic skills potentially leading to a reduction of diagnostic errors, avoiding unnecessary treatment and pain for patients and reducing healthcare costs.

The strategy for public engagement of the project focuses on online communication channels. The researcher set up a project-related research portfolio (; updates about the project, such as results, new dissemination material are published in a journal integrated into the portfolio. Videos about the project have been published in a YouTube channel (
The results of the project have been presented and discussed on international medical education conferences and on local meetings of the project participants.