Virtual patients in the acquisition of clinical reasoning skills: does presentation mode matter? A quasi-randomized controlled trial

Abstract

Background: The objective of this study is to compare two different instructional methods in the curricular use of computerized virtual patients in undergraduate medical education. We aim to investigate whether using many short and focused cases - the key feature principle - is more effective for the learning of clinical reasoning skills than using few long and systematic cases.

Methods: We conducted a quasi-randomized, non-blinded, controlled parallel-group intervention trial in a large medical school in Southwestern Germany. During two seminar sessions, fourth- and fifth-year medical students (n = 56) worked on the differential diagnosis of the acute abdomen. The educational tool - virtual patients - was the same, but the instructional method differed: In one trial arm, students worked on multiple short cases, with the instruction being focused only on important elements ("key feature arm", n = 30). In the other trial arm, students worked on few long cases, with the instruction being comprehensive and systematic ("systematic arm", n = 26). The overall training time was the same in both arms. The students' clinical reasoning capacity was measured by a specifically developed instrument, a script concordance test. Their motivation and the perceived effectiveness of the instruction were assessed using a structured evaluation questionnaire.

Results: Upon completion of the script concordance test with a reference score of 80 points and a standard deviation of 5 for experts, students in the key feature arm attained a mean of 57.4 points (95% confidence interval: 50.9-63.9), and in the systematic arm, 62.7 points (57.2-68.2), with Cohen's d at 0.337. The difference is statistically non-significant (p = 0.214). In the evaluation survey, students in the key feature arm indicated that they experienced more time pressure and perceived the material as more difficult.

Conclusions: In this study powered for a medium effect, we could not provide empirical evidence for the hypothesis that a key feature-based instruction on multiple short cases is superior to a systematic instruction on few long cases in the curricular implementation of virtual patients. The results of the evaluation survey suggest that learners should be given enough time to work through case examples, and that caution should be taken to prevent cognitive overload.

Keywords: Clinical reasoning; Instructional methods; Key features; Undergraduate medical education; Virtual patients.

Fig. 1

Study design and realization: Timeline and methodology

Fig. 2

CONSORT diagram of the study

Fig. 3

SCT results. Subscale gastrointestinal hemorrhage. KF, key feature arm; syst, systematic arm. Left side: Simple line plot, indicating point estimate with 95% confidence interval. Right side: Boxplots, indicating minimum score, 1st quartile, median, 3rd quartile, maximum score, and potential outliers

Fig. 4

SCT results. Subscale acute abdomen. KF, key feature arm; syst, systematic arm. Left side: Simple line plot, indicating point estimate with 95% confidence interval. Right side: Boxplots, indicating minimum score, 1st quartile, median, 3rd quartile, maximum score, and potential outliers

Fig. 5

Results of the evaluation survey. Dimensions of the questionnaire: 1 = Relevance and usefulness of the material; 2 = Teacher’s behaviour towards the students; 3 = Adequacy of difficulty and quantity of the material; 4 = Methodology, structure and clarity of the seminar; 5 = Involvement/Commitment of the students