Case-based MCQ generator: A custom ChatGPT based on published prompts in the literature for automatic item generation.

WHAT IS THE EDUCATIONAL CHALLENGE?: A fundamental challenge in medical education is creating high-quality, clinically relevant multiple-choice questions (MCQs). ChatGPT-based automatic item generation (AIG) methods need well-designed prompts. However, the use of these prompts is hindered by the time-consuming process of copying and pasting, a lack of know-how among medical teachers, and the generalist nature of standard ChatGPT, which often lacks the medical context. WHAT ARE THE PROPOSED SOLUTIONS?: The Case-based MCQ Generator, a custom GPT, addresses these challenges. It has been trained by using GPT Builder, which is a platform designed by OpenAI for customizing ChatGPT to meet specific needs, in order to allow users to generate case-based MCQs. By using this free tool for those who have ChatGPT Plus subscription, health professions educators can easily select a prompt, input a learning objective or item-specific test point, and generate clinically relevant questions. WHAT ARE THE POTENTIAL BENEFITS TO A WIDER GLOBAL AUDIENCE?: It enhances the efficiency of MCQ generation and ensures the generation of contextually relevant questions, surpassing the capabilities of standard ChatGPT. It streamlines the MCQ creation process by integrating prompts published in medical education literature, eliminating the need for manual prompt input. WHAT ARE THE NEXT STEPS?: Future development aims at sustainability and addressing ethical and accessibility issues. It requires regular updates, integration of new prompts from emerging health professions education literature, and a supportive digital ecosystem around the tool. Accessibility, especially for educators in low-resource countries, is vital, demanding alternative access models to overcome financial barriers.

Clinical reasoning: What do nurses, physicians, and students reason about.

Clinical reasoning is a core ability in the health professions, but the term is conceptualised in multiple ways within and across professions. For interprofessional teamwork it is indispensable to recognise the differences in understanding between professions. Therefore, our aim was to investigate how nurses, physicians, and medical and nursing students define clinical reasoning. We conducted 43 semi-structured interviews with an interprofessional group from six countries and qualitatively analysed their definitions of clinical reasoning based on a coding guide. Our results showed similarities across professions, such as the emphasis on clinical skills as part of clinical reasoning. But we also revealed differences, such as a more patient-centered view and a broader understanding of the clinical reasoning concept in nurses and nursing students. The explicit sharing and discussion of differences in the understanding of clinical reasoning across health professions can provide valuable insights into the perspectives of different team members on clinical practice and education. This understanding may lead to improved interprofessional collaboration, and our study's categories and themes can serve as a basis for such discussions.

Why is it so difficult to implement a longitudinal clinical reasoning curriculum? A multicenter interview study on the barriers perceived by European health professions educators.

BACKGROUND: Effective clinical reasoning is a core competency of health professionals that is necessary to assure patients' safety. Unfortunately, adoption of longitudinal clinical reasoning curricula is still infrequent. This study explores the barriers that hinder the explicit teaching of clinical reasoning from a new international perspective. METHODS: The context of this study was a European project whose aim is to develop a longitudinal clinical reasoning curriculum. We collected data in semi-structured interviews with responders from several European countries who represent various health professions and have different backgrounds, roles and experience. We performed a qualitative content analysis of the gathered data and constructed a coding frame using a combined deductive/inductive approach. The identified themes were validated by parallel coding and in group discussions among project members. RESULTS: A total of 29 respondents from five European countries participated in the interviews; the majority of them represent medicine and nursing sciences. We grouped the identified barriers into eight general themes: Time, Culture, Motivation, Clinical Reasoning as a Concept, Teaching, Assessment, Infrastructure and Others. Subthemes included issues with discussing errors and providing feedback, awareness of clinical reasoning teaching methods, and tensions between the groups of professionals involved. CONCLUSIONS: This study provides an in-depth analysis of the barriers that hinder the teaching of explicit clinical reasoning. The opinions are presented from the perspective of several European higher education institutions. The identified barriers are complex and should be treated holistically due to the many interconnections between the identified barriers. Progress in implementation is hampered by the presence of reciprocal causal chains that aggravate this situation. Further research could investigate the perceptual differences between health professions regarding the barriers to clinical reasoning. The collected insights on the complexity and diversity of these barriers will help when rolling out a long-term agenda for overcoming the factors that inhibit the implementation of clinical reasoning curricula.

The need for longitudinal clinical reasoning teaching and assessment: Results of an international survey.

Background: Clinical reasoning is a key ability essential for practising health professionals. However, little is known about the current global adoption of clinical reasoning teaching and assessment.Purpose: We aimed to provide insights into how clinical reasoning is deliberately taught and assessed in curricula worldwide and to identify needs and perceived barriers for teaching clinical reasoning to students and educators.Methods: A questionnaire was devised by an international expert group and distributed in a large international medical education community. Data were collected in 2018 and analysed using descriptive statistics. We identified themes in free-text responses using content analysis.Results: Three hundred and thirteen responses from 76 countries were collected. Most respondents were from Europe (34%). While the presence of a longitudinal clinical reasoning curriculum was only reported by 28%, 85% stated that such a curriculum was needed. The lack of awareness of the need to explicitly teach clinical reasoning was the most commonly identified barrier. For assessment, the greatest need identified was for more workplace-based assessment.Conclusions: Global respondents indicate the need to implement explicit longitudinal clinical reasoning curricula. Our findings suggest that efforts should be put into improving faculty development, including evidence-based materials on how to teach and assess clinical reasoning.

Virtual Patient Simulations in Health Professions Education: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration.

BACKGROUND: Virtual patients are interactive digital simulations of clinical scenarios for the purpose of health professions education. There is no current collated evidence on the effectiveness of this form of education. OBJECTIVE: The goal of this study was to evaluate the effectiveness of virtual patients compared with traditional education, blended with traditional education, compared with other types of digital education, and design variants of virtual patients in health professions education. The outcomes of interest were knowledge, skills, attitudes, and satisfaction. METHODS: We performed a systematic review on the effectiveness of virtual patient simulations in pre- and postregistration health professions education following Cochrane methodology. We searched 7 databases from the year 1990 up to September 2018. No language restrictions were applied. We included randomized controlled trials and cluster randomized trials. We independently selected studies, extracted data, and assessed risk of bias and then compared the information in pairs. We contacted study authors for additional information if necessary. All pooled analyses were based on random-effects models. RESULTS: A total of 51 trials involving 4696 participants met our inclusion criteria. Furthermore, 25 studies compared virtual patients with traditional education, 11 studies investigated virtual patients as blended learning, 5 studies compared virtual patients with different forms of digital education, and 10 studies compared different design variants. The pooled analysis of studies comparing the effect of virtual patients to traditional education showed similar results for knowledge (standardized mean difference [SMD]=0.11, 95% CI -0.17 to 0.39, I2=74%, n=927) and favored virtual patients for skills (SMD=0.90, 95% CI 0.49 to 1.32, I2=88%, n=897). Studies measuring attitudes and satisfaction predominantly used surveys with item-by-item comparison. Trials comparing virtual patients with different forms of digital education and design variants were not numerous enough to give clear recommendations. Several methodological limitations in the included studies and heterogeneity contributed to a generally low quality of evidence. CONCLUSIONS: Low to modest and mixed evidence suggests that when compared with traditional education, virtual patients can more effectively improve skills, and at least as effectively improve knowledge. The skills that improved were clinical reasoning, procedural skills, and a mix of procedural and team skills. We found evidence of effectiveness in both high-income and low- and middle-income countries, demonstrating the global applicability of virtual patients. Further research should explore the utility of different design variants of virtual patients.

Virtual Reality for Health Professions Education: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration.

BACKGROUND: Virtual reality (VR) is a technology that allows the user to explore and manipulate computer-generated real or artificial three-dimensional multimedia sensory environments in real time to gain practical knowledge that can be used in clinical practice. OBJECTIVE: The aim of this systematic review was to evaluate the effectiveness of VR for educating health professionals and improving their knowledge, cognitive skills, attitudes, and satisfaction. METHODS: We performed a systematic review of the effectiveness of VR in pre- and postregistration health professions education following the gold standard Cochrane methodology. We searched 7 databases from the year 1990 to August 2017. No language restrictions were applied. We included randomized controlled trials and cluster-randomized trials. We independently selected studies, extracted data, and assessed risk of bias, and then, we compared the information in pairs. We contacted authors of the studies for additional information if necessary. All pooled analyses were based on random-effects models. We used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to rate the quality of the body of evidence. RESULTS: A total of 31 studies (2407 participants) were included. Meta-analysis of 8 studies found that VR slightly improves postintervention knowledge scores when compared with traditional learning (standardized mean difference [SMD]=0.44; 95% CI 0.18-0.69; I2=49%; 603 participants; moderate certainty evidence) or other types of digital education such as online or offline digital education (SMD=0.43; 95% CI 0.07-0.79; I2=78%; 608 participants [8 studies]; low certainty evidence). Another meta-analysis of 4 studies found that VR improves health professionals' cognitive skills when compared with traditional learning (SMD=1.12; 95% CI 0.81-1.43; I2=0%; 235 participants; large effect size; moderate certainty evidence). Two studies compared the effect of VR with other forms of digital education on skills, favoring the VR group (SMD=0.5; 95% CI 0.32-0.69; I2=0%; 467 participants; moderate effect size; low certainty evidence). The findings for attitudes and satisfaction were mixed and inconclusive. None of the studies reported any patient-related outcomes, behavior change, as well as unintended or adverse effects of VR. Overall, the certainty of evidence according to the GRADE criteria ranged from low to moderate. We downgraded our certainty of evidence primarily because of the risk of bias and/or inconsistency. CONCLUSIONS: We found evidence suggesting that VR improves postintervention knowledge and skills outcomes of health professionals when compared with traditional education or other types of digital education such as online or offline digital education. The findings on other outcomes are limited. Future research should evaluate the effectiveness of immersive and interactive forms of VR and evaluate other outcomes such as attitude, satisfaction, cost-effectiveness, and clinical practice or behavior change.

Virtual Patients in a Behavioral Medicine Massive Open Online Course (MOOC): A Qualitative and Quantitative Analysis of Participants' Perceptions.

OBJECTIVE: The purpose of this article is to explore learners' perceptions of using virtual patients in a behavioral medicine Massive Open Online Course (MOOCs) and thereby describe innovative ways of disseminating knowledge in health-related areas. METHODS: A 5-week MOOC on behavioral medicine was hosted on the edX platform. The authors developed two branched virtual patients consisting of video recordings of a live standardized patient, with multiple clinical decision points and narration unfolding depending on learners' choices. Students interacted with the virtual patients to treat stress and sleep problems. Answers to the exit survey and participant comments from the discussion forum were analyzed qualitatively and quantitatively. RESULTS: In total, 19,236 participants enrolled in the MOOC, out of which 740 received the final certificate. The virtual patients were completed by 2317 and 1640 participants respectively. Among survey respondents (n = 442), 83.1% agreed that the virtual patient exercise was helpful. The qualitative analysis resulted in themes covering what it was like to work with the virtual patient, with subthemes on learner-centered education, emotions/eustress, game comparisons, what the participants learned, what surprised them, how confident participants felt about applying interventions in practice, suggestions for improvement, and previous experiences of virtual patients. CONCLUSIONS: Students were enthusiastic about interacting with the virtual patients as a means to apply new knowledge about behavioral medicine interventions. The most common suggestion was to incorporate more interactive cases with various levels of complexity. Further research should include patient outcomes and focus on interprofessional aspects of learning with virtual patients in a MOOC.

A qualitative analysis of virtual patient descriptions in healthcare education based on a systematic literature review.

BACKGROUND: Virtual Patients (VPs) have been in the focus of research in healthcare education for many years. The aim of our study was to analyze how virtual patients are described in the healthcare education literature, and how the identified concepts relate to each other. METHODS: We performed a literature review and extracted 185 descriptions of virtual patients from the articles. In a qualitative content analysis approach we inductively-deductively developed categories and deducted subcategories. We constructed a concept map to illustrate these concepts and their interrelations. RESULTS: We developed the following five main categories: Patient, Teacher, Virtual Patient, Curriculum, and Learner. The concept map includes these categories and highlights aspects such as the under-valued role of patients in shaping their virtual representation and opposing concepts, such as standardization of learner activity versus learner-centeredness. CONCLUSIONS: The presented concept map synthesizes VP descriptions and serves as a basis for both, VP use and discussions of research topics related to virtual patients.

Exploring the validity and reliability of a questionnaire for evaluating virtual patient design with a special emphasis on fostering clinical reasoning.

BACKGROUND: Virtual patients (VPs) are increasingly used to train clinical reasoning. So far, no validated evaluation instruments for VP design are available. AIMS: We examined the validity of an instrument for assessing the perception of VP design by learners. METHODS: Three sources of validity evidence were examined: (i) Content was examined based on theory of clinical reasoning and an international VP expert team. (ii) The response process was explored in think-aloud pilot studies with medical students and in content analyses of free text questions accompanying each item of the instrument. (iii) Internal structure was assessed by exploratory factor analysis (EFA) and inter-rater reliability by generalizability analysis. RESULTS: Content analysis was reasonably supported by the theoretical foundation and the VP expert team. The think-aloud studies and analysis of free text comments supported the validity of the instrument. In the EFA, using 2547 student evaluations of a total of 78 VPs, a three-factor model showed a reasonable fit with the data. At least 200 student responses are needed to obtain a reliable evaluation of a VP on all three factors. CONCLUSION: The instrument has the potential to provide valid information about VP design, provided that many responses per VP are available.

Virtual patients--what are we talking about? A framework to classify the meanings of the term in healthcare education.

BACKGROUND: The term "virtual patients" (VPs) has been used for many years in academic publications, but its meaning varies, leading to confusion. Our aim was to investigate and categorize the use of the term "virtual patient" and then classify its use in healthcare education. METHODS: A literature review was conducted to determine all articles using the term "virtual patient" in the title or abstract. These articles were categorized into: Education, Clinical Procedures, Clinical Research and E-Health. All educational articles were further classified based on a framework published by Talbot et al. which was further developed using a deductive content analysis approach. RESULTS: 536 articles published between 1991 and December 2013 were included in the study. From these, 330 were categorized as educational. Classifying these showed that 37% articles used VPs in the form of Interactive Patient Scenarios. VPs in form of High Fidelity Software Simulations (19%) and Virtual Standardized Patients (16%) were also frequent. Less frequent were other forms, such as VP Games. Analyzing the literature across time shows an overall trend towards the use of Interactive Patient Scenarios as the predominant form of VPs in healthcare education. CONCLUSIONS: The main form of educational VPs in the literature are Interactive Patient Scenarios despite rapid technical advances that would support more complex applications. The adapted classification provides a valuable model for VP developers and researchers in healthcare education to more clearly communicate the type of VP they are addressing avoiding misunderstandings.

A framework for different levels of integration of computational models into web-based virtual patients.

BACKGROUND: Virtual patients are increasingly common tools used in health care education to foster learning of clinical reasoning skills. One potential way to expand their functionality is to augment virtual patients' interactivity by enriching them with computational models of physiological and pathological processes. OBJECTIVE: The primary goal of this paper was to propose a conceptual framework for the integration of computational models within virtual patients, with particular focus on (1) characteristics to be addressed while preparing the integration, (2) the extent of the integration, (3) strategies to achieve integration, and (4) methods for evaluating the feasibility of integration. An additional goal was to pilot the first investigation of changing framework variables on altering perceptions of integration. METHODS: The framework was constructed using an iterative process informed by Soft System Methodology. The Virtual Physiological Human (VPH) initiative has been used as a source of new computational models. The technical challenges associated with development of virtual patients enhanced by computational models are discussed from the perspectives of a number of different stakeholders. Concrete design and evaluation steps are discussed in the context of an exemplar virtual patient employing the results of the VPH ARCH project, as well as improvements for future iterations. RESULTS: The proposed framework consists of four main elements. The first element is a list of feasibility features characterizing the integration process from three perspectives: the computational modelling researcher, the health care educationalist, and the virtual patient system developer. The second element included three integration levels: basic, where a single set of simulation outcomes is generated for specific nodes in the activity graph; intermediate, involving pre-generation of simulation datasets over a range of input parameters; advanced, including dynamic solution of the model. The third element is the description of four integration strategies, and the last element consisted of evaluation profiles specifying the relevant feasibility features and acceptance thresholds for specific purposes. The group of experts who evaluated the virtual patient exemplar found higher integration more interesting, but at the same time they were more concerned with the validity of the result. The observed differences were not statistically significant. CONCLUSIONS: This paper outlines a framework for the integration of computational models into virtual patients. The opportunities and challenges of model exploitation are discussed from a number of user perspectives, considering different levels of model integration. The long-term aim for future research is to isolate the most crucial factors in the framework and to determine their influence on the integration outcome.

Game Elements in the Design of Simulations in Military Trauma Management Training: Protocol for a Systematic Review.

BACKGROUND: Military trauma teams are commonly operating in civilian hospitals during peacetime; in a war situation they must adjust their practices to the austere conditions. Simulations can replicate austere conditions to allow training in a safe environment that tolerates errors. Gamification, understood as the use of game elements to motivate and engage learners in nongame contexts, is gaining interest in medical education and military training. Applying game elements in the design of military trauma management simulations has the potential to provide learners with active learning opportunities and prepare them for providing medical services under austere conditions. Although gamification is known for its engaging and motivational benefits, there are controversies about its pedagogical value. The controversies can be attributed to the fact that various gamification strategies may consist of a different combination of game elements, leading to different outcomes. OBJECTIVE: This systematic review aims to understand how game elements are used in the design of simulations in military trauma management training and their reported outcomes. METHODS: We have designed a search strategy for the purpose of the review. Two researchers will independently assess the identified studies based on the defined inclusion and exclusion criteria. The selection process will be represented using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram. The search will be repeated and updated as necessary prior to publication of the review. Two reviewers will independently extract and manage the data for each of the articles using a structured data extraction form. Any disagreement that arises between reviewers will be resolved through discussion, and a third review author will be consulted when needed. We are going to conduct a thematic synthesis of the extracted game element descriptions. The results are going to be presented in a diagrammatic or tabular form, alongside a narrative summary. The quality of the studies will be assessed. RESULTS: We implemented and tested the developed search strategy in May 2023. We retrieved 1168 study abstracts, which were reduced to 630 abstracts after deduplication. We have piloted the screening on 20% (126/630) of the identified abstracts in groups of 2 reviewers. CONCLUSIONS: Although gamification has the potential to motivate learners in various ways, there is a lack of understanding about specific game elements and how they can inform instructional design in different contexts. Our findings will increase the understanding of how game elements are used in the design of simulations in military trauma management training and, thus, contribute to more effective development of future simulations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/45969.

The association between quality of connections and diagnostic accuracy in student-generated concept maps for clinical reasoning education with virtual patients.

Objectives: Concept maps are a learning tool that fosters clinical reasoning skills in healthcare education. They can be developed by students in combination with virtual patients to create a visual representation of the clinical reasoning process while solving a case. However, in order to optimize feedback, there is a need to better understand the role of connections between concepts in student-generated maps. Therefore, in this study we investigated whether the quality of these connections is indicative of diagnostic accuracy. Methods: We analyzed 40 concept maps created by fifth-year medical students in the context of four virtual patients with commonly encountered diagnoses. Half of the maps were created by students who made a correct diagnosis on the first attempt; the other half were created by students who made an error in their first diagnosis. The connections in the maps were rated by two reviewers using a relational scoring system. Analysis of covariance was employed to examine the difference in mean connection scores among groups while controlling for the number of connections. Results: There were no differences between the groups in the number of concepts or connections in the maps; however, maps made by students who made a correct first diagnosis had higher scores for the quality of connections than those created by students who made an incorrect first diagnosis (12.13 vs 9.09; p=0.03). We also observed students' general reluctance to use connections in their concept maps. Conclusion: Our results suggest that the quality, not the quantity, of connections in concept maps is indicative of their diagnostic accuracy.

Developing a European longitudinal and interprofessional curriculum for clinical reasoning.

Clinical reasoning is a complex and crucial ability health professions students need to acquire during their education. Despite its importance, explicit clinical reasoning teaching is not yet implemented in most health professions educational programs. Therefore, we carried out an international and interprofessional project to plan and develop a clinical reasoning curriculum with a train-the-trainer course to support educators in teaching this curriculum to students. We developed a framework and curricular blueprint. Then we created 25 student and 7 train-the-trainer learning units and we piloted 11 of these learning units at our institutions. Learners and faculty reported high satisfaction and they also provided helpful suggestions for improvements. One of the main challenges we faced was the heterogeneous understanding of clinical reasoning within and across professions. However, we learned from each other while discussing these different views and perspectives on clinical reasoning and were able to come to a shared understanding as the basis for developing the curriculum. Our curriculum fills an important gap in the availability of explicit clinical reasoning educational materials both for students and faculty and is unique with having specialists from different countries, schools, and professions. Faculty time and time for teaching clinical reasoning in existing curricula remain important barriers for implementation of clinical reasoning teaching.

Effects of introducing a voluntary virtual patient module to a basic life support with an automated external defibrillator course: a randomised trial.

BACKGROUND: The concept of virtual patients (VPs) encompasses a great variety of predominantly case-based e-learning modules with different complexity and fidelity levels. Methods for effective placement of VPs in the process of medical education are sought. The aim of this study was to determine whether the introduction of a voluntary virtual patients module into a basic life support with an automated external defibrillator (BLS-AED) course improved the knowledge and skills of students taking the course. METHODS: Half of the students were randomly assigned to an experimental group and given voluntary access to a virtual patient module consisting of six cases presenting BLS-AED knowledge and skills. Pre- and post-course knowledge tests and skills assessments were performed, as well as a survey of students' satisfaction with the VP usage. In addition, time spent using the virtual patient system, percentage of screen cards viewed and scores in the formative questions in the VP system throughout the course were traced and recorded. RESULTS: The study was conducted over a six week period and involved 226 first year medical students. The voluntary module was used by 61 (54%) of the 114 entitled study participants. The group that used VPs demonstrated better results in knowledge acquisition and in some key BLS-AED action skills than the group without access, or those students from the experimental group deliberately not using virtual patients. Most of the students rated the combination of VPs and corresponding teaching events positively. CONCLUSIONS: The overall positive reaction of students and encouraging results in knowledge and skills acquisition suggest that the usage of virtual patients in a BLS-AED course on a voluntary basis is feasible and should be further investigated.

Criteria to assess the quality of virtual patients.

Quality assessment of virtual patients (VP) is important but still insufficiently standardized. We developed categories and criteria to assess the quality of virtual patients. These categories reflect the life cycle of a VP from the planning to the development, implementation and evaluation. Such elaborated criteria will help authors to create VPs and curriculum planners to assess the quality of implemented VPs and choose high quality VPs from repositories.

New approaches to linking clinical guidelines to virtual patients.

An often reported challenge of evidence-based medicine concerns increasing use of clinical guidelines in practice. One of the proposed improvements is to promote guidelines by presenting them in conjunction with virtual patients. Three approaches to linking clinical guidelines to virtual patients are presented in this paper: (1) guidelines as a source for generating virtual patients; (2) guidelines hyper-flowchart as a virtual patient progress indicator; (3) guidelines flowchart reconstruction as a learning activity in virtual patient systems. The scenarios have been preliminarily evaluated using two demonstrator applications: Bit Pathways and CASUS. Challenges and direction for further development are proposed.

Planning a Collection of Virtual Patients to Train Clinical Reasoning: A Blueprint Representative of the European Population.

BACKGROUND: Virtual patients (VPs) are a suitable method for students to train their clinical reasoning abilities. We describe a process of developing a blueprint for a diverse and realistic VP collection (prior to VP creation) that facilitates deliberate practice of clinical reasoning and meets educational requirements of medical schools. METHODS: An international and interdisciplinary partnership of five European countries developed a blueprint for a collection of 200 VPs in four steps: (1) Defining the criteria (e.g., key symptoms, age, sex) and categorizing them into disease-, patient-, encounter- and learner-related, (2) Identifying data sources for assessing the representativeness of the collection, (3) Populating the blueprint, and (4) Refining and reaching consensus. RESULTS: The blueprint is publicly available and covers 29 key symptoms and 176 final diagnoses including the most prevalent medical conditions in Europe. Moreover, our analyses showed that the blueprint appears to be representative of the European population. CONCLUSIONS: The development of the blueprint required a stepwise approach, which can be replicated for the creation of other VP or case collections. We consider the blueprint an appropriate starting point for the actual creation of the VPs, but constant updating and refining is needed.

Push and pull models to manage patient consent and licensing of multimedia resources in digital repositories for case-based reasoning.

Patient consents for distribution of multimedia constitute a significant element of medical case-based repositories in medicine. A technical challenge is posed by the right of patients to withdraw permission to disseminate their images or videos. A technical mechanism for spreading information about changes in multimedia usage licenses is sought. The authors gained their experience by developing and managing a large (>340 cases) repository of virtual patients within the European project eViP. The solution for dissemination of license status should reuse and extend existing metadata standards in medical education. Two methods: PUSH and PULL are described differing in the moment of update and the division of responsibilities between parties in the learning object exchange process. The authors recommend usage of the PUSH scenario because it is better adapted to legal requirements in many countries. It needs to be stressed that the solution is based on mutual trust of the exchange partners and therefore is most appropriate for use in educational alliances and consortia. It is hoped that the proposed models for exchanging consents and licensing information will become a crucial part of the technical frameworks for building case-based repositories.

Teams managing civilian and military complex trauma: What are the competencies required in austere environments and the potential of simulation technology to address them?

Surgical training in civilian hospitals may not be sufficient for managing complex trauma in a setting where such care is not commonly practiced. Understanding the challenges that civilian teams face when moving to austere environments can inform the competencies that need to be trained. The aim of this study was to explore the competencies required in austere environments for teams managing complex trauma, and how they can be trained with simulation technologies. Ethnographic field observations were conducted, and field notes were synthesized. The field notes were structured with the elements of Activity Theory to generate the teams' competencies that need to be trained. A literature review was conducted to verify the results and identify examples of relevant simulation modalities. The analysis resulted in a structured list of competencies for civilian teams to manage complex trauma in an austere environment and recommendations which simulation technologies could be used in training of those competencies based on published studies. Our study contributes to understanding the challenges that civilian teams face when operating in an austere environment. A systematized list of competencies with suggested simulation technologies directs future research to improve quality of complex trauma training in civilian and military collaboration.