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 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.

User acceptance of neuroanatomy virtual reality course: Contrasting views between undergraduate and postgraduate students.

Virtual Reality (VR) offers cost-efficient and effective tools for spatial 3-dimensional neuroanatomy learning. Enhancing users-system relationship is necessary for successful adoption of the system. The current study aimed to evaluate students' acceptance of VR for neuroanatomy. An exploratory qualitative case study based on Unified Theory of Acceptance and Use of Technology (UTAUT) framework carried out at [details omitted for double-anonymized peer review]. Participants in this study were students participating in a VR session, followed by a semi-structured interview. Deductive framework analysis employed to retrieve students' perspective and experience. A total of six undergraduate and 13 postgraduate students participated in this study. The following UTAUT constructs validated to be significant: Performance Expectancy, Effort Expectancy and Facilitating Conditions. System usability, depth of lesson and hardware optimizations are among concern for further improvements. In conclusion, students are accepting VR as a neuroanatomy learning resource. The findings of this research highlight the importance of system performance and user-centred approach in technology development for educational purposes.

Trauma surgical simulation: discussing the replacement of live animals used as human patient simulators.

BACKGROUND: Despite advances in simulator technology, live anaesthetised animals continue to be used as human patient simulators for medical professionals to practice techniques in the management of surgical trauma. This article describes the process of convening a working group of individuals with a professional interest in simulation to discuss the use of live animals and consider if and how they can be replaced in the future. MAIN BODY: A working group was formed of voluntary attendees to a workshop held at the SESAM 2023 conference. Iterative discussions reflecting on the topic were used to produce statements summarising the working group's opinions. The working group determined that live animals are used as human patient simulators due to the presence of accurate and responsive physiology in the presence of bleeding, realistic tissue tactility and an emotional response experienced by the learner due to interaction with the animal. They were unable to reach a consensus on replacement, determining that there is currently no single model which is able to provide all the learning aspects which a live animal model can provide. Several suggestions were made regarding development of technologies and pedagogical change. CONCLUSION: Replacement of live animals in surgical simulation is not straightforward but should be an aspiration, if possible. For the ongoing development of trauma surgical simulation models, it is important to combine the knowledge, skills and perspectives of medical stakeholders and educators, academic researchers and industry experts in producing alternative options to the use of live animal simulators.

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.

Involving Patients into the LifeChamps Project: Preliminary Findings.

Patient involvement in research has been highlighted as a major requirement for the development of products and services that cover actual patients' needs. However, there has not been an agreement on a commonly used standard for patient involvement in research, at least not in the EU, partially because of lack of common terminology and implementation methodology. Within the standardization activities of "LifeChamps: A Collective Intelligent Platform To Support Cancer Champions", this qualitative study was developed to discover patients' views for their engagement in research. This is an ongoing qualitative study of semi-structured interviews of cancer survivors aged over 65 years of age, exiting the feasibility studies of the LifeChamps project in Stockholm and Thessaloniki. Findings from the thematic analysis of this study are expected to indicate requirements for involvement of patients in research studies as participants.

Streamlining Tangible 3D Printed and Intangible XR Content Creation and Evaluation: The ENTICE Experience.

ENTICE aimed to use co-creative methodologies in order to build a solid creation pipeline for medical experiential content. The project has developed and evaluated immersive learning resources and tools aiming to support well-defined learning objectives using tangible and intangible resources (AR/VR/MR, 3D printing) that are highly sought in the fields of anatomy and surgery. In this paper the preliminary results from the evaluation of the learning resources and tools in 3 countries as well as the lessons learnt are presented towards to the improvement of the medical education process.

Knowledge transfer of eLearning objects: Lessons learned from an intercontinental capacity building project.

BACKGROUND: Effective knowledge transfer of eLearning objects can hasten the adoption and dissemination of technology in teaching and learning. However, challenges exist which hinder inter-organisational knowledge transfer, particularly across continents. The ACoRD project aimed to transfer knowledge on digital learning development from UK/EU (provider) to Malaysian (receiver) higher education institutions (HEIs). This study explores the challenges encountered during the knowledge transfer process and lessons learned. METHODS: This is a qualitative study involving both the knowledge providers and receivers in focus group discussions (n = 25). Four focus group discussions were conducted in the early (n = 2) and mid-phase (n = 2) of the project by trained qualitative researchers using a topic guide designed to explore experiences and activities representing knowledge transfer in multi-institutional and multi-cultural settings. The interviews were audio-recorded, transcribed verbatim, and checked. The transcripts were analysed using thematic analysis. RESULTS: Five main themes emerged from this qualitative study: mismatched expectations between providers and receivers; acquiring new knowledge beyond the professional "comfort zone"; challenges in cascading newly acquired knowledge to colleagues and management; individual and organisational cultural differences; and disruption of knowledge transfer during the COVID-19 pandemic. CONCLUSION: This study highlights the need to create a conducive platform to facilitate continuous, timely and bi-directional needs assessment and feedback; this should be done in the early phase of the knowledge transfer process. The challenges and strategies identified in this study could guide more effective knowledge transfer between organisations and countries.

Supporting Healthcare Integration of Refugees Exploiting Reusable Learning Objects: The ASPIRE Framework.

The significant increase of refugees' migration has demonstrated an overwhelming need for their access and integration to healthcare systems. E-learning, especially in the form of experiential digital learning, has been highlighted as an important ally in supporting refugees' health needs. This paper aims to discuss the design and development process of Reusable Learning Objects (RLOs) to enhance digital health applications for refugees and integrate them to healthcare systems. The participatory approach based on the "ASPIRE" framework was followed. Using the "ASPIRE" process, 9 stakeholders were involved in the first phase of the development process, where a co-creation storyboarding workshop was held in Greece by the Medical Physics Laboratory of the Aristotle University of Thessaloniki. Essential qualitative and quantitative feedback was collected from stakeholders through an online questionnaire administered in Google Forms. Overall, enlightening ideas were expressed and all stakeholders commented positively on the value and efficacy of the workshop.

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.

Computerized history-taking improves data quality for clinical decision-making-Comparison of EHR and computer-acquired history data in patients with chest pain.

Patients' medical histories are the salient dataset for diagnosis. Prior work shows consistently, however, that medical history-taking by physicians generally is incomplete and not accurate. Such findings suggest that methods to improve the completeness and accuracy of medical history data could have clinical value. We address this issue with expert system software to enable automated history-taking by computers interacting directly with patients, i.e. computerized history-taking (CHT). Here we compare the completeness and accuracy of medical history data collected and recorded by physicians in electronic health records (EHR) with data collected by CHT for patients presenting to an emergency room with acute chest pain. Physician history-taking and CHT occurred at the same ED visit for all patients. CHT almost always preceded examination by a physician. Data fields analyzed were relevant to the differential diagnosis of chest pain and comprised information obtainable only by interviewing patients. Measures of data quality were completeness and consistency of negative and positive findings in EHR as compared with CHT datasets. Data significant for the differential of chest pain was missing randomly in all EHRs across all data items analyzed so that the dimensionality of EHR data was limited. CHT files were near complete for all data elements reviewed. Separate from the incompleteness of EHR data, there were frequent factual inconsistencies between EHR and CHT data across all data elements. EHR data did not contain representations of symptoms that were consistent with those reported by patients during CHT. Trial registration: This study is registered at https://www.clinicaltrials.gov (unique identifier: NCT03439449).

Prioritising topics for developing e-learning resources in healthcare curricula: A comparison between students and educators using a modified Delphi survey.

BACKGROUND: Engaging students in the e-learning development process enhances the effective implementation of e-learning, however, students' priority on the topics for e-learning may differ from that of the educators. This study aims to compare the differences between the students and their educators in prioritising the topics in three healthcare curricula for reusable e-learning object (RLO) development. METHOD: A modified Delphi study was conducted among students and educators from University Malaya (UM), Universiti Putra Malaysia (UPM) and Taylor's University (TU) on three undergraduate programmes. In Round 1, participants were asked to select the topics from the respective syllabi to be developed into RLOs. Priority ranking was determined by using frequencies and proportions. The first quartile of the prioritised topics was included in Round 2 survey, which the participants were asked to rate the level of priority of each topic using a 5-point Likert scale. The mean score of the topics was compared between students and educators. RESULT: A total of 43 educators and 377 students participated in this study. For UM and TU Pharmacy, there was a mismatch in the prioritised topics between the students and educators. For UPM, both the educators and students have prioritised the same topics in both rounds. To harmonise the prioritisation of topics between students and educators for UM and TU Pharmacy, the topics with a higher mean score by both the students and educators were prioritised. CONCLUSION: The mismatch in prioritised topics between students and educators uncovered factors that might influence the prioritisation process. This study highlighted the importance of conducting needs assessment at the beginning of eLearning resources development.

Students' Perceptions on Chatbots' Potential and Design Characteristics in Healthcare Education.

Chatbots may have the potential to support healthcare education by enabling personalized learning. Trust is a pre-requisite for the users to accept the chatbots. In this study we analyzed students' assignments of the MSc course "User Needs, Requirements Engineering and Evaluation" at Karolinska Institutet, aiming to explore the chatbots' potential in healthcare education and the design characteristics of chatbots that may enhance the trust. The students identified two courses: pharmacology and medical law, that have the potential to leverage chatbots' characteristics. Our analyses on the design characteristics they suggested resulted in: recognition; visibility of system status; anthropomorphism in communication; knowledge expertise, linguistic consistency; realistic interaction. Our results are in line with previous research. Future studies could investigate the educational impact on the learning outcomes and students' satisfaction when interacting with chatbots.

Modelling Feedback in Virtual Patients: An Iterative Approach.

Virtual Patients (VPs) offer learners the opportunity to practice clinical reasoning skills and have recently been integrated in Massive Open Online Courses (MOOCs). Feedback is a central part of a branched VP, allowing the learner to reflect on the consequences of their decisions and actions. However, there is insufficient guidance on how to design feedback models within VPs and especially in the context of their application in MOOCs. In this paper, we share our experiences from building a feedback model for a bladder cancer VP in a Urology MOOC, following an iterative process in three steps. Our results demonstrate how we can systematize the process of improving the quality of VP components by the application of known literature frameworks and extend them with a feedback module. We illustrate the design and re-design process and exemplify with content from our VP. Our results can act as starting point for discussions on modelling feedback in VPs and invite future research on the topic.

KIUrologyX: Urology As You Like It-A Massive Open Online Course for Medical Students, Professionals, Patients, and Laypeople Alike.

KIUrologyX is a massive open online course in clinical urology that allows a broad range of people access to important clinical knowledge. It is a course that can be made available to an unlimited number of students, professionals, patients, and their kin.

Using Competency-Based Digital Open Learning Activities to Facilitate and Promote Health Professions Education (OLAmeD): A Proposal.

BACKGROUND: Traditional learning in medical education has been transformed with the advent of information technology. We have recently seen global initiatives to produce online activities in an effort to scale up learning opportunities through learning management systems and massive open online courses for both undergraduate and continued professional education. Despite the positive impact of such efforts, factors such as cost, time, resources, and the specificity of educational contexts restrict the design and exchange of online medical educational activities. OBJECTIVE: The goal is to address the stated issues within the health professions education context while promoting learning by proposing the Online Learning Activities for Medical Education (OLAmeD) concept which builds on unified competency frameworks and generic technical standards for education. METHODS: We outline how frameworks used to describe a set of competencies for a specific topic in medical education across medical schools in the United States and Europe can be compared to identify commonalities that could result in a unified set of competencies representing both contexts adequately. Further, we examine how technical standards could be used to allow standardization, seamless sharing, and reusability of educational content. RESULTS: The entire process of developing and sharing OLAmeD is structured and presented in a set of steps using as example Urology as a part of clinical surgery specialization. CONCLUSIONS: Beyond supporting the development, sharing, and repurposing of educational content, we expect OLAmeD to work as a tool that promotes learning and sets a base for a community of medical educational content developers across different educational contexts.

Virtual Patients in a Behavioral Medicine Massive Open Online Course (MOOC): A Case-Based Analysis of Technical Capacity and User Navigation Pathways.

BACKGROUND: Massive open online courses (MOOCs) have been criticized for focusing on presentation of short video clip lectures and asking theoretical multiple-choice questions. A potential way of vitalizing these educational activities in the health sciences is to introduce virtual patients. Experiences from such extensions in MOOCs have not previously been reported in the literature. OBJECTIVE: This study analyzes technical challenges and solutions for offering virtual patients in health-related MOOCs and describes patterns of virtual patient use in one such course. Our aims are to reduce the technical uncertainty related to these extensions, point to aspects that could be optimized for a better learner experience, and raise prospective research questions by describing indicators of virtual patient use on a massive scale. METHODS: The Behavioral Medicine MOOC was offered by Karolinska Institutet, a medical university, on the EdX platform in the autumn of 2014. Course content was enhanced by two virtual patient scenarios presented in the OpenLabyrinth system and hosted on the VPH-Share cloud infrastructure. We analyzed web server and session logs and a participant satisfaction survey. Navigation pathways were summarized using a visual analytics tool developed for the purpose of this study. RESULTS: The number of course enrollments reached 19,236. At the official closing date, 2317 participants (12.1% of total enrollment) had declared completing the first virtual patient assignment and 1640 (8.5%) participants confirmed completion of the second virtual patient assignment. Peak activity involved 359 user sessions per day. The OpenLabyrinth system, deployed on four virtual servers, coped well with the workload. Participant survey respondents (n=479) regarded the activity as a helpful exercise in the course (83.1%). Technical challenges reported involved poor or restricted access to videos in certain areas of the world and occasional problems with lost sessions. The visual analyses of user pathways display the parts of virtual patient scenarios that elicited less interest and may have been perceived as nonchallenging options. Analyzing the user navigation pathways allowed us to detect indications of both surface and deep approaches to the content material among the MOOC participants. CONCLUSIONS: This study reported on first inclusion of virtual patients in a MOOC. It adds to the body of knowledge by demonstrating how a biomedical cloud provider service can ensure technical capacity and flexible design of a virtual patient platform on a massive scale. The study also presents a new way of analyzing the use of branched virtual patients by visualization of user navigation pathways. Suggestions are offered on improvements to the design of virtual patients in MOOCs.

Beyond xMOOCs in healthcare education: study of the feasibility in integrating virtual patient systems and MOOC platforms.

Background. Massive Open Online Courses (MOOCs) are an emerging trend in online learning. However, their technology is not yet completely adjusted to the needs of healthcare education. Integration of Virtual Patients within MOOCs to increase interactivity and foster clinical reasoning skills training, has been discussed in the past, but not verified by a practical implementation. Objective. To investigate the technical feasibility of integrating MOOCs with Virtual Patients for the purpose of enabling further research into the potential pedagogical benefits of this approach. Methods. We selected OpenEdx and Open Labyrinth as representative constituents of a MOOC platform and Virtual Patient system integration. Based upon our prior experience we selected the most fundamental technical requirement to address. Grounded in the available literature we identified an e-learning standard to guide the integration. We attempted to demonstrate the feasibility of the integration by designing a "proof-of-concept" prototype. The resulting pilot implementation was subject of verification by two test cases. Results. A Single Sign-On mechanism connecting Open Labyrinth with OpenEdx and based on the IMS LTI standard was successfully implemented and verified. Conclusion. We investigated the technical perspective of integrating Virtual Patients with MOOCs. By addressing this crucial technical requirement we set a base for future research on the educational benefits of using virtual patients in MOOCs. This provides new opportunities for integrating specialized software in healthcare education at massive scale.

Virtual patients in massive open online courses--design implications and integration strategies.

Massive Open Online Courses (MOOCs) are raising extensive attention across disciplines, while it becomes evident that rethinking of learning designs that work well in these environments is needed. In the field of medical education, where the technology of MOOCs is not widely adopted yet, we wish to investigate the potential offered by virtual patients for the purpose of clinical reasoning skills training. In this paper we describe three use case scenarios employing virtual patients' features in MOOCs: (1) collective evaluation of decision making in the context of uncertainty; (2) collective repurposing of cases and division of discussion into subgroups focusing on local variances in healthcare; (3) division of content in short cases for flexible selection and adaptive learning with virtual patients. We also present technical requirements for implementing the use case scenarios and future work plans.