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

Internal medicine clerks' motivation in an online course: a mixed-methods study

PURPOSE

At LUMC, a Small Private Online Course (SPOC) was developed complementary to the clinical learning environment of the internal medicine clerkship. The developers used the self-determination theory in the design of the SPOC's assignments aiming to improve learners' intrinsic motivation. This study investigates the impact of the SPOC and its specific assignments on student motivation.

METHODS

The study uses a mixed-methods approach. The authors describe a quantitative analysis of students' responses on an intrinsic motivation inventory (IMI), and a qualitative thematic analysis of semi-structured group interviews, respectively.

RESULTS

Seventy-eight students (response rate 42%) filled out the IMI. Their scores were (7-point Likert scale): interest/enjoyment 3.76, competence 4.02, choice 3.53, value/usefulness 4.20, relatedness 3.85. Thematic analysis of the interviews (14 students) revealed seven themes: collaboration with peers, usefulness, SPOC-related factors, workload, motivation, and performance.

CONCLUSIONS

Motivation could be optimized creating useful, authentic cases that train skills that are directly transferrable to clinical practice. Challenging, interesting and student-generated assignments positively influenced students' autonomy and motivation. Lack of awareness of online performance negatively affected the feeling of competence. Perceptions of online collaboration were suboptimal. The study can be helpful for other teachers to enhance motivation while developing online courses.

Will AI reshape or deform pharmacy education?

The integration of artificial intelligence (AI) into pharmacy education offers transformative opportunities but also introduces significant challenges. This commentary explores whether AI will reshape or deform pharmacy education by analyzing its effects on personalized learning, complex concept comprehension, simulation-based clinical training, interprofessional education, and administrative efficiency. While AI-driven tools provide adaptive learning experiences, immersive visualizations, and streamlined administrative processes, concerns persist about overreliance on technology, skill atrophy, ethical and legal challenges, erosion of humanistic skills, inequities stemming from the digital divide, and faculty preparedness. To address these risks while harnessing AI's potential, a balanced approach is essential. Key strategies include integrating AI into curricula alongside traditional teaching methods, fostering digital literacy and critical thinking, enhancing humanistic education, supporting faculty development, ensuring equitable access, and establishing ethical frameworks. By thoughtfully implementing these strategies, pharmacy educators can prepare students to thrive in an AI-driven healthcare landscape while preserving core professional competencies.

Does online case-based learning foster clinical reasoning skills? A mixed-methods study

Background

Blended learning, integrating face-to-face and virtual methods, has become essential in clinical education, enhancing student satisfaction, engagement and knowledge outcomes. Particularly, online case-based learning emerges as a promising pedagogy to foster clinical reasoning skills. Despite the well-documented clinical reasoning cultivation through face-to-face case-based learning, the ability of online case-based learning to cultivate clinical reasoning remains unexplored. This study investigates the role of online case-based learning in fostering clinical reasoning skills among clinical-year medical students.

Methods

A mixed-methods sequential explanatory research study was adopted. In the first phase, quantitative data were gathered through a 16-item Likert scale questionnaire adapted from validated clinical reasoning questionnaires. In the second phase, focus group discussions were conducted to expand on the understanding of quantitative results.

Results

In total, 160 students completed the questionnaire (45% response rate), and 26 participated in focus group discussions. Participants agreed that online case-based learning fostered clinical reasoning skills (mean = 2.94) through different formats, such as clinical role play, simulated ward rounds and virtual consultation. Compared to face-to-face clinical teaching, the focus group revealed that participants were allowed to practise giving explanations to patients, engage in more in-depth discussions, and receive more comprehensive feedback on their clinical reasoning skills during online case-based learning. The barriers to online clinical reasoning skills development were poorer communication skills development and reduced student engagement. The lack of patient complexities of cases and the inability to perform physical examinations hindered students' clinical reasoning ability. Suggestions to improve clinical reasoning cultivation include utilising actual patient cases, increasing case complexity and session interactivity.

Conclusion

This study highlights how online case-based learning can support the development of clinical reasoning skills in medical students, encouraging future educators to adopt a blended learning approach. Future research should focus on objective assessments, long-term impacts and innovative methods to improve clinical reasoning skill development continuously.

Choose Your Own Adventure: Using Twine for Gamified Interactive Learning in Veterinary Anaesthesia

Veterinary anaesthesia requires theoretical knowledge and quick decision-making skills. Traditional education may not adequately prepare students, while simulation-based learning enhances engagement and skill development. This study evaluates the effectiveness of a Twine-based web system in improving experiential learning, engagement, knowledge retention, and decision-making skills in veterinary anaesthesia students. Five interactive clinical cases were developed using Twine, simulating realistic anaesthesia scenarios with decision points and gamified elements, such as scoring systems and resource management. These modules were accessible on various devices via the web. Following a workshop for second- to fourth-year students of the Degree in Veterinary Sciences, an anonymous survey assessed the module's effectiveness. Quantitative data were analysed descriptively, while qualitative feedback was processed through a hybrid AI-human thematic analysis. Out of 849 invited students, 367 responded (42% response rate). Feedback was highly positive; 90.8% found it effective for training, and 97.0% agreed it improved knowledge. User-friendliness was rated as "easy" or "very easy" by 94.6%. Regarding overall satisfaction, 96.7% of students described the workshop as "good" or "excellent". Some participants suggested improvements in mobile device compatibility and the need for additional resources to understand the concepts better. Twine's interactive format fosters experiential learning while reducing reliance on live animals, aligning with modern ethical standards. Its accessibility via web and translation-enabled browsers enhances its reach. Future research should examine Twine's impact on clinical skills retention and adaptability in various educational contexts, providing a flexible approach to veterinary anaesthesia education through gamified learning.

A virtual patient authoring tool for transcatheter aortic valve replacement

PURPOSE

Computer-based medical training scenarios, derived from patient's records, often lack variability, modifiability, and availability. Furthermore, generating image datasets and creating scenarios is resource-intensive. Therefore, patient authoring tools for rapid dataset-independent creation of virtual patients (VPs) is a pressing need.

METHODS

An authoring tool and a virtual catheterization laboratory environment were developed. The tool allows customised VP generation through a real-time morphable heart model and Euroscore parameters. The generated VP can be examined inside the vCathLab using a fluoroscopy and monitoring device, both on desktop and immersive virtual reality. Seven board-certified experts evaluated the proposed method from three aspects, i.e. System Usability Scale, qualitative feedback, and its performance in VR.

RESULTS

All participants agreed that this method could provide the necessary information and is anatomically correct within an educational context. Its modifiability, variability, and simplicity were well recognised. The prototype achieved excellent usability score and considerable performance results.

CONCLUSION

We present a highly variable VP authoring tool that enhances variability in medical training scenarios. Although this work does not aim to explore didactic aspects, the potential of using this approach in an educational context has been confirmed in our study. Accordingly, these aspects can benefit from a thorough investigation in the future. In addition, our tool can be improved to provide more realistic parameter ranges for procedure-specific cases.

User evaluation of clinical simulation-based learning developed by FORCE (Framework for Online Radiographer Clinical Education)

INTRODUCTION

The FORCE initiative, funded by the EU, was created in response to the COVID-19 pandemic's impact on radiography education. It offers a virtual learning environment (VLE) filled with clinical simulation scenarios targeting Diagnostic Imaging, Nuclear Medicine, and Radiotherapy. These scenarios are designed to provide open-access, simulation-based learning (SBL) resources that help radiography undergraduates engage in problem-based learning across relevant clinical knowledge and professional awareness. This study presents the results of an online survey aimed at evaluating the FORCE VLE and SBL resources to guide future development.

METHODS

The survey targeted academic and clinical staff in Radiography and student Radiographers. It was based on the Course Experience Questionnaire (CEQ) and modified to include topics relevant to online learning, using a five-point Likert Scale (LS). The questionnaire consisted of four sections: research information and consent; socio-demographic data; LS-based questions on case structure, content, interactivity, technical aspects, multimedia quality, and overall experience; and open-text responses.

RESULTS

Of the 407 invited participants, 109 (27 %) responded, with 77 % being students and 23 % clinical or academic radiographers from 13 countries. English proficiency was reported by 76 % of respondents. The median LS was consistently 4 across all categories, indicating high satisfaction. Content analysis of 159 open-text comments revealed 139 positive opinions on the SBL resources.

CONCLUSION

The FORCE VLE SBL resources were highly regarded for their interactivity, applicability, and support in consolidating knowledge and enhancing patient care. Suggestions for improvement were minor, mainly focusing on navigation and specific content preferences.

IMPLICATIONS FOR PRACTICE

Expanding the availability of online SBL cases could enhance Radiographer education and promote inclusivity across the field.

The Emerging Influence of Artificial Intelligence on Traditional Medical Textbooks

This review provides a comprehensive exploration of how artificial intelligence (AI) is reshaping medical education and the role of traditional textbooks. The historical context underscores the evolution of medical knowledge bridging past advances with current AI-driven innovations, highlighting the indispensable role of both printed and electronic medical textbooks. The strengths and limitations of traditional and digital textbooks are considered. The potential for AI to enhance medical education through real-time updates, personalized learning, and advanced visual aids is particularly compelling. This perspective is critical for practitioners and educators who are navigating the integration of AI in their fields.

Body donor reperfusion and re-ventilation in medical training: an Italian study testing SimLife®

Background

Medical simulations have emerged as a valuable tool in anatomical-medical training, allowing healthcare professionals to gain hands-on experience in a controlled and safe environment. One such simulation platform is SimLife®, which uses the Pulse for Practice (P4P) system to enable realistic restoration of airflow ("re-ventilation") and blood flow ("revascularization") in bodies donated to science.

Objective

This study aimed to evaluate the feasibility of introducing SimLife® technology in Italy. Additionally, it assessed the impact of this technology across various medical specialties, utilizing a minimal number of donated bodies.

Methods

The study utilized the existing body donation program and dissection rooms at the Anatomy Center of the University of Bologna. 62 participants from 13 medical specialties performed simulations using the SimLife® P4P platform. Post-simulation, structured interviews were used to collect data on the interventions performed, participant perceptions of the technology's usefulness, enjoyment, and willingness to repeat the experience, as well as critical issues encountered.

Results

Key findings include that 86% of participants rated SimLife® technology as extremely useful for post-lauream training, while 84% found it highly beneficial for team-building activities. A total of 31 interventions were successfully performed across various anatomical regions, with participants reporting high satisfaction and a strong willingness to repeat the simulation experience.

Conclusion

The findings support the effectiveness of SimLife® technology for body donor re-ventilation and revascularization, reinforcing its value for medical training across various specialties.

Case-Based Virtual Reality Simulation for Severe Pelvic Trauma Clinical Skill Training in Medical Students: Design and Pilot Study

BACKGROUND

Teaching severe pelvic trauma poses a significant challenge in orthopedic surgery education due to the necessity of both clinical reasoning and procedural operational skills for mastery. Traditional methods of instruction, including theoretical teaching and mannequin practice, face limitations due to the complexity, the unpredictability of treatment scenarios, the scarcity of typical cases, and the abstract nature of traditional teaching, all of which impede students' knowledge acquisition.

OBJECTIVE

This study aims to introduce a novel experimental teaching methodology for severe pelvic trauma, integrating virtual reality (VR) technology as a potent adjunct to existing teaching practices. It evaluates the acceptability, perceived ease of use, and perceived usefulness among users and investigates its impact on knowledge, skills, and confidence in managing severe pelvic trauma before and after engaging with the software.

METHODS

A self-designed questionnaire was distributed to 40 students, and qualitative interviews were conducted with 10 teachers to assess the applicability and acceptability. A 1-group pretest-posttest design was used to evaluate learning outcomes across various domains, including diagnosis and treatment, preliminary diagnosis, disease treatment sequencing, emergency management of hemorrhagic shock, and external fixation of pelvic fractures.

RESULTS

A total of 40 students underwent training, with 95% (n=38) affirming that the software effectively simulated real-patient scenarios. All participants (n=40, 100%) reported that completing the simulation necessitated making the same decisions as doctors in real life and found the VR simulation interesting and useful. Teacher interviews revealed that 90% (9/10) recognized the VR simulation's ability to replicate complex clinical cases, resulting in enhanced training effectiveness. Notably, there was a significant improvement in the overall scores for managing hemorrhagic shock (t39=37.6; 95% CI 43.6-48.6; P<.001) and performing external fixation of pelvic fractures (t39=24.1; 95% CI 53.4-63.3; P<.001) from pre- to postsimulation.

CONCLUSIONS

The introduced case-based VR simulation of skill-training methodology positively influences medical students' clinical reasoning, operative skills, and self-confidence. It offers an efficient strategy for conserving resources while providing quality education for both educators and learners.

Lilobot: A Cognitive Conversational Agent to Train Counsellors at Children's Helplines : Design and Initial Evaluation

To equip new counsellors at a Dutch child helpline with the needed counselling skills, the helpline uses role-playing, a form of learning through simulation in which one counsellor-in-training portrays a child seeking help and the other portrays a counsellor. However, this process is time-intensive and logistically challenging-issues that a conversational agent could help address. In this paper, we propose an initial design for a computer agent that acts as a child help-seeker to be used in a role-play setting. Our agent, Lilobot, is based on a Belief-Desire-Intention (BDI) model to simulate the reasoning process of a child who is being bullied at school. Through interaction with Lilobot, counsellors-in-training can practise the Five Phase Model, a conversation strategy that underpins the helpline's counselling principle of keeping conversations child-centred. We compared a training session with Lilobot to a text-based training, inviting experienced counsellors from the Dutch child helpline to participate in both sessions. We conducted pre- and post-measurement comparisons for both training sessions. Contrary to our expectations, the results show a decrease in counselling self-efficacy at post-measurement, particularly in Lilobot's condition. Still, the counsellors' qualitative feedback indicated that, with further development and refinements, they believed Lilobot could potentially serve as a useful supplementary tool for training new helpline counsellors. Our work also highlights three future research directions for training simulators in this domain: integrating emotions into the model, providing guided feedback to the counsellor, and incorporating Large Language Models (LLMs) into the conversations.

A Symbolic AI Approach to Medical Training

In traditional medical education, learners are mostly trained to diagnose and treat patients through supervised practice. Artificial Intelligence and simulation techniques can complement such an educational practice. In this paper, we present GLARE-Edu, an innovative system in which AI knowledge-based methodologies and simulation are exploited to train learners "how to act" on patients based on the evidence-based best practices provided by clinical practice guidelines. GLARE-Edu is being developed by a multi-disciplinary team involving physicians and AI experts, within the AI-LEAP (LEArning Personalization of AI and with AI) Italian project. GLARE-Edu is domain-independent: it supports the acquisition of clinical guidelines and case studies in a computer format. Based on acquired guidelines (and case studies), it provides a series of educational facilities: (i) navigation, to navigate the structured representation of the guidelines provided by GLARE-Edu, (ii) automated simulation, to show learners how a guideline would suggest to act, step-by-step, on a specific case, and (iii) (self)verification, asking learners how they would treat a case, and comparing step-by-step the learner's proposal with the suggestions of the proper guideline. In this paper, we describe GLARE-Edu architecture and general features, and we demonstrate our approach through a concrete application to the melanoma guideline and we propose a preliminary evaluation.

Key challenges and countermeasures: a review of undergraduate teaching of neurology in outpatient settings

In the modern medical education system, teaching of clinical neurology in outpatient settings is crucial for training future neurologists. The neurology outpatient clinic is a pivotal setting for both initial consultations and follow-up visits. It plays a significant role in the prevention, diagnosis, treatment, and ongoing monitoring of neurological disorders, and is a critical platform for clinical education. Under the guidance of experienced physicians during their clinical rotations, medical students enhance their clinical reasoning ability and skills by learning about the diagnosis and treatment of neurological diseases, thereby laying a solid foundation for becoming competent doctors. Despite the advancements in this field, there is a lack of comprehensive reports on the current status and challenges of teaching neurology in outpatient settings. This gap significantly impedes the development of scientific policies to improve teaching standards. We need to clarify the existing issues to develop effective strategies, such as actively embracing advanced educational achievements and experiences, continuously refining teaching models and methods, and enhancing the quality of education, to cultivate more outstanding medical professionals. This article summarizes the current state and issues of teaching clinical neurology in outpatient settings, and analyzes countermeasures to provide a foundation for future practice and study.

Effect of a Standardized Education Program for Interhospital Transport of Critically Ill Patients on Knowledge and Confidence in South Korea: A Pilot Study

Critical care transport (CCT) education and training for health care providers are important for patient safety. In this study, a structured education and training program for CCT was implemented as a pilot in South Korea, and the effects of improving knowledge and confidence among health care providers were evaluated. This retrospective observational study analyzed pre- and post-test scores and survey responses from participants in the education program. The education program consisted of a didactic lecture, skill practice, and simulation for 9 categories lasting 80 hours. The participants included nurses and emergency medical technicians with experience in emergency or critical care. The study consisted of 2 phases, with data collected through web-based evaluation forms and structured questionnaires. The program involved 20 participants across the 2 phases. Posteducation assessments revealed significant improvements in knowledge and confidence in CCT practices. The participants were especially satisfied with their skill in trauma management and advanced CCT simulations. The Korean Critical Care Transport Curriculum education program effectively enhanced the knowledge and confidence of health care providers in CCT. This standardized education model should be considered by policy makers and stakeholders to improve patient safety in emergency medical systems.

Effectiveness of immersive teaching strategies on pressure injury: Impact on nurses' knowledge, attitudes and self-efficacy - A partially randomized participant preference (PRPP) controlled trial

AIMS

This study evaluated the effectiveness of a pressure injury educational intervention on nurses' knowledge, attitudes, self-efficacy and perceived barriers.

BACKGROUND

Pressure injuries remain a global healthcare challenge. Efficient teaching strategies like immersive learning are crucial to translating theoretical knowledge into practical skills.

DESIGN

A single-center, partially randomized participant preference (PRPP) controlled trial was conducted in a regional teaching hospital.

METHOD

A total of 335 nurses consented to participate, with 79 in the experimental group and 218 in the control group completing the study. The experimental group received an immersive learning intervention that included learning manuals, multimedia videos and workshops designed to enhance pressure injury management. In contrast, the control group's immersive learning intervention involved only the use of learning manuals. Assessments were conducted both before and immediately after the intervention to measure outcomes, including knowledge, attitudes and self-efficacy related to pressure injury care.

RESULTS

Both groups showed significant improvements in knowledge, attitudes and self-efficacy post-intervention (p < .05). The experimental group demonstrated significantly higher post-test scores compared with the control group (p < .05). Pearson correlation analysis revealed a strong positive relationship between knowledge and attitude (r = 0.592, p < .001).

CONCLUSION

The immersive educational intervention significantly improved nurses' knowledge, attitudes and self-efficacy in managing pressure injuries. The experimental group showed greater progress, emphasizing the value of interactive multimedia tools and workshops in nursing education. The strong correlation between knowledge and attitude highlights the importance of comprehensive educational approaches in enhancing patient care and addressing healthcare challenges.

Navigating the Intersection of Technology and Surgical Education: Advancements, Challenges, and Ethical Considerations in Orthopedic Training

The emergence of technological advancements such as artificial intelligence, virtual reality, and robotics may offer new solutions to address crucial deficiencies in surgical residency training. However, these technologies also introduce ethical dilemmas and practical complexities. Achieving a balance between embracing innovation and refining traditional surgical techniques is essential in molding well-rounded, proficient surgeons. Addressing concerns such as disparities in access to technology and the risk of excessive automated system dependence demands thorough deliberation and the establishment of universal guidelines. By approaching these challenges with care and insight, surgeons can utilize new technology to elevate both surgical training and outcomes.

The value of virtual simulation in training GP residents in advance care planning conversations

INTRODUCTION

Advance care planning (ACP) aims at empowering patients with chronic progressive disease to express and communicate their preferences for future care, but is not yet consistently applied in general practice. We explored GP residents' experiences with practicing ACP conversations through virtual simulation and its educational value.

METHODS

Our study with Dutch GP residents in their first year of training used a hermeneutic phenomenological approach. Eleven participants were observed while engaging in virtual simulation, followed by an in-depth interview. Data was analysed in an iterative manner, starting from the first interview.

RESULTS

Although the virtual simulation was mostly experienced as not realistic because it lacked the possibility of nuanced wording and personal adjustments, the GP residents did find it valuable to learn what topics can be addressed and how. The learning experience was primarily shaped by GP residents' prior real-life ACP experiences.

DISCUSSION

Virtual simulation is a valuable part of a blended curriculum, facilitating residents to get started with or refresh the basic knowledge and skills of ACP. It is crucial that virtual simulation is followed by critical reflection with peers and supervising GPs and practice with actors or real patients to ensure GP residents can further develop their skills regarding ACP conversations.

The effect of case-based mobile virtual patient application on students' academic achievement in clinical reasoning skills

This mixed-method study aims to determine the effect of the use of mobile virtual patient application with narrated case-based virtual patients as an assistive technology on students' clinical reasoning skills. It makes a notable contribution by exploring the impact of mobile virtual patient applications on healthcare students' clinical skills and their preparation for real-world patient care. In addition, the accuracy of the analysis results regarding the effect on student achievement was analyzed with a second dataset tool, and thus, aiming to increase reliability by verifying the same research question with a different quantitative analysis technique. In the qualitative part of the study, students' views on the implementation were collected through an open-ended questionnaire and the data were subjected to content analysis. An achievement test was also developed to determine the development of students' clinical reasoning skills, which revealed that each of the learning environments had different outcomes regarding students' achievement and that supporting the traditional environment with the mobile virtual patient application yielded better results for increasing students' achievement. Students' opinions about the mobile virtual patient application and the process also support the increase in academic achievement aimed at measuring clinical reasoning skills. The content analysis showed that the students, who generally reported multiple positive factors related to the application, thought that the stories and cases presented created a perception of reality, and they especially highlighted the contribution of the application to learning the story organization. Based on all these results, it can be said that the application supports clinical reasoning, provides practical experience, improves academic achievement, and contributes positively to motivation.

Effect of behavior modification combined with health belief model education on adherence to skin moisturizing care in patients with psoriasis vulgaris

To examine the impact of an educational approach incorporating behavioral modification and the Health Belief Model on the adherence to skin moisturizing care, itch severity, self-efficacy, and quality of life among individuals diagnosed with psoriasis vulgaris. A study involving 108 psoriasis vulgaris patients (November 2022-October 2023) utilized random allocation to form experimental and control groups. The control group received standard care, including medication guidance, general health education, and basic nursing support. In contrast, the experimental group underwent an enhanced intervention that combined behavior modification techniques and education based on the Health Belief Model. This included biweekly educational sessions, personalized behavioral assessments, and self-monitoring tools like self-supervision cards, which were not provided to the control group. Assessments pre- and post-intervention measured itchiness, self-efficacy, and quality of life. Comparative analyses included pruritus, self-efficacy, adherence, and quality of life using various scales. The study aimed to evaluate the impact of combined interventions on these parameters in psoriasis patients. Following the intervention, both groups exhibited improvements in itching degree, itching frequency, and affected areas compared to pre-intervention levels, with the experimental group showing superior outcomes over the control group. GSES scores in both groups increased post-intervention, with the experimental group surpassing the control group. Both groups demonstrated enhanced scores post-intervention across various aspects, including forgetting to use medication, willingness to use medication, influencing factors, medication timing, frequency, and quality of life (assessed by DLQI). Furthermore, MORISKY scores for medication timing, frequency, and self-discontinuation decreased in both groups post-intervention, with the experimental group recording lower scores than the control group. DLQI scores for symptom feelings, daily life, leisure and recreation, work and study, interpersonal relationships, and treatment were reduced in both groups after the intervention, with the experimental group showing lower scores than the control group. Combining behavior modification and health belief model education effectively improves adherence to skincare, relieves itching in psoriasis patients, and enhances self-efficacy and overall quality of life.

Enhancing medical education with chatbots: a randomized controlled trial on standardized patients for colorectal cancer

INTRODUCTION

Combination of Standardized Patient (SP) and Case Based Learning (CBL) is a common method in medical education, but traditional SP (TSP) may not be conducive to students' mastery of basic medical knowledge and the cultivation of clinical thinking. Therefore, it is necessary to innovate SP to optimize SP combined with CBL teaching method.

OBJECTIVE

This study aims to explore the effectiveness of a chatbot utilizing standardized patients based on CBL (CSP-CBL) for colorectal cancer education.

METHODS

61 medical students who have studied the theoretical knowledge of colorectal cancer were selected as the study objects and randomly divided into experimental group and control group. The experimental group used CSP-CBL, and the control group used traditional SP based on CBL (TSP-CBL). Before the intervention, basic knowledge test and clinical thinking ability assessment scale were used to investigate basic ability. After the intervention, we compared the effectiveness of two teaching methods in training colorectal cancer diagnosis and treatment skills through basic knowledge test, clinical thinking ability assessment scale, course experience questionnaire and client satisfaction questionnaire.

RESULT

The majority of participants were female (62.3%, 38/61), 67.2% (41/61) were in the top 60% of school grades, and only 13.1% (8/61) had a medical background. There were no significant differences between the two groups in terms of demographic and sociological characteristics. There was no difference in pre-test of basic knowledge scores between the two groups (P = 0.489), but the CSP-CBL group scored significantly higher at post-intervention compared to the TSP-CBL group (SMD = -0.629, P < 0.05, 95% CI = (-0.789,-0.468)) and the CSP-CBL group also scored significantly higher than their baseline scores (SMD = - 0.991, p < 0.05, 95% CI = (-1.241,-0.740)). In terms of clinical thinking skills, the CSP-CBL group significantly improved their total score from (79.6 ± 15.9) to (86.2 ± 17.3) after the intervention (SMD = - 0.398, p < 0.05, 95% CI = (-0.498,-0.297)), but there was no significant difference between the two groups.The CSP-CBL group had a significantly lower academic load and course stress than the TSP-CBL group (SMD = -0.941, p < 0.01, 95% CI = (-1.181,-0.701); SMD = -0.6, p < 0.05, 95% CI = (-0.753,-0.447)) and scored significantly higher on the evaluation of future knowledge value (SMD = 0.603, p < 0.05, 95% CI = (0.449,0.757)). There was no significant difference between the two groups in terms of overall satisfaction, but the CSP-CBL group was significantly more satisfied than the TSP-CBL group in terms of meeting learning needs (SMD = 0.532, P < 0.05, 95% CI=(0.396,0.668)). There was no significant difference between the two groups in willingness to reuse the learning model.

CONCLUSION

The results show that CSP-CBL teaching can significantly improve the basic knowledge and clinical thinking of clinical medical students learning colorectal cancer, better meet the learning needs of students and reduce the learning burden appropriately.

TRIAL REGISTRATION

ChiCTR2300072017 (registered on 31/05/2023).

Integrating GPT-Based AI into Virtual Patients to Facilitate Communication Training Among Medical First Responders: Usability Study of Mixed Reality Simulation

BACKGROUND

Training in social-verbal interactions is crucial for medical first responders (MFRs) to assess a patient's condition and perform urgent treatment during emergency medical service administration. Integrating conversational agents (CAs) in virtual patients (VPs), that is, digital simulations, is a cost-effective alternative to resource-intensive human role-playing. There is moderate evidence that CAs improve communication skills more effectively when used with instructional interventions. However, more recent GPT-based artificial intelligence (AI) produces richer, more diverse, and more natural responses than previous CAs and has control of prosodic voice qualities like pitch and duration. These functionalities have the potential to better match the interaction expectations of MFRs regarding habitability.

OBJECTIVE

We aimed to study how the integration of GPT-based AI in a mixed reality (MR)-VP could support communication training of MFRs.

METHODS

We developed an MR simulation of a traffic accident with a VP. ChatGPT (OpenAI) was integrated into the VP and prompted with verified characteristics of accident victims. MFRs (N=24) were instructed on how to interact with the MR scenario. After assessing and treating the VP, the MFRs were administered the Mean Opinion Scale-Expanded, version 2, and the Subjective Assessment of Speech System Interfaces questionnaires to study their perception of the voice quality and the usability of the voice interactions, respectively. Open-ended questions were asked after completing the questionnaires. The observed and logged interactions with the VP, descriptive statistics of the questionnaires, and the output of the open-ended questions are reported.

RESULTS

The usability assessment of the VP resulted in moderate positive ratings, especially in habitability (median 4.25, IQR 4-4.81) and likeability (median 4.50, IQR 3.97-5.91). Interactions were negatively affected by the approximately 3-second latency of the responses. MFRs acknowledged the naturalness of determining the physiological states of the VP through verbal communication, for example, with questions such as "Where does it hurt?" However, the question-answer dynamic in the verbal exchange with the VP and the lack of the VP's ability to start the verbal exchange were noticed. Noteworthy insights highlighted the potential of domain-knowledge prompt engineering to steer the actions of MFRs for effective training.

CONCLUSIONS

Generative AI in VPs facilitates MFRs' training but continues to rely on instructions for effective verbal interactions. Therefore, the capabilities of the GPT-VP and a training protocol need to be communicated to trainees. Future interactions should implement triggers based on keyword recognition, the VP pointing to the hurting area, conversational turn-taking techniques, and add the ability for the VP to start a verbal exchange. Furthermore, a local AI server, chunk processing, and lowering the audio resolution of the VP's voice could ameliorate the delay in response and allay privacy concerns. Prompting could be used in future studies to create a virtual MFR capable of assisting trainees.

Effectiveness of Virtual Simulations Versus Mannequins and Real Persons in Medical and Nursing Education: Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials

BACKGROUND

Virtual simulation (VS) is a developing education approach with the recreation of reality using digital technology. The teaching effectiveness of VSs compared to mannequins and real persons (RPs) has never been investigated in medical and nursing education.

OBJECTIVE

This study aims to compare VSs and mannequins or RPs in improving the following clinical competencies: knowledge, procedural skills, clinical reasoning, and communication skills.

METHODS

Following Cochrane methodology, a meta-analysis was conducted on the effectiveness of VSs in pre- and postregistration medical or nursing participants. The Cochrane Library, PubMed, Embase, and Educational Resource Information Centre databases were searched to identify English-written randomized controlled trials up to August 2024. Two authors independently selected studies, extracted data, and assessed the risk of bias. All pooled estimates were based on random-effects models and assessed by trial sequential analyses. Leave-one-out, subgroup, and univariate meta-regression analyses were performed to explore sources of heterogeneity.

RESULTS

A total of 27 studies with 1480 participants were included. Overall, there were no significant differences between VSs and mannequins or RPs in improving knowledge (standard mean difference [SMD]=0.08; 95% CI -0.30 to 0.47; I2=67%; P=.002), procedural skills (SMD=-0.12; 95% CI -0.47 to 0.23; I2=75%; P<.001), clinical reasoning (SMD=0.29; 95% CI -0.26 to 0.85; I2=88%; P<.001), and communication skills (SMD=-0.02; 95% CI: -0.62 to 0.58; I2=86%; P<.001). Trial sequential analysis for clinical reasoning indicated an insufficient sample size for a definitive judgment. For procedural skills, subgroup analyses showed that VSs were less effective among nursing participants (SMD=-0.55; 95% CI -1.07 to -0.03; I2=69%; P=.04). Univariate meta-regression detected a positive effect of publication year (β=.09; P=.02) on communication skill scores.

CONCLUSIONS

Given favorable cost-utility plus high flexibility regarding time and space, VSs are viable alternatives to traditional face-to-face learning modalities. The comparative effectiveness of VSs deserves to be followed up with the emergence of new technology. In addition, further investigation of VSs with different design features will provide novel insights to drive education reform.

TRIAL REGISTRATION

PROSPERO CRD42023466622; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=466622.

How to Partner With Persons Living With Mental Health Conditions: A Guide for Meaningful Simulation Cocreation

SUMMARY STATEMENT

Screen-based simulation is an effective educational strategy that can enhance health care students' engagement with content and critical thinking across various topics, including mental health. To create relevant and realistic simulations, best-practice guidelines recommend the involvement of experts in the development process. We collaborated with persons with lived experience and community partners to cocreate a mental health-focused screen-based simulation. Cocreating meant establishing a nonhierarchical partnership, with shared decision-making from start to finish.In this article, we present 8 principles developed to guide our cocreation with persons with lived experience: person-centeredness, trauma-informed approaches and ethical guidance, supportive environment, two-way partnership, mutual respect, choice and flexibility, open communication, and room to grow. These principles provide practical guidance for educators seeking to engage the expertise of persons who have been historically disadvantaged in society. By sharing these principles, we strive to contribute to a more equitable process in simulation development and promote meaningful, respectful, and safer collaborations.

Virtual patients with substance use disorders in healthcare professional education: a scoping review

Background and objective

Virtual patient simulations are cost-effective methods for training health professionals. Yet, this teaching method is rarely used with clinicians who work or plan on working with people with substance use disorders. This scoping review summarizes the current state of the literature concerning virtual substance use disorder patient simulations in health professionals' training and provides suggestions for future directions.

Methods

Online databases were searched for peer-reviewed articles published between January 2010 and June 2024.

Results

Twelve studies were included. The development, administration, and evaluation of performance of the simulations are diverse. Most simulations aim to develop screening, brief interventions or referring skill, they target a variety of health professionals' disciplines and report positive learning outcomes. Virtual simulations have good acceptance rates from learners.

Conclusions

Enhancing the diversity of clinical skills and patient populations portrayed in simulations, alongside adherence to best practices in simulation development and implementation is suggested to optimize training outcomes in this critical area of healthcare education.

Enhancing clinical reasoning skills for medical students: a qualitative comparison of LLM-powered social robotic versus computer-based virtual patients within rheumatology

Virtual patients (VPs) are increasingly used in medical education to train clinical reasoning (CR) skills. However, optimal VP design for enhancing interactivity and authenticity remains unclear. Novel interactive modalities, such as large language model (LLM)-enhanced social robotic VPs might increase interactivity and authenticity in CR skill practice. To evaluate medical students' perceptions of CR training using an LLM-enhanced social robotic VP platform compared with a conventional computer-based VP platform. A qualitative study involved 23 third-year medical students from Karolinska Institutet, who completed VP cases on an LLM-enhanced social robotic platform and a computer-based semi-linear platform. In-depth interviews assessed students' self-perceived acquirement of CR skills using the two platforms. Thematic analysis was employed to identify themes and sub-themes. Three main themes were identified: authenticity, VP application, and strengths and limitations. Students found the social robotic platform more authentic and engaging. It enabled highly interactive communication and expressed emotions, collectively offering a realistic experience. It facilitated active learning, hypothesis generation, and adaptive thinking. Limitations included lack of physical examination options and, occasionally, mechanical dialogue. The LLM-enhanced social robotic VP platform offers a more authentic and interactive learning experience compared to the conventional computer-based platform. Despite some limitations, it shows promise in training CR skills, communication, and adaptive thinking. Social robotic VPs may prove useful and safe learning environments for exposing medical students to diverse, highly interactive patient simulations.

Assessment of communication skills in health professions education; Ottawa 2024 consensus statement

Despite the increasing inclusion of communication skills in accreditation standards and an increase in time dedicated to teaching these skills, communication is often regarded as a separate skill and is therefore, not consistently represented in overall systems of assessment in Health Professions Education (HPE). The ascendence of competency-based medical education, programmatic assessment, artificial intelligence, and widespread use of telehealth, alongside changing patient expectations warrant an update in thinking about the assessment of communication skills in health professions education. This consensus statement draws on existing literature, expert pinion, and emerging challenges to situate the assessment of communication skills in the contemporary health professions education context. The statement builds on previous work to offer an update on the topic and include new developments related to assessment, particularly: the challenges and opportunities associated with systems of assessment; patient and peer perspectives in assessment; assessment of interprofessional communication, cross-cultural communication, digital communication; and assessment using digital technologies. Consensus was reached through extensive discussion among the authors and other experts in HPE, exploration of the literature, and discussion during an Ottawa 2024 conference workshop. The statement puts forward a summary of available evidence with suggestions for what educators and curriculum developers should consider in their planning and design of the assessment of communication.

Comparative Effectiveness of Developed Serious Game Versus Standardized Patients' Simulation in Nursing Education

Background: Serious games provide a realistic environment in nursing education, a stimulating and experiential learning environment for developing skills necessary for learning, recognizing, analyzing, selecting, and applying information. Methods: This study aims to determine the impact of serious games and standard patient practices developed for nursing education on students' knowledge levels, satisfaction, self-confidence, critical thinking, and problem-solving skills. A serious game was designed using the educational principles of the diabetes course and developed using the 3D interactive content creation platform UNITY. One group played the game online, whereas another had a face-to-face experience. Both groups completed forms before, after, and 4 weeks later via Google Forms. Results: Quantitative analysis showed significant improvements in knowledge and increases in student satisfaction and confidence in learning in both the serious game and standardized patient groups. The groups had no significant differences in problem-solving and critical-thinking abilities (P > 0.005). Conclusion: Developing advanced clinical proficiencies in nursing students requires an engaging and reliable educational environment. Using serious games and standardized patient simulations in nursing instruction highlights the need for diverse digital teaching tools. Therefore, it is essential to support the professional development of nursing educators in these innovative modalities.

Comparison of virtual and in-person simulations for sepsis and trauma resuscitation training in Singapore: a randomized controlled trial

PURPOSE

This study aimed to compare cognitive, non-cognitive, and overall learning outcomes for sepsis and trauma resuscitation skills in novices with virtual patient simulation (VPS) versus in-person simulation (IPS).

METHODS

A randomized controlled trial was conducted on junior doctors in 1 emergency department from January to December 2022, comparing 70 minutes of VPS (n=19) versus IPS (n=21) in sepsis and trauma resuscitation. Using the nominal group technique, we created skills assessment checklists and determined Bloom’s taxonomy domains for each checklist item. Two blinded raters observed participants leading 1 sepsis and 1 trauma resuscitation simulation. Satisfaction was measured using the Student Satisfaction with Learning Scale (SSLS). The SSLS and checklist scores were analyzed using the Wilcoxon rank sum test and 2-tailed t-test respectively.

RESULTS

For sepsis, there was no significant difference between VPS and IPS in overall scores (2.0; 95% confidence interval [CI], -1.4 to 5.4; Cohen’s d=0.38), as well as in items that were cognitive (1.1; 95% CI, -1.5 to 3.7) and not only cognitive (0.9; 95% CI, -0.4 to 2.2). Likewise, for trauma, there was no significant difference in overall scores (-0.9; 95% CI, -4.1 to 2.3; Cohen’s d=0.19), as well as in items that were cognitive (-0.3; 95% CI, -2.8 to 2.1) and not only cognitive (-0.6; 95% CI, -2.4 to 1.3). The median SSLS scores were lower with VPS than with IPS (-3.0; 95% CI, -1.0 to -5.0).

CONCLUSION

For novices, there were no major differences in overall and non-cognitive learning outcomes for sepsis and trauma resuscitation between VPS and IPS. Learners were more satisfied with IPS than with VPS (clinicaltrials.gov identifier: NCT05201950).

Enhancing Clinical Reasoning with Virtual Patients: A Hybrid Systematic Review Combining Human Reviewers and ChatGPT

OBJECTIVES

This study presents a systematic review aimed at evaluating the effectiveness of virtual patients in enhancing clinical reasoning skills in medical education. A hybrid methodology was used, combining human reviewers and ChatGPT to assess the impact of conversational virtual patients on student learning outcomes and satisfaction.

METHODS

Various studies involving conversational virtual patients were analyzed to determine the effect of these digital tools on clinical competencies. The hybrid review process incorporated both human assessments and AI-driven reviews, allowing a comparison of accuracy between the two approaches.

RESULTS

Consistent with previous systematic reviews, our findings suggest that conversational virtual patients can improve clinical competencies, particularly in history-taking and clinical reasoning. Regarding student feedback, satisfaction tends to be higher when virtual patients' interactions are more realistic, often due to the use of artificial intelligence (AI) and natural language processing (NLP) in the simulators. Furthermore, the study compares the accuracy of AI-driven reviews with human assessments, revealing comparable results.

CONCLUSIONS

This research highlights AI's potential to complement human expertise in academic evaluations, contributing to more efficient and consistent systematic reviews in rapidly evolving educational fields.

The evolution of medical education in the era of Covid-19 and beyond: a longitudinal study

BACKGROUND

The COVID-19 pandemic has brought about profound transformations in nearly all aspects of life, leaving its impact on the global community as a whole. Nowhere has this transformation been more pronounced than in the sphere of education, including medical education. Healthcare professionals and educators faced the daunting task of preparing the next generation of practicing physicians amid the ongoing public health crisis.

METHODS

The study involved students from three different Chinese medical universities (groups A, B, and C, respectively). The research employed two instruments: a Scale of Satisfaction with Simulation-Based Education and a Scale of Satisfaction with Telemedicine Competency Education. Data were collected at three different time points: 2020-2021 (online/distance learning), 2021-2022 (hybrid learning), and 2022-2023 (traditional face-to-face learning).

RESULTS

It was revealed that students demonstrated the highest level of satisfaction during the hybrid learning period (Time Point 2), while online/distance learning (Time Point 1) received the lowest ratings. Statistical analysis indicated significant differences in satisfaction levels across the various time points.

CONCLUSIONS

Hybrid learning emerged as the preferred method among students, yielding the highest level of satisfaction. Online/distance learning during the 2020-2021 academic year and traditional face-to-face instruction in 2022-2023 exhibited lower satisfaction levels. The research findings underscore the practical significance of hybrid learning for students in medical educational programs, suggesting its potential for optimizing educational curricula and resources within academic institutions.

AI's pivotal impact on redefining stakeholder roles and their interactions in medical education and health care

Artificial Intelligence (AI) has the potential to revolutionize medical training, diagnostics, treatment planning, and healthcare delivery while also bringing challenges such as data privacy, the risk of technological overreliance, and the preservation of critical thinking. This manuscript explores the impact of AI and Machine Learning (ML) on healthcare interactions, focusing on faculty, students, clinicians, and patients. AI and ML's early inclusion in the medical curriculum will support student-centered learning; however, all stakeholders will require specialized training to bridge the gap between medical practice and technological innovation. This underscores the importance of education in the ethical and responsible use of AI and emphasizing collaboration to maximize its benefits. This manuscript calls for a re-evaluation of interpersonal relationships within healthcare to improve the overall quality of care and safeguard the welfare of all stakeholders by leveraging AI's strengths and managing its risks.

Gamification in the Design of Virtual Patients for Swedish Military Medics to Support Trauma Training: Interaction Analysis and Semistructured Interview Study

BACKGROUND

This study explores gamification in the design of virtual patients (VPs) to enhance the training of Swedish military medics in trauma care. The challenges related to prehospital trauma care faced on the battlefield require tailored educational tools that support military medics' education and training.

OBJECTIVE

The aim of the study is to investigate how to design VPs with game elements for Swedish military medics to support learning in military trauma care. By understanding the reasoning and perceptions of military medics when interacting with VPs, this study aims to provide insights and recommendations for designing VPs with game elements that are specifically tailored to their needs.

METHODS

The study involved 14 Swedish military medics of the Home Guard-National Security Forces participating in a tactical combat care course. Participants interacted with 3 different VP cases designed to simulate military trauma scenarios. Data were collected through think-aloud sessions and semistructured interviews. The data were analyzed using interaction analysis, structured by the unawareness, problem identification, explanation, and alternative strategies or solutions (uPEA) framework, and reflexive thematic analysis to explore participants' reasoning processes and perceptions and identify possible game elements to inform the VP design.

RESULTS

Mapping the military medics' reasoning to the uPEA framework revealed that study participants became more creative after making a mistake followed by feedback and after receiving a prompt to make a new decision. The thematic analysis revealed 6 themes: motivation, "keep on trying"; agency in interaction with VPs; realistic tactical experience; confidence, "I know that the knowledge I have works"; social influence on motivation; and personalized learning. Participants suggested that game elements such as scoring; badges; virtual goods; progress bars; performance tables; content unlocking; hints; challenge; control; imposed choice; narrative; avatars; sensation; randomness; difficulty adapting; competition; leaderboards; social pressure; progression; and renovation can promote engagement, motivation, and support confidence in decision-making.

CONCLUSIONS

Gamification in the design of VPs represents a promising approach to military medical training, offering a platform for medics to practice medical and tactical decision-making in a risk-free environment. The insights gained by the study may encourage designing VPs with game elements, as well as including possibly wrong decisions, their consequences, and relevant feedback, that may support military medics' reflections and decision-making.

Gaming the System? A Qualitative Exploration of Physician Assistant Learner Perceptions of Virtual Patient Education

INTRODUCTION

Virtual patients (VPs) are increasingly used in health professions education. How learners engage with VPs and the relationship between engagement and authenticity is not well understood. We explored learners' perceptions of VP education to gain an understanding of the characteristics promoting meaningful engagement in learning, including perceived authenticity.

METHODS

Using a constructivist grounded theory approach, we conducted interviews and focus groups with 11 students from 2 Canadian Physician Assistant programs, where VP learning was implemented to supplement clinical education during the COVID-19 pandemic. We explored trainee perspectives on the use of VPs as an educational modality. Data were iteratively collected and descriptively analyzed thematically using a constant comparison approach until theoretical sufficiency was reached.

RESULTS

We identified 3 groups of factors influencing these students' VP learning experiences: (1) technical factors related to the VP platform influenced the perceived authenticity of the patient interactions; (2) individual factors of learners' attitudes influenced their engagement and motivation; and (3) contextual factors related to the learning environment influenced the acceptability and perceived value of the learning experience. Overall, the psychological authenticity of the learning platform and students' motivation for self-directed learning were perceived as most important for students' learning experiences.

CONCLUSIONS

Implementing VP learning as a supplement to clinical education should be done with consideration of factors that enhance the psychological authenticity of the learning platform, promote learner engagement and accountability, and encourage acceptability of the learning modality through curricular placement and messaging.

Spaced Digital Education for Health Professionals: Systematic Review and Meta-Analysis

BACKGROUND

Spaced digital education applies digital tools to deliver educational content via multiple, repeated learning sessions separated by prespecified time intervals. Spaced digital education appears to promote acquisition and long-term retention of knowledge, skills, and change in clinical behavior.

OBJECTIVE

The aim of this review was to assess the effectiveness of spaced digital education in improving pre- and postregistration health care professionals' knowledge, skills, attitudes, satisfaction, and change in clinical behavior.

METHODS

This review followed Cochrane's methodology and PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-Analyses) reporting guidelines. We searched MEDLINE, Embase, Web of Science, ERIC, PsycINFO, CINAHL, CENTRAL, and ProQuest Dissertation and Theses databases from January 1990 to February 2023. We included randomized controlled trials (RCTs), cluster RCTs, and quasi-RCTs comparing spaced digital education with nonspaced education, spaced nondigital education, traditional learning, or no intervention for pre- or postregistration health care professionals. Study selection, data extraction, study quality, and certainty of evidence were assessed by 2 independent reviewers. Meta-analyses were conducted using random effect models.

RESULTS

We included 23 studies evaluating spaced online education (n=17, 74%) or spaced digital simulation (n=6, 26%) interventions. Most studies assessed 1 or 2 outcomes, including knowledge (n=15, 65%), skills (n=9, 39%), attitudes (n=8, 35%), clinical behavior change (n=8, 35%), and satisfaction (n=7, 30%). Most studies had an unclear or a high risk of bias (n=19, 83%). Spaced online education was superior to massed online education for postintervention knowledge (n=9, 39%; standardized mean difference [SMD] 0.32, 95% CI 0.13-0.51, I2=66%, moderate certainty of evidence). Spaced online education (n=3, 13%) was superior to massed online education (n=2, 9%) and no intervention (n=1, 4%; SMD 0.67, 95% CI 0.43-0.91, I2=5%, moderate certainty of evidence) for postintervention clinical behavior change. Spaced digital simulation was superior to massed simulation for postintervention surgical skills (n=2, 9%; SMD 1.15, 95% CI 0.34-1.96, I2=74%, low certainty of evidence). Spaced digital education positively impacted confidence and satisfaction with the intervention.

CONCLUSIONS

Spaced digital education is effective in improving knowledge, particularly in substantially improving surgical skills and promoting clinical behavior change in pre- and postregistration health care professionals. Our findings support the use of spaced digital education interventions in undergraduate and postgraduate health profession education. Trial Registration: PROSPERO CRD42021241969.

TRIAL REGISTRATION

PROSPERO CRD42021241969; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=241969.

Effectiveness of a virtual patient simulation training on improving provider engagement in suicide safer care

BACKGROUND

Health care providers have a critical opportunity to mitigate the public health problem of suicide. Virtual patient simulations (VPS) allow providers to learn and practice evidence-based suicide prevention practices in a realistic and risk-free environment. The purpose of this study was to test whether receiving VPS training increases the likelihood that providers will engage in effective suicide safer care practices.

METHODS

Behavioral health and non-behavioral health providers (N = 19) at a Federally Qualified Health Center who work with patients at risk for suicide received the VPS training on risk assessment, safety planning, and motivation to engage in treatment. Providers' electronic health records were compared 6 months pre- and post-VPS training on their engagement in suicide safer care practices of screening, assessment, safety planning, and adding suicide ideation to the problem list.

RESULTS

Most behavioral health providers were already engaging in evidence-based suicide prevention care prior to the VPS training. Findings demonstrated the VPS training may impact the likelihood that non-behavioral health providers engage in suicide safer care practices.

CONCLUSION

VPS training in evidence-based suicide prevention practices can optimize and elevate all health care providers' skills in suicide care regardless of role and responsibility, demonstrating the potential to directly impact patient outcomes.

An e-learning platform for clinical reasoning in cardiovascular diseases: a study reporting on learner and tutor satisfaction

BACKGROUND

Medical students gain essential skills through hospital training and internships, which complement their theoretical education. However, virtual patient platforms have been shown to effectively promote clinical reasoning and enhance learning outcomes. This study evaluates a web-based platform designed for learning clinical reasoning in cardiovascular diseases, detailing its functionalities and user satisfaction.

METHODS

The Virtual Patient platform presents medical students with clinically valid scenarios, encompassing stages such as patient description, anamnesis, objective examination, presumptive diagnosis, health investigations, treatment planning, complications, differential and final diagnoses, and prognosis. Scenarios are generated either automatically or manually by professors, based on labeled and annotated clinical data. The Virtual Patient contains two types of medical cases: simple scenarios describing patients with one pathology, and complex scenarios describing patients with several related pathologies. The platform was evaluated by a total of 210 users: 178 medical students, 7 professors, and 25 engineering students, using questionnaires adjusted for each evaluation round to assess satisfaction and gather feedback. The evaluation by medical students was performed in four rounds, each round corresponding to successive enhancements of the platform functionalities and addition of new cases, with a total number of 1,098 evaluation sessions.

RESULTS

The platform was evaluated at different implementation stages, involving simple and complex scenarios for various heart diseases. The majority of students found the platform very useful (82.58%), with significant appreciation for its features and functionalities, for example the dialogue module supporting natural language interactions in Romanian and English or the feed-back obtained during interaction. Professors highly valued the platform's flexibility in scenario generation, real-time feedback provision, and data management capabilities. They appreciated the possibility to provide feedback and score student performance in real-time or after the session, though some professors suggested improving the explainability of the scores.

CONCLUSIONS

The Virtual Patient platform enables medical students to virtually replicate hospital interactions, diagnose patients, and plan treatments in clinically valid scenarios for cardiovascular diseases. User evaluations demonstrated high satisfaction and appreciation for the platform's features. Future work will focus on expanding medical cases, enhancing the dialogue module, improving scenario generation for complex cases, and extending the synthetic data generation component to produce additional types of medical investigations.

Harnessing Innovative Technologies to Train Nurses in Suicide Safety Planning With Hospital Patients: Formative Acceptability Evaluation of an eLearning Continuing Education Training

BACKGROUND

Suicide is the 12th leading cause of death in the United States. Health care provider training is a top research priority identified by the National Action Alliance for Suicide Prevention; however, evidence-based approaches that target skill building are resource intensive and difficult to implement. Novel computer technologies harnessing artificial intelligence are now available, which hold promise for increasing the feasibility of providing trainees opportunities across a range of continuing education contexts to engage in skills practice with constructive feedback on performance.

OBJECTIVE

This pilot study aims to evaluate the feasibility and acceptability of an eLearning training in suicide safety planning among nurses serving patients admitted to a US level 1 trauma center for acute or intensive care. The training included a didactic portion with demonstration, practice of microcounseling skills with a web-based virtual patient (Client Bot Emily), role-play with a patient actor, and automated coding and feedback on general counseling skills based on the role-play via a web-based platform (Lyssn Advisor). Secondarily, we examined learning outcomes of knowledge, confidence, and skills in suicide safety planning descriptively.

METHODS

Acute and intensive care nurses were recruited between November 1, 2021, and May 31, 2022, to participate in a formative evaluation using pretraining, posttraining, and 6-month follow-up surveys, as well as observation of the nurses' performance in delivering suicide safety planning via standardized patient role-plays over 6 months and rated using the Safety Plan Intervention Rating Scale. Nurses completed the System Usability Scale after interacting with Client Bot Emily and reviewing general counseling scores based on their role-play via Lyssn Advisor.

RESULTS

A total of 18 nurses participated in the study; the majority identified as female (n=17, 94%) and White (n=13, 72%). Of the 17 nurses who started the training, 82% (n=14) completed it. On average, the System Usability Scale score for Client Bot Emily was 70.3 (SD 19.7) and for Lyssn Advisor was 65.4 (SD 16.3). On average, nurses endorsed a good bit of knowledge (mean 3.1, SD 0.5) and confidence (mean 2.9, SD 0.5) after the training. After completing the training, none of the nurses scored above the expert-derived cutoff for proficiency on the Safety Plan Intervention Rating Scale (≥14); however, on average, nurses were above the cutoffs for general counseling skills per Lyssn Advisor (empathy: mean 4.1, SD 0.6; collaboration: mean 3.6, SD 0.7).

CONCLUSIONS

Findings suggest the completion of the training activities and use of novel technologies within this context are feasible. Technologic modifications may enhance the training acceptability and utility, such as increasing the virtual patient conversational abilities and adding automated coding capability for specific suicide safety planning skills.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/33695.

Medical Students' Perception Toward Using AI in Medical Education in the Kurdistan Region, Iraq: A Cross-Sectional Study

Background and aim AI is revolutionizing medical education by offering innovative tools and simulations that augment traditional teaching methods. This study explored the perceptions and expectations of medical students in the Kurdistan region, Iraq, regarding AI integration in medical education. Methods A cross-sectional online survey collected data from 224 medical students over four months. A descriptive analysis was conducted to present the student's attitudes.  Results In total, 224 medical students responded to the online survey. The majority of them were female (n=129; 57.6%), while 95 were male (42.4%). Additionally, most of the participants were in stage 4 (54 (24.1%); stage 1, 48 (21.4%); and stage 2, 43 (19.2%). In terms of measuring students' perceptions of AI integration in medical education, 186 (83%) of the students wanted to use smartphones and tablets, and 38 (17%) of them reported wanting hard copies. In addition, 112 (50%) of the medical students considered themselves experts in using AI and 98 (43.8%) did not know exactly what AI was used; however, only a few of them (6.3%) did not use AI. Few patients reported using Manikins instead of real patients (42 (18.8%)), while 140 (62.5%) reported that they could be used but not an alternative. Conclusion While many agree that digital tools and simulations are useful teaching tools, they are frequently viewed as adjunctive approaches. Better integration and training are required for the infrequent use of AI tools in medical education.

Exploring barriers to the effective use of computer-based simulation in pharmacy education: a mixed-methods case study

Background

At the University of Tasmania (UTAS), pharmacy education traditionally relies on placements to provide students with hands-on experience. However, these placements have become increasingly limited due to logistical challenges and growing student numbers. Computer-based simulation (CBS) has the potential to offer a scalable, effective alternative to enhance learning and critical thinking. However, integrating CBS in pharmacy education faces several barriers that must be addressed for successful implementation.

Objective

To gain insight into pharmacy educators' and students' views regarding the barriers, and potential solutions, to integrating CBS in pharmacy practice education.

Methods

This mixed-methods case study involved semi-structured interviews with pharmacy educators and quantitative surveys with pharmacy students. The data underwent thematic coding for interview transcripts and statistical analysis for survey responses. The findings were integrated by examining convergence, complementarity, and discrepancy, revealing insights into how pharmacy students and educators perceive implementation barriers and improvement strategies for CBS.

Results

Ten interviews were conducted, and 75 survey responses were collected, with a 62.5% response rate. Key barriers to CBS integration included educators' heavy workload, scepticism about CBS's educational value, and general integration challenges. Students, however, showed high acceptance of CBS, with 70.7% agreeing that CBS could assess their knowledge, 69.3% emphasising its role in developing problem-solving skills, and 80% viewing CBS as a complement to classroom study. Proposed solutions for enhancing CBS uptake included additional institutional support by appointing dedicated simulation technicians, leveraging champions to advocate for CBS, and aligning CBS with educational objectives.

Conclusion

A significant gap between students' readiness and educators' hesitancy to use CBS in pharmacy education was identified. While students are eager to adopt new technologies, educators expressed reservations, primarily due to workload concerns and uncertainties about the efficacy of CBS. The feedback from educators suggests that institutions may see improved uptake by employing dedicated support personnel and initiating targeted training programs. Future research should focus on exploring barriers and facilitators, using larger and more diverse samples, and gaining deeper insights into decision-makers' perspectives to enhance the integration and efficacy of CBS in pharmacy education.

Model-driven engineering for digital twins: a graph model-based patient simulation application

Introduction

Digital twins of patients are virtual models that can create a digital patient replica to test clinical interventions in silico without exposing real patients to risk. With the increasing availability of electronic health records and sensor-derived patient data, digital twins offer significant potential for applications in the healthcare sector.

Methods

This article presents a scalable full-stack architecture for a patient simulation application driven by graph-based models. This patient simulation application enables medical practitioners and trainees to simulate the trajectory of critically ill patients with sepsis. Directed acyclic graphs are utilized to model the complex underlying causal pathways that focus on the physiological interactions and medication effects relevant to the first 6 h of critical illness. To realize the sepsis patient simulation at scale, we propose an application architecture with three core components, a cross-platform frontend application that clinicians and trainees use to run the simulation, a simulation engine hosted in the cloud on a serverless function that performs all of the computations, and a graph database that hosts the graph model utilized by the simulation engine to determine the progression of each simulation.

Results

A short case study is presented to demonstrate the viability of the proposed simulation architecture.

Discussion

The proposed patient simulation application could help train future generations of healthcare professionals and could be used to facilitate clinicians' bedside decision-making.

[Exploring Needs, Motivations, and Limitations Towards Healthy Eating and Digital Resources: A Qualitative Study in a Mexican Primary Education Setting]

OBJECTIVE

To explore the needs, motivations, and limitations related to healthy eating and digital materials, as well as to identify patterns for their design as a strategy aimed at Mexican families.

DESIGN

A qualitative observational study of the phenomenon through focus group sessions.

LOCATION

A public primary education center in the city of Querétaro, Mexico.

PARTICIPANTS

Children aged 9 to 11 years and parents, mothers, or caregivers with children in primary education.

METHOD

Twelve sessions were conducted with three groups of students and two sessions with parents, mothers, or caregivers using an interview guide. Various digital materials, developed based on social cognitive theory, were presented during the sessions. The sessions were recorded with the participants' or their guardians' prior consent and transcribed for analysis. Coding was performed for key points of analysis, and information saturation was confirmed.

RESULTS

Students expressed motivation towards digital material that promotes play and experimentation, especially within the family context. The main perceived barrier was the caregivers' resistance to change. Parents expressed motivation and a need for explanatory material on diseases, with economic and time-related barriers.

CONCLUSIONS

Digital material based on social cognitive theory, designed to improve nutrition, can be an effective strategy in nutritional education if it considers the circumstances of the target population. It is advisable to include affective and behavioral elements to achieve meaningful learning within households.

The Use of Immersive Virtual Reality Training for Developing Nontechnical Skills Among Nursing Students: Multimethods Study

BACKGROUND

Immersive virtual reality (IVR) is a niche technology rising in popularity in nursing education. Although there is an abundance of evidence to demonstrate the effect of virtual reality (VR) on desired learning outcomes, this evidence is limited to technical or procedural skills or managing a single patient with clinical problems. Nontechnical skills (NTS), such as communication, decision-making, teamwork, situation awareness, and managerial skills, have not been explored using IVR technology.

OBJECTIVE

This study aimed to (1) investigate the potential efficacy of the IVR system virtual reality hospital (VR-Hospital, or VR-Hosp), a single-user game we developed, on nursing students' NTS, sense of presence in the virtual clinical environment, and satisfaction and self-confidence in learning; (2) identify variables that predict NTS; and (3) explore students' experience in using VR-Hosp.

METHODS

A multimethods design with a quantitative and qualitative approach was adopted. Participants were provided with VR-Hosp with 3 scenarios in training. VR-Hosp adopted a multibed, multipatient, multitask approach and was embedded with various clinical situations. Learning outcomes were measured after the training, followed by group interviews.

RESULTS

In total, 202 students joined the study. Results revealed high levels of satisfaction and self-confidence in learning. Significant achievement in NTS was perceived by the students. The levels of satisfaction and self-confidence in learning and the involvement and sensory fidelity domains in the sense of presence were positive predictors of NTS.

CONCLUSIONS

The promising results offer a basis for designing IVR activities for nursing education. Further investigations are imperative to determine the impact of IVR technology on learning outcomes in clinical practice.

Integrating virtual patients into undergraduate health professions curricula: a framework synthesis of stakeholders' opinions based on a systematic literature review

BACKGROUND

Virtual patients (VPs) are widely used in health professions education. When they are well integrated into curricula, they are considered to be more effective than loosely coupled add-ons. However, it is unclear what constitutes their successful integration. The aim of this study was to identify and synthesise the themes found in the literature that stakeholders perceive as important for successful implementation of VPs in curricula.

METHODS

We searched five databases from 2000 to September 25, 2023. We included qualitative, quantitative, mixed-methods and descriptive case studies that defined, identified, explored, or evaluated a set of factors that, in the perception of students, teachers, course directors and researchers, were crucial for VP implementation. We excluded effectiveness studies that did not consider implementation characteristics, and studies that focused on VP design factors. We included English-language full-text reports and excluded conference abstracts, short opinion papers and editorials. Synthesis of results was performed using the framework synthesis method with Kern's six-step model as the initial framework. We appraised the quality of the studies using the QuADS tool.

RESULTS

Our search yielded a total of 4808 items, from which 21 studies met the inclusion criteria. We identified 14 themes that formed an integration framework. The themes were: goal in the curriculum; phase of the curriculum when to implement VPs; effective use of resources; VP alignment with curricular learning objectives; prioritisation of use; relation to other learning modalities; learning activities around VPs; time allocation; group setting; presence mode; VPs orientation for students and faculty; technical infrastructure; quality assurance, maintenance, and sustainability; assessment of VP learning outcomes and learning analytics. We investigated the occurrence of themes across studies to demonstrate the relevance of the framework. The quality of the studies did not influence the coverage of the themes.

CONCLUSIONS

The resulting framework can be used to structure plans and discussions around implementation of VPs in curricula. It has already been used to organise the curriculum implementation guidelines of a European project. We expect it will direct further research to deepen our knowledge on individual integration themes.

The application of blended teaching in medical practical course of clinical skills training

BACKGROUND

Blended teaching is an effective approach that combines online and offline teaching methods, leading to improved outcomes in medical education compared to traditional offline teaching. In this study, we examined the impact of blended teaching in clinical skills training, a medical practice course.

METHODS

This study involved forty-eight undergraduate students studying clinical medicine in the fifth semester at Wuhan University of Science and Technology. The students were divided into two groups: the control group, which received traditional offline teaching, and the experimental group, which received hybrid teaching. Following the completion of the 4-month course, both groups underwent the Objective Structured Clinical Examination (OSCE) to evaluate their proficiency in clinical skills. Furthermore, the experimental group was given a separate questionnaire to gauge their feedback on the Blended Teaching approach.

RESULTS

Based on the OSCE scores, the experimental group outperformed the control group significantly (P<0.05). The questionnaire results indicated that a majority of students (54.2%, 3.71 ± 1.06) believed that blended teaching is superior to traditional offline teaching, and a significant number of students (58.3%, 3.79 ± 1.15) expressed their willingness to adopt blended teaching in other courses. Furthermore, students in the experimental group displayed varying levels of interest in different teaching contents, with emergency medicine (79.2%), internal medicine (70.8%), and surgery (66.7%) being the most popular among them.

CONCLUSIONS

This research demonstrates for the first time that blended teaching can achieve a good pedagogical effectiveness in the medical practice course, clinical skills training and practice. Moreover, in different teaching contents, the teaching effects are different. In the content of Emergency Medicine and Surgery, which is more attractive to students, the application of blended teaching could result in a better pedagogical outcome than other contents.

Dry eye in primary care: the relationship between digital display device usage and dry eye syndrome (DES) in medical students

OBJECTIVE

As digital display devices become more and more indispensable, associated health problems have started to increase. We aimed to investigate the frequency and relationship of digital display device usage behaviours and dry eye syndrome (DES) in medical students.

METHODS

An observational, cross-sectional study was conducted on medical school students who voluntarily participated in our study online, about the duration and variety of their digital screen use, usage patterns, and protective measures, together with the Ocular Surface Disease Index (OSDI) questionnaire. Where necessary, the Schirmer-I, tear break-up time, and fluorescein staining tests were carried out.

RESULTS

Of the 255 participants, 75.3% (n = 192) were female, 63.1% (n = 161) had no refractive vision defects, and 45.9% used smartphones for more than 5 h a day. According to the OSDI scores for DES screening, only 36.1% of the participants were normal, 17.3% had mild DES, 20.4% had moderate DES, and 26.3% had severe DES. A positive correlation was found between digital display usage time in hours per day and a high OSDI score. As the distance between the eye and the screen decreased, the DES score increased, which is significant for computer, e-book, and tablet use (P < 0.005). The DES rate of the 25 participants who underwent further evaluation was 40% for the tear break-up time test and 52% for the fluorescein staining test.

CONCLUSION

The high prevalence of DES due to digital screen use among medical school students highlights the importance of DES screening as a preventive measure in family medicine.

Findings Favor Haptics Feedback in Virtual Simulation Surgical Education: An Updated Systematic and Scoping Review

BACKGROUND

Virtual simulations (VSs) enhance clinical competencies and skills. However, a previous systematic review of 9 RCT studies highlighted a paucity of literature on the effects of haptic feedback in surgical VSs. An updated systematic and scoping review was conducted to encompass more studies and a broader range of study methodologies.

METHODS

A systematic literature search was conducted on July 31, 2023, in MEDLINE, Embase, and Cochrane. English language studies comparing haptic vs non-haptic conditions and using VSs were included. Studies were evaluated and reported using PRISMA-ScR guidelines.

RESULTS

Out of 2782 initial studies, 51 were included in the review. Most studies used RCT (21) or crossover (23) methodologies with medical residents, students, and attending physicians. Most used post-intervention metrics, while some used pre- and post-intervention metrics. Overall, 34 performance results from studies favored haptics, 3 favored non-haptics, and the rest showed mixed or equal results.

CONCLUSION

This updated review highlights the diverse application of haptic technology in surgical VSs. Haptics generally enhances performance, complements traditional teaching methods, and offers personalized learning with adequate simulator validation. However, a sparsity of orienting to the simulator, pre-/post-study designs, and small sample sizes poses concerns with the validity of the results. We underscore the urgent need for standardized protocols, large-scale studies, and nuanced understanding of haptic feedback integration. We also accentuate the significance of simulator validation, personalized learning potential, and the need for researcher, educator, and manufacturer collaboration. This review is a guidepost for navigating the complexities and advancements in haptic-enhanced surgical VSs.

Comparing Face-to-Face, Blended and Online Teaching Approaches for Practical Skill Acquisition: A Randomised Controlled Trial

Introduction

The efficacy of blended and online teaching methods for practical skill acquisition remains ambiguous, particularly for skills requiring haptic awareness and/or sensory training. This study aims to compare three teaching methods (face-to-face, blended, online) for the acquisition of skills requiring sensory learning and haptic awareness. A secondary aim was to explore student experience of each teaching approach.

Design

A post-test only randomised controlled trial.

Methods

Forty-seven participants chose between learning two skills: manual measurement of blood pressure during exercise (BPM) and/or skin fold measurement using callipers (SKM). Participants were randomised to one of three learning groups: face-to-face (n = 23), blended (n = 22) and online (n = 26). Assessors determined skill competency during an in-person skill demonstration session. A survey captured student experiences.

Results

For SKM, there was a statistically significant difference in skill competency between the online learning group (17% achieved competency) and both the face-to-face (75% achieved competency; p = 0.011) and blended (89% achieved competency; p = 0.001) learning groups. For BPM, the online group had the lowest percentage of participants achieve overall skill competency. Both knowledge-based and sensory-based sub-competencies were negatively affected by the online learning method. For both skills, students in the face-to-face and blended learning group were significantly more confident in their knowledge and their ability to perform the skill in a clinical setting, compared to the online learning group.

Conclusion

Both face-to-face and blended teaching methods were more effective at leading to skill acquisition and were preferred by students when compared to a fully online teaching method.

Knowledge of Antibiotic Use and Resistance Among Medical Students in Saudi Arabia

Introduction

The World Health Organization (WHO) has placed great importance on providing thorough, hands-on training to medical students regarding responsible and appropriate antibiotic prescription. Accordingly, this study aims to gain a better perspective on the knowledge of antibiotic use and resistance among medical students in Jeddah, Saudi Arabia.

Methods

A questionnaire-based cross-sectional study was conducted among medical students in Jeddah, Saudi Arabia, from 1 September to 30 November 2023. The categorical variables are presented as frequencies and percentages. Mann-Whitney and Kruskal-Wallis tests were used to compare the outcomes, and generalised linear regression models were constructed to predict the students' knowledge of antibiotics and antibiotic resistance. A p-value of < 0.05 was taken to indicate statistical significance.

Results

The study included a total of 353 medical students. First-year medical students represented 28.60% of the participants, while females represented 76.80%. Most participants (92.40%) agreed that antibiotics are effective against bacteria, whereas only 25.20% agreed about antibiotics' effectiveness against viruses. More than half of the participants (53.80%) believed that bacterial infections can be resolved without antibiotics. A significant majority (78.20%) agreed that the unnecessary use of antibiotics makes them less effective. More than half of the participants (56.90%) acknowledged that infections caused by resistant bacteria are increasing in Saudi Arabia, and two-thirds (75.10%) believed that healthcare workers could effectively reduce antibiotic resistance in Saudi Arabia. Male students had low knowledge about antibiotics [Beta = -1.429, 95% CI (-2.618, -0.241), P value = 0.019].

Conclusion

Improving the curriculum by incorporating topics like resistance mechanisms and responsible antibiotic usage can address the knowledge gap among male students. This comprehensive training, utilizing various educational methods, is essential for fostering responsible antibiotic practices among future healthcare professionals.

Virtual patients versus standardized patients for improving clinical reasoning skills in ophthalmology residents. A randomized controlled trial

BACKGROUND

History taking and clinical reasoning are important skills that require knowledge, cognition and meta-cognition. It is important that a trainee must experience multiple encounters with different patients to practice these skills. However, patient safety is also important, and trainees are not allowed to handle critically ill patients. To address this issue, a randomized controlled trial was conducted to determine the effectiveness of using Virtual Patients (VP) versus Standardized Patients (SP) in acquiring clinical reasoning skills in ophthalmology postgraduate residents.

METHODS

Postgraduate residents from two hospitals in Lahore, Pakistan, were randomized to either the VP group or the SP group and were exposed to clinical reasoning exercise via the VP or SP for 30 min after the pretest. This was followed by a posttest. One month after this activity, a follow-up posttest was conducted. The data were collected and analysed using IBM-SPSS version 25. Repeated measures ANOVA was used to track the effect of learning skills over time.

RESULTS

The mean age of the residents was 28.5 ± 3 years. The male to female ratio was 1:1.1. For the SP group, the mean scores were 12.6 ± 3.08, 16.39 ± 3.01 and 15.39 ± 2.95, and for the VP group, the mean scores were 12.7 ± 3.84, 16.30 ± 3.19 and 15.65 ± 3.18 for the pretest, posttest and follow-up posttest, respectively (p value < 0.00). However, the difference between the VP and SP groups was not statistically significant (p = 0.896). Moreover, there was no statistically significant difference between the VP and SP groups regarding the retention of clinical reasoning ability. In terms of learning gain, compared with the VP group, the SP group had a score of 51.46% immediately after clinical reasoning exercise as compared to VP group, in which it was 49.1%. After one month, it was 38.01 in SP and 40.12% in VP group.

CONCLUSION

VPs can be used for learning clinical reasoning skills in postgraduate ophthalmology residents in a safe environment. These devices can be used repeatedly without any risk to the real patient. Although similarly useful, SP is limited by its nonavailability for repeated exercises.

The use of virtual patients for breaking bad news: A rapid review

BACKGROUND

Breaking bad news is an imperative skill for clinical practice that health care professionals struggle with. Virtual patients have been adopted as a new teaching aide in medical education and have shown efficacy in teaching clinical skills; however, there is limited research for use in communication skills. Virtual patients are especially well-suited for difficult communication skills, as students can practice without risk to patients. This rapid review aimed to review literature observing the potential of virtual patients as an effective means to teach breaking bad news.

METHOD

A systematic search strategy was applied for papers published between November 2012 and November 2022 on Medline and Embase databases. Following the application of inclusion criteria, three studies were included. The Medical Education Research Study Quality Instrument and Critical Appraisal Skills Programme checklist were used for quality appraisal of the studies. Tabular and narrative synthesis was used to present the findings.

FINDINGS

The findings of the studies suggest that when teaching breaking bad news, virtual patients are valuable compared with no intervention and are not inferior compared with simulated patients. An unexpected benefit of virtual patients was videotaping. A barrier to learning was the lack of affect and interaction. More research into the design of virtual simulations and its integration into existing curricula is required.

CONCLUSION

Virtual patients are a valuable educational tool for breaking bad news; however, they are yet to replace existing educational approaches. There is a need for more large-scale, homogeneous studies to inform instructional design and curriculum integration.