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Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 137-140

Medical students accept virtual patients as a helping tool to achieve their study plan objectives

Department of Clinical Sciences, College of Medicine, Sulaiman Al Rajhi Colleges, Qassim, Saudi Arabia; Department of Internal Medicine, Faculty of Medicine, Cairo University, Egypt

Date of Web Publication9-Dec-2019

Correspondence Address:
Dr. Mohammed Ewid
Sulaiman Al Rajhi Colleges, P.O. Box: 777, Al Bukairyah 51941, Saudi Arabia

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjhs.sjhs_155_19

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Background: Technical innovation in medical education is a new era that can augment students' problem-solving capabilities. Virtual patients (VPs) have a recognized position in this new era. Research is still ongoing regarding the role of VPs in the learning process of medical students. Aim: The aim of the study was to explore the perception of preclinical and clinical medical students toward VPs in problem-based learning environment. Methods: Thirty-one medical students, 21 preclinical (3rd year) and 10 clinical (4th year) from Sulaiman Al Rajhi Medical College, Saudi Arabia ( first two patches), were enrolled in this cross-sectional study after their acceptance to participate. Necessary orientation was given prior to start by content experts; then, a curriculum-mapped standardized VP case was offered to each group. Following the completion of the VP case, each group had the same standardized validated VP questionnaire to assess their perception and attitude. Results: Respectively, 3rd and 4th year students had the following perceptions regarding VPs: 62% versus 70% considered it a useful learning experience, 48% versus 70% liked practicing it in small groups, and 60% versus 90% recommended incorporating it in upcoming year courses. Eighty percent of the clinical students considered VPs realistic. Clinical and preclinical students' perceptions toward VPs showed no significant difference in all questionnaire items. Conclusion: VPs had a positive impact on medical students and can be implemented in both pre and clinical settings to accomplish their study plan objectives.

Keywords: Medical simulation, patient safety, students' perception, virtual patients

How to cite this article:
Ewid M. Medical students accept virtual patients as a helping tool to achieve their study plan objectives. Saudi J Health Sci 2019;8:137-40

How to cite this URL:
Ewid M. Medical students accept virtual patients as a helping tool to achieve their study plan objectives. Saudi J Health Sci [serial online] 2019 [cited 2021 Jan 28];8:137-40. Available from: https://www.saudijhealthsci.org/text.asp?2019/8/3/137/272440

  Introduction Top

Patient safety and minimizing medical errors is a continuous target in all medical education programs.[1]

VPs have the capability to train medical students on a wide spectrum of medical problems and to enable them to take safe medical decisions before their hospital practice and real patient contact through proper clinical reasoning and problem-solving skills.[2]

In addition to safe training offered by VPs, prompt specific feedback could be given to the practicing students. This feedback is crucial to orient them about their weak points that need fixation and improvement for quality medical practice.[3]

In real life, many obstacles limit students' learning opportunities including the increased number of medical students, relative deficiency in both training places and experienced faculty, in addition to continuous updates in medical knowledge, making it very challenging to cover all aspects of balanced medical curricula through real patient contact.

As a solution for the above limitations, VPs can fill the gaps and compensate for the deficiency of real cases and inaccessibility to proper training opportunities.[4]

Based on the cumulative evidence, most of the medical curricula are nowadays shifting to student-centered learning where the student is the core of the learning process not only observing and receiving knowledge in a passive way but also actively participating in the learning process through problem-solving and communication skills.

Virtual patients (VPs) could be used as an effective medical education tool for achieving student-centered medical competencies such as knowledge, cognition, communication, and even psychomotor skills.

There is so little research conducted in Saudi Arabia in relation to the incorporation of VPs into problem-based learning (PBL) system and exploring both clinical and preclinical students' perceptions toward these VPs.

  Methods Top

This is a cross-sectional study conducted in Sulaiman Al Rajhi Medical College, Qassim, Saudi Arabia, that was approved by the college research and medical education units with final approval from the college vice dean of academic affairs.

Thirty-one medical students, 21 preclinical from the college's second patch (3rd year) and 10 clinical, the whole 1st patch (4th year), agreed to participate in the study.

Students were oriented about the aim of the study, nature of the VPs as well as the study questionnaire.

The study was conducted in the college computer laboratory, and a VP case matching students' year curriculum was selected and offered by content experts in collaboration with the college medical education unit to each group.

Necessary orientation was given by the content experts before offering each curriculum-mapped VP case to each group to practice it under their supervision.

VPs were directed to test the students' medical management approach, with the 3rd year case related to the chest pain approach, while the 4th year case related to the otitis media clinical approach.

Each VP case was composed of the usual clinical management steps, including history taking, physical examination findings, investigations, differential diagnosis, and the most probable final diagnosis, with each step followed by related interactive questions.

A validated five Likert scale questionnaire adopted from Maastricht University medical education department was used to record the students' perception regarding the following points: VPs as a useful teaching tool, general impression about VPs, practicing VPs in small groups, and recommending VPs for the upcoming courses, with an additional item offered only to the clinical group asking them about their perception regarding the reality of the case.

Statistical methods

Qualitative variables were presented as frequency and proportion, while the quantitative ones were presented as mean (M) ± standard deviation. Comparative analysis between 3rd and 4th year students' survey scores was done through the nonparametric Mann-Whitney U-test for detecting any significant score changes. P ≤ 0.05 was considered statistically significant. SPSS Statistics version 25 (SPSS Inc., Chicago, IL, USA) was used to perform the statistical analysis.

  Results Top

Respectively, 3rd and 4th year students had the following perceptions regarding VPs: 62 versus 70% considered it a useful learning experience, 48% versus 70% liked practicing it in small groups, and 60% versus 90% recommended incorporating it in the upcoming year courses. About 80% of the clinical students considered VP case realistic [Figure 1] and [Figure 2]. Clinical and preclinical students' perceptions toward VPs showed no significant difference in all questionnaire items [Table 1].
Figure 1: Gathered 3rd year students' responses

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Figure 2: Gathered 4th year students' responses

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Table 1: Comparison between 3rd and 4th year responses using Mann-Whitney U-test

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  Discussion Top

In the current study, the main outcome of interest was to investigate medical students' satisfaction toward VPs as an initial VPs research in our college, which is adopting the PBL system.

Quality hospital practice and patient-centered care are considered cornerstone components in almost all missions of medical programs and as priority competencies in worldwide medical education institutes. Achieving safe medical practice necessitates the preparation of undergraduate medical students in a safe learning environment (skill laboratory and medical simulations including VPs) for achieving the planned study objectives before the students' future practice.[5]

Although skill laboratories had been incorporated into many medical programs, not only those adopting the PBL system but also those adopting discipline learning or hybrid systems, VPs are still lagging as an effective simulation tool in most of these programs.

VPs research is still a debatable area in the literature with a wide pool of research goals, such as the impact of VPs on achieving required knowledge,[6],[7],[8],[9] skills,[10],[11] its efficacy versus other traditional tools of education,[11],[12] comparison between VPs' different designs,[9],[13] evaluating students' attitudes,[14],[15],[16] and satisfaction after practicing it.[15],[17],[18]

There are multiple ways to integrate VPs into medical curricula; in our study, we tested it as a formative teaching tool during a slot of students' self-directed learning followed by group discussion and interactive feedback.

VPs can achieve curriculum-based intended learning outcomes through different methodologies, including using it during skill laboratory training, interactive team-based learning, as a flipped learning tool, during self-directed learning as an electronic reference, or to have a mix of the previously mentioned ways of integration as the case in this study.[19]

The main finding in the current study is that both preclinical and clinical students accepted VPs and considered it feasible and beneficial to their study, a finding that matches previous research done by Yang et al.,[20] where they investigated surgical VPs cases and concluded that VPs could be used in undergraduate surgical teaching and that students showed a positive experience after practicing it.

VPs' positive experience is also documented for other medical specialties including internal medicine which is another cornerstone subject in undergraduate medical curricula as highlighted by Jeimy et al.[18] where the students enjoyed VPs and considered it helpful for their practical experience.

In addition, the study showed that our students liked practicing VPs in a teamwork manner and hoped to incorporate it into their future medical subjects which also matches the conclusion that VPs are effective tools for continuous medical education and could close the gap in achieving medical competencies by medical students as highlighted by Lehmann et al.[21]

An important observation in this study is that both clinical and preclinical students' positive perceptions toward VPs showed no significant difference in all questionnaire items, indicating that VPs can be helpful to achieve both basic and clinical intended learning outcomes.

Moreover, the clinical students in this study considered VPs realistic to their general practice which also matches the conclusion given by Sobocan and Klemenc-Ketis[22] where they recommend to incorporate VPs in primary care clerkships as VPs can closely simulate commonly encountered medical problems.

On the other hand, there are some limitations for VPs practice as highlighted by Kononowicz et al.,[23] including technical issues, language barrier, inappropriate depth of knowledge incorporated, unrealistic designs, lack of universal benchmarking for each type of VPs, and its increased cost.

The discrepancy among studies regarding the students' perception toward VPs could be attributed to different research methodologies, heterogeneous VP formats, depth of knowledge variability, and degree of orientation about the value of medical simulation including VPs.

Limitations of the current study include its relatively small sample size; however, this was compensated by comparing two groups of students including both preclinical and clinical students and by adopting a validated questionnaire from Maastricht University.

Future recommendation is to have larger multicenter studies and to follow-up students' perception after graduation to test the long-term effect of VPs on their medical practice.

  Conclusion Top

VPs had a positive impact on medical students learning in a PBL environment and can be implemented and incorporated into both preclinical and clinical settings to achieve students' study plan objectives.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med 2005;165:1493-9.  Back to cited text no. 1
Friedrich MJ. Practice makes perfect: Risk-free medical training with patient simulators. JAMA 2002;288:2808, 2811-2.  Back to cited text no. 2
Gigante J, Dell M, Sharkey A. Getting beyond “Good job”: How to give effective feedback. Pediatrics 2011;127:205-7.  Back to cited text no. 3
Hanson JL, Bannister SL, Clark A, Raszka WV Jr. Oh, what you can see: The role of observation in medical student education. Pediatrics 2010;126:843-5.  Back to cited text no. 4
Ochsmann EB, Zier U, Drexler H, Schmid K. Well prepared for work? Junior doctors' self-assessment after medical education. BMC Med Educ 2011;11:99.  Back to cited text no. 5
Wahlgren CF, Edelbring S, Fors U, Hindbeck H, Ståhle M. Evaluation of an interactive case simulation system in dermatology and venereology for medical students. BMC Med Educ 2006;6:40.  Back to cited text no. 6
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Maier EM, Hege I, Muntau AC, Huber J, Fischer MR. What are effects of a spaced activation of virtual patients in a pediatric course? BMC Med Educ 2013;13:45.  Back to cited text no. 8
Braun LT, Zottmann JM, Adolf C, Lottspeich C, Then C, Wirth S, et al. Representation scaffolds improve diagnostic efficiency in medical students. Med Educ 2017;51:1118-26.  Back to cited text no. 9
Bearman M, Cesnik B, Liddell M. Random comparison of 'virtual patient' models in the context of teaching clinical communication skills. Med Educ 2001;35:824-32.  Back to cited text no. 10
Kononowicz AA, Krawczyk P, Cebula G, Dembkowska M, Drab E, Frą czek B, et al. Effects of introducing a voluntary virtual patient module to a basic life support with an automated external defibrillator course: A randomised trial. BMC Med Educ 2012;12:41.  Back to cited text no. 11
Lehmann R, Thiessen C, Frick B, Bosse HM, Nikendei C, Hoffmann GF, et al. Improving pediatric basic life support performance through blended learning with web-based virtual patients: Randomized controlled trial. J Med Internet Res 2015;17:e162.  Back to cited text no. 12
Foster A, Chaudhary N, Kim T, Waller JL, Wong J, Borish M, et al. Using virtual patients to teach empathy: A randomized controlled study to enhance medical students' empathic communication. Simul Healthc 2016;11:181-9.  Back to cited text no. 13
Deladisma AM, Gupta M, Kotranza A, Bittner JG 4th, Imam T, Swinson D, et al. A pilot study to integrate an immersive virtual patient with a breast complaint and breast examination simulator into a surgery clerkship. Am J Surg 2009;197:102-6.  Back to cited text no. 14
Wang CL, Chinnugounder S, Hippe DS, Zaidi S, O'Malley RB, Bhargava P, et al. Comparative effectiveness of hands-on versus computer simulation-based training for contrast media reactions and teamwork skills. J Am Coll Radiol 2017;14:103-10000.  Back to cited text no. 15
Kaltman S, Talisman N, Pennestri S, Syverson E, Arthur P, Vovides Y. Using technology to enhance teaching of patient-centered interviewing for early medical students. Simul Healthc 2018;13:188-94.  Back to cited text no. 16
Foster A, Chaudhary N, Murphy J, Lok B, Waller J, Buckley PF. The use of simulation to teach suicide risk assessment to health profession trainees-rationale, methodology, and a proof of concept demonstration with a virtual patient. Acad Psychiatry 2015;39:620-9.  Back to cited text no. 17
Jeimy S, Wang JY, Richardson L. Evaluation of virtual patient cases for teaching diagnostic and management skills in internal medicine: A mixed methods study. BMC Res Notes 2018;11:357.  Back to cited text no. 18
Ellaway R, Topps D, Lee S, Armson H. Virtual patient activity patterns for clinical learning. Clin Teach 2015;12:267-71.  Back to cited text no. 19
Yang RL, Hashimoto DA, Predina JD, Bowens NM, Sonnenberg EM, Cleveland EC, et al. The virtual-patient pilot: Testing a new tool for undergraduate surgical education and assessment. J Surg Educ 2013;70:394-401.  Back to cited text no. 20
Lehmann R, Hanebeck B, Oberle S, Simon A, Choukair D, Tönshoff B, et al. Virtual patients in continuing medical education and residency training: A pilot project for acceptance analysis in the framework of a residency revision course in pediatrics. GMS Z Med Ausbild 2015;32:Doc51.  Back to cited text no. 21
Sobocan M, Klemenc-Ketis Z. Enhancing primary care clerkships with virtual patients. Educ Prim Care 2016;27:451-4.  Back to cited text no. 22
Kononowicz AA, Woodham LA, Edelbring S, Stathakarou N, Davies D, Saxena N, et al. Virtual patient simulations in health professions education: Systematic review and meta-analysis by the digital health education collaboration. J Med Internet Res 2019;21:e14676.  Back to cited text no. 23


  [Figure 1], [Figure 2]

  [Table 1]


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