Focus group interviews were the methodology chosen for this study. From the array of qualitative methods, both questionnaires and individual in-depth interviews would have been reasonable alternatives. After discussing the possibility of using in-depth interviews and questionnaires as opposed to focus groups, we chose the latter. The reason was that we intended to collect as much data as possible while still keeping the project feasible. We felt that while allowing the collection of sufficient, good quality data, it was also a practical way-financially and time-wise-to investigate the participants' opinions. The students have also come up with novel information, i.e. descriptions, explorations and ideas that brought up issues new to the researchers, which in our understanding might have not surfaced with individual interviews or questionnaires.
Clinical reasoning development
is already recognized by the literature as the main scope of VPS in education [2
]. Our study adds the "factual and core knowledge" input via the virtual patient application, which was considered by the participants as a highly desirable feature of VPS.
Instead of re-experiencing the daily frustration of not knowing what happened with their patients (rotation ended, patient was moved to another floor etc.), the students conveyed the importance of getting closure by means of patient feedback.
The students indicate that the transfer of knowledge
to the real patient is the ultimate goal of simulation technology, in agreement with the literature [12
Medical students feel they remember more with VPS. Retention enhancement
with VPS has previously been demonstrated in the same cohort of students, where the effect of VPS on early and late retention was studied [11
Making mistakes was not expected to rise to the level of category. Free from a stressful context (patient, family, hospital staff), the students still perceive errors as serious events, but at the same time as meaningful learning opportunities, to the point that they consider their repetition as unlikely in their future clinical practice.
Communication. In our experience, VPS are not a proper tool for communication skills development. This opinion is shared by the VPS community at large and by the participants in our study. The latter found their motivation in the reduced interactivity of the system, which does not reflect the richness of direct interaction with the real patient.
Teaching and assessment
The students in our study had used VPS both for learning and for assessment in their Internal Medicine course, where Web-SP was a curricular component. Not surprisingly, they do not envisage a use for VPS outside of the curricular context, e.g. as an add-on. They would like other major clinical specialties to offer the opportunity to work with VPS; especially so if certain topics are not comprised in the study plan, but are likely to surface in the first level of attention, finding in alignment with the recent accreditation requirements of the Liaison Committee on Medical Education (LCME) [1
]. Other than that, they also express the need for solving cases of common, frequent diseases, particularly cases already complicated at debut, patients with several co-morbidities, as well as cases of drug interaction. To our surprise, the participants evoked a regulatory effect of VPS at individual level (to help program their learning) and at institutional level (to even out the differences in disease range among rotation sites).
As for summative assessment, we were not surprised to see that participants consider VPS a good evaluation tool [10
]. To come across the conviction that VPS assessment is qualitatively different in comparison with other evaluation methods was however quite unexpected. A further benefit of a virtual patient application is that assessment may not feel as an exam, leading to an increased motivation for learning itself. The students are also aware that they can and should learn from assessment; feedback is deemed crucial for such learning through assessment to occur. They do not support, however, a VPS assessment directed to anything else than knowledge and skills essential for the clinical practice as a general practitioner, or the use of VPS outside regular course evaluation. Caution should be exerted when generalizing a benefit for learning across different systems, as the assessment formats are different (open-ended questions in Web-SP, multiple choice in other systems) and the feedback, if provided, also varies in layout.
of the application should reflect the reality of clinical practice [4
] and offer localized menus and content choices [9
]. Authenticity might be increased by considering the actual costs involved in diagnosing and treating the virtual patient, but we believe that such a development should be subject to a localization demand. Layouts that feel artificial in terms of menus or content do not meet their educational goal and are considered by participants as downright misleading [14
]. In contrast, knowledge derived from virtual cases created from real life clinical records is thought to be directly transferred
to actual patients, which is a novel finding. An additional possible benefit of using real cases to create virtual patients is a further enhancement of authenticity to such level as to consider the application as a surrogate for reality (a desirable feature in the case of rare diseases, topics not seen during a clinical rotation, diseases unavailable geographically or seasonally etc.). Feedback derived from real cases greatly adds to the realism of the application.
In our experience, media use should serve an educational goal and not become
a goal. The literature [2
] supports our results, that authenticity can be conveyed by means as simple as the face photo, together with shots of the main findings of the physical exam. We were somewhat puzzled by the students' emphasis on the importance of the face photo; nevertheless, the Spanish version of Web-SP features photos of genuinely ill individuals, who may well wait in line for a consult at the clinic. The students responded empathetically to faces they considered familiar. We believe that more media resources are rarely needed. In our experience at Karolinska Institutet, the creation of such cases is unnecessarily expensive and their added value is minimal, if not null. Informed consent for any media use is an obvious must for cases created from actual clinical records, as well as for the content of the medical history itself.
More cases equate more knowledge in the students' opinion. However, they seem aware of the practical difficulties of achieving even a modest goal, such as one case per topic; here, as previously discussed, the options are wide: common diseases, pathologies not seen during the clinical rotations and/or not included in the study plan etc. Such difficulties are more apparent if the cases are to be created from real life records (mainly patient informed consent issues and hospital approval for retrieving information from clinical records).
Most participants recommend that the availability of the application be restricted to certain term timeslots, as a means of external regulation. Such a position is conflicting with the scope of a web-based application-namely round-the-clock access from any site-and might reflect special characteristics of the student population (whose identification was beyond the scope and the methodology of this study).
The exchange of virtual patient cases is not a priority for many institutions [14
] and time will tell to what extent current inter-operability efforts are worth undertaking (e.g. as number of user sessions per case exchanged).
Based on our experience at LIME with VPS of a linear design, we believe our findings could be generalized to such systems. However, our setting was somewhat unusual, in the sense that the virtual patient cases were created from real life clinical records and included the actual clinical follow-up in the feedback section. Furthermore, the sample population-undergraduate medical students in Latin America-may well have different socio-cultural characteristics than participants in other studies (which makes appealing the option of designing VPS adapted to specific categories of learners).