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1.  Virtual Patients in Primary Care: Developing a Reusable Model That Fosters Reflective Practice and Clinical Reasoning 
Primary care is an integral part of the medical curriculum at Karolinska Institutet, Sweden. It is present at every stage of the students’ education. Virtual patients (VPs) may support learning processes and be a valuable complement in teaching communication skills, patient-centeredness, clinical reasoning, and reflective thinking. Current literature on virtual patients lacks reports on how to design and use virtual patients with a primary care perspective.
The objective of this study was to create a model for a virtual patient in primary care that facilitates medical students’ reflective practice and clinical reasoning. The main research question was how to design a virtual patient model with embedded process skills suitable for primary care education.
The VP model was developed using the Open Tufts University Sciences Knowledgebase (OpenTUSK) virtual patient system as a prototyping tool. Both the VP model and the case created using the developed model were validated by a group of 10 experienced primary care physicians and then further improved by a work group of faculty involved in the medical program. The students’ opinions on the VP were investigated through focus group interviews with 14 students and the results analyzed using content analysis.
The VP primary care model was based on a patient-centered model of consultation modified according to the Calgary-Cambridge Guides, and the learning outcomes of the study program in medicine were taken into account. The VP primary care model is based on Kolb’s learning theories and consists of several learning cycles. Each learning cycle includes a didactic inventory and then provides the student with a concrete experience (video, pictures, and other material) and preformulated feedback. The students’ learning process was visualized by requiring the students to expose their clinical reasoning and reflections in-action in every learning cycle. Content analysis of the focus group interviews showed good acceptance of the model by students. The VP was regarded as an intermediate learning activity and a complement to both the theoretical and the clinical part of the education, filling out gaps in clinical knowledge. The content of the VP case was regarded as authentic and the students appreciated the immediate feedback. The students found the structure of the model interactive and easy to follow. The students also reported that the VP case supported their self-directed learning and reflective ability.
We have built a new VP model for primary care with embedded communication training and iterated learning cycles that in pilot testing showed good acceptance by students, supporting their self-directed learning and reflective thinking.
PMCID: PMC3906652  PMID: 24394603
virtual patients; clinical reasoning; reflection; primary care; medical education
2.  An innovative method to assess clinical reasoning skills: Clinical reasoning tests in the second national medical science Olympiad in Iran 
BMC Research Notes  2011;4:418.
Clinical reasoning plays a major role in the ability of doctors to make a diagnosis and reach treatment decisions. This paper describes the use of four clinical reasoning tests in the second National Medical Science Olympiad in Iran: key features (KF), script concordance (SCT), clinical reasoning problems (CRP) and comprehensive integrative puzzles (CIP). The purpose of the study was to design a multi instrument for multiple roles approach in clinical reasoning field based on the theoretical framework, KF was used to measure data gathering, CRP was used to measure hypothesis formation, SCT and CIP were used to measure hypothesis evaluation and investigating the combined use of these tests in the Olympiad. A bank of clinical reasoning test items was developed for emergency medicine by a scientific expert committee representing all the medical schools in the country. These items were pretested by a reference group and the results were analyzed to select items that could be omitted. Then 135 top-ranked medical students from 45 medical universities in Iran participated in the clinical domain of the Olympiad. The reliability of each test was calculated by Cronbach's alpha. Item difficulty and the correlation between each item and the total score were measured. The correlation between the students' final grade and each of the clinical reasoning tests was calculated, as was the correlation between final grades and another measure of knowledge, i.e., the students' grade point average.
The combined reliability for all four clinical reasoning tests was 0.91. Of the four clinical reasoning tests we compared, reliability was highest for CIP (0.91). The reliability was 0.83 for KF, 0.78 for SCT and 0.71 for CRP. Most of the tests had an acceptable item difficulty level between 0.2 and 0.8. The correlation between the score for each item and the total test score for each of the four tests was positive. The correlations between scores for each test and total score were highest for KF and CIP. The correlation between scores for each test and grade point average was low to intermediate for all four of the tests.
The combination of these four clinical reasoning tests is a reliable evaluation tool that can be implemented to assess clinical reasoning skills in talented undergraduate medical students, however these data may not generalizable to whole medical students population. The CIP and KF tests showed the greatest potential to measure clinical reasoning skills. Grade point averages did not necessarily predict performance in the clinical domain of the national competitive examination for medical school students.
PMCID: PMC3215186  PMID: 22005350
3.  Virtual patient simulation: what do students make of it? A focus group study 
BMC Medical Education  2010;10:91.
The learners' perspectives on Virtual Patient Simulation systems (VPS) are quintessential to their successful development and implementation. Focus group interviews were conducted in order to explore the opinions of medical students on the educational use of a VPS, the Web-based Simulation of Patients application (Web-SP).
Two focus group interviews-each with 8 undergraduate students who had used Web-SP cases for learning and/or assessment as part of their Internal Medicine curriculum in 2007-were performed at the Faculty of Medicine of Universidad el Bosque (Bogota), in January 2008. The interviews were conducted in Spanish, transcribed by the main researcher and translated into English. The resulting transcripts were independently coded by two authors, who also performed the content analysis. Each coder analyzed the data separately, arriving to categories and themes, whose final form was reached after a consensus discussion.
Eighteen categories were identified and clustered into five main themes: learning, teaching, assessment, authenticity and implementation. In agreement with the literature, clinical reasoning development is envisaged by students to be the main scope of VPS use; transferable skills, retention enhancement and the importance of making mistakes are other categories circumscribed to this theme. VPS should enjoy a broad use across clinical specialties and support learning of topics not seen during clinical rotations; they are thought to have a regulatory effect at individual level, helping the students to plan their learning. The participants believe that assessment with VPS should be relevant for their future clinical practice; it is deemed to be qualitatively different from regular exams and to increase student motivation. The VPS design and content, the localization of the socio-cultural context, the realism of the cases, as well as the presence and quality of feedback are intrinsic features contributing to VPS authenticity.
Five main themes were found to be associated with successful VPS use in medical curriculum: Learning, Teaching, Assessment, Authenticity and Implementation. Medical students perceive Virtual Patients as important learning and assessment tools, fostering clinical reasoning, in preparation for the future clinical practice as young doctors. However, a number of issues regarding VPS design, authenticity and implementation need to be fulfilled, in order to reach the potential educational goals of such applications.
PMCID: PMC3014956  PMID: 21129220
4.  Medical Students' Exposure to and Attitudes about the Pharmaceutical Industry: A Systematic Review 
PLoS Medicine  2011;8(5):e1001037.
A systematic review of published studies reveals that undergraduate medical students may experience substantial exposure to pharmaceutical marketing, and that this contact may be associated with positive attitudes about marketing.
The relationship between health professionals and the pharmaceutical industry has become a source of controversy. Physicians' attitudes towards the industry can form early in their careers, but little is known about this key stage of development.
Methods and Findings
We performed a systematic review reported according to PRISMA guidelines to determine the frequency and nature of medical students' exposure to the drug industry, as well as students' attitudes concerning pharmaceutical policy issues. We searched MEDLINE, EMBASE, Web of Science, and ERIC from the earliest available dates through May 2010, as well as bibliographies of selected studies. We sought original studies that reported quantitative or qualitative data about medical students' exposure to pharmaceutical marketing, their attitudes about marketing practices, relationships with industry, and related pharmaceutical policy issues. Studies were separated, where possible, into those that addressed preclinical versus clinical training, and were quality rated using a standard methodology. Thirty-two studies met inclusion criteria. We found that 40%–100% of medical students reported interacting with the pharmaceutical industry. A substantial proportion of students (13%–69%) were reported as believing that gifts from industry influence prescribing. Eight studies reported a correlation between frequency of contact and favorable attitudes toward industry interactions. Students were more approving of gifts to physicians or medical students than to government officials. Certain attitudes appeared to change during medical school, though a time trend was not performed; for example, clinical students (53%–71%) were more likely than preclinical students (29%–62%) to report that promotional information helps educate about new drugs.
Undergraduate medical education provides substantial contact with pharmaceutical marketing, and the extent of such contact is associated with positive attitudes about marketing and skepticism about negative implications of these interactions. These results support future research into the association between exposure and attitudes, as well as any modifiable factors that contribute to attitudinal changes during medical education.
Please see later in the article for the Editors' Summary
Editors' Summary
The complex relationship between health professionals and the pharmaceutical industry has long been a subject of discussion among physicians and policymakers. There is a growing body of evidence that suggests that physicians' interactions with pharmaceutical sales representatives may influence clinical decision making in a way that is not always in the best interests of individual patients, for example, encouraging the use of expensive treatments that have no therapeutic advantage over less costly alternatives. The pharmaceutical industry often uses physician education as a marketing tool, as in the case of Continuing Medical Education courses that are designed to drive prescribing practices.
One reason that physicians may be particularly susceptible to pharmaceutical industry marketing messages is that doctors' attitudes towards the pharmaceutical industry may form early in their careers. The socialization effect of professional schooling is strong, and plays a lasting role in shaping views and behaviors.
Why Was This Study Done?
Recently, particularly in the US, some medical schools have limited students' and faculties' contact with industry, but some have argued that these restrictions are detrimental to students' education. Given the controversy over the pharmaceutical industry's role in undergraduate medical training, consolidating current knowledge in this area may be useful for setting priorities for changes to educational practices. In this study, the researchers systematically examined studies of pharmaceutical industry interactions with medical students and whether such interactions influenced students' views on related topics.
What Did the Researchers Do and Find?
The researchers did a comprehensive literature search using appropriate search terms for all relevant quantitative and qualitative studies published before June 2010. Using strict inclusion criteria, the researchers then selected 48 articles (from 1,603 abstracts) for full review and identified 32 eligible for analysis—giving a total of approximately 9,850 medical students studying at 76 medical schools or hospitals.
Most students had some form of interaction with the pharmaceutical industry but contact increased in the clinical years, with up to 90% of all clinical students receiving some form of educational material. The highest level of exposure occurred in the US. In most studies, the majority of students in their clinical training years found it ethically permissible for medical students to accept gifts from drug manufacturers, while a smaller percentage of preclinical students reported such attitudes. Students justified their entitlement to gifts by citing financial hardship or by asserting that most other students accepted gifts. In addition, although most students believed that education from industry sources is biased, students variably reported that information obtained from industry sources was useful and a valuable part of their education.
Almost two-thirds of students reported that they were immune to bias induced by promotion, gifts, or interactions with sales representatives but also reported that fellow medical students or doctors are influenced by such encounters. Eight studies reported a relationship between exposure to the pharmaceutical industry and positive attitudes about industry interactions and marketing strategies (although not all included supportive statistical data). Finally, student opinions were split on whether physician–industry interactions should be regulated by medical schools or the government.
What Do These Findings Mean?
This analysis shows that students are frequently exposed to pharmaceutical marketing, even in the preclinical years, and that the extent of students' contact with industry is generally associated with positive attitudes about marketing and skepticism towards any negative implications of interactions with industry. Therefore, strategies to educate students about interactions with the pharmaceutical industry should directly address widely held misconceptions about the effects of marketing and other biases that can emerge from industry interactions. But education alone may be insufficient. Institutional policies, such as rules regulating industry interactions, can play an important role in shaping students' attitudes, and interventions that decrease students' contact with industry and eliminate gifts may have a positive effect on building the skills that evidence-based medical practice requires. These changes can help cultivate strong professional values and instill in students a respect for scientific principles and critical evidence review that will later inform clinical decision-making and prescribing practices.
Additional Information
Please access these Web sites via the online version of this summary at
Further information about the influence of the pharmaceutical industry on doctors and medical students can be found at the American Medical Students Association PharmFree campaign and PharmFree Scorecard, Medsin-UKs PharmAware campaign, the nonprofit organization Healthy Skepticism, and the Web site of No Free Lunch.
PMCID: PMC3101205  PMID: 21629685
5.  Smoking-related knowledge and attitudes of senior Australian medical students 
Tobacco Control  1996;5(4):271-279.
OBJECTIVE: To assess the smoking-related knowledge and attitudes of senior medical students and to compare knowledge and attitude changes in students exposed to four different smoking cessation skills training interventions. DESIGN: A survey questionnaire, assessing knowledge and attitudes, was administered pre- and post-intervention for each of the four intervention conditions. SUBJECTS: A cohort of 219 fifth-year medical students at the University of Sydney. INTERVENTIONS: Students were randomised into one of four intervention conditions: (1) a traditional didactic lecture mode (control group); (2) the use of role plays and audiotaped feedback; (3) role plays with peer feedback; and (4) video feedback. MAIN OUTCOME MEASURES: Knowledge on morbidity and mortality associated with smoking, intervention strategies, intervention effectiveness, and cessation practices; anticipated clinical behaviour related to smoking; and attitudes towards medical practitioner involvement in smoking cessation. RESULTS: Smoking knowledge was significantly greater at post-test (mean unweighted scores of 69% before and 74% after intervention). All groups had improved knowledge levels at post-test. However, after controlling for pre-test differences, the control group, video feedback, and peer feedback groups were found to have improved significantly over the audio feedback group. Scores were higher on items related to morbidity and mortality and intervention effectiveness than for items on intervention strategies and cessation practices. Positive student attitudes towards their role in smoking cessation were also found. There was an almost universally held view that doctors can have a significant impact on reducing smoking levels. Although most students perceived smoking intervention to be a worthwhile activity, they remained pessimistic about the ease with which patients' smoking behaviour could be changed. CONCLUSIONS: Positive smoking cessation knowledge changes can be readily achieved through training. However, specific smoking cessation training is needed for medical trainees to develop appropriate skills and strategies. Attention to particular weaknesses related to specific intervention strategies and cessation practices is required to develop competence in this area and to maximise the chances of new medical graduates fully using the opportunities available to them. 

PMCID: PMC1759529  PMID: 9130360
6.  Teaching Medical Students the Important Connection between Communication and Clinical Reasoning 
Journal of General Internal Medicine  2005;20(12):1108-1113.
Medical students are rarely taught how to integrate communication and clinical reasoning. Not understanding the relation between these skills may lead students to undervalue the connection between psychosocial and biomedical aspects of patient care.
To improve medical students' communication and clinical reasoning and their appreciation of how these skills interrelate in medical practice.
In 2003, we conducted a randomized trial of a curricular intervention at Johns Hopkins University School of Medicine. In a 6-week course, participants learned communication and clinical reasoning skills in an integrative fashion using small group exercises with role-play, reflection and feedback through a structured iterative reflective process.
Second-year medical students.
All students interviewed standardized patients who evaluated their communication skills in establishing rapport, data gathering and patient education/counseling on a 5-point scale (1=poor; 5=excellent). We assessed clinical reasoning through the number of correct problems listed and differential diagnoses generated and the Diagnostic Thinking Inventory. Students rated the importance of learning these skills in an integrated fashion.
Standardized patients rated curricular students more favorably in establishing rapport (4.1 vs 3.9; P=.05). Curricular participants listed more psychosocial history items on their problem lists (65% of curricular students listing ≥1 item vs 44% of controls; P=.008). Groups did not differ significantly in other communication or clinical reasoning measures. Ninety-five percent of participants rated the integration of these skills as important.
Intervention students performed better in certain communication and clinical reasoning skills. These students recognized the importance of biomedical and psychosocial issues in patient care. Educators may wish to teach the integration of these skills early in medical training.
PMCID: PMC1490291  PMID: 16423099
communication skills; clinical reasoning; medical education (undergraduate); reflection; feedback
7.  Effect of ethnicity on performance in a final objective structured clinical examination: qualitative and quantitative study 
BMJ : British Medical Journal  2003;326(7393):800-803.
To assess the effect of ethnicity on student performance in stations assessing communication skills within an objective structured clinical examination.
Quantitative and qualitative study.
A final UK clinical examination consisting of a two day objective structured clinical examination with 22 stations.
82 students from ethnic minorities and 97 white students.
Main outcome measures
Mean scores for stations (quantitative) and observations made using discourse analysis on selected communication stations (qualitative).
Mean performance of students from ethnic minorities was significantly lower than that of white students for stations assessing communication skills on days 1 (67.0% (SD 6.8%) and 72.3% (7.6%); P=0.001) and 2 (65.2% (6.6%) and 69.5% (6.3%); P=0.003). No examples of overt discrimination were found in 309 video recordings. Transcriptions showed subtle differences in communication styles in some students from ethnic minorities who performed poorly. Examiners' assumptions about what is good communication may have contributed to differences in grading.
There was no evidence of explicit discrimination between students from ethnic minorities and white students in the objective structured clinical examination. A small group of male students from ethnic minorities used particularly poorly rated communicative styles, and some subtle problems in assessing communication skills may have introduced bias. Tests need to reflect issues of diversity to ensure that students from ethnic minorities are not disadvantaged.
What is already known on this topicUK medical schools are concerned that students from ethnic minorities may perform less well than white students in examinationsIt is important to understand whether our examination system disadvantages themWhat this study addsMean performance of students from ethnic minorities was significantly lower than that of white students in a final year objective structured clinical examinationTwo possible reasons for the difference were poor communicative performance of a small group of male students from ethnic minorities and examiners' use of a textbook patient centred notion of good communicationIssues of diversity in test construction and implementation must be addressed to ensure that students from ethnic minorities are not disadvantaged
PMCID: PMC153100  PMID: 12689978
8.  A Capstone Course with a Comprehensive and Integrated Review of the Pharmacy Curriculum and Student Assessment as a Preparation for Advanced Pharmacy Practice Experiences 
Objective. To create a capstone course that provides a comprehensive and integrated review of the pharmacy curriculum with a broad range of assessment tools to evaluate student knowledge and skills as a final preparation prior to beginning fourth-year advanced pharmacy practice experiences (APPEs).
Design. The capstone course was a 4 credit-hour, case-based course. Eight comprehensive cases were assigned to students over the course of the term. The cases were designed to mimic complex clinical scenarios that students were likely to encounter during an APPE. Students were required to prepare a written and oral presentation for each case and were assessed on material covered during the cases. Faculty members presented weekly reviews on selected topics such as calculations, pharmacokinetics, and pharmaceutical compounding. At the end of the course, students took an observed structured clinical examination (OSCE), which simulated the Georgia Board of Pharmacy Practical Examination, and a comprehensive examination designed to mimic the NAPLEX (North American Pharmacy Licensure Examination).
Assessment. Evaluation of student outcomes was based on written and verbal presentations of the cases, multiple-choice examinations, a short-answer calculations examination, an “Errors and Omissions” examination, a standardized patient encounter, and pharmaceutical compounding examinations. Ninety-five percent of students successfully passed the course on their first attempt. Student feedback indicated satisfaction with the depth, breadth, and organization of material covered and felt that the course helped prepare them for APPEs.
Conclusion. The culminating experience of the capstone course gave students a thorough review of practical, clinical, and communication skills and provided faculty members with feedback regarding the curriculum through robust assessment.
PMCID: PMC4315214  PMID: 25657379
Capstone; case-based learning; integrated curriculum; communication; advanced pharmacy practice experience
9.  Student perception of two different simulation techniques in oral and maxillofacial surgery undergraduate training 
BMC Medical Education  2011;11:82.
Yearly surveys among the undergraduate students in oral and maxillofacial surgery at Karolinska Institutet have conveyed a wish for increased clinical training, and in particular, in surgical removal of mandibular third molars. Due to lack of resources, this kind of clinical supervision has so far not been possible to implement. One possible solution to this problem might be to introduce simulation into the curriculum. The purpose of this study was to investigate undergraduate students' perception of two different simulation methods for practicing clinical reasoning skills and technical skills in oral and maxillofacial surgery.
Forty-seven students participating in the oral and maxillofacial surgery course at Karolinska Institutet during their final year were included. Three different oral surgery patient cases were created in a Virtual Patient (VP) Simulation system (Web-SP) and used for training clinical reasoning. A mandibular third molar surgery simulator with tactile feedback, providing hands on training in the bone removal and tooth sectioning in third molar surgery, was also tested. A seminar was performed using the combination of these two simulators where students' perception of the two different simulation methods was assessed by means of a questionnaire.
The response rate was 91.5% (43/47). The students were positive to the VP cases, although they rated their possible improvement of clinical reasoning skills as moderate. The students' perception of improved technical skills after training in the mandibular third molar surgery simulator was rated high. The majority of the students agreed that both simulation techniques should be included in the curriculum and strongly agreed that it was a good idea to use the two simulators in concert. The importance of feedback from the senior experts during simulator training was emphasised.
The two tested simulation methods were well accepted and most students agreed that the future curriculum would benefit from permanent inclusion of these exercises, especially when used in combination. The results also stress the importance of teaching technical skills and clinical reasoning in concert.
PMCID: PMC3209444  PMID: 21992604
10.  Promotion of Self-directed Learning Using Virtual Patient Cases 
Objective. To assess the effectiveness of virtual patient cases to promote self-directed learning (SDL) in a required advanced therapeutics course.
Design. Virtual patient software based on a branched-narrative decision-making model was used to create complex patient case simulations to replace lecture-based instruction. Within each simulation, students used SDL principles to learn course objectives, apply their knowledge through clinical recommendations, and assess their progress through patient outcomes and faculty feedback linked to their individual decisions. Group discussions followed each virtual patient case to provide further interpretation, clarification, and clinical perspective.
Assessments. Students found the simulated patient cases to be organized (90%), enjoyable (82%), intellectually challenging (97%), and valuable to their understanding of course content (91%). Students further indicated that completion of the virtual patient cases prior to class permitted better use of class time (78%) and promoted SDL (84%). When assessment questions regarding material on postoperative nausea and vomiting were compared, no difference in scores were found between the students who attended the lecture on the material in 2011 (control group) and those who completed the virtual patient case on the material in 2012 (intervention group).
Conclusion. Completion of virtual patient cases, designed to replace lectures and promote SDL, was overwhelmingly supported by students and proved to be as effective as traditional teaching methods.
PMCID: PMC3776905  PMID: 24052654
virtual patients; technology; self-directed learning; simulation; virtual learning
11.  Web-Based Virtual Patients in Nursing Education: Development and Validation of Theory-Anchored Design and Activity Models 
Research has shown that nursing students find it difficult to translate and apply their theoretical knowledge in a clinical context. Virtual patients (VPs) have been proposed as a learning activity that can support nursing students in their learning of scientific knowledge and help them integrate theory and practice. Although VPs are increasingly used in health care education, they still lack a systematic consistency that would allow their reuse outside of their original context. There is therefore a need to develop a model for the development and implementation of VPs in nursing education.
The aim of this study was to develop and evaluate a virtual patient model optimized to the learning and assessment needs in nursing education.
The process of modeling started by reviewing theoretical frameworks reported in the literature and used by practitioners when designing learning and assessment activities. The Outcome-Present State Test (OPT) model was chosen as the theoretical framework. The model was then, in an iterative manner, developed and optimized to the affordances of virtual patients. Content validation was performed with faculty both in terms of the relevance of the chosen theories but also its applicability in nursing education. The virtual patient nursing model was then instantiated in two VPs. The students’ perceived usefulness of the VPs was investigated using a questionnaire. The result was analyzed using descriptive statistics.
A virtual patient Nursing Design Model (vpNDM) composed of three layers was developed. Layer 1 contains the patient story and ways of interacting with the data, Layer 2 includes aspects of the iterative process of clinical reasoning, and finally Layer 3 includes measurable outcomes. A virtual patient Nursing Activity Model (vpNAM) was also developed as a guide when creating VP-centric learning activities. The students perceived the global linear VPs as a relevant learning activity for the integration of theory and practice.
Virtual patients that are adapted to the nursing paradigm can support nursing students’ development of clinical reasoning skills. The proposed virtual patient nursing design and activity models will allow the systematic development of different types of virtual patients from a common model and thereby create opportunities for sharing pedagogical designs across technical solutions.
PMCID: PMC4004162  PMID: 24727709
virtual patient; patient simulation; nursing education; clinical reasoning; e-learning, simulation technology
12.  Do different medical curricula influence self-assessed clinical thinking of students? 
Objectives: As a fundamental element of medical practice, clinical reasoning should be cultivated in courses of study in human medicine. To date, however, no conclusive evidence has been offered as to what forms of teaching and learning are most effective in achieving this goal. The Diagnostic Thinking Inventory (DTI) was developed as a means of measuring knowledge-unrelated components of clinical reasoning. The present pilot study examines the adequacy of this instrument in measuring differences in the clinical reasoning of students in varying stages of education in three curricula of medical studies.
Methods: The Diagnostic Thinking Inventory (DTI) comprises 41 items in two subscales (“Flexibility in Thinking” and “Structure of Knowledge in Memory”). Each item contains a statement or finding concerning clinical reasoning in the form of a stem under which a 6-point scale presents opposing conclusions. The subjects are asked to assess their clinical thinking within this range. The German-language version of the DTI was completed by 247 student volunteers from three schools and varying clinical semesters. In a quasi-experimental design, 219 subjects from traditional and model courses of study in the German state of North Rhine-Westphalia took part. Specifically, these were 5th, 6th and 8th semester students from the model course of study at Witten/Herdecke University (W/HU), from the model (7th and 9th semester) and traditional (7th semester) courses of study at the Ruhr University Bochum (RUB) and from the model course of study (9th semester) at the University of Cologne (UoC). The data retrieved were quantitatively assessed.
Results: The reliability of the questionnaire in its entirety was good (Cronbach’s alpha between 0.71 and 0.83); the reliability of the subscales ranged between 0.49 and 0.75. The different groups were compared using the Mann-Whitney test, revealing significant differences among semester cohorts within a school as well as between students from similar academic years in different schools. Among the participants from the model course of study at the W/HU, scores increased from the 5th to the 6th semester and from the 5th to the 9th semester. Among individual cohorts at RUB, no differences could be established between model and traditional courses of study or between 7th and 9th semester students in model courses of study. Comparing all participating highest semester students, the 8th semester participants from the W/HU achieved the highest scores – significantly higher than those of 9th semester RUB students or 9th semester UoC students. Scores from the RUB 9th semester participants were significantly higher than those of the 9th semester UoC participants.
Discussion: The German-language version of the DTI measures self-assessed differences in diagnostic reasoning among students from various semesters and different model and traditional courses of study with satisfactory reliability. The results can be used for discussion in the context of diverse curricula. The DTI is therefore appropriate for further research that can then be correlated with the different teaching method characteristics and outcomes of various curricula.
PMCID: PMC4027808  PMID: 24872858
clinical thinking; clinical reasoning; PBL; diagnostic thinking inventory
13.  Patients’ approaches to students’ learning at a clinical education ward-an ethnographic study 
BMC Medical Education  2014;14:131.
It is well known that patients’ involvement in health care students’ learning is essential and gives students opportunities to experience clinical reasoning and practice clinical skills when interacting with patients. Students encounter patients in different contexts throughout their education. However, looking across the research providing evidence about learning related to patient-student encounters reveals a lack of knowledge about the actual learning process that occurs in encounters between patients and students. The aim of this study was to explore patient-student encounters in relation to students’ learning in a patient-centered health-care setting.
An ethnographic approach was used to study the encounters between patients and students. The setting was a clinical education ward for nursing students at a university hospital with eight beds. The study included 10 observations with 11 students and 10 patients. The observer followed one or two students taking care of one patient. During the fieldwork observational and reflective notes were taken. After each observation follow-up interviews were conducted with each patient and student separately. Data were analyzed using an ethnographic approach.
The most striking results showed that patients took different approaches in the encounters with students. When the students managed to create a good atmosphere and a mutual relationship, the patients were active participants in the students’ learning. If the students did not manage to create a good atmosphere, the relationship became one-way and the patients were passive participants, letting the students practice on their bodies but without engaging in a dialogue with the students.
Patient-student encounters, at a clinical education ward with a patient-centred pedagogical framework, can develop into either a learning relationship or an attending relationship. A learning relationship is based on a mutual relationship between patients and students resulting in patients actively participating in students’ learning and they both experience it as a joint action. An attending relationship is based on a one-way relationship between patients and students resulting in patients passively participating by letting students to practice on their bodies but without engaging in a learning dialogue with the students.
PMCID: PMC4094893  PMID: 24989155
Patient-student encounters; Clinical education ward; Patient-centeredness; Learning relationship; Attending relationship
14.  An integrative OSCE methodology for enhancing the traditional OSCE program at Taipei medical university ospital - a feasibility study 
BMC Medical Education  2013;13:102.
Continuous development and use of new technologies and methodologies are key features in improving the learning, performance, and skills of medical students and students of all health care professions. Although significant improvements in teaching methodologies have been made in all areas of medicine and health care, studies reveal that students in many areas of health care taking an objective structured clinical examination (OSCE) express difficulties. Thus, this study was planned as a feasibility study to assess the educational effectiveness of an integrated objective structured clinical examination (iOSCE) using both standardized patients and virtual patients.
Thirty (30) medical students in their first year of internship at Taipei Medical University volunteered to be part of a feasibility study for demonstrating the concept of iOSCE. They divided themselves into five groups of six students each and were requested to evaluate two cases: 1) a patient with abdominal pain and 2) a patient with headache using a combination of a standardized patient and a virtual patient. For each of the two cases, five stations were designed in which students were given ten minutes per station leading to a final diagnosis and concluded with a debriefing. The five stations were:
• Station 1) Interacting with the standardized patient.
• Station 2) Writing the patient note and developing a differential diagnosis.
• Station 3) Selecting appropriate laboratory and imaging studies.
• Station 4) Making a final diagnosis and stating the evidence for it.
• Station 5) Having the debriefing.
Each group of 6 students was assigned 2 hours per day for each case. All participants completed a survey regarding the usefulness and efficiency of the iOSCE.
All medical students (30/30; 100%) found the iOSCE program to be very satisfactory, and all expressed that they would like to have further iOSCE experiences if given the opportunity. In terms of ease and helpfulness, the students rated the program an average of 4.4 for the 1st case (abdominal pain) and 4.5 for the 2nd case (headache) on a scale of 1–5, with 5 being the highest and 1 being the lowest score.
The participants felt that the iOSCE program can offer certain advantages over the traditional OSCE with the SP alone. They cited that the iOSCE provided improved clarity of what was being assessed as well as providing an opportunity to improve their diagnostic reasoning.
PMCID: PMC3729372  PMID: 23885884
Medical education; iOSCE; OSCE; Standardized patient; Virtual patient
15.  Something going on in Milan: a review of the 4th International PhD Student Cancer Conference 
ecancermedicalscience  2010;4:198.
The 4th International PhD Student Cancer Conference was held at the IFOM-IEO-Campus in Milan from 19–21 May 2010
The Conference covered many topics related to cancer, from basic biology to clinical aspects of the disease. All attendees presented their research, by either giving a talk or presenting a poster. This conference is an opportunity to introduce PhD students to top cancer research institutes across Europe.
The core participanting institutes included: European School of Molecular Medicine (SEMM)—IFOM-IEO Campus, MilanBeatson Institute for Cancer Research (BICR), GlasgowCambridge Research Institute (CRI), Cambridge, UKMRC Gray Institute of Radiation Biology (GIROB), OxfordLondon Research Institute (LRI), LondonPaterson Institute for Cancer Research (PICR), ManchesterThe Netherlands Cancer Institute (NKI), Amsterdam
‘You organizers have crushed all my prejudices towards Italians. Congratulations, I enjoyed the conference immensely!’ Even if it might have sounded like rudeness for sure this was supposed to be a genuine compliment (at least, that’s how we took it), also considering that it was told by a guy who himself was the fusion of two usually antithetical concepts: fashion style and English nationality.
The year 2010 has marked an important event for Italian research in the international scientific panorama: the European School of Molecular Medicine (SEMM) had the honour to host the 4th International PhD Student Cancer Conference, which was held from 19–21 May 2010 at the IFOM-IEO-Campus ( in Milan.
The conference was attended by more than one hundred students, coming from a selection of cutting edge European institutes devoted to cancer research. The rationale behind it is the promotion of cooperation among young scientists across Europe to debate about science and to exchange ideas and experiences. But that is not all, it is also designed for PhD students to get in touch with other prestigious research centres and to create connections for future post docs or job experiences. And last but not least, it is a golden chance for penniless PhD students to spend a couple of extra days visiting a foreign country (this motivation will of course never be voiced to supervisors).
The network of participating institutes has a three-nation core, made up of the Netherlands Cancer Institute, the Italian European School of Molecular Medicine (SEMM) and five UK Cancer Research Institutes (The London Research Institute, The Cambridge Research Institute, The Beatson Institute for Cancer Research in Glasgow, The Patterson Institute for Cancer Research in Manchester and the MRC Gray Institute for Radiation Oncology and Biology in Oxford).
The conference is hosted and organised every year by one of the core institutes; the first was in Cambridge in 2007, Amsterdam in 2008 and London in 2009, this year was the turn of Milan.
In addition to the core institutes, PhD students from several other high-profile institutes are invited to attend the conference. This year participants applied from the Spanish National Cancer Centre (CNIO, Madrid), the German Cancer Research Centre (DKFZ, Heidelberg), the European Molecular Biology Labs (EMBL, Heidelberg) and the San Raffaele Institute (HSR, Milan). Moreover four ‘special guests’ from the National Centre for Biological Sciences of Bangalore (India) attended the conference in Milan. This represents a first step in widening the horizons beyond Europe into a global worldwide network of talented PhD students in life sciences.
The conference spread over two and a half days (Wednesday 19th to Friday 21st May) and touched on a broad spectrum of topics: from basic biology to development, from cancer therapies to modelling and top-down new generation global approaches. The final selection of presentations has been a tough task for us organisers (Chiara Segré, Federica Castellucci, Francesca Milanesi, Gianluca Varetti and Gian Maria Sarra Ferraris), due to the high scientific level of the abstracts submitted. In the end, 26 top students were chosen to give a 15-min oral presentation in one of eight sessions: Development & Differentiation, Cell Migration, Immunology & Cancer, Modelling & Large Scale approaches, Genome Instability, Signal Transduction, Cancer Genetics & Drug Resistance, Stem Cells in Biology and Cancer.
The scientific programme was further enriched by two scientific special sessions, held by Professor Pier Paolo di Fiore and Dr Giuseppe Testa, Principal Investigators at the IFOM-IEO-Campus and by a bioethical round table on human embryonic stem cell research moderated by Silvia Camporesi, a senior PhD student in the SEMM PhD Programme ‘Foundation of Life Science and their Bioethical Consequences’.
On top of everything, we had the pleasure of inviting, as keynote speakers, two leading European scientists in the fields of cancer invasion and biology of stem cells, respectively: Dr Peter Friedl from The Nijmegen Centre for Molecular Life (The Netherlands) and Professor Andreas Trumpp from The Heidelberg Institute for Stem Cell Technology and Experimental Medicine (Heidelberg).
All the student talks have distinguished themselves for the impressive quality of the science; an encouraging evidence of the high profile level of research carried out in Europe. It would be beyond the purposes of this report to summarise all 26 talks, which touched many different and specific topics. For further information, the Conference Abstract book with all the scientific content is available on the conference Web site ( In what follows, the special sessions and the keynote lectures will be discussed in detail.
PMCID: PMC3234021  PMID: 22276043
16.  Pharmacy cases in Second Life: an elective course 
Interactive pharmacy case studies are an essential component of the pharmacy curriculum. We recently developed an elective course at the Rangel College of Pharmacy in pharmacy case studies for second- and third-year Doctor of Pharmacy students using Second Life® (SL), an interactive three-dimensional virtual environment that simulates the real world. This course explored the use of SL for education and training in pharmacy, emphasizing a case-based approach. Virtual worlds such as SL promote inquiry-based learning and conceptual understanding, and can potentially develop problem-solving skills in pharmacy students. Students were presented ten case scenarios that primarily focused on drug safety and effective communication with patients. Avatars, representing instructors and students, reviewed case scenarios during sessions in a virtual classroom. Individually and in teams, students participated in active-learning activities modeling both the pharmacist’s and patient’s roles. Student performance and learning were assessed based on SL class participation, activities, assignments, and two formal, essay-type online exams in Blackboard 9. Student course-evaluation results indicated favorable perceptions of content and delivery. Student comments included an enhanced appreciation of practical issues in pharmacy practice, flexibility of attendance, and an increased ability to focus on course content. Excellent student participation and performance in weekly active-learning activities translated into positive performance on subsequent formal assessments. Students were actively engaged and exposed to topics pertinent to pharmacy practice that were not covered in the required pharmacy curriculum. The multiple active-learning assignments were successful in increasing students’ knowledge, and provided additional practice in building the communication skills beneficial for students preparing for experiential clinical rotations.
PMCID: PMC3650877  PMID: 23762008
Second Life; virtual worlds; pharmacy case studies; computer simulation; health education; pharmacy education
17.  Virtual patients: the influence of case design and teamwork on students’ perception and knowledge – a pilot study 
BMC Medical Education  2014;14:137.
Virtual patient (VP) cases are an effective teaching method, although little is known about how to design and implement them for maximum effectiveness. The aim of this study was to explore the effect of case design and teamwork on students’ learning outcome.
One hundred forty-six undergraduate medical students participated in a mandatory medical computer science course consisting of five seminars. At the end of each seminar, they worked on one VP case, either in teams of two or individually. Each student filled out an introductory and a final survey and a feedback sheet after completing each case. Additionally, there was a surprise multiple choice (MC) test after the last seminar with three questions regarding each case.
Students with more clinical experience and students who had worked in a team performed significantly better on MC questions. Students with less clinical experience more frequently used information which had been positioned less prominently on the case material. Certain aspects of case design were rated more positively by students who had an interest in e-learning. In general, students preferred to work on cases for less than 15 minutes.
Clinically more advanced students and students working with a partner seem to benefit most from short VP cases with prominently presented information.
PMCID: PMC4115466  PMID: 25000965
CASUS; E-learning; Teamwork; Virtual patients
18.  Assessing communication skills of clinical call handlers working at an out-of-hours centre: development of the RICE rating scale 
Out-of-hours centres provide telephone support to patients with medical problems. In most of these centres specially-trained nurses handle incoming telephone calls. They assess patients' needs, the degree of urgency, and determine the level of care required. Assessment of the medical problem and the quality of ‘care-by-phone’ depend on the medical and communication skills of the call handlers.
To develop a valid, reliable, and practical rating scale to evaluate the communication skills of call handlers working at an out-of-hours centre and to improve quality of communication.
Design of study
Qualitative study with focus groups followed by validation of the rating scale and measurement of reliability (internal consistency)
Out-of-hours centres in the Netherlands.
A focus group developed the rating scale. Experts with experience in training and evaluating communication skills of medical students and GPs commented on the scale to ensure content validity. The reliability of the rating scale was tested in a pilot in which ten specially-trained assessors scored six telephone calls each.
The scale, known as the RICE rating scale, has 17 items divided over four different phases of the telephone consultation: Reason for calling; Information gathering; Conclusion; and Evaluation (RICE). Content validity of the scale was assessed by two experts. Reliability of the scale tested in the pilot was 0.73 (Cronbach's α).
Establishing a rating scale to assess the communication skills of call handlers which meets common scientific demands, such as content validity and reliability, proved successful. This instrument can be used to give feedback to call handlers.
PMCID: PMC2047013  PMID: 17504589
after-hours; care; communication; quality assessment; telephone consultation
19.  Medical students' application of published evidence: randomised trial 
BMJ : British Medical Journal  2003;326(7388):536-538.
To determine how medical students apply research evidence that varies in validity of methods and importance of results to a clinical decision.
Students examined a standardised patient with a whiplash injury, decided whether to order a cervical spine radiograph, and rated their confidence in their decision. They then read one of four randomly assigned variants of a structured abstract from a study of a decision rule that argued against such a procedure in this patient. Variants factorially combined two levels of validity of methods (prospective cohort or chart review) with two levels of importance of results (high sensitivity or high specificity rule). After reading the abstract, students repeated their choice and rated their confidence.
Academic medical centre in the United States.
164 graduating medical students.
Main outcome measures
Proportion of students in each group whose beliefs shifted or stayed the same.
When abstracts were of low importance students were more likely to shift their beliefs in favour of radiography, which was not supported by the evidence (odds ratio 3.42, 95% confidence interval 1.10 to 10.66). Neither methodological validity nor the interaction between validity and importance influenced decision shift. Few students acquired all necessary clinical data from the patient.
Although the students could apply concepts of diagnostic testing, greater focus is needed on appraisal of validity and application of evidence to a particular patient.
What is already known on this topicEvidence based medicine is increasingly emphasised and taught in medical schoolsFew studies have assessed the ability of physicians to apply literature findings to clinical decisionsWhat this paper addsIn making decisions about ordering investigations during a standardised patient exam students were sensitive to the importance of resultsThis effect was not moderated by validity of the study that produced the results or whether the students had collected enough information to apply the results
PMCID: PMC150467  PMID: 12623916
20.  Assessing critical thinking in medical sciences students in two sequential semesters: Does it improve? 
Critical thinking is an important outcome criterion of higher education in any discipline. Medical and paramedical students always encounter with many new problems in clinical settings and medicinal laboratory, and critical thinking is an essential skill in obtaining a better approach for problem solving. We performed a pre-and post-test to evaluate the change of critical thinking skills in medical sciences students who enrolled in Isfahan University of Medical Sciences in Iran during the academic years 2008-2010.
In a longitudinal design study, the critical thinking skills were compared in medical sciences students in two sequential semesters using the California Critical Thinking Skills Test. The test is divided into two parts (parts 1 and 2), including 17 items in each part. Based on proportional stratified sampling, a groups of students (group 1, n=159) were selected from the university population, who enrolled in medicine, pharmacy, nursing, and rehabilitation colleges. The students in group 1 were asked to complete the part 1 of the test (phase I). After one semester, another group (group 2, n=138) from the same population was randomly selected, and they were asked to complete the part two (phase II). The students’ demographic data also were recorded. The California critical thinking skills test was translated and it validity and reliability were approved before.
No significant difference was observed between the two groups in the demographic data. The students critical thinking scores in phase II significantly reduced in comparison with phase 1 (p<0.05). The phase II scores in subdivisions of analysis, inference, inductive reasoning, and deductive reasoning also failed to demonstrate improvement.
It seems curriculum reform is necessary to improve the students’ critical thinking.
PMCID: PMC3778642  PMID: 24083255
Critical thinking; curriculum; higher education; medical sciences
21.  A Learner-Centered Technique and Clinical Reasoning, Reflection, and Case Presentation Attributes in Athletic Training Students 
Journal of Athletic Training  2013;48(3):362-371.
Providing opportunities to develop clinical decision-making skills, including clinical reasoning, is an important aspect of clinical education. The learner-centered technique of summarizing the history and findings, narrowing the differential, analyzing the differential, probing the instructor about uncertainties, plan management, and selecting an issue for self-directed study (SNAPPS) is used in medicine to express clinical reasoning.
To investigate the effects of SNAPPS on the clinical reasoning, reflection, and 4 case presentation attributes (length, conciseness, case summary, and expression of clinical reasoning) in athletic training students.
Randomized controlled clinical trial.
Three undergraduate programs accredited by the Commission on Accreditation of Athletic Training Education.
Patients or Other Participants:
We randomly assigned 38 athletic training students (17 men, 21 women; age = 21.53 ± 1.18 years, grade point average = 3.25 ± 0.31) who had completed at least 1 year of clinical education and all orthopaedic evaluation coursework to the SNAPPS group or the usual and customary group using a stratification scheme.
The SNAPPS group completed four 45-minute clinical reasoning and case presentation learning modules led by an investigator to learn the SNAPPS technique, whereas the usual and customary group received no formal instruction. Both groups audio recorded all injury evaluations performed over a 2-week period.
Main Outcome Measures:
Participants completed the Diagnostic Thinking Inventory and Reflection in Learning Scale twice. Case presentations were analyzed for 4 attributes: length, conciseness, case summary, and expression of clinical reasoning.
Case presentations were longer (t18.806 = −5.862, P < .001) but were more concise (t32 = 11.297, P < .001) for the SNAPPS group than for the usual and customary group. The SNAPPS group performed better on both the case summary subscale (t32 = 2.857, P = .007) and the clinical reasoning subscale (t25.773 = −14.162, P < .001) than the other group. We found a time effect for Diagnostic Thinking Inventory scores (F1,34 = 6.230, P = .02) but observed no group effects (F1,34 = 0.698, P = .41) or time-by-group interaction (F1,34 = 1.050, P = .31). The Reflection in Learning Scale scores analysis revealed no group-by-time interaction (F1,34 = 1.470, P = .23) and no group (F1,34 = 3.751, P = .06) or time (F1,34 = 0.835, P = .37) effects.
The SNAPPS is an effective and feasible clinical education technique for case presentations. This learner-centered technique provides the opportunity for the expression of clinical reasoning skills.
PMCID: PMC3655750  PMID: 23675796
learning styles; metacognition; clinical education
22.  Virtual patient design: exploring what works and why. A grounded theory study 
Medical Education  2013;47(6):595-606.
Virtual patients (VPs) are online representations of clinical cases used in medical education. Widely adopted, they are well placed to teach clinical reasoning skills. International technology standards mean VPs can be created, shared and repurposed between institutions. A systematic review has highlighted the lack of evidence to support which of the numerous VP designs may be effective, and why. We set out to research the influence of VP design on medical undergraduates.
This is a grounded theory study into the influence of VP design on undergraduate medical students. Following a review of the literature and publicly available VP cases, we identified important design properties. We integrated them into two substantial VPs produced for this research. Using purposeful iterative sampling, 46 medical undergraduates were recruited to participate in six focus groups. Participants completed both VPs, an evaluation and a 1-hour focus group discussion. These were digitally recorded, transcribed and analysed using grounded theory, supported by computer-assisted analysis. Following open, axial and selective coding, we produced a theoretical model describing how students learn from VPs.
We identified a central core phenomenon designated ‘learning from the VP’. This had four categories: VP Construction; External Preconditions; Student–VP Interaction, and Consequences. From these, we constructed a three-layer model describing the interactions of students with VPs. The inner layer consists of the student's cognitive and behavioural preconditions prior to sitting a case. The middle layer considers the VP as an ‘encoded object’, an e-learning artefact and as a ‘constructed activity’, with associated pedagogic and organisational elements. The outer layer describes cognitive and behavioural change.
This is the first grounded theory study to explore VP design. This original research has produced a model which enhances understanding of how and why the delivery and design of VPs influence learning. The model may be of practical use to authors, institutions and researchers.
PMCID: PMC3677415  PMID: 23662877
23.  “Best Practice” Skills Lab Training vs. a “see one, do one” Approach in Undergraduate Medical Education: An RCT on Students’ Long-Term Ability to Perform Procedural Clinical Skills 
PLoS ONE  2013;8(9):e76354.
Benefits of skills lab training are widely accepted, but there is sparse research on its long-term effectiveness. We therefore conducted a prospective, randomised controlled-trial to investigate whether in a simulated setting students trained according to a "best practice" model (BPSL) perform two skills of different complexity (nasogastral tube insertion, NGT; intravenous cannulation, IVC) better than students trained with a traditional "see one, do one" teaching approach (TRAD), at follow-up of 3 or 6 months.
Methodology and Principal Findings
94 first-year medical students were randomly assigned to one of four groups: BPSL training or TRAD teaching with follow-up at 3 (3M) or 6 (6M) months. BPSL included structured feedback, practice on manikins, and Peyton’s "Four-Step-Approach", while TRAD was only based on the "see one - do one" principle. At follow-up, manikins were used to assess students’ performance by two independent blinded video-assessors using binary checklists and a single-item global assessment scale. BPSL students scored significantly higher immediately after training (NGT: BPSL3M 94.8%±0.2 and BPSL6M 95.4%±0.3 percentage of maximal score ± SEM; TRAD3M 86.1%±0.5 and TRAD6M 84.7%±0.4. IVC: BPSL3M 86.4%±0.5 and BPSL6M 88.0%±0.5; TRAD3M 73.2%±0.7 and TRAD6M 72.5%±0.7) and lost significantly less of their performance ability at each follow-up (NGT: BPSL3M 86.3%±0.3 and TRAD3M 70.3%±0.6; BPSL6M 89.0%±0.3 and TRAD6M 65.4%±0.6; IVC: BPSL3M 79.5%±0.5 and TRAD3M 56.5%±0.5; BPSL6M 73.2%±0.4 and TRAD6M 51.5%±0.8). In addition, BPSL students were more often rated clinically competent at all assessment times. The superiority at assessment after training was higher for the more complex skill (IVC), whereas NGT with its lower complexity profited more with regard to long-term retention.
This study shows that within a simulated setting BPSL is significantly more effective than TRAD for skills of different complexity assessed immediately after training and at follow-up. The advantages of BPSL training are seen especially in long-term retention.
PMCID: PMC3783438  PMID: 24086732
24.  Student-Generated Case Reports 
When students create teaching materials, learning can be enhanced. Therefore, a project was designed based on the traditional clinical case report and the chiropractic technique and principles curriculum at the University of Bridgeport College of Chiropractic. The objectives were to increase mastery in a clinical topic, increase awareness of different patient presentations and management options, and enhance information technology skills. Following lectures about the components of a case report and neurological reflexes related to visceral comorbidities and subluxation and joint dysfunction, students created a case report based on a template provided by the instructor. A survey gathered student perspectives on the exercise. More than 70% of the surveyed students felt the project was at least moderately helpful in improving understanding of a case report, the condition investigated, their clinical reasoning, and the ability to integrate information. Most felt that they improved their understanding of neurological reflexes, use of the literature, and the practice of evidence-based care. The majority believed that they identified weakness in knowledge, improved self-learning skills, and increased confidence in managing patients. Most enjoyed it at least somewhat and 70% agreed that the project should be continued. Many believed that they were better prepared for national boards and had improved their writing skills.
PMCID: PMC2759994  PMID: 19826544
case reports (publication type); chiropractic; education
25.  Casebook: a virtual patient iPad application for teaching decision-making through the use of electronic health records 
Virtual Patients are a well-known and widely used form of interactive software used to simulate aspects of patient care that students are increasingly less likely to encounter during their studies. However, to take full advantage of the benefits of using Virtual Patients, students should have access to multitudes of cases. In order to promote the creation of collections of cases, a tablet application was developed which makes use of electronic health records as material for Virtual Patient cases. Because electronic health records are abundantly available on hospital information systems, this results in much material for the basis of case creation.
An iPad-based Virtual Patient interactive software system was developed entitled Casebook. The application has been designed to read specially formatted patient cases that have been created using electronic health records, in the form of X-ray images, electrocardiograms, lab reports, and physician notes, and present these to the medical student. These health records are organised into a timeline, and the student navigates the case while answering questions regarding the patient along the way. Each health record can also be annotated with meta-information by the case designer, such as insight into the thought processes and the decision-making rationale of the physician who originally worked with the patient. Students learn decision-making skills by observing and interacting with real patient cases in this simulated environment. This paper discusses our approach in detail.
Our group is of the opinion that Virtual Patient cases, targeted at undergraduate students, should concern patients who exhibit prototypical symptoms of the kind students may encounter when beginning their first medical jobs. Learning theory research has shown that students learn decision-making skills best when they have access to multitudes of patient cases and it is this plurality that allows students to develop their illness scripts effectively. Casebook emphasises the use of pre-existing electronic health record data as the basis for case creation, thus, it is hoped, making it easier to produce cases in larger numbers. By creating a Virtual Patient system where cases are built from abundantly available electronic health records, collections of cases can be accumulated by institutions.
PMCID: PMC4149039  PMID: 25100051
Electronic health records; Decision-making; Diagnostic reasoning

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