Online patient simulation training to improve clinical reasoning: a feasibility randomised controlled trial

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Abstract

Background

Online patient simulations (OPS) are a novel method for teaching clinical reasoning skills to students and could contribute to reducing diagnostic errors. However, little is known about how best to implement and evaluate OPS in medical curricula. The aim of this study was to assess the feasibility, acceptability and potential effects of eCREST — the electronic Clinical Reasoning Educational Simulation Tool.

Methods

A feasibility randomised controlled trial was conducted with final year undergraduate students from three UK medical schools in academic year 2016/2017 (cohort one) and 2017/2018 (cohort two). Student volunteers were recruited in cohort one via email and on teaching days, and in cohort two eCREST was also integrated into a relevant module in the curriculum. The intervention group received three patient cases and the control group received teaching as usual; allocation ratio was 1:1. Researchers were blind to allocation. Clinical reasoning skills were measured using a survey after 1 week and a patient case after 1 month.

Results

Across schools, 264 students participated (18.2% of all eligible). Cohort two had greater uptake (183/833, 22%) than cohort one (81/621, 13%). After 1 week, 99/137 (72%) of the intervention and 86/127 (68%) of the control group remained in the study. eCREST improved students’ ability to gather essential information from patients over controls (OR = 1.4; 95% CI 1.1–1.7, n = 148). Of the intervention group, most (80/98, 82%) agreed eCREST helped them to learn clinical reasoning skills.

Conclusions

eCREST was highly acceptable and improved data gathering skills that could reduce diagnostic errors. Uptake was low but improved when integrated into course delivery. A summative trial is needed to estimate effectiveness.

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Most cited references 20

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Research in clinical reasoning: past history and current trends.

Geoffrey R Norman (2005)

Research in clinical reasoning has been conducted for over 30 years. Throughout this time there have been a number of identifiable trends in methodology and theory. This paper identifies three broad research traditions, ordered chronologically, are: (a) attempts to understand reasoning as a general skill--the "clinical reasoning" process; (b) research based on probes of memory--reasoning related to the amount of knowledge and memory; and (c) research related to different kinds of mental representations--semantic qualifiers, scripts, schemas and exemplars. Several broad themes emerge from this review. First, there is little evidence that reasoning can be characterised in terms of general process variables. Secondly, it is evident that expertise is associated, not with a single basic representation but with multiple coordinated representations in memory, from causal mechanisms to prior examples. Different representations may be utilised in different circumstances, but little is known about the characteristics of a particular situation that led to a change in strategy. It becomes evident that expertise lies in the availability of multiple representations of knowledge. Perhaps the most critical aspect of learning is not the acquisition of a particular strategy or skill, nor is it the availability of a particular kind of knowledge. Rather, the critical element may be deliberate practice with multiple examples which, on the hand, facilitates the availability of concepts and conceptual knowledge (i.e. transfer) and, on the other hand, adds to a storehouse of already solved problems.

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Virtual patients: a critical literature review and proposed next steps.

Marc M Triola, Bruce Cook (2009)

The opposing forces of increased training expectations and reduced training resources have greatly impacted health professions education. Virtual patients (VPs), which take the form of interactive computer-based clinical scenarios, may help to reconcile this paradox. We summarise research on VPs, highlight the spectrum of potential variation and identify an agenda for future research. We also critically consider the role of VPs in the educational armamentarium. We propose that VPs' most unique and cost-effective function is to facilitate and assess the development of clinical reasoning. Clinical reasoning in experts involves a non-analytical process that matures through deliberate practice with multiple and varied clinical cases. Virtual patients are ideally suited to this task. Virtual patients can also be used in learner assessment, but scoring rubrics should emphasise non-analytical clinical reasoning rather than completeness of information or algorithmic approaches. Potential variations in VP design are practically limitless, yet few studies have rigorously explored design issues. More research is needed to inform instructional design and curricular integration. Virtual patients should be designed and used to promote clinical reasoning skills. More research is needed to inform how to effectively use VPs.

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Computerized virtual patients in health professions education: a systematic review and meta-analysis.

Bruce Cook, Marc M Triola, Patricia Erwin (2010)

Educators increasingly use virtual patients (computerized clinical case simulations) in health professions training. The authors summarize the effect of virtual patients compared with no intervention and alternate instructional methods, and elucidate features of effective virtual patient design. The authors searched MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, and Scopus through February 2009 for studies describing virtual patients for practicing and student physicians, nurses, and other health professionals. Reviewers, working in duplicate, abstracted information on instructional design and outcomes. Effect sizes were pooled using a random-effects model. Four qualitative, 18 no-intervention controlled, 21 noncomputer instruction-comparative, and 11 computer-assisted instruction-comparative studies were found. Heterogeneity was large (I²>50%) in most analyses. Compared with no intervention, the pooled effect size (95% confidence interval; number of studies) was 0.94 (0.69 to 1.19; N=11) for knowledge outcomes, 0.80 (0.52 to 1.08; N=5) for clinical reasoning, and 0.90 (0.61 to 1.19; N=9) for other skills. Compared with noncomputer instruction, pooled effect size (positive numbers favoring virtual patients) was -0.17 (-0.57 to 0.24; N=8) for satisfaction, 0.06 (-0.14 to 0.25; N=5) for knowledge, -0.004 (-0.30 to 0.29; N=10) for reasoning, and 0.10 (-0.21 to 0.42; N=11) for other skills. Comparisons of different virtual patient designs suggest that repetition until demonstration of mastery, advance organizers, enhanced feedback, and explicitly contrasting cases can improve learning outcomes. Virtual patients are associated with large positive effects compared with no intervention. Effects in comparison with noncomputer instruction are on average small. Further research clarifying how to effectively implement virtual patients is needed.

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Author and article information

Contributors

Ruth Plackett:

ORCID: http://orcid.org/0000-0002-3351-1478

ruth.plackett.15@ucl.ac.uk

Journal

Journal ID (nlm-ta): BMC Med Educ

Journal ID (iso-abbrev): BMC Med Educ

Title: BMC Medical Education

Publisher: BioMed Central (London )

ISSN (Electronic): 1472-6920

Publication date (Electronic): 31 July 2020

Publication date PMC-release: 31 July 2020

Publication date Collection: 2020

Volume: 20

Electronic Location Identifier: 245

Affiliations

[1 ]GRID grid.83440.3b, ISNI 0000000121901201, Department of Applied Health Research, , University College London, ; 1-19 Torrington Place, London, WC1E 7HB UK

[2 ]GRID grid.83440.3b, ISNI 0000000121901201, Institute of Education, UCL, ; London, UK

[3 ]GRID grid.8991.9, ISNI 0000 0004 0425 469X, Department of Global Health and Development, , London School of Hygiene and Tropical Medicine, ; London, UK

[4 ]GRID grid.83440.3b, ISNI 0000000121901201, UCL Medical School, UCL, ; London, UK

[5 ]GRID grid.83440.3b, ISNI 0000000121901201, Primary Care and Population Health Department, , UCL, ; London, UK

[6 ]GRID grid.8273.e, ISNI 0000 0001 1092 7967, Norwich Medical School, , UEA, ; Norwich, UK

[7 ]GRID grid.8391.3, ISNI 0000 0004 1936 8024, Institute of Health Service Research, , University of Exeter, ; Exeter, UK

[8 ]GRID grid.4868.2, ISNI 0000 0001 2171 1133, Wolfson Institute of Preventive Medicine, , QMUL, ; London, UK

Author information

Ruth Plackett http://orcid.org/0000-0002-3351-1478

Article

Publisher ID: 2168

DOI: 10.1186/s12909-020-02168-4

PMC ID: 7395338

PubMed ID: 32736583

SO-VID: 97acf3d6-3d94-4e44-98da-367a3ad80f44

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 6 April 2020

Date accepted : 22 July 2020

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100000272, National Institute for Health Research;

Award ID: 106/0001

Award Recipient : Jessica Sheringham

Funded by: FundRef http://dx.doi.org/10.13039/501100000724, Health Foundation;

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ScienceOpen disciplines: Education

Keywords: clinical reasoning,simulation,virtual patient,online learning,medical students,medical education,feasibility study

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ScienceOpen disciplines: Education

Keywords: clinical reasoning, simulation, virtual patient, online learning, medical students, medical education, feasibility study

Online patient simulation training to improve clinical reasoning: a feasibility randomised controlled trial

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Abstract

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Journal of Medical Education Research

Most cited references 20

Research in clinical reasoning: past history and current trends.

Virtual patients: a critical literature review and proposed next steps.

Computerized virtual patients in health professions education: a systematic review and meta-analysis.

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