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      Assessment of Diagnostic Competences With Standardized Patients Versus Virtual Patients: Experimental Study in the Context of History Taking


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          Standardized patients (SPs) have been one of the popular assessment methods in clinical teaching for decades, although they are resource intensive. Nowadays, simulated virtual patients (VPs) are increasingly used because they are permanently available and fully scalable to a large audience. However, empirical studies comparing the differential effects of these assessment methods are lacking. Similarly, the relationships between key variables associated with diagnostic competences (ie, diagnostic accuracy and evidence generation) in these assessment methods still require further research.


          The aim of this study is to compare perceived authenticity, cognitive load, and diagnostic competences in performance-based assessment using SPs and VPs. This study also aims to examine the relationships of perceived authenticity, cognitive load, and quality of evidence generation with diagnostic accuracy.


          We conducted an experimental study with 86 medical students (mean 26.03 years, SD 4.71) focusing on history taking in dyspnea cases. Participants solved three cases with SPs and three cases with VPs in this repeated measures study. After each case, students provided a diagnosis and rated perceived authenticity and cognitive load. The provided diagnosis was scored in terms of diagnostic accuracy; the questions asked by the medical students were rated with respect to their quality of evidence generation. In addition to regular null hypothesis testing, this study used equivalence testing to investigate the absence of meaningful effects.


          Perceived authenticity (1-tailed t 81=11.12; P<.001) was higher for SPs than for VPs. The correlation between diagnostic accuracy and perceived authenticity was very small ( r=0.05) and neither equivalent ( P=.09) nor statistically significant ( P=.32). Cognitive load was equivalent in both assessment methods ( t 82=2.81; P=.003). Intrinsic cognitive load (1-tailed r=−0.30; P=.003) and extraneous load (1-tailed r=−0.29; P=.003) correlated negatively with the combined score for diagnostic accuracy. The quality of evidence generation was positively related to diagnostic accuracy for VPs (1-tailed r=0.38; P<.001); this finding did not hold for SPs (1-tailed r=0.05; P=.32). Comparing both assessment methods with each other, diagnostic accuracy was higher for SPs than for VPs (2-tailed t 85=2.49; P=.01).


          The results on perceived authenticity demonstrate that learners experience SPs as more authentic than VPs. As higher amounts of intrinsic and extraneous cognitive loads are detrimental to performance, both types of cognitive load must be monitored and manipulated systematically in the assessment. Diagnostic accuracy was higher for SPs than for VPs, which could potentially negatively affect students’ grades with VPs. We identify and discuss possible reasons for this performance difference between both assessment methods.

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                Author and article information

                J Med Internet Res
                J Med Internet Res
                Journal of Medical Internet Research
                JMIR Publications (Toronto, Canada )
                March 2021
                4 March 2021
                : 23
                : 3
                [1 ] Institute for Medical Education University Hospital, LMU Munich Munich Germany
                [2 ] Department of Psychology Ludwig-Maximilians-Universität München Munich Germany
                [3 ] Munich Center of the Learning Sciences Ludwig-Maximilians-Universität München Munich Germany
                Author notes
                Corresponding Author: Maximilian C Fink maximilian.fink@ 123456yahoo.com
                ©Maximilian C Fink, Victoria Reitmeier, Matthias Stadler, Matthias Siebeck, Frank Fischer, Martin R Fischer. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 04.03.2021.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

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