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Cited by 129Simulation-Based Education in HealthcareInnovations in Medical EducationSurgical Simulation and Training

The virtual patient as a learning tool: a mixed quantitative qualitative study

Open access
Isaza-Restrepo, Andrés, Gómez, María Teresa, Cifuentes, Gary, Argüello, Arturo·2018·BMC Medical Education
DOI 10.1186/s12909-018-1395-8PMC PMC6282259
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Abstract

BACKGROUND: The use of simulation in medical education has been widely accepted. There are different types of medical simulators that vary in both accuracy to emulate the real world (fidelity) and cost of development or acquisition. There is significant evidence that supports the use of high-fidelity simulators (i.e. mannequins or dummies) to prepare students for clinical environments, less attention has been given to low-fidelity simulators. This article aims to present evidence regarding the effectiveness of a low-fidelity simulator: Virtual Patient (VP), which develops several interactive computer-based clinical scenarios, seeking to promote an alternative learning environment and the development of necessary medical skills such as clinical reasoning in students of medicine. METHODS: A quasi-experimental study was designed to investigate the results on the development of history taking and clinical reasoning skills in a group of undergraduate medical students, in a course devised under the concepts of constructivism in education, which used the Virtual Patient as the fundamental teaching tool. Results were measured through a mixed, quantitative and qualitative study, triangulating the results of the students' skills evaluation when facing a clinical case represented by an actor patient before and after the course. Additionally, the description of the students' and tool's performance was measured by way of a qualitative study. RESULTS: The comparison of the students' skills on the evaluation matrix before-and-after the course evidenced a statistically significant advance (p < 0.01) in all aspects (interview, physical exam, clinical judgment, relevance of medical exams, and presentation of case). Students described the VP as an easy-to-use and motivating tool for learning without stress, especially at the beginning of their career. VP allowed them to create logical and structured processes, to be wrong without consequences, and to review and reassess information available. From the professor perspective, it allowed a better follow-up of the students' learning process and favored reflections on the teaching-learning process. CONCLUSIONS: VP proved to be a valuable and useful tool for the development of clinical reasoning and history taking skills in medical students, as part of a constructivist learning course.

AI snapshot

Written from the paper’s full text.

TL;DR

In a 16-week elective course using a web-based Virtual Patient as the core tool, 20 preclinical medical students at Universidad del Rosario showed statistically significant pre-post improvement in history taking and clinical reasoning skills when assessed with an actor patient. Qualitative data indicated the VP was easy to use, motivating, and allowed error without patient risk, though the authors caution that effects cannot be attributed to the VP alone.

Key findings

  • All five assessed skills—interview, physical exam, clinical judgment, relevance of medical exams, and presentation of case—improved significantly from pre- to post-course by Wilcoxon signed rank test across three evaluators (abstract reports p < 0.01 in all aspects; Table 3 reports p values from <0.01 to 0.02).
  • Students described the VP as easy-to-use and motivating, allowing them to make mistakes without consequences, review/reassess information, and build logical/structured processes; it was seen as especially useful early in the career.
  • Professors reported better follow-up of students’ learning and reflection on the teaching-learning process; qualitative categories included use of the tool, perceptions on learning, construction of knowledge/competencies, and contributions to teaching.
  • Cost per hour of VP was USD 12, compared with USD 160–800 per hour for high-fidelity simulators and USD 30–40 per hour for standardized patients; software and faculty time cost $49,000 USD.

Methods

  • Quasi-experimental before-and-after mixed-methods study. Participants: 20 voluntary undergraduate medical students from first to fifth academic periods at Universidad del Rosario, first half of 2012, without prior semiology course; elective “Introduction to clinical reasoning” lasted 16 weeks with two-hour weekly sessions using VP cases of abdominal pain.
  • Quantitative: each student handled a clinical case enacted by a professional actor in first and last sessions; performances videotaped and scored by three evaluators on a 1–3 matrix for five skills; non-parametric analysis (Wilcoxon signed rank test) in SPSS v22; matrix validated by three evaluators with Kappa coefficient.
  • Qualitative: student focus group, professor field journals, and ethnographic observation by an anthropologist; data transcribed, digitized, coded by predefined categories and analyzed/triangulated in Atlas.ti v7.0; mixed concurrent/triangulated design.

Limitations

  • Stated: the VP was embedded in a course designed with solid pedagogical principles, so observed changes cannot be completely attributed to the VP; no comparison was made with other learning strategies; cost-effectiveness analysis was outside the study scope.
  • Stated: current VP development is insufficient to simulate the complexity of physician–patient interaction; as sole methodology it can become monotonous, may have technical problems, and requires complementary methodologies.
  • Evident from the text: small sample (20 students), single institution, voluntary elective, and no control group; pre-post design leaves possible confounding by course structure, teacher guidance, peer collaboration, and self-selection.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/s12909-018-1395-8

Cites

32 of 32 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 33 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    The Virtual Patient allowed students to learn to recognize the importance of each piece of information that may be provided by a patient.

    “It was found that the VP allowed students to learn to recognize the importance of each piece of information that may be provided by a patient, as well as the need for conducting a logical process that contributes to being more organized and methodical, and building structured mental schemes, which guide them towards possible diagnoses.”
    Quote in the paperSubstantial claim
  • Findingown data

    The Virtual Patient allowed students to review and reassess information available.

    “VP allowed them to create logical and structured processes, to be wrong without consequences, and to review and reassess information available.”
    • Also stated in: § Use of the tool · plain
      “The VP enabled getting to know a patient, tackling a clinical case, broadening and feeding the curiosity over the unknown, asking questions again, re-examining, and going back to revisit and evaluate all the information.”
    Quote in the paperSubstantial claim
  • Findingown data

    Throughout the implementation of the Virtual Patient during the course, more advantages than disadvantages were observed.

    “Throughout the implementation of the tool during the course, it was possible to observe more advantages than disadvantages.”
    Quote in the paperNot a substantial claim
  • Findingown data

    The Virtual Patient allowed students to create logical and structured processes.

    “VP allowed them to create logical and structured processes, to be wrong without consequences, and to review and reassess information available.”
    Quote in the paperSubstantial claim
  • Findingown data

    The Virtual Patient enabled students to broaden and feed curiosity over the unknown.

    “The VP enabled getting to know a patient, tackling a clinical case, broadening and feeding the curiosity over the unknown, asking questions again, re-examining, and going back to revisit and evaluate all the information.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 32
  • The quote only partly states this claim. 1
  • Classified as probably not a substantial claim. 27

  • May combine two claims.

    Findingown data

    The Virtual Patient allowed students to learn the need for conducting a logical process that contributes to being more organized and methodical, and building structured mental schemes that guide them towards possible diagnoses.

    “It was found that the VP allowed students to learn to recognize the importance of each piece of information that may be provided by a patient, as well as the need for conducting a logical process that contributes to being more organized and methodical, and building structured mental schemes, which guide them towards possible diagnoses.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Students acquired new knowledge with the Virtual Patient, applied prior knowledge, and made connections without the pressure from the professor or from a real patient, which translated into being able to act without fear of making a mistake.

    “By the same token, it was observed that they acquired new knowledge with the tool, they applied prior knowledge, and made connections without the pressure from the professor or from a real patient, which translated into being able to act “without fear of making a mistake.””
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Students perceived the Virtual Patient as an easy-to-use and motivating tool for learning without stress, especially at the beginning of their career.

    “Students described the VP as an easy-to-use and motivating tool for learning without stress, especially at the beginning of their career.”
    Quote in the paperSubstantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    In undergraduate medical students who took the 16-week constructivist course using the Virtual Patient, scores on the evaluation matrix for history taking and clinical reasoning (interview, physical exam, clinical judgment, relevance of medical exams, and presentation of case) were significantly higher after the course than before, as assessed by three evaluators.

    “The comparison of the students’ skills on the evaluation matrix before-and-after the course evidenced a statistically significant advance (p < 0.01) in all aspects (interview, physical exam, clinical judgment, relevance of medical exams, and presentation of case).”
    • Also stated in: § Results · plain
      “The student skills of history taking and clinical reasoning significantly improved after taking the course (Table 3).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The actor-patient clinical case exercise is the closest to authentic clinical performance of a physician.

  • May combine two claims.

    Findingown data

    The effect from both the Virtual Patient tool and the course design proved to be favorable for learning to take place.

    “As can be seen, the effect from both the tool and the course design proved to be favorable for learning to take place.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    From the professor perspective, the Virtual Patient allowed better follow-up of the students' learning process and favored reflections on the teaching-learning process.

    “From the professor perspective, it allowed a better follow-up of the students’ learning process and favored reflections on the teaching-learning process.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The Virtual Patient enabled students to get to know a patient and tackle a clinical case.

    “The VP enabled getting to know a patient, tackling a clinical case, broadening and feeding the curiosity over the unknown, asking questions again, re-examining, and going back to revisit and evaluate all the information.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Findingown data

    The virtual patient helped students learn to organize their ideas and understand that all actions must have a specific end (verify-reject ideas).

    “I have learned to organize my ideas and I understand that all my actions must have a specific end (verify-reject ideas).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The professor reported seeing evidence of learning in the classroom with this course more than in other courses.

    “Professor: Of course, as a professor you know what your student is intended to learn so activities that allow the student to build that knowledge, develop such skills, such attitudes are proposed… and few times I have been able to see that evidence of learning in the classroom as with this course…”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Findingown data

    The virtual patient enables putting into practice and relating concepts learned, as well as strengthening concepts.

    “The VP enables putting into practice and relating concepts learned, as well as strengthening concepts.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The use of the virtual patient tool allowed for better follow-up of the students' learning process and, for the professor, for a reflection on the teaching-learning process.

    “The use of the VP tool also allowed for a better follow-up of the students’ learning process and, in the case of the professor, for a reflection on the teaching-learning process:”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Findingown data

    The virtual patient allowed students to relate various concepts, encouraged research of conditions they do not understand, and improved critical reasoning skills.

    “The Virtual Patient has allowed me to relate various concepts. Likewise, I feel that it has encouraged me to research those conditions that I do not understand and to improve my critical reasoning skills.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    History taking skills significantly improved after the course, despite the virtual patient being a Web-based simulator using chat-like interviewing and click-based physical examination.

    “It should be noted that although the VP is a Web-based simulator that uses a chat-like interviewing methodology and a click-based physical examination, history taking skills significantly improved after the course.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Findingown data

    The course led students to reflect on the importance of controlling their own bias and avoiding taking the easy way out when producing a diagnosis because it may lead to serious mistakes.

    “that it is important to control “your own bias” and taking the easy way out when producing a diagnosis because it may lead to serious mistakes; they have reflected on the importance of taking the medical act with all due seriousness, also given the risks involved in taking it lightly;”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    A contribution was made regarding guidance and the relevance for requesting additional tests geared towards confirming the diagnosis, as well as the presentation of clinical cases, as evidence for the abilities of students for clinical reasoning.

    “For the same reason, a contribution was made regarding guidance and the relevance for requesting additional tests geared towards confirming the diagnosis, as well as the presentation of clinical cases, a set of skills considered in this research, as evidence for the abilities of students for clinical reasoning.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Findingnone given

    The auto-filling feature of questions is determined by the development level of the simulation model, which to a certain extent substitutes the student's effort to consider the relevant questions within the clinical reasoning process.

    “On another note, it is worth mentioning that the auto-filling feature of such questions is determined by the development level of the simulation model, which to a certain extent substitutes the student’s effort to consider the relevant questions within the clinical reasoning process.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Findingown data

    The virtual patient is a good practice where students can put into practice their knowledge and practice at a consultation without compromising anyone's life or health.

    “I feel it is a good practice, where we can not only put into practice our knowledge, but also our practice at a consultation without compromising anyone’s life or health.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The course led students to see that they cannot ask questions and pay attention indefinitely, but must focus the interview on relevant aspects without neglecting the rest.

    “I also believe they have seen that they cannot afford to ask questions and pay attention indefinitely, but rather, that they must start to somehow focus the interview on the relevant aspects (without neglecting the rest).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingown data

    The virtual patient's structure allowed students to infer part of the clinical logic with which the doctor intervenes regarding the disease.

    “From the Virtual Patient‘s structure, browsing the various tabs allowed the students to infer part of the clinical logic with which the doctor intervenes regarding the disease.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The cost per hour of the virtual patient was USD 12, which is low compared to high-fidelity simulators (between USD 160 and 800 per hour) and standardized patients (from USD 30 to 40 per hour).

    “From a cost perspective, the cost per hour of the VP was USD 12, which is noteworthy as it is low compared to high-fidelity simulators (between USD 160 and 800 per hour) and standardized patients (from USD 30 to 40 per hour).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    The cost of the software and faculty time was $49,000 USD, similar to what was previously reported in the literature.

    “The cost of the software and faculty time was similar to what was previously reported in the literature [30]: $49,000. USD.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] Schwid HA, Souter KJ. Resident perceptions and cost analysis of a virtual patient application for anesthesia-related critical incidents. J Educ Perioper Med. 2014;16:E077.

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    The results were measured through a mixed concurrent or triangulated study.

    “The results were measured through a mixed concurrent or triangulated study [19–21].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [19] Greene JC, Caracelli VJ, Graham WF. Toward a conceptual framework for mixed-method evaluation designs. Educational Evaluation and Policy Analysis. 1989;11:255–74. source

      Not checked in the free run.

    • cites [20] Brewer J, Hunter A. Foundations of multimethod research. California: Thousand Oaks; 2018. https://doi.org/10.4135/9781412984294 . source

      Not checked in the free run.

    • cites [21] Greene JC. Mixed methods in social inquiry. 1st ed. San Francisco, CA: Jossey-Bass; 2007.

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    The evaluation matrix for history taking and clinical reasoning skills was validated by three evaluators using the Kappa coefficient with a 95% reliability interval, and its construct and content and inter-observer agreement were validated.

    “Validation of the matrix was established by three evaluators using the agreement test through the Kappa coefficient, with a 95% reliability interval. Construct and content of the matrix were validated, as well as agreement amongst the observers (Table 1).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Virtual Patient has been accepted by the Liaison Committee on Medical Education (LCME) as a resource to teach rare but necessary clinical situations.

    “This tool has been accepted by the Liaison Committee on Medical Education (LCME) as a resource to teach rare but necessary clinical situations [13].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] Cendan J, Lok B. The use of virtual patients in medical school curricula. Adv Physiol Educ. 2012;36:48–53. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Virtual Patient has been part of the United States Medical Licensing Examination (USMLE Step 3) since 1999.

    “In addition, it is part of the United States Medical Licensing Examination (USMLE Step 3) since 1999 [13, 14].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [13] Cendan J, Lok B. The use of virtual patients in medical school curricula. Adv Physiol Educ. 2012;36:48–53. source

      Not checked in the free run.

    • cites [14] Mehta NP, Kramer DB. A critique of the USMLE clinical skills examination. Medscape Gen Med. 2005;7:76–6.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Prior authorization from the University was requested, as well as informed consent from all students involved.

    “Prior authorization from the University was requested, as well as an informed consent from all students involved.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The improvement in history taking skills could be related to the simulator's function of displaying patient question suggestions to the student.

    “This finding could be related to the simulator’s function of displaying patient question suggestions to the student.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation

    Clinical reasoning is an essential skill that must be applied in every moment of patient attendance.

    “This process is known as clinical reasoning, an essential skill that must be applied in every moment of patient attendance [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Norman G. Research in clinical reasoning: past history and current trends. Med Educ. 2005;39:418–27. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Patient safety is recognized around the world as a priority, where trial-error-based learning cannot be an option in a real patient.

    “Hence, patient safety is recognized around the world as a priority, where “trial-error”-based learning cannot be an option in a real patient [4].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [4] Aggarwal R, Mytton OT, Derbrew M, Hananel D, Heydenburg M, Issenberg B, et al. Training and simulation for patient safety. Qual Saf Health Care. 2010;19 Suppl 2:i34. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Medical error represents one of the leading causes of death.

    “Current evidence suggests that medical error represents one of the leading causes of death [1–3].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [1] Weingart SN, McL Wilson R, Gibberd RW, Harrison B. Epidemiology of medical error. West J Med. 2000;172:390–3. source

      Not checked in the free run.

    • cites [2] Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000.

      Not checked in the free run.

    • cites [3] Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165:1493–9. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation

    Getting together relevant information such as personal and psychosocial state, related personal and family medical background, the reason for consulting, plus physical examination findings, should allow the physician to generate a diagnosis hypothesis.

    “Getting together the relevant information such as personal and psychosocial state, related personal and family medical background, the reason for consulting, plus the physical examination findings, should allow the physician to generate a diagnosis hypothesis.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] Keifenheim KE, Teufel M, Ip J, Speiser N, Leehr EJ, Zipfel S, et al. Teaching history taking to medical students: a systematic review. BMC Medical Education. 2015;15:159. source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Emergent teaching strategies based on constructivist concepts highlight the importance of repeated interaction between the learner and the object of learning, and the importance of others in knowledge construction.

    “Emergent strategies are based on constructivist concepts, which highlight the importance of the repeated interaction between the learner and the object of learning, and the importance of others in the process of knowledge construction [6].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [6] Phillips DC. The good, the bad, and the ugly: the many faces of constructivism. Educ Res. 1995;24:5–12. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    The virtual patient results in a valuable learning experience for the student, who at first has difficulties in asking questions, especially when it comes to sensitive issues or aspects relative to the patient's private life.

    “This results in a valuable learning experience for the student, who at first has difficulties in asking questions, especially when it comes to sensitive issues or aspects relative to the patient’s private life [22–24].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [22] Edelbring S, Dastmalchi M, Hult H, Lundberg IE, Dahlgren LO. Experiencing virtual patients in clinical learning: a phenomenological study. Adv Health Sci Educ Theory Pract. 2011;16:331–45. source

      Not checked in the free run.

    • cites [23] Sandroni S. Enhancing clinical teaching with information technologies: what can we do right now? Academic medicine : journal of the Association of American Medical Colleges. 1997;72:770–4. source

      Not checked in the free run.

    • cites [24] Spencer J. Teaching about professionalism. Med Educ. 2003;37:288–9. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    The aim of the Virtual Patient is to expose students to virtual scenarios that would otherwise be difficult to find or to deal with in real life.

    “The aim of VP is to expose students to virtual scenarios that would otherwise be difficult to find or to deal with in real life [11, 12].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [11] Friedrich MJ. Practice makes perfect: risk-free medical training with patient simulators. JAMA. 2002;288(2808):2811–2.

      Not checked in the free run.

    • cites [12] Ellaway R, Masters K. AMEE guide 32: e-learning in medical education part 1: learning, teaching and assessment. Med Teach. 2008;30:455–73. source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductreasoning

    The main limitation of the study is that the virtual patient was immersed in a course designed following solid pedagogical principles to strengthen history taking and clinical reasoning skills, so it is not possible to completely attribute the observed changes to the virtual patient.

    “Nevertheless, the main limitation of the study is that the VP was immersed in a course that was designed following solid pedagogical principles to strengthen history taking and clinical reasoning skills. Hence, it is not possible to completely attribute the observed changes to the VP.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Simulation facilitates learning when used in appropriate conditions that include providing feedback, repetition, curriculum integration, individualized learning and controlled environment.

    “However, it has been accepted that simulation facilitates learning when it is used in the appropriate conditions that include providing feedback, repetition, curriculum integration, individualized learning and controlled environment [28].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [28] Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005;27:10–28. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    The virtual patient proposes a logical order and familiarizes the student with the way of asking questions, previously introduced by medical instructors who apply them in their actual professional context.

    “In other terms, the VP proposes a logical order and familiarizes the student with the way of asking questions, previously introduced by medical instructors who apply them in their actual professional context.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    These circumstances make it necessary to introduce changes to medical education.

    “These circumstances make it necessary to introduce changes to medical education [5].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [5] Ypinazar VA, Margolis SA. Clinical simulators: applications and implications for rural medical education. Rural Remote Health. 2006;6:527.

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Simulation in medical education allows students to repeat a given scenario as many times as needed, make mistakes, learn from errors, ponder, receive proper feedback, trace a learning curve, and improve clinical skills without compromising patients' safety, as well as reduce stress from direct interaction with real patients.

    “Simulation emerges as a new medical educational strategy allowing students to repeat a given scenario as many times as needed, make mistakes, learn from errors, ponder, receive proper feedback, trace a learning curve, and finally, improve the clinical skills required in clinical practice without compromising patients’ safety, as well as to reduce the stress produced by direct interaction with real”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [5] Ypinazar VA, Margolis SA. Clinical simulators: applications and implications for rural medical education. Rural Remote Health. 2006;6:527.

      Not checked in the free run.

    • cites [10] Aper L, Reniers J, Derese A, Veldhuijzen W. Managing the complexity of doing it all: an exploratory study on students’ experiences when trained stepwise in conducting consultations. BMC Med Educ. 2014;14:206. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    The virtual patient challenges traditional preferences but not as a single tool, rather in a constructivist context.

    “However, as it has been described above, VP challenges traditional preferences but not as a single tool, rather in a constructivist context.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    The virtual patient was used as the main tool of a course designed with solid pedagogical foundation, making it difficult to completely attribute the results to the single tool.

    “However, VP was used as the main tool of a course that was designed with solid pedagogical foundation, making it difficult to completely attribute the results to the single tool.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Medical students prefer a more traditional approach to learning (reflectors and theorists) than a pragmatic or even an activist, and instructional strategies should encourage students to self-directed learning.

    “Additionally, as has been suggested by Guraya et al., medical students prefer a more traditional approach to learning (reflectors and theorists) than a pragmatic or even an activist, and that instructional strategies should encourage students to self-directed learning [27].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [27] Guraya SS, Guraya SY, Habib FA, Khoshhal KI. Learning styles of medical students at Taibah University: trends and implications. J Res Med Sci. 2014;19:1155–62. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Systematic reviews include studies where the virtual patient has been compared with other strategies and showed positive results against traditional lectures and even standardized patients, but evidence is not conclusive and heterogeneity of the data suggests that more research is needed.

    “Moreover, it is possible to find systematic reviews that include studies where VP has been compared with some of those strategies and where it showed positive results against traditional lectures and even standardized patients, but evidence is not [7] conclusive and heterogeneity of the data suggest that more research is needed [7, 26, 29].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [7] Keifenheim KE, Teufel M, Ip J, Speiser N, Leehr EJ, Zipfel S, et al. Teaching history taking to medical students: a systematic review. BMC Medical Education. 2015;15:159. source

      Not checked in the free run.

    • cites [26] Cook DA, Erwin PJ, Triola MM. Computerized virtual patients in health professions education: a systematic review and meta-analysis. Acad Med. 2010;85:1589–602. source

      Not checked in the free run.

    • cites [29] Cook DA, Triola MM. Virtual patients: a critical literature review and proposed next steps. Med Educ. 2009;43:303–11. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationown data

    A learning environment that promotes individual construction through peer interaction, meaningful learning, repetition of the same problem with different variations, learning by doing and proper permanent feedback are essential to ensuring the efficacy of a Web-based virtual patient for developing clinical reasoning and history taking skills.

    “Results suggest that a learning environment that promotes individual construction through peer interaction, meaningful learning, repetition of the same problem with different variations, learning by doing and a proper permanent feedback are essential to ensuring the efficacy of a Web-based virtual patient for developing clinical reasoning and history taking skills.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationnone given

    Permanent collaborative work amongst small student groups must have influenced the outcome.

    “There was permanent collaborative work amongst small student groups, which must have influenced the outcome.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The virtual patient and simulation in general are merely tools for training purposes, and success in their use does not depend so much on the accuracy of the simulation but rather on how it is used by the instructor and the student.

    “We agree with Aggarwal et al. [4] on the importance of bearing in mind that the VP and the simulation in general are merely tools for training purposes, and that success in their use does not depend so much on the accuracy of the simulation but rather on how it is used by the instructor and the student.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [4] Aggarwal R, Mytton OT, Derbrew M, Hananel D, Heydenburg M, Issenberg B, et al. Training and simulation for patient safety. Qual Saf Health Care. 2010;19 Suppl 2:i34. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The scope of the study did not include a cost-effectiveness analysis.

    “Nonetheless, the scope of the study did not include a cost-effectiveness analysis and prospective studies are needed.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

    Interpretationcitation

    Instructional strategies, whether technology-based or not, must include some solid principles from pedagogical theory that were incorporated to the virtual patient course and some of what Issenberg et al. described as key for simulation-based learning.

    “This suggests that instructional strategies, whether technology-based or not, must include some solid principles from pedagogical theory that were incorporated to the VP course and some of what Issenberg et al. described as key for simulation-based learning [28].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [28] Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005;27:10–28. source

      Not checked in the free run.

48 of 48

  • The paper relies on this without support.

    The actor-patient clinical case exercise is the closest to authentic clinical performance of a physician.

    “This exercise was considered as the closest to authentic clinical performance of a physician.”

  • The paper relies on this without support.

    The 20 undergraduate medical students from Universidad del Rosario are representative of medical students in general, so the study's conclusions can generalize to medical students.

    “The course involved 20 voluntary undergraduate medical students from first to fifth academic periods from Universidad del Rosario in the first half of 2012, who had not had a prior semiology course.”

  • The paper relies on this without support.

    Less attention has been given to low-fidelity simulators than to high-fidelity simulators.

    “There is significant evidence that supports the use of high-fidelity simulators (i.e. mannequins or dummies) to prepare students for clinical environments, less attention has been given to low-fidelity simulators.”

  • The paper relies on this without support.

    The Virtual Patient is still under development and relatively unexplored from a pedagogic perspective.

    “VP is still under development and relatively unexplored from a pedagogic perspective.”

  • The paper relies on this without support.

    A greater number of worked cases results in better performance in real life.

    “Evidence shows that a greater number of worked cases results in a better performance in real life.”
5 of 5

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • In the 3 included studies of virtual patients, users in all 3 reported liking that it provided a platform for risk-free learning because they were not practicing on real patients.

    “In the included studies, 3 of the conversational agents were virtual patients, and users in all 3 studies reported liking that it provided a platform for risk-free learning because they were not practicing on real patients [15,41,50].”

    From The Effectiveness of Artificial Intelligence Conversational Agents in Health Care: Systematic Review (2020) · cites this paper as [15]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Not all assessed skills had p < 0.01

    Minor

    The abstract says every assessed aspect improved at p < 0.01, but Table 3 reports p = 0.02 for clinical judgment as assessed by Evaluator 2.

1 of 1

Cites

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Cited by

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Related

Authors
Isaza-Restrepo, A., Gómez, M. T., Cifuentes, G., & Argüello, A.
Affiliations
  • Universidad del Rosario (CO)
  • Universidad de Los Andes (CO)
Corresponding author
Isaza-Restrepo, Andrés
ORCID
Venue
BMC Medical Education
Publisher
Springer Science and Business Media LLC
Published
2018-12
Volume
18
Issue
1
Pages
297-297
ISSN
1472-6920 (ISSN-L)
DOI
10.1186/s12909-018-1395-8
PMC
PMC6282259
OpenAlex
W2902116953
Semantic Scholar
3f86d9f962c6ca562369957d9a85f7c2a573ef0b
Cited by
129
References
32
Citations by year
2026: 11 · 2025: 14 · 2024: 21 · 2023: 20 · 2022: 32 · 2021: 17 · 2020: 11 · 2019: 3
FWCI
5.31
Type
journal article
Language
en
Open access
Licence
Locations
  • BMC Medical Education (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, other-oa)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • LA Referencia (Red Federada de Repositorios Institucionales de Publicaciones Científicas) (submittedVersion, other-oa)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Greater South Information System
Funders
  • Universidad de los Andes
  • Universidad del Rosario
  • Fundación Santa Fe de Bogotá
Topics
  • Health Sciences › Medicine › Physiology › Simulation-Based Education in Healthcare
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Innovations in Medical Education
  • Health Sciences › Medicine › Surgery › Surgical Simulation and Training
Keywords
virtual patients, low-fidelity simulation, simulation-based medical education, clinical reasoning, medical history, undergraduate medical students, constructivist learning
MeSH terms
Clinical Competence, Computer-Assisted Instruction, Education, Medical, Educational Measurement, Evaluation Studies as Topic, Humans, Health Knowledge, Attitudes, Practice, Learning, Manikins, Physical Examination, Students, Medical, User-Computer Interface, Patient Simulation, Problem-Based Learning, Qualitative Research

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

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