Virtual patients help expand the experience of medical students

Tomorrow’s doctors can practise their diagnostic skills outside the University

virtuaalipotilas-JRRS“A virtual patient” brings to mind either a character in a computer game or a real patient contacting his or her doctor from the living room sofa using an unreliable web camera. However, the virtual patients used in medical training are something more meaningful and educational.

Virtual patients suffer from a host of the most common complaints, and their cases are based on real patients. However, the virtual patients’ cases have been assembled by combining information from several different patients. To further enhance the scenario, imaginary test results can also be added. Anonymised fictional patient cases can be used for instruction purposes, but the real patient’s permission is needed if pictorial material is added.

The cases are available on the Moodle learning management system only for the medical students of the University of Tampere.

“We now have over fifty virtual patient cases and I would imagine that the number will grow to about a hundred by next summer,” says Director of Medical Education Kati Hakkarainen from the School of Medicine.

“We are working on new cases, for example in the fields of neurology, cardiology and pulmonary diseases.”

Students encounter their first virtual patient cases in their second year of study, but practising diagnostic skills starts on a wider scale in the third year. It is then that the students also work more with virtual patients.
Even though the virtual data is of high quality and facilitates learning, it is usually not a compulsory part of the curriculum. However, such data has been very popular among the students, and most of the feedback has been positive.

The students also prepare their answers to the virtual patient exercises carefully, even though completing the cases is not counted among the study attainments included in the medical degree.

Hakkarainen has included virtual content in her own study modules and other instructors have followed suit.

“When these study modules are designed, a medical specialist in the field must always be involved. They know best how the cases should be presented and therefore they are the ones to produce the content,” Hakkarainen says.

“For example, video material is not necessary in a study module on dermatology, but videos are almost indispensable in describing the various symptoms of neurological patients, as a video can depict very unique ranges of symptoms.

There are fifteen different study modules in dermatology in which the patients have the most common skin symptoms or diseases, such as itching or moles.

Having a large array of patients is the most important advantage of virtual patients. When medical students practise clinical skills, they only spend a limited time in given disciplines in hospital wards, which can be too short a time to encounter even the most common cases,” she explains.

Students can repeatedly revisit the virtual patients, whereas real patients cannot be endlessly bothered for educational purposes.

Because patients often spend a very short time in hospital, longitudinal follow up is usually out of the question. Following up on the patients is especially important in neurological cases, for instance. However, virtual patients can shed light on the course of such diseases and the cases may even extend over several years.

“When students follow up on chronic patients, they learn how such patients can be treated in basic health care, when a specialist should be consulted and when the patient must be referred to demanding specialist care in hospital,” Hakkarainen explains.

There is proof that virtual patients improve diagnostic skills. Bedside manner is still learned as always through real patient contacts during clinical training in hospitals. Virtual patients can never replace learning from real patients; they simply complement it.

“It is obvious that the more the students encounter patients, the more they learn. However, it is not always possible in clinical training to contact instructors or senior ward physicians and get their feedback on one’s learning,” Hakkarainen points out.

“Having to answer interactive questions when treating virtual patients offers the students a way to evaluate their own capacity to cope independently.”

An example of the process of treating a virtual patient:
1.    The patient and his or her health and symptoms are described followed by the question: What is the likely cause of these symptoms?
2.    The correct answer is provided on the next page along with questions on background information, such as what biological mechanism causes the ailment (e.g. an allergy, diabetes). Students may be able to watch an animated film, an interview with a professor or an extract of a lecture video.
3.    A multiple choice exercise follows: What symptoms are caused by the ailment? Students are allowed to pick multiple answers, after which they get feedback. The programme might say “You found some of the correct answers” followed by a summary of the correct and incorrect answers.
4.    Students are next asked, Are further tests needed? In answering this open-ended question, students can give the grounds for their decision.
5.    The patient has another appointment with the doctor to which he or she brings the test results. The content of the test result form are invented but plausible. What do the test results show? Students must answer this open ended question by giving a diagnosis.
6.    Multiple choice questions follow on, for example, care instructions or the ordering of more tests, after which the correct answers and feedback are given.
7.    Next come more open-ended questions: What else should be taken into account? What else should be tested and with what methods?

At the end, students can download and save the completed virtual patient case as a PDF file or send it to the instructor for grading. At the bottom of the page, students can continuously see the points they are accumulating while completing the exercise.

Students can also write “teacher’s materials”, i.e. learning materials for other students. Marja Liisa Sumelahti, clinical teacher of neurology, is also cooperating with a group of twenty students in order to produce new material.

“A good and useful addition”
Ville Alvila, a fourth-year medical student, comes to the interview just before his on-call duty begins at Tampere University Hospital. He has also worked as a doctor at a health centre in Sastamala and at Acuta, the accident and emergency unit at Tampere University Hospital. Alvila has also treated virtual patients, both in the spring of his third year of studies and last autumn when his fourth year started.

“The most positive aspect about virtual patients is that it is a new method of studying. When one encounters similar problems in different ways, one’s recall becomes stronger,” Alvila says.

However, working as a doctor means interacting with patients. Virtual patients do not improve the doctor’s bedside manner, but Alvila points out that that is not the intention.

“The most important thing to remember is that virtual patients can never replace contact with real patients. Virtual patients are above all a good and useful addition to other medical studies,” Alvila says.

Text: Satu Saari
Photographs: Jonne Renvall