@Article{info:doi/10.2196/65670, author="Weisman, Dan and Sugarman, Alanna and Huang, Ming Yue and Gelberg, Lillian and Ganz, A. Patricia and Comulada, Scott Warren", title="Development of a GPT-4--Powered Virtual Simulated Patient and Communication Training Platform for Medical Students to Practice Discussing Abnormal Mammogram Results With Patients: Multiphase Study", journal="JMIR Form Res", year="2025", month="Apr", day="17", volume="9", pages="e65670", keywords="standardized patient", keywords="virtual simulated patient", keywords="artificial intelligence", keywords="AI", keywords="large language model", keywords="LLM", keywords="GPT-4", keywords="agent", keywords="communication skills training", keywords="abnormal mammography results", keywords="biopsy", abstract="Background: Standardized patients (SPs) prepare medical students for difficult conversations with patients. Despite their value, SP-based simulation training is constrained by available resources and competing clinical demands. Researchers are turning to artificial intelligence and large language models, such as generative pretrained transformers, to create communication training that incorporates virtual simulated patients (VSPs). GPT-4 is a large language model advance allowing developers to design virtual simulation scenarios using text-based prompts instead of relying on branching path simulations with prescripted dialogue. These nascent developmental practices have not taken root in the literature to guide other researchers in developing their own simulations. Objective: This study aims to describe our developmental process and lessons learned for creating a GPT-4--driven VSP. We designed the VSP to help medical student learners rehearse discussing abnormal mammography results with a patient as a primary care physician (PCP). We aimed to assess GPT-4's ability to generate appropriate VSP responses to learners during spoken conversations and provide appropriate feedback on learner performance. Methods: A research team comprised of physicians, a medical student, an educator, an SP program director, a learning experience designer, and a health care researcher conducted the study. A formative phase with in-depth knowledge user interviews informed development, followed by a development phase to create the virtual training module. The team conducted interviews with 5 medical students, 5 PCPs, and 5 breast cancer survivors. They then developed a VSP using simulation authoring software and provided the GPT-4--enabled VSP with an initial prompt consisting of a scenario description, emotional state, and expectations for learner dialogue. It was iteratively refined through an agile design process involving repeated cycles of testing, documenting issues, and revising the prompt. As an exploratory feature, the simulation used GPT-4 to provide written feedback to learners about their performance communicating with the VSP and their adherence to guidelines for difficult conversations. Results: In-depth interviews helped establish the appropriate timing, mode of communication, and protocol for conversations between PCPs and patients during the breast cancer screening process. The scenario simulated a telephone call between a physician and patient to discuss the abnormal results of a diagnostic mammogram that that indicated a need for a biopsy. Preliminary testing was promising. The VSP asked sensible questions about their mammography results and responded to learner inquiries using a voice replete with appropriate emotional inflections. GPT-4 generated performance feedback that successfully identified strengths and areas for improvement using relevant quotes from the learner-VSP conversation, but it occasionally misidentified learner adherence to communication protocols. Conclusions: GPT-4 streamlined development and facilitated more dynamic, humanlike interactions between learners and the VSP compared to branching path simulations. For the next steps, we will pilot-test the VSP with medical students to evaluate its feasibility and acceptability. ", doi="10.2196/65670", url="https://formative.jmir.org/2025/1/e65670" } @Article{info:doi/10.2196/63130, author="Ferr{\'e}, Fabrice and Allassonni{\`e}re, St{\'e}phanie and Chadebec, Cl{\'e}ment and Minville, Vincent", title="Generating Artificial Patients With Reliable Clinical Characteristics Using a Geometry-Based Variational Autoencoder: Proof-of-Concept Feasibility Study", journal="J Med Internet Res", year="2025", month="Apr", day="17", volume="27", pages="e63130", keywords="digital health", keywords="artificial data", keywords="variational autoencoder", keywords="data science", keywords="artificial intelligence", keywords="health monitoring", keywords="deep learning", keywords="medical imaging", keywords="imaging", keywords="magnetic resonance imaging", keywords="Alzheimer disease", keywords="anesthesia", keywords="prediction", keywords="data augmentation", abstract="Background: Artificial patient technology could transform health care by accelerating diagnosis, treatment, and mapping clinical pathways. Deep learning methods for generating artificial data in health care include data augmentation by variational autoencoders (VAE) technology. Objective: We aimed to test the feasibility of generating artificial patients with reliable clinical characteristics by using a geometry-based VAE applied, for the first time, on high-dimension, low-sample-size tabular data. Methods: Clinical tabular data were extracted from 521 real patients of the ``MAX'' digital conversational agent (BOTdesign) created for preparing patients for anesthesia. A 3-stage methodological approach was implemented to generate up to 10,000 artificial patients: training the model and generating artificial data, assessing the consistency and confidentiality of artificial data, and validating the plausibility of the newly created artificial patients. Results: We demonstrated the feasibility of applying the VAE technique to tabular data to generate large artificial patient cohorts with high consistency (fidelity scores>94\%). Moreover, artificial patients could not be matched with real patients (filter similarity scores>99\%, $\kappa$ coefficients of agreement<0.2), thus guaranteeing the essential ethical concern of confidentiality. Conclusions: This proof-of-concept study has demonstrated our ability to augment real tabular data to generate artificial patients. These promising results make it possible to envisage in silico trials carried out on large cohorts of artificial patients, thereby overcoming the pitfalls usually encountered in in vivo trials. Further studies integrating longitudinal dynamics are needed to map patient trajectories. ", doi="10.2196/63130", url="https://www.jmir.org/2025/1/e63130" } @Article{info:doi/10.2196/68486, author="Cook, A. David and Overgaard, Joshua and Pankratz, Shane V. and Del Fiol, Guilherme and Aakre, A. Chris", title="Virtual Patients Using Large Language Models: Scalable, Contextualized Simulation of Clinician-Patient Dialogue With Feedback", journal="J Med Internet Res", year="2025", month="Apr", day="4", volume="27", pages="e68486", keywords="simulation training", keywords="natural language processing", keywords="computer-assisted instruction", keywords="clinical decision-making", keywords="clinical reasoning", keywords="machine learning", keywords="virtual patient", keywords="natural language generation", abstract="Background: Virtual patients (VPs) are computer screen--based simulations of patient-clinician encounters. VP use is limited by cost and low scalability. Objective: We aimed to show that VPs powered by large language models (LLMs) can generate authentic dialogues, accurately represent patient preferences, and provide personalized feedback on clinical performance. We also explored using LLMs to rate the quality of dialogues and feedback. Methods: We conducted an intrinsic evaluation study rating 60 VP-clinician conversations. We used carefully engineered prompts to direct OpenAI's generative pretrained transformer (GPT) to emulate a patient and provide feedback. Using 2 outpatient medicine topics (chronic cough diagnosis and diabetes management), each with permutations representing different patient preferences, we created 60 conversations (dialogues plus feedback): 48 with a human clinician and 12 ``self-chat'' dialogues with GPT role-playing both the VP and clinician. Primary outcomes were dialogue authenticity and feedback quality, rated using novel instruments for which we conducted a validation study collecting evidence of content, internal structure (reproducibility), relations with other variables, and response process. Each conversation was rated by 3 physicians and by GPT. Secondary outcomes included user experience, bias, patient preferences represented in the dialogues, and conversation features that influenced authenticity. Results: The average cost per conversation was US \$0.51 for GPT-4.0-Turbo and US \$0.02 for GPT-3.5-Turbo. Mean (SD) conversation ratings, maximum 6, were overall dialogue authenticity 4.7 (0.7), overall user experience 4.9 (0.7), and average feedback quality 4.7 (0.6). For dialogues created using GPT-4.0-Turbo, physician ratings of patient preferences aligned with intended preferences in 20 to 47 of 48 dialogues (42\%-98\%). Subgroup comparisons revealed higher ratings for dialogues using GPT-4.0-Turbo versus GPT-3.5-Turbo and for human-generated versus self-chat dialogues. Feedback ratings were similar for human-generated versus GPT-generated ratings, whereas authenticity ratings were lower. We did not perceive bias in any conversation. Dialogue features that detracted from authenticity included that GPT was verbose or used atypical vocabulary (93/180, 51.7\% of conversations), was overly agreeable (n=56, 31\%), repeated the question as part of the response (n=47, 26\%), was easily convinced by clinician suggestions (n=35, 19\%), or was not disaffected by poor clinician performance (n=32, 18\%). For feedback, detractors included excessively positive feedback (n=42, 23\%), failure to mention important weaknesses or strengths (n=41, 23\%), or factual inaccuracies (n=39, 22\%). Regarding validation of dialogue and feedback scores, items were meticulously developed (content evidence), and we confirmed expected relations with other variables (higher ratings for advanced LLMs and human-generated dialogues). Reproducibility was suboptimal, due largely to variation in LLM performance rather than rater idiosyncrasies. Conclusions: LLM-powered VPs can simulate patient-clinician dialogues, demonstrably represent patient preferences, and provide personalized performance feedback. This approach is scalable, globally accessible, and inexpensive. LLM-generated ratings of feedback quality are similar to human ratings. ", doi="10.2196/68486", url="https://www.jmir.org/2025/1/e68486", url="http://www.ncbi.nlm.nih.gov/pubmed/39854611" } @Article{info:doi/10.2196/64619, author="Hiley, Katherine and Bi-Mohammad, Zanib and Taylor, Luke and Burgess-Dawson, Rebecca and Patterson, Dominic and Puttick-Whiteman, Devon and Gay, Christopher and Hiscoe, Janette and Munsch, Chris and Richardson, Sally and Knowles-Lee, Mark and Beecham, Celia and Ralph, Neil and Chatterjee, Arunangsu and Mathew, Ryan and Mushtaq, Faisal", title="Extended Reality--Enhanced Mental Health Consultation Training: Quantitative Evaluation Study", journal="JMIR Med Educ", year="2025", month="Apr", day="2", volume="11", pages="e64619", keywords="mental health", keywords="training", keywords="consultation", keywords="extended reality", keywords="virtual reality", keywords="augmented reality", abstract="Background: The use of extended reality (XR) technologies in health care can potentially address some of the significant resource and time constraints related to delivering training for health care professionals. While substantial progress in realizing this potential has been made across several domains, including surgery, anatomy, and rehabilitation, the implementation of XR in mental health training, where nuanced humanistic interactions are central, has lagged. Objective: Given the growing societal and health care service need for trained mental health and care workers, coupled with the heterogeneity of exposure during training and the shortage of placement opportunities, we explored the feasibility and utility of a novel XR tool for mental health consultation training. Specifically, we set out to evaluate a training simulation created through collaboration among software developers, clinicians, and learning technologists, in which users interact with a virtual patient, ``Stacey,'' through a virtual reality or augmented reality head-mounted display. The tool was designed to provide trainee health care professionals with an immersive experience of a consultation with a patient presenting with perinatal mental health symptoms. Users verbally interacted with the patient, and a human instructor selected responses from a repository of prerecorded voice-acted clips. Methods: In a pilot experiment, we confirmed the face validity and usability of this platform for perinatal and primary care training with subject-matter experts. In our follow-up experiment, we delivered personalized 1-hour training sessions to 123 participants, comprising mental health nursing trainees, general practitioner doctors in training, and students in psychology and medicine. This phase involved a comprehensive evaluation focusing on usability, validity, and both cognitive and affective learning outcomes. Results: We found significant enhancements in learning metrics across all participant groups. Notably, there was a marked increase in understanding (P<.001) and motivation (P<.001), coupled with decreased anxiety related to mental health consultations (P<.001). There were also significant improvements to considerations toward careers in perinatal mental health (P<.001). Conclusions: Our findings show, for the first time, that XR can be used to provide an effective, standardized, and reproducible tool for trainees to develop their mental health consultation skills. We suggest that XR could provide a solution to overcoming the current resource challenges associated with equipping current and future health care professionals, which are likely to be exacerbated by workforce expansion plans. ", doi="10.2196/64619", url="https://mededu.jmir.org/2025/1/e64619" } @Article{info:doi/10.2196/66821, author="El Kababji, Samer and Mitsakakis, Nicholas and Jonker, Elizabeth and Beltran-Bless, Ana-Alicia and Pond, Gregory and Vandermeer, Lisa and Radhakrishnan, Dhenuka and Mosquera, Lucy and Paterson, Alexander and Shepherd, Lois and Chen, Bingshu and Barlow, William and Gralow, Julie and Savard, Marie-France and Fesl, Christian and Hlauschek, Dominik and Balic, Marija and Rinnerthaler, Gabriel and Greil, Richard and Gnant, Michael and Clemons, Mark and El Emam, Khaled", title="Augmenting Insufficiently Accruing Oncology Clinical Trials Using Generative Models: Validation Study", journal="J Med Internet Res", year="2025", month="Mar", day="5", volume="27", pages="e66821", keywords="generative models", keywords="study accrual", keywords="recruitment", keywords="clinical trial replication", keywords="oncology", keywords="validation", keywords="simulated patient", keywords="simulation", keywords="retrospective", keywords="dataset", keywords="patient", keywords="artificial intelligence", keywords="machine learning", abstract="Background: Insufficient patient accrual is a major challenge in clinical trials and can result in underpowered studies, as well as exposing study participants to toxicity and additional costs, with limited scientific benefit. Real-world data can provide external controls, but insufficient accrual affects all arms of a study, not just controls. Studies that used generative models to simulate more patients were limited in the accrual scenarios considered, replicability criteria, number of generative models, and number of clinical trials evaluated. Objective: This study aimed to perform a comprehensive evaluation on the extent generative models can be used to simulate additional patients to compensate for insufficient accrual in clinical trials. Methods: We performed a retrospective analysis using 10 datasets from 9 fully accrued, completed, and published cancer trials. For each trial, we removed the latest recruited patients (from 10\% to 50\%), trained a generative model on the remaining patients, and simulated additional patients to replace the removed ones using the generative model to augment the available data. We then replicated the published analysis on this augmented dataset to determine if the findings remained the same. Four different generative models were evaluated: sequential synthesis with decision trees, Bayesian network, generative adversarial network, and a variational autoencoder. These generative models were compared to sampling with replacement (ie, bootstrap) as a simple alternative. Replication of the published analyses used 4 metrics: decision agreement, estimate agreement, standardized difference, and CI overlap. Results: Sequential synthesis performed well on the 4 replication metrics for the removal of up to 40\% of the last recruited patients (decision agreement: 88\% to 100\% across datasets, estimate agreement: 100\%, cannot reject standardized difference null hypothesis: 100\%, and CI overlap: 0.8-0.92). Sampling with replacement was the next most effective approach, with decision agreement varying from 78\% to 89\% across all datasets. There was no evidence of a monotonic relationship in the estimated effect size with recruitment order across these studies. This suggests that patients recruited earlier in a trial were not systematically different than those recruited later, at least partially explaining why generative models trained on early data can effectively simulate patients recruited later in a trial. The fidelity of the generated data relative to the training data on the Hellinger distance was high in all cases. Conclusions: For an oncology study with insufficient accrual with as few as 60\% of target recruitment, sequential synthesis can enable the simulation of the full dataset had the study continued accruing patients and can be an alternative to drawing conclusions from an underpowered study. These results provide evidence demonstrating the potential for generative models to rescue poorly accruing clinical trials, but additional studies are needed to confirm these findings and to generalize them for other diseases. ", doi="10.2196/66821", url="https://www.jmir.org/2025/1/e66821", url="http://www.ncbi.nlm.nih.gov/pubmed/40053790" } @Article{info:doi/10.2196/63312, author="Borg, Alexander and Georg, Carina and Jobs, Benjamin and Huss, Viking and Waldenlind, Kristin and Ruiz, Mini and Edelbring, Samuel and Skantze, Gabriel and Parodis, Ioannis", title="Virtual Patient Simulations Using Social Robotics Combined With Large Language Models for Clinical Reasoning Training in Medical Education: Mixed Methods Study", journal="J Med Internet Res", year="2025", month="Mar", day="3", volume="27", pages="e63312", keywords="virtual patients", keywords="clinical reasoning", keywords="large language models", keywords="social robotics", keywords="medical education", keywords="sustainable learning", keywords="medical students", abstract="Background: Virtual patients (VPs) are computer-based simulations of clinical scenarios used in health professions education to address various learning outcomes, including clinical reasoning (CR). CR is a crucial skill for health care practitioners, and its inadequacy can compromise patient safety. Recent advancements in large language models (LLMs) and social robots have introduced new possibilities for enhancing VP interactivity and realism. However, their application in VP simulations has been limited, and no studies have investigated the effectiveness of combining LLMs with social robots for CR training. Objective: The aim of the study is to explore the potential added value of a social robotic VP platform combined with an LLM compared to a conventional computer-based VP modality for CR training of medical students. Methods: A Swedish explorative proof-of-concept study was conducted between May and July 2023, combining quantitative and qualitative methodology. In total, 15 medical students from Karolinska Institutet and an international exchange program completed a VP case in a social robotic platform and a computer-based semilinear platform. Students' self-perceived VP experience focusing on CR training was assessed using a previously developed index, and paired 2-tailed t test was used to compare mean scores (scales from 1 to 5) between the platforms. Moreover, in-depth interviews were conducted with 8 medical students. Results: The social robotic platform was perceived as more authentic (mean 4.5, SD 0.7 vs mean 3.9, SD 0.5; odds ratio [OR] 2.9, 95\% CI 0.0-1.0; P=.04) and provided a beneficial overall learning effect (mean 4.4, SD 0.6 versus mean 4.1, SD 0.6; OR 3.7, 95\% CI 0.1-0.5; P=.01) compared with the computer-based platform. Qualitative analysis revealed 4 themes, wherein students experienced the social robot as superior to the computer-based platform in training CR, communication, and emotional skills. Limitations related to technical and user-related aspects were identified, and suggestions for improvements included enhanced facial expressions and VP cases simulating multiple personalities. Conclusions: A social robotic platform enhanced by an LLM may provide an authentic and engaging learning experience for medical students in the context of VP simulations for training CR. Beyond its limitations, several aspects of potential improvement were identified for the social robotic platform, lending promise for this technology as a means toward the attainment of learning outcomes within medical education curricula. ", doi="10.2196/63312", url="https://www.jmir.org/2025/1/e63312", url="http://www.ncbi.nlm.nih.gov/pubmed/40053778" } @Article{info:doi/10.2196/62688, author="Koivisto, Jaana-Maija and K{\"a}m{\"a}r{\"a}inen, Sanna and Mattsson, Katri and Jumisko-Pyykk{\"o}, Satu and Ikonen, Riikka and Haavisto, Elina", title="Exploring Nursing Students' Experiences of Empathy and User Experiences in an Immersive Virtual Reality Simulation Game: Cross-Sectional Study", journal="JMIR Serious Games", year="2025", month="Feb", day="13", volume="13", pages="e62688", keywords="education", keywords="nursing", keywords="learning", keywords="empathy", keywords="virtual reality", keywords="simulation", keywords="user experience", keywords="cross sectional", abstract="Background: Empathy is associated with better clinical outcomes and patient-care experiences, and it has been demonstrated that training can improve nursing students' empathy. The use of virtual reality (VR) as an experiential learning strategy may increase the empathetic behavior of caregivers. Although much research exists on the use of VR in education, there is still little research on learning empathy in nursing education through immersive VR games that include a head-mounted display and hand controllers. In addition, it is important to study both learning and user experiences in nursing education that utilizes VR technology. Objective: This study aims to explore nursing students' experiences of empathy and user experiences in an immersive VR simulation game. Methods: A cross-sectional design was used. A total of 52 graduating nursing students from 3 universities of applied sciences in Finland participated in the study. The immersive VR simulation game employed in the study was played with a head-mounted display and hand controllers. The instruments used were the Basic Empathy Scale in Adults (BES-A) before the VR simulation gaming session and the Comprehensive State Empathy Scale (CSES) and AttrakDiff 2.0 Scale after the session. Results: The students' overall level of empathy experienced in the immersive VR simulation game was favorable (CSES; mean 2.9, SD 0.57). Participants who had a higher level of empathy (BES-A) before playing the immersive VR simulation game also experienced slightly more feelings of empathy after playing (CSES). However, the association between the measures was not statistically significant (r=0.187, P=.18). The overall empathy (CSES) experienced in the immersive VR simulation game was positively correlated with its subscales. The use of the VR simulation provided a positive user experience in all 4 factors of the AttrakDiff 2.0 Scale. Overall User Experience and Emotion Sharing correlated negatively (r=?0.248, P=.042), as did Attractiveness and Emotion Sharing (r=?0.327, P=.018). Hedonic Quality Stimulation correlated negatively with Cognitive Empathy (r=--0.279, P=.045). Conclusions: The results of this study indicate that the use of an immersive VR simulation game in nursing education as a means of increasing empathy seems promising and justified. The immersive VR simulation game offered positive user experiences, which further supported the idea of implementing it in education. However, more research is needed on what kinds of VR environments are the most effective in promoting empathy among nursing students. Furthermore, when using VR technology in learning, one should consider that the VR setting must not be too technical but rather simple, straightforward, and predictable. ", doi="10.2196/62688", url="https://games.jmir.org/2025/1/e62688" } @Article{info:doi/10.2196/64780, author="Chang, Wen and Lin, Chun-Chih and Crilly, Julia and Lee, Hui-Ling and Chen, Li-Chin and Han, Chin-Yen", title="Virtual Reality Simulation for Undergraduate Nursing Students for Care of Patients With Infectious Diseases: Mixed Methods Study", journal="JMIR Med Educ", year="2025", month="Feb", day="11", volume="11", pages="e64780", keywords="virtual reality", keywords="infection control", keywords="learning motivation", keywords="learning attitudes", keywords="nursing education", abstract="Background: Virtual reality simulation (VRS) teaching offers nursing students a safe, immersive learning environment with immediate feedback, enhancing learning outcomes. Before the COVID-19 pandemic, nursing students had limited training and opportunities to care for patients in isolation units with infectious diseases. However, the pandemic highlighted the ongoing global priority of providing care for patients with infectious diseases. Objective: This study aims to (1) examine the effectiveness of VRS in preparing nursing students to care for patients with infectious diseases by assessing its impact on their theoretical knowledge, learning motivation, and attitudes; and (2) evaluate their experiences with VRS. Methods: This 2-phased mixed methods study recruited third-year undergraduate nursing students enrolled in the Integrated Emergency and Critical Care course at a university in Taiwan. Phase 1 used a quasi-experimental design to address objective 1 by comparing the learning outcomes of students in the VRS teaching program (experimental group) with those in the traditional teaching program (control group). Tools included an infection control written test, the Instructional Materials Motivation Survey, and a learning attitude questionnaire. The experimental group participated in a VRS lesson titled ``Caring for a Patient with COVID-19 in the Negative Pressure Unit'' as part of the infection control unit. In phase 2, semistructured interviews were conducted to address objective 2, exploring students' learning experiences. Results: A total of 107 students participated in phase 1, and 18 students participated in phase 2. Both the VRS and control groups showed significant improvements in theoretical knowledge scores (for the VRS group t46=--7.47; P<.001, for the control group t59=--4.04; P<.001). However, compared with the control group, the VRS group achieved significantly higher theoretical knowledge scores (t98.13=2.70; P=.008) and greater learning attention (t105=2.30; P=.02) at T1. Additionally, the VRS group demonstrated a statistically significant higher regression coefficient for learning confidence compared with the control group ($\beta$=.29; P=.03). The students' learning experiences in the VRS group were categorized into 4 themes: Applying Professional Knowledge to Patient Care, Enhancing Infection Control Skills, Demonstrating Patient Care Confidence, and Engaging in Real Clinical Cases. The core theme identified was Strengthening Clinical Patient Care Competencies. Conclusions: The findings suggest that VRS teaching significantly enhanced undergraduate nursing students' infection control knowledge, learning attention, and confidence. Qualitative insights reinforced the quantitative results, highlighting the holistic benefits of VRS teaching in nursing education, including improved learning outcomes. The positive impact on student motivation and attitudes indicates a potentially transformative approach to nursing education, particularly in the post--COVID-19 era, where digital and remote learning tools play an increasingly vital role. ", doi="10.2196/64780", url="https://mededu.jmir.org/2025/1/e64780" } @Article{info:doi/10.2196/68743, author="Shikino, Kiyoshi and Yamauchi, Kazuyo and Araki, Nobuyuki and Shimizu, Ikuo and Kasai, Hajime and Tsukamoto, Tomoko and Tajima, Hiroshi and Li, Yu and Onodera, Misaki and Ito, Shoichi", title="Understanding Community Health Care Through Problem-Based Learning With Real-Patient Videos: Single-Arm Pre-Post Mixed Methods Study", journal="JMIR Med Educ", year="2025", month="Jan", day="31", volume="11", pages="e68743", keywords="community health care", keywords="community-oriented medical education", keywords="mixed method", keywords="problem-based learning", keywords="real-patient video", abstract="Background: Japan faces a health care delivery challenge due to physician maldistribution, with insufficient physicians practicing in rural areas. This issue impacts health care access in remote areas and affects patient outcomes. Educational interventions targeting students' career decision-making can potentially address this problem by promoting interest in rural medicine. We hypothesized that community-based problem-based learning (PBL) using real-patient videos could foster students' understanding of community health care and encourage positive attitudes toward rural health care. Objective: This study investigated the impact of community-based PBL on medical students' understanding and engagement with rural health care, focusing on their knowledge, skills, and career orientation. Methods: Participants were 113 fourth-year medical students from Chiba University, engaged in a transition course between preclinical and clinical clerkships from October 24 to November 2, 2023. The students were randomly divided into 16 groups (7-8 participants per group). Each group participated in two 3-hour PBL sessions per week over 2 consecutive weeks. Quantitative data were collected using pre- and postintervention questionnaires, comprehension tests, and tutor-assessed rubrics. Self-assessment questionnaires evaluated the students' interest in community health care and their ability to envision community health care settings before and after the intervention. Qualitative data from the students' semistructured interviews after the PBL sessions assessed the influence of PBL experience on clinical clerkship in community hospitals. Statistical analysis included median (IQR), effect sizes, and P values for quantitative outcomes. Thematic analysis was used for qualitative data. Results: Of the 113 participants, 71 (62.8\%) were male and 42 (37.2\%) female. The total comprehension test scores improved significantly (pretest: median 4.0, IQR 2.5-5.0; posttest: median 5, IQR 4-5; P<.001; effect size r=0.528). Rubric-based assessments showed increased knowledge application (pretest: median 8, IQR 7-9; posttest: median 8, IQR 8-8; P<.001; r=0.494) and self-directed learning (pretest: median 8, IQR 7-9; posttest: median 8, IQR 8-8; P<.001; r=0.553). Self-assessment questionnaires revealed significant improvements in the students' interest in community health care (median 3, IQR 3-4 to median 4, IQR 3-4; P<.001) and their ability to envision community health care settings (median 3, IQR 3-4 to median 4, IQR 3-4; P<.001). Thematic analysis revealed key themes, such as ``empathy in patient care,'' ``challenges in home health care,'' and ``professional identity formation.'' Conclusions: Community-based PBL with real-patient videos effectively enhances medical students' understanding of rural health care settings, clinician roles, and the social needs of rural patients. This approach holds potential as an educational strategy to address physician maldistribution. Although this study suggests potential for fostering positive attitudes toward rural health care, further research is needed to assess its long-term impact on students' career trajectories. ", doi="10.2196/68743", url="https://mededu.jmir.org/2025/1/e68743" } @Article{info:doi/10.2196/57331, author="Mayer, Anja and Hege, Inga and Kononowicz, A. Andrzej and M{\"u}ller, Anja and Sudacka, Ma?gorzata", title="Collaborative Development of Feedback Concept Maps for Virtual Patient--Based Clinical Reasoning Education: Mixed Methods Study", journal="JMIR Med Educ", year="2025", month="Jan", day="30", volume="11", pages="e57331", keywords="clinical reasoning", keywords="consensus building process", keywords="concept map", keywords="consensus map", keywords="virtual patient", keywords="international collaboration", keywords="health professionals' education", keywords="undergraduate", keywords="collaborative", keywords="development", keywords="feedback", keywords="content analysis", keywords="health professional", keywords="medical student", keywords="mixed method", keywords="Europe", keywords="questionnaire", keywords="descriptive analysis", abstract="Background: Concept maps are a suitable method for teaching clinical reasoning (CR). For example, in a concept map, findings, tests, differential diagnoses, and treatment options can be documented and connected to each other. When combined with virtual patients, automated feedback can be provided to the students' concept maps. However, as CR is a nonlinear process, feedback concept maps that are created together by several individuals might address this issue and cover perspectives from different health professionals. Objective: In this study, we aimed to develop a collaborative process for creating feedback concept maps in virtual patient--based CR education. Methods: Health professionals of different specialties, nationalities, and levels of experience in education individually created concept maps and afterward reached a consensus on them in structured workshops. Then, medical students discussed the health professionals' concept maps in focus groups. We performed a qualitative content analysis of the transcribed audio records and field notes and a descriptive comparison of the produced concept maps. Results: A total of 14 health professionals participated in 4 workshops, each with 3?4 participants. In each workshop, they reached a consensus on 1 concept map, after discussing content and presentation, as well as rationales, and next steps. Overall, the structure of the workshops was well-received. The comparison of the produced concept maps showed that they varied widely in their scope and content. Consensus concept maps tended to contain more nodes and connections than individual ones. A total of 9 medical students participated in 2 focus groups of 4 and 5 participants. Their opinions on the concept maps' features varied widely, balancing between the wish for an in-depth explanation and the flexibility of CR. Conclusions: Although the number of participating health professionals and students was relatively low, we were able to show that consensus workshops are a constructive method to create feedback concept maps that include different perspectives of health professionals with content that is useful to and accepted by students. Further research is needed to determine which features of feedback concept maps are most likely to improve learner outcomes and how to facilitate their construction in collaborative consensus workshops. ", doi="10.2196/57331", url="https://mededu.jmir.org/2025/1/e57331" } @Article{info:doi/10.2196/58623, author="Guti{\'e}rrez Maquil{\'o}n, Rodrigo and Uhl, Jakob and Schrom-Feiertag, Helmut and Tscheligi, Manfred", title="Integrating GPT-Based AI into Virtual Patients to Facilitate Communication Training Among Medical First Responders: Usability Study of Mixed Reality Simulation", journal="JMIR Form Res", year="2024", month="Dec", day="11", volume="8", pages="e58623", keywords="medical first responders", keywords="verbal communication skills", keywords="training", keywords="virtual patient", keywords="generative artificial intelligence", keywords="GPT", keywords="large language models", keywords="prompt engineering", keywords="mixed reality", abstract="Background: Training in social-verbal interactions is crucial for medical first responders (MFRs) to assess a patient's condition and perform urgent treatment during emergency medical service administration. Integrating conversational agents (CAs) in virtual patients (VPs), that is, digital simulations, is a cost-effective alternative to resource-intensive human role-playing. There is moderate evidence that CAs improve communication skills more effectively when used with instructional interventions. However, more recent GPT-based artificial intelligence (AI) produces richer, more diverse, and more natural responses than previous CAs and has control of prosodic voice qualities like pitch and duration. These functionalities have the potential to better match the interaction expectations of MFRs regarding habitability. Objective: We aimed to study how the integration of GPT-based AI in a mixed reality (MR)--VP could support communication training of MFRs. Methods: We developed an MR simulation of a traffic accident with a VP. ChatGPT (OpenAI) was integrated into the VP and prompted with verified characteristics of accident victims. MFRs (N=24) were instructed on how to interact with the MR scenario. After assessing and treating the VP, the MFRs were administered the Mean Opinion Scale-Expanded, version 2, and the Subjective Assessment of Speech System Interfaces questionnaires to study their perception of the voice quality and the usability of the voice interactions, respectively. Open-ended questions were asked after completing the questionnaires. The observed and logged interactions with the VP, descriptive statistics of the questionnaires, and the output of the open-ended questions are reported. Results: The usability assessment of the VP resulted in moderate positive ratings, especially in habitability (median 4.25, IQR 4-4.81) and likeability (median 4.50, IQR 3.97-5.91). Interactions were negatively affected by the approximately 3-second latency of the responses. MFRs acknowledged the naturalness of determining the physiological states of the VP through verbal communication, for example, with questions such as ``Where does it hurt?'' However, the question-answer dynamic in the verbal exchange with the VP and the lack of the VP's ability to start the verbal exchange were noticed. Noteworthy insights highlighted the potential of domain-knowledge prompt engineering to steer the actions of MFRs for effective training. Conclusions: Generative AI in VPs facilitates MFRs' training but continues to rely on instructions for effective verbal interactions. Therefore, the capabilities of the GPT-VP and a training protocol need to be communicated to trainees. Future interactions should implement triggers based on keyword recognition, the VP pointing to the hurting area, conversational turn-taking techniques, and add the ability for the VP to start a verbal exchange. Furthermore, a local AI server, chunk processing, and lowering the audio resolution of the VP's voice could ameliorate the delay in response and allay privacy concerns. Prompting could be used in future studies to create a virtual MFR capable of assisting trainees. ", doi="10.2196/58623", url="https://formative.jmir.org/2024/1/e58623", url="http://www.ncbi.nlm.nih.gov/pubmed/39661979" } @Article{info:doi/10.2196/56195, author="Jiang, Nan and Zhang, Yuelun and Liang, Siyu and Lyu, Xiaohong and Chen, Shi and Huang, Xiaoming and Pan, Hui", title="Effectiveness of Virtual Simulations Versus Mannequins and Real Persons in Medical and Nursing Education: Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials", journal="J Med Internet Res", year="2024", month="Dec", day="5", volume="26", pages="e56195", keywords="artificial intelligence", keywords="clinical virtual simulation", keywords="medical education", keywords="meta-analysis", keywords="nursing education", keywords="virtual patient", keywords="virtual reality", abstract="Background: Virtual simulation (VS) is a developing education approach with the recreation of reality using digital technology. The teaching effectiveness of VSs compared to mannequins and real persons (RPs) has never been investigated in medical and nursing education. Objective: This study aims to compare VSs and mannequins or RPs in improving the following clinical competencies: knowledge, procedural skills, clinical reasoning, and communication skills. Methods: Following Cochrane methodology, a meta-analysis was conducted on the effectiveness of VSs in pre- and postregistration medical or nursing participants. The Cochrane Library, PubMed, Embase, and Educational Resource Information Centre databases were searched to identify English-written randomized controlled trials up to August 2024. Two authors independently selected studies, extracted data, and assessed the risk of bias. All pooled estimates were based on random-effects models and assessed by trial sequential analyses. Leave-one-out, subgroup, and univariate meta-regression analyses were performed to explore sources of heterogeneity. Results: A total of 27 studies with 1480 participants were included. Overall, there were no significant differences between VSs and mannequins or RPs in improving knowledge (standard mean difference [SMD]=0.08; 95\% CI --0.30 to 0.47; I2=67\%; P=.002), procedural skills (SMD=--0.12; 95\% CI --0.47 to 0.23; I2=75\%; P<.001), clinical reasoning (SMD=0.29; 95\% CI --0.26 to 0.85; I2=88\%; P<.001), and communication skills (SMD=--0.02; 95\% CI: --0.62 to 0.58; I2=86\%; P<.001). Trial sequential analysis for clinical reasoning indicated an insufficient sample size for a definitive judgment. For procedural skills, subgroup analyses showed that VSs were less effective among nursing participants (SMD=--0.55; 95\% CI --1.07 to --0.03; I2=69\%; P=.04). Univariate meta-regression detected a positive effect of publication year ($\beta$=.09; P=.02) on communication skill scores. Conclusions: Given favorable cost-utility plus high flexibility regarding time and space, VSs are viable alternatives to traditional face-to-face learning modalities. The comparative effectiveness of VSs deserves to be followed up with the emergence of new technology. In addition, further investigation of VSs with different design features will provide novel insights to drive education reform. Trial Registration: PROSPERO CRD42023466622; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=466622 ", doi="10.2196/56195", url="https://www.jmir.org/2024/1/e56195" } @Article{info:doi/10.2196/58753, author="Yamamoto, Akira and Koda, Masahide and Ogawa, Hiroko and Miyoshi, Tomoko and Maeda, Yoshinobu and Otsuka, Fumio and Ino, Hideo", title="Enhancing Medical Interview Skills Through AI-Simulated Patient Interactions: Nonrandomized Controlled Trial", journal="JMIR Med Educ", year="2024", month="Sep", day="23", volume="10", pages="e58753", keywords="medical interview", keywords="generative pretrained transformer", keywords="large language model", keywords="simulation-based learning", keywords="OSCE", keywords="artificial intelligence", keywords="medical education", keywords="simulated patients", keywords="nonrandomized controlled trial", abstract="Background: Medical interviewing is a critical skill in clinical practice, yet opportunities for practical training are limited in Japanese medical schools, necessitating urgent measures. Given advancements in artificial intelligence (AI) technology, its application in the medical field is expanding. However, reports on its application in medical interviews in medical education are scarce. Objective: This study aimed to investigate whether medical students' interview skills could be improved by engaging with AI-simulated patients using large language models, including the provision of feedback. Methods: This nonrandomized controlled trial was conducted with fourth-year medical students in Japan. A simulation program using large language models was provided to 35 students in the intervention group in 2023, while 110 students from 2022 who did not participate in the intervention were selected as the control group. The primary outcome was the score on the Pre-Clinical Clerkship Objective Structured Clinical Examination (pre-CC OSCE), a national standardized clinical skills examination, in medical interviewing. Secondary outcomes included surveys such as the Simulation-Based Training Quality Assurance Tool (SBT-QA10), administered at the start and end of the study. Results: The AI intervention group showed significantly higher scores on medical interviews than the control group (AI group vs control group: mean 28.1, SD 1.6 vs 27.1, SD 2.2; P=.01). There was a trend of inverse correlation between the SBT-QA10 and pre-CC OSCE scores (regression coefficient --2.0 to --2.1). No significant safety concerns were observed. Conclusions: Education through medical interviews using AI-simulated patients has demonstrated safety and a certain level of educational effectiveness. However, at present, the educational effects of this platform on nonverbal communication skills are limited, suggesting that it should be used as a supplementary tool to traditional simulation education. ", doi="10.2196/58753", url="https://mededu.jmir.org/2024/1/e58753", url="http://www.ncbi.nlm.nih.gov/pubmed/39312284" } @Article{info:doi/10.2196/50705, author="Gray, Megan and Baird, Austin and Sawyer, Taylor and James, Jasmine and DeBroux, Thea and Bartlett, Michelle and Krick, Jeanne and Umoren, Rachel", title="Increasing Realism and Variety of Virtual Patient Dialogues for Prenatal Counseling Education Through a Novel Application of ChatGPT: Exploratory Observational Study", journal="JMIR Med Educ", year="2024", month="Feb", day="1", volume="10", pages="e50705", keywords="prenatal counseling", keywords="virtual health", keywords="virtual patient", keywords="simulation", keywords="neonatology", keywords="ChatGPT", keywords="AI", keywords="artificial intelligence", abstract="Background: Using virtual patients, facilitated by natural language processing, provides a valuable educational experience for learners. Generating a large, varied sample of realistic and appropriate responses for virtual patients is challenging. Artificial intelligence (AI) programs can be a viable source for these responses, but their utility for this purpose has not been explored. Objective: In this study, we explored the effectiveness of generative AI (ChatGPT) in developing realistic virtual standardized patient dialogues to teach prenatal counseling skills. Methods: ChatGPT was prompted to generate a list of common areas of concern and questions that families expecting preterm delivery at 24 weeks gestation might ask during prenatal counseling. ChatGPT was then prompted to generate 2 role-plays with dialogues between a parent expecting a potential preterm delivery at 24 weeks and their counseling physician using each of the example questions. The prompt was repeated for 2 unique role-plays: one parent was characterized as anxious and the other as having low trust in the medical system. Role-play scripts were exported verbatim and independently reviewed by 2 neonatologists with experience in prenatal counseling, using a scale of 1-5 on realism, appropriateness, and utility for virtual standardized patient responses. Results: ChatGPT generated 7 areas of concern, with 35 example questions used to generate role-plays. The 35 role-play transcripts generated 176 unique parent responses (median 5, IQR 4-6, per role-play) with 268 unique sentences. Expert review identified 117 (65\%) of the 176 responses as indicating an emotion, either directly or indirectly. Approximately half (98/176, 56\%) of the responses had 2 or more sentences, and half (88/176, 50\%) included at least 1 question. More than half (104/176, 58\%) of the responses from role-played parent characters described a feeling, such as being scared, worried, or concerned. The role-plays of parents with low trust in the medical system generated many unique sentences (n=50). Most of the sentences in the responses were found to be reasonably realistic (214/268, 80\%), appropriate for variable prenatal counseling conversation paths (233/268, 87\%), and usable without more than a minimal modification in a virtual patient program (169/268, 63\%). Conclusions: Generative AI programs, such as ChatGPT, may provide a viable source of training materials to expand virtual patient programs, with careful attention to the concerns and questions of patients and families. Given the potential for unrealistic or inappropriate statements and questions, an expert should review AI chat outputs before deploying them in an educational program. ", doi="10.2196/50705", url="https://mededu.jmir.org/2024/1/e50705", url="http://www.ncbi.nlm.nih.gov/pubmed/38300696" } @Article{info:doi/10.2196/45946, author="Antoniou, Panagiotis and Dafli, Eleni and Giannakoulas, George and Igimbayeva, Gaukhar and Visternichan, Olga and Kyselov, Serhii and Lykhasenko, Ivetta and Lashkul, Dmytro and Nadareishvili, Ilia and Tabagari, Sergo and Bamidis, D. Panagiotis", title="Education of Patients With Atrial Fibrillation and Evaluation of the Efficacy of a Mobile Virtual Patient Environment: Protocol for a Multicenter Pseudorandomized Controlled Trial", journal="JMIR Res Protoc", year="2024", month="Jan", day="23", volume="13", pages="e45946", keywords="atrial fibrillation", keywords="virtual patient", keywords="scenario based learning", keywords="technology enhanced learning", keywords="mHealth", keywords="mobile health", keywords="patient engagement", keywords="patient education", keywords="cardiac arrhythmia", keywords="mortality", keywords="mobile application", keywords="mobile app", keywords="health education", keywords="randomized control trial", keywords="cardiology", keywords="cardiac", keywords="heart", keywords="Greece", keywords="Ukraine", keywords="Kazakhstan", keywords="clinical decision support systems", keywords="CDSS", keywords="virtual patient scenario", keywords="myocardial infarction", keywords="arrhythmia", keywords="stroke", abstract="Background: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is a leading cause of mortality and morbidity. Patient knowledge about AF and its management is paramount but often limited. Patients need to be appropriately informed about treatment options, medicinal adherence, and potential consequences of nonadherence, while also understanding treatment goals and expectations from it. Mobile health apps have experienced an explosion both in their availability and acceptance as ``soft interventions'' for patient engagement and education; however, the prolific nature of such solutions revealed a gap in the evidence base regarding their efficacy and impact. Virtual patients (VPs), interactive computer simulations, have been used as learning activities in modern health care education. VPs demonstrably improved cognitive and behavioral skills; hence, they have been effectively implemented across undergraduate and postgraduate curricula. However, their application in patient education has been rather limited so far. Objective: This work aims to implement and evaluate the efficacy of a mobile-deployed VP regimen for the education and engagement of patients with AF on crucial topics regarding their condition. A mobile VP app is being developed with the goal of each VP being a simple scenario with a set goal and very specific messages and will be subsequently attempted and evaluated. Methods: A mobile VP player app is being developed so as to be used for the design of 3 educational scenarios for AF management. A pseudorandomized controlled trial for the efficacy of VPs is planned to be executed at 3 sites in Greece, Ukraine, and Kazakhstan for patients with AF. The Welch t test will be used to demonstrate the performance of patients' evaluation of the VP experience. Results: Our study is at the development stage. A preliminary study regarding the system's development and feasibility was initiated in December 2022. The results of our study are expected to be available in 2024 or when the needed sample size is achieved. Conclusions: This study aims to evaluate and demonstrate the first significant evidence for the value of VP resources in outreach and training endeavors for empowering and patients with AF and fostering healthy habits among them. International Registered Report Identifier (IRRID): PRR1-10.2196/45946 ", doi="10.2196/45946", url="https://www.researchprotocols.org/2024/1/e45946", url="http://www.ncbi.nlm.nih.gov/pubmed/38261376" } @Article{info:doi/10.2196/53961, author="Holderried, Friederike and Stegemann--Philipps, Christian and Herschbach, Lea and Moldt, Julia-Astrid and Nevins, Andrew and Griewatz, Jan and Holderried, Martin and Herrmann-Werner, Anne and Festl-Wietek, Teresa and Mahling, Moritz", title="A Generative Pretrained Transformer (GPT)--Powered Chatbot as a Simulated Patient to Practice History Taking: Prospective, Mixed Methods Study", journal="JMIR Med Educ", year="2024", month="Jan", day="16", volume="10", pages="e53961", keywords="simulated patient", keywords="GPT", keywords="generative pretrained transformer", keywords="ChatGPT", keywords="history taking", keywords="medical education", keywords="documentation", keywords="history", keywords="simulated", keywords="simulation", keywords="simulations", keywords="NLP", keywords="natural language processing", keywords="artificial intelligence", keywords="interactive", keywords="chatbot", keywords="chatbots", keywords="conversational agent", keywords="conversational agents", keywords="answer", keywords="answers", keywords="response", keywords="responses", keywords="human computer", keywords="human machine", keywords="usability", keywords="satisfaction", abstract="Background: Communication is a core competency of medical professionals and of utmost importance for patient safety. Although medical curricula emphasize communication training, traditional formats, such as real or simulated patient interactions, can present psychological stress and are limited in repetition. The recent emergence of large language models (LLMs), such as generative pretrained transformer (GPT), offers an opportunity to overcome these restrictions Objective: The aim of this study was to explore the feasibility of a GPT-driven chatbot to practice history taking, one of the core competencies of communication. Methods: We developed an interactive chatbot interface using GPT-3.5 and a specific prompt including a chatbot-optimized illness script and a behavioral component. Following a mixed methods approach, we invited medical students to voluntarily practice history taking. To determine whether GPT provides suitable answers as a simulated patient, the conversations were recorded and analyzed using quantitative and qualitative approaches. We analyzed the extent to which the questions and answers aligned with the provided script, as well as the medical plausibility of the answers. Finally, the students filled out the Chatbot Usability Questionnaire (CUQ). Results: A total of 28 students practiced with our chatbot (mean age 23.4, SD 2.9 years). We recorded a total of 826 question-answer pairs (QAPs), with a median of 27.5 QAPs per conversation and 94.7\% (n=782) pertaining to history taking. When questions were explicitly covered by the script (n=502, 60.3\%), the GPT-provided answers were mostly based on explicit script information (n=471, 94.4\%). For questions not covered by the script (n=195, 23.4\%), the GPT answers used 56.4\% (n=110) fictitious information. Regarding plausibility, 842 (97.9\%) of 860 QAPs were rated as plausible. Of the 14 (2.1\%) implausible answers, GPT provided answers rated as socially desirable, leaving role identity, ignoring script information, illogical reasoning, and calculation error. Despite these results, the CUQ revealed an overall positive user experience (77/100 points). Conclusions: Our data showed that LLMs, such as GPT, can provide a simulated patient experience and yield a good user experience and a majority of plausible answers. Our analysis revealed that GPT-provided answers use either explicit script information or are based on available information, which can be understood as abductive reasoning. Although rare, the GPT-based chatbot provides implausible information in some instances, with the major tendency being socially desirable instead of medically plausible information. ", doi="10.2196/53961", url="https://mededu.jmir.org/2024/1/e53961", url="http://www.ncbi.nlm.nih.gov/pubmed/38227363" } @Article{info:doi/10.2196/52711, author="Hsieh, Hsing-yen and Lin, Chyi-her and Huang, Ruyi and Lin, Guan-chun and Lin, Jhen-Yu and Aldana, Clydie", title="Challenges for Medical Students in Applying Ethical Principles to Allocate Life-Saving Medical Devices During the COVID-19 Pandemic: Content Analysis", journal="JMIR Med Educ", year="2024", month="Jan", day="5", volume="10", pages="e52711", keywords="virtual patient", keywords="virtual patients", keywords="medical resources distribution", keywords="medical ethical education", keywords="COVID-19 pandemic", keywords="ethics", keywords="medical student", keywords="medical students", keywords="medical ethics", keywords="decision-making", keywords="ethical dilemna", keywords="simulation", keywords="reasoning", keywords="decision support", keywords="medical guideline", keywords="medical guidelines", keywords="medical devices", keywords="medical device", keywords="life-saving", keywords="thematic analysis", keywords="virtual platform", abstract="Background: The emergence of the COVID-19 pandemic has posed a significant ethical dilemma in the allocation of scarce, life-saving medical equipment to critically ill patients. It remains uncertain whether medical students are equipped to navigate this complex ethical process. Objective: This study aimed to assess the ability and confidence of medical students to apply principles of medical ethics in allocating critical medical devices through the scenario of virtual patients. Methods: The study recruited third- and fourth-year medical students during clinical rotation. We facilitated interactions between medical students and virtual patients experiencing respiratory failure due to COVID-19 infection. We assessed the students' ability to ethically allocate life-saving resources. Subsequently, we analyzed their written reports using thematic analysis to identify the ethical principles guiding their decision-making. Results: We enrolled a cohort of 67 out of 71 medical students with a mean age of 34 (SD 4.7) years, 60\% (n=40) of whom were female students. The principle of justice was cited by 73\% (n=49) of students while analyzing this scenario. A majority of them expressed hesitancy in determining which patient should receive life-saving resources, with 46\% (n=31) citing the principle of nonmaleficence, 31\% (n=21) advocating for a first-come-first-served approach, and 25\% (n=17) emphasizing respect for patient autonomy as key influencers in their decisions. Notably, medical students exhibited a lack of confidence in making ethical decisions concerning the distribution of medical resources. A minority, comprising 12\% (n=8), proposed the exploration of legal alternatives, while 4\% (n=3) suggested medical guidelines and collective decision-making as potential substitutes for individual ethical choices to alleviate the stress associated with personal decision-making. Conclusions: This study highlights the importance of improving ethical reasoning under time constraints using virtual platforms. More than 70\% of medical students identified justice as the predominant principle in allocating limited medical resources to critically ill patients. However, they exhibited a lack of confidence in making ethical determinations and leaned toward principles such as nonmaleficence, patient autonomy, adherence to legal and medical standards, and collective decision-making to mitigate the pressure associated with such decisions. ", doi="10.2196/52711", url="https://mededu.jmir.org/2024/1/e52711", url="http://www.ncbi.nlm.nih.gov/pubmed/38050366" } @Article{info:doi/10.2196/44766, author="Hong, Chengang and Wang, Liping", title="Virtual Reality Technology in Nursing Professional Skills Training: Bibliometric Analysis", journal="JMIR Serious Games", year="2023", month="Aug", day="21", volume="11", pages="e44766", keywords="virtual reality", keywords="VR", keywords="nursing professional skills", keywords="bibliometric analysis", keywords="visual content analysis", keywords="extended reality", keywords="XR", keywords="augmented reality", keywords="AR", keywords="mixed reality", abstract="Background: Nursing professional skills training has undergone significant transformation due to the exponential growth of computer and medical technology. The innovative use of virtual reality (VR) in nursing education has emerged as a cutting-edge technical support technique that has gained attention as a highly effective method for improving nurse training quality. Objective: This study aims to review the current status of VR technology in nursing professional skills training, research hotspots, and emerging trends in the last 15 years. Methods: The Web of Science Core Collection database was used to search for literature on VR technology in nursing professional skills training covering the period from 2006 to 2022. Biblioshiny (K-Synth Srl) was used to import and convert the records to Bibliometrix (K-Synth Srl) for analysis, and R (R Core Team) was used for descriptive bibliometric analysis. VOSviewer (Leiden University) was used to cluster co-occurring keywords, and Scimago Graphica (version 1.0.16; Scimago Lab) was used to generate a geographical visualization of published countries and regions. Results: A total of 1073 papers were analyzed, indicating a surge in research on the application of VR in nursing professional skills training in recent years, as evidenced by a positive trend in annual publication of relevant literature. The majority of studies were from the United States (n=340) and Canada (n=107), and Margaret Verkuyl was the most prolific author, leading the way with 9 publications. Furthermore, ``Computerized Virtual Patients in Health Professions Education: a Systematic Review and Meta-Analysis'' was the most frequently cited reference. Keywords such as education, simulation, skills, students, and care were most commonly used by researchers. Conclusions: The bibliometric analysis provides a comprehensive overview of the use of VR in nursing professional skills training, indicating that VR-based training is an effective means of improving the skills and competencies of nursing students and professionals alike. The COVID-19 pandemic has reinforced the importance of developing VR-based distance education, despite challenges such as integrating virtual and real-world training and mitigating safety risks. ", doi="10.2196/44766", url="https://games.jmir.org/2023/1/e44766", url="http://www.ncbi.nlm.nih.gov/pubmed/37603389" } @Article{info:doi/10.2196/47748, author="Liaw, Ying Sok and Tan, Zhi Jian and Bin Rusli, Dzakirin Khairul and Ratan, Rabindra and Zhou, Wentao and Lim, Siriwan and Lau, Ching Tang and Seah, Betsy and Chua, Ling Wei", title="Artificial Intelligence Versus Human-Controlled Doctor in Virtual Reality Simulation for Sepsis Team Training: Randomized Controlled Study", journal="J Med Internet Res", year="2023", month="Jul", day="26", volume="25", pages="e47748", keywords="artificial intelligence", keywords="interprofessional education", keywords="interprofessional communication", keywords="sepsis care", keywords="team training", keywords="virtual reality", keywords="simulation", keywords="AI", keywords="health care education", keywords="nursing student", keywords="nursing education", keywords="medical education", abstract="Background: Interprofessional communication is needed to enhance the early recognition and management of patients with sepsis. Preparing medical and nursing students using virtual reality simulation has been shown to be an effective learning approach for sepsis team training. However, its scalability is constrained by unequal cohort sizes between medical and nursing students. An artificial intelligence (AI) medical team member can be implemented in a virtual reality simulation to engage nursing students in sepsis team training. Objective: This study aimed to evaluate the effectiveness of an AI-powered doctor versus a human-controlled doctor in training nursing students for sepsis care and interprofessional communication. Methods: A randomized controlled trial study was conducted with 64 nursing students who were randomly assigned to undertake sepsis team training with an AI-powered doctor (AI-powered group) or with medical students using virtual reality simulation (human-controlled group). Participants from both groups were tested on their sepsis and communication performance through simulation-based assessments (posttest). Participants' sepsis knowledge and self-efficacy in interprofessional communication were also evaluated before and after the study interventions. Results: A total of 32 nursing students from each group completed the simulation-based assessment, sepsis and communication knowledge test, and self-efficacy questionnaire. Compared with the baseline scores, both the AI-powered and human-controlled groups demonstrated significant improvements in communication knowledge (P=.001) and self-efficacy in interprofessional communication (P<.001) in posttest scores. For sepsis care knowledge, a significant improvement in sepsis care knowledge from the baseline was observed in the AI-powered group (P<.001) but not in the human-controlled group (P=.16). Although no significant differences were found in sepsis care performance between the groups (AI-powered group: mean 13.63, SD 4.23, vs human-controlled group: mean 12.75, SD 3.85, P=.39), the AI-powered group (mean 9.06, SD 1.78) had statistically significantly higher sepsis posttest knowledge scores (P=.009) than the human-controlled group (mean 7.75, SD 2.08). No significant differences were found in interprofessional communication performance between the 2 groups (AI-powered group: mean 29.34, SD 8.37, vs human-controlled group: mean 27.06, SD 5.69, P=.21). However, the human-controlled group (mean 69.6, SD 14.4) reported a significantly higher level of self-efficacy in interprofessional communication (P=.008) than the AI-powered group (mean 60.1, SD 13.3). Conclusions: Our study suggested that AI-powered doctors are not inferior to human-controlled virtual reality simulations with respect to sepsis care and interprofessional communication performance, which supports the viability of implementing AI-powered doctors to achieve scalability in sepsis team training. Our findings also suggested that future innovations should focus on the sociability of AI-powered doctors to enhance users' interprofessional communication training. Perhaps in the nearer term, future studies should examine how to best blend AI-powered training with human-controlled virtual reality simulation to optimize clinical performance in sepsis care and interprofessional communication. Trial Registration: ClinicalTrials.gov NCT05953441; https://clinicaltrials.gov/study/NCT05953441 ", doi="10.2196/47748", url="https://www.jmir.org/2023/1/e47748", url="http://www.ncbi.nlm.nih.gov/pubmed/37494112" } @Article{info:doi/10.2196/43699, author="Horst, Rebecca and Witsch, Lea-Mara and Hazunga, Rayford and Namuziya, Natasha and Syakantu, Gardner and Ahmed, Yusuf and Cherkaoui, Omar and Andreadis, Petros and Neuhann, Florian and Barteit, Sandra", title="Evaluating the Effectiveness of Interactive Virtual Patients for Medical Education in Zambia: Randomized Controlled Trial", journal="JMIR Med Educ", year="2023", month="Jun", day="29", volume="9", pages="e43699", keywords="global health", keywords="Zambia", keywords="health care workers", keywords="medical skills", keywords="e-logbook, digital global health", abstract="Background: Zambia is facing a severe shortage of health care workers, particularly in rural areas. Innovative educational programs and infrastructure have been established to bridge this gap; however, they encounter substantial challenges because of constraints in physical and human resources. In response to these shortcomings, strategies such as web-based and blended learning approaches have been implemented, using virtual patients (VPs) as a means to promote interactive learning at the Levy Mwanawasa Medical University (LMMU) in Zambia. Objective: This study aimed to evaluate the students' knowledge acquisition and acceptance of 2 VP medical topics as a learning tool on a Zambian higher education e-learning platform. Methods: Using a mixed methods design, we assessed knowledge acquisition using pre- and posttests. In a randomized controlled trial setting, students were assigned (1:1) to 2 medical topics (topic 1: appendicitis and topic 2: severe acute malnutrition) and then to 4 different learning tools within their respective exposure groups: VPs, textbook content, preselected e-learning materials, and self-guided internet materials. Acceptance was evaluated using a 15-item questionnaire with a 5-point Likert scale. Results: A total of 63 third- and fourth-year Bachelor of Science clinical science students participated in the study. In the severe acute malnutrition--focused group, participants demonstrated a significant increase in knowledge within the textbook group (P=.01) and the VP group (P=.01). No substantial knowledge gain was observed in the e-learning group or the self-guided internet group. For the appendicitis-focused group, no statistically significant difference in knowledge acquisition was detected among the 4 intervention groups (P=.62). The acceptance of learning materials exhibited no substantial difference between the VP medical topics and other learning materials. Conclusions: In the context of LMMU, our study found that VPs were well accepted and noninferior to traditional teaching methods. VPs have the potential to serve as an engaging learning resource and can be integrated into blended learning approaches at LMMU. However, further research is required to investigate the long-term knowledge gain and the acceptance and effectiveness of VPs in medical education. Trial Registration: Pan African Clinical Trials Registry (PACTR) PACTR202211594568574; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=20413 ", doi="10.2196/43699", url="https://mededu.jmir.org/2023/1/e43699", url="http://www.ncbi.nlm.nih.gov/pubmed/37384369" } @Article{info:doi/10.2196/46601, author="Perez, Analay and Fetters, D. Michael and Creswell, W. John and Scerbo, Mark and Kron, W. Frederick and Gonzalez, Richard and An, Lawrence and Jimbo, Masahito and Klasnja, Predrag and Guetterman, C. Timothy", title="Enhancing Nonverbal Communication Through Virtual Human Technology: Protocol for a Mixed Methods Study", journal="JMIR Res Protoc", year="2023", month="Jun", day="6", volume="12", pages="e46601", keywords="human technology", keywords="MPathic-VR", keywords="nonverbal communication behavior", keywords="patient-provider communication", keywords="virtual human", abstract="Background: Communication is a critical component of the patient-provider relationship; however, limited research exists on the role of nonverbal communication. Virtual human training is an informatics-based educational strategy that offers various benefits in communication skill training directed at providers. Recent informatics-based interventions aimed at improving communication have mainly focused on verbal communication, yet research is needed to better understand how virtual humans can improve verbal and nonverbal communication and further elucidate the patient-provider dyad. Objective: The purpose of this study is to enhance a conceptual model that incorporates technology to examine verbal and nonverbal components of communication and develop a nonverbal assessment that will be included in the virtual simulation for further testing. Methods: This study will consist of a multistage mixed methods design, including convergent and exploratory sequential components. A convergent mixed methods study will be conducted to examine the mediating effects of nonverbal communication. Quantitative (eg, MPathic game scores, Kinect nonverbal data, objective structured clinical examination communication score, and Roter Interaction Analysis System and Facial Action Coding System coding of video) and qualitative data (eg, video recordings of MPathic--virtual reality [VR] interventions and student reflections) will be collected simultaneously. Data will be merged to determine the most crucial components of nonverbal behavior in human-computer interaction. An exploratory sequential design will proceed, consisting of a grounded theory qualitative phase. Using theoretical, purposeful sampling, interviews will be conducted with oncology providers probing intentional nonverbal behaviors. The qualitative findings will aid the development of a nonverbal communication model that will be included in a virtual human. The subsequent quantitative strand will incorporate and validate a new automated nonverbal communication behavior assessment into the virtual human simulation, MPathic-VR, by assessing interrater reliability, code interactions, and dyadic data analysis by comparing Kinect responses (system recorded) to manually scored records for specific nonverbal behaviors. Data will be integrated using building integration to develop the automated nonverbal communication behavior assessment and conduct a quality check of these nonverbal features. Results: Secondary data from the MPathic-VR randomized controlled trial data set (210 medical students and 840 video recordings of interactions) were analyzed in the first part of this study. Results showed differential experiences by performance in the intervention group. Following the analysis of the convergent design, participants consisting of medical providers (n=30) will be recruited for the qualitative phase of the subsequent exploratory sequential design. We plan to complete data collection by July 2023 to analyze and integrate these findings. Conclusions: The results from this study contribute to the improvement of patient-provider communication, both verbal and nonverbal, including the dissemination of health information and health outcomes for patients. Further, this research aims to transfer to various topical areas, including medication safety, informed consent processes, patient instructions, and treatment adherence between patients and providers. International Registered Report Identifier (IRRID): DERR1-10.2196/46601 ", doi="10.2196/46601", url="https://www.researchprotocols.org/2023/1/e46601", url="http://www.ncbi.nlm.nih.gov/pubmed/37279041" } @Article{info:doi/10.2196/43988, author="Schmidt, Christian and Keszty{\"u}s, Dorothea and Haag, Martin and Wilhelm, Manfred and Keszty{\"u}s, Tibor", title="Proposal of a Method for Transferring High-Quality Scientific Literature Data to Virtual Patient Cases Using Categorical Data Generated by Bernoulli-Distributed Random Values: Development and Prototypical Implementation", journal="JMIR Med Educ", year="2023", month="Mar", day="9", volume="9", pages="e43988", keywords="medical education", keywords="computer programs and programming", keywords="probability", keywords="rare diseases", keywords="diagnosis", keywords="medical literature", keywords="automation", keywords="automated", keywords="virtual patient", keywords="simulation", keywords="computer based", keywords="Bernoulli", abstract="Background: Teaching medicine is a complex task because medical teachers are also involved in clinical practice and research and the availability of cases with rare diseases is very restricted. Automatic creation of virtual patient cases would be a great benefit, saving time and providing a wider choice of virtual patient cases for student training. Objective: This study explored whether the medical literature provides usable quantifiable information on rare diseases. The study implemented a computerized method that simulates basic clinical patient cases utilizing probabilities of symptom occurrence for a disease. Methods: Medical literature was searched for suitable rare diseases and the required information on the respective probabilities of specific symptoms. We developed a statistical script that delivers basic virtual patient cases with random symptom complexes generated by Bernoulli experiments, according to probabilities reported in the literature. The number of runs and thus the number of patient cases generated are arbitrary. Results: We illustrated the function of our generator with the exemplary diagnosis ``brain abscess'' with the related symptoms ``headache, mental status change, focal neurologic deficit, fever, seizure, nausea and vomiting, nuchal rigidity, and papilledema'' and the respective probabilities from the literature. With a growing number of repetitions of the Bernoulli experiment, the relative frequencies of occurrence increasingly converged with the probabilities from the literature. For example, the relative frequency for headache after 10.000 repetitions was 0.7267 and, after rounding, equaled the mean value of the probability range of 0.73 reported in the literature. The same applied to the other symptoms. Conclusions: The medical literature provides specific information on characteristics of rare diseases that can be transferred to probabilities. The results of our computerized method suggest that automated creation of virtual patient cases based on these probabilities is possible. With additional information provided in the literature, an extension of the generator can be implemented in further research. ", doi="10.2196/43988", url="https://mededu.jmir.org/2023/1/e43988", url="http://www.ncbi.nlm.nih.gov/pubmed/36892938" } @Article{info:doi/10.2196/38599, author="Tran, Carrie and Toth-Pal, Eva and Ekblad, Solvig and Fors, Uno and Salminen, Helena", title="Medical Students' Learning About Other Professions Using an Interprofessional Virtual Patient While Remotely Connected With a Study Group: Mixed Methods Study", journal="JMIR Med Educ", year="2023", month="Jan", day="17", volume="9", pages="e38599", keywords="interprofessional learning", keywords="virtual patient", keywords="medical students", keywords="remote learning", keywords="distance learning", keywords="medical education", abstract="Background: Collaboration with other professions is essential in health care education to prepare students for future clinical teamwork. However, health care education still struggles to incorporate interprofessional education. Distance learning and virtual patients (VPs) may be useful additional methods to increase students' possibilities for interprofessional learning. Objective: This study had two aims. The first was to assess if an interprofessional VP case could facilitate medical students' learning about team collaboration in online groups. The second was to assess how students experienced learning with the VP when remotely connected with their group. Methods: A mixed methods design was used. The VP case was a 73-year-old man who needed help from different health professions in his home after a hip fracture. Questionnaires were answered by the students before and directly after each session. Qualitative group interviews were performed with each group of students directly after the VP sessions, and the interviews were analyzed using qualitative content analysis. Results: A total of 49 third-year medical students divided into 15 groups participated in the study. Each group had 2 to 5 students who worked together with the interprofessional VP without a teacher's guidance. In the analysis of the group interviews, a single theme was identified: the interprofessional VP promoted student interaction and gave insight into team collaboration. Two categories were found: (1) the structure of the VP facilitated students' learning and (2) students perceived the collaboration in their remotely connected groups as functioning well and being effective. The results from the questionnaires showed that the students had gained insights into the roles and competencies of other health care professions. Conclusions: This study demonstrates that an interprofessional VP enabled insights into team collaboration and increased understanding of other professions among student groups comprising only medical students. The interprofessional VP seemed to benefit students' learning in an online, remote-learning context. Although our VP was not used as an interprofessional student activity according to the common definition of interprofessional education, the results imply that it still contributed to students' interprofessional learning. ", doi="10.2196/38599", url="https://mededu.jmir.org/2023/1/e38599", url="http://www.ncbi.nlm.nih.gov/pubmed/36649071" } @Article{info:doi/10.2196/40082, author="Zeng, Minrui and Cai, Yiyuan and Cao, Jin and He, Qianyu and Wang, Xiaohui and Lu, Yun and Liang, Huijuan and Xu, Dong and Liao, Jing", title="The Agreement Between Virtual Patient and Unannounced Standardized Patient Assessments in Evaluating Primary Health Care Quality: Multicenter, Cross-sectional Pilot Study in 7 Provinces of China", journal="J Med Internet Res", year="2022", month="Dec", day="2", volume="24", number="12", pages="e40082", keywords="virtual patient", keywords="unannounced standardized patient", keywords="primary health care", keywords="primary care", keywords="quality assessment", keywords="quality improvement", keywords="scenario", keywords="simulation", keywords="simulate", keywords="medical education", keywords="cross-sectional", keywords="digital health", keywords="eHealth", abstract="Background: The unannounced standardized patient (USP) is the gold standard for primary health care (PHC) quality assessment but has many restrictions associated with high human and resource costs. Virtual patient (VP) is a valid, low-cost software option for simulating clinical scenarios and is widely used in medical education. It is unclear whether VP can be used to assess the quality of PHC. Objective: This study aimed to examine the agreement between VP and USP assessments of PHC quality and to identify factors influencing the VP-USP agreement. Methods: Eleven matched VP and USP case designs were developed based on clinical guidelines and were implemented in a convenience sample of urban PHC facilities in the capital cities of the 7 study provinces. A total of 720 USP visits were conducted, during which on-duty PHC providers who met the inclusion criteria were randomly selected by the USPs. The same providers underwent a VP assessment using the same case condition at least a week later. The VP-USP agreement was measured by the concordance correlation coefficient (CCC) for continuity scores and the weighted $\kappa$ for diagnoses. Multiple linear regression was used to identify factors influencing the VP-USP agreement. Results: Only 146 VP scores were matched with the corresponding USP scores. The CCC for medical history was 0.37 (95\% CI 0.24-0.49); for physical examination, 0.27 (95\% CI 0.12-0.42); for laboratory and imaging tests, --0.03 (95\% CI --0.20 to 0.14); and for treatment, 0.22 (95\% CI 0.07-0.37). The weighted $\kappa$ for diagnosis was 0.32 (95\% CI 0.13-0.52). The multiple linear regression model indicated that the VP tests were significantly influenced by the different case conditions and the city where the test took place. Conclusions: There was low agreement between VPs and USPs in PHC quality assessment. This may reflect the ``know-do'' gap. VP test results were also influenced by different case conditions, interactive design, and usability. Modifications to VPs and the reasons for the low VP-USP agreement require further study. ", doi="10.2196/40082", url="https://www.jmir.org/2022/12/e40082", url="http://www.ncbi.nlm.nih.gov/pubmed/36459416" } @Article{info:doi/10.2196/29941, author="Finkelstein, B. Julia and Tremblay, S. Elise and Van Cain, Melissa and Farber-Chen, Aaron and Schumann, Caitlin and Brown, Christina and Shah, S. Ankoor and Rhodes, T. Erinn", title="Pediatric Clinicians' Use of Telemedicine: Qualitative Interview Study", journal="JMIR Hum Factors", year="2021", month="Dec", day="2", volume="8", number="4", pages="e29941", keywords="pediatrics", keywords="telemedicine", keywords="video visits", keywords="communication", keywords="webside manner", abstract="Background: Bedside manner describes how clinicians relate to patients in person. Telemedicine allows clinicians to connect virtually with patients using digital tools. Effective virtual communication or webside manner may require modifications to traditional bedside manner. Objective: This study aims to understand the experiences of telemedicine providers with patient-to-provider virtual visits and communication with families at a single large-volume children's hospital to inform program development and training for future clinicians. Methods: A total of 2 focus groups of pediatric clinicians (N=11) performing virtual visits before the COVID-19 pandemic, with a range of experiences and specialties, were engaged to discuss experiential, implementation, and practice-related issues. Focus groups were facilitated using a semistructured guide covering general experience, preparedness, rapport strategies, and suggestions. Sessions were digitally recorded, and the corresponding transcripts were reviewed for data analysis. The transcripts were coded based on the identified main themes and subthemes. On the basis of a higher-level analysis of these codes, the study authors generated a final set of key themes to describe the collected data. Results: Theme consistency was identified across diverse participants, although individual clinician experiences were influenced by their specialties and practices. A total of 3 key themes emerged regarding the development of best practices, barriers to scalability, and establishing patient rapport. Issues and concerns related to privacy were salient across all themes. Clinicians felt that telemedicine required new skills for patient interaction, and not all were comfortable with their training. Conclusions: Telemedicine provides benefits as well as challenges to health care delivery. In interprofessional focus groups, pediatric clinicians emphasized the importance of considering safety and privacy to promote rapport and webside manner when conducting virtual visits. The inclusion of webside manner instructions within training curricula is crucial as telemedicine becomes an established modality for providing health care. ", doi="10.2196/29941", url="https://humanfactors.jmir.org/2021/4/e29941", url="http://www.ncbi.nlm.nih.gov/pubmed/34860669" } @Article{info:doi/10.2196/22745, author="Jacklin, Simon and Maskrey, Neal and Chapman, Stephen", title="Shared Decision-Making With a Virtual Patient in Medical Education: Mixed Methods Evaluation Study", journal="JMIR Med Educ", year="2021", month="Jun", day="10", volume="7", number="2", pages="e22745", keywords="shared decision making", keywords="virtual patient", keywords="communication", keywords="medical education", abstract="Background: Shared decision-making (SDM) is a process in which clinicians and patients work together to select tests, treatments, management, or support packages based on clinical evidence and the patient's informed preferences. Similar to any skill, SDM requires practice to improve. Virtual patients (VPs) are simulations that allow one to practice a variety of clinical skills, including communication. VPs can be used to help professionals and students practice communication skills required to engage in SDM; however, this specific focus has not received much attention within the literature. A multiple-choice VP was developed to allow students the opportunity to practice SDM. To interact with the VP, users chose what they wanted to say to the VP by choosing from multiple predefined options, rather than typing in what they wanted to say. Objective: This study aims to evaluate a VP workshop for medical students aimed at developing the communication skills required for SDM. Methods: Preintervention and postintervention questionnaires were administered, followed by semistructured interviews. The questionnaires provided cohort-level data on the participants' views of the VP and helped to inform the interview guide; the interviews were used to explore some of the data from the questionnaire in more depth, including the participants' experience of using the VP. Results: The interviews and questionnaires suggested that the VP was enjoyable and easy to use. When the participants were asked to rank their priorities in both pre- and post-VP consultations, there was a change in the rank position of respecting patient choices, with the median rank changing from second to first. Owing to the small sample size, this was not analyzed for statistical significance. The VP allowed the participants to explore a consultation in a way that they could not with simulated or real patients, which may be part of the reason that the VP was suggested as a useful intervention for bridging from the early, theory-focused years of the curriculum to the more patient-focused ones later. Conclusions: The VP was well accepted by the participants. The multiple-choice system of interaction was reported to be both useful and restrictive. Future work should look at further developing the mode of interaction and explore whether the VP results in any changes in observed behavior or practice. ", doi="10.2196/22745", url="https://mededu.jmir.org/2021/2/e22745", url="http://www.ncbi.nlm.nih.gov/pubmed/34110299" } @Article{info:doi/10.2196/24723, author="Plackett, Ruth and Kassianos, P. Angelos and Timmis, Jessica and Sheringham, Jessica and Schartau, Patricia and Kambouri, Maria", title="Using Virtual Patients to Explore the Clinical Reasoning Skills of Medical Students: Mixed Methods Study", journal="J Med Internet Res", year="2021", month="Jun", day="4", volume="23", number="6", pages="e24723", keywords="computer simulation", keywords="web-based patient simulation", keywords="computer-assisted instruction", keywords="educational technology", keywords="medical education", keywords="clinical decision support systems", keywords="clinical decision making", keywords="clinical reasoning", keywords="clinical skills", keywords="primary care", keywords="diagnosis", abstract="Background: Improving clinical reasoning skills---the thought processes used by clinicians to formulate appropriate questions and diagnoses---is essential for reducing missed diagnostic opportunities. The electronic Clinical Reasoning Educational Simulation Tool (eCREST) was developed to improve the clinical reasoning of future physicians. A feasibility trial demonstrated acceptability and potential impacts; however, the processes by which students gathered data were unknown. Objective: This study aims to identify the data gathering patterns of final year medical students while using eCREST and how eCREST influences the patterns. Methods: A mixed methods design was used. A trial of eCREST across 3 UK medical schools (N=148) measured the potential effects of eCREST on data gathering. A qualitative think-aloud and semistructured interview study with 16 medical students from one medical school identified 3 data gathering strategies: Thorough, Focused, and Succinct. Some had no strategy. Reanalysis of the trial data identified the prevalence of data gathering patterns and compared patterns between the intervention and control groups. Patterns were identified based on 2 variables that were measured in a patient case 1 month after the intervention: the proportion of Essential information students identified and the proportion of irrelevant information gathered (Relevant). Those who scored in the top 3 quartiles for Essential but in the lowest quartile for Relevant displayed a Thorough pattern. Those who scored in the top 3 quartiles for Relevant but in the lowest quartile for Essential displayed a Succinct pattern. Those who scored in the top 3 quartiles on both variables displayed a Focused pattern. Those whose scores were in the lowest quartile on both variables displayed a Nonspecific pattern. Results: The trial results indicated that students in the intervention group were more thorough than those in the control groups when gathering data. The qualitative data identified data gathering strategies and the mechanisms by which eCREST influenced data gathering. Students reported that eCREST promoted thoroughness by prompting them to continuously reflect and allowing them to practice managing uncertainty. However, some found eCREST to be less useful, and they randomly gathered information. Reanalysis of the trial data revealed that the intervention group was significantly more likely to display a Thorough data gathering pattern than controls (21/78, 27\% vs 6/70, 9\%) and less likely to display a Succinct pattern (13/78, 17\% vs 20/70, 29\%; $\chi$23=9.9; P=.02). Other patterns were similar across groups. Conclusions: Qualitative data suggested that students applied a range of data gathering strategies while using eCREST and that eCREST encouraged thoroughness by continuously prompting the students to reflect and manage their uncertainty. Trial data suggested that eCREST led students to demonstrate more Thorough data gathering patterns. Virtual patients that encourage thoroughness could help future physicians avoid missed diagnostic opportunities and enhance the delivery of clinical reasoning teaching. ", doi="10.2196/24723", url="https://www.jmir.org/2021/6/e24723", url="http://www.ncbi.nlm.nih.gov/pubmed/34085940" } @Article{info:doi/10.2196/24073, author="Furlan, Raffaello and Gatti, Mauro and Men{\`e}, Roberto and Shiffer, Dana and Marchiori, Chiara and Giaj Levra, Alessandro and Saturnino, Vincenzo and Brunetta, Enrico and Dipaola, Franca", title="A Natural Language Processing--Based Virtual Patient Simulator and Intelligent Tutoring System for the Clinical Diagnostic Process: Simulator Development and Case Study", journal="JMIR Med Inform", year="2021", month="Apr", day="9", volume="9", number="4", pages="e24073", keywords="COVID-19", keywords="intelligent tutoring system", keywords="virtual patient simulator", keywords="natural language processing", keywords="artificial intelligence", keywords="clinical diagnostic reasoning", abstract="Background: Shortage of human resources, increasing educational costs, and the need to keep social distances in response to the COVID-19 worldwide outbreak have prompted the necessity of clinical training methods designed for distance learning. Virtual patient simulators (VPSs) may partially meet these needs. Natural language processing (NLP) and intelligent tutoring systems (ITSs) may further enhance the educational impact of these simulators. Objective: The goal of this study was to develop a VPS for clinical diagnostic reasoning that integrates interaction in natural language and an ITS. We also aimed to provide preliminary results of a short-term learning test administered on undergraduate students after use of the simulator. Methods: We trained a Siamese long short-term memory network for anamnesis and NLP algorithms combined with Systematized Nomenclature of Medicine (SNOMED) ontology for diagnostic hypothesis generation. The ITS was structured on the concepts of knowledge, assessment, and learner models. To assess short-term learning changes, 15 undergraduate medical students underwent two identical tests, composed of multiple-choice questions, before and after performing a simulation by the virtual simulator. The test was made up of 22 questions; 11 of these were core questions that were specifically designed to evaluate clinical knowledge related to the simulated case. Results: We developed a VPS called Hepius that allows students to gather clinical information from the patient's medical history, physical exam, and investigations and allows them to formulate a differential diagnosis by using natural language. Hepius is also an ITS that provides real-time step-by-step feedback to the student and suggests specific topics the student has to review to fill in potential knowledge gaps. Results from the short-term learning test showed an increase in both mean test score (P<.001) and mean score for core questions (P<.001) when comparing presimulation and postsimulation performance. Conclusions: By combining ITS and NLP technologies, Hepius may provide medical undergraduate students with a learning tool for training them in diagnostic reasoning. This may be particularly useful in a setting where students have restricted access to clinical wards, as is happening during the COVID-19 pandemic in many countries worldwide. ", doi="10.2196/24073", url="https://medinform.jmir.org/2021/4/e24073", url="http://www.ncbi.nlm.nih.gov/pubmed/33720840" } @Article{info:doi/10.2196/21196, author="Fink, C. Maximilian and Reitmeier, Victoria and Stadler, Matthias and Siebeck, Matthias and Fischer, Frank and Fischer, R. Martin", title="Assessment of Diagnostic Competences With Standardized Patients Versus Virtual Patients: Experimental Study in the Context of History Taking", journal="J Med Internet Res", year="2021", month="Mar", day="4", volume="23", number="3", pages="e21196", keywords="clinical reasoning", keywords="medical education", keywords="performance-based assessment", keywords="simulation", keywords="standardized patient", keywords="virtual patient", abstract="Background: 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. Objective: 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. Methods: 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. Results: Perceived authenticity (1-tailed t81=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 (t82=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 t85=2.49; P=.01). Conclusions: 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. ", doi="10.2196/21196", url="https://www.jmir.org/2021/3/e21196", url="http://www.ncbi.nlm.nih.gov/pubmed/33661122" } @Article{info:doi/10.2196/17146, author="Thompson, Jessica and White, Simon and Chapman, Stephen", title="Interactive Clinical Avatar Use in Pharmacist Preregistration Training: Design and Review", journal="J Med Internet Res", year="2020", month="Nov", day="6", volume="22", number="11", pages="e17146", keywords="virtual patient", keywords="high-fidelity simulation training", keywords="patient simulation", keywords="pharmacy education", keywords="pharmacy practice education", keywords="virtual reality", abstract="Background: Virtual patients are interactive computer-based simulations that are being increasingly used in modern health care education. They have been identified as tools that can provide experiential learning and assessment in a standardized and safe environment. However, the study of high-fidelity virtual patients such as interactive clinical avatars within pharmacy is limited. Objective: The aim of this paper is to describe the design and review of three interactive clinical avatar simulations as part of pharmacist preregistration training. Methods: A multistep design approach was taken to create interactive clinical avatar simulations on the topics of emergency hormonal contraception (EHC), calculation of renal function, and childhood illnesses. All case studies were reviewed by registered pharmacists to establish content and face validity. The EHC case study and data collection questionnaire were also reviewed by a purposive sample of preregistration trainees and newly qualified pharmacists. The questionnaire used Likert ranking statements and open-ended questions to obtain users' feedback on the design, usability, and usefulness of the interactive clinical avatars as learning tools. Descriptive statistics and content analysis were undertaken on the data. Results: Ten preregistration trainees and newly qualified pharmacists reviewed the EHC interactive clinical avatars and data collection questionnaire. The data collection questionnaire was associated with a Cronbach alpha=.95, demonstrating good reliability. All three interactive clinical avatar simulations were reported as usable and appropriately designed for preregistration training. Users perceived they were developing skills and knowledge from the simulations. The high-fidelity nature of the avatars and relevance of the simulations to real-life practice were reported as aspects that encouraged the application of theory to practice. Improvements were suggested to ensure the simulations were more user-friendly. Conclusions: The design and creation of the interactive clinical avatar simulations was successful. The multistep review process ensured validity and reliability of the simulations and data collection questionnaire. The in-depth explanation of the design process and provision of a questionnaire may help widen the use and evaluation of interactive clinical avatars or other simulation tools in pharmacy education. The interactive clinical avatars were reported as novel learning tools that promoted experiential learning and allowed users to feel like they were engaging in real-life scenarios, thus developing transferable knowledge and skills. This may be potentially beneficial for many health care training courses as a way to provide standardized experiences promoting active learning and reflection. ", doi="10.2196/17146", url="https://www.jmir.org/2020/11/e17146", url="http://www.ncbi.nlm.nih.gov/pubmed/33155983" } @Article{info:doi/10.2196/17425, author="Katz, Daniel and Shah, Ronak and Kim, Elizabeth and Park, Chang and Shah, Anjan and Levine, Adam and Burnett, Garrett", title="Utilization of a Voice-Based Virtual Reality Advanced Cardiac Life Support Team Leader Refresher: Prospective Observational Study", journal="J Med Internet Res", year="2020", month="Mar", day="12", volume="22", number="3", pages="e17425", keywords="video game", keywords="experimental game", keywords="virtual reality", keywords="advanced cardiac life support", abstract="Background: The incidence of cardiac arrests per year in the United States continues to increase, yet in-hospital cardiac arrest survival rates significantly vary between hospitals. Current methods of training are expensive, time consuming, and difficult to scale, which necessitates improvements in advanced cardiac life support (ACLS) training. Virtual reality (VR) has been proposed as an alternative or adjunct to high-fidelity simulation (HFS) in several environments. No evaluations to date have explored the ability of a VR program to examine both technical and behavioral skills and demonstrate a cost comparison. Objective: This study aimed to explore the utility of a voice-based VR ACLS team leader refresher as compared with HFS. Methods: This prospective observational study performed at an academic institution consisted of 25 postgraduate year 2 residents. Participants were randomized to HFS or VR training and then crossed groups after a 2-week washout. Participants were graded on technical and nontechnical skills. Participants also completed self-assessments about the modules. Proctors were assessed for fatigue and task saturation, and cost analysis based on local economic data was performed. Results: A total of 23 of 25 participants were included in the scoring analysis. Fewer participants were familiar with VR compared with HFS (9/25, 36\% vs 25/25, 100\%; P<.001). Self-reported satisfaction and utilization scores were similar; however, significantly more participants felt HFS provided better feedback: 99 (IQR 89-100) vs 79 (IQR 71-88); P<.001. Technical scores were higher in the HFS group; however, nontechnical scores for decision making and communication were not significantly different between modalities. VR sessions were 21 (IQR 19-24) min shorter than HFS sessions, the National Aeronautics and Space Administration task load index scores for proctors were lower in each category, and VR sessions were estimated to be US \$103.68 less expensive in a single-learner, single-session model. Conclusions: Utilization of a VR-based team leader refresher for ACLS skills is comparable with HFS in several areas, including learner satisfaction. The VR module was more cost-effective and was easier to proctor; however, HFS was better at delivering feedback to participants. Optimal education strategies likely contain elements of both modalities. Further studies are needed to examine the utility of VR-based environments at scale. ", doi="10.2196/17425", url="http://www.jmir.org/2020/3/e17425/", url="http://www.ncbi.nlm.nih.gov/pubmed/32163038" } @Article{info:doi/10.2196/14428, author="Setrakian, Jean and Gauthier, Genevi{\`e}ve and Bergeron, Linda and Chamberland, Martine and St-Onge, Christina", title="Comparison of Assessment by a Virtual Patient and by Clinician-Educators of Medical Students' History-Taking Skills: Exploratory Descriptive Study", journal="JMIR Med Educ", year="2020", month="Mar", day="12", volume="6", number="1", pages="e14428", keywords="virtual patients", keywords="medical history taking", keywords="automated scoring", keywords="simulation training", keywords="medical education", keywords="medical students", keywords="educational assessment", keywords="computer software", keywords="medical history--taking skills", keywords="medical history--taking skills assessment", abstract="Background: A virtual patient (VP) can be a useful tool to foster the development of medical history--taking skills without the inherent constraints of the bedside setting. Although VPs hold the promise of contributing to the development of students' skills, documenting and assessing skills acquired through a VP is a challenge. Objective: We propose a framework for the automated assessment of medical history taking within a VP software and then test this framework by comparing VP scores with the judgment of 10 clinician-educators (CEs). Methods: We built upon 4 domains of medical history taking to be assessed (breadth, depth, logical sequence, and interviewing technique), adapting these to be implemented into a specific VP environment. A total of 10 CEs watched the screen recordings of 3 students to assess their performance first globally and then for each of the 4 domains. Results: The scores provided by the VPs were slightly higher but comparable with those given by the CEs for global performance and for depth, logical sequence, and interviewing technique. For breadth, the VP scores were higher for 2 of the 3 students compared with the CE scores. Conclusions: Findings suggest that the VP assessment gives results akin to those that would be generated by CEs. Developing a model for what constitutes good history-taking performance in specific contexts may provide insights into how CEs generally think about assessment. ", doi="10.2196/14428", url="http://mededu.jmir.org/2020/1/e14428/", url="http://www.ncbi.nlm.nih.gov/pubmed/32163036" } @Article{info:doi/10.2196/15459, author="Guetterman, C. Timothy and Sakakibara, Rae and Baireddy, Srikar and Kron, W. Frederick and Scerbo, W. Mark and Cleary, F. James and Fetters, D. Michael", title="Medical Students' Experiences and Outcomes Using a Virtual Human Simulation to Improve Communication Skills: Mixed Methods Study", journal="J Med Internet Res", year="2019", month="Nov", day="27", volume="21", number="11", pages="e15459", keywords="cancer", keywords="virtual reality", keywords="health communication", keywords="interprofessional relations", keywords="informatics", keywords="nonverbal communication", keywords="computer simulation", keywords="physician-nurse relations", keywords="empathy", abstract="Background: Attending to the wide range of communication behaviors that convey empathy is an important but often underemphasized concept to reduce errors in care, improve patient satisfaction, and improve cancer patient outcomes. A virtual human (VH)--based simulation, MPathic-VR, was developed to train health care providers in empathic communication with patients and in interprofessional settings and evaluated through a randomized controlled trial. Objective: This mixed methods study aimed to investigate the differential effects of a VH-based simulation developed to train health care providers in empathic patient-provider and interprofessional communication. Methods: We employed a mixed methods intervention design, involving a comparison of 2 quantitative measures---MPathic-VR--calculated scores and the objective structured clinical exam (OSCE) scores---with qualitative reflections by medical students about their experiences. This paper is a secondary, focused analysis of intervention arm data from the larger trial. Students at 3 medical schools in the United States (n=206) received simulation to improve empathic communication skills. We conducted analysis of variance, thematic text analysis, and merging mixed methods analysis. Results: OSCE scores were significantly improved for learners in the intervention group (mean 0.806, SD 0.201) compared with the control group (mean 0.752, SD 0.198; F1,414=6.09; P=.01). Qualitative analysis revealed 3 major positive themes for the MPathic-VR group learners: gaining useful communication skills, learning awareness of nonverbal skills in addition to verbal skills, and feeling motivated to learn more about communication. Finally, the results of the mixed methods analysis indicated that most of the variation between high, middle, and lower performers was noted about nonverbal behaviors. Medium and high OSCE scorers most often commented on the importance of nonverbal communication. Themes of motivation to learn about communication were only present in middle and high scorers. Conclusions: VHs are a promising strategy for improving empathic communication in health care. Higher performers seemed most engaged to learn, particularly nonverbal skills. ", doi="10.2196/15459", url="http://www.jmir.org/2019/11/e15459/", url="http://www.ncbi.nlm.nih.gov/pubmed/31774400" } @Article{info:doi/10.2196/14658, author="Shorey, Shefaly and Ang, Emily and Yap, John and Ng, Debby Esperanza and Lau, Tiang Siew and Chui, Kong Chee", title="A Virtual Counseling Application Using Artificial Intelligence for Communication Skills Training in Nursing Education: Development Study", journal="J Med Internet Res", year="2019", month="Oct", day="29", volume="21", number="10", pages="e14658", keywords="artificial intelligence", keywords="communication", keywords="learning", keywords="nursing education", keywords="patients", keywords="technology", keywords="virtual reality", abstract="Background: The ability of nursing undergraduates to communicate effectively with health care providers, patients, and their family members is crucial to their nursing professions as these can affect patient outcomes. However, the traditional use of didactic lectures for communication skills training is ineffective, and the use of standardized patients is not time- or cost-effective. Given the abilities of virtual patients (VPs) to simulate interactive and authentic clinical scenarios in secured environments with unlimited training attempts, a virtual counseling application is an ideal platform for nursing students to hone their communication skills before their clinical postings. Objective: The aim of this study was to develop and test the use of VPs to better prepare nursing undergraduates for communicating with real-life patients, their family members, and other health care professionals during their clinical postings. Methods: The stages of the creation of VPs included preparation, design, and development, followed by a testing phase before the official implementation. An initial voice chatbot was trained using a natural language processing engine, Google Cloud's Dialogflow, and was later visualized into a three-dimensional (3D) avatar form using Unity 3D. Results: The VPs included four case scenarios that were congruent with the nursing undergraduates' semesters' learning objectives: (1) assessing the pain experienced by a pregnant woman, (2) taking the history of a depressed patient, (3) escalating a bleeding episode of a postoperative patient to a physician, and (4) showing empathy to a stressed-out fellow final-year nursing student. Challenges arose in terms of content development, technological limitations, and expectations management, which can be resolved by contingency planning, open communication, constant program updates, refinement, and training. Conclusions: The creation of VPs to assist in nursing students' communication skills training may provide authentic learning environments that enhance students' perceived self-efficacy and confidence in effective communication skills. However, given the infancy stage of this project, further refinement and constant enhancements are needed to train the VPs to simulate real-life conversations before the official implementation. ", doi="10.2196/14658", url="https://www.jmir.org/2019/10/e14658", url="http://www.ncbi.nlm.nih.gov/pubmed/31663857" } @Article{info:doi/10.2196/14676, author="Kononowicz, A. Andrzej and Woodham, A. Luke and Edelbring, Samuel and Stathakarou, Natalia and Davies, David and Saxena, Nakul and Tudor Car, Lorainne and Carlstedt-Duke, Jan and Car, Josip and Zary, Nabil", title="Virtual Patient Simulations in Health Professions Education: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration", journal="J Med Internet Res", year="2019", month="Jul", day="02", volume="21", number="7", pages="e14676", keywords="computer simulation", keywords="professional education", keywords="computer-assisted instruction", keywords="systematic review", keywords="meta-analysis", abstract="Background: Virtual patients are interactive digital simulations of clinical scenarios for the purpose of health professions education. There is no current collated evidence on the effectiveness of this form of education. Objective: The goal of this study was to evaluate the effectiveness of virtual patients compared with traditional education, blended with traditional education, compared with other types of digital education, and design variants of virtual patients in health professions education. The outcomes of interest were knowledge, skills, attitudes, and satisfaction. Methods: We performed a systematic review on the effectiveness of virtual patient simulations in pre- and postregistration health professions education following Cochrane methodology. We searched 7 databases from the year 1990 up to September 2018. No language restrictions were applied. We included randomized controlled trials and cluster randomized trials. We independently selected studies, extracted data, and assessed risk of bias and then compared the information in pairs. We contacted study authors for additional information if necessary. All pooled analyses were based on random-effects models. Results: A total of 51 trials involving 4696 participants met our inclusion criteria. Furthermore, 25 studies compared virtual patients with traditional education, 11 studies investigated virtual patients as blended learning, 5 studies compared virtual patients with different forms of digital education, and 10 studies compared different design variants. The pooled analysis of studies comparing the effect of virtual patients to traditional education showed similar results for knowledge (standardized mean difference [SMD]=0.11, 95\% CI ?0.17 to 0.39, I2=74\%, n=927) and favored virtual patients for skills (SMD=0.90, 95\% CI 0.49 to 1.32, I2=88\%, n=897). Studies measuring attitudes and satisfaction predominantly used surveys with item-by-item comparison. Trials comparing virtual patients with different forms of digital education and design variants were not numerous enough to give clear recommendations. Several methodological limitations in the included studies and heterogeneity contributed to a generally low quality of evidence. Conclusions: Low to modest and mixed evidence suggests that when compared with traditional education, virtual patients can more effectively improve skills, and at least as effectively improve knowledge. The skills that improved were clinical reasoning, procedural skills, and a mix of procedural and team skills. We found evidence of effectiveness in both high-income and low- and middle-income countries, demonstrating the global applicability of virtual patients. Further research should explore the utility of different design variants of virtual patients. ", doi="10.2196/14676", url="https://www.jmir.org/2019/7/e14676/", url="http://www.ncbi.nlm.nih.gov/pubmed/31267981" } @Article{info:doi/10.2196/11529, author="Padilha, Miguel Jos{\'e} and Machado, Puga Paulo and Ribeiro, Ana and Ramos, Jos{\'e} and Costa, Patr{\'i}cio", title="Clinical Virtual Simulation in Nursing Education: Randomized Controlled Trial", journal="J Med Internet Res", year="2019", month="Mar", day="18", volume="21", number="3", pages="e11529", keywords="clinical virtual simulation", keywords="nursing education", keywords="virtual patient", keywords="user-computer interface", abstract="Background: In the field of health care, knowledge and clinical reasoning are key with regard to quality and confidence in decision making. The development of knowledge and clinical reasoning is influenced not only by students' intrinsic factors but also by extrinsic factors such as satisfaction with taught content, pedagogic resources and pedagogic methods, and the nature of the objectives and challenges proposed. Nowadays, professors play the role of learning facilitators rather than simple ``lecturers'' and face students as active learners who are capable of attributing individual meanings to their personal goals, challenges, and experiences to build their own knowledge over time. Innovations in health simulation technologies have led to clinical virtual simulation. Clinical virtual simulation is the recreation of reality depicted on a computer screen and involves real people operating simulated systems. It is a type of simulation that places people in a central role through their exercising of motor control skills, decision skills, and communication skills using virtual patients in a variety of clinical settings. Clinical virtual simulation can provide a pedagogical strategy and can act as a facilitator of knowledge retention, clinical reasoning, improved satisfaction with learning, and finally, improved self-efficacy. However, little is known about its effectiveness with regard to satisfaction, self-efficacy, knowledge retention, and clinical reasoning. Objective: This study aimed to evaluate the effect of clinical virtual simulation with regard to knowledge retention, clinical reasoning, self-efficacy, and satisfaction with the learning experience among nursing students. Methods: A randomized controlled trial with a pretest and 2 posttests was carried out with Portuguese nursing students (N=42). The participants, split into 2 groups, had a lesson with the same objectives and timing. The experimental group (n=21) used a case-based learning approach, with clinical virtual simulator as a resource, whereas the control group (n=21) used the same case-based learning approach, with recourse to a low-fidelity simulator and a realistic environment. The classes were conducted by the usual course lecturers. We assessed knowledge and clinical reasoning before the intervention, after the intervention, and 2 months later, with a true or false and multiple-choice knowledge test. The students' levels of learning satisfaction and self-efficacy were assessed with a Likert scale after the intervention. Results: The experimental group made more significant improvements in knowledge after the intervention (P=.001; d=1.13) and 2 months later (P=.02; d=0.75), and it also showed higher levels of learning satisfaction (P<.001; d=1.33). We did not find statistical differences in self-efficacy perceptions (P=.9; d=0.054). Conclusions: The introduction of clinical virtual simulation in nursing education has the potential to improve knowledge retention and clinical reasoning in an initial stage and over time, and it increases the satisfaction with the learning experience among nursing students. ", doi="10.2196/11529", url="http://www.jmir.org/2019/3/e11529/", url="http://www.ncbi.nlm.nih.gov/pubmed/30882355" } @Article{info:doi/10.2196/13028, author="Chon, Seung-Hun and Timmermann, Ferdinand and Dratsch, Thomas and Schuelper, Nikolai and Plum, Patrick and Berlth, Felix and Datta, Raj Rabi and Schramm, Christoph and Haneder, Stefan and Sp{\"a}th, Richard Martin and D{\"u}bbers, Martin and Kleinert, Julia and Raupach, Tobias and Bruns, Christiane and Kleinert, Robert", title="Serious Games in Surgical Medical Education: A Virtual Emergency Department as a Tool for Teaching Clinical Reasoning to Medical Students", journal="JMIR Serious Games", year="2019", month="Mar", day="05", volume="7", number="1", pages="e13028", keywords="serious game", keywords="surgical education", keywords="clinical reasoning", keywords="virtual emergency department", keywords="medical education", abstract="Background: Serious games enable the simulation of daily working practices and constitute a potential tool for teaching both declarative and procedural knowledge. The availability of educational serious games offering a high-fidelity, three-dimensional environment in combination with profound medical background is limited, and most published studies have assessed student satisfaction rather than learning outcome as a function of game use. Objective: This study aimed to test the effect of a serious game simulating an emergency department (``EMERGE'') on students' declarative and procedural knowledge, as well as their satisfaction with the serious game. Methods: This nonrandomized trial was performed at the Department of General, Visceral and Cancer Surgery at University Hospital Cologne, Germany. A total of 140 medical students in the clinical part of their training (5th to 12th semester) self-selected to participate in this experimental study. Declarative knowledge (measured with 20 multiple choice questions) and procedural knowledge (measured with written questions derived from an Objective Structured Clinical Examination station) were assessed before and after working with EMERGE. Students' impression of the effectiveness and applicability of EMERGE were measured on a 6-point Likert scale. Results: A pretest-posttest comparison yielded a significant increase in declarative knowledge. The percentage of correct answers to multiple choice questions increased from before (mean 60.4, SD 16.6) to after (mean 76.0, SD 11.6) playing EMERGE (P<.001). The effect on declarative knowledge was larger in students in lower semesters than in students in higher semesters (P<.001). Additionally, students' overall impression of EMERGE was positive. Conclusions: Students self-selecting to use a serious game in addition to formal teaching gain declarative and procedural knowledge. ", doi="10.2196/13028", url="http://games.jmir.org/2019/1/e13028/", url="http://www.ncbi.nlm.nih.gov/pubmed/30835239" } @Article{info:doi/10.2196/10088, author="Jacklin, Simon and Maskrey, Neal and Chapman, Stephen", title="Improving Shared Decision Making Between Patients and Clinicians: Design and Development of a Virtual Patient Simulation Tool", journal="JMIR Med Educ", year="2018", month="Nov", day="06", volume="4", number="2", pages="e10088", keywords="clinical decision making", keywords="education", keywords="medical education", keywords="mobile phone", keywords="pharmacy education", keywords="virtual patient", keywords="virtual reality", abstract="Background: Shared decision making (SDM) involves the formation of a collaborative partnership between the patient and clinician combining both of their expertise in order to benefit decision making. In order for clinicians to be able to carry out this skilled task, they require practice. Virtual reality, in the form of a virtual patient, could offer a potential method of facilitating this. Objective: The objective of this study was to create a virtual patient that simulated a primary care consultation, affording the opportunity to practice SDM. A second aim was to involve patients in the design of a virtual patient simulation and report the process of the design. Methods: We employed a multistep design process drawing on patient and expert involvement. Results: A virtual patient, following a narrative style, was built, which allows a user to practice and receive feedback; both clinical and communication skills are required for the simulation. The patient group provided multiple insights, which the academic team had overlooked. They pertained mostly to issues concerning the patient experience. Conclusions: It is possible to design a virtual patient that allows a learner to practice their ability to conduct SDM. Patient input into the design of virtual patient simulations can be a worthwhile activity. ", doi="10.2196/10088", url="http://mededu.jmir.org/2018/2/e10088/", url="http://www.ncbi.nlm.nih.gov/pubmed/30401667" } @Article{info:doi/10.2196/mededu.9137, author="Edelbring, Samuel and Parodis, Ioannis and Lundberg, E. Ingrid", title="Increasing Reasoning Awareness: Video Analysis of Students' Two-Party Virtual Patient Interactions", journal="JMIR Med Educ", year="2018", month="Feb", day="27", volume="4", number="1", pages="e4", keywords="medical education", keywords="clinical decision making", keywords="problem solving", keywords="computer-assisted instruction", abstract="Background: Collaborative reasoning occurs in clinical practice but is rarely developed during education. The computerized virtual patient (VP) cases allow for a stepwise exploration of cases and thus stimulate active learning. Peer settings during VP sessions are believed to have benefits in terms of reasoning but have received scant attention in the literature. Objective: The objective of this study was to thoroughly investigate interactions during medical students' clinical reasoning in two-party VP settings. Methods: An in-depth exploration of students' interactions in dyad settings of VP sessions was performed. For this purpose, two prerecorded VP sessions lasting 1 hour each were observed, transcribed in full, and analyzed. The transcriptions were analyzed using thematic analysis, and short clips from the videos were selected for subsequent analysis in relation to clinical reasoning and clinical aspects. Results: Four categories of interactions were identified: (1) task-related dialogue, in which students negotiated a shared understanding of the task and strategies for information gathering; (2) case-related insights and perspectives were gained, and the students consolidated and applied preexisting biomedical knowledge into a clinical setting; (3) clinical reasoning interactions were made explicit. In these, hypotheses were followed up and clinical examples were used. The researchers observed interactions not only between students and the VP but also (4) interactions with other resources, such as textbooks. The interactions are discussed in relation to theories of clinical reasoning and peer learning. Conclusions: The dyad VP setting is conducive to activities that promote analytic clinical reasoning. In this setting, components such as peer interaction, access to different resources, and reduced time constraints provided a productive situation in which the students pursued different lines of reasoning. ", doi="10.2196/mededu.9137", url="http://mededu.jmir.org/2018/1/e4/", url="http://www.ncbi.nlm.nih.gov/pubmed/29487043" } @Article{info:doi/10.2196/jmir.7548, author="Bergeron, David and Champagne, Jean-Nicolas and Qi, Wen and Dion, Maxime and Th{\'e}riault, Julie and Renaud, Jean-S{\'e}bastien", title="Impact of a Student-Driven, Virtual Patient Application on Objective Structured Clinical Examination Performance: Observational Study", journal="J Med Internet Res", year="2018", month="Feb", day="22", volume="20", number="2", pages="e60", keywords="peer-assisted learning", keywords="virtual patient", keywords="medical education", keywords="undergraduate", abstract="Background: Peer-assisted learning (PAL) refers to a learning activity whereby students of similar academic level teach and learn from one another. Groupe de perfectionnement des habilet{\'e}s cliniques (Clinical Skills Improvement Group), a student organization at Universit{\'e} Laval, Canada, propelled PAL into the digital era by creating a collaborative virtual patient platform. Medical interviews can be completed in pairs (a student-patient and a student-doctor) through an interactive Web-based application, which generates a score (weighted for key questions) and automated feedback. Objectives: The aim of the study was to measure the pedagogical impact of the application on the score at medical interview stations at the summative preclerkship Objective Structured Clinical Examination (OSCE). Methods: We measured the use of the application (cases completed, mean score) in the 2 months preceding the OSCE. We also accessed the results of medical interview stations at the preclerkship summative OSCE. We analyzed whether using the application was associated with higher scores and/or better passing grades (?60\%) at the OSCE. Finally, we produced an online form where students could comment on their appreciation of the application. Results: Of the 206 students completing the preclerkship summative OSCE, 170 (82.5\%) were registered users on the application, completing a total of 3133 cases (18 by active user in average, 7 minutes by case in average). The appreciation questionnaire was answered online by 45 students who mentioned appreciating the intuitive, easy-to-use, and interactive design, the diversity of cases, and the automated feedback. Using the application was associated with reduced reported stress, improved scores (P=.04), and improved passing rates (P=.11) at the preclerkship summative OSCE. Conclusions: This study suggests that PAL can go far beyond small-group teaching, showing students' potential to create helpful pedagogical tools for their peers. ", doi="10.2196/jmir.7548", url="http://www.jmir.org/2018/2/e60/", url="http://www.ncbi.nlm.nih.gov/pubmed/29472175" } @Article{info:doi/10.2196/mededu.8100, author="Hege, Inga and Kononowicz, A. Andrzej and Adler, Martin", title="A Clinical Reasoning Tool for Virtual Patients: Design-Based Research Study", journal="JMIR Med Educ", year="2017", month="Nov", day="02", volume="3", number="2", pages="e21", keywords="learning", keywords="educational technology", keywords="computer-assisted instruction", keywords="clinical decision-making", abstract="Background: Clinical reasoning is a fundamental process medical students have to learn during and after medical school. Virtual patients (VP) are a technology-enhanced learning method to teach clinical reasoning. However, VP systems do not exploit their full potential concerning the clinical reasoning process; for example, most systems focus on the outcome and less on the process of clinical reasoning. Objectives: Keeping our concept grounded in a former qualitative study, we aimed to design and implement a tool to enhance VPs with activities and feedback, which specifically foster the acquisition of clinical reasoning skills. Methods: We designed the tool by translating elements of a conceptual clinical reasoning learning framework into software requirements. The resulting clinical reasoning tool enables learners to build their patient's illness script as a concept map when they are working on a VP scenario. The student's map is compared with the experts' reasoning at each stage of the VP, which is technically enabled by using Medical Subject Headings, which is a comprehensive controlled vocabulary published by the US National Library of Medicine. The tool is implemented using Web technologies, has an open architecture that enables its integration into various systems through an open application program interface, and is available under a Massachusetts Institute of Technology license. Results: We conducted usability tests following a think-aloud protocol and a pilot field study with maps created by 64 medical students. The results show that learners interact with the tool but create less nodes and connections in the concept map than an expert. Further research and usability tests are required to analyze the reasons. Conclusions: The presented tool is a versatile, systematically developed software component that specifically supports the clinical reasoning skills acquisition. It can be plugged into VP systems or used as stand-alone software in other teaching scenarios. The modular design allows an extension with new feedback mechanisms and learning analytics algorithms. ", doi="10.2196/mededu.8100", url="http://mededu.jmir.org/2017/2/e21/", url="http://www.ncbi.nlm.nih.gov/pubmed/29097355" } @Article{info:doi/10.2196/mededu.6305, author="Schoenthaler, Antoinette and Albright, Glenn and Hibbard, Judith and Goldman, Ron", title="Simulated Conversations With Virtual Humans to Improve Patient-Provider Communication and Reduce Unnecessary Prescriptions for Antibiotics: A Repeated Measure Pilot Study", journal="JMIR Med Educ", year="2017", month="Apr", day="19", volume="3", number="1", pages="e7", keywords="simulation training", keywords="health communication", keywords="patient activation", keywords="motivational interviewing", keywords="decision making", abstract="Background: Despite clear evidence that antibiotics do not cure viral infections, the problem of unnecessary prescribing of antibiotics in ambulatory care persists, and in some cases, prescribing patterns have increased. The overuse of antibiotics for treating viral infections has created numerous economic and clinical consequences including increased medical costs due to unnecessary hospitalizations, antibiotic resistance, disruption of gut bacteria, and obesity. Recent research has underscored the importance of collaborative patient-provider communication as a means to reduce the high rates of unnecessary prescriptions for antibiotics. However, most patients and providers do not feel prepared to engage in such challenging conversations. Objectives: The aim of this pilot study was to assess the ability of a brief 15-min simulated role-play conversation with virtual humans to serve as a preliminary step to help health care providers and patients practice, and learn how to engage in effective conversations about antibiotics overuse. Methods: A total of 69 participants (35 providers and 34 patients) completed the simulation once in one sitting. A pre-post repeated measures design was used to assess changes in patients' and providers' self-reported communication behaviors, activation, and preparedness, intention, and confidence to effectively communicate in the patient-provider encounter. Changes in patients' knowledge and beliefs regarding antibiotic use were also evaluated. Results: Patients experienced a short-term positive improvement in beliefs about appropriate antibiotic use for infection (F1,30=14.10, P=.001). Knowledge scores regarding the correct uses of antibiotics improved immediately postsimulation, but decreased at the 1-month follow-up (F1,30=31.16, P<.001). There was no change in patient activation and shared decision-making (SDM) scores in the total sample of patients (P>.10) Patients with lower levels of activation exhibited positive, short-term benefits in increased intent and confidence to discuss their needs and ask questions in the clinic visit, positive attitudes regarding participation in SDM with their provider, and accurate beliefs about the use of antibiotics (P<.10). The results also suggest small immediate gains in providers' attitudes about SDM (mean change 0.20; F1,33= 8.03, P=.01). Conclusions: This pilot study provided preliminary evidence on the efficacy of the use of simulated conversations with virtual humans as a tool to improve patient-provider communication (ie, through increasing patient confidence to actively participate in the visit and physician attitudes about SDM) for engaging in conversations about antibiotic use. Future research should explore if repeated opportunities to use the 15-min simulation as well as providing users with several different conversations to practice with would result in sustained improvements in antibiotics beliefs and knowledge and communication behaviors over time. The results of this pilot study offered several opportunities to improve on the simulation in order to bolster communication skills and knowledge retention. ", doi="10.2196/mededu.6305", url="http://mededu.jmir.org/2017/1/e7/", url="http://www.ncbi.nlm.nih.gov/pubmed/28428160" } @Article{info:doi/10.2196/mededu.7042, author="Blok, C. Amanda and May, N. Christine and Sadasivam, S. Rajani and Houston, K. Thomas", title="Virtual Patient Technology: Engaging Primary Care in Quality Improvement Innovations", journal="JMIR Med Educ", year="2017", month="Feb", day="15", volume="3", number="1", pages="e3", keywords="virtual patients", keywords="interdisciplinary health teams", keywords="clinical staff engagement", keywords="environment design", keywords="health promotion", keywords="tobacco use cessation", abstract="Background: Engaging health care staff in new quality improvement programs is challenging. Objective: We developed 2 virtual patient (VP) avatars in the context of a clinic-level quality improvement program. We sought to determine differences in preferences for VPs and the perceived influence of interacting with the VP on clinical staff engagement with the quality improvement program. Methods: Using a participatory design approach, we developed an older male smoker VP and a younger female smoker VP. The older male smoker was described as a patient with cardiovascular disease and was ethnically ambiguous. The female patient was younger and was worried about the impact of smoking on her pregnancy. Clinical staff were allowed to choose the VP they preferred, and the more they engaged with the VP, the more likely the VP was to quit smoking and become healthier. We deployed the VP within the context of a quality improvement program designed to encourage clinical staff to refer their patients who smoke to a patient-centered Web-assisted tobacco intervention. To evaluate the VPs, we used quantitative analyses using multivariate models of provider and practice characteristics and VP characteristic preference and analyses of a brief survey of positive deviants (clinical staff in practices with high rates of encouraging patients to use the quit smoking innovation). Results: A total of 146 clinical staff from 76 primary care practices interacted with the VPs. Clinic staff included medical providers (35/146, 24.0\%), nurse professionals (19/146, 13.0\%), primary care technicians (5/146, 3.4\%), managerial staff (67/146, 45.9\%), and receptionists (20/146, 13.7\%). Medical staff were mostly male, and other roles were mostly female. Medical providers (OR 0.031; CI 0.003-0.281; P=.002) and younger staff (OR 0.411; CI 0.177-0.952; P=.038) were less likely to choose the younger, female VP when controlling for all other characteristics. VP preference did not influence online patient referrals by staff. In high-performing practices that referred 20 or more smokers to the ePortal (13/76), the majority of clinic staff were motivated by or liked the virtual patient (20/26, 77\%). Conclusions: Medical providers are more likely motivated by VPs that are similar to their patient population, while nurses and other staff may prefer avatars that are more similar to them. ", doi="10.2196/mededu.7042", url="http://mededu.jmir.org/2017/1/e3/", url="http://www.ncbi.nlm.nih.gov/pubmed/28202429" } @Article{info:doi/10.2196/games.6448, author="Creutzfeldt, Johan and Hedman, Leif and Fell{\"a}nder-Tsai, Li", title="Cardiopulmonary Resuscitation Training by Avatars: A Qualitative Study of Medical Students' Experiences Using a Multiplayer Virtual World", journal="JMIR Serious Games", year="2016", month="Dec", day="16", volume="4", number="2", pages="e22", keywords="avatars", keywords="cardiopulmonary resuscitation", keywords="educational technology", keywords="medical students", keywords="experiences", keywords="multiplayer virtual worlds", keywords="patient simulation", keywords="virtual learning environments", abstract="Background: Emergency medical practices are often team efforts. Training for various tasks and collaborations may be carried out in virtual environments. Although promising results exist from studies of serious games, little is known about the subjective reactions of learners when using multiplayer virtual world (MVW) training in medicine. Objective: The objective of this study was to reach a better understanding of the learners' reactions and experiences when using an MVW for team training of cardiopulmonary resuscitation (CPR). Methods: Twelve Swedish medical students participated in semistructured focus group discussions after CPR training in an MVW with partially preset options. The students' perceptions and feelings related to use of this educational tool were investigated. Using qualitative methodology, discussions were analyzed by a phenomenological data-driven approach. Quality measures included negotiations, back-and-forth reading, triangulation, and validation with the informants. Results: Four categories characterizing the students' experiences could be defined: (1) Focused Mental Training, (2) Interface Diverting Focus From Training, (3) Benefits of Practicing in a Group, and (4) Easy Loss of Focus When Passive. We interpreted the results, compared them to findings of others, and propose advantages and risks of using virtual worlds for learning. Conclusions: Beneficial aspects of learning CPR in a virtual world were confirmed. To achieve high participant engagement and create good conditions for training, well-established procedures should be practiced. Furthermore, students should be kept in an active mode and frequent feedback should be utilized. It cannot be completely ruled out that the use of virtual training may contribute to erroneous self-beliefs that can affect later clinical performance. ", doi="10.2196/games.6448", url="http://games.jmir.org/2016/2/e22/", url="http://www.ncbi.nlm.nih.gov/pubmed/27986645" } @Article{info:doi/10.2196/jmir.6040, author="Walldorf, Jens and J{\"a}hnert, Tina and Berman, B. Norman and Fischer, R. Martin", title="Using Foreign Virtual Patients With Medical Students in Germany: Are Cultural Differences Evident and Do They Impede Learning?", journal="J Med Internet Res", year="2016", month="Sep", day="27", volume="18", number="9", pages="e260", keywords="virtual patients", keywords="medical education", keywords="cultural differences", keywords="competency-based education", keywords="e-learning", abstract="Background: Learning with virtual patients (VPs) is considered useful in medical education for fostering clinical reasoning. As the authoring of VPs is highly demanding, an international exchange of cases might be desirable. However, cultural differences in foreign VPs might hamper learning success. Objective: We investigated the need for support for using VPs from the United States at a German university, with respect to language and cultural differences. Our goal was to better understand potential implementation barriers of a intercultural VP exchange. Methods: Two VPs were presented to 30 German medical students featuring a cultural background different from German standards with respect to diagnostic and therapeutic procedures, ethical aspects, role models, and language (as identified by a cultural adaptation framework). Participants were assigned to two groups: 14 students were advised to complete the cases without further instructions (basic group), and 16 students received written explanatory supplemental information specifically with regard to cultural differences (supplement group). Using a 6-point scale (6=strongly agree), we analyzed the results of an integrated assessment of learning success as well as an evaluation of cases by the students on usefulness for learning and potential issues regarding the language and cultural background. Results: The German students found it motivating to work with cases written in English (6-point scale, 4.5 points). The clinical relevance of the VPs was clearly recognized (6 points), and the foreign language was considered a minor problem in this context (3 points). The results of the integrated learning assessment were similar in both groups (basic 53\% [SD 4] vs supplement 52\% [SD 4] correct answers, P=.32). However, students using the supplemental material more readily realized culturally different diagnostic and therapeutic strategies (basic 4 vs supplement 5 points, P=.39) and were less affirmative when asked about the transferability of cases to a German context (basic 5 vs supplement 3 points, P=.048). Conclusions: German students found English VPs to be highly clinically relevant, and they rated language problems much lower than they rated motivation to work on cases in English. This should encourage the intercultural exchange of VPs. The provision of supplemental explanatory material facilitates the recognition of cultural differences and might help prevent unexpected learning effects. ", doi="10.2196/jmir.6040", url="http://www.jmir.org/2016/9/e260/", url="http://www.ncbi.nlm.nih.gov/pubmed/27678418" } @Article{info:doi/10.2196/mededu.5350, author="Lino, Arcanjo Juliana and Gomes, Carvalho Gabriela and Sousa, Canjura Nancy Delma Silva Vega and Carvalho, K. Andrea and Diniz, Bezerra Marcelo Emanoel and Viana Junior, Brazil Antonio and Holanda, Alcantara Marcelo", title="A Critical Review of Mechanical Ventilation Virtual Simulators: Is It Time to Use Them?", journal="JMIR Med Educ", year="2016", month="Jun", day="14", volume="2", number="1", pages="e8", keywords="positive-pressure respiration", keywords="medical education", keywords="computer simulation", keywords="learning", abstract="Background: Teaching mechanical ventilation at the bedside with real patients is difficult with many logistic limitations. Mechanical ventilators virtual simulators (MVVS) may have the potential to facilitate mechanical ventilation (MV) training by allowing Web-based virtual simulation. Objective: We aimed to identify and describe the current available MVVS, to compare the usability of their interfaces as a teaching tool and to review the literature on validation studies. Methods: We performed a comparative evaluation of the MVVS, based on a literature/Web review followed by usability tests according to heuristic principles evaluation of their interfaces as performed by professional experts on MV. Results: Eight MVVS were identified. They showed marked heterogeneity, mainly regarding virtual patient's anthropomorphic parameters, pulmonary gas exchange, respiratory mechanics and muscle effort configurations, ventilator terminology, basic ventilatory modes, settings alarms, monitoring parameters, and design. The Hamilton G5 and the Xlung covered a broader number of parameters, tools, and have easier Web-based access. Except for the Xlung, none of the simulators displayed monitoring of arterial blood gases and alternatives to load and save the simulation. The Xlung obtained the greater scores on heuristic principles assessments and the greater score of easiness of use, being the preferred MVVS for teaching purposes. No strong scientific evidence on the use and validation of the current MVVS was found. Conclusions: There are only a few MVVS currently available. Among them, the Xlung showed a better usability interface. Validation tests and development of new or improvement of the current MVVS are needed. ", doi="10.2196/mededu.5350", url="http://mededu.jmir.org/2016/1/e8/", url="http://www.ncbi.nlm.nih.gov/pubmed/27731850" } @Article{info:doi/10.2196/jmir.5294, author="Liaw, Ying Sok and Wong, Fun Lai and Lim, Ping Eunice Ya and Ang, Leng Sophia Bee and Mujumdar, Sandhya and Ho, Yin Jasmine Tze and Mordiffi, Zubaidah Siti and Ang, Kim Emily Neo", title="Effectiveness of a Web-Based Simulation in Improving Nurses' Workplace Practice With Deteriorating Ward Patients: A Pre- and Postintervention Study", journal="J Med Internet Res", year="2016", month="Feb", day="19", volume="18", number="2", pages="e37", keywords="Web-based simulation", keywords="clinical deterioration", keywords="nursing education", keywords="online learning", keywords="transfer of learning", keywords="nursing practice", abstract="Background: Nurses play an important role in detecting patients with clinical deterioration. However, the problem of nurses failing to trigger deteriorating ward patients still persists despite the implementation of a patient safety initiative, the Rapid Response System. A Web-based simulation was developed to enhance nurses' role in recognizing and responding to deteriorating patients. While studies have evaluated the effectiveness of the Web-based simulation on nurses' clinical performance in a simulated environment, no study has examined its impact on nurses' actual practice in the clinical setting. Objective: The objective of this study was to evaluate the impact of Web-based simulation on nurses' recognition of and response to deteriorating patients in clinical settings. The outcomes were measured across all levels of Kirkpatrick's 4-level evaluation model with clinical outcome on triggering rates of deteriorating patients as the primary outcome measure. Methods: A before-and-after study was conducted on two general wards at an acute care tertiary hospital over a 14-month period. All nurses from the two study wards who undertook the Web-based simulation as part of their continuing nursing education were invited to complete questionnaires at various time points to measure their motivational reaction, knowledge, and perceived transfer of learning. Clinical records on cases triggered by ward nurses from the two study wards were evaluated for frequency and types of triggers over a period of 6 months pre- and 6 months postintervention. Results: The number of deteriorating patients triggered by ward nurses in a medical general ward increased significantly (P<.001) from pre- (84/937, 8.96\%) to postintervention (91/624, 14.58\%). The nurses reported positively on the transfer of learning (mean 3.89, SD 0.49) from the Web-based simulation to clinical practice. A significant increase (P<.001) on knowledge posttest score from pretest score was also reported. The nurses also perceived positively their motivation (mean 3.78, SD 0.56) to engage in the Web-based simulation. Conclusions: This study provides evidence on the effectiveness of Web-based simulation in improving nursing practice when recognizing and responding to deteriorating patients. This educational tool could be implemented by nurse educators worldwide to address the educational needs of a large group of hospital nurses responsible for patients in clinical deterioration. ", doi="10.2196/jmir.5294", url="http://www.jmir.org/2016/2/e37/", url="http://www.ncbi.nlm.nih.gov/pubmed/26895723" } @Article{info:doi/10.2196/jmir.5035, author="Kleinert, Robert and Heiermann, Nadine and Plum, Sven Patrick and Wahba, Roger and Chang, De-Hua and Maus, Martin and Chon, Seung-Hun and Hoelscher, H. Arnulf and Stippel, Ludger Dirk", title="Web-Based Immersive Virtual Patient Simulators: Positive Effect on Clinical Reasoning in Medical Education", journal="J Med Internet Res", year="2015", month="Nov", day="17", volume="17", number="11", pages="e263", keywords="medical education", keywords="simulation", keywords="virtual patients", keywords="immersive", abstract="Background: Clinical reasoning is based on the declarative and procedural knowledge of workflows in clinical medicine. Educational approaches such as problem-based learning or mannequin simulators support learning of procedural knowledge. Immersive patient simulators (IPSs) go one step further as they allow an illusionary immersion into a synthetic world. Students can freely navigate an avatar through a three-dimensional environment, interact with the virtual surroundings, and treat virtual patients. By playful learning with IPS, medical workflows can be repetitively trained and internalized. As there are only a few university-driven IPS with a profound amount of medical knowledge available, we developed a university-based IPS framework. Our simulator is free to use and combines a high degree of immersion with in-depth medical content. By adding disease-specific content modules, the simulator framework can be expanded depending on the curricular demands. However, these new educational tools compete with the traditional teaching Objective: It was our aim to develop an educational content module that teaches clinical and therapeutic workflows in surgical oncology. Furthermore, we wanted to examine how the use of this module affects student performance. Methods: The new module was based on the declarative and procedural learning targets of the official German medical examination regulations. The module was added to our custom-made IPS named ALICE (Artificial Learning Interface for Clinical Education). ALICE was evaluated on 62 third-year students. Results: Students showed a high degree of motivation when using the simulator as most of them had fun using it. ALICE showed positive impact on clinical reasoning as there was a significant improvement in determining the correct therapy after using the simulator. ALICE positively impacted the rise in declarative knowledge as there was improvement in answering multiple-choice questions before and after simulator use. Conclusions: ALICE has a positive effect on knowledge gain and raises students' motivation. It is a suitable tool for supporting clinical education in the blended learning context. ", doi="10.2196/jmir.5035", url="http://www.jmir.org/2015/11/e263/", url="http://www.ncbi.nlm.nih.gov/pubmed/26577020" } @Article{info:doi/10.2196/jmir.3650, author="Antoniades, Athos and Nicolaidou, Iolie and Spachos, Dimitris and Myll{\"a}ri, Jarkko and Giordano, Daniela and Dafli, Eleni and Mitsopoulou, Evangelia and Schizas, N. Christos and Pattichis, Constantinos and Nikolaidou, Maria and Bamidis, Panagiotis", title="Medical Content Searching, Retrieving, and Sharing Over the Internet: Lessons Learned From the mEducator Through a Scenario-Based Evaluation", journal="J Med Internet Res", year="2015", month="Oct", day="09", volume="17", number="10", pages="e229", keywords="searching and sharing of medical educational content", keywords="repurposing", keywords="metadata", keywords="evaluation", abstract="Background: The mEducator Best Practice Network (BPN) implemented and extended standards and reference models in e-learning to develop innovative frameworks as well as solutions that enable specialized state-of-the-art medical educational content to be discovered, retrieved, shared, and re-purposed across European Institutions, targeting medical students, doctors, educators and health care professionals. Scenario-based evaluation for usability testing, complemented with data from online questionnaires and field notes of users' performance, was designed and utilized for the evaluation of these solutions. Objective: The objective of this work is twofold: (1) to describe one instantiation of the mEducator BPN solutions (mEducator3.0 - ``MEdical Education LINnked Arena'' MELINA+) with a focus on the metadata schema used, as well as on other aspects of the system that pertain to usability and acceptance, and (2) to present evaluation results on the suitability of the proposed metadata schema for searching, retrieving, and sharing of medical content and with respect to the overall usability and acceptance of the system from the target users. Methods: A comprehensive evaluation methodology framework was developed and applied to four case studies, which were conducted in four different countries (ie, Greece, Cyprus, Bulgaria and Romania), with a total of 126 participants. In these case studies, scenarios referring to creating, sharing, and retrieving medical educational content using mEducator3.0 were used. The data were collected through two online questionnaires, consisting of 36 closed-ended questions and two open-ended questions that referred to mEducator 3.0 and through the use of field notes during scenario-based evaluations. Results: The main findings of the study showed that even though the informational needs of the mEducator target groups were addressed to a satisfactory extent and the metadata schema supported content creation, sharing, and retrieval from an end-user perspective, users faced difficulties in achieving a shared understanding of the meaning of some metadata fields and in correctly managing the intellectual property rights of repurposed content. Conclusions: The results of this evaluation impact researchers, medical professionals, and designers interested in using similar systems for educational content sharing in medical and other domains. Recommendations on how to improve the search, retrieval, identification, and obtaining of medical resources are provided, by addressing issues of content description metadata, content description procedures, and intellectual property rights for re-purposed content. ", doi="10.2196/jmir.3650", url="http://www.jmir.org/2015/10/e229/", url="http://www.ncbi.nlm.nih.gov/pubmed/26453250" } @Article{info:doi/10.2196/mededu.4394, author="Kononowicz, A. Andrzej and Berman, H. Anne and Stathakarou, Natalia and McGrath, Cormac and Barty?ski, Tomasz and Nowakowski, Piotr and Malawski, Maciej and Zary, Nabil", title="Virtual Patients in a Behavioral Medicine Massive Open Online Course (MOOC): A Case-Based Analysis of Technical Capacity and User Navigation Pathways", journal="JMIR Medical Education", year="2015", month="Sep", day="10", volume="1", number="2", pages="e8", keywords="computer-assisted instruction", keywords="education, medical", keywords="medical informatics applications", abstract="Background: Massive open online courses (MOOCs) have been criticized for focusing on presentation of short video clip lectures and asking theoretical multiple-choice questions. A potential way of vitalizing these educational activities in the health sciences is to introduce virtual patients. Experiences from such extensions in MOOCs have not previously been reported in the literature. Objective: This study analyzes technical challenges and solutions for offering virtual patients in health-related MOOCs and describes patterns of virtual patient use in one such course. Our aims are to reduce the technical uncertainty related to these extensions, point to aspects that could be optimized for a better learner experience, and raise prospective research questions by describing indicators of virtual patient use on a massive scale. Methods: The Behavioral Medicine MOOC was offered by Karolinska Institutet, a medical university, on the EdX platform in the autumn of 2014. Course content was enhanced by two virtual patient scenarios presented in the OpenLabyrinth system and hosted on the VPH-Share cloud infrastructure. We analyzed web server and session logs and a participant satisfaction survey. Navigation pathways were summarized using a visual analytics tool developed for the purpose of this study. Results: The number of course enrollments reached 19,236. At the official closing date, 2317 participants (12.1\% of total enrollment) had declared completing the first virtual patient assignment and 1640 (8.5\%) participants confirmed completion of the second virtual patient assignment. Peak activity involved 359 user sessions per day. The OpenLabyrinth system, deployed on four virtual servers, coped well with the workload. Participant survey respondents (n=479) regarded the activity as a helpful exercise in the course (83.1\%). Technical challenges reported involved poor or restricted access to videos in certain areas of the world and occasional problems with lost sessions. The visual analyses of user pathways display the parts of virtual patient scenarios that elicited less interest and may have been perceived as nonchallenging options. Analyzing the user navigation pathways allowed us to detect indications of both surface and deep approaches to the content material among the MOOC participants. Conclusions: This study reported on first inclusion of virtual patients in a MOOC. It adds to the body of knowledge by demonstrating how a biomedical cloud provider service can ensure technical capacity and flexible design of a virtual patient platform on a massive scale. The study also presents a new way of analyzing the use of branched virtual patients by visualization of user navigation pathways. Suggestions are offered on improvements to the design of virtual patients in MOOCs. ", doi="10.2196/mededu.4394", url="http://mededu.jmir.org/2015/2/e8/", url="http://www.ncbi.nlm.nih.gov/pubmed/27731844" } @Article{info:doi/10.2196/jmir.4141, author="Lehmann, Ronny and Thiessen, Christiane and Frick, Barbara and Bosse, Martin Hans and Nikendei, Christoph and Hoffmann, Friedrich Georg and T{\"o}nshoff, Burkhard and Huwendiek, S{\"o}ren", title="Improving Pediatric Basic Life Support Performance Through Blended Learning With Web-Based Virtual Patients: Randomized Controlled Trial", journal="J Med Internet Res", year="2015", month="Jul", day="02", volume="17", number="7", pages="e162", keywords="virtual patients", keywords="blended learning", keywords="simulation", keywords="pediatric basic life support", keywords="performance", abstract="Background: E-learning and blended learning approaches gain more and more popularity in emergency medicine curricula. So far, little data is available on the impact of such approaches on procedural learning and skill acquisition and their comparison with traditional approaches. Objective: This study investigated the impact of a blended learning approach, including Web-based virtual patients (VPs) and standard pediatric basic life support (PBLS) training, on procedural knowledge, objective performance, and self-assessment. Methods: A total of 57 medical students were randomly assigned to an intervention group (n=30) and a control group (n=27). Both groups received paper handouts in preparation of simulation-based PBLS training. The intervention group additionally completed two Web-based VPs with embedded video clips. Measurements were taken at randomization (t0), after the preparation period (t1), and after hands-on training (t2). Clinical decision-making skills and procedural knowledge were assessed at t0 and t1. PBLS performance was scored regarding adherence to the correct algorithm, conformance to temporal demands, and the quality of procedural steps at t1 and t2. Participants' self-assessments were recorded in all three measurements. Results: Procedural knowledge of the intervention group was significantly superior to that of the control group at t1. At t2, the intervention group showed significantly better adherence to the algorithm and temporal demands, and better procedural quality of PBLS in objective measures than did the control group. These aspects differed between the groups even at t1 (after VPs, prior to practical training). Self-assessments differed significantly only at t1 in favor of the intervention group. Conclusions: Training with VPs combined with hands-on training improves PBLS performance as judged by objective measures. ", doi="10.2196/jmir.4141", url="http://www.jmir.org/2015/7/e162/", url="http://www.ncbi.nlm.nih.gov/pubmed/26139388" } @Article{info:doi/10.2196/jmir.3922, author="Woodham, A. Luke and Ellaway, H. Rachel and Round, Jonathan and Vaughan, Sophie and Poulton, Terry and Zary, Nabil", title="Medical Student and Tutor Perceptions of Video Versus Text in an Interactive Online Virtual Patient for Problem-Based Learning: A Pilot Study", journal="J Med Internet Res", year="2015", month="Jun", day="18", volume="17", number="6", pages="e151", keywords="problem-based learning", keywords="educational technology", keywords="multimedia", keywords="Internet", keywords="audiovisual aids", abstract="Background: The impact of the use of video resources in primarily paper-based problem-based learning (PBL) settings has been widely explored. Although it can provide many benefits, the use of video can also hamper the critical thinking of learners in contexts where learners are developing clinical reasoning. However, the use of video has not been explored in the context of interactive virtual patients for PBL. Objective: A pilot study was conducted to explore how undergraduate medical students interpreted and evaluated information from video- and text-based materials presented in the context of a branched interactive online virtual patient designed for PBL. The goal was to inform the development and use of virtual patients for PBL and to inform future research in this area. Methods: An existing virtual patient for PBL was adapted for use in video and provided as an intervention to students in the transition year of the undergraduate medicine course at St George's, University of London. Survey instruments were used to capture student and PBL tutor experiences and perceptions of the intervention, and a formative review meeting was run with PBL tutors. Descriptive statistics were generated for the structured responses and a thematic analysis was used to identify emergent themes in the unstructured responses. Results: Analysis of student responses (n=119) and tutor comments (n=18) yielded 8 distinct themes relating to the perceived educational efficacy of information presented in video and text formats in a PBL context. Although some students found some characteristics of the videos beneficial, when asked to express a preference for video or text the majority of those that responded to the question (65\%, 65/100) expressed a preference for text. Student responses indicated that the use of video slowed the pace of PBL and impeded students' ability to review and critically appraise the presented information. Conclusions: Our findings suggest that text was perceived to be a better source of information than video in virtual patients for PBL. More specifically, the use of video was perceived as beneficial for providing details, visual information, and context where text was unable to do so. However, learner acceptance of text was higher in the context of PBL, particularly when targeting clinical reasoning skills. This pilot study has provided the foundation for further research into the effectiveness of different virtual patient designs for PBL. ", doi="10.2196/jmir.3922", url="http://www.jmir.org/2015/6/e151/", url="http://www.ncbi.nlm.nih.gov/pubmed/26088435" } @Article{info:doi/10.2196/jmir.3492, author="Kleinert, Robert and Wahba, Roger and Chang, De-Hua and Plum, Patrick and H{\"o}lscher, H. Arnulf and Stippel, L. Dirk", title="3D Immersive Patient Simulators and Their Impact on Learning Success: A Thematic Review", journal="J Med Internet Res", year="2015", month="Apr", day="08", volume="17", number="4", pages="e91", keywords="immersive patient simulators", keywords="Web-based learning", keywords="validity", keywords="immersion", keywords="procedural knowledge", abstract="Background: Immersive patient simulators (IPSs) combine the simulation of virtual patients with a three-dimensional (3D) environment and, thus, allow an illusionary immersion into a synthetic world, similar to computer games. Playful learning in a 3D environment is motivating and allows repetitive training and internalization of medical workflows (ie, procedural knowledge) without compromising real patients. The impact of this innovative educational concept on learning success requires review of feasibility and validity. Objective: It was the aim of this paper to conduct a survey of all immersive patient simulators currently available. In addition, we address the question of whether the use of these simulators has an impact on knowledge gain by summarizing the existing validation studies. Methods: A systematic literature search via PubMed was performed using predefined inclusion criteria (ie, virtual worlds, focus on education of medical students, validation testing) to identify all available simulators. Validation testing was defined as the primary end point. Results: There are currently 13 immersive patient simulators available. Of these, 9 are Web-based simulators and represent feasibility studies. None of these simulators are used routinely for student education. The workstation-based simulators are commercially driven and show a higher quality in terms of graphical quality and/or data content. Out of the studies, 1 showed a positive correlation between simulated content and real content (ie, content validity). There was a positive correlation between the outcome of simulator training and alternative training methods (ie, concordance validity), and a positive coherence between measured outcome and future professional attitude and performance (ie, predictive validity). Conclusions: IPSs can promote learning and consolidation of procedural knowledge. The use of immersive patient simulators is still marginal, and technical and educational approaches are heterogeneous. Academic-driven IPSs could possibly enhance the content quality, improve the validity level, and make this educational concept accessible to all medical students. ", doi="10.2196/jmir.3492", url="http://www.jmir.org/2015/4/e91/", url="http://www.ncbi.nlm.nih.gov/pubmed/25858862" } @Article{info:doi/10.2196/jmir.3497, author="Pantziaras, Ioannis and Fors, Uno and Ekblad, Solvig", title="Training With Virtual Patients in Transcultural Psychiatry: Do the Learners Actually Learn?", journal="J Med Internet Res", year="2015", month="Feb", day="16", volume="17", number="2", pages="e46", keywords="mental health", keywords="transcultural psychiatry", keywords="virtual systems", keywords="PTSD", keywords="medical informatics", keywords="education", keywords="patient simulation", abstract="Background: The rapid increase in the number of patients with diverse ethnic backgrounds and previous exposure to severe mental trauma dictates the need for improvement in the quality of transcultural psychiatric health care through the development of relevant and effective training tools. Objective: This study aimed to evaluate the impact of training with a virtual patient on the learner's knowledge of posttraumatic stress disorder symptoms, clinical management, and basic communication skills. Methods: The authors constructed an interactive educational tool based on virtual patient methodology that portrayed a refugee with severe symptoms of posttraumatic stress disorder and depression. A total of 32 resident psychiatrists tested the tool and completed a pre-interaction and post-interaction knowledge test, including skills, at the time and several weeks later. Results: All of the participants (N=32) completed the pre-interaction and post-interaction test, and 26 (81\%) of them completed the online follow-up test. The mean pre-interaction score was 7.44 (male: 7.08, female: 7.65, no statistical significance). The mean post-interaction score was 8.47, which was significantly higher (P<.001) than the pre-interaction score (mean score 7.44). The mean score for the follow-up test several weeks later was 8.38, higher than the pre-interaction score by 0.69 points but not statistically significant. Conclusions: Our results suggest that virtual patients can successfully facilitate the acquisition of core knowledge in the field of psychiatry, in addition to developing skills such as clinical reasoning, decision making, and history taking. Repeated training sessions with virtual patients are proposed in order to achieve sustainable educational effects. ", doi="10.2196/jmir.3497", url="http://www.jmir.org/2015/2/e46/", url="http://www.ncbi.nlm.nih.gov/pubmed/25689716" } @Article{info:doi/10.2196/jmir.3933, author="Dafli, Eleni and Antoniou, Panagiotis and Ioannidis, Lazaros and Dombros, Nicholas and Topps, David and Bamidis, D. Panagiotis", title="Virtual Patients on the Semantic Web: A Proof-of-Application Study", journal="J Med Internet Res", year="2015", month="Jan", day="22", volume="17", number="1", pages="e16", keywords="semantics", keywords="medical education", keywords="problem-based learning", keywords="data sharing", keywords="patient simulation", keywords="educational assessment", abstract="Background: Virtual patients are interactive computer simulations that are increasingly used as learning activities in modern health care education, especially in teaching clinical decision making. A key challenge is how to retrieve and repurpose virtual patients as unique types of educational resources between different platforms because of the lack of standardized content-retrieving and repurposing mechanisms. Semantic Web technologies provide the capability, through structured information, for easy retrieval, reuse, repurposing, and exchange of virtual patients between different systems. Objective: An attempt to address this challenge has been made through the mEducator Best Practice Network, which provisioned frameworks for the discovery, retrieval, sharing, and reuse of medical educational resources. We have extended the OpenLabyrinth virtual patient authoring and deployment platform to facilitate the repurposing and retrieval of existing virtual patient material. Methods: A standalone Web distribution and Web interface, which contains an extension for the OpenLabyrinth virtual patient authoring system, was implemented. This extension was designed to semantically annotate virtual patients to facilitate intelligent searches, complex queries, and easy exchange between institutions. The OpenLabyrinth extension enables OpenLabyrinth authors to integrate and share virtual patient case metadata within the mEducator3.0 network. Evaluation included 3 successive steps: (1) expert reviews; (2) evaluation of the ability of health care professionals and medical students to create, share, and exchange virtual patients through specific scenarios in extended OpenLabyrinth (OLabX); and (3) evaluation of the repurposed learning objects that emerged from the procedure. Results: We evaluated 30 repurposed virtual patient cases. The evaluation, with a total of 98 participants, demonstrated the system's main strength: the core repurposing capacity. The extensive metadata schema presentation facilitated user exploration and filtering of resources. Usability weaknesses were primarily related to standard computer applications' ease of use provisions. Most evaluators provided positive feedback regarding educational experiences on both content and system usability. Evaluation results replicated across several independent evaluation events. Conclusions: The OpenLabyrinth extension, as part of the semantic mEducator3.0 approach, is a virtual patient sharing approach that builds on a collection of Semantic Web services and federates existing sources of clinical and educational data. It is an effective sharing tool for virtual patients and has been merged into the next version of the app (OpenLabyrinth 3.3). Such tool extensions may enhance the medical education arsenal with capacities of creating simulation/game-based learning episodes, massive open online courses, curricular transformations, and a future robust infrastructure for enabling mobile learning. ", doi="10.2196/jmir.3933", url="http://www.jmir.org/2015/1/e16/", url="http://www.ncbi.nlm.nih.gov/pubmed/25616272" } @Article{info:doi/10.2196/jmir.3748, author="Poulton, Terry and Ellaway, H. Rachel and Round, Jonathan and Jivram, Trupti and Kavia, Sheetal and Hilton, Sean", title="Exploring the Efficacy of Replacing Linear Paper-Based Patient Cases in Problem-Based Learning With Dynamic Web-Based Virtual Patients: Randomized Controlled Trial", journal="J Med Internet Res", year="2014", month="Nov", day="05", volume="16", number="11", pages="e240", keywords="problem-based learning", keywords="decision making", keywords="education, medical", keywords="virtual patients", keywords="curriculum", abstract="Background: Problem-based learning (PBL) is well established in medical education and beyond, and continues to be developed and explored. Challenges include how to connect the somewhat abstract nature of classroom-based PBL with clinical practice and how to maintain learner engagement in the process of PBL over time. Objective: A study was conducted to investigate the efficacy of decision-PBL (D-PBL), a variant form of PBL that replaces linear PBL cases with virtual patients. These Web-based interactive cases provided learners with a series of patient management pathways. Learners were encouraged to consider and discuss courses of action, take their chosen management pathway, and experience the consequences of their decisions. A Web-based application was essential to allow scenarios to respond dynamically to learners' decisions, to deliver the scenarios to multiple PBL classrooms in the same timeframe, and to record centrally the paths taken by the PBL groups. Methods: A randomized controlled trial in crossover design was run involving all learners (N=81) in the second year of the graduate entry stream for the undergraduate medicine program at St George's University of London. Learners were randomized to study groups; half engaged in a D-PBL activity whereas the other half had a traditional linear PBL activity on the same subject material. Groups alternated D-PBL and linear PBL over the semester. The measure was mean cohort performance on specific face-to-face exam questions at the end of the semester. Results: D-PBL groups performed better than linear PBL groups on questions related to D-PBL with the difference being statistically significant for all questions. Differences between the exam performances of the 2 groups were not statistically significant for the questions not related to D-PBL. The effect sizes for D-PBL--related questions were large and positive (>0.6) except for 1 question that showed a medium positive effect size. The effect sizes for questions not related to D-PBL were all small (?0.3) with a mix of positive and negative values. Conclusions: The efficacy of D-PBL was indicated by improved exam performance for learners who had D-PBL compared to those who had linear PBL. This suggests that the use of D-PBL leads to better midterm learning outcomes than linear PBL, at least for learners with prior experience with linear PBL. On the basis of tutor and student feedback, St George's University of London and the University of Nicosia, Cyprus have replaced paper PBL cases for midstage undergraduate teaching with D-PBL virtual patients, and 6 more institutions in the ePBLnet partnership will be implementing D-PBL in Autumn 2015. ", doi="10.2196/jmir.3748", url="http://www.jmir.org/2014/11/e240/", url="http://www.ncbi.nlm.nih.gov/pubmed/25373314" } @Article{info:doi/10.2196/jmir.3343, author="Antoniou, E. Panagiotis and Athanasopoulou, A. Christina and Dafli, Eleni and Bamidis, D. Panagiotis", title="Exploring Design Requirements for Repurposing Dental Virtual Patients From the Web to Second Life: A Focus Group Study", journal="J Med Internet Res", year="2014", month="Jun", day="13", volume="16", number="6", pages="e151", keywords="education", keywords="medical", keywords="dental", keywords="focus groups", keywords="patient simulation", keywords="problem-based learning", keywords="video games", abstract="Background: Since their inception, virtual patients have provided health care educators with a way to engage learners in an experience simulating the clinician's environment without danger to learners and patients. This has led this learning modality to be accepted as an essential component of medical education. With the advent of the visually and audio-rich 3-dimensional multi-user virtual environment (MUVE), a new deployment platform has emerged for educational content. Immersive, highly interactive, multimedia-rich, MUVEs that seamlessly foster collaboration provide a new hotbed for the deployment of medical education content. Objective: This work aims to assess the suitability of the Second Life MUVE as a virtual patient deployment platform for undergraduate dental education, and to explore the requirements and specifications needed to meaningfully repurpose Web-based virtual patients in MUVEs. Methods: Through the scripting capabilities and available art assets in Second Life, we repurposed an existing Web-based periodontology virtual patient into Second Life. Through a series of point-and-click interactions and multiple-choice queries, the user experienced a specific periodontology case and was asked to provide the optimal responses for each of the challenges of the case. A focus group of 9 undergraduate dentistry students experienced both the Web-based and the Second Life version of this virtual patient. The group convened 3 times and discussed relevant issues such as the group's computer literacy, the assessment of Second Life as a virtual patient deployment platform, and compared the Web-based and MUVE-deployed virtual patients. Results: A comparison between the Web-based and the Second Life virtual patient revealed the inherent advantages of the more experiential and immersive Second Life virtual environment. However, several challenges for the successful repurposing of virtual patients from the Web to the MUVE were identified. The identified challenges for repurposing of Web virtual patients to the MUVE platform from the focus group study were (1) increased case complexity to facilitate the user's gaming preconception in a MUVE, (2) necessity to decrease textual narration and provide the pertinent information in a more immersive sensory way, and (3) requirement to allow the user to actuate the solutions of problems instead of describing them through narration. Conclusions: For a successful systematic repurposing effort of virtual patients to MUVEs such as Second Life, the best practices of experiential and immersive game design should be organically incorporated in the repurposing workflow (automated or not). These findings are pivotal in an era in which open educational content is transferred to and shared among users, learners, and educators of various open repositories/environments. ", doi="10.2196/jmir.3343", url="http://www.jmir.org/2014/6/e151/", url="http://www.ncbi.nlm.nih.gov/pubmed/24927470" } @Article{info:doi/10.2196/jmir.2556, author="Georg, Carina and Zary, Nabil", title="Web-Based Virtual Patients in Nursing Education: Development and Validation of Theory-Anchored Design and Activity Models", journal="J Med Internet Res", year="2014", month="Apr", day="10", volume="16", number="4", pages="e105", keywords="virtual patient", keywords="patient simulation", keywords="nursing education", keywords="clinical reasoning", keywords="e-learning, simulation technology", abstract="Background: 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. Objective: The aim of this study was to develop and evaluate a virtual patient model optimized to the learning and assessment needs in nursing education. Methods: 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. Results: 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. Conclusions: 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. ", doi="10.2196/jmir.2556", url="http://www.jmir.org/2014/4/e105/", url="http://www.ncbi.nlm.nih.gov/pubmed/24727709" } @Article{info:doi/10.2196/jmir.2593, author="Kononowicz, A. Andrzej and Narracott, J. Andrew and Manini, Simone and Bayley, J. Martin and Lawford, V. Patricia and McCormack, Keith and Zary, Nabil", title="A Framework for Different Levels of Integration of Computational Models Into Web-Based Virtual Patients", journal="J Med Internet Res", year="2014", month="Jan", day="23", volume="16", number="1", pages="e23", keywords="computer simulation", keywords="computer-assisted instruction", keywords="education, medical", keywords="medical informatics applications", abstract="Background: Virtual patients are increasingly common tools used in health care education to foster learning of clinical reasoning skills. One potential way to expand their functionality is to augment virtual patients' interactivity by enriching them with computational models of physiological and pathological processes. Objective: The primary goal of this paper was to propose a conceptual framework for the integration of computational models within virtual patients, with particular focus on (1) characteristics to be addressed while preparing the integration, (2) the extent of the integration, (3) strategies to achieve integration, and (4) methods for evaluating the feasibility of integration. An additional goal was to pilot the first investigation of changing framework variables on altering perceptions of integration. Methods: The framework was constructed using an iterative process informed by Soft System Methodology. The Virtual Physiological Human (VPH) initiative has been used as a source of new computational models. The technical challenges associated with development of virtual patients enhanced by computational models are discussed from the perspectives of a number of different stakeholders. Concrete design and evaluation steps are discussed in the context of an exemplar virtual patient employing the results of the VPH ARCH project, as well as improvements for future iterations. Results: The proposed framework consists of four main elements. The first element is a list of feasibility features characterizing the integration process from three perspectives: the computational modelling researcher, the health care educationalist, and the virtual patient system developer. The second element included three integration levels: basic, where a single set of simulation outcomes is generated for specific nodes in the activity graph; intermediate, involving pre-generation of simulation datasets over a range of input parameters; advanced, including dynamic solution of the model. The third element is the description of four integration strategies, and the last element consisted of evaluation profiles specifying the relevant feasibility features and acceptance thresholds for specific purposes. The group of experts who evaluated the virtual patient exemplar found higher integration more interesting, but at the same time they were more concerned with the validity of the result. The observed differences were not statistically significant. Conclusions: This paper outlines a framework for the integration of computational models into virtual patients. The opportunities and challenges of model exploitation are discussed from a number of user perspectives, considering different levels of model integration. The long-term aim for future research is to isolate the most crucial factors in the framework and to determine their influence on the integration outcome. ", doi="10.2196/jmir.2593", url="http://www.jmir.org/2014/1/e23/", url="http://www.ncbi.nlm.nih.gov/pubmed/24463466" } @Article{info:doi/10.2196/jmir.2616, author="Salminen, Helena and Zary, Nabil and Bj{\"o}rklund, Karin and Toth-Pal, Eva and Leanderson, Charlotte", title="Virtual Patients in Primary Care: Developing a Reusable Model That Fosters Reflective Practice and Clinical Reasoning", journal="J Med Internet Res", year="2014", month="Jan", day="06", volume="16", number="1", pages="e3", keywords="virtual patients", keywords="clinical reasoning", keywords="reflection", keywords="primary care", keywords="medical education", abstract="Background: 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. Objective: 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. Methods: 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. Results: 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. Conclusions: 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. ", doi="10.2196/jmir.2616", url="http://www.jmir.org/2014/1/e3/", url="http://www.ncbi.nlm.nih.gov/pubmed/24394603" } @Article{info:doi/10.2196/jmir.2651, author="Papadopoulos, Lazaros and Pentzou, Afroditi-Evaggelia and Louloudiadis, Konstantinos and Tsiatsos, Thrasyvoulos-Konstantinos", title="Design and Evaluation of a Simulation for Pediatric Dentistry in Virtual Worlds", journal="J Med Internet Res", year="2013", month="Oct", day="29", volume="15", number="10", pages="e240", keywords="virtual patient", keywords="virtual world", keywords="pediatric dentistry", keywords="simulation", keywords="Second Life", keywords="OpenSim", keywords="communication", keywords="tell-show-do", keywords="behavior management", abstract="Background: Three-dimensional virtual worlds are becoming very popular among educators in the medical field. Virtual clinics and patients are already used for case study and role play in both undergraduate and continuing education levels. Dental education can also take advantage of the virtual world's pedagogical features in order to give students the opportunity to interact with virtual patients (VPs) and practice in treatment planning. Objective: The objective of this study was to design and evaluate a virtual patient as a supplemental teaching tool for pediatric dentistry. Methods: A child VP, called Erietta, was created by utilizing the programming and building tools that online virtual worlds offer. The case is about an eight-year old girl visiting the dentist with her mother for the first time. Communication techniques such as Tell-Show-Do and parents' interference management were the basic elements of the educational scenario on which the VP was based. An evaluation of the simulation was made by 103 dental students in their fourth year of study. Two groups were formed: an experimental group which was exposed to the simulation (n=52) and a control group which did not receive the simulation (n=51). At the end, both groups were asked to complete a knowledge questionnaire and the results were compared. Results: A statistically significant difference between the two groups was found by applying a t test for independent samples (P<.001), showing a positive learning effect from the VP. The majority of the participants evaluated the aspects of the simulation very positively while 69\% (36/52) of the simulation group expressed their preference for using this module as an additional teaching tool. Conclusions: This study demonstrated that a pediatric dentistry VP built in a virtual world offers significant learning potential when used as a supplement to the traditional teaching techniques. ", doi="10.2196/jmir.2651", url="http://www.jmir.org/2013/10/e240/", url="http://www.ncbi.nlm.nih.gov/pubmed/24168820" } @Article{info:doi/10.2196/jmir.1715, author="Creutzfeldt, Johan and Hedman, Leif and Heinrichs, LeRoy and Youngblood, Patricia and Fell{\"a}nder-Tsai, Li", title="Cardiopulmonary Resuscitation Training in High School Using Avatars in Virtual Worlds: An International Feasibility Study", journal="J Med Internet Res", year="2013", month="Jan", day="14", volume="15", number="1", pages="e9", keywords="Serious games", keywords="virtual learning environments", keywords="MMVW", keywords="avatars", keywords="students", keywords="cardiopulmonary resuscitation", keywords="patient simulation", keywords="self-efficacy", keywords="concentration", abstract="Background: Approximately 300,000 people suffer sudden cardiac arrest (SCA) annually in the United States. Less than 30\% of out-of-hospital victims receive cardiopulmonary resuscitation (CPR) despite the American Heart Association training over 12 million laypersons annually to conduct CPR. New engaging learning methods are needed for CPR education, especially in schools. Massively multiplayer virtual worlds (MMVW) offer platforms for serious games that are promising learning methods that take advantage of the computer capabilities of today's youth (ie, the digital native generation). Objective: Our main aim was to assess the feasibility of cardiopulmonary resuscitation training in high school students by using avatars in MMVM. We also analyzed experiences, self-efficacy, and concentration in response to training. Methods: In this prospective international collaborative study, an e-learning method was used with high school students in Sweden and the United States. A software game platform was modified for use as a serious game to train in emergency medical situations. Using MMVW technology, participants in teams of 3 were engaged in virtual-world scenarios to learn how to treat victims suffering cardiac arrest. Short debriefings were carried out after each scenario. A total of 36 high school students (Sweden, n=12; United States, n=24) participated. Their self-efficacy and concentration (task motivation) were assessed. An exit questionnaire was used to solicit experiences and attitudes toward this type of training. Among the Swedish students, a follow-up was carried out after 6 months. Depending on the distributions, t tests or Mann-Whitney tests were used. Correlation between variables was assessed by using Spearman rank correlation. Regression analyses were used for time-dependent variables. Results: The participants enjoyed the training and reported a self-perceived benefit as a consequence of training. The mean rating for self-efficacy increased from 5.8/7 (SD 0.72) to 6.5/7 (SD 0.57, P<.001). In the Swedish follow-up, it subsequently increased from 5.7/7 (SD 0.56) to 6.3/7 (SD 0.38, P=.006). In the Swedish group, the mean concentration value increased from 52.4/100 (SD 9.8) to 62.7/100 (SD 8.9, P=.05); in the US group, the concentration value increased from 70.8/100 (SD 7.9) to 82.5/100 (SD 4.7, P<.001). We found a significant positive correlation (P<.001) between self-efficacy and concentration scores. Overall, the participants were moderately or highly immersed and the software was easy to use. Conclusions: By using online MMVWs, team training in CPR is feasible and reliable for this international group of high school students (Sweden and United States). A high level of appreciation was reported among these adolescents and their self-efficacy increased significantly. The described training is a novel and interesting way to learn CPR teamwork, and in the future could be combined with psychomotor skills training. ", doi="10.2196/jmir.1715", url="http://www.jmir.org/2013/1/e9/", url="http://www.ncbi.nlm.nih.gov/pubmed/23318253" }