Abstract:

Introduction:
The efficacy of virtual patients (VPs) as learning tools in medical education is well documented but literature comparing the efficacy of different case progression types is minimal. The most commonly used are the Linear Interactive (LI) and Branched Narrative (BN) models. In the LI model, the storyline progresses in a single direction with options. Students are prevented from following wrong paths by immediate correction. In the BN model, the VP storyline changes as the student makes critical decisions and the student is offered multiple choices with multiple outcomes.

Objectives:
To compare the value of LI (using cardiology cases) and BN (using respiratory cases) VP progression types as learning tools among Year 3 medical students.

Method:
Cases were adapted from ‘Clinical Sense’, a free digital mobile application into LI (cardiology n = 4) and BN (respiratory medicine n = 4) case progression with the use of iSpring Quiz Maker. All Year 3 students in their first clinical rotation of medical school were invited via social media to participate in four peer-led VP sessions synchronised with their respective clinical rotations where cases [two cardiology (LI) and two respiratory (BN)] were discussed. Before and after each session, students responded to identical 28 Single Best Answer (SBA) cardiology and respiratory questions. Student feedback was collected at the end of each session.

Results:
Twelve groups, each of 3-7 students participated in two weekly cardiology (LI) and respiratory (BN) VP sessions. Thirty of the 60 students who attended the first session completed all eight clinical cases in the four-week programme. Paired samples t-test show that, on average, the increment in the mean percentage score between the pre- and the post-test was 16.2% for the respiratory test (BN) and 15.2% for the cardiology test (LI) (p <0.001). There was no statistically significant difference in the pre/post test scores between the LI and BN cases.
Student feedback after LI and BN sessions was equally good. The mean score for “ The VP interaction accurately simulated real life” was 3.7 on a scale of 1 to 5 (where 1 is strongly disagree and 5 is strongly agree); “Working on these VP cases improved my clinical reasoning skills” was 4.1; “Working on the cases was a worthwhile way to learn medicine” was 4.3; “I learnt more by tackling the cases in a group (as opposed to tackling them alone)”, was 4.2; “I would recommend VP cases to my peers” was 4.2; “The type of case progression used in this VP session was a valuable way to learn” was 4.2 for LI and 4.4 for BN.

Conclusions:
Peer-led sessions among students following their first clinical medicine rotations resulted in improved SBA clinical medicine test scores and were perceived to be equally valuable in terms of learning and exam preparation. Both LI and BN case progression type of VPs should be incorporated into clinical curricula. These findings will be further explored through a focus group with the study participants.

Keywords:

Virtual Patients, Branched Narrative, Linear Interactive, medical education.