Medical students are taught to become general practitioners, after which they can focus on different fields of medicine. The course in primary health care medicine, however, lasts only about four weeks. One week is included in the third study year, and three weeks in the fifth study year. Of these three weeks during the fifth year, the first week focuses on theory, which prepares students for a two-week period of practical studies in a health centre.
During the first four study years, medical studies are very disease- and hospital-oriented. One of the main goals of the course in general practice and primary health care is to help the students to adopt a perspective which focuses on the patient as both a person and a member of his or her family and society. In the hospital world, different patients come and go, but they all have similar problems within one field of medicine (e.g. eye diseases, delivery), whereas in primary health care, the same persons come and go, but potentially present a new problem for each appoint-ment. The symptoms can be diffuse and their severity can vary consider-ably. This change of perspective is pointed out to the students and is also included in a less candid manner throughout the entire course.
During the only week of theoretical studies in general practice, we use virtual patients in the classroom. The students are asked to log into the VPP and to choose one of the cases; all students use the same case si-multaneously. The two teachers (one professor, one clinical teacher) are present in the classroom. By walking around in the classroom, the
107 ers observe how the students work in the VPP system. After all students have solved the case, the case is discussed in the group.
The short duration of the course enables us to focus on one major symp-tom: fatigue. All the virtual patients presented during the study week have come to see the doctor because they feel tired. There are five virtual pa-tients to use during the course and they all have a different underlying condition which causes the fatigue. Each disease is discussed in the group from the perspective of practical primary care.
The general practice study week also consists of traditional lecturing, but in small groups. About one fourth of the week consists of VPP group ses-sions. The symptoms and underlying conditions discussed during the VPP sessions are also discussed during a part of the lectures, and the clinical management of tired patients is evaluated in the examination, which takes place two to three weeks after the week of theoretical studies.
According to the principle of constructive alignment (Biggs and Tang 2007, 50-63), the teaching and evaluation methods should be aligned with both the learning activities and the objectives of the course. By using vir-tual patients during the course in general practice and primary health care, we simulate the clinical situations present in primary care.
If none of the students makes any grave mistakes and if none of them opposes, the summarizing statistics are shown to the group when all have solved the case. This enables self-evaluation on a larger scale than the simple system feedback, where the diagnosis is either right or wrong in a very black-and-white sort of way. The students can see how fast or slow they were, how much money they have used on diagnostics and how great a proportion of the questions they asked where relevant – all in comparison to their peers.
108 Picture 2. The summarizing statistics. In the column “Oik”, 1 stands for a correct and 0 for an incorrect diagnosis. “Kesto” is the time spent with the patient. The number of questions asked is listed in “Anm”, the number of clinical investigation procedures in “Sta”, and the number of laboratory investigations in “Lab”. “Kust” shows the money spent on diagnostic pro-cedures. The teacher has defined which questions and investigations are relevant for the case; the proportion of relevant procedures conducted by each student appear as a percentage (Anm%, Sta%). (This particular case did not include absolutely relevant laboratory or radiologic (Rtg) in-vestigations.)
We found that the group discussion is more active immediately after the students have solved the virtual patient case than when the students are assigned a virtual patient case on their own and discuss it afterwards in the classroom.
According to Chickering and Gamson (1987), good practice in undergra-duate education
1. encourages contact between students and faculty, 2. develops reciprocity and cooperation among students, 3. encourages active learning,
4. provides prompt feedback,
5. emphasizes time spent on an assigned task, 6. communicates high expectations, and
7. respects diverse talents and styles of learning.
109 These Seven Principles for Good Practice in Undergraduate Education, which in our opinion represent ”common sense” at its best, are empha-sized in teaching general practice. In primary health care, teamwork is essential, and communication with colleagues should be encouraged dur-ing the studies. In our opinion, the virtual patient cases have stimulated to discussion to a greater extent than have traditional lectures. The virtual patient system actually measures up to the standards of all the above mentioned principles of good practice in undergraduate education.
According to the principle of constructive alignment, the evaluation me-thods should be in line with both the objectives and the teaching meme-thods of the course. The course examination in general practice includes patient cases, the management and treatment of which the students are expected to write about. Thus far, we have used only paper-based cases in the examination, but are planning to include a virtual patient case in future examinations. This has been done elsewhere, e.g., in Germany (Wald-mann et al. 2008). In this German study, however, the correlation between the level of performance in the virtual patient examination and the tradi-tional examination was only moderate. The students preferred the virtual patient examination, because it enabled them to apply their knowledge and skills.
Both the Finnish universities in general and our own university in particu-lar have defined quality criteria for web-based education. According to these, the use of virtual patients in our course fulfils the criteria of good quality: the learning objectives, teaching methods and assessment are set, the course consists of versatile learning situations and methods, and individual feedback is a natural part of the learning process.
For many years, virtual patients have served in medical education in other universities in several countries. To our knowledge, our course is the only one in Finland where virtual patients are used in a blended learning situa-tion. The general feedback from the students has been very positive.
When asked specifically which they prefer, virtual patient cases or paper-based cases, all have unanimously preferred virtual cases.
We have implemented the use of virtual patients in a blended learning situation in groups consisting of 8 to 14 students. A small group size is
110 essential to enable sufficient teacher supervision during the virtual session and to ensure a relevant group discussion after each case.
Creating new patient cases is time-consuming, which other medical teachers have also noted (Huang et al 2007, Voelker 2003). In previous studies, students have acquired even better diagnostic and communica-tion skills with virtual patients than with so called standardized patients (which usually means professional actors) (Deladisma et al 2007, Stevens et al 2006, Triola et al 2006). In these studies, however, the virtual patient system was technically more advanced than our VPP system.
We cannot teach communication and interaction in the doctor-patient rela-tionship – a very important skill, which often is discussed in society in general - by using virtual patients in the classroom. On the other hand, a blended learning situation provides teachers an opportunity to emphasize this component of real patient encounters. We also trust that the way teachers act in the classroom when providing feedback to students serves as a model to the students when they meet and interact with patients, nurses and colleagues in primary health care.
References
Biggs, J. & Tang, C. (2007). Teaching for quality learning at university (Third edition). Maidenhead: Open University
Press/McGraw Hill.
Chickering A, Gamson Z. (1987). Seven principles of good practice in undergraduate education. The American Association for Higher
Education Bulletin, March 1987.
Deladisma, A.M., Cohen, M., Stevens, A., Wagner, P., Lok, B., Bernard, T., Oxendine, C., Schumacher, L., Johnsen, K., Dickerson, R., Raij, A,. Wells, R., Duerson, M., Harper, J.G. & Lind, D.S. (2007).
Association for surgical education. Do medical students respond empathetically to a virtual patient? American Journal of Surgery, 193(6):756-760.
111 Huang, G., Reynolds, R. & Candler, C. (2007). Virtual patient simulation at
US and Canadian medical schools. Academic Medicine, 82(5):446-451.
Kuusi, T., Romanov, K (2008). The use of virtual patients and students’
clinical knowledge. The Association for Medical Education in Europe 2008, abstracts 4X/P12.
Nevgi, A., Löfström, E. & Evälä, A. (2007) (Eds.) Laadukkaasti verkossa.
Yliopistollisen verkko-opetuksen ulottuvuudet. Kasvatustieteen laitoksen julkaisuja. Helsinki: Yliopistopaino.
The Teaching Evaluation Matrix, University of Helsinki. Available online at:
http://www.helsinki.fi/julkaisut/aineisto/hallinnon_julkaisuja_
44_2007.pdf .
Stevens, A., Hernandez, J., Johnsen, K., Dickerson, R., Raij, A., Harrison, C., DiPietro, M., Allen, B., Ferdig, R., Foti, S., Jackson, J., Shin, M., Cendan, J., Watson, R., Duerson, M., Lok, B., Cohen, M., Wagner, P. & Lind, D.S. (2006). The use of virtual patients to teach medical students history taking and communication skills.
American Journal of Surgery, 191(6):806-11.
Triola, M., Feldman, H., Kalet, A.L., Zabar, S., Kachur, E.K., Gillespie, C.
Anderson, M., Griesser, C. & Lipkin, M. A. (2006). Randomized trial of teaching clinical skills using virtual and live standardized patients.
Journal of General Internal Medicine ,21(5):424-429.
Verkko-opetuksen laatukäsikirja, VOPLA (2005). Available online at:
http://www.vopla.fi/laatukasikirja/ .
Voelker R. (2003). Virtual patients help medical students link basic science with clinical care. JAMA, 290(213): 1700-1701.
112