Learners requested information from the virtual patient using menus (N = 24; 53%), natural language (N = 10; 22%), or both (N = 2; 4%); we could not determine this for 9 studies. Two studies45,54 compared methods of requesting information. Fourteen virtual patients (31%) used free navigation case progression, 12 (28%) used a linear pattern, 10 (22%) were branching, and one study compared free versus branching progression, while in 8 studies the case progression could not be determined. Learners collaborated in groups to complete virtual patients in 6 (13%) studies. Twenty-three virtual patients (55%) provided high interactivity, 15 (36%) provided high feedback, 8 (18%) incorporated many learning strategies, 17 (38%) provided opportunity for repetitive practice, 16 (36%) were integrated into the curriculum, and 26 (58%) reflected clinical variation in disease presentation. None of the virtual patients reflected a range of task difficulty, and none provided for individualized learning aside from branching scenarios based on learner choices.
Eighteen studies (1,359 participants) reported comparison with a preintervention assessment or a no-intervention control group. Of these, 11 reported knowledge outcomes (Figure 2), with a pooled ES of 0.94 (95% CI, 0.69–1.19, P < .001). Because ESs >0.8 are considered large,42 this suggests that virtual patient interventions are associated with substantial knowledge gains. However, we also found large inconsistency among studies, with ESs ranging from 0.27 to 2.07 and I2 = 81%. An asymmetric funnel plot suggested possible publication bias. Assuming this asymmetry reflects publication bias, trim and fill analyses provided a revised pooled ES of 0.90 (95% CI, 0.65–1.15).
For the five studies reporting clinical reasoning outcomes, the pooled ES was large (0.80 [95% CI, 0.52–1.08], P < .001), with moderate inconsistency (I2 = 46%). The funnel plot appeared symmetric.
Nine studies reported skill outcomes, with a large pooled ES of 0.90 (0.61–1.19, P < .001) and large inconsistency (I2 = 82%). The funnel plot was asymmetric. Again assuming that this reflects bias, trim and fill analyses yielded a revised pooled ES of 0.79 (95% CI, 0.48–1.10).
In planned subgroup analyses, we found no statistically significant interactions with virtual patient design features of interactivity, feedback, number of instructional strategies, or time spent learning (see Supplemental Digital Table 3, at http://links.lww.com/ACADMED/A23). We found no significant interaction with blinding or overall quality score, but we did find a significant interaction with number of groups; namely, two-group studies demonstrated a smaller pooled ES (0.49) than one-group pretest–posttest studies (0.92; Pinteraction = .015). We obtained virtually identical results for all outcomes in sensitivity analyses excluding studies published before 1991.
Twenty articles reported 21 studies (1,546 participants) comparing virtual patients with various noncomputer interventions, including traditional instruction (typically lecture), standardized patients, paper instruction (handouts, textbooks, or latent-image paper cases), slide-tape instruction, routine clinical activities, and training with a physiologically responsive manikin. One study51 compared a virtual patient with both latent image and slide-tape instruction. Because these comparisons are not independent, we selected one—slide-tape instruction—for reported meta-analyses. However, sensitivity analyses substituting the latent image data yielded virtually identical results.
The pooled ES for the 10 studies reporting reasoning outcomes was −0.004 (95% CI, −0.30 to 0.29; P = .98) with I2 = 70%. Eleven studies reported skill outcomes, with a pooled ES of 0.10 (95% CI, −0.21 to 0.42; P = .52) and I2 = 84%. As with knowledge, this suggests small and statistically nonsignificant associations between use of virtual patients and other instructional methods for reasoning or skill outcomes. Finally, the eight studies evaluating satisfaction outcomes yielded a pooled ES of −0.17 (95% CI, −0.57 to 0.24; P = .42) with I2 = 71%.
Subgroup analyses exploring associations between methodological quality or virtual patient design features and performance revealed no statistically significant interactions (see Supplemental Digital Table 3 at http://links.lww.com/ACADMED/A23). Funnel plots and the Egger asymmetry test did not suggest publication bias for any outcomes. Sensitivity analyses excluding studies published before 1991 yielded almost identical results for all outcomes.
Comparisons between virtual patient formats can illuminate how different virtual patient design features affect learning outcomes. Eleven studies took this approach, comparing one virtual patient with another.45,48,50,51,53,54,63,65,68,70,73 Because the differences between virtual patients varied substantially for each study, we could not perform a quantitative synthesis, so we present a narrative synthesis instead. Because study designs and statistical tests varied, we report ES and sample size (which in some substudies is smaller than that reported in Table 2) rather than tests of statistical significance. Space limitations prohibit a full description of each method and context, and interested readers may wish to consult the original studies for additional details.
Two randomized studies explored different ways to structure the virtual patient interaction. The first, described above, found improved knowledge but decreased satisfaction for structured, educationally enriched virtual patients compared with realistic, unstructured cases.54 The other study found similar communication skills following use of an unstructured problem-solving format and a format structured to emphasize temporal relationships (ES 0.12, N = 157),63 although a phenomenological qualitative study found that learners established better rapport with the narrative patient.88
Finally, a study found that imposing a two-hour time limit lowered the rate of case completion (ES 2.13, N = 82).65
We found that virtual patients, in comparison with no intervention, are consistently associated with higher learning outcomes. Pooled ESs were large (≥0.80)42 for outcomes of knowledge, clinical reasoning, and other skills, and CIs excluded small effects (<0.5). However, the magnitude of effect varied for individual studies (large inconsistency), and subgroup analyses exploring differences in virtual patient designs largely failed to explain this variation. By contrast, the pooled ESs for studies comparing virtual patients with noncomputer interventions were small (−0.17 to 0.10) and nonsignificant (CIs encompassing zero [no effect]). CIs excluded moderate effects (≥0.5) but could not exclude small effects (0.2 to 0.5). Once again, inconsistency (heterogeneity) among studies was large, and subgroup analyses did little to explain these inconsistencies.
Although the above subgroup analyses did not answer our question regarding the effectiveness of different virtual patient designs, comparisons between virtual patient formats address this issue. For example, mastery learning, advance organizers, enhanced feedback, and explicitly contrasting cases improved learning outcomes in randomized trials, with ESs ranging 0.29 to 1.47. Variations in virtual patient structure and the method of information exchange were also associated with differences in learning outcomes. Qualitative research studies further suggest that natural case evolution and working as groups are important. These findings suggest that at least some of the inconsistency noted above arises from differences in interventions.
Subgroup analyses of no-intervention-comparison studies revealed a significant interaction with study design, with two-group studies demonstrating smaller pooled ESs and somewhat lower inconsistency than one-group studies. It makes sense that studies with a comparison group, which helps control for maturation and learning outside the intervention, would show smaller effects than single-group studies. However, these findings could also be due to chance or to other between-study differences such as variation in virtual patient design, concurrent nonvirtual patient learning opportunities, and the sensitivity of the outcome measure. By contrast, we found no statistically significant interactions with other quality measures for no intervention or media-comparative studies.
As in any review, the inferences we draw are limited by the quantity and quality of available studies. Many reports failed to clearly describe key features of the context, instructional design, or outcomes. Fewer than half the comparative studies were randomized, and most studies had other important methodological limitations. The modest number of studies and participants limits the precision of our meta-analysis results and the power of our subgroup analyses. The age of some studies makes them of questionable relevance, but excluding older studies did not appreciably alter the results. We found large inconsistency among studies, and statistical pooling cannot account for all potentially important differences in learner groups, clinical topics, interventions, study designs, and outcome measures.93 However, because all no-intervention-comparison studies favored virtual patients, this heterogeneity suggests that virtual patients may be effective across a broad range of learners and topics. Because virtual patients are designed for health professions training, we did not include studies from non-health-related fields. Finally, of necessity, we abstracted information on only a few virtual patient design features. Although we selected these features after considering numerous possibilities19 and evidence from related fields,15 we still might have missed important features.
Our review also has several strengths, including a timely and important question; a systematic literature search aided by an experienced reference librarian, including multiple databases and supplemented by hand searches; explicit and reproducible inclusion criteria encompassing a broad range of learners, outcomes, and study designs; duplicate, independent, and reproducible data abstraction; rigorous coding of methodological quality; and focused analyses. We reviewed in detail both quantitative comparative and qualitative studies and summarized many descriptive studies including several non-English reports (see Supplemental Digital Table 1, at http://links.lww.com/ACADMED/A23). We used funnel plots to assess for publication bias, and although this method is limited in the presence of large inconsistency,38 it did not suggest that publication bias substantially affected our conclusions.
To our knowledge, this is the first systematic review to address the topic of virtual patients in health professions education. A recent narrative review19 identified a number of important questions regarding virtual patients, but it selectively included studies and did not provide a quantitative synthesis of outcomes. Similar to the present study, a meta-analysis of laparoscopic surgery simulation16 found improved outcomes for simulation training compared with no training, as did systematic reviews of surgical simulation in general17 and of colonoscopy and laparoscopic cholecystectomy simulation.18 Another systematic review suggested that feedback, curricular integration, and multiple learning strategies are essential features of simulation15; we cannot corroborate or refute these conclusions. Our findings of large ESs for comparisons with no intervention and small ESs for comparisons with other active interventions are consistent with a recent meta-analysis of Internet-based instruction.20
The use of virtual patients as learning tools is associated with improved outcomes in comparison with no intervention for medical students, dental students, nursing students, and a variety of other health professionals across a range of clinical topics. Evidence does not indicate superiority of virtual patients over other training methods, but allowing for the uncertainty of the CIs and imperfections of the outcome measures, they may be noninferior in some instances. Inasmuch as virtual patients resolve logistic barriers13,14,94 or provide unquantified advantages (such as those identified in the qualitative studies or predicted by education theories), they may warrant use to enhance cognitive clinical skills among student and practicing health professionals.
The virtual patients we identified varied widely in their design, implementation, and effectiveness. Unfortunately, available evidence answers only in part our question regarding what virtual patient design variations lead to improved learning outcomes. Subgroup analyses failed to identify significant interactions involving instructional designs, but between-study (rather than within-study) comparisons are an inefficient research method.95 By contrast, direct comparisons of two virtual patient designs were few but generally supported theories predicting that cognitive interactivity, learning to mastery, and feedback yield better outcomes.
We believe that theory-based comparisons between different virtual patient designs, and rigorous qualitative studies, will clarify how to effectively use virtual patients for training health professionals. Frameworks such as multimedia learning,96,97 analytical and nonanalytical reasoning,19 deliberate practice,98 and formative feedback99,100 may be useful. The associations found in several studies between changes intended to make the virtual patient more realistic and neutral or negative outcomes raise questions regarding for whom, in what contexts, and for what outcomes greater realism is beneficial.101 Most research to-date has involved students; the role of virtual patients in postgraduate and continuing education requires further study. Research outcomes have largely focused on short-term knowledge, clinical reasoning, and other skills. Perhaps new measures (e.g., different clinical reasoning assessments19) or different outcomes (e.g., decision-making behaviors, health care costs, or medical errors) would more closely align with the long-term objectives of using virtual patients. Finally, we hope that future researchers can avoid the weaknesses of previous research by designing studies that minimize bias, achieve appropriate power, and avoid confounding.102
This work was supported by intramural funds and by a Commissioned Review Award from the Society of Directors of Research in Medical Education. The funding sources for this study played no role in the design and conduct of the study; in the collection, management, analysis, and interpretation of the data; or in the preparation of the manuscript. The funding sources did not review the manuscript.
As no human subjects were involved, ethical approval was not required.
Portions of this work were presented in symposia at the 2009 meetings of the Association for Medical Education in Europe (Málaga, Spain) and Association of American Medical Colleges (Boston, Massachusetts), and as an abstract at the 2010 Annual International Meeting on Simulation in Healthcare (Phoenix, Arizona).
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*Funnel plots graph each study's effect size against the study's sample size in attempt to discern whether small studies have been left unpublished because they failed to show statistically significant results (publication bias). Asymmetric funnel plots suggest (but do not confirm) publication bias, while symmetric plots suggest (but do not guarantee) its absence. The trim and fill method attempts to balance an asymmetric plot in order to determine a more trustworthy (unbiased) effect size estimate. However, both the funnel plot and the trim and fill method have important limitations, as noted in the references cited above. Results of both methods should be considered at best tentative or suggestive.