1. Faculty of Health, Medicine and Life Sciences School of Health Professions Education Prof. dr. Albert Scherpbier The combination of virtual patients and small group discussions to promote reflective practice Bas de Leng, PhD ICVP London, 26 April 2010

2. Faculty of Health, Medicine and Life Sciences Risks of life…

3. Faculty of Health, Medicine and Life Sciences Medical errors  Diagnostic errors: 5-15% of medical diagnosis  Taxonomy of diagnostic error (Graber,2005): –No-fault errors –System-related errors –Cognitive errors  Cognitive errors contribute to 75% of all diagnostic errrors  ‘Premature closure’ most common cognitive error

4. Faculty of Health, Medicine and Life Sciences Education to prevent cognitive errors Relationships between reliability and effort of diagnostic decision making (Graber, 2009) Effort Accuracy LowHigh Less More Deductive reasoning Expert thinking Monitoring, reflection Expert thinking Pre-expert reasoning: heuristics ideas for educational approaches

5. Faculty of Health, Medicine and Life Sciences Increase expertise  Deliberate practice with coaching and feedback by more accomplished professionals (Ericsson, 2003)  Access to a large numbers of patients with similar symptoms for which the correct diagnosis is validated  Virtual patients can supplement real patient encounters

6. Faculty of Health, Medicine and Life Sciences Learn to apply reflective thinking Learning to:  Recognize and understand the most likely diagnostic pitfalls (Croskerry, 2003)  Use a checklist for the diagnostic process including ‘reflection’.

7. Faculty of Health, Medicine and Life Sciences Clinical reasoning sessions Ingredients:  Virtual patients based on real cases in which ‘premature closure’ had occurred  Procedure to induce reflective diagnostic reasoning (Mamede, 2008)

8. Faculty of Health, Medicine and Life Sciences Clinical reasoning sessions Procedure:  All residents simultaneously worked out the same virtual patient  And the end of the work-up they had a moderated discussion on their clinical reasoning  The logged actions and their notes were starting points for the discussion

9. Faculty of Health, Medicine and Life Sciences Evaluation of perceptions Two student questionnaires: 1.Experiences with the use virtual patients. With 12 statements on:  Authenticity  Professional approach  Coaching  Learning effect  Overall judgment 2.Experiences with the integration of virtual patients. With 20 statements on:  Teaching presence  Cognitive presence  Social presence  Learning effect  Overall judgment

10. Faculty of Health, Medicine and Life Sciences Conclusion  Residents perceived a session combining individual virtual patient workup with small group discussions as a valuable learning activity for clinical reasoning.  The clinical supervisor found the presented teaching approach feasible for the medical specialist training at the workplace.

11. Faculty of Health, Medicine and Life Sciences Future research Evaluation of clinical reasoning sessions with VPs on 3 rd and 4 th level of Kirkpatrick:  Do they learn clinical reasoning and reflective practice from this activity?  Do the learning outcomes transfer to clinics and wards?