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

Faculty of Health, Medicine and Life Sciences

Risks of life…

Faculty of Health, Medicine and Life Sciences

719

28

46

FactorsNo fault

Only system

Only cognitive

Both system and cognitve

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 contributeto 75% of all diagnostic errrors

‘Premature closure’ mostcommon cognitive error

Faculty of Health, Medicine and Life Sciences

Education to prevent cognitive errorsRelationships between reliability and effort of diagnostic decision making (Graber, 2009)

Effort

AccuracyLow High

Less

More

Deductive reasoning

Expert thinking

Monitoring, reflection

Expert thinking

Pre-expert reasoning: heuristics

ideas for educational approaches

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

Faculty of Health, Medicine and Life Sciences

Learn to apply reflective thinkingLearning to: Recognize and understand the most likely

diagnostic pitfalls (Croskerry, 2003) Use a checklist for the diagnostic process including

‘reflection’.

Faculty of Health, Medicine and Life Sciences

Clinical reasoning sessionsIngredients:Virtual patients based on real cases in which ‘premature closure’ had occurredProcedure to induce reflective diagnostic reasoning (Mamede, 2008)

Faculty of Health, Medicine and Life Sciences

Clinical reasoning sessionsProcedure:All residents simultaneously worked out the same virtual patientAnd the end of the work-up they had a moderated discussion on their clinical reasoningThe logged actions and their notes were starting points for the discussion

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

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.

Faculty of Health, Medicine and Life Sciences

Future research

Evaluation of clinical reasoning sessions with VPs on 3rd and 4th level of Kirkpatrick:Do they learn clinical reasoning and reflective practice from this activity?Do the learning outcomes transfer to clinics and wards?