title: Virtual patients design and its effect on clinical reasoning and student experience: a protocol for a randomised factorial multi-centre study.
abstract: BACKGROUND
  Virtual Patients (VPs) are web-based representations of realistic clinical cases. They are proposed as being an optimal method for teaching clinical reasoning skills. International standards exist which define precisely what constitutes a VP. There are multiple design possibilities for VPs, however there is little formal evidence to support individual design features. The purpose of this trial is to explore the effect of two different potentially important design features on clinical reasoning skills and the student experience. These are the branching case pathways (present or absent) and structured clinical reasoning feedback (present or absent).
  
  
  METHODS
  This is a multi-centre randomised 2 x 2 factorial design study evaluating two independent variables of VP design, branching (present or absent), and structured clinical reasoning feedback (present or absent).The study will be carried out in medical student volunteers in one year group from three university medical schools in the United Kingdom, Warwick, Keele and Birmingham. There are four core musculoskeletal topics. Each case can be designed in four different ways, equating to 16 VPs required for the research. Students will be randomised to four groups, completing the four VP topics in the same order, but with each group exposed to a different VP design sequentially. All students will be exposed to the four designs. Primary outcomes are performance for each case design in a standardized fifteen item clinical reasoning assessment, integrated into each VP, which is identical for each topic. Additionally a 15-item self-reported evaluation is completed for each VP, based on a widely used EViP tool. Student patterns of use of the VPs will be recorded.In one centre, formative clinical and examination performance will be recorded, along with a self reported pre and post-intervention reasoning score, the DTI. Our power calculations indicate a sample size of 112 is required for both primary outcomes.
  
  
  CONCLUSIONS
  This trial will provide robust evidence to support the effectiveness of different designs of virtual patients, based on student performance and evaluation. The cases and all learning materials will be open access and available on a Creative Commons Attribution-Share-Alike license.
authors.affiliation: Education and Development Research Team, Warwick Medical School, Coventry CV4 7AL, UK. james.bateman@warwick.ac.uk
authors.forename: James
authors.initials: J
authors.lastname: Bateman
authors.forename: Maggie E
authors.initials: ME
authors.lastname: Allen
authors.forename: Jane
authors.initials: J
authors.lastname: Kidd
authors.forename: Nick
authors.initials: N
authors.lastname: Parsons
authors.forename: David
authors.initials: D
authors.lastname: Davies
mesh_terms: D002983:Clinical Competence; D004501:Education, Medical / Q000379:methods*; D004521:Educational Measurement; D006801:Humans; D016544:Patient Simulation; D013337:Students, Medical / Q000523:psychology; D013663:Teaching / Q000379:methods; D014584:User-Computer Interface