title: Virtual patients in primary care: developing a reusable model that fosters reflective practice and clinical reasoning.
abstract: BACKGROUND
  Primary care is an integral part of the medical curriculum at Karolinska Institutet, Sweden. It is present at every stage of the students' education. Virtual patients (VPs) may support learning processes and be a valuable complement in teaching communication skills, patient-centeredness, clinical reasoning, and reflective thinking. Current literature on virtual patients lacks reports on how to design and use virtual patients with a primary care perspective.
  
  
  OBJECTIVE
  The objective of this study was to create a model for a virtual patient in primary care that facilitates medical students' reflective practice and clinical reasoning. The main research question was how to design a virtual patient model with embedded process skills suitable for primary care education.
  
  
  METHODS
  The VP model was developed using the Open Tufts University Sciences Knowledgebase (OpenTUSK) virtual patient system as a prototyping tool. Both the VP model and the case created using the developed model were validated by a group of 10 experienced primary care physicians and then further improved by a work group of faculty involved in the medical program. The students' opinions on the VP were investigated through focus group interviews with 14 students and the results analyzed using content analysis.
  
  
  RESULTS
  The VP primary care model was based on a patient-centered model of consultation modified according to the Calgary-Cambridge Guides, and the learning outcomes of the study program in medicine were taken into account. The VP primary care model is based on Kolb's learning theories and consists of several learning cycles. Each learning cycle includes a didactic inventory and then provides the student with a concrete experience (video, pictures, and other material) and preformulated feedback. The students' learning process was visualized by requiring the students to expose their clinical reasoning and reflections in-action in every learning cycle. Content analysis of the focus group interviews showed good acceptance of the model by students. The VP was regarded as an intermediate learning activity and a complement to both the theoretical and the clinical part of the education, filling out gaps in clinical knowledge. The content of the VP case was regarded as authentic and the students appreciated the immediate feedback. The students found the structure of the model interactive and easy to follow. The students also reported that the VP case supported their self-directed learning and reflective ability.
  
  
  CONCLUSIONS
  We have built a new VP model for primary care with embedded communication training and iterated learning cycles that in pilot testing showed good acceptance by students, supporting their self-directed learning and reflective thinking.
authors.affiliation: Centre for Family Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden. helena.salminen@ki.se.
authors.forename: Helena
authors.initials: H
authors.lastname: Salminen
authors.forename: Nabil
authors.initials: N
authors.lastname: Zary
authors.forename: Karin
authors.initials: K
authors.lastname: Björklund
authors.forename: Eva
authors.initials: E
authors.lastname: Toth-Pal
authors.forename: Charlotte
authors.initials: C
authors.lastname: Leanderson
mesh_terms: D006801:Humans; D016544:Patient Simulation; D018802:Patient-Centered Care; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care; D013548:Sweden
keywords: clinical reasoning; medical education; primary care; reflection; virtual patients