Efficacy of virtual patients in medical education: A meta-analysis of randomized studies Fabrizio Consorti * , Rosaria Mancuso, Martina Nocioni, Annalisa Piccolo Department of Cardiocirculatory Pathophysiology, Anestesiology and General Surgery – 1st Faculty of Medicine University “Sapienza” of Rome, viale del Policlinico, 00161 Rome, Italy article info Article history: Received 3 September 2010 Received in revised form 11 April 2012 Accepted 25 April 2012 Keywords: Distance education and telelearning Evaluation of CAL systems Simulations Multimedia/hypermedia systems abstract A meta-analysis was performed to assess the Effect Size (ES) from randomized studies comparing the effect of educational interventions in which Virtual patients (VPs) were used either as an alternative method or additive to usual curriculum versus interventions based on more traditional methods. Meta-analysis was designed, conducted and reported according to QUORUM statement on quality of reporting of meta-analyses. Twelve randomized controlled studies were retrieved, assessing a total of 25 different outcomes. Under a random-effect model, meta-analysis showed a clear positive pooled overall effect for VPs compared to other educational methods (Odds Ratio: 2.39; 95% C.I. 1.48 O 3.84). A positive effect has been documented both when VPs have been used as an additive resource (O.R.: 2.55; C.I. 1.36 O 4.79) and when they have been compared as an alternative to a more traditional method (O.R.: 2.19; 1.06 O 4.52). When grouped for type of outcome, the pooled ES for studies addressing communication skills and ethical reasoning was lower than for clinical reasoning outcome. There is evidence that VPs are effective but further research is needed to clarify which is their best possible integration in curricula and their value and cost/benefit ratio with respect to other active learning methods. Ó 2012 Elsevier Ltd. All rights reserved. 1. Introduction Virtual patients (VPs) are computer-based simulations of clinical cases allowing the users to interact with the system and train their clinical reasoning skills. The term “virtual patient” has been referred to various educational tools and methods like simulated patients in the form of actors (Cleland, Abe, & Rethans, 2009), software-based physiological simulators (Holzinger, Kickmeier, Wassertheurer, & Hessinger, 2009), physical manikins and advanced technological simulators (Khan, Pattison, & Sherwood, 2011). A further new learning method near to the concept of Virtual patients is based on platforms to use real patient records to teach undergraduate students decision making and clinical reasoning (Bloice, Simonic, Kreuzthaler, & Holzinger, 2011). There is however a general consensus in considering a VP an “interactive computer simulation of real-life clinical scenarios for the purpose of healthcare and medical training, education or assessment” (Ellaway, Poulton, Fors, McGee, & Albright, 2008). VPs can provide a way to overcome the reduced student access to real patients, as well as a structured and safe environment for students to practice; they are therefore more and more extensively used in medical education but their efficacy is still a matter of debate (Poulton & Balasubramaniam, 2011). A recent review provided a critical evaluation of relevant literature but it could find mainly descriptive articles, many articles measuring students’ satisfaction with VPs but few studies providing evidence about the efficacy of VPs (Cook & Triola, 2009). One of the issues raised by Cook in his review was the way in which VPs are integrated in the curriculum. VPs have been used in many different instructional designs and educational applications (Huwendiek et al., 2009) but not always the terminology used to describe the learning environment and VPs usage was uniform. At this proposal, in her recent paper (Ellaway & Davies, 2011), Rachel Ellaway proposes to apply activity theory to redefine Virtual patients “from a software artifact to an intrinsic part of an activity that mediates the ways that learners and their * Corresponding author. Dip. di Fisiopatologia Cardiocircolatoria, Anestesiologia e Chirugia Generale, viale del Policlinico, 00161 Rome, Italy. Tel.: þ39 0649970634; fax: þ39 06491695. E-mail addresses: fabrizio.consorti@uniroma1.it (F. Consorti), rosaria_mancuso1987@libero.it (R. Mancuso), martinanocioni@yahoo.it (M. Nocioni), annalisa.piccolo@ yahoo.it (A. Piccolo). Contents lists available at SciVerse ScienceDirect Computers & Education journal homepage: www.elsevier.com/locate/compedu 0360-1315/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.compedu.2012.04.017 Computers & Education 59 (2012) 1001–1008