Optimal learning in a virtual patient simulation of cranial nerve palsies: The interaction between social learning context and student aptitude

Figures & data

Figure 1. NERVE VP responds to user-typed directive for ophthalmoscope use.

Table

Practice points

Simulation in medical education provides students with opportunities to practice interviews, examinations, and diagnosis formulation of rare and complex medical conditions without risk of patient harm. VP simulators, in particular, hold great promise for use in the medical curriculum as they offer venues for training in the diagnosis of neurological abnormalities, such as CN disorders, that standardized patients are not able to feign. At relatively lower aptitudes, medical students achieved significantly greater learning gains following team-based learning experiences with VPs, as compared to students who interacted with VPs as individuals. Following simulation use, students who interacted with VPs in a team setting reported significantly greater confidence in their abilities to diagnose CN palsies than did students who interacted with VPs as individuals. Careful consideration should be given to determining the optimal social context in which educational activities are arranged, and to recognizing the potential for ATI effects with use of simulation systems and other novel pedagogical tools.

Figure 2. Research procedure. Notes: ^aStudy instrument was completed individually by every student; students participating as members of a team were instructed not to confer about responses. ^bStudy activity was completed by students within their respective treatments. ^cStudy instrument was submitted individually by every student; however, students participating as members of a team were permitted to confer about content for inclusion on the case note forms.

Figure 3. Example feedback module for VP case.

Figure 4. Pre-/post-test score^a scatterplots by treatment: disordinal interaction with simultaneous regions of significance and crossover point defined. Note: ^aScores are displayed as number of items correct.

Figure 5. Mean pre-/post-test scores^a by treatment for students who scored ≤ 50% at pre-test. Note: ^aMean post-test scores differ significantly between treatments, p = 0.02.

Table 1.  Student perspectives survey: mean ratings^a of system usability and student confidence

Survey item		Individual (n = 27) mean	Team (n = 30) mean
I am satisfied with the NERVE clinical skills experience		4.0	4.1
The simulation scenarios held my attention		4.1	4.1
I feel as though I learned from the simulation experience		4.0	4.3
The tutorial adequately prepared me to use the simulation		4.1	4.2
The mouse-based interface was intuitive		3.7	4.1
The VP responded appropriately to my questions		3.2	2.9
The VP responded appropriately to physical exam directions		3.8	4.0
I am confident in my ability to correctly diagnose a patient with a CN III or CN VI injury^b		3.4	4.0

Notes: ^aFive-point Likert-type rating scale, where 1 = strongly disagree and 5 = strongly agree.

^bMean ratings of confidence differ significantly between treatments, p = 0.02.

Table 2.  Student perspectives survey: top responses^a to open-ended items

Response by item	Total (n = 57) n (%)	Individual (n = 27) n (%)	Team (n = 30) n (%)
What did you like most about NERVE?
Facilitation of learning	11 (19%)	4 (15%)	7 (23%)
Communication with VP	11 (19%)	8 (30%)	3 (10%)
Observation of abnormal findings	9 (16%)	1 (4%)	8 (27%)
Ease of system use	7 (12%)	4 (15%)	3 (10%)
Presentation of immediate feedback	6 (10%)	4 (15%)	2 (7%)
Reinforcement of Year 1 content	6 (10%)	2 (7%)	4 (13%)
Engagement – fun, interesting, novel	5 (9%)	2 (7%)	3 (10%)
Interactive nature of system	5 (9%)	2 (7%)	3 (10%)
Collaboration afforded by team setting	4 (7%)	–	4 (13%)
Opportunity to practice physical exam	3 (5%)	2 (7%)	1 (3%)
Ability to work at own pace	3 (5%)	1 (4%)	2 (7%)
What did you like least about NERVE?
Communication with VP – limited response set	42 (74%)	16 (59%)	26 (87%)
Communication with VP – typing feature	3 (5%)	2 (7%)	1 (3%)
Lack of review of content prior to exercise	3 (5%)	2 (7%)	1 (3%)
Tutorial – long, not interactive, limited examples	3 (5%)	2 (7%)	1 (3%)
What changes would you like to see for the NERVE simulation exercises to make them more beneficial?
Communication with VP – expand response set	26 (46%)	12 (44%)	14 (47%)
Exam tools and functions – include more	6 (10%)	3 (11%)	3 (10%)
Feedback – expand, imbed, individualize	6 (10%)	4 (15%)	2 (7%)
Application to CN injuries – include other nerves	5 (9%)	2 (7%)	3 (10%)
What were the benefits of participating in the NERVE simulation exercises independently?
Ability to work at own pace	–	14 (52%)	–
Facilitation of independent/critical thinking	–	6 (22%)	–
What were the disadvantages of participating in the NERVE simulation exercises independently?^b
Absence of others – to ask for help	–	18 (67%)	–
Absence of others – to hear opinions	–	3 (11%)	–
Absence of others – to be more efficient	–	3 (11%)	–
What were the benefits of participating in the NERVE simulation exercises in a team?
Presence of others – to ask for help	–	–	16 (53%)
Presence of others – to share and discuss ideas	–	–	15 (50%)
What were the disadvantages of participating in the NERVE simulation exercises in a team?^b
Longer duration of activity	–	–	8 (27%)
Lack of independent thinking/self-direction	–	–	6 (20%)
Sharing one computer	–	–	5 (17%)

Notes: ^aResponse reported when >2 students from total sample offered similar comment.

^b10/27 (37%) students in the individual treatment indicated that they would like to experience NERVE as a member of a small team; 7/30 (23%) students in the team treatment indicated that they would like to experience NERVE as an individual; no significant differences in distribution of preferences by treatment group, χ² = 1.28, p = 0.26.