Cost-effectiveness of virtual patient integration in dermatology education: evidence for precision education by learner expertise

Background Educational technology adoption accelerates despite limited evidence of incremental value within already-effective curricula. Pragmatic evaluations examining cost-effectiveness and differential benefits across learner populations with varying expertise remain scarce. Objectives To evaluate virtual patient integration into established flipped classroom curriculum, examining incremental educational outcomes, comprehensive cost-effectiveness, and systematic variation by training level. Methods Sequential implementation study at a tertiary teaching hospital in Taiwan (2022–2025). Flipped classroom (FC; 2022–2023, N = 131) was followed by FC with virtual patients (FC + VP; 2024–2025, N = 161). Primary outcomes: knowledge acquisition (Cohen’s d , achievement rates ≥ 80%). Incremental cost-effectiveness ratios (ICERs) were calculated by training level. Results Both approaches achieved extremely large learning effects (FC: d = 2.27; FC + VP: d = 2.43; >98% achievement; between-group differences non-significant). FC + VP required 3.08-fold higher per-student investment ($163 vs. $53). Cost-effectiveness varied dramatically: undergraduates showed meaningful gains (Δ d = + 0.29, ICER = $383/ d ), while postgraduates showed minimal benefit (Δ d = + 0.02, ICER = $4,670/ d )—a 12.2-fold difference. Germane cognitive load was associated with learning progress ( r = .196, R² = 8.5%); critical thinking was not independently associated ( p = .497). Conclusions Near-universal competency is attainable through multiple instructional approaches. Virtual patient integration was associated with differential incremental value by learner expertise—meaningful for novices but negligible for advanced learners achieving comparable outcomes more efficiently. Findings support precision education frameworks targeting technology investments based on cost-effectiveness profiles rather than universal deployment.