Virtual Patients: Are We in a New Era?

To the Editor: We read with interest the comprehensive systematic review by Cook et al1 providing the first substantive quantitative review evidence supporting the educational impact of virtual patients (VPs). While this review summarizes well the historical uses of VPs, we would like to highlight important changes to VP design and authorship that have implications for the interpretation of the review article. The review includes computerized patient cases from 1991. Although cases both pre- and post-1991 in the review may be by definition virtual patients, we argue that this arbitrary cutoff introduces a historical bias obscuring a more recent VP technology shift. Advances in software during the past five years have brought about a change of direction in VP development toward clinicians being the primary authors, designers, editors, publishers, and distributors of cases.2 The MedBiquitous Virtual Patient interoperability standard introduced in 2009 has facilitated the sharing of VP cases and collaboration, resulting in a standardized point of reference for VP design and perhaps a tighter definition of what a VP is.3 Consequently, all major VP authoring systems now use exclusively Web-based authoring and editing. With clinicians now able to directly edit, restructure, and repurpose cases, the authenticity of cases may be enhanced, with the opportunity to adapt branching structures as needed. In practical terms these changes have led to international collaboration in open-access research projects (such as the European Union's cofunded Electronic Virtual Patient Programme, eViP), lower development costs, and a shift toward clinician-centered VPs in our own student curricula.4 In terms of Cook and colleagues' review, we therefore suggest that the current generation of VPs being developed represents a significant shift from previous cases, and this should be carefully considered when interpreting evidence from the older, non-Web-based commissioned computerized clinical cases. We propose that against the backdrop of these new technology advances, further weight should be added to the call from Cook et al for robust research into theory-based comparisons of current VPs. James Bateman, MBChB Education research fellow, Institute of Clinical Education, Warwick Medical School, Coventry, United Kingdom; [email protected]. David Davies, PhD Associate professor in medical education and elearning, Institute of Clinical Education, Warwick Medical School, Coventry, United Kingdom.