Virtual Patients as CPD for early
diagnosis of cancer: A case study
Dr Alison J. Wint, Dr Sarah J. Street, Simon Messer
Abstract
The UK has poorer cancer survival outcomes than comparable European countries. Education of GPs
to improve referral is part of the government’s strategy to rectify this. This project evaluates the use of
Virtual Patients (VPs) for GP CPD in raising awareness of early signs of cancer and supporting
referral decision making. Six VP cases were created to simulate a GP surgery, 4 of which were cases
with early signs of cancer. They were authored by GPs as part of a collaborative project between
Avon Somerset and Wiltshire Cancer services and the University of the West of England. Participants
for the project (n=72) were recruited from GP practices. Evaluation was by a self administered equestionnaire that captured both quantitative and qualitative data. The data were evaluated using
statistical and thematic analysis. The results showed that the VPs served to highlight the importance
of early diagnosis of cancer and to increase awareness of cancer assessment tools and knowledge of
available support. The study also showed that participants found the VPs very engaging; the benefits
include being online, quick and fun to do. There was significant agreement that VPs provide an
authentic e-learning solution and that further cases would be beneficial.
Keywords; Computer simulation; General Practice; cancer; consultation and referral;
education
How this fits in: This fits with the aims of the National Awareness and Early Diagnosis
Initiativeworking to promote awareness and earlier diagnosis of cancer.
1.0 Introduction
It has been recognised since the publication of the cancer Reform strategy in 2007 1 and the Improving
Outcome Strategy of 20112, that the national outcomes for Cancer, although improving have not yet
equalled those of countries with comparable health care systems.
Prof Sir Mike Richards the cancer Tsar in 2009 proposed that 5,000 lives could be saved if Britain’s
cancer outcomes matched the average in Europe and 10,000 lives would be saved if the UK could
achieve standard of the best in Europe3. A variety of factors have been found to influence outcomes
and in response to address these factors, the National Awareness and Earlier Diagnosis Initiative
(NAEDI) was launched in 20084. It included several strands of work, one of which reviewed systems,
process, access and clinical practice in Primary Care. Several primary care Tools to aid decision
making, management and referral from Primary Care of patients suspected of having a cancer
diagnosis have been developed5.
In 2011 the Department of Health invited bids from Cancer Networks for the funding of initiatives
which would support GPs in making a cancer diagnosis and increase the reach and impact of the
NEADI agenda. The Avon Somerset & Wilshire Cancer Network was successful in securing funds to
partner with the University of The West of England for the development of an innovative educational
tool which would achieve this.
GPSim is a simulation focussed on providing Continuing Professional Development (CPD) for GPs
around early signs of cancer. The innovation comes from using a set of virtual patients that provide an
engaging online, multimedia and interactive experience. Commissioned by the Avon Somerset &
Wiltshire Cancer services (ASWCs) network and authored by GPs, each case simulates a
consultation with focus on increasing awareness of early signs for cancer as well as the support
available to GPs from the network. The cases are deployed in UChoose, a VP player and authoring
tool developed by UWE to the international Medbiquitous standard for virtual patients6. The cases are
presented as branching narrative systems that offer the learner various pathways and outcomes
depending upon the decisions that they make. The learner is able to engage in a conversation with
each patient, represented as an avatar, as well as access pertinent data such as medical records to
inform their decisions. The patient set consists of mix of cases, some with early signs of cancer and
some without, so that the consultation is not a foregone outcome.
2.0 Literature Review
Virtual patient systems were first seen in the early 1970s 7 and since then have evolved greatly,
helped both by the advancements in multimedia technology and the opportunities provided by the
expanding World Wide Web.
The benefits of using virtual patients in teaching, learning and assessment has been clearly
demonstrated8 as well as its application in offering a wide range of learning design 9. Ellaway notes
the strength of virtual patients is to promote and/or assess clinical reasoning particularly in complex
and emergent settings. Such virtual patient systems have also been shown to enable to learner to
acquire clinical problem-solving skills more efficiently10.
Although the idea of virtual patient education is not new, it is still regarded as an educational
innovation and widespread regular use of this method of learning is yet to come into everyday
practice11.
St Georges Medical School, London is one of the few UK medical schools that contradict this
statement. They have been using web-based branched narrative virtual patients to replace traditional
linear paper based problem based learning (PBL) cases since 2005 and educators there have
observed evidence of “deep learning” and “critical thinking” related to the key decision points in the
virtual patient cases.
A major step in the field of virtual patient instruction was the inclusion of virtual patients in the United
States Medical Licensing Exam (USMLE) in 2007.
The educational strength of virtual patient education if felt to be most notable in promoting clinical
reasoning, an important aspect of clinical learning11.
Simulations have the ability to engage the learner in repetitive and deliberate practice in a safe and
reproducible environment with personalised expert feedback 12. Patient simulations also allow
curriculum administrators to fill in gaps in clinical exposure and introduce learners to unusual and rare
conditions13.
Virtual patients offer some practical and educational advantages when compared to other popular
simulation technologies like mannequin-based physical simulators and human actors. When
delivered over the internet, virtual patients are relatively inexpensive to distribute and update
compared with their physical counterparts, (McGee, University of Pittsburg School of Medicine).
A recent systematic literature review on the value of virtual patients in medical education listed the
following advantages: efficiency, standardisation, easy accessibility, interactivity, decreased instructor
workload, exposure to rare but critical cases (eg a ruptured aortic aneurysm), personalised learning,
immediate and personalised instruction and feedback, efficiency, improvement of clinical skills in a
non threatening experimental environment, student autonomy and links to the medical literature14.
Other advantages discussed in the literature on virtual patients are that they enable the teaching of
practical decision making, offer the rehearsal of common clinical scenarios, allow the time and place
of learning to be convenient to the learner and are also fun to take partake in.
The disadvantages of virtual patients discussed in the review are as follows: potentially expensive
and resource intensive, difficult to integrate into medical curricula, difficult to edit and author, limited
by technology, limited by lack of diversity (race, culture and discipline) and poor at evaluating complex
cognitive skills such as empathy, negotiation and breaking bad news 14. Other disadvantages
discussed are inflexibility of cases, difficulty achieving realism as requires realistic choices which in
turn become exponential and therefore difficult to develop.
In spite of promising research results in recent years and some attempts to integrate virtual patients in
different medical curricula, the effective use requires evidence to guide design and integration.
3.0 Methodology
3.1 Case design
A team of six GPs were recruited and funded for the equivalent of six sessions by ASWCs to author
the content for the cases.ASWCS provided the project management and administrative support and
were responsible for introducing the authors to NAEDI and the Primary Care tools to aid earlier
diagnosis of cancer, and defining the clinical learning objectives 5. A series of workshops jointly run
with UWE provided training in use of the software, guidance on how to author a case, preliminary
planning of the case narratives and the opportunity for peer review. Additional one-to-one authoring
support was provided by UWE as required. Authors also created supporting materials including
patient records and links to assessment tools and web-based information.
The digital media assets, including the audio of patients’ speech and the avatars used to represent
the patients were created by the team at UWE.
Six cases were written which were released in two groups of three with each group consisting of one
placebo non-cancer case and two patients with early signs of a more common, non-gender specific
cancer.
The cases are available here:http://uchoose.uwe.ac.uk/uchoosehub and can be accessed by
entering the code ‘GPsim1’ once registered on the site.
3.2 The pilot
A self-administered questionnaire was developed as a web form using Survey Monkey. The
instrument produced quantitative data from Likert rated statements as well as qualitative data from
free text responses. The survey was divided into three sections consisting of items that:



provided demographic data,
answered questions relating to learning outcomes about earlier referral for cancer and tools
and resources that support Primary Care
answered questions about e-learning and the use of virtual patients
72 GPs from across the network region .were recruited by ASWCS for the pilot.
4.0 Results
There were 72 participants. Gender and age are presented in Figure 1.
[Figure1: Demographic Data]
4.1 Opinions of the Usefulness of the tool
This part of the survey was intended to gauge opinion about the usefulness of the simulation tool to
increase awareness of early signs of cancer. The results are presented in Table 1.
[Table 1: Opinions on the usefulness of the tool]
4.2Opinions on e-learning and the use of Virtual Patients
This part of the survey gauged opinion about e-learning and the use of Virtual Patient cases for online
simulation.
4.2.1 I feel that I benefit from being able to learn online
The quantitative data for participants’ attitude to this statement are presented in Figure 2. 94.4%of
respondents either strongly agreed or agreed that they benefited from online learning.
[Figure 2: “I feel that I benefit from being able to learn online”]
4.2.2 Case based learning using virtual patients is a good way of engaging with online
learning
The quantitative data for participants’ attitude to this statement are presented in Figure 3.
91.7% respondents either strongly agreed or agreed that Virtual Patients were a good way of
engaging with online learning
[Figure 3: “Case based learning using virtual patients is a good way of engaging with online learning”]
A number of themes are evident including those of interactivity, and ease of access as well as the
cases requiring some improvements, specifically with respect to the lack of options relating to what
can be said to the patient at any one time. This is discussed further in section 6.0 below.
4.2.3 I would like to see more of these cases being developed for GP CPD
The quantitative data for participants’ attitude to this statement are presented in Figure 4. 88.9%
respondents either strongly agreed or agreed that this simulation was useful for their CPD.
[Figure 4: “I would like to see more of these cases being developed for GP CPD”]
4.3 Additional Open comments
This part of the survey was designed to allow participants the opportunity to comment on the
positive aspects of the simulation as well as identify any issues and make suggestions for
improvement. The resulting qualitative data was subjected to thematic analysis and the major
themes are presented in Figure 5.
[Figure 5: Qualitative comments about the positive and weak aspects of the learning resource.]
5.0 Statistics
Quantitative data were analyzed using the SPSS 17.0 programme. Due to the ordinal nature of the
quantitative data, the descriptive statistics involve univariate analysis and include the median and
frequency distribution. Data is presented in tables with a corresponding bar chart.
Qualitative data were subjected to thematic analysisusing a grounded theory approach. ComputerAssisted Qualitative Data Analysis (CAQDAS) was conducted using XSight™ by QSR International.
5.0 Discussion
5.1 Summary
Evidence from this pilot shows that learners benefited from interacting with the virtual patient cases
which have served to:





Highlight the importance of early diagnosis of cancer
Increase awareness of Primary Care cancer assessment tools
Increase confidence in 2WW referral
Increase knowledge of available support to GPs
Increase awareness of the late effects of cancer
5.2 Strengths and limitations
The study has shown that participants feel they benefit from online working and that the virtual
patient cases have provided a useful addition to CPD activity. Of particular value was the
supplementary information and resources that were attached to each case, e.g. links to external web
resources, NICE guidance and cancer assessment tools.
Participants found the interactive nature of the VPs engaging, and highlighted the benefits of them
being online, quick and fun to do.
Four comments were received regarding technical issues including poor audio quality and the
simulation being slow to load. A helpline was established in order to deal with such issues during the
pilot and the problems were identified as relating to the users accessing the cases via NHS
computers with very old versions of Internet Explorer.
The main limitation of the tool identified related to the lack of options available as one progresses
through a case, with learners expressing frustration at not being able to ask questions previously
available to them. This is not thought to be a fault of the tool itself nor the concept of virtual
patients, but relates to a lack of experience in case authoring. This was the first time this particular
approach of using virtual patients was used and all the authors were new to this. The experience
gained from this pilot, will address this issue by enabling the personal development through
experience of the case authors and the technical team..
5.3 Comparison with existing literature
The findings of this study are in concord with the literature. Respondents were able to practice their
clinical decision making in a risk free simulation and found the Virtual Patient cases to be interactive,
fun and easily accessible (11). The disadvantages, in terms of difficulty in authoring realistic choices
have also been highlighted (14).
5.4 Implications for research and/or practice
Overall, this pilot study has shown that the use of virtual patient cases for CPD around the early signs
of cancer was very favourably received by participants. There was significant agreement that case
based learning using virtual patients provides an authentic online learning solution and that further
cases would be beneficial. As a result of this positive response, ASWCS commissioned a further set of
eight cases, again themed around 10 minute consultations and early signs of cancer, but also
included cases of rarer cancers.
6.0 Additonal Information
Funding: this project was funded by Avon Somerset & Wiltshire Cancer services.
Ethical approval: University of the West of England
Competing interests: None
Acknowledgements: Case authors: Dr Barbara Barton, Dr Sanjeev Popli, Dr Amelia Randle Dr Knut
Schroeder, Dr Kate Staveley, Dr Sarah Street.
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