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Virtual reality‐based assessment of clinical reasoning ability

What problems were addressed? The reliable and valid assessment of the clinical competence of doctors is essential for patient safety. Virtual realitybased clinical cases offer a form of assessment that can provide information on a student’s clinical reasoning and decision-making ability. Further work is required to determine the validity of using virtual worlds for this purpose. What was tried? The Otago Virtual Hospital (ovh. otago.ac.nz) is a multi-user, three-dimensional, avatar-based computer environment in which clinical performance can be assessed while participants manage an open-ended simulated clinical case. Through their avatars, students are able to move around the hospital, communicate with patients and peers via text chat (2-minute video at http://bit.ly/ xZ0Net), examine, order and evaluate investigations, and write medical notes. In a pilot study, 12 participants (three cohorts comprised of medical students in Years 3 and 5, and qualified doctors) participated in a simulated clinical case. Participant performance (obtained from text chat and examination, investigation and action logs) was measured quantitatively according to the achievement of set outcomes representing optimal management, and qualitative thematic analysis of case transcripts was undertaken to compare clinical reasoning skills. Scores of performance showed that qualified doctors scored significantly higher than the Year 3 student group, and were better able to make correct full diagnoses and achieve safe clinical management compared with both student cohorts. Thematic analysis identified three themes consistent with current theories of clinical reasoning: efficient ‘pattern recognition’ with the formation of illness scripts; elaborated knowledge (illustrated by accuracy of diagnosis), and recognition of key features within the case. Results indicated that more experienced participants generated correct diagnoses more efficiently, made more accurate diagnoses, and were better able to transform presenting information into key clinical concepts. Also observed was a superior ability to communicate clinical information succinctly, and to construct effective patient management plans. What lessons were learned? Virtual reality-based clinical cases offer a method of assessing competence and, specifically, clinical reasoning. The openended nature of the cases, coupled with the scenario transcript (via the text chat and action logs), means this assessment evaluates not only diagnostic aptitude, but also the ability to elicit relevant information, and clinical decision making. It provides some unique insights into the participant’s clinical thinking and may provide an innovative means of assessing a participant’s clinical reasoning processes. The results from this study support the construct validity of this innovative means of assessment. The thematic analyses suggest that simulated virtual cases can provide a valid means of assessing clinical reasoning. As competence assessment is known to be context-specific, further research is required to examine this new format of assessment across multiple cases. However, a virtual reality-based clinical case is a promising new format for the standardised assessment of clinical competence and clinical reasoning.