Principles and Pointers to Aid Writing of Effective Virtual Patients


Dr Jonathan Round, Dr Terry Poulton, , E-learning Unit, St. George’s, University of London, Tooting.


What makes a VP work?


Virtual patients work in medical education because they force the player to use their knowledge and experience to progress in the case. The student will learn both from having to ponder which choice is best and by experiencing the consequence (good or bad) of the choice they have made.

Better VPs typically –

1.     Are involving because of realistic narrative, realistic scenarios and realistic developments.

2.     Have scenarios and choices relevant to what the student is learning at that stage.

3.     Relate to common or important problems.

4.     Retain interest by compelling consequences for correct and incorrect choices


What are you trying to do?

Vps can be used in many places in a curriculum, and different styles need to be employed for different settings.

·       For student directed learning, alongside a course. These Vps are more ‘for fun’ and allow a student to test their learning in a risk-free environment. Cases should therefore be complex, with many choice points and multiple choices in each.

·       For group work, for students to use together. Here there will be plenty of discussion, and unrealistic choices avoided. Therefore cases are best with fewer choice points, but with carefully constructed options. Narrative will need to be adjusted to make the choices of similar merit.

·       For use as the patient in PBL, in the context of a course, it is essential that each group in the course experiences similar learning. Therefore cases must start and end at the same place, and cover similar ground whatever the route taken through the case. Devices, such as the intervention of a senior colleague, may be needed to keep the group ‘on track’. As with group work, fewer choices will be needed. Lastly choices are best constructed around key learning objectives for the week.

·       In assessment, Vps can be developed to test students. Here choices must test important knowledge or management skills. Scoring could be on the path taken, time needed or the outcome.

Where to start?

Writing must start by deciding on the position in a course and the purpose of the VP. Learning objectives that should be covered (if any) with the VP should be identified before writing.

Next a suitable case should be identified. This should be common or important, perhaps with emphasis on conditions that cannot readily be seen by the student – critical illness, or where the case develops over months.

The player must adopt a role within the case so that he or she must make decisions, and this must be explicit at the start of the case. This might be as a junior doctor or general practitioner for instance.

Lastly, the ideal course of the case is outlined – what would ideally happen if the patient were managed properly. (fig 1)


Figure 1: An ideal pathway. Each box represents a new development, with purple ones identifying the start of a new phase of the case (e.g. history, examination)


The purpose of choice

Choice is essential in a VP. This allows the player to integrate their knowledge and experience with the case in an attempt to ‘treat’ the VP. Choices should change the condition of the patient depending on what has been chosen and so may lead to different further choices, which is involving for the player. Choice also produces consequences, which, if well constructed, give the player clinical experience of how particular clinical errors might affect real patients.

Choice and consequence in a VP multiplies complexity of the case as each choice could add a new arm to the pathway (fig 2). Therefore choices must be properly planned and integrated with the learning objectives for the case.


Figure 2: A VP map with an ideal pathway and numerous choice and consequence boxes. Some initially adverse choices can be corrected, but others lead to a dead end

Developing choice starts with imagining what else could someone decide at a particular stage in the case. It is often hard for clinicians to imagine bad or sloppy practise. The writer must then decide what would happen if that bad choice were made – what would happen to the patient, and what reasonable choices would then be available. Some might lead to the patient returning to the ideal pathway, but further bad choices might lead to a negative outcome.

Development of narrative

Once the case is outlines as boxes, as in fig 2, narrative for each box must be developed. Characterisation of key figures in the case is needed as this promotes involvement of the player with the case. Images and sound can be added at this stage, including radiographs or ECG’s.



It is very difficult to write a good case alone. Initial storyboarding is best done in a small group, although narrative is better done by one person. Case review is essential to look for inconsistencies, broken connections and unrealism.

Once the case is being used, writers should monitor the use of the VP.



1.     Decide who you are writing for, how the VP will be used and related learning objectives.

2.     Chose a case and plan out an idealised path.

3.     Identify places for alternate choices away from the ideal path.

4.     Map out the consequences for the other choices and subsequent choices.

5.     Develop narrative to bring to life characters in the VP and make decision harder for the player

6.     Review the case for technical problems and content.

JR 08_09