Students Language Proficiency and

Cross-Cultural Use of Virtual Patients

Valentin Muntean*, Uno Fors**, Nabil Zary**, Tudor Calinici*

* “Iuliu Hatieganu” University of Medicine, Cluj-Napoca, Romania**Karolinska Institutet, Stockholm, Sweden

Email:valentin.muntean@gmail.com

Sharing educational resources, specifically virtual patients (VP’s), among medical schools, is a way to improve education. However, several cultural aspects may have an impact on the development and the use of VP’s.

This study focus on the influence of learners language proficiency on cross-cultural use of VP’s.

Language Proficiency and Cross-Cultural Use of VP’s

As a part of the eViP-project, 42 fifth year Romanian medical students from the Faculty of Medicine in Cluj, Romania, enrolled in the optional lecture “Methods of teaching and evaluation for medical students” were asked to participate in a pilot study with virtual patients.

The students’ previous training was exclusively in Romanian and none of them had worked with VPs before, however, a requisite for participation in the study was a good understanding of English.

Language Proficiency and Cross-Cultural Use of VP’s

Language Proficiency and Cross-Cultural Use of VP’s

Three cases developed by faculty in internal medicine, surgery and endocrinology were used. Every case had an English and a Romanian version. The content of the versions was identical and translation into English was performed by the case authors and reviewed by a native English speaker.

Language Proficiency and Cross-Cultural Use of VP’s

30 out of the 42 students considered themselves as having a good or very good understanding of English and agreed to participate in the study.

The identity of the students remained unknown for researchers throughout the study. Every student was given a code name (anonymous) and was randomly assigned two different cases, one in English and one in Romanian. The access to the cases was given for a two-week period. The students logged to the cases through the Internet from home.

Language Proficiency and Cross-Cultural Use of VP’s

NUME student / caz

caz ROMm(R) sau ENGgl(E)

timp/caz (min)

nr.intrebari anamneza

nr.de date de examen obiectiv

nr.de examinari de lab/radiologice

diagnostic corect (YES/NO)

tratament corect (YES/NO/INCOMPLETE)

raspunsuri student date in ROM(R) sau ENGLl(E)

nr de cuvinte in justificarea diagnosticului

student049 BT-ROM 40 48 11 19 YES INCOMPLETE ROM 51

student058 BT-ROM 25 21 10 12 YES YES ROM 11

student 23 BT-ROM 80 103 81 50 INCOMPLETE YES ROM 53

student 3 BT-ENG 50 29 5 12 YES INCOMPLETE ENG 50

student 57 BT-ENG 90 98 31 43 YES YES ROM 37

student 9 BT-ENG 32 90 7 33 INCOMPLETE INCOMPLETE ROM 29

student048 BT-ENG 70 32 28 38 YES INCOMPLETE ROM 48

student054 BT-ENG 52 55 7 33 YES INCOMPLETE ROM 51

student055 BT-ENG 34 25 8 21 YES YES ROM 8

student 20 BT-ENG 75 97 99 19 INCOMPLETE INCOMPLETE ROM 57

student 26 D.R. ROM 52 141 118 25 INCOMPLETE NO ROM 36

student 27 D.R. ROM 120 131 158 28 NO NO ROM 84

student 29 D.R. ROM 42 117 27 38 INCOMPLETE INCOMPLETE ROM 31

student 41 D.R. ROM 46 119 39 37 YES INCOMPLETE ROM 31

student 5 D.R. ROM 35 135 15 19 YES YES ROM 75

student 9 D.R. ROM 52 117 20 46 INCOMPLETE YES ROM 40

student047 D.R. ROM 46 92 5 35 INCOMPLETE INCOMPLETE ROM 25

student056 D.R. ROM 60 123 64 50 NO NO ROM 51

student059 D.R. ROM 44 65 7 6 YES YES ROM 37

student046 D.R. ENG 30 93 36 32 NO NO ROM 31

student045 D.R. ENG 50 156 171 47 INCOMPLETE NO ROM 38

student 24 D.R. ENG 47 35 20 12 INCOMPLETE INCOMPLETE ROM 99

student049 D.R. ENG 40 56 71 37 INCOMPLETE NO ROM 38

student044 D.R. ENG 23 30 8 7 YES NO ENG 23

student 24 SV ROM 70 71 68 34 YES YES ROM 242

student044 SV ROM 85 104 73 19 YES INCOMPLETE ROM 48

student 3 SV ROM 55 29 34 24 YES YES ROM 22

student 57 SV ROM 70 104 82 58 YES YES ROM 25

student046 SV ROM 40 75 4 12 INCOMPLETE INCOMPLETE ROM 5

student048 SV ROM 90 51 39 51 YES YES ROM 63

student054 SV ROM 51 42 14 50 YES YES ROM 29

student045 SV ROM 58 39 44 34 YES YES ROM 25

student 20 SV ROM 31 80 19 69 INCOMPLETE INCOMPLETE ROM 19

student055 SV ROM 43 47 28 33 YES INCOMPLETE ROM 35

student 27 SV ENG 60 76 73 41 NO NO ROM 68

student 23 SV ENG 55 81 70 24 INCOMPLETE YES ROM 63

student 26 SV ENG 37 42 24 14 INCOMPLETE INCOMPLETE ROM 14

student 29 SV ENG 25 42 14 21 YES INCOMPLETE ROM 37

student 41 SV ENG 40 118 0 39 YES YES ROM 42

student047 SV ENG 41 107 72 51 INCOMPLETE INCOMPLETE ROM 12

student 5 SV ENG 30 26 16 18 NO NO ROM 29

student056 SV ENG 90 111 143 87 YES INCOMPLETE ROM 46

student058 SV ENG 31 37 10 32 INCOMPLETE INCOMPLETE ENG 11

student059 SV ENG 60 64 11 14 NO NO ROM 30

Language Proficiency and Cross-Cultural Use of VP’s

Of the 30 students enrolled in the study, 8 did not finalize both cases and were excluded from the final analysis of the results. The following criteria were analyzed: Time per case (average +/-SD) No. of history questions asked (average +/-SD) No. of tests ordered for physical examination (average +/-

SD) No. of lab or imaging tests ordered (average +/-SD) Correct diagnosis and treatment (Yes, Incomplete or No) Student answer (in English or Romanian) No. of words in diagnosis justification (average +/-SD)

Language Proficiency and Cross-Cultural Use of VP’s

NUME student / caz

caz ROMm(R) sau ENGgl(E)

timp/caz (min)

nr.intrebari anamneza

nr.de date de examen obiectiv

nr.de examinari de lab/radiologice

diagnostic corect (YES/NO)

tratament corect (YES/NO/INCOMPLETE)

raspunsuri student date in ROM(R) sau ENGLl(E)

nr de cuvinte in justificarea diagnosticului

student049 BT-ROM 40 48 11 19 YES INCOMPLETE ROM 51

student058 BT-ROM 25 21 10 12 YES YES ROM 11

student 23 BT-ROM 80 103 81 50 INCOMPLETE YES ROM 53

student 3 BT-ENG 50 29 5 12 YES INCOMPLETE ENG 50

student 57 BT-ENG 90 98 31 43 YES YES ROM 37

student 9 BT-ENG 32 90 7 33 INCOMPLETE INCOMPLETE ROM 29

student048 BT-ENG 70 32 28 38 YES INCOMPLETE ROM 48

student054 BT-ENG 52 55 7 33 YES INCOMPLETE ROM 51

student055 BT-ENG 34 25 8 21 YES YES ROM 8

student 20 BT-ENG 75 97 99 19 INCOMPLETE INCOMPLETE ROM 57

student 26 D.R. ROM 52 141 118 25 INCOMPLETE NO ROM 36

student 27 D.R. ROM 120 131 158 28 NO NO ROM 84

student 29 D.R. ROM 42 117 27 38 INCOMPLETE INCOMPLETE ROM 31

student 41 D.R. ROM 46 119 39 37 YES INCOMPLETE ROM 31

student 5 D.R. ROM 35 135 15 19 YES YES ROM 75

student 9 D.R. ROM 52 117 20 46 INCOMPLETE YES ROM 40

student047 D.R. ROM 46 92 5 35 INCOMPLETE INCOMPLETE ROM 25

student056 D.R. ROM 60 123 64 50 NO NO ROM 51

student059 D.R. ROM 44 65 7 6 YES YES ROM 37

student046 D.R. ENG 30 93 36 32 NO NO ROM 31

student045 D.R. ENG 50 156 171 47 INCOMPLETE NO ROM 38

student 24 D.R. ENG 47 35 20 12 INCOMPLETE INCOMPLETE ROM 99

student049 D.R. ENG 40 56 71 37 INCOMPLETE NO ROM 38

student044 D.R. ENG 23 30 8 7 YES NO ENG 23

student 24 SV ROM 70 71 68 34 YES YES ROM 242

student044 SV ROM 85 104 73 19 YES INCOMPLETE ROM 48

student 3 SV ROM 55 29 34 24 YES YES ROM 22

student 57 SV ROM 70 104 82 58 YES YES ROM 25

student046 SV ROM 40 75 4 12 INCOMPLETE INCOMPLETE ROM 5

student048 SV ROM 90 51 39 51 YES YES ROM 63

student054 SV ROM 51 42 14 50 YES YES ROM 29

student045 SV ROM 58 39 44 34 YES YES ROM 25

student 20 SV ROM 31 80 19 69 INCOMPLETE INCOMPLETE ROM 19

student055 SV ROM 43 47 28 33 YES INCOMPLETE ROM 35

student 27 SV ENG 60 76 73 41 NO NO ROM 68

student 23 SV ENG 55 81 70 24 INCOMPLETE YES ROM 63

student 26 SV ENG 37 42 24 14 INCOMPLETE INCOMPLETE ROM 14

student 29 SV ENG 25 42 14 21 YES INCOMPLETE ROM 37

student 41 SV ENG 40 118 0 39 YES YES ROM 42

student047 SV ENG 41 107 72 51 INCOMPLETE INCOMPLETE ROM 12

student 5 SV ENG 30 26 16 18 NO NO ROM 29

student056 SV ENG 90 111 143 87 YES INCOMPLETE ROM 46

student058 SV ENG 31 37 10 32 INCOMPLETE INCOMPLETE ENG 11

student059 SV ENG 60 64 11 14 NO NO ROM 30

Language Proficiency and Cross-Cultural Use of VP’s

Interestingly, the average time per case was longer for the Romanian versions of VPs (55.7 +/- 21.3 min) versus English versions (48.2 +/- 18.8).

When comparing individual cases, students working with the Romanian version used more time per case than for the English version in two of the cases and less in one.

Case(ROM or ENG) Time/case (min) SD

BT-ROM 48,3 28,4

DR-ROM 55,2 25,21

SV-ROM 59,3 19,3

ROM 55,7 21,3

     

BT-ENG 57,56 21,6

DR-ENG 38.0 11,3

SV-ENG 46,9 19,6

ENG 48,2 18,8

     

Language Proficiency and Cross-Cultural Use of VP’s

There were more history questions asked for Romanian VPs (84.4 +/- 36.8) when compared with English versions (68.1 +/- 35.1).

In two cases, the students asked more questions for the English VPs and in one many more questions for the Romanian cases.

Case(ROM or ENG) No. question/history SD

BT-ROM 57,3 41,7

DR-ROM 115,6 23,5

SV-ROM 64,2 26,7

ROM 84,4 36,7

     

BT-ENG 60,8 33,4

DR-ENG 74.0 52,1

SV-ENG 70,4 33,5

ENG 68,1 35,1

     

Language Proficiency and Cross-Cultural Use of VP’s

The number of tests ordered for physical examination and lab or imaging tests ordered was almost the same for Romanian and English cases.

Case (ROM or ENG)

No. physical exam. ordered SD

No. lab./imaging ordered SD

BT-ROM 34.0 40,7 27.0 20,2

DR-ROM 50,3 53,7 31,5 13,6

SV-ROM 40,5 26,3 38,4 18,1

ROM 43,5 38,2 33,6 15,7

         

BT-ENG 26,44 33,7 28,4 11,2

DR-ENG 61,2 65,7 27.0 16,9

SV-ENG 43,3 45,1 34,1 22,3

ENG 42,1 45 30,4 17

         

Language Proficiency and Cross-Cultural Use of VP’s

We found high differences for correct diagnosis between Romanian and English VPs. The diagnosis was

correct in 13 of the Romanian VPs and 9 of English VPs, incomplete in 7 Romanian and 9 English cases and wrong in 2 Romanian and 4 English cases.

Case (ROM or ENG) Correct diagnosis

(YES/INCOMPLETE/NO)

BT-ROM 2/Y. 1/I

DR-ROM 3/Y. 4/I. 2/N

SV-ROM 8/Y. 2/I

ROM 13/Y. 7/I. 2/N

   

BT-ENG 5/Y. 2/I

DR-ENG 1/Y. 3/I. 1/N

SV-ENG 3/Y. 4/I. 3/N

ENG 9/Y. 9/I. 4/N

   

Language Proficiency and Cross-Cultural Use of VP’s

The differences between the two versions were even greater for treatment plan.

The correct treatment plan was given in 11 Romanian and 4 English VPs, the answer was incomplete in 8 Romanian and 10 English and wrong in 3 Romanian and 7 English cases.

Case (ROM or ENG) Correct treatment

(YES/INCOMPLETE/NO)

BT-ROM 2/Y. 1/I

DR-ROM 3/Y. 3/Y. 3/N

SV-ROM 6/Y. 4/I

ROM 11/Y. 8/I. 3/N

   

BT-ENG 2/Y. 5/I

DR-ENG 1/I. 4/N

SV-ENG 2/Y. 45I. 3/N

ENG 4/Y. 10/I. 7/N

   

Language Proficiency and Cross-Cultural Use of VP’s

The student answers were in Romanian in all Romanian cases and in Romanian for most English VPs (19 out of 22).

Case (ROM or ENG) Studnt answer

(ROM/ENGL)

BT-ROM 2/ROM

DR-ROM 9/ROM

SV-ROM 10/ROM

ROM 22/ROM

   

BT-ENG 6/ROM. 1/ENG

DR-ENG 4/ROM. 1/ENG

SV-ENG 9/ROM. 1/ENG

ENG 19/ROM. 3/ENG

   

Language Proficiency and Cross-Cultural Use of VP’s

The number of words in diagnosis justification was larger for Romanian versions of VPs (46.7 +/- 4.6) when compared with English versions (39.4 +/- 2.0).

The difference is due to only one of individual cases, in the other two the figures being almost the same.

Case (ROM or ENG) No.words in

diagnosis justification

BT-ROM 38,3

DR-ROM 45,5

SV-ROM 51,3

ROM 46,7

   

BT-ENG 40.0

DR-ENG 45,8

SV-ENG 35,2

ENG 39,4

   

Language Proficiency and Cross-Cultural Use of VP’s

We found unexpected high differences of student performance on Romanian and English versions of VP’s.

Further studies are necessary to refine those differences and to understand their significance.

Language Proficiency and Cross-Cultural Use of VP’s

Number of students Number of cases/student Student English proficiency Student training/experience with VP’s

and diferent players Student experience for a specific

domain of medicine Case difficulty/complexity Case cultural specificity

Language Proficiency and Cross-Cultural Use of VP’s

Planned future studies:

Cultural/content Cases from Karolinska, London, Munchn,

Heidelberg versus “Home made cases” - Cluj Language

English/Swedish versus Romanian Students

Romanian versus International students Players

Web-SP, Labyrinth, Casus, Campus

Language Proficiency and Cross-Cultural Use of VP’s

VP’s could play a role in addressing the cultural diversity that exists in the society and increased mobility of healthcare professionals, students and patients.

Curriculum reform: what next?

OUR VP’s PROGRAM IS NOW UNDER CONSTRUCTION

Curriculum reform: what next?

It’s already a *** PROGRAM / although it needs time to grow

Curriculum reform: what next?

We are getting ready for the next season