The process of conducting clinical assessment is a highly complex task [1, 2].It encompasses the application of knowledge to collect and integrate information from various sources to arrive at a diagnosis and treatment plan [3]. Healthcare students acquire clinical decision-making skills during their education and continue to build upon them in their work [4]. It is important to give students a solid foundation of diagnostic skills early in their health care studies, to allow them to develop proper operating schemes and procedures, used in both the education process and future professional careers [5].
The first papers about using computer interactive simulations in clinical decision-making were published in the 1970s and rapidly gained popularity in medical education [6–10]. The virtual patient (VP) has gradually become a significant teaching method in training and assessing students for real patient encounters, and supporting their clinical decision-making competencies [11–13]. There are many ways how VP can enhance decision-making skills [14]. Moreover VP has been integrated into undergraduate healthcare curricula in different forms, such as blended learning scenarios [15], during clinical clerkships [16], and as assessment tools [17, 18].
The standard training of healthcare students in clinical decision-making should teach them with skills, such as building a cooperative relationship with the patient and collecting diagnostic data. Furthermore, students should also dynamically search, accumulate and select developing knowledge about different types of psychological mechanisms [3, 19], which involves equally the necessity of analysing and integrating complex data coming from the patient, causing significant cognitive burdens and social interactions involving the element of social exposition. In addition, contact with patient’s personal problems is a source of emotional burden [20].
The virtual patient tool
The VP is online representation of clinical case study which enhance student's learning [21]. The VP in this study is based on the psychological assessment model resulting from the evidence-based assessment approach: EBA [22]. The diagnosis focuses on dimensions that, according to the results of research, most effectively predict the effects of the psychological / psychiatrically treatment, matching it to the patient and their problems. Those dimensions increase the chances for effectiveness treatment [23]. In our study, students evaluate symptoms presented by VP. In turn, we check how effectively they can learn this kind of clinical assessment. In the research we looked for factors which could significantly affect the process of learning. There is no model or list of individual factors that affect the level of performance of this type of task. We are convinced that this is of great importance that the authorities responsible for process of medical education take advantage of those factors affective learning in their programmes. Our research is innovative in this matter. The available data is mostly related to cognitive distortions in clinical decision-making. Based on those distortions, we assessed the level of performance, the individual characteristics of diagnosticians [24], as well as the factors that should naturally affect the learning process. In the pilot study we examined many different variables (e.g., anxiety, well-being, temperament or attention shifting), but here we present only those that gave preliminary significant results. We recognise the level of theoretical knowledge and intelligence as necessary to control.
Goal of the study
A review of the literature shows almost no interest in the matter of the conditions for the development of diagnostic competencies. The goal of this exploratory study is to analyse which psychological characteristics of clinical psychology students are related to the effectiveness of learning clinical decision-making skills with the use of VP. In our research individual psychological characteristics of students are independent variables. Efficiency measurement of learning clinical decision-making skills with the use of VP are dependent variables. Although the study concerns clinical psychology students, we believe that the results will be applicable to a wider group of health care students, who need the competence of collecting interview with the patient.
Model of the study
The independent variables are psychological features that may affect the effectiveness of the clinical decision-making
- Need for cognitive closure is a tendency to formulate judgments immediately, to take the very first hypotheses as final conclusions, with an unwillingness to look for alternative solutions [25].
- Ability to achieve closure refers to the individual’s ability to reach swift decisions and structure in life. The level of the AAC can be understood as the extent to which individuals are able to use different styles of information processing according to their NFC [26].
- Beliefs of changeability vs stability on human traits are meaningful for the level of motivation, the tendency to take up challenges, social-emotional functioning, and engagement in effortful tasks, which translates into, among other things, educational achievements and the ability to cope with stressful situations [27, 28].
- A high level of hope fosters psychological wellness, which involves taking up challenges and achieving goals that are important for the individual [29]. A high level of hope can thus be related to a readiness to invest more resources in the task, which can prevent the negative influence of anxiety [30].
- Intelligence. Conducting a clinical interview is a very complex cognitive task [1]. Therefore, it seems necessary to control the intelligence level of the participants.
- Positive affect/negative affect. Positive affect is associated with better cognitive functioning and can improve verbal fluency performance [31, 32]. It has also emerged that positive affect is related to a higher level of cognitive control [33], as well as a higher level of problem-solving and decision-making abilities, facilitating flexible, creative, and effective cognitive processing [34].
- Level of academic knowledge. In the situation of performing a cognitively complex task which involves analysing a lot of data of diverse significance, limited abilities in conscious information processing constitute a significant difficulty [35]. Possessed knowledge is helpful in dealing with limited abilities in conscious data processing [36].
The dependent variables are the measures of learning efficiency based on the following dimensions presented in VP
1) The negative and positive aspects of functioning of a patient are understood as the level of disorders closest to psychiatrically diagnosis (classification) [37]. Positive aspects are understood as patients’ resources and strengths, important to designing optimal forms of intervention [38].
2) The reactance of a patient is a stable personality trait. A reactant patient is easily provoked and responds oppositional to perceived external demands. High reactance indicates the need for nondirective, patient-directed interventions during psychological treatment, which improves clinical outcomes [39].
3) The coping style of a patient is an enduring personality trait when a person confronts new problematic situations. We distinguish two styles: externalising (impulsive, stimulation-seeking, extraverted) and internalising (self-critical, inhibited, introverted). Symptom-focused “interventions” are more effective in psychological treatment of externalising patients. Use of insight and awareness-enhancing “interventions” is typically most effective among internalising patients [23].
4) The stage of change of a patient represents a person’s readiness to psychological change, defined as a period of time and set of tasks needed for movement to the next stage. The stages are behaviour- and time-specific, not enduring personality traits [23].
5) The following are cognitive errors in clinical decision-making:
(a) Confirmation bias: the tendency to look for confirming evidence to support a diagnosis rather than look for disconfirming evidence to refute it, despite the latter often being more persuasive and definitive [40].
(b) Overconfidence bias: a universal tendency to believe we know more than we do. Overconfidence reflects a tendency to act on incomplete information, intuitions or hunches. More faith is placed in opinion instead of carefully gathered evidence [40].
(c) Multiple alternative bias: a multiplicity of options on a differential diagnosis may lead to significant conflict and uncertainty [40].
(d) Overpathologisation bias: is not explicitly mentioned in medical literature, however, are very similar to other biases distinguished, e.g.: premature closure, representativeness restraint, search satisficing [41], ascertainment bias, diagnosis momentum [40] and focusing effect[42]. It concerns the assumption, in advance, that a person has a problem and narrows the search for data to the problem and interprets the incoming data as evidence of the disorder of the examined person.
6) Adequacy of collected data. Quality and completeness of collected diagnostic data presented by VP.
7) General quality of assessment. General measurement of quality of diagnosis.