A virtual patient-based training program to enhance clinical decision-making competencies in general practice residents: mixed-methods study

BACKGROUND: Clinical decision-making (CDM) represents a fundamental competency for general practice (GP) residents, yet traditional training approaches often provide limited opportunities for deliberate practice. Virtual patient (VP) platforms have emerged as promising educational tools that offer standardized, repeatable, and risk-free environments for developing clinical reasoning competency. However, empirical evidence examining the effectiveness of structured VP training programs in enhancing CDM competencies among GP residents remains limited, particularly regarding the mechanisms through which such training facilitates competency improvement. This study aimed to evaluate the effectiveness of a VP training program in enhancing CDM competencies among GP residents, and to explore their perceptions of the program's value and barriers in developing these competencies. METHODS: An explanatory sequential mixed-methods design was employed, comprising a quantitative pre-post assessment followed by qualitative exploration. Over 12 weeks, 50 GP residents participated in a curriculum involving weekly exposure to two VP cases for self-paced practice, supplemented by weekly facilitated workshops to discuss these cases. Quantitative pre-post assessments included OSCEs (history-taking, physical examination, clinical reasoning, medical record writing) and a theoretical test. Subsequently, eight focus group interviews were conducted to explore their learning experiences and perceived barriers to improvement of CDM competencies. Data were analyzed using paired t-tests for quantitative data and thematic analysis for qualitative data. RESULTS: Quantitative assessment of the 50 participants (mean age 25.5 years; 70% female) demonstrated statistically significant but differential improvements in clinical competencies. Following the VP training program, GP residents demonstrated significant improvements in clinical knowledge (mean increase 6.7 points, 95% CI [4.2, 9.1]), history-taking (mean diff.=10.2, 95% CI [7.6, 12.8]), and clinical reasoning (mean diff.=11.2, 95% CI [8.8, 13.6]). Conversely, observed improvements in physical examination (mean diff.=2.4, 95% CI [-0.1, 4.8]) and medical record writing (mean diff.=1.2, 95% CI [-0.1, 2.5]) were not statistically significant. Qualitative findings suggested that residents attributed their CDM competency development to the platform's structured design, which cultivated systematic diagnostic reasoning, adaptive competence in uncertainty, and promoted reflective learning. Technological fidelity limitations in physical exam simulation, restrictive documentation interfaces, challenges in skill transfer to real practice, and variable workshop effectiveness were identified as core barriers to the implementation of VP training program. CONCLUSION: A structured VP curriculum embedded in GP residency was associated with improved clinical knowledge, history-taking, and clinical reasoning, while showing limited effects on physical examination and medical record writing. Future development should prioritize advancing technological realism in these areas, optimizing curricular integration through facilitated debriefing, and investigating the long-term transfer and retention of acquired competencies into clinical practice.