The Mesozoic Era experienced several instances of abrupt environmental change that are associated with instabilities in the climate, reorganizations of the global carbon cycle, and elevated extinction rates. Often during these perturbations, oxygen-deficient conditions developed in the oceans resulting in the widespread deposition of organic-rich sedimentsthese events are referred to as Oceanic Anoxic Events or OAEs. Such events have been linked to massive injections of greenhouse gases into the ocean-atmosphere system by transient episodes of voluminous volcanism and the destabilization of methane clathrates within marine environments. Nevertheless, uncertainty surrounds the specific environmental drivers and feedbacks that occurred during the OAEs that caused perturbations in the carbon cycle; this is particularly true of the Early Jurassic Toarcian OAE (~183.1 Ma). Here, we present biostratigraphically constrained carbon isotope data from western North America (Alberta and British Columbia, Canada) to better assess the global extent of the carbon cycle perturbations. We identify the large negative carbon isotope excursion associated with the OAE along with high-frequency oscillations and steps within the onset of this excursion. We propose that these high-frequency carbon isotope excursions reflect changes to the global carbon cycle and also that they are related to the production and release of greenhouse gases from terrestrial environments on astronomical timescales. Furthermore, increased terrestrial methanogenesis should be considered an important climatic feedback during Ocean Anoxic Events and other similar events in Earth history after the proliferation of land plants.

Virtual patients as a form of educational intervention can take many forms and can provide highly effective ways of addressing reduced student access to real patients, the need for standardised and well-structured educational patient encounters, and opportunities for students to practice in safe and responsive environments. However, virtual patients can also be complicated and costly to develop. As a result collaborative and distributed development is best suited to their widespread take up. This paper considers the development and use of virtual patients and the steps that have been taken to support authors in making this approach more sustainable and adaptable. In particular, this has involved the development of a common data interoperability standard, which in turn has engaged a number of communities that have developed, or are developing, virtual patient commons, consisting of shared resources, tools and knowledge for mutual benefit. The paper illustrates how innovative and otherwise difficult to sustain models for supporting and extending healthcare education, such as virtual patients, can be supported using a commons approach with commonly agreed data standards and specifications at their core.

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St George's University of London (SGUL) has a Problem-Based Learning (PBL) curriculum for its undergraduate medicine course, using traditional paper-based patient cases. To counter the limitation that paper cases are linear and do not allow students to explore the consequences of decisions, interactive online virtual patients (VPs) were developed which allowed students to consider options as the cases unfold, and allow students to explore the consequences of their actions. A PBL module was converted to VPs, and delivered to 72 students in 10 tutorial groups, with 5 groups each week receiving VPs with options and consequences, and 5 groups receiving online VPs but without options. A comprehensive evaluation was carried out, using questionnaires, and interviews.Both tutors and students believed that the ability to explore options and consequences created a more engaging experience and encouraged students to explore their learning. They regretted the loss of paper and neither group could see any value in putting cases online without the options. SGUL is now adapting its transitional year between the early campus years and the clinical attachment years. This will include the integration of all technology-based resources with face-to-face learning and create a more adaptive, personalised, competency-based style of learning.

Collaborative learning through case-based or problem-based learning (PBL) scenarios is an excellent way for students to acquire knowledge and develop decision-making skills. However, the process is threatened by the movement towards more self-directed learning and the migration of students from campus-based to workplace-based learning. Paper-based PBL cases can only proceed in a single direction which can prevent learners from exploring the impact of their decisions. The PREVIEW project, outlined in this article, trialled a replacement to traditional paper PBL with virtual patients (VPs) delivered through a virtual world platform. The idea was that an immersive 3D environment could provide (a) greater realism (b) active decision-making and (c) a suitable environment for collaboration amongst work-based learners meeting remotely. Five VP scenarios were designed for learners on a Paramedic Foundation Degree within the virtual world second life (SL). A player using the MedBiquitous VP international standard allowed cases to be played both within SL and on the web. Three testing days were run to evaluate the scenarios with paramedic students and tutors. Students unfamiliar with the SL environment worked through five PBL scenarios in small groups, shadowed by 'in-world' facilitators. Feedback indicated that the SL environment engages students effectively in learning, despite some technology barriers. Students believed SL could provide a more authentic learner environment than classroom-based PBL.

2010 was a vintage year for virtual patients (VPs) with an almost continuous sequence of publications and presentations at the major conferences. Notable examples include AMEE and its subsidiary e-Learning Symposium, the 2nd International Conference on VPs, and a large number of keynote presentations in national and international e-Learning and educational conferences. The increase in international collaboration, coupled to a reduction in VP creation costs and simpler creation tools, has all contributed to this sharp increase in interest. VPs have finally become embedded in the curriculum: in problem-based learning; as core components of lectures, tutorials and seminars; as assessment tools. The medical education community can increasingly turn its attention to the ways in which VPs can be used with the greatest efficiency and pedagogic value. Meanwhile, where will technology next take the VP? It is now possible to consider the extension of the current, relatively lightweight, VP into a truly interactive patient simulation, moving towards the concept of an 'e-human' or 'digital avatar'. At that stage, the simulation may take on new capabilities, offering authentic patient management, clinical and communication skills training, and the potential capability to mimic the health or disease of any citizen.

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BackgroundThe impact of the use of video resources in primarily paper-based problem-based learning (PBL) settings has been widely explored. Although it can provide many benefits, the use of video can also hamper the critical thinking of learners in contexts where learners are developing clinical reasoning. However, the use of video has not been explored in the context of interactive virtual patients for PBL.ObjectiveA pilot study was conducted to explore how undergraduate medical students interpreted and evaluated information from video- and text-based materials presented in the context of a branched interactive online virtual patient designed for PBL. The goal was to inform the development and use of virtual patients for PBL and to inform future research in this area.MethodsAn existing virtual patient for PBL was adapted for use in video and provided as an intervention to students in the transition year of the undergraduate medicine course at St George’s, University of London. Survey instruments were used to capture student and PBL tutor experiences and perceptions of the intervention, and a formative review meeting was run with PBL tutors. Descriptive statistics were generated for the structured responses and a thematic analysis was used to identify emergent themes in the unstructured responses.ResultsAnalysis of student responses (n=119) and tutor comments (n=18) yielded 8 distinct themes relating to the perceived educational efficacy of information presented in video and text formats in a PBL context. Although some students found some characteristics of the videos beneficial, when asked to express a preference for video or text the majority of those that responded to the question (65%, 65/100) expressed a preference for text. Student responses indicated that the use of video slowed the pace of PBL and impeded students’ ability to review and critically appraise the presented information.ConclusionsOur findings suggest that text was perceived to be a better source of information than video in virtual patients for PBL. More specifically, the use of video was perceived as beneficial for providing details, visual information, and context where text was unable to do so. However, learner acceptance of text was higher in the context of PBL, particularly when targeting clinical reasoning skills. This pilot study has provided the foundation for further research into the effectiveness of different virtual patient designs for PBL.