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Year : 2009  |  Volume : 22  |  Issue : 2  |  Page : 269

Blended E-learning in a Web-based Virtual Hospital: A Useful Tool for Undergraduate Education in Urology

Department of Urology, University of Tuebingen, Germany

Date of Submission25-Oct-2008
Date of Acceptance15-Jul-2009
Date of Web Publication02-Aug-2009

Correspondence Address:
M Horstmann
Hoppe Seyler Str. 3, 72076 Tuebingen, Department of Urology
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Source of Support: None, Conflict of Interest: None

PMID: 20029750

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Introduction: E-learning is a teaching tool used successfully in many medical subspecialties. Experience with its use in urology, however, is scarce. We present our teaching experience with the INMEDEA simulator to teach urological care to medical students.
Methods: The INMEDEA simulator is an interactive e-learning system built around a virtual hospital which includes a department of urology. It allows students to solve virtual patient cases online. In this study, students were asked to prepare two urological cases prior to discussion of the cases in small groups. This blended teaching approach was evaluated by students through anonymous questionnaires.
Results: Of 70 4th year medical students 76% judged this teaching method as good or very good. Eighty-seven percent felt that it offered a good way to understand urological diseases better and 72% felt that learning with this method was fun. Nevertheless, 30 out of 70 free text statements revealed that further improvements of the program, including an easier and more comfortable navigation and a faster supply of information are necessary.
Conclusions: Virtual patient cases offer a practicable solution for teaching based on problem solving in urology with a high acceptance rate by students.

Keywords: E-learning, patient simulation, urology, virtual hospital

How to cite this article:
Horstmann M, Renninger M, Hennenlotter J, Horstmann C C, Stenzl A. Blended E-learning in a Web-based Virtual Hospital: A Useful Tool for Undergraduate Education in Urology. Educ Health 2009;22:269

How to cite this URL:
Horstmann M, Renninger M, Hennenlotter J, Horstmann C C, Stenzl A. Blended E-learning in a Web-based Virtual Hospital: A Useful Tool for Undergraduate Education in Urology. Educ Health [serial online] 2009 [cited 2023 Jan 29];22:269. Available from:


Undergraduate teaching in medical schools is often based on traditional methods like textbook reading and lectures carried out by students either alone at home or in large classroom groups. Student contact with individual patients is often difficult to obtain as a lot of students are confronted only with few patients (Schwartz et al., 1992). This is particularly true for teaching in urology, which is a small subspecialty with few patients on the wards and often afforded only a few hours of time in the curriculum (Seabra et al., 2004).

Education reforms emphasize practical teaching of medical skills and problem solving approaches. Instead of teaching approaches that require students to memorize static concepts, new approaches foster active learning in order to promote greater retention of knowledge (Scalese et al., 2008; Weller, 2004). In this new concept, students are asked to play a more active part in learning and problem solving (Dantas & Kemm, 2008).

E-learning with virtual patients is where a student-user learns through simulation cases by playing the role of the physician responsible for treating patients. In general e-learning has proven to be an effective teaching tool for teaching in many medical subspecialties (Pinto et al., 2008), particularly in specialties where images provide most of the necessary information needed for cases, such as in radiology and dermatology (Scarsbrook et al., 2006; Wahlgren et al., 2006). E-learning has also become common in specialties that use standardized treatment pathways, for example emergency medicine (Freeman et al., 2001; Friedl et al., 1996; Weller et al., 2004). However, e-learning programs that include patient simulations remain scarce as they are expensive and time-consuming to create (Huang et al., 2007; Morin et al., 2004; Zary et al., 2006). To our knowledge, there are only a few published e-learning experiences in urology (Elves et al., 1997; Khadra & Guinea, 1996; Seabra et al., 2004; Teichman & Richards, 1999) and no experiences with urological patient simulations have been previously published.

We conducted this study to evaluate the use of a computer-based e-learning approach combined with classical face-to-face education methods to teach the fundamentals of urology to the medical students of our school. The aim of the study was to understand students’ judgements of the technical aspects, the structure and the learning success of this approach.


After an initial two years of preclinical work, German medical students complete another four years of clinical training leading up to their final exams. During their clinical years, they attend general lectures for each subspecialty that are held for all students of one semester. This is accompanied by classical textbook reading and obligatory courses that are held in smaller groups. Courses should also give students practical experiences through direct contact with patients. Especially in smaller subspecialties time reserved for patient contact is very limited. In urology at the University of Tuebingen for example the course only takes two days. Therefore teaching methods other than lectures and small group work with hard-to-arrange direct patient care are needed to provide students with practical knowledge. In this context, web-based patient simulation via the available INMEDEA simulator was recognized by our faculty as a possible and reasonable solution.

The INMEDEA simulator is a web-based interactive e-learning management system built around a virtual hospital. The simulated hospital includes a department of urology in addition to other virtual departments, including internal medicine, gynaecology, paediatrics, general surgery and orthopaedics. The INMEDEA simulator is owned by the INMEDEA GmbH Company, which independently cooperates with several medical schools in Germany who contract for its services. The project started under the name of “Prometheus” at the University of Tuebingen and was initially supported by the German Ministry of Education and Science. After winning the Medida Prix (prize) for digital media in scientific education in 2005, a small group of enthusiasts continued their work on this project by founding the INMEDEA GmbH company.

The simulator can be accessed at after individual online password registration which makes it available all over the world at any time. Initially the internet platform was only in German language but has now been translated into English and French. New cases can be easily created and reviewed by a special online author tool.

The virtual hospital within the simulator has a fully drawn graphical illustration created by a single designer, with each department having its own virtual rooms, paralleling a real university hospital. Student-users ask patients to enter the virtual rooms. Students then take a medical history of the patient, which is done with a mouse to select sequential menus and standardized questions built into the program (Figure 1). Next, students conduct a physical examination, with findings obtained either in a written form or by multimedia presentation to illustrate the case. Students then order laboratory, radiological, endoscopic and functional tests to arrive at the correct diagnosis for the patient’s condition and then offer treatment. Again results of tests are provided to students in either written form or multimedia format.

In principal, the entire range of modern urological diagnostics can be performed. Nevertheless, the students are asked to choose the most adequate investigations in order to save time and money. After finding the correct diagnosis, students end by proposing further medical and/or surgical treatment.

Figure 1:  Screen shot of INMEDEA simulator’s medical history taking page.

During the whole case procedure students act as the treating physician and can order or perform any available diagnostic test, even repeatedly. An accompanying virtual expert is available for background information and advice. Students’ performance can be evaluated by the correctness of their diagnostic steps, their diagnosis and treatment and the time they took in finding the right diagnosis.

In comparison to other patient simulation programs, the INMEDEA simulator offers a problem solving approach that allows students to navigate freely within the system and to determine by themselves their next diagnostic steps at all times. This differentiates it from other platforms. Examples include “Casus” from Munich or “Campus” from Heidelberg, in which students are guided through each case by distinct questions and narrative information that are provided only after each previous step has been completed (Martinez-Jarreta et al., 2009; Ruderich et al., 2004). Another advantage is that the simulator is web-based and therefore can be used directly on a standard internet browser. Additionally, unlike other simulations, patients can be seen in several visits so that students have the opportunity to have follow-up with their patients. Until now, no reports describing students’ acceptance and the effectiveness of the INMEDEA simulator have been published, whereas students’ acceptance of virtual patient-based learning on other platforms have been described (Huang et al., 2007; Zary et al., 2006).


The virtual department of urology was evaluated during a regular, fourth year course of urology in the 2007 - 2008 academic year, as part of the curriculum for all students. The evaluation was of a blended e-learning approach that involved both online case simulations and small group seminars of six to eight students and an instructor. All students were asked to solve two new patient cases previously unknown to them. Students completed the cases online at home or anywhere they had access to the internet. Students were allowed to solve the cases alone or working with others.

After completing the cases as pre-class preparation, the cases were discussed and solved again together in the seminars with a medical teacher during the regular classroom portion of the course. To evaluate students’ impressions of this blended educational approach, 83 students were asked to anonymously and voluntarily fill out a standardized questionnaire. Seventy of the 83 students completed the questionnaire. Participation had no influence on students’ standing in the course or school and was anonymous.

The first virtual patient was “Mr Schmidt” who presented to the urological outpatient clinic because of elevated PSA levels (Figures 1-2). After a complete urological work-up the students were supposed to perform a prostate biopsy. The final diagnosis of this patient was a localized prostate cancer (Figure 3), which was treated by a radical prostatectomy in this case.

Figure 2:  Screen shot of INMEDEA simulator’s imaging diagnostics page.

Figure 3:  Screen shot of INMEDEA simulator’s page showing histopathological findings after prostate biopsy.

The second virtual patient was “Mr Schachtner” who presented to the urological outpatient clinic because of flank pain on his right side. The urological work-up revealed the following pathological findings: highly elevated PSA levels, a positive digital rectal examination and a hydronephrosis on the right side. After biopsy of the prostate, the diagnosis of prostate cancer could be confirmed. Further staging revealed bone and retroperitoneal metastases. After ureteral stenting to relieve the hydronephrosis, anti-hormonal cancer treatment was to be started.

After preparation of these cases at home they were summarized and discussed in small groups by one of two teachers (M. Renninger and M. Horstmann). The evaluation questionnaire comprised 18 questions or statements which addressed the INMEDEA simulator and the blended teaching approach. Students provided responses on a 5-point Likert scale with responses of either fully disagree, disagree, neither agree nor disagree, agree and strongly agree, or from very poor to very good.

The questionnaire also provided open space giving the students the possibility to make free text statements about this teaching method. For interpretation, free text statements were categorized and analyzed within three categories: 1) what students liked or judged as positive 2) what students judged as negative and/or should be improved and 3) general remarks without a judgement.

Free text statements where further subcategorized according to the themes they addressed: a) technical aspects of the program, b) structure and graphical design of the program c) subjective teaching results and d) other (miscellaneous) statements. Coding was done independently by two authors and in more than 95% of cases they were in agreement in their initial coding. When there were discrepancies in coding, the authors came to a consensus after a short discussion.


The age of the participating students ranged from 22 to 35 years. Fifty-one (73%) of students were female and 19 (27%) were male; 36 (51%) worked on the cases alone, 2 (3%) worked in a group of two students and 32 (46%) worked in groups of more than two students. Forty-seven (67%) students worked on the cases on their own computers and the remaining 23 (33%) used public computers, for example those accessible in libraries. Thirteen (19%) students spent less than 20 minutes with the computer system, 48 (69%) more than 20 minutes but less than 120 minutes and 5 (7%) more than 120 minutes. Twenty-eight (40%) students had previous experience with e-learning.


The first six statements of the questionnaire mainly addressed students’ experiences with the general aspects of the IMEDEA player (Table 1). Herein the majority of the students agreed or fully agreed with the statement that the web-based program ran without any technical problems (66%); however, 26% disagreed with this statement. Most students agreed with the statement that the time invested for learning was in an appropriate relationship to learning they obtained (57%), whereas 43 % of the students either disagreed with this statement or were neutral about it.

The multimedia approach was considered helpful for learning by 56%. More than half (54%) of the students disagreed with the statement that the program was “too complicated” but nearly half agreed with this statement or were at least undecided about it (46%). Most students judged the optical design (80%) and structure (61%) of the virtual hospital to be good or very good. Only a few students considered the design and structure to be poor or very poor (6% and 13%, respectively).

Table 1:  Grouped Likert scale responses to 18 questions about the INMEDEA simulator, the virtual department of urology and blended e-learning approach (n=70)

The next 6 statements of the questionnaire concerned particular aspects of the virtual department of urology and the blended teaching approach. In this section most students agreed or fully agreed with the statements that the cases were well-realized (77%), that they were helpful for students to better understand urological diseases (87%) and that multimedia features were useful for their illustration (64%).

Despite the generally positive evaluations of various aspects of this system, only half of the students agreed with the statements that this teaching method provided them with sufficient information (52%) and that it would increase their interest in urology (49%). Also only slightly more than half came to the conclusion that this way of teaching should be an inherent part of the urological curriculum (57%).

The final statements of the questionnaire addressed the general satisfaction of the students with this teaching approach. In this section 72% of the students stated that they had fun learning with this teaching method, whereas 28% did not have fun or were neutral. Next, 64% of the students would recommend the program to others and 72% would like to use it for other subspecialties, whereas 13% and 11% would not do so. Less than half (44%) of the students considered this program as a useful preparation for their exams and only 36% of the students saw this program as a good tool for medical exams.

In the last statement as a general evaluation 76% students judged the blended teaching approach as good or very good, 8% of the students judged it as poor or very poor, and 13% as neither good nor poor.

Free text statements

Altogether 70 free text statements were registered: 21 students (30%) made one statement, 22 (31%) made two or more and 27 (39%) provided no free text statements. Thirty-three (47%) statements were categorized as positive, 32 (46%) as negative or offering suggestions for improvement and 5 (7%) as statements without implying any judgement.

In the positive group were statements that either addressed the structure or graphical design of the program (n=9) or the subjective teaching results (n=19) which were judged as positive. Interestingly out of these 19 remarks addressing the teaching results 13 included the importance of the blended teaching approach. Typical statements were: “To discuss and evaluate the case together with other students and teachers is extremely important for the teaching success” or “To discuss the case in details with the medical teacher was very instructive” etc. Even though several students critically remarked that this program served as good preparation for real patients they clearly stated that it should not be used to reduce their already limited contact to “real teachers” or “real patients” (n=6).

Further positive statements addressed general aspects of this teaching approach. For example, one student judged it as “helpful, interesting and very impressive”, and another as a “good approach, which should be available in other subspecialties”. Still none of the positive statements noted anything about the technical aspects of the program.

In contrast, 10 of the negative statements addressed the technical aspects of the program. Most statements said that it was absolutely necessary to have a fast internet supply that allows navigating comfortably within the virtual case and that it was sometimes difficult to login to the program. The other negative statements or suggestions for improvement mainly addressed the structure and design of the program (n=20), saying for example that it was too complicated to navigate within a case (n=8) or that some tests were difficult to find (n=4). Eight further statements addressed particular mistakes that were found by students but did not include a general negative judgement. Only 2 statements were found that negatively addressed the subjective teaching results.

Five statements did not include any positive or negative judgement. They included proposals or general remarks, for example that the program should be available even after the course or that until now e-learning was relatively unknown to them.


Advances in computer technology offer new possibilities in medical teaching (Khadra & Guinea, 1996; Rogers et al., 1998) especially when it comes to clinical problem solving approaches. As presented here, one way to realize this approach are virtual patient cases (Freeman et al., 2001; Huang et al., 2007; Scalese et al., 2008). This method offers students at least virtual contact with patients when contact with actual patients otherwise might be rare.

The evaluation of our teaching approach revealed a high acceptance rate by the students. Of 70 students who took part in the survey 76% judged it as positive. This high acceptance rate was likely related to the blended teaching approach which was considered as helpful by 87% of the students and was noted by several students in their free text statements. Also, students in open-ended comments in this and in an earlier study (Seabra et al., 2004) felt that it was important that this teaching approach is not used to reduce contact with real teachers and patients but is to be used as an additional source of information.

Even though the study design does not allow us to know if students who worked with the simulator learned more than students who did not use the simulator, almost nine out of 10 students subjectively felt that this approach helped them understand urological diseases better and half stated that it provided them with sufficient information.

Still in the present study a significant number of students did not have the impression that this teaching approach provided them with sufficient information (24%) or were at least undecided about it (24%). Almost half of the students did not consider it as helpful as preparation for their exams (42%) or could imagine it as a tool for medial exams (44%). These evaluations might be due to the fact that at the Tuebingen School of Medicine medical exams test only knowledge of medical facts, which are better summarized in textbooks, and do not test practical knowledge and problem solving skills, which are more the scope of the INMEDEA simulator. Still, as problem solving and practical knowledge might become more of a focus in our education in the near future, patient simulations might also get their chance as tools for medical exams.

Aspects that were judged negatively by the students mainly addressed the technical and structural problems with the online program. Even though most students stated that the program ran without problems, some students noted technical problems through both the close-ended and open-ended statements. These problems mainly concerned internet speed and login problems which should be solvable in the near future. Others found that the program was too complicated (23%) or that it was not easy enough to navigate within the cases. Eight students found specific mistakes in the cases.

An advantage of the simulator is that content can be added, changed or deleted more easily than with printed media (Seabra et al., 2004), which means that cases can be easily amended or created anew. This option is provided by an integrated authors’ tool that allows authors to readily change content via the internet. Urological patient cases are relatively easy to create and illustrate, as the results of most diagnostic tests ordered by students can be illustrated with simple photographs and radiological images. Other advantages of the e-learning approach are that once the online cases are available they offer a standardized quality of instruction to each group of students, which can be repeated easily at any time (Zary et al., 2006). Besides its advantages, it should be noted that e-learning comes with significant costs. The hardware needed for a fast and reliable internet source is expensive and not available at all medical schools. This of course will limit the use of e-learning especially in some developing countries.

Further potential weaknesses of the study lie in the fact that it was conducted only in one individual medical school during one year; therefore findings cannot be confidently extrapolated to all other medical schools, especially because medical education differs from country to country. Also the study design does not allow us to objectively evaluate students’ learning and their retention of what they learned. These data reflect only students’ subjective impression of their learning via this teaching approach, and do not allow us to directly compare how well students learned to what they might have learned through traditional teaching methods such as textbook reading or lectures.

In conclusion, these data show that virtual patient cases can be a useful tool in undergraduate education of urology within a blended teaching approach. Patient cases emphasize more practical clinical knowledge and problem solving than classical teaching methods and offer a good way to prepare students for their contact with real patients. These data also suggest that further improvements are needed in the system we used and that e-learning with a virtual patient simulation should remain integrated within a curriculum where students remain in contact with real teachers and real patients.

Financial disclosure

This study was done independently without financial support from the INMEDEA GmbH or any other source. The authors are in no way connected to the creators, owners and managers of the INMEDEA simulator, except for Marcus Horstmann who worked as an independent case author in a paid position for the INMEDEA GmbH.


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