1. The forms of learning – learning by doing

Kong Qiu (alias Confucius) said ca. 500 BC that „I hear and I forget, I see and I remember. I do and I understand.” He already understood and iterated that the most effective way of learning is “learning by doing”. As demonstrated in the previous paper (1): present medical education is still largely textbook / lecture based, even in the clinical fields. However, learning occurs when improvement in an activity results from understanding gained from prior experience (2). The steps of “learning by doing” include 1. DO, 2. FEEDBACK, 3. CONCLUDE, 4. DECIDE. From these steps, feedback is the most important element to accelerate the learning curve. Without feedback the learning cycle is interrupted.

The forms of learning can be categorized according to their efficiency. 1. PASSIVE learning is acquiring information without physical activity (ie, listening to a lecture or watching films). This is the least active form with minimal measurable brain activity. 2. ACTIVE learning is more effective, when the learning process is accompanied by physical activity (eg,: taking notes during the lecture). 3. The next level is CONSTRUCTIVE learning: individually producing information beyond that is provided (eg.: connect concepts to prior knowledge). 4. Finally, the most effective way of learning is INTERACTIVE learning either with fellow students or with an instructor. This is the most effective due to feedback.

2. Feedback

Mark Twain, was credited as saying, “College is a place where a professor’s lecture notes go straight to the students’ lecture notes, without passing through the brains of either.” While Twain’s statement was made in the late 19th century, MIT research found very similar results in 2010 while investigating student brain activity. Brain activity measured during lectures (class) was similar to that observed when watching TV, and lower than during periods of sleep (3). This study alone is evidence enough that now is the time to transform the lecture space. The key to transforming the lecture space is to get students engaged and thinking critically. 

Figure 1. Brain activity measured during different activities including lectures (source: 4)

Thus, there is a current paradigm shift about feedback: from information giving to students (in the form of comments) to feedback that is a key feature of learning – to help learners to improve their quality of work. Most papers on feedback start with: “we know, that high quality feedback has the strongest influence on student’s achievements. Learners do not always learn much from purely being told (even when they are told repeatedly and in the kindest possible way). The old (and still often prioritized) feedback is information given to the student by the teacher (summative assessment), where key messages often remain hidden. Effective feedback is not something teachers do, but a process where students are involved in seeking, processing and using feedback information to develop. Thus, the new concept is that feedback is a process with student involvement (formative assessment). Effective feedback is a sequence, where the student needs opportunities to apply the feedback to future tasks. This new concept is also called feedback literacy – that is the ability to apply and utilize effective feedback, which enable student uptake of the feedback (5,6).

3. The difference between formative and summative assessment

FORMATIVE assessment refers to tools that identify misconceptions, struggles, and learning gaps along the way and assess how to close those gaps. It is a process intended to help learning, and can even bolster students’ abilities to take ownership of their learning when they understand that the goal is to improve learning, not apply final marks (7). Thus, formative assessment yields information for both students and teachers to shape instruction to meet students’ needs and that students can use to better understand and advance their learning. The purpose is to promote leaning (7). Providing feedback is one of the greatest advantages of formative assessment (8).

In contrast, SUMMATIVE assessments evaluate student learning, knowledge, proficiency, or success at the conclusion of an instructional period (9). Thus, summative assessment used by teachers to form final judgments about what students have learned by the end of a course (7).

Main characteristics of formative and summative assessment are summarized in figure 2.

Figure 2. Main characteristics of formative and summative assessment (source: 8).

4. Virtual patients in medical education

Virtual patients (VPs) are increasingly used in medical education. They have the advantage of the lack of the bedside setting. VPs are especially suitable to improve students reasoning, history taking and diagnostic skills. However, documenting and assessing skills acquired through a VP is a challenge. One main issue is the lack of outcome measures to monitor the impact of VPs on student learning (10,11) in most VP providing programs. However, InSimu has layed a strong emphasis on the assessment of student learning built into the platform. The application itself gives a detailed overview for the student after diagnosing a patient including information on the correct diagnosis, time spent, costs of tests used and comparison with the optimal pathway according to current guidelines. Furthermore, in the InSimu group performance analysis report the health profession educator leading the course can get an analytic summary about students’ individual and course-overall performance within the course including data on the number of patients solved and time spent by students, gained experience, diagnostic accuracy and correctly and incorrectly used tests.

5. Formative assessment with virtual patients

Formative assessments are used specifically in identifying the strengths and weaknesses of students, addressing the areas of need for each student, helping teachers identify gaps in learning and working to close those gaps. VPs – especially an infinite number of cases are a valuable tool to establish a fine-tuning of a course where students need can be identified and the course can be shaped individually by assigning repetitive cases to students tailored to their specific strengths and gaps. Furthermore, the infinite number of cases enables a more precise evaluation of the strengths and weaknesses of students’ diagnostic skills.

Figure 3. Formative and summative assessment with virtual patients

6. Summative assessment with virtual patients

Summative assessment at the end of the course also provides valuable feedback to both students about their gained knowledge and health profession educators about the strengths and weaknesses of the course, which help to shape the next course better and tailor it to students needs more effectively. The learning process of the teacher is just as important as the learning of the students. However, this factor remains often unrecognized by educators especially if they tend to deliver the same course year-by-year without improving it. The assessment analytics provided by the InSimu platform are especially aimed to highlight the strengths and weaknesses of the course.

About the Author

Peter Hamar, MD, PhD, is full professor at Semmelweis University. His scientific interests in understanding novel mechanisms induced by modulated electro hyperthermia in triple-negative breast cancer. Furthermore, initiating from a strong background in renal transplantation currently, we try to identify key mechanisms of post-ischemic renal fibrosis. Besides being a PI at Semmelweis, P. Hamar intensely collaborates with several research groups including the Immune Disease Institute at Harvard Medical School, Boston, USA. They were the first to harness RNA interference for the kidney (PNAS). Furthermore, they demonstrated endosomal escape of siRNA from lipid nanoparticles with high-resolution microscopy (Nat Genet). P. Hamar has co-authored 89 original papers (google scholar). Teaching activity: teaching pathophysiology, ECG, hematology, laboratory medicine and translational medicine for graduate students at Semmelweis and Pécs Medical Universities since 1994 regularly in Hungarian, English and German languages. Specialization: Clinical Laboratory Diagnostics (2001).


(1) previous blog paper

(2)  Waldman, J. Deane, Yourstone, Steven A., Smith, Howard L.: Learning Curves in Health Care. Health Care Management Review 2003: 28/1, 41 – 54.

(3) https://commons.wikimedia.org/w/index.php?curid=11351079

(4) Eric Mazur’s data of student brain activity.

(5) David Carless (2020): Double duty, shared responsibilities and feedback literacy, NCBI, Perspect Med Educ. 2020 Aug; 9(4): 199–200.Published online 2020 Aug 21. doi: 10.1007/s40037-020-00599-9

(6) Naomi Winstone, David Carless ( 2020): Designing Effective Feedback Processes in Higher Education – A Learning-Focused Approach, Routledge

(7) Trumbull, E., & Lash, A. (2013). Understanding Formative Assessment: Insights from Learning Theory and Measurement Theory

(8) Kurt, S. “Formative and Summative Assessment,” in Educational Technology, November 11, 2020. Retrieved from Educationaltechonolgy.net

 (9) Yale Poorvu Center for Teaching and Learning: Strategic resources and digital publications, Feedback on Student Learning, Formative and Summative Assessments.

(10) Jean SetrakianGeneviève GauthierLinda BergeronMartine Chamberland, and Christina St-Onge : Comparison of Assessment by a Virtual Patient and by Clinician-Educators of Medical Students’ History-Taking Skills: Exploratory Descriptive Study. JMIR Med Educ. 2020 Jan-Jun; 6(1): e14428. doi: 10.2196/14428.

(11) Parsons TD, Kenny P, Rizzo AA. Virtual Human Patients for Training of Clinical Interview and Communication Skills. Proceedings of the 7th Virtual Reality and Associated Technology Conference with ArtAbilitation; ICDVRAT’08; September 8-11, 2008; Maia, Portugal. UK: The University of