‘Virtual Clinical Environment’ — adjunct to undergraduate GP teaching but no substitute for ‘hands-on’ experience

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At face value the virtual clinical environment (VCE; that is, remote video transmission from consultation room to student audiences online) offers a solution to the GP undergraduate placement crisis. Because VCE is rewarded with clinical tariff (that is, higher rate reimbursement)¹ and can be upscaled for large student numbers online, its use is likely to expand rapidly.

VCE offers new opportunities for observing consultation skills, indirectly experiencing auscultation, otoscopy and ophthalmoscopy and familiarity with normal examination findings. It overlooks, however, the ‘practice’ of medicine: repetition of skills, ‘knowing your tools’ and using them as an extension of one’s hands. Likewise, VCE lacks opportunities for key senses like touch (such as palpating the abdomen) and smell (such as alcohol on the patient’s breath).

Medical students’ first experience of general practice constitutes a ‘golden window’ for practical learning and shaping vocations. Substituting direct patient contact with VCE at that critical moment risks further undermining negative perceptions of general practice. The General Medical Council’s new Medical Licensing Assessment sets out a generic curriculum across UK medical schools that is re-focusing student learning upon clinical signs, diagnostic tests and medical/surgical interventions — all of which are frequently absent in general practice.² This tension makes it ever harder to support students in valuing the ‘special technique’ of general practice: managing clinical uncertainty through a process of careful history taking, focused examination, incremental management and safety netting.³

Introduction of VCE requires careful evaluation of student attendance, engagement and perceptions of general practice. Evaluation must consider the commercial motivations of technology companies and medical schools’ desire to attract ‘clinical tariff’. Likewise, it should examine challenges upscaling VCE beyond a small group of passionate GP teachers who — despite risks of technological problems — are comfortable being observed so closely from afar. Supervised practice in the hands-on ‘art’ of general practice remains fundamental to inspiring and preparing students for the primary care workplace. At a time when primary care is under pressure to adopt ‘medicine by numbers’ (for example, early warning systems),⁴ VCR risks turning general practice into an arms-length and vicarious learning experience for medical students.