Virtual Standardized Patients Versus Traditional Academic Training for Improving Clinical Competence Among Traditional Chinese Medicine Students: Prospective Randomized Controlled Trial

Background The practical training course of internal medicine of traditional Chinese medicine (PTC-IMTCM) is primarily based on traditional case teaching, which can be stressful for teachers. The use of virtual standardized patient (VSP) applications could be an alternative; however, there is limited evidence regarding their feasibility and effectiveness. Objective This study aimed to build a VSP-TCM application according to the characteristics of PTC-IMTCM and the needs of students and to compare its efficacy with that of traditional teaching in improving TCM clinical competence among students. Methods A prequestionnaire investigation was conducted before the course, and a VSP-TCM system was developed based on the results of the questionnaire. A randomized controlled trial was then conducted between February 26, 2020, and August 20, 2021. A total of 84 medical students were included and were divided into 2 groups: an observation group, trained with VSP-TCM (n=42, 50%), and a control group, trained with traditional academic training (n=42, 50%). Formative and summative assessments were conducted to evaluate teaching effectiveness. After completing the course, the students were administered a questionnaire to self-assess their satisfaction with the course. A questionnaire was also administered to 15 teachers to uncover their perspectives on VSP-TCM. Results All participants completed the study. In the formative assessment, the VSP-TCM group performed better in medical interviewing ability (mean 7.19, SD 0.63, vs mean 6.83, SD 0.81; P=.04), clinical judgment (mean 6.48, SD 0.98, vs mean 5.86, SD 1.04; P=.006), and comprehensive ability (mean 6.71, SD 0.59, vs mean 6.40, SD 0.58; P=.02) than the control group. Similarly, in the summative evaluation, the VSP-TCM group performed better in the online systematic knowledge test (OSKT; mean 86.62, SD 2.71, vs mean 85.38, SD 2.62; P=.046), application of TCM technology (mean 87.86, SD 3.04, vs mean 86.19, SD 3.08; P=.02), TCM syndrome differentiation and therapeutic regimen (mean 90.93, SD 2.42, vs mean 89.60, SD 2.86; P=.03), and communication skills (mean 90.67, SD 4.52, vs mean 88.24, SD 4.56; P=.02) than the control group. There was no significant difference in medical writing between both groups (mean 75.07, SD 3.61, vs mean 75.71, SD 2.86; P=.37). The postcourse feedback questionnaire indicated that VSP-TCM can better enhance students’ TCM thinking ability (n=39, 93%, vs n=37, 88%; P=.002), medical history collection (n=38, 90%, vs n=30, 72; P=.001), syndrome differentiation and treatment and critical thinking (n=38, 90%, vs n=37, 88%; P=.046), comprehensive clinical application ability (n=40, 95%, vs n=36, 86%; P=.009), interpersonal communication skills (n=36, 86%, vs n=28, 67%; P=.01), and autonomous learning ability (n=37, 88%, vs n=28, 67%; P=.01) than traditional academic training. Similarly, the teachers held a positive perspective on VSP-TCM. Conclusions VSP-TCM enhances students’ TCM clinical competence and dialectical thinking and improves their ability to work autonomously. Moreover, the VSP-TCM system is feasible, practical, and cost-effective and thus merits further promotion in TCM education.

Recommended "Dose" * What do the instructions for users say on how often the app should be used?
Approx. Percentage of Users (starters) still using the app as recommended after 3 months * yes: all primary outcomes were signi cantly better in intervention group vs control partly: SOME primary outcomes were signi cantly better in intervention group vs control no statistically signi cant difference between control and intervention potentially harmful: control was signi cantly better than intervention in one or more outcomes inconclusive: more research is needed 其 他 : not submitted yet -in early draft status not submitted yet -in late draft status, just before submission submitted to a journal but not reviewed yet submitted to a journal and after receiving initial reviewer comments submitted to a journal and accepted, but not published yet

1a-i) Identify the mode of delivery in the title
Identify the mode of delivery. Preferably use "web-based" and/or "mobile" and/or "electronic game" in the title. Avoid ambiguous terms like "online", "virtual", "interactive". Use "Internet-based" only if Intervention includes non-web-based Internet components (e.g. email), use "computer-based" or "electronic" only if o ine products are used. Use "virtual" only in the context of "virtual reality" (3-D worlds). Use "online" only in the context of "online support groups". Complement or substitute product names with broader terms for the class of products (such as "mobile" or "smart phone" instead of "iphone"), especially if the application runs on different platforms.
subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 1a-i? * Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "A Prospective Randomized Trial."

1a-ii) Non-web-based components or important co-interventions in title
Mention non-web-based components or important co-interventions in title, if any (e.g., "with telephone support").
Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study 1a-iii) Primary condition or target group in the title Mention primary condition or target group in the title, if any (e.g., "for children with Type I Diabetes") Example: A Web-based and Mobile Intervention with Telephone Support for Children with Type I Diabetes: Randomized Controlled Trial 清 除 所 选 内 容 Does your paper address subitem 1a-iii? * Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "Clinical Competence among Traditional Chinese Medicine Students." subitem not at all important 1 2 3 4 5 essential 1b-i) Key features/functionalities/components of the intervention and comparator in the METHODS section of the ABSTRACT Mention key features/functionalities/components of the intervention and comparator in the abstract. If possible, also mention theories and principles used for designing the site. Keep in mind the needs of systematic reviewers and indexers by including important synonyms. (Note: Only report in the abstract what the main paper is reporting. If this information is missing from the main body of text, consider adding it) 清 除 所 选 内 容 Does your paper address subitem 1b-i? * Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "To build a VSP-TCM application according to the characteristics of PTC-IMTCM and the needs of students and to compare its efficacy with traditional teaching in improving TCM clinical competence among students." subitem not at all important 1 2 3 4 5 essential 1b-ii) Level of human involvement in the METHODS section of the ABSTRACT Clarify the level of human involvement in the abstract, e.g., use phrases like "fully automated" vs. "therapist/nurse/care provider/physician-assisted" (mention number and expertise of providers involved, if any). (Note: Only report in the abstract what the main paper is reporting. If this information is missing from the main body of text, consider adding it) 清 除 所 选 内 容 Does your paper address subitem 1b-ii?
Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study 您 的 回 答 subitem not at all important 1 2 3 4 5 essential 1b-iii) Open vs. closed, web-based (self-assessment) vs. face-to-face assessments in the METHODS section of the ABSTRACT Mention how participants were recruited (online vs. o ine), e.g., from an open access website or from a clinic or a closed online user group (closed usergroup trial), and clarify if this was a purely web-based trial, or there were face-to-face components (as part of the intervention or for assessment). Clearly say if outcomes were self-assessed through questionnaires (as common in web-based trials Does your paper address subitem 2a-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "Therefore, trained actors are incorporated as standardized patients (SPs) to not only train students for medical education but to also help reduce their anxiety, recreate the medical environment, and improve teaching efficiency by providing real-time feedback on students' diagnoses and therapeutic activities"; "An alternative training approach could be the use of virtual standardized patient (VSP) programs, which employ computerized characters for SP encounters." subitem not at all important 1 2 3 4 5 essential 2a-ii) Scientific background, rationale: What is known about the (type of) system Does your paper address CONSORT subitem 2b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "In this study, we compared the effect of VSP-TCM and traditional academic training on students' clinical competence. We hypothesized that medical students who received VSP-TCM training would perform better than those who received traditional academic training in the following areas: 1) medical history collection; 2) medical writing; 3) syndrome differentiation and treatment; and 4) self-study ability. Finally, we hypothesized that students who received VSP-TCM training would be more satisfied than those who received traditional academic training." Does your paper address CONSORT subitem 3a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "First, we conducted a questionnaire investigation to gain the perspectives of TCM students who have taken the PTC-IMTCM course. The final version of the VSP-TCM system was designed and developed based on the characteristics of TCM and the results of the questionnaire investigation. Subsequently, we conducted a single-blind, two-group, paralleltraining randomized trial to compare the effectiveness of VSP-TCM and academic training for improving clinical competence among TCM medical students. Figure 1 shows the flow of this study." 3b) Important changes to methods after trial commencement (such as eligibility criteria), with reasons subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 3b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study No. The study was conducted in strict accordance with the study protocol. There was no change.

3b-i) Bug fixes, Downtimes, Content Changes
Bug xes, Downtimes, Content Changes: ehealth systems are often dynamic systems. A description of changes to methods therefore also includes important changes made on the intervention or comparator during the trial (e.g., major bug xes or changes in the functionality or content) (5-iii) and other "unexpected events" that may have in uenced study design such as staff changes, system failures/downtimes, etc.
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study 您 的 回 答 Does your paper address CONSORT subitem 4a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "TCM (5+3 integration) students in their second year at CDUTCM were included. The exclusion criteria were as follows: 1) participants who have received VSP or SP training; 2) have taken courses related to IMTCM, such as PTC-IMTCM and reception and clinical thinking skills; and 3) failed to adhere to the study schedule or withdrew from the study." subitem not at all important 1 2 3 4 5 essential 4a-i) Computer / Internet literacy Computer / Internet literacy is often an implicit "de facto" eligibility criterion -this should be explicitly clari ed.
Does your paper address subitem 4a-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study 您 的 回 答 subitem not at all important 1 2 3 4 5 essential 4a-ii) Open vs. closed, web-based vs. face-to-face assessments: Open vs. closed, web-based vs. face-to-face assessments: Mention how participants were recruited (online vs. o ine), e.g., from an open access website or from a clinic, and clarify if this was a purely web-based trial, or there were face-to-face components (as part of the intervention or for assessment), i.e., to what degree got the study team to know the participant. In online-only trials, clarify if participants were quasi-anonymous and whether having multiple identities was possible or whether technical or logistical measures (e.g., cookies, email con rmation, phone calls) were used to detect/prevent these.
Does your paper address subitem 4a-ii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "The participants were recruited offline from 112 TCM (5+3 integration) sophomores enrolled in CDUTCM in 2019. All participants have provided written informed consent before participating in the study. Based on previous studies, a minimum sample size of 78 is required." subitem not at all important 1 2 3 4 5 essential 4b) Settings and locations where the data were collected 4a-iii) Information giving during recruitment Information given during recruitment. Specify how participants were briefed for recruitment and in the informed consent procedures (e.g., publish the informed consent documentation as appendix, see also item X26), as this information may have an effect on user self-selection, user expectation and may also bias results.
Does your paper address subitem 4a-iii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 4b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "This study was initiated on February 26, 2020, and concluded on August 20, 2021. From the start of the study to March 2021, staff not involved in the study conducted a prequestionnaire investigation and gathered data on the participants' performance in basic TCM and WM courses. Then, the 13-week PTC-IMTCM course was conducted from April 1, 2021, to July 10, 2021 (first 12 weeks, training; 13th week, evaluation). Finally, investigators who did not take part in the study collected and analyzed the data by August 20, 2021."

4b-i) Report if outcomes were (self-)assessed through online questionnaires
Clearly report if outcomes were (self-)assessed through online questionnaires (as common in web-based trials) or otherwise.
subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 4b-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "A previous study's questionnaire was modified for a new audience [8]. After the course, a survey was administered to both groups to assess the students' attitudes toward the course, command of knowledge, and proficiency in clinical skills to help us optimize the course. In addition, we conducted a questionnaire investigation among 15 teachers responsible for PTC-IMTCM to assess the potential impact of VSP-TCM on their work."

4b-ii) Report how institutional affiliations are displayed
Report how institutional a liations are displayed to potential participants [on ehealth media], as a liations with prestigious hospitals or universities may affect volunteer rates, use, and reactions with regards to an intervention.(Not a required item -describe only if this may bias results) Does your paper address subitem 4b-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study The interventions for each group with sufficient details to allow replication, including how and when they were actually administered subitem not at all important 1 2 3 4 5 essential

5-i) Mention names, credential, affiliations of the developers, sponsors, and owners
Mention names, credential, a liations of the developers, sponsors, and owners [6] (if authors/evaluators are owners or developer of the software, this needs to be declared in a "Con ict of interest" section or mentioned elsewhere in the manuscript).
Does your paper address subitem 5-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study subitem not at all important 1 2 3 4 5 essential 5-ii) Describe the history/development process Describe the history/development process of the application and previous formative evaluations (e.g., focus groups, usability testing), as these will have an impact on adoption/use rates and help with interpreting results.
Does your paper address subitem 5-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study subitem not at all important 1 2 3 4 5 essential

5-iii) Revisions and updating
Revisions and updating. Clearly mention the date and/or version number of the application/intervention (and comparator, if applicable) evaluated, or describe whether the intervention underwent major changes during the evaluation process, or whether the development and/or content was "frozen" during the trial. Describe dynamic components such as news feeds or changing content which may have an impact on the replicability of the intervention (for unexpected events see item 3b).
Does your paper address subitem 5-iii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study subitem not at all important 1 2 3 4 5 essential

5-iv) Quality assurance methods
Provide information on quality assurance methods to ensure accuracy and quality of information provided [1], if applicable.
Does your paper address subitem 5-iv?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study subitem not at all important 1 2 3 4 5 essential 5-v) Ensure replicability by publishing the source code, and/or providing screenshots/screen-capture video, and/or providing flowcharts of the algorithms used Ensure replicability by publishing the source code, and/or providing screenshots/screencapture video, and/or providing owcharts of the algorithms used. Replicability (i.e., other researchers should in principle be able to replicate the study) is a hallmark of scienti c reporting.
Does your paper address subitem 5-v?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study subitem not at all important 1 2 3 4 5 essential

5-vi) Digital preservation
Digital preservation: Provide the URL of the application, but as the intervention is likely to change or disappear over the course of the years; also make sure the intervention is archived (Internet Archive, webcitation.org, and/or publishing the source code or screenshots/videos alongside the article). As pages behind login screens cannot be archived, consider creating demo pages which are accessible without login.
Does your paper address subitem 5-vi?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study subitem not at all important 1 2 3 4 5 essential

5-vii) Access
Access: Describe how participants accessed the application, in what setting/context, if they had to pay (or were paid) or not, whether they had to be a member of speci c group. If known, describe how participants obtained "access to the platform and Internet" [1]. To ensure access for editors/reviewers/readers, consider to provide a "backdoor" login account or demo mode for reviewers/readers to explore the application (also important for archiving purposes, see vi).
Does your paper address subitem 5-vii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Does your paper address subitem 5-viii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "The operation procedures of VSP-TCM ( Figure 2) were as follows: 1) after loging in, select a disease to practice; 2) send commands via voice or text to obtain medical history, including chief complaints, current medical history, past medical history, personal history, and family history; 3) perform targeted physical examinations according to collected medical history, including vital signs, various systems, and TCM tongue and pulse; 4) conduct appropriate auxiliary examinations, including laboratory and imaging examinations; 5) perform diagnosis according to the above information, including diagnosis and antidiastole of TCM and Western medicine (WM) and TCM syndrome differentiation; 6) create treatment plans based on specific diagnoses, including TCM and WM treatment; 7) inform precautions to the patient; and 8) end the medical visit. The system then summarizes the users' knowledge of the disease and evaluates their performance in real-time."

5-ix) Describe use parameters
Describe use parameters (e.g., intended "doses" and optimal timing for use). Clarify what instructions or recommendations were given to the user, e.g., regarding timing, frequency, heaviness of use, if any, or was the intervention used ad libitum.
subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 5-ix?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study 您 的 回 答

5-x) Clarify the level of human involvement
Clarify the level of human involvement (care providers or health professionals, also technical assistance) in the e-intervention or as co-intervention (detail number and expertise of professionals involved, if any, as well as "type of assistance offered, the timing and frequency of the support, how it is initiated, and the medium by which the assistance is delivered". It may be necessary to distinguish between the level of human involvement required for the trial, and the level of human involvement required for a routine application outside of a RCT setting (discuss under item 21 -generalizability).
Does your paper address subitem 5-x?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study subitem not at all important 1 2 3 4 5 essential 5-xi) Report any prompts/reminders used Report any prompts/reminders used: Clarify if there were prompts (letters, emails, phone calls, SMS) to use the application, what triggered them, frequency etc. It may be necessary to distinguish between the level of prompts/reminders required for the trial, and the level of prompts/reminders for a routine application outside of a RCT setting (discuss under item 21 -generalizability).
Does your paper address subitem 5-xi? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study No. At present, VSP-TCM is mainly carried out in the classroom. After class, students can volunteer for training. The system does not prompt information.
subitem not at all important 1 2 3 4 5 essential 5-xii) Describe any co-interventions (incl. training/support) Describe any co-interventions (incl. training/support): Clearly state any interventions that are provided in addition to the targeted eHealth intervention, as ehealth intervention may not be designed as stand-alone intervention. This includes training sessions and support [1]. It may be necessary to distinguish between the level of training required for the trial, and the level of training for a routine application outside of a RCT setting (discuss under item 21 -generalizability. Completely defined pre-specified primary and secondary outcome measures, including how and when they were assessed Does your paper address subitem 5-xii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "PTC-IMTCM was conducted in the second semester of sophomore year (36 class hours, 3 class hours/week, a total of 12 weeks). Both groups had the same teaching materials, such as PowerPoint presentations and textbooks. The VSP-TCM group received 36 class hours of VSP-TCM training. The teaching methods were as follows: 1) teacher discussed the fundamentals of the disease, including etiology, pathogenesis, diagnosis, antidiastole, syndrome differentiation and treatment, and key points of history collection; 2) students logged into the VSP-TCM system, selected a disease to practice, and entered the simulated medical scene; 3) students completed the diagnosis and treatment with VSP following the process shown in Figure 2 within the specified time frame; 4) students repeated the exercise according to feedback from the VSP-TCM system; and 5) students voluntarily completed after-school exercises and recorded their learning time. The control group received 36 class hours of academic training, which included teacher teaching and group discussion. Concretely, the teaching methods were as follows: 1) teacher discussed the fundamentals of the disease and syndrome, similar to the VSP-TCM group; 2) students were randomly assigned to several study groups; 3) students discussed the case provided by the teacher and made a diagnosis and suggested treatments for the disease within the specified time frame; 4) the teacher evaluated the answers and provided feedback to the students; and 5) students voluntarily completed after-school exercises and recorded their learning time." Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "Evaluation of Training Effectiveness Formative Evaluation Mini Clinical Evaluation Exercise (Mini-CEX), a tool developed by the American College of Internal Medicine in 1995 based on the traditional clinical evaluation exercise, has teaching functions and was used to assess the residents' clinical ability. Mini-CEX has several advantages, including direct observation, simple form, a key evaluation, and real-time feedback. According to a 9-point evaluation system, the scale comprehensively evaluates the clinical competence of residents from four aspects: history collection ability, physical examination ability, clinical judgment ability, and overall ability. To better evaluate the students' clinical ability, we slightly modified the Mini-CEX according to Chen's research. The modified Mini-CEX could evaluate clinical competence through five aspects: medical interview ability, physical examination ability, clinical judgment ability, disease treatment ability, and comprehensive ability. Multimedia Appendix 1 demonstrates the modified Mini-CEX and its usage for formative evaluation. Summative Assessment After the course, the students were given 1 week to review for the assessment, and the summative assessment was conducted on a day in week 13. The summative assessments were divided into online and offline assessments. The participants completed the systematic knowledge test of PTC-IMTCM online before entering the clinical skills center of CDUTCM for offline assessment. The offline assessment included the following steps: 1) collecting medical history from OSP; 2) medical writing; and 3) syndrome differentiation and treatment.
Online Systematic Knowledge Test After the course, the participants completed an objective and standardized online casebased examination. The students had 90 minutes to complete six cases. For the first five cases, there were five multiple-choice questions in each case, and students were required to select the right diagnosis, syndrome, treatment principle, treatment method, and prescription. Each multiple-choice question was worth 2 points. The sixth case was a case analysis question. Students were required to provide TCM diagnosis (5 points), syndrome differentiation (5 points), syndrome differentiation basis (15 points), treatment (5 points), prescription (5 points), and prescription analysis (15 points) of the patient in the case. The examination had a total score of 100.
Offline Clinical Skill Test Following the online examination, the students proceeded to the clinical skills center of CDUTCM for a 45-minute offline clinical skills test. For this test, we used previously developed offline clinical skills assessment methods [8]. Students encountered OSP that we had previously trained during testing at the site. Students had 15 minutes to complete the medical history collection process, including a medical interview and physical examination. They were then given 30 minutes to complete medical records and treatment based on syndrome differentiation. Scores for the application of TCM technology In the assessment process, a TCM professional who was not part of the research team and did not participate in activities such as teaching and proposition scored the students' clinical skills using a pre-established checklist. The checklist included the following items: introduction (4 points), chief complaint (8 points), current medical history (30 points), past medical history (12 points), personal medical history (12 points), family medical history (8 points), physical examination and four TCM examinations (16 points), and summary (10 points). Scores of written medical records The medical writing checklist included the following items: general information (3 points) and chief complaint (5 points), current medical history (30 points), past medical history (10 points), personal medical history (10 points), family medical history (6 points), physical subitem not at all important 1 2 3 4 5 essential points), personal medical history (10 points), family medical history (6 points), physical examination (20 points), and four TCM examinations (16 points). Individual item scores were calculated and processed. Scores of TCM syndrome differentiation and therapeutic regimen The following were the content and scores of TCM treatment based on syndrome differentiation: TCM diagnosis (6 points); basis of TCM diagnosis (6 points); WM diagnosis (6 points); basis of WM diagnosis (14 points); TCM syndrome type (10 points); analysis of TCM syndrome differentiation (24 points); TCM treatment method (8 points); formula (8 points); medication, administration method, and corresponding dosage (14 points); and medical advice (4 points). The examination was scored using predetermined standards. OSP real-time assessment scores Following each interaction, OSP used the Arizona Clinical Interviewing Rating (ACIR) to assess students' interpersonal communication and interview skills. The ACIR was a 20-item scale, with points ranging from 1-5 points, with 5 being the highest. Post-course Feedback Questionnaire A previous study's questionnaire was modified for a new audience. After the course, a survey was administered to both groups to assess the students' attitudes toward the course, command of knowledge, and proficiency in clinical skills to help us optimize the course. In addition, we conducted a questionnaire investigation among 15 teachers responsible for PTC-IMTCM to assess the potential impact of VSP-TCM on their work." 6a-i) Online questionnaires: describe if they were validated for online use and apply CHERRIES items to describe how the questionnaires were designed/deployed . After the course, a survey was administered to both groups to assess the students' attitudes toward the course, command of knowledge, and proficiency in clinical skills to help us optimize the course. In addition, we conducted a questionnaire investigation among 15 teachers responsible for PTC-IMTCM to assess the potential impact of VSP-TCM on their work." 7a) How sample size was determined NPT: When applicable, details of whether and how the clustering by care provides or centers was addressed subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 6b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study No. The study was conducted in strict accordance with the study protocol. There was no change to trial outcomes.

7a-i) Describe whether and how expected attrition was taken into account when calculating the sample size
Describe whether and how expected attrition was taken into account when calculating the sample size.
When applicable, explanation of any interim analyses and stopping guidelines 8a) Method used to generate the random allocation sequence NPT: When applicable, how care providers were allocated to each trial group Does your paper address subitem 7a-i?
Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study 您 的 回 答 Does your paper address CONSORT subitem 7b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "The exclusion criteria were as follows: 1) participants who have received VSP or SP training; 2) have taken courses related to IMTCM, such as PTC-IMTCM and reception and clinical thinking skills; and 3) failed to adhere to the study schedule or withdrew from the study." Does your paper address CONSORT subitem 8a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "Using computer-generated randomization, the participants were randomly assigned to either the VSP-TCM group or the control group in a 1:1 ratio. The randomization was performed by individuals who were not in contact with the participants. The participants, staff, and investigators were blinded to the training assignments. Data analysis was deferred until all data were collected by investigators who were blinded to the outcomes." 8b) Type of randomisation; details of any restriction (such as blocking and block size) 9) Mechanism used to implement the random allocation sequence (such as sequentially numbered containers), describing any steps taken to conceal the sequence until interventions were assigned 10) Who generated the random allocation sequence, who enrolled participants, and who assigned participants to interventions Does your paper address CONSORT subitem 8b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "Using computer-generated randomization, the participants were randomly assigned to either the VSP-TCM group or the control group in a 1:1 ratio. The randomization was performed by individuals who were not in contact with the participants. The participants, staff, and investigators were blinded to the training assignments. Data analysis was deferred until all data were collected by investigators who were blinded to the outcomes." Does your paper address CONSORT subitem 9? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "Using computer-generated randomization, the participants were randomly assigned to either the VSP-TCM group or the control group in a 1:1 ratio. The randomization was performed by individuals who were not in contact with the participants. The participants, staff, and investigators were blinded to the training assignments. Data analysis was deferred until all data were collected by investigators who were blinded to the outcomes." 11a) If done, who was blinded after assignment to interventions (for example, participants, care providers, those assessing outcomes) and how NPT: Whether or not administering co-interventions were blinded to group assignment subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 10? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "Using computer-generated randomization, the participants were randomly assigned to either the VSP-TCM group or the control group in a 1:1 ratio. The randomization was performed by individuals who were not in contact with the participants. The participants, staff, and investigators were blinded to the training assignments. Data analysis was deferred until all data were collected by investigators who were blinded to the outcomes." 11a-i) Specify who was blinded, and who wasn't Specify who was blinded, and who wasn't. Usually, in web-based trials it is not possible to blind the participants [1, 3] (this should be clearly acknowledged), but it may be possible to blind outcome assessors, those doing data analysis or those administering cointerventions (if any).
subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 11a-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "Using computer-generated randomization, the participants were randomly assigned to either the VSP-TCM group or the control group in a 1:1 ratio. The randomization was performed by individuals who were not in contact with the participants. The participants, staff, and investigators were blinded to the training assignments. Data analysis was deferred until all data were collected by investigators who were blinded to the outcomes." 11a-ii) Discuss e.g., whether participants knew which intervention was the "intervention of interest" and which one was the "comparator" Informed consent procedures (4a-ii) can create biases and certain expectations -discuss e.g., whether participants knew which intervention was the "intervention of interest" and which one was the "comparator".
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study 您 的 回 答 11b) If relevant, description of the similarity of interventions (this item is usually not relevant for ehealth trials as it refers to similarity of a placebo or sham intervention to a active medication/intervention) 12a) Statistical methods used to compare groups for primary and secondary outcomes NPT: When applicable, details of whether and how the clustering by care providers or centers was addressed Does your paper address CONSORT subitem 11b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "Teachers in the course group underwent standardized training 1 month before the course started. The standardized training planning was set based on the "Eight-Year Undergraduate Talent Training Guide of Traditional Chinese Medicine" issued by CDUTCM. Subsequently, experienced clinical experts were invited to assess the teachers' qualifications. Finally, we selected two teachers who were closely matched in terms of age, sex, teaching experience, and teaching style. Using a random coin toss, they were then assigned to either the VSP-TCM group or the control group." Does your paper address CONSORT subitem 12a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "A blinded research analyst conducted the test. The intraclass correlation coefficient (ICC) was calculated to determine the consistency of the Mini-CEX scores. The statistical analysis was conducted using SPSS 25.0 (IBM, Armonk, NY). Continuous variables were expressed as mean ± standard deviation (SD) and categorical variables as frequency or percentage. The Kolmogorov-Smirnov test was used to determine the normality of all the data. When the data has a normal distribution, the independent-samples t-test was used, otherwise, the Mann-Whitney test was employed. The Chi-squared (χ2) test was used to compare proportions. P-values ≤0.05 indicated significant differences." subitem not at all important 1 2 3 4 5 essential 12b) Methods for additional analyses, such as subgroup analyses and adjusted analyses 12a-i) Imputation techniques to deal with attrition / missing values Imputation techniques to deal with attrition / missing values: Not all participants will use the intervention/comparator as intended and attrition is typically high in ehealth trials. Specify how participants who did not use the application or dropped out from the trial were treated in the statistical analysis (a complete case analysis is strongly discouraged, and simple imputation techniques such as LOCF may also be problematic [4]).

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Does your paper address subitem 12a-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "TCM (5+3 integration) students in their second year at CDUTCM were included. The exclusion criteria were as follows: 1) participants who have received VSP or SP training; 2) have taken courses related to IMTCM, such as PTC-IMTCM and reception and clinical thinking skills; and 3) failed to adhere to the study schedule or withdrew from the study." Does your paper address CONSORT subitem 12b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study No. There were no subgroup or adjust analysis in this study.

X26-i) Comment on ethics committee approval
subitem not at all important 1 2 3 4 5 essential Does your paper address subitem X26-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "The study was approved by the Ethics Committee of CDUTCM (approval no. 25382) and adhered to the principles of the Declaration of Helsinki. The curriculum planning adhered to the guidelines set by the "Undergraduate Medical Education Standards -Traditional Chinese Medicine" issued by the National Advisory Committee on Higher Traditional Chinese Medicine Education of the Ministry of Education and the "Eight-Year Undergraduate Talent Training Guide of Traditional Chinese Medicine" issued by CDUTCM. The current study followed the CONSORT-EHEALTH (Consolidated Standards of Reporting Trials of Electronic and Mobile HEalth Applications and onLine TeleHealth) checklist to report its findings [23]. "

x26-ii) Outline informed consent procedures
Outline informed consent procedures e.g., if consent was obtained o ine or online (how? Checkbox, etc.?), and what information was provided (see 4a-ii). See [6] for some items to be included in informed consent documents.

RESULTS
Does your paper address subitem X26-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study 您 的 回 答

X26-iii) Safety and security procedures
Safety and security procedures, incl. privacy considerations, and any steps taken to reduce the likelihood or detection of harm (e.g., education and training, availability of a hotline) Does your paper address subitem X26-iii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study 您 的 回 答 13a) For each group, the numbers of participants who were randomly assigned, received intended treatment, and were analysed for the primary outcome NPT: The number of care providers or centers performing the intervention in each group and the number of patients treated by each care provider in each center 13b) For each group, losses and exclusions after randomisation, together with reasons Does your paper address CONSORT subitem 13a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "A total of 84 students participated in this study and were randomly assigned to the VSP-TCM group (n=42) and the control group (n=42). There was no significant difference in age (P=.11) and sex (P=.64) between the two groups. At baseline, there was no significant difference between both groups in TCM basic courses (P=.74), WM basic courses (P=.31), or the grade point average (P=.33)"; "Summative Assessment Online systematic knowledge test After 12 weeks of the course, participants in the VSP-TCM group mastered the systematic knowledge of the course better than those in the control group ( Figure 4A). In the online systematic knowledge test, participants in the VSP-TCM group scored higher than those in the control group (86.62±2.71vs. 85.38±2.62, U=660.5, P=.046).
Offline clinical skills test Scores for the application of TCM technology Participants in the VSP-TCM group outperformed those in the control group in receiving VSP-TCM. Participants in the VSP-TCM group performed better in the application of TCM skills (87.86±3.04 vs. 86.19±3.08, t=2.464, P=.02, d=82) ( Figure 4B). Scores of written medical records VSP-TCM did not provide the expected benefits in improving the participants' ability to write medical records. Participants in the VSP-TCM group scored lower than those in the control group (75.07±3.61 vs. 75.71±2.86, t=0.8945, P=.37, d=82) ( Figure 4C). Scores of TCM syndrome differentiation and therapeutic regimen VSP-TCM effectively improved the core TCM skills, including syndrome differentiation and treatment. The VSP-TCM group had higher scores for TCM syndrome differentiation and treatment than the control group (90.93±2.42 vs. 89.60±2.86, U=636, P=.03) ( Figure 4D). Real-time assessment scores from OSP VSP-TCM had a satisfactory effect on improving participants' interpersonal communication and interview skills. The real-time evaluation score from OSP in the VSP-TCM group was significantly higher than the control group (90.67±4.52 vs. 88.24±4.56, U=618.5, P=.02) ( Figure 4E)." subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 13b? (NOTE: Preferably, this is shown in a CONSORT flow diagram) * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study No. We excluded 28 students from 112 students based on inclusion and exclusion criteria.A total of 84 students were randomized and all completed the study.

13b-i) Attrition diagram
Strongly recommended: An attrition diagram (e.g., proportion of participants still logging in or using the intervention/comparator in each group plotted over time, similar to a survival curve) or other gures or tables demonstrating usage/dose/engagement.
Does your paper address subitem 13b-i?
Copy and paste relevant sections from the manuscript or cite the gure number if applicable (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Does your paper address CONSORT subitem 14a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "This study was initiated on February 26, 2020, and concluded on August 20, 2021. From the start of the study to March 2021, staff not involved in the study conducted a prequestionnaire investigation and gathered data on the participants' performance in basic TCM and WM courses. Then, the 13-week PTC-IMTCM course was conducted from April 1, 2021, to July 10, 2021 (first 12 weeks, training; 13th week, evaluation). Finally, investigators who did not take part in the study collected and analyzed the data by August 20, 2021."

14a-i) Indicate if critical "secular events" fell into the study period
Indicate if critical "secular events" fell into the study period, e.g., signi cant changes in Internet resources available or "changes in computer hardware or Internet delivery resources" 14b) Why the trial ended or was stopped (early) 15) A

15-i) Report demographics associated with digital divide issues
In ehealth trials it is particularly important to report demographics associated with digital divide issues, such as age, education, gender, social-economic status, computer/Internet/ehealth literacy of the participants, if known.

16-i) Report multiple "denominators" and provide definitions
Report multiple "denominators" and provide de nitions: Report N's (and effect sizes) "across a range of study participation [and use] thresholds" [1], e.g., N exposed, N consented, N used more than x times, N used more than y weeks, N participants "used" the intervention/comparator at speci c pre-de ned time points of interest (in absolute and relative numbers per group). Always clearly de ne "use" of the intervention. Does your paper address subitem 16-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. A total of 84 students participated in this study and were randomly assigned to the VSP-TCM group (n=42) and the control group (n=42). There was no significant difference in age (P=.11) and sex (P=.64) between the two groups. At baseline, there was no significant difference between both groups in TCM basic courses (P=.74), WM basic courses (P=.31), or the grade point average (P=.33) ( Table 2).

16-ii) Primary analysis should be intent-to-treat
Primary analysis should be intent-to-treat, secondary analyses could include comparing only "users", with the appropriate caveats that this is no longer a randomized sample (see 18-i).
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study 您 的 回 答 17a) For each primary and secondary outcome, results for each group, and the estimated effect size and its precision (such as 95% confidence interval) Does your paper address CONSORT subitem 17a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "Evaluation of Training Effectiveness Formative Evaluation Figure 3 shows the Mini-CEX results for both groups. The consistency among physicians responsible for evaluating the participants' performance was high (ICC=0.82). After 6 weeks of training, participants assigned to the VSP-TCM group gained higher scores in medical interview (7.19±0.63 vs. 6.83±0.81, U=656.5, P=.04), clinical judgment (6.48±0.98 vs. 5.86±1.04, U=590, P=.006), and comprehensive ability (6.71±0.59 vs. 6.40±0.58, U=634.5, P=.02) than those assigned to the control group. However, participants in the VSP-TCM group did not show the expected advantages in physical examination (6.14±1.19 vs. 6.29±1.20, U=830, P=.64) and disease treatment (6.88±0.98 vs. 6.74±1.16, U=827, P=.62), and the score was slightly lower than the control group. Summative Assessment Online systematic knowledge test After 12 weeks of the course, participants in the VSP-TCM group mastered the systematic knowledge of the course better than those in the control group ( Figure 4A). In the online systematic knowledge test, participants in the VSP-TCM group scored higher than those in the control group ( Figure 4D). Real-time assessment scores from OSP VSP-TCM had a satisfactory effect on improving participants' interpersonal communication and interview skills. The real-time evaluation score from OSP in the VSP-TCM group was significantly higher than the control group (90.67±4.52 vs. 88.24±4.56, U=618.5, P=.02) ( Figure 4E)." subitem not at all important 1 2 3 4 5 essential 17b) For binary outcomes, presentation of both absolute and relative effect sizes is recommended 17a-i) Presentation of process outcomes such as metrics of use and intensity of use In addition to primary/secondary (clinical) outcomes, the presentation of process outcomes such as metrics of use and intensity of use (dose, exposure) and their operational de nitions is critical. This does not only refer to metrics of attrition (13-b) (often a binary variable), but also to more continuous exposure metrics such as "average session length". These must be accompanied by a technical description how a metric like a "session" is de ned (e.g., timeout after idle time) [1] (report under item 6a).
Does your paper address subitem 17a-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study 您 的 回 答 18) Results of any other analyses performed, including subgroup analyses and adjusted analyses, distinguishing pre-specified from exploratory Does your paper address CONSORT subitem 17b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. " Table 3 displays the results of the post-course feedback questionnaire administered to the students. Six of the 11 items in the questionnaire showed significant differences between both groups. Of 42 participants in the VSP-TCM group, 39 (93%) believed that the course improved their TCM thinking ability as opposed to 37 participants (88%) in the control group (P=.002). Regarding medical history collection, 38 participants (90%) in the VSP-TCM group found the course beneficial as opposed to 30 participants (72%) in the control group (P=.001). In terms of syndrome differentiation and treatment and critical thinking ability, 38 participants (90%) found VSP-TCM helpful, and 37 participants (88%) found traditional academic training helpful (P=.046). In addition, 40 participants (95%) in the VSP-TCM group gained better clinical comprehensive application ability as opposed to 36 participants (86%) in the control group (P=.009). Furthermore, 36 participants (86%) trained with VSP-TCM grasped better interpersonal communication skills, whereas only 28 students (67%) grasped the same skills in the control group (P=.01). Interestingly, 37 (88%) participants who received VSP-TCM teaching significantly improved their autonomous learning ability; however, only 28 students (67%) endorsed this viewpoint in the control group (P=.01). Overall, participants in both groups were satisfied with the course (P=.23); however, VSP-TCM did not improve their medical writing ability than academic training (P=.13)"; " Table 4 shows the results of the feedback questionnaire administered to teachers. Overall, we found that teachers held a positive perspective toward VSP-TCM. No less than 12 teachers (80%) expressed their belief that VSP-TCM has the potential to become a prominent trend in TCM education and expressed their willingness to integrate it into their teaching practices. Simultaneously, they recognized the benefits of utilizing VSP-TCM to enhance students' motivation for learning (12/15, 80%), regarding it as a valuable adjunct to bedside instruction (15/15, 100%). Furthermore, it is worth mentioning that teachers preferred to develop VSP based on syndromes (14/15, 93%) rather than diseases (11/15, 73%), which highlighted the characteristics of "treatment based on syndrome differentiation." Finally, all teachers unanimously agreed that VSP-TCM has the potential to enhance teaching efficiency while effectively minimizing teaching expenses, thus establishing it as a cost-effective instructional resource." subitem not at all important 1 2 3 4 5 essential

19) All important harms or unintended effects in each group
(for speci c guidance see CONSORT for harms) Does your paper address CONSORT subitem 18? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study No. There were no subgroup or adjusted analyses in this study.

18-i) Subgroup analysis of comparing only users
A subgroup analysis of comparing only users is not uncommon in ehealth trials, but if done, it must be stressed that this is a self-selected sample and no longer an unbiased sample from a randomized trial (see 16-iii).
Does your paper address subitem 18-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study 您 的 回 答 subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 19? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study No. The VSP-TCM was a virtual clinical and did not cause any harm to the participants.

19-i) Include privacy breaches, technical problems
Include privacy breaches, technical problems. This does not only include physical "harm" to participants, but also incidents such as perceived or real privacy breaches [1], technical problems, and other unexpected/unintended incidents. "Unintended effects" also includes unintended positive effects [2]. 清 除 所 选 内 容 Does your paper address subitem 19-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study 您 的 回 答  Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study 您 的 回 答 subitem not at all important 1 2 3 4 5 essential 22-i) Restate study questions and summarize the answers suggested by the data, starting with primary outcomes and process outcomes (use) Restate study questions and summarize the answers suggested by the data, starting with primary outcomes and process outcomes (use).

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Does your paper address subitem 22-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "This study demonstrated that, compared with academic training, VSP-TCM significantly improved abilities in medical interview, clinical judgment, TCM technology application, and systematic knowledge among TCM students. The VSP-TCM system enabled TCM education to be more efficient and less stressful for teachers. It was also helpful for reforming the course and achieving the goal of training applied talents."

20-i) Typical limitations in ehealth trials
Typical limitations in ehealth trials: Participants in ehealth trials are rarely blinded. Ehealth trials often look at a multiplicity of outcomes, increasing risk for a Type I error. Discuss biases due to non-use of the intervention/usability issues, biases through informed consent procedures, unexpected events.

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Does your paper address subitem 20-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Yes. "Although the findings of this study are positive, it has some limitations that should be acknowledged. First, in this prospective study, we only evaluated the clinical skills of students during and after the course, with no long-term follow-up. We were unaware of how VSP-TCM maintained the trainees' competence. Secondly, VSP-TCM could not convey some physical signs of real patients. For example, TCM-specific pulse conditions can only be displayed through images, preventing trainees from gaining real clinical experience in pulse diagnosis [8]. In addition, it was a single-center study, which affected the universality of the findings. All the participants were from CDUTCM. It was challenging to represent all TCM students. Therefore, future large-scale, multicenter studies are warranted." subitem not at all important 1 2 3 4 5 essential

21-i) Generalizability to other populations
Generalizability to other populations: In particular, discuss generalizability to a general Internet population, outside of a RCT setting, and general patient population, including applicability of the study results for other organizations 清 除 所 选 内 容 Does your paper address subitem 21-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study Discuss if there were elements in the RCT that would be different in a routine application setting (e.g., prompts/reminders, more human involvement, training sessions or other cointerventions) and what impact the omission of these elements could have on use, adoption, or outcomes if the intervention is applied outside of a RCT setting.
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or brie y explain why the item is not applicable/relevant for your study 您 的 回 答