•Case-based versus traditional didactic pedagogies yielded higher virtual patient evaluated clinical reasoning scores but lower clinical management scores.•Previous experiences through reading or seeing a similar case significantly affects a student’s perception of their clinical reasoning and management confidence.•Experiential learning through computerized virtual patient simulations demonstrated an effective pedagogy for teaching competent clinical decision-making.•Well-structured pedagogies using virtual patient simulations can provide the educational scaffolding of “knowing” and “knowing how” for demonstrating “doing” within live precepted patient encounters increasing clinical competence and confidence. This improvement project explored using virtual patient simulations to increase an AGANCP students’ confidence applying clinical decision-making skills. A statistical analysis compared students clinical reasoning, clinical. management, and confidence scores between clinical courses with differing pedagogies focused on case-based learning versus traditional didactics. Students showed higher clinical reasoning scores with a virtual-patient case-base pedagogy, and higher clinical management scores using traditional didactics. Higher clinical confidence scores were more frequent within the case-based approach than the traditional pedagogy. A well-structured educational strategy using virtual-patient cases showed effectiveness in gaining competence and confidence learning clinical decision-making.