Do medical students respond empathetically to a virtual patient?

doi:10.1016/j.amjsurg.2007.01.021

The American Journal of Surgery

Volume 193, Issue 6, June 2007, Pages 756-760

Presented at the Association for Surgical Education meeting in Tucson, AZ, March 25, 2006

https://doi.org/10.1016/j.amjsurg.2007.01.021 Get rights and content

Abstract

Background

Significant information exchange occurs between a doctor and patient through nonverbal communication such as gestures, body position, and eye gaze. In addition, empathy is an important trust-building element in a physician: patient relationship. Previous work validates the use of virtual patients (VP) to teach and assess content items related to history-taking and basic communication skills. The purpose of this study was to determine whether more complex communication skills, such as nonverbal behaviors and empathy, were similar when students interacted with a VP or standardized patient (SP).

Methods

Medical students (n = 84) at the University of Florida (UF) and the Medical College of Georgia (MCG) underwent a videotaped interview with either a SP or a highly interactive VP with abdominal pain. In the scenario, a life-sized VP was projected on the wall of an exam room in SP teaching and testing centers at both institutions. VP and SP scripted responses to student questions were identical. To prompt an empathetic response (ie, acknowledging the patients’ feelings), during the interview the VP or SP stated “I am scared; can you help me?” Clinicians (n = 4) rated student videotapes with respect to nonverbal communication skills and empathetic behaviors using a Likert-type scale with anchored descriptors.

Results

Clinicians rated students interacting with SPs higher with respect to the nonverbal communication skills such as head nod (2.78 ± .79 vs 1.94 ± .44, P < .05), and body lean (2.97 ± .94 vs 1.93 ± .58, P < .05), level of immersion in the scenario (3.31 ± .49 vs 2.26 ± .52, P < .05), anxiety (1.16 ± .31 vs 1.45 ± .33, P < .05), attitude toward the patient (3.24 ± .43 vs 2.89 ± .36, P < .05), and asking clearer questions (3.06 ± .32 vs 2.51 ± .32, P < .05) compared to the VP group. The students in the SP group also had a higher empathy rating (2.75 ± .86 vs 2.16 ± .83, P < .05) and better overall rating (4.29 ± 1.32 vs 3.24 ± 1.06, P < .05) than the VP group. Empathy was positively correlated with the observed nonverbal communication behaviors. Eye contact was the most strongly correlated with empathy (r = .57, P < .001), followed by head nod (r = .55, P < .001) and body lean (r = .49, P < .001).

Conclusions

Medical students demonstrate nonverbal communication behaviors and respond empathetically to a VP, although the quantity and quality of these behaviors were less than those exhibited in a similar SP scenario. Student empathy in response to the VP was less genuine and not as sincere as compared to the SP scenario. While we will never duplicate a real physician/patient interaction, virtual clinical scenarios could augment existing SP programs by providing a controllable, secure, and safe learning environment with the opportunity for repetitive practice.

Section snippets

Methods

Through an interdisciplinary collaboration involving medical educators and computer scientists, we created an interactive, life-sized VP with acute abdominal pain (Fig. 1). In the virtual scenario, the VP (DIgital ANimated Avator, DIANA) is projected on the wall of a standard examination room in SP teaching and testing centers at the Medical College of Georgia (MCG) and the University of Florida (UF). Prior to beginning the VP interaction, the student spends 10 minutes creating a voice profile

Results

Table 2 shows a comparison of student behaviors when interacting with a VP versus an SP. Students interacting with SPs were more likely to demonstrate greater head nod and body lean compared to the VP group, while there was no difference in eye contact observed between the 2 groups. Clinicians rated students interacting with SPs higher with respect to level of immersion in the scenario, anxiety, attitude toward the patient, and asking clearer questions compared to the VP group. The students in

Comments

Effective communication skills are essential for good medical practice. Interpersonal communication is the primary method by which a physician and patient exchange information. While verbal communication skills are important, significant information exchange occurs between a doctor and patient through nonverbal communication such as gestures, body position, and eye gaze. The appropriate use of nonverbal communication skills is positively correlated with patient satisfaction [7]. In addition,

References (11)

L.M.L. Ong et al.
Doctor–patient communication: a review of the literature
Soc Sci Med
(1995)
K. Johnsen et al.
Evolving an immersive medical communication skills trainer
J Presence Teleoperators Virtual Environ
(2006)
R. Dickerson et al.
Virtual patients: assessment of synthesized versus recorded speech
Stud Health Technol Inform
(2006)
A. Stevens et al.
The use of virtual patients to teach medical students communication skills
Am J Surg
(2006)
A. Raij et al.
Interpersonal scenarios: virtual ≈ real?

There are more references available in the full text version of this article.

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Association for Surgical EducationDo medical students respond empathetically to a virtual patient?

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Comments

Soc Sci Med

Evolving an immersive medical communication skills trainer

J Presence Teleoperators Virtual Environ

Virtual patients: assessment of synthesized versus recorded speech

Stud Health Technol Inform

The use of virtual patients to teach medical students communication skills

Am J Surg

Interpersonal scenarios: virtual ≈ real?

Association for Surgical Education
Do medical students respond empathetically to a virtual patient?