Using a computer simulation for teaching communication skills: A blinded multisite mixed methods randomized controlled trial
Introduction
Communication is the most important component of the doctor-patient encounter [1], [2]. Evidence confirms that poor clinician communication skill is associated with lower levels of patient satisfaction, higher rates of complaints, poorer health outcomes, and an increased risk of malpractice claims [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20]. Failure of empathic communication also results in unnecessary return visits, unnecessary and unwanted somatic treatments, excessive diagnostic testing, missed diagnoses, symptom amplification, and missed opportunities for reassurance and appropriate counseling [21], [22], [23], [24], [25].
Communication between and across healthcare teams is also crucial for safe and effective patient care. Among healthcare professionals, communication failures in the hospital setting are consistently the most frequent contributors to sentinel events reported to the Joint Commission [22]. Reducing the potential for adverse patient events requires that interprofessional communication meet the same standard for empathy and respect as clinician-patient communication [23], [24], [25], [26].
Acknowledgment that good communication skills are essential for high quality, cost-effective, collegial, and safe medical practice [21], [27], [28], [29], [30] has led to widespread support for early introduction and training of communication skills in medical education [31], [32], [33], [34], [35]. However, since communication between doctor and patient is a complex phenomenon with many different factors interacting simultaneously, [1], [36] effective communication assessment and training is correspondingly complex. Communication involves both cognitive and affective domains, and is mediated through verbal and nonverbal channels [1], [37], [38]. Over the past 60 years, various coding methods have been developed to analyze the many elements of medical encounters. Although these methods can provide a detailed understanding of communication dynamics, they are resource-intensive, logistically challenging, and impractical for mainstream education [37], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51]. Current teaching methods typically include small groups of learners, with a focus on role-playing with each other or with simulated patients. However, this is also resource-intensive, and with different trainers, discrepancies between groups can appear. Choosing the most suitable trainer for communication skills is difficult, as is the selection and training of simulated patients [52]. Finally, research on clinical communication training demonstrating efficacy and sustained effects is sparse [53]; most studies do not involve a comparison or control condition, and even fewer involve a randomized controlled trial [54]. These challenges underscore the need for the creation and study of practical, innovative methods to help learners master the complexity of healthcare communication, and develop excellent communication skills that will meet current and future competency-oriented accreditation standards [55].
MPathic-VR (an acronym derived from the grant Modeling Professionalism and Teaching Humanistic Communication in Virtual Reality, NIH 5R44TR000360-04/2R44CA141987-02) is a computer-based system designed to address this need. MPathic-VR teaches healthcare learners to handle challenging conversations by enabling them to talk with virtual humans. MPathic-VR’s virtual humans are intelligent conversational agents with human appearance and the capacity to interact using a wide range of communication behaviors that one would expect in face-to-face conversation between humans [56], [57], [58], [59], [60]. As learners talk with virtual humans, they are challenged to interpret the virtual humans’ verbal and nonverbal communication, and respond with communication strategies that drive desired outcomes. MPathic-VR records and stores learners’ conversational choices and nonverbal behaviors. Analyses of these data drive assessment and feedback functions, and enable real-time variation of virtual human behavior during the simulation.
Creating an effective learning experience required taking many factors into account. These include: building the backbone of the system on specific communication skill learning objectives and techniques identified in the medical literature, creating an experiential-based learning environment sufficiently similar to the real challenges that learners face, providing appropriate feedback in a timely fashion, providing encouragement to the learner, supporting reflection and practice, and considering characteristics that facilitate transfer.
As a foundation, MPathic-VR was designed to provide learners with a toolkit of useful skills [61]. Each conversational exchange between the learners and virtual humans is based on learning objectives directed at specific communication skills including: reflective listening, empathy enhancers, avoiding empathy blockers, appropriate use of facial expression (i.e., brow raises, smiles) or body language (i.e., nodding, body lean), which support the development of rapport [62]. Learning objectives were also drawn from established communication protocols, such as SPIKES [63], CRASH [64], and TeamSTEPPS [65], [66]. SPIKES (Set-up, Perception, Invitation, Knowledge, Emotion, Summary) emphasizes principles for breaking bad news, CRASH (Culture, Respect, Assess and Sensitivity and Self-awareness, Humility) emphasizes principles of cultural competence, and TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) emphasizes principles for effective interprofessional communication. These skills align with many of those detailed in the Calgary-Cambridge guide [67], [68], but the MPathic-VR virtual human simulation is not solely skills-based. It also allows for creativity, because learners can view themselves in conversation with virtual humans and repeat interactions, during which they are free to experiment with different dialogue, expressions, and body language [69]. The system also encourages reflection during (reflection-in-action) and after (reflection-on-action) their interaction with virtual humans, guided by theories first introduced by Dewey [70] and advanced by Argyris and Shön [71], [72], [73], [74], [75], [76], [77], as a means to promote the development of adaptive expertise [78], [79], [80]. This acknowledges calls for integrating reflection into communication training [61].
These elements are incorporated within a simulation-based medical education (SBME) framework for effective learning, elements of which include context authenticity, consistent and precise measurement that informs individualized learner feedback, appropriate simulation fidelity, sequence of instruction, and opportunity for deliberate practice [81], [82], [83], [84]. The system is grounded in the theory of multimedia learning [85], which holds that people learn better through words and pictures than through either alone. Last, it is further guided by an interactive instructional approach [86], [87] that stresses a dynamic relationship between the learner and the learning system, and integrates system-based elements that have the potential to engage the behavioral, cognitive, and emotional activities of the learner. This contrasts to other multimedia learning activities that might be termed interactive, but do not consider the integration of these components.
For the Print Version of this Article: To demonstrate MPathic-VR in use, a video component is available. The link to the demonstration video is incorporated into the caption of the image visible below.
For the Electronic Version of this article: To demonstrate MPathic-VR in use, a video component is available and accompanies the electronic version of this manuscript. To access this video component, simply click on the image visible below.
To examine whether MPathic-VR is useful for teaching advanced communication skills, the investigators developed and tested the following hypotheses: 1) students randomized to learn with MPathic-VR would improve their communication performance after engaging in a communication scenario, receiving feedback on their performance, and then applying the feedback in a second run-through of the scenario; and 2) knowledge acquired through MPathic-VR would be resilient (i.e., students would incorporate learned materials into their manner of communication), and that the performance of MPathic-VR-trained students assessed in a subsequent advanced communication objective structured clinical exam (OSCE) would be scored higher than students trained with a conventional, widely-used multimedia method, computer-based learning (CBL). The investigators also asked the mixed methods research question, how do qualitative findings from students’ reflective comments and responses to an attitudinal survey compare for the MPathic-VR and the CBL experiences?
Section snippets
Design
Investigators conducted a single-blinded, mixed methods, randomized controlled trial at three medical schools. Framed by an ethnographic approach, investigators researched students’ experiences when taking the modules. The Institutional Review Boards of all participating medical schools approved this research.
Setting
The studies were conducted at three US medical schools: Eastern Virginia Medical School (EVMS); the University of Michigan Medical School (UM); and the University of Virginia School of
Demographic characteristics
The MPathic-VR group (N = 210) had a mean age of 25.4 years (SD = 2.6) with 104 (49.5%) females, and race distribution of 117 (55.7%) Caucasian-American, 45 (21.4%) Asian-American, 14 (6.7%) African-American, 2 (1%) Native-American/indigenous people, and 32 (15.2%) other/no response. The CBL control (N = 211) had a mean age of 25.5 years (SD = 2.9), with 94 (44.5%) females, and race distribution of 112 (53.1%) Caucasian-American, 40 (19.0%) Asian-American, 25 (11.8%) African-American, (1) 0.5%
Discussion
This study assessed the usefulness of a virtual human simulation, as embodied in MPathic-VR, for teaching advanced communication skills to second-year medical students. The investigators’ first hypothesis was that students who interacted with MPathic-VR, received feedback, and immediately applied that knowledge in a second run-through would show an improvement in scores. The results confirm this hypothesis. Students’ scores were nearly halved (i.e., they chose more appropriate statements) and
Funding/support
This research was conducted as part of an SBIR I grant, “Modeling Professional Attitudes and Teaching Humanistic Communication in VR” National Cancer Institute, (NCI) Project ID 1R43CA141987-01 (Co-PIs Frederick Kron and Michael Fetters), and an SBIR II grant, “Modeling Professional Attitudes and Teaching Humanistic Communication in Virtual Reality” sponsored by the National Center for Advancing Translational Sciences (NCATS), Project ID 2 R44 CA141987-02A1, (Co-PIs Frederick Kron and Michael
Other disclosures
Frederick Kron serves as president and Michael Fetters has stock options in Medical Cyberworlds, Inc., the entity receiving SBIR II grant funds for this project—the University of Michigan Conflict of Interest Office considered potential for conflict of interest, and concluded that no formal management plan was required.
Ethical approval
This research was deemed exempt by the Institutional Review Boards of all three participating medical schools.
Disclaimer
None
Previous presentations
- 1.
The 13th International Conference on Communication in Healthcare, Poster Presentation October 2015.
- 2.
The 43rd North American Primary Care Research Group (NAPCRG) Annual Meeting, Oral Presentation, October 2015.
Acknowledgements
This research could not have been possible without the support of many individuals across multiple institutions: Consultants – Paul Ekman, Erika Rosenberg, Michael Chmilar; Eastern Virginia Medical School – C. Donald Combs, Mekbib Gemeda, Thomas Hubbard; University of Michigan – Stacie Buckler, Michael Lukela, Kelly Poszywak, Joel Purkiss, Sally Santen, Jamie Schingeck; University of Virginia – Leslie Blackhall, Randy Canterbury, Anne Chapin, Francis Nelson, Norman Oliver; National Cancer
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