Conceptual
Framework
It has been suggested that, "brief, targeted [experiential learning] interventions can have major and lasting impact on student’s ability to display empathy in patient interactions” (Stepien & Baernstein, 2006, p. 529),
The medical student as patient navigator as an approach to teaching empathy.
In the study with Henry-Tillman et al. (2002) the authors describe a technique called, “The Patient Navigator Project.” In this project the lecture is replaced with a patient-centered experiential learning activity. Through the project, students, “attend a medical clinic visit from the patient’s perspective in order to share some of the experiences, feelings and concerns of patients during an anxiety-producing clinical encounter” (Henry-Tillman et al., 2002, p, 660). The objective of the project is to create student’s understanding of the emotionally charged experience as well as their frustrations. After clinic visits, students meet in small groups with faculty and program evaluators to reflect on the experience. I am familiar with similar techniques and curriculum structures due to my career in medical education at the Schulich School of Medicine & Dentistry at Western University. Schulich refers to it as “Professional Portfolio” and is designed as a mentorship program that takes place in the Pre-Clerkship Years (first two years of medical school).
The results of the project presented by Henry-Tillman et al. (2002) are mostly positive. 64% of the students indicated it was a positive experience. However, 21% expressed, “negative experiences [including] patients who were unable to communicate owing to the nature of their disease, physician misunderstandings about the nature of the project and poor examples of physician empathy.” (Henry-Tillman et al., 2002, p. 660). The most difficult aspect of the project was the logistics, as connecting the students to the patients was challenging and there was no control of the clinical visit results. For example, 30 of the students were sent to observe radiation treatments, "these experiences were interesting, but not useful in terms of meeting the students’ learning objectives” (Henry-Tillman et al., 2002, p. 660).
Unfortunately, the authors insist that didactic teaching is still the most effective method when they state that, “although patient-centered learning experiences are powerful, the lecture remains the traditional tool for teaching throughout the preclinical years of medical school owing to its high efficiency” (Henry-Tillman et al., 2002, p. 661). Furthermore, Stepien & Baernstein (2006) indicate that, “a pre- and post intervention survey showed no significant change, analysis of small group discussions following the intervention showed 70% of students felt empathy for the patient they accompanied” (p. 528). Small groups are often rated the most valuable of medical education, which is not surprising, but it is disappointing to see that there was no real significant change when students take on an observational role in a clinical environment.
Do medical students respond empathetically to a virtual patient?
There are many educational interventions for experiential learning. Deladisma et al. (2007) explore and compare students learning with virtual patients and standardized patients. In their preliminary studies, the researchers found that students are willing to participate in virtual learning in order to prepare for their interactions with standardized patients and real-life patients. “The purpose of this study was to determine whether more complex communication skills, such as nonverbal behaviours and empathy, were similar when students interacted with a virtual patient versus a standardized patient” (Deladisma et al., 2007, p. 757). In order to create a life-sized virtual patient, medical educators and computer scientists collaborated to create an interactive experience on acute abdominal pain.
Prior to the interaction with the virtual patient, students are required to create a voice profile and must learn basic instructions on how to communicate with the computer. The virtual patient for this study was programmed to answer specific questions based on the students’ responses. 84 students in their second year of medical school were randomly assigned to videotaping the interaction with either a standardized patient or virtual patient. “To prompt empathetic student responses, a challenge was built into the scenario in which the virtual patient or standardized patient stated, ‘I am scared, can you help me?’ A standardized scoring sheet was developed through a consensus of experienced clinician raters to assess nonverbal communication elements considered important in a physician/patient interaction” (Deladisma et al., 2007, p. 757). When comparing real patients to standardized patients to virtual patients Deladisma et al., argue that real patients are the more effective in training and standardized patients are expensive and time-consuming, while, “virtual characters or computer-based representations of humans, have been previously employed in several interpersonal training scenarios” (2007, p. 758). Computer simulation is also a innovative pedagogical practice that includes technology as a tool.
Overall, the researchers found that medical students perform better on their communication skills and respond more empathetically with standardized patients versus virtual patients. “Student responses to the virtual patient empathetic responses lacked emotion. This difference in empathetic responses may be due to the artificial nature of the virtual patient interaction and improvements in the virtual patient’s expressiveness (ie, voice volume, tone and facial expressions) may augment student empathetic responses” (Deladisma et al., 2007, p. 759). The researchers recommended that virtual patients may be best suited for medical students when learning the basic communication skills. The concluding thoughts also suggest that, “refinements in the virtual patient interaction could allow for its future use in the teaching and assessment of higher order communication skills” (Deladisma et al., 2007, p. 760).
Benefits of
Experiential Learning
Challenges of
Experiential Learning
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There is an extensive amount of literature on experiential learning
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May involve real, standardized or virtual patients
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Involves active participation
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Facilitators act as role-models
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Many opportunities for self-reflection
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"Simulation may be an appropriate educational methodology for developing empathy and/or empathetic behaviours in pre-service health professional students" (Bearman et al., 2015, p. 316).
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Time-consuming
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Involving real patients or people can be challenging as there may be little control of the outcomes
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Need supervision and well-trained facilitators
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Logistically difficult
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Expensive
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Dependent on the educational features of simulations
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In order for simulation or role-play to work it is recommended to have, "realistic roles, alignment of roles and tasks appropriately designed for the participants’ level of practice and structured feedback” (Bosse et al., 2011, p. 300).