Can Computers Teach Empathy? A Randomized Controlled Study Using Virtual Patients to Enhance Medical Students’ Empathic Communication Adriana Foster, MD 1, Neelam Chaudhary 1, James Murphy, MD 1, Thomas Kim, MD 1, Benjamin Lok, PhD 2, and Peter Buckley, MD 1 1 Psychiatry and Health Behavior, Georgia Regents University (GRU), Augusta, GA 2 Computer and Information Science and Engineering, University of Florida (UF), Gainesville, FL 2 Background: Physician empathy improves clinical outcomes, but only few tools are available for deliberate practice of empathic communication. Empathy is the result of complex interaction between the patient and caregiver. In this study, we examined the verbal manifestation of empathy. Purpose: A virtual patient (VP) was utilized to teach empathy. We evaluated whether medical students, who had received immediate feedback about their empathy after interviewing a VP, showed greater empathy towards standardized patients (SPs) compared to students who hadn’t received such feedback. In a GRU and UF IRB-approved study, 70 first-year medical students were randomly assigned to the intervention group (VP with empathy feedback) vs. control group (without empathy feedback) (Fig. 2.) Study Procedures:  Teaching Tool: Cynthia Young 1 VP (Fig. 1) is a 21 year old college student, who had lost her cousin in car accident 8 months ago and subsequently becomes isolated and fails two courses (Fig. 1). After the VP interaction, students received feedbacks on the following:  1) Ability to elicit symptoms of depression and convey empathy (Intervention Group) or  2) Ability to elicit depression symptoms only (Control Group). The controls were further divided into subgroups without a video (- Video) or with a video (+Video) of the patient in her home environment; the latter group aimed to simulate patient shadowing.  The consent form mentioned empathy as focus of the study and made students aware that, if assigned to the intervention group, they would receive empathy feedback after the VP interaction. Assessment Methods:  VP Student Satisfaction Survey after the VP interaction.  SP Communication Checklist after the SP interaction: 1) Empathy responses; 2) Symptoms; 3) Communication Items; 4) Rapport Items.  Reliable Raters (Inter-rater reliability=0.81) coded students’ empathic responses on a 0-6 scale (from denial-0 to sharing personal experience-6 ), using the Empathic Communication Coding System 2. Data Analysis: We utilized Chi-square, t-tests, or one-way ANOVA to examine differences in variables between groups. Complete data are available from 64 students (Fig. 2). At baseline, prior to empathy feedback, in the VP interactions, there was a significant difference in the mean empathy scores between the intervention group (2.2) vs. control group (1.9) (P=0.029) (Fig. 3). Post-Empathy Feedback, the intervention group elicited a mean of empathic opportunities per SP interaction, compared to 8.58 in the control group (P= ). The Intervention Group had a significantly higher mean empathy scores for the SP interaction, compared to control group (P=0.02) (Fig. 3). Background: Physician empathy improves clinical outcomes, but only few tools are available for deliberate practice of empathic communication. Empathy is the result of complex interaction between the patient and caregiver. In this study, we examined the verbal manifestation of empathy. Purpose: A virtual patient (VP) was utilized to teach empathy. We evaluated whether medical students, who had received immediate feedback about their empathy after interviewing a VP, showed greater empathy towards standardized patients (SPs) compared to students who hadn’t received such feedback. In a GRU and UF IRB-approved study, 70 first-year medical students were randomly assigned to the intervention group (VP with empathy feedback) vs. control group (without empathy feedback) (Fig. 2.) Study Procedures:  Teaching Tool: Cynthia Young 1 VP (Fig. 1) is a 21 year old college student, who had lost her cousin in car accident 8 months ago and subsequently becomes isolated and fails two courses (Fig. 1). After the VP interaction, students received feedbacks on the following:  1) Ability to elicit symptoms of depression and convey empathy (Intervention Group) or  2) Ability to elicit depression symptoms only (Control Group). The controls were further divided into subgroups without a video (- Video) or with a video (+Video) of the patient in her home environment; the latter group aimed to simulate patient shadowing.  The consent form mentioned empathy as focus of the study and made students aware that, if assigned to the intervention group, they would receive empathy feedback after the VP interaction. Assessment Methods:  VP Student Satisfaction Survey after the VP interaction.  SP Communication Checklist after the SP interaction: 1) Empathy responses; 2) Symptoms; 3) Communication Items; 4) Rapport Items.  Reliable Raters (Inter-rater reliability=0.81) coded students’ empathic responses on a 0-6 scale (from denial-0 to sharing personal experience-6 ), using the Empathic Communication Coding System 2. Data Analysis: We utilized Chi-square, t-tests, or one-way ANOVA to examine differences in variables between groups. Complete data are available from 64 students (Fig. 2). At baseline, prior to empathy feedback, in the VP interactions, there was a significant difference in the mean empathy scores between the intervention group (2.2) vs. control group (1.9) (P=0.029) (Fig. 3). Post-Empathy Feedback, the intervention group elicited a mean of empathic opportunities per SP interaction, compared to 8.58 in the control group (P= ). The Intervention Group had a significantly higher mean empathy scores for the SP interaction, compared to control group (P=0.02) (Fig. 3). METHODS INTRODUCTION RESULTS  After the Depression Symptom-Related Opportunities were eliminated (Fig. 3):  5.96 opportunities/SP vs. 4.33/SP interaction remained in the intervention vs. control group (P=0.0289) AND  The mean empathy increased and remained significantly higher for the intervention group vs. control group (P=0.0095) for the remaining empathic opportunities (Emotion and Challenge Type) There were no significant differences between the groups in the frequency with which medical students elicited symptoms of major depressive episode, medical, family, substance and alcohol use history in the SP interviews. The students in the intervention group and control sub-group with video exposure were perceived by SPs to be significantly more empathic in the following areas: Offering encouraging, supportive, and empathetic statements (p < ) Appearing warm and caring (p = ) Establishing good rapport (p = ) VP tools provide immediate feedback on empathic communication and can improve students’ verbal empathy in SP Interactions. This is consistent with literature showing that live-feedback on communication skills enhances the quality of patient-physician encounters 3. Limitations:1) We assessed only verbal empathy in the Student-SP interaction; 2) It is unknown whether verbal interaction with an SP predicts clinical behavior; 3) Students’ empathy was not rated prior to describing the study procedures; 4) Our study has no longitudinal follow-up. Student’s awareness of being assigned to the intervention group increased their empathy in VP interactions. Deliberate practice with a VP further increased students’ empathy in SP interactions, as illustrated by expert coding of empathy and SP perceptions. VPs could become valuable tools for teaching and reinforcing empathic communication skills. This study was sponsored by a research grant from the Arnold P. Gold Foundation. 1.Shah H, et al Interactive Virtual Patient Scenarios: An Evolving Tool in Psychiatric Education, Acad Psych 2012, 36(2), Bylund C, Makoul G, Empathic communication and gender in the physician-patient encounter, Patient Educ Couns 2002, 48: Moulton CA, et al, Teaching communication skills using the integrated procedural performance instrument (IPPI): A randomized controlled trial, The American Journal Of Surgery, 2009, 197, ADMSEP 2014;  After the Depression Symptom-Related Opportunities were eliminated (Fig. 3):  5.96 opportunities/SP vs. 4.33/SP interaction remained in the intervention vs. control group (P=0.0289) AND  The mean empathy increased and remained significantly higher for the intervention group vs. control group (P=0.0095) for the remaining empathic opportunities (Emotion and Challenge Type) There were no significant differences between the groups in the frequency with which medical students elicited symptoms of major depressive episode, medical, family, substance and alcohol use history in the SP interviews. The students in the intervention group and control sub-group with video exposure were perceived by SPs to be significantly more empathic in the following areas: Offering encouraging, supportive, and empathetic statements (p < ) Appearing warm and caring (p = ) Establishing good rapport (p = ) VP tools provide immediate feedback on empathic communication and can improve students’ verbal empathy in SP Interactions. This is consistent with literature showing that live-feedback on communication skills enhances the quality of patient-physician encounters 3. Limitations:1) We assessed only verbal empathy in the Student-SP interaction; 2) It is unknown whether verbal interaction with an SP predicts clinical behavior; 3) Students’ empathy was not rated prior to describing the study procedures; 4) Our study has no longitudinal follow-up. Student’s awareness of being assigned to the intervention group increased their empathy in VP interactions. Deliberate practice with a VP further increased students’ empathy in SP interactions, as illustrated by expert coding of empathy and SP perceptions. VPs could become valuable tools for teaching and reinforcing empathic communication skills. This study was sponsored by a research grant from the Arnold P. Gold Foundation. 1.Shah H, et al Interactive Virtual Patient Scenarios: An Evolving Tool in Psychiatric Education, Acad Psych 2012, 36(2), Bylund C, Makoul G, Empathic communication and gender in the physician-patient encounter, Patient Educ Couns 2002, 48: Moulton CA, et al, Teaching communication skills using the integrated procedural performance instrument (IPPI): A randomized controlled trial, The American Journal Of Surgery, 2009, 197, ADMSEP 2014; Figure 1. Image of Web-based Interaction with Depression VP (Cynthia Young) Figure 2. Project Flow for N=70 Medical Students N=35 Intervention Group Depression VP with Empathy Feedback N=35 Control Group Depression VP without Empathy Feedback (N=17 +Video, N=18 –Video) 35 VP Transcripts 35 VP Student Surveys 32 SP Transcripts 32 SP Checklists 35 VP Transcripts 35 VP Student Surveys 32 SP Transcripts 32 SP Checklists Figure 3. Mean Empathy Response Scores in Medical Students’ VP and SP Interactions DISCUSSION CONCLUSIONS ACKNOWLEDEGEMENTS REFERENCES