Empathic Communication in Medical Students' Interactions with Mental Health Virtual Patient Scenarios: A Descriptive Study Using the Empathic Communication Coding System

Research Article

Austin J Psychiatry Behav Sci. 2014;1(3): 1014.

Empathic Communication in Medical Students’ Interactions with Mental Health Virtual Patient Scenarios: A Descriptive Study Using the Empathic Communication Coding System

Adriana Foster1,2*, Jason Harms1, Brittany Ange2, Brent Rossen3, Benjamin Lok 3, Scott Lind D4, Christie Palladino2

1Department of Psychiatry and Health Behavior, Georgia Regents University, USA

2Education Innovation Institute Georgia Regents University, USA

3Department of Computer and Information Science and Engineering, University of Florida, USA

4Department of Surgery, Drexel University College of Medicine, USA

*Corresponding author: Adriana Foster, Department of Psychiatry and Health Behavior, Medical College of Georgia, Georgia Regents University, 997 St. Sebastian Way, Augusta, GA, 30912, USA

Received: March 31, 2014; Accepted: April 01, 2014; Published: April 03, 2014


Empathy is the ability to identify another person’s feelings and to view the world from their perspective. Self-assessed empathy declines throughout medical school and residency training. Technology plays an increasing role in today’s medical education system, which requires delivery of curriculum and assessment of knowledge and skills in standardized manner at geographically distant campuses. Our project assessed whether students communicate empathy in interactions with technology-based teaching tools. We explored student interactions with virtual–patient scenarios and asked the following questions: 1) Do medical students respond empathically to virtual–patients portraying mental healthscenarios?2) If present, does empathy vary with students’ level of training? We analyzed empathy in 155 medical student interactions with depression and bipolar virtual–patients, using the Empathic Communication Coding System. The mean empathic intensity of responses was 1.5 (0–7 scale) for depression and 2.2 for a bipolar scenario. Third–year students responded to the depression virtual–patient with significantly more empathy than 1st (p<0.001) and 2nd–year students (p<0.001).Medical students communicated empathically with virtual patients, but showed less empathy than physicians interacting with live patients. The intensity of the empathic responses increased with the year of training in our sample, which supports the view that empathy can be learned.

Keywords: Empathic Communication; Virtual Patient Scenarios; Descriptive Study Using the Empathic


ECCS : Empathic Communication Coding System; IRB : Institutional Review Board; GRU : Georgia Regents University; SP : Standardized Patient; VP : Virtual Patient.


Empathy represents the ability to identify another person’s feelings and experiences, and to view the world from their perspective. In the physician –patient interaction, empathy improves interpersonal communication and fosters therapeutic alliance [1]. Empathy has been shown to correlate with patient satisfaction and interpersonal trust, to improve medical care outcomes and physician satisfaction [2–4]. Therefore, empathy is an essential communication skill for all physicians.

Some studies demonstrate that self–assessed empathy declines throughout medical school and residency [5–7]. However, other studies, using standardized patient (SP) interactions to measure the behavioral component of empathy, show that while self–measured empathy declines, students display more empathy in clinical encounters, as they progress through medical school [8]. In addition, targeted educational interventions, such as communication skills workshops, can enhance the behavioral dimension of empathy [4]. Yet, it is difficult to retrieve, quantify and provide feedback on student empathic responses and behaviors outside of a clinical skills center environment.

Virtual patient (VP) scenarios are computerized representations of real–life patients and may provide another avenue for evaluating students’ empathic responses. Studies involving hundreds of health professions’ students and practicing clinicians suggest that these virtual clinical scenarios mimic real clinical scenarios, lessen learner anxiety, improve communication skills, and provide tools for standardized, repetitive practice in a safe environment [9–13]. We have previously demonstrated that medical students respond empathically to a life–size VP with abdominal pain [13] but have not investigated such interactions in more portable, web–based VP scenarios. To expand this research, we sought to find out whether medical students express empathy in interactions with web–based VP scenarios focused on depression and bipolar disorder [9,10].

In this study, our research questions were:

1. Do medical students respond empathically to a webbased VP portraying a mental health scenario, like previously demonstrated with a life–size VP with a physical complaint?

2. If found, does medical students’ empathy vary with their level of training?

To answer these questions, we analyzed medical students’ empathic responses in mental health VP scenarios using the Empathic Communication Coding System (ECCS), which assesses how empathy is communicated verbally [14]. We intend to use the results of the analysis to enhance our VP’s capability to elicit empathy and potentially use them as an innovative tooltoteach and assess this fundamental clinical skill in medical school curricula.


VP scenarios

Through a collaborative effort involving medical educators at Georgia Regents University (GRU) and computer scientists at the University of Florida, we have created, evaluated, and integrated VP systems into health professions’ curricula. The two scenarios used for the present study were created in Virtual People Factory [15], a webbrowser interface that permits students to interact with VPs using text–based chat in which a user types an input and receives a textbased response (Figure1).

Students log into the system any wherewith Internet access. They are presented with a brief introduction similar to that encountered before an SP interview, and then are ushered into the chat interface. Once inside the interface, users can engage the virtual patient in a natural–language conversation by typing questions in their own words, to obtain a full medical history. In this study, we analyzed transcripts (i.e. VP–student exchanges) from two Virtual People Factory scenarios (depression and bipolar disorder). The depression VP scenario involves a 21–year–old college student referred to a physician by her campus counselor with complaints of fatigue and anhedonia [9]. The bipolar VP scenario involves a 43–year–old woman with three children who has just moved to the area and comes for her first visit to a psychiatrist, complaining of insomnia [10].

Empathy measurement tool

We coded how empathy is communicated in each of the transcripts using the previously validated ECCS [14,16]. The first part of the ECCS identifies empathic opportunities presented by the patient, divided into three categories:

1. Emotion opportunities are statements where the patient describes herself or himself feeling an emotion at the time, for example joy, fear, hate, sorrow [14] (e.g. statement: “I’ve been thinking a lot of death since my cousin died in a car wreck 8 months ago but I’m scared to kill myself”).

2. Progress opportunities are statements about positive physical or psychosocial developments in patients’ lives (e.g. I’ve cut down (smoking) quite a bit”). No examples of progress opportunities were found in the transcripts analyzed in our study.

3. Challenge opportunities are statements about the negative effect of a physical or psychosocial problem is having on patient’s quality of life (e.g. VP statement: “My clothes don’t fit anymore. It feels like all I do is eat and sleep“).