Evidence demonstrates that a doctor-patient relationship of trust, respect, and understanding improves the patient's adherence to treatment recommendations, and results in better physical and emotional outcomes (Stewart M. Cancer Prev Control. 1999;3:25-30.) Most medical schools teach physician-patient communication skills to create effective therapeutic relationships with patients. However, studentsâ opportunities for enhancing their skills through practice and feedback are limited by the expenses of faculty time and the cost of standardized patient activities. A method that would allow for structured practice, coaching and feedback between students could greatly augment current teaching programs.
At Drexel University College of Medicine, we have developed a number of online programs designed to enhance the communication competencies of medical trainees, including DocCom and WebPatientEncounter (WPE). DocCom in an online learning resource for learning healthcare communication, featuring 42 modules and over 400 videos (http://webcampus.drexelmed.edu/doccom). DocCom has been adopted by over 70 programs; had close to 50,000 active users, and been translated into Japanese, German and Portuguese. WPE facilitates online interactions between medical trainees and standardized patients (SPs). SPs play patients with certain illnesses and, after an interaction with a trainee, give structured feedback, showing replays of key moments in the interactions and contrasting them with prerecorded videos of senior clinicians demonstrating effective skills. We have published two articles that demonstrate the effectiveness of using DocCom and WPE to improve residentsâ skills in breaking bad news and substance abuse detection and counseling. (Acad Med. 2015 Mar;90(3):345-54).
Because WPE requires considerable logistical support to train and schedule SPs, we conceived the idea of WebRolePlay, developing the WPE platform to allow students to coach each other in enhancing their mutual skills, while increasing their understanding of patientsâ perspectives.
WebRolePlay could be used beyond medical school in any profession where empathy, conflict resolution, and other interpersonal skills matter.
1) Create WebRolePlay
The main objective of this project is to develop WebRolePlay: a competency based, engaging online tool for learners to engage in remote role plays for the practice and assessment of interpersonal skills. Interpersonal skills competence is key for effective communication, empathy building, and conflict resolution, amongst other applications. We won't create WebRolePlay from scratch, but build it as a further development of our WebPatientEncounter technology.
2) Test if WebRolePlay is feasible to engage learners in remote role-plays
At the core of WebRolePlay is our remote technology that facilitates role plays between 2 to 12 participants. In role plays, one learner assumes the role of a patient or customer who has an issue, while the other learner(s) assume the role(s) of provider(s) who engage in an interaction. We will write relevant cases for the role plays and survey the learners on ease of use, engagement, and more.
3) Test if Learners can score each other accurately and provide objective feed-back
The novel concept of WebRolePlay is to allow the learners' and not trained specialists' to provide scoring and feed-back to each other. For this to work, they need to study materials that help them understand the patient's or customer's perspective. Then they must study their role and learn the effective interpersonal skills, plus a feed-back sentence for each of these items. WebRolePlay allows them to mark when any of the effective interpersonal skills are being shown. These markers are then used to create a score and enhance the feedback by allowing playback of the recording at the time when a specific interpersonal skill is being shown. We will survey the learners on the perceived accuracy of scoring and feedback. In addition, specialists will review the recordings and re-score them.
We propose to build WebRolePlay as a further development of our existing WebPatientEncounter (WPE) technology. WPE is a web-based technology that facilitates remote audio-visual encounters between learners and Standardized Patients (SPs), who represent a medical case scenario. The learner is provided with interpersonal tasks (e.g. providing bad news, smoking cessation counselling) that are performed during the encounter, with the SP simulating a real patient. During the encounter, the SP carefully observes whether the learner employs certain skills effectively, and, on a prepared scoring list, notes the learner's degree of proficiency with these interpersonal tasks (i.e., complete, incomplete, not at all). The encounter and scoring times are recorded, allowing specific feedback on the encounter. For feedback after the encounter, the SP becomes a coach, providing objective structured feedback enhanced by recordings from the encounter, plus prepared video vignettes that role model best behavior; (e.g., "This is what you did when I started crying [play recording], and this is what an expert would have done in this situation" [play video vignette]). See http://webcampus.drexelmed.edu/webosce/.
We are working right now on a new version of WebPatientEncounter that is based on the most current technology available (WebRTC server on UBUNTU). The main benefit that we expect for WPE is better performance and the ability to allow up to 12 learners to practice together - which is highly anticipated for training of inter-professional teams.
If funding for the development of WebRolePlay becomes available, we will take the WebPatientEncounter technology -which is based on a "one-way" paradigm where students practice on Standardized Patients who score them and provide feedback - and develop it into WebRolePlay: a "multi-way" technology with all its technological challenges and implications on the educational design, where students practice on each other and become their coaches.
We hypothesize that the following factors are engaging:
Sitting in the driver's seat
Inexperienced learners often don't know what they don't know. Enabling them to realize this fact is the first and most important step to engaging them in learning. By participating in role plays, learners must act as if they are in real-life scenarios. Role play feedback confronts them with their true skill levels and need for learning.
Becoming a coach
The participant portrays "the patient," scores the exercise, and acts as a coach when providing feedback to the encountering participant. To prepare for coaching, the participants learn the scoring items and the feedback scripts, which are not hard to do, since they already must study the subject matter and understand it. We hypothesize that preparing to coach another learner will result in a deeper understanding of the subject matter - and provides a base for an engaging feedback session.
The case's quality and relevance during the role plays are key to WebRolePlay's success. Vygotzky (1978) describes the "Zone of Proximal Development" where skills expertise is just within reach of learners' abilities. Practice there provides strong engagement and optimal learning outcomes. Vygotsky also views interaction with peers as an effective way to develop skills and strategies.
WebRolePlay will allow up to 12 participants from different locations and professions to engage in a common task. WebRolePlay's remote nature allows multi-disciplinary groups to engage in much needed interpersonal skills practice (Medical Education Online 2011, 16: 6035).
By bringing together participants from different institutions, WebRolePlay aims at making competition work to benefit participants' learning. As a representative of their institution (comparable to a college sports team), participants may be motivated to prepare harder since they score not only for themselves but also for their institution.
WebPatientEncounter, the predecessor of WebRolePlay, is already having an impact. At Drexel University College of Medicine, each of 260 medical students annually must work through 6 WebPatientEncounters during the clinical clerkship year. At the Gift of Life Institute, the nonprofit organ procurement organization serving the eastern half of Pennsylvania, southern New Jersey and Delaware, WebPatientEncounter is being used to train organ donation counselors locally and worldwide; recently WebPatientEncounter was licensed to DecisionSim, Inc.,(https://www.decisionsim.com/) to enhance communication skills of United States Veterans Administration Health System physicians. During its first 4 years of use, WebPatientEncounter has found its place and is furthering its impact. However, the cost of providing WebPatientEncounter can be prohibitive and difficult to scale up, because Standardized Patients must be trained, scheduled, and paid for each encounter. WebRolePlay aims to provide a similarly powerful learning experience, but for a fraction of the costs.
For these reasons, we conclude that WebRolePlay has the potential to transform interpersonal skills learning:
1) It takes the limiting factor, which is experts' availability, out of the equation
-> Provides plenty of structured training that is needed for skills acquisition
2) It keeps learners in the learning cycle until they show proficiency
-> Allows for integration into competency based curricula
3) It allows students to engage in learning by facilitating the free creation of learning groups from 2 to 12 participants
-> Allows for student's self-organized peer learning
4) It facilitates bringing together learners from various places, institutions, and professions, to engage in common tasks
-> Fosters inter-professional team building and training
5) The required study of materials providing insight into the patient's perspective results in better understanding of patients' hopes and fears
-> Enhances understanding, empathy, and conflict resolution
Develop Technology and Educational Design for "WebRolePlay": changing the "one way" paradigm (WebPatientEncounter) to "multi way traffic" (WebRolePlay).
Write and validate scripts for WebRolePlay cases (in addition to imported WebPatientEncounter cases) for multi-professional teams
Usability testing and interface refinement
Designing a small international multi-center pilot study(*) to assess
1) Learner engagement in WebRolePlay (survey)
2) Quality of scoring (quantitative study)
3) Quality of feed-back (survey)
4) Comparing interpersonal skills competency between WebRolePlay-trained and control groups (quantitative study)
a. Peer-learning remotely using WebRolePlay
b. Standardized Patient facilitated learning with WebPatientEncounter (same case)
c. Control group with no specific learning intervention
*Participation in our international multi-center pilot study was assured by
USA - PHILADELPHIA: Dennis Novack from Drexel University College of Medicine. Dennis Novack is the Associate Dean for Medical Education. He is a founding member of the American Academy on Communication in Healthcare and a well published researcher in medial education.
SWITZERLAND - BERN: Sissel Guttormsen from the University of Berne's Institute on Medical Education (IML) in Berne, Switzerland. Sissel Guttormsen is the head of the IML, which is responsible for the Medical Knowledge and Skills Assessment in all 5 Swiss Medical Schools.
SWEDEN - STOCKHOLM: Nabil Zary from the Karolinska Institute in Stockholm, Sweden. Nabil Zary is the Director of the Centre for Learning and Knowledge (CLK) and Director of the interdisciplinary research and innovation Laboratory for Emerging Technologies (LET).