Brief Reports

Avatar-Mediated Training in the Deliveryof Bad News in a Virtual World

Allen D. Andrade, M.D.,1,3 Anita Bagri, M.D.,1,3 Khin Zaw, M.D.,1–3

Bernard A. Roos, M.D.,1,3,4 and Jorge G. Ruiz, M.D., FACP,1,3,4

Abstract

Background: Delivering bad news to patients is an essential communication skill for physicians. Educatorscommonly use standardized patient (SP) encounters to train physicians in the delivery of bad news. It isexpensive to use actors, for logistical reasons such as travel and scheduling, and there are limits to the charactersand conditions an actor can portray in teaching encounters. Thus we studied the feasibility of creating SP avatarsin a virtual world for the task of training medical trainees to delier bad news. The SP avatars are easilycustomized for different scenarios and amenable to distance learning.Methods: We recruited 10 medical trainees to interact with a standardized female avatar in a three-dimensionalsimulated clinic, where the trainee was to inform the avatar of her newly diagnosed breast cancer. The traineeevaluated his or her self-efficacy in delivering bad news via an affective competency score (ACS) before and afterthe encounter. Two palliative care specialists evaluated each trainee’s performance using the Bad News As-sessment Schedule and the performance ACS.Results: The self-efficacy ACS scores of the trainees improved overall: before, 20� 4, versus after, 24� 3,p¼ 0.001 (maximum score¼ 30). All participants considered the experience positive and commended the novelapproach, although noting that the avatars were not able to portray body language cues.Conclusion: Participants viewed the avatar-mediated training as an excellent approach for learning how todeliver bad news but believed it could not substitute for real patient interactions. However, participant self-efficacy improved, which suggests that avatar-mediated training in a virtual world is a viable educationalapproach for skill training in delivering bad news.

Introduction

Delivering bad news (DBN) is a skill physicians mustcommonly use in various clinical settings. The way

physicians disclose bad news can have a significant impact on apatient’s outcome and performance expectation, emotionaladjustment, adherence with treatment recommendations, andlikelihood of litigation.1–3 Both experienced clinicians andmedical trainees find the task difficult, daunting, and stressful.2

Traditionally, medical trainees learn the skill of DBN applyinga protocol such as SPIKES (setting; perception; invitation;knowledge; emotions; summary).4 Acquring this skill is diffi-cult due to the shortage of training experiences that involveinteractions with real or standardized patients (SP). The most

common method to teach the delivery of bad news is throughSPs.5–8 However, SPs involve expensive logistical issues relatedto having to be in certain places at certain times as well as thelimited ability of any one SP to participate in multiple characterroles during the same sitting. Avatar-mediated training invirtual worlds offers a possible alternative, and in some aspectsmore desirable, instructional method to train health care pro-fessionals when the use of real SPs is not practical.

Virtual worlds are three-dimentional computer-generatedsimulated environments in which users interact via graphicalcharacter representations called avatars. Individuals re-presented by their avatars can talk with each other in real-timevia voice-over-Internet Protocol (VoIP) communication.Avatar-mediated training in a virtual world offers a controlled

1Geriatric Research, Education, and Clinical Center (GRECC), and Bruce W. Carter 2Geriatrics and Extended Care, Veterans AffairsMedical Center, Miami, Florida.

3Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Miami Miller School of Medicine and JacksonMemorial Hospital, Miami, Florida.

4Stein Gerontological Institute, Miami Jewish Health Systems, Miami, Florida.Accepted July 16, 2010.

JOURNAL OF PALLIATIVE MEDICINEVolume 13, Number 12, 2010ª Mary Ann Liebert, Inc.DOI: 10.1089/jpm.2010.0108

1415

environment to implement simulated patient encounters fordeliberate practice of DBN. Avatar-mediated training in avirtual world has several advantages over real-world SP en-counters. Virtual SP avatars have the ability to work at adistance, wear multiple avatar personas, and manipulate race,voice, age, and body mass in different virtual settings.9–12 Asfar as we know, our study is the first to use avatar-mediatedtraining in virtual worlds to train medical trainees in DBN. Inthis pilot study we investigated the technical feasibility andtrainee acceptability of a virtual world platform to practiceDBN with avatar SPs. We measured effectiveness by com-paring preencounter and postencounter self-efficacy results.We also looked at the association of ‘‘presence,’’ or sense ofbeing in the environment, with performance and self-efficacyin DBN.

Virtual world researchers describe ‘‘presence’’ in the con-text of virtual learning environments as ‘‘being there,’’ whereyou feel that you ‘‘exist’’ in the simulated rather than the realworld.13,14 The association between presence and perfor-mance depends on the task. In conceptual learning tasks, anincreasing level of presence does not increase performance.15

However, during three-dimensional navigation activities, thehigher the level of presence the better the performance.16

Methods

Subjects and setting

In this single-group study with posttest design, we re-cruited ten medical trainees from the Jackson Memorial

Hospital/University of Miami Miller School of Medicine (fivefirst-year clinical geriatric medicine fellows and five internalmedicine PGY1s). The screen-capture software failed to re-cord two of the participants, so they were not included in thefinal analysis. The mean age of the participants was 29þ 4years, and there were five men and three women. Self-reported ethnic backgrounds included four Caucasian, threeHispanic, and one Asian medical trainee. The investigatorsused two office spaces separated by a corridor, each furnishedwith an Intel Pentium 2.13 Ghz desktop (Dell), 256MB NVI-DIA Graphics card, and 17-inch computer monitor withbroadband Internet connection.

Intervention and data collection

Participants first completed demographic data and the self-efficacy affective competency score (ACS),17 a tool that mea-sures communication self-efficacy in DBN. The ACS, whenscored by the trainee, reflects self-efficacy; when rated by afaculty observer, the ACS measures the trainee’s performance.The trainees then completed a 10-minute computer-basedtutorial on the SPIKES protocol for DBN. The study investi-gators logged the participants into Second Life (Linden Labs,San Francisco, CA), where they interacted with an SP avatarusing headsets for VoIP communication. A female SP con-trolled the SP avatar in a separate office (Fig. 1).

The DBN task took place in a three-dimensional simulatedphysician office, in which the participant, acting as an inter-nist, was to inform the SP avatar of her newly diagnosedbreast cancer. At the end of the encounter the investigator

FIG. 1. (A) Virtual world set-up with medical trainees (MT) and standardized patients (SP). (B) Real-world MT to SPencounter. (C) Virtual world avatar encounter.

1416 ANDRADE ET AL.

debriefed the trainee participants, who then completed thepostencounter self-efficacy ACS and the Witmer’s PresenceQuestionnaire.17,18 Witmer’s questionnaire is a validated in-strument that measures presence in virtual environments.19

Each encounter took approximately an hour and initially re-quired coordination in obtaining and training qualified SPsand scheduling participants. The investigators recorded thevirtual encounters using the screen-capture software Camta-sia Recorder (Techsmith, Okemos, Michigan).

Two palliative care specialists reviewed each recording andassessed performance using a previously validated ModifiedBreaking Bad News Assessment Schedule (BAS)20 and thefaculty-rated performance ACS. The investigators debriefedparticipants on their virtual world experience, in informalinterviews about what they liked and disliked about the en-counter and if they had any trouble performing the task in thesimulated environment. Common themes identified in these in-terviews were included with the participants’ written comments.

Data analysis

The investigators entered the data collected into SPSS 16(SPSS Inc., Chicago, IL). We calculated changes in the self-efficacy ACS before and after with two-tailed paired Student’st test. We generated Pearson correlation coefficients betweenperformance (BAS, performance ACS), presence, and self-efficacy in the simulated encounter.

Results

The investigators did not encounter any technical issuesfrom set-up through to the avatar interaction.The trainees felt

engaged, involved, and in control, reporting the environmentas natural and responsive and the virtual encounter as easy toadjust to. The desktop interface did not interfere in the task(Table 1).

The self-efficacy ACS improved after the encounter: before,20� 4, versus after, 24� 3, with a maximum score of 30( p¼ 0.001). The BAS was 47� 7, out of a maximum score of105. There was no difference in the mean performance offellows and interns on the faculty-rated performance ACS orBAS. The presence scale showed a moderate correlation withtrainees’ assessment with post-encounter self-efficacy ACS(r¼ 0.35) and a small correlation with the BAS (r¼ 0.11). Therewas a small correlation between performance rated by theexpert observers and the trainees’ self-efficacy ACS (r¼ 0.11).These correlations were not statistically significant. Traineesprovided the investigators with written comments and in-formal feedback. The participants repeatedly noted their in-ability to observe SP body language and emotions in thevirtual world. All participants considered the experiencepositive and commended the novel approach. Participantsviewed the virtual world method as an excellent resource forlearning DBN, but believed it could not supplant interactionswith real patients.

Discussion

This study is the first feasibility pilot study of educatingmedical trainees on DBN in a virtual world. Participantsviewed the avatar-mediated training in a virtual world as anexcellent instructional method for learning how to deliver badnews, but acknowledge the diffculty caused by the lack of

Table 1. Medical Trainees’ Responses to Witmer’s Presence Questionnaire

Witmer’s Presence Questionnaire (Likert Scale 1–7) Mean SD

How much were you able to control events in the encounter? 5.60 1.07How responsive was the environment to actions that you performed? 5.40 0.84How natural did your interaction with the environment seem? 4.80 1.40How completely were all of your senses engaged? 5.10 1.20How much did the visual aspects of the environment involve you? 4.50 1.08How much did the auditory aspects of the environment involve you? 6.30 1.25How natural was the mechanism that controlled movement in the environment? 4.40 1.26How compelling was your sense of objects or virtual subjects moving? 4.70 1.42How inconsistent or disconnected was the information coming from your

various senses?3.10 1.60

How much did your experience in the virtual environment seem consistentwith your real-world experience?

4.60 1.35

Were you able to anticipate what would happen next in response to the actionsthat you performed?

5.20 1.23

To what degree did you feel confused or disoriented at the beginning or at theend of the experiment session?

2.80 1.93

How involved were you in the virtual encounter experience? 5.60 0.97How quickly did you adjust to the virtual environment experience? 5.60 0.70How proficient in interacting with the virtual environment did you feel at the end

of the experience?5.00 1.05

How much did the visual display quality interfere or distract you from performingassigned tasks or required activities?

3.20 1.69

How much did the control devices interfere with the performance of assigned tasksor with other activities?

3.00 1.33

How well could you concentrate on the assigned tasks rather than on the mechanismsused to perform those tasks?

4.90 0.88

Were you involved in the task to the extent that you lost track of time? 5.20 1.03Did you learn new techniques that enabled you to improve your performance? 4.70 2.00

DELIVERY OF BAD NEWS IN VIRTUAL WORLDS 1417

nonverbal cues in the avatar SPs. We found the virtual worldplatform of Second Life acceptable and feasible for our DBNtraining. Trainees’ self-efficacy in DBN improved with prac-tice in the virtual world environment. Although not signifi-cant, trainees’ self-efficacy correlated with presence andcorrelated weakly with examiners’ observations.

Other studies have found that medical learners were en-thusiastic and receptive to the use of avatar-mediated virtualworld platforms for training.21–23 One study demonstratedthe feasibility of using avatars to train medical students, res-idents, and practicing clinicians in communication skills.23 Aswas also true for our subjects, participants noted the difficultyof simulating an important element of human communicationat the end of life, nonverbal cues, with avatars and virtualworlds,,24 More immersive technologies can now create muchmore realistic simulations of emotional states, facial expres-sions, and the mimicry of nonverbal behavior.10,11,25 Theseinnovative approaches will undoubtedly address currentlimitations of dynamic avatars, potentially enhancing theability of trainees to practice communication skills such asDBN. Furthermore, others have been able to modify avatarcharacteristics allowing the manipulation of skin color, age,and body habitus.9,10,12 The effect of manipulating avatarappearance promises an innovative training approach to im-prove patient–physician communication at the end of life withspecific minority populations and with persons with gender-and age-specific attributes.26–28

The concept of self-efficacy pertains to an individual’sperception of his/her competence when engaging in specifictasks.29 Social cognitive theorists propose that the most ef-fective way to increase self-efficacy is through successfulpractice of assigned tasks.30 Individuals with high self-efficacy set higher goals for themselves and achieve higherperformance than individuals with low self-efficacy.31,32 Areview of teaching medical trainees bad news delivery skillsidentified self-efficacy improvement as a learner outcome inSP encounters.33 DBN training in via workshops or SPs hasresulted in improvements in self-efficacy.34,35 Participants’improvement in self-efficacy in this study supports the feasi-bility of avatar-mediated DBN training in a nonthreatening,safe practice environment. The significance of improved self-efficacy lies in evidence from meta-analysis suggesting thatself-efficacy strongly correlates with performance.36

The association of presence with performance in our studyindicates that the more the participants engage themselves inthe task, the greater their ability to deliver bad news effec-tively to the avatar confederate. The task of DBN can generateintense emotions for trainees.3 Under these conditions, pres-ence can be a reaction to sensory stimulus on emotional lev-els.37 There is evidence for a relation between presence andemotion under experimental conditions and in clinical con-texts using virtual reality environments as therapeutictools.38,39 Presence in the educational context becomes animportant construct as it may mediate the learning and per-formance effects of avatars and virtual worlds. A systematicreview using virtual environments evoking spatial immersionrevealed the association of higher levels of presence withbetter memorizing, understanding, and repetitive tasks.40

Avatar research suggests that high presence enhances learn-ing, and the lack of fidelity of the simulation may have only alimited impact on learning.41,42 More light on this issue willcome from further research on the role of presence in the

contexts of practice of emotionally charged communicationskills such as the delivery of bad news.

Several study limitations affect the applicability of our re-sults. The small convenient sample size of geriatrics fellowsand interns on a geriatric medicine rotation precluded a morerobust analysis. Improvements in self-efficacy may be theresult of a "Hawthorne effect," whereby trainees believe theyhave improved their self-efficacy by virtue of participating inthe study.43 Future studies should include comparison groupswith trainees interacting with real- world SPs in order to de-scribe a clear effect. Nevertheless, our small study clearlysuggests that avatar-mediated training in a virtual world is aviable educational method to facilitate and improve trainees’DBN self-efficacy.

Acknowledgments

We are grateful to University of Miami faculty and MiamiVA GRECC staff support for this project. No funding bodyprovided direct support. The investigators presented thisbrief report in abstract form at the 2009 Society of GeneralInternal Medicine Annual Meeting, May 13, 2009, Miami,Florida.

Author Disclosure Statement

No competing financial interests exist.

References

1. Ptacek JT, Ptacek JJ: Patients’ perceptions of receiving badnews about cancer. J Clin Oncol 2001;19:4160–4164.

2. Fallowfield L, Jenkins V: Communicating sad, bad, anddifficult news in medicine. Lancet 2004;363:312–319.

3. Rosenbaum ME, Ferguson KJ, Lobas JG: Teaching medicalstudents and residents skills for delivering bad news: A re-view of strategies. Acad Med 2004;79:107–117.

4. Buckman R: Communication skills in palliative care: Apractical guide. Neurol Clin 2001;19:989–1004.

5. Colletti L, Gruppen L, Barclay M, Stern D: Teaching studentsto break bad news. Am J Surg 2001;182:20–23.

6. Eid A, Petty M, Hutchins L, Thompson R: "Breaking badnews": Standardized patient intervention improves com-munication skills for hematology-oncology fellows and ad-vanced practice nurses. J Cancer Educ 2009;24:154–159.

7. Freer JP, Zinnerstrom KL: The palliative medicine extendedstandardized patient scenario: A preliminary report. J PalliatMed 2001;4:49–56.

8. Garg A, Buckman R, Kason Y: Teaching medical studentshow to break bad news. Can Med Assoc J 1997;156:1159–1164.

9. Yee N, Bailenson J: The Proteus effect: The effect of trans-formed self-representation on behavior. Hum Commun Res2007;33:271–290.

10. Bailenson JN, Yee N, Merget D, Schroeder R: The effect ofbehavioral realism and form realism of real-time avatar faceson verbal disclosure, nonverbal disclosure, emotion recog-nition, and copresence in dyadic interaction. Presence2006;15:359–372.

11. Bailenson JN, Yee N: Digital chameleons. Automatic assim-ilation of nonverbal gestures in immersive virtual environ-ments. Psychol Sci 2005;16:814–819.

12. Fox J, Bailenson JN: Virtual self-modeling: The effects ofvicarious reinforcement and identification on exercise be-haviors. Media Psychol 2009;12:1–25.

1418 ANDRADE ET AL.

13. IJsselsteijn WA, Riva G: Being there: The experience ofpresence in mediated environments. In: Riva G, Davide F,IJsselsteijn WA (eds): Being There—Concepts, Effects andMeasurements of User Presence in Synthetic Environments.Amsterdam: Ios Press, 2003;4–14.

14. Slater M: Place illusion and plausibility can lead to realisticbehaviour in immersive virtual environments. Phil Trans RSoc B 2009;364:3549–3557.

15. Dede C: The evolution of constructivist learning environ-ments: Immersion in distributed, virtual worlds. EducTechnol 1995;35:46–52.

16. Winn WD, Windschitl M, Fruland R, Lee Y-L: Features ofvirtual environments that contribute to students’ under-standing of earth science. Annual meeting of the NationalAssociation for Research in Science Teaching, New Orleans,LA, April 2002 (Abstract)

17. Quest TE, Ander DS, Ratcliff JJ: The validity and reliabilityof the affective competency score to evaluate death disclo-sure using standardized patients. J Palliat Med 2006;9:361–370.

18. Witmer BG, Singer MJ: Measuring presence in virtual envi-ronments: A presence questionnaire. Presence 1998;7:225–240.

19. Witmer BG, Jerome CJ, Singer MJ: The factor structure of thepresence questionnaire. Presence 2005;14:298–312.

20. Miller SJ, Hope T, Talbot DC: The development of a struc-tured rating schedule (the BAS) to assess skills in breakingbad news. Br J Cancer 1999;80:792–800.

21. Alverson DC, Saiki SM Jr, Kalishman S, Lindberg M, Men-nin S, Mines J, Sema L, Summers K, Jacobs J, Lozanoff S,Lozanoff B, Saland L, Mitchell S, Umland B, Greene G, Bu-chanan HS, Keep M, Wilks D, Wax DS, Coulter R, Gold-smith TE, Caudell TP: Medical students learn over distanceusing virtual reality simulation. Simul Healthc 2008;3:10–15.

22. Alverson DC, Saiki SM Jr, Caudell TP, Summers K, Pa-naiotis, Sherstyuk A, Nickles D, Holten J III, Goldsmith TE,Stevens SM, Kihmm K, Mennin S, Kalishman S, Mines J,Serna L, Mitchell S, Lindberg M, Jacobs J, Nakatsu C, Lo-zanoff S, Was DS, Saland L, Norenberg J, Shuster G, Keep M,Baker R, Buchanan HS, Stewart R, Bowyer M, Liu A, MunizG, Coulter R, Maris C, Wilks D: Distributed immersive vir-tual reality simulation development for medical education. JInt Assoc Med Sci Educ 2005;15:19–30.

23. Youngblood P, Harter PM, Srivastava S, Moffett S, HeinrichsWL, Dev P: Design, development, and evaluation of anonline virtual emergency department for training traumateams. Simul Healthc 2008;3:146–153.

24. Huang MP, Alessi NE: Current limitations into the appli-cation of virtual reality to mental health research. In: Riva G,Wiederhold BK, Molinari E (eds): Virtual Environments inClinical Psychology and Neuroscience. Amsterdam: Ios Press,1998;63–66.

25. Bailenson JN, Yee N: A longitudinal study of task perfor-mance, head movements, subjective report, simulator sick-ness, and transformed social interaction in collaborativevirtual environments. Presence 2006;15:699–716.

26. Zapka JG, Carter R, Carter CL, Hennessy W, Kurent JE,DesHarnais S: Care at the end of life: Focus on communi-cation and race. J Aging Health 2006;18:791–813.

27. Lobb EA, Butow PN, Kenny DT, Tattersall MHN: Commu-nicating prognosis in early breast cancer: Do womenunderstand the language used? Med J Aust 1999;171:290–294.

28. Siegler EL, Levin BW: Physician–older patient communica-tion at the end of life. Clin Geriatr Med 2000;16:175–204, xi.

29. Irizarry R: Self-efficacy & motivation effects on online psy-chology student retention. The effects of self-efficacy andlevel of motivation on retention for learners in online grad-uate psychology programs. United States Distance LearningAdministration Journal [online] 2002;16, No. 12.

30. Pajares F: Current directions in self-efficacy research. In:Maehr M, Pintrich PR (eds): Advances in Motivation andAchievement. Greenwich, CT: JAI Press, 1997; pp. 1–49.

31. Thomas KM, Mathieu JE: Role of causal attributions in dy-namic self-regulation and goal processes. J Appl Psychol1994;79:812–818.

32. Wood R, Bandura A: Impact of conceptions of ability on self-regulatory mechanisms and complex decision making. J PersSoc Psychol 1989;56:407–415.

33. Rosenbaum ME, Ferguson KJ, Lobas JG: Teaching medicalstudents and residents skills for delivering bad news: A re-view of strategies. Acad Med 2004;79:107–117.

34. Schildmann J, Harlein J, Burchardi N, Schlogl M, VollmannJ: Breaking bad news: Evaluation study on self-perceivedcompetences and views of medical and nursing studentstaking part in a collaborative workshop. Support CareCancer 2006;14:1157–1161.

35. Kahn MJ, Sherer K, Alper AB, Lazarus C, Ledoux E, Ander-son D, Szerlip H: Using standardized patients to teach end-of-life skills to clinical clerks. J Cancer Educ 2001;16:163–165.

36. Stajkovic AD, Luthans F: Self-efficacy and work-relatedperformance: A meta-analysis. Psychol Bull 1998;124:240–261.

37. IJsselsteijn W: Elements of a multi-level theory of presence:Phenomenology, mental processing and neural correlates. InProceedings of Presence 2002, pp. 245–259.

38. Meehan M: An objective surrogate for presence: Physiolo-gical response. Presence 2000. 3rd International Workshopon Presence. Delft, The Netherlands, 27–28. www.cs.unc.edu/*meehan/presence2000/MeehanPresence2000.htm(Last accessed October 27, 2010).

39. Difede J, Hoffman HG: Virtual reality exposure therapy forWorld Trade Center post-traumatic stress disorder: A casereport. Cyberpsychol Behav 2002;5:529–535.

40. Selverian MM, Hwang HS: In search of presence: A systematicevaluation of evolving VLEs. Presence 2003;12:512–522.

41. Whitelock D, Brna P, Holland S: What is the value of virtualreality for conceptual learning? Towards a theoreticalframework. In: Brna P, Paiva A, Self JA (eds): Proceedings ofthe European Conference on Artificial Intelligence in Edu-cation. Lisbon: Edicoes Colibri, 1996, pp. 136–141.

42. Moreno R, Mayer RE: Learning science in virtual realitymultimedia environments: Role of methods and media. JEduc Psychol 2002;94:598–610.

43. McCarney R, Warner J, Iliffe S, van Haselen R, Griffin M,Fisher P: The Hawthorne effect: A randomised, controlledtrial. BMC Med Res Methodol 2007;7:30.

Address correspondence to:Jorge G. Ruiz, M.D., FACP

VAMC GRECC (11GRC)1201 NW 16 Street

Bruce W. Carter VA Medical CenterMiami, FL 33125

E-mail: jruiz2@med.miami.edu

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