Perspective Chapter: Empathy Training in Medical Students – An Overview of the Potential of Virtual Reality

Abstract

The World Health Organization has identified the job situation as one of the main contributors to mental disorders. The healthcare sector is particularly affected, given the profound relationships among doctors, patients, and caregivers that extend beyond clinical practice, encompassing the psychological and emotional spheres. This distress becomes even more crucial when doctors engage with patients—and their caregivers—facing terminal illnesses such as cancer. In this context, the use of empathic skills is imperative. Empathy training is gaining prominence in medical education, as the empathic attitude of doctors has been shown to enhance patient satisfaction and treatment adherence. Despite existing training programs relying on imagination and role play, which have demonstrated some limitations, Virtual Reality is emerging as a promising tool for empathy training. This chapter aims to outline the current state of vulnerability factors affecting the healthcare sector and how they impact communication with patients. Furthermore, it intends to present the potential of Virtual Reality as a valuable tool in the education curricula for physician students to cultivate empathetic and compassionate skills.

1. Introduction

1.1 Factors of vulnerability in physician students

The World Health Organization (WHO) has reported that approximately 450 million people worldwide suffer from mental disorders, with one in every four individuals expected to develop one or more of these disorders during their lifetime, leading to disability and premature death globally [1]. According to WHO [2], the treatment and prevention of mental disorders, as well as the promotion of mental health, should be integral components of public health systems. The job situation is considered one of the main causes of mental illness [3]. Factors related to employment can significantly affect mental well-being, and the prevalence of mental health issues varies among different professions and industries. The medical community stands out as the organizational sector with the highest incidence of mental disorders [4]. Physicians and other healthcare professionals often confront unique stressors and challenges in their work, contributing to mental health issues such as high levels of stress, depression, stigmatization, and burnout. This is particularly evident in junior doctors who may have a lower capacity to cope with patients’ illnesses [5]. Specifically, working with patients with terminal illness demands a considerable amount of mental and psychological effort, which can create emotional distance between doctors and patients [6].

1.2 The emotional challenges

Working with patients in advanced stages of severe illnesses can be emotionally demanding. Despite medical assistance, doctors often find themselves helping patients and their families come to terms with end-of-life issues [7, 8], this happens, for example, in the case of oncology patients that frequently endure pain, suffering, and fear, and many of them face a terminal diagnosis. The terminal illness introduces uncertainty, requiring doctors to communicate prognoses and potential treatment outcomes, which can be emotionally stressful given the often-limited certainty they can provide [9, 10]. Due to these challenges, there is a widespread consensus on the critical importance of clinical empathy in healthcare when communicate with patients and their love ones [11].

2. Clinical empathy

Clinical empathy is considered as a fluid state of disposition to connect doctors and patient through an interactive engagement or communication that draws on the cognitive, affective and imaginative aspects of empathy [12]. A response that is primarily cognitive rather than emotional involves understanding the patient’s pain and suffering more than feeling it. This response is coupled with the ability to communicate this understanding and an intention to foster a sense of clinical empathy in a healthcare context [13]. Clinical empathy is commonly recognized as a necessary trait to provide effective patient care [14]. Patients are inclined to trust physicians who reciprocate their anxiety with empathetic concern, and this has been linked to improved adherence to treatment [15, 16]. This includes the capacity of doctors to perceive and identify the subject’s emotional state, and using cognitive abilities such as perspective taking to understand the patient’s experience [17, 18]. However, there are several barriers to empathy between physicians and patients: first, anxiety interferes with empathy. That is, during the daily round visit, time pressure is invoked as a concrete barrier to listening to patients, doctors have very tight deadlines to visit each patient and they feel the pressure to do not have much time to dedicate with passion and care [19]. On the other side, time limit could become a psychological barrier, making doctors anxious and frustrate as they cannot give the care and attention they want to their patients. Another obstacle to empathy is the perception held by many physicians that patients’ emotional needs are not integral to illness and care. Instead, their focus remains predominantly on the medical and technical aspects of the doctor-patient relationship. Additionally, a third impediment to empathy arises from the negative emotions that may surface during tensions between patients and physicians [20]. Sometime patients are hostile to receive the attention from the doctors due, for example, to their inability to understand the medical language and to the irrational thoughts that doctors are incapable. On the other side, doctors may respond to patients’ attitude in a non-empathetic way generating tension and negative emotions [21].

2.1 The role of empathy in severe patients’ engagement

In the context of patient engagement, there is a growing emphasis on empathy as a crucial element in care delivery [22]. Empathic care holds particular significance for patients with terminal diseases like cancer, who often grapple with intense emotional distress, including feelings of fear, worry, anxiety, anger, and sadness [23]. Previous studies suggest that doctors who regularly include the psychological dimensions of care and are more empathetic is associated with higher patient satisfaction, better psychosocial adjustment, reduced psychological distress, and increased adherence to treatment recommendations [11, 19]. According to Davis’s theoretical model, empathy comprises two factors: emotional and cognitive empathy. The former, occasionally referred to as affective empathy, entails experiencing emotions in response to the emotions or expressions of others. The latter involves understanding others’ thoughts and feelings without necessarily reacting emotionally [24]. Both factors play a key role in preserving human social relationships. Empathic communication is therefore crucial for sharing sensitive information with patients in a clear, understandable, and digestible manner [25]. In instances where communication is perceived as empathetic, patients are more inclined to pose questions and seek clarification when faced with uncertainty. Furthermore, clinical empathy not only contributes to the well-being of patients but also exerts a positive influence on physicians’ quality of life and professional satisfaction, serving as a preventive measure against burnout symptoms [26]. Recognizing its importance, educational programs have emerged to train empathic communication among health professionals, demonstrating their effectiveness [27]. Furthermore, fostering empathy facilitates the challenge and transformation of stigmatizing behaviors and beliefs. However, Brito and colleagues [28] argue that empathy and compassion should not be explicitly taught but should instead arise naturally through practice. Among the various empathy training, the common technique adopted is perspective-taking through imagination where individuals are called to imagine themselves as another person. Nevertheless, this approach has some limitations.

2.2 Difficulty in empathy training

The main challenge in training empathy through perspective-taking is related to imaginative skills. In empathy training programs for medical students, participants are encouraged to envision patients’ emotions in relation to their clinical conditions, often supported by narratives or videos [27]. This form of training relies on imaginative processes, such as the creation and maintenance of a mental image [29]. However, many individuals find it difficult to generate a mental image due to the lack of information available to construct a clear picture of the clinical situation. Even when the creation of a mental image is possible, there is a challenge in maintaining it, as people often struggle to keep a mental image clear for more than a few seconds. Research has demonstrated that mental images rapidly decay, with an average duration of only 250 milliseconds, corresponding to the time it takes to make an eye movement [30].

3. Virtual Reality as a system to foster empathy

During his 2015 TED talk, immersive filmmaker Chris Milk asserted that Virtual Reality (VR) serves as a transformative tool, fostering heightened levels of compassion, connection, and empathy in individuals. Milk emphasized that VR establishes profound connections among people, surpassing the capabilities of any other media form. He went on to coin VR as “the ultimate empathy machine” [31]. In brief, VR is an advanced technology that allow users to be present and to interact with a three-dimensional environment [32], and a recent meta-analysis demonstrated its significance in eliciting empathy [33]. There are three primary reasons why VR holds the potential to evoke empathy. Firstly, VR provides a concrete experience, as immersive virtual environments may demand less cognitive effort for perspective-taking compared to traditional exercises relying on mental simulation [34]. Secondly, individuals immersed in VR often exhibit a reduced presence in the physical world and an increased presence in the virtual realm, potentially leading to decreased self-awareness during empathy training compared to conventional methods. Thirdly, utilizing VR for perspective-taking can be instrumental in mitigating stereotypes. For instance, if a medical student harbors negative stereotypes about patients with a particular illness, traditional mental imagery might perpetuate negative biases. Conversely, crafting a perspective-taking narrative through VR offers a means to circumvent such stereotypes and create a more accurate representation of the patient, thereby enhancing research outcomes [33]. Furthermore, perspective-taking offers, indeed, an embodied simulation experience, which is essential for properly understanding another person’s point of view. In fact, VR has the features to induce the body swap illusion that allows user to perceive themselves as another person [35]. The paradigm of the body illusion through VR was adopted to study empathy and prosocial behavior demonstrating positive effect [33, 34, 36, 37, 38]. The potentiality of VR to foster empathy has promote its application in medical education context to train students to be more empathetic and compassionate toward patients and by improving the interpersonal communication.

3.1 Virtual Reality in empathy training for physician students

Promoting empathy in healthcare professionals can be challenging. Virtual Reality (VR) has proven to be a valuable tool for training empathetic and compassionate skills [33, 39, 40]. Due to its features, VR allows users, especially doctors in this case, to adopt the patients’ perspective and immerse themselves in their inner experiences, including thoughts and emotions. The degree of immersion in this perspective-taking experience can vary based on the VR system used. During immersive experiences, participants wear a Head Mounted Display, a device that creates the illusion of being inside a virtual environment and embodying a virtual avatar, which represents the patients in this scenario [41]. The key factor ensuring the authenticity of this experience is the full-body illusion, wherein users feel they are the virtual patients. If the illusion is successful, they experience a sense of ownership, agency to move the patient’s body, and a feeling of being located in the virtual hospital room [35]. Immersive technology enables doctors to walk in the patients’ shoes, providing a unique perspective [42]. On the other hand, non-immersive experiences involve virtual avatars displayed on a screen simulating patients’ responses to doctors’ interactions. In this scenario, doctors interact with the virtual patient through a computer that conveys emotions and physical states for them to address. According to the literature, utilizing virtual patients for training presents several advantages over live patient interactions, including: (1) the simulation of challenging clinical scenarios that are difficult to replicate in the real world, (2) providing doctors with ample time to consider their responses, (3) standardized content, (4) immediate feedback after interactions, and (5) enabling safe and repetitive practice with different participants [43]. Additionally, in a comparative study between 2-dimensional and 3-dimensional virtual environments, VR resulted in greater engagement and higher levels of empathy and perspective-taking scores from before to after exposure to characters featured in the story [44].

4. Conclusions

According to the World Health Organization, the healthcare sector is highly impacted by mental disorders, particularly anxiety and depression. This is especially true when doctors are tasked with caring for patients facing terminal illnesses such as cancer. Working with this population can be emotionally demanding as healthcare professionals must confront the end-of-life situations of patients and provide support for both the patients and their caregivers, dealing with a range of complex emotions [3]. It has been demonstrated that empathetic skills are essential in fostering positive relationships between doctors and patients. Specifically, doctors who exhibit empathy contribute to improve communication with patients and enhance their satisfaction, as well as adherence to treatment plans [16]. Recognizing the significance of this skill, various empathy training programs have been developed, primarily focusing on perspective-taking through role-playing. In these training sessions, medical students engage in scenarios where they take on the roles of both doctors and patients, simulating potential interactions. Recently, both immersive and non-immersive Virtual Reality (VR) have been employed to facilitate perspective-taking between doctors and patients [42]. VR has proven to be effective in promoting empathy by allowing users to embody a virtual avatar representing an external group, including aspects such as age, gender, or race. In this context, participants have the opportunity to experience the emotions of others, and, when applied to the healthcare sector, doctors can gain insight into what it means to walk in a patient’s shoes [41]. However, a limitation must be arisen, that is the interaction with virtual patients is less realistic than the real patients so the emotion sometime cannot be translated to reality.

This chapter aims to present and synthesize the potential of Virtual Reality (VR) in training and enhancing empathy among healthcare professionals. Introducing an educational curriculum that incorporates empathy training through VR could provide an opportunity for medical students to confront the emotional challenges of working with chronic patients, particularly those facing terminal illnesses, in the initial stages of their education.

Acknowledgments

This work was funded by a Margarita Sala postdoctoral fellowship for the requalification of the Spanish university system from the Ministry Government of Spain and financed by the European Union NextGeneration EU (grant UP2021-044).

Conflict of interest

The author declares no conflict of interest.