Timothy C. Guetterman, PhD tguetter@umich.edu Collaborators - PowerPoint PPT Presentation

Timothy C. Guetterman, PhD tguetter@umich.edu

Collaborators ¡ Michael D. Fetters ¡ Mas Jimbo ¡ Pedja Klasnja ¡ Larry An ¡ Rich Gonzalez ¡ Erika Rosenberg, UC Berkley/Consultancy ¡ Fredrick W. Kron, MCI ¡ Mark W. Scerbo, Old Dominion University Funding ¡ 1-K01-LM-012739, NIH/NLM, Guetterman (PI), Enhancing Verbal and Nonverbal Communication through Virtual Human Technology

¡ Background - communication training with MPathic-VR ¡ Mixed Methods Randomized Controlled Trial ¡ Current research in progress

Decreased Satisfaction Harm/errors Patient /malpractice attrition lawsuits Poor Communication Poorer Poorer team Outcomes functioning

¡ Yes

¡ Emotional care ¡ Cognitive care Outcomes information empathy Blood pressure Cognitive care Emotional Care gathering respect Pain sharing medical trust Quality of Life information genuineness patient acceptance education warmth expectation management

¡ Under-addressed in medical training ¡ Need experiential learning and practice ¡ Teach techniques ¡ Standardized patient instructors

S—SETTING UP THE INTERVIEW P—ASSESSING THE PATIENT’S PERCEPTION I—OBTAINING THE PATIENT’S INVIT A TION K—GIVING KNOWLEDGE AND INFORMATION TO THE PATIENT E—ADDRESSING THE PATIENT’S EMOTIONS WITH EMP A THIC RESPONSES S—STRATEGY AND SUMMARY

¡ Reflective listening ¡ Empathy enhancers ¡ Avoiding empathy blockers ¡ Appropriate use of facial expression (i.e., brow raises, smiles) ¡ Appropriate body language (i.e., nodding, body lean)

¡ Mehrabian and Ferris reported only 7% of emotional communication is conveyed verbally; 38% is conveyed by voice tone and inflections, and 55% is transferred by facial expressions

¡ Intelligent virtual agent ¡ Simulate human behavior and appearance using computer technology ¡ Design with the capability to present humanlike behavior for interaction

¡ Cost savings ¡ Reliability ¡ Interactive ¡ Enhanced motivation to learn

¡ Goal: Understand how new media can be used to develop a breaking bad news prototype featuring a one-on-one interaction with a virtual human patient NIH 3R03LM010052-0151, Kron FW, Fetters MD (Co-Pis)

Teaching Points: This is where the identifies learner behaviors that were either good, or could use improvement. It gives individualized feedback on communication that allows learners to reflect on their performance, then go back and try to improve. Used with Permission of Medical Cyberworlds, Inc.

¡ The learner § wears headphones with microphone, § clicks on MPathic Icon, § selects gender for voice recognition profile ¡ For each scenario, the learner § chooses from three choices that are spoken into the microphone § options include bad, better, best with different point values for each

¡ Robin presents with unstoppable nose bleed ¡ Her labs demonstrate she has a severe form of leukemia ¡ Player discloses to Robin she has cancer. She flares with disbelief and anger…...

¡ Breaking bad news and intercultural communication ¡ Provider-provider tension Screenshots with Permission of Medical Cyberworlds, Inc.

Screenshots with Permission of Medical Cyberworlds, Inc.

481 assessed for eligibility 46 excluded • 39 declined to participate • 6 enrolled but declined to 435 Randomized have data used • 1 excused 220 assigned to intervention 215 assigned to control 210 received as assigned 9 did not receive (technical problems) 1 discontinued intervention 4 discontinued control 210 included in analysis 205 included in analysis (OSCE, Attitudinal Scale, (MPathic score, OSCE, Attitudinal Scale, written written qualitative reflection qualitative reflection at at completion) completion)

¡ Attitudinal Scale ¡ Qualitative written reflections and observations ¡ MPathic-VR game score ¡ Objective Structured Clinical Examination with Standardized Patient Instructor ¡ Video recordings of interaction ¡ Kinect sensor nonverbal data

MPathic Score QUANTITATIVE QUALITATIVE • A lower score in MPathic-VR reflects better performance-less ¡ MPathic score improved ¡ Verbal communication optimal choices were penalized pre-post, intercultural and ¡ Nonverbal communication with higher values inter-professional scenarios ¡ Engagement of training • Best of the three options scored ( p <.001) ¡ Supplemental training 0 points; two suboptimal ¡ Immediate feedback options had higher point values • Intercultural scenario included 16 exchanges (0 to 29 points) • Inter-professional scenario had 13 exchanges (0 to 25 points)

QUANTITATIVE OSCE • SPIs blinded to the trial ¡ OSCE Composite Score ¡ Verbal communication • Evaluated each student’s between groups better for ¡ Nonverbal communication performance (intervention and MPathic ( p =.01) ¡ Engagement of training control arms) using a 5-point ¡ Supplemental training grading format ¡ Immediate feedback • Four domains: openness/defensiveness, collaborative/competitive, nonverbal communication, and presence (awareness of others) • α = 0.82.

QUANTITATIVE Attitudinal Scale ¡ Student attitudes scale • 12 items more positive for MPathic • 7-point Likert-type (p <.001) • Four domains: clarity, purpose, utility, and likelihood to recommend the learning experience • α = .95

Written Reflection QUALITATIVE • “Reflect on how you think this learning experience in advanced ¡ Verbal communication communication skills could be ¡ Nonverbal communication improved” ¡ Engagement of training • “Reflect about the three most ¡ Supplemental training important things you learned ¡ Immediate feedback from this interaction.” • “Reflect on how interacting with the system has influenced your understanding about nonverbal communication.”

Domain Intervention Control MM Inference MPathic-VR CBL Domain Attitudinal Qualitative Reflection Attitudinal Qualitative Reflection Interpretation of mixed Item Mean Illustrative Quotes Item Mean Illustrative Quotes methods findings (SD) (SD) Verbal 4.11 “How to introduce myself 2.77 “This educational module Intervention arm comments Communication without making was useful for clarifying suggest deeper (1.85) (1.45) assumptions about the the use of SBAR and understanding of the cultural background of addressing ways that all content than teaching using the patient and the members of a health care memorization and family” team can improve patient mnemonics as in the care through better control, a difference communication skills” confirmed by higher attitudinal scores. Nonverbal 5.13 “Effective 2.34 None Intervention arm comments Communication communication involves address the value of (1.48) (1.35) non-verbal facial learning non-verbal expression like smiling communication, the and head nodding” difference confirmed by attitudinal scores. Training was 5.43 “Reviewing the video 3.69 “This experience can be Intervention arm comments engaging review was a great way to improved by incorporating reflect engagement through (1.55) (1.62) see my facial expressions more active participation. the after action review and it allowed me to For example, there could while the control comments improve on these skills have been a scenario in suggested the need for the second time around” which we would have to interaction, the difference select the appropriate confirmed by higher hand-off information per attitudinal scores. SBAR guideline”

Theme Quan data -categorized OSCE Advanced Communication Assessment Themes Low Medium High (<.55) (.54 - .98) (> .98) N/A “Effective communication both verbal and non “Useful in making sure I used inclusive language Useful communication verbal will be essential in getting the best care and was sensitive to the feelings of others” skills for patients” “I vs. we…” “Smiling and nodding is also important” (6%) “Body language is super important in “Helped teach how to read facial expressions Remembering establishing relationships with patients and from people such as when the nurse was upset” nonverbals colleagues”(65%) N/A N/A “It would be interesting to go through other Motivated to learn more scenarios, and to see if this actually has a positive effect on my future interactions with patients” “hard to engage in non-verbal communication “think that training for communication with “true response can only come from human to Prefer humans when you know you are just talking at a patients is better done with live patients” human interaction…program is much stronger computer” at allowing a person to think about their verbal responses” “I mostly just got annoyed” “Repeating was boring…I would have asked N/A “Too repetitive” clarifying questions that weren't listed.” “I was really annoyed when I had to redo one “'non-verbal' advice was probably less helpful. It N/A Doubting nonverbals module because I didn't smile at a computer is hard to get fully emotionally engaged with a image or "raise my eyebrows." In theory, I feel module the same way one would with a real like this exercise would be fine, but not in person” practice”