Abstract
Background
Empathy is an important factor in the doctor-patient relationship, but mental illness is more difficult to understand than other diseases. Besides traditional skills, virtual reality (VR) has been identified as a promising tool in empathy education. This study aimed to investigate the ability of empathy enhancement, the feasibility of depression education, and the changes in thoughts and attitudes in medical students through a single VR experience.
Methods
We recruited medical students and randomly assigned them to two groups based on their completed Interpersonal Response Index scores. Two sets of VR systems were provided; the intervention group experienced the daily life of the depressed medical student, while the control group experienced the general medical student scenario. The improvement of empathy was assessed using the Jefferson Scale of Empathy-Health Professional Students (JSE-HPS), and the change of attitude was assessed through the Implicit Association Test. In addition, other questionnaires were used to evaluate the user experience of this VR system, and correlation analysis was conducted to examine the association between the use of VR and changes in the JSE and IAT scores.
Results
A total of 59 medical students were enrolled in this study. The intervention group showed a significant increase in the perspective-taking (pre: mean 5.817, SD 0.536; post: mean 5.947, SD 0.620; P = .03) and compassionate care (pre: mean 5.546, SD 0.581; post: mean 5.721, SD 0.629; P = .01) domains of the JSE score and a significant decrease in the standing in the patient’s shoes (SP) domain (pre: mean 3.583, SD 1.253; post: mean 2.967, SD 1.252; P = .002). The Pearson correlation analysis found a significant positive correlation between the JSE score with immersion aspect (r = .308, P = .049) and presence aspect (r = .415, P = .01), and we also found a significant negative correlation between the IAT score and presence aspect (r=-.333, P = .04).
Conclusions
This study is the first randomized case-control study to investigate the effect of two different versions of VR on empathy development toward depression for medical students. Although the single VR experience was unable to induce a great improvement in empathy or attitude, the VR system could help medical students enhance their understanding of depressive disorders.
Trial registration
This trial was retrospectively registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) (21/03/2024, ACTRN12624000297527). https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=386683&isReview=true.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12909-024-06009-6.
Keywords: Virtual reality, Major depressive disorder, Mental illness, Empathy, Education
Introduction
Empathy is defined as the ability to understand others’ emotional, moral, cognitive, and behavioral dimensions [1]. Research on empathy lacks conceptual coherence. Therefore, it is essential for studies in this field to operationalize the concept [2]. Although there is a consensus on the importance of empathy in patient care, there is no clear consensus on its definition in this context [3]. In this study, empathy is defined as a cognitive attribute rather than an affective or emotional one. It involves comprehending the pain and suffering of the patient instead of experiencing it and includes the ability to convey this understanding along with an intention to help [4]. Based on this operational definition, the Jefferson Scale of Empathy (JSE) was developed specifically for healthcare providers.
In medical practice, empathy is essential for the doctor-patient relationship; a doctor’s empathy can improve communication, patient compliance, and health outcomes [5]. This is also applicable in mental health care [6, 7]. However, mental illness tends to be more challenging to comprehend and is often not taken seriously by the general population and even healthcare workers. Despite depression being one of the most common mental disorders [8], individuals with depression may be hesitant to seek medical care due to stigmas and discriminations, leading to delays in treatment and a worsening of the illness progression [9].
Empathy can be cultivated and developed [10], and it is an essential skill that medical students should possess [11]. Current medical empathy education is conducted through seminars and workshops [12, 13], learning from seniors during clinical exposure [14], reflective writing [15, 16], role-playing [17–19], group interaction [20], narrative medicine [21], and patient shadowing [22]. Some review articles also mention that perspective-taking and embodied simulation are key elements for achieving success in empathy education [23, 24]. However, traditional empathy education encounters challenges in replicating realistic scenarios and fostering an authentic environment. Limitations include time consumption and the requirement for a face-to-face setting.
Extended reality (XR), encompassing augmented reality (AR), mixed reality (MR), and virtual reality (VR), has recently been identified as a promising and innovative method in medical education [25]. AR and VR have primarily been used for training in the field of surgical techniques. On the other hand, MR and VR can provide an immersive experience in either real or virtual environments, facilitating the sharing of gaze, emotions, and physiological cues, thus offering significant potential for empathy training [26]. VR, in particular, can create a sense of presence in a virtual environment by simulating the actions of characters and their subsequent sensory experiences [27]. The immersion and body transfer characteristics of VR represent a form of perspective-taking and may serve as a potential foundation for empathy development [28]. Strategies for using VR to enhance empathy can be divided into two categories. One involves creating virtual standardized patients, enabling students to practice empathy skills through interaction [29]. The second involves providing an immersive experience by creating a first-person perspective of patients, similar to role-play and patient shadowing in traditional education [30–32].
Immersive virtual reality (VR) has proven successful in fostering empathy for illnesses characterized by physical discomfort, such as chronic pain and the degeneration associated with the elderly [33, 34]. An increasing number of studies are exploring the enhancement of empathy in mental illness. A review article has shown that VR can lead to improvements in knowledge, attitudes, empathy, and reduction in stigma regarding individuals with mental illnesses such as schizophrenia, dementia, and depression [35]. VR can provide an immersive experience into the lives of stigmatized groups, effectively reducing participants’ negative social stereotypes [36]. Some VR systems have added a voiceover to help participants better understand patients’ thoughts and emotions [29, 32]. Caregivers demonstrated improved empathy and confidence in caring for individuals with dementia after experiencing a VR simulation movie with a first-person perspective accompanied by an inner voice [37]. Medical students under VR simulation of psychosis revealed significantly reduced stigma and increased knowledge and empathy compared to traditional visits to patients under supervision [38].
However, within the realm of medical education, there are limited studies addressing the enhancement of empathy in depression through VR. Presently, most studies concentrate on empathy towards dementia and psychosis [39], as authentically portraying the psychological symptoms of depression in a scenario proves challenging. In order to mitigate iatrogenic stigma [40], it is crucial to strengthen empathy training for patients with depression in medical education.
To distinguish our study from previous ones, we provided a VR system experience for both groups, comparing the change in empathy between the two groups with different content experiences (depressed medical students and healthy medical students). This study integrated medical education experience with VR technology to simulate a day in the life of a depressed medical student to explore the efficacy of an immersive VR experience in enhancing the empathy of medical students. Subsequently, we evaluated the user experience of this VR system in various aspects. We hypothesized that VR would increase the attitude and empathy among the two controlled groups.
Methods
Participants
This randomized controlled study was conducted by the National Tsing Hua University and the Chang Gung Memorial Hospital, Taoyuan, Taiwan. The inclusion criteria for this study were fifth-year and sixth-year medical students of any gender or age from Chang Gung University. The exclusion criteria included medical students who had previously received training in the psychiatry department, as well as students with depression or mental health issues. We disseminate recruitment information effectively by leveraging class student social media announcements, sending personalized emails to each student, and utilizing student organizations as channels to ensure widespread awareness of the information. This randomized controlled study adheres to CONSORT guidelines, and the CONSORT checklist is attached as supplementary material 1. This study protocol was approved by the Institutional Review Board of the Chang Gung Memorial Hospital (202001315B0D001).
Procedure
Measurement questionnaires
Interpersonal Reactivity Index (IRI)
IRI was used to measure individual differences in trait empathy, and the test-retest reliability was 0.61–0.81 [41, 42]. This instrument consists of the following four dimensions: perspective taking (PT), fantasizing (FN), empathic concern (EC), and personal distress (PD). Each dimension has seven questions for a total of 28 questions, all answered by a 5-point Likert-type scale. This index was added to the pre-test to ensure that both groups consisted of approximately equal numbers of those with higher and lower empathy scores. We only selected two parts of the index (PT and EC) since they were more relevant to empathy, totaling 14 questions with a maximum score of 70 points (Supplementary Material 2).
Jefferson Scale of Empathy (JSE)
We used the Chinese version of the Jefferson Scale of Empathy for Health Professional Students (JSE-HPS) to measure empathy level. The validity and reliability were 0.89 and 0.92, respectively [43]. JSE-HPS consists of 20 items and three domains, which are perspective taking (PT), compassionate care (CC), and standing in the patient’s shoes (SP). There are 10 positively worded items and 10 negatively worded items, and each item is answered on a 7-point Likert-type scale (1 = Strongly Disagree, 7 = Strongly Agree) [44–46]. Total scores range from 20 to 140, with higher scores indicating a higher level of empathy.
Implicit Association Test (IAT)
The attitude toward depression was measured by IAT. The IAT program was first written by Tony Greenwald, Mahzarin Banaji, and Brian Nosek in 1988 and aimed to investigate bias and disparities in society, with faster response times representing stronger automatic associations [47, 48]. Factors vary between different IAT tests, so the reliability and validity remain controversial. We referred to a study that examined implicit attitudes and stereotypes of depression and physical illness and then created an IAT test using Python software (Supplementary Material 3) [49].
Other questionnaires for VR
Self-Assessment Manikin (SAM) is a pictorial tool used to assess one’s emotional response to experiences regarding the three dimensions of valence, arousal, and dominance. Each dimension has five pictures assisting a 9-point scale [50]. Internal consistency reliability in previous research showed 0.98 in the arousal dimension and 0.63–0.82 in the valence dimension [51]. We examined two dimensions of the SAM post-test, in which lower scores in the valence and arousal dimensions representing more negative and more stable emotions, respectively, following the VR experience. The presence questionnaire 3.0 was used to measure the sense of immersion in our VR system [52, 53] (Supplementary Material 4). Body ownership and agency (BOA) and inclusion of others in the self (IOS) were combined and used to measure the sense of embodiment [34, 36, 54] (Supplementary Material 5). We also referred to previous studies for measuring the sense of presence, such as spatial presence, social presence, and character identification [55, 56] (Supplementary Material 6). The virtual reality sickness questionnaire (VRSQ) was used to measure levels of physical discomfort during the VR experience [57].
Study design
Participants received an online pre-test questionnaire including the Interpersonal Response Index (IRI) and Jefferson Scale of Empathy (JSE) one week before the day of the experiment. We employed stratified randomization to ensure that the IRI scores in both groups are similar, encompassing individuals with both strong and weak empathy. Participants were initially divided into three groups based on their pre-test IRI scores (high, intermediate, and low), and then each group was randomly allocated in a 1:1 ratio into control and intervention groups by the hospital’s Clinical Trial Data Center. On the day of the experiment, we explained the purpose of this research and the experiment process to the participants and required participants to read and sign the consent form. Before the VR experience, they performed a pre-test questionnaire, including the Implicit Association Test (IAT). After completing the IAT questionnaire, participants put on the VR head-mounted displays and began the VR experience, which lasted about 15–20 min. We conducted the VR experience in the Department of Psychiatry at Linkou Chang Gung Memorial Hospital. Then, post-test questionnaires (IAT, JSE, and other questionnaires for VR) were completed. The IAT questionnaire, VR experience and post-test questionnaires were conducted with the assistance of a research assistant. Figure 1 displays the procedure of this study.
Fig. 1.
Flow chart
Equipment
The virtual environment was displayed using an HTC VIVE Cosmos (Taipei, Taiwan). The VR application for both groups was developed with Unity software (2019 Version, San Francisco, American) and was connected to the VIVE device via SteamVR (2.6.1. Version, Washington, America).
VR system
We used shadowing and creating a first-person perspective viewpoint to let the participants experience the daily life and symptoms of the patients, which are strengthened by the story plot, role-playing, and audiovisual technologies. The design of the background setting was similar to that of the participant (the character is a medical student), and the depressed student mainly presented the nine symptoms of depressive disorder based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The two scenes were the same (classroom, hospital, home) but had different content (Supplementary Material 7, Supplementary Material 8); the control group included a typical set of medical students, involving classroom learning at school, internships at the hospital, and scenarios of spending leisure time at home. Certain tasks were placed in the scenario to allow participants to feel more engaged. Several special elements were added in the intervention group, such as the blurred face of other characters, a dimly lit background, repeated internal monologue, and unattainable tasks (to present learners with a helpless situation), which separately present the characteristics of a depressed person such as inattention, a monotonous and boring feeling toward life, ruminating thoughts, and feelings of fatigue. Professional theatrical performers were invited to record the voice-overs. During the development of our VR system, we collaborated with psychiatrists from Chang Gung Hospital and psychologists from Tsinghua University to deepen our understanding of depression and refine the realism of the storyline. Following the completion of the VR system, we conducted testing with a diverse group, including four medical students (two in their third year and two in their sixth year, with one student experiencing anxiety and depression) and three individuals (aged 24 to 26) who had not previously used VR. Their feedback was predominantly positive, and they provided some suggestions during the focused workshop. They found it challenging to empathize with the character’s helplessness, so we made modifications to the monologue. To enhance immersion, we implemented changes such as narrating the initial background story in the first person. Additionally, adjustments were made to the movement functionality to prevent prolongation and abruptness, ensuring a smoother experience.
Statistical analysis
We performed data analysis using Microsoft Excel Add-ins. A simple t-test was used to compare the difference between the pre-test and post-test of the two groups. We adopted the paired t-test to explore the difference between the pre-test and post-test in the same group. Pearson correlation was used to investigate the relation between the domains of JSE and the various elements of the VR experience. We obtained the reliability of measurement by computing the value of Cronbach’s alpha. A two-sided p < .05 was considered statistically significant. This is a pilot prospective study, conducted without reference to relevant VR research on empathy enhancement during the experimental design phase for calculating the necessary sample size. In 2022, a pilot study was published utilizing VR devices to reduce depression stigma. The study involved a sample size of 16 individuals, but the findings did not demonstrate statistical significance in the primary outcome [58]. We made diligent efforts to ensure the sample size in our pilot study represents medical students adequately. We used the general G-power method to calculate that 60 cases need to be admitted, which is equivalent to 30 people in each group (effect size = 0.5, power = 0.85, sample number = 59).
Results
The participant recruitment was conducted from January 2021 to June 2021. We recruited a total of 59 medical students for this study, of which 32 (54%) were male and 27 (46%) were female. No participants were excluded from this study. The demographic characteristics of the participants are shown in Table 1. The intervention group was composed of 14 (46%) males and 16 (53%) females, and the control group was composed of 18 (62%) males and 11 (38%) females. The chi-squared test showed no significant difference in gender distribution between the two groups (P = .24).
Table 1.
Demographic Characteristics of Participants
| Characteristics | Intervention Group | Control Group | P valuea | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Gender | Male | Female | Total | Male | Female | Total | |||
| 14 (47) | 16 (53) | 30 (100) | 18 (62) | 11 (38) | 29 (100) | 0.24 | |||
| Year of Medical School, n (%) | |||||||||
| Fifth | 10 (33) | 5 (17) | 15 (50) | 11 (38) | 6 (21) | 17 (59) | 0.36 | ||
| Sixth | 4 (13) | 11 (37) | 15 (50) | 7 (24) | 5 (17) | 12 (41) | |||
| Age, n (%) | |||||||||
| 22–23 | 2 (7) | 1 (3) | 3 (10) | 7 (24) | 0 | 7 (24) | 0.34 | ||
| 24–25 | 9 (30) | 11 (37) | 20 (67) | 8 (28) | 9 (31) | 17 (59) | |||
| > 25 | 3 (10) | 4 (13) | 7 (23) | 3 (10) | 2 (7) | 5 (17) | |||
| Medical Specialty Preference, n (%) | |||||||||
| Internal Medicine | 4 (13) | 5 (17) | 9 (30) | 5 (17) | 3 (10) | 8 (28) | 0.58 | ||
| General Surgery | 2 (7) | 3 (10) | 5 (17) | 3 (10) | 2 (7) | 5 (17) | |||
| Undecided | 1 (3) | 3(10) | 4 (13) | 2 (7) | 1 (3) | 3 (10) | |||
| Pediatrics | 1 (3) | 1 (3) | 2 (7) | 3 (10) | 1 (3) | 4 (14) | |||
| Emergency | 1 (3) | 0 | 1 (3) | 3 (10) | 1 (3) | 4 (14) | |||
| Others | 4 (13) | 5 (17) | 9 (30) | 2 (7) | 3 (10) | 5 (17) | |||
| IRIb, mean (SD) | 3.769 (SD 0.473) | 3.720 (SD 0.380) | .65c | ||||||
aChi-square test between the two groups
bIRI: Interpersonal Reactivity Index
cOne-tailed simple t-test
Interpersonal Reactivity Index (IRI)
During the pre-test, the participants were divided into three levels (high, intermediate, and low) by an IRI score and were then randomly assigned into the intervention group or the control group. The mean score of IRI was 3.769 (SD 0.473) in the intervention group and 3.720 (SD 0.380) in the control group. The T-test showed no significant difference in the IRI mean score between both groups (P = .65), indicating that the average of individual trait empathy was similar between the two groups.
Jefferson Scale of Empathy (JSE)
Table 2 demonstrates the results of the JSE score before and after the VR experience in the intervention and control groups. Results showed no significant differences in the increase between the two groups in the JSE score (P = .39). We also observed no significant increase in the JSE score between the pre-test and post-test separately in the two groups. Cronbach α of this scale was 0.788 pre-test and 0.821 post-test. Comparing the three empathy domains between both groups, the results showed a significant decrease in the SP domain (P = .001) in the intervention group when compared to the control group. In the intervention group, the result indicated a significant increase from the pre-test to the post-test in the PT and CC domains, but a significant decrease in the SP domain (Fig. 2). In the control group, we found no statistically significant change in any of the three domains between the pre-test and post-test results.
Table 2.
The JSEa score of both groups before and after the VRb experience
| Intervention Group (n = 30) | Control Group (n = 29) | P valued | |||||
|---|---|---|---|---|---|---|---|
| Pre, mean (SD) | Post, mean (SD) | P valuec | Pre, mean (SD) | Post, mean (SD) | P valuec | ||
| JSE | 5.485 (0.422) | 5.558 (0.509) | 0.08 | 5.597 (0.468) | 5.691 (0.490) | 0.05 | 0.39 |
| JSE-PTe | 5.817 (0.536) | 5.947 (0.620) | 0.03 | 5.928 (0.455) | 5.976 (0.519) | 0.27 | 0.22 |
| JSE-CCf | 5.546 (0.581) | 5.721 (0.629) | 0.01 | 5.659 (0.614) | 5.750 (0.564) | 0.16 | 0.23 |
| JSE-SPg | 3.583 (1.253) | 2.967 (1.252) | 0.002 | 3.690 (1.137) | 4.034 (1.239) | 0.07 | 0.001 |
aJSE: Jefferson Scale of Empathy
bVR: Virtual Reality
cOne-tailed Paired T-test
dOne-tailed Simple T-test
eJSE-PT: Jefferson Scale of Empathy-Perspective Taking
fJSE-CC: Jefferson Scale of Empathy-Compassionate Care
gJSE-SP: Jefferson Scale of Empathy-Standing in a Patient’s Shoes
Fig. 2.
Three domains of the JSE score in the intervention group
The Implicit Association Test (IAT)
No significant increases were found in IAT scores in the two groups (Supplementary Material 9). We also observed no significant difference in the increase of IAT scores between both groups (P = .31).
Other questionnaires for VR
Among the other questionnaires for VR, only the valence dimension of SAM showed a significant difference (P < .001) between the control group and the intervention group (Supplementary Material 10). The mean score of VRSQ (Cronbach α 0.819) was 1.267 ± 0.285, and no specific discomfort was mentioned following the VR experience.
Pearson correlation analysis
A Pearson correlation coefficient was computed to determine the relationship between the JSE score and the various elements of VR that were measured after the VR experience in the intervention group (Table 3). Results showed a significant positive medium correlation between the score in the immersion aspect and the JSE score (r = .308, P = .049). A significant positive medium correlation was also observed between the score in the present aspect and the JSE score (r = .415, P = .01) and the PT domain (r = .416, P = .01). Significant negative medium correlation was found in the score in the presence aspect and the IAT score (r=-.333, P = .04). The Pearson correlation coefficient of the control group was demonstrated in Supplementary Material 11, with results showing a significant positive medium correlation between the CC domain of JSE and the immersion, embodied simulation, and presence scores. The Cronbach’s alpha values for the sense of immersion, embodiment, and presence were 0.761, 0.869, and 0.887, respectively.
Table 3.
Correlation coefficients between the JSEa scores and the various elements of the VRb experience in the intervention group
| The VR Experience Questionnaire | Factor | Correlation Coefficient | P valuesc |
|---|---|---|---|
| SAMd-Valence | JSE | -0.121 | 0.26 |
| JSE-PTe | -0.169 | 0.19 | |
| JSE-CCf | -0.073 | 0.35 | |
| JSE-SPg | 0.072 | 0.35 | |
| IATh | 0.080 | 0.34 | |
| SAM-Arousal | JSE | -0.190 | 0.16 |
| JSE-PT | -0.206 | 0.14 | |
| JSE-CC | -0.159 | 0.20 | |
| JSE-SP | 0.056 | 0.38 | |
| IAT | 0.175 | 0.18 | |
| Immersion | JSE | 0.308 | 0.049 |
| JSE-PT | 0.302 | 0.05 | |
| JSE-CC | 0.238 | 0.10 | |
| JSE-SP | 0.025 | 0.45 | |
| IAT | -0.052 | 0.39 | |
| Embodied Simulation | JSE | 0.135 | 0.24 |
| JSE-PT | 0.177 | 0.18 | |
| JSE-CC | 0.048 | 0.40 | |
| JSE-SP | 0.012 | 0.47 | |
| IAT | -0.136 | 0.24 | |
| Presence | JSE | 0.415 | 0.01 |
| JSE-PT | 0.416 | 0.01 | |
| JSE-CC | 0.186 | 0.16 | |
| JSE-SP | 0.281 | 0.07 | |
| IAT | -0.333 | 0.04 |
aJSE: Jefferson Scale of Empathy
bVR: Virtual Reality
cPearson Correlation Analysis
dSAM: Self-Assessment Manikin
eJSE-PT: Jefferson Scale of Empathy-Perspective Taking
fJSE-CC: Jefferson Scale of Empathy-Compassionate Care
gJSE-SP: Jefferson Scale of Empathy-Standing in Patient’s Shoes
hIAT: Implicit Association Test
Discussion
In this study, we aim to evaluate the impact of VR on medical students, specifically in enhancing their empathy and attitudes towards depression. This topic has been relatively unexplored, with only a few studies addressing it [39]. The primary hypothesis of this study was that a well-designed VR experience could enhance medical students’ empathy towards patients with depression. But, in our results did not show a statistically significant difference in the total scores of the JSE scales between the experimental group and the control group. The lack of significant differences in this single-blind, randomized controlled study indicates that a single VR session may not be sufficient to promote empathy. Improvements in empathy scale scores were seen in both the control and experimental groups, aligning with previous studies using VR to enhance empathy. However, the absence of significant differences could be attributed to the fact that not every aspect of empathy was sufficiently enhanced by VR stimulation, as well as certain limitations in this study. Additionally, we did not observe any improvement in attitudes towards depression following a single VR experience in this study.
Our study revealed no significant difference in the change of the JSE score before and after the VR experience between the two groups. This finding may be explained by the factors described below. First, the participants were composed of fifth-year and sixth-year medical students, who were shown to have high self-reported JSE scores [12]. In this study, the JSE total score during the pre-test was 109 and 111 respectively, out of 140 points in the interventional and control group, which may have caused a ceiling effect. Second, the institutional review board of the hospital regulates that all participants should be informed of the purpose, process, method, and content of the study in advance. Consequently, students in the control group may have had a sham effect because they may have assumed that the VR experience was being used to enhance empathy. In addition, the significant decrease in the SP domain in the intervention group offset the increase in the PT and CC domains, resulting in a non-significant improvement in the overall JSE score [46].
Significant improvement was observed in the PT and CC domains in the intervention group following the VR experience (Table 2), which verifies the success in user experience and content design of this VR system [59]. Role-playing achieved a powerful reinforcement in perspective-taking through a first-person perspective in a VR scenario of a depressed medical student. Visual effects for creating a negative emotional atmosphere and the continuous monologues made it easier for the participants to synchronize with the psychological perspectives of the character and thus enable them to be more compassionate [29, 32]. Conversely, the SP domain significantly decreased in the intervention group. This system highlighted the cognitive distortions and negative thinking patterns caused by depression, allowing participants to recognize how differently they thought and behave compared to those with depression and how difficult it is to stand in their shoes. Such disorienting dilemmas can catalyze changes in beliefs, starting from a foundation of self-questioning [36]. However, experiencing or witnessing the symptoms of depression can be interpreted or felt differently by various medical students. Merely experiencing depression symptoms through VR, without the intervention of other educational methods, may not generate a sufficient and accurate understanding of these symptoms. Instead, it could potentially lead to the opposite effect, resulting in a decline in the SP domain.
The valence dimension of SAM showed significantly more negative emotion in the intervention group than in the control group (Supplementary Material 10), which indicated the success of the melancholic atmosphere created in the VR scenario [50]. However, it did not lead to significant changes in either JSE or IAT scores (Table 3).
The correlation test revealed several meaningful findings. Significant positive correlation was found between the immersion aspect score and the JSE score, indicating that the participants would be more empathetic if they felt more of a sense of immersion from the VR experience [52, 53]. The result of the correlation analysis between the presence aspect and the JSE and IAT scores indicated that the participants could be more empathetic and have a lesser negative attitude towards depression if they felt a stronger sense of presence in the VR experience [55, 56]. Nevertheless, we cannot rule out that a higher level of empathy has the potential to influence inter personal emotions, thus resulting in more of a realistic sense of immersion and presence.
Our results are consistent with previous studies that found that role-playing through VR could be used to improve participants’ empathy [29, 32]. Most virtual reality relies on visual feedback, such as the reflection of others [60], a simulated environment [29], and an image of a virtual avatar [36]. Students may exhibit diverse learning styles [61], so we need to strive to diversify learning methods whenever possible, and virtual reality may benefit particular learners. Our system focused on creating an atmosphere and designing monologues, elements that proved to be effective in our results (Table 2). The monologue section is based on narrative medicine [62], and such an integrated patient experience could be easier and more efficient than having a direct conversation with patients. The current effect of traditional empathy education may be inconsistent due to the different training processes of each person, but such an issue could be solved through standardized and repeated VR training. We also hope that the VR system can be used as an adjunct tool for routine empathy education, offering a long-term impact on students. Furthermore, VR was an extremely useful way of teaching mental health when person-to-person gatherings were forced to be suspended due to the COVID-19 pandemic.
This study had several limitations. First, the participants are all fifth-year and sixth-year medical students from a single university, and the sample size was small due to the influence of the COVID pandemic. Although we designed the VR experience to reflect the daily life of a general medical student, the diverse experiences of individual students present challenges to the generalizability of our VR design. In order to recruit a sufficient number of participants, we opened the experiment to medical students who met the criteria and were willing to participate. This may result in self-selection bias. Second, a single experience may not be strong enough to induce a significant change in empathy or attitude, and a longer period of intervention may be required in future studies [13, 62]. Furthermore, long-term follow-up of these medical students in their dealings with depressive disorder patients was not examined in our study. Third, the JSE scale has a potential ceiling effect on measuring medical students’ empathy, and we should thus choose a more sensitive Chinese version of a measurement tool in future practices. Also, we made no direct comparison of efficacy with current traditional empathy education in this study. Fourth, we still experienced many technical problems. The equipment would overheat if we kept it on too long, so we had to limit the experience time to 20 min. Fifth, the VR scenario should be optimized to strengthen the sense of immersion. Finally, we used the DSM-5 criteria for major depressive disorder as the basis for designing the VR simulation of a depression patient. However, this approach may oversimplify the patient’s symptoms and overlook individual differences. This is a critical point that must be carefully considered when using VR in medical education.
Conclusion
This study is the first randomized case-control study to investigate the effect of VR on empathy education regarding depression for medical students. Our results demonstrated that a single VR experience could only improve certain aspects of empathy and did not significantly change attitudes towards people with depression. This indicates that a single VR experience is insufficient and should be complemented with additional medical education methods. We also observed that in scenarios where both groups involve VR, there is a need for more effort to enhance the realism and immersion of VR to differentiate between the depression group and the general student group. The VR experience provided a unique perspective, allowing students to experience and identify the symptoms of depression. Future research should aim to enhance the realism of VR, extend the VR experience to a longer-term course, and integrate additional educational methods.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Supplementary Material 1: CONSORT checklist
Supplementary Material 2: Interpersonal Reactivity Index
Supplementary Material 3: Implicit Association Test
Supplementary Material 4: The sense of immersion
Supplementary Material 5: The sense of embodiment
Supplementary Material 6: The sense of presence
Supplementary Material 7: Scenes of the Control Group
Supplementary Material 8: Scenes of the Intervention Group
Supplementary Material 9: Comparison of IAT between the Two Groups
Supplementary Material 10: Comparison of Other Questionnaires for VR between the Two Groups
Supplementary Material 11: Correlation Coefficients between the JSE Scores and the Various Elements of the VR Experience in the Control Group
Acknowledgements
This study was conducted by the National Tsing Hua University and the Chang Gung Memorial Hospital. All authors contributed to the article and approved the submitted version.
Abbreviations
- CC
Compassionate Care
- IAT
Implicit Association Test
- IRI
Interpersonal Reactivity Index
- JSE-HP
Jefferson Scale of Empathy-Health Professional Students
- JSE
Jefferson Scale of Empathy
- PT
Perspective Taking
- SAM
Self-Assessment Manikin
- SD
Standard Deviation
- SP
Standing in the Patient’s Shoes
- VR
Virtual Reality
- VRSQ
Virtual Reality Sickness Questionnaire
Author contributions
NW Yu, YS Huang, HL Lin, ML Huang, and YC Hsu: Conception and Design of the Project. HL Lin, YC Wang, and I Tang: Data Collection. ML Huang and I Tang: Data Analysis. HL Lin, YC Wang, and YS Huang: Article Draft, Manuscript Editing, and Critical Revision of the Article. YS Huang and YC Hsu: Final Approval of the Version to be Published.
Funding
This study was supported by the Chang Gung Memorial Hospital Research Grants (CMRPG CORPG3L0021) and (CMRPG3N0491) awarded to HL Lin and YC Hsu.
Data availability
Data is provided within the manuscript or supplementary information files.
Declarations
Ethical approval
The protocol of this randomized controlled trial was approved by the Institutional Review Board of Chang Gung Memorial Hospital (202001315B0D001). All participants signed their informed consent.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Yu-Chen Hsu and Yu-Shu Huang contributed equally to this work.
Contributor Information
Yu-Chen Hsu, Email: ychsu@mx.nthu.edu.tw.
Yu-Shu Huang, Email: yushuhuang1212@gmail.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary Material 1: CONSORT checklist
Supplementary Material 2: Interpersonal Reactivity Index
Supplementary Material 3: Implicit Association Test
Supplementary Material 4: The sense of immersion
Supplementary Material 5: The sense of embodiment
Supplementary Material 6: The sense of presence
Supplementary Material 7: Scenes of the Control Group
Supplementary Material 8: Scenes of the Intervention Group
Supplementary Material 9: Comparison of IAT between the Two Groups
Supplementary Material 10: Comparison of Other Questionnaires for VR between the Two Groups
Supplementary Material 11: Correlation Coefficients between the JSE Scores and the Various Elements of the VR Experience in the Control Group
Data Availability Statement
Data is provided within the manuscript or supplementary information files.