The Feasibility of Virtual VitalTalk Workshops in Japanese: Can Faculty Members in the US Effectively Teach Communication Skills Virtually to Learners in Japan?

Abstract

Background:

VitalTalk is an established training program for serious illness conversations in the US. Previously, this training course has been provided in-person in Japanese, but never virtually.

Objectives:

To evaluate the feasibility of a virtually administered VitalTalk workshop in Japanese.

Setting/Subjects:

We conducted a virtual workshop which consisted of 2 days (3 hours per day) of synchronous sessions and preceding asynchronous modules. Five VitalTalk faculty members in the US facilitated 4 workshops for 48 physicians from 33 institutions across Japan. Learners completed surveys before and after the workshop.

Measurements:

To evaluate the feasibility, learners were asked for their satisfaction with the workshop and the virtual format as primary outcomes and their self-assessed preparedness in serious illness communication as the secondary outcome. Each question employed a 5-point Likert scale.

Results:

All learners (n = 48, male 79%) participated in the survey. The mean score of the learners’ satisfaction was 4.69 or higher in all questions. The mean score of the virtual format’s satisfaction was 4.33 or higher in all questions. The mean score of self-reported preparedness on the 11 questions were between 2.30 and 3.34 before the workshop, all of which significantly increased to 3.08 through 3.96 after the workshop (p < 0.01 in all questions).

Conclusion:

Learners in Japan perceived the virtual format of our VitalTalk workshop as satisfactory, and their self-reported preparedness improved significantly after the workshop. VitalTalk faculty members in the US were able to provide virtual communication training to physicians in Japan.

Introduction

For clinicians caring for critically ill patients, serious illness communication skills are paramount to delivering patient-centered care. These skills help clinicians build a relationship of trust with patients, improve the quality of life of patients and their families at the end of life, and reduce healthcare costs.^1–4

VitalTalk is an established training program for medical professionals on communication skills with critically ill patients and their families.¹ The founders of VitalTalk started training oncologists in communication skills about 20 years ago and the training has since evolved for all medical professionals. VitalTalk courses teach a variety of communication tools for discussing “bad news.” The methods for their courses are evidence-based, incorporating results of various studies for effective educational methods. VitalTalk courses have been modified for various specialties, such as “GeriTalk” for geria-tricians,⁵ “IntensiveTalk” for intensivists,⁶ “NephroTalk” for nephrologists,⁷ and “EMTalk” for emergency clinicians.^8,9 To date, there have been more than 10,000 VitalTalk course attendees in the U.S. and there are over 500 certified facilitators. (http://www.vitaltalk.org/about-us)

In order to train physicians practicing in Japan, our team adapted VitalTalk pedagogy into the Japanese language. We held in-person workshops and trained 24 physicians in Japan.¹⁰ While in-person workshops were well received overall, one significant barrier was its resource-intensiveness because faculty members in the US have to travel to Japan.

The COVID-19 pandemic has accelerated changes in how education occurs and unexpectedly created an opportunity to abolish this barrier. Our group developed a virtual communication training workshop based on VitalTalk pedagogy. We held the workshop 4 times and trained 48 physicians from 33 institutions throughout Japan.

The feasibility of a virtual version of GeriTalk has been reported previously.¹¹ However, at this time, there are no reports of a virtual VitalTalk program being conducted over multiple countries in a language other than English. The aim of this study is to evaluate whether it is feasible for VitalTalk faculty members in the US to provide a virtual communication training program in Japanease for learners in Japan.

Materials and Methods

Adaptation From an In-Person to a Virtual Format

Previously, our group created an in-person Vital Talk workshop in Japanese.¹⁰ It was a 4-hour session in 1 day and covered a six-step protocol for breaking bad news (SPIKES; Setting, Perception, Invitation, Knowledge, and Summarize)¹² and skills for responding to patients’ emotions (NURSE statements; Name, Understand, Respect, Support, and Explore).¹³

For the virtual format, we developed a course which consisted of two 3-hour sessions with a 1-week interval (Figure 1). In order to accommodate learners’ various schedules from different practice settings and the time difference between the US and Japan, synchronous sessions were scheduled on Sunday mornings in Japan. Twelve learners were recruited for each workshop. Learners were divided into 2 groups of 6 learners and 1 to 2 faculty members facilitated the workshop in each group. Each learner was recommended to participate in a quiet room with privacy.

Figure 1.

Virtual vital talk Japan workshop schedule and content. SPIKES; an acronym for setting, perception, invitation, knowledge, emotion, and summarize. NURSE; an acronym for name, understand, respect, support, and explore. REMAP; an acronym for reframe, expect emotion, map out patient goals, align with goals, and propose a plan.

Asynchronous modules included a series of videos of lectures and skill demonstrations. These modules were sent to the learners 1 week before each synchronous session for them to watch. The structure of role-play and curricular material were adapted from VitalTalk’s Virtual Mastering Tough Conversations course.¹⁴

After the previous in-person training sessions, learners’ feedback included that they would like to practice eliciting goals of care and discussing life-sustaining treatment. Accordingly, in this virtual workshop, day 1 covered breaking bad news and responding to emotions, and day 2 covered eliciting goals of care and discussing life-sustaining treatment (REMAP; Reframe, Expect emotion, Map out patient goals, Align with goals, and Propose a plan).¹⁵

Recruitment of Learners

We held 4 workshops and recruited a total of 48 learners (12 learners per workshop). The course information for recruitment was posted on our website (https://www.facebook.com/vitaltalk.jp) and emailed to a pool of physicians who previously participated in our presentations regarding VitalTalk at conferences in Japan. All learners registered our workshops voluntarily. All learners and standardized patients were physically in Japan at the time of participation in our workshops.

Faculty Profiles

There are 5 faculty members in our group, all of which are natives of Japan, are fluent in both English and Japanese, and have obtained VitalTalk faculty certification in the United States. Our faculty facilitated sessions in different time zones: 2 in Eastern Standard Time, one in Pacific Standard Time, one in Hawaii Standard Time, and one in Japan Standard Time.

Survey instruments.

We conducted 3 types of surveys, one for learners’ satisfaction with our workshop, one for a self-assessment of preparedness in communicating with critically ill patients, and one for the evaluation of the virtual format. Learners completed all surveys anonymously using the online survey application “Google Form.” Surveys for a self-assessment of preparedness were conducted before day 1, and immediately after day 2. All other surveys were done immediately after day 2. We adapted our survey questions for the learners’ satisfaction and the self-assessment of preparedness from the course evaluation of OncoTalk.¹⁶ The survey has been used as a general method to evaluate the teaching effectiveness of various VitalTalk-derived communication training programs, therefore, we considered it as a standardized evaluation indicator. In addition, specifically for this virtual format, we added questions to evaluate the learners’ satisfaction with the technical aspects of the virtual workshops. The survey on the technical aspects of the virtual format was developed based on the survey used in the VitalTalk virtual course in the United States. These questions were iteratively discussed among our group. Each question employed a 5-point Likert scale (e.g., 1 = Not at all and 5 = Very much).

Outcome Measures

In order to evaluate the feasibility of our workshop, we defined our primary outcomes as learners’ satisfaction with the workshop as well as the technical aspects of the virtual format. As a secondary outcome, we measured the improvement of self-reported preparedness after the workshop.

Data Collection and Analysis

All survey responses were collected anonymously and de-identified. Mann-Whitney U test was used to compare the results of the communication preparedness before and after the virtual training. P value <0.05 was considered statistically significant, and all reported p values were 2-tailed. Statistical analysis was performed using IBM SPSS (for Mac, version 27.0; IBM Corp., Armonk, New York). Institutional Review Board in Teikyo University reviewed and approved this study.

Results

Demographics

A total of 48 physicians from 33 institutions throughout Japan participated in our virtual VitalTalk workshops. Learners’ demographics were summarized in Table 1. The mean age was 40.0 ± 9.4 years and the mean years in practice was 14.3 ± 10.8 years. Regarding the specialties of the learners, 20 (41.7%) were internal medicine, 10 (20.8%) family medicine, and 6 (12.5%) palliative medicine. While 29 learners (60.4%) had received some communication training in the past, only 3 learners (6.3%) had experienced communication training in a virtual format. There were 4 learners (8.3%) who had attended our in-person workshops in the past. All 48 learners completed the pre- and post-survey.

Table 1.

Baseline Characteristics.

	N = 48
Age, year, mean ± SD	40.0 ± 9.4
Years in practice, mean ± SD	14.3 ± 10.8
Male, n (%)	38 (79%)
Specialty, n (%)
Internal Medicine	20 (41.7)
Family Medicine	10 (20.8)
Palliative care	6 (12.5)
Critical Care	4 (8.3)
Emergency Medicine	2 (4.2)
Pulmonology	2 (4.2)
Oncology	1 (2.1)
Pediatrics	1 (2.1)
Others	2 (4.2)
Any communication training in the past	29 (60.4)
Any virtual communication training in the past	3 (6.3)

Learners’ Satisfaction

The results of the learners’ satisfaction were summarized in Table 2. The mean score was 4.69 or higher in all questions. The mean score of the questions, “How would you rate the education quality of the program?” and “Would you recommend this training course to other physicians?,” were both 4.92.

Table 2.

Summary of learners’ satisfaction.

Learners’ satisfaction with the virtual VitalTalk workshop in Japanese	Score (mean)
How would you rate the importance of training to the development of your own clinical skills?	4.98
Usefulness of the recorded lectures for preparation	4.75
Usefulness of the communication skills small group practice sessions	5.00
Effectiveness of the small-group leaders	4.83
Usefulness of reflective exercises (taking it home session)	4.77
Overall, how would you rate the educational quality of the program?	4.92
I would recommend this training workshop to other physicians	4.92
Commitment to changing 2 self-identified communication behaviors	4.69
How would you rate the importance of good communication skills to being an excellent physician?	4.92

Five point Likert scale (1 = Not at all, 5 = Very much).

The mean score of the evaluation of the virtual format was 4.33 or higher in all questions. The mean score of the question, “How realistic was the virtual encounter compared to an in-person encounter?,” was 4.38 (Table 3).

Table 3.

Feasibility of the virtual format.

Evaluation of the virtual format	score (mean)
Accessibility to the course via zoom link	4.40
How clear were the lecture slides to you?	4.63
How clear was the sound during the lecture?	4.58
How clear was the video image when it was your turn to role-play?	4.58
How clear was the sound when it was your turn to role-play?	4.54
How clear was the video image when it was other learner’s turn to role-play?	4.71
How clear was the sound when it was other learner’s turn to role-play?	4.52
How clear was the video image during the time-out discussion?	4.65
How clear was the sound during the time-out discussion?	4.56
How easy was it to ask a question to facilitators?	4.33
How realistic was the virtual encounter compared to an in-person encounter?	4.38

Five point Likert scale (1 = Not at all, 5 = Very much).

Self-Reported Preparedness

The results of self-reported preparedness for serious illness conversations were summarized in Table 4. Before the workshop, the mean scores on the 11 questions were between 2.30 and 3.34, which improved to 3.08 through 3.96 after the workshop. All the improvements were statistically significant.

Table 4.

Self-Reported Preparedness.

How well prepared do you feel to do the following?	Pre	Post	p value
Giving bad news to a family about their loved one’s illness	3.09	3.77	<0.001
Conducting a family conference	3.26	3.81	<0.001
Expressing empathy	3.34	3.96	<0.001
Discussing various treatment options, including palliative care, with the family of critically ill patients	3.13	3.83	<0.001
Responding to family members who deny the seriousness of their loved one’s illness	2.60	3.44	<0.001
Discussing discontinuing intensive care treatment	2.85	3.63	<0.001
Responding to family members who want treatments that you believe are not indicated	2.55	3.31	<0.001
Discussing code status (DNR) with the family	3.21	3.79	<0.001
Discussing religious or spiritual issues with the family	2.45	3.23	<0.001
Discussing a family’s request to hasten death	2.30	3.08	<0.001
Eliciting a family’s concerns at the end of a patient’s life	3.13	3.69	0.004

Five point Likert scale (1 = Not at all, 5 = Very much).

Discussion

In this study, we evaluated the feasibility of a virtual communication skills workshop in the Japanese language. To assess the feasibility, we measured learners’ satisfaction with the workshop and its effects on self-reported preparedness. A virtual format of VitalTalk training was recently reported, where geriatric and palliative medicine fellows in 3 urban academic institutions were trained.¹¹ Our workshop is unique in 2 aspects. Firstly, our virtual VitalTalk workshop was conducted in a language other than English. Secondly, the virtual format allowed facilitators in 4 different time zones in the US and Japan to provide communication skills training to 48 learners with various backgrounds and different previous experience with communication skills training from 33 institutions in Japan.

The most important finding is that learners in Japan were satisfied with our virtual VitalTalk workshop. The learners rated the educational quality highly and all of them stated that they would highly recommend our workshop to other physicians. The mean scores of the learners’ satisfaction were 4.69 or higher on a 5-point Likert scale, and these scores were comparable to previous studies with in-person VitalTalk workshops.^11,17,18 Learners also highly rated the technical aspects of the virtual workshops, such as the screen and the sound.

We held in-person VitalTalk workshops in Japanese in the past.¹⁰ While it was well-received, it was resource-intensive because it required our faculty members in the US to travel to Japan as well as learners in various institutions to travel to a set location in Tokyo.The virtual format allowed us to eliminate the cost and time of travel for both faculty and learners as well as the need of setting up a venue. This suggests that workshops can be held more frequently and at a lower cost, making it possible for more learners to access the training more easily. It also allowed us to schedule 2 synchronous sessions with 1 week in between. Multiple learners reported that it helped them to try the skills they learned on day 1 (SPIKES/NURSE) in their clinical practice, which helped their learning on day 2, because skills in day 1 are necessary for eliciting goals of care and discussing life-sustaining treatments.

Furthermore, the learners’ self-reported preparedness significantly improved after the workshop. The previous study of virtual GeriTalk worshops showed improvement on self-assessed preparedness comparable to in-person workshops.¹¹ Our data also suggested that the virtual format of VitalTalk in Japanese was able to provide a satisfying learning experience for learners in Japan. There were 4 learners who participated in both the in-person and virtual workshops, but the anonymous survey did not allow us to separate their responses from the rest of the learners. Given the overall positive responses in the current study, we do not think their responses will minimize the learning effects of a virtual workshop.

There are several limitations in our study. First, we do not have data about self-reported preparedness of in-person VitalTalk courses in Japanese, and therefore we are not able to directly compare the effectiveness between the virtual format and in-person format. Yet, we expect similar results compared to previously established training in English given the same content of the training. Second, many of the learners were physicians with a high interest in communication skills training, and their survey results may differ from those of physicians in general. Since many of these physicians had taken other existing communication training courses in Japan prior to our workshop, we would trust their judgment in evaluating ours. Lastly, our workshop in Japanese is still in the development stage and under research for cultural adaptation, and therefore it is unknown whether the content itself is fully suitable for Japanese culture. In our previous qualitative study, there were opinions that our in-person VitalTalk workshop did not incorporate enough of the cultural differences of Japanese people, such as their tendency to hide their emotions. In response, we plan to conduct a Delphi panel involving medical practitioners in Japan who have a deep knowledge of communication skills and Japanese culture to further refine our workshops.

Conclusions

Learners in Japan were satisfied with the virtual format of the VitalTalk workshop. It was effective to improve learners’ self-reported preparedness for serious illness communication. It was feasible for faculty members in the US to provide communication training virtually to learners in Japan. It is possible that our virtual VitalTalk workshops in Japanese will likely help accelerate the spread of this pedagogy among clinicians in Japan.