Standardized patients (SPs) are routinely used to teach medical students communication and physical diagnosis skills (1–5). Standardization and decreased risk of possible harm being committed by training students (6) are only a few of the advantages provided by SPs. SPs can provide a detailed history, can answer directly to the students, and give feedback for improvement (1, 6, 7). However, SP interactions are limited by the availability of the actors, time constraints, and costs (8). An alternative to SPs is use of computer simulation. Virtual-patient (VP) systems are computer programs that simulate real-life clinical scenarios in which the learner can complete a patient interview and physical exam, while making diagnostic and therapeutic decisions (9). VP systems allow standardized instruction, immediate and objective performance feedback, and unlimited opportunity for repetitive practice (10).

VPs and computer simulations are already used in various branches of medicine to teach communication, counseling, crisis management, procedures, leadership, teamwork, and medical decision-making skills (11). Virtual reality is already used as exposure therapy to treat panic disorders, posttraumatic stress disorder, (12) social phobias, and specific phobias (13, 14). In 1966, ELIZA (15) became the first virtual psychiatric tool by engaging the user in a text-based psychotherapy session. It was never used as an actual treatment protocol, but it did set the stage for using computer simulation as a tool in diagnosing and treating mental illnesses (13). However, even with the foundation laid, there are only a few published applications of a psychiatric VP scenario used as a training modality in medical student education (8, 16). We present the preliminary evaluation of a web-based VP scenario that assesses students' ability to elicit symptoms of major depression. The study was performed using the online application called Virtual People Factory (VPF; http://www.virtualpeoplefactory.com), (17) developed by the University of Florida's Virtual Experiences Research Group. Currently, many VP systems entail the learners' going through an evolving scenario where they sequentially answer multiple-choice questions about history, diagnosis, and management of patients. VPF is a web-based, instant-messaging application that elicits a VP's medical history, based on the questions a user asks, therefore allowing students to make their own assessments of the most appropriate next step in the interview, rather than passively choosing from a list of possible answers.

The process of creating a VPF interaction entails the following steps: Initially, an editor creates a script of the medical scenario, including what can be potentially said to the VP (questions/statements) and what the VP will respond back (speeches). Next, the scenario is sent out to users. Users log in to the system, are presented with a brief introduction of the patient similar to the introduction given to students before they enter the room to interview an SP, and then ushered into the chat interface. Once inside the interface, the user can engage the patient in conversation to obtain a full medical history. Every user's input will yield a speech response. If there is not a speech response affiliated with a question or if the speech response is incorrect for a given question, the event is logged for the editor, to either create a new speech response or connect it correctly with the right question. Numerous user interactions will therefore allow for a robust database of the various questions and speech responses to be built for any medical scenario.

Using VPF, we created a hypothetical scenario involving “Ms. Cynthia Young,” a 21-year-old college student, who has been referred to the doctor by her college campus counselor. With a recent history of failing courses, decreased concentration, decreased hygiene, and apathy, she visits with the chief complaint of fatigue and anhedonia. We used Ms. Young as the virtual patient with 3rd-year medical students on their psychiatry clerkship at the Georgia Health Sciences University. The initial evaluation of our emerging tool took place during September 2008 through January 2009 after Human Assurance Committee approval and informed consent.

Sixty-seven students were first presented with a lecture on psychiatric interviewing, which included a description of a major depressive episode; they then participated in an online interaction with Ms. Young. At the end of the interaction, they completed a questionnaire, rating this emerging educational tool on a 5-point Likert scale. On the basis of the survey responses of the 3rd-year students and their comments suggesting that such virtual interactions would be useful in earlier years of medical training, a second study was run to introduce the scenario to students in their 1st and 2nd year. This study took place in November 2009 through January 2010. We presented the study to the 2nd-year class at the completion of a mood-disorders lecture in November 2009 and to the 1st-year class after a lecture about neurotransmitters and mood, in January 2010. Unlike lectures of the 3rd-year students, in a computer lab for orientation, these lectures took place in a large classroom, where computer access was limited to students who brought their own laptops. Also, although each class has 190 students registered, not all the students were in attendance on the day when the studies were announced. The students were asked to complete the interaction and the survey on their own time, but within a week from the date of signing consent. Of the 1st- and 2nd-year classes, only 71 of 162 students who consented interacted with the VP. Because of the number of ways in which a question can be formulated, not all questions and speech responses were available in the script during our initial evaluation.

The script evolved as the scenario was used by students, progressing from approximately 500 questions and fewer than 200 speech responses in the first study to 1,205 questions and 341 speech responses at the time of the second study. The increased robustness of the script was reflected in the results we obtained from the two studies. We compared the two versions of the VP script in terms of the differences in the distribution of the questionnaire items and discoveries (symptoms of major depressive episode elicited) between the two group years (2008–2009 and 2009–2010). We examined these differences with a chi-square test or Fisher's exact test. All statistical analyses were performed with SAS 9.3, and statistical significance was assessed at an alpha level of 0.05. The 3rd-year students, who interacted with an earlier version of the script, valued the availability of the immediate feedback (discoveries and transcripts) and the ease of the VP interaction. Overall, our second study showed improvement in students' opinions about this tool in most areas covered by our questionnaire (Table 1). Significant differences were found between the two group years: 1st- and 2nd-year students in the 2009–2010 group rated the following questions Good or Excellent more frequently than the 3rd-year students in the 2008–2009 group; the virtual patient helped to formulate questions; its answers were appropriate; it simulated real life; the student enjoyed the interaction; the student felt that the virtual patient was a good educational tool; the student felt that the topic flow was useful, and felt overall interaction satisfaction.

Also, during the interaction, students received instant feedback regarding their ability to elicit report of symptoms of major depression (discoveries) as defined by the criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV-TR) (18). Table 2 shows the distribution of the various discovery items by group-year as well as the results of the chi-square tests. Only two items showed statistically increased discovery by the students in the 2009–2010 group, as compared with the 2008–2009 group: decreased concentration/indecisiveness, and worthlessness or guilt. The most difficult symptom to identify was psychomotor retardation. During the first study, the interaction was purely text-based, with no visual cues regarding the patient, and, thus, students were unable to observe patient movements during the interview. To address the absence of a visual representation of the character in the first rendering of the scenario, for the second study, an animated image of “Ms. Young” was added to the chat interface (Figure 1), which allows her facial expression to change on the basis of questions asked. Nonetheless, the visual cues added did little to improve the ability to discern psychomotor retardation. Students' difficulty in eliciting this symptom points to the fact that naturalistic virtual human body movement is not a realistic goal for web-based VPs because of limitations of current technology. Furthermore, although the current technology causes errors in question recognition to diminish with increased use of the scenario, they will continue to exist. We are exploring adding additional animations and voice-recordings to mirror the VP's current text-based responses in order to further refine this type of scenario and provide more psychomotor indications. Also, emphasis can be placed on psychomotor retardation as a symptom of depression during classroom-based teaching or in a study guide that can accompany the VP assignment. Overall, our studies indicated that students appeared receptive to using this novel tool. An obvious limitation was the modest number of students who interacted with the VP scenario. Potential causes for the limited student participation could include offering no incentive to complete our study and a certain amount of “survey fatigue,” given the competing demands of research participation of students by various other sources. A recruitment bias may have also been present, with students more familiar with or friendly to issues of mental health and chat interfaces completing the interaction. A limitation identified in the student feedback about the VP addressed the lack of or inappropriate response of the VP to empathetic statements. Previous research has shown that medical students do respond empathetically to a VP (9). Further development of our depression scenario could involve qualitative analysis of the empathetic statements made by the users and building script responses to these statements. Despite their limitations, interactive VPs are potentially versatile tools for psychiatry educators, who can create scenarios based on their own course objectives. Although medical students in preclinical years can use VPs as self-study materials, to practice interviewing on their personal time and augment classroom learning, during clinical years, interactive VPs with complex disease scenarios can potentially be used to consolidate or fill gaps in live clinical exposure in certain areas.

The authors thank Jennifer Waller, Ph.D., for her help with statistical analysis and Candelario Laserna, M.D., for his help with study recruitment and data management.