YuLin Zhen, Photography Editor

During the pandemic, Yale medical students trained virtually to learn how to break bad news. A new Yale study asks what might be lost when these conversations were practiced virtually instead of face-to-face. 

Researchers at the School of Medicine investigated whether Yale medical students performed differently after receiving virtual or in-person instruction. They compared students’ performance on Objective Structured Clinical Examinations, or OSCEs, which are structured role-play exercises in which students interact with trained actors playing patients. These exams are designed to test how well future doctors communicate and make decisions in realistic scenarios, such as delivering bad news or discussing end-of-life care. 

While students performed well in both settings, the results suggested that virtual OSCEs may not give students the same chance to reflect deeply or emotionally connect with patients as compared to in-person sessions. 

“Prior and during the pandemic, there was concern for lack of nonverbal and empathic communication in the virtual format. But our study results show that students were able to exhibit a similar level of empathic communication skills in the virtual format, which aligns with other studies,” Choi wrote in an email to the News. 

After participating in OSCEs, students participated in structured debriefs led by faculty. The study assessed student performance using two tools: the modified Medical Interaction Rating Scale, or mMIRS, and the Case-Based Checklist, or CBC. 

The mMIRS measured interpersonal behaviors like showing empathy or avoiding medical jargon, while the CBC evaluated whether students asked clinically relevant questions and collected the correct information for each case. 

According to Choi, the study found that mMIRS scores stayed consistent across both formats, but CBC scores were lower for those who participated virtually. 

The researchers proposed several explanations for this discrepancy. Some students may not engage with virtual formats as effectively as with in-person instruction, they suggested, while others might find virtual learning more cognitively demanding. In addition, Choi noted, the tools and materials used in person may not translate seamlessly to a virtual setting.

Choi also pointed to several possible reasons for the decline in CBC scores, including the steeper learning curve associated with virtual learning and individual differences in how students engage with digital environments.

“There may be a subset of students who do not engage with the virtual format as easily as their peers,” Choi wrote. “Some students may require a higher level of cognitive load to stay focused during virtual education, which would be a barrier to reaching more advanced stages of learning.”

To better understand those patterns, the researchers conducted a second, qualitative study by analyzing transcripts of post-OSCE debriefing sessions. 

They found that students in virtual sessions tended to ask more factual or procedural questions, while in-person participants were more likely to reflect on the emotional challenges of the scenarios.

“Our qualitative study focused on the post-OSCE debriefs, and found that during those debriefs, students asked more matter-of-fact questions about the cases than challenges they experienced,” Choi wrote. “This supports our idea that some students may struggle with experiential learning in the virtual format, and have difficulty accessing or practicing their reflective observation skills.”

Despite the differences in outcomes, Choi emphasized that virtual OSCEs remain a viable option in specific contexts. Their convenience and cost-effectiveness make them attractive in resource-limited settings or for formative assessments.

“Many studies have shown the advantages of virtual OSCEs, mainly focusing on resources (e.g. saving time, no need to reserve physical space, convenience, easier to recruit faculty/student),” Choi wrote. “And although our quantitative/qualitative studies showed a significant difference between virtual and in-person format, overall the students still performed above expectations.”

Dr. Jaideep Talwalkar, associate professor of internal medicine and co-author of the study, said the project began during the early months of the pandemic. Educators had concerns that emotionally complex content might not land the same way on screen and realized there was little existing research on the topic.

“We looked to the literature to see if our informal observations were backed up by previous publications and were surprised when we couldn’t find anything,” Talwalkar wrote. “There were lots of studies about virtual learning but not about teaching students how to handle emotionally intense medical conversations.”

The study revealed that while students were able to maintain empathic behaviors virtually, they were less likely to explore uncertainty or reflect on their own discomfort. Talwalkar said this difference was especially evident in scenarios that pushed students emotionally.

“There were subtle differences in these teaching sessions with the virtual shift that we wouldn’t have been able to pinpoint without doing the research,” Talwalkar wrote. “These were challenging cases so we think that students were less able to adapt to that challenge in the virtual setting.”

Student perspectives reflected this variation in emotional engagement. Julia Eisen, a fourth-year medical student who participated in the in-person OSCE and later wrote about the study, said certain conversations cannot be fully learned online.

“Learning how to tell a parent that their child has died or learning how to disclose a medical error to a patient — these are not scenarios in which virtual learning is acceptable, in my opinion,” Eisen wrote. “My personal experience with the OSCE taught me that the only way to learn how to have these conversations is practice, and that starts with the in-person OSCE.”

Other students found the OSCEs useful as skill-building exercises, but not necessarily representative of real hospital interactions. Kaelan Yao MED ’24 said the simulations were best understood as assessments rather than emotional mirrors of clinical life.

“They serve as a good outlet to assess your own comfort with different patient cases,” Yao wrote. “But OSCEs are conducted in a very standardized and sterile environment that is not necessarily representative of real hospital experiences.”

Still, Yao emphasized the broader role of experiential learning in making classroom material more memorable. For many students, seeing a simulated patient can bring years of training into focus.

“In my experience, experiential learning is extremely effective in solidifying understanding of all the different aspects of a certain disease process or patient care,” Yao wrote. “Often times this not only helps to learn about the disease process but also helps in general to consolidate information under an exemplar of the thing you are learning about.”

As Yale returns to in-person OSCEs, the researchers say lessons from virtual instruction remain relevant. Telehealth continues to expand, and medical students will be forced to develop fluency across multiple communication platforms.

“In future virtual sessions on challenging content, we’ll need to consider more safeguards to better replicate what we do during in person discussions,” Talwalkar wrote. “This might require smaller groups and more time for debriefing with more deliberate faculty training to push students to discuss their areas of uncertainty.”

For now, the researchers and students agree: virtual platforms may offer flexibility, but when it comes to teaching medicine’s hardest conversations, in-person presence is imperative.

Satisfactory performance on the OSCEs is a graduation requirement for the MD program.