The findings of this study confirm the importance of using simulation when training medical students in delivering BN; this can improve communication between patients and the medical team. We used a new technology (Affect-tag) to analyse the emotional impact of HFS among medical students during BN training. After two training sessions, ED and EP improved significantly and TEP increased. HFS is a good method for this type of training, considering the emotional impact of delivering BN. We found that participants were emotionally and effectively involved in the HFS training without being completely overwhelmed by their emotions, which may be an inherent element of the training format. Individual feedback improved significantly on several dimensions. Together, these results confirm that Affect-tag can be used as an additional method to assess communication behaviour among clinicians.
Communication skills training research programs have been conducted in the last few decades. Brown et al. reported that physicians find that delivering BN is a stressful experience, particularly inexperienced and/or tired physicians . Poor communication performance has been linked to burnout and fatigue, resulting in significant stress, which can be assessed physiologically [25, 26]. This is particularly interesting, as a meta-analysis revealed emotional exhaustion in 32% of oncologists . Simulations can improve stress-related symptoms and thus the skills of surgeons , and can also help reduce emotional exhaustion .
Various methods are available to evaluate and improve physician confidence, knowledge, empathy, and skills in delivering BN . Previous studies have demonstrated that student emotions, an important parameter when delivering BN, can be incorporated into coaching and medical simulations. In the present study, we explored unpredictable and unexpected emotions during the delivery of BN to investigate the usefulness of the Affect-tag system. We analysed three emotional aspects, and the results suggest that these parameters can be used as tools, rather than being feared or ignored. These emotional parameters can help teachers assess whether medical students are comfortable in a given situation.
Several factors explain the modification of these emotional parameters, such as EP and ED. In the initial encounter, students learned to control their emotions and those of others. Second, the training provided techniques for reducing the negative emotional impact, so students learned to detect certain markers in patients during interviews. Thus, the medical students included in this study had a high EP before the training and this parameter decreased significantly after coaching.
New knowledge from the consultation helped students perceive the interview in new ways and also to perceive less noticeable but equally important stimuli during the interview. We found that the participants were emotionally involved in the HFS training without being completely overwhelmed by their emotions. BN training can also be improved through objective practice and self-assessment by participants.
CL theory was initially proposed in the 1980s by John Sweller . According to Sweller, working memory is extremely limited and requires energy, whereas long-term memory, correlated to human experience, is immense and can be used immediately, without cognitive effort . In this study, the CL was stable, which can be explained by Sweller’s concept. During the first training, students learned something new using their working memory, and thus they were stressed and apprehensive, which generated mental load. Nevertheless, they were not focused on the coach’s emotions. After the training, they delivered BN more easily because this concept was familiar using their long-term memory, but their CL was stable compared to the first session because they intellectualised the interview. Finally, the CL was not lower but was more focused on the essential elements during the interview. This CL parameter confirmed that most of us can only process some bits of information at a time and the repetition of pedagogical exercises can help medical coaches with their teaching.
One solution is HFS, which has been shown to improve not only self-efficacy (subjective performance) in doctors and nurses, but also communication skills (objective performance) .
HFS can reduce stress during a BN consultation, but paradoxically it can generate stress during training. The environment created by the HFS could affect participant motivation to learn, so it was important to assess the impact of the emotions generated by the HFS. Positive emotions improve attention and ability to process information, thereby facilitating learning, whereas negative emotions reduce working memory. To date, most studies have indirectly evaluated emotions by assessing physiological data [32, 33]. Some have found that simulation is associated with increased learner anxiety  and that it may have negative consequences on student performance and the learning experience . One study reported that HFS training increases heart rate but not blood pressure . However, this finding should be interpreted with caution. The very purpose of HFS is to create a stressful situation before an actual BN consultation. Thus, it was difficult to differentiate what was related to training and what was related to the actual consultation. Some research indicates that students perceive the stress associated with role-play scenarios similar to that encountered in everyday life . Moreover, training skills and familiarity with the environment do not necessarily reduce stress levels during simulated high-acuity scenarios . Physicians experience increased stress during the pre-information phase (briefing) with a significant decrease in heart rate (p < 0.0001) between the beginning and end of a BN consultation . Finally, the benefit is similar whether we consider undergraduate students or health professionals [18, 39].
A common criticism of using HFS is that it may not produce a valid interview experience. However, studies on undercover simulated patients visiting practicing physicians have reported low detection rates, suggesting that the simulations can be very authentic . Using a trained coach experienced in the field of medical communication may have limited between-subject variance in this study. This study had some biases, including a few students who had completed simulation training before this study but we evaluated the kinetics of some parameters and each student engaged in self-reporting. We were also limited by the number of participants, but the study population was larger than in previously published studies. Finally, an insufficient number of students underwent two training sessions, which can be explained by the difficulty including students, as documented by a recent study .