The Diabetes Simulation Challenge: Enhancing Patient Perspective-Taking for Medical Students

When operating under a patient-centered care model, empathy is necessary to develop the patient-physician relationship (3). Developing empathy involves communicating with patients to gain a better understanding of their perspectives, situation, and feelings (4). Many studies have demonstrated the importance of empathy in the patient-physician relationship relative to favorable health outcomes and patient satisfaction across a variety of medical settings and among those with numerous illnesses or diseases (5,6). Individuals who perceive high levels of empathy from their physicians have reported less severe symptoms that also mitigate in a shorter period of time (7). In addition, health care provider satisfaction is correlated with the ability to demonstrate empathy toward patients (8).

Despite the need for this skill to provide high-quality care, several studies have demonstrated a decline in empathy over the course of both pre-service training and career span (9,10). Reynolds and Scott (11) found that different helping professional trainees such as students of psychology, medicine, and education need explicit training in how to develop awareness of other people’s feelings and experiences. Therefore, there is a need to foster and enhance empathy in medical trainees in ways that lead to their long-term perceived value and use of this skill.

Developing empathy in helping professionals can be accomplished through perspective training that leverages experiential learning activities and reflection opportunities (12). A few studies have analyzed experiential learning or simulated teaching of patient health conditions and associated treatments with cohorts of health care trainees, particularly students in nursing programs. These studies have taken place in both inpatient and outpatient settings. Inpatient experiential learning activities have included simulation of a hospital stay under various assigned diagnoses (13). After their hospital stay, students reported on the need for improved communication and attention to patients’ comfort. Although these results are promising, such activities likely pose feasibility challenges for student training programs with regard to available space, costs, and other logistics.

One study used an experiential educational activity in which nursing students were fitted with an ostomy bag and then instructed to wear the bag for 48 hours while performing normal daily activities (14). Analyses of the frequency of empathetic statements in student reflections after the activity demonstrated increased empathy toward patients. A 7-day simulation of living with diabetes was conducted among a cohort of student pharmacists and involved completing common diabetes self-care activities such as monitoring blood glucose before meals, initiating an exercise routine consistent with diabetes management recommendations, and quantifying carbohydrates consumed (15). Students also completed post-experience reflective narratives, with most reporting increases in empathy as well as difficulty adhering to the care regimen.

Further expansion of simulations of living with the common diseases trainees will eventually manage in clinical practice is needed to determine the best methodology for and general effectiveness of activities to enhance empathy and improve related outcomes. Another patient-perspective training experience that has been implemented for several years involves weekly interactions between undergraduate premedical students and people with early to moderate dementia (16). Analysis of students’ weekly reflections has demonstrated decreased stigma and improved communication skills and empathy.

Some bias may be evidenced in these results given that students volunteered to participate in the program, and the long-term pairing of student-patient dyads also poses logistical challenges. Enhancement and broader implementation of such simulations and corresponding evaluation methods are needed to further determine the effectiveness of these hands-on learning experiences. In addition, trainers who have implemented such experiences have noted the importance of participants having sufficient didactic preparation before the activities (13).

A specialized medical student leadership program offered through a large medical school in the southeastern United States aims to go beyond traditional medical school training and cultivate medical professionals who are well-versed and immersed in patient-centered care. The program extends students’ didactic training to include topics such as health-related quality of life, communication and collaboration among multiple disciplines, motivational interviewing, and active listening. A perspective-taking simulation known as the Diabetes Simulation Challenge was developed for this program to enhance students’ empathy toward patients.

The Diabetes Simulation Challenge offered a unique learning experience for students preparing to work with individuals with chronic health conditions. Before the challenge, students met with people affected by type 1 diabetes to hear about their daily life managing the disease and the adversities they face. They then participated in a 24-hour simulation that included elements of living with type 1 diabetes to experience first-hand the challenges expressed by the individuals with whom they spoke before the simulation.

The purpose of this study was to gather information from medical students who participated in this unique training opportunity to foster empathy as part of a patient-centered care orientation within their medical school curriculum. Medical students reflected on their experiences with the Diabetes Simulation Challenge. These responses were analyzed to investigate whether the perspective-taking activity led to expressions of empathy or perceived changes in thoughts and beliefs regarding the care of individuals with chronic health conditions.

Thirty-two second-year medical students from a specialized leadership program at a southeastern U.S. medical school participated in the study. The cohort was diverse with respect to race and ethnicity, and all participants were receiving financial aid to support their medical school expenses.

A portion of the materials used for the simulation were donated by a pharmaceutical company; the remaining supplies were purchased through grant funds. These materials included blood glucose meters and test strips for each participant to use during the 24-hour simulation. A messaging service was contracted to assist with the 24-hour text-a-thon (described below). Arrangements were made for the text messages to be sent out to all participants at their preferred phone number.

This study was conducted as part of a programmatic review of a specialized curriculum, and the assignment was required of all students in the cohort. To better understand the patient experience, students participated in a two-part learning opportunity consisting of 1) a patient interaction and 2) a 24-hour simulation of living with diabetes. The main purpose of this activity was to challenge these students to “live” experiences consistent with those of individuals with a diagnosis of type 1 diabetes for a period of 24 hours. The experience began with a half-day training session on type 1 diabetes conducted by a team that included an adult, a young adult, and a teen living with diabetes, as well as a parent of two young adults with this condition. This training session included an overview of the disease, followed by small-group breakout sessions for further discussion and a large-group question-and-answer session. Students were then provided with blood glucose meters and guidance on how to check their glucose levels.

To simulate disease management activities and health-related decision-making that individuals with type 1 diabetes routinely face, students participated in a 24-hour text-a-thon. Starting at 7:30 a.m. the next morning, all students received 18 text messages at random intervals providing them with instructions or health-related choices. These text messages were developed by a team of professionals affiliated with the training program, including those with expertise and first-hand experience of living with type 1 diabetes. Table 1 contains a list of all of the text messages received. If students felt uncomfortable for any reason with the simulation procedures (e.g., pricking their finger to perform blood glucose checks), they were offered the option of an alternative assignment. This assignment consisted of viewing preselected videos of individuals with type 1 diabetes and responding to questions about what they learned. Only three students chose this alternative assignment, and their responses were not included in the qualitative analyses.

As part of the simulation, before every meal and snack, before and after exercise, during the midafternoon and at bedtime, students were required to record the time of day and their blood glucose level. They also recorded carbohydrate intake every time they ate. Additionally, participants logged the time of day and any thoughts and reactions to text messages they received throughout the day. To summarize their response to the overall experience, students were required to write a brief, open-ended reflection paper. Instructions were simply to write a one-page reflective narrative and submit it within 2 days of completing the experience, to allow students to reflect on and share what they found most significant and/or meaningful.

A phenomenological qualitative approach was taken to provide a composite description of the simulated experience of living with type 1 diabetes. A multistep, iterative procedure was followed to manually code the student reflections and conduct thematic analysis. The study team followed a consistent and exhaustive process to ensure internal validity throughout the coding process (17). Inductive inference of thematic content was used.

First, four research team members independently read through a random sample of the written reflections several times, highlighted meaningful text, and assigned preliminary labels/categories. The team discussed and compared labels/categories to identify specific themes and developed a preliminary codebook based on these themes. The original codebook consisted of implicit and explicit categories of themes, with 10 codes in each category. Team members then coded a subset of the reflections using this codebook. However, a large number of overlapping codes led to low interrater agreement. The codebook was significantly revised by combining similar/overlapping codes and creating more concrete and objective categories for the themes (e.g., Experience-Specific and Perspective Taking).

With the refined codebook, an iterative process was used in which researchers independently coded a random sample of reflections and reconvened using agreements and disagreements to further refine and revise the codes. For example, a Lack of Empathy code was added, and codes such as Food Regulation and Glucose Monitoring were combined into a single code for Responsibility With Management. The team then formed two coding teams that aligned with the process for generating intercoder reliability outlined by Hruschka et al. (17). Each pair coded randomly assigned reflections to establish intrapair reliability. Within pairs, coding continued until interrater reliability of >80% was achieved.

Once intrapair reliability was established, another random sample of reflections was coded by each pair to establish interpair reliability. Upon reaching acceptable reliability between pairs (i.e., >80%), each pair then independently coded half of the reflections and then reconvened to conduct a reliability check and agree on final codes. The two pairs then continued coding the second half of the reflections and calculated overall interrater reliability. A final interrater reliability of 78% was achieved.

Thirty-two medical students participated. Six reflections were excluded from the analysis because the students either completed an alternative assignment or did not follow the reflection instructions (i.e., submitted a food log without reflection on the simulation activities). Thus, the analysis included written reflections from 26 medical students.

Analysis of the medical students’ written reflections resulted in 142 meaningful quotes. Themes were grouped into two main categories: Experience-Specific and Perspective-Taking. The Experience-Specific category was further divided into themes of Positive Experience and Negative Experience. The Perspective-Taking category was divided into six themes: Responsibility With Management, Empathy, Competency, Emotional Discomfort, Sense of Lack of Control, and Strain on Resources. An additional stand-alone theme, Lack of Empathy, also emerged. Each theme is discussed below in the order of frequency, and illustrative quotes are included. Table 2 displays the frequency counts of each theme, as well as the number of student reflections that included each theme.

Fifty-six (39.44%) of the meaningful quotes referred specifically to either positive or negative experiences during the simulation challenge. These quotes represent personal responses to the challenge without taking on the perspective of a person with a chronic illness.

Twenty-four (16.90%) of the experience-specific statements referred to an appreciation of, or positive experience with, the challenge-related activities. A few of these quotes were general statements, such as:

Many of the medical students referred to specific aspects of the challenge that they appreciated. For example, students discussed the unique learning opportunity the challenge provided.

Additionally, many of the positive reflections highlighted the challenge’s impact on students’ understanding of the daily challenges faced by individuals with chronic illnesses.

Most medical students (73.08%) reflected on the discomfort, pain, or inconvenience of the simulation activities. Thirty-two (22.54%) of these statements referred to a negative aspect of the challenge. The physical pain associated with the finger pricks required to test blood glucose levels was frequently mentioned in the reflections through quotes, such as:

In addition to the physical discomfort that accompanied the management activities, the students indicated that monitoring glucose levels and keeping a food log introduced various interruptions to their daily routines, as in:

Multiple medical students also discussed the inconvenience of receiving text messages throughout the day:

Out of the meaningful quotes from the medical students’ reflections, 86 (60.56%) demonstrated perspective-taking of individuals with chronic illnesses. Statements were considered to take on the perspective of others if they explicitly referenced others’ experiences by using a third-person narrative. Six perspective-taking themes emerged and are described in detail below, in the order of frequency.

This theme encompasses references to the amount of consideration and responsibility associated with the treatment management of a chronic condition. These statements (16.20%) demonstrated an appreciation of “the diligence and dedication it takes to manage the disease.” As one student put it:

Quotes that went beyond expressing an understanding of having a chronic illness and referred to a greater degree of sympathy, respect, or empathy related to those with chronic illness or diabetes fell into this theme (9.86% of statements). Examples include:

Multiple students also recognized the need for health care professionals to display empathy and respect in their treatment of these individuals. As one student noted:

Finally, this theme included expressions of empathy and understanding regarding the permanence and pervasiveness of a chronic condition such as type 1 diabetes. One student noted:

As individuals currently in training to treat people with various illnesses, many of the medical students discussed the impact of this challenge on their medical education. Thirteen (9.15%) instances in the reflections referred to increased confidence in knowledge, skills, or empathy related to the future care of individuals with a chronic illness. For example, one student said:

Other students discussed a greater competency in their ability to relate to future patients and their struggles with coping and treatment management:

One student summarized:

References to the emotional discomfort that accompanies diabetes or other chronic illnesses were coded into this theme. These thirteen (9.15%) statements reflected multiple emotions such as embarrassment and distress. Examples include:

One student also referred to the impact a chronic illness would have on an individual’s relationship with others:

Another student discussed the initial adjustment to this diagnosis, saying:

Seven (4.93%) of the quotes discussed frustration or emotional distress related to the lack of control over physiological symptoms. The reflections within this theme centered around two major feelings. First was fear of not having complete control over one’s condition. For example:

Second was the frustration of having to experience poor health conditions despite following prescribed guidelines related to treatment management:

One student discussed the emotional turmoil upon simply receiving this diagnosis, saying:

Five quotes (3.52%) referred to the necessary time, money, and energy required by those with conditions such as diabetes just to maintain homeostasis.

Eleven (7.75%) of the statements within the reflections contained meaningful text but were antithetical to the purpose of the assignment. Therefore, a stand-alone them, Lack of Empathy, was created to encompass these quotes. It should be noted that five (19.23%) of the medical students made statements that fell into this theme. Some quotes indicated that they did not take the simulation seriously, lacked an appreciation for the challenges that those with a chronic illness face, and did not attempt to take on the perspective of an individual with type 1 diabetes.

The purpose of the Diabetes Simulation Challenge was to introduce a novel method of fostering empathy in medical students. In contrast to traditional didactic methods, this technique aimed to provide a role-taking simulation that afforded students with experiences similar to those faced by individuals with type 1 diabetes. Analyses of written reflections indicate that the Diabetes Simulation Challenge enabled medical students to experience some of the daily struggles related to a chronic illness and engage in perspective-taking that yielded increased expressions of empathy.

Statements related specifically to the tasks that comprised the Diabetes Simulation Challenge (e.g., pricking a finger for glucose checks and monitoring diet) were the most prevalent, as demonstrated by the frequency of positive and negative experience–specific statements. The positive experience code did not reflect that medical students enjoyed the tasks, but rather that they expressed an appreciation for the participation, knowledge, or perspective obtained by the challenge. Most medical students discussed at least one aspect of the simulation in a negative way. The negative experience code was not indicative of the students expressing that they did not gain empathy from the experience. Instead, this code demonstrated that students experienced some of the hardships and negative daily challenges related to living with a chronic illness, such as pain or discomfort. Those reactions are aligned with the goals of the exercise and also illustrate that the students actively participated in the activity.

Beyond simply experiencing the challenges related to a chronic health condition, the activity provided an opportunity for medical students to cultivate their empathy toward future patients by engaging in perspective-taking. Twenty-three of the 26 student reflections included some type of perspective-taking, demonstrating increased empathy for individuals with chronic illnesses. This illustrates that the Diabetes Simulation Challenge achieved its goal of fostering empathy.

Interestingly, the medical students expressed perspective-taking on a rich variety of the aspects of living with a chronic illness. They articulated deep reflections related to the behavioral, emotional, and social challenges experienced, as demonstrated in the use of six unique themes capturing perspective-taking comments: Responsibility With Management, Empathy, Competency, Emotional Discomfort, Sense of Lack of Control, and Strain on Resources. Of these themes, the first, which encompassed reflections on the necessity for and difficulty of maintaining a high level of treatment management, was discussed most frequently. Half of the students’ reflections indicated that they had a greater appreciation for the hardships related to constantly monitoring and managing type 1 diabetes. Given that health care professionals are partners in creating and maintaining a patient’s treatment regimen, developing empathy regarding the unending diligence needed to adhere to a treatment plan is a fundamental aspect of patient-centered care.

Another encouraging finding was that multiple medical students directly connected the influence of this activity to their future understanding of, and relationships with, patients living with chronic health conditions. As encompassed in the Competency theme, students reflected not only on the understanding of the struggles related to a chronic illness, but also on how this perspective-taking has the potential to improve their patient-centered care. This finding demonstrates that the Diabetes Simulation Challenge was a valuable tool in training emotionally intelligent physicians.

Findings from the thematic analyses of the self-reported impact of this activity are similar to a previous diabetes simulation experience for pharmacy students (15); however, many of those participants also indicated making changes to improve their own health after the experience. Differences in duration of the simulation and specific activities included in the two experiences may account for the variation in results. Further implementation of simulation experiences of living with diabetes across various types of training programs may help educators determine the specific method most useful in enhancing empathy and related outcomes for future health care providers.

In summary, these reflections indicated that the simulation provided medical students with the opportunity to experience a snapshot of the hardships faced by people living with type 1 diabetes and develop a greater sense of empathy toward these individuals. The hope is that this activity would generalize to enhanced empathy and improved care of patients with a diverse range of chronic illnesses, as many students reflected on patient care in general as opposed to strictly the care of individuals with type 1 diabetes.

Although medical students experienced some of the challenges related to a chronic illness, it is important to note that there are many aspects of diabetes management that could not be simulated in a 24-hour text-a-thon format. For example, issues related to strain on resources and a sense of lack of control were less frequently discussed by students. Although some students may have experienced burden related to time management, the long-term stress many people with diabetes experience related to financial strain could not be simulated. Similarly, although students commented on their fear of and frustration with the unpredictable nature of a chronic illness, they could not fully experience these emotions, knowing that the activity was time limited. The social implications of living with a chronic illness were illustrated in the Emotional Discomfort theme, particularly feelings of embarrassment and isolation. Yet, the challenge could not simulate the long-term social and interpersonal challenges that accompany living with a chronic illness. To enrich the experience and address aspects that the text-a-thon could not duplicate, medical students also heard testimonies from individuals who live with type 1 diabetes and caregivers of individuals with diabetes. Many students mentioned the added value of listening to these accounts before engaging in the simulation.

The majority of the medical students provided rich and thoughtful reflections that aligned with the goals of the activity. However, a few of the students did not actively participate in the challenge, as evidenced in the stand-alone Lack of Empathy theme. In addition, two students did not appear to truly experience an increased sense of empathy, as illustrated by a reflection paper that included both Empathy and Lack of Empathy themes. This finding indicates that, even among medical students, perspective-taking can be a difficult task.

This study is further limited because it used an unstructured response format for student reflections on their simulated experience of living with type 1 diabetes. Although this format allowed students to freely discuss the aspects of the simulation that they believed most relevant, it made the task of developing thematic categories more challenging. Future researchers may consider developing a more structured response format to aid in the qualitative analyses. Group debriefing or focus group meetings after the simulation also may yield richer data.

Finally, the duration of the simulation experience was limited to only 24 hours. Although the students were able to experience various aspects of a day in the life of a young adult living with type 1 diabetes, an extended simulation (e.g., 1 week) may have afforded the students the opportunity to experience the disease more fully.

It is recommended that this simulation be included in medical school programs as a multidisciplinary experience to provide multiple perspectives and further promote the tenets of patient-centered care. Professionals who collaborate with physicians to provide care, such as psychologists and nurses, may similarly benefit from participating in this empathy training activity. Finally, it is recommended that future research use a longitudinal design to determine the need for booster sessions or continued reflections on developing understanding and empathy for those living with chronic health conditions.

The purpose of this study was to provide medical students with an experience that would mirror a day in the life of an individual living with type 1 diabetes. Through this 24-hour text-a-thon, students had the opportunity to better understand the impact of a chronic health condition on a patient’s lifestyle, daily decisions, and overall quality of life. Qualitative analyses of student reflections demonstrated that students developed an understanding of the behavioral, social, and emotional challenges related to living with a diabetes, and empathy toward people with type 1 diabetes was illustrated in many of the students’ reflections. Overall, this simulation offered a rich training experience for medical students as they continue to grow in their knowledge and skills related to patient-centered care.

The authors thank the people with diabetes and their families who participated in the didactic portion of the Diabetes Simulation Challenge. This study was supported by Bringing Science Home and the Patterson Foundation.

No potential conflicts of interest relevant to this article were reported.

E.S.-H., S.H.O., and K.B.-K. researched data and wrote the manuscript. N.J. reviewed and edited the manuscript. E.S.-H. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.