DIALOGUE: A Generative AI-Based Pre–Post Simulation Study to Enhance Diagnostic Communication in Medical Students Through Virtual Type 2 Diabetes Scenarios
Abstract
1. Introduction
2. Materials and Methods
2.1. Study Design and Overview
2.2. Participants
2.3. Study Phases
2.3.1. Pre-Test Phase
2.3.2. Educational Intervention: AI-Based Training
2.3.3. Post-Test Phase
2.4. Evaluation Instruments
2.5. Data Collection and Analysis
2.6. Qualitative Analysis of AI Feedback
2.7. Use of Generative AI in the Study
2.8. Statistical Analysis
3. Results
3.1. Participant Flow and Baseline Characteristics
3.1.1. Participant Flow
3.1.2. Baseline Characteristics
3.2. Baseline Diagnostic-Communication Performance
3.3. Post-Intervention Diagnostic Performance and Pre–Post Comparison
3.3.1. Post-Test Performance Across Scenarios
3.3.2. Pre–Post Intervention Gains
3.4. Predictors of Improvement
3.5. Learner Profiles and Cluster Patterns
3.6. Post-Test Surveys
3.7. Adverse Events and Missing Data
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Abbreviations
AI | Artificial intelligence |
AIC | Akaike information criterion |
API | Application programming interface |
GENAI | Generative artificial intelligence |
GPA | Grade point average |
GPT-4 | Generative Pretrained Transformer 4 |
ICC | Intraclass correlation coefficient |
ITT | Intention-to-treat |
JSE | Jefferson Scale of Empathy |
LLM | Large language model |
OSCE | Objective structured clinical examination |
SE | Standard error |
SP | Standardized patient |
SPIKES | Setting, perception, invitation, knowledge, emotions, strategy (protocol for breaking bad news) |
T2DM | Type 2 diabetes mellitus |
VIF | Variance inflation factor |
WA | Weighted average |
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Variable | Category/Units | N (%) or Mean ± SD |
---|---|---|
Age | Years | 21.1 ± 4.1 |
Sex | Female | 22 (73.33%) |
Male | 8 (26.66%) | |
Clinical semester | 2 | 4 (13.33%) |
4 | 19 (63.33%) | |
6 | 2 (6.66%) | |
7 | 5 (16.66%) | |
Cumulative GPA | 0–10 | 8.31 ± 0.50 |
Prior formal course in diagnostic communication | Yes | 0 (0%) |
Prior ECOE completed | Median (IQR) | 0 (0%) |
Prior experience with real patients | Yes | 12 (40.00%) |
Prior ChatGPT/LLM use | ≥10 interactions | 21 (70%) |
<10 interactions | 9 (30%) | |
Never | 1 (3.33%) | |
Digital self-efficacy † | Very high/high | 13 (43.33%) |
Medium | 16 (53.33%) | |
Low | 1 (3.33%) | |
Device most used for simulation | Laptop/PC | 22 (73.33%) |
Tablet | 4 (13.33%) | |
Smartphone | 4 (13.33%) | |
Self-rated internet quality | Good | 17 (56.66%) |
Medium | 10 (32.25%) | |
Poor | 3 (10%) | |
Motivation score (1–10) | 0–10 | 9 |
Self-confidence score, 1–5 | Explain lab results | 3.3 ± 0.7 |
Explain DM criteria | 3.0 ± 0.8 | |
Convey bad news empathetically | 3.2 ± 0.8 | |
Teach-back | 2.3 ± 0.8 | |
Anxiety reduction | 2.4 ± 0.7 | |
Jefferson Scale of Empathy, total (20–140) | - | 116 ± 15 |
Item | Domain/Skill (Abridged) | Scenario 1 Mean ± SD | Scenario 2 Mean ± SD | p |
---|---|---|---|---|
1 | Relationship | 3.10 ± 0.58 | 3.15 ± 0.55 | 0.50 |
1.1 | Eye contact and open posture | 3.86 ± 0.73 | 3.83 ± 0.79 | 0.74 |
1.2 | Friendly body language | 3.46 ± 0.86 | 3.56 ± 0.72 | 0.41 |
1.3 | Self-introduction and role | 2.00 ± 1.16 | 2.06 ± 1.20 | 0.70 |
2 | Opening | 1.81 ± 0.71 | 1.92 ± 0.69 | 0.22 |
2.1 | Greeting and ID verification | 1.73 ± 0.63 | 1.63 ± 0.71 | 0.18 |
2.2 | States purpose of visit | 1.90 ± 0.84 | 2.13 ± 0.89 | 0.06 |
2.3 | Explores patient expectations | 1.80 ± 0.98 | 2.00 ± 0.94 | 0.22 |
3 | Information gathering | 2.71 ± 0.64 | 2.58 ± 0.69 | 0.12 |
3.1 | Uses open questions | 2.00 ± 1.01 | 2.30 ± 0.99 | 0.76 |
3.2 | Listens without interrupting | 4.00 ± 0.18 | 3.90 ± 0.54 | 0.32 |
3.3 | Summarizes to confirm | 2.13 ± 1.04 | 1.83 ±1.11 | 0.08 |
4 | Patient perspective | 1.91 ± 0.85 | 2.00 ± 0.84 | 0.36 |
4.1 | Elicits beliefs about illness | 1.80 ± 1.06 | 1.70 ± 1.02 | 0.57 |
4.2 | Explores worries/concerns | 2.13 ± 0.97 | 1.96 ± 1.03 | 0.23 |
4.3 | Assesses daily-life impact | 1.8 ± 0.92 | 2.33 ± 1.12 | 0.02 |
5 | Information sharing | 1.76 ± 0.76 | 2.05 ± 0.83 | 0.18 |
5.1 | Explains diagnosis in plain language | 1.80 ± 1.06 | 1.70 ± 1.02 | 0.57 |
5.2 | Uses visual aids/examples | 2.13 ± 0.97 | 1.96 ± 1.03 | 0.23 |
5.3 | Checks understanding (teach-back) | 1.80 ± 0.92 | 2.33 ± 1.12 | 0.01 |
6 | Plan negotiation | 2.03 ± 0.65 | 2.03 ± 0.53 | 1.00 |
6.1 | Discusses therapeutic options | 2.36 ± 0.85 | 2.10 ± 0.99 | 0.07 |
6.2 | Involves patient in decisions | 2.06 ± 0.90 | 2.16 ± 0.74 | 0.44 |
6.3 | Negotiates realistic goals | 1.66 ± 0.80 | 1.83 ± 0.83 | 0.20 |
7 | Closure | 1.67 ± 0.62 | 2.01 ± 0.59 | 0.06 |
7.1 | Provides final summary | 1.63 ± 0.71 | 1.86 ± 0.81 | 0.05 |
7.2 | Checks for residual questions | 1.53 ± 0.93 | 1.86 ± 0.93 | 0.07 |
7.3 | Closes with empathy and follow-up | 1.86 ± 0.97 | 2.30 ± 0.83 | 0.02 |
8 | Diabetes specific | 1.88 ± 0.56 | 1.93 ± 0.56 | 0.73 |
8.1 | Explains lab results (HbA1c) | 1.80 ± 0.71 | 1.90 ± 0.71 | 0.50 |
8.2 | Provides initial plan and alleviates anxiety | 1.96 ± 0.71 | 1.90 ± 0.75 | 0.57 |
Total | Overall score (23–115) | 48.83 ± 9.65 | 51.1 ± 9.82 | 0.05 |
Item | Domain/Skill (Abridged) | Scenario 1 Mean ± SD | Scenario 2 Mean ± SD | p |
---|---|---|---|---|
1 | Relationship | 4.05 ± 0.63 | 4.15 ± 0.67 | 0.36 |
1.1 | Eye contact and open posture | 4.15 ± 0.54 | 4.26 ± 0.86 | 0.21 |
1.2 | Friendly body language | 4.26 ± 0.55 | 4.26 ± 0.62 | 1.00 |
1.3 | Self-introduction and role | 3.85 ± 0.84 | 3.81 ± 0.86 | 0.82 |
2 | Opening | 3.71 ± 0.64 | 3.86 ± 0.81 | 0.25 |
2.1 | Greeting and ID verification | 3.81 ± 0.71 | 4.35 ± 0.84 | 0.01 |
2.2 | States purpose of visit | 3.68 ± 0.78 | 3.93 ± 0.96 | 0.11 |
2.3 | Explores patient expectations | 3.63 ± 0.81 | 3.30 ± 1.04 | 0.16 |
3 | Information gathering | 3.86 ± 0.60 | 4.01 ± 0.68 | 0.19 |
3.1 | Uses open questions | 3.88 ± 0.67 | 3.96 ± 0.00 | 0.56 |
3.2 | Listens without interrupting | 4.21 ± 0.31 | 4.43 ± 0.40 | 0.01 |
3.3 | Summarizes to confirm | 3.50 ± 1.09 | 3.63 ± 1.12 | 0.08 |
4 | Patient perspective | 3.43 ± 0.62 | 3.61 ± 0.54 | 0.31 |
4.1 | Elicits beliefs about illness | 3.21 ± 0.78 | 3.15 ± 0.82 | 0.79 |
4.2 | Explores worries/concerns | 3.91 ± 0.57 | 3.60 ± 0.53 | 0.11 |
4.3 | Assesses daily-life impact | 3.50 ± 0.75 | 3.76 ± 0.52 | 0.15 |
5 | Information sharing | 3.43 ± 1.05 | 3.61 ± 1.04 | 0.31 |
5.1 | Explains diagnosis in plain language | 3.21 ± 1.09 | 3.15 ± 0.97 | 0.79 |
5.2 | Uses visual aids/examples | 3.91 ± 1.16 | 3.60 ± 1.10 | 0.11 |
5.3 | Checks understanding (teach-back) | 3.50 ± 1.23 | 3.76 ± 1.16 | 0.15 |
6 | Plan negotiation | 3.41 ± 0.95 | 3.55 ± 1.00 | 0.34 |
6.1 | Discusses therapeutic options | 3.53 ± 097 | 3.70 ± 0.90 | 0.42 |
6.2 | Involves patient in decisions | 3.43 ± 1.11 | 3.55 ± 1.16 | 0.37 |
6.3 | Negotiates realistic goals | 3.26 ± 1.15 | 3.40 ± 1.10 | 0.47 |
7 | Closure | 3.53 ± 1.11 | 3.74 ± 0.99 | 0.14 |
7.1 | Provides final summary | 3.30 ± 1.24 | 3.46 ± 0.93 | 0.36 |
7.2 | Checks for residual questions | 3.62 ± 0.97 | 3.75 ± 1.02 | 0.41 |
7.3 | Closes with empathy and follow-up | 3.68 ± 1.28 | 4.01 ± 1.10 | 0.06 |
8 | Diabetes specific | 3.80 ± 0.81 | 4.12 ± 0.79 | 0.03 |
8.1 | Explains lab results (HbA1c) | 3.81 ± 0.80 | 4.05 ± 0.71 | 0.12 |
8.2 | Provides initial plan and alleviates anxiety | 3.78 ± 0.97 | 4.20 ± 0.74 | 0.02 |
Total | Overall score (23–115) | 84.46 ± 17.75 | 88.93 ± 17.37 | 0.08 |
Item | Domain/Skill (Abridged) | Pre-Intervention Mean ± SD | Post-Intervention Mean ± SD | Δ Mean | 95% CI (Δ) | Cohen’s d | p |
---|---|---|---|---|---|---|---|
1 | Relationship | 3.13 ± 0.56 | 4.10 ± 0.65 | 0.97 | 0.74–1.20 | 1.59 | 0.001 |
1.1 | Eye contact and open posture | 3.85 ± 0.75 | 4.20 ± 0.60 | 0.35 | 0.09–0.61 | 0.51 | 0.004 |
1.2 | Friendly body language | 3.51 ± 0.79 | 4.26 ± 0.58 | 0.75 | 0.49–1.01 | 1.08 | 0.001 |
1.3 | Self-introduction and role | 2.03 ± 1.19 | 3.83 ± 0.84 | 1.80 | 1.41–2.19 | 1.74 | 0.001 |
2 | Opening | 1.86 ± 0.70 | 3.78 ± 0.73 | 1.92 | 1.65–2.19 | 2.68 | 0.001 |
2.1 | Greeting and ID verification | 1.68 ± 0.67 | 4.08 ± 0.83 | 2.40 | 2.12–2.68 | 3.18 | 0.001 |
2.2 | States purpose of visit | 2.01 ± 0.87 | 3.80 ± 0.87 | 1.79 | 1.46–2.12 | 2.05 | 0.001 |
2.3 | Explores patient expectations | 1.90 ± 0.96 | 3.46 ± 0.94 | 1.56 | 1.20–1.92 | 1.64 | 0.001 |
3 | Information gathering | 2.65 ± 0.56 | 3.93 ± 0.64 | 1.28 | 1.05–1.51 | 2.12 | 0.001 |
3.1 | Uses open questions | 2.01 ± 0.99 | 3.92 ± 0.68 | 1.91 | 1.59–2.23 | 2.24 | 0.001 |
3.2 | Listens without interrupting | 3.95 ± 0.38 | 4.32 ± 0.37 | 0.37 | 0.23–0.51 | 0.98 | 0.001 |
3.3 | Summarizes to confirm | 1.98 ± 1.11 | 3.56 ± 1.09 | 1.58 | 1.17–1.99 | 1.43 | 0.001 |
4 | Patient perspective | 1.95 ± 0.56 | 3.52 ± 1.04 | 1.57 | 1.25–1.89 | 1.87 | 0.001 |
4.1 | Elicits beliefs about illness | 1.75 ± 1.03 | 3.18 ± 1.13 | 1.43 | 1.02–1.84 | 1.32 | 0.001 |
4.2 | Explores worries/concerns | 2.05 ± 0.99 | 3.75 ± 1.13 | 1.70 | 1.30–2.10 | 1.60 | 0.001 |
4.3 | Assesses daily-life impact | 2.06 ± 1.05 | 3.63 ± 1.18 | 1.57 | 1.15–1.99 | 1.40 | 0.001 |
5 | Information sharing | 1.91 ± 0.56 | 3.57 ± 0.92 | 1.66 | 1.37–1.95 | 2.17 | 0.001 |
5.1 | Explains diagnosis in plain language | 2.28 ± 1.09 | 3.54 ± 1.05 | 1.26 | 0.86–1.66 | 1.17 | 0.001 |
5.2 | Uses visual aids/examples | 1.91 ± 0.99 | 3.06 ± 1.33 | 1.15 | 0.71–1.59 | 0.98 | 0.001 |
5.3 | Checks understanding (teach-back) | 1.53 ± 0.92 | 3.65 ± 1.10 | 2.12 | 1.74–2.50 | 2.09 | 0.001 |
6 | Plan negotiation | 2.03 ± 0.56 | 3.48 ± 0.97 | 1.45 | 1.15–1.75 | 1.83 | 0.001 |
6.1 | Discusses therapeutic options | 2.23 ± 092 | 3.61 ± 1.00 | 1.38 | 1.02–1.74 | 1.43 | 0.001 |
6.2 | Involves patient in decisions | 2.11 ± 0.82 | 3.49 ± 1.13 | 1.38 | 1.01–1.75 | 1.39 | 0.001 |
6.3 | Negotiates realistic goals | 1.75 ± 0.81 | 3.33 ± 1.11 | 1.58 | 1.21–1.95 | 1.62 | 0.001 |
7 | Closure | 1.84 ± 0.62 | 3.63 ± 1.05 | 1.79 | 1.46–2.12 | 2.07 | 0.001 |
7.1 | Provides final summary | 1.75 ± 0.77 | 3.38 ± 1.24 | 1.63 | 1.24–2.02 | 1.57 | 0.001 |
7.2 | Checks for residual questions | 1.70 ± 0.94 | 3.68 ± 0.99 | 1.98 | 1.62–2.34 | 2.05 | 0.001 |
7.3 | Closes with empathy and follow-up | 2.08 ± 0.92 | 3.85 ± 1.19 | 1.77 | 1.37–2.17 | 1.66 | 0.001 |
8 | DM-specific | 1.90 ± 0.56 | 3.96 ± 0.81 | 2.06 | 1.80–2.32 | 2.95 | 0.001 |
8.1 | Explains lab results (HbA1c) | 1.85 ± 0.70 | 3.93 ± 0.88 | 2.08 | 1.78–2.38 | 2.61 | 0.001 |
8.2 | Provides initial plan and alleviates anxiety | 1.93 ± 0.73 | 3.99 ± 0.89 | 2.06 | 1.75–2.37 | 2.53 | 0.001 |
Total | Overall score (23–115) | 49.96 ± 9.72 | 86.70 ± 17.56 | 36.74 | 31.39–42.09 | 2.58 | 0.001 |
Outcome Variable | Cluster A (n = 10) | Cluster B (n = 12) | Cluster C (n = 8) | p |
---|---|---|---|---|
Δ-score (total rubric) | 58.7 ± 10.2 | 33.4 ± 11.5 | 16.2 ± 9.3 | <0.001 |
Relationship (Domain 1) | 1.23 ± 0.40 | 0.68 ± 0.28 | 0.31 ± 0.17 | <0.001 |
Opening (Domain 2) | 1.79 ± 0.52 | 0.96 ± 0.41 | 0.37 ± 0.25 | <0.001 |
Information gathering (D3) | 1.42 ± 0.61 | 0.89 ± 0.36 | 0.34 ± 0.30 | <0.001 |
Patient perspective (D4) | 1.51 ± 0.77 | 0.79 ± 0.45 | 0.21 ± 0.33 | <0.001 |
Information sharing (D5) | 1.76 ± 0.91 | 1.03 ± 0.59 | 0.45 ± 0.38 | <0.001 |
Plan negotiation (Domain 6) | 1.55 ± 0.87 | 0.92 ± 0.44 | 0.33 ± 0.28 | <0.001 |
Closure (Domain 7) | 1.62 ± 0.89 | 0.87 ± 0.53 | 0.41 ± 0.26 | <0.001 |
DM-specific (Domain 8) | 2.04 ± 0.80 | 1.07 ± 0.62 | 0.54 ± 0.41 | <0.001 |
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Suárez-García, R.X.; Chavez-Castañeda, Q.; Orrico-Pérez, R.; Valencia-Marin, S.; Castañeda-Ramírez, A.E.; Quiñones-Lara, E.; Ramos-Cortés, C.A.; Gaytán-Gómez, A.M.; Cortés-Rodríguez, J.; Jarquín-Ramírez, J.; et al. DIALOGUE: A Generative AI-Based Pre–Post Simulation Study to Enhance Diagnostic Communication in Medical Students Through Virtual Type 2 Diabetes Scenarios. Eur. J. Investig. Health Psychol. Educ. 2025, 15, 152. https://doi.org/10.3390/ejihpe15080152
Suárez-García RX, Chavez-Castañeda Q, Orrico-Pérez R, Valencia-Marin S, Castañeda-Ramírez AE, Quiñones-Lara E, Ramos-Cortés CA, Gaytán-Gómez AM, Cortés-Rodríguez J, Jarquín-Ramírez J, et al. DIALOGUE: A Generative AI-Based Pre–Post Simulation Study to Enhance Diagnostic Communication in Medical Students Through Virtual Type 2 Diabetes Scenarios. European Journal of Investigation in Health, Psychology and Education. 2025; 15(8):152. https://doi.org/10.3390/ejihpe15080152
Chicago/Turabian StyleSuárez-García, Ricardo Xopan, Quetzal Chavez-Castañeda, Rodrigo Orrico-Pérez, Sebastián Valencia-Marin, Ari Evelyn Castañeda-Ramírez, Efrén Quiñones-Lara, Claudio Adrián Ramos-Cortés, Areli Marlene Gaytán-Gómez, Jonathan Cortés-Rodríguez, Jazel Jarquín-Ramírez, and et al. 2025. "DIALOGUE: A Generative AI-Based Pre–Post Simulation Study to Enhance Diagnostic Communication in Medical Students Through Virtual Type 2 Diabetes Scenarios" European Journal of Investigation in Health, Psychology and Education 15, no. 8: 152. https://doi.org/10.3390/ejihpe15080152
APA StyleSuárez-García, R. X., Chavez-Castañeda, Q., Orrico-Pérez, R., Valencia-Marin, S., Castañeda-Ramírez, A. E., Quiñones-Lara, E., Ramos-Cortés, C. A., Gaytán-Gómez, A. M., Cortés-Rodríguez, J., Jarquín-Ramírez, J., Aguilar-Marchand, N. G., Valdés-Hernández, G., Campos-Martínez, T. E., Vilches-Flores, A., Leon-Cabrera, S., Méndez-Cruz, A. R., Jay-Jímenez, B. O., & Saldívar-Cerón, H. I. (2025). DIALOGUE: A Generative AI-Based Pre–Post Simulation Study to Enhance Diagnostic Communication in Medical Students Through Virtual Type 2 Diabetes Scenarios. European Journal of Investigation in Health, Psychology and Education, 15(8), 152. https://doi.org/10.3390/ejihpe15080152