Virtual Humans Playing the Role of Patients in Self-medication
Consultations: Perspectives of Undergraduate Pharmacy Students
Ana Paula Cláudio
, Maria Beatriz Carmo
, Mara Pereira Guerreiro
, Afonso Cavaco
Vítor Pinto
and Ana Pinha
BioISI- Biosystems & Integrative Sciences Institute, Faculty of Sciences, University of Lisboa, Lisboa, Portugal
Faculty of Pharmacy, University of Lisboa, Lisboa, Portugal
CiiEM -
Instituto Superior de Ciências da Saúde Egas Moniz, Monte da Caparica, Portugal
Escola Superior de Enfermagem de Lisboa, Lisboa, Portugal
Keywords: Virtual Humans, Consultation Skills, Communication Skills, Pharmacy Students, Self-medication.
Abstract: This paper describes an interactive application conceived to improve non-prescription medicines consultation
skills in undergraduate Pharmacy students and a user test carried out with two sets of participants. Resorting
to virtual humans that play the role of patients and communicate with the students by speech and by facial
and body language, the application stimulates students’ engagement in true-to-life situations in a controllable
environment. Two usage modes are available: the training mode, used autonomously by the student, and the
assessment mode which is used by the teacher to evaluate the student’s performance. A BackOffice Web
application was also implemented to assist teachers’ work. It supports the collection of data about students’
performance, the creation of new self-medication situations and their posterior insertion in the application.
The overall opinion of the participants in the user-study was quite positive about the usefulness of the
application as a tool to improve students’ non-prescription medicines consultation skills. Moreover, some
valuable suggestions were gathered during this testing process.
Self-medication is common in community pharmacy.
For example, research indicates that about a quarter
of the clients in urban Portuguese pharmacies
purchased medicines without physicians’ advice
(Martins et al., 2002). It is acknowledged that self-
medication has a number of potential advantages for
stakeholders - consumers, health professionals,
pharmaceutical industry and the health system - but it
is not without risks, namely adverse effects (Asseray
et al., 2013) (Schmiedl et al., 2014) and misuse
(Cooper, 2013). International and national
organizations, such as the World Health
Organisation, have advocated a role for community
pharmacists in assisting consumers who present
minor ailments or request non-prescription
In his seminal work on quality of care Donabedian
considered both technical and interpersonal elements
in the performance of practitioners (Donabedian,
1988). The latter was regarded as “the vehicle by
which technical care is implemented and on which its
success depends”. In other words, a successful
consultation relies not only in clinical knowledge and
judgment but also on communication; self-
medication consultations are no exception. Therefore
pharmacy educators are faced with the challenge of
developing both clinical and communication skills in
This paper describes an interactive application to
support skills training and assessment of
undergraduate Pharmaceutical Sciences students and
continues previous works from the same team
(Cláudio et al., 2015a). Although training and
assessing professional competence is a
multidimensional reality, which involves trainees’
work beyond passing or failing exams, but collecting
evidence of competence (i.e. the use of skills
according to standards of qualification) (Epstein and
Hundert, 2002), simulation is increasingly being used
for competencies based training and assessment. This
is a result of changes in health care delivery and
academic environments (e.g. the safety culture and
limited patient availability, respectively), and the
Cláudio, A., Carmo, M., Guerreiro, M., Cavaco, A., Pinto, V. and Pinha, A.
Virtual Humans Playing the Role of Patients in Self-medication Consultations: Perspectives of Undergraduate Pharmacy Students.
DOI: 10.5220/0005720002960303
In Proceedings of the 11th Joint Conference on Computer Vision, Imaging and Computer Graphics Theory and Applications (VISIGRAPP 2016) - Volume 1: GRAPP, pages 298-305
ISBN: 978-989-758-175-5
2016 by SCITEPRESS Science and Technology Publications, Lda. All rights reserved
shift to outcomes-based education, being clear the
advantages of simulation to demonstrate the
acquisition of basic competences (Scalese et al.,
2008). The present prototype simulates realistic self-
medication consultations using Virtual Humans
(VH), with the purpose of improving students’
clinical and communication skills in self-medication.
The prototype was developed with the aid of
Unity3D, a software tool for videogames. Both
Portuguese and English versions are available.
Firstly, users must select a self-medication
scenario and then, one VH must be chosen from four
characters (both genders and two different age
groups). The VH is depicted in a community
pharmacy environment and has natural body
movements, obtained by motion capture. Users,
playing the role of a pharmacist, communicate with
the VH by choosing textual options in the application
interface. Options are scored according to their level
of correctness at each point of the non-prescription
medicine consultation process; the goal is to obtain
the highest score by selecting the options that are
more correct.
The VH communicates verbally, by a synthetic
voice synchronised with the movements of the lips,
and non-verbally, by emulating facial and body
expressions as a response to the options chosen by the
When the consultation is completed, users receive
feedback on their overall score and on their test score
in different consultation stages (e.g. patient
assessment and counselling). The application saves
the tests scores for each user, enabling data analysis
and progress monitoring over time.
A preliminary evaluation of the prototype was
conducted with seven experts (academic and
practitioners), from different organisations (Cláudio
et al., 2015a). This paper describes a user-study
involving two sets of students.
The paper is organized as follows: next section
presents the most relevant work in the area; sections
III to V describe our application; section VI reports
the evaluation; and section VII presents conclusions
and future work.
Healthcare education has used VH as a useful
resource (Cláudio et al., 2015b; Hoffman, 2000),
although its application in pharmacy education seems
scarce. Thus, one first step in ascertaining
pedagogical usefulness would be exploring the
advantages provided by VH in the development of
pharmacists’ clinical and communication skills.
A systematic review with meta-analysis on the use
of computer-based VH solutions for health
professions, evaluated the outcome of this
educational resource on users’ satisfaction,
knowledge, attitudes and communication/clinical
skills (Cook et al., 2010). Total of 3,285 learners
(2,115 medical students, 272 nursing students, both
professionals and other learners) allowed concluding
that VH were associated with large positive effects
compared with no intervention. However, VH effect
compared with non-computer instruction was on
average smaller, and not always statistically
significant, suggesting lower effectiveness on a wider
sample of healthcare learners. The large
inconsistency among study results led the authors to
exert caution when drawing conclusions about true
effectiveness differences between methods.
Cook and colleagues reported also results from
four qualitative studies with medical students, which
returned interesting accounts on learners’ views
concerning the use of VH (Cook et al., 2010). These
were perceived to bring advantages over other
educational methods, especially in what concerns
convenience of access, a relaxing learning
environment, and case evolution according to
learners’ actions and feedback. Actually, these were
key determinants of participants’ satisfaction and
engagement. Case realism was associated both with
the VH presentation and case material, including the
type of case presented. Additional topics contributing
to improve learning outcomes comprised repetition
until demonstration of proficiency, enhanced
feedback, and explicitly contrasting cases (Cook et
al., 2010).
A more recent review by Jabbur-Lopes and
colleagues focused on the use of VH in
pharmaceutical care education to pharmacy students
(Jabbur-Lopes et al., 2012). Using less stringent
criteria than the work of Cook et al., this review found
seven articles, four of which were conducted in North
America. The authors conclude that the paucity of
published studies involving VH suggests an under use
of this tool in pharmacy education and this conclusion
is supported by a cross-sectional survey in a
convenience sample of 194 European pharmacy
undergraduates (Cavaco and Madeira, 2012), where
only 12 students, from six universities in six different
countries reported experiences with VH. Those were
satisfied with this educational method and non-users
revealed themselves in favour of the potential benefits
of VH in pharmacy education.
Virtual Humans Playing the Role of Patients in Self-medication Consultations: Perspectives of Undergraduate Pharmacy Students
Computerised approaches make use of video clips
to create tools for skills training, while others fall
back on non-computerised virtual patients. One
example of the last comes from teaching self-care
consultation skills to pharmacy students in North
America (Orr, 2007); this study found an
improvement in overall knowledge and
communication skills. An example of the former i.e.
a VH application based on video images, photographs
of people in full size and realistic background sounds,
received the name of Virtual Practice Environment
(VPE) (Hussainy et al., 2012). This solution tries to
create a 3D immersive environment for high fidelity
patient care training in community pharmacies.
Furthermore, background images can also be
combined with previous recordings of staged
situations. Another example of high-end proposals is
the Interactive Simulated Patient (Bergin and Fors,
2003). This multimedia application was developed
for healthcare students, to explore and solve clinical
cases, aiming to help students’ practice of their
clinical reasoning skills. This is a sophisticated
resource where the interaction with the virtual patient
is made through natural language, with text input in a
dialog box, and the patient’s answers being offered
through video clips.
The AVATALK is a device that uses VH for skills
training in different areas (Hubal et al., 2000). The
main features comprise emotions expression with, the
possibility of behaviour modelling, using natural
language processing techniques. As with previous
proposals there is an option of integration of three-
dimensional scenarios. It was tested in medical
practice training together with another application,
the Trauma Patient Simulator, which defines
scenarios, medical histories, and the rules of
simulation between the patient and the trainee. The
learning results from the two last applications
evaluation were quite encouraging.
Compared to these solutions, our application has
additional features: it can be used both in training and
assessment mode; it includes a BackOffice
application to support teachers’ work, in particular it
offers an easy-to-use process for definition of new
self-medication cases that requires no informatics
skills from the user; and the application uses the
overall information contained in these definitions to
automate a set of choices concerning the VH that
populate the simulation. Next sessions gives details
about these features.
Virtual Pharmacy was designed to be used by
Pharmaceutical Sciences students in two usage
contexts: training and assessment. In both cases, the
student selects, from a list, a self-medication
situation. After that, he chooses a VH among a set of
four possibilities (both genres, young and old
The application recreates the chosen situation of
self-medication which takes place in a virtual
community pharmacy, represented as a background
image that is randomly selected from a set of images.
The VH plays the role of a patient suffering from that
particular clinical condition and requiring the
assistance of a healthcare professional (Figure 1). The
VH communicates verbally by a synthetic voice
synchronised with the lips.
Along with verbal communication, the VH also
communicates through body animations and by
changing his facial expressions (neutral, satisfied and
discontent). The initial expression is random and may
change in the course of the interaction, as a response
to the right or wrong choices made by the student
(Figure 2). The student, playing the role of a
pharmacist behind the counter, interacts with the VH
by selecting one of three textual options displayed in
the application interface (right side of Figure 1). Each
set of three options includes questions with different
levels of correctness to which are assigned different
scores. The course of the simulation is guided by the
options sequentially chosen by the student.
After performing a sequence of interactions with
the VH, the student completes the virtual consultation
and receives feedback on his overall scores.
When in training mode, the student uses the
application autonomously and, by the end of each
virtual consultation, together with his overall scores,
he receives detailed information about the correctness
of his previous choices and about his progress along
successive training sessions. The application also
provides links to educational contents related to the
topics of the self-medication situations presented.
In assessment mode, the application displays the
student’s overall scores and stores results in a
database for posterior analysis by the teacher with the
purpose of assigning him a mark.
GRAPP 2016 - International Conference on Computer Graphics Theory and Applications
Figure 1: Application interface- the animated virtual patient
describing his problem (a headache) using speech and
gesture; below this, the subtitles of the speech that
accompanies the speech sound; on the right side, the three
options presented for the user to choose one.
Figure 2: Virtual Patient exhibiting three distinct facial
expressions (from left to right): neutral, satisfied and
3.1 Architecture of the Application
The Virtual Pharmacy application was developed for
PC. It has three main components: the VP_SIM, the
VP_Office and the Speech Generator. Each one of
these components contains several modules.
The VP_SIM is the core component that is
intended to be used by the students. It is implemented
in C#, using Unity3D, and comprises the User
Interface and the Application Controller that
commands the simulation of the situations.
The VP_Office implements the BackOffice
Application (BOA) that supports teachers’ tasks. Its
main component is the Dialogue Creator,
implemented using a javascript libray, JointJS
(, to build graphs. The Dialogue Creator
offers a graphical interactive interface to define or
edit self-medication situations, described as a graph.
Each node in the graph corresponds to a phrase that is
articulated by the VH or to an option and its
associated score. The nodes representing the speech
of the patient are connected to several nodes which
are the options to be shown to the student. In contrast,
the nodes that correspond to an option presented to
the student have only one link to a phrase of the
patient; this node corresponds to the reaction of the
virtual patient to the choice made by the student.
Using the graph to build the dialogues does not
require informatics skills.
The BOA application provides also other
functionalities for the teachers: an interface to upload
complementary elements of study to be shown in the
training mode of VP_SIM; and an interface to
monitor students’ progress over time. A MySQL
database is used to store the information which is
shared by the VP_SIM and the VP_Office.
When the VP_SIM application is launched, the
Data Controller module reads from the database the
information necessary to create the list of situations
to be displayed in the interface and to manage the
course of the simulations. Detailed information can
be obtained in (Cláudio et al., 2015a).
The third component, Speech Generator is
responsible for the VH correct articulation of the
speech as explained in the following section.
3.2 Animations and Speech
The four VH’s models in the application represent
adults of both genders and two different age groups:
young and old. They were obtained from DazStudio
( and enriched with body and facial
animations using two different animation techniques:
skeletal animation for the body and morph target
animation for the face. Both facial and body
animations were combined in Blender (
and then exported to Unity3D.
Facial animations comprise the expression of
emotions and the movement of the lips synchronized
with speech. Body animations were built based on
motion capture data downloaded from the Unity3D
assets store.
To attain a good level of realism, the
synchronization of the lips with the sound is an
essential feature in speech animation, because
observers are very sensitive to small errors (Xu,
2013). The component of the application that
processes speech generation is the Speech Generator
which relies on a Microsoft speech library
?id=10121) to convert text to speech. Taking into
account the age and gender of the character, for each
phrase of the dialogue two files are created: an audio
file, in wav format, with the speech of the character,
and an XML file, with the respective animation.
Body animations of the VH are triggered by
keywords in the dialogue that are connected to the
self- medication situation. For instance, the character
Virtual Humans Playing the Role of Patients in Self-medication Consultations: Perspectives of Undergraduate Pharmacy Students
brings his hand to the head while he articulates a
sentence describing the symptoms for headache. The
module Character Behavior Controller is responsible
for analysing the speech lines of the VH in the graph
to detect the keywords connected with animations.
This module also controls the facial animation of the
VH, reacting to the student’s performance while
using the tool.
A preliminary version of VP_SIM was evaluated with
7 experts on pharmacy practice, to study the usability
and suitability of the application. The results of this
user-study revealed that these professionals
considered VP_SIM a valuable tool for training and
assessing students’ OTC (over-the-counter, i.e., drugs
that do not require a doctor’s prescription)
counselling skills (Cláudio et al., 2015a). But some
associated dangers were identified: normal
limitations related to a predefined dialogue that does
not cover all possible patient reactions and events in
a real situation. In their opinion, the contact with the
simulated situations in the application should
preferably be followed by real interactions in a true
community pharmacy.
The majority of panel experts were not supportive
of replacing the face-to-face teaching or the
internship, since there are behavioural competencies
that need real interactions and experience. In their
opinion, the application as a starting point should be
kept in a mix training environment. The subsequent
version of VP_SIM was fine-tuned and evaluated
with students.
4.1 Participants and Procedure
The evaluation resorted to two distinct sets of
volunteer Pharmaceutical Sciences students. A first
set comprised 10 undergraduate Pharmaceutical
Sciences students in their 4th year of studies; a second
set was composed by 42 students in the last year of
their Pharmaceutical Sciences course, performing
their curricular internship behind a counter in a
community pharmacy. Students in both sets were
from the same university to ensure identical learning
backgrounds. Each student tried the application,
performing the same list of suggested tasks and
afterwards answered to a set of questions in a Google
Forms questionnaire.
The list of suggested tasks included: i) to start the
application and make the registration and login steps;
ii) to solve the Headache situation choosing the
younger male character; iii) to solve the Cough
situation with a character of their own choice among
the available 4 in the interface; iv) and finally, to
consult the summarized information about his/her
performance in the resolution of the situations.
Besides the biographical questions to obtain a
general profile of the user, three groups of questions
were asked: i) specific questions about the interface
of the application and the VH, and some questions to
gather an overall evaluation; ii) a SUS (System
Usability Scale) questionnaire (Brooke,1996); and
iii) questions to infer about application’s suitability
and potential use for students’ training and
assessment in the area of Pharmaceutical Sciences.
The majority of the questions in groups 1 and 2
were answered using a Likert scale ( from 1- strongly
disagree to 5- strongly agree). All questions in group
3 were open-ended questions. Both set of users
answered to the 3 groups of questions in a Google
Forms questionnaire.
The user-study started with the 10 students (5
women, 5 men) in the 4
year. They made the tests in
a classroom in their own faculty, just after a class, and
all of them used the same computer with the
following characteristics: CPU- Intel Core i7, 2,4
GHz; RAM: 8GB; GPU: Nvidia GeForce GT 650M,
The interviewer, observing the students while
they were performing the suggested tasks, was able to
perceive the difficulties the participants were
experiencing with the interface and registered all their
verbal comments. This feedback collected by the
interviewer was used to eliminate some ambiguities
in the interface of the application before the
evaluation with the internship students. The 42
internship students (35 women, 7 men) received an
email explaining how to download and execute the
application in their own computer, the list of
suggested tasks and the link to the Google Forms
questionnaire to fulfil afterwards.
Students of the 4th year, still with no contact
experience with real patients, used the training
version of VP_SIM and internship students used the
assessment version. As mentioned before, the latter
displays only the overall scores of the student, while
the training version provides detailed information
about the correctness of the previous choices, on the
progress over successive sessions of training and
links to educational content.
GRAPP 2016 - International Conference on Computer Graphics Theory and Applications
Table 1: Median values of the answers to questions about the interface (group 1).
Questions about the interface
(answered with a Likert scale: from
1- strongly disagree to 5- strongly agree)
4th year
The information is properly displayed on the screen (e.g. number and locations of
4 4
2 Performing tasks is straightforward, i.e., the choice of options and/or menus is easy 4 4
3 The operation speed of the application is adequate 5 4
4 The choice of self-medication situations is clear 4 4
5 The choice of self-medication situations is straightforward, i.e., it does not require too many steps 4 4
6 The choices given to the user are meaningful 4.5 4
Table 2: Median values of the answers to questions about the Virtual Humans (group 1).
Questions about the Virtual Humans
(answered with a Likert scale: from
1- strongly disagree to 5- strongly agree)
4th year
1 The selection of the virtual human is clear 5 4
The selection of the virtual human is straightforward, i.e., it does not
require too many steps
5 4
3 The virtual humans are very realistic 4 3
4 The cloths of the virtual humans are very realistic 3.5 3
5 The way the virtual humans look is very realistic 4 3
6 The movements of the virtual humans’ bodies are very realistic 3 3
7 It is easy to hear / understand the sentences articulated by the virtual humans 4 4
8 The movements of the virtual humans’ lips are synchronized with the voice 4 3
The feedback provided by the virtual humans’ facial expressions is useful for the user of the
4 4
Table 3: Median values of the answers to questions about the overall opinion of the application (group 1).
Questions about the overall opinion of the application
(answered with a Likert scale: from
1- strongly disagree to 5- strongly agree)
4th year
I am content with the information the application gives me about my performance in the
resolution of the cases
5 4
I am content with the summarized information the application gives me about my performance
in the resolution of all the previous cases
5 4
3 The application is easy to use 5 4
4 The application responds to my anticipated goals 5 4
4.2 Results and Discussion
The results (median of users’ scores) of the questions
in group 1 are presented in table 1 (interface), table 2
(VH) and table 3 (general opinion). The overall
results are quite positive; lower scores appear in table
2 and are related to the realistic appearance and
behavior of the VH playing the role of patients.
Higher quality models, eventually commercial,
would most probably produce better user scores,
concerning the questions in lines 3, 4 and 5; body
movements can also be improved resorting, for
instance, to better motion capture data. The non-
controllable issue is in line 8, because a natural
speech articulation requires a very good
synchronization between lips’ animation and sound,
a demanding requirement in terms of hardware. It
should be noticed that internships used their own
computers, so we do not have control on the quality
of the hardware.
We could have asked those participants about the
hardware they were using. But we considered this
question counter-productive because i) that can be a
hard question to answer by someone potentially
without informatics skills, and ii) that question would,
most likely, prevent them from participating.
That is, a “less-good” computer may have
produced a lower impression on the user. This
speculation should be proved in future evaluations,
probably using always the same (type of) computer,
like 4
year students did. However, we have to be
cautious because this requirement of using the same
type of computer may hinder user testing.
Regarding the feedback provided by the virtual
humans’ facial expressions, reflecting his/her
performance (Table 2, line 9), students in the two sets
Virtual Humans Playing the Role of Patients in Self-medication Consultations: Perspectives of Undergraduate Pharmacy Students
agreed that it is useful (scores’ median = 4). Half of
the participants mentioned that more expressions
were needed, such as surprised, feeling pain,
doubtful, confused, concerned and angry.
Students in the 4th year scored with 5 the
questions in table 3 (general opinion), while
internships scored only with 4. Notice that these
results are not directly comparable because the last
ones tried the assessment version and some of them
wrote in the open-ended questions that they would
like to have more information about the resolution of
the cases, for instance the pathologies.
In the SUS questionnaire all the questions
received scores 4 and 5, except two that had a median
score of 3 and reveal that the users feel the usage of
the application is somehow restrictive. This result is
coherent with the mentioned small number of
available situations to solve, also expressed in open-
ended questions.
In the open-ended questions, 4
year students
emphasized as positive aspects the possibility of
interaction with the virtual patients resorting to a
logic dialogue that support the training of the
protocols (for instance, the correct sequence of
questions to pose); they also enjoyed the possibility
of choosing a particular character. The application
was considered as a valid learning tool, adequate to
help the learning process and to review the concepts
explained in classes.
As a negative characteristic they mentioned the
rapid end of the interaction with the patient when the
student makes a mistake at the beginning of the case
The internships considered the prototype could
become a powerful tool to learn and to consolidate
knowledge, as long as it offers more situations. They
mentioned that it can be a tool for students, but also
for professionals that need to review and update their
professional capacities: it can help remembering
concepts and principles learned in school but already
As negative aspects, they referred that real
patients in pharmacy are usually not so predictable
and sometimes not as civilized as the virtual ones in
the application.
The majority of participants mentioned that a
negative aspect is the very limited number of
situations (just two, for the time being). All the
participants agreed that the tool cannot substitute a
real teacher, but it can be a good adjuvant learning
tool, corroborating the opinion of the experts that
tested the preliminary version of the prototype.
We developed and implemented an interactive
application to support training and assessment of self-
medication consultation skills in pharmacy students,
using VHs animated with facial expressions, body
movements and speech communication.
The abbreviated usability study allowed checking
for potential advantages of using this software,
clearly as an additional source of students’ motivation
to practice their counselling skills scenarios: students
were optimistic in relation to move away from
traditional paper-based clinical cases into a closer
sense of professional interaction.
Another strong point of this prototype is its
BackOffice web application, which can be operated
by users without informatics skills. It allows
instructors to develop the consultation dialogues in an
intuitive and user-friendly graphical interface and
provides data on students’ performance.
The evaluation of pharmacy students was
positive, both in terms of usability and usefulness.
This is in accordance with experts’ views, who were
also of the opinion that the application could be used
for postgraduate continuing education.
The overall results obtained are encouraging and
justify the development of an improved version which
will respond to most users’ suggestions. Additionally
we intend to include principles of “gamification”, by
adjusting the level of difficulty to the scores
previously obtained. This may increase motivation of
young students to use the application in the training
mode. An escalation of difficulty relies, from a
communication standpoint, in more variability in the
VHs behaviour and in a wider range of simulated
moods (for instance, less cooperating patients, more
voice tones, more facial and body expressions).
Currently the application includes virtual humans
speaking Portuguese and English, a feature we wish
to maintain in the next version. In the near future, it is
also our intention to widen the evaluation to
pharmacy students and practitioners in Portuguese-
speaking countries. This will certainly shed light on
improvements and functionalities needed to yield
versions that are appropriate for different countries
and cultures.
We acknowledge the financial support of BioISI
R&D unit, UID/MULTI/04046/2013 funded by
GRAPP 2016 - International Conference on Computer Graphics Theory and Applications
FCT/MCTES/PIDDAC, Portugal and of the “Secção
Regional do Sul e Regiões Autónomas da Ordem dos
Farmacêuticos” that granted a BInov scholarship to
our research. We also thank Microsoft Portugal for
the license of the TTS voice.
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