Background Communication skills are commonly taught with simulated patients (SP), which is resource-intensive and difficult to scale. Immersive virtual reality (VR) promises repeatable, low-cost practice but its equivalence to SP encounters is unclear. Methods We randomised 96 fourth-year medical students to a VR scenario or an SP encounter on delivering a difficult diagnosis, and crossed over after two weeks. Primary outcome was the Calgary–Cambridge observation guide score rated by blinded assessors. Results Non-inferiority of VR was shown (Δ = −0.8, 95 % CI −2.1 to 0.5; margin 3.0). Students rated presence higher in VR and perceived authenticity higher with SPs. Conclusions VR can replace a share of SP encounters for communication training without loss of measured skill.