Virtual Environments in Healthcare - Community Networking Group

Virtual Environments in Healthcare: Immersion, Disruption, and Flow

Jeffrey M. Taekman, MD Duke University Medical Center Durham, North Carolina

Kirk Shelley, MD, PhD Yale University New Haven, Connecticut

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Historic Views

Old forms of education are slowly crumbling under the weight of rapidly advancing computer and communication technologies along with the demands of learners who have grown up digital.1,2 These advances necessitate new thinking about the ways we educate and assess our healthcare workforce. Choosing anesthesiology (or any other healthcare profession) constitutes a commitment to life-long learning.3 Our careers span decades, and therefore, we need to constantly update our knowledge and skills. Yet, the traditional model of medical education has not changed in more than 100 years.4 The majority of our preclinical, and continuing education comes in the form of passive teacher-centric lectures. To paraphrase an example used by Sir Ken Robinson in his book, The Element,5 if we had a time machine and were able to bring a student forward in time from the 18th century, our educational system would be one of the few parts of society they would recognize. REPRINTS: JEFFREY M. TAEKMAN, MD, DEPARTMENT OF ANESTHESIOLOGY, BOX 3094 DUKE UNIVERSITY MEDICAL CENTER, DURHAM, NC 27710. E-MAIL: [email protected] INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 48, Number 3, 101–121 r 2010, Lippincott Williams & Wilkins

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A large body of literature condemns lecture-based education as inefficient and ineffective in changing learned behaviors.6–8 Lectures are inefficient in that students cannot ask enough questions to meet their needs2 and ineffective in that lectures do not commonly alter performance. Yet our ultimate success as teachers is judged on ‘‘not what our students know, but what they do.’’4 Just as healthcare is shifting toward patient-centricity, so too is medical education moving in the direction of learner-centric models. Learner-centric education places responsibility for learning squarely on the shoulders of the student. The traditional role of the teacher as the source of knowledge is evolving into a network of facilitators. The facilitators shape the objectives of the learning experience, but students are largely responsible for how they learn the material–both individually and in groups. The teacher/facilitator role shifts from being in the spotlight to a supporting role–to guide students in the right direction and help to overcome problems as they arise. Reminiscent of the ancient Platonic dialogs, the facilitator leads the students through scenarios allowing the student to discover (or according to Plato, rediscover) the correct approach the situations presented. Recently, interactive forms of education such as problem-based learning, team-based learning (TBL), and other immersive forms of education have gained significant roles in medical education. Similarly, the last decade has seen an increasing emphasis on simulation in healthcare education. Cooper defines a ‘‘Simulator’’ as a physical object or representation of the full or part task to be replicated. ‘‘Simulation’’ refers to application of simulators to education or training.9 David Gaba,10 a leader in the field of medical simulation, defines simulation as ‘‘a technique—not a technology—to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.’’ Simulation encompasses a broad continuum that includes standardized patients, high-fidelity simulation, and most recently virtual environments (VE). Bainbridge defines a virtual world as ‘‘an electronic environment that visually mimics complex physical spaces, where people can interact with each other and with virtual objects, and where people are represented by animated characters.’’11 Only a subset of activities in virtual world are considered simulation. VEs may be used for entertainment (eg, video games) or socializing (eg, SecondLife). In fact, many virtual environments are based on gaming technology (Fig. 1). Among the VEs, massively multiplayer online games have been among the most successful. They are characterized by their ability to support thousands of players simultaneously within a persistent virtual world. They have their humble origins in the 1970’s as text-based adventures running on university computers. This evolved into the game Meridian 59, characterized by a rich 3 dimensional environment www.anesthesiaclinics.com

Virtual Environments in Healthcare

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Figure 1. Simulation games-based learning/virtual environments sit at the intersection of simulation and video games.

that players could experience from a first person’s perspective. Launched in 1996, it still exists to this day online. Its popularity helped spawned Ultima Online followed by EverQuest. On the basis of role playing fantasy themes, these games allow its players to experience Lord of the Rings like adventures within very rich and engaging environments. The most popular multiplayer online game presently played is World of Warcraft (WoW) by Blizzard Entertainment (http:// us.blizzard.com/en-us/). WoW has over 11.5 million subscribers worldwide who log on, on a daily basis. The impact of these types of games on educational technology should not be underestimated. This manuscript will focus on VEs for healthcare education. We will focus first on VEs as a disruptive technology. We will then discuss the psychological state of ‘‘Flow’’ and what it means for education. Next, will be the examination of factors that are catalyzing a change in medical education, followed by discussion of the strengths and weaknesses of mannequin-based learning (MBL). We will then turn our attention to why games-based learning will have a prominent place in education, discussing the theory behind why they work, the advantages of VEs over MBL, and their limitations. There will be a brief discussion of the efforts to prove the efficacy of this learning technique. Finally, we will cover the possible opportunities enabled by VEs. What constitutes a game versus a simulation is beyond the scope of this paper. For our purposes, VE and games-based learning (GBL) will be used interchangeably. The semantics are irrelevant for our discussion. What is evident is that GBL is a disruptive technology that sits at the intersection of high-fidelity simulation, computer-based learning, and distance education. www.anesthesiaclinics.com

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Disruptive Technology What is a Disruptive Technology?

Clay Christensen, in his seminal work The Innovators Dilemma,12 describes a theory of how companies fail. In essence, a company’s legacy technology becomes an impediment to their success in a changing market. Using the computer hard drive industry as an example, he explores how the rise and fall of technical innovations caused company after company to become the market leader followed by near bankruptcy. Christensen described 2 types of technology: sustaining technologies and disruptive technologies. Sustaining technologies improve the performance of an existing product. Disruptive technologies, in contrast, are innovations that initially result in poorer performance, but fulfill a basic need of the customer base. Disruptive technologies are usually simpler, less expensive, and/or more convenient to use than the legacy product. Disruptive technologies are often ignored by the legacy company. Although the legacy company is busy adding features to its existing technology (to satisfy high-end customers), the disruptive technology builds capability and market share primarily from the bottom end of the value chain. Over time, the capabilities of the new technology surpass that of the old, completely unseating the legacy technology, and often destroying the legacy company. Examples of disruptive technologies include the personal computer, desktop publishing, digital photography, and musical synthesizers. Why Do Virtual Environments Fit the Definition?

Today, VEs, especially those based on gaming technology, are considered little more than entertainment. Very few professions (with the exception of the US military) have embraced VEs for education. But the advantages of VEs over other immersive learning techniques (including convenience, scalability, cost, and distributability) are undeniable. Why is Disruptive Technology Important?

Although VEs will have a prominent place in healthcare education, We do not expect them to completely supersede other interactive educational techniques such as MBL—at least for some time. To get to that point we would need something similar to Star Trek Holodeck— with fidelity indistinguishable from reality and artificial intelligence able to adapt to any contingency. There will continue to be a need for live, instructor-lead activities, especially in the later phases of education in which the student is practicing complex, intertwined behaviors. These types of behaviors are still too complex to be replicated or evaluated in www.anesthesiaclinics.com


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VEs. But a large percentage of our preclinical didactics, nonclinical graduate education, and continuing education currently can be efficiently and effectively delivered in VEs. ’

‘‘Flow’’ in Education What is Flow

‘‘Flow’’ is a concept familiar to game designers, but may not be to medical educators. Have you ever become so immersed in learning (or any other activity) that you lose track of time and your surroundings? Common colloquialisms for this concept include ‘‘being in the zone’’ or ‘‘having your head in the game.’’ Mihaly Csikszentmihalyi described this psychological state as ‘‘FLOW.’’ Flow is the mental state in which the person is fully engaged, focused, and committed to the success of the activity. Flow is an enjoyable experience for the learner13 and has been shown to improve performance in artistic and scientific creativity.14 Inducing a flow state is a key goal in commercial game design and should be strived for in medical education. A learner cannot consciously force themselves into a flow state, but 3 conditions make flow more likely: 1. The learner must be immersed in an activity in which the goals are clearly stated. These objectives give the exercise structure and context. 2. The learner must believe they possess the skills to overcome the perceived challenge. 3. The task must include prompt and coherent feedback. This allows the person to adjust their performance to accommodate changing demands. Flow in Commercial Games

Game designers construct challenges that build upon earlier knowledge. Each challenge is not so easy that it quickly becomes boring, nor so hard that the learner gets frustrated and gives up. Instead, game designers strive to embed challenges that are right at the edge of the gameplayer’s competence. In essence, each step slightly ‘‘stretches’’ the players competence. Once a particular challenge is achieved, the game player moves on to the next challenge building on their new knowledge. Flow in Education

Interestingly, flow is a critical component of efficient learning and is essential when developing expertise through deliberate practice.15 Our learners need learning interventions designed to induce Flow. Until recently, however, it was novel for education to be interactive, much less www.anesthesiaclinics.com

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provide the conditions for a flow state. Interestingly, well thought-out simulation scenarios contain all the prerequisites for Flow. Despite the prerequisite conditions being present for flow, most mannequin-based simulations are conducted with teams. It is highly unlikely that all team members would enter a flow state simultaneously. Despite the effectiveness of high-fidelity simulation, one cannot personalize the experience for each learner. With immersive technologies, especially those built with the same tools used for commercial games, the goal of personalized, interactive, flow-inducing education is finally within our grasp. VEs can be real-time tutors, always available to mentor the student through each phase of the learning process. GBL offers us capabilities for personalization and selfdiscovery that have earlier been unknown. ’

Catalysts of Change

In 1910 Abraham Flexner wrote a book-length study of medical education for the Carnegie Foundation. That study resulted in radical changes in medical education throughout the United States.4 Medical education has changed little since then. But, finally, more than 100 years after the Flexner Report, there are several factors catalyzing the needed changes in medical education. These factors include: information overload, a new breed of learner, an increased emphasis on outcomesbased education, the phenomenon of time-limited certification, and the changing demands on the healthcare team. Information Explosion

All of us can appreciate the impact of information overload during our professional careers. Information now doubles every 5 years.16 One hundred years ago, it may have been possible to memorize the breadth of medical information–but no longer. In the length of time, it takes our anesthesiology residents to complete their formal training and a fellowship, the amount of medical information will have doubled. Clearly, today’s educational processes, focused largely on the memorization of facts rather than concepts, is neither safe nor sustainable.17,18 Learners

Much has been written about the Millennials—the children of the Baby Boom Generation (born 1980s through 1990s). The Millennials are the largest generation America has ever seen. They have been interconnected through computers and network technologies their entire lives. They increasingly forego passive activities such as watching television in favor of online gaming and surfing the Internet. They value collaboration. They multitask. Many dislike reading, but use the internet as their www.anesthesiaclinics.com


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personal library. Most abhor passive learning.1 They expect information to be available 24 hours a day, 7 days a week, 365 days a year.1 The technologies that Millennials use in their free time—especially those used for their entertainment (internet, games, computers)— profoundly influence their learning.19 As of their heavy use of games, their visual attention and perception is unrivaled when compared with earlier generations.19 Playing video games also seems to enhance their multitasking abilities.19–21 Despite some of their abilities being enhanced, others are compromised. Abilities such as inductive problem solving, critical thinking, and imagination are all hampered by their choices in media and entertainment.19 What is needed are educational methods that take advantage of the Millennials new strengths whereas compensating for their weaknesses. We are beginning to observe the impact of the Millennial new skills. Recent studies show the impact of video game play on clinical practice. Rosser studied the correlation between video game use and surgical laparoscopic skills.22 Video game play of 3 hours a week correlated with 37% fewer errors and a 27% faster completion of a laparoscopic surgery task. Those that played video games more than 3 hours per week scored even higher. Rosser et al22 concluded that video game skill and past videogame experience were significant predictors of laparoscopic skill.19 Outcomes-based Education

The days of destination-based, passive continuing medical education (CME) are numbered. There is a strong movement in medical education away from isolated facts and toward outcomes. In the future, CME credit may only be granted for learning interventions proven to impact behavior, and ultimately patient outcome. The shift away from ineffective, passive education has already begun. Time-limited Certification

Another important trend amplifying the need for effective forms of education is time limited board certification. For instance, the American Board of Anesthesiology now issues 10 year time-limited certificates. To remain certified, an anesthesiologist must participate in the Maintenance of Certification in Anesthesiology (MOCA) program–showing knowledge, practice improvement, and self-reflection. There is a growing demand, in our specialty and others, for convenient, quality, interactive education; both to review basic concepts and to keep current. Clinical Pressures

Clinical pressures in healthcare abound. Although the bulk of education for learners traditionally has fallen on the attending physicians, this is www.anesthesiaclinics.com

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becoming less and less so. As of clinical burdens on faculty23–25 they have less time to teach. As a result, the majority of teaching now falls on the shoulders of senior colleagues and their own peers. With the advent of the 80 hour work week, students and residents have even a greater reliance on textbooks, internet sources, and their peers for their formal education. ’

High-fidelity Simulation: Strengths and Limitations

High-fidelity simulated environments recreate clinical situations found in healthcare. Students practice their craft in scripted scenarios designed to challenge their clinical decision making, critical thinking, and teamwork. Simulation has many advantages over lecture-based education. Among the most important factors are: Interactivity and immediacy—making choices and immediately seeing the result of actions Applying knowledge in context Allowing time for reflection (thinking through their choices and patient outcomes) Group learning (learning from peers and from facilitator) Most laymen would agree that learning with simulators is preferable to learning on patients. Many are concerned when they heard the old medical adage ‘‘See one, do one, teach one.’’ Some consider the use of simulation a ‘‘moral imperative.’’26 Gaba27 summarized many of the advantages of learning on simulators instead of patients. Advantages include: Learners EXPERIENCE the key elements of patient care in a manner that does not put lives at risk. The learner can experience common conditions, or those they may see once in their entire career. Learners PRACTICE their cognitive, psychomotor, and affective skills without placing patients at risk. Learners COLLABORATE, working together in teams to achieve goals–similar to true clinical practice. Learners REPEAT the process until they achieve the required mastery of the concept. Learners EXPERIMENT trying alternate approaches to a problem or making intentional mistakes to practice error recovery. Learners REFLECT on the impact of their decisions and those of others on patient outcome. Facilitators STANDARDIZE training opportunities (to make sure every learner is exposed to core content and the most critical rare situations). Facilitators TRACK the successes and failures of learners and can benchmark their performance. www.anesthesiaclinics.com


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Despite the success of high-fidelity simulation in healthcare, there are also limitations. High-fidelity simulation requires expensive equipment, a complex video and computer infrastructure, and dedicated personnel. Other major limitations include the requirement for individuals to colocate. ’

Advantages Over Mannequin-based Simulation

Advantages such as interactivity, the ability to foster situated cognition, the ability to practice without risk, and the ability to involve multiple senses are common to both GBL and MBL. However, GBLs offer these advantages over MBL. Scalability, Convenience, and Distributability

GBLs have the interactivity of high-fidelity simulation with the added benefits of convenience, scalability, and distributability. Unlike mannequins in simulation centers, digital environments may be duplicated and distributed at almost no additional cost. Cost and learner throughput has been a major impediment large scale mannequin-based healthcare training. GBL allows the learner to connect from anywhere in the world using just a personal computer. It is now possible to deploy large scale interactive learning or to disseminate learning activities to anywhere in the world. Compensate for Weaknesses

Millenials, because of their preferences in media and entertainment are developing new cognitive strengths (and weaknesses).1 Millenials read less than earlier generations.19 Reading has been associated with critical thinking and the ability to reflect on new knowledge.19 GBL may be designed to both challenge the new learner’s strengths whereas compensating for their weaknesses. Augment Reality

Virtual environments may either perfectly replicate reality or augment what is possible in the real world. Augmented reality will be a key component of learning in GBL. As an example, consider a new anesthesiology resident. He could learn the anatomy, equipment, and procedures of ultrasound-assisted central venous cannulation in augmented reality. ‘‘Road signs’’ could be digitally imposed over the anatomic structures. One might ‘‘peel’’ away layers of tissue to examine the relationship of various structures. Similarly, he could learn to manipulate a digital ultrasound machine in the virtual world, learning the physics behind ultrasonography, whereas safely learning to www.anesthesiaclinics.com

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manipulate the buttons and dials. Whatever the application, the ability to augmented reality will enable powerful learning opportunities. Repetition

Unlike MBL, GBL can be inexpensively repeated over and over until an objective is achieved. ‘‘The best training situations focus on activities of short duration with the opportunity for immediate feedback, reflection, and corrections.’’28 GBL allows limitless cycles of repetition and reflection. Tracking

Unlike MBL, GBL is conducted completely within a computer. Every object and every decision is tracked and can be exported to a learning management system. The ability to track will become vital for learners to assess their own progress, and eventually being used both for formative and summative assessment. Anonymity

We have built a prototype virtual environment for team training called 3DiTeams.29 One of the unanticipated benefits of 3DiTeams was the ability for individuals to interact anonymously. Learners who could remain anonymous in group learning activities are more willing to ask questions, and less inhibited than if they were identifiable. As interdisciplinary education becomes more prominent, anonymity will allow other interesting twists on traditional education such as role exploration (Fig. 2). Cost

Unlike high-fidelity simulation that can cost as much as $300,000 to 400,000 per simulator, virtual environments can run on a personal computer. All that is needed is an Internet connection, a headset, and a microphone. One of the costly differentiators of high-end simulators is their integrated physiology engine. However, healthcare virtual environment products such as HumanSim (Applied Research Associates/ Virtual Heroes) now have this capability as well. Although the initial cost of building virtual environments may be high, assets may be reused. The same defibrillator, anesthesia machine, or hospital bed can be infinitely duplicated and reused in other scenarios. Standardization and Assessment

Assessment requires standardization. There is a high degree of variability when using MBL owing to both learners and facilitators. www.anesthesiaclinics.com


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Figure 2. A screen shot of 3DiTeams: a virtual environment to practice TeamSTEPPS (an evidence-based system to improve communication and teamwork skills among health care professionals). Photo courtesy of Duke University’s Human Simulation and Patient Safety Center.

Currently, there are fledgling projects to begin the validation process needed to use high-fidelity simulation in high-stakes assessment– including the standardization of scenarios (Weinger et al). But the level of standardization of MBL can never reach that achievable through GBL. Every aspect of a GBL learning exercise may be standardized. It is likely virtual environments will some day become the preferred method for high-stakes assessment. The attractiveness of standardizing complex interactive scenarios, tracking behaviors and movement, and delivering the environments is undeniable. However, before that can happen, we will need a similar thoughtful approach to validation of GBL that is now being conducted for high-fidelity simulation by Weinger et al. ’

Further Rationale for Games-based Learning Familiarity for New Generation Learners

Our students spend a great deal of their leisure time playing video games. This frequent interaction with commercial games will drive expectations for the fidelity and ‘‘fun’’ in their learning assignments. Games-based learning approximates the activities the learners conduct in their free time. Personalization and Chaining

Chaining is an instructional concept attributed to BF Skinner. Chaining is achieved by breaking down complex behavior into multiple www.anesthesiaclinics.com

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individual behaviors-called links. Each link must be mastered before moving onto the next. Each link reinforces the behaviors mastered before it. Chaining is an effective and efficient way to teach individuals a complex behavior currently beyond their abilities.30 GBL modules may be designed to teach complex tasks through small interwoven, interactive links. Well designed GBL will not only chain information, but will allow learners to proceed at their own pace. Convenience

GBLs are highly interactive, yet are unhampered by the issues we see with mannequin-based education. GBL requires only a computer and sometimes an internet connection to participate. GBL exercises may be developed for individuals or for groups that gather together in a shared virtual space. GBL is accessible at anytime from anywhere in the world. Instant Feedback

Key components of adult education are feedback and reflection. Virtual environments offer the opportunity for immediate, frequent, and customized feedback for every learner.31 Unlike MBL, the feedback and reflection can be personalized (rather than for teams of learners)— especially critical in the early phases of learning. Once all learners have reached a certain level of competence, they can work together as a team and reflect (as a team) on their decisions. Time on Task

Ericsson studied top performers in multiple fields and concluded ‘‘the best training situations focus on activities of short duration with the opportunity for immediate feedback, reflection, and corrections.’’28 McGaghie et al32 conducted a meta-analysis of the effects of practice using simulation and objective learning outcomes. They found repetitive practice using simulation is associated with improved learner outcomes with more being better. Collaboration

Millennials seek collaboration in their education, their professional lives, and their leisure time.1 By its very nature, anesthesiology is collaborative profession. Importantly, GBL can allow learners to collaborate and learn from one another regardless of location or time. GBL can act as a patient tutor, immediately available to help the learner understand concepts and repeat them until they are mastered. Similarly, convenient access to interactive education will enable exposure to a greater number of interactive topics than is currently possible. www.anesthesiaclinics.com


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Rewards and Competition

Competition is a powerful intrinsic motivator. The recent success of innovations in mannequin based simulation such as ‘‘Sim Wars’’33 highlight the power of competition in learning. GBL offer the ability for individuals to compete locally, nationally, or internationally. Each individual could compare themselves with the average performers and/or the top performers and make adjustments accordingly. Poor performers would be identified and remediated early. The highest achievers could be honored with unique content and/or public recognition. High achievers could be also offered select opportunities (such as top residencies, top employment positions, or the ability to consult). ’

Limitations of GBL Culture

Can it be fun to learn? Can you learn from technology initially used to develop games? The traditions of medicine are not easily broken. My feeling is we should be striving for Flow in every aspect of medical education. Anything that makes the learning process more effective and engaging should ultimately benefit our patients. Lack of Technical Standards

A technical standard is ‘‘an established norm or requirement. It is usually a formal document that establishes uniform engineering or technical criteria, methods, processes and practices.’’34 Technical standards for flight simulators paved the way for their use in pilot certification.35 Healthcare lags far behind. Currently virtual environments, and mannequin-based simulators, are being developed in silos. The lack of technical standards has slowed both investment in this type of learning technology and the acceptance of simulation for high-stakes assessment. Technical standards are needed for healthcare simulation. With the high cost and difficulty of conducting assessment, it is imperative that standards are developed. There are currently no accepted technical standards for virtual worlds. Organizations such as the Web 3D Consortium (www.web3d.org/x3d/) are developing standards for 3D healthcare objects. Medbiquitous (http://www.medbiq.org/) released their standards for virtual patients,36 and the Kauffman Foundation (http:// www.kauffman.org/) has publicly announced its intent to attempt to standardize assessment in games-base-learning.31 But, what is needed is

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a truly concerted effort in technical standards development for all forms of simulation. Computer Literacy/Virtual Environment Literacy

In our experience with 3DiTeams,29 we found a large discrepancy in virtual environment literacy (or competency). Individuals that lacked computer skills, or that never played a video game, have a very steep learning curve in virtual environments. Unfamiliarity with virtual environments greatly detracted from learner’s ability to focus on the objectives of the exercise—they are too busy trying to navigate. Navigation is critical in VEs. In several studies, the ability to navigate effectively was found to influence learning outcomes, enjoyment, and motivation.31,37,38 We expect this lack of computer literacy will diminish over time. But, for the immediate future, this phenomenon must be considered when deploying virtual environments to a broad range of learners. Lack of Nonverbal Communication

Nonverbal communication is an important component of human interaction. Yet, nonverbal communication has been slow to develop in virtual worlds. This is an important shortcoming, and one that must be improved for teaching such skills such as teamwork and communication. Level of Fidelity

Issues of fidelity in virtual environments remain to be elucidated. It is likely that different levels of fidelity will be required for different activities. For instance, carrying out virtual surgery will require a highly realistic environment and patient anatomy, whereas scenarios focusing on other elements of patient care (eg, teamwork and communication) may not have the same requirements. Understanding the impact of fidelity (environmental, social, anatomic, and temporal) on learning outcomes will be a key component of understanding how and when to deploy virtual worlds in healthcare education. Cost

For the time being, development of learning modules and virtual environments requires a team of subject matter experts paired with game developers. It is expensive to build an interactive GBL platform that includes all the features we need. Never-the-less, generous foundations such as the Nanaline Duke Fund of the Duke Endowment, have funded nascent efforts in GBL (such as the Immersive Learning Environment @ Duke). www.anesthesiaclinics.com


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The tipping point for use of GBL in healthcare will be when users are able to generate their own content independent of game designers (or even facilitators). One need only look to the popularity and scalability of commercial games like ‘‘Little Big Planet’’ (http://www.littlebigplanet.com/ en-us/) to understand the direction we are headed. ’

Proving Efficacy

Educators and administrators still desire proof GBL is superior and cost-effective when compared with other educational methods. Much like mannequin-based simulation, definitive proof may never be possible.10 Assessment of Effectiveness

However, the ability to differentiate between good and bad learning products will likely be a major contributor to the progress and success of GBL in healthcare. To understand quality, one must first be able to measure it.31 Unfortunately, the limited number of studies conducted thus far, on educational outcomes in medicine using GBL, have been inadequate.39 Akl et al39 reviewed the influence of GBL on learning outcomes in medical students and found only a single study of adequate methodological design. As of the complexities of assessing games, foundations such as Marion Kauffman have expressed an interest in developing an assessment infrastructure for GBL (focused primarily on K-12).31 What is needed is a similar infrastructure for healthcare GBL. Efforts to Date

Despite the lack of coordinated efforts at assessing efficacy, several groups have, or will soon attempt to measure learning outcomes orchestrated by their learning platforms. Our group at Duke is completing an Agency for Healthcare Research and Quality funded study comparing knowledge, skill, and attitude gains in team coordination skills using virtual environments versus high-fidelity simulation.40 Other groups have shown the effectiveness of GBL on patient populations. Kato showed an increase in treatment compliance and disease knowledge in young adults undergoing cancer treatment when trained with a game called Re-Mission.41 The impact of this form of learning is not limited to healthcare. GBL is being adopted in corporate training. Estimates are that by 2014, 1 in 5 of the largest companies in the United States will be investing in games to educate their workers.42 Despite the paucity of evidence, businesses have decided that investment in GBL will yield a good return on investment. www.anesthesiaclinics.com

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Future Directions Team-based Learning

Team-based learning, initially popularized in business school, is being increasingly used in healthcare. Duke National University of Singapore has moved its entire preclinical curriculum to TBL. Despite its effectiveness, it is still plagued by some shortcomings. Group sessions are not convenient, forcing learners to colocate for activities. What is needed is an online platform that facilitates the peer-to-peer interaction of the learners and amplifies the opportunities available to experience and reflect on new concepts. Our team at Duke is in the early phase of a multiple year grant to build a GBL platform for TBL we are calling ILE@D (the Immersive Learning Environment @ Duke). Development of Expertise

As mentioned earlier, a key component in the development of expertise is the process of deliberate practice.43 VEs, because of their scalability and flexibility, offer limitless possibilities for experts to continue to hone their cognitive skills. As the capabilities of virtual worlds improve (eg, haptics, nonverbal communication, artificial intelligence), so will the breadth of activities that may be deliberately practiced. Scientific Research Potential

Online worlds have been recognized for their research potential in social, behavioral, and economic sciences.11 Lofgren and Fefferman44 study disease outbreaks in virtual environments in an attempt to predict human behavior in the real world. As an example, young (K-12) players of Whyville (http://www.whyville.net), an online gaming targeting girls, contracted fictitious ‘‘Whypox.’’ Students were incentivized to find a cure as the disease impeded their ability to interact socially. Fefferman et al observed many curious behaviors and were able to systematically study player’s reactions.45 The nascent technique of studying virtual worlds, once validated, will open up many new possibilities in epidemiology and disease management.44 Continuing Education

The majority of our discussion thus far has focused on undergraduate and graduate medical education. But VEs should have a similar impact in CME. The expectations and accreditation standards of CME continue to evolve. What is evident is that there will be a need in the future for an interactive, distributable, effective means of education that is both engaging and convenient for the end user. VEs could be used as an adjunct to the ASA’s Self-Education and Evaluation and www.anesthesiaclinics.com


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Anesthesiology Continuing Education resources—delivering short realistic vignettes to the user before (or after) answering the each question (or set of questions). Similarly, VEs could be used as a prerequisite to the simulation component of Maintenance of Certification in Anesthesiology (MOCA), where the candidates prestudy simulation scenarios before arriving at an ASA endorsed center for their required session. Virtual Environments for Assessment

Today’s standardized tests mostly measure the ability to recall facts. Paper and pencil tests are not an ideal means of measuring higher level thinking skills or learner behaviors. Nor is a written test a good way to measure vital healthcare skills like teamwork and communication. Written and oral tests have flourished because there has been no alternative. Virtual environments, on account of their computer parentage, can track every action and every choice made within the environment. Realistic situations may be presented to a learner who must make choices using higher level thinking and conceptual knowledge in real time. Critical skills such as teamwork, communication, and leadership can more accurately be determined. However, the day when virtual environments will be used for assessment is still distant. GBL for assessment must be validated in a deliberate fashion–a long and laborious process. Possibilities

We see a bright future for healthcare education using VEs. Charles Friedman, in his 1999 address at the AAMC, spoke of how medical education could be ‘‘unstuck in time.’’46 His fictitious ‘‘medical education machine’’ would deliver interactive healthcare education anywhere at anytime to anyone. GBL is the embodiment of much of what Dr. Friedman foresaw. In GBL, activities are scored in real time. If the learner reaches competency in a particular activity, they can move on. One could imagine a time when there were no constraints on the time allocated to preclinical medical work. One could take as little or as long as needed. Patient-specific Information (eg, Surgical Prep) One can imagine the day when patient-specific information is accessible in VEs. Some of these capabilities are already available. For instance, imaging technologies such as MRI are able to export 3 dimensional data (using technical standards). One day soon, this data will feed into a VE where the healthcare team is able to ‘‘rehearse’’ the critical components of the procedure. www.anesthesiaclinics.com

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Patient Education Just as virtual environments will be useful for educating our professional learners, they will also be used to educate our patients. Products are being developed to help patients learn about and manage their chronic diseases whereas feeding real-time data to their healthcare provider. These patient-centric technologies are being developed for diabetes management, cystic fibrosis, obesity, and more. Ender’s Game Finally, one can imagine a future similar to that described in Ender game.47 A young boy is led to believe he is learning increasingly difficult skills in a virtual world, when in actuality his activities are being used to determine real-world outcomes. One could imagine a future in which a global, interconnected web of healthcare students are able to work on real-world problems. There are already hints of this exciting new future. During the H1N1 outbreak, K-12 students inspired by conquering the ‘‘Whypox’’ flu in ‘‘Whyville,’’ logged in to the CDC and attempted to predict the course of the realworld pandemic.45 Other attempts to harness the collective wisdom of scientists and nonscientists worldwide are being attempted—with interesting results.48 ’

Conclusions

We are on the cusp of a massive paradigm shift in healthcare education. Virtual environments will enable a broad new range of possibilities in learning, assessment, and discovery. These environments will continue to expand in both the personal and professional lives of our learners. We need to develop a science around GBL to understand both its implications and limitations for education.49 To see a collection of healthcare educational games, see the Games and Simulation for Healthcare (http://projects.hsl.wisc.edu/healthcaregames/). Finally, reflect on this quote from The Master Game by de Ropp50: ‘‘Seek, above all, for a game worth playing. Such is the advice of the oracle to modern man. Having found the game, play it with intensity—play as if your life and sanity depended on it. (They do depend on it.) Follow the example of the French existentialists and flourish a banner bearing the word ‘‘engagement.’’ Though nothing means anything and all roads are marked ‘‘NO EXIT,’’ yet move as if your movements had some purpose. If life does not seem to offer a game worth playing then invent one. For it must be clear, even to the most clouded intelligence, that any game is better than no game.’’

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Acknowledgments

The authors thank these agencies for the support that led to this manuscript: Telemedicine and Advanced Technology Research Center www.anesthesiaclinics.com


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(W81XWH-06-1-0720) and the Agency for Healthcare Research and Quality (U18 HS016653-01). We are grateful to the Nanaline Duke Trust of the Duke Endowment for their generous support of ILE@D. ’

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