Patricia Youngblood

Simulation for Team Training and Assessment: Case Studies of Online Training with Virtual Worlds

Individuals in clinical training programs concerned with critical medical care must learn to manage clinical cases effectively as a member of a team. However, practice on live patients is often unpredictable and frequently repetitive. The widely substituted alternative for real patients—high-fidelity, manikin-based simulators (human patient simulator)—are expensive and require trainees to be in the same place at the same time, whereas online computer-based simulations, or virtual worlds, allow simultaneous participation from different locations. Here we present three virtual world studies for team training and assessment in acute-care medicine: (1) training emergency department (ED) teams to manage individual trauma cases; (2) prehospital and in-hospital disaster preparedness training; (3) training ED and hospital staff to manage mass casualties after chemical, biological, radiological, nuclear, or explosive incidents. The research team created realistic virtual victims of trauma (6 cases), nerve toxin exposure (10 cases), and blast trauma (10 cases); the latter two groups were supported by rules-based, pathophysiologic models of asphyxia and hypovolemia. Evaluation of these virtual world simulation exercises shows that trainees find them to be adequately realistic to “suspend disbelief,” and they quickly learn to use Internet voice communication and user interface to navigate their online character/avatar to work effectively in a critical care team. Our findings demonstrate that these virtual ED environments fulfill their promise of providing repeated practice opportunities in dispersed locations with uncommon, life-threatening trauma cases in a safe, reproducible, flexible setting.

Design, Development, and Evaluation of an Online Virtual Emergency Department for Training Trauma Teams

Background: Training interdisciplinary trauma teams to work effectively together using simulation technology has led to a reduction in medical errors in emergency department, operating room, and delivery room contexts. High-fidelity patient simulators (PSs)—the predominant method for training healthcare teams—are expensive to develop and implement and require that trainees be present in the same place at the same time. In contrast, online computer-based simulators are more cost effective and allow simultaneous participation by students in different locations and time zones. In this pilot study, the researchers created an online virtual emergency department (Virtual ED) for team training in crisis management, and compared the effectiveness of the Virtual ED with the PS. We hypothesized that there would be no difference in learning outcomes for graduating medical students trained with each method. Methods: In this pilot study, we used a pretest-posttest control group, experimental design in which 30 subjects were randomly assigned to either the Virtual ED or the PS system. In the Virtual ED each subject logged into the online environment and took the role of a team member. Four-person teams worked together in the Virtual ED, communicating in real time with live voice over Internet protocol, to manage computer-controlled patients who exhibited signs and symptoms of physical trauma. Each subject had the opportunity to be the team leader. The subjects’ leadership behavior as demonstrated in both a pretest case and a posttest case was assessed by 3 raters, using a behaviorally anchored scale. In the PS environment, 4-person teams followed the same research protocol, using the same clinical scenarios in a Simulation Center. Guided by the Emergency Medicine Crisis Resource Management curriculum, both the Virtual ED and the PS groups applied the basic principles of team leadership and trauma management (Advanced Trauma Life Support) to manage 6 trauma cases—a pretest case, 4 training cases, and a posttest case. The subjects in each group were assessed individually with the same simulation method that they used for the training cases. Results: Subjects who used either the Virtual ED or the PS showed significant improvement in performance between pretest and posttest cases (P < 0.05). In addition, there was no significant difference in subjects’ performance between the 2 types of simulation, suggesting that the online Virtual ED may be as effective for learning team skills as the PS, the method widely used in Simulation Centers. Data on usability and attitudes toward both simulation methods as learning tools were equally positive. Discussion: This study shows the potential value of using virtual learning environments for developing medical students’ and resident physicians’ team leadership and crisis management skills.

Evaluation of a surgical simulator for learning clinical anatomy.

Background  New techniques in imaging and surgery have made 3‐dimensional anatomical knowledge an increasingly important goal of medical education. This study compared the efficacy of 2 supplemental, self‐study methods for learning shoulder joint anatomy to determine which method provides for greater transfer of learning to the clinical setting.

The use of virtual patients to assess the clinical skills and reasoning of medical students: initial insights on student acceptance

Background: Web-based clinical cases (“virtual patients”, VPs) provide the potential for valid, cost-effective teaching and assessment of clinical skills, especially clinical reasoning skills, of medical students. However, medical students must embrace this teaching and assessment modality for it to be adopted widely. Method: We examined student acceptance of a web-based VP system, Web-SP, developed for teaching and assessment purposes, in a group of 15 second-year and 12 fourth-year medical students. Results: Student acceptance of this web-based method was high, with greater acceptance in pre-clinical (second-year) compared with clinical (fourth-year) medical students. Students rated VPs as realistic and appropriately challenging; they particularly liked the ability of VPs to show physical abnormalities (such as abnormal heart and lung sounds, skin lesions, and neurological findings), a feature that is absent in standardized patients. Conclusions: These results document high acceptance of web-based instruction and assessment by medical students. VPs of the complexity used in this study appear to be particularly well suited for learning and assessment purposes in early medical students who have not yet had significant clinical contact.

Using collaborative haptics in remote surgical training

We describe the design and trial of a remotely conducted surgical master class, using a haptic virtual environment. The instructor was located in the United States and the class was in Australia. The responses of the audience and participants are presented.

Facilitating online learning: A descriptive study

Many authors cite the potential of Web‐based technologies for transforming education. However, little research has been done to explore what skills are required. This paper reports a four‐phase study conducted to clarify the role of the facilitator and to identify other factors that support or inhibit online learning. Postgraduate students who had participated in online learning were asked to rate the relative importance of 12 facilitator tasks. Next, students and lecturers were interviewed to determine factors that influence the success of online courses. Results show that facilitators must clarify expectations, initiate and guide online discussions and explain assessment criteria.

Interactive Simulated Patient: Experiences with Collaborative E-Learning in Medicine.

Interactive Simulated Patient (ISP) is a computer-based simulation tool designed to provide medical students with the opportunity to practice their clinical problem solving skills. The ISP system allows students to perform most clinical decision-making procedures in a simulated environment, including history taking in natural language, many hundreds of laboratory tests (e.g., images and endoscopy), and physical examination procedures. The system has been evaluated in a number of courses at three universities, Karolinska Institutet and Uppsala University in Sweden, and Stanford University in the United States. This article describes a study conducted in 2002, with an emphasis on results that pertain to collaboration between students. Results indicate that ISP is engaging and stimulates more active student involvement than traditional paper-based case presentation methods and that students seem to collaborate more easily when using ISP compared to traditional paper-based methods.

Cardiopulmonary resuscitation training in High School using Avatars in Virtual Worlds : An International Feasibility Study

Background Approximately 300,000 people suffer sudden cardiac arrest (SCA) annually in the United States. Less than 30% of out-of-hospital victims receive cardiopulmonary resuscitation (CPR) despite the American Heart Association training over 12 million laypersons annually to conduct CPR. New engaging learning methods are needed for CPR education, especially in schools. Massively multiplayer virtual worlds (MMVW) offer platforms for serious games that are promising learning methods that take advantage of the computer capabilities of today’s youth (ie, the digital native generation). Objective Our main aim was to assess the feasibility of cardiopulmonary resuscitation training in high school students by using avatars in MMVM. We also analyzed experiences, self-efficacy, and concentration in response to training. Methods In this prospective international collaborative study, an e-learning method was used with high school students in Sweden and the United States. A software game platform was modified for use as a serious game to train in emergency medical situations. Using MMVW technology, participants in teams of 3 were engaged in virtual-world scenarios to learn how to treat victims suffering cardiac arrest. Short debriefings were carried out after each scenario. A total of 36 high school students (Sweden, n=12; United States, n=24) participated. Their self-efficacy and concentration (task motivation) were assessed. An exit questionnaire was used to solicit experiences and attitudes toward this type of training. Among the Swedish students, a follow-up was carried out after 6 months. Depending on the distributions, t tests or Mann-Whitney tests were used. Correlation between variables was assessed by using Spearman rank correlation. Regression analyses were used for time-dependent variables. Results The participants enjoyed the training and reported a self-perceived benefit as a consequence of training. The mean rating for self-efficacy increased from 5.8/7 (SD 0.72) to 6.5/7 (SD 0.57, P<.001). In the Swedish follow-up, it subsequently increased from 5.7/7 (SD 0.56) to 6.3/7 (SD 0.38, P=.006). In the Swedish group, the mean concentration value increased from 52.4/100 (SD 9.8) to 62.7/100 (SD 8.9, P=.05); in the US group, the concentration value increased from 70.8/100 (SD 7.9) to 82.5/100 (SD 4.7, P<.001). We found a significant positive correlation (P<.001) between self-efficacy and concentration scores. Overall, the participants were moderately or highly immersed and the software was easy to use. Conclusions By using online MMVWs, team training in CPR is feasible and reliable for this international group of high school students (Sweden and United States). A high level of appreciation was reported among these adolescents and their self-efficacy increased significantly. The described training is a novel and interesting way to learn CPR teamwork, and in the future could be combined with psychomotor skills training.

Simulated learning environments in anatomy and surgery delivered via the next generation internet.

The Next Generation Internet (NGI) will provide high bandwidth, guaranteed Quality of Service, collaboration and security, features that are not available in todays Internet. Applications that take advantage of these features will need to build them into their pedagogic requirements. We present the Anatomy Workbench and the Surgery Workbench, two applications that require most of these features of the NGI. We used pedagogic need and NGI features to define a set of applications that would be difficult to operate on the current Internet, and that would require the features of the NGI. These applications require rich graphics and visualization, and extensive haptic interaction with biomechanical models that represent bony and soft tissue. We are in the process of implementing these applications, and some examples are presented here. An additional feature that we required was that the applications be scalable such that they could run on either on a low-end desktop device with minimal manipulation tools or on a fully outfitted high-end graphic computer with a realistic set of surgical tools. The Anatomy and Surgery Workbenches will be used to test the features of the NGI, and to show the importance of these new features for innovative educational applications.

An augmented reality tool for learning spatial anatomy on mobile devices: Learning Spatial Anatomy on Mobile Devices

Augmented Realty (AR) offers a novel method of blending virtual and real anatomy for intuitive spatial learning. Our first aim in the study was to create a prototype AR tool for mobile devices. Our second aim was to complete a technical evaluation of our prototype AR tool focused on measuring the systems ability to accurately render digital content in the real world. We imported Computed Tomography (CT) data derived virtual surface models into a 3D Unity engine environment and implemented an AR algorithm to display these on mobile devices. We investigated the accuracy of the virtual renderings by comparing a physical cube with an identical virtual cube for dimensional accuracy. Our comparative study confirms that our AR tool renders 3D virtual objects with a high level of accuracy as evidenced by the degree of similarity between measurements of the dimensions of a virtual object (a cube) and the corresponding physical object. We developed an inexpensive and user‐friendly prototype AR tool for mobile devices that creates highly accurate renderings. This prototype demonstrates an intuitive, portable, and integrated interface for spatial interaction with virtual anatomical specimens. Integrating this AR tool with a library of CT derived surface models provides a platform for spatial learning in the anatomy curriculum. The segmentation methodology implemented to optimize human CT data for mobile viewing can be extended to include anatomical variations and pathologies. The ability of this inexpensive educational platform to deliver a library of interactive, 3D models to students worldwide demonstrates its utility as a supplemental teaching tool that could greatly benefit anatomical instruction. Clin. Anat. 30:736–741, 2017.