Executive Summary of Results

The combined efforts of the IU School of Medicine and the School of Informatics, New Media program at IUPUI bring video game technology together with medical pedagogy. This has resulted in an immersive simulation/video game that allows the use of medical data and techniques yet promotes the importance of split second decision-making and sound bedside manner through the virtual experience. The XML database allows for assessment for student competency and progress that can be quickly made available to both student and instructor. The SBC grant created the alpha stage, which serves as a framework for these goals and has a database to support a limited simulation scenario.

Need for the Project

It is easy to teach and measure facts, figures, and techniques in the field of medical education. However, these traditional modes of education cannot properly prepare residents for the practical role of care-giver or equip them with skills for interpersonal/professional interaction.

As a tool in the competency curriculum of IUSM, this experience will assist faculty in teaching and assessing the competency of lifelong learning. Upon completion of the game environment, students will be exposed to concepts important to lifelong learning.

However, this simulation has grounding in the video game field. As such, this video game is designed to be entertaining for residents who are under incredible workload already. This simulation is designed to supplement their education and an effort was made to make the game an entertaining experience. From cartoony character designs designed to be caricatures of people in the work place to tongue-in-cheek diseases with real-world methodology and classification, a balance between gaming and medical practice has been achieved.

Use of Technology

This teaching tool is designed to both educate and entertain. Medical students will undertake different modules as part of their lifelong learning competency. Resident physicians will engage in the virtual environment as part of their practice management curriculum. Learners will undergo the simulation that matches their level as the duties and responsibilities become more challenging from year to year. The day's events and tasks are random for each learner in the virtual environment, with no two learners having the exact same day even if they are sitting side by side when playing asynchronously. The game clock will be sped up so that an entire shift at the hospital can be completed in one sitting, allowing the learner to undergo this simulation experience at home or on campus.

No two game experiences will be alike. The NPCs’ reactions to the player are dependent on how the player undergoes tasks. This interaction accurately represents real life situations and conversations. If the player is curt with a nurse, the way you treated the character will go into the XML database under the nurse's ID number so that later interactions with this character will be more contentious–the nurse’s actions as well as her demeanor affected by the player's interaction.

Finally, the paradigm of Medical Decision-Making is instituted in this game. Differential diagnosis is promoted in gameplay when residents first encounter the first of many possible diseases. Each disease has been a range of symptoms which trigger responses in NPC sounds, textures, or animations. However, the database has symptoms that overlap from disease to disease. Therefore, stage one side effects of “Elvis-Impersonator Disease” can coincide with “Mulletism” and only through tracking down clues in the research database can you yield the correct prescription. The different types of problems that patients have will also be run by a XML database to be able to randomize the patients so that it is never the same experience twice and to be sure the player doesn’t get the same patient that they have already worked with.

Instructional Design Plan

Describe how the use of technology used supported your teaching approach:

• What student learning outcomes were expected?
• How did your teaching plan encourage active learning, provide feedback, address respective learning styles, and build collaboration?
• What resources were used? (campus technology support services, etc.)
• Would your project be easily understood and executed by other faculty?

The simulation level is designed using Alias Maya, Adobe Photoshop, and UnrealEd. The game engine used is the Unreal Engine. The Unreal Engine utilizes the some of newest and most advanced features in the game industry. The Unreal Engine contains networking capabilities built into the engine itself, utilizes a Karma physics engine for realistic collision detection and other types of complicated physics equations such as gravity and masses in a virtual world and supports mod programming. The backend database part of the game–which controls dialogue strings, disease cures, patient and non-patient background, and additional information–is linked together with XML. XML is the standard for database utilization on today’s most sophisticated technologies. The game is back ended to this database, making the information easy to collect and assess. Results can be posted quickly both to the curriculum coordinator and to the learner upon completion of the level. Learners will also have the ability to play the game again to improve upon their decision-making.

Potential to Impact Student Learning

Clearly define how your project improved student learning - include specific examples of how your project:

• Fostered depth of learning
  
• Fostered the learning of large numbers of students
  
• Has broader applications that will affect learning K-12 or community environments?
  
• The PDAs were used in K-12 schools not only by IUS faculty and students, but by a select group of classroom teachers.

Once the medical simulation is fully operational, the goal is to facilitate intercampus and interdisciplinary interaction, with medical students and resident physicians assigned to simulation "teams" in an online iteration of the project. Each of the "teams" will compete with one another to get the most team members to the highest simulation level. Increasing levels will be associated with increased demonstration of competency in the healthcare management concepts. By reconstituting the data, the levels will become harder and more complex to complete as the student progresses from year to year.

In the next iteration, students from all levels at all nine IU medical locations will interact within a synchronous virtual environment. In an online, synchronous environment, characters played by the learners can conceivably roam the same halls of the same virtual hospital at different levels, being called to undertake group tasks, each in accord with his/her skill level. In this way, learners at many levels can truly interact with each other, giving the experience yet another layer of believability. This is possible using the networking abilities of the Unreal Engine. A player will choose to play multiplayer on a server over any Internet connection, making it possible to learn from home as well as in the lab. Using Unreal Engine’s networking technology will bridge the gap of distance (for medical students at distant campuses) and time (for resident physicians with varied work hours).

Assessment Plan

Briefly explain the effectiveness of your assessment plan:

• What measure of assessment was used?
• How did your approach obtain measures of performance?
• Did you feel your measurement was accurate and effective?

Difficult decisions will have to be made and all options are written in ways that will be appropriate to even the clearest personality type. The decisions made as the resident goes through his/her day will then be measured and assessed. Suggestions will be offered to promote more effective strategies to accomplish the many tasks experienced in the simulation.

Using Bayesian methods, decision trees branching off of primary nodes have been developed. Learners will make decisions in the simulation environment, which will move them down the branches of the decision trees. Factors such as time, money, and interpersonal relationships determine which branches the player moves in. This is further augmented by how the NPCs view the player. The player can also augment this view by correct or adverse interactions.

Decisions will be organized based on best and most probable outcomes by a panel of expert medical educators. The simulation experience will track and grade the decision responses based on these expert ratings. This textbook analysis will serve as a compare the decision-making skills of the resident. Pointers for better efficiency can be noted within the database.
Results and subsequent data will be available to both the learner and the curriculum coordinator. During initial piloting of the tool, learners were surveyed regarding satisfaction with different components or aspects of the experience, including the simulation as a learning tool, aesthetics, mechanics, ease of use, ease of access, and enjoyment.

Plan for Colleague Development

Describe your role and activities as a mentor:

• What mentoring activities were implemented to assist colleagues
• Faculty were provided with bi-weekly mini workshops to coach them in the use of the PDAs and Practicum students were given in-services on the uses and applications of PDAs which helped to develop colleague's instructional technology skills.
• One of the more surprising effects of the project was the increased use of desktop computers in conjunction with their PDA. There was a significant increase in faculty use of several desktop software programs. The use of MS Outlook and database software on desktop computers increased 29 and 21 percent respectively over previous implementations. The use of the PDAs went from zero to 100% due to the fact no faculty had used them before. Faculty used the PDAs in unexpected ways such as note taking with supplied keyboards (86%), using electronic resources with the PDA (64%), and spreadsheets (54%) by the participants.

• How do you think your contributions to the Knowledge Base will help colleagues planning similar projects? 

In the final iteration of this game, we would like to open up the medsim project to all medical students of all levels and colleagues throughout the United States. For instance, one of the scenarios developed under the IUSM grant is based on the Practice-Based Learning and Improvement competency domain described as "Facilitate the learning of students and other health care professionals". In this scenario, the resident physician playing the game is asked to teach simulated students and ancillary staff about fluid and electrolyte balance. It is a goal that additional iterations of this simulation will expand this scenario to have increased levels of competency within a simultaneous environment. In the additional levels, the medical student as well as a resident physician could access, utilize, and empirically assess relevant medical literature on the topic of fluid management. This simulation would teach and assess skills in lifelong learning for the medical students. For competency in lifelong learning, medical students must be able to identify and analyze relevant scientific and medical literature. Another domain under the practice based learning and improvement competency for resident physicians is locate, appraise, and assimilate evidence from scientific studies related to their patients’ health. Thus, by adding complexity to the scenario which requires the learner to access, utilize and empirically assess the literature, the virtual environment will become a tool for developing and assessing both medical student and resident physician competency.

Final Comments on Project Results

The scope of this project was vast and multi-faceted. A scaling down of goals occurred upon project start-up, and to accomplish our Alpha goals, a team-structure was implemented. Deanna Willis, MD, MBA, Eric Ebenroth, MD, Palmer Mackie, MD, and Shaun Grannis, MD, MS were instrumental in the development and structure of this simulation. Ryan Christy, Fredrik Skarstedt and Jason Silverman headed up the programming and art teams comprised of New Media students. The talented, dedicated and enthusiastic students who created the game environment from the ground up included: Markus Creasy, Guin Thompson, Greg Lindquist, Jason Guy, Linsey Hughey, Rob Guernsey, Thorston Jonas, Michael Kingemann, Mark Casselman, J.B. Buckner, Matt Bell, Sabrina Fowler, Danielle Sevastianos, Michael Davison, Jon Lanker, Steve Hicks and Kira Peavley.

Not only did this project allow for a real-world experience for students of the School of informatics, but it allowed for collaboration to exist with the IU School of Medicine and the School of Informatics, IUPUI. Mike Rein president of Epic Games donated the Unreal Engine for this research project creating an unexpected ally during this project.

Finally, this project has been presented internationally. A summation of presentations include:

Published paper, The 9th World Multi-Conference on Systemics, Cybernetics and Informatics, Volume 7, International Institute of Informatics and Systemics, 199-205 (July 2005). This paper was named “Best in Session”.

Poster and presentation, 2005 SBC Summer Leadership Forum, Indianapolis, IN, May 13, 2005.

Presentation, 2004 Society of Teachers of Family Medicine, 37th STFM Annual Spring Conference, Toronto, ONT, Canada, May 12-16, 2004.

Published paper, 2004 International Symposium on Collaborative Technologies and Systems, Simulation Series, Volume 36, Number 1, The Society for Modeling and Simulation International, 296-302 (January 2004).

Future publications include:
The Journal of Systemics, Cybernetics and Informatics (http:www.iiisci.org/Journal/CSI.

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Last updated: 18 May, 2007

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