For years, medical education has traditionally been passive, mainly using a lecture format. Over time, the trend of interactive learning, also known as ‘flipping the classroom,’ started to evolve as a more effective way to learn. Although engaging, one downside to in-person interactive learning is that it’s not as scalable as a lecture. That’s why Duke Anesthesiology and its collaborators believe the answer lies somewhere in the middle and that immersive learning will be a game changer.
In 2009, Dr. Jeffrey Taekman and former project manager, Michael Steele, spearheaded an initiative called Immersive Learning Environments at Duke (ILE@D). Their grand vision was to build an educational framework (using immersive learning in virtual training) to support a variety of inter-professional health care training scenarios. The ultimate goal of the initiative was to become a hub of virtual health care education.
Seven years after its launch, we look back at the creation of ILE@D as the department advances it to the next level by officially implementing it into the Duke School of Medicine’s curriculum and in a Massive Open Online Course on Coursera.
Q: How did the concept for ILE@D come about?
A: (Dr. Taekman) I became interested in the addictive nature of video games, and wondered if some of the psychology and technology behind commercial games might be applied to health care learning. In 2004, we developed our first simulation, 3DiTeams, which allowed health care teams to practice teamwork and communication in a virtual space. The popularity of this type of learning snowballed into many unique projects. Accessible from any internet-connected computer, ILE@D provides an innovative, interactive, “front-end” to distance education for health care professionals.
Q: What is ILE@D ?
A: (Dr. Taekman) ILE@D leverages commercial video game platforms to build educational modules for health care. It has a lot of interactivity, can be scaled to a larger size, and engrosses the student in the learning process. We believe ILE@D has the potential to improve the efficiency of the learning process. We don’t expect screen-based simulation to replace mannequins, but instead they will be complimentary. We expect ILE@D, when used early in the learning process, to improve face-to-face interactions between teachers and students. ILE@D will improve the face time through early self-directed, team-based, and facilitator-led preparatory activities in a virtual environment. The lessons students learn in virtual environments can be applied to real-world scenarios (this process is called abstraction). An added benefit of computers is their ability to collect data. This data can then be collated and analyzed. For this reason, we believe virtual environments and screen-based simulation will have a huge impact on the certification and recertification processes.
(Michael Steele) It’s a three-dimensional, collaborative world, essentially acting as an umbrella that encompasses five virtual learning experiences:
1.) Stroke – a neurological exam that trains users how to identify the signs and symptoms of a stroke
2.) Handover – aims to improve communication and decrease preventable adverse events related to operating room to Neuro-ICU handovers
3.) Medic – trains Army medics and other medical personnel to manage the top causes of death in the modern battlefield, including hemorrhage, airway obstruction and tension pneumothorax. These cases are also applicable for civilian medical personnel practicing treatment of trauma cases.
4.) Hemorrhage – trains clinicians on effective teamwork and communication behaviors in the context of a postpartum hemorrhage case
5.) Sedation – teaches and refreshes the cognitive skills of rapid sequence intubation and moderate/deep sedation to non-anesthesia providers
Q: How did you determine the need for these five virtual environments?
A: (Dr. Taekman) When we first started exploring what we could do with the technology, team training was in its infancy in health care and simulation wasn’t as far along as it is now. We were looking for a scalable, distributable way to conduct team training, which is how the idea for Hemorrhage came about.
For the other projects, we tried to intertwine national needs, aligning these needs with funding opportunities. For example, Sedation was developed at at a time when both military and civilian medicine had a need to train non-anesthesiologists about moderate sedation.
Treatment of stroke is also a huge national issue. Although our Stroke software was developed to train nursing and medical students to perform a neuro exam, I really believe there is potential for Stroke in telehealth, where health related services and information are delivered remotely via telecommunications technologies. Health care providers in outlying hospitals may not care for stroke patients very often. This type of software will allow those clinicians to practice diagnosing and treating a virtual stroke patient to better prepare them to collaborate with central hospital staff during a real emergency.
Q: Who are you specifically targeting to engage with this program?
A: (Dr. Taekman) ILE@D is targeted primarily at medical and nursing students, but I think the greatest unmet need is in the health system, training physicians and nurses. Currently, physicians receive much of their training as lectures, but hundreds of studies dating back to the 1990s prove that lectures are ineffective in changing behaviors.
The way you change behavior is by having individuals learn information in the context of how they will use the information in the future, then letting them apply what they learn and learn from mistakes. Obviously, we wouldn’t willingly allow mistakes to happen with live patients, but in virtual environments we can. Ultimately, that’s where immersive learning will be used more frequently in the health system—as a scalable distributable form of simulation.
Q: How does it work?
A: (Michael Steele) There are different learning experiences for each of the tools we’ve developed. For example, Stroke is a single-player environment which allows the learner to experience a neurological exam with a virtual patient named Carl. There’s an electronic health record where a learner records all of their findings and will receive immediate feedback on their performance and diagnosis. Then, there’s a phase where they map patient deficits to parts of the brain and arteries. It’s an opportunity for the learner to apply and synthesize what they’ve learned in lectures.
Hemorrhage is the second generation of our teamwork and communication trainers. It is a multi-player simulation we have used to train learners in Africa and Australia. It’s focused on teamwork training in the context of obstetric hemorrhage. It is meant to promote interaction between players and practice communication skills. We’ve added additional scalability by adding a tagging system based on the TeamSTEPPS materials, where observers can watch the simulation in real time and tag TeamSTEPPS behaviors.
Q: Have you seen a direct impact with ILE@D?
A: (Dr. Taekman) We just submitted a paper to Anesthesia and Analgesia on our experience using the Hemorrhage software in Uganda with an inter-professional education. We looked at users’ confidence and their ability to manage post-partum hemorrhage. With the software as the center piece of their experience, we found that Hemorrhage increased learner confidence across all the three domains of Bloom’s Taxonomy: (1) affective; (2) cognitive, and (3) psychomotor. The increased psychomotor confidence was an unexpected finding given that the users did not practice any psychomotor tasks. There is precedent in sports and other psychomotor tasks showing mental rehearsal has real-world impact in performance. This finding needs more exploration, but if it holds up, it will unveil a range of new and exciting possibilities.
Q: How is ILE@D being funded?
A: (Dr. Taekman) Over the past five or so years, the Duke Endowment has provided nearly $3 million in funding to initiate this effort with the goal of making the platform broadly available to the health care community. We received other funding from the military, primarily the U.S. Army’s Telemedicine and Advanced Technology Research Center (TATRC) and Research, Development and Engineering Command (RDECOM). Other sources of support have included Agency for Healthcare Research and Quality (AHRQ), the U.S. Department of Health and Human Services (HHS), and global pharmaceutical and health care companies. At the end of this month (March 2016), our Duke Endowment grant comes to an end. While the program is currently free for users, we welcome other funding opportunities and hope that organizations will be interested in licensing ILE@D because we are finding that it truly fulfills a need in the health care community.
Q: What projects are coming up the pipeline?
A: (Dr. Taekman) It’s an exciting time for us as ILE@D is now being incorporated into the School of Medicine’s curriculum. We just launched Stroke, which medical students started using last month (February 2016). It’s plugged into Coursera, an education platform that partners with top universities and organizations to offer online courses for anyone to take. We’re hoping to generate some data from this partnership. In the future, we’re looking to develop relationships with companies on projects such as central line training.
Q: What are your long-term goals for ILE@D?
A: (Dr. Taekman) We’d like to expand the amount of content we have. We’re still in the beginning phases of screen-based simulation/games-based learning in health care but ultimately, I see immersive learning playing a key role in education because of the accessibility of computers and all of the data that it generates. In the future, we may hand our students and staff a Playstation.
A huge opportunity is using health system data to develop interactive cases. Through electronic health record data, we can identify the gaps in patient care and develop interactive, immersive technology to address those issues. We could then use pooled data from the electronic health record to see whether we’ve made a difference. This screen-based simulation can be pooled locally, nationally and internationally, and then analyzed. This data and the accompanying analytics will open up all sorts of new opportunities in education and patient safety/quality improvement.
As for national organizations using screen-based simulation, the American Society of Anesthesiologists (ASA) Ad-Hoc Screen-based Simulation Committee has taken the first step towards a national initiative. They recently named an ad hoc committee on screen-based simulation, which I am fortunate to be involved with, to develop screen-based simulation for anesthesiologists nationwide. It’s been nice to see the momentum for screen-based simulation building after such an investment in time. It validates that we’re on the right track. We don’t have all of the answers, but it’s nice to see that taking place outside of here. I’m really interested to see what happens with all of the new technology coming out.
(Michael Steele) In terms of new technology, virtual reality will offer new opportunities as well, increasing the immersion experience. For example, instead of sitting in front of a flat screen, you may don goggles and walk around a virtual operating room. There are also new devices, like Kinect, which sense your body and can actually place you into a true virtual environment, such as a mock operating room. Even though you’d be walking around in regular space, the things that you would be seeing and doing would be reflected in a virtual world.
Microsoft HoloLens, which I’m most excited about, will project virtual patients into the actual environment. Though you won’t be able to feel or touch, the technology will know where you are and allow you to interact with a holographic patient.
(Dr. Taekman) The sense of touch is the slowest one to develop in virtual worlds. It makes it more challenging to do procedural-based things. There are companies working on producing realistic feeling computerized tissues. Devices like the Hololens “mix reality,” but eventually, we imagine simulations like the holodeck in Star Trek. That won’t happen for quite a while – but probably sooner than you think.
Q: How can people access these programs or participate?
A: (Michael Steele) All five virtual environments can be found at ILE@D’s website: vw.simcenter.duke.edu. Stroke will be available for a limited time for Duke’s Medical Neuroscience Coursera users, which we hope will prompt some additional interest in the other programs.
If you’re interested in learning more about ILE@D, gaining access to its five simulations, or would like to explore a potential funding opportunity, please email ILEAD@duke.edu or visit vw.simcenter.duke.edu.