Second Life™: a novel simulation platform for the training of surgical residents

Abstract

A virtual world is a three-dimensional, computer-generated, simulated environment. Human users create “avatars,” or virtual projections of themselves, in order to explore this virtual environment and interact with the objects and structures inside it. Second Life™ is one such virtual world accessible freely via the internet, which has been used to construct a virtual hospital complete with reception areas, changing rooms, offices, and hospital wards. Early pioneering studies have demonstrated the advantages of using virtual worlds in the education of surgical residents in a number of ways, from introductions to the clinical environment, initial patient assessment, and managing adverse outcomes, to gaining informed consent, hospital-wide training, and medical device development.

Keywords::

• Second Life^TM
• simulated operating suite
• simulation
• virtual patient
• virtual world
• ward simulation

The traditional model for educating surgical residents involves practice in the operating room on real patients under guided supervision. This model necessarily increases both the time taken for these procedures and the number of preventable medical errors and is therefore no longer feasible either financially or ethically. Advances in surgical simulation within the past two decades have attempted to address these issues and these new methods for training have been consistently validated as an appropriate adjunct to the traditional model [1]. But despite their success, these modalities only focus on the technical skills of performing the surgical procedures themselves. They cannot teach a novice surgeon how to assess the patient initially, how to gain informed consent for the procedure, how to function effectively as part of a multidisciplinary team or how to manage postoperative complications, all of which have been shown to be important aspects of clinical care [2]. Presently, surgical residents learn these skills through didactic courses, on-the-job training and/or scenarios with standardized patients in simulated settings [3]. However, there is an intriguing new technology that may offer a better solution to these training challenges: the virtual world.

A virtual world is a three-dimensional, computer-generated, simulated environment, in which human users create ‘avatars,’ or virtual projections of themselves. The user can then manipulate his or her avatar in order to explore this virtual environment, interact with the objects and structures inside it and engage in social activities with other avatars. One particular virtual world accessible freely via the Internet is Second Life™. Developers in Second Life are able to use a three-dimensional modeling tool included in the software to create unique virtual objects, which they can arrange inside buildings they themselves have designed. In order to add interactivity to these objects, a computer coding language is used to incorporate scripted commands into their physical structure. Using this platform, Imperial College London has constructed a virtual hospital on its own island, complete with reception areas, changing rooms, offices and hospital wards. Any user with appropriate access can create an avatar within Second Life and visit this hospital, walk around the floors, interact with functional medical equipment such as cardiac monitors and hospital beds, and converse with other avatars, often either hospital staff or other ‘patients.’

Recent studies featuring this virtual hospital in Second Life have revealed the potential of the virtual world as a complementary tool for the training of surgical residents. Patel et al. in conjunction with the UK Intercollegiate Surgical Curriculum Project (the framework for systematic training from intern grade through to attending), created virtual patients who presented with three common pathologies encountered by surgical trainees, that is, lower GI bleed, acute pancreatitis and small bowel obstruction at three degrees of complexity [4]. Trainee surgeons then used avatars to assess these virtual patients by, for example, performing an abdominal exam by clicking on different regions of the virtual patient’s abdomen and hearing from the patient if a particular region was tender. Further examination included ordering blood tests and X-rays, the results of which could be accessed on a wallboard within the hospital. After gathering this information, the trainee surgeon then had to select an appropriate management plan. Since the virtual patients could express varying degrees of complexity for these scenarios, surgeon educators were able to evaluate a particular trainee’s approach to the case and determine whether he or she had reached the appropriate competence for their level of training. Importantly, this study demonstrated both that virtual patients are capable of displaying realism appropriate for actual clinical scenarios, and that virtual scenarios of various difficulties are able to discriminate between different levels of performance, which together suggest that the virtual world could be useful as a means for training and assessing surgical residents.

All surgeons must learn how to obtain proper informed consent for a procedure, and virtual worlds may be useful for this purpose as well. It has been proposed that both novice and experienced surgeons could exploit the interactive nature of a virtual hospital to grant patients access to information about diagnostic investigations, surgical procedures, emergency care facilities and ward activities [5]. Patients would be able to actively proceed through the standard pathway for their potential procedure in a simulated environment, which closely mimics the real encounter, perhaps guided by a health professional’s avatar. In this way, patients might gain a better understanding of what is involved in the procedure and become more at ease with the experience before it has occurred. Informed patients who have been encouraged to take an active role in their care would also have a deeper relationship with their surgeon and this could lead to improved clinical outcomes.

In the past few years, it has become evident that one challenge to the future of surgical practice lies in the recruitment surgical residents. Early in the surgical clerkship, medical students are thrust into the high pressure, dynamic environment of the operating room (OR) and with no defined role, their first exposure is too often both intimidating and unproductive. In part, because of this experience, there has been a recent decline in interest in general surgery among medical graduates, and there is currently a requirement to provide a structured introduction to the OR in order to reverse this trend. Although didactic lectures and simulated operating suites have both been shown to be effective for this end, an OR introduction using a virtual world offers some distinct advantages [6]. First, a virtual world would be accessible from each medical student’s personal computer and would therefore not require students or educators to be physically present for the training. Second, it would be accessible at any time, so that training would be repeatable across multiple rotations throughout the clerkship year. Lastly, alleviating the logistical constraints associated with multiple lectures or sessions in the simulated operating suite negates the need to pay for administrative staff to run them.

The Second Life virtual world has also been utilized to educate health care professionals in the management of adverse events involving medical devices [7]. Because a virtual world allows the user to create unique and interactive objects, researchers at the Medical Media Design Laboratory at Imperial College London, were able to design a new intravenous infusion device in accordance with the recommendations of the National Patient Safety Agency, with the aim of improving usability and enhancing patient safety. Forty nurses, using their avatars, proceeded through a simulated scenario with a virtual patient, which was designed to highlight some of the adverse events associated with the use of intravenous devices, and engage the user in managing these events. Almost all users agreed that interacting with the virtual patient and virtual device accurately portrayed a real-life clinical scenario and that they could apply the newly acquired skills in their daily work. These results verify that virtual worlds can impart familiarity with new medical devices to mass numbers of health care professionals, and assess their ability to manage adverse events, with a direct impact on patient safety. As an aside, this study also demonstrates their utility in designing and testing new medical devices without having to physically produce real devices, thus cutting costs for development.

Finally, an important advantage of virtual worlds is their ability to train multiple users simultaneously. Another recent study developed a set of connected scenarios that involved numerous paramedics responding to a mass casualty incident in a field environment with hazardous materials, and then transferred these virtual patients to a virtual emergency department, where hospital teams practiced receiving multiple casualties [8]. This capability of virtual world technology to support multiple teams of users exercising together across various sites could be employed within the hospital as well to build interdisciplinary team-working skills within a virtual OR, or to educate large numbers of staff at the departmental level.

Of course, virtual worlds have their limitations. For example, it has not yet been shown that virtual worlds are any more effective at educating students than other immersive experiences such as simulated operating suites and standardized patients, or other e-learning technologies like prerecorded online lectures. Then, there is the issue of cost. Developers must be paid to design and create the virtual environments, technicians to operate the computer hardware and faculty to write the clinical scenarios and evaluate students’ performance. The virtual land must be purchased with real currency, and there is an upkeep cost for the computer servers. All of these expenses are highly variable, making it difficult to determine whether virtual worlds are any more cost-effective than current educational modalities. Clearly, larger scale and longer term studies are needed to compare the effectiveness of virtual worlds to other training methods, and to develop a more accurate sense of their start-up and upkeep costs, before we can confirm that they should be integrated into the established training curriculum.

Regardless, early pioneering studies have certainly revealed the advantages of using virtual worlds in the education of surgical residents, and their applications are readily transferable to many aspects of clinical care training. Virtual worlds offer a realistic, immersive experience for trainees, accessible from any place, at any time and by many users at once. Their utility is apparent in various facets of medical education, from introductions to the clinical environment, initial patient assessment and managing adverse outcomes, to gaining informed consent, hospital-wide training and medical device development.

Financial & competing interests disclosure

R Aggarwal is funded by a Clinician Scientist Award, National Institute of Health Research, Department of Health, UK. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.