Todd P. Chang, James Gerard and Martin V. Pusic
© Springer International Publishing Switzerland 2016
V. J. Grant, A. Cheng (eds.), Comprehensive Healthcare Simulation: Pediatrics, Comprehensive Healthcare Simulation, DOI 10.1007/978-3-319-24187-6_9 T. P. Chang ()
Department of Pediatrics, Division of Emergency Medicine & Trans- port, University of Southern California Keck School of Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA e-mail: [email protected]
J. Gerard
Department of Pediatrics, Division of Emergency Medicine, Saint Louis University School of Medicine, SSM Cardinal Glennon Chil- dren’s Medical Center, St. Louis, MO, USA
e-mail: [email protected] M. V. Pusic
Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA
e-mail: [email protected]
Simulation Pearls
1. Screen-based simulation (SBS) has inherent advantages of replicability, portability, asynchrony, distribution, and data tracking compared to most other forms of simula- tion.
2. SBS has substantial up-front financial and labor costs, is less appropriate for team-based education, and has limi- tations in its functional fidelity when compared to other forms of simulation.
3. SBS development requires early and continued collabo- ration between programmers, designers, clinical subject matter experts, and experts in education.
Introduction
Screen-based simulation (SBS) in health care education is a form of simulation in which a clinical scenario with one or more patients is presented through a digital screen surface [1, 2]. As with other forms of simulation, SBS provides the learner with a cognitively realistic and experiential setting without danger of actual patient or population harm [3]. It is best used when instruction is required for a wide audi- ence of learners separated by space and time and the learning
objectives match a cognitive or psychomotor task that can be portrayed using simulation. Current technologies using flat-screen computers, wireless Internet, and mobile connec- tivity, as well as access to tablets and smartphones have cre- ated a ready-made infrastructure for SBS that is not possible with mannequin-based simulation (MBS). Depending on the knowledge, skills, behaviors, and attitudes being taught through SBS, the type of SBS may vary.
Types of Screen-Based Simulation Virtual Patients
Within SBS, there are many different types of simulations, each with unique features and capabilities. One of the most common types is Virtual Patients (VPs). VPs use a rendering of a single patient to replicate a physician–patient encounter, often to teach and assess diagnostic skills. This method is favored by primary care specialties like pediatrics, and pe- diatric subspecialties such as hospital pediatrics or pediatric emergency medicine, as it emphasizes data gathering skills and interaction with the patient or family [4]. Pediatric VPs are particularly useful in demonstrating rare or subtle find- ings and pathologies that are otherwise difficult or unethical to convey in MBS or in real patients. National organizations such as the Committee for Student Education in Pediatrics (COMSEP) have coordinated interinstitutional collabora- tives such as the Computer-assisted Learning in Pediatrics Program (CLIPP) cases, available to students at more than 80 US institutions [5]. The more robust VP simulators allow for naturalistic conversations using a keyboard or even voice recognition. Image and case banks allow for the deliberate practice with feedback on large numbers of virtual cases [6].
A large systematic review of VPs identified 45 quantita- tive, comparative studies and four qualitative studies [7, 8].
VPs as an educational intervention, in general, tend to have large effects in knowledge, clinical reasoning, and other skills when compared to no intervention; however, VPs have
not shown improved outcome measures compared to other modes of teaching such as traditional lectures [7].
Virtual Worlds
Virtual worlds (VWs) are different from VPs. VWs immerse the learner within a virtual world through a controllable ava- tar and can present multiple patients, austere environments, and social interaction; Second Life is a common example [9, 10]. VWs are typically portrayed on the screen and use prin- ciples and technologies of virtual reality (VR). The ability to render three-dimensional graphics and rotate freely within the virtual space is now commonplace in many VW games and training programs and can be done on a screen. For ex- ample, a pediatric disaster triage simulation that would focus on triaging many patients quickly rather than focusing on the details of one patient would be best represented in a VW format. At some institutions, including military, avia- tion, and civilian simulation centers, VR technology has ad- vanced such that a learner can be immersed within a large warehouse-like enclosure environment with multiple floor- to-ceiling screens to provide a total immersive experience.
Such a custom-designed physical space may not be neces- sary using newer tools like Oculus Rift that instead use im- mersive, personal VR [11].
Virtual Task Trainers
Surgical and procedural subspecialties tend to use virtual task trainers (VTs), which are distinct from other SBSs; these focus on developing hand–eye coordination and psychomo- tor skills. Medical procedures that would normally use a screen—for example, laparoscopies, bronchoscopies—are commonly simulated using SBS and a haptic simulator, a handheld device that approximates the actual device used in the procedure. Haptic simulators are devices that simu- late the weight, movement, and feel of handheld devices common in pediatric procedures and borrow principles and technologies from mannequins. Commercial procedural and surgical simulators are now widely available for a variety of procedures in adult and pediatric patients.
Resource Management Simulators Resource management simulators are a unique class of simulators often designed to demonstrate large population patterns; these simulations are used often at operational levels, by hospital or public health officials to simulate discrete events or mass casualty scenarios to look at municipal or global trends in resource allocation. Examples in pediatrics include disaster training, in which an entire ward, battlefield, or city ruins are por- trayed in SBS. However, as panel management becomes
increasingly relevant to primary care practitioners, resource management simulators could become more prevalent in pediatric education [12].
Advantages of Screen-Based Simulation
The inherent differences between SBS and MBS are found in its advantages and disadvantages. Notably, SBS has an edge over MBS because of five facets: replicability/standardiza- tion, portability, asynchrony, distribution, and data tracking.
Replicability/Standardization
The first and foremost advantage of SBS is its replicabil- ity or standardization. In MBS, a facilitator is running the simulation session. Although much of MBS can be pro- grammed—for example, changing patient physiologies in response to correct and incorrect actions—the facilitator is free to change or add to the scenario depending on the learner needs and on other factors (e.g., not enough time).
Facilitators, debriefers, and the course of MBS scenarios can vary from session to session, adding an element of variation when repeating MBS sessions across time or space. Often the variation is inconsequential, but it may mean differences in the way learners enjoy or learn from MBS. Controlling for variation between sessions in MBS is particularly trouble- some in simulation-based research, as standardizing the sce- narios is one of the requirements of preserving internal va- lidity [13]. SBS, on the other hand, does not have problems with unintended variation.
Because the root of SBS is a digital coded program, it is inherently replicable. In other words, students using a virtual- reality SBS on an iPad in California are using the same pro- gram as those in Australia. Although the scenario may unfold differently depending on the user, the actual setup and SBS are identical, and the degree of variation can be controlled by the SBS developer as needed for training or for research. It is important to understand that despite this easy replicability and standardization, SBS is not used in isolation; SBS is inte- grated within the educational context, curricular pathway, or the learning resources provided for the student. Institutional differences may have substantial effect even with the identi- cal SBS because of different contexts [14].
Portability
In addition, SBS is portable. Given the ubiquity of smart phones, tablets, and computers, SBS can be brought to the learner to their own device with only a download or active Internet connection. Most SBSs require only electricity or
battery power, with no heavy mannequin parts to transport, repair, or safeguard, and no consumable parts that require replacing. Portability also refers to the lack of setup in SBS, particularly in contrast to complex high-fidelity MBS that often requires associated equipment and materials to create a highly realistic environment. Some higher-technology SBS requiring a large virtual space may require dedicated loca- tions and dedicated VR equipment or haptic equipment, but the program itself on the screen is quite portable. SBS that only requires a tablet can be taken anywhere, allowing em- ployees and healthcare workers to train and practice in the immediate healthcare arena or in the privacy of their own home. It can also be a useful training adjunct in areas of the world in which space is at a premium, for example, war zones or in commercial airplanes.
Asynchrony
Portability also leads to asynchrony, a major strength of SBS.
Although just-in-time training and self-guided learning [15, 16] requires some facilitator or instructor to supervise the training process, SBS-based education can be done at any time without a facilitator immediately available. Most learn- ers are unable to create, run, and debrief MBS scenarios on their own—at least, effectively, using best practices that a simulation-trained facilitator can. Facilitation time can be costly in MBS. With SBS, however, much of the simulation can be done at the learner’s own discretion and time. Often, computer-based SBS and e-learning tend to occur during the evenings when personnel are sparse.
Distribution
Distribution also lies at the heart of the digital code of SBS.
SBS can be distributed to large groups of people and devices across the world with a simple Internet connection or ex- changing of disks, drives, and other solid-state media. With MBS, a scenario guide may be distributed, but multiple man- nequins would be required. An Advanced Cardiac Life Sup- port session using MBS cannot be distributed widely without incurring large costs for multiple mannequins, whereas an SBS-based session can be distributed to multiple devices in- stantly using file sharing or even an application store.
Data Collection
Finally, SBS can facilitate live data collection that can be utilized for learning, assessment, or research purposes. For most MBS sessions, video recordings, audio recordings, and a complex array of sensors within the MBS can record learn-
er actions and errors well. All of these are naturally encom- passed within the SBS programming, and a detailed score or report is much easier to derive than from MBS sessions.
Some SBS can continuously collect data as the session is running (e.g., data such as latency—the time during which no active action is taking place). SBS is superior to MBS in collecting interaction data as long as its programming is designed to record that data; often, the decision on what not to track is more important than what to track, given the al- most infinite possibilities within the software. Data about the learner is a trickier problem, but heart rate monitors [17], gaze-tracking software [18], and other add-ons allow data collection about the learner specifically. Even metadata such as how often and for how long a user participated within an SBS can be automatically collected.
Disadvantages of Screen-Based Simulation However, the problems with SBS are not trivial, and the aforementioned advantages do not mean that all simulation scenarios should use SBS rather than MBS. The three most significant problems: high front-end costs, technological limitations, and screen limitations and fidelity, are detailed here.
High Front-End Costs
SBS are not trivial, and the aforementioned advantages do not mean that all simulation scenarios should use SBS rather than MBS. The three most significant problems are detailed here. SBS has much higher front-end costs and development time. Although MBS requires the actual mannequin, once the mannequin and equipment are procured, a low-fidelity scenario can be led by a skilled facilitator quickly. With SBS, without completing all of the design, development, piloting, and distribution, there is nothing to work with at all. Skilled facilitators can manage a scenario with missing equipment or occasional glitches with a mannequin simulator. For SBS, the core programming must be completed before use. Fur- thermore, as the technology to provide greater fidelity and realism is available to programmers, the skill level and staff needed to develop an SBS from scratch is prohibitive to those who do not have a background in coding or game de- velopment. Educators, teachers, and researchers must work with programmers and software developers to get through this first bar, which leads to large front-end costs. The high- est proportion of this cost is usually programming or graphic design labor, with a smaller proportion on physical server space, distribution plans, and subject matter expert (SME) fees. Keep in mind that all of the advantages listed above depend on the programming; appropriate data collection in
an analyzable form to an instructor or a researcher requires considerable preparation and programming. Often this high cost of admission is enough to dissuade many SBS-based projects. Furthermore, high front-end costs also mean that a developer that undertakes the SBS development also takes on much of the time costs. Most developers or firms are in- terested in recouping costs in the commercial application and development of SBS products. Early alignment between the healthcare workforce, educator, and researcher interests with the developers and programmers is necessary to get past this obstacle.
Technological Limitations
As with all computing technology, the occasional technical problem is inevitable. This can have mild effects during MBS but can single-handedly shut down SBS. Technical problems are particularly prone in synchronous SBS, when multiple learners are present from different geographic locales. When it works, the SBS is extremely powerful. However, one is de- pendent on appropriate power, stable Internet bandwidth and connectivity, adequate processing speeds on all devices, and all audiovisual add-ons and hardware working cross-plat- form. SBS requires considering different devices, operating systems, and input methods. Even well-funded massive mul- tiplayer online role-playing games such as World of Warcraft require a minimum set of resources and requirements for a pleasant playing experience, and most SBS development has a fraction of the funding and support staff to maintain that atmosphere. Therefore, SBS needs some level of back-up or contingency plan to rapidly fix unanticipated issues in ex- ecution.
Screen Limitations and Fidelity
Finally, we come to the inherent limitation of the screen in SBS. The use of a two-dimensional screen means SBS must work harder to match the functional fidelity that can be rep- licated by MBS. This is in contrast to physical fidelity, de- fined as the raw audiovisual realism that SBS can do quite well—with well-financed programming. Functional fidelity, also termed functional task alignment [19], is arguably the most important for SBS [19–21]. Functional fidelity refers to the realism of outputs in response to inputs as part of cogni- tive fidelity—does the method of interaction feel authentic [21,22]? There are some that argue that functional fidelity is more important for learning in MBS than physical fidelity;
this is likely true with SBS [21, 23].
Because SBS is experiential learning, the learner must experience the SBS in as natural and logical a context to the real setting [24]. For example, suppose a colonoscopy simu-
lator has rich graphics that looks exactly like a real patient’s colon, there may even be a timer and audiovisual cues to im- prove psychological fidelity and engagement. Psychological fidelity is the immersive property of the simulation to invoke realistic emotions from the participant—anxiety, relief, or a sense of challenge. But if the simulator does not simulate the haptic or visual feedback of bumping into and stretch- ing a colonic wall, the SBS feels fake. Devices portrayed by VTs should function like real colonoscopes, bronchoscopes, and laryngoscopes; if a scope bumps into a colon wall, there should be consequences: the tactile feedback to the learner, perhaps bleeding, and even a negative score [25]. Without this fidelity, learners could easily learn incorrect psychomo- tor habits. SBS has an inherent barrier to functional fidel- ity—the two-dimensional screen—and psychomotor func- tions, particularly for VTs, feel awkward and unrealistic when simple gestures on a tablet or keyboard entries do not match what is done in reality. As a result, SBS for psycho- motor tasks often use haptic devices that simulate the feel, weight, and function of the handheld device.
Therefore, the limitations on functional fidelity for SBS is high enough that certain applications such as psychomotor skills requiring three-dimensional tactile skills (e.g., palpat- ing a vein) are more realistically constructed using MBS.
When an activity inherently requires a screen—a cardiopul- monary monitor, a laparoscopy monitor, a simulated tele- medicine encounter—this limitation is minimized, since the screen is the actual device. When scenarios require signifi- cant team communication using both verbal and nonverbal cues, SBS can be a poorer construct than MBS. Scenarios requiring rapid, successive actions on a patient can be very difficult to convey if a complex array of menus and options is the featured user interface of the SBS. Even when learners prefer menus, it has minimal functional fidelity to the real- world setting [7]. Similarly, the concepts of team-based care are difficult to convey through SBS. SBSs that use multiple learners do exist; they require a level of collaboration to di- agnose or treat a VP successfully [7]. However, the interac- tions afforded by the SBS and online technologies do not yet match the realities of how the majority of healthcare teams behave.
Screen-Based Simulation and Ideal Uses
That being said, SBS is more efficient than MBS for the following: screen-based task trainers, long narrative-based scenarios, and mass casualty or large resource-management scenarios. Screen-based task trainers are uniquely fit to use simulation that replicates the screen, as mentioned earlier.
Narratives and storylines are particularly germane to SBS and the video game world [26] and is more poorly defined in a MBS session. This may mean a series of different en-
counters with a growing patient avatar for a primary care practitioner—which would require multiple different man- nequins if using MBS—and encounters in which patient–
provider communication is replicated using powerful speech engines and computerized facial expressions. For mass ca- sualties or resource-management scenarios, SBS is ideal as the addition of another patient has minimal resource require- ments whereas running a mass casualty scenario using MBS is very costly, and using human volunteers can be cost- or time-prohibitive. Resource-management scenarios require a more macro view of a clinic, ward, hospital, or city, which is almost impossible to simulate effectively using MBS.
Selected Examples of Screen-Based Simulation in the Medical Literature
Virtual Patients VPs are often used with medical students and in other disciplines in which communication and differ- ential diagnoses are prevalent topics (Fig. 9.1). Psychiatric residents have demonstrated diagnostic skills using VPs por- traying psychiatric disease and a system to navigate through history-taking and branching custom conversations [27, 28].
Even in the early 2000s, VPs with voice recognition were
Fig. 9.1 Screenshot of a virtual patient encounter in a two-dimensional manner patient simulator. (Courtesy of BreakAway, Ltd., Hunt Valley, Maryland, USA. Reproduced with permission)
successfully used to teach and assess communication skills [29]. We anticipate improvements in the ability of VPs to simulate nuanced emotional responses and recognize users' facial gestures that could further SBS in this arena. In the physical exam portrayals, VPs can portray limited exam find- ings for disaster triage [30]—which requires very minimal information—to more complex emergency medicine diag- noses [31]. A very realistic VP was developed simulating obesity's effects on respiratory physiology; anesthesiology residents correctly diagnosed obstructive sleep apnea more often with VPs than with hired standardized patient actors who otherwise provided identical histories [32]. In this way, SBS was able to better simulate a needed exam finding that was unethical or uncomfortable (i.e., unable to be done any other way); as a result, VPs can reinforce and even assess the learner’s ability to come to diagnoses and management plans.
Virtual Worlds VWs in the twenty-first-century literature often use Second Life (Linden Lab, San Francisco, CA) or other similar three-dimensional avatar software in which the learner can move freely in a virtual environment to inter- act with other avatars. This SBS lends itself to having live instructors within the environment that can give customized feedback and coaching. Second Life was used for emergency medicine residents to practice mock oral boards skills in a