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CYBERPSYCHOLOGY & BEHAVIORVolume 9, Number 2, 2006© Mary Ann Liebert, Inc.

Simulation and Virtual Reality in Medical Education and Therapy: A Protocol

MICHAEL J. ROY, M.D., M.P.H.,1 DEBORAH L. STICHA, M.B.A., B.S.,2PATRICIA L. KRAUS, B.A.,1 and DALE E. OLSEN, Ph.D., M.S.2

ABSTRACT

Continuing medical education has historically been provided primarily by didactic lectures,though adult learners prefer experiential or self-directed learning. Young physicians have ex-tensive experience with computer-based or “video” games, priming them for medical educa-tion—and treating their patients—via new technologies. We report our use of standardizedpatients (SPs) to educate physicians on the diagnosis and treatment of biological and chemi-cal warfare agent exposure. We trained professional actors to serve as SPs representing expo-sure to biological agents such as anthrax and smallpox. We rotated workshop participantsthrough teaching stations to interview, examine, diagnose and treat SPs. We also trained SPsto simulate a chemical mass casualty (MASCAL) incident. Workshop participants worked to-gether to treat MASCAL victims, followed by discussion of key teaching points. More re-cently, we developed computer-based simulation (CBS) modules of patients exposed tobiological agents. We compare the strengths and weaknesses of CBS vs. live SPs. Finally, wedetail plans for a randomized controlled trial to assess the efficacy of virtual reality (VR) ex-posure therapy compared to pharmacotherapy for post-traumatic stress disorder (PTSD).PTSD is associated with significant disability and healthcare costs, which may be amelio-rated by the identification of more effective therapy.

INTRODUCTION

THE MOST DEADLY terrorist attack in Americanhistory, on September 11, 2001, led to military

deployments to Afghanistan and Iraq, coupledwith the dissemination of anthrax through theU.S. mail the next month, and profoundly influ-enced medical education as well as the health ofmany soldiers and citizens.

VR IN MEDICAL EDUCATION

Prior to 2001, the health consequences ofweapons of mass destruction received scant atten-

tion in medical school and residency program cur-ricula. However, fear of further terrorism, includ-ing clandestine use of chemical or biologicalagents, change. Rapid improvement in medical ca-pabilities demands change not only in training cur-ricula, but also continuing medical education(CME) for physicians already in practice. A didacticapproach is relatively impractical and ineffective—physicians, like other adults, fare better with expe-riential learning, such as participatory training. In2002, an expert panel of medical educators identi-fied simulation as the preferred method of learn-ing.1 Examples of simulation include synthetic oranimal models, standardized patients (SPs), com-puter-based simulation (CBS), and virtual reality

1Department of Medicine, Uniformed Services University, Bethesda, Maryland.2SIMmersion LLC, Columbia, Maryland.

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(VR). Simulation provides greater realism than di-dactics, and enables individualization of the levelof difficulty with immediate feedback. Simulationcan equal or exceed the breadth of real clinical en-counters, with greater safety and more flexiblescheduling. Teamwork can be enhanced by learnersalternating roles in scenario replays.

We describe the advantages and disadvantagesof various approaches, from the conventional to theapplication of “cutting edge” technology, utilizedto educate physicians on bioterrorism. We wrote atextbook2 featuring chapters on each biological andchemical agent, as well as first response, radiation,conventional weaponry, and psychological seque-lae. The reviews indicate we made a dense subjectmatter readable, but we suspect it remains lesslikely to enhance durable knowledge retentionthan experiential learning. Subsequently, we au-thored case-based bioterrorism educational book-lets3,4 with CME credit and an internet-based formfor easy access. The booklets maximize portabilityand brevity but lack the imprinting power of expe-riential learning.

The prime method of experiential learning inmedicine is the live patient. However, bioterrorismagents are rarely encountered clinically, makingthis subject ideal for simulation. Our first simula-tion utilized SPs we trained to mimic the effects offour biologic agents—smallpox, anthrax, Staphylo-coccal Enterotoxin B, and botulism—chosen fortheir diverse presentations and differential diag-noses. Physicians at national meetings rotatedthrough SP teaching stations in small groups toconduct interviews and exams, order pertinenttests, and establish a diagnosis and managementplan. SP-provided histories were buttressed bymoulaged skin findings and corresponding vitalsigns, lab and radiology results. A second part ofthe workshop featured SP simulation of a mass ca-sualty (MASCAL) incident involving a terroristspraying a nerve agent on a city bus. Learnersworked together either as first responders or at thenearby hospital to treat MASCAL victims, followedby detailed discussion. Enhancing realism, SPsdisplayed elements of mass hysteria, guilt, andheroism, and some learners became secondary ca-sualties. The educational and memorable programimproved retention of learning objectives morethan conventional methods, but it was expensive,with large personnel requirements and relativelyfew learners trained.

We are now incorporating the workshop scenar-ios into CBS, to facilitate repeated use while limit-ing resource requirements. In our first module, wefilmed an actor moulaged to exhibit smallpox as

well as easily mistaken conditions such as chickenpox. We developed a large set of questions thatmedical personnel might ask, scripted a range ofresponses to each question, and filmed the actorproviding the responses. The simulation technol-ogy developed by SIMmersion™ LLC createsCBS’s of people with whom trainees can hold de-tailed conversations, with successful prior applica-tions ranging from suicide intervention torecruiting interviews. The simulations can buildskills, increase learning retention, improve traineeconfidence, and change behavior. Actors are morelife-like than computer-generated characters, andthe simulations incorporate memory and emotionsto enhance response authenticity. Learners con-verse with simulated characters via microphone ormouse, and can access physical findings, medicalimages, and audio recordings such as heart sounds.Scripts include a variety of choices emulating realinterviews, resulting in nearly free-form conversa-tion that differs each time, enabling virtually un-limited practice. Rapid qualitative and quantitativefeedback is facilitated by embedded metrics to as-sess learner performance, along with detailed con-versational analysis. Compared to SPs in a liveworkshop, CBS requires greater initial investment,but has lower marginal costs and considerable re-turn on investment. Simulations can be run repeat-edly to enhance understanding and retention,anywhere, anytime—ideal for “just-in-time” train-ing, such as when a physician anticipates imminentapplication of the subject matter. A single SP can berecorded to train many individuals, eliminating theneed for advance notice and many personnel. CBSalso enables different levels for different users (e.g.,medical student, resident, infectious diseases spe-cialist).

VR IN MEDICAL THERAPY

Computer-based technologies can be applied tomedical therapy as well as education. Their poten-tial is especially great for psychological disorders,where reluctance and non-compliance with stan-dard therapies are common. We are developingprograms to treat post-traumatic stress disorder(PTSD) in Operation Iraqi Freedom veterans. Phar-macologic and non-pharmacologic therapies are ef-fective for PTSD, but response rates are typically40–60%. A recent Cochrane Review found cognitivebehavioral therapy (CBT) with an exposure ther-apy element superior to other non-pharmacologictherapies,5 but we believe that combining this withpharmacologic therapy should prove superior to

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either alone. This hypothesis has not yet been ade-quately tested, but needs to be done in a well-con-trolled study. Functional magnetic resonanceimaging or another objective measure of impact onneural pathways should be valuable to incorporatein such studies.

VR is a particularly promising form of exposuretherapy, with success for a range of phobias,6–9 anx-iety disorders,10 and PTSD. Recent treatmentguidelines tout imaginal exposure as the non-phar-macologic treatment of choice for PTSD,11 but somepatients will not or can not engage in imaginal ex-posure, and case series of Vietnam war veterans12

and World Trade Center survivors13 improved withprogressively more realistic and intense VR expo-sures. We have assembled an experienced team ofexperts to conduct a randomized controlled trialassessing the efficacy of combined pharmacother-apy and CBT/VR exposure therapy versus mono-therapy. The VR environment is based upon theMicrosoft X-box game Full Spectrum Warrior.

CONCLUSION

We believe computer-based technologies can sig-nificantly enhance important aspects of medical ed-ucation and therapy. Younger health professionalsand patients in particular are likely to embrace newapproaches, which should be carefully assessed incontrolled studies to document the degree of bene-fit achieved with their adoption.

ACKNOWLEDGMENTS

The opinions or assertions contained herein arethe private views of the authors and are not to beconstrued as official or as representing the opinionof the Department of the Army or the Departmentof Defense.

REFERENCES

1. Turner, M., Wilson, C., Gausman, K., et al. (2003).Optimal methods of learning for military medicaleducation. Military Medicine 168:46–50.

2. Roy, M.J. (2004). Physician’s guide to terrorist attack.Totawa, NJ: Humana Press.

3. Durning, S.J., & Roy, M.J. (2005). Viral hemorrhagicfevers. Bioterrorism CME case series booklet. Chicago:Rush University Medical Center.

4. Roy, M.J., Durning, S.J., & Hall, M. (2005). Anthrax.Bioterrorism CME case series booklet. Chicago: RushUniversity Medical Center.

5. Bisson, J., & Andrew, M. (2005). Psychological treat-ment of post-traumatic stress disorder (PTSD).Cochrane Database Systematic Reviews 2:CD003388.

6. Botella, C., Banos, R.M., Perpina, C., et al. (2002). Vir-tual reality treatment of claustrophobia: a case re-port. Behavioral Research and Therapeutics 36:239–246.

7. Rothbaum, B.O., Hodges, L., Smith, S., et al. (2000). Acontrolled study of virtual reality exposure therapyfor the fear of flying. Journal of Consultative and Clini-cal Psychology 68:1020–1026.

8. Emmelkamp, P.M., Bruynzeel, M., Drost, L., et al.(2001). Virtual reality treatment in acrophobia: acomparison with exposure in vivo. CyberPsychology& Behavior 4:335–339.

9. Garcia-Palacios, A., Hoffman, H., Carlin, A., et al.(2002). Virtual reality in the treatment of spider pho-bia: a controlled study. Behavioral Research and Thera-peutics 40:983–993.

10. Rothbaum, B.O., & Hodges, L.F. (1999). The use ofvirtual reality exposure in the treatment of anxietydisorders. Behavior Modification 23:507–525.

11. Ballenger, J.C., Davidson, J.R., Lecrubier, Y., et al.(2000). Consensus statement on posttraumatic stressdisorder from the International Consensus Group onDepression and Anxiety. Journal of Clinical Psychiatry61:60–66.

12. Rothbaum, B.O., Hodges, L.F., Ready, D., et al.(2001). Virtual reality exposure therapy for Vietnamveterans with posttraumatic stress disorder. Journalof Clinical Psychiatry 62:617–622.

13. Difede, J., & Hoffman, H.G. (2002). Virtual reality ex-posure therapy for World Trade Center posttrau-matic stress disorder: a case report. CyberPsychology& Behavior 5:529–535.

Address reprint requests to:Dr. Michael J. Roy

Department of Medicine, Rm. A3062Uniformed Services University

4301 Jones Bridge Rd.Bethesda, MD 20814

E-mail: mroy@usuhs.mil

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