25 (2007) 321336Virtual Worlds and Team Training
Parvati Dev, PhDa,*, Patricia Youngblood, PhDa,W. LeRoy Heinrichs, MD, PhDa,
Laura Kusumoto, MSb
aSUMMIT, Stanford University School of Medicine, Stanford, CA 943055466, USAbForterra Systems, 1855 South Grant Road, 3rd Floor,
San Mateo, CA 94402, USA
Medical education has increasingly adopted situated or experientiallearning as an important component of medical training . This traininghas taken the form of learning in a variety of simulated environments rang-ing from encounters with simulated patients to participation in team-basedsimulated medical activities [2,3]. A well-accepted simulation-based learningenvironment is one where a high-fidelity human simulator, an instrumentedmannequin running a computational model of physiology and pharmacol-ogy, represents the patient, and a team of health care personnel managethe simulated medical case in a physical space representing an operatingroom or other hospital space. Virtual worlds provide the opportunity to rep-licate and extend this learning environment, supporting participation bymultiple remotely located learners who access the virtual world simulationthrough the Internet, and manage the medical case as though they were to-gether in a real space.
What is a virtual world?
The concept of a geometrically accurate, earth-size, virtual world, ormetaverse, was first articulated in a science-fiction novel . It definesa virtual world as a computer-based, three-dimensional, spatially realistic,simulated environment intended to represent a real or fictional location. The virtual world is operated on a server computer, or computer cluster,and users connect to the world from their local computers by the Internet.
This work was supported by the Wallenberg Foundation, the Telemedicine and Advanced
Technology Research Center, and Adobe Systems.
* Corresponding author.
E-mail address: firstname.lastname@example.org (P. Dev).1932-2275/07/$ - see front matter 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.anclin.2007.03.001 anesthesiology.theclinics.com
322 DEV et alThe virtual world resembles the real world, and has real world rules, suchas distance, gravity, and the ability to move within the world. Buildings canbe entered and explored. Objects may be interacted with, moved, or ex-changed. In some virtual worlds, users can create new objects, creatingnew environments.
The virtual world may have multiple inhabitants, called avatars, eachselected from a library, and controlled by a person from their own com-puter. Avatars see each other in the world, and interact through voice ortyped chat. Each person sees the world from the point-of-view of his orher avatar. The avatars movement and action are controlled by the userskeyboard and mouse. Some inhabitants are controlled by computer pro-grams, not live users, and have a predetermined suite of actions. These sim-ulated inhabitants, called robots, robotars, or nonplayer characters,may take many roles, such as participants in a crowd or a character witha limited set of required actions. Artificial intelligence programming maybe added to these characters, increasing their capabilities, a factor that is im-portant in medical virtual worlds.
Some virtual worlds have only one controllable character or avatar, andall other characters are computer controlled. Computer-controlled charac-ters are preanimated, with a limited set of behaviors or animations thatare rendered in response to the learners actions. Artificial intelligencemay be used to increase the range of behaviors available to these com-puter-controlled characters. Many medical virtual worlds are single-playerworlds where the learner is placed in a crisis situation and must make deci-sions to manage the medical problem . In contrast, in multiplayer worlds,most characters are controlled by real people . The animations may belimited but voice, or text chat, allow freeform interaction.
A multiperson virtual world is a persistent world that exists even whenthe user logs off. This is different from many games and simulation environ-ments that are active only while the user interacts with them. A virtual worldcontinues to evolve while the user is away. Meanwhile, other users who arelogged in can interact, exchange information, and modify, create, or removeobjects, while the first user is away. A virtual world represents an approxi-mation to some aspects of the real world, and may be used as a reasonablefacsimile of a variety of real medical locations, such as hospital wards andintensive care units.
For those familiar with networked games, such as Sims Online, in multi-player medical virtual worlds, the setting might be a hospital or other site,and each Sim character would be controlled by a different person. If anyperson logged off, the other characters might continue to play and evolvethe state of the world. If a character was the patient and was controlledby a medical model, then the patients state would evolve over time.
Simulated, or virtual, worlds were developed first by the military. Tech-nology for airplane flight simulation grew rapidly during and after WorldWar II, and was used to train pilots in necessary skills before they operated
323VIRTUAL WORLDS AND TEAM TRAININGthe actual airplane. These systems included a detailed simulation of aircraftmechanics and a three-dimensional rendering of the virtual world as seenthrough the aircraft windows [13,14]. By the 1980s, multiple such simula-tions were being linked, within one large three-dimensional virtual space,to support team learning in war games. Through these developments, con-siderable technologic expertise was developed both in the modeling and ren-dering of three-dimensional worlds and in real-time communication overnetworks .
At the same time, there was a grass-roots effort, mostly in academia, tomake games available on the computer. Games that linked players overthe network drew their inspiration from the popular Dungeons and Dragonsboard game. A multiuser dungeon or domain or dimension (MUD) is a mul-tiplayer computer game that includes fantasy role-playing, battles, and so-cial chat [15,16]. The game is text-based. Players read descriptions of rooms,objects, events, and other characters, and they interact with the surroundingspace and each other through typed, English-like commands. MUD object-oriented (MOO), an extension of MUDs, even allowed players to extend theworld themselves, adding objects and spaces to customize their virtual world.MOOs proliferated as educational tools, particularly in teaching writingand composition, as students used descriptive text to build new rooms andcreate new behaviors for objects in their game. MOO technology and gameprinciples were influential in the subsequent development of graphicalvirtual worlds.
As the Internet became widely available, and as graphics capability im-proved, text-based networked games evolved into rich visual worlds, withrealistic-looking characters and objects (usually weapons). These massivelymultiplayer online role-playing games shared some basic characteristics, de-rived from MOOs. The players moved in a three-dimensional world. Gameplay included quests, monsters, and loot. A point system was reflected incharacter development and levels of play. An associated economy existedfor trade in weapons and tools. Social organization emerged, with guildsfor collaborative action against enemies.
Multiplayer social worlds were an outgrowth of multiplayer game worlds[17,18]. A key capability of these social worlds is the creation of new objectsby the user. The ability to personalize ones own character, and any virtualspace that one has purchased, has allowed dramatic expansion of the num-ber of activities available in these worlds. From three-dimensional chatrooms these worlds have evolved into spaces with many of the activitiesof the real world. Businesses have created virtual stores just as they createdvirtual store-fronts on the World Wide Web . News organizations havevirtual offices and reporters in these worlds [20,21].
The technology of online video games combined with the story tellingexperience of cinema were perceived as a rich source for fulfilling the train-ing needs of the US Army. The potential of this confluence was demon-strated in an emotionally charged game scenario of an army lieutenant
324 DEV et alon a virtual Bosnian street, facing a complex decision-making situation. Another army training game, Americas Army, about training a sol-dier through simulated combat missions, was developed as a recruitingtool for the Army, and has since been developed into a series of gamesfor actual soldier training [23,24]. This use of game technology for seriouslearning became an impetus for similar development in many other areas,including medicine.
Today there are many multiplayer game engines available. A gameengine is the core software of a computer game. It provides rendering oftwo- or three-dimensional graphics of the world and its avatars. It mayalso compute the physics of gravity and of collisions in the world, the spati-alization of sound, and any rules of interaction between avatars and withobjects. Customizable engines include scripting languages to author objectsand behaviors, and some provide the entire source code for full customiza-tion. The game engine also deals with all system issues, such as managingtransmissions across the network, and synchronizing what is seen by allthe players in the world.
Virtual worlds in medicine
Medical virtual worlds are specialized virtual worlds. The three-dimen-sional space includes buildings that represent a hospital, a clinic, or an emer-gency department. Objects include a range of medically rel