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Immersive patient simulators (IPSs) combine the simulation of virtual patients with a three-dimensional (3D) environment and, thus, allow an illusionary immersion into a synthetic world, similar to computer games. Playful learning in a 3D environment is motivating and allows repetitive training and internalization of medical workflows (ie, procedural knowledge) without compromising real patients. The impact of this innovative educational concept on learning success requires review of feasibility and validity.
It was the aim of this paper to conduct a survey of all immersive patient simulators currently available. In addition, we address the question of whether the use of these simulators has an impact on knowledge gain by summarizing the existing validation studies.
A systematic literature search via PubMed was performed using predefined inclusion criteria (ie, virtual worlds, focus on education of medical students, validation testing) to identify all available simulators. Validation testing was defined as the primary end point.
There are currently 13 immersive patient simulators available. Of these, 9 are Web-based simulators and represent feasibility studies. None of these simulators are used routinely for student education. The workstation-based simulators are commercially driven and show a higher quality in terms of graphical quality and/or data content. Out of the studies, 1 showed a positive correlation between simulated content and real content (ie, content validity). There was a positive correlation between the outcome of simulator training and alternative training methods (ie, concordance validity), and a positive coherence between measured outcome and future professional attitude and performance (ie, predictive validity).
IPSs can promote learning and consolidation of procedural knowledge. The use of immersive patient simulators is still marginal, and technical and educational approaches are heterogeneous. Academic-driven IPSs could possibly enhance the content quality, improve the validity level, and make this educational concept accessible to all medical students.
One key factor of clinical education is the transfer of declarative knowledge (ie, “what to do”) into procedural knowledge (ie, “how to do”). It is performed most effectively in small groups accompanied by a medical teacher [
The user can playfully immerse himself/herself into the digital environment and faces the consequences of different decisions (ie, trial and error) without putting real patients at risk. By repetitive and playful training of medical procedures, procedural knowledge can be internalized and consolidated. Therefore, IPSs potentially allow time- and location-independent learning and an effective preparation for bedside teaching. However, evaluation of the impact of IPSs on knowledge gain is a demanding task, as gain in procedural experience can hardly be objectivized and is influenced by many educational factors. For medical teachers, information about validity and usability are essential parameters for a possible implementation of such simulators in the current medical curriculum. Furthermore, development of such a simulation is time- consuming and cost-intensive and only worthwhile when there is a proven effect on knowledge gain.
It was the aim of this paper to give a thematic review of the available immersive patient simulators in virtual worlds (VWs) and to evaluate whether the use of these simulators have an impact on knowledge gain by summarizing the existing validation studies.
Example of a 3D virtual environment streamed via the Internet directly onto the learner’s computer (ie, Web-based) where the user can freely walk around and interact with the environment—authors’ project in collaboration with Clemson University, SC, USA.
A systematic search of literature via PubMed of articles from 1986 to 2014 on IPSs was performed with a focus on education of medical students. IPSs were defined as digital environments that simulate medical workflows and show the characteristics of real-time simulation with free interaction in a 3D setting. As browser technology is developing fast, not only workstation-based simulators, but also Web-based simulators were included. Simulation of one-step procedures (ie, intubation, puncturing) were excluded. Search terms included a combination of “simulation,” “virtual reality,” or “virtual worlds,” and “education”
Validation was assessed according to the consensus guidelines for validation of virtual reality surgical simulators [
The systematic literature search (
A total of 13 publications were identified as relevant in terms of describing the use of virtual worlds in medical education (
List of available virtual patient simulators.
Virtual world | Type | Content | Immersion | Content level | Reference |
VNEC | WBa | Neurological disorders | Medium | Medium | [ |
Play2Train | WB | Emergency medicine | Medium | Medium | [ |
MeRiTS | WB | Emergency medicine | Medium | Low | [ |
Second Health London | WB | Emergency medicine | Medium | Medium | [ |
CliniSpace | WB | Emergency medicine | Very high | High | [ |
Pulse | WB | Emergency medicine | High | High | [ |
3D Emergency Department | WB | Emergency medicine | Medium | High | [ |
Inmedea | WB | Various clinical cases | Low | High | [ |
Olive | WB | Emergency medicine | Medium | Low | [ |
Project TOUCH | CBb | Various clinical cases | High | Medium | [ |
Virtual Emergency Department | CB | Emergency medicine | High | High | [ |
TriageTrainer | CB | Triage | High | Low | [ |
Burn Center | CB | Burn wounds | High | Medium | [ |
aWeb-based (WB).
bComputer-based (CB) (aka, workstation based).
Search strategy for literature on virtual patient simulators.
Out of 9 Web-based IPSs, 5 of them use the 3D technology of the widely used social network, Second Life (SL). All of these 5 IPSs were developed by university groups. None of these IPSs are routinely used in the education of medical students or medical staff, as they are technical feasibility projects with general medical content and focus on medical knowledge exchange [
Web-based simulators are comparable to SL simulators, however, the main difference is the technical background. Web-based simulators use a proprietary 3D engine program, which makes development of 3D worlds more resource intensive, but enables more possibilities in graphical quality and custom program design. Of the 4 remaining Web-based IPSs, 1 was already presented in 2003 and uses a custom-made 3D world. Again, the key aspect of the simulator is a feasibility study, in this case particularly with regard to distance learning [
Workstation-based IPSs need to be installed on a computer and offer high immersion with high-fidelity 3D graphics, as they are not limited by the technical handicaps of Internet broadcasting. Out of the 4 simulators, 3 of them are still undergoing feasibility studies, as they were not already validated for their effectiveness [
The literature search uncovered 5 articles that included validation studies, however, no study assessed all levels of validity. One of the available VW simulators validated the coherence between simulated content and real content (ie, content validity) in training of emergency procedures [
Overview of the validity level of all currently available virtual patient simulators.
Validity type and study | Number of participants | Virtual world | Reference | |
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Cohen et al, 2013 | 23 | Second Health London | [ |
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LeRoy Heinrichs et al, 2008 | 30 | 3D Emergency Department | [ |
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Youngblood et al, 2008 | 30 | Virtual Emergency Department | [ |
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Funke et al, 2012 | 116 | Inmedea | [ |
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Knight et al, 2010 | 91 | Triage Trainer | [ |
This paper gives an overview of the available IPSs and corresponding validation studies and, therefore, summarizes the current situation in learning in virtual worlds. Previous studies revealed that using virtual patient simulators can have a positive impact on learning success [
Immersive patient simulators can potentially promote learning and consolidation of procedural knowledge. Web-based simulators allow time- and location-independent learning at an individual pace. The use of immersive patient simulators is still marginal, and technical and educational approaches are heterogeneous. Academic-driven IPSs could possibly enhance the content quality, improve the validity level, and make this educational concept accessible to all medical students. The development and validation of such a simulator will be the subject of our future research.
three-dimensional
immersive patient simulator
Second Life
virtual world
None declared.