Second Life Continuing Medical Education Pilot

CME Pilot in Second Life

CME Pilot in Second Life

On June 15, 2009 Boston University School of Medicine hosted its first ever Continuing Medical Education (CME) event in the virtual world of Second Life.  The workshop, Adding Insulin in Type 2 Diabetes, was intended for practicing physicians to improve treatment of their diabetic patients.  I was fortunate enough to work as one of the event organizers and, so, had a front row seat on all the details. This one-hour workshop was the result of roughly four weeks of preparation.  In the wake of the event, I’ve been processing the lessons learned and insights gained and look forward to sorting out my thoughts as I blog about it (you can see photos from the event in my flickr stream in the right margin of the blog). This is going to be a long one, so I’ll insert a “more tag” to spare those of you uninterested in this topic.  Click more to read on….

First, a bit of background. Practicing physicians in the U.S. regularly update and enhance their knowledge and skills by taking supplementary courses and workshops.  The Boston University School of Medicine (BUSOM) has developed a number of online offerings and recently decided to expand their educational activities into the virtual world with a run of this pilot in Second Life.

We recruited doctors through various medical listservs.  Interested physicians were contacted through email and further qualified.  We needed participants who had access to the hardware and internet connections that could support the SL application as well as the time required to get up to speed.  We started with a potential pool of 40 which eventually whittled down to 15.  Of the 15, three had previous Second Life experience.  The remaining 12 were offered a one-on-one coaching session with me.  While this wasn’t the most efficient way to coach new virtual world residents, it was necessary due to the doctors’ jam-packed schedules.

There were some interesting lessons that emerged from the coaching sessions.  On average, I spent one hour with each participant (some were 45 minutes, some as long as 90 minutes).  The challenges experienced by the doctors while learning about SL can be grouped into two, general categories:

1.  Difficulty grasping the metaphor. Many participants had trouble understanding where they were when in the virtual environment. This was expressed by questions like “Who is that?’  (meaning the trainer’s avatar), “What is it we’re trying to do here?” “I’m confused about where I am?”,  “What is a virtual world?”.  Similarly some participants had difficulty distinguishing between what was “real” and what was “virtual”.  For instance, when they were given landmarks for SL places to visit (e.g. Vassar University or Chichen Itza) and one participant commented, “But these places exist in the real world.” Sometimes this confusion was overcome by taking them to the Second Life map and showing where we were in relationship to the entire Second Life world but, since the map itself is a metaphor, this did not work for everyone. Another example was repeated instances of participants going to the Second Life web site instead of opening the Second Life application on their desktop, in order to enter the virtual world.

2.  Technical Skills. For some doctors, mastering the menus, keyboard commands, and interface elements were no problem at all.  Others had significant trouble remembering how to perform basic tasks (sitting, chatting, accessing inventory, setting landmarks).  The variability in coaching time reflects those differences and is, most likely, related to the time spent online and/or working with other applications. Participants with gaming experience were much more adept at mastering the basics.

It was also interesting to notice the differences in approach to learning.  Some of the physicians needed to understand the context for any new navigational command (e.g. “Why would you need to take a snapshot in Second Life?”, “When would you use that function?”); while others were perfectly content to run through a list of skills and tick them off, with no need to attach relevance.

I observed that subjects tended to choose avatars that looked like them in real life. For example, one African American participant explained, “but I need the avatar skin to be darker”… This is consistent with previous studies showing that people choose avatars for self-representation based primarily on how similar the avatar is to themselves. It also implies the increased sense of presence afforded by the virtual world.

For the workshop’s content, Dr. Elliot Sternthal (Clinical Director of the Outpatient Diabetes Program, Boston Medical Center) developed a 45 minute talk (PPT deck) on the topic.  We worked with Dr. Sternthal to hone the talk, add visual elements, increase the interactivity, and leverage the unique affordances of Second Life. We came up with a plan to introduce mock patients into the workshop (and we recruited SL experts to play the part of these patients).  We constructed lab results for them crafted to illustrate important clinical points and interventions.  My colleague, Liz Dorland, who is very experienced with Second Life, played one of the diabetic patients and helped me to design Dr. Sternthal’s avatar (to resemble him in real life) and the two mock-patient avatars (to resemble classic diabetic patient profiles).

In addition to the mock avatars, we inserted planned interactions with the participants which would be conducted in local chat.  The interactions and the mock patient interviews were scripted.  The entire session was rehearsed twice and contingency plans were established for a range of possible technical challenges (e.g. problems with in-world voice, connectivity issues, and inexperienced avatar glitches).

Since the organizers and the speaker lived in the same geographical area, we decided to host the event together in order to offer improved support for the speaker and easier coordination.  Here’s a photo of Dr. Sternthal, John Weicha, and me – hard at work on the night of the workshop.

The back-stage area for the CME event.The workshop seemed to go by in a minute – before I knew it, it was over.  The doctor-participants were very engaged and fully participated in all the planned interactivities. We also managed to avoid any technical problems. As a result, the event went remarkably well.  As I reflect back on the experience, here are the insights that rise to the surface for me:

  • An event like this has to be designed in such a way so that it answers the question, “why SL?”, before it gets asked.  In other words, it is critical to take advantage of the unique affordances of the virtual world to push the experience beyond what could be delivered via a web site or a webinar.
  • With so many opportunities to “go wrong” in a technically complex platform, it is clear that thorough planning is paramount.  This event was meticulously planned, rehearsed, and buttressed with contingency plans.
  • The time investment to plan, prepare, and deliver a one-hour event is steep and the learning curve for the doctor-participants is not trivial.
  • Virtual world events require a skilled and unflappable speaker. They must be knowledgeable, confident in their expertise, unruffled with the inevitable technical glitches, good humored, in-tune with the students, and able to field questions from the back chat, while still keeping an eye on the content and the timing.
  • There is a “sizzle”, a certain excitement that comes from just being there, all together, in the virtual world. The physician participants are more forthcoming, brave, involved and present.
  • There is an interesting “protection” effect that comes with the avatar anonymity.  Many of the doctors commented on it and you could certainly sense an openness and willingness to venture further from the back chat log.
  • While the back chat offers an opportunity for increased interactivity, it can be distracting.  Organizers should prepare participants for this and set ground rules (depending on your preferences) about the chat.
  • I think it’s important to leverage the more playful aspects of Second Life (without drifting into unprofessional behavior, of course). In this event, the mock-patient avatars’ responses, the 15-minute conversational warm-up before the session started, and serving “champagne” at the end (thanks, Liz!) all helped to serve that purpose.

Of the 15 participant physicians, 11 completed the post survey. Their responses to the questions about Second Life as a CME platform were very positive.  The data, as well as the follow-up emails, all indicate very favorable reactions to the event and found it be a helpful way to fulfill their CME requirements.  What’s more the pre-post test score differentials show that they met the workshop’s learning objectives.

While they consistently rated the SL experience as more superior to other online methods, there was less agreement on the SL experience being superior to face-to-face methods (with six of the subjects feeling neutral or disagreeing).

Dr. Sternthal talking with one of the mock patients near the screen showing her lab results.

Dr. Sternthal talking with one of the mock patients near the screen showing her lab results.

Many of the participants noted the convenience of an online seminar as one of the most important advantages – no travel required and able to participate from the comfort of their own homes.  Since other online methods of instruction also offer this convenience, to justify the expense of a virtual world course, there have to be additional, unique advantages offered by the virtual world. In this pilot, I think there were  two important virtual world advantages:  the added sense of presence afforded by a representative avatar and the added real-life application provided by mock-patients. Judging by the participant comments, the injected realism of mock patients was effective and added to the seminar’s impact. These methods required considerable dexterity on the part of Dr. Sternthal.  The speaker must maintain fidelity to their planned script but, at the same time, pay attention to the back chat, adjust comments to answer participant questions, role play with the mock patient, and roll with whatever technical limitations, unexpected results, or problems arise.

From my perspective, I dub this pilot experience a definite success.  There is still much to be learned and many ways I can imagine enhancing the experience and the efficiency, but the results show that virtual worlds offer tremendous opportunity to provide a space for constructivist learning at its best and to enhance learning outcomes beyond that provided by traditionally rendered online courses.

A February 2010 update: The Journal of Medical Internet Research has just published our article on the pilot and John Wiecha just presented our work at the Medicine 2.0 Conference in Toronto, Canada.



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8 responses to “Second Life Continuing Medical Education Pilot

  1. Marjorie

    Wow, Robin! This is terrific. Great depth & excellent insights. Your point about “play” at the end struck me in particular. Thanks for sharing this.

  2. rheyden

    Thanks, Marjorie! nice to “see” you here 🙂

  3. Simon Fowler

    This is a very interesting case, Robin. Thanks for sharing the story and your insights.

    With the participants who needed a lot of help initially, to what degree do you think they’re now generally more comfortable with technology? In other words, if they were presented with another new technology to use for learning, do you think they would require the same amount of training & support or would they adapt/adopt more quickly?

    • rheyden

      Great question, Simon. I’m not sure but my guess would be ease with the next technology would depend on whether or not they continued to practice with the first environment, successfully transfering the skills to long-term memory.

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