Tag Archives: Virtual Worlds

The Radix Endeavor

The Radix Endeavor

The Radix Endeavor

There’s a new MMO in town – brought to us by the MIT Education Arcade, financed by the Bill & Melinda Gates Foundation, in collaboration with Filament Games. It’s the Radix Endeavor. This massively multiplayer online game (MMO) is designed for STEM learning in middle and high school. I just spent the last hour, on a quest with my avatar character in the Radix world, trying to get a feel for its possibilities.

My Radix character.

My Radix character.

The first thing to notice about the Radix Endeavor is that it’s browser-based. So no messy downloads, no firewall problems, and, from appearances, not a huge bandwidth requirement.  Check out the minimum hardware requirements here.

In order to play the game you create a (free) player account, click the “play game” link on their website and – poof! – you land on the island of Ysola. This is a fictionalized world with made up names for people, plants and animals. There are biological problems to be solved, quests to be taken – all in the service of solving the health problems that seem to have befallen the inhabitants of the island.

The developers offer teacher and student accounts.  I created a teacher account which gives me a dashboard to monitor my students progress in the game.

So let’s start with the good stuff:

  • Great that it’s browser-based in terms of access, but of course, that also means some serious disappointments (see below)
  • The game action is quest-based  (i.e. “use your measuring tool to find a feltspittle flower that is a least 3 tomes high” and “capture a jngspout so we can feed him the feltspittle flower and analyze his excrement”…what middle schooler doesn’t want to hear that?)
  • The world is persistent.  I collected feltspittle flowers, logged off, signed in again, and my inventory persisted and my dialog with the doctor picked up where we left off.
  • The game is designed to align with the Common Core standards in math and Next Generation Science Standards for high school.
  • The teacher portal will aggregate data on the students’ decisions, strategies, and progress so that they can tailor what goes on in the classroom to the students’ needs.

On the not-so-good side:

  • The look of the game feels very young to my eye.  Simple line-drawn structures and characters, not much dimension, shadow or nuance. It feels like a paper-doll-cut-out world and I worry about that in contrast to the rich and sophisticated look of the other MMOs students know.
  • No one else was in the world when I was there so I was only able to have “canned” conversations with bots.  Not very satisfying.
  • Extremely annoying and repetitive background music.  I muted that right away.  No need for that.
  • Navigation is clunky – places you can’t go but you only figure that out when your avatar just won’t move forward (like hitting an invisible wall).  Teleporting from region to region is verrrrry slow.
  • There is a map you can summon but I was longing for the ability to change my camera position and see the whole scene around me – to zoom out.
  • There doesn’t seem to be any way to take artifacts from your work in the world out of the world – that would be a nice touch for students creating blog posts or other artifacts of their learning.
  • Adding to my inventory.

    Adding to my inventory.

    Even though the quests are akin to real world problems (curing a mysterious lung ailment called “polyflux”, I worry about all the fictional names for animals, plants, and diseases.  Just seems a shame to introduce yet another vocabulary when our students already have so much trouble with the existing language of science.

  • There seems to be a system of badges/points you earn on your various quests (good!) but that function wasn’t yet in place in my tour of duty. Despite the fact that I correctly surrendered my feltspittle flower and my jingspout, my points did not go up (wah).
  • I didn’t get too far past my initial three quests, but in the first hour, I felt like I was mostly doing busy work. Going and getting things, placing them in my backpack, bringing them to someone else to “judge” (did I get the right thing?). Not sure how long it would take to get to something meatier, but I would guess that most teenagers would have given up before I did.
  • Teachers will need solid support materials to help them connect the quest structure of Radix to the rest of their plan in a biology course.  I’m sure the developers are planning that but I didn’t find any such materials yet on their site.
The map.

The map.

It’s great to see so much thought and creativity applied to the development of meaningful STEM games. Many of the negatives I point out above are tradeoffs that must (now at least) be surrendered  in exchange for a browser-based virtual world and its important to add that Radix is in beta. I could see tremendous potential for growth here but, right now, it feels a bit rough.

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Learning in a Virtual World: Population Dynamics

Population Control: Past Policies and Future Challenges

The World Health Organization (WHO) and the Geneva Foundation for Medical Education and Research (GFMER) offer courses to healthcare providers around the globe.  Often, their “students” are doctors, nurses, and other practitioners in remote locations with minimal support and limited time.  Consequently, many of their courses are offered online.  Once such course, Sexual Health and Reproductive Health Research is offered each year to over 150 healthcare workers all over the globe, as you can see in this map of their students’ base locations:

Map of GFMER course participants.

In their quest to innovate and offer the best possible learning solutions, Dr. Mario Meraldi, from WHO and Dr. Karim Abawa and Dr. Aldo Campana, from GFMER recently partnered with Dr. John Wiecha, from Boston University Medical School to offer one such course in an online 3D virtual world.  Participants from Ethiopia, Italy, Switzerland, France, Pakistan, Nigeria, India, Kenya, Sudan, Afghanistan, and the U.S. came together as avatars for a learning event on Population Dynamics:  Past Policies and Future Challenges.  Those with spotty internet connections joined the event through a synchronous broadcast delivered via Livestream.

The event was one hour in length and took place on the WHO/BU island in the virtual world of Second Life.  Working with the session’s facilitator, Dr. Marloes Schoonheim (a GFMER demographer), we designed a learning space that led participants along a learning ramp, with stops along the way. Here you see an aerial view of the designed space, followed by a diagram showing the numbered learning stops:

The learning space, showing the ramp which bends around a mountain.

Learning stop map.

Dr. Schoonheim gathered the learners at each stop and talked through visuals or an experience designed to illustrate her particular point. In the following picture set, you first see a graph depicting world population growth estimates between 1950 and 2010, followed by a visualization of thousands of babies’ faces on a rotating cylinder to underscore her point.

World population growth 1950-2010.

A visualization effect for world population growth.

The instructional designers and producers for the session were:  Neil and Robin Heyden, Janalee Redmond, and Liz Dorland. We started with Dr. Schoonheim’s PowerPoint slides, which after some discussion, turned into a storyboard. Brainstorming as a team, we came up with ideas for the visual displays and effects. As we designed this learning space, we kept in mind the principles in the Open University article, Designing for Navigation and Wayfinding in 3D VirtualLearning Spaces, by Shailey Minocha and Christopher Hardy (2011). In their article, the authors make clear that the design of a learning space impacts the processing of information and the learner’s grasp of new concepts. For example, we made the route clear by adding a well-worn dirt path texture to the ramps, as seen here:

A clearly defined path.

Stacked, rotating photo cubes provided a good presenter perch.

Each stop was marked by a large visual (photograph, book cover, map, or graph).  The graphics were all created by designer and Photoshop expert, Kate Motter. Additional visuals were displayed on slowly rotating cubes, stacked at the stop.  In a playful touch, Dr. Schoonheim sat on the stacked cubes, to indicate where the learners’ attention should focus, as she gave her remarks. World maps reinforced the location of each case study. Dr. Schoonheim infused her comments with locational language (for example: “to your left”, “in the next gallery”, and “follow me up the ramp to the world map”) to help direct the avatars.

At the halfway point, we offered a short break with virtual snacks served on a platform, overlooking a stunning vista (complete with waterfall).  The learning ramp, bent around to deposit the participants back to the starting point, where they assembled in an open-air seating arrangement for a question-and-answer session.  The chat was lively with questions coming in from the Livestream audience, as well as the in-world learners.

Snack break, with a view.

With 19 avatars in Second Life and 40 viewers in the Livestream audience (many of whom watched in small groups, clustered around one computer), the event reached a significant audience.  In addition to managing the broadcast, Ariella Furman recorded the session so that others could later, asynchronously, review the session.

In our after-session-review we noted the following opportunities for improvement:

– Time between stops, while feeling like natural transitions to the avatars in Second Life, felt like dead air time to the Livestream audience.  In the future, we should design to fill those gaps, and keep our broadcast audience in mind, as well as the avatars.

– Highly visual elements, like the rotating photo cylinder, take a few minutes to rez for most viewers therefore sufficient time must be accounted for in order to achieve the desired effect.

– Rehearsal time was mandatory.  Our crew conducted three rehearsals – the first was a run through of the content with discussion amongst the team at each point.  The second was a technical rehearsal to test the video, livestream, and simulated effects.  The third was a dress rehearsal, conducted in real-time (without interruption), just as the live event would be.  With each rehearsal, the transitions smoothed and the problems lessened.

Marloes’ avatar.

– The facilitator’s comfort in the virtual world was an essential ingredient.  Though new to online virtual worlds, Dr. Schoonheim quickly took to the medium.  She invested many preparation hours in Second Life, getting used to the navigation and the “feel” of being in an avatar.  The avatar’s look was important to her. Liz Dorland helped her with hair, skin and clothes to match her real world appearance. We also gave her a speaker’s animation effect (pacing and gesturing), and added a notepad into her hand.

– It’s difficult to balance the positive impact of interactivity (fielding questions throughout the session) with the importance of keeping on track and sticking to the alloted time. Participants posed questions during the session which the producers acknowledged and queued up for the final question and answer session (given how impossible it is for the speaker to give their talk and monitor a flowing chat window simultaneously).  Marloes led an engaging discussion session in the last 10 minutes of the event by addressing those saved questions. In hindsight it might have worked well to have a second content expert, a sort of teaching assistant, to type answers to questions as they came up in local chat during the session. If the audience feels their questions are attended to, they will engage further.

All in all, the event went smoothly.  Here are additional photographs and here is an Economist article, on the topic of population dynamics and fertility rates that Marloes recommends for further information. Be sure to check back in a few weeks, when I will post Here is a montage video of the event, currently being created by Ariella Furman.

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11 Lessons Learned Conducting Training Events in Virtual Worlds

Over the last three years I’ve planned, designed, and orchestrated a dozen learning events in the virtual world of Second Life.  I’ve been fortunate enough to work with extremely experienced and talented programmers, producers, content experts, scripters, and machinima artists from whom I have learned volumes about planning and staging successful learning events.  As I reflect on these experiences, I’ve drawn up a list of the top eleven (ten seemed so predictable…) most important lessons I’ve learned (as you might imagine, this list has a well-matched, ancestral double called,  “the most egregious mistakes I have made”).

1.    Train for a just-enough (and no more).

As with most virtual worlds, Second Life is chock-a-block full of intriguing possibilities.  You can fly, build, photograph, gesture, control the time of day!  In addition to all that, the interface is rich/complex and there is always more than one-way to accomplish any task.  It’s tempting, when introducing someone to a virtual world, to show them everything – or to show them just oonnnne more really cool skill as it might be the tipping point to infuse them with the enthusiasm you have for the possibilities.  However, I have finally learned to resist that temptation.  On their own, learners will perform a calculation – if the preparation for the learning event outstrips its value to them, they will deem it unsuccessful.  So it is in everyone’s best interest to keep the skills training to the barest minimum.  Not only that, most people can’t absorb tons of information in one sitting; I know that I didn’t – why should I expect that others will? Our pre-event training regimes include only those skills the learners will need in order to participate in the event and no more.

Learner Preparation < Value of Event

2.    Establish the learning goals upfront and use them as a filter.

In the early planning stages, work with your content experts and the program sponsor to establish a short and well-defined list of learning goals.  What is it that you want your learners to exit the program knowing?  That list will serve the team well in many ways. It will drive decisions about how to spend money (will that fun simulation help you meet the learning goals?), clarify how to allocate time on the agenda, and serve as a filter when the inevitable “mission creep” begins.

3.    Make sure your back up plan has a back up plan.

The old saying really is true, if it can go wrong, it will. I have seen so many “unexpected” problems crop up in every event I’ve been a part of – sound problems, connectivity hassles, access issues, electrical problems, region shut-downs, you name it.  It seems obvious, but the very best way to avoid these inevitable glitches ruining your event is to anticipate them and have a plan in place to address each one.  For example, it’s good to have phone numbers and/or skype IDs for all learner participants (if they have sound problems, you can always skype them in).

4.    The power of two facilitators.

Our learning events always include a content expert who has worked with us to develop the session’s content and then, typically, serve the lecturer/facilitator role.  We now recommend two facilitators.  Hopefully you can line up colleagues, who are used to working together, but it can work equally well with experts who you bring together for the cause.  Why two?  It’s helpful for the learner to hear two perspectives, two voices and it improves the event’s flow to hand-off one to the other.  Very importantly, while one is speaking/leading, the other can monitor the local chat, provide feedback, and address content questions that arise.  If the instructional design calls for small group work, then you instantly have two small group leaders (voila!). They also serve as back-ups for each other (if one is having sound problems, the other can pinch hit).

5.    Measure twice, cut once.

That age-old seamstress mantra totally applies here. There is just no substitute for rehearsals where you can go through your program to work out all the kinks. Run your facilitators, producers, and other program staff through at least one full rehearsal, preferably two.  If the calendar doesn’t permit time for two, full rehearsals, then opt for a “blocking” rehearsal.  That is, rehearse all the transitions, without the intervening content (when people come on, go off, all the movements and transitions).

6.    Answer the question, “why are we doing this in a virtual world?” before it gets asked.

No doubt about it, conducting learning events in virtual worlds (any virtual world) is a lot of work – for the sponsor, the producers, and for the learners.  So it only makes sense to use virtual world technology if you are making use of its unique affordances.  That is, if you are doing things that can only be done in a virtual world.  If you bring your learners into a beautiful virtual environment and then talk at them with a PowerPoint deck for an hour, everyone will leave feeling cheated.  Instead, make it work for you. Devise a simulation, do some role plays, leverage some whimsy, do some collaborative building, defy the laws of physics – make it clear why you have all gone to the trouble to be there.

7.    Experienced technical support producers are essential.

In addition to your upfront investment in learner training, participants will need technical support on the day of the event. Count on it.  The presence of experienced, calm, and professional technical support (we call them “producers”) is a must.  Did I say “calm”?  Let me say it again.  Calm. My preferred ratio is one producer for every eight new learners. Make sure you have a private back-chat channel open (IM, group chat, or Skype) for the producers to strategize, share, and hand-off among themselves.  Consider asking the learners to come 15-20 minutes early in order to troubleshoot any pesky technical issues before the event gets underway (not all will be able to, but those who do will be taken care of, freeing your producers to focus on the just-on-time or late arrivals).  Have your producers wear a “Ask Me for Tech Help” label on their avatar.

8.    Consider venue design carefully.

Our open air event venue

After playing with a number of event location design options, I’ve gravitated to the simplest possible.  Our events typically have outdoor seating (no doorways to navigate, no walls to bump into, and no ceilings to hinder the view) with very large and simple visuals (to avoid view problems).  I tend toward natural looking scenes (a few trees, open sky, and a blue-water view) with very little visual clutter.  But, of course, you also want the design to reflect and support the content of your event. Design your seating with automatic sit (upon clicking) and encourage all participants to be seated as soon as they arrive (which helps to calm things down).  Landscape simplicity also helps to keep the prim count low to reduce the processing load.

9.    Document everything as you go.

I am continually amazed by how quickly I forget useful things. Who attended?  What was the plan?  How much did we rehearse?  How long did it take?  What happened in local chat?  Keep a record of it all, including a blog post or two (like this one!) to sum up your major take-home lessons.  You’ll be glad you did when the planning for the next event begins.

10.  Don’t forget to assess.

It is important to find a way to build evaluation into your learning plan. Often, we get so caught up in the work of producing the event, we forget to gather feedback from the learners when it’s over.  Even if it’s just a short questionnaire, provided as a link, at the end of the session, find a way for your learners to tell you honestly what worked (and didn’t work) for them.  You might also consider gathering similar feedback from the facilitators and producers. They often catch glitches that you might miss.

11. Find a way to make it fun.

One of the things we all love about virtual worlds is that touch of fantasy about them.  Even though it may be important for your event to project a serious and professional tone, your learners are sure to enjoy at least one touch of whimsy somewhere in the program (we typically do this on a break or at the end).  It could be something as simple as some virtual food and drink, served up to your guests.  Maybe an automatic dance floor for everyone to trip the light fantastic?  Fireworks are always fun.  A simple t-shirt emblazoned with your company or program logo, given to each avatar at the end of the session can be a surprising hit.

Chimera Cosmos puts on a fireworks display for our group session.

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The Value of Third Person Perspective

The default, third-person perspective in Second Life

As writers we know that third person perspective is a form of storytelling in which the narrator relates all the action in the form of another person, making use of the pronouns “he” and “she” (as in, “She boarded the ship bound for Venice.”).  This produces a very different effect from telling the story using a first person voice (“I will tell you the story of my trip to Venice.”).  Writers often feel more comfortable storytelling from the first person point of view, but that third person perspective actually gives the writer more headroom, more freedom to spin the yarn in unusual ways.

I’ve been thinking more about the third-person perspective, as it relates to virtual worlds. The photo you see above is the typical viewer perspective in virtual worlds, like Open Sim, Second Life, Jibe, Kitely, Wonderland, etc.  It’s as if you are floating just behind your avatar, looking over his or her shoulder.  Seeing what your avatar sees in front of them, but including your avatar in the frame of reference, as a constant reminder of their presence.  You are not them, as you are in a “first person” perspective virtual experience (like first-person shooter games – Call of Duty, Halo, etc). This third person perspective makes it clear that there is another – an avatar, an alternate you.

A recent blog post by Christopher Hutchison (Khosian Fisher in SL) got me thinking more about this.  In his post, Hutchison (who is a computer science lecturer in the UK) talks about the notion of imaginary friends.  That intriguing and mysterious element of childhood, when we manufacture imaginary friends through which we play out the dramas of our young minds.  Psychologists have long pointed to this behavior as normative and healthy – a way for children to work out their fears, anxieties, as well as their joys. He references the work of Marjorie Taylor, professor at University of Oregon and author of the book, Imaginary Companions and the Children Who Create Them.  Taylor’s book explains that these imaginary friends allow children to explore relationships, anticipate the consequences of behavior, and role-play various emotional encounters in life.  Children who have imaginary friends (and it’s more common than not) tend to be less shy and more able to see things from anothers’ perspective.

So it’s not a huge leap (and Chris makes it beautifully) to think of these avatars we create in virtual worlds as adult versions of these “imaginary friends”.  When we interact with others in a virtual setting, we are offered the anonymity and comfort of working out conversations, navigating relationships, and grappling with new ideas.  As if we are rehearsing all of that for real life.  The space may well be virtual but the rehearsal is very real, and the lessons learned from it apply directly.

When I first began exploring virtual worlds about three years ago, I remember being immediately taken with the way that colleagues, more experienced than me, referred to their avatar. It was always in the third person and always in a way that playfully implied how very real that person was to them. For example, a colleague who’s avatar’s name is “Flora” would say to me, over the phone, “Flora will meet you there at 3:00.” She would never say, “I’ll meet you in the virtual world at 3:00”. There is also the endearing cultural phenomenon of using local chat to write (in italic) an action or a thought that the real person attributes to their avatar.  For example:

Spiral:  Hi, Flora!  Good to see you.

Flora:  Hey there.  How are you?

Spiral:  Fine, thanks.  How long have you been here?

Flora:  looks knowingly at her watch

Flora:  Since 3:00, but I had lots to catch up on, so that’s ok.

The italic phrases are always playful.  A sort of thought-bubble – a wink and a nudge.  A comment that, in this case, Flora is making, but letting you in on the secret.  And this habit has always carried the nuance, for me, of the avatar’s puppeteer coming through and showing themselves, reminding us of the third person perspective. I love this cultural artifact of virtual worlds.

Vishnu and his ten avatars

It’s worthwhile to remember the origins of the word “avatar”.  It derives from the Sanskrit word, “avatara”, meaning “descent”, as in a deity descending from heaven to Earth. In English the word has come to mean an incarnation, a representation, a manifestation. The term is often associated with Vishnu and the varying list of avatars in Hindu scripture. It seems to be less about incarnation of a deity (in the Christian sense) and more about manifestations of the divine in human life and the natural world.  It’s interesting to ponder the many ways that these interactions our avatars have (with us, as their puppeteers) manifest themselves in our regular lives…how are they influencing us?

My musings about the power of the third person perspective came to a head this week with this Science Daily article, The Third Person Perspective is Helpful in Meeting Goals.  The article’s authors, psychologists at Cornell University, investigated the impact of referring to and reflecting on events in your past in the third person versus the first person.  In the article they conclude that reflecting in the third person helps give valuable perspective and can actually help accentuate changes made, over similar reflections made in the first person.  To quote one of the investigators, Thomas Gilovich, directly:

“We have found that perspective can influence your interpretation of past events. In a situation in which change is likely, we find that observing yourself as a third person — looking at yourself from an outside observer’s perspective — can help accentuate the changes you’ve made more than using a first-person perspective.”

I can draw a clear line of sight between this observation and the experience we’ve had working with various learners in the virtual world. Take, for instance, working with diabetes patients in the Women in Control project (Co-PIs John Wiehca and Milagros Rosal).  Women in Control (WIC) is an NIH-funded study to measure health behavior changes between two groups – those who participate in a health behaviors intervention in face-to-face sessions conducted in the real world, and those who engage in the same intervention in the virtual world.  I’ve blogged about this work in earlier posts here and here.

As we’ve worked with the patients in this study, I’ve taken particular note of the way they refer to their avatars.  The subjects get quite chummy with their virtual representations, right from the beginning, and they consistently refer to their avatars in the third person. Great concern is expressed over their avatar’s appearance (clothes, shoes, hair, jewelry as well as their size and shape).  They consistently ask where the avatar “goes” after they quit the virtual world and express a desire to put her “in a safe place”.  When they first navigate their avatar around the virtual space they’ll say things like, “Oh, no!!  She went in the water and now she’s all wet!”  or “I can’t get her to do what I want her to do.”  or   “I want to make her fly!”.  They consistently refer to this virtual being they’ve just met in the third person – and that referencing continues throughout the eight-week intervention.  The WIC team is still hard at work on this project, but stay tuned for the results.

Another example is a project with family practice physicians, learning patient communication techniques in a virtual setting.  In this case, the doctors, present as avatars, role play interactions with standardized patients (also avatars).  The third person perspective here, I think, gives them a certain anonymity; a distance, while still being very present, that allows them to take greater risks.  In a profession that demands consistently upheld expertise, it must indeed feel quite risky to be a beginner and make mistakes in front of your peers.  I suspect that the third person perspective of the avatar offers them a safe remove to be a novice and allow for a natural, stumbling learning curve.

In both of these projects, I can see the inherent value in the third person perspective awarded by the virtual world.  A unique affordance, over and above the more obvious advantages of expense, travel, and ease of access. For me, it gives a whole new meaning to the phrase, “it depends on your perspective.”

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Summing It Up With Video

In earlier posts (here and here), I’ve written about the continuinng medical education (CME) programs we’ve been conducting in the virtual world of Second Life. The most recent of these – Smoking Cessation with Motivational Interviewing – was a three-event series (sponsored by CS2day) that ran in June, 2011.  Working with the enormously talented machinima artist, Ariella Furman, from Framed in 3D, we put together a summary video of the program:

I love the way this video captures the feeling of the workshop – the presence you feel from the avatars listening, the tentativeness of their attempts at role-play (and how hard that is), the sense of the physical space where the events took place, and the dynamism in the facilitator’s explanations of motivational interviewing technique.  Considering the fact that this program ran for six hours in real time, you get a pretty darned good take on it in three minutes.

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It’s a Wrap!

On the Boston Medical Center Island in Second Life

Last night concluded our three-part Motivational Interviewing for Smoking Cessation CME Workshop for practicing physicians in the virtual world.  And we did it in spite of hurricanes (three of our participating docs volunteered to help out in Joplin, MO) and tornadoes (breaking weather here in New England, as the third event got under way). You can read about the first two events of this continuing medical education series here and here.

Despite the biblical weather, we all arrived in Second Life at the appointed hour with surprisingly few technical glitches.  No doubt the able problem solving skills of Chimera Cosmos and Jenn Forager, during the previous two workshops, had well prepared everyone to triage all those handy steps themselves!

Dr. Suzanne Mitchell and Dr. Jay Lee

But before our participating healthcare professionals arrived at this third event, they had a homework assignment.  We posted machinima (videos shot in Second Life, created by Ariella Furman) of their event #2 role plays onto a community blog site which they were asked to visit, watch their own video, comment, and then comment on the video of at least one other participant.  Our instructors, Suzanne Mitchell and Jay Lee, also posted coaching comments on each video entry.  There was something powerful about watching those role-plays collectively.  Patterns quickly emerged (oh, the power of video!) and it was amazing to see the variation in approach with just a few patient scenarios.

* The HCPs were very, very good at expressing empathy – reflecting back to the patient how hard it is to quit smoking, how frustrating it can be.

* Less in evidence was the knack of developing discrepancy with the patients, a key motivational interviewing skill (e.g. “On the one hand smoking is a very social thing for you, but on the other hand you are concerned about your breathlessness and coughing”).

* Rather, they relied heavily on information giving (e.g. “Let me tell you about treatment options…”)

* Repeatedly you hear the HCP’s use of the pronoun “we” when talking about what the patient will do (e.g. “WE’RE going to need to get that blood pressure down”  or “What WE should do…”).  This phrasing side-steps the patient self-efficacy that underlies MI.

So event #3 started with recap of those role play videos and a conversation – what did you learn from watching your own video?  What patterns did you see?  I was particularly taken with one HCP who said that she was surprised to discover the mismatch between her actual role-play and what happened in her own head.  After that, Jay Lee lead us through some helpful treatment, quit plan, and pharmacological information and then it was up to the role-playing platforms to try it all again.

Role playing up on the small group platform

This time we stuck with the same cases from event #2, starting with the assumption that the patient was returning, after hearing all the medical information they needed, and the object of the role-play was specifically to discuss their smoking.  Jay and Suzanne gave each HCP their opening line with the patient.  For instance, “Glad you’ve got your blood pressure under control, Bill, that’s great.  I remember the last time we talked about your smoking, is it alright if we continue that conversation today?”  This way each role-play focused like a laser beam on exploring and excavating the reasons why this patient smokes and what they want to do about it.  You could almost hear the mental wheels turning.

There was an observable shift in the patterns observed during event #2 and some dramatic changes in approach.  During the role play, the audience members typed their thoughts and suggestions in local chat and the coaches gave advice and support.  “Nice job showing empathy…” , “Try reflecting back what the patient is telling you…”  “Point out the discrepancy in what she is saying…”   “Be careful of making comparisons with other patients.”   After each role play, the coach asked the HCP how they thought it went and asked the patient how it felt to them.

Only 8 minutes in length, it was amazing to see how much progress could be made on the smoking issue in each role play!  I was struck by two things:  1) how much could be learned from just watching the other HCPs doing their role play and 2) how very difficult it is to use motivational interviewing well.  As Cynthia Kear, this project’s leader, put it so well, “like a lot of complex things in life – it sounds simple on the surface, but when you get in there to actually do it, it’s more difficult than you imagined”.

A little Second Life dancing

After the hard work of role-playing, we all teleported down to the ground level, chatting about the experience and – what else? – dancing.  It was great to hear everyone’s pleasure over something so simple and fun.

All in all, a very succesful workshop series. If you’d like to read more, you can read a from-the-event, live Twitter stream on CS2Day’s Twitter feed.  The program’s sponsor CS2Day, with the California Academy of Family Physicians as the lead partner,  should be very proud of their visionary leadership as they explore unchartered territory in continuing medical education.

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Smoking Cessation Medical Training in Second Life

The first of Cease Smoking Today (CS2Day)’s three-event, Smoking Cessation Continuing Medical Education (CME) workshop program took place on May 18th, 2011.  But the healthcare providers attending this CME workshop didn’t have to drive or get on a plane in order to obtain their CME credit. From the comfort of their offices or living room couches, they fired up their computers and joined the workshop in the virtual world of Second Life.

The program consists of three, two-hour, successive events (May 18, 25, and June 1) where participants attend and interact as avatars in this immersive, 3D virtual world.  Intended for healthcare professionals (family medicine doctors, nurse practitioners, and residents), this CME program focuses on the technique of motivational interviewing to help HCPs help their patients to stop smoking.

At this first kick-off event, participants were given an overview of the Motivational Interviewing (MI) technique from the workshop’s facilitators, Dr. Jay Lee and Dr. Suzanne Mitchell.  There were 34 attendees at the session coming into the virtual world from all over the United States (with one attendee from Indonesia, where it was 5:00 a.m.!).  The overview focused on the MI skills of rolling with resistance, expressing empathy, avoiding argumentation, developing discrepancy, and supporting self efficacy.  The session slides are archived here.

The program facilitators enlivened their talk with a few intriguing, virtual world simulated effects.  In this photo you can see Jay Lee demonstrating how many cigarettes a smoker with a pack-a-day habit would smoke in one year.

How many cigarettes would you smoke in a year with a pack-a-day habit?

And in this photo you can see Suzanne Mitchell demonstrating the significance and impact of issue and relational resistance.  These unique effects demonstrate the high visual impact offered by the virtual world  – seeing what you might only imagine in your mind’s eye as a metaphor or an explanation.

The distinction between "issue" resistance and "relationship" resistance.

In addition to the special effects, Suzanne and Jay used the local chat function to full advantage. Throughout their talk, they posed questions to the healthcare providers, asking them to type their answers in local chat. The HCPs quickly caught onto the value of the local chat stream, not only giving feedback to the speakers but also commenting on each other’s thoughts and opinions and connecting with each other.

The virtual world offers an interesting alternative to standard face-to-face continuing medical education.  Virtual world settings provide constructivist and connective approaches to learning where participants can interact, simulate, role-play, and reflect with their colleagues and instructors in a cooperative and context-rich environment from the comfort of their own homes.

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Motivational Interviewing for Smoking Cessation CME: Event One

"Opening Night" Event #1 of the CS2Day CME Program

Last night was the first of our three-event, Smoking Cessation Continuing Medical Education (CME) workshop program in the virtual world of Second Life.  The program is sponsored by Cease Smoking Today (CS2Day), an educational collaborative made up of nine partner organizations. Intended for healthcare professionals (family medicine doctors, nurse practitioners, etc), this CME program focuses on the technique of motivational interviewing to help HCPs help their patients to stop smoking.

The in-world events, which began last night, will take place on three successive Wednesday evenings (May 18, 25, and June 1).  At last night’s kick-off event, our participants were given an overview of the Motivational Interviewing (MI) technique from the workshop’s facilitators, Dr. Jay Lee and Dr. Suzanne Mitchell.  There were 34 attendees at the session coming into the virtual world from all over the United States (with one attendee from Indonesia, where it was 5:00 a.m.!).  The overview focused on the MI skills of rolling with resistance, expressing empathy, avoiding argumentation, developing discrepancy, and supporting self efficacy.  You can view the session slides here.

How many cigarettes in a year? (effect by Electric Pixels)

Our facilitators enlivened their talk with a few intriguing, virtual world special effects.  In this photo you can see Jay Lee demonstrating how many cigarettes a smoker with a pack-a-day habit would smoke in one year.

Issue and relational resistance. (effect by Mel Primswitch)

And in this photo you can see Suzanne Mitchell demonstrating the significance and impact of issue and relational resistance.  These unique effects demonstrate the high visual impact offered by the virtual world  – seeing what you might only imagine in your mind’s eye as a metaphor or an explanation.

In addition to the special effects, Suzanne and Jay used the local chat function to full advantage. Throughout their talk, they posed questions to the audience, asking them to type their answers in local chat. The HCPs quickly caught onto the value of the local chat stream, not only giving feedback to the speakers but commenting on each other’s thoughts and opinions.

Here is a typical local-chat exchange, excerpted from the transcript, in response to Suzanne giving them a patient scenario (smoking patient with high blood pressure who feels good and doesn’t think their smoking is a problem) and asking them for their thoughts – what questions would they ask this patient:

[17:34] Bronxdoc: It great that you feel good. Do you have any concerns about smoking?

[17:34] rwmorrowmd: what’s your favorite part of smoking?

[17:34] Abigail Mhia: Sounds like your health has been good

[17:34] Mona Willful: well that’s great that you feel fine, but what are your concerns about smoking

[17:35] jbrow0: you have not felt health effects from your smoking yet?

[17:35] Mar Scientist: I undersatnd you feel fine, but do you have … shortness of breath? does your family complain about your smoking?

[17:35] Boggsly: where do you see yourself in 5 years in regard to smoking?

[17:35] Mona Willful: It seems like he’s scared of something and not telling me, I want to dig into that

[17:35] jbrow0: just restating; not meant in ominouis tone

[17:36] jbrow0: you feel ok; no problems now

[17:39] Mona Willful: I see that this pt is very scared, and is in ambivalence. This is good for change

[17:40] rwmorrowmd: yes

[17:41] ttran72: what have you tried….

[17:41] RadhaLew: So on one hand you see some value in quitting but it sounds like you have a lot of stress in your life right now

[17:41] Bronxdoc: sounds like you would like to quit smoking but you feel that there are benefits as well

[17:41] rwmorrowmd: yes, it’s hard

[17:41] Boggsly: how important is it for you to try to quit right now?

[17:41] Mar Scientist: beating themselves up because they’ve not been successful;

[17:41] ttran72: maybe we can look at those failures and turn them into success by working together

[17:41] familydocwonk: you seem stressed about quitting smoking yet feel that smoking helps relieve your stress

[17:41] jbrow0: quitting smoking is important to you, but you are worried it might increase your stress levels

[17:41] Mona Willful: so you have tried quitting. What are some things you’ve tried? Are there any other things to lower your stress?

[17:41] Abigail Mhia: so on one hand, you feel smoking helps manage stress, but on the other, you see that quitting smoking is something you would like to do.

[17:44] Mona Willful: empathy, rolling with some resistance, support is definitely there

As you can see, the local chat is a great way to get a bead on audience-thinking, find out what they know, and allow everyone to “hear” each other.  It also becomes a permanent record of the exchange – and there was no problem getting these HCPs to contribute!

Although the overall event went very smoothly we, of course, experienced some technical problems.  For the most part, our attendees were brand new to Second Life and had no formal training in advance of the event. Though we had set up a tutorial web site for them, as busy professionals, most of them did not have time to get up to speed in advance. Anticipating this, we had the absolute best in the business on hand to triage and solve anyone’s challenges – Janalee Redmond (SL=Jennette Forager) and Liz Dorland (SL=Chimera Cosmos). And here, sporting our spiffy CS2Day team t-shirts is our fearless crew:

Left to right: Chimera Cosmos, Spiral Theas, Jenn Forager, Cynthia Kear, and Neil Lastchance.

Here were the most commonly encountered technical issues:

– Basic/Advanced Mode.  The latest version of the SL viewer has a toggle option for “Basic” and “Advanced” modes on the log-in screen.  The Basic mode, which gives limited functionality, is the default.  We needed our avatars in Advanced  mode so that they could hear, control the volume, change their view, etc.  Our most commonly encountered technical issue was “I can’t hear.” and it was typically solved by asking them to re-log and change to “Advanced” mode.

– Invisible Avatar.  We had one participant who could not get his avatar to completely appear.  He was showing up as hair and a pair of shoes only. It was comical to see, but I’m sure, not very fun for him.  Turns out it was the “two monitor problem”.  Once we had him shut down his second monitor, he rezzed in full form.

– Getting messages to new avatars.  As the session began and participant’s needed to solve technical issues (sound problems, view problems) it was difficult to get them to transfer the conversation around their problem from local chat to the less-intrusive IM (instant message)/private chat.  In hindsight, we should have done a mini tutorial on how to send and respond to IMs at the beginning of the event.

In addition to those technical matters, there were a few instructional design items that worked well, in addition to some changes that, in hindsight, we’d make to the instructional design:

– Alter the Landing Point.  All participants were given a SLurl to a landing point just behind the main venue.  We had thought that this would be an unobtrusive point to first appear and had a greeter stationed there to meet the HCPs as they arrived and guide them to the main stage.  Unfortunately, many of them took off running or flying as soon as they arrived.  Not knowing about the map function, they just headed off in any old direction, seeking out their colleagues.  Our poor greeter had to run laps to keep up with them, get their attention and direct them to the location.  It might have been better to position the landing point right near the seating area.

– Instructional Time.  Knowing that our participants were all busy professionals and most likely would not have the time to get up to speed on Second Life, we should have taken a little time at the front-end of the session to show them a few basics.

– Second Life Etiquette.  We spent a bit of time at start of the session, reviewing “SL-etiquette” (try to resist playing with the gestures during the talk, encourage them to use local chat to give feedback and comments) but we could have gone into more detail on this (maybe with some helpful visuals?).

– Technical Help by Color Group.  We divided the participants into two groups (red and blue) and indicated their group membership with color-coded signs.  Jenn and Chimera were each assigned to a group so that they were only (ha!) responsible for the technical issues in that group.  This streamlined the technical support and each HCP knew who to go to for help.

Red and blue signs indicated group assignments

It was a terrific event – great job on the part of the presenters, fulsome participation on the part of all the HCPs, and heroic efforts on the part of the technical crew.  Huzzah!!  And now, onto events 2 and 3 where the HCPs will do role-plays (wth standardized patients) which the amazing Ariella Furman and her crew will video record for evaluation and comment.  Can’t wait to see those!

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Getting Ready for Smoking Cessation CME Program in Second Life

We’re almost ready.  Our Motivational Interviewing for Smoking Cessation Continuing Medical Educationn (CME) program is about to begin.  And what a mouthful of a title that is.  But each word of the title is significant.  The main goal of this workshop program is to help healthcare providers (HCPs) help their patients to stop smoking.  The participants will use motivational interviewing to do that.  And the program provides continuing medical education, for which the attendees will earn AMA PRA Category 1 or AAFP prescribed CME credit. And there is no charge for participation.

The program, sponsored by the CS2Day collaborative, consists of three consecutive in-world events (May 18, May 25, and June 1), two hours each, conducted in the virtual world of Second Life.  Here’s a photo of the event venue:

The Second Life CME event venue

There will be 25 healthcare professionals (nurse practitioners, family practice doctors, and residents) in attendance, along with our team (10 of us).  And here’s the overall curriculum plan for the three events:

CME Instructional Design

As you can see, role-play is a critical program element.  Participating HCPS will have roughly three hours of role play practice, with standardized patients, on a variety of patient cases.  This is a solid application of virtual world technology – a chance to try it out, in a low-stakes setting, where everyone can enjoy the anonymity of role-playing as an avatar. Practice makes perfect, afterall.

But why do this in an online virtual world instead of a webinar?  Virtual worlds give the participants an added feeling of presence – of being there.  We hope that this immersive quality will enhance the effectiveness of the program.

The role play sessions will be preceded by information giving sessions and model interviews, with our two content experts:  Jay Lee (MD, MPH, Director of Health Policy, Long Beach Memorial Family Medicine Residence Program) and Suzanne Mitchell (MD, MS Assistant Professor of Family Medicine at Boston University Medical School).

In between the second and third events, the participants be assigned homework.  They will visit a blog site where videos of their in-world role plays will be posted for review.  They will be asked to review (and comment upon) their own video and the videos of two other participants.  This sort of intentional, thoughtful scrutiny and assessment of their role plays will lead to a fuller and more nuanced understanding of the delicate dance that is motivational interviewing.

Our program includes a companion research portion.  Volunteers HCPs are participating in “pre” and “post” patient/doctor interviews, conducted and recorded via Skype, with a standardized patient.  The difference in their MI-effectiveness (from before the 3-event program to after) will be measured.  Stay tuned for results and details!

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Reflections on Learning in Second Life

Our working Second Life working space

Last week we conducted a pilot Second Life training with two “test” subjects for our forthcoming health behaviors study, to be conducted in the virtual world of Second Life.  I’ve blogged about this project in an earlier post.  In a nutshell, this is an NIH-funded health behaviors study with African-American women who have uncontrolled diabetes type 2. The project team has finalized the curriculum, set out a plan for subject recruitment and secured the IRB approval.  My part of the project is everything to do with the subject cohort who will experience the program in Second Life.  To that end, in anticipation of the program’s start in May, we have built out the Second Life space (shown above), trained all of the educators, designed Second Life activities, and designed an SL orientation for the subjects.  It was that orientation that we tested last week.

It is unlikely that any of this program’s subjects will have virtual world experience.  In fact, for the most part, our subjects will not have all that much computer experience.  So we will start with

Spiral Theas, my avatar

the basics.  Their orientation consists of two, two-hour in-person sessions. The first one is an orientation to the laptops and the wireless modem they will use for the program (Macbook laptops and Verizon USB modem devices).  At the conclusion of that first session, I take them into Second Life in what I’m thinking of as a passive, “first-look” view.  I projected my computer onto the room’s media screen, dimmed the lights, and encouraged them to just sit back and enjoy.  I logged into SL and introduced them to Spiral Theas, my avatar.  She waved.  They gasped.

Then I walked around the island, showed them how she could turn right and left, sit, dance, and even fly.  Another gasp.  Then I teleported her to Paris and cammed back to take in the full height and majesty of the Eiffel Tower.  Another gasp.  By this time our test subjects were laughing, joking, asking questions.  “When can we go in?”  “What will my avatar look like”, “Can you climb up in that Eiffel Tower?”  “Are those other people speaking French??!”

We left them there – with lots of questions and anticipation. The next two-hour session, held three days later, was going to be all about Second Life.  They came in, hooked up their laptops, and fired them up.  Without too much trouble, they all got in-world and met their avatars (that we’d prepared for them in advance).  They walked, ran, danced, and sat down.  We went over how to chat, how to speak (fiddled with headsets).  We opened the map (“oooh, it’s like looking down at the world from a plane!”).  We opened their inventory (“where are my clothes?”).  We teleported to another location.

It all went so much more smoothly than we thought it would.  They were excited, interested, and not at all intimidated by the interface or the complexity. There were some confounding gaps in their computer knowledge that tripped me up. Here’s one that took us by surprise:  When we were using local chat to send messages to each other, one of the subject’s messages appeared with no spaces between the words.  She asked me how did I get the spaces between the words and I explained that you just hit the space bar when you finished typing a word in order to advance one blank space and type the next word.  “Where’s the space bar?”.

Another had to do with physical orientation to the space.  I had thought that a projection of my laptop to the front of the room would help them – if they got lost as to what to do, they could look up on the big screen and I could demonstrate.  Instead, they kept referring to the big screen over their own, smaller screen and getting very confused about their “view”.  After a few minutes of this confusion, I disconnected my laptop.  They were then able to focus on their own screens and seemed relieved.  Less to manage.

The navigational task that they found the most challenging were (not surprisingly) controlling their camera view.  We made a program decision to not have a mouse with the computers and rely instead on the track pad.  We figured that since these subjects did not have much in the way of computer experience, learning to use a mouse would be just as much of a task as learning to use a track pad and then we’d have one less appliance to worry about.  The track pad is a bit tricky (one finger or two?  swipe or drag?) but the element that caught me by surprise was that one of the subjects had longish fingernails and it was much harder for her to use because of them.

By far and away, my favorite quote of the session from one of the subjects was, “Well, I can’t dance in real life, but I can dance in Second Life!”

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