Medical students learn over distance using virtual reality simulation.

INTRODUCTION: This article presents the results of a demonstration project that was designed with the goal to determine the feasibility and acceptability of medical students in using distance technology and virtual reality (VR) simulation within a problem-based learning (PBL). METHODS: This pilot project involved students from the Universities of New Mexico and Hawaii and compared (1) control groups consisting of medical students in a tutor-guided PBL session using a text-based case, (2) distance groups using the same text-based case but interacting over distance from multiple sites, (3) groups using a VR simulation scenario integrated into the case without interaction over distance, and (4) combination groups interacting over distance from multiple sites with integration of a VR simulation scenario. RESULTS: The study results suggest that it is possible to successfully conduct a PBL tutorial with medical students from two institutions with the integration VR and distributed distance interaction in combination or independently. The addition of these modalities did not interfere with learning dynamics when compared with traditional tutorial sessions. CONCLUSIONS: These findings suggest the feasibility and acceptability by students in the use of VR simulation integrated into a PBL learning session, as well as multipoint distance technologies that allowed interaction between students and tutors in different locations. The authors believe that these modalities can be applied where students and tutors from different institutions are in separate locations and can be used to support interactive experiential learning in a distributed network or on site and suggest areas for additional research.

Chronic ethanol exposure increases the association of hippocampal mu-opioid receptors with G-protein receptor kinase 2.

Opioid receptors (ORs) have been shown to have a significant role in the central nervous system (CNS) effects of chronic ethanol consumption. The OR antagonist, naltrexone, is used clinically to reduce continued intake. We previously observed that chronic ethanol consumption, by adult male Sprague-Dawley rats, induced a reduction in functional coupling of mu- and delta-ORs to G-proteins in rat CNS regions, including the hippocampus. G-protein receptor kinase (GRK) 2 phosphorylates G-protein coupled receptors, including ORs, after agonist binding, as part of normal regulation and desensitization. We tested the hypothesis that chronic ethanol exposure affects the association of the GRK2 with the mu-OR. Co-immunoprecipitation methods were used to determine if mu-OR association with GRK2 is elevated in the hippocampus after chronic ethanol, when compared to controls. Hippocampal homogenates from chronic ethanol and pair-fed control rats were treated with affinity-purified rabbit polyclonal antibodies (ab) to mu-OR, and immune complexes were probed for GRK2 by immunoblotting techniques. Results demonstrate an association of GRK2 with mu-ORs in chronic ethanol-treated rats, but not in the controls. Possible changes in GRK2 association with ORs after chronic ethanol may be related to levels of phosphorylation and subsequent trafficking of the receptors.

Comparative usability studies of full vs. partial immersive virtual reality simulation for medical education and training.

Virtual reality (VR) simulation provides a means of making experiential learning reproducible and reusable. This study was designed to determine the efficiency and satisfaction components of usability. Previously, it was found that first year medical students using a VR simulation for medical education demonstrated effectiveness in learning as measured by knowledge structure improvements both with and without a head mounted display (HMD) but students using a HMD showed statistically greater improvement in knowledge structures compared to those not using a HMD. However, in this current analysis of other components of usability, there were no overall significance differences in efficiency (ease of use), nor in satisfaction, within this same group of randomized subjects comparing students using a HMD to those not using a HMD. These types of studies may be important in determining the most appropriate, cost effective VR simulation technology needed to achieve specific learning goals and objectives.

The effect of degree of immersion upon learning performance in virtual reality simulations for medical education.

Simulations are being used in education and training to enhance understanding, improve performance, and assess competence. However, it is important to measure the performance of these simulations as learning and training tools. This study examined and compared knowledge acquisition using a knowledge structure design. The subjects were first-year medical students at The University of New Mexico School of Medicine. One group used a fully immersed virtual reality (VR) environment using a head mounted display (HMD) and another group used a partially immersed (computer screen) VR environment. The study aims were to determine whether there were significant differences between the two groups as measured by changes in knowledge structure before and after the VR simulation experience. The results showed that both groups benefited from the VR simulation training as measured by the significant increased similarity to the expert knowledge network after the training experience. However, the immersed group showed a significantly higher gain than the partially immersed group. This study demonstrated a positive effect of VR simulation on learning as reflected by improvements in knowledge structure but an enhanced effect of full-immersion using a HMD vs. a screen-based VR system.

Reification of abstract concepts to improve comprehension using interactive virtual environments and a knowledge-based design: a renal physiology model.

Several abstract concepts in medical education are difficult to teach and comprehend. In order to address this challenge, we have been applying the approach of reification of abstract concepts using interactive virtual environments and a knowledge-based design. Reification is the process of making abstract concepts and events, beyond the realm of direct human experience, concrete and accessible to teachers and learners. Entering virtual worlds and simulations not otherwise easily accessible provides an opportunity to create, study, and evaluate the emergence of knowledge and comprehension from the direct interaction of learners with otherwise complex abstract ideas and principles by bringing them to life. Using a knowledge-based design process and appropriate subject matter experts, knowledge structure methods are applied in order to prioritize, characterize important relationships, and create a concept map that can be integrated into the reified models that are subsequently developed. Applying these principles, our interdisciplinary team has been developing a reified model of the nephron into which important physiologic functions can be integrated and rendered into a three dimensional virtual environment called Flatland, a virtual environments development software tool, within which a learners can interact using off-the-shelf hardware. The nephron model can be driven dynamically by a rules-based artificial intelligence engine, applying the rules and concepts developed in conjunction with the subject matter experts. In the future, the nephron model can be used to interactively demonstrate a number of physiologic principles or a variety of pathological processes that may be difficult to teach and understand. In addition, this approach to reification can be applied to a host of other physiologic and pathological concepts in other systems. These methods will require further evaluation to determine their impact and role in learning.

Growth-associated protein 43 (GAP-43) and synaptophysin alterations in the dentate gyrus of patients with schizophrenia.

Growth-associated protein 43 (GAP-43) expression is critical for the proper establishment of neural circuitry, a process thought to be disrupted in schizophrenia. Previous work from our laboratory demonstrated decreased GAP-43 levels in post-mortem tissue from the entire hippocampal formation of affected individuals. In the present study, we used immunocytochemical techniques to localize alterations in GAP-43 protein to specific synapses. GAP-43 distribution was compared to that of synaptophysin, another synaptic protein known to be altered in schizophrenia. The levels and distribution of GAP-43 and synaptophysin proteins were measured in the dentate gyrus of subjects with schizophrenia and sex-, age-, and postmortem interval-matched normal controls and subjects with bipolar disorder. Tissue from subjects was provided by the Harvard Brain Tissue Resource Center. In control subjects, GAP-43 immunostaining was prominent in synaptic terminals in the inner molecular layer and hilar region. Subjects with schizophrenia had significant decreases in GAP-43 immunoreactivity in the hilus (p<0.05, paired t-test) and inner molecular layer (p<0.05, paired t-test) but not in the outer molecular layer. In the same tissues, synaptophysin immunoreactivity was significantly reduced in both the inner and outer molecular layers of the dentate gyrus (both p<0.01 by paired t-test), but not in the hilus. In contrast to patients with schizophrenia, GAP-43 and synaptophysin levels in subjects with bipolar disorder did not differ from controls. Given the relationship of GAP-43 and synaptophysin with the development and plasticity of synaptic connections, the observed alterations in the hippocampus of patients with schizophrenia may be related to cognitive deficits associated with this illness.

Virtual reality training improves students' knowledge structures of medical concepts.

Virtual environments can provide training that is difficult to achieve under normal circumstances. Medical students can work on high-risk cases in a realistic, time-critical environment, where students practice skills in a cognitively demanding and emotionally compelling situation. Research from cognitive science has shown that as students acquire domain expertise, their semantic organization of core domain concepts become more similar to those of an expert's. In the current study, we hypothesized that students' knowledge structures would become more expert-like as a result of their diagnosing and treating a patient experiencing a hematoma within a virtual environment. Forty-eight medical students diagnosed and treated a hematoma case within a fully immersed virtual environment. Student's semantic organization of 25 case-related concepts was assessed prior to and after training. Students' knowledge structures became more integrated and similar to an expert knowledge structure of the concepts as a result of the learning experience. The methods used here for eliciting, representing, and evaluating knowledge structures offer a sensitive and objective means for evaluating student learning in virtual environments and medical simulations.

Distributed interactive virtual environments for collaborative experiential learning and training independent of distance over Internet2.

Medical knowledge and skills essential for tomorrow's healthcare professionals continue to change faster than ever before creating new demands in medical education. Project TOUCH (Telehealth Outreach for Unified Community Health) has been developing methods to enhance learning by coupling innovations in medical education with advanced technology in high performance computing and next generation Internet2 embedded in virtual reality environments (VRE), artificial intelligence and experiential active learning. Simulations have been used in education and training to allow learners to make mistakes safely in lieu of real-life situations, learn from those mistakes and ultimately improve performance by subsequent avoidance of those mistakes. Distributed virtual interactive environments are used over distance to enable learning and participation in dynamic, problem-based, clinical, artificial intelligence rules-based, virtual simulations. The virtual reality patient is programmed to dynamically change over time and respond to the manipulations by the learner. Participants are fully immersed within the VRE platform using a head-mounted display and tracker system. Navigation, locomotion and handling of objects are accomplished using a joy-wand. Distribution is managed via the Internet2 Access Grid using point-to-point or multi-casting connectivity through which the participants can interact. Medical students in Hawaii and New Mexico (NM) participated collaboratively in problem solving and managing of a simulated patient with a closed head injury in VRE; dividing tasks, handing off objects, and functioning as a team. Students stated that opportunities to make mistakes and repeat actions in the VRE were extremely helpful in learning specific principles. VRE created higher performance expectations and some anxiety among VRE users. VRE orientation was adequate but students needed time to adapt and practice in order to improve efficiency. This was also demonstrated successfully between Western Australia and UNM. We successfully demonstrated the ability to fully immerse participants in a distributed virtual environment independent of distance for collaborative team interaction in medical simulation designed for education and training. The ability to make mistakes in a safe environment is well received by students and has a positive impact on their understanding, as well as memory of the principles involved in correcting those mistakes. Bringing people together as virtual teams for interactive experiential learning and collaborative training, independent of distance, provides a platform for distributed "just-in-time" training, performance assessment and credentialing. Further validation is necessary to determine the potential value of the distributed VRE in knowledge transfer, improved future performance and should entail training participants to competence in using these tools.

Integration of advanced technologies to enhance problem-based learning over distance: Project TOUCH.

Distance education delivery has increased dramatically in recent years as a result of the rapid advancement of communication technology. The National Computational Science Alliance's Access Grid represents a significant advancement in communication technology with potential for distance medical education. The purpose of this study is to provide an overview of the TOUCH project (Telehealth Outreach for Unified Community Health; http://hsc.unm.edu/touch) with special emphasis on the process of problem-based learning case development for distribution over the Access Grid. The objective of the TOUCH project is to use emerging Internet-based technology to overcome geographic barriers for delivery of tutorial sessions to medical students pursuing rotations at remote sites. The TOUCH project also is aimed at developing a patient simulation engine and an immersive virtual reality environment to achieve a realistic health care scenario enhancing the learning experience. A traumatic head injury case is developed and distributed over the Access Grid as a demonstration of the TOUCH system. Project TOUCH serves as an example of a computer-based learning system for developing and implementing problem-based learning cases within the medical curriculum, but this system should be easily applied to other educational environments and disciplines involving functional and clinical anatomy. Future phases will explore PC versions of the TOUCH cases for increased distribution.

Anatomy and the access grid: exploiting plastinated brain sections for use in distributed medical education.

Computerized animation is becoming an increasingly popular method to provide dynamic presentation of anatomical concepts. However, most animations use artistic renderings as the base illustrations that are subsequently altered to depict movement. In most cases, the artistic rendering is a schematic that lacks realism. Plastinated sections provide a useful alternative to artistic renderings to serve as a base image for animation. The purpose of this study is to describe a method for developing animations by using plastinated sections. This application is used in Project TOUCH as a supplemental learning tool for a problem-based learning case distributed over the National Computational Science Alliance's Access Grid. The case involves traumatic head injury that results in an epidural hematoma with transtentorial uncal herniation. In addition, a subdural hematoma is animated permitting the student to contrast the two processes for a better understanding of dural hematomas, in general. The method outlined uses P40 plastinated coronal brain sections that are digitized and to which contiguous anatomical structures are rendered. The base illustration is rendered, interpolated, and viewed while audio narration describes the event. This method demonstrates how realistic anatomical animations can be generated quickly and inexpensively for medical education purposes by using plastinated brain sections.