A Discussion of the Use of Virtual Reality for Training Healthcare Practitioners to Recognize Child Protection Issues.

Background: Virtual reality technology is a rapidly developing tool which has been shown to have exciting prospects in the field of medical education (1). In a recent, subsequent study, Pan et al. consider the potential of the same technology in the realm of child protection training and safeguarding issues (2). To build upon the Pan et al. (2) study, a panel discussion was held at The Centre for Behavior Change Annual Conference 2018 to discuss the question "Can a virtual reality communication scenario be used to teach General Practitioners and trainees how to recognize and manage child protection issues?." Methodology: The above study comprised an immersive virtual reality consultation, in which the ability of 63 doctors to pick up covert safeguarding cues was tested in the context of a consultation with an adult patient, where the patient's child happened to be present as well. The study and its findings were discussed at the Centre for Behavior Change 4th Annual Conference, and this paper summarizes the opinions of both the panel and the audience. Viewpoint: Safeguarding is a challenging area of practice where we must listen to the child, and tackle difficult conversations with parents. Within medical training, role play is the gold standard for teaching how to communicate in difficult scenarios. Given the ethical questions surrounding children being asked to role play such abuse, the use of virtual reality characters could have a key role in upgrading current practices in medical education on safeguarding.

Why and how to use virtual reality to study human social interaction: The challenges of exploring a new research landscape.

As virtual reality (VR) technology and systems become more commercially available and accessible, more and more psychologists are starting to integrate VR as part of their methods. This approach offers major advantages in experimental control, reproducibility, and ecological validity, but also has limitations and hidden pitfalls which may distract the novice user. This study aimed to guide the psychologist into the novel world of VR, reviewing available instrumentation and mapping the landscape of possible systems. We use examples of state-of-the-art research to describe challenges which research is now solving, including embodiment, uncanny valley, simulation sickness, presence, ethics, and experimental design. Finally, we propose that the biggest challenge for the field would be to build a fully interactive virtual human who can pass a VR Turing test - and that this could only be achieved if psychologists, VR technologists, and AI researchers work together.

Understanding dual realities and more in VR.

The five commentaries on our paper (Pan & Hamilton, 2018, Br. J. Psychol.) provide a useful summary of the key issues we raise, and also bring to the foreground some new and important questions, touching on a range of issues including presence and the conceptualization of dual realities. We highlight here some important themes and directions for future investigation.

A Discussion of Virtual Reality As a New Tool for Training Healthcare Professionals.

BACKGROUND: Virtual reality technology is an exciting and emerging field with vast applications. Our study sets out the viewpoint that virtual reality software could be a new focus of direction in the development of training tools in medical education. We carried out a panel discussion at the Center for Behavior Change 3rd Annual Conference, prompted by the study, "The Responses of Medical General Practitioners to Unreasonable Patient Demand for Antibiotics--A Study of Medical Ethics Using Immersive Virtual Reality" (1). METHODS: In Pan et al.'s study, 21 general practitioners (GPs) and GP trainees took part in a videoed, 15-min virtual reality scenario involving unnecessary patient demands for antibiotics. This paper was discussed in-depth at the Center for Behavior Change 3rd Annual Conference; the content of this paper is a culmination of findings and feedback from the panel discussion. The experts involved have backgrounds in virtual reality, general practice, medicines management, medical education and training, ethics, and philosophy. VIEWPOINT: Virtual reality is an unexplored methodology to instigate positive behavioral change among clinicians where other methods have been unsuccessful, such as antimicrobial stewardship. There are several arguments in favor of use of virtual reality in medical education: it can be used for "difficult to simulate" scenarios and to standardize a scenario, for example, for use in exams. However, there are limitations to its usefulness because of the cost implications and the lack of evidence that it results in demonstrable behavior change.

A Study of Professional Awareness Using Immersive Virtual Reality: The Responses of General Practitioners to Child Safeguarding Concerns.

The art of picking up signs that a child may be suffering from abuse at home is one of those skills that cannot easily be taught, given its dependence on a range of non-cognitive abilities. It is also difficult to study, given the number of factors that may interfere with this skill in a real-life, professional setting. An immersive virtual reality environment provides a way round these difficulties. In this study, we recruited 64 general practitioners (GPs), with different levels of experience. Would this level of experience have any impact on general practitioners' ability to pick up child-safeguarding concerns? Would more experienced GPs find it easier to pick up subtle (rather than obvious) signs of child-safeguarding concerns? Our main measurement was the quality of the note left by the GP at the end of the virtual consultation: we had a panel of 10 (all experienced in safeguarding) rate the note according to the extent to which they were able to identify and take the necessary steps required in relation to the child safeguarding concerns. While the level of professional experience was not shown to make any difference to a GP's ability to pick up those concerns, the parent's level of aggressive behavior toward the child did. We also manipulated the level of cognitive load (reflected in a complex presentation of the patient's medical condition): while cognitive load did have some impact upon GPs in the "obvious cue" condition (parent behaving particularly aggressively), this effect fell short of significance. Furthermore, our results also suggest that GPs who are less stressed, less neurotic, more agreeable and extroverted tend to be better at raising potential child abuse issues in their notes. These results not only point at the considerable potential of virtual reality as a training tool, they also highlight fruitful avenues for further research, as well as potential strategies to support GP's in their dealing with highly sensitive, emotionally charged situations.

Reduced Mimicry to Virtual Reality Avatars in Autism Spectrum Disorder.

Mimicry involves unconsciously copying the actions of others. Increasing evidence suggests that autistic people can copy the goal of an observed action but show differences in their mimicry. We investigated mimicry in autism spectrum disorder (ASD) within a two-dimensional virtual reality environment. Participants played an imitation game with a socially engaged avatar and socially disengaged avatar. Despite being told only to copy the goal of the observed action, autistic participants and matched neurotypical participants mimicked the kinematics of the avatars' movements. However, autistic participants mimicked less. Social engagement did not modulate mimicry in either group. The results demonstrate the feasibility of using virtual reality to induce mimicry and suggest mimicry differences in ASD may also occur when interacting with avatars.

The Responses of Medical General Practitioners to Unreasonable Patient Demand for Antibiotics--A Study of Medical Ethics Using Immersive Virtual Reality.

BACKGROUND: Dealing with insistent patient demand for antibiotics is an all too common part of a General Practitioner's daily routine. This study explores the extent to which portable Immersive Virtual Reality technology can help us gain an accurate understanding of the factors that influence a doctor's response to the ethical challenge underlying such tenacious requests for antibiotics (given the threat posed by growing anti-bacterial resistance worldwide). It also considers the potential of such technology to train doctors to face such dilemmas. EXPERIMENT: Twelve experienced GPs and nine trainees were confronted with an increasingly angry demand by a woman to prescribe antibiotics to her mother in the face of inconclusive evidence that such antibiotic prescription is necessary. The daughter and mother were virtual characters displayed in immersive virtual reality. The specific purposes of the study were twofold: first, whether experienced GPs would be more resistant to patient demands than the trainees, and second, to investigate whether medical doctors would take the virtual situation seriously. RESULTS: Eight out of the 9 trainees prescribed the antibiotics, whereas 7 out of the 12 GPs did so. On the basis of a Bayesian analysis, these results yield reasonable statistical evidence in favor of the notion that experienced GPs are more likely to withstand the pressure to prescribe antibiotics than trainee doctors, thus answering our first question positively. As for the second question, a post experience questionnaire assessing the participants' level of presence (together with participants' feedback and body language) suggested that overall participants did tend towards the illusion of being in the consultation room depicted in the virtual reality and that the virtual consultation taking place was really happening.

Automatic imitation in a rich social context with virtual characters.

It has been well established that people respond faster when they perform an action that is congruent with an observed action than when they respond with an incongruent action. Here we propose a new method of using interactive Virtual Characters (VCs) to test if social congruency effects can be obtained in a richer social context with sequential hand-arm actions. Two separate experiments were conducted, exploring if it is feasible to measure spatial congruency (Experiment 1) and anatomical congruency (Experiment 2) in response to a VC, compared to the same action sequence indicated by three virtual balls. In Experiment 1, we found a robust spatial congruency effect for both VC and virtual balls, modulated by a social facilitation effect for participants who felt the VC was human. In Experiment 2 which allowed for anatomical congruency, a form by congruency interaction provided evidence that participants automatically imitate the actions of the VC but do not imitate the balls. Our method and results build a bridge between studies using minimal stimuli in automatic interaction and studies of mimicry in a rich social interaction, and open new research venue for future research in the area of automatic imitation with a more ecologically valid social interaction.

A method for generating an illusion of backwards time travel using immersive virtual reality-an exploratory study.

We introduce a new method, based on immersive virtual reality (IVR), to give people the illusion of having traveled backwards through time to relive a sequence of events in which they can intervene and change history. The participant had played an important part in events with a tragic outcome-deaths of strangers-by having to choose between saving 5 people or 1. We consider whether the ability to go back through time, and intervene, to possibly avoid all deaths, has an impact on how the participant views such moral dilemmas, and also whether this experience leads to a re-evaluation of past unfortunate events in their own lives. We carried out an exploratory study where in the "Time Travel" condition 16 participants relived these events three times, seeing incarnations of their past selves carrying out the actions that they had previously carried out. In a "Repetition" condition another 16 participants replayed the same situation three times, without any notion of time travel. Our results suggest that those in the Time Travel condition did achieve an illusion of "time travel" provided that they also experienced an illusion of presence in the virtual environment, body ownership, and agency over the virtual body that substituted their own. Time travel produced an increase in guilt feelings about the events that had occurred, and an increase in support of utilitarian behavior as the solution to the moral dilemma. Time travel also produced an increase in implicit morality as judged by an implicit association test. The time travel illusion was associated with a reduction of regret associated with bad decisions in their own lives. The results show that when participants have a third action that they can take to solve the moral dilemma (that does not immediately involve choosing between the 1 and the 5) then they tend to take this option, even though it is useless in solving the dilemma, and actually results in the deaths of a greater number.

Socially anxious and confident men interact with a forward virtual woman: an experimental study.

BACKGROUND: Male volunteers entered an immersive virtual reality that depicted a party, where they were approached by a lone virtual woman who initiated a conversation. The goal was to study how socially anxious and socially confident men would react to this event. Interest focused on whether the socially anxious participants would exhibit sustained anxiety during the conversation or whether this would diminish over time, and differ from the responses of the more socially confident men. METHODOLOGY: The scenario was a party with five virtual characters, four sitting at a distance from the participant and talking amongst themselves and one lone woman standing closer. The woman approached the participant, introduced herself and initiated a conversation that was first about mundane matters and then became more personal and intimate. Participants were men who were either relatively socially confident (18) or socially anxious in their relationships with women (18). A second experimental factor was whether or not the other four characters occasionally looked towards the participant. There was a post-trial questionnaire about social anxiety in relation to the experience, and skin conductance and ECG physiological measures were recorded. Our expectation was that the socially anxious participants would show greater anxiety throughout. CONCLUSIONS: Compared to baseline readings both socially confident and socially anxious groups on average showed signs of significantly increased stress at the initial approach of the virtual woman. The stress then diminished once the conversation entered into the mundane phase and then did not significantly change. Comparing pre- and post-questionnaire anxiety scores there was no change for the more confident participants but a significant decrease in average score amongst the anxious group. The methodology of placing socially anxious participants in a virtual reality where they can gain experience of how to act in a stressful situation promises a novel way forward for treating social anxiety.