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Several universities worldwide are grappling with the challenges of medical education in the context of reduced access to preoperative patients . This is especially important given that most would accept that "the single most important function of 'modern' academic surgical units relates to the provision of a well-structured and imaginative educational programme for undergraduates" . Educational tools that offer engaging modes of interaction were identified as absolute necessary to attract not only candidates to surgical training programs, but students to medical programs in general. One solution that could theoretically address both of these needs simultaneously involves the use of computer-simulated or "virtual" patients.
Second Life is an online, virtual world created by Linden Lab. Within any Second Life simulated environment, users exist through avatars—or virtual representations of themselves—which interact realistically with other avatars online. The use of avatars provides participants with an added sense of immersion and presence in the virtual world [3, 4].
Second Life has a discernable presence in education [5, 6, 7] with several institutions —including Harvard and Stanford University—creating Second Life environments in order to enhance educational opportunities. In addition, The Department of Biosurgery and Surgical Technology at Imperial College London has created an online facility called Second Health, which is designed to provide patients and students with an auxiliary means of gaining health care information.
This article presents an assessment of the prospective viability of a Second Life-based simulated "learning environment" for the purposes of medical educational instruction. In particular, the authors aimed to explore the enhancement of learning and teaching by creating virtual patients within the virtual world platform known as Second Life.
The objectives of the pilot study were to: explore the potential of the virtual world, Second Life, for medical education in the form of (problem-based learning) PBL; determine the limitations, barriers and solutions associated with the Second Life platform for medical education activities; and measure participant satisfaction outcomes and feedback.
In consultation with the Second Life design and development team from the New Media Consortium (NMC), the Discipline of Surgery at the University of Sydney created a Second Life simulated 3-D virtual hospital. In conjunction with the hospital development, were two "proof of concept" simulated patients (including relevant histories, labs, imaging and management) based on current Sydney Medical School PBL cases.
Student participants engaged in virtual PBL scenarios, providing them with the ability to practice their history taking, assessment and management skills in a state-of-the-art training environment (i.e., as an adjunct learning activity)—keeping with the recent enhancements to the University of Sydney medical program curriculum instituted in 2009.
The evaluation of the Second Life PBL experience focused on four different domains pertaining to the PBL session and also acquired details regarding user demographics. Participants responded to several questions or statements regarding the setup, concept, content, and experience of the Second Life PBL sessions.
Twenty-two respondents were invited to take part in the project. Participants were limited to students currently enrolled in the Sydney Medical School program.
None of the participants had had any prior interactive experience with Second Life. Approximately 40 percent of respondents indicated that the requisite installation and setup time required to access the online virtual environment was unreasonably long. More favorably, however, approximately 73 percent of participants agreed that suitable technical support was available during the setup process to address any questions or to help manage difficulties.
More than 90 percent of participants were enthusiastic about the concept of PBL being explored through a virtual environment. All of the participants were interested in seeing virtual PBLs become available in the future and more than 80 percent felt that the degree of virtual world immersion was suitable to facilitate the virtual PBL process.
More than 85 percent of participants agreed that the clinical content delivered in the virtual PBL was comparable to that of a classic PBL session. Additionally, 95 percent of participants felt that the clinical content was well suited to the interactive virtual world environment. Moreover, more than 80 percent agreed that equal or more clinical content was retained using the virtual PBL process.
Participants rated the Second Life PBL experience on the following attributes with accompanying positive participant feedback scores listed; Engaging (95%), Realistic (86%), Intuitive (59%), Efficient Learning Tool (77%), Ability to Deliver Practical Knowledge (86%) and Overall Experience (100%). A total of 82 percent of participants reported positive scores in support of having their next PBL delivered using the virtual Second Life experience.
Collectively, the 22 participant surveyed conveyed an averaged positive feedback score of 84 percent across the aforementioned feedback domains—with a mean score on the modified four-point Likert scale of 3.25.
This study was designed to gather data on participant satisfaction regarding Second Life as a plausibly suitable platform for future virtual world medical education [i.e., assessed across a variety of domains relevant to the Second Life PBL experience]. Our results support the utility of the Second Life platform and the virtual PBL sessions and the extension of this methodology as a means of enhancing surgical education.
The setup findings indicate that despite Second Life's growing popularity in both the social networking and medical educational realms, none of our participants had had any previous experience with Second Life. This may partially account for why 40 percent of participants reported that installation and setup of the Second Life software had taken an unreasonably long time. Comments and feedback related to the lengthy installation and setup revolved primarily around audio/video and "in-world" voice chat issues.
Nevertheless, based on the concept section of the virtual PBL feedback, we ascertained that students were decisively enthusiastic about the possibility of virtual world teaching. Moreover, they appear eager to see this style of teaching incorporated into future curriculums.
The content of the virtual world PBL experience, which was duplicated from the current medical curriculum, was deemed to be well suited to an interactive virtual environment. Participants felt that equal or more clinical knowledge was retained using the Second Life PBL experience. Our pilot data supports continued use and further implementation of additional Sydney Medical School PBL scenarios using this format.
Participant feedback data shows that the overall experience was invariably positive. Still, the results indicate that some improvements in the intuitive nature of Second Life and/or the PBL scenario implementation would be welcomed. In addition, when analyzed further, the data did not show any correlation of intuitiveness with any other domain. Future studies, therefore, might seek to identify which factors contribute to participants' feedback on intuitiveness.
While all participants reported that their Second Life PBL experiences were generally positive, not all indicated that they would like to participate in their next PBL using the Second Life platform. Further research, therefore, intended to surface and assess factors affecting this discrepancy would be invaluable to virtual world medical education planners and developers.
The mean value of feedback SCORES across all domains was 3.25 (on 4.0) on the modified four-point Likert scale. This positive result indicates that our theoretical hypothesis regarding the use of virtual worlds as a suitable learning environment for medical education has been supported. PBL's delivered in accord with the simulated world of Second Life appear—at this preliminary stage—to demonstrate potential as a promising and innovative learning method, further reinforced by the recent research undertaken by Wiecha, Schmidt, and Stewart [8, 9, 10].
There are some limitations which may be encountered using Second Life. In order to conduct meetings, events or learning sessions all participants must possess the necessary technical proficiencies required to successfully download and install the requisite software. They must also possess the knowledge or capabilities required to manage virtual interactive exchanges. As such, these two criteria alone could represent significant barriers to entry for prospective users and pose considerable challenges to large scale, Second Life ventures.
As a result, a Second Life implementation should incorporate adequate training and allow time for participants to attain an acceptable level of knowledge and proficiency prior to use. It is not known whether it will be plausible to ensure a positive user experience for participants not initially inclined to participate in a virtual milieu. It would appear, therefore, that both the scale of the project and the willingness of participants to adopt and endorse Second Life as a viable tool for medical education will be of paramount importance in assessing the viable success of Second Life projects in the future.
Given this new feedback surrounding the utility of virtual environments to effectively replicate clinical PBL scenarios—combined with the possibility to design, develop and implement future scenarios—this tool, both Second Life specifically and virtual learning in general, could manage to considerably augment, if not eventually, revolutionize medical education.
Virtual world medical education appears well suited to eventually accommodating the demand for new teaching techniques and learning environments. As a corollary, virtual learning may potentially facilitate superior medical instruction while ensuring enhanced patient care and safety.
Importantly, and as identified by the Royal Australasian College of Surgeons' 2010 Annual Scientific Congress presentation "How do Today's Trainees Differ?" , each successive generation engages increasingly advanced computer technology at progressively earlier ages. Hence, educational curriculums must be prepared to deliver material using suitable techniques and platforms capable of generating or maintaining interest and enthusiasm in the educational process. Moreover, as available teaching time in anatomy and surgery are expected to continue to decline, the adoption of unique instructional methods such as virtual learning may serve not only to attract more technologically inclined candidates but also improve the efficacy of the relatively fewer opportunities that will remain.
This project was inspired by the work of Professor John Windsor, University of Auckland, Faculty of Medical and Health Sciences; Scott Diener, University of Auckland, IT Services, and David Bodily, Western Wyoming Community College, Department of Nursing.
Dr. Nicholas A. Spooner holds advanced degrees in both medicine and engineering. Specifically, in addition to a Medical Bachelor, Bachelor of Surgery (M.B.,B.S.) from The University of Sydney, he has completed a master's degree in applied science in biomedical engineering (M.A.Sc.) from Carleton University in collaboration with the University of Ottawa`s Heart Institute, and a bachelor's degree in aerospace engineering from Carleton University.
Dr. Patrick C. Cregan is an Associate Professor of Surgery at the University of Western Sydney, the Clinical Director of Surgery at Sydney West Area Health Service, the Chair of the Surgical Services Taskforce for the NSW Department of Health, board member of the NSW Cancer Institute, and Chairman of the Board of Directors for MedicVision. His clinical interests include endocrinology, laparoscopic surgery, and bariatric (obesity) surgery; his research interests are surgical robotics, high-performance computing and surgery, hapto-visual environments, and the ViCCU (Virtual Critical Care Unit)Project.
Dr. Mohamed Khadra is a Professor of Surgery at Sydney University, Head of Urology at Nepean Hospital, and a bestselling author. His books, Making the Cut (Random House, 2007) and The Patient (Random House, 2009), are both bestsellers. His most recent book, Terminal Decline, was released last year. He has postgraduate degrees in surgery, computing, and education. His roles have included being Inaugural Chair of Surgery at the Australian National University, Pro Vice Chancellor for Health, Design and Science at the University of Canberra, Professor and Head of the School of Rural Health for the University of New South Wales, and, most recently, founder of the Institute of Technology Australia, a higher education provider with a social justice mission to take quality education to students in developing countries.
 Diener, S., Windsor, J., and Bodily, D. Design and development of medical simulations in Second Life and OpenSim. Educause Australasia 2009.  Taylor, I. Surgery in the undergraduate curriculum. Education and Professional Development Committee of the Society of Academic and Research Surgery, 2008.  Messinger, P.R. On the relationship between my avatar and ayself. Journal of Virtual Worlds Research 1,2 (Nov. 2008).  Zhao, S. Toward a taxonomy of copresence. Presence: Teleoperators and Virtual Environments12,5 (2003):445-455.  Beard, L., Wilson, K., Morra, D., and Keelan, J. A survey of health-related activities on Second Life. Journal of Medical Internet Research 11,2 (2009).  Boulos, M.N.K., Hetherington, L., and Wheeler, S. Second Life: An overview of the potential of 3-D virtual worlds in medical and health education. Health Information and Libraries Journal 24,4 (2007): 233-45.  Kamel Boulos, M.N., Ramloll, R., Jones, R., and Toth-Cohen, S. Web 3D for public, environmental and occupational health: Early examples from second life. International Journal of Environmental Research and Public Health 5,4 (2008):290-317.  Wiecha, J., Heyden, R., Sternthal, E., and Merialdi, M. Learning in a virtual world: Experience with using Second Life for medical education. Journal of Medical Internet Research12,1 (2010).  Schmidt, B. and Stewart, S. Implementing the virtual reality learning environment Second Life. Nurse Educator 34,4 (2009): 152-155.  Stewart, S., Pope, D., and Duncan, D. Using Second Life to enhance ACCEL an online accelerated nursing BSN program. Studies in Health Technology and Informatics 146, (2009)636-640.  Jefferies, S. How do today's trainees differ? In Annual Scientific Congress 2010; (Perth, Australia, May 4-7). Royal Australasian College of Surgeons.
 Diener, S., Windsor, J., and Bodily, D. Design and development of medical simulations in Second Life and OpenSim. Educause Australasia 2009.
 Taylor, I. Surgery in the undergraduate curriculum. Education and Professional Development Committee of the Society of Academic and Research Surgery, 2008.
 Messinger, P.R. On the relationship between my avatar and ayself. Journal of Virtual Worlds Research 1,2 (Nov. 2008).
 Zhao, S. Toward a taxonomy of copresence. Presence: Teleoperators and Virtual Environments12,5 (2003):445-455.
 Beard, L., Wilson, K., Morra, D., and Keelan, J. A survey of health-related activities on Second Life. Journal of Medical Internet Research 11,2 (2009).
 Boulos, M.N.K., Hetherington, L., and Wheeler, S. Second Life: An overview of the potential of 3-D virtual worlds in medical and health education. Health Information and Libraries Journal 24,4 (2007): 233-45.
 Kamel Boulos, M.N., Ramloll, R., Jones, R., and Toth-Cohen, S. Web 3D for public, environmental and occupational health: Early examples from second life. International Journal of Environmental Research and Public Health 5,4 (2008):290-317.
 Wiecha, J., Heyden, R., Sternthal, E., and Merialdi, M. Learning in a virtual world: Experience with using Second Life for medical education. Journal of Medical Internet Research12,1 (2010).
 Schmidt, B. and Stewart, S. Implementing the virtual reality learning environment Second Life. Nurse Educator 34,4 (2009): 152-155.
 Stewart, S., Pope, D., and Duncan, D. Using Second Life to enhance ACCEL an online accelerated nursing BSN program. Studies in Health Technology and Informatics 146, (2009)636-640.
 Jefferies, S. How do today's trainees differ? In Annual Scientific Congress 2010; (Perth, Australia, May 4-7). Royal Australasian College of Surgeons.
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