Investigating the disruptive effect of computer game technologies on medical education and training

The computer gaming industry has begun to export powerful products and technologies from its initial entertainment roots to a number of "serious" industries. Game technologies are being adapted to defense, medicine, architecture, education, city planning, and government applications. Each of these industries is already served by an established group of companies that typically do not use computer games to serve their customers. The rapid growth in the power of game technologies and the growing social acceptance of these technologies has created an environment in which these are displacing other industry-specific computer hardware and software tools. This dissertation proposes four hypotheses concerning the impact and acceptance of virtual reality and computer game technologies in education and training for laparoscopic surgery. It focuses on laparoscopic surgery because of the similarities between that form of surgery and virtual reality systems. The research indicates that the following four hypotheses are supported by the literature published in the field. Hypothesis 1: Training in laparoscopic surgery can be accomplished at a lower cost using virtual reality and game technology-based tools than through existing methods of training. Hypothesis 2: Virtual reality and game technology-based training environments provide better access to representative patient symptoms and allow more repetitive practice than existing forms of training. Hypothesis 3: Virtual reality and game technology-based training environments can reduce the training time required to achieve proficiency in laparoscopic procedures. Hypothesis 4: Virtual reality and game technology-based training can reduce the number of medical errors caused by residents and surgeons learning to perform laparoscopic procedures. I also proposed a model of medical education in which virtual reality, including game technology, is the next major addition to or transformation of the medical education curriculum. The strong evidence collected in this study indicates that these systems are becoming much more accepted in medical education and that the technical limitations that existed when these devices were first introduced are already being overcome.ABSTRACT Title of Dissertation: INVESTIGATING THE DISRUPTIVE EFFECT OF COMPUTER GAME TECHNOLOGIES ON MEDICAL EDUCATION AND TRAINING Roger D. Smith, Doctor of Management, 2008 Dissertation Directed By: Dr. Michael Evanchik, Graduate School of Management and Technology, University of Maryland University College The computer gaming industry has begun to export powerful products and technologies from its initial entertainment roots to a number of “serious” industries. Game technologies are being adapted to defense, medicine, architecture, education, city planning, and government applications. Each of these industries is already served by an established group of companies that typically do not use computer games to serve their customers. The rapid growth in the power of game technologies and the growing social acceptance of these technologies has created an environment in which these are displacing other industry-specific computer hardware and software tools. This dissertation proposes four hypotheses concerning the impact and acceptance of virtual reality and computer game technologies in education and training for laparoscopic surgery. It focuses on laparoscopic surgery because of the similarities between that form of surgery and virtual reality systems. The research indicates that the following four hypotheses are supported by the literature published in the field. • Hypothesis 1: Training in laparoscopic surgery can be accomplished at a lower cost using virtual reality and game technology-based tools than through existing methods of training. • Hypothesis 2: Virtual reality and game technology-based training environments provide better access to representative patient symptoms and allow more repetitive practice than existing forms of training. • Hypothesis 3: Virtual reality and game technology-based training environments can reduce the training time required to achieve proficiency in laparoscopic procedures. • Hypothesis 4: Virtual reality and game technology-based training can reduce the number of medical errors caused by residents and surgeons learning to perform laparoscopic procedures. I also proposed a model of medical education in which virtual reality, including game technology, is the next major addition to or transformation of the medical education curriculum. The strong evidence collected in this study indicates that these systems are becoming much more accepted in medical education and that the technical limitations that existed when these devices were first introduced are already being overcome. INVESTIGATING THE DISRUPTIVE EFFECT OF COMPUTER GAME TECHNOLOGIES ON MEDICAL EDUCATION AND TRAINING By Roger D. Smith. Dissertation submitted to the Faculty of the Graduate School of the University of Maryland University College, in partial fulfillment of the requirements for the degree of Doctor of Management 2008 Advisory Committee: Dr. Michael Evanchik, Chair Dr. Monica Bolesta, Member Dr. Joseph D’Mello, Member © Copyright by Roger D. Smith 2008 ii Acknowledgements I would like to thank the members of my dissertation committee: Dr. Michael Evanchik, Dr. Monica Bolesta, and Dr. Joseph D’Mello for their guidance and help in structuring this research so that it makes a valuable contribution toward understanding current and future changes in the business of medical education. I also appreciate the opportunity that this degree program and its faculty have given me to expand my understanding of business, management, and innovation. This knowledge has been tremendously helpful to me in contributing to the companies and government organizations with which I have been associated. I am indebted to my mother and father for the foundations that they established in my early years and for always believing that I could accomplish great things. I only wish that my father had lived to see this newest accomplishment. Finally, my gratitude to my wife and children for allowing me to spend years shut in my office working toward this goal. Your understanding and support have been greatly appreciated. iii Table of Contents Acknowledgements............................................................................................................. ii Table of Contents............................................................................................................... iii List of Tables ...................................................................................................................... v List of Figures .................................................................................................................... vi Chapter 1: Introduction and Research Problem.................................................................. 1 Virtual Reality................................................................................................................. 2 Computer Game Technologies ....................................................................................... 3 3D Engine ................................................................................................................... 5 Graphical User Interface ............................................................................................. 7 Physical Models.......................................................................................................... 8 Artificial Intelligence .................................................................................................. 8 Networking ................................................................................................................. 9 Persistence................................................................................................................. 10 Terminology Issues....................................................................................................... 11 Surgical Practice and Education ................................................................................... 12 Research Problem ......................................................................................................... 16 Chapter 2: Literature Review............................................................................................ 20 Medical Education with Virtual Reality ....................................................................... 20 Pioneers in Medical Simulation ................................................................................ 21 Simulation as a Tool for Education .......................................................................... 23 Cost Factors in Medical Education........................................................................... 26 Access to Patient Symptoms and Virtual Reality ..................................................... 28 Simulation and VR Impact on Training Time .......................................................... 31 Potential to Reduce Medical Errors .......................................................................... 33 Game Technology for Non-Entertainment Applications.............................................. 35 Historical Applications ............................................................................................. 35 Educational Applications .......................................................................................... 36 Business Aspects of Games ...................................................................................... 40 Games as Technology Products ................................................................................ 44 Social Acceptance of Games .................................................................................... 45 Dissertations on Computer Games................................................................................ 48 Social Impacts........................................................................................................... 48 Educational Applications .......................................................................................... 51 Business Aspects of Games ...................................................................................... 51 Technology in Games ............................................................................................... 52 Simulation ..................................................................................................................... 53 History of Technology .................................................................................................. 55 Disruptive Innovation and Creative Destruction .......................................................... 59 Chapter 3: Conceptual Framework and Research Method ............................................... 64 Conceptual Framework................................................................................................. 66 Rationale ....................................................................................................................... 72 The Hypotheses............................................................................................................. 74 iv Research Method .......................................................................................................... 76 Reference Coding.......................................................................................................... 82 Chapter 4: Data Analysis, Results, and Conclusions........................................................ 86 Data Analysis ................................................................................................................ 86 Hypothesis 1: Lower Cost......................................................................................... 86 Hypothesis 2: Better Access ..................................................................................... 95 Hypothesis 3: Reduced Training Time ................................................................... 101 Hypothesis 4: Reduced Errors ................................................................................ 106 Results........................................................................................................................ 112 H1 Lower Cost: Supported ..................................................................................... 113 H2 Better Access: Supported.................................................................................. 113 H3 Reduced Training Time: Supported.................................................................. 114 H4 Reduced Errors: Supported ............................................................................... 115 Model of Medical Education: Supported................................................................ 116 Misleading Domain Assumptions............................................................................... 117 Assumption 1: Didactic Education is Effective ...................................................... 117 Assumption 2: Cost of Systems is Not an Issue ..................................................... 118 Assumption 3: Sufficient Access to Faculty and Patients is Possible .................... 119 Assumption 4: Practicing on Live Patients is Acceptable ...................................... 120 Discussion................................................................................................................... 121 Conclusion .................................................................................................................. 122 Chapter 5: Recommendations for Future Work............................................................. 125 Appendix 1. Medical VR Reference Coding Matrix ...................................................... 127 Appendix 2. Medical VR and Simulation Vendors in the Literature Reviewed ............ 154 Appendix 3. Personal Communication in Support of Dissertation Topic ...................... 158 References...................................................................................................................... 170 VR for Laparoscopic Surgical Education ................................................................... 170 General Medical Education and Virtual Reality......................................................... 176 Game Technology for Non-Entertainment Applications............................................ 185 Dissertations on Computer Games.............................................................................. 188 Simulation ................................................................................................................... 190 History of Technology ................................................................................................ 190 Disruptive Innovation and Creative Destruction ........................................................ 191 v List of Tables Table 1. MIST-VR implementations used in the literature............................................... 81 Table 2. Cost/benefit of an AccuTouch laparoscopic simulator....................................... 91 Table 3. Cost categories associated with each method of psychomotor training. ............ 92 Table 4. MIST-VR training program for laparoscopic instrument proficiency.............. 103 vi List of Figures Figure 1. Sim One computerized training mannequin in 1967........................................... 2 Figure 2. Six core game technologies that are disruptive to other industries. .................... 5 Figure 3. Visual comparison of 3D scenes from 1992 and 2005........................................ 6 Figure 4. Unique domains of simulations, virtual environments, and computer games..... 7 Figure 5. Denson (left) and Hoffman (right) demonstrate Sim One in 1967.................... 22 Figure 6. Medical education model .................................................................................. 66 Figure 7. Medical education model by example............................................................... 67 Figure 8. Minimally Invasive Surgical Trainer – Virtual Reality (MIST-VR) system .... 81 Figure 9. Medical VR coding matrix. ............................................................................... 83 Figure 10. Medical VR reference coding items. ............................................................... 83 Figure 11. Exercises in MIST-VR skills course ............................................................. 104 1 Chapter 1: Introduction and Research Problem Medical education has traditionally been conducted on live patients, cadavers, live animals, collections of tissue and organs, and inanimate mannequins. The “gold standard” for perfecting operations has been the use of porcine subjects in place of humans. But for over 40 years researchers, surgeons, and scientists have been introducing computerized devices to augment or replace many of the traditional tools for training. The “Sim One” computerized mannequin is considered one of the first applications of computers to medical training. This system was conceived at an aerospace company in 1964, funded with a $272,000 grant from the Department of Education, and first demonstrated on March 17, 1967. Sim One delivered a mechanically animated, computer controlled mannequin that could receive and respond to two forms of gaseous anesthesia and four forms of injection. The “patient” breathed, had a heart beat, presented temporal and carotid pulse, and maintained blood pressure. The mannequin opened and closed its mouth, blinked its eyes, and changed these behaviors in response to anesthesia administered through a mask or a tube (Abrahamson, 1997). The device was enhanced in 1971 to deliver training in respirator application, endotrachael intubation, intramuscular injection, recovery room care, and the measurement of pulse and respiration (Hoffman & Abrahamson, 1975). Figure 1 shows the system in a classroom as it would be used for education. 2 Figure 1. Sim One computerized training mannequin in 1967. Source: Abrahamson, 1997 Hoffman and Abrahamson (1975) summarized the results of 15 different studies into the effectiveness of the device in improving performance in medical practice. These studies demonstrated improvements in “learning gain per unit of time, amount of student time required to reach criterion levels of performance, and investment of faculty time necessary for student learning.” The educational improvements that were achieved using what would today be considered primitive computers and animatronics were very impressive and suggest that further development of these devices could grow these advantages and add others that were not achievable forty years ago. Virtual Reality With Sim One and many later computerized mannequins as a foundation, new computer technologies have been introduced into medical training with the hope of carrying improvements 3 deeper into the educational curriculum. One group of these technologies includes virtual reality and the software being created for modern computer games. The first medical virtual reality system based on a head mounted display and a data glove was introduced by Richard Satava and Jaron Lanier in 1991 (Satava, 1993). Lanier had coined the term “virtual reality” around 1984 to refer to the use of electronic devices for immersing humans into a computer generated world (the head mounted display) and to provide a tool with which to interact with that world (the data glove). Satava applied these to medical training and demonstrated how such a system might be employed to teach surgery. Satava’s assessment of that system was that the technology was no where near good enough to be used in real training. He felt that it would take at least ten more years for the technology to reach a useful state (R. Satava, personal communication, January 10, 2008). Early definitions of “virtual reality” required that a system must immerse at least one of the senses by cutting off access to the outside world and replacing it with a computer generated stimuli. However, a less strict definition often allows that the visual, audible, or tactile stimuli can be presented without totally eliminating external, non-computerized stimuli. This latter view has proven to be more practical and less expensive to develop and to sell to customers. In medical education, the term virtual reality is usually applied to any system where 3D computer images are being presented and manipulated. This categorization leads to computer games being referred to as virtual reality in most of the medical literature. Computer Game Technologies The computer gaming industry has begun to export powerful products and technologies from its initial entertainment roots to a number of “serious” industries. Game technologies are being adapted in defense, medical, architectural, educational, social, and governmental 4 applications. Each of these industries is already served by an established group of companies that typically do not use computer games to serve their customers. The rapid growth in the power of game technologies and the growing social acceptance of these technologies has created an environment in which these are displacing other industry-specific computer hardware and software tools. Computer games provide a rich environment in which to train a wide variety of tasks. The availability of the necessary computer hardware and game-based software technologies makes these an attractive alternative to existing methods of training (Lane, 1995; Mayo, 2007). This attraction is motivated by lower costs, higher effectiveness, and the in