USF Health's Over the Counter simulation was modeled after the futuristic Pharmacy Plus. (Top photo courtesy of Harvard Jolly).Virtual Simulations at USF began in 2010 when Joshua Jackson was handed a copy of Second Life and asked to utilize it in some way. He took the online 3D social networking world and created a comprehensive, immersive learning experience for students in both Morsani College of Medicine and the College of Pharmacy.
The Four USF Health Simulations
Virtual simulation is a role playing scenario where participants interact with virtual patients which are avatars in a 3D space. This type of learning is especially helpful in the healthcare field, because not only is it affordable, it is a way for students to practice patient interaction.
There are four major Virtual Standardized Patient (VSP) simulations that Josh has worked on for the USF College of Pharmacy and Morsani College of Medicine.
The smoking cessation simulation has been used by Morsani College of Medicine and College of Pharmacy students. Students interact with Courtney, a young smoker who is looking for advice on how to quit her habit. Students practice ‘motivational interviewing’ to help Courtney embrace a healthier lifestyle.
In this basic simulation, a mother, Jill, comes in to fill a prescription for her child's ear infection. Although she already has the prescription on hand, the student must confirm it, fill it, and give instructions on how Jill should administer it.
The third virtual simulation was created in collaboration with Dr. Angela Hill and Dr. Carol Fox for the geriatrics course. This simulation is designed around the pharmacist’s role in mental evaluations that go on every week at the Byrd Institute on the USF campus. Here, the students must evaluate Robert an elderly gentleman who may or may not be presenting warning signs for Alzheimer’s. Through interacting with Robert and his daughter, students must evaluate his mental state and decide what part, if any, pharmaceuticals may play in improving his overall condition.
Over The Counter (OTC)
The latest simulation is based in USF’s Pharmacy Plus, and is designed for Dr. Rachel Franks’ Over the Counter (OTC) course. In this simulation, students interact with multiple patients, each with a unique medical issue that needs to be treated. These conditions range anywhere from bug bites, athlete’s foot, lice, to latex allergies. Using what students have learned in their OTC class, they handle each individual situation as it pertains to the individual’s basic needs.The simulations are primarily conducted outside of classroom hours. The students are provided with instructions and videos on how to access the system and navigate to the patient they have been assigned to. Once within the simulation, the students, converse with the virtual patient, analyze the best course of action, and then give comprehensive pharmaceutical and medical recommendations. The simulations are not there to teach the students, as much as they are designed for reflective reinforcement. The students bring with them prior knowledge and instruction they have learned in class, then apply it as they would in real world situations, which the simulations are meant to imitate.
Virtual Simulation Architect
Joshua Jackson, Virtual Simulation Designer and creator of these Virtual Health worlds has been immersed in higher education since 1999. In 2002 he graduated
with a Bachelor’s degree in Theater Arts and Writing. Eight years later he earned his second Bachelor’s degree, in Media Arts and Animation. He has worked for USF since 2008 and is currently finishing his Master’s in Education and deciding on pursuing a doctorate with a focus on his continuing work in virtual education design.
“Fundamentally I’m a designer. Everything I build has a very distinct look and feel to it. It not only needs to be completely sound as an educational tool, but ascetically it must meet a certain criteria. If it looks bad, it is bad. No matter how amazing a tool may be, if it doesn’t have a clean and usable design, and isn’t something that actual people can interact with than it is a failure. When I build virtual people and the world they interact with, I work with graduate students and I take into account their input on everything level in order to enhance authenticity and realism in every detail from the characters personalities to the various medical instruments that would be in the room they are meeting in.”
Simulation and USF Health Students
In 2014 Joshua collaborated with Ariel Penaranda, a med student in the SELECT program. Ariel was recruited as a recommendation from Dr. Vinita Kiluk, who runs the 3rd year primary care rotation. Over that summer they worked to improve the smoking cessation simulation. Immediately it became clear that collaborating with students was incredibly beneficial and showed Josh that he needed to bring more students on board to take his simulations to the next level.
By the time Pharmacy students reach their fourth year, they have completed all of the required curriculum, so they spend their final year on several rotations that have them moving between different specialties within the pharmacy field. Josh worked with a few students recommended by Dr. Jaclyn Cole and Dr. Melissa Ruble, who teaches the Pharmacy Skills I course, to update and repair that simulation before it was ran for the fourth time. Within six weeks of reviewing scripts and deconstructing the character, the interactions were far better equipped than it had been since its inception three years earlier. There was a sizable drop in the error rates that the class doing the simulation had experienced which proved that this kind of design process had merit.
“A lot of the time educational simulations aren’t designed with a particular passion for the human angle or the story that goes into it. When we redesigned the character used for the Prescription Encounter simulation it became clear that working with students who are the peer group of the people that are using the simulation was the key to bringing depth and authenticity to it.”
During the process of improving the character created for the Prescription Encounter simulation, Josh was introduced to Dr. Rachel Franks who teaches the Over the Counter class in the 3rd year at the College of Pharmacy. Between August and December he began to working with students in the next few rotations to create the first eight OTC characters and in early December presented the simulation concept to Dr. Franks, Dr. Puja Patel, Dr. Radha Patel and Dr. Olivia Pane. Promising them that it would be ready the simulation ran for the first time at the end of the 2015 spring semester with 14 characters, and the design work of 15 fourth year students. Total creation time from concept to execution was 8 months.
In the subsequent years in addition to designing new characters and spreading out the review and repair process to all four VSP projects 100 different students from 11 professors have worked on the VSP project. The OTC project for example has now expanded to 21 characters and over the three years that it has been run has seen a steady decline in errors and other issues that plagued the earliest efforts in virtual simulations dating back to its inception in 2010.
The Virtual Patients and How They're Created
The foundation of every single virtual character is its character bible. Josh’s background in theatre arts and writing helps him to create patients with very diverse backgrounds. These simulated patients then evolve based on the details present in their character bibles. Some demographics included in these bibles are name, age, socioeconomic status, education level, medical conditions, medical allergies, current pharmaceuticals, and a brief biography. All these things are then used by Josh and the students to mold the way that the character answers any question. For example, one of the OTC characters is a hypochondriac mother who takes her child to the doctor as soon as he sneezes. Another is a Canadian tourist who spent too much time on the beach, and then there is the club hopping college student who has way too much self-esteem. Each one of these patients has a unique perspective which enhances the interaction between patient and student.
There are two types of characters in the simulations. First there are light background characters like the OTC characters who require specific details about their lives that help authenticate personality and emphasize medical issues. Second are the deep background characters like Courtney Appletor, the smoking cessation character, and Robert the Alzheimer’s character. Courtney’s character bible is 20 pages long with four dedicated to her, and the rest dedicated to the various people in her life that she mentions. She can cover subjects ranging from her relationship with her four best friends, to the stress in her life caused by her helicopter mother who would probably eat her alive if she knew that she was a smoker. Robert on the other hand has an equally specific character bible, which has very specific details about the many issues he has manifested lately that may be strong indicators that he is suffering from early signs of a form of dementia that may be Alzheimer’s.
The review and repair process evolved to identify and repair holes or flaws in the characters’ knowledge, or further solidify the characters’ ability to handle questions presented by a growing multitude of users. Keeping continuity is the most important aspect from the perspective of the users. While the simulation itself is very complex it doesn’t actually understand context. For example, you could start a conversation with “goodbye” and the character would not know the difference, so any and all continuity and context flows entirely from the individual user.
“It has been my observation that everyone has their own specific way of asking just about any questions. The ultimate goal of the design process is to have as many students as possible speak to the avatars in order to find as many different ways as possible to ask similar questions. I often liken it to the game Jeopardy. The characters speeches are the answer, and it’s our job to come up with an always growing list of questions that will fit that answer. Also when asked if I’m sure the students are asking the right questions and giving the right advice, I usually respond. If 9 out of 10 students agree that a solution is the correct one after going through the entire curriculum then I’d bet my health that what they’re suggesting is correct. I trust our professors, and I trust our curriculum. You can’t trust both of those implicitly and not trust our students who have learned from both.”
Almost every week throughout the school year Josh meets with students to review, update and further develop the virtual humans he has created. The process, which started out as a chaotic attempt at making virtual people “real”, evolved into a finely tuned pipeline that has seen an ongoing rate of success.
The Simulations’ Effectiveness
The effectiveness of the simulations is measured in how well the characters respond to students who are interacting with these virtual humans in classroom environments. Since 2010 Josh has been collecting and reviewing simulation transcripts in order to improve their responsiveness, but to also identify knowledge holes and improve overall continuity. Through this process of review and repair issues with the characters and the overall simulation have been identified and addressed within the design process.
“When I look at the error and response data for Angie I can clearly see how effective the process has become over the life of this project. The first year we ran Angie she was built at haste in the last three months of the development phase in order to have enough avatars ready in time. The second year, we fixed a majority of her larger issues at understanding the questions of the students. That can be seen in the significant drop in the number of unanswered questions. This year with the massive updates to the characters overall personality and motivations all the numbers in all three indexes dropped and that is all due to the valiant efforts of the 100 students who have worked with me on this and all my design projects over the better part of this decade.”
Looking to the Future
“Bringing a human aspect to something that has no more humanity than a cell phone or a toaster has been and is the goal of pretty much everyone working in the field of creating relatable simulations. Every single day we become more intertwined with our technology, and simulation technologies such as these being created and implemented by USF are the educational distant cousins of technologies such as Alexa, Siri and Watson. While they may lack the sophistication of those well-known responsive technologies the principles back them up are the same. Bridging the uncanny valley between what is real and what is artificial, our students are able to make relatable characters that are used by their underclassmen as reflective learning tools.”
Moving forward the simulations that have been created will continue to evolve into new and more advanced simulations in multiple complex platforms. Fully utilizing the virtual environments they will be more interactive, and contain a level of realism that up to this point has only been part of a wish list down the road. Ultimately the designer would like to see the OTC simulation become a standalone application that will place our students into an immersive version of the Pharmacy Plus which exists in the real world in our Morsani Center for Advanced Healthcare.
“Students have a hard enough time practicing various parts of their craft in real world situations, and I like to create safe spaces for them to use the skills that they’ve already got. If they can open one of my simulations, which will randomly pull four or five of the characters we’ve created each time it’s opened, the laws of probability state that it’s very unlikely they’ll have the same experience twice. Just like in real life they’ll encounter a person with a problem, ask a series of pertinent questions and then render a reasonable solution to whatever health crisis.”