Game Changers? Time Will Tell.

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic, ADEA President and CEO, looks at two trends that are paving the way for individualized learning—virtual reality and serious games.

If you subscribe to The New York Times, you may have recently received something curious in the mail: a sturdy cardboard box with oddly shaped cutouts, strategically placed Velcro tabs and two plastic lenses. The Google Cardboard viewer is remarkably similar to the 3-D viewers that have been around since the dawn of photography, but with one important distinction: Instead of a slot for slides, the box contains a space for a smart phone. Download a virtual reality app such as NYT VR, call up a video on your smart phone and you can use the box to immerse yourself in a virtual world. Look right. Look left. Gaze up. Gaze down. Turn around, and your view continues seamlessly in every direction. Not only is the image before you three-dimensional, your view has no boundaries, like the world itself.

In education, we’ve been using the term “virtual reality” for years to describe artificially created experiences that simulate real-world conditions and allow learners to practice their skills. Role-playing activities of all sorts—even those that were merely text-based or incorporated only still images—once earned this moniker, but as time has passed, we increasingly use the term to denote digital technologies, especially those that strive to replicate the look and sound and even the tactile sensations of an experience.

In 2003, Second Life—the web-based world where many universities and a few dental schools established virtual outposts—began allowing users to log in from their computers and socialize, learn and conduct business with people across the globe. Today, if you’re willing to spend some serious money, the Oculus Rift and its Touch controllers will give you a much more engaging virtual-reality experience. Although the technology is primarily used to play video games at present, some observers predict that its widespread educational applications will not be far behind. According to Fortune magazine, the U.S. military, a pioneer in the use of educational simulation and gaming, is already employing the Oculus Rift to train soldiers to use the Patriot air defense system.

While I don’t know of any ADEA members currently working with this particular virtual reality technology (if you are, please let me know), I just learned that Meharry Medical College School of Dentistry and the Case Western Reserve University School of Dental Medicine have been approved as developer sites for the Microsoft HoloLens holographic simulation technology, which may someday help students visualize anatomic structures and surgical techniques. I’ll be keeping my eyes on that project, slated to begin later this year.

Meanwhile, the use of nonholographic simulation is well-established in dental education and in recent years has become more sophisticated. DentSim—manufactured by ADEA Corporate Member Image Navigation Ltd.—and the other augmented-reality dental-training simulators on the market introduced computer visualization and assessment to traditional preclinical learning. These systems provide precise and immediate feedback—during a procedure and after it is completed—freeing up faculty and allowing students to perform more preparations than they would otherwise be able to. Since practice makes perfect, the advent of computer-assisted simulation represents a major advance over working on typodonts unaided.

The introduction of haptics—the science of integrating the sense of touch into computer applications—has added yet another dimension to simulation in the preclinical arena. ADEA Corporate Member MOOG—working with Academisch Centrum Tandheelkunde Amsterdam (ACTA), a Netherlands-based dental school—was the first to harness this technology for dental education. Their Simodont® Dental Trainer creates a simulated learning environment in which students can practice a wide range of psychomotor skills and procedures while receiving the same type of feedback provided by earlier virtual-reality simulators. Working with Novint Technologies, our colleagues at the Harvard School of Dental Medicine (HSDM) have developed an advanced prototype for another haptic simulator, the Virtual Reality Dental Training System, which may also be widely available one day.

Haptic simulators represent a significant step forward in simulation fidelity and efficiency. They eliminate the need for typodonts and manikin heads, and most everyone who has tried these systems is wowed by their ability to replicate the feel of dental instruments interacting with different types of human tissue. While some evidence suggests that students trained using haptic devices perform better than their peers, the body of research supporting the use of haptics in clinical education remains limited, and they face another barrier to widespread adoption: their upfront costs.

To get a read on this issue and other advances in learning technology, I called Elise Eisenberg, D.D.S., M.A., Senior Director of Informatics at New York University College of Dentistry, who has been following these developments for years.

“Schools want to know if a given technology will enable more efficient and effective pedagogies,” Elise told me. “Will they improve the economics of delivering education and the potential for student success?”

Even though digital simulation systems obviate the need for purchasing typodonts and other disposable items and reduce the number of faculty needed to assess preclinical performance, they are not widely perceived as affordable—at least that’s the impression of several people with whom I spoke. Issues of cost aside, Elise sees a compelling reason to bring virtual reality into preclinical and specialty education: The generation of students just now entering dental school is seeking a different type of education.

“Generation Z’s approach to learning is much more personalized, not as prescriptive,” Elise says, “and virtual reality allows for that type of learning.”

Generational learning preferences are even more salient in the latest pedagogical trend: gamefication. If you’re not familiar with the concept, this infographic provides a quick introduction. In a nutshell, gamefication is about applying the elements of game play—entertainment, competition, rewards and such—in other contexts. In the educational arena, some innovators are taking inspiration from a medium that the current generation has been steeped in almost since birth: video games.

As early as 2009, ADEA Corporate Member Nobel Biocare USA, LLC worked with a company called Breakaway Games and the Dental College of Georgia at Augusta University to release a role-playing video game called the Virtual Dental Implant Trainer (V-DIT). The game involves both interviewing patients to determine whether an implant would be appropriate and simulating implant placement, giving students a chance to practice dental implant decision-making.

In 2014, our colleagues at the American Association of Colleges of Pharmacy (AACP) undertook an even more ambitious project: the creation of a massively multiplayer online role-playing game (MMORPG) that health professions students can play to develop interprofessional competencies. Mimycx, as the game is called, places students in a futuristic health care setting. Players choose avatars to represent them on screen, and game play resembles what you would find in World of Warcraft or Grand Theft Auto. But the goal—to seek information from the right health professional at the right time to make better patient-care decisions—is decidedly rooted in the world of health care.

“Mimycx is an educational tool to meet students where they are now,” says AACP Associate Executive Vice President Ruth Nemire, Pharm.D., Ed.D., “so they can learn 24/7, so they can learn from each other and so they have a safe environment in which to learn.”

AACP created the game in partnership with the Virginia Serious Games Institute (VSGI), based at George Mason University. Three schools are currently using Mimycx on a research basis, and the partners hope to market it widely, offering it to schools via an enterprise license or directly to students in the same way electronic textbooks are sold. According to VSGI Founding Director Scott Martin, “What we hope is that as more students have access to the game, they will find teammates anywhere in the world who are using it at the same time, just as they would with standard MMORPGs.”

Social interaction is a key element in games, as Elise Eisenberg pointed out when we spoke, so it makes sense to create virtual environments where learners can engage with one another. “I don’t know of anyone currently creating MMORPGs specifically for dental education,” Elise told me, “but it’s not far away.”

In the meantime, I know of at least two dental schools that are harnessing the appeal of digital games to help their students with knowledge acquisition and review. One of these is the University of Pittsburgh School of Dental Medicine, where Associate Professor of Oral & Maxillofacial Pathology Elizabeth Bilodeau, D.M.D., M.D., M.S.Ed., has developed the University of Pittsburgh Dental School Pathology Game. As with most inventions, this game was developed to solve a problem. Elizabeth observed that students typically performed poorly on image-based exams. Their inability to distinguish conditions by their appearance suggested to her that many students would have difficulty applying their oral-pathology knowledge in a clinical setting.

In response, she created a digital oral pathology atlas, working from a colleague’s rich trove of 2×2 slides that no one was using anymore. To get students to take advantage of this resource, she turned the atlas into a game, with a leader board listing top scorers to motivate players to practice and improve their scores.

“I think there’s a lot of promise in gamefication,” Elizabeth told me, “but I’ve learned it’s incredibly challenging to do it well.”

She says creating the pathology game has been a labor of love, and with students handling the programming, it has also required time and patience. Nevertheless, she remains upbeat about the potential of games and other digital initiatives.

“These tools create a safe environment that simulates the clinical environment,” Elizabeth observes. “Students can fail, and you can actually let them fail. There’s a lot to be said for that.”

Michelle Robinson, D.M.D., M.A., is also enthusiastic about the potential of digital games to enhance dental education. The Associate Professor and Associate Dean for Health Information and Business Systems at the University of Alabama at Birmingham (UAB) School of Dentistry recently developed a game for residents in periodontics. Using the Kaizen (Japanese for “continuous improvement”) platform developed at the UAB medical school, Michelle created an online knowledge-review game to prepare the residents for a mock standardized exam. New content was released each morning, and students who played the game daily were rewarded with extra points. The students’ regular practice appears to have paid off. Michelle told me the program director was “floored” by the improvements he saw in exam scores and plans to use the game again next year.

Michelle and her colleagues are analyzing the data they’ve collected and plan to publish it, so I’ll let them share the details with you later, but I want to mention one other observation she made. Students’ use of the game eliminated the need for faculty to conduct general review sessions prior to the exam. As a result, faculty could spend review time answering questions that arose when students played the game.

As Michelle put it, “If technology means your face-to-face time is more valuable, then that’s even better.” Makes sense to me.

Will digital games and virtual reality bring us closer to a future in which learning can occur anywhere at any time, and effectively prepare our students for clinical practice? The jury is still out, but it certainly appears that we’re headed in that direction, and forthcoming research will help us determine how far away that future lies and what types of detours we may take along the way.

Meanwhile, I applaud our colleagues—in industry as well as academia—who are investing their time and energy in breaking new ground. Only through experimentation, bringing new technologies to market and vigorous research can we learn whether it is possible to realize the promise of virtual reality and gaming.

Related content from previous issues of Charting Progress

New Buildings Support the Use of 21st Century Tools

Is Dental Education Ready for MOOCs?

Perhaps Old Dogs Can Learn New Tricks 

The Not So Distant Future: Dental Education in 2050

Catching the Waves of e-Learning and Distance Education

See also the Spring 2014 ADEA CCI Liaison Ledger: eLearning

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