EXPERIENCES WITH A SIMULATED LEARNING ENVIRONMENT-THE SIMUSCAPE © : VIRTUAL ENVIRONMENTS IN MEDICAL EDUCATION

Simulaton as a tool for medical educaton has gained considerable importance in the past years. Various studies have shown that the mastering of basic skills happens best if taught in a realistc and workplace-based context. It is necessary that simulaton itself takes place in the realistc background of a genuine clinical or in an accordingly simulated learning environment. A panoramic projecton system that allows the simulaton of diferent scenarios has been created at the medical school of the Westphalian Wilhelms-University Muenster/Germany. The SimuScape is a circular training room of six meters in diameter and has the capacity to generate pictures or moving images as well as the corresponding background noises for medical students, who are then able to interact with simulated patents inside a realistc environment. About 1,000 students have been instructed using the SimuScape in the courses of emergency medicine, family medicine and anesthesia. The SimuScape, with its 270°-panoramic projecton, gives the students the impression “of being right in the center of acton”. It is a fexible learning environment that can be easily integrated into curricular teaching and which is in full operaton for 10 days per semester. The SimuScape allows the establishment of new medical areas outside the hospital and surgery for simulaton and it is an extremely adaptable and cost-efectve utlizaton of a lecture room. In this simulated environment it is possible to teach objectves like self-protecton and patent care during disturbing environmental infuences in practce.


INTRODUCTION
The role of simulaton in medical educaton has considerably increased in the past years, as there is a rising demand for a skills-oriented medical tutoring on the one hand, and a rising consciousness about patent safety on the other (Okuda, Bryson, DeMaria, Jacobson, Quinones, Shen et al., 2009;Ziv, Wolpe, Small & Glick, 2003).This concept comprises, among other aspects, the integraton of simulators and simulated patents.We know from the feld of cognitve psychology that the retrieval of knowledge and its applicaton functons best, if taught and practced in a realistc and workplace-based context that ofers students the opportunity to gain clinical skills and experience (Bransford, Brown & Cocking, 1999;Issenberg, McGaghie, Petrusa, Lee Gordon & Scalese, 2005;Weller, 2004).Furthermore, a workplace-based training scenario has been shown to be an important factor for higher learning-outcomes when mastering clinical skills (Byrne, Pugsley & Hashem, 2008).
The advantages of medical simulatons are that the student is becoming the focal point in the educatonal process, unlike during clinical care, where the patent is in the main focus and learning is rather a by-product (Kneebone, Arora, King, Bello, Sevdalis, Kassab et al., 2010).Furthermore, the student is allowed to make mistakes without causing harm, which is regarded as a very powerful learning experience (Arora, Sevdalis, Nestel, Tierney, Woloshynowych & Kneebone, 2009;Ziv, Ben-David & Ziv, 2005).Students are able to further focus on mastering basic skills and gaining a degree of competence without the c omplexites of dealing with real patents.(Weller, Nestel, Marshall, Brooks & Conn, 2012) An environment is required that meets the demands of providing an efectve educaton without endangering patents (Kneebone, 2005) and it is important to allow medical educaton take place within the realistc context of a genuine clinical or in an accordingly simulated learning environment (Donaldson, 2009;Khan, Patson & Sherwood, 2011;Koutantji, McCulloch, Undre, Gautama, Cunnife, Sevdalis et al., 2008;Moorthy, Munz, Adams, Pandey & Darzi, 2005;Undre, Sevdalis, Healey, Darzi & Vincent, 2007).The integraton of a virtual learning environment in the curriculum provides the f-protecton, coping with disturbing environmental distractons as well as the generaton following advantages for the educaton of medical students: • Establishment of new medical areas outside the hospital and surgery for simulaton • Teaching aims like self-protecton, coping with disturbing environmental distractons as well as the generaton following advantages for the educaton of medical students: • of relevant informaton from the surroundings can be taught in practce • Extremely adaptable and cost-efectve utlizaton of a lecture room In order to establish the necessary authentc learning environments it is important to reconstruct all possible clinical situatons, which may include house calls or emergencies in public setngs.Many atempts have been made to provide a variety of simulaton environments, including Kneebone et al. (2010) who have developed an infatable environment where pull-up banners with photographs of clinical equipment are used in order to implement reality.Another project located in Rovaniemi/Finnland is the "ENVI -Virtual Center of Wellness Campus", a constructon that consists of four rooms where students can practce seamless co-operaton during the entre healthcare process, from the scene of an accident over to a virtual hospital, and lastly the rehabilitaton facility (ENVI, 2010).A slightly diferent approach was done at the Wide Area Virtual Environment (WAVE) in Maryland which focuses on the creaton of a virtual setng.It is a large-scale simulator designed to train medical teams in batlefeld and natural-disaster scenarios with three-dimensional (3D) images displayed on three vertcal screens.Team members are able to interact with each other and real equipment within a large area of 743 square meters (WAVE, 2012).
These projects however have many disadvantages; some require a lot of storage or space, others have very limited possibilites, and additonally with regard to the size and the technical equipments most can be assumed to be very costly.While there are an abundance of possibilites, their respectve approach is difcult to implement both logistcally and fnancially.This is why the Faculty of Medicine in Muenster/Germany has contnued to search for ways to present the numerous varying surroundings in beneft of medical educaton outside the usual confnes of day centers and hospital wards.Therefore, we describe the implementaton of the SimuScape © .

SIMUSCAPE © DEVELOPMENT
In the course of this project and in cooperaton with the "Fraunhofer-Insttute for Computer Architecture and Sofware Technology (Fraunhofer FIRST)", a panoramic projecton system that allowed the simulaton of diferent scenarios, such as an intersecton or a park, has been developed for teaching purposes.Furthermore, for the projecton of any learning environment new techniques for recording and reproducing have been established.The simulaton is generated with pictures or moving images and corresponding background noises.
In additon, it is necessary that the panoramic projecton is wide enough to allow a broad view of the simulated environment as it has to provide the possibility to augment the generated area with simulated patents or simulators.
A circular training room of six meters in diameter has been created in the premises of the Studienhospital, giving students with its 270°-panoramic projecton the impression "of being right in the center of acton" (Figure 1).The cylindrical building extension comprises an area of about 25 square meters.The screen has a diameter of 6m and a height of 2.3m.The resultng length of the curved projecton is 14.43m and the recorded image has an aspect rato of 6.14:1.The resultng overall resoluton of the panoramic image or video amounts to 3968 x 640 pixels.The remainder of the simulated area (foor, walls, etc.) is designed in black.Suitable materials such as carpet on the foor and curtains on the walls were chosen in order to absorb as much noise as possible.Due to the large diameter of the projecton area, the students and the simulated patents are able to walk and act freely within a circle of 3.5m in diameter.Outside this range they are partly situated in the projected beam, with the result that they may cast shadows on the screen.

Stll Images
Seven projectors are arranged in a cluster in the projecton system.Standard DLP projectors with Short Throw Focus (Optoma ex525ST) have been installed in a height of 2.8m and arranged in a ring with a diameter of 1.2m with a distance to the center of the rotunda of 0.9m.Each projector is installed upside-down and bent slightly downwards.The segments of the photos, taken with a digital camera, are tuned accurately next to each other and are distributed to the projectors.The sound that matches the simulated environment is provided by a 5.1 sound system.

Recording
For the recording of simple images of real-world environments, real scenes of streets, intersectons or parks have been depicted with a camera.Depending on the scenario, people can be seen in the recorded images, for example in the background of a road accident located in the city.When flming in public areas the legal situaton in Germany allows for the photo and video material to be used, even if people are depicted on it.However, it should be ensured no scenes are used for teaching units, in which people are shown in embarrassing situatons.

Video Editng
In contrast to stll images, the producton of surround videos has proven to be more complex.For the recording of the learning environments a camera system has been purchased that corresponded to the need for a simple handling.The acquired camera (Ladybug3; PTGrey, Vancouver, BC, Canada) is a spherical digital video camera that only requires a single laptop for video capturing.The camera itself has a diameter of 12.2cm and a height of 14cm and is also water resistant, meaning it can be used during rain.The externally supplied sofware that accompanied the PTGrey-camera produces video fles with a resoluton of 5400 x 2700 pixels.The area required for the projecton secton (270 x 42 degrees) corresponds to a resoluton of 4000 x 656 pixels, which is compatble to the required resoluton of the projecton system.The Ladybug3 is similar to the cameras used for Google Street View and able to generate a 360 degree image by taking six single videos at once when positoned in the middle of a scene.In concurrence to the video capture, a tme-synchronous sound recording is realized with an external surround microphone.In a subsequent step the sound is added to the video.The camera saves the PGR compressed raw material on a hard disk which is converted into a series of frames during the following ofine-procedure.The program (LadybugCapPro; PTGrey, Vancouver, BC, Canada) is provided by PTGrey for this process.It is further necessary that these image series are cut and encoded into a flm.Optonally, subsequent cutng with Adobe Afer Efects and Adobe Premiere is possible.
Finally, using Adobe Afer Efects, the frame rate from the camera is converted to a higher frame rate to create a smoother video experience for the learner.All these separate procedures are composed in a workfow for an entre panoramic flm.
Altogether, the workfow is structured into the following parts: • Capture of video with the Ladybug3 camera and recording the sound with a surround microphone on a laptop.A clapperboard is used to assist in the synchronizaton of picture and sound and to mark picture intakes, the manual synchronizaton of the video and audio data is performed in postprocessing • Creaton of single images from the raw data using "LadybugCapPro".Optonal use of diferent calibraton data for scenes with either close or distant objects • Cropping (cutng of the desired image area), as well as video and audio editng in Adobe Premiere • Export of single image sequences and surround audio with Adobe Premiere • Encoding of the video from separate images in the M2v video format fle • Creaton of a show by the Sofware "ShowManager" that is able to play the video.This sofware enables the constructon of shows from diferent elements (videos, stll images, audio) and the whole projecton cluster can be started and controlled.
For the development and concepton of the installaton and the synchronized reproducton of the video, two programs are required.The ScreenConfgurator sofware which additonally has an auto-calibraton system through cameras, has proven to be efectve for the planning and setng up of the installaton.However, for the synchronized play out, the ScreenPlayer is used which further handles the geometric correcton and the blending on the client computer.

Cost Calculaton
The overall cost of the project has amounted to 110,000 Euro (142,000 USD) (Table 1).

IMPLEMENTATION
Untl the present tme, the Studienhospital Münster® and the representatves of the courses in emergency medicine and family medicine have acquired more than three years of experience with the projected learning environment.Approximately 1,000 students have been instructed using the SimuScape © (Figure 2) in the courses of emergency medicine, family medicine and anesthesia.Accordingly, the SimuScape © is in full operaton for a total of 10 days per semester (i.e.20 days per year), which allows for practcal situatons of the diferent courses to be carried out in a nearly realistc environment.The remaining tme is used for technical development, recording of scenes and the generaton of content.The use and applicaton of the SimuScape © is uncomplicated for the lecturers.Afer consultaton with the Studienhospital, a scene is produced within 3-7 days with photo or flm.The scene is subsequently operated manually and easily by the lecturer during the teaching units.This provides the possibility to mediate certain teaching aims, such as staf safety in the event of an emergency in an "actvity-oriented" context.In the specifc scenario of road trafc emergency one student performs the role of the emergency doctor and two other students act as paramedics assistng him.On the projecton area of the SimuScape © an ambulance is visible which has earlier driven into the scene, as well as fast moving cars in the background.Additonally, the loud honking of the cars which cannot drive past the accident can be heard.The students' task is twofold: First to save the patent, represented by a mannequin, and secondly manage the scene of the accident adequately to ensure staf safety.This is achieved by placing portable warning triangles around the scene of the accident, or in an extreme case, frst removing the patent from a dangerous situaton such as a highway.The images of the fast driving cars underlined by acceleraton noises and the sounds of the blowing horns provide a higher level of stress for the students than an exercise in the normal surroundings of a classroom.Post performance, the student has the possibility to express his impression of how he has felt in the situaton and feedback is provided by the students and instructor who have watched the scene.To support the realistc applicability of each scene, the incorporaton of a pre-history in the respectve video sequences has been included.For example, an arriving ambulance has been integrated into the flm making it possible for the lecturer to explain the acton more pictorially.In this case the sequence of events is accurately planned for recording purposes and when actors playing patents or other people appear, a script is created.As a result, a man can be seen falling of his bike in trafc and a few minutes later the ambulance arrives accompanied by the sound of sirens.The student, in the role of the emergency doctor, has to take care of the patent in the middle of loud trafc noise and disturbing spectators.
Meanwhile, promising atempts have been conducted at integratng simulated patents into the scenes.The high value of these simulators is that they enhance the students' acquisiton of communicaton skills as well as provide constructve feedback from the patent perspectve (Kneebone et al., 2010).According to students frst impressions, their atenton is primarily focused on patents and thus is being distracted from the environment, which is a very positve outcome as in real life the patents wellbeing should always be paramount.However, sometmes it may prove difcult to focus on a patent as required being that there is many distractng noise and movement from trafc or by-passers.The SimuScape© allows for the practce of ignoring distractng sounds or motons during an emergency.Another factor in proper patent care is that in some cases the surrounding area can be very important in gaining benefcial background informaton.With the SimuScape©, the possibilites of creatng diferent environments are numerous.Simulated patents can be included and case-specifc details can be added.For example; a container of plant poison in the background setng of an unconscious person in order to provide further disease-related informaton.Further examples for the use of simulated patents and stll images as backgrounds are the scenes of a graveyard and the unusual scenery of a toilet at the train staton.In one case a graveyard can be seen in the background and an aged lady collapses on a bench afer tending a grave (Figure 3).In the other scene the restricted space of a toilet at a train staton is visible and the students have to take care of an unconscious drug addict.In both cases the student has to gain informaton from the context of the scene and care for the patent preferably according to the possible cause -hypoglycemia afer too much exercise in one case or an overdose of drugs in the other.

Figure 3. Student takes care of a patent on a graveyard
The SimuScape © also ofers opportunites to enhance the learning of students beyond its role in depictng prehospital clinical environments.For instance the course "self-awareness" takes place at the simulated environment.Based on edited images, students are able to experience how elderly people feel who are limited by an eye disease.The broad projecton area makes it especially possible for the students to get a realistc impression.One can understand this as important, with empathy and compassion increasingly emphasized in medical didactcs.
Additonal impressions from the students have been obtained from the EVALuna evaluaton system.The online evaluaton of each course via the EVALuna system (Binary Design GmbH, Muenster) is a requirement for the registraton of exams at the Medical Faculty of Muenster.
The system guarantees anonymous evaluaton of each curricular course and students are asked to evaluate the teaching units on a visual analogue scale from 1 ("very good") to 100 ("very poor").In additon, there is the possibility to enter comments in free text form.The results are regularly published and visible for students and lectures.As the students are asked to evaluate the courses specifcally, we do not have data directly asking for an evaluaton of the SimuScape©.However, in the courses were the SimuScape© has been used, we have received numerous free text comments in favor for the simulated environment: "The part in the SimuScape was awesome, I felt like actually being at the scene of an accident", "It's a pity not more courses take place at the SimuScape" and "It's a great preparaton for clinical practce", just to name a few.Further comments are that the scene feels "real" and they don't think the situaton has been only a teaching unit while involved in the generated scene.In additon, some felt really "excited" and "nervous" and they take their task very seriously.Moreover, the students learn that the environment plays a large role as a possible distractor, principally when loud noises from the trafc are present.A small questonnaire evaluatng the self-assessment of students has been carried out in the winter semester of 2010/2011 in which cardiopulmonary resuscitaton (CPR) has been taught in two groups; one group in a conventonal classroom (n = 37, control group), and the other group in the SimuScape© (n = 62, interventon group).In total 99 questonnaires have been obtained.In the survey, the students were asked to provide a self-assessment by answering eight questons on a 5-point Likert scale ranged from 5 (strongly agree) to 1 (strongly disagree).Means and standard deviatons were calculated as descriptve parameters.T-tests were used to test the diferences between the groups, the level of signifcance was defned at p ≤ 0.05.The statement "The course was fun" has reached a signifcant level (p < 0.01) in the group that has been taught in the SimuScape© (4.37) compared to the control group taught in the classroom (4.03).Other items, for example whether the students feel that they have learned something (control group 4.22, interventon group 4.35; p ≥ 0.05) or whether they feel secure in applying CPR (control group 3.32, interventon group 3.48; p ≥ 0.05) have reached a higher level of acceptance for the group trained in the SimuScape©, however, they did not reach a signifcant level.Some lectures have stated they had the impression that students have taken the situatons carried out in the SimuScape© more seriously than when played in the classroom.Due to the easy handling of the SimuScape©, lecturers are not hesitant to instruct using this facility, on the contrary, increasing requests to teach using this simulated environment are being observed.

DISCUSSION
As already mentoned, various other projects exist that deal with simulated environments.The ENVI project combines physical environments and simulaton mannequins with immersive full-scale 3D simulaton projectons.On top of all, an input device exists that is used to move through the scenarios, open doors or switch lights on and of.(ENVI, 2010) However, with all these technical devices there is the risk that the students concentrate more on maneuvering through the virtual reality, rather than focusing on the patent.A negatve consequence might be that the educatonal emphasis for course developers becomes overly focused on fdelity and less on the learning objectves.With the SimuScape© it is noted that students as well as lecturers include the simulated environment at the beginning of the scene in their range of atenton, however, this efect lessens with every minute of the simulaton so that no further interference efects are registered, unless intentonal.Another substantal disadvantage of the ENVI project is the space required by its constructon and the cost of such a project.The limitatons of the infatable environment by Kneebone are that only hospital setngs can be realized.The WAVE project on the one hand allows for training of medical teams in diferent scenarios but on the other hand limits the focus to teaching non-students in batle feld scenarios (WAVE, 2012) rather than educatng medical students.With the SimuScape©, a learning environment has been created which can be used fexibly, is changeable when necessary and can easily be integrated into curricular teaching.This enables the presentaton of diferent aspects of medical acton beyond the outpatent and inpatent area in a realistc manner.In the projected learning environment of the SimuScape©, medical students can respond actvely in realistc situatons, which has a high impact on the motvaton for the respectve course, as well as the lowering of the threshold for certain practcal actons.The feeling that a scene is not real dissipates with corresponding pictures or videos accompanied with sound and the student is able to put himself more in the situaton.

Limitatons
Problems in the creaton of stll pictures or videos occur when the individual images, which display a panorama, show moving objects.If people appear on the edge of the picture and move to the corresponding picture, they cannot be found in the previous body posture as the sofware has limits.The automatc superimposing of the images results in the efect that only half of the presented body or object can be seen.However, it is important that this does not happen or the representaton of the reality would lose its credibility.Accordingly, too many changes from one camera image to the next should be avoided and the material in which this efect occurs should not be used.Furthermore, it is important that each reality-refectng image presents a natural pictureexcerpt.This means in partcular that the respectve surface -whether it is grass, asphalt or carpet -are in clear view.Only when this circumstance is provided, the human eye is able to add the surface of the SimuScape © to the projecton, resultng in a realistc impression.Further restrictons are visible during recording.Scenes, in which both proximate as well as distant objects are visible in the overlapping area, cannot be displayed sharply in the whole image.These blurring's (parallax faults) can be partally corrected in the post-processing.Educatonal challenges concern primarily the integraton of practcal actons that have earlier taken place in the classroom into the rotunda of the SimuScape © .The students task is stll to focus on the patent, however, now the students must also observe their surroundings in order to establish clues to what has most-likely happened to the patent or to simply secure the place of the accident.This "mult-tasking" is a new feature of teaching and it is the duty of the instructor to observe whether the student heeds atenton to all aspects of the scene while saving the patent at the same tme.Furthermore, because of the limited space in the rotunda of the SimuScape © , only a restricted number of students can act in the scene.In rare cases it may happen that a student obstructs the projecton beam, thus castng a shadow on the screen.However, such an incident occurs very seldom as the focus of the plot is in the middle of the rotunda in a relatvely large diameter.Even if a student would briefy obstruct the projecton beam, he probably wouldn't notce it as his atenton is primarily on the patent.

CONCLUSION AND PROSPECTS
Our experience with the SimuScape © has shown that its implementaton in medical teaching gives students a unique opportunity to apply their acquired skillset in a realistc environment.As constant practce is essental for provision of professional help in a real emergency, the SimuScape © provides benefcial training for medical students.The tme consuming producton of the photo or flm sequence is easily compensated for the high fexibility of the applicaton.The SimuScape © requires only one training room that is utlized through changes of setngs in many diferent ways.Afer a certain tme, an archive of various images and videos is obtained, so that it won't be necessary to create a new projecton for each teaching session.Moreover, rare environments such as dangerous workplaces in the industry can be created.
For the implementaton of a virtual environment such as the SimuScape © we highly recommend paying atenton to the appropriate usability because this is crucial for the extent of how ofen such a resource is used.Videos are basically what consttute the SimuScape © .Images could also be displayed in other ways (i.e.photo walls), but even in this case the advantage lies in the possibility of the rapid changing of images.The SimuScape © ofers the opportunity to learn how to act professionally under unfamiliar and ofen unfavorable conditons in a protected setng.To evaluate the full extent of the efect of the simulated environment on teaching objectves, formal study data are needed.A randomized controlled trial to compensate for these defcits is planned.

Figure 2 .
Figure 2. Students are able to interact with simulaton patents within the SimuScape ©

Table 1 .
The remaining costs of about 19,000 Euro (24,500 USD) have been used for structural changes of the rotunda.Cost diferentaton of the SimuScape ©