1.DOI: 10.1111/j.1471-1842.2007.00733.xSecond Life: an overview of the potential of 3-D virtual Blackwell Publishing Ltd worlds in medical and health education Maged N. Kamel Boulos*, Lee Hetherington & Steve Wheeler, *Faculty of Health and Social Work, Institute of Digital Art and Technology and Faculty of Education, University of Plymouth, Plymouth, UK Abstract This hybrid review-case study introduces three-dimensional (3-D) virtual worlds and their educational potential to medical/health librarians and educators. Second life (http://secondlife.com/) is perhaps the most popular virtual world platform in use today, with an emphasis on social interaction. We describe some medical and health education examples from Second Life, including Second Life Medical and Consumer Health Libraries (Healthinfo Islandfunded by a grant from the US National Library of Medicine), and VNEC (Virtual Neurological Education Centredeveloped at the University of Plymouth, UK), which we present as two detailed case studies. The pedagogical potentials of Second Life are then discussed, as well as some issues and challenges related to the use of virtual worlds. We have also compiled an up-to-date resource page (http://healthcybermap.org/sl.htm), with additional online material and pointers to support and extend this study.high-resolution avatar that can be nely customized Introduction to the nth degree. Second Life also has a thriving A virtual world is a computer-based, simulatedeconomy that currently boasts millions of US dollars multi-media environment, usually running over the in monthly transactions via the in-world unit-of- Web, and designed so that users can inhabit and trade, the Linden dollar, which can be converted to interact via their own graphical self representa- US dollars at a number of online Linden Dollar tions known as avatars. Linden Labs (http:// exchanges.1,2 lindenlab.com/) Second Life (http://slife.com/) is The popularity of Second Life is well deserved perhaps the most popular virtual world platform thanks to its host of advanced technologies (e.g. in use today, with an emphasis on social interactiona unique in-world weather system, with realistic (other platforms also exist, e.g. Therehttp:// daynight cycle support)3 which, combined, place www.there.com/ and Active Worldshttp://it well above all other virtual world platforms on activeworlds.com/). the market today.The population of Second Life has more than Three-dimensional (3-D) virtual worlds like doubled since January 2007, and, as at 2 MaySecond Life can be considered as 3-D social net- 2007, has reached more than six million virtual works, where people can collaboratively create and citizens or Lifers, all with their own fully textured edit objects in the virtual world (like a collaborative 3-D wiki space), besides meeting each other and interacting with existing objects. (The reader is referred to Kamel Boulos & Wheeler4 for a detailed Correspondence: Maged N. Kamel Boulos, Faculty of Health and Social Work, University of Plymouth, Drake Circus, Plymouth PL4 discussion of conventional social networks and 8AA, Devon, UK. E-mail: mnkamelboulos@plymouth.ac.ukwikis.) 2007 The authors Journal compilation 2007 Health Libraries Group. Health Information and Libraries Journal, 24, pp.233245 233

2. 234 Second Life in medical and health education, Maged N. Kamel Boulos et al.Compared with the conventional 2-D Web,software driver [like Screaming Bee (http:// virtual worlds offer novel, intuitive ways to:www.screamingbee.com/)] can be optionally used navigate multi-media content (streaming audio/to hide the speakers identity, or just for somevideo/TV collectionssee, for example, Secondadded fun!Life SONY BMG Music Entertainment onThe potential of such a rich and engagingMedia Island);5experience in education must be great. In fact, real browse information spaces/document collectionsand virtual world conferences have been (andin 3-D virtual libraries (see, for example, Second are being) organized to explore and discuss theLife Medical and Consumer Health Libraries ineducational potentials of Second Life,1214 while aHealthinfo Island6described below); recent project, Sloodle (for Second Life (SL) + relax, visit new places, and sample new culturesMoodlehttp://sloodle.com/), developed a mashup(virtual tourism, e.g. visit Virtual Morocco inbetween Second Life and the popular learning/Second Life7 or Egypts pyramids and Sphinx in course management system, Moodle (http://There.com);moodle.org/). play multi-player games in the virtual world,Furthermore, in April 2007, the New Mediaincluding educational, health related games;8Consortium (NMChttp://www.nmc.org/), an buy, sell and advertise virtual and real-life goods international, US-based not-for-prot consortiumand servicesmany real-world, famous brand of nearly 250 learning-focused organizationsnames have already established a presence in dedicated to the exploration and use of new mediaSecond Life;9and new technologies, advertised the availability develop social skills (and even clinical skillsof low-cost Second Life educational sims (landsee, for example, Second Life Heart Murmur parcels with pre-built educational facilities) forSim,10described below)/socialize and interact rental to educational institutions.15 Indeed, in a vir-with other people via customisable, realistic, tual world, educational institutions and educators3-D, fully textured and animated avatars (3-Dcan create online communities that students cansocial networking);log into and interact in. Within these educational attend and participate in live events like Second virtual worlds, students can, among other things,Life lectures, conferences, festivals, and concerts; use their avatar to learn about new assignmentsand build communities, including learners and to create projects that are viewable within thecommunities and patient support groups, amongvirtual world.16,17many other things.In the next section, we describe some medicalThe latest Second Life client also supportsand health education examples from Second Life, advanced, realistic voice chat (in addition to text including Second Life Medical and Consumer chat and instant messaging), featuring 3-D-mapped Health Libraries (Healthinfo Island), and VNEC voice with audio focusing capabilities and speech (Virtual Neurological Education Centre). The gestures.11 (As a user walks around someone who pedagogical potentials of Second Life are then is speaking to them in Second Life, they will heardiscussed, as well as some issues and challenges the voice move around in 3-D, based on whererelated to the use of virtual worlds. We have also they are relative to that avatar. If the user turns compiled a companion resource page (http:// toward someone who is speaking and moves closer,healthcybermap.org/sl.htm), with additional up- the voice will get louder. Also, as each speakersto-date online material and pointers to support volume is attenuated/boosted by their distanceand extend this study. from the users camera position in Second Life, the user can thus use the camera controls to create Medical and health education examples from a momentary audio focus on a given speaker. Second Life Speech gestures are customizable head, arm/hand and body movements that animate an avatar while Second Life currently features a good number of speaking, and are triggered by different speech medical and health education projects (see the key intensity levels.) A voice-changing Windows presentation entitled Second Life in Medical and 2007 The authorsJournal compilation Health Libraries Group 2007 Health Information and Libraries Journal, 24, pp.233 245 3. Second Life in medical and health education, Maged N. Kamel Boulos et al. 235 Health Education: A Quick Visual Tour and the ways social media can be used to reach out to more section entitled Top educational locations in audiences and promote public health.24,25 Two Second Life, both at http://healthcybermap.org/ other Second Life examples, Healthinfo Island sl.htm). and VNEC, are discussed in some detail below.For example, at the Ohio University Sim in Second Life, visitors can play a Nutrition GameHealthinfo IslandSecond Life Medical and to learn about the impact fast food has on health.8Consumer Health Libraries This is achieved by allowing players to experiment with different eating styles in simulated fast-foodHealthInfo Island (http://infoisland.org/health_info) restaurants to learn about the short- and long-termand reference6 is entirely funded by a $US40 000 health impacts of their choices. The goal for an grant from the US National Library of Medicine individual player is to make healthy choices that(NLM)/Greater Midwest Region of the National will result in a high score for the game and a Network to provide consumer health information positive effect on health.18 services in Second Life.26 The NLM-fundedThe Heart Murmur Sim in Second Life10,19 is project is ofcially entitled Providing Consumer another example. Conceived by Jeremy Kemp, anHealth Outreach and Library Programs to Virtual instructional designer at San Jos State University, World Residents in Second Life (20062008). CA, USA, it provides an educational virtual worldProject partners include the Alliance Library System for cardiac auscultation training that allows(ALS), the University of Illinois Library of the visitors (clinical students) to tour a virtual clinicHealth Sciences-Peoria, the Central Medical Library, and test their skills at identifying the sounds of the University Medical Center Groningen (UMCG) different types of heart murmurs, based on sound in the Netherlands, and TAP Information Services. les from McGill Universitys Virtual Stethoscope The following description of HealthInfo Island project (http://sprojects.mmi.mcgill.ca/mvs/ is derived with permission from a personal e-mail mvsteth.htm).communication (by the rst author) that tookReaders interested in genetics should visit the place on 1 May 2007 with Carol Perryman, the Gene Pool in Second Life.20,21 This is an inter- Project Coordinator, and Guus van den Brekel active genetics lab/museum and learning area,from UMCG. Perryman is a medical and consumer featuring simulated lab experiments, tutorials and health librarian with years of experience, and also simple videos to enhance the learning experience.a PhD student at the University of North Carolina Visitors can learn about DNA and human chromo- at Chapel Hill, USA, with research interests in somes in great detail, explore a giant 3-D eukaryoticevidence-based library and information practice, cell, and play the Mating Game at a realisticand consumer health information behaviours.27 mock-up of the Augustinian Abbey at Brno, wherevan den Brekel is Coordinator of Electronic Services Mendel did his work about the laws of inheritance. at the Central Medical Library of the University The Gene Pool was conceived by Mary Anne Medical Center Groningen, the Netherlands.28 Clark at Texas Wesleyan University in Fort Worth, USA.Purpose and audienceAt the University of California, Davis, USA, Peter Yellowlees and James Cook developed andThe project is dedicated to health information in evaluated a special place in Second Life to educatevarious forms. It aims at providing training pro- people about schizophrenic hallucinations22 andgrammes, outreach to virtual medical communities, concluded in a paper they published in Novemberimportant consumer health resources, and one- 2006 that the use of Internet-connected graphicson-one support to Second Life residents. The environments holds promise for public educationtarget populations for HealthInfo Island include about mental illness.23 Second Life residents participating in identiedThe US Centers for Disease Control andin-world medical groups (e.g. groups dealing with Prevention (CDChttp://www.cdc.gov/) also have stroke support, cerebral palsy, mental health and a pilot presence in Second Life, and are looking atautism), or interested in learning more about 2007 The authors Journal compilation Health Libraries Group 2007 Health Information and Libraries Journal, 24, pp.233245 4. 236 Second Life in medical and health education, Maged N. Kamel Boulos et al.Figure 1 The NLM SIS HealthInformation Outreach Research Labbuilding in Second Life health and wellness, in addition to outside groups/encourage comfort and create a warm environ- professionals who might be interested in Secondment where Second Life residents can feel at home. Life as a platform for providing services andThe design of the library, the landscaping, and all outreach for health services.displays are intended to be accessible, interactive,and to encourage a collaborative, friendly atmos-phere. Like the Medical Library, the Consumer Description and unique featuresHealth Library showcases innovative information Healthinfo Island is run by a team of medical/ objects whose primary intent is to engage the consumer health librarians and information viewer interactively. Some of these objects lead professionals, in collaboration with an epidemi- the participant through a decision tree by using ologist, an internal medical physician, a retiredquestions, eventually providing a tailored response pharmacist, an educator in nursing, some library in the form of a Flash tutorial, a PDF document, para-professionals, and many others, to accomplish links to in-depth information, or even teleport the grant objectives.links to other landmarks within Second Life.The Medical Library is one of three main The third building, the Health and Wellness buildings on HealthInfo Island. It has three oors Center, was developed to bring patient advocacy intended to highlight health displays both insideto Second Life. To achieve its objectives, the centre and on the roof. In its current incarnation at the intends to collaborate with non-prot groups time of writing (May 2007), the ground oor serves and organizations, and to host special in-world as a showcase of different ways to offer medical meetings and events. The centre uses skyboxes, so information as content in Second Life. Education that support groups or smaller consultations are and research on medically related subjects inensured privacy.29 Second Life will be displayed in the Medical Research Besides the three main building described Room, while another room houses a Breastabove, a Health Information Outreach Research Cancer Awareness centre. The second oor is Lab building was created by the Specialized used by contractors employed by the US NationalInformation Services (SIShttp://sis.nlm.nih.gov/) Institutes of Health (NIH) to explore potentialDivision of the US National Library of Medicine applications of the virtual environment. Plans (Fig. 1). SIS is exploring Second Life as a venue to for further development of the Medical Library provide health information to special populations, include displays of historical medical images. and as a platform for testing new informationThe second main building on HealthInfo Island,delivery technologies. Their building on Health- the Consumer Health Library, looks like aInfo Island currently hosts an interface to Tox Town home. This design choice was made on purpose, to (http://toxtown.nlm.nih.gov/), an environmental 2007 The authors Journal compilation Health Libraries Group 2007 Health Information and Libraries Journal, 24, pp.233 245 5. Second Life in medical and health education, Maged N. Kamel Boulos et al. 237 health portal, as well as links to other well-known always has an answerand sometimes, even a NLM information products. SIS is working to relevant one. Chatbots are able to provide infor- bring more health information products to Secondmation in the form of a web address or Second Life, and to host a number of outreach activities inLife teleport link, results from a Google dene Second Life in the future.search, or even images on demand. A focal feature of the new HealthInfo Island is the landscaping. The Gardens and Mountains ofVNECvirtual neurological education centre Healthinfo Island provide excellent meeting spaces for large and small groups, and for collabo-Purpose and audience. The Virtual Neurological rative events and activities. For example, the islandEducation Centre (VNEChttp://www.vnec.co.uk/) hosted a Second Life Diabetes Support Groupwas developed by Lee Hetherington at the Univer- event, in which an internal medicine physician sity of Plymouth, Devon, UK.30 It demonstrates a with a strong interest in patient education partici- virtual simulated online experience, where pated in a casual question-and-answer session that people are able to actively expose themselves to was held in the beautiful mountain gardens.the most common symptoms that a person suffer- Other services piloted by the project include: ing from a neurological disability may encounter. It Trial access to Ebscos Consumer Health Data-also provides related information, events, and base and to Reuters Consumer Health News,facilities through the virtual world of Second Life. accompanied with workshops on the ConsumerThe VNEC offers an immersive, interactive Health Database and the evaluation of health experience with a unique feeling of presence31 information on the Internet. with synthetic sensations that make the user feel Collecting and presenting quality consumer like they are in another reality. Through the health resources about illness, drugs, allied/ VNEC building, users are able to select a range of alternative and complementary medicine neurological symptomsmotor, sensory, and using US, European and other resources. This balancethat animate their avatar, resulting in an includes also presenting information about effective method of limiting and restricting their freely available scientic medical research (inindependence, movement and coordination. e-books, e-journals, and online databases and The purpose of the project is to make more repositories), as well as podcast modules forpeople aware of neurological disabilities and allow on-demand listening to themed audio sessions.people suffering from a disability a place to further Providing in-world medical and health relatedtheir knowledge and understanding, offering them RSS (Really Simple Syndication) feeds. support, information and rehabilitation training. An in-world PubMed search has also been made The VNEC in Second Life aims to allow people available in the Medical Library building. with a neurological disability a second identify, Infostations: These offer an in-world search without any reality restrictions, a place for social- interface to PubMed and consumer health andizing and to be involved with activities that may patient information, trying to bridge the gapnot be possible in the real world. between the conventional Web and Second Life. The VNEC has already attracted a wide range Infostations can also be monitored from Inter- of audiences from around the world, but speci- net web pages, and interaction with live avatars cally would be appealing to neurological doctors, from the real world is possible using chat.researchers, physiotherapists, occupation therapists, Automated tours of the island to give visitors caregivers and patients, and can provide educa- information about specic services and events, tional material for family members and friends. especially at times when there is no in-world human librarian coverage.Description and unique features. The VNEC has An articial intelligence chat experimentbeen built in the form of an L-Shape, two-story dubbed Healthy is being piloted that enables building (Fig. 2), with ve main areasreception, patrons to ask health related questions in Secondofce, theatre, lecture and information point. All Life, even when there is nobody around. Healthyof the ve areas have individual features, assisting 2007 The authors Journal compilation Health Libraries Group 2007 Health Information and Libraries Journal, 24, pp.233245 6. 238 Second Life in medical and health education, Maged N. Kamel Boulos et al.Figure 2 The VNEC building in SecondLifeFigure 3 The VNEC medical theatre inSecond Life the user with information blocks describing thedoctors or other sufferers of a neurological disability location they are in and the options that arein a safe and non-restricting environment could available to them. occur.At the entrance to the VNEC, the user enters The upstairs of the VNEC represents the design the reception area that holds information regard-of a reality theatre (Fig. 3). Within the theatre, ing a range of neurological disabilities in threeusers are able to navigate around and explore formatsweb-based (URLs), uploaded podcasts, machines and operating equipment that can be and viewable videos about neurological disabilities, found in the neurological department of a hospital. rehabilitation techniques and comments fromThe theatre can be used for medical training and people who have visited the VNEC.staff awareness; this primarily is an informationThe ofce area entices the user to experience area with detailed descriptions of equipment for neurological symptoms: by selecting a chosen people in the medical profession. disability, the user is presented with informationThe VNEC also includes a fully functional about the disability and a wearable badge that oncelecture theatre for online lectures, meetings and worn will affect the performance of their avatar conferences. The lecture theatre is situated outside, (cf. Yellowlees and Cooks Virtual Hallucinationswith views looking on to the VNEC. The area has project).23 The ofce has three areas of interestpotential to stream live video, presentations and and usageconference, desk and seating for socialimages through a virtual plasma screen, which is interactionwhere the possibility to talk to real-life set up prior to the event. 2007 The authors Journal compilation Health Libraries Group 2007 Health Information and Libraries Journal, 24, pp.233 245 7. Second Life in medical and health education, Maged N. Kamel Boulos et al. 239The nal and perhaps most important area ofIndividual islands in Second Life have limitations the VNEC is the information point. The informa-on the amount of prims that can be placed within tion point advertises companies that offer support,the purchased land. In mid-design of the VNEC, help and advice for people suffering from a neuro- the project encountered the issue of using all of the logical disorder. The advertisement links the user prims that were available. As a result of this, the directly through to the chosen companys website,purchase of another island in the same region was which the user can then use to contact the company necessary that had the same amount of prims, personally or to nd out more about what the com-which would be transferred and included in an pany can offer to them in their individual cases.overall amount, allowing further development toThe VNEC Member group, found in Secondcontinue (another partial workaround could have Life, offers members regular newscasts about the been to use some prim-saving script to rez or VNEC, including events, new features and visitor resolve objects on demand when an avatar enters experiences. The group has full access to thethe immediate area, thus allowing prims to be used VNEC building, including all of its facilities, with only when needed). frequent meetings to discuss future development plans and suggestions to improve the overallDiscussion experience.The future development of the VNEC will allowThe pedagogical potential of Second Life the opportunity for medical professionals in reality a chance to enter the digital world, and beThe educational communities within Second Life involved in online consultations, advice, and medicaland other virtual worlds are growing quickly, as care in individual private rooms within Second teachers begin to see the potential 3-D virtual Life. Furthermore, by making it possible to have environments have to enhance the learning experi- a second, virtual life, the VNEC considers the pro-ences of their students. Teachers are also interested spect of people who possibly in reality have neuro-in widening access for geographically remote logical restrictions; Second Life offers a new way studentsdistance learners. The 2007 Horizon of living in an extensive virtual environment. Report from NMC and Educause predicts thatvirtual learning spaces will be adopted on a wide- Challenges and limitations. People suffering fromscale basis in education within the next 5 years.33 a neurological disorder may present with indi- This may be a conservative estimate. Students and vidual forms of disabilities, which in some casesteachers in many colleges and universities, parti- are felt as personal to the patient. Many people cularly across the USA, have already been gathering diagnosed with a neurological disability absorbvirtually on islands, for discussions, seminar it into part of their lifestyle, not seeing it as an (3-D webinar) presentations and other learning impingement to their way of life. The VNEC onlyactivities where digital materials are created, demonstrates a selection of symptoms of a neuro- stored and used.34 Second Life is proving to be logical disorder, because of the wide variety of ideal for those studying at a distance from their possible symptoms and the range of intensity,parent institution, and entry into the virtual world extent and effect variations that these symptoms seems to be a great leveller, proving a very popular may show at different disease stages.and equitable method of interaction. Second LifesOn the technical side of things, the VNEC game-based learning potential also holds great building has been built within Second Life, buteducational promise,35 although the virtual world also using additional 3-D software that has thehas much more to offer than a mere 3-D multi- capability of outputting and importing in to player game or collection of games. Second Life, at a cost. Objects imported or built Second Life hosts a dedicated education page at into Second Life are made up of individual shapeshttp://slife.com/education containing a number called prims (primitives).32 Prims can be mani-of resources for educators to use. It also runs a pulated in many ways to create objects of thededicated Healthcare Support and Education designers choice. mailing list36 and even provides free temporary 2007 The authors Journal compilation Health Libraries Group 2007 Health Information and Libraries Journal, 24, pp.233245 8. 240 Second Life in medical and health education, Maged N. Kamel Boulos et al. land grants for those interested in testing out themistakes without serious repercussions. Second pedagogical potential of the virtual space. ForLife may therefore prove to be an ideal simulation those educators who decide to set up professionalresource where medical students can gain new skills practice within Second Life, the purchase of landwithout risk of harm to patients or themselves. enables the creation of a secure area, i.e. with restricted access (if needed), for teachers andStudent participation students.Engagement in previous online collaborativelearning environments has been observed to Avatarsmirror engagement levels in traditional classrooms. In Second Life, not only can students exchange Students are roughly divided into three groups. messages in real time, they can actually see ani-The rst group tend to engage fully with the mated images of each otherdigital alter egos programme of study, contributing regularly to on their screens. The students and teachers usediscussion groups and responding to the postings avatarsdigital representations of themselvesof their peers. The second group are more likely to that they have createdthat can take any numberengage sporadically, and post contributions of forms, some bizarre, some comical. But theirregularly, whilst the nal group may never visit business of learning in Second Life is very seriousthe website, and fail to take part at all. Second Life and avatars may yet play a crucial role in the may hold a different set of outcomes in store, but success of failure of education in such space. research is yet too patchy to determine if levels of Baylor and Ryu37 for example, report that students student engagement will change. However, it has tend to gravitate toward pedagogical agents (auto- been demonstrated that better participation in mated tutors) with avatars that closely resemble computer conferences can be encouraged through their own real life appearances. Ethnic groups, foronline activity which is purposeful, authentic and example, might be more comfortable studyingembedded deeply within the programme.38 with a tutor whose avatar represents a member of the same ethnic group, whilst younger studentsReective practice would be attracted to studying with a teacher who was represented digitally as being cool or The use of virtual learning environments has hip. We should, however, accept such ndings been shown to facilitate better reection and the with caution, for the simple reason that learning is trading of stories between online learners,39 diverse and multi-faceted. What young medicalwhich can lead toward better building of com- student, for example, would not be at least curiousmunities of practice.40 Reective processes can to study at the feet of a teacher who uses the avatarbe supported through the use of asynchronous of Alexander Fleming?discussion boards, but more likely, interaction (inSecond Life) will be synchronous in real time, andwithin visual range of all other contributors, Navigation of learning spaceproviding users with a sense of immediacy and Moving around in Second Life is both easierengagement that has an equivalency to a telephone and more fanciful than moving around in a real conference call. Discussion about a ward round, classroom. Students can walk, but they can alsoprevious conversations or tutorials with professors, manoeuvre around by ying, riding virtual vehicles,or simply a reection on a lesson learned, can all or even teleporting to different locations aroundleave their digital trails in Second Lifeproffering their virtual space, making access to learning students with a means to revisit exchanges that experiences more synchronous and rapid. Such have taken place. spaces provide students with a psychologicallyThere is the potential for students and teachers safe environment within which they can parti-to enhance or change their professional identities cipate in experiential learning, practice skills, trythrough reective use of virtual and online learning out what if hypothetical scenarios, and make environments.41 Angela Thomas,42 for example, 2007 The authors Journal compilation Health Libraries Group 2007 Health Information and Libraries Journal, 24, pp.233 245 9. Second Life in medical and health education, Maged N. Kamel Boulos et al.241 reports about a student who, subsequent to spendingLife and properly render the 3-D virtual world. time in her Second Life class, was noted by a col- (For a visual comparison of a low-end graphics league to have blossomed ofine (i.e. in real life). card versus a high-end graphics card renderingof a scene in Second Life, the reader is referred tothe gure entitled A tale of two graphics cards Other issues and challenges aheadin Second Life, which can be found at the bottom Caveats and workarounds. From the examples weof the companion resource page at http:// have presented in this paper and our discussion so healthcybermap.org/sl.htm.) far, 3-D virtual worlds then appear to have muchSecond Life allows users to alter the preferences creative collateral to offer to education as socialfor in-world graphics, for example, avatar render- spaces for learning, but, as with all media anding, shading, lighting and terrain details can all applications, there are caveats. be changed/tweaked,47 but sometimes the graphicsThe conventional Web/Web 2.0 and social card software driver settings, for example, those networks like MySpace (http://myspace.com/) also controlling anti-aliasing to reduce the jaggedness share many of these caveats and issues,4 which of edges, also need to be adjusted separately out- include Internet addiction, gambling,43 violence,side the Second Life client for optimal visual/3-D pornography, trust, identity and privacy issues, experience.48 copyright issues, health information quality and quackery issues, vandalism, and the need to masterSecond Life for older people and people with new skills depending on virtual-world user rolephysical disabilities (ordinary resident, learner, educator and developer/ builder).44Second Life could be used to entertain olderAs in the conventional Web, guidelines forpeople and people with physical disabilities, and evidence-based content development should also help them combat social isolation and loneliness. be used in Second Life and further rened andIndeed, a recent video interview by CBC.ca of a adapted for the new medium to ensure thatSecond Life user with cerebral palsy, who runs a products built by those with little experience indance club in Second Life called Wheelies, proves health care or library practices will meet quality this.49 standards and criteria like information currency, But 3-D virtual worlds may pose potential user non-biasedness and proper attribution. Residents interface, 3-D navigation/accessibility issues for should also be educated to carefully appraiseolder people and people with physical disabilities. content they come across in Second Life, and toCurrent virtual world navigation requires relatively always consider quackery a possibility in thegood dexterity, so the methods of interacting with virtual world, as it is in the conventional Web. the virtual world may need to be reconsidered/Also, as in conventional wikis where adminis- redesigned to better suit these user groups; for trators have several options to protect contentexample, using large screens, special joysticks, against vandalism,45 landowners in Second Life eye-tracking control and voice navigation (voice can prohibit others from building or droppingchatting has already been introduced in Second objects on their lands (or editing existing objects).Life, and is a major improvement in this respect Users can also report abuse and harassment compared with typing text messages on the through the Second Life software client (under the keyboard), motion-sensitive controllers that use Help menu). The Second Life Police Blotter pagemulti-axial accelerometer-based sensors (like the displays the most recent disciplinary actions takenWiimote), etc. by the Second Life Abuse Team.46It is noteworthy that Wii (http://www.wii.com/)In addition to the above issues, a high-specicationand its motion-sensitive controller (Wiimote) are machine, with a high-end graphics card (with now popular among many older people50 and software drivers supporting OpenGLhttp://www. Second Life and Wii are expected to very soon merge opengl.org/) and a fast broadband Internet con-in different ways, offering many more exciting nection, is also needed to smoothly run Second opportunities.51 It has also been reported that 2007 The authors Journal compilation Health Libraries Group 2007 Health Information and Libraries Journal, 24, pp.233245 10. 242 Second Life in medical and health education, Maged N. Kamel Boulos et al. Carol Perryman of the Second Life Consumer Zygmunt Lozinski has recently demonstrated his Health Library (described above) has approachedvision, which involves using mobile phones as a members of IBM, which has a massive in-world true bridge between Second Life and the physical presence in Second Life, to propose their involve- world, and not just for simple access to the virtual ment in assistive technology identication and world.53 adaptation for the virtual world.52 The 3-D Web is born! But how much of the con-However, the question that remains is that of the ventional (2-D) Web is going to converge with 3-D underpinning business model and affordabilityvirtual worlds remains to be seen over the next of these developments: who pays for these newmonths and few years. However, 3-D virtual worlds technologies and their integration into Second are more likely to continue as a (major) extension Life? If it is only the older person or the disabled to, rather than a full replacement of, the conven- end user, then a digital divide might soon appeartional Web, at least for some time, until a mature and between those who can afford the new 3-D techno- stable 3-D web browser client and corresponding logies and those who cannot. server infrastructure are developed, that allowmuch tighter and seamless integration of 3-Dvirtual worlds with existing web resources and The 3-D Web: real or virtual?Web 2.0 content and applications. The recent The border between what belongs to the real worldmove of Second Life toward Open Source (http:// and what is virtual is getting more and more www.opensource.org/) is a very promising step in blurred and fuzzier, as 3-D virtual worlds likethis direction.54 Second Life are rapidly becoming part of the everyday lives of millions of users around theConclusions world, who are relying on these worlds for com- munication and social networking, education, and Virtual worlds like Second Life are not mere 3-D even serious business. Many real-world big brand multi-player games. The immersive, rich experience names and businesses (e.g. Adidas, Autodesk, that such environments offer combines many of BMW, Cisco, Dell, Fiat, Intel, Mazda, Mercedes the features of Web 2.0, such as group instant Benz, Philips, Reebok, Reuters, Sony, Sun Micro- messaging, voice chat, proles and real-time social systems, Toyota, and Vodafone, to name onlynetworking, and a unique form of online social some) have already established a strong presence interaction that involves sharing various objects in Second Life,9 a phenomenon reminiscent of the and creative collaboration on building and running early days of the World Wide Web, when all major places and services in the virtual world (user- brands and companies were similarly eager to generated content). establish their own foothold and online corporate Virtual worlds are thus a major part of the identity on what was then the new medium.future of the Web. Virtual medical and healthThe Metaverse RoadmapPathways to the 3D libraries, access to remote librarians, and other Web initiative (http://metaverseroadmap.org/) medical and health related educational applications poses some very interesting and challengingthrough such worlds are not remote possibilities. questions on its homepage: What happens whenIndeed, 3-D virtual worlds offer great potential video games meet Web 2.0? When virtual worldsto creative medical and health educators and meet geospatial maps of the planet? When simula- librarians, but more research is needed into their tions get real and life and business go virtual? Whenuse in medical and health education (also as the you use a virtual Earth to navigate the physical technology underpinning 3-D virtual worlds Earth, and your avatar becomes your online agent? develops and matures over the coming months and Indeed, all reality is rapidly becoming mixed oryears). Many of the associated educational and blended reality, as virtual and physical/real-world library-related possibilities still need to be fully spaces, activities and applications are progressivelyidentied, explored in various settings/scenarios, converging and feeding back increasingly into oneand carefully researched, rened and evaluated to another. In the same vein, IBMs master inventor document best practices, as well as the pitfalls that 2007 The authors Journal compilation Health Libraries Group 2007 Health Information and Libraries Journal, 24, pp.233 245 11. Second Life in medical and health education, Maged N. Kamel Boulos et al. 243 are to be avoided, before they can be extensivelyImplications for Practice used in daily teaching and learning activities. Educators and their institutions need tothink out of the box. 3-D virtual worlds Authors contributionsshould enable educators and learners to be MNKB conceived and drafted the manuscript. more creative and to develop new effective LH contributed the subsection about VNEC and ways of teaching and learning, rather than to provided Figs 2 and 3. SW wrote the Discussion purely replicate real life and classrooms in subsection entitled The pedagogical potential ofSecond Life! Second Life. All authors revised and approved the We need to especially identify and focus/ nal manuscript. capitalise on what 3-D virtual worlds are bestat; those useful things and scenarios that canonly be effectively carried out in virtual worldsand not via any other electronic medium (asKey Messageseffectively), and also determine and dissemi-Implications for Policy nate the optimal formulae for blendedapproaches that combine 2-D and 3-D media. Second Life represents a relatively new gener- Research is still needed to make 3-D virtualation of 3-D virtual learning environmentsworlds more accessible and user friendly.that has not been fully evaluated yet, and inLearners, educators, and developers in thesewhich there is enormous potential for thevirtual environments also need to acquire anddevelopment of creative and dynamic educa-master new sets of competencies and skills intional experiences.order for them to make the most efcient and Second Life is part of the Web 2.0 movementeffective use of 3-D virtual worlds in learningand its future. Second Life is all about people,and teaching.online communities, and 3-D social networks.It is a unique social experience, allowingpeople to meet and interact with each otherReferencesand in groups, using a comprehensive andwell integrated range of asynchronous and1 Second Life. Second LifeThe Marketplace. Availablereal time communication tools. from: http://secondlife.com/whatis/marketplace.php Second Life is also about reusing, remixing, (accessed 2 May 2007). 2 Second Life. Up-to-date Second Life economy statisticsand mashing up user-created content and and graphs. Available from: http://secondlife.com/whatis/objects. As such, it can be seen as a vast economy_stats.php (accessed 2 May 2007).collaborative 3-D wiki and an immersive3 Second Life. Second Life Technology. Available from:audio-visual spatial experience that multiplehttp://teen.secondlife.com/whatis/technology (accessedusers can experiment with together, edit, and2 May 2007). 4 Kamel Boulos, M. N. & Wheeler, S. The emerging Web 2.0see the changes in real time! social software: an enabling suite of sociable technologies in The affordances of the 2-D Web and 3-D health and healthcare education. Health Information andmulti-user, immersive virtual worlds are Libraries Journal 2007, 24, 223.different. They are not mutually exclusive 5 Second Life. Second Life SONY BMG Music Entertor a substitute for one another, but ratherainment on Media Island. Available from: http://slurl.m/very complementary and synergistic in many secondlife/Media/166/80/46/ (accessed 2 May 2007). 6 Second Life. Second Life Healthinfo Island. Available from:ways. http://slurl.com/secondlife/Healthinfo%20Island/130/139/ 3-D virtual worlds are here to stay, mature, 23/ (accessed 2 May 2007).and eventually become one with, and tightly7 Second Life. Second Life Virtual Morocco. Available from:and seamlessly integrated into, the 2-D Webhttp://slurl.com/secondlife/Casablanca/135/87/26/and the real world/our daily lives over the(accessed 2 May 2007). 8 Second Life. Second Life Nutrition Game (Ohio Universitycoming months and years. Second Life Campus). Available from: http:// 2007 The authors Journal compilation Health Libraries Group 2007 Health Information and Libraries Journal, 24, pp.233245 12. 244 Second Life in medical and health education, Maged N. Kamel Boulos et al.vital.cs.ohiou.edu/index.php/Nutrition_Game (accessed 24 Second Life. The US Centers for Disease Control and2 May 2007). Prevention (CDC) test site in Second Life. Available from:9 Second Life. Second Life Brand Map. Available from:http://slurl.com/secondlife/Juwangsan/218/223 (accessedhttp://www.kzero.co.uk/blog/?page_id=431 (accessed 2 May 2007).2 May 2007).25 Weinreich, N. K. The CDCs Second Life. Available 10 Second Life. Second Life Heart Murmur Sim. Available from: http://www.social-marketing.com/blog/11/from: http://slurl.com/secondlife/waterhead/124/56/32/ cdcs-second-life.html (accessed 2 May 2007).(accessed 2 May 2007).26 Internet. NLM Grant received for Consumer Health Library 11 Second Life. Bringing Voice to Second Life. AvailableServices in Second Life. Available from: http://from: http://blog.secondlife.com/2007/02/27/ infoisland.org/2006/11/02/alliance-library-system-bringing-voice-to-second-life/ (accessed 2 May 2007).receives-grant-to-provide-consumer-health-information- 12 Livingstone, D. & Kemp, J., eds. Proceedings of the Second services-in-virtual-world/ (accessed 2 May 2007).Life Education Workshop at the Second Life Community27 Perryman, Carole. Project Coordinator of ProvidingConvention, San Francisco, 20 August 2006. Available Consumer Health Outreach and Library Programs tofrom: http://www.simteach.com/SLCC06/slcc2006- Virtual World Residents in Second Life (NLM grant).proceedings.pdf (accessed 2 May 2007). Available from: http://www.unc.edu/~cperryma/Research/ 13 Second Life Community Convention. 2nd Second LifeResearch%20page.htm (accessed 2 May 2007).Education Workshop, 24 26 August 2007 at the Chicago 28 van den Brekel, Guus. Blogger: user prole. Available from:Hilton, USA. Available from: http://slcc2007.wordpress.com/http://www.blogger.com/prole/05563838801421698112(accessed 2 May 2007). (accessed 2 May 2007). 14 Internet. Second Life Best Practices in Education 29 Second Life. Second Life Knowledge Base: How do I getConference 2007 (In Venues all over the Second Life World).some privacy in Second Life? Live in a Skybox. AvailableAvailable from: http://slbestpractices2007.wikispaces.com/ from: http://secondlife.com/knowledgebase/(accessed 2 May 2007). article.php?id=358 (accessed 2 May 2007). 15 The New Media Consortium. NMC Announces Parcel30 Second Life. VNECVirtual Neurological EducationLeases in Three New Educational Communities in SecondCentre in Second Life. Available from: http://slurl.com/Life. Available from: http://virtualworlds.nmc.org/.04/01/ secondlife/Lost %20Islands%20NW/48/83/22 (accessedleases/ (accessed 2 May 2007). 2 May 2007). 16 Antonacci, D. M. & Modaress, N. Second Life: The31 Sheridan, T. B. Telepresence and virtual presence. PresenceEducational Possibilities of a Massively Multiplayer 1992, 1, 1205.Virtual World (MMVW). 2005. Available from: http:// 32 Wiki. PrimitiveSecond Life Wiki. Available from: http://www2.kumc.edu/tlt/SLEDUCAUSESW2005/wiki.secondlife.com/wiki/Prim (accessed 2 May 2007).SLPresentationOutline.htm (accessed 2 May 2007).33 2007 Horizon Project Advisory Board. The Horizon 17 Wikipedia. Virtual World (In the Classroom)Wikipedia. Report2007 Edition (NMC and Educause). AvailableAvailable from: http://en.wikipedia.org/wiki/from: http://www.nmc org/pdf/2007_Horizon_Report.pdfVirtual_world#In_the_classroom (accessed 2 May 2007).(accessed 2 May 2007). 18 Wiki. Nutrition Gamethe VITAL Laboratory at Ohio 34 Lagorio, C. The ultimate distance learning. New YorkUniversity. Available from: http://vital.cs.ohiou.edu/ Times, 7 January 2007. Excerpt. Available from: http://index.php/Nutrition_Game (accessed 2 May 2007).e-learning-teleformacion.blogspot.com/2007/01/ 19 Kemp, J. Second Life Heart Murmur Sim videoultimate-distance-learning-christine.html (accesseddemonstration. Available from: http://youtube.com/ 2 May 2007).watch?v=xJY2Iwbzop4 (accessed 2 May 2007).35 Delwiche, A. Massively multiplayer online games (MMOs) 20 Second Life. The Gene Pool in Second Life. Available from: in the new media classroom. Educational Technology &http://slurl.com/secondlife/Immaculate/212/208/21Society 2006, 9, 16072. Available from: http://(accessed 2 May 2007). www.ifets.info/journals/9_3/14.pdf (accessed 2 May 2007). 21 Clark, M. A. The Gene Pool PPT Tour (4 parts). Available36 Second Life. Second Life Healthcare Support andfrom: http://department.txwes.edu/bio/Gene_Pool/ Education mailing list. Available from: https://Gene_Pool_I.ppt; http://department.txwes.edu/bio/lists.secondlife.com/cgi-bin/mailman/listinfo/healthcareGene_Pool/Gene_Pool_II.ppt; http://department. (accessed 2 May 2007).txwes.edu/bio/Gene_Pool/Gene_Pool_III.ppt; http://37 Baylor, A. L. & Ryu, J. Does the presence of imagedepartment.txwes.edu/bio/Gene_Pool/Gene_Pool_IV.pptand animation enhance pedagogical agent persona?(accessed 2 May 2007). Journal of Educational Computing Research, 2003, 22 Second Life. Second Life Virtual Hallucinations (UC28, 37395.Davis). Available from: http://slurl.com/secondlife/sedig/38 Barker, S. Virtual learning environments for constructivist26/45/21/ (accessed 2 May 2007). teaching in biosciences to promote sustainable 23 Yellowlees, P. M. & Cook, J. N. Education aboutdevelopment in higher education. CAL-laborate Journalhallucinations using an Internet virtual reality system: 2002, 8. Available from: http://science.uniserve.edu.au/ a qualitative survey. Academic Psychiatry 2006, 30, 5349.pubs/callab/vol8/barker.html (accessed 2 May 2007). 2007 The authors Journal compilation Health Libraries Group 2007 Health Information and Libraries Journal, 24, pp.233 245 13. Second Life in medical and health education, Maged N. Kamel Boulos et al.245 39 Kirkup, G. Teacher or avatar? Identity issues in 47 Second Life. Second Life Preferences Guide. Available from:computer-mediated contexts. In: Burge, E. J. & Haughey, http://secondlife.com/knowledgebase/article.php?id=335M. (eds). Using Learning Technologies: International(accessed 2 May 2007).Perspectives on Practice. London: Routledge Falmer, 2001.48 Internet. TweakGuides.comNvidia Forceware Tweak 40 Wenger, E. Communities of Practice: Learning, Meaning Guide. Available from: http://www.tweakguides.com/and Identity. Cambridge: Cambridge University Press,NVFORCE_6.html (accessed 2 May 2007).1998.49 Internet. Second Life: Excellent Review from CBC. 41 Wheeler, S., Kelly, P. & Gale, K. The inuence of onlineAvailable from: http://www.dlc-solutions.com/blogs/problem-based learning on teachers professional practice jeremylundberg/2006/11/second-life-excellent-review-styles. ALT-J: Research in Learning Technology, 2005, 13, from-cbc.html (accessed 2 May 2007).12537.50 Internet. Wii Invades Retirement Home. Available 42 Thomas, A. My teaching semester in Second Life: pitfalls, from: http://www.dailyTechnicalcom/Wii+Invades+challenges and joys. SLATE Magazine, 2006. AvailableRetirement+Home/article6191.htmfrom: http://www.slatenight.com/(accessed 2 May 2007).index.php?option=com_content&task=view&id=107&Ite51 Wallace, M. Wii Interface for SL? Available from: http://mid=40 (accessed 2 May 2007). www.3pointd.com (accessed 2 May 2007). 43 Internet. FBI checks out gambling in Second Life. Reuters, 52 Peters, T. & Bell, L. MUVEing toward accessibilitysoaring3 April 2007. Available from: http://secondlife.reuters.com/beyond physical challenges in virtual worlds. Computersstories/2007/04/03/fbi-probes-second-life-gambling/ in Libraries 2007, 27, 347. Available from: http://(accessed 2 May 2007).www.technewsworld.com/story/56880.html (accessed 44 Swaine, C. Second Life Core Competency Framework2 May 2007).(Education UK). Available from: http://www.53 Kelly, S. Mobile talk moves to Web 2.0. BBC News,sleducationuk.net/?q=node/3 (accessed 2 May 2007).Click Programme, 23 February 2007. Available from: 45 Kamel Boulos, M. N., Maramba, I. & Wheeler, S. Wikis, http://news.bbc.co.uk/2/hi/programmes/click_online/blogs and podcasts: a new generation of web-based tools for 6389469.stm (accessed 2 May 2007).virtual collaborative clinical practice and education. BMC 54 Internet. Second Life goes open source. vnunet.com,Medical Education 2006, 6, 41, Available from: http://9 January 2007. Available from: http://www.vnunet.com/dx.doi.org/10.1186/1472-6920-6-41 (accessed 2 May 2007).vnunet/news/2172099/second-life-goes-open-source 46 Second Life. Second Life Police blotter. Available from:(accessed 2 May 2007).http://secondlife.com/community/blotter.php (accessed2 May 2007). Received 3 May 2007; Accepted 28 June 2007 2007 The authors Journal compilation Health Libraries Group 2007 Health Information and Libraries Journal, 24, pp.233245