BackgroundDealing with insistent patient demand for antibiotics is an all too common part of a General Practitioner’s daily routine. This study explores the extent to which portable Immersive Virtual Reality technology can help us gain an accurate understanding of the factors that influence a doctor’s response to the ethical challenge underlying such tenacious requests for antibiotics (given the threat posed by growing anti-bacterial resistance worldwide). It also considers the potential of such technology to train doctors to face such dilemmas.ExperimentTwelve experienced GPs and nine trainees were confronted with an increasingly angry demand by a woman to prescribe antibiotics to her mother in the face of inconclusive evidence that such antibiotic prescription is necessary. The daughter and mother were virtual characters displayed in immersive virtual reality. The specific purposes of the study were twofold: first, whether experienced GPs would be more resistant to patient demands than the trainees, and second, to investigate whether medical doctors would take the virtual situation seriously.ResultsEight out of the 9 trainees prescribed the antibiotics, whereas 7 out of the 12 GPs did so. On the basis of a Bayesian analysis, these results yield reasonable statistical evidence in favor of the notion that experienced GPs are more likely to withstand the pressure to prescribe antibiotics than trainee doctors, thus answering our first question positively. As for the second question, a post experience questionnaire assessing the participants’ level of presence (together with participants’ feedback and body language) suggested that overall participants did tend towards the illusion of being in the consultation room depicted in the virtual reality and that the virtual consultation taking place was really happening.

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BackgroundVirtual reality technology is an exciting and emerging field with vast applications. Our study sets out the viewpoint that virtual reality software could be a new focus of direction in the development of training tools in medical education. We carried out a panel discussion at the Center for Behavior Change 3rd Annual Conference, prompted by the study, “The Responses of Medical General Practitioners to Unreasonable Patient Demand for Antibiotics––A Study of Medical Ethics Using Immersive Virtual Reality” (1).MethodsIn Pan et al.’s study, 21 general practitioners (GPs) and GP trainees took part in a videoed, 15-min virtual reality scenario involving unnecessary patient demands for antibiotics. This paper was discussed in-depth at the Center for Behavior Change 3rd Annual Conference; the content of this paper is a culmination of findings and feedback from the panel discussion. The experts involved have backgrounds in virtual reality, general practice, medicines management, medical education and training, ethics, and philosophy.ViewpointVirtual reality is an unexplored methodology to instigate positive behavioral change among clinicians where other methods have been unsuccessful, such as antimicrobial stewardship. There are several arguments in favor of use of virtual reality in medical education: it can be used for “difficult to simulate” scenarios and to standardize a scenario, for example, for use in exams. However, there are limitations to its usefulness because of the cost implications and the lack of evidence that it results in demonstrable behavior change.

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The art of picking up signs that a child may be suffering from abuse at home is one of those skills that cannot easily be taught, given its dependence on a range of non-cognitive abilities. It is also difficult to study, given the number of factors that may interfere with this skill in a real-life, professional setting. An immersive virtual reality environment provides a way round these difficulties. In this study, we recruited 64 general practitioners (GPs), with different levels of experience. Would this level of experience have any impact on general practitioners' ability to pick up child-safeguarding concerns? Would more experienced GPs find it easier to pick up subtle (rather than obvious) signs of child-safeguarding concerns? Our main measurement was the quality of the note left by the GP at the end of the virtual consultation: we had a panel of 10 (all experienced in safeguarding) rate the note according to the extent to which they were able to identify and take the necessary steps required in relation to the child safeguarding concerns. While the level of professional experience was not shown to make any difference to a GP's ability to pick up those concerns, the parent's level of aggressive behavior toward the child did. We also manipulated the level of cognitive load (reflected in a complex presentation of the patient's medical condition): while cognitive load did have some impact upon GPs in the "obvious cue" condition (parent behaving particularly aggressively), this effect fell short of significance. Furthermore, our results also suggest that GPs who are less stressed, less neurotic, more agreeable and extroverted tend to be better at raising potential child abuse issues in their notes. These results not only point at the considerable potential of virtual reality as a training tool, they also highlight fruitful avenues for further research, as well as potential strategies to support GP's in their dealing with highly sensitive, emotionally charged situations.

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The aim of this paper is to underline the relevance of Schmitt's critique of Kelsenian normativism in the context of today's debate about the status of legal positivism. Schmitt's underlining of the limits which a certain kind of positivism imposes upon itself highlights a contemporary issue about what legal theory should aim at when accounting for the normative dimension of law. Schmitt's ultimate failure to take up the theoretical challenge he himself raised (with its well-known consequences) is deemed to illustrate-negatively-the importance of providing a plausible account of the social practices which bring law into existence.As a critic of bourgeois liberalism, Schmitt is often remembered for denouncing the "empty form" of parliamentarianism. By contrast with the "metaphysics of indecision" that supposedly characterises the liberal ideology, Schmitt put forward a substantive vision of politics, based on the distinction between friend and enemy. As a lawyer, Schmitt devoted considerable amounts of energy to undermining liberalism's theory of law (legal positivism), which Hans Kelsen aimed at organising into a "pure science," detached from any political or ideological considerations. According to Schmitt, such an allegedly pure theory falls prey to the same "mechanical formalism" as the liberal conception of politics it echoes. To be "pure," Kelsen's legal positivism indeed needs to proceed from the assumption that the problem of how a legal order is possible in the first place is only an apparent problem or a problem that does not need to be solved. This exclusion of any question relating to the emergence of law allows normativist theories à la Kelsen to avoid the threatening arbitrariness of power struggles and conflicts of interest.

Background: Virtual reality technology is a rapidly developing tool which has been shown to have exciting prospects in the field of medical education (1). In a recent, subsequent study, Pan et al. consider the potential of the same technology in the realm of child protection training and safeguarding issues (2). To build upon the Pan et al. (2) study, a panel discussion was held at The Centre for Behavior Change Annual Conference 2018 to discuss the question “Can a virtual reality communication scenario be used to teach General Practitioners and trainees how to recognize and manage child protection issues?.”Methodology: The above study comprised an immersive virtual reality consultation, in which the ability of 63 doctors to pick up covert safeguarding cues was tested in the context of a consultation with an adult patient, where the patient's child happened to be present as well. The study and its findings were discussed at the Centre for Behavior Change 4th Annual Conference, and this paper summarizes the opinions of both the panel and the audience.Viewpoint: Safeguarding is a challenging area of practice where we must listen to the child, and tackle difficult conversations with parents. Within medical training, role play is the gold standard for teaching how to communicate in difficult scenarios. Given the ethical questions surrounding children being asked to role play such abuse, the use of virtual reality characters could have a key role in upgrading current practices in medical education on safeguarding.