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Recent study demonstrates that medical students who trained in a VR environment showed significantly greater procedural accuracy and higher procedure completion rates compared to students who trained using a technique guide alone.

Digital transformation has accelerated the modernization of medical and surgical education. Its adoption and acceptability has been facilitated by a generation that is more receptive to the use of technology, the technological advancements in the field of virtual reality (VR), and the increased accessibility of extended reality hardware such as headsets. 

Despite its widespread adoption, only a few research studies have presented high-level evidence (randomized controlled trials, systematic reviews, meta-analyses) for the effectiveness of use of VR as a surgical training tool - the majority of which have come from the laparoscopic or endoscopic surgical field. While laparoscopic or endoscopic procedures often require fine motor dexterity, other common procedures requiring open surgery such as C-sections, by-pass grafting, or joint arthroplasties procedures require versatile and large bimanual movements. Since they require different skill sets, evidence specific to these skill sets must be presented to establish construct validity (i.e. the degree to which the simulator develops skills that it was designed for).


This was attempted in a recent study conducted by a team from the University of Illinois, Chicago, in which they evaluated the effectiveness of VR in training specific skills relevant to orthopedic surgery. Using an assessor-blinded, randomized controlled study design the team assessed the superiority of using VR simulator over traditional methods to train residents in the insertion of a tibial intramedullary nail (IM) -typically used as the treatment of choice for unstable and displace tibial shafts in the adult.


Specifically, the team aimed to compare the procedural accuracy and completion rates for IM insertion training provided in a VR setup compared to the use of a technique guide i.e. documents and videos with information and instructions. The results demonstrated that medical students who trained in a VR environment (with or without a technique guide) showed significantly greater procedural accuracy and higher procedure completion rates than students who trained using a technique guide alone.


Twenty-five, inexperienced, first and second-year medical students were randomly allocated to one of three intervention groups: a) VR training, b) VR training + technique guide, c) training using technique guide only. Using the assigned training method, students learned how to perform a tibial IM nail insertion on a bone model over 10-14 days, after which they were evaluated on their ability to perform the procedure on a bone model. A video of the surgical procedure was evaluated by a blinded evaluator who did not know who the student was or to which group the student was assigned.


Results showed that a greater proportion of students who were randomized to the VR or VR+  technique guide completed the procedure compared to the technique guide only group. Moreover, students in the two VR groups had fewer incorrect steps and finished the procedure more quickly than the control group.


Even though the study was performed on a small number of students the findings are important. Since the students were randomly assigned to one of three groups, it can be safe to assume that any variability in the skills, previous experiences, baseline knowledge, confidence and other factors are evened out across groups. Since the assessor was blinded to the group allocation the assessor bias, if any, is unlikely to influence how the students were assessed. 


Similar results were observed in another study evaluating the efficacy (the ability to produce desired outcomes) of VR training for Tibial IM nail insertion. Students trained in VR repeatedly performed better than students who used technique guides across categories including a) time and motion, b) instrument handling, c) knowledge of instruments, d) flow of operation and forward planning, and e) knowledge of specific procedure while also performing a greater number of steps correctly – a difference of 230-250%. Importantly, when re-tested 2 weeks later, the average improvement in the VR group was 4 times that of the group that only used the technique guide.


These findings are particularly useful since the use of traditional technical guides appears to create a competency gap for core procedures in almost 20% of graduating surgical residents. Therefore, active training methods such as the use of VR, which improve accuracy, allow for repetitive practice, and adjustable complexity will translate to superior patient safety and outcomes compared to passive learning methods such as use of technique guides.


The American board of surgery and American College of Surgery have highlighted the need to improve preparedness of students before they enter their residencies. VR can be the right tool to achieve this – by allowing students to “learn by doing” in an immersive environment, providing the right personalized feedback, at their own pace, while reducing the burden of teaching on preceptors that exist in a typical apprenticeship model. The evidence that the skills learned are not only retained but exponentially improved with practice over time further supports the value of using a VR training system.  


In this study the students were evaluated by a human evaluator. However, VR can also be used to objectively assess skills and performances in a standardized manner – rates of errors, time to complete, number and types of hints/assistance required, device positioning, procedural steps completed etc. can be easily monitored, tracked asynchronously, and remotely. Reports can be generated to identify areas of improvement, and institutions can use data to identify trends and patterns in skill competencies and gaps.


VR allows for training and assessment of soft skills such as bedside manners, team management, performance in rare scenarios, or the use of new instruments. On a logistical level, training to use new surgical equipment using VR would be less cumbersome than travelling to 2-day workshops, and will allow surgeons to practice techniques when they need to refresh their skills, i.e. “VR warm-ups”. VR may even be designed to support and train surgeons to perform telesurgeries in distant locations.


Challenges with shorter training periods, greater baseline expectations on entry to practice, and an accelerating surgical technological advancement has made it difficult for the regular training model to prepare the trainees adequately. Teaching and training can be elevated by using innovations such as VR. While large-scale and high-quality studies will be required to determine best-practices, there is little doubt that VR will play a big role in training the surgeons of the future.

Gayatri Aravind is Dark Slope’s Science Director and Advisor on Learning Science. Contact us to learn more about how your organization can use XR technologies to improve medical training.

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