Abstract
Objective
A key part of gynecologic education is the gynecologic examination, especially the bimanual pelvic examination (BPE). Many medical students feel unsure and unprepared when they do pelvic examinations. The present study focused on whether immersive mixed reality (MR) technology can help to improve training efficiency in teaching BPE. The teaching efficiency was assessed by students' performance, satisfaction, and motivation.
Methods
This was a prospective cohort study. We enrolled 120 students from the class of 2021 at Xiangya Hospital and divided them into two groups. One group trained with the MR gynecologic examination training system (MR + traditional group) and the other group used traditional teaching methods (tTraditional group). We accessed the efficiency of MR technology in teaching BPE through quizzes, surveys about user experience, and the Revised Instructional Materials Motivation Survey (RIMMS).
Results
The RIMMS results showed that the MR + traditional group demonstrated significant improvements in operational skills and student motivation compared to the traditional group, with substantial increment in attention (13.1 ± 0.92 vs. 9.87 ± 1.29, p < 0.001), relevance (12.8 ± 0.84 vs. 12.2 ± 1.24, p = 0.003), confidence (13.0 ± 0.97 vs. 11.4 ± 0.95, p < 0.001), and satisfaction (12.8 ± 0.94 vs. 10.8 ± 1.08, p < 0.001). Results of the subjective learner survey shows MR significantly increment in useful for learning (4.15 ± 0.63 vs. 3.55 ± 0.57, p < 0.001), enjoyable (4.20 ± 0.61 vs. 3.60 ± 0.62, p < 0.001), engaging (4.13 ± 0.70 vs. 3.38 ± 0.64, p < 0.001) and recommendation (4.15 ± 0.61 vs. 3.27 ± 0.55, p < 0.001), while easy‐to‐use scores were comparable between both groups (3.48 ± 0.50 vs. 3.45 ± 0.50, p = 0.717).
Conclusion
This study shows that MR technology is effective for training medical students in BPE. It helps to increase engagement and motivation. MR technology adds to traditional training methods by providing a more interactive learning environment. Adding MR technology to medical training can significantly improve the quality of education for future medical professionals in BPE.
Keywords: bimanual pelvic examination, gynecologic education, learner motivation, medical students, mixed reality
Abbreviations
- BPE
bimanual pelvic examination
- CAI
computer‐assisted instruction
- MR
mixed reality
- RIMMS
Revised Instructional Materials Motivation Survey
1. INTRODUCTION
Clinical examination is the cornerstone of daily medical practice, and it has been demonstrated that teaching and learning clinical examination are safe when conducted in well‐supervised settings. Clinical skills are important in undergraduate medical education. 1 The pelvic examination, including the bimanual pelvic examination (BPE), is a fundamental gynecologic examination skill. The pelvic examination is a key tool for finding different women's health issues. It is an important skill that medical students must learn to become good doctors. The pelvic examination is also a necessary part of checking patients before gynecologic surgeries, ensuring the safe and successful completion of the planned surgery. Even with its importance, many medical students say they do not have enough experience, training, and confidence to perform this examination. 2 These challenges highlight significant shortcomings in traditional teaching methods. First, the teaching is “blind” because students and teachers cannot see the internal finger movements. Relying only on the teacher's words and demonstrations does not provide a full understanding. Second, the sensitive nature of the examination, along with more medical students and difficulties in getting patient consent for vaginal examinations, means students get fewer chances to practice on real patients. 3 Consequently, these issues urgently need to be resolved within the traditional teaching process.
Many teaching methods are used to instruct pelvic examination, including lectures, small groups, textbooks, manikins, anesthetized patients, and gynecology teaching associates. 4 Recently, computer‐assisted instruction (CAI) has been introduced. CAI provides consistent and efficient teaching with quick feedback and personalized learning. 5 The high expense of employing gynecology teaching associates, despite their effectiveness, is one factor contributing to the shift from gynecology teaching associates‐based training to CAI. 6 New technologies like virtual reality (VR), augmented reality (AR), and mixed reality (MR) are now being used in medical education. MR, in particular, combines real‐world environments with digital objects. It provides features like haptic feedback, motion tracking, and flexible content. These features help students learn better. 7 MR technology addresses many limitations of traditional teaching. For example, MR allows students to visualize internal structures during pelvic exams. This solves the “blind” problem in traditional training. MR also provides a safe, controlled environment for practice. Students can repeat procedures without relying on real patients. This addresses the issue of limited patient consent. MR improves student confidence and technical skills. It also enhances clinical reasoning and judgment. Despite these benefits, using MR in medical education has challenges. These include high costs, technical complexity, and the need for faculty training. However, research shows that MR can increase student motivation and engagement. Motivated students are more likely to perform well academically. This makes MR a promising tool for medical education. Studies have shown that MR can significantly improve student motivation, clinical reasoning, and assessment skills, making it a promising tool for medical education. 8
As educators integrate new technologies into the curriculum, it is crucial to consider students' predicted use and adoption of these tools to assess their value fully. Insufficient learner motivation and limited time are big challenges to using these new technologies effectively. 9 Research shows a strong connection between learner motivation, productivity, scholarship, and academic achievement. 10 Therefore, when evaluating new educational methods, we must consider how they affect student motivation.
Although MR technology is recognized as a valuable tool in medical education. There is limited objective data supporting its use in teaching undergraduate clinical rotations, particularly for BPE. The aim of this study was to evaluate the effects of immersive MR simulation on achievement, learner satisfaction, and motivation in instructing gynecologic examinations to undergraduate medical students.
2. MATERIALS AND METHODS
This was a prospective cohort study. A total of 120 students from the Class of 2021 participated in this experiment. These students were enrolled in a 5‐year clinical program at Xiangya Hospital of Central South University. Upon enrollment, the entire class was randomly divided into subgroups for clinical practice. For this experiment, 10 subgroups were selected, with 12 students in each subgroup, making a total of 120 participants. Subgroups 1, 3, 5, 7, and 9 were assigned to the MR gynecologic examination training system (MR + traditional group). Subgroups 2, 4, 6, 8, and 10 were assigned to the traditional gynecologic examination model (traditional group). None of the students had any prior learning experience in gynecologic examinations. The MR + traditional group used a mixed teaching method that included both the MR gynecologic examination training system and the traditional gynecologic examination model. The traditional group was taught only with the traditional model. The study was approved by the Ethics Committee of Xiangya Hospital (approval no. 2024005). This study was conducted in accordance with the principles outlined in the Declaration of Helsinki.
2.1. Educational interventions
The MR gynecologic examination training system has a simulated female pelvic model and a virtual software system. The system is designed for training and assessing gynecologic examination skills. The system supports both teacher and student login. Teachers can record expert techniques, view scores, and manage users. Students can practice and take examinations. The pelvic model includes key anatomical structures. These include the vulva, vagina, uterus, and ovaries. It supports bimanual, trilateral, and rectal examinations. The system also offers seven models. These include normal and various pathologic conditions of the uterus and appendages. The software tracks and detects finger movements in real‐time. Users can see the position of the fingers and measure distances accurately. It also checks the pressure used during the BPE. Real‐time feedback is provided to improve learning. The traditional teaching process for the gynecologic examination works as follows: (1) The teacher explains the basics of the gynecologic examination, covering topics such as communication, privacy, the importance of the examination, and key points of how to perform the examination. This part is shown using slides and lasts for a total of 45 min. (2) The teacher conducts the operation on a traditional gynecologic examination model, and students practice on the gynecologic examination model for 90 min. (3) The teacher leads the students into the clinical gynecologic examination room, and the students observe the gynecologic examination operation for 45 min. For the MR + traditional group, the traditional gynecologic examination model teaching in the second stage will be replaced by a combination of the MR gynecologic examination training system and traditional gynecologic examination models. The first and third steps remain unchanged from traditional teaching (Figure 1).
FIGURE 1.
Diagram of the experimental design.
2.2. Assessment
The primary outcome was an enhancement in the proficiency of gynecologic examination operational skills, as measured by performance on relevant quizzes. The test will be conducted 8 weeks after the end of the course. The gynecologic skills assessment and scoring system follows the standards used by Xiangya Hospital. The highest score is 100 points. The assessment scores are composed of the following sections: Preparation, examination of external genitalia, speculum examination, BPE, and overall performance. The specific scoring standards can be found in Appendix S1. The assessment results did not affect student's academic grades. After the experiment, students who have not used the MR gynecologic examination training system will be allowed to use it again, in order to ensure the fairness of education.
2.3. Subjective user experience survey and RIMMS
The secondary outcomes were a subjective user experience survey and a validated survey to assess learner motivation. The user experience survey includes five key ratings: the usefulness of the learning tools, enjoyment of the learning process, attractiveness of the learning courses, willingness to recommend the learning models, and the ease of use of the learning models. A 5‐point Likert‐type scale was used to rate each item, with higher scores indicating higher satisfaction (Table 1).
TABLE 1.
Items of the subjective learner survey.
| Question |
|---|
|
Note: Each item was scored on a 5‐point Likert‐type scale, and higher scores indicating higher satisfaction.
In our study, we employed the Revised Instructional Materials Motivation survey (RIMMS) to evaluate the motivational impact of the MR gynecologic examination training system. The RIMMS, an enhanced version of the original Instructional Materials Motivation Survey (IMMS), was selected for its strong alignment with the ARCS model of motivation. This model emphasizes four key components: Attention, relevance, confidence, and satisfaction. By concentrating on these critical elements, the RIMMS proved to be a reliable tool in measuring student engagement and assessing the overall effectiveness of our teaching methods on their learning experience. 11 The RIMMS comprises 12 statements. Students are required to rate the accuracy of each statement according to a Likert‐type scale. More detailed information about the survey and its scoring system can be found in Appendix S2.
2.4. Statistical analysis
Two‐tailed, independent samples student t‐tests were employed to compare quiz, RIMMS, and user experience survey scores between the two groups. The categorical variables were compared between the two groups using the chi‐square test. Statistical analyses were performed using R software (version 4.4.1, www.R‐project.org).
3. RESULTS
A total of 120 medical students were involved in the present study, with 60 students in the traditional group and 60 students in the MR + traditional group. Among them, there were 53 (44.2%) male students and 67 (55.8%) female students. The gender distribution was relatively balanced across both groups (p = 0.713). The age of participants was similarly distributed, with a slight variance that did not reach statistical significance (p = 0.106). There was no difference in the scores of the gynecologic examination operational skills test between the two groups (p = 0.939) (Table 2). The MR + traditional group demonstrated significant improvements in attention (13.1 ± 0.92 vs. 9.87 ± 1.29, p < 0.001), relevance (12.8 ± 0.84 vs. 12.2 ± 1.24, p = 0.003), confidence (13.0 ± 0.97 vs. 11.4 ± 0.95, p < 0.001), and satisfaction (12.8 ± 0.94 vs. 10.8 ± 1.08, p < 0.001) when compared to the traditional group. The average (12.9 ± 0.68 vs. 11.1 ± 0.69, p < 0.001) and total (51.8 ± 2.72 vs. 44.3 ± 2.77, p < 0.001) RIMMS scores were also significantly higher in the MR + traditional group, suggesting a more motivating learning experience (Table 3). The MR + traditional group rated significantly higher in terms of finding the learning tool useful for learning (4.15 ± 0.63 vs. 3.55 ± 0.57, p < 0.001), enjoyable (4.20 ± 0.61 vs. 3.60 ± 0.62, p < 0.001), engaging (4.13 ± 0.70 vs. 3.38 ± 0.64, p < 0.001), and they were more willing to recommend it to their peers (4.15 ± 0.61 vs. 3.27 ± 0.55, p < 0.001). While the ease of use of the system (3.48 ± 0.50 vs. 3.45 ± 0.50, p = 0.717) was not significantly different between the two groups. The MR + traditional group had a higher average (4.02 ± 0.40 vs. 3.45 ± 0.37, p < 0.001) and total (20.1 ± 1.98 vs. 17.2 ± 1.83, p < 0.001) scores of learner survey compared to the traditional group, showing a better learning experience (Table 4).
TABLE 2.
Participant demographics and the scores of the gynecologic examination operational skills test.
| Total (120) | Traditional group (60) | MR + traditional group (60) | p Value | |
|---|---|---|---|---|
| Gender | ||||
| Male | 53 (44.2%) | 28 (46.7%) | 25 (41.7%) | 0.713 |
| Female | 67 (55.8%) | 32 (53.3%) | 35 (58.3%) | |
| Age | 21.2 (±0.62) | 21.1 (±0.58) | 21.3 (±0.65) | 0.106 |
| Score | 90.9 (±5.88) | 90.8 (±6.60) | 90.9 (±5.12) | 0.939 |
Abbreviation: MR, mixed reality.
TABLE 3.
RIMMS results: Comparison of traditional and MR + traditional groups.
| Total (120) | Traditional group (60) | MR + traditional group (60) | p Value | |
|---|---|---|---|---|
| Attention | 11.5 (±1.97) | 9.87 (±1.29) | 13.1 (±0.92) | <0.001 |
| Relevance | 12.6 (±1.10) | 12.2 (±1.24) | 12.8 (±0.84) | 0.003 |
| Confidence | 12.2 (±1.23) | 11.4 (±0.95) | 13.0 (±0.97) | <0.001 |
| Satisfaction | 11.8 (±1.45) | 10.8 (±1.08) | 12.8 (±0.94) | <0.001 |
| Average | 12.0 (±1.16) | 11.1 (±0.69) | 12.9 (±0.68) | <0.001 |
| RIMMS.total | 48.1 (±4.64) | 44.3 (±2.77) | 51.8 (±2.72) | <0.001 |
Abbreviations: MR, mixed reality; RIMMS, Revised Instructional Materials Motivation Survey.
TABLE 4.
Results of subjective learner survey.
| Total (120) | Traditional group (60) | MR + traditional group (60) | p Value | |
|---|---|---|---|---|
| Useful for learning | 3.85 (±0.67) | 3.55 (±0.57) | 4.15 (±0.63) | <0.001 |
| Enjoyable | 3.90 (±0.68) | 3.60 (±0.62) | 4.20 (±0.61) | <0.001 |
| Engaging | 3.76 (±0.77) | 3.38 (±0.64) | 4.13 (±0.70) | <0.001 |
| Recommend to others | 3.71 (±0.73) | 3.27 (±0.55) | 4.15 (±0.61) | <0.001 |
| Easy to use | 3.47 (±0.50) | 3.45 (±0.50) | 3.48 (±0.50) | 0.717 |
| Average | 3.74 (±0.48) | 3.45 (±0.37) | 4.02 (±0.40) | <0.001 |
| Total | 18.7 (2 ± 0.38) | 17.2 (±1.83) | 20.1 (±1.98) | <0.001 |
Note: Each item was scored on a 5‐point Likert‐type scale, and higher scores indicating higher satisfaction.
Abbreviation: MR, mixed reality.
4. DISCUSSION
The integration of digital strategies has brought about a paradigm shift in healthcare education, which is now reflected in many educational curricula. 12 MR technologies have long been anticipated to be disruptive, with potential applications in medical education, training, surgical planning, and guiding complex procedures. In recent years, virtual augmentation and MR guidance have been increasingly utilized in medical education. The quality of the existing studies and applications including the educational benefits of the display technologies remain unclear at the moment. This highlights a need for further investigation into the effectiveness of MR in medical education and how it can be optimally integrated into curriculums to enhance learning and skill development.
MR technology has not yet been widely adopted in the instruction of BPE across most medical education programs. This is likely due to the lack of well‐designed, commercially available MR applications. A notable exception is the E‐pelvis, a computer‐based pelvic simulator that incorporates pressure sensors, allowing both instructors and learners to visualize the areas touched by the examiner and assess the pressure applied. 13 In recent studies, VR has been employed to develop virtual patients for gynecologic examinations, with the objective of enhancing students' communication skills and procedural abilities. 7 In this experiment, we used the MR gynecologic examination training system. It solves the problem of finger visibility during vaginal examinations. It also improves interaction and questioning between students and instructors. The system helps students learn proper finger positioning and pressure during BPE. It also allows for the use of different modules. These modules simulate various clinical scenarios. Students can practice BPE on the pelvis under different pathologic conditions. This enhances their clinical experience. These features are hard to achieve with traditional training methods.
The present study demonstrated that MR technology is as effective as traditional teaching methods in improving student examination performance. In this study, the traditional gynecologic examination model is still used for skill assessment, and the scoring criteria are also based on traditional standards, without using the system's built‐in scoring criteria. The items that need to be assessed in the MR system, such as finger position, abdominal compression depth, and strength, have not been assessed. Therefore, the current assessment cannot fully represent the skill level of students. Further improvement of the assessment system is needed. Our research results are in agreement with those reported by numerous scholars, 14 with some studies even demonstrating superior knowledge retention levels. 15 Dilaveri et al. 16 conducted a meta‐analysis demonstrating that simulation training with low‐fidelity pelvic task trainers significantly enhances technical competence. This indicates that simulation teaching is an effective skill enhancement tool, especially in the field of BPE.
Our study also found that MR technology can significantly enhance students' confidence, a finding that aligns with several studies. 15 Although Smith et al. 17 found that simulation teaching using gynecology teaching associates can improve student confidence and satisfaction, the high cost of gynecology teaching associates must be taken into account. Telles Dias et al. also found that simulation‐based training for pelvic and breast physical examinations significantly reduces anxiety and boosts the self‐confidence of medical students. This result highlights the effectiveness of immersive training methods, such as MR, in mitigating the psychological stress that often accompanies the learning of intimate medical procedures and in strengthening students' confidence in their clinical abilities. 18
In the learning process, motivation is especially crucial, and an effective teaching model can increase students' willingness to learn. To create and assess courses, numerous research employs the attention, relevance, confidence, and satisfaction (ARCS) instructional design frameworks. 19 In the present study, we used the RIMMS survey to measure students' learning motivation. The results showed that MR technology greatly increases motivation. This matches the findings of Stepan et al. 20 However, traditional teaching methods also improved motivation, though not as much as MR technology. This suggests that combining MR technology with traditional methods could create a better and more complete learning experience.
In a subjective learner survey, we found that students in the MR + traditional group generally consider learning tools to be useful, enjoyable, and highly engaging. In addition, students in the MR + traditional group are more willing to recommend this learning mode to their peers. These findings indicate that MR technology has significant advantages in improving students' learning experience. However, there was no significant difference in the usability of the system between the two groups, indicating that both the traditional model and MR technology have reached a similar level of user‐friendliness. These results emphasize the potential of MR technology in enhancing learning motivation and engagement. The high evaluation of MR learning tools by students may be related to the immersive experience provided by the technology, which makes the learning process more vivid and interactive. In addition, students have a higher willingness to recommend MR learning tools, which may reflect their positive attitude towards this novel learning method and recognition of its educational value. This increased willingness to recommend may come from greater confidence and less anxiety. Using MR technology helps students feel more prepared and capable in their learning.
The present study demonstrates significant advantages in multiple aspects. The demographic characteristics of the two groups of participants are very similar, and the number of subjects in the study matched the sample size calculation. We used two questionnaires, RIMMS and subjective learner survey, to assess learners' motivation. The use of strict and mature tools such as RIMMS has increased the effectiveness of our findings on student engagement and motivation. By focusing on objective (test scores) and subjective (motivation and satisfaction) results, we provide a comprehensive perspective on the effectiveness of MR.
There were several limitations to this study. First, it was not a RCT, the sample size was not limited and the study was from a single university, which may have affected the generalizability of the results; Second, the skill assessment process relies on traditional gynecologic examination models, and the scoring criteria also use conventional standards, which does not fully utilize the built‐in scoring criteria of the MR system. This limits the ability to evaluate students' finger pressure and positioning, restricting the comprehensive assessment of the effectiveness of MR teaching. In addition, although the RIMMS questionnaire was used to assess learning motivation, the study lacks objective tools such as objective structured clinical examination (OSCE) to comprehensively measure students' learning outcomes. Beyond these study‐specific limitations, MR technology itself faces challenges. One major issue is cost. This includes not only the initial price of MR equipment but also the expenses for training instructors and maintaining the technology over time. Another challenge is integrating MR into existing medical school curricula. This may require significant changes to teaching schedules and resources. Finally, the study did not provide a cost–benefit analysis of MR technology, which is crucial for evaluating its economic feasibility in resource‐limited educational environments. Future research should focus on addressing these issues to enhance the application and effectiveness evaluation of MR technology in medical education.
5. CONCLUSIONS
This study has provided evidence that the use of MR simulations in the BPE educational setting can be as effective as traditional teaching methods in terms of student examination performance. The study has demonstrated that the MR simulation was superior in several subjective measurements, including engagement, enjoyment, usefulness, and learner motivation, as evidenced by the higher scores in these areas from both the RIMMS and the subjective learner survey. Integrating MR technology into the medical curriculum significantly enhances BPE training. Future research should focus on longitudinal studies. These studies can track students' knowledge retention. They can also look at how well students apply skills learned through MR training in clinical settings. Additionally, exploring the potential use of MR technology in other medical fields is important. This can offer new insights. It can also provide new strategies to improve medical education. This MR integration fosters effective learning strategies, equipping students with the confidence and competence needed for clinical BPE. Consequently, this approach represents a transformative advancement in the training of future medical professionals in the field of gynecology.
AUTHOR CONTRIBUTIONS
Hong Zeng: conceptualization, methodology, faculty facilitators and writing – original draft. Mingqing Li: conceptualization, methodology and writing – original draft. Nenghui Liu: conceptualization and writing – editing. Shuyi Li: conceptualization and writing – original draft.
FUNDING INFORMATION
The study was funded by the Natural Science Foundation of Hunan Province (grant no.: 2023JJ40959). The funders had no role in the study design, data collection, analysis and interpretation, writing, decision to publish or preparation of the manuscript.
CONFLICT OF INTEREST STATEMENT
The authors declare they have no competing interests.
Supporting information
Appendix S1.
Appendix S2.
Zeng H, Li M, Liu N, Li S. Mixed reality in medical education: A study on bimanual pelvic examination. Int J Gynecol Obstet. 2025;170:1243‐1249. doi: 10.1002/ijgo.70153
DATA AVAILABILITY STATEMENT
The data analyzed in the current study are available from the corresponding author on reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Appendix S1.
Appendix S2.
Data Availability Statement
The data analyzed in the current study are available from the corresponding author on reasonable request.