Using virtual reality or slideshow to teach ultrasound-guided lumbar puncture: immersion increases fun

Abstract

Purpose

Virtual reality (VR) has been used to teach a variety of procedural skills in medical education. Ultrasound-guided lumbar puncture (USG LP) shows promise to increase procedural success in adults and pediatric patients without impactfully increasing procedure duration. We explore engagement, enjoyment, and procedure performance of medical students learning this skill from a pre-recorded slideshow or VR lecture.

Method

We recorded a slideshow lecture and a virtual reality lecture teaching background knowledge and technique necessary for performing USG LPs. Medical Students were randomized to participate in one of these modalities and filled out a survey on their experience. They were then timed and graded on their performance of the procedure on an LP task trainer.

Results

Fifty-five medical students (27 slideshow, 28 VR) at two universities were involved in the study. Level of fun was rated higher in the VR group (4.5 [4.0, 5.0] vs. 4.0 [3.0, 4.0], p = 0.0002) along with perceived effectiveness of the lectures (4.0 [4.0, 5.0] vs. 4.0 [4.0, 4.0], p = 0.0265) and level of enjoyment (5.0 [4.0, 5.0] vs. 4.0 [4.0, 5.0], p = 0.0232), while level of boredom (2.0 [1.0, 3.0] vs. 3.0 [2.0, 4.0], p = 0.0308) was rated lower in VR. There was no statistically significant difference in simulated cerebrospinal (CSF) acquisition, LP checklist score, or procedure duration. VR participants reported more side effects and technology issues.

Conclusions

Virtual reality is perceived as more fun, more effective, and a more enjoyable training modality with increased learner engagement compared to slideshow lectures when learning ultrasound guided-lumbar puncture. Procedural results were similar between the learning modalities, though there is a learning curve to understand and troubleshoot technological issues that may arise when utilizing VR.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12909-026-09611-y.

Introduction

Lumbar puncture (LP), a critical diagnostic and therapeutic procedure, has historically been completed using palpation of anatomic landmarks. This approach is often complicated by patient body habitus, underlying anatomic abnormalities, traumatic or unsuccessful prior attempts, patient discomfort, and/or positioning challenges. Ultrasound-guided lumbar puncture (USG LP) is associated with improved success rates, patient tolerance, and decreased procedural complications in adults, including those with obesity [1–5]. Within pediatric populations, one meta-analysis suggests using ultrasound-guidance for every LP [6]. While ultrasound guidance clearly has notable advantages, the optimal method for teaching this technique remains an area of ongoing exploration.

Simulation in medical education has allowed learners access to necessary procedural equipment and a safe learning environment without compromising patient-safety, all while leading to improved confidence and increased success rate in certain procedures [7]. However, the need for specialized equipment, protected time for content experts, and adequate space, are all barriers to incorporating procedural simulation into curriculum. Virtual reality (VR) has emerged as a promising modality to address these barriers, offering immersive, interactive, and realistic simulations that can enhance learning outcomes using limited space and resources. This technology may enhance episodic memory via the learner’s virtual presence navigating within a computer-generated classroom, allowing them to visualize the space and recall items along the way [8–10]. This memory tool is actively being incorporated into VR software and mobile apps, allowing for a more captivating learning experience for users [11–13].

In medical education, VR has been used across a range of specialties to teach procedures including endoscopy, laparoscopic surgery, echocardiography, umbilical venous catheter placement, and surgeries in neurosurgery and orthopedics [14–19]. VR has been found to be significantly more popular amongst medical trainees with high levels of satisfaction and confidence in procedures, while also improving test scores, clinical skills, and time to complete some surgeries [20–24]. Regarding lumbar punctures, previous studies have shown that virtual reality training of traditional technique is feasible and led to higher learner satisfaction [25, 26]. It remains to be determined whether teaching with interactive VR results in safer, quicker, or improved performance in this procedure.

In this study, our primary outcome aimed to compare the level of fun of VR-based training versus a traditional slideshow presentation in teaching ultrasound-guided lumbar puncture. Using an innovative VR content creation platform, we made an interactive VR experience that was able to closely match the contents of a slideshow lecture. We hypothesized that a lecture using virtual reality would be rated as more fun compared to a slideshow lecture teaching USG LP, without negatively affecting procedure performance.

Method

This dual site randomized controlled trial was conducted at the Doug Meijer Medical Innovation Building through Michigan State University College of Human Medicine (MSU) and Corewell Health West (CHW) in Grand Rapids as well as Jump Simulation Center, a collaboration between University of Illinois College of Medicine at Peoria (UICOMP) and Order of St. Francis (OSF) HealthCare. The project was approved by both medical college’s institutional review boards.

Participant recruitment and randomization

Medical students were recruited through email listservs, information dissemination to interest groups, and posters across both campuses with the assistance of MSU and UICOMP research team members. Medical students were chosen as it was unlikely that they had performed LPs or USG LPs previously, thus limiting confounding.

Students were provided with a sheet outlining study details, risks, benefits, and participant rights, including notification that participation was voluntary and that they could withdraw from the study at any time. All participants had to sign acknowledgement of receipt of information prior to scheduling their session. They selected a date to arrive for the lecture, survey, and task-trainer performance. Weighted randomization then occurred using Microsoft Excel, splitting students into a pre-recorded slideshow lecture group or a pre-recorded VR lecture group. Students were not notified of their group until they arrived for their session. Students were sent email reminders 1 week prior and 1 day prior to their session.

Lecture information

The slideshow lecture was created with Microsoft PowerPoint and voiceover was recorded by the lead author. Each section had an assessment question at the end to test learners’ retention. Members of the research team helped develop slides and assessment questions and assisted with proofreading and editing. The duration of the slideshow lecture was 33 min and 20 s.

The VR lecture was made with Enduvo software. The headsets used for the VR lecture were Meta Quest 2. The headsets were linked to gaming laptops with compatible graphics cards and Enduvo downloaded. Each section of the VR lecture had the same assessment question as the slideshow, adapted to the VR environment. Assessments did not have to be completed prior to moving to the next session. 3D models were developed by Enduvo and JUMP Simulation Center and included an ultrasound probe, components of a lumbar puncture tray, and an anatomical model with relevant structures as removable layers for improved visualization. The duration of the VR lecture was 32 min and 27 s.

Learners could pause, rewind, and replay both lectures as often as they desired prior to the evaluation portion of the study. Both lectures were edited multiple times to have the same outline (Introduction to USG LPs, Ultrasound Basics and Physics, Procedure: Pre-Sterile Preparation, Procedure: Sterile Preparation, and Procedure: Insertion and CSF Collection) and similar wording in recordings. The same photos and videos were used in the two lectures to ensure similar content. Each lecture taught learners how to use the Butterfly iQ+ ultrasound probe and operating system attached to an Apple iPad, as this was what was used for all stations at each research site. The Virtual reality lecture and slideshow lecture were both set up prior to participant arrival and only required the users to press play when they were ready to begin (Fig. 1a-e).

Fig. 1.

a Comparison of relevant anatomy in slideshow lecture (top) and VR lecture (bottom). b Comparison of assessment question from US Basics section in slideshow lecture (top) and VR lecture (bottom). c Comparison of transverse view of US images in slideshow (top) and VR lecture (bottom). d Comparison of longitudinal view of US images in slideshow (top) and VR lecture (bottom). e Lumbar puncture preparation in VR lecture

Evaluation

After participants arrived for their session, they were notified of the group to which they were randomized and given a study identification number. They then watched their lecture on a provided laptop for the slideshow group, or on a VR headset for the virtual reality group. After the lectures, participants accessed a de-identified online survey via QR code where they entered their identification number and answered demographic and study-specific questions. Post-lecture survey questions used a Likert scale (1 = Strongly Disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly Agree; satisfaction question 1 = Very Dissatisfied, 2 = Dissatisfied, 3 = Neutral, 4 = Satisfied, 5 = Very Satisfied) to gauge participants’ responses. The survey was created in Microsoft Forms by the research team. The survey aimed to assess participants’ level of fun (amusement with lecture), level of enjoyment (enjoy process of learning USG LP from lecture), level of boredom (entertainment during lecture), level of perceived effectiveness (lecture effective for teaching USG LP), level of confidence (lecture gave confidence to perform USG LP with supervision), level of recommendation (recommend lecture to others learning USG LP), and level of satisfaction (lecture satisfaction).

After completion of the survey, they were asked to perform an ultrasound-guided lumbar puncture on an adult LP task trainer (Simulab at MSU, CAE Blue Phantom at UICOMP) (Fig. 2). They were notified that researchers would be timing procedure duration, counting needle insertions, and checking steps off a standardized rubric modified from Lumbar Puncture Procedure Module on MedEdPortal [27]. Researchers also stated they were not to give advice or answer questions during the procedure. Study IDs were placed at the top of the scoring rubric and allowed researchers to match questionnaires with respective scoring rubrics. Duration of the procedure was defined as the moment the ultrasound touched the skin to the first drop of CSF or until the student abandoned attempts. Students were allowed a max of three needle insertions, and if they removed the needle after the third insertion, this also ended their time. The rubric had 15 steps which could be marked as “Yes”, “No”, or “Partial”. All results were collected anonymously and confidentially and entered in a Microsoft Excel Spreadsheet.

Fig. 2.

Comparison of Simulab lumbar puncture task trainer used at MSU site (top) and CAE Blue Phantom task trainer used at UICOMP (bottom)

Statistical analysis

Analysis was performed with SAS 9.4. A Chi-Square test was performed to determine if the proportion of students who acquired CSF differed between virtual reality and slideshow groups. A two-sample independent t-test was performed to compare the average difference in the number of boxes checked “yes” or “partial” to “no” on the rubric and procedure duration for each lecture type. A Wilcoxon Rank Sum test was performed to compare the difference of the median number of each survey question and needle insertions for the lecture types. Frequency of symptoms in the VR group was reported as percentages. Significance level was set at p < 0.05. Level of fun was our primary outcome and other post-lecture survey outcomes were exploratory. Using G*Power a post-hoc power calculation was completed on the variable of fun, and it was determined the power was 0.96, therefore meeting power.

Results

Fifty-five medical students participated in the study. Forty-two students were recruited from MSU initially. A total of 34 students completed the study at the MSU campus. Twenty-seven students were recruited from UICOMP, with 21 completing the study. Most participants (51, 92.73%) had used virtual reality 5 times or less and only 5 students (9.09%) had performed one LP prior to their participation (Table 1).

Table 1.

Characteristics of participants in each group

Characteristic	Total N = 55	PowerPoint N = 27	Virtual Reality N = 28
Age
• 20–25	30 (54.55%)	15 (55.56%)	15 (53.57%)
• 26–30	21 (38.18%)	11 (40.74%)	10 (35.71%)
• 31–35	3 (5.45%)	1 (3.70%)	2 (7.14%)
• 36 +	1 (1.82%)	0 (0.00%)	1 (3.57%)
Gender
• Male	29 (52.73%)	19 (70.37%)	10 (35.71%)
• Female	25 (45.45%)	8 (29.63%)	17 (60.71%)
• Non-Binary	1 (1.82%)	0 (0.00%)	1 (3.57%)
• Prefer not to answer	0 (0.00%)	0 (0.00%)	0 (0.00%)
Medical school year
• 1	31 (56.36%)	14 (51.85%)	17 (60.71%)
• 2	17 (30.91%)	7 (25.93%)	10 (35.71%)
• 3	7 (12.73%)	6 (22.22%)	1 (3.57%)
• 4	0 (0.00%)	0 (0.00%)	0 (0.00%)
Medical school
• MSU	34 (61.82%)	15 (55.56%)	19 (67.86%)
• UICOMP	21 (38.18%)	12 (44.44%)	9 (32.14%)
Number of times you have used virtual reality prior to your lecture
• 0–1	30 (54.55%)	12 (44.44%)	18 (64.29%)
• 2–5	21 (38.18%)	13 (48.15%)	8 (28.57%)
• 6 +	4 (7.27%)	2 (7.41%)	2 (7.14%)
Number of times you have performed LP prior to your lecture
• 0	50 (90.91%)	22 (81.48%)	28 (100.00%)
• 1	5 (9.09%)	5 (18.52%)	0 (0.00%)

Students were allowed to take as many breaks as they desired during the study. Tech issues were more frequent in the VR group, with 10 (18.18%) students reporting this as a reason for their break. Distraction was listed as a reason for break in 5 (9.09%) of the slideshow group participants and none of the VR participants. Two students (3.63%) in the VR group and 1 (1.82%) in the slideshow group listed discomfort as a reason for break (Table 2). Students in the VR group rated their experience with several symptoms known to be associated with VR headset usage as “none”, “minimal”, “moderate” or “severe”. Only one student (3.57%) reported severe symptoms (headaches), though they did not report this as a reason for taking a break. Twenty-three (82.14%) participants had no or minimal symptoms in the categories listed (Table 3).

Table 2.

Number and types of breaks for participants in each group

Distraction Results	Total N = 55	PowerPoint N = 27	Virtual Reality N = 28
Number of breaks
• 0	31 (56.36%)	18 (66.67%)	13 (46.43%)
• 1	13 (23.64%)	7 (25.93%)	6 (21.43%)
• 2	5 (9.09%)	0 (0.00%)	5 (17.86%)
• 3	2 (3.64%)	0 (0.00%)	2 (7.14%)
• 4 +	4 (7.27%)	2 (7.41%)	2 (7.14%)
Reasons for break	N = 24	N = 9	N = 15
• Discomfort	3 (12.50%)	1 (11.11%)	2 (13.33%)
• Tech Issue	11 (45.83%)	1 (11.11%)	10 (66.67%)
• Distraction	5 (20.83%)	5 (55.56%)	0 (0.00%)
• Phone call or text	1 (4.17%)	1 (11.11%)	0 (0.00%)
• Other	4 (16.67%)	1 (11.11%)	3 (20.00%)
If Other, then why?	N = 4	N = 1	N = 3
• “Bathroom”	1 (25.00%)	0 (0.00%)	1 (33.33%)
• “Standing too long”	1 (25.00%)	0 (0.00%)	1 (33.33%)
• “Threw trash away and sanitized hands”	1 (25.00%)	1 (100.00%)	0 (0.00%)
• “None”	1 (25.00%)	0 (0.00%)	1 (33.33%)

Table 3.

Symptoms of cyber sickness experienced in the virtual reality group

Symptoms in Virtual Reality group
	No	Minimal	Moderate	Severe
Dizziness	18 (64.29%)	8 (28.57%)	2 (7.14%)	0 (0.00%)
Nausea	20 (71.43%)	7 (25.00%)	1 (3.57%)	0 (0.00%)
Headaches	13 (46.43%)	14 (50.00%)	0 (0.00%)	1 (3.57%)
Eye pain	16 (57.14%)	7 (25.00%)	5 (17.86%)	0 (0.00%)

Students in the virtual reality intervention enjoyed learning how to perform an ultrasound guided lumbar puncture more than those in the slideshow (5.0 [4.0, 5.0] vs. 4.0 [4.0, 5.0], p = 0.0232), reported less boredom than the slideshow group (2.0 [1.0, 3.0] vs. 3.0 [2.0, 4.0], p = 0.0308), and agreed that the class was fun more than the slideshow cohort (4.5 [4.0, 5.0] vs. 4.0 [3.0, 4.0], p = 0.0002) (Table 3). The VR group agreed that the lecture was effective for teaching USG LP more than the slideshow students (4.0 [4.0, 5.0] vs. 4.0 [4.0, 4.0], p = 0.0265). Level of fun was our primary outcome while the other variables were exploratory. Level of fun was generalizable as this metric was appropriately powered given our sample size (Tables 4 and 5).

Table 4.

Measured metrics and survey questions

Measured Metric	Survey Question	Likert Response Options
Level of Enjoyment	I enjoyed learning how to perform an ultrasound guided lumbar puncture from the lecture	Strongly Disagree = 1, Disagree = 2, Neutral = 3, Agree = 4, Strongly Agree = 5
Level of Perceived Effectiveness	The lecture’s teaching methods were effective to understand how to perform ultrasound guided lumbar puncture procedure	Strongly Disagree = 1, Disagree = 2, Neutral = 3, Agree = 4, Strongly Agree = 5
Level of Boredom	I felt that at times the lecture was boring	Strongly Disagree = 1, Disagree = 2, Neutral = 3, Agree = 4, Strongly Agree = 5
Level of Confidence	The lecture gave me confidence to perform ultrasound-guided lumbar puncture with guidance from a supervising staff member	Strongly Disagree = 1, Disagree = 2, Neutral = 3, Agree = 4, Strongly Agree = 5
Level of Fun	The class was fun	Strongly Disagree = 1, Disagree = 2, Neutral = 3, Agree = 4, Strongly Agree = 5
Level of Recommendation	I would recommend this lecture to others seeking to understand how to perform ultrasound guided lumbar puncture procedure	Strongly Disagree = 1, Disagree = 2, Neutral = 3, Agree = 4, Strongly Agree = 5
Level of Satisfaction	Overall, rate how satisfied you were with the lecture	Very dissatisfied = 1, dissatisfied = 2, Neutral = 3, Satisfied = 4, Very Satisfied = 5

Table 5.

Post lecture survey responses

Likert Responses	Total N = 55	PowerPoint N = 27	Virtual Reality N = 28	P-Value
Level of Enjoyment	4.0 [4.0, 5.0]	4.0 [4.0, 5.0]	5.0 [4.0, 5.0]	0.0232
Level of Perceived Effectiveness	4.0 [4.0, 5.0]	4.0 [4.0, 4.0]	4.0 [4.0, 5.0]	0.0265
Level of Boredom	3.0 [2.0, 3.0]	3.0 [2.0, 4.0]	2.0 [1.0, 3.0]	0.0308
Level of Confidence	4.0 [3.0, 4.0]	4.0 [3.0, 4.0]	4.0 [3.0, 4.0]	0.7719
Level of Fun	4.0 [3.0, 5.0]	4.0 [3.0, 4.0]	4.5 [4.0, 5.0]	0.0002
Level of Recommendation	4.0 [4.0, 5.0]	4.0 [4.0, 5.0]	5.0 [4.0, 5.0]	0.0569
Level of Satisfaction	4.0 [4.0, 4.0]	4.0 [4.0, 4.0]	4.0 [4.0, 4.5]	0.6276

For the procedure evaluation portion of our study, there was no statistically significant difference between groups for number of needle insertions, duration of procedure, number of boxes checked “yes” or “partial” on the grading rubric, or acquisition of CSF. There were several rubrics which did not have all the boxes checked and therefore were marked as “partial”. One student’s evaluation was cut off at 50 min due to no longer having the research space reserved. Evaluations were performed both with this outlier included and removed (Table 6).

Table 6.

Results of ultrasound guided lumbar puncture on task trainers

Procedure Analysis	Total N = 55	PowerPoint N = 27	Virtual Reality N = 28	P-Value
Needle insertions	2.0 [1.0, 3.0]	2.0 [1.0, 3.0]	2.0 [1.0, 3.0]	0.2538
Procedure duration (minutes)	13.4 ± 6.9	14.1 ± 8.7	12.7 ± 4.6	0.4515
Procedure duration (minutes) with outlier removed	12.7 ± 4.8	N = 26 12.8 ± 5.0	12.7 ± 4.6	0.9667
Number of “Yes” or “Partial” on rubric	12.2 ± 2.0	12.3 ± 2.0	12.1 ± 2.1	0.7333
CSF Obtained
• Yes	38 (69.09%)	19 (70.37%)	19 (67.86%)	0.5400
• No	16 (29.09%)	7 (25.93%)	9 (32.14%)
• Unknown	1 (1.82%)	1 (3.70%)	0 (0.00%)

Discussion

We found that medical students in the VR group rated the level of fun of their lecture higher than the slide show group. Furthermore, the VR group disagreed that the lecture was boring, and more strongly agreed that the lecture was enjoyable and effective at teaching USG LP compared to the slideshow group. We felt the distinction between fun, boredom, and how enjoyable a process is was important to make, as students may have enjoyed the class, but not the process of learning and performing the procedure, or vice versa. Additionally, they may have enjoyed the process of learning the procedure but found the class boring. There was no difference in duration of procedure, score on an LP checklist, or acquisition of CSF between the groups. These results confirmed our hypotheses.

Vrillon et al. previously developed a 180-degree non-interactive video for LP training that resulted in high satisfaction and perceived benefit for users, though there was no comparator group nor skills evaluation in this study [25]. We attempted to make a more interactive and immersive VR experience, allowing users to move, resize, and view different layers of 3D models. Mid-range interactivity has been linked to moderate improvements in clinical skills performance [28]. High interactivity, however, may require more cognitive demand and result in distraction from the material of interest per cognitive load theory [29, 30]. To address this, we designed the VR environment relatively simply with PDF screenshots, video of ultrasound images, audio recording and 3D models in the sections. Learners could move around the environment while the pre-recorded audio and baton pointed to items of interest.

Like Vrillon et al., our study showed positive user feedback in those using VR. We add to a growing body of literature supporting virtual reality as a useful pedagogical method for undergraduate medical education. One meta-analysis showed improvement in knowledge and skills in learners taking part in VR interventions [23]. While we did not see a difference in procedural outcomes between groups, learner-centered outcomes such as engagement should have a high priority in medical education given association with improved teaching effectiveness and deeper student understanding [31, 32].

We found a high level of agreement that our VR lecture was fun. The number of distractions were higher in the slideshow group, further suggesting that VR is more engaging and enjoyable than traditional teaching methods. Games, mobile apps, augmented reality, and VR are increasingly being used in medical education to increase enjoyment and engagement [33]. While we often focus on knowledge outcomes of teaching interventions in traditional medical education, the enjoyment of the process is often neglected. Medical students are under high levels of stress with high stakes clinical evaluations and testing. Given the long hours required of medical students to meet clinical expectations and to study for board exams, educators ought to make our teaching as enjoyable as possible. Medical students are at high risk for burnout and have been shown to have rates as high as 44% [34]. Finding ways to improve learner enjoyment and satisfaction with their education may be one facet of tackling this well-known challenge.

Several participants in the study noted symptoms of “cybersickness”, a phenomenon similar to motion sickness that has been recognized for decades [35]. While the cause of cybersickness is debated, longer duration of exposure is well known to increase frequency and severity of symptoms [36]. Our VR lecture was broken down into 5-minute sections followed by an assessment question. This allows users to take a break if needed, however, it was possible for participants to advance to the next section, for the entire 32-minute lecture, without taking their headset off. Stanney et al. found a nearly 50% dropout rate from VR environments with hour-long exposures [37]. Inserting a prompt suggesting a break within the presentation may be a way to mitigate these negative effects. It should be noted that only one student reported severe symptoms (headaches), though they did not report this as a reason for taking a break. Twenty-three (82.14%) participants had no or minimal symptoms in the categories we assessed.

Technological issues were more common in the virtual reality groups. There were issues with internet connectivity for several sessions as we were assigned different rooms in the simulation center. When we had a reliable source of Wi-Fi nearby, we did not have issues with connectivity. Furthermore, as this was many of the learners’ first exposure to VR and this software, there was a learning curve to figuring out controls and navigating the user interface for this specific software. As medical students become increasingly adept with technology, and with additional usage of VR, these technological issues would likely decrease.

Considering that VR is not yet ubiquitous in medical education, the financial threshold for incorporating VR into curriculum remains a barrier to implementation. However, given the cost of simulation faculty, equipment, and space, the initial investment in VR may be a more equitable way of ensuring learners have access to procedural simulation. Though the cost of a simulation program can be difficult to estimate, the fixed cost of an established simulation program has been estimated at $361,425 with variable costs around $311 per course hour [38]. For this research study, we applied for an internal grant that covered a $960 gaming laptop with an appropriate graphics card, $200 for the VR headset, and $17 for a link cable, though Meta Quest 2 has a wireless linking option also. Our upfront cost for 3 sets of equipment was $3,531. The physical space needed for VR immersion is minimal, with stationary mode only requiring clearance of obstructions within arm’s reach from the floor up. We have created several VR lectures, and in our experience the time cost of creating a VR presentation is approximately the same as making a slideshow lecture once one becomes familiar with the VR hardware and software. With dedicated faculty, VR could be incorporated into a flipped classroom model, bolstering face-to-face instruction and complementing procedural demonstration on a task trainer. VR modalities are by no means a replacement for faculty-led guidance, but they could potentially decrease in-person time commitments required of faculty and thus cut back on cost for simulation centers. VR allows repeatable self-guided education and given the higher levels of enjoyment, fun, and lower boredom compared to slideshows this may prompt learners to revisit material where they otherwise may not.

We recognize several limitations in our study. First, the size of our study limits generalizability, except for the level of fun noted in our VR cohort. Future studies would benefit from a larger sample size. Several limitations existed due to our lecture formats as well. The recorded slideshow lecture had assessments built in asking participants to pause and guess the answer prior to revealing the correct answer. For the VR slideshow, assessments had to be clicked, but they were not required to be completed to advance to the next lecture. For both groups, there is no guarantee that the participants engaged with the assessments, though the slideshow group at minimum was exposed to the questions and answers.

Given the multi-site nature of our study, there were limitations inherent in the design and implementation of this project. Students were randomized at each site, thus there is an imbalance in our randomization which may have impacted results. Additionally, more students were randomized than completed the study (34 of 42 completed at MSU, and 21 of 27 completed at UICOMP). The task trainers at the MSU site and UICOMP site differed, and thus, there were slight differences in tactile feedback and appearance of ultrasound images obtained. However, as the task trainers are both simulation-grade and facilitators completed US-guided LPs on both without issue, this likely had little impact on outcomes. The process followed by our facilitators at both study sites for the procedural portion of our study was standardized to limit variability between outcomes like duration and acquisition of CSF. Facilitators did not give guidance and started timing once the US probe (Butterfly iQ + at both sites) touched skin, and ended once CSF was elicited within three attempts, or the student gave up.

Due to our limited budget, we re-used skin blocks in our task trainers, so it is possible that participants could see locations where previous participants had inserted LP needles. For one participant, we ended the procedure at 50 min as we no longer had the space reserved. Duration analysis was conducted with and without this outlier. A few rubrics had a box that was not checked by our researchers, and we elected to give students partial credit for these as our researchers agreed that students skipping steps was noticeable enough to prompt marking “no” on the check list. We counted “partial” and “yes” equally in our study given the participants unfamiliarity with ultrasound and landmark-based LP. US guidance is a novel technique for performing LP, and there is a learning curve to both interpreting US images and performing a lumbar puncture. Thus, future studies looking at US image acquisition by those familiar with LP may be helpful.

Conclusion

Immersive technologies like VR have an ever-growing role in medical education and can add variety and engagement to curricula. As clinician educators, we are often competing against distractions from technology (smartphones, laptops, etc.) for our students’ attention. Engagement can be elusive in teacher-student interactions in the 21st century. VR is a way to harness technology to augment engagement and enjoyment, though logistical and technological issues should be recognized as potential surmountable barriers. VR also has exceptional utility in understanding complex 3D structures and engaging in high stakes, low frequency procedures/ medical scenarios compared to traditional 2D modalities. Our study suggests that virtual reality can be utilized with similar procedural outcomes as a slideshow lecture for teaching medical students ultrasound guided lumbar puncture, a skill that is gaining evidence for improved outcomes compared to its landmark-based counterpart. We add to the growing body of literature supporting VR to develop procedural skills, improve memory and knowledge, and importantly, use novel techniques to teach medical students in a fun and engaging way.

Abbreviations

LP

Lumbar puncture

USG LP

Ultrasound guided lumbar puncture

VR

Virtual reality

CSF

Cerebrospinal fluid

MSU

Michigan State University

CHW

Corewell Health West

UICOMP

University of Illinois College of Medicine at Peoria

OSF

Order of St. Francis

Authors' contributions

J.S. crafted the idea for the study, made the lectures, co-wrote the grant for VR equipment, crafted assessment questions, adapted the checklist for LP, made the post lecture survey, arranged dates for lectures and simulation, supervised LP stations and VR stations, and wrote manuscript. J.H and A.R assisted with sections of the lectures, co-wrote the grant for VR equipment, supervised LP stations, and assisted with writing introduction and conclusion of manuscript. C.S and D.S reviewed grant for VR equipment and manuscript with significant contributions to both. They supervised LP stations and VR stations. J.M., J.W., and C.F. assisted with recruitment of medical students including in-person recruitment, making fliers, and sending emails. They converted the post lecture survey to an electronic version. They supervised LP stations and reviewed the final manuscript. R.S, A.P, J.C, and M.M recruited and scheduled students at our second site, created site-specific fliers, set up task trainers and VR stations there, and supervised LP and VR stations. They reviewed the final manuscript.

Funding

Virtual reality headsets, link cables, and gaming laptops were purchased with internal grants and research funds (RI1089-2022). Butterfly iQ+ ultrasound probes and software and Apple iPads were supplied by Corewell Health West Simulation Team for use at both research sites. Simulab manikins and LP kits used at the MSU site were provided by the Corewell Health West Simulation Team. CAE Blue Phantom manikins and LP kits used at UICOMP site were provided by JUMP Simulation Center. Enduvo Virtual reality software license was provided free of charge for educational purposes. Microsoft Office subscription was provided by Corewell Health West.

Data availability

Data sets generated during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. The study protocol was reviewed and approved by the Institutional Review Boards at Corewell Health West, Michigan State University, and University of Illinois College of Medicine (IRB# 2022 − 445). Corewell Health West Institutional Review Board (previously Spectrum Health Human Research Protection Program) determined this to be exempt research per 45 CFR Part 46.104(d) categories 1 & 3, thus participants’ signatures were waived. All participants were provided with an informational sheet that outlined the project, risks and benefits of participation, and rights of the participants including withdrawal at any time.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.