Virtual Reality Simulation: Evaluating an Experiential Tool for the Clinical Application of Pathophysiology

Abstract

At our medical school, MS3 students experience minimal patient contact. Our research shows that virtual reality simulation (VRS) supports students’ transition back to patient care by increasing post-intervention confidence in clinical decision-making, management, and patient communication. VRS shows potential to teach pathophysiology, and bridges clinical and basic science instruction.

Virtual reality simulation (VRS) is an emerging technological aid in medical student education. Despite its increasing use, there are few reports on the use of VRS in educating medical students on the application of basic science knowledge to clinical decision-making (CDM) [1–4]. In a review of 92 studies examining VRS in undergraduate medical education published through 2021, only 17% used it in the context of CDM [4]. VRS supplemented by debriefing is a pedagogical approach that is attracting interest [3]. Our study uses attitudinal learning outcomes such as changes in learners’ confidence levels to evaluate the usefulness of VRS in reviewing pathophysiologic mechanisms of CDM.

Students at our school enter clerkships in their MS2 year and engage in advanced degree courses or research in their MS3 year, requiring an intensive “transition week” to reintroduce them to clinical medicine at the end of their third year. We conducted a pilot study to evaluate the impact of a VRS-based exercise with debriefing to help integrate basic science knowledge and CDM.

Eight MS3 students volunteered to use the Oxford Medical Simulation platform in groups of two or three in Spring 2021. The VRS program generated an immersive 360-degree experience to replicate a clinical situation via a head-mounted display (HMD). Each student performed a unique 15-min scenario in an HMD, while one to two peers and one clinician faculty observed on a screen. Clinical faculty selected five scenarios representing common, life-threatening diagnoses relevant across multiple medical disciplines, each programmed with skills that correlated with our learning objectives. Learners became physicians immersed in an emergency room setting interacting with patient and nurse avatars. By performing a focused history and physical examination, ordering and interpreting tests, they diagnosed and initiated appropriate treatment in a timely manner while communicating with the patient, nurse, and other providers.

At the end of the scenario, each student received tailored feedback centered around their application of pathophysiologic and pharmacologic principles to CDM. Students completed an online 17-item retrospective pre/post-questionnaire which assessed their confidence level in diagnosing and managing the patients (3-point scale: 1 = not very confident, 2 = somewhat confident, 3 = confident). Students also rated the usefulness of the experience in their preparation to return to clinical work (4-point scale: 1 = not at all useful, 2 = somewhat useful, 3 = useful, 4 = very useful).

Students rated their post-intervention confidence levels higher than their pre-intervention level in all areas (Table 1). Pre- and post-confidence ratings were compared using a nonparametric Wilcoxon signed-rank test. This showed a statistically significant improvement in students’ confidence in making appropriate and timely clinical decisions, effectively managing the team, and updating the patient (Table 1). Those skills which showed the greatest benefit, such as ordering appropriate labs, intravenous access, fluids, oxygen, and medications, and seeing their effects on the patient, reflected the dynamic and responsive nature of VRS. Most students indicated the experience was “very useful” preparation for reintroduction to clinical medicine during MS3 year (mean = 3.88, SD = 0.35), and all would recommend this modality to their peers to help refresh clinical skills. We would argue that this method can be used systemically to review the pathophysiology of common medical conditions.

Table 1.

Comparison and effect size of students’ pre-post VRS intervention confidence ratings using the Wilcoxon signed-rank test

Survey item (n = 8)	Pre-intervention mean confidence rating	Post-intervention mean confidence rating	Z statistic	p-value	Effect size (r)**
Patient and team management and information gathering
Focused H&P	2.38	2.75	−1.732	0.25	0.61
Appropriate and timely clinical decisions	1.38	2.5	−2.714	0.008*	0.96
Ordering appropriate labs	1.38	2.25	−2.646	0.016*	0.94
Patient comfort	2.25	2.5	−1.414	0.5	0.5
Effectively manage team	1.63	2.38	−2.449	0.031*	0.87
Seeking help	1.88	2.38	−2.0	0.125	0.71
Calling appropriate consultations	1.25	2.13	−2.070	0.063	0.73
Ordering appropriate critical management actions
IV access	1.5	2.25	−2.714	0.008*	.87
Interpreting continuous vitals	2.25	2.75	−2.0	0.5	0.71
Deciding on oxygen needs	2.13	2.75	−2.236	0.063	0.79
Performing volume resuscitation	1.63	2.38	−2.449	0.031*	0.87
Selecting meds	1.38	2.25	−2.646	0.016*	0.94
Ordering analgesia	1.63	2.25	−2.236	0.063	0.79
Using antiemetics	1.75	2.38	0.63	0.063	0.79
Effectively communicating with the patient during care
Updating patients with their results	1.88	2.63	−2.449	0.031*	0.87
Answering questions	2.0	2.38	−1.732	0.25	0.61
Providing reassurance	2.38	2.63	−1.414	0.5	0.5

^*p-value < 0.05, statistically significant difference in pre-/post-confidence levels; ^**effect size small (r = 0.1), medium (r = 0.3), large (r = 0.5)

Similar to findings by other researchers [3], our pilot study demonstrated improved confidence levels in clinical decision-making. The emotional impact of immersion along with in-person debriefing has been shown to facilitate learning and ultimately promote students’ learning satisfaction [2, 4, 5]. Feedback tailored to individual needs increases efficiency in learning and reduces time to achieve proficiency [6].

Unlike a simulation-based learning center with high-fidelity mannequins and standardized patients, VRS replicates real-world clinical situations in a risk-free environment that is immersive, repeatable, and individually trackable [1, 2, 4–6]. As computer technology has become more readily available, VRS platforms have become less expensive and more accessible worldwide [4, 5]. Rather than a written case-based discussion, VRS introduces learners in “real-time” to an immersive, physiologically responsive patient. This participation-based clinical scenario could be used as a springboard for further discussion on the physiology and pathophysiology of specific disease processes, with the VRS patient modeling dynamically the system(s) of interest. As medical education continues to move toward earlier introduction and integration of clinical medicine [1], we believe that VRS would be an excellent tool to help bridge the gap that often separates the basic sciences and clinical medicine.

For the development of future curricula utilizing VRS patient scenarios in undergraduate medical student education, we encourage larger scale studies of the following areas: (a) use common clinical scenarios to teach pathophysiology and its application to clinical reasoning, studying improvements in knowledge and confidence; (b) study the extent to which in-person faculty debriefing during VRS sessions augments learning; (c) study both immediate and sustained retention in the domains of knowledge and confidence in the application of basic sciences to clinical reasoning.

Declarations

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants involved in the study.

Conflict of Interest

The authors declare no competing interests.