Initially associated with the world of video games, virtual reality (VR) is becoming an essential training tool in specific fields, including medicine and paramedicine. Its advantages are enhanced by the fact that it has evolved rapidly in recent years in terms of performance and ergonomics while becoming more accessible. To respect the ethical principle of “never the first time on the patient,” simulation in its various forms has been an integral part of the training of healthcare professionals in North America for several decades. VR appears to be the technology of the future par excellence to ensure the acquisition of a wide range of practical and experiential learning necessary for these professionals’ initial and ongoing training. Here is what you need to know to better understand its potential for medical education.
What is a simulation in healthcare?
The term simulation in healthcare refers to “the use of a device, such as a mannequin, a task trainer, virtual reality, or a standardized patient, to emulate a real device, patient, or patient care situation or environment to teach therapeutic and diagnostic procedures, processes, medical concepts, and decision-making to a health care professional.”
House of Representatives USA, 111th Congress 02-2009
In their book Learning with Digital Technology (2020), Frank Amadieu and André Tricot note some considerable and lesser-known advantages of simulation for medical training: “The advantage of simulators in medical training is not only in the reduction of (human) costs. They allow for better planning of training and objectives, progression and tasks. Progression, in particular, is of major interest: with a simulator, you can start with what is simple — even simplify the situation — and then move on to complexity. With a patient, the complexity is immediately present. For example, in resuscitation, the complexity of the learning situation is strongly linked to emotions, especially those linked to the death of the patient. [see Fraser K. et al., 2014]”
What is patient safety?
The Royal College of Physicians and Surgeons of Canada, the national professional association that oversees the medical education of specialists in this country, is also the body that accredits simulation programs. In its document on accreditation of simulation programs, the Royal College defines patient safety as “the pursuit of the reduction and mitigation of unsafe acts within the health care system, as well as the use of best practices shown to lead to optimal patient outcomes. Risk management, in the context of clinical care, refers to the activities undertaken to identify, analyze, educate and structure processes to reduce the likelihood of adverse events.” The Royal College also states that as professionals, physicians have a duty to promote and protect the health and well-being of others, both individually and collectively.
A unique training technology
Virtual reality is a fascinating technology that allows the users to immerse themselves in a dynamic and adaptive 3D 360-degree synthetic world in which they can move and interact with tactile and sensory feedback; all this by simply wearing a headset and, if necessary, haptic gloves or controllers. VR makes it possible to create realistic or unrealistic universes and to integrate customized scenarios. Thanks to artificial intelligence (see Mini glossary of artificial intelligence), VR can have an adaptive and predictive facet, more personalized and dynamic. In Le traité de la réalité virtuelle (Fuchs et al.), its authors specify that VR “can be defined according to two main elements: technological (the set of tools allowing the experience), and individual (the subjective construction of the experience). The first is immersion and the second is presence (shortened to “telepresence”). The latter can be defined as the sensation of being physically present in the virtual environment, perceiving it as real and forgetting the technology that gives it life and the underlying real world. The International Society for Presence Research, a non-profit organization founded to support academic research related to the concept of (tele)presence, defines presence as “the perceptual illusion of non-mediation”: what characterizes the feeling of presence at a distance is primarily the ability to forget the mediating role played by the technology, which is then either invisible to the user or transformed into a social entity (Lombard and Ditton, 1997). Finally, it should be noted that presence promotes immersion.
Of all the technologies that can serve “reality-like” functions – that is, high-fidelity medical simulation technologies – it is by far the most powerful in convincing the user’s brain that they are indeed in a world of their own and in generating sensations and emotions of the intensity of those experienced in real life settings. In a recent editorial article (June 2022) in the journal Frontiers on immersive technologies in healthcare, the three authors summarize some interesting study findings on realism in healthcare simulation training:
“It has been suggested that the fidelity of the simulation might impact the cognitive and clinical skills of healthcare providers interacting with the simulation (Lasater, 2007; Lee and Oh, 2015). A high level of fidelity and realism is associated with effective learning (Barry Issenberg et al., 2005) and is required by the National Council State Boards of Nursing (National Council of State Boards of Nursing and National Council of State Boards of Nursing, 2009). The closer the realism is to clinical reality, the easier it is for participants to engage in the simulation scenario (Dieckmann et al., 2007). Different aspects within these simulations have their own fidelities, including the facilities, clinical methodology, and patients. The patient aspect encompasses the representation of interactions with all or part of a patient, such as communicating with or performing a procedure on a patient, and considers the fidelity of appearance, anatomy, and physiology (Tun et al., 2015). In this Research Topic, Carnell et al. evaluate virtual patient interaction fidelity with advanced communication skills learners, and found that the level of learners affects the choice of interface.”
For training purposes, VR offers the ability to recreate a wide variety of professional environments and tasks that learners can practice safely and free from the judgment of others until they are fully proficient. It is ideal for practicing skills required in environments that are complex to replicate, remote, or involve some degree of danger. For example, the aviation industry, which has been using VR simulation for several decades, has estimated that it has reduced airplane accidents related to human error by nearly 50% since the 1970s. In the same industry, the Boeing Company has integrated VR training (as well as augmented reality) and has estimated that this approach would reduce training time per employee by as much as 75%. The vice president of global educational solutions at the Johnson & Johnson Institute says that in an independent study conducted by Imperial College London, 83% of surgeons who trained in VR could successfully perform the actual operation with minimal guidance. At the same time, in the control group that received traditional training, 0% of surgeons could perform the operation without assistance. On another note, the possibilities of gamification offered by VR are not negligible since we know today that the virtues of games for learning are to be taken seriously even among adults (see Is having fun in education the way forward? and Adult learners and games: 5 research findings).
With its multiplayer feature, VR opens the door to peer learning and teamwork, where multiple users can come together in the same virtual world and interact with each other and the environment. With this feature, which abolishes borders, a learner can be supervised by an expert located anywhere else on the planet or join a group from a distant university to perfect a new approach. This advantage of virtual reality allows for collaborations and sharing of best practices in medical education on an international scale, which also means greater democratization of access to such education. This advantage is also valid for medical research, where specific experiments usually carried out in the same physical environment can now be done remotely.
With this technology, educational institutions can offer on-demand, empirically based training to a large number of learners in a standardized way. Furthermore, while VR equipment remains expensive – although it is becoming increasingly accessible – it can be a cost-effective investment when compared to other resources needed to deliver quality simulation training (various technological devices, physical locations, teaching staff, different stakeholders to design simulations, etc.). This technology also meets today’s learners’ need for flexibility and autonomy, giving them access to hyper-sophisticated distance learning that requires little setup time and practice space. Moreover, since the equipment is becoming more and more portable, it can be used anywhere and at any time, which is advantageous in terms of practicality and learning since the user can optimally scale their training (see Neuroscience: 3 mistakes to avoid when studying). Finally, it should be noted that with the new realities brought about by the COVID-19 pandemic, educational institutions can no longer postpone their entry into the digital age. Consequently, VR becomes a wise choice to invest in the long term.
Its relevance in medical education
The integration of virtual reality in medical training is not intended to replace the theoretical teaching given in class nor to take the place of the expert teacher when their supervision is necessary. Regarding the simulation component, it must be emphasized that certain pedagogical objectives are better served in a real context and that others do not require immersion in a complex situation. That said, in general, while practical learning tends to replace rote learning (when possible), teaching certain notions would benefit from being transferred to virtual reality. This is the case, for example, with anatomy lessons, which this technology can present in a much more precise, global and attractive way than conventional media. Thus, rather than having to learn by looking at a two-dimensional image, VR allows the learner to explore at will the different parts of the human body in 3D and see the metabolic processes in action. It is important to note that these are very powerful computer programs that allow specific 3D images to be obtained by merging the results of two-dimensional images from MRI machines, ultrasounds and CT scans. It is even possible to recreate a patient’s “digital twin” in virtual reality based on their imaging results and clinical data.
Among the great strengths of VR for medical training is that it offers optimal conditions for maximizing the competence of practitioners without jeopardizing patient safety. Let’s remember that it is by practicing that we learn best and that the right to make mistakes is fundamental in this process (see Neuroscience: learning in 4 steps). In this sense, this technology represents an ideal test field: not only does it allow the learner to make mistakes and to practice as long as necessary to master a skill and develop good reflexes, but it also corrects the learner in real time. Thanks to neuroscience, we now know that this immediate feedback, this return on error, is a crucial step for effective learning. In addition, VR has the advantage of collecting data on user behaviour and performance, allowing for precise adjustment and personalization of training. An important point to emphasize is that this function is also relevant for evaluating the skills of a future practitioner or for revalidating those of a practitioner. VR can, therefore, also be used in certification, recertification and hiring processes.
Virtual reality is ideal for learning to master technical gestures such as certain surgical procedures and manipulate various tools and medical devices. It is also very useful to allow practitioners to familiarize themselves with new equipment or to integrate new care techniques.
Here are some examples developed by us on the use of medical tools and devices in VR. Note that these examples are prototypes and can be customized as needed.
VR also lends itself to developing non-technical skills, which are also essential in diagnostic and therapeutic interventions. To this end, it is possible to recreate different care environments and situations in which healthcare professionals are called upon to intervene. For example, a virtual ward can be recreated in which the learner will have to interact with several avatars – patients, colleagues, and patients’ families – in scenarios where a hospital’s typical activity and rhythm are also reproduced. This type of exercise aims to sharpen the learner’s clinical reasoning, interpersonal and communication skills, critical thinking and decision-making abilities while allowing them to manage stress better and increase self-confidence in such contexts. Such training allows the learner to practice in all the stages of their future practice: they can question the patient about their situation, evaluate them, make a diagnosis and then treat them.
Finally, by allowing the learner to take on the role of another avatar – that of a patient, a member of the patient’s family or a colleague – VR can help the learner develop more empathy for those they encounter in their professional environment and thus gain a better understanding of the issues they face. Empathy is increasingly viewed in medicine as a communication skill that should be central to the patient-physician relationship (Empathy, Education and Interpersonal Engagement by Dr. Edward G. Spilg of the University of Ottawa’s Faculty of Medicine). Several studies have identified numerous benefits to improving empathy among practitioners, including:
- Higher ratings of clinical competence (Hojat et al, 2002)
- Improved patient satisfaction (Blatt et al, 2010; Reiss et al, 2012; Krasner et al, 2009)
- More favourable health outcomes (Derksen et al, 2013)
- Improved adherence to medical recommendations or regimens (Hojat at al, 2011)
- Reduced medical-legal risk (Levinson et al, 1997, Moore et al, 2000)
- Reduced health care costs (Epstein et al, 2005)
- Better emotional regulation for physicians
- Individuals who can regulate their own affective responses to maintain an optimal level of emotional arousal have greater expressions of empathic concern for others (Decety and Meyer, 2008)
- Reduced depersonalization and burnout (Thomas et al, 2007)
- Higher feelings of well-being (Shanafelt et al, 2005)
At the cutting edge of technology, offering the most realistic, captivating and personalized learning experiences available, virtual reality is a highly effective training tool perfectly adapted to the current and future realities of the medical profession. It has undeniable advantages for learners and educational institutions and opens the door to greater collaboration without borders, more knowledge sharing and more democratization throughout the medical teaching and learning community worldwide.