Virtual reality simulation in training endoscopic skills: A systematic review

Reviewing the current state of virtual reality integration in medical education - a scoping review

BACKGROUND

In medical education, new technologies like Virtual Reality (VR) are increasingly integrated to enhance digital learning. Originally used to train surgical procedures, now use cases also cover emergency scenarios and non-technical skills like clinical decision-making. This scoping review aims to provide an overview of VR in medical education, including requirements, advantages, disadvantages, as well as evaluation methods and respective study results to establish a foundation for future VR integration into medical curricula.

METHODS

This review follows the updated JBI methodology for scoping reviews and adheres to the respective PRISMA extension. We included reviews in English or German language from 2012 to March 2022 that examine the use of VR in education for medical and nursing students, registered nurses, and qualified physicians. Data extraction focused on medical specialties, subjects, curricula, technical/didactic requirements, evaluation methods and study outcomes as well as advantages and disadvantages of VR.

RESULTS

A total of 763 records were identified. After eligibility assessment, 69 studies were included. Nearly half of them were published between 2021 and 2022, predominantly from high-income countries. Most reviews focused on surgical training in laparoscopic and minimally invasive procedures (43.5%) and included studies with qualified physicians as participants (43.5%). Technical, didactic and organisational requirements were highlighted and evaluations covering performance time and quality, skills acquisition and validity, often showed positive outcomes. Accessibility, repeatability, cost-effectiveness, and improved skill development were reported as advantages, while financial challenges, technical limitations, lack of scientific evidence, and potential user discomfort were cited as disadvantages.

DISCUSSION

Despite a high potential of VR in medical education, there are mandatory requirements for its integration into medical curricula addressing challenges related to finances, technical limitations, and didactic aspects. The reported lack of standardised and validated guidelines for evaluating VR training must be overcome to enable high-quality evidence for VR usage in medical education. Interdisciplinary teams of software developers, AI experts, designers, medical didactics experts and end users are required to design useful VR courses. Technical issues and compromised realism can be mitigated by further technological advancements.

Validation of a Tool-Based Visual Anorectal Examination Advanced Simulator for the Early Detection of Colorectal Cancer

Rectal examination through proctoscopy or rigid sigmoidoscopy is a common investigation in clinical practice. It is an important diagnostic tool for the workup and management of anorectal pathologies. Performing the examination can be daunting not only for patients but also for junior doctors. There are associated risks with the procedure, such as pain, diagnostic failure, and perforation of the bowel. Simulation-based training is recognised as an important adjunct in clinical education. It allows students and doctors to practice skills and techniques at their own pace in a risk-free environment. These skills can then be transferred to and developed further in clinical practice. There is extensive research published regarding the role of simulation-based training in endoscopy, however, we identified no published study regarding simulation-based training in rigid sigmoidoscopy or proctoscopy. This study aims to establish the initial face, content, and construct validity of a tool-based visual anorectal examination advanced simulator model for proctoscopy and rigid sigmoidoscopy. This innovative, highly realistic simulated environment aims to enhance the training of healthcare professionals and improve the efficiency of detecting and diagnosing distal colorectal disease.

Development and evaluation of artificial organ models for ERCP training in patients with surgically altered anatomies

Endoscopy training models (ETM) using artificial organs are practical, hygienic and comfortable for trainees. However, few models exist for training endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy. This training is necessary as the number of bariatric surgeries performed worldwide increases. ETM with human-like anatomy were developed to represent the postoperative anatomy after Billroth II (BII) reconstruction for a standard duodenoscope and the situs of a long-limbed Roux-en-Y (RY) for device-assisted enteroscopy (DAE). In three independent workshops, the models were evaluated by international ERCP experts. In RY model, a simulation for small bowel behavior in endoscopy was created. Thirty-three experts rated the ETM in ERCP expert courses. The BII model was evaluated as suitable for training (school grades 1.36), with a haptic and visual impression rating of 1.73. The RY model was rated 1.50 for training suitability and 2.06 for overall impression. Animal tissue-free ETMs for ERCP in surgically altered anatomy were successfully created. Evaluation by experienced endoscopists indicated that the models are suitable for hands-on ERCP training, including device-assisted endoscopy. It is expected that patient care will improve with appropriate training in advanced procedures.

Development of an interactive elective "altered anatomy" for students as part of the Z-curriculum according to the NKLM 2.0

Objective

Many patients have undergone visceral surgery. The effects on anatomy and physiology, which can result in further surgical or gastroenterological clinical pictures, are equally significant and require special knowledge. This content should be taught in an interdisciplinary elective course. The draft of the new 2025 approval regulation and the current approval regulation specify that preclinical and clinical content should specifically be combined within the framework of a Z-curriculum and that the new elective course should meet these requirements.

Methodology

Practical and theoretical aspects of recognising and treating patients with postoperative modified anatomy are to be taught and the findings are to be demonstrated using anatomical and artificial preparations. The curriculum of the preclinical course covers anatomy and physiology. The target group of the curriculum is all participating students with a special interest in topics such as anatomy, visceral surgery and gastroenterology. However, the goal is to involve student tutors of the anatomical dissection courses, who, in turn, will pass on knowledge of modified anatomy to the supervised preclinical students.

Results

According to Thomas and Kern, the curriculum development process entails the following six stages: general needs assessment, targeted needs assessment, the formulation of goals and content, the description of strategies, planned implementation and evaluation.

Conclusion

A "modified anatomy" curriculum for an interdisciplinary elective course in surgery, gastroenterology, and anatomy was developed. Through the training of anatomy table tutors, a "dovetailing" with the preclinical stage is to be achieved. In addition, new concepts related to the transfer of knowledge and competencies were introduced and should be evaluated for suitability.

July effect in clinical outcomes of esophagogastroduodenoscopy performed at teaching hospitals in the United States

Background

Esophagogastroduodenoscopy (EGD) is a common procedure used for both diagnosis and treatment, but carries risks such as bleeding and perforation. The "July effect"-described as increased complication rates during the transition of new trainees-has been studied in other procedures, but has not been thoroughly evaluated for EGD.

Methods

We used the National Inpatient Sample database for 2016 to 2018 to compare outcomes in EGD performed between July to September and April to June.

Results

Approximately 0.91 million patients in the study received EGD between July to September (49.35%) and April to June (50.65%), with no significant differences between the two groups in terms of age, gender, race, income, or insurance status. Of the 911,235 patients, 19,280 died during the study period following EGD, 2.14% (July-September) vs 1.95% (April-June), with an adjusted odds ratio of 1.09 (P < 0.01). The adjusted total hospitalization charge was $2052 higher in July-September ($81,597) vs April to June ($79,023) (P < 0.005). The mean length of stay was 6.8 days (July-September) vs 6.6 days (April-June) (P < 0.001).

Conclusions

The results of this study are reassuring as the July effect on inpatient outcomes for EGDs was not significantly different according to our study. We recommend seeking prompt treatment and improving new trainee training and interspecialty communication for better patient outcomes.

Simulator-based training method in gastrointestinal endoscopy training and currently available simulators

The apprenticeship-based training method (ABTM) is highly effective for gastrointestinal (GI) endoscopic training. However, the conventional ABTM has significant issues. Although many supplementary training methods (TMs) have been developed and utilized, they cannot entirely replace the ABTM, which remains the major TM strategy. Currently, new TM construction is crucial and necessary due to financial constraints, difficulty of obtaining sufficient training time due to patient safety-related regulations, and catastrophic damage caused by disasters such as the coronavirus disease 2019 pandemic. The simulator-based TM (SBTM) is widely accepted as an alternative to the ABTM, owing to the SBTM's advantages. Since the 1960s, many GI endoscopy training simulators have been developed and numerous studies have been published on their effectiveness. While previous studies have focused on the simulator's validity, this review focused on the accessibility of simulators that were introduced by the end of 2021. Although the current SBTM is effective in GI endoscopic education, extensive improvements are needed to replace the ABTM. Incorporating simulator-incorporated TMs into an improved ABTM is an attempt to overcome the incompleteness of the current SBTM. Until a new simulator is developed to replace the ABTM, it is desirable to operate a simulator-integrated and well-coordinated TM that is suitable for each country and institution.

Simulation-based mastery learning in gastrointestinal endoscopy training

Simulation-based mastery learning (SBML) is an emerging form of competency-based training that has been proposed as the next standard method for procedural task training, including that in gastrointestinal endoscopy. Current basic gastrointestinal endoscopy training relies on the number of procedures performed, and it has been criticized for its lack of objective standards that result in variable skills among trainees and its association with patient safety risk. Thus, incorporating simulators into a competency-based curriculum seems ideal for gastrointestinal endoscopy training. The curriculum for SBML in gastrointestinal endoscopy is currently being developed and has promising potential to translate into the clinical performance. Unlike the present apprenticeship model of “see one, do one, teach one,” SBML integrates a competency-based curriculum with specific learning objectives alongside simulation-based training. This allows trainees to practice essential skills repeatedly, receive feedback from experts, and gradually develop their abilities to achieve mastery. Moreover, trainees and trainers need to understand the learning targets of the program so that trainees can focus their learning on the necessary skills and trainers can provide structured feedback based on the expected outcomes. In addition to learning targets, an assessment plan is essential to provide trainees with future directions for their improvement and ensure patient safety by issuing a passing standard. Finally, the SBML program should be planned and managed by a specific team and conducted within a developed and tested curriculum. This review discusses the current state of gastrointestinal endoscopy training and the role of SBML in that field.