A Virtual Reality Resident Training Curriculum on Behavioral Health Anticipatory Guidance: Development and Usability Study

A Modified Delphi Study for Curricular Content of Simulation-Based Medical Education for Pediatric Residency Programs

OBJECTIVE

We sought to establish core knowledge topics and skills that are important to teach pediatric residents using simulation-based medical education (SBME).

METHODS

We conducted a modified Delphi process with experts in pediatric SBME. Content items were adapted from the American Board of Pediatrics certifying exam content and curricular components from pediatric entrustable professional activities (EPAs). In round 1, participants rated 158 items using a four-point Likert scale of importance to teach through simulation in pediatric residency. A priori, we defined consensus for item inclusion as ≥70% rated the item as extremely important and exclusion as ≥70% rated the item not important. Criteria for stopping the process included reaching consensus to include and/or exclude all items, with a maximum of three rounds.

RESULTS

A total of 59 participants, representing 46 programs and 25 states participated in the study. Response rates for the three rounds were 92%, 86% and 90%, respectively. The final list includes 112 curricular content items deemed by our experts as important to teach through simulation in pediatric residency. Seventeen procedures were included. Nine of the seventeen EPAs had at least one content item that experts considered important to teach through simulation as compared to other modalities.

CONCLUSIONS

Using consensus methodology, we identified the curricular items important to teach pediatric residents using SBME. Next steps are to design a simulation curriculum to encompass this content.

Virtual, augmented, and mixed reality: potential clinical and training applications in pediatrics

BACKGROUND

COVID-19 pandemic has significantly impacted the field of medical training, necessitating innovative approaches to education and practice. During this period, the use of novel technologies like virtual reality (VR), augmented reality (AR), and mixed reality (MR) has become increasingly vital. These technologies offer the advantage of transcending the limitations of time and space, thus enabling medical professionals to access various personalized programs for both education and service delivery. This shift is particularly relevant in the realm of pediatric medicine, where traditional training and clinical methods face unique challenges.

PURPOSE

The primary aim of this study is to explore the application of VR, AR, and MR technologies in pediatric medical settings, with a focus on both clinical applications and the training of pediatric medical professionals. We aim to comprehensively search and review studies that have utilized these technologies in the treatment of pediatric patients and the education of healthcare providers in this field.

METHODS

Peer-reviewed articles published in PubMed, the Cochrane Library, ScienceDirect, Google Scholar, and Scopus from January 1, 2018, to March 1, 2023, were comprehensively searched. The review was conducted according to the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analyses) guidelines. Among the 89 studies, 63 investigated the clinical applications of VR (n=60) or AR (n=3) in pediatric patients, and 25 investigated the applications of VR (n=19), AR (n=5), or MR (n=1) for training medical professionals.

RESULTS

A total of 36 randomized controlled trials (RCTs) for clinical application (n=31) and medical training (n=5) were retrieved. Among the RCTs, 21 reported significant improvements in clinical applications (n=17) and medical training (n=4).

CONCLUSION

Despite a few limitations in conducting research on innovative technology, such research has rapidly expanded, indicating that an increasing number of researchers are involved in pediatric research using these technologies.

Motivational Interviewing Education in North American Family Medicine Clerkships: A CERA Study

BACKGROUND AND OBJECTIVES

Many health conditions are preventable or modifiable through behavioral changes. Motivational interviewing (MI) is an evidence-based communication technique that explores a patient's reasons for behavioral changes. This study assesses the current landscape of MI training in North American Family Medicine (FM) clerkships.

METHODS

We analyzed data gathered as part of the 2022 Council of Academic Family Medicine's Educational Research Alliance (CERA) survey of FM clerkship directors (CDs). The survey was distributed via email invitation to 159 US and Canadian FM CDs in June 2022.

RESULTS

Of the 94 responses received, 61% indicated that MI training is provided in their FM clerkship. Medical school type, class size, and location were associated with MI training priority, offerings, and duration in the clerkship, respectively. CD experience correlated with MI training duration; student MI skill training level was associated with MI training duration and priority; the rigor of student MI skills evaluation was correlated with MI teaching methods and training duration; self-reported student MI competency was associated with the length of time students spent with FM community preceptors as well as MI training priority and teaching methods; and several items emerged as predictors of student, CD, and FM faculty MI training expansion.

CONCLUSIONS

Opportunities exist to enhance the volume, content, and rigor of MI training in North American FM clerkships as well as to improve self-reported student MI competency within those clerkships.

Virtual Reality to Assess Resident Recognition of Impending Respiratory Failure During COVID-19

OBJECTIVES

To assess the performance of pediatric residents in recognizing a decompensating patient with impending respiratory failure and appropriately escalating care using a virtual reality (VR) simulated case of an infant with bronchiolitis after an extended period of decreased clinical volumes during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

Sixty-two pediatric residents at a single academic pediatric referral center engaged in a 30-minute VR simulation on respiratory failure in a 3-month-old admitted to the pediatric hospital medicine service with bronchiolitis. This occurred in a socially distant manner across the Zoom platform during the COVID-19 pandemic (January-April 2021). Residents were assessed on their ability to (1) recognize altered mental status (AMS), (2) designate clinical status as "(impending) respiratory failure," and (3) escalate care. Statistical differences between and across postgraduate year (PGY) levels were examined using χ2 or Fisher's exact test, followed by pairwise comparison and posthoc multiple testing using the Hochberg test.

RESULTS

Among all residents, 53% successfully recognized AMS, 16% identified respiratory failure, and 23% escalated care. No significant differences were seen across PGY levels for recognizing AMS or identifying respiratory failure. PGY3+ residents were more likely to escalate care than PGY2 residents (P = .05).

CONCLUSIONS

In the setting of an extended period with decreased clinical volumes during the COVID-19 pandemic, pediatric residents across all PGY levels demonstrated challenges with identifying (impending) respiratory failure and appropriately escalating care during VR simulations. Though limited, VR simulation may serve as a safe adjunct for clinical training and assessment during times of decreased clinical exposure.

Impact of Virtual and Augmented Reality on Quality of Medical Education During the COVID-19 Pandemic: A Systematic Review

Background

The COVID-19 pandemic and the subsequent mandatory social distancing led to widespread disruption of medical education. This contributed to the accelerated introduction of virtual reality (VR) and augmented reality (AR) technology in medical education.

Objective

The objective of this quantitative narrative synthesis review is to summarize the recent quantitative evidence on the impact of VR and AR on medical education.

Methods

A literature search for articles published between March 11, 2020 and January 31, 2022 was conducted using the following electronic databases: Embase, PubMed, MEDLINE, CINAHL, PsycINFO, AMED, EMCARE, BNI, and HMIC. Data on trainee confidence, skill transfer, information retention, and overall experience were extracted.

Results

The literature search generated 448 results, of which 13 met the eligibility criteria. The studies reported positive outcomes in trainee confidence and self-reported knowledge enhancement. Additionally, studies identified significant improvement in the time required to complete surgical procedures in those trained on VR (mean procedure time 97.62±35.59) compared to traditional methods (mean procedure time 121.34±12.17). However, participants also reported technical and physical challenges with the equipment (26%, 23 of 87).

Conclusions

Based on the studies reviewed, immersive technologies offer the greatest benefit in surgical skills teaching and as a replacement for lecture- and online-based learning. The review identified gaps that could be areas for future research.

Effectiveness of a Curriculum for Pediatric Residents to Address Adolescent Nonsuicidal Self-Injury

OBJECTIVE

The present study assessed changes in pediatric resident competence in addressing adolescent nonsuicidal self-injury (NSSI) following a brief, single-session didactic training during the educational unit in adolescent medicine. This study also evaluated knowledge acquisition and retention over time, overall helpfulness of the training, and changes in the perception of how important residents believe that physicians receive training in NSSI.

METHODS

Pediatric residents participated in a single-session NSSI curriculum delivered as part of a monthlong clinical rotation from August 2016 to February 2019. Participants completed pretest, posttest, and 6-month follow-up surveys, and t tests and analyses of variance with post hoc comparisons evaluated changes in variables across the three time points.

RESULTS

One hundred twenty-seven of 162 eligible residents participated (78.4% response rate), and 69 completed the 6-month follow-up (54.3% retention rate). Prior to the NSSI didactic, 107 (85.6%) reported feeling not at all competent or only somewhat competent in responding to patients with a history of NSSI. Residents' self-perceived competence increased significantly (p < .001) from pretest to posttest and was sustained longitudinally. A measure of objective knowledge also showed retention over time. Residents were significantly (p < .001) more likely after the didactic to believe that training in NSSI for physicians is very important compared to before the training.

CONCLUSIONS

Following NSSI training, residents demonstrated increased knowledge and subjective competence in caring for adolescents who self-injure. It is feasible and important to integrate a brief, single-session NSSI curriculum into pediatric residency programs, such as in the adolescent medicine rotation.

A Virtual Reality Curriculum to Enhance Residents' Behavioral Health Anticipatory Guidance Skills: A Pilot Trial

OBJECTIVE

Effective educational strategies to train and assess residents' skills in behavioral health competencies have been limited. We hypothesized that a training curriculum using virtual reality (VR) simulations would enhance residents' evidence-based skills related to behavioral health anticipatory guidance (BHAG) and motivational interviewing (MI).

METHODS

We conducted a randomized controlled pilot trial of our curriculum within an urban academic clinic. Intervention and control groups received four 15-minute, monthly didactics on BHAG and MI followed by VR simulations to 1) deliberately practice delivering BHAG by verbally counseling avatars, who responded real-time (intervention group) or 2) assessing pediatric respiratory distress (control group). Two months post-VR training, all residents participated in a unique VR behavioral health scenario which was recorded and coded by pediatric psychologists via an observation instrument to assess residents' skills. Differences in BHAG and MI competencies were assessed via independent samples t tests for continuous variables and Fisher's exact tests for categorical variables.

RESULTS

Sixty-six percent (n = 55) of eligible residents completed all study protocols comprising 35 intervention and 20 control participants. Intervention participants demonstrated an increase in BHAG skills (P = .002), percentage of open-ended questions asked (P = .04), and percentage of MI adherent behaviors (P = .04) when compared to the control group.

CONCLUSIONS

VR may be an effective educational strategy for residents to acquire BHAG and MI skills though deliberate practice. Next steps will focus on assessing the generalizability of the VR curriculum as well as exploring the opportunities to enhance its scalability through artificial intelligence.

The Acceptability of Avatar Patients for Teaching and Assessing Pediatric Residents in Communicating Medical Ambiguity

BACKGROUND

Simulation offers a means to assess resident competence in communication, but pediatric standardized patient simulation has limitations. A novel educational technology, avatar patients (APs), holds promise, but its acceptability to residents, educational relevance, and perception of realism have not been determined.

OBJECTIVE

To determine if APs are acceptable, provide a relevant educational experience, and are realistic for teaching and assessment of a complex communication topic.

METHODS

Pediatric residents at one academic institution participated in an AP experience from 2019 to 2021 consisting of 2 scenarios representing issues of medical ambiguity. After the experience, residents completed a survey on the emotional relevance, realism, and acceptability of the technology for assessment of their communication competence.

RESULTS

AP actor training required approximately 3 hours. Software and training was provided free of charge. Actors were paid $30/hour; the total estimated curricular cost is $50,000. Sixty-five of 89 (73%) pediatric residents participated in the AP experience; 61 (93.8%) completed the survey. Forty-eight (78.7%) were emotionally invested in the scenarios. The most cited emotions evoked were anxiety, uncertainty, concern, and empathy. The conversations were rated by 49 (80.3%) as realistic. APs were rated as beneficial for learning to communicate about medical ambiguity by 40 (65.5%), and 41 (66.7%) felt comfortable having APs used to assess their competence in this area.

CONCLUSIONS

Pediatric residents were emotionally invested in the AP experience and found it to be realistic. The experience was rated as beneficial for learning and acceptable to be used for assessment of how to communicate medical ambiguity.

Impact of a Virtual Reality Curriculum on Human Papillomavirus Vaccination: A Pilot Trial

Although the strongest predictor of human papillomavirus (HPV) vaccination is a high-quality recommendation, physicians often provide weak recommendations. Thus, the authors developed Virtual Immersive Communication Training on Recommending Immunizations (VICTORI), a virtual reality (VR)‒based intervention that provided physicians the opportunity to deliberately practice recommendation behaviors. VICTORI included VR simulations during which participants counseled caregiver avatars hesitant to vaccinate. Before participation in VICTORI, participants reviewed a smartphone application on recommendation behaviors. A nonrandomized control trial of VICTORI was conducted with licensed and resident physicians. The intervention group completed the application and VICTORI simulations, whereas a comparison group completed only the application. The hypothesis was that HPV vaccination rates would increase for patients in the intervention group. The preintervention period was defined as the 6 months before allocated training (February 1, 2020-July 31, 2020), and the postintervention period was the 6 months after (October 1, 2020-March 31, 2021). The primary outcome was a change in the rates of human papillomavirus vaccine initiation among eligible patients presenting to clinic before and after. Of 142 eligible physicians, 134 (94%) chose to participate, with 93 of /97 (96%) intervention and 30 of 37 (81%) comparison participants completing study protocols. There was a statistically significant increase in patients' HPV vaccine initiation rates after training within the intervention group (54.3%‒72.4%; 18.1% difference [95% CI=11.0, 25.8]; p<0.001) but not within the comparison group (59.5%‒63.4%; 3.9% difference [95% CI= -11.0, 19.0]; p=0.609). In conclusion, HPV vaccine initiation increased after VR training, and further study is warranted.

Virtual Reality Applications in Medicine During the COVID-19 Pandemic: Systematic Review (Preprint)

Background

Virtual reality can play an important role during the COVID-19 pandemic in the health care sector. This technology has the potential to supplement the traditional in-hospital medical training and treatment, and may increase access to training and therapies in various health care settings.

Objective

This systematic review aimed to describe the literature on health care–targeted virtual reality applications during the COVID-19 crisis.

Methods

We conducted a systematic search of the literature on the PsycINFO, Web of Science, and MEDLINE databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The search string was as follows: “[(virtual reality)] AND [(COVID-19) OR (coronavirus) OR (SARS-CoV-2) OR (healthcare)].” Papers published in English after December 2019 in peer-reviewed journals were selected and subjected to the inclusion and exclusion criteria. We used the Mixed Methods Appraisal Tool to assess the quality of studies and the risk of bias.

Results

Thirty-nine studies met the inclusion criteria. Seventeen studies showed the usefulness of virtual reality during the COVID-19 crisis for reducing stress, anxiety, depression, and pain, and promoting physical activity. Twenty-two studies revealed that virtual reality was a helpful learning and training tool during the COVID-19 crisis in several areas, including emergency medicine, nursing, and pediatrics. This technology was also used as an educational tool for increasing public understanding of the COVID-19 pandemic. Different levels of immersion (ie, immersive and desktop virtual reality), types of head-mounted displays (ie, PC-based, mobile, and standalone), and content (ie, 360° videos and photos, virtual environments, virtual reality video games, and embodied virtual agents) have been successfully used. Virtual reality was helpful in both face-to-face and remote trials.

Conclusions

Virtual reality has been applied frequently in medicine during the COVID-19 pandemic, with positive effects for treating several health conditions and for medical education and training. Some barriers need to be overcome for the broader adoption of virtual reality in the health care panorama.

Trial Registration

International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY) INPLASY202190108; https://inplasy.com/inplasy-2021-9-0108/