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Year : 2021  |  Volume : 12  |  Issue : 3  |  Page : 113-115

The future role of augmented reality and virtual reality simulation in clinical skills assessment

Department of Medical Education, Nova Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA

Date of Submission04-Apr-2021
Date of Acceptance04-Apr-2021
Date of Web Publication30-Jul-2021

Correspondence Address:
Ms. Neha Bapatla
Neha Bapatla 3200 South University Drive Terry Building Suite 1523C, Davie, Florida - 33328
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_41_21

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How to cite this article:
Bapatla N, Fine L, Rajput V. The future role of augmented reality and virtual reality simulation in clinical skills assessment. Indian J Med Spec 2021;12:113-5

How to cite this URL:
Bapatla N, Fine L, Rajput V. The future role of augmented reality and virtual reality simulation in clinical skills assessment. Indian J Med Spec [serial online] 2021 [cited 2022 Dec 9];12:113-5. Available from: http://www.ijms.in/text.asp?2021/12/3/113/322782

  Introduction Top

Clinical skills assessment in undergraduate medical education has evolved to reflect the needs of its time. While methods that tested students in a real-time setting such as long case, short case, and viva-voce examinations were initially utilized, the introduction of OSCEs in 1979 by R. M. Harden established simulation-based assessment as the primary tool to assess clinical competency in student physicians.[1] While OSCEs have remained the superior tool in assessment, the COVID-19 pandemic has served as a barrier to its smooth implementation. The resulting standstill in medical education should usher in a new era in education that further builds on the foundation of OSCEs by implementing technology that allows for social distancing guidelines and enhances student learning.

George Miller's hierarchical pyramid has served as a template from which clinical education assessment has evolved. Each step of the pyramid reflects a specific learned physician behavior. Ascending from the base are the following steps: “knows” reflects the knowledge that is required of a physician, “knows how” describes the appropriate actions that are taken when faced with a specific circumstance in an examination, “shows how” reflects the ability to perform, and “does” is a physician's ability to perform in real-life clinical settings.[2] For example, paper-based assessments function at the level of “knows how” while simulation-based assessment functions at the layer of “shows how.”[3] Assessment tools that target higher layers of the pyramid tests increasingly important critical skills such as the application of clinical knowledge at the bedside; for example, workplace-based assessments (WPBA) target the “does” aspect of Miller's pyramid by examining physician performance in the authentic setting.[4] However, while WPBAs has been increasingly popular in assessing competency in graduate medical education it could be argued that simulation may be superior to WPBA at the undergraduate level. The many barriers to implementing WPBAs include difficulty in organization, the time-consuming nature, expense, and the risk and complexity of learning in the workplace.[5] A prior study that aimed to understand the perceived difficulties of conducting WPBAs for 3rd year clerkships for medical students found that not only were clerkships too short in length to allow for accurate and fair judgments, but faculty members struggled with providing narrative feedback to students because they felt they were evaluating their own teaching methods.[6]

  Simulation in Assessment Top

By comparison, simulation is arguably superior to WPBAs because it allows a safe environment to practice clinical skills and for manipulation of the degree of difficulty that is appropriate for the skills level of the student.[5] In the spirit of improvement, the appropriate next step would be adding technology as an adjunctive method to current tools of simulation. Augmented reality (AR) and virtual reality (VR) have the potential to improve on simulation-based assessments.

While often used interchangeably, AR and VR are distinguishable entities that offer their own unique risks and benefits. AR superimposes synthetic stimuli on real-world objects to enhance the user experience; essentially, AR overlays computer-generated information on objects and places.[7] Head-mounted displays, wearable computers, projected displays, and overlays of computer screens are commonly utilized to augment reality.[7] In comparison, VR uses immersive three-dimensional characteristics to replicate real-world situations while remaining in the digital world.[7] VR uses physical interfaces such as head-mounted displays, haptic devices, and motion sensors in conjunction with a computer keyboard, mouse, and voice recognition that are required to build the virtual reality.[7] Haptic feedback provides realistic tactile sensation, which allows the user to sense a physical object and manipulate it in a realistic manner.[7] [Table 1] succinctly summarizes the aforementioned criteria of AR and VR.
Table 1: Comparison of augmented reality and virtual reality in medical education

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While the use of AR and VR has yet to be integrated into undergraduate medical education, its use in various specialties has conferred benefit as a futuristic assessment tool. VR has been deemed particularly advantageous in emergency medicine where it is used for training in high-acuity, low-frequency events such as disasters and mass casualties.[7] In this instance, VR allows medical professionals to practice skills required for events that rarely occur but require endurance, competence, and expertise. In addition, AR has served as a superior training tool in surgical subspecialties. The nature of AR allows the superimposition of digital information into the real world, which blends both worlds together.[8] AR bolsters the amount of information available for a surgeon but requires the surgeon to critically consider this information in order to appropriately utilize it. Thus, AR is particularly advantageous at training surgical residents to improve situational awareness.[8]

  Benefits of Augmented Reality and Virtual Reality in Assessment Top

The use of AR and VR may require extensive work to adequately integrate it into undergraduate medical education, but the benefits may be worthy of the effort. For example, previous studies have indicated many benefits to learning for students and trainees. AR and VR have shown to increase learner motivation and engagement while simultaneously enhancing spatial knowledge representation and developing stellar technical abilities.[7] The improved learning outcomes stem in part from the ability of these technologies to offer highly realistic medical learning experiences, especially those that may be high acuity but low incidence such as mass casualties.[9] AR specifically offers a training environment that may be very similar to the actual work environment, thus offering immense benefit to students who require training in certain skill sets without the risk of harming others.[9] For example, standard 3rd year clerkship curricula require medical students to practice a specific skill, such as placement of a Foley catheter or arterial blood gas, on patients in their designated hospital or clinic. While real-life experience is necessary, this often causes anxiety in patients and may limit the ability of students to practice these skills. AR and VR provide opportunities for 3rd year medical students to learn critical procedural skills without compromising patient care and safety. Students may gain confidence in their core skills in a safe and realistic environment before applying it in the real world. In addition, AR allows for real-time feedback to the trainee without a required presence of an instructor, which productively enhances learning.[9] Physician availability often serves as a barrier to offering practice to students. AR can serve as a useful and convenient source of feedback to students. Perhaps most advantageous, AR and VR allow for the opportunity for multiple spaced observations to ensure competency in particular tasks and skills, such as history taking, clinical decision-making, and patient education.[7] These modalities offer frequent opportunities of realistic patient scenarios that elevate student experiences in medical school.

  Limitations of Augmented Reality and Virtual Reality in Clinical Assessment Top

However, application into the current simulation-based assessment, such as OSCEs, may prove difficult. It may not be feasible to afford the necessary equipment to run AR and VR simultaneously, students and faculty will require additional training to understand how to conduct OSCEs in this setting, and technological glitches may cause difficulties to deliver cases fluidly. In addition, the need for haptic feedback serves as a major challenge to creating VR-associated procedural simulations.[7] While haptic feedback is arguably more important in the setting of procedural training for residents, this challenge may be mitigated by primarily utilizing VR for clinical competencies such as history taking and clinical reasoning.

Furthermore, COVID-19 poses additional challenges to the implementation of new technologies in medical education. Abrupt nationwide school closures in March 2020 left medical schools unprepared for the challenges that come with providing remote learning, such as integrating in-person OSCEs into a deliverable online format through video modalities such as Zoom. There are many logistical questions that must be addressed to integrate AR and VR into undergraduate medical education while still maintaining safety of those involved. First and foremost, it is imperative to assess the ability to perform AR and VR simulations while maintaining social distancing guidelines. With properly trained staff, medical schools can limit the number of people who are involved in a simulation and ensure that social distancing guidelines are being followed. However, adequate and swift training of staff may pose an additional challenge to implementing AR and VR in medical education due to the nature of this technology. In addition, COVID-19 has been known to spread from surface-to-surface contact of respiratory droplets, which may pose a health risk due to multiple students using the same equipment. Standard precautions to mitigate spread should include the requirement of N-95 masks, the use of gloves and other appropriate PPE, and disinfection of equipment between simulations.

Perhaps the most concerning point regarding the use of AR and VR in clinical skills assessment is the potential loss of fidelity and challenges in creating a highly translatable assessment method. This requires us to pose the question asked time and time again: Can technology replace the authentic human experience? Previous studies have indicated that simulation-based assessments in medical education can be used effectively; however, its value as a stand-alone tool requires further research.[5]

  Conclusion Top

At this time, the use of AR and VR is extremely limited and relatively new in medical education. The current research is in its early stages for implementation of AR technology in medical education, and it lacks evidence-based support for its widespread application.[10] Recognizing that AR and VR technology has potential to improve learning outcomes in medical students is imperative to promoting future research in this field of medical education. These technologies not only enhance learning experience but also if conducted appropriately can increase opportunities to practice high-stakes situations and exercise clinical competencies without the need for organizing multiple faculty members and standardized patients. Simulation has established its role in undergraduate medical education as a superior tool for assessing clinical skills in medical students. Adjunctive technology in simulation-based assessments may be difficult to implement initially, but has incredible potential to improve training in future medical professionals. The COVID-19 pandemic has abruptly changed the way in which medical education tests and trains students, but it presents a unique opportunity to enhance learning with innovative simulation techniques such as AR and VR, subsequently leading us into the next era of undergraduate medical education.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Harden RM, Stevenson M, Downie WW, Wilson GM. Assessment of clinical competence using objective structured examination. Br Med J 1975;1:447-51.  Back to cited text no. 1
Dauphinee W. Assessing clinical performance. Where do we stand and what might we expect? J Am Med Assoc 1995;274:741-3.  Back to cited text no. 2
Schuwirth LW, van der Vleuten CP. The use of clinical simulations in assessment. Med Educ 2003;37 Suppl 1:65-71.  Back to cited text no. 3
Liu C. An introduction to workplace-based assessments. Gastroenterol Hepatol Bed Bench 2012;5:24-8.  Back to cited text no. 4
Ryall T, Judd BK, Gordon CJ. Simulation-based assessments in health professional education: A systematic review. J Multidiscip Health 2016;9:69-82.  Back to cited text no. 5
Daelmans HE, Mak-van der Vossen MC, Croiset G, Kusurkar RA. What difficulties do faculty members face when conducting workplace-based assessments in undergraduate clerkships? Int J Med Educ 2016;7:19-24.  Back to cited text no. 6
McGrath JL, Taekman JM, Dev P, Danforth DR, Mohan D, Kman N, et al. Using virtual reality simulation environments to assess competence for emergency medicine learners. Acad Emerg Med 2018;25:86-195.  Back to cited text no. 7
Barsom EZ, Graafland M, Schijven MP. Systematic review on the effectiveness of augmented reality applications in medical training. Surg Endosc 2016;30:4174-83.  Back to cited text no. 8
Kamphuis C, Barsom E, Schijven M, Christoph N. Augmented reality in medical education? Perspect Med Educ 2014;3:300-11.  Back to cited text no. 9
Tang KS, Cheng DL, Mi E, Greenberg PB. Augmented reality in medical education: A systematic review. Can Med Educ J 2020;11:e81-96.  Back to cited text no. 10


  [Table 1]

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