Virtual reality or personal computer-based gynecologic pelvic exam simulation: medical student preferences | BMC Medical Education

The study was reviewed by the University of California, San Francisco Institutional Review Board and determined exempt (Protocol #21–33982). Informed consent to participate was obtained from all participants in the study.

Application design and development

Overview of application curriculum

The Virtual Approach to Gynecology Project application consists of three modules. In module 1, a 360-degree video of a GPE is shown from the provider viewpoint. In module 2, the user enters a virtual space where they participate in a guided interactive simulation of a GPE. As a part of the simulation, the participants review the examination instruments (e.g. gynecologic speculum, cervical cytology “Pap test” and sexually transmitted infection (STI) swab materials), and perform the procedure steps modeled directly from the 360-degree video in a guided format. (Fig. 1A and B). In module 3, the user performs the same simulation conducted in module 2, but without the use of the guide. Throughout modules 2 and 3, a virtual tablet serves as an interface for the user and tracks the user’s progress. Short multiple-choice question knowledge checks are provided via the tablet between modules to assess learner comprehension for module content (e.g. clinical skills, anatomy knowledge). The following sections provide details of each module.

The Virtual Approach to Gynecology, Selected Images from Modules 2 and 3. A Virtual Simulation Tray Tour and Tablet. B Virtual Speculum Examination with Specimen Collection for Pap Test. The user is instructed to perform specific actions: locking the speculum into place, inserting and rotating a cervical broom multiple times for the cervical cytology collection, inserting the STI swab and sampling both sides of the vaginal wall, placing specimens in the appropriate vials, then unlocking and removing the speculum, and finally re-draping the patient

Module 1: 360-degree video

A GPE performed by a licensed obstetrics and gynecology clinician (“provider”) with a “patient” (portrayed by a gynecologic teaching assistant/standardized patient) was recorded with a 360-degree video camera. The camera was positioned between the provider and patient to give the viewer the provider’s perspective. The video depicts the provider asking the patient’s permission to enter the exam space to ensure patient readiness, lifting the drape, examining the vulva, inserting the speculum and visualizing the cervix, and collecting specimens for routine screening (a cervical cytology “Pap test” with cervical broom and vaginal swab for gonorrhea and chlamydia screening). This 360-degree video was used as the basis for the VR and PC software applications.

Modules 2 and 3: Interactive software

The interactive software application for this study was developed for two different hardware types: VR Oculus Quest 2 headsets (Meta Platforms Inc., Menlo Park, CA) and PC (i.e., desktop or laptops). While each hardware differed in user experience and degree of interaction, the structure, sequence, and user interface were identical across both mediums. The interactive applications for both the PC and VR simulation were built using the Unity 3D Engines (Unity Technologies, San Francisco, CA), enabling the repurposing of 80% of the architecture for both platforms.

Module 2 begins by introducing the user to the environment, the virtual tablet, and their virtual tutor – a virtual avatar named “Uty” provides verbal instructions which are also written in adjacent text boxes. The user is instructed on how to request permission to enter the exam room. Once inside the examination space, an introductory “tray tour” familiarizes them with the instruments (Fig. 1A). In VR, hand-held controllers are used to manipulate the instruments, while the computer version utilizes a mouse and keyboard. After the tray tour, the user is instructed to ask for consent from the patient to lift the drape. Once the patient is undraped, vulvar anatomy is reviewed with supplemental anatomical diagrams alongside the virtual patient. Next the user is guided through the speculum exam. The user is instructed to perform specific actions: locking the speculum into place, inserting and rotating a cervical broom multiple times for the cervical cytology collection, inserting the STI swab and sampling both sides of the vaginal wall, placing specimens in the appropriate vials, then unlocking and removing the speculum, and finally re-draping the patient (Fig. 1B). In module 3, the virtual tutor and introductory tray tour are absent. The user is expected to perform each step sequentially without prompts.

Participants and setting

This study took place at a large urban academic medical institution. All first- and second-year medical students at the principal investigator’s institution were recruited to participate in this study via email, student online forum post, and an announcement made before a gross anatomy lecture. As an incentive to participate in the study, students were offered to receive a $20 gift card. Students who responded with an interest in participating were scheduled into one of five group sessions based on availability, with a maximum of five students per group. Focus groups were conducted between November 2021 and April 2022, and did not correspond to gynecologic-related learning blocks within the wider medical school curriculum. First year students had yet to complete the endocrine and reproductive learning blocks, while second year students had completed those blocks.

Study design and procedures

This study utilized a randomized 2 × 2 crossover design (Fig. 2). After the groups were assigned to a scheduled date, the authors randomly assigned each group to begin with either the VR or PC version of the simulation. Due to the first-time use of VR headsets for many participants, study staff were available for participant questions related to VR headset use. Twenty minutes were allotted for the first simulation session, followed by time for written feedback, and then focus group discussion. After the first focus group discussion, participants immediately began a second twenty-minute simulation session using the other device (e.g. if starting with PC, they would follow with VR). Once completed, participants answered a second set of written questions about the second simulation experience, as well as questions comparing PC to VR versions of the application, and questions about their attitudes toward VR in medical education generally. Finally, when all participants completed their forms, a final focus group was conducted. Both focus group sessions for a scheduled group were recorded and then transcribed verbatim by one author (RP).

Two by two crossover study design

Outcome instruments

Written surveys and focus group discussion prompts were adapted from previously validated instruments that were used for an internal evaluation of the 360-degree video module alone (see Supplement). The internal evaluation was conducted in 2020, however it was discontinued due to COVID-19 restrictions.

Written survey

Participants were first asked to rate their familiarity with VR (“Not Familiar”, “Rarely Use”, “Somewhat Familiar”, and “Very Familiar”). The survey then included a 4-point Likert-scale (“Disagree”, “Somewhat Agree”, “Agree”, and “Strongly Agree”) for the following statements referring to the simulation:

• This was easy to use

• This felt like a realistic experience

• This could help me feel more comfortable performing pelvic exams on live patients

• This could help me feel more confident performing pelvic exams on live patients

• I would recommend this to a colleague

Likert-scale responses were converted to numeric scores 1–4, where 1 corresponded to “Disagree” and 4 corresponded to “Strongly Agree”. Scores for each of the five metrics were then averaged for the PC and VR responses and compared. Statistical significance was tested with Wilcoxon Rank Sum.

Focus group interviews

The first focus group discussions were prompted by the following open-ended questions, which were asked sequentially by the facilitator, an assistant professor in the epidemiology and biostatistics department who had no previous relationship to the participants (RP):

• (1) What are your thoughts about this application?

• (2) What were your impressions, or emotional responses while you were using the application?

• (3) How could you envision using this module in the future?

The second focus group discussion consisted of the following prompts:

• (1) What are your thoughts about the VR and the desktop (i.e. PC) in comparison?

• (2) Do you prefer the VR or desktop version and why?

• (3) How do you envision using this module in the future, not just individually, but for education in general? Where would this fit in in your education?

Statistical analysis

Likert-scale analysis compared scoring for VR and PC modalities for all five metrics. Wilcoxen Rank Sum was used to determine statistically significant differences.

Focus group transcripts and open-ended narrative data from the focus group guide were subjected to open coding using Microsoft Excel (Microsoft Corp., Redmond, WA) by two authors (RP and BK). Individual comments from focus group participants were coded. Codes were developed directly from the data, were not predetermined, and then were condensed into parent codes. Consensus of coding interpretation was reached, and coding discrepancies were reconciled between two authors (RP and BK).