Augmented, Mixed, and Virtual Reality-Based Head-Mounted Devices for Medical Education: Systematic Review

Background:
Augmented reality (AR), mixed reality (MR), and virtual reality (VR), realized as head-mounted devices (HMDs), may open up new ways of teaching medical content for low-resource settings. The advantages are that HMDs enable repeated practice without adverse effects on the patient in various medical disciplines; may introduce new ways to learn complex medical content; and may alleviate financial, ethical, and supervisory constraints on the use of traditional medical learning materials, like cadavers and other skills lab equipment.

Objective:
We examine the effectiveness of AR, MR, and VR HMDs for medical education, whereby we aim to incorporate a global health perspective comprising low- and middle-income countries (LMICs).

Methods:
We conducted a systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) and Cochrane guidelines. Seven medical databases (PubMed, Cochrane Library, Web of Science, Science Direct, PsycINFO, Education Resources Information Centre, and Google Scholar) were searched for peer-reviewed publications from January 1, 2014, to May 31, 2019. An extensive search was carried out to examine relevant literature guided by three concepts of extended reality (XR), which comprises the concepts of AR, MR, and VR, and the concepts of medicine and education. It included health professionals who took part in an HMD intervention that was compared to another teaching or learning method and evaluated with regard to its effectiveness. Quality and risk of bias were assessed with the Medical Education Research Study Quality Instrument, the Newcastle-Ottawa Scale-Education, and A Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies of Interventions. We extracted relevant data and aggregated the data according to the main outcomes of this review (knowledge, skills, and XR HMD).

Results:
A total of 27 studies comprising 956 study participants were included. The participants included all types of health care professionals, especially medical students (n=573, 59.9%) and residents (n=289, 30.2%). AR and VR implemented with HMDs were most often used for training in the fields of surgery (n=13, 48%) and anatomy (n=4, 15%). A range of study designs were used, and quantitative methods were clearly dominant (n=21, 78%). Training with AR- and VR-based HMDs was perceived as salient, motivating, and engaging. In the majority of studies (n=17, 63%), HMD-based interventions were found to be effective. A small number of included studies (n=4, 15%) indicated that HMDs were effective for certain aspects of medical skills and knowledge learning and training, while other studies suggested that HMDs were only viable as an additional teaching tool (n=4, 15%). Only 2 (7%) studies found no effectiveness in the use of HMDs.

Conclusions:
The majority of included studies suggested that XR-based HMDs have beneficial effects for medical education, whereby only a minority of studies were from LMICs. Nevertheless, as most studies showed at least noninferior results when compared to conventional teaching and training, the results of this review suggest applicability and potential effectiveness in LMICs. Overall, users demonstrated greater enthusiasm and enjoyment in learning with XR-based HMDs. It has to be noted that many HMD-based interventions were small-scale and conducted as short-term pilots. To generate relevant evidence in the future, it is key to rigorously evaluate XR-based HMDs with AR and VR implementations, particularly in LMICs, to better understand the strengths and shortcomings of HMDs for medical education.

The Future of Immersive Technology in Global Surgery Education

The second wave of immersive reality technology is required that enhances and exploits current applications, empirical evidence and worldwide interest. If this is successful, low- and middle-income countries will have improved access, less costs and reduced practical limitations. Affordability, availability, accessibility and appropriateness are determinates, and help from several innovative areas can achieve these targets. Artificial intelligence will allow autonomous support of trainees to accelerate their skills when interacting on mobile applications, as deep learning algorithms will generate models that identify data and patterns within them and provide feedback much like a human educator. Future immersive content needs to be high quality, tailored to the learners’ needs and created with minimal time and expenses. The co-creation process involves the integration of learners into the entire development process and a single learning goal can be identified that will have high reusability to surgical students. Sustainability of the material is ensured in the design stage leading to increased cost-effectiveness benefits. One framework has a proven high impact on the co-design of healthcare resources and is discussed. The connectivity of future immersive technology resources has been a major obstacle between regions in their uptake. A handful of collaboration platforms have been created that can deliver immersive content and experiences; the spearhead in this area will be from augmented reality and telesurgery. Opportunity for powerful, large-scale data culture via blockchain collaboration will be an emerging theme that will also drive towards affordability, availability, accessibility and appropriateness in the future global landscape of immersive technology in surgical education.

Undergraduate Surgical Education: a Global Perspective

Undergraduate surgical education is failing to prepare medical students to care for patients with surgical conditions, and has been significantly compromised by the COVID-19 pandemic. We performed a literature review and undertook semi-structured reflections on the current state of undergraduate surgical education across five countries: Egypt, Morocco, Somaliland, Kenya, and the UK. The main barriers to surgical education at medical school identified were (1) the lack of standardised surgical curricula with mandatory learning objectives and (2) the inadequacy of human resources for surgical education. COVID-19 has exacerbated these challenges by depleting the pool of surgical educators and reducing access to learning opportunities in clinical environments. To address the global need for a larger surgical workforce, specific attention must be paid to improving undergraduate surgical education. Solutions proposed include the development of a standard surgical curriculum with learning outcomes appropriate for local needs, the incentivisation of surgical educators, the incorporation of targeted online and simulation teaching, and the use of technology.

Augmented Package of Palliative Care for Women With Cervical Cancer: Responding to Refractory Suffering

The essential package of palliative care for cervical cancer (EPPCCC), described elsewhere, is designed to be safe and effective for preventing and relieving most suffering associated with cervical cancer and universally accessible. However, it appears that women with cervical cancer, more frequently than patients with other cancers, experience various types of suffering that are refractory to basic palliative care such as what can be provided with the EPPCCC. In particular, relief of refractory pain, vomiting because of bowel obstruction, bleeding, and psychosocial suffering may require additional expertise, medicines, or equipment. Therefore, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an augmented package of palliative care for cervical cancer with which even suffering refractory to the EPPCCC often can be relieved. The package consists of medicines, radiotherapy, surgical procedures, and psycho-oncologic therapies that require advanced or specialized training. Each item in this package should be made accessible whenever the necessary resources and expertise are available.

Qualities of Effective Vital Anaesthesia Simulation Training Facilitators Delivering Simulation-Based Education in Resource-Limited Settings

BACKGROUND:
Lack of access to safe and affordable anesthesia and surgical care is a major contributor to avoidable death and disability across the globe. Effective education initiatives are a viable mechanism to address critical skill and process gaps in perioperative teams. Vital Anaesthesia Simulation Training (VAST) aims to overcome barriers limiting widespread application of simulation-based education (SBE) in resource-limited environments, providing immersive, low-cost, multidisciplinary SBE and simulation facilitator training. There is a dearth of knowledge regarding the factors supporting effective simulation facilitation in resource-limited environments. Frameworks evaluating simulation facilitation in high-income countries (HICs) are unlikely to fully assess the range of skills required by simulation facilitators working in resource-limited environments. This study explores the qualities of effective VAST facilitators; knowledge gained will inform the design of a framework for assessing simulation facilitators working in resource-limited contexts and promote more effective simulation faculty development.

METHODS:
This qualitative study used in-depth interviews to explore VAST facilitators’ perspectives on attributes and practices of effective simulation in resource-limited settings. Twenty VAST facilitators were purposively sampled and consented to be interviewed. They represented 6 low- and middle-income countries (LMICs) and 3 HICs. Interviews were conducted using a semistructured interview guide. Data analysis involved open coding to inductively identify themes using labels taken from the words of study participants and those from the relevant literature.

RESULTS:
Emergent themes centered on 4 categories: Persona, Principles, Performance and Progression. Effective VAST facilitators embody a set of traits, style, and personal attributes (Persona) and adhere to certain Principles to optimize the simulation environment, maximize learning, and enable effective VAST Course delivery. Performance describes specific practices that well-trained facilitators demonstrate while delivering VAST courses. Finally, to advance toward competency, facilitators must seek opportunities for skill Progression.

Interwoven across categories was the finding that effective VAST facilitators must be cognizant of how context, culture, and language may impact delivery of SBE. The complexity of VAST Course delivery requires that facilitators have a sensitive approach and be flexible, adaptable, and open-minded. To progress toward competency, facilitators must be open to self-reflection, be mentored, and have opportunities for practice.

CONCLUSIONS:
The results from this study will help to develop a simulation facilitator evaluation tool that incorporates cultural sensitivity, flexibility, and a participant-focused educational model, with broad relevance across varied resource-limited environments.

Analysing a Global Health Education Framework for Public Health Education Programs in India

Academic global health is of increasing interest to educators and students in public health but competency domains as well as education pathways that deliver this training, are still being identified and refined. This thesis was undertaken using an education program development paradigm and aimed to analyse the factors shaping global health education in India by examining multistakeholder perspectives. The research framework consisted of four components: curriculum and content, students, faculty and key experts, and employers. Studies captured the perspectives of students through a survey and focus group discussions, faculty and other key experts through semi-structured interviews, and employers through job advertisement analysis. We identified eleven global health competency domains focussed on three aspects: foundational competencies, core public health skills and soft skills. Global health and public health were seen as interconnected, with global health having transnational context and public health having a more national focus. Global health was seen as a nascent concept in India and although integration of global health education into the public health curriculum was supported, there were concerns given that public health is still too new a discipline in India. Global health competencies were seen as a ‘step up’ from the public health competencies. Based on the results, a two-level approach to global health education is proposed for Indian public health institutions. The first approach, targeted at recent graduates, focuses on a ‘foundational global health education’ within public health programs such as an MPH. The second approach is an ‘Executive Global Health Certificate Program’, aimed at experienced public health professionals planning to enter the global health workforce. This thesis has outlined a framework for Indian and other LMIC institutions looking to expand the scope of public health education and intend to develop global health education programs.

Barriers and facilitators to online medical and nursing education during the COVID-19 pandemic: perspectives from international students from low- and middle-income countries and their teaching staff

Background
The COVID-19 pandemic posed a huge challenge to the education systems worldwide, forcing many countries to provisionally close educational institutions and deliver courses fully online. The aim of this study was to explore the quality of the online education in China for international medical and nursing students from low- and middle-income countries (LMICs) as well as the factors that influenced their satisfaction with online education during the COVID-19 pandemic.

Methods
Questionnaires were developed and administered to 316 international medical and nursing students and 120 teachers at a university in China. The Chi-square test was used to detect the influence of participants’ personal characteristics on their satisfaction with online education. The Kruskal–Wallis rank-sum test was employed to identify the negative and positive factors influencing the online education satisfaction. A binary logistic regression model was performed for multiple-factor analysis to determine the association of the different categories of influential factors—crisis-, learner-, instructor-, and course-related categories, with the online education satisfaction.

Results
Overall, 230 students (response rate 72.8%) and 95 teachers (response rate 79.2%) completed the survey. It was found that 36.5% of students and 61.1% of teachers were satisfied with the online education. Teachers’ professional title, students’ year of study, continent of origin and location of current residence significantly influenced the online education satisfaction. The most influential barrier for students was the severity of the COVID-19 situation and for teachers it was the sense of distance. The most influential facilitating factor for students was a well-accomplished course assignment and for teachers it was the successful administration of the online courses.

Conclusions
Several key factors have been identified that affected the attitudes of international health science students from LMICs and their teachers towards online education in China during the COVID-19 pandemic. To improve the online education outcome, medical schools are advised to promote the facilitating factors and cope with the barriers, by providing support for students and teaching faculties to deal with the anxiety caused by the pandemic, caring for the state of mind of in-China students away from home, maintaining the engagement of out-China students studying from afar and enhancing collaborations with overseas institutions to create practice opportunities at students’ local places.

Medical and Nursing Students’ Perception and Experience of Virtual Classrooms during the COVID-19 Pandemic in Nepal

Background: On March 9, 2020, the government of Nepal declared suspension of all academic activities in line with a nationwide lockdown following the COVID-19 outbreak. To keep pace with the academic calendar, medical universities resumed their teaching and learning activities through virtual means on account of nonfeasibility of holding physical classes. The present study sought to identify the perception and experiences of undergraduate medical and nursing students regarding the virtual classrooms.
Methods: We adopted a sequential explanatory mixed method design whereby data were collected in two phases. Quantitative data were gathered from a survey (n=737) and qualitative data from focused group discussion (n=14). The participants were recruited using a non-probability Peer Esteem Snowballing technique. Quantitative data were analyzed using descriptive and inferential statistics, whereas qualitative data was examined using a narrative thematic analytic approach.
Results: Mean age of participants was 22±2.01 with (81%) female participation. The quantitative findings revealed that the “synchrony” domain had the highest mean score (4.10±0.47) and “course interaction” had the lowest mean score (2.93±0.81) amongst the four domains. The domains were significantly correlated to each other (P=0.01) and (P=0.05). Results from focus group discussion indicated that interactions were lower in the virtual classes and there was a great variation between the learners’ perception and their experiences of virtual classrooms. Students preferred blended classes to be implemented in future sessions.
Conclusion: In spite of various challenges, the students perceived the transition from traditional to virtual classrooms in a positive and enthusiastic way. An effective virtual learning experience requires a modified instructional approach on the part of educators and a consistent attitude from learners.

The evaluation of a surgical task-sharing program in South Sudan

Background: Five billion people lack timely, affordable, and safe surgical services. Sub-Saharan Africa (SSA) is the region with the scarcest access to surgical care. The surgical workforce is crucial in closing this gap. In SSA, South Sudan has one of the lowest surgical workforce density. Task-sharing being a cost-effective training method, in 2019, the University of British Columbia collaborated with Médecins Sans Frontières to create the Essential Surgical Skills program and launched it in South Sudan. This study aims to evaluate this pilot program. Methods: This is a mixed-method prospective cohort study. Quantitative data include pre- and post-training outputs (number and types of surgeries, complication, re-operation, and mortality) and surgical proficiency of the trainees (quiz, Entrustable Professional Activity (EPA), and logbook data), and online survey for trainers. Semi-structured interviews were performed with trainees at the program completion. Results: Since July 2019, trainees performed 385 operations. The most common procedures were skin graft (14.8%), abscess drainage (9.61%), wound debridement and transverse laparotomy (7.79% each). 172 EPAs have been completed, out of which 136 (79%) showed that the trainee could independently perform the procedure. During the training, the operating room and surgical ward mortality remained similar to the pre-training phase. Furthermore, the surgical morbidity decreased from 25% to less than 5%. The pass rate for all quizzes was 100%. Interviews and survey showed that trainees’ surgical knowledge, interprofessional teamwork, trainers’ global insight on surgical training in Low- and Middle-Income Countries (LMICs), and patient care has improved. Also, the program empowered trainees, developed career path, and local acceptance and retention. The modules were relevant to community needs. Conclusions: This study casts light on the feasibility of training surgeons through a virtual platform in under-resourced regions. The COVID-19 global pandemic highlighted the need to make LMICs independent from fly-in trainers and traditional apprenticeship. Knowledge translation of this training platform’s evaluation will hopefully inform Ministries of Health and their partners to develop their National Surgical, Obstetric and Anesthesia Plans (NSOAPs). Furthermore, thanks to its scalability, both across levels of training and geography, it paves the way for virtual surgical education everywhere in the world.

Foundation for International Education in Neurosurgery: The Next Half-Century of Service Through Education

The Foundation for International Education in Neurological Surgery (FIENS) was founded in 1969, decades before globalization became a worldwide phenomenon (1–3). Initially, efforts were focused on service delivery in under-resourced areas via short mission trips by individual neurosurgeons. The wisdom of furthering the impact by creating sustainable training programs in partnership with host organizations developed over time (3). FIENS is a neurosurgeons foundation working in partnership with various organizations to increase global access to neurosurgery missions through the principle of “service through education (3).” FIENS shifted its focus from a service delivery-centered approach to an approach centered on global health systems strengthening by emphasizing local neurosurgery resident education and residency program development (3). It has become clear that the integration of neurosurgical efforts within the local health system amplifies the overall impact of FIENS initiatives by promoting sustainable change through collaborative action in the service of local health system goals. From this point forward, initiatives coordinated by FIENS incorporated local stakeholders and workforce in addition to mechanisms for service delivery, health infrastructure, information management, governance, and funding.

Additionally, FIENS-supported trainees expressed the need for ongoing support in the early stages of their careers. In response, the Foundation expanded its scope to include postgraduate education, evolved, as global health organizations must, understand that lasting impact occurs through teaching, leading to self-sustaining health systems in regions of need.