Evaluating Virtual Reality Simulator Training On Surgical Residents Perceptions of Stress: A Randomized Controlled Trial

Kamran Samakar, MD, J Andres Astudillo, MD, Mallika Moussavy, MA, Joanne Baerg, MD, Mark Reeves, MD, Carlos Garberoglio, MD. Loma Linda University Medical Center

Background:  Standardized curriculum and educational models such as the Fundamentals of Laparoscopic Surgery (FLS) have provided a means to teach, practice, and test surgical trainees. Virtual reality simulation (VRS) and training boxes have augmented operative teaching opportunities. At our institution, we implemented a laparoscopic curriculum for surgical residents to progress between post-graduate years. The curriculum consists of graduated skill acquisition through online study, box training, VRS, objective structured assessment of technical skills (OSATS) evaluation, and ultimately FLS certification. Evaluation of our education curriculum was carried out through a number of objective measures as well as reports of subjective experiences by trainees. We hypothesized that VRS training would attenuate surgical trainees stress related to laparoscopic surgery.  We report the results of resident performance on VRS and their subjective experiences of self-efficacy and task-specific stress associated with laparoscopic surgery.

Methods: After Institutional Review Board approval, a prospective, randomized controlled study was designed for surgical residents in their second, third, and fourth year of clinical training (n=19). Participants in the experimental group underwent virtual reality simulator (VRS) training composed of 5 training modules culminating in the completion of a VR laparoscopic cholecystectomy during a 60 period.  Objective measurements, including total operative time, efficiency, and complications were recorded by the simulator and subsequently analyzed for residents in the experimental group.  The control group did not undergo VRS training. All study participants were then asked to complete the State Trait Anxiety Inventory (STAI) questionnaire to measure subjective levels of task-specific stress prior to performance of a laparoscopic cholecystectomy on a human patient. Subjective experience of stress was calculated using the validated STAI questionnaire. Stress scores were quantified on a scale from 20-80, with higher scores indicative of greater subjective stress levels. Results from the STAI questionnaire were compared by Pearson chi-square test and p<0.05 achieved significance.  

Results:  Average STAI score in the experimental group was 36.2 with a SD of 10.8 (n=8). Average STAI score in the control group was 35.5 with a SD of 11.3 (n=11). Average operative time for a VR laparoscopic cholecystectomy was 15.5 minutes with a SD of 8.7. No significant difference was observed between the two groups in subjective stress scores (P=0.91). High stress scores were associated with lower performance on VRS as measured by objective indices.

Conclusion: Practice in a Virtual Reality Simulator may not significantly reduce the stress experienced by trainees prior to performance in a real laparoscopic cholecystectomy. Evaluating an educational curriculum will require objective measurements and an understanding of the subjective perceptions of trainees. Ongoing studies on the transition from trainee practice to actual performance and competency will inform future educational modalities.

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