Doing Virtually Anything to Educate Students.

502 www.pccmjournal. org May 2020 • Volume 21 • Number 5 An essential skill for all members of the healthcare team is the ability to recognize a critically ill patient and rapidly distinguish “sick” from “not sick. ” However, this clinical skill is one of the most difficult to teach because it requires not only medical knowledge, but involves learning assessment skills and clinical decision-making (1). Just as cognitive errors—from faulty data collection or interpretation, flawed reasoning, or incomplete knowledge—are potential sources of medical error, the rapid recognition of a deteriorating patient with appropriate escalation is crucial for patient safety (2). In pediatric patients, rapid identification of degree of illness can be lifesaving for a child in impeding respiratory failure given that most pediatric in-hospital arrests are respiratory in origin (3), and mortality for these patients approaches 50% (4). Data clearly demonstrate that a focus on early identification of respiratory deterioration improves outcomes for these fragile patients (5). For many years, educators across disciplines have worked to address this issue to enhance ability of providers to better recognize and characterize degree of illness, but acquisition of this important competency has traditionally relied primarily on time and clinical experience (6). Pattern recognition and analytical processing of information have been demonstrated as essential components in the development of this skill (7), and in recent years, simulation has become commonplace to address both technical and nontechnical skills (8). A simulation-based approach allows for augmented exposure to clinical scenarios as learners practice and develop pattern recognition skills, all without compromising patient safety (9, 10). Virtual reality (VR) is a relatively new simulation-based technique that allows users engage in a fully immersive computer-based experience that includes visual, auditory, and tactile components, but this technique has not been fully embraced in many facets of medical education (11, 12). In this issue of Pediatric Critical Care Medicine, Zackof et al (13) report the impact of using VR to fully replicate clinical scenarios that emphasize key clinical findings (i.e., mental status, work of breathing, perfusion) critical for accurate assessment of an infant with various degrees of respiratory distress and failure. To our knowledge, this investigation is the first randomized, controlled, prospective study using VR for clinical assessment in this context. Medical students experienced an immersive 3D VR environment, including avatars (individualized computerized characters) for both the preceptor and the patient. The preceptors followed detailed algorithms with standardized clinical scenarios to facilitate a fully interactive experience, followed by immediate individualized feedback at the end of each encounter. Prior evidence demonstrates that the use of an active learning approach in this manner (through simulation or other means) coupled with immediate informative feedback provides the optimal conditions for performance improvement (14). Students with incorrect assessments were coached in real time and provided the opportunity to repeat the scenario prior to their assessment by an instructor. The current investigation is consistent with prior evidence published by McGaghie et al (8), which similarly demonstrated that deliberate practice with simulated experiences yields fewer errors and more successes when translating the skills from the simulated environment to the bedside with actual patients. In the current investigation, students exposed to the VR curriculum demonstrated improved recognition and interpretation of mental status, classification of overall respiratory status, and recognition of the need for escalation of care when compared to those exposed to the traditional approach, which notably included high fidelity simulation experiences. This approach appears to bridge the gap between theoretical knowledge and skills and actual behavioral outcomes in a dynamic setting (14). Zackof et al (13) demonstrate in this study that the use of VR to augment education in clinical assessment improves overall medical student ability to recognize a deteriorating patient. It would be interesting to continue to follow those medical students trained using this augmented VR curriculum and their ability to recognize and manage sick patients when compared to their colleagues who were not trained using VR. As such, further research is needed to measure direct patient outcomes that are impacted by educational approaches of this nature. Although these results are promising and suggest further investigation of this technique is warranted, there are potential limitations. VR, as with any simulation-based technique, may not adequately replicate all clinical scenarios, and it may not fully account for real-life factors which impact decision-making. As is the case with any simulation-based educational program, there are some aspects of high-level clinical judgment and decision-making that may be elusive. It is also possible that a lower fidelity technique using simple videos or other approaches may be able to achieve the same goals as a VR curriculum. As consideration is made for education resource allocation, it is important to balance the cost of any given technique with the *See also p. 477.