GPP08 Presentation Time: 9:50 AM: From Learning Outcomes to Game Design: Basic Brickwork in Virtual Reality Simulation of Cervical Brachytherapy Procedures

Abstract

<h3>Purpose</h3> Even before the pandemic, clinical training opportunity for brachytherapy (BT) procedures has been decreasing. In locally advanced cervix cancer (CC), this has been linked to declining BT utilization and poorer clinical outcomes. This work describes the culmination of our early exploration into how to augment resident training in CCBT, distilling and integrating educational keys for a first-in-kind immersive, hands-on, and interaction-enabled virtual reality (VR) simulator for CCBT applicator insertion procedures. <h3>Materials and Methods</h3> Informal needs assessment in consultation with frontline experts and novice stakeholders identified the basic competencies thought to be required to successfully execute a CCBT applicator insertion procedure according to local standards. There was early recognition that, even before a curricular intervention could be designed, a versatile training tool would be needed. After reviewing international guidelines relating to CCBT and BT training, procedure-based learning outcomes were articulated, then selected and simplified for programming a basic goal-oriented simulation (sim) in VR. A clinical vignette of a typical CC case was crafted, with specific narrative stops amenable to building knowledge, skills, and behaviors. Emphasis on the "why" and the "how" of certain BT steps was built in. Procedural milestones were generalizable to trainees with varying degrees of clinical BT experience, with some steps or ‘interactions' made evaluable (go, no go) in this linear design. Gamification expanded options for cross-linking and reinforcing learning concepts. To the extent feasible, realism was incorporated into the physical representation of sim objects, such as CT-scanned surgical instruments and an intracavitary/interstitial BT applicator (Elekta, Netherlands; with permission), extracted as user-configurable additions to the 3D immersive operating room (OR) environment coded on Unreal engine v. 2.46 (Epic Games, US). <h3>Results</h3> A working prototype was generated for a single-player VR sim, broadly mimicking the procedural steps for actual CCBT applicator insertion. Despite an estimated runtime of 20 minutes, depending on user proficiency with CCBT and with VR technology (headset, hand controllers), the sim can start/stop at user discretion, and be shown on-screen to non-playing observers in a classroom setting. The game can also be run iteratively offline, enabling self-paced study of CCBT procedural steps in sequence, repeated execution for kinesthetic learning, and easy focus on recurring problem areas. The user starts the sim in OR, with a computer-generated patient draped and BT instrument tray at the ready. The case vignette and step-by-step instructions trigger the user to complete specific procedural tasks in the correct order; sim will not advance otherwise. Hints are given when needed. Pop-up multiple choice questions, in between BT sim interactions, are formative, drawing on basic recall, understanding, and application, to strengthen learning of core concepts in CCBT. Further contextual information is given at end of sim, to better situate procedural learnings with post-procedure processes (e.g. applicator verification and BT planning). <h3>Conclusions</h3> A novel VRsim tool, inspired by educational design principles, was created as proof-of-concept for guided performance-oriented learning of CCBT procedural aspects. Broader range and complexity of simulated procedures is planned, with higher level of user interaction and realism. Prospective evaluation of face (realism) and content (usefulness) validity will inform on its potential, as part of comprehensive CCBT instructional programming.