Discussion
fatigue, auditory learning, headaches, visual and kinaesthetic learning
SECONDARY
This randomised study has shown that students who participate in surgical skills tuition delivered via MR technology demonstrate greater and more consistent skill progression, in addition to reporting a higher quality educational experience when compared to traditional video-based skills tuition.The HoloLens teaching session gave consistently better results to all learners. Specifically, it led to significant improvements in instrument selection and more consistent improvements in technical performance. These observations could be due to the nature of the HoloLens content that supported a more structured approach to skill practice for the participant. The interactive tutorial provided reinforcement and immediate confirmation of the key procedural steps by producing holographic representations of each surgical instrument in order of use, in addition to highlighting the correct instrument within the surgical field and providing visual guidance for exact instrument placement on the surgical jig, as illustrated in Fig. Differing participant learning styles appeared to influence the effectiveness of the intervention. Participants were either multi-modal learners or reported a single preferred learning style, with an equal distribution across each study group. Participants who included auditory learning as one of their preferred learning styles performed similarly across the two study groups as would be expected given that the audio commentary provided for both teaching modalities were identical. Participants who included visual and kinaesthetic learning as one of their preferred learning styles performed significantly better in the HoloLens group. Although both groups received the same video material and practice time, the addition of holographic content and markers, and interactive task guide in the HoloLens group created a more dynamic learning environment that supported a multi-modal approach to learning. It is well documented that more interactive teaching sessions delivered through a diverse range of media lead to increased engagement and better performances [Suture quality remained consistent across the two interventions. This was a secondary measure of the study, and instructions and tuition on improving suture quality were not delivered with novel MR content. The lack of significant difference between groups may be accounted for by the limited specificity of the suture quality assessment methodology, however, this observation may also reflect the fact that the students did not have the opportunity to reach a performance plateau in their motor skills [The global need for improved surgical skills teaching is clear [Unfamiliarity and the learning curve associated with new technologies often results in slow adoption [Most participants (72.2%, 13/18) who used the HoloLens did not experience any negative symptoms with the device, with the few symptoms that were experienced being mild. Studies have shown that prolonged use of the HoloLens may lead to symptoms such as headaches or fatigue [A key limitation of this study was provided by the technology itself which remains in relative infancy. The battery life of the device and other technical aspects of its operation were principal concerns. When running a Microsoft Dynamics 365 Guide, such as used in this study, it is much shorter than advertised and lasts for only 90 min. Whilst not of direct consequence in this study as each participant used the device for 40 min, it may limit the scalability of the technology across a wider range of subject areas and skills that require a longer instructional period. Further to this, periods of minimal head movement, for example whilst watching a video through the device, can lead it to automatically go to sleep and therefore interrupt the tutorial. Finally, the device is designed to be operated through specific hand gestures such as tapping the inside of the wrist with two fingers to return to the main menu. Whilst through to be unique in other settings, these were sometimes confused with normal movements undertaken in clinical contexts such as putting on gloves which once again may unintentionally disrupt the tutorial; this could be easily resolved through basic software developments that consider the clinical context. This study was conducted in an institution that had the technical resource to develop the bespoke content, and financial resource to purchase the devices which cost of around $3,500 each. Expert technical knowledge is required to effectively create and deliver the MR content, even with a mature software package such as Dynamics 365 Guides that was used in this instance. A multi-step process is required to film and segment the video content, generate bespoke 3D holographic content through a distinct software application, create a task-specific spatially orientated practice environment in which the suturing skill was performed and finally to link these in a single joined-up interactive guide. This resource requirement may act as a barrier to adoption and the potential scalability of the technology, however, over time it is likely the cost of the technology will fall and therefore it will become a more feasible option for widespread use in medical education. In addition, any technology-based trial, particularly involving novel technology, will likely be affected by some degree of technology bias.Further to the technical limitations, this study looked solely at improvements in proficiency in a tightly defined individual task over a short period of time, potentially limiting the applicability of the findings to generalised surgical proficiency over the longer term. Secondly, whilst insignificant, there was a difference in baseline participant performance between each group that may have partially contributed to the observed findings. Future studies would benefit from retesting participants at longer time interval to determine if MR teaching methods minimise longitudinal skill fade and improve knowledge retention, and from stratifying participants according to baseline proficiency to assess their effectiveness across different performance levels. It is also important to assess the efficacy of the technology across a wider range of topics, skills and contexts.