Feasibility of a cinematic-virtual reality training program about opioid use disorder for osteopathic medical students: a single-arm pre–post study

Ethics approval

Ethics approval for the study was obtained from the Ohio University Office of Research Compliance Institutional Review Board (Institutional Review Board # 22-X-18). In complying with federal, state, and local laws and regulations for human subjects, we ensured that our research met the requirements set forth in the regulations on public welfare in Part 46 of Title 45 of the Code of Federal Regulations (45 CFR 46); the principles are set forth in “The Belmont Report,” and the Helsinki Declaration of 1975. Informed consent was obtained from all participants and all participants consented to be included in the study.

Cine-VR episode content

The cine-VR episodes were designed to educate medical students about OUD, social determinants of health, and implicit bias. In the “Using Virtual Reality to Visualize the Opioid Crisis” cine-VR training program, participants watched 12 cine-VR episodes, ranging in length from 2 to 5 min. The main character, Destiny, is a 23-year-old woman from Appalachian Ohio who is pregnant and battling opioid addiction. Destiny lives in the same town where she grew up. Her mother and siblings live in an abusive home where Destiny refuses to stay. Instead, she lives with her abusive and unsupportive boyfriend who also has OUD. Destiny reaches out for help to her grandmother, but her grandmother stigmatizes her because of her OUD and threatens to take her unborn baby away. Despite Destiny’s struggles, we learn about the strengths she finds in her desire to be a good mother, as well as the resiliency one person can have if providers invest the time to connect with her. In the cine-VR episodes, participants observe Destiny interacting with physicians, nurses, social workers, family, employers, and the community.

Cine-VR episode format

The cine-VR training contains two six-episode story arcs. The first cine-VR story arc focuses on Destiny’s relationship with her obstetrical nurse, and the second series focuses on the relationship with her social worker. In the first story arc, the first episode depicts a suboptimal clinical interaction between Destiny and her obstetrical nurse, with her nurse blaming her for delaying her first prenatal visit until she was 6 months along and for utilizing opioids while pregnant. This is followed by three cine-VR simulations that open narrative windows into her daily life, her world, and her struggles. The fifth and sixth episodes of each series are “guided simulations,” or pre-recorded cine-VR face-to-face conversations, with Destiny’s provider and Destiny herself. These high-stakes conversations give participants a chance to practice difficult conversations without the pressures of being watched or failing. Participants are encouraged to speak predetermined dialogue to the character and listen for responses. For the first series, the “guided simulation” includes a conversation between the participant and the obstetrical nurse. The participant assumes the role of a colleague and points out how blame and stigma negatively impact care and follow-up. The second “guided simulation” gives the participant an opportunity to recreate the initial visit to correct the “errors” from the first clinical interaction. This six-video pattern repeated with a social worker focusing on OAT for OUD and identifying a support system.

Cine-VR training program curricular content

To complete the cine-VR OUD training program, we developed curricular content to be taught synchronously with the cine-VR episodes. The curriculum included 12 brief modules or reflections that reinforced the key takeaways from each cine-VR episode. Cine-VR episodes 1–4 and 7–10 focused on social determinants of health and implicit bias (i.e., stigma toward OUD), whereas episodes 5–6 and 11–12 emphasized clinical pearls to improve patient-physician communication and build trust. The key takeaways from each cine-VR episode focused on the following content: (1) bias toward OUD; (2) lack of transportation; (3) job insecurity; (4) childhood trauma; (5) interprofessional communication; (6) motivational interviewing (Part 1); (7) connecting patients with community resources; (8) housing insecurity; (9) living below the federal poverty level; (10) lack of supportive relationships; (11) identifying strengths in Destiny’s life; and (12) motivational interviewing (Part 2). Integrity of the content was ensured via written materials, a peer-review process of all materials, and user testing of the website.

Online cine-VR website

The cine-VR training program is on a website hosted on the university domain. The cine-VR episodes were viewed in two-dimensional videos utilizing a computer, laptop, or smart device. Participants could move their cursor or smart device in any direction to see the 360-degree video. This created an active viewing experience with the participant choosing what they want to focus their attention on, which in turn increased immersion as well as engagement in the cine-VR. For example, observant participants may have noticed subtle details, such as Destiny’s boyfriend’s heroin on the kitchen counter or the cigarette butts left in dirty dishes. In turn, participants may have felt a sense of accomplishment as they noticed subtle details planted by the filmmaking team, which in turn may have heightened their viewing experience.

Pilot study recruitment

Osteopathic medical students were recruited from a large medical school in the Midwest with three campuses. An electronic, anonymous survey was distributed to all osteopathic medical students enrolled at a medical school in the Midwest with three campuses during the summer of the 2021–2022 academic year. The email invitation was sent by the study investigator (DR) through school-maintained class listservs. All osteopathic medical students enrolled during the 2021–2022 academic year were eligible to participate in the study; there were no exclusion criteria. The study opened on June 6, 2022, and closed on July 18, 2022. Participation in the study was completely voluntary.

Power analysis

We did not conduct an a priori power analysis for this pilot study. We followed the recommendation by Lancaster et al. [22] to recruit a sample size of 30 participants. When we recruited a minimum of 30 matched pairs, we closed recruitment for the pilot study.

Theoretical frameworks

For the cine-VR training program, we applied three learning frameworks. First, we applied Vygotsky’s [23] “scaffolding theory” to our cine-VR education. Scaffolding is a technique in which new information is introduced gradually with sufficient structure and support to assist the learner. As the learner progresses throughout the cine-VR training, the learner/participant will become more independent and the level of support will taper [23]. This allows the participant to acclimate to the new material at their own pace. Second, we created the cine-VR training program based on the core elements of Adult Learning Theory [24]. Specifically, we facilitated self-directed learning by allowing osteopathic medical students to take the initiative to enroll in the cine-VR training. Additionally, the online cine-VR training program was task-oriented allowing the participant to exercise problem-solving skills to solve unanswered questions posed in each cine-VR episode and reflection. Third, the foundation for our cine-VR rested on the theory of Recursive Reminding, or why “errors enhance learning.” [25] Learning about errors facilitates retrieval of the original episodic event in which both the mistake and correct answer were embedded. According to this theory, the learner should able to remember the context of the error as well as the surrounding context where the correction was applied. We intentionally filmed scenes with negative clinical interactions and situations (episodes 1–4 and 7–10) to provide “correct answers” in the guided simulations (episodes 5–6 and 11–12) so that the participant can integrate the information into memory and improve future clinical practice.

Measures

To assess the feasibility of the cine-VR OUD training program, we measured recruitment, retention, length of time required to recruit, rate of completion of the cine-VR training program, and feasibility of the data-collection measures. Additionally, participants provided sociodemographic factors (age, gender, race, ethnicity, year in school) and completed the following measures:

Adapted Opening Minds Survey for Health Professional Students [26, 27]: A 20-item scale that measures stigma toward OUD. The 20 items are answered on a five-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). Total scores were summed for a composite stigma score (minimum=20, maximum=100). The scale demonstrates good internal consistency (Cronbach’s alpha=0.85).

Jefferson Scale of Empathy Healthcare Provider Students Version [28]: A 20-item scale that measures empathy. The 20 items are answered on a seven-point Likert scale, ranging from 1 (strongly disagree) to 7 (strongly agree). 10 questions are worded positively, and 10 questions are worded negatively. Scores are summed for a composite score (minimum=20, maximum=140). The scale demonstrates good internal consistency (Cronbach’s α=0.85).

Data collection

Participants completed the demographic questions, Adapted Opening Minds Survey for Health Professional Students, and the Jefferson Scale of Empathy via the online questionnaire service Qualtrics (Qualtrics, Provo, UT). All participants provided online informed consent. Completion of the measures took approximately 10–15 min. For completing the study, participants received a $25 gift card as compensation. To receive the gift card, participants clicked on a separate Qualtrics link that was not connected to their survey responses. This step was necessary to ensure that their survey data was not linked to their identity. However, given the anonymous nature of the study, it was possible that participants received compensation without completing all of the pre-and postmeasures. Participants with questions about the study were directed to email or call the principal investigator (EAB).

Statistical analysis

Initial analysis examined distribution and other descriptive data to ensure that the data met the assumptions of statistical tests. We assessed participants’ demographic factors utilizing descriptive statistics and presented them as means and standard deviations or sample size and percentages. Next, we assessed skewness and kurtosis to determine which statistical test to utilize to analyze the pre-post data. The values for skewness and kurtosis were between −2 and +2, which is considered acceptable for a normal distribution [29]. Then, we performed paired sample t tests to examine changes in stigma toward OUD and empathy before and after the cine-VR OUD training program. In addition, we calculated effect sizes utilizing Cohen’s d, with a small effect=0.2, medium effect=0.5, and a large effect=0.8. We defined statistical significance as a p value less than 0.05 and conducted analyses in SPSS statistical software version 29.0 (SPSS Inc., Chicago, IL).

Feasibility

All osteopathic medical students at the Midwestern medical school were invited to participate. We successfully recruited 48 participants in less than 6 weeks. All 48 participants completed the online cine-VR OUD training program for 100 % retention. No technological difficulties were reported with the website or cine-VR episodes. The self-reported completion time ranged from 90 to 120 min. Lastly, we received no negative feedback about the cine-VR OUD training program.

For our assessment, 48 participants (48/1,011, 5 % response rate) provided informed consent to participate in the pilot study (Table 1). The mean age of participants was 24.5±2.1 years. Thirty-eight participants (79.2 %) self-identified as women, and 10 self-identified as men (20.8 %); no other genders were self-reported. Participants self-identified their race as follows: 9 (18.8 %) Asian or Pacific Islander, 2 (4.2 %) Black or African American, 2 (42 %) Middle Eastern, and 34 White (70.8 %); also, one participant (2.1 %) self-identified as Hispanic/Latino. Participants from all4 years of medical school were represented, with the most from the second year (n=21, 43.8 %).

Stigma towards OUD findings

Baseline OUD stigma scores ranged from 39.0 to 67.0, with a mean and standard deviation of 52.7±7.9. Post-cine-VR training OUD stigma scores ranged from 12.0 to 64.0, with a mean and standard deviation of 42.0±16.2. Comparison of mean OUD stigma scores showed positive changes in total stigma (mean change=10.8, t=4.402, p≤0.001, Table 2). This change had a Cohen’s d of 0.64, indicating a medium effect. This finding suggests that the cine-VR OUD training may reduce participants’ stigma toward OUD.

Empathy findings

Baseline empathy scores ranged from 60.0 to 123.0, with a mean and standard deviation of 88.7±14.6. Post-cine VR training empathy scores ranged from 72.0 to 126.0, with a mean and standard deviation of 93.8±16.0. Note, only 36 of the 48 participants provided complete empathy data for the analysis. Paired t tests revealed improvements in participants’ empathy scores (mean change=−5.1, t=−2.376, p=0.023, Table 2), with a Cohen’s d of 0.40 signifying a small effect. This finding suggests that the cine-VR OUD training may increase empathy.

Limitations

Limitations of this study include the small and homogenous sample, selection bias, nonresponse bias, subject bias, and lack of a control group. Although a final sample of 48 participants was small, it was sufficient to pilot the online cine-VR training program. Also, it is important to note that we had complete empathy scores for only 36 of the 48 participants, which introduces nonresponse bias. Data from one osteopathic medical school limits the generalizability of the findings to all osteopathic medical students; however, the findings suggest that the methods and procedures of the pilot study can be replicated for a larger educational trial. A future trial should include a more diverse sample of osteopathic medical students from multiple colleges of osteopathic medicine. Next, our findings may be susceptible to selection bias, because individuals who volunteered to participate may have been more willing or motivated to participate in this online VR training program about OUD. In addition, the responses may be susceptible to social desirability bias given that the participants may have felt undue pressure to provide positive responses on the training session. A similar susceptibility to subject bias may be ascribed to the use of new technology encouraging people to provide positive feedback. Finally, this pilot study presents findings from a 2 h cine-VR training program on OUD. We did not include a control condition as a comparison group. To determine the effectiveness of the cine-VR OUD training program, future research necessitates a randomized-control design to compare the effectiveness of the OUD VR-training arm vs. an attention control arm to assess changes in osteopathic medical students’ stigma toward OUD and empathy.