In-person (IP) education that emphasizes learning through clinical experiences, patient encounters, and hands-on training is a core concept of medical education. This concept was recently challenged when maintaining adequate physical distance from others was prioritized. Remote or distance learning where technology is utilized to relay information online between students and educators not physically present in a traditional classroom environment has been an inadequate substitute for mastery of surgical techniques during hands-on experiences.¹ As the world prepares for future pandemics given worsening climate change and declining vaccination rates, it is crucial that the surgical community is prepared with effective means to continue training future professionals.^2,3 Mixed reality (MR), in contrast to augmented reality that only superimposes a computer-generated image on a user’s view of the real world, is a technology that merges real and virtual worlds allowing physical and digital objects to co-exist and interact in real time, unlocking the connection between participants during a hands-on educational interaction.⁴ These innovative MR technologies have the potential to transform the delivery of surgical education,⁵ and help tackle many of the challenges currently faced in the delivery of high-quality, hands-on education globally including quality, consistency, accessibility, and cost.^6,7

The Simulation Innovation Laboratory at the University of Rochester, New York, combined 3 technologies: MR cloud-based software to merge 2 video streams in real time, Vuzix M4000 smart glasses to seamlessly view the merged environments, and 3D-printing hydrogel models with incorporated performance metrics to facilitate remote instruction in a risk-free manner.⁸ To evaluate the efficacy of MR-based remote instruction relative to that of IP instruction during a transrectal ultrasound biopsy (TRUS-Bx), 30 urology trainees reviewed educational videos on relevant anatomy, interpreting ultrasound, and performing the TRUS-Bx prior to randomization into MR and IP groups. Each trainee completed a pre-test, 3 training sessions, and post-test. During test sessions, participants independently administered local anesthesia, measured the prostate, and obtained 14 biopsies on a hydrogel testing model with individually-colored biopsy regions. Accuracy was defined as the percentage of core with the corresponding color for the given biopsy region (Fig. 1, A). During training sessions participants were guided through procedural steps of the TRUS-Bx on training single-colored models. MR sessions utilized Zoom to transmit the ultrasound view to the instructor and Vuzix smart glasses to display the superimposed view of the surgical field with the remote instructor’s guidance to the participant (Fig. 1, B). Post-training surveys assessed trainee perceptions of the session and proctors evaluated trainee performance.

Pre-test core percentages were similar between groups (MR: 17.9% vs IP: 26.7%, P = .44). While post-test core percentages showed significant improvement in performance for both groups (MR: 75.9% and IP: 62.3%), MR group performance increase between tests was 1.5 times greater than that of IP groups (MR: +58:0% vs IP: +35.9%, P < .01) despite pre-session participant perceptions that remote training may hinder their ability to learn (Fig. 2). Proctor evaluations of participants on transrectal ultrasound manipulation, prostate measurement, anesthetic administration, and biopsy ranging from 1 to 3 (below to above expectations) showed higher averaged post-test performance for the MR group by +0.5, +0.1, +0.8, and +0.5, respectively.

This application of MR technology to remote learning not only contradicted the perceptions of the trainees, but demonstrated its effectiveness in instructing a technical surgical procedure. These results are not only promising for remote learning moving forward, but can also set a new standard for cross-institutional and global surgical instruction.