Development Strategies in Medical Education

Introduction
Educational approach enhances the acquisition of skills and knowledge in clinical areas while providing a safe environment for practitioners without compromising patient safety [4]. Virtual reality (VR) plays an important role in simulation-based medical education, providing innovative teaching methods and increasing learning experiences. VR simulations provide a safe environment for medical students and professionals to practice various procedures including surgical techniques and emergency scenarios without compromising patient safety [6]. These simulations are more accessible, repeatable, and cost-effective compared to traditional face-to-face simulation training, making them increasingly popular [6, 7]. VR-based surgical simulators improve traditional training methods by providing realistic scenarios for endoscopy, laparoscopy, and other gynecological procedures [10]. Moreover, these simulators differentiate between surgical skill levels among female residents, indicating their potential to improve surgical competencies [13]. 
Understanding the learning curve associated with VR-based training is critical to optimizing its effectiveness and ensuring proficiency among learners. A learning curve refers to the path of skill acquisition and performance improvement over time as individuals engage with a new technology or learning method. Learning curves are often shown graphically with time or experience on the X-axis and performance or skill improvement on the Y-axis. In VR-based training, the learning curve includes evaluating the speed of learners in understanding the necessary skills, moving in the virtual environment, and achieving competence in different methods. While VR offers exciting opportunities for obstetrics and gynecology education, the learning curve associated with this technology is not yet well understood. By reviewing studies that have evaluated the learning curve of VR-based training in obstetrics and gynecology, we aim to provide information on the efficiency, effectiveness, and challenges associated with integrating VR into obstetrics and gynecology educational curricula.

Methods
This is a systematic review study that was conducted according to the PRISMA guidelines. The search was conducted in online databases including PubMed/MEDLINE, Embase, Scopus, and Cochrane Library, SID, MagIran and Elment, and Google Scholar to identify relevant studies published until March 2024 (without time limit) using the keywords related to virtual reality, learning curve, and obstetrics and gynecology based on the MeSH terms and using Boolean operators (OR, AND). In addition, reference section of relevant articles was manually searched for finding more articles. Studies that had used the learning curve in obstetrics and gynecology and published in English or Persian were included. Titles and abstracts of retrieved articles were first independently screened by two authors. Full-text articles of relevant articles were then assessed for eligibility. Disagreements in article selection were resolved through discussion or consultation with the third author. A standardized data extraction form was designed to extract relevant information from the included articles. Data on study characteristics (e.g., design, population, intervention), outcomes related to learning curve assessment, and key findings were extracted from the articles.

Results
The initial search yielded 785 records. After removing duplicates, 620 remained for screening. After screening by title and abstract, full-texts of 78 articles were screened for eligibility. Finally, 12 studies [18-29] met the inclusion criteria and were included in the systematic review. The studies included participants with various skill levels, from novice to expert. Results showed that experienced surgeons performed better than novices in using VR simulators. VR simulation significantly improved performance and reduced the performance gap between different skill levels. Novices showed significant improvements by increasing iterations, especially after the second to sixth iterations, while experts showed shorter learning curves, with improvements occurred much earlier (in the second iteration).

Conclusion
Overall, the results of studies highlight a positive correlation between experience and performance, with fluctuations indicating the need for ongoing practice and modifications to maintain and strengthen acquired skills. VR simulation offers a promising platform for increasing skill acquisition over time in obstetrics and gynecology education compared to traditional training methods. However, the exact point at which the plateau phase of skill acquisition occurs, varies depending on the specific criteria and training sessions. 

Ethical Considerations
Compliance with ethical guidelines
This is review study. No experiments on human or animal samples were conducted. All publications ethics such as avoiding plagiarism were considered.

Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors' contributions
The authors contributed equally to preparing this article

Conflicts of interest
The authors declare no conflict of interest.
 

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