title: Assessing visual control during simulated and live operations: gathering evidence for the content validity of simulation using eye movement metrics.
abstract: BACKGROUND
  Although virtual reality (VR) simulators serve an important role in the training and assessment of surgeons, they need to be evaluated for evidence of validity. Eye-tracking technology and measures of visual control have been used as an adjunct to the performance parameters produced by VR simulators to help in objectively establishing the construct validity (experts vs. novices) of VR simulators. However, determining the extent to which VR simulators represent the real procedure and environment (content validity) has largely been a subjective process undertaken by experienced surgeons. This study aimed to examine the content validity of a VR transurethral resection of the prostate (TURP) simulator by comparing visual control metrics taken during simulated and real TURP procedures.
  
  
  METHODS
  Eye-tracking data were collected from seven surgeons performing 14 simulated TURP operations and three surgeons performing 15 real TURP operations on live patients. The data were analyzed offline, and visual control metrics (number and duration of fixations, percentage of time the surgeons fixated on the screen) were calculated.
  
  
  RESULTS
  The surgeons displayed more fixations of a shorter duration and spent less time fixating on the video monitor during the real TURP than during the simulated TURP. This could have been due to (1) the increased complexity of the operating room (OR) environment (2) the decreased quality of the image of the urethra and associated anatomy (compared with the VR simulator), or (3) the impairment of visual attentional control due to the increased levels of stress likely experienced in the OR.
  
  
  CONCLUSIONS
  The findings suggest that the complexity of the environment surrounding VR simulators needs to be considered in the design of effective simulated training curricula. The study also provides support for the use of eye-tracking technology to assess the content validity of simulation and to examine psychomotor processes during live operations.
authors.affiliation: College of Life and Environmental Sciences, University of Exeter, St. Luke's Campus, Heavitree Road, Exeter, Devon, EX1 2LU, UK, s.j.vine@exeter.ac.uk.
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Vine
authors.forename: John S
authors.initials: JS
authors.lastname: McGrath
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Bright
authors.forename: Thomas
authors.initials: T
authors.lastname: Dutton
authors.forename: James
authors.initials: J
authors.lastname: Clark
authors.forename: Mark R
authors.initials: MR
authors.lastname: Wilson
mesh_terms: D000328:Adult; D001288:Attention; D002983:Clinical Competence; D003198:Computer Simulation / Q000592:standards*; D003194:Computer-Assisted Instruction / Q000592:standards*; D003479:Curriculum; D003626:Data Display / Q000592:standards; D005133:Eye Movements; D005403:Fixation, Ocular; D006801:Humans; D008297:Male; D011597:Psychomotor Performance; D020728:Transurethral Resection of Prostate / Q000193:education / Q000379:methods; D013520:Urologic Surgical Procedures / Q000193:education* / Q000295:instrumentation / Q000379:methods*; D014584:User-Computer Interface