Cognitive Simulation Using Mental Rehearsal for Procedural Learning in Medical Students: A Narrative Review

Abstract

Mental rehearsal, defined as the deliberate cognitive rehearsal of tasks without action, is an emerging approach to procedural skills learning in healthcare education. In particular, mental rehearsal has been associated with durable improvement of complex skills in various fields such as aviation, high performance sports and surgery. Despite this, mental rehearsal-based practices in healthcare are challenged with mainly informal and highly heterogeneous practice. Given this, the efficacy of mental rehearsal in medical education remains poorly characterised. Furthermore, there is currently no evidence-based approach to integrating mental rehearsal in the medical curriculum, nor frameworks to guide development of mental rehearsal skills for students. This narrative review explores mental rehearsal in medical education and evaluates the current principles of mental rehearsal and how these can be applied to improve procedural skills learning for medical students.

Introduction

A key challenge for medical educators is to provide adequate learning opportunities to develop well-rounded medical graduates. This involves developing competencies across multiple domains including medical knowledge, clinical history and examination, non-technical skills (such as communication, cultural awareness, empathy, research) and procedural skills. ¹ Traditionally, educators provide opportunities for development of these skills through clinical placements.^2–4 Challenges remain with clinical placement opportunities, including competing interests of teaching clinicians, distractions in the clinical workplace and lack of placement structure to meet the specific learning needs of the student.^5–7 Due to this, it is not unexpected that medical students often feel underprepared for their transitions to becoming junior doctors. ⁸

Contemporary medical curricula have transitioned to experiential learning pedagogies, specifically simulation-based modalities to provide additional learning opportunities for students to practice and learn in a safe and standardised manner.^1,9 Although heterogeneous in design, simulation-based teaching sessions have been shown to improve technical and non-technical skills of medical students in settings that mirror real-life clinical practice. ⁹ Despite this, students continue to highlight barriers to effective learning with simulation, including the development of negative emotions such as anxiety. ⁹ These emotions particularly become relevant in learning procedural skills.^10,11

An extension of simulation-based learning are cognitive training methods, a term that describes learning through mental activities associated with thinking, learning and memory training. ¹² In particular, mental rehearsal (MR), defined as cognitive rehearsal of tasks in the absence of physical movement or performance, has gained increasing recognition as an effective approach to improving procedural skills.^13,14 These benefits of MR have been demonstrated in the aviation, music and elite sporting industries.^15–17 In healthcare, MR is adopted, albeit informally, in surgical training, with durable results in improving procedural and surgical skill with co-benefits of reducing stress.^12,18 Furthermore, it has also been demonstrated that the more MR skills are developed, the greater the improvement with stress. ¹⁹ Preliminary evidence suggests the potential for MR to augment the procedural learning of medical students.^13,20,21 However, MR remains poorly utilised in formal procedural educational opportunities in medical student training. Additionally, contemporary medical education provides scarce opportunity to develop MR skills for self-directed learning. This narrative review explores the principles of MR and opportunities for more standardised integration of this approach to improve the procedural learning of medical students.

MR and Theory Behind the Practice

An overview of learning theories is provided in Figure 1.

Figure 1.

Overview of learning theories and concepts underlying mental rehearsal.

Dual-coding theory and cognitive theory

The origins of MR theory derive from cognitive psychology. In particular, dual-coding theory suggests that all cognition arises from a duality of actions: verbal code such as language and non-verbal code which incorporates mental imagery.^22,23 Furthermore, cognitive theory suggests that information is best learnt and applied when it has been mentally encoded through both language and mental images. These principles are applied in the contemporary delivery of procedural education for medical students. For example, students in learning new procedural skills will be firstly introduced to written guideline or framework (language), followed by visual material such as videos, simulations or real-life clinical demonstrations (imagery). The emphasis however for the key consolidation of procedural learning has been through deliberate practice, which in the case of procedural skills includes purposeful and systematic clinical skills sessions, simulated practice and direct observation of procedural skills prior to utilising these procedural skills within clinical placements.^24,25 Evidently, the practice of deliberate mental imagery to guide skills acquisitions has been under-recognised, particularly in the landscape of technological advancement that has allowed for a myriad of competing resources. Surgical specialties adopt MR more regularly, utilising it to cognitively simulate upcoming surgical procedures to assist with recollecting and consolidating the steps required for upcoming actual practice.^12,21 Therefore, cognitive theory lends itself to the landscape of clinical education and practice, existing as an important adjunct to deliberate physical practice. Importantly, dual-coding theory has also been noted to be applicable outside of the individual context, with team-based MR allowing for sharing of imagery to develop working cognition and improved problem solving.^26,27

Cognitive load theory

Cognitive load theory when applied to MR derives from findings related to the “imagination effect,” whereby learners who imagine a concept or procedure are demonstrated to perform better on subsequent testing than learners who study without imagination. ²⁸ Central to this theory is the notion that information that is postulated and imagined is more likely to be solidified as long-term memory. ²⁸ Furthermore, it has been demonstrated learning material that required information to be learnt simultaneously, or with higher interactivity, between concepts lends itself better to the use of imagery. ²⁸ In the context of medical education, procedural skills may be considered one of high interactivity, given learners are required to absorb multiple stimuli including steps of the procedure, various tools required, interactions with educators or patients (simulated or non-simulated) and overall desired outcomes that need to be achieved with the procedure.

Neuroplasticity

Neuroplasticity in this context refers to the development and reinforcement of neural pathways associated with performing actions. The theory behind MR and neuroplasticity arises from the physiological evidence that similar neuronal and synaptic changes occur when MR is applied compared to directly performing the same action. ²⁹ Specifically, MR-based practice has been demonstrated to engage synaptic connections of the motor frontal cortex and primary visual cortex in the absence of direct physical practice or direct visualisation, respectively.^29,30 Furthermore, analyses of elite archers demonstrate that with applications of MR, there is a demonstrable shift from activity in the premotor cortex, supplementary motor cortex, basal ganglia and cerebellum to more intense supplementary motor cortex activity. ³¹ These findings suggest that the learning phase is associated with greater degree of activity to “learn and rehearse” the task which subsequently requires less activity when consolidated. ³¹ It is precisely due to these pathways MR-based practices have been adopted in many areas of improving physical performance, such as high-performance athletic programmes and in the rehabilitation of stroke patients.^32,33

Actor network theory

Actor network theory (ANT) describes a sociological perspective with two key denominations; the actor (person, group, idea, object), which produces the action of interest, and the network (person, group, idea, object) which is the interaction of actors and various strings of actions. ³⁴ MR-based practiced has been considered within the ANT, whereby purposeful actions, ideas and processes culminate to produce certain outcomes. ³⁵ Ibrahim et al. in a qualitative study of orthopaedic trauma surgery suggest that MR, through ANT, is a mechanism by which the surgeon links their pre-operative preparations to the procedure and its desired outcomes, therefore fitting into an interactive network of agents, policies, frameworks and tools to drive performance. ³⁵

Schema theory

Schema theory emphasises the role of cognition in motor learning, specifically highlighting the role of developing a well-rehearsed plan of movements to ensure an action is performed efficiently and smoothly. ³⁶ This notion is commonly drawn upon in sporting practice, where athletes utilise visualisation to plan and execute performance, such as in a golf swing or tennis serve. ³⁷ Sherwood et al. suggest these benefits of MR are derived from the ability of the individual to rehearse symbolic, visual and spatial aspects of the task. ³⁶ Furthermore, it is suggested that similar to cognitive load theory, MR is best suited for tasks that require higher cognition as the more effort associated with developing mental images, the greater the strengthening, consolidation and retention of memory.^38,39

Applications of MR: Lessons From Clinical Practice

The introduction of MR-based practices in clinical medicine has drawn from robust data from other industries such as in high performance sports and aviation.^31,40,41 In particular, MR appears to derive the most benefit for tasks that are complex and require judicious hand-eye coordination. For example, Surburg et al. in a randomised-controlled trial demonstrated that when MR is applied prior to practice, there was significant improvement in the execution of tennis strokes. ⁴² Furthermore, MR has been noted to improve a pilots ability to apply knowledge in the operational environment, with improvements noted in overall flight performance by more than 30%.^40,43 Importantly, the aviation industry acknowledges the significant benefits of cognitive simulation in this way, with many programmes integrated intentional MR for aviation training.

Given these outcomes, it is unsurprising that MR has increasingly become recognised as a valuable learning technique, particularly in the field of surgery where procedural skills are emphasised. A meta-analysis of cognitive training by Wallace et al. identified a growing body of randomised-clinical trials demonstrating objective improvements in surgical skill, in addition to co-benefits of reduced stress in training surgeons. ¹² Of note, the authors report heterogeneous methods of which MR is delivered in these trials, including through engaging with MR 30 min prior to laparoscopic cholecystectomies using validated mental imagery scripts, engaging in 1 on 1 MR training with a focus on self-talk and visualisation, self-directed MR using a booklet after observing direct surgical demonstration and other forms of self-directed practice ranging from 3 min a day to 15 min a day.^19,44–47 These outcomes are also durable outside of emergency general surgery situations, with Komesu et al. highlighting improvements in flexible cystoscopy performance with pre-operative MR compared to textbook reading. ⁴⁸ Interestingly, one of these trials which involved medical students demonstrated no improvement in surgical proficiency with MR, indicating perhaps there is a level of experience and clinical expertise that is required in order to complement this learning modality. ⁴⁷ This concept is supported by findings from a meta-analysis on MR and surgical technical skills training by Rao et al., who demonstrated baseline skill is another factor that influences the efficacy of MR. ⁴⁹ Despite this, a randomised-controlled trial by Raison et al. demonstrated that MR led to improvement in robotic surgery skills development, even in novice participants. ⁵⁰ Given the heterogeneity of MR-based interventions, it appears that more standardised and robust approaches to MR programmes are required to further characterise the true efficacy of MR.

Evidence supporting MR has also been found for complex tasks outside of surgery. In particular, Lorello et al. demonstrated in a randomised-controlled trial that Advanced Trauma Life Support (ATLS) performance was improved when MR was applied prior to performing simulated resuscitation. ²⁶ This finding was also consistent irrespective of the underlying resident specialty, including anaesthetics, emergency medicine and surgery. ²⁶ Moreover, Bucher et al. demonstrated gloving practices improved when MR is applied prior to physical practice, indicating the benefits of MR also extend to fields of nursing. ⁵¹ Additionally, in non-surgical specialties, the co-benefits of reduced stress also persist. ⁵²

Although there is a great degree of evidence that deems MR to be transferrable to clinical practice, particularly in procedural skills learning, MR remains an informal practice, with lack of incorporation into evidence-based guidelines, frameworks or educational curricula. One argument for this is the lack of high-quality data supporting the efficacy of MR, which arises due to the heterogeneity of many studies assessing the benefit of MR in clinical practice. ¹⁸ Despite this, a qualitative study of General Surgeons Australia trainees demonstrate support for MR-based practices as a useful adjunct to supporting their clinical and procedural training. ⁵³ Furthermore, a review by Anton et al. on the effectiveness of mental skills training in surgery identified that in addition to improved surgical performance, mental skills-based practices were associated with additional benefits of improved communication skills, confidence, more effective team-based skills, improved resource consumption and improved cost-efficiency in training. ⁵⁴ For clinical educators, the potential benefits of MR integration in standardised formal curriculum, learning and teaching approaches are appealing for skills improvement in the healthcare setting. Despite this, it is clear that paradigms in procedural teaching adopt more varied and informal approaches to incorporating MR. Further research is required to evaluate the best practice methods and design principles in order to derive durable efficacy of MR for procedural learning across the multidisciplinary environment of healthcare.

MR and Procedural Learning for Medical Students

Medical students mirror the challenges of clinicians with procedural skills learning. Given this, the potential for MR to be used as an adjunct for skills development has led to a developing research base that explores the utility of MR for this purpose. Despite this, there is a notable paucity in empirical evidence for MR in medical education compared to other aforementioned industries such as surgery, aviation and elite sporting. Interestingly, studies examining higher order procedural skills did not demonstrate any improvement in performance with MR. For example, Jungmann et al. in a randomised-controlled trial of standardised MR practice performed at least 3 min a day for 4 days prior to simulated laparoscopic knot tying demonstrated no overall difference between medical students exposed to MR versus control (knot tying video prior to practice). ⁴⁶ Similarly, Mulla et al. in a randomised-controlled trial assessing basic laparoscopic skills demonstrated no difference in in medical student performance irrespective of whether they were exposed to MR or control interventions prior. ⁴⁷ Another randomised-controlled trial by Sanders et al. assessing MR implemented as 30 min sessions at 1 week intervals prior to surgery on a live rabbit also failed to appreciate a performance benefit with MR on basic surgical skills such as needle handling, suturing and operative handling of tissue. ²¹ Despite this, they did note improved surgical efficiency and timing. ²¹ The same group subsequently demonstrated however that when compared with textbook practice, MR was associated with improved performance during live rabbit surgery. ⁵⁵ On evaluating the literature further, there are only a few randomised-controlled trials that have further assessed the impact of MR on medical student surgical proficiency has yielded mixed results. For example, Dimitriou et al., Eldred-Evans et al. and Stefanidis et al. also evaluated the role of MR in relation to basic laparoscopic skills. Dimitriou et al. demonstrated there was no difference in laparoscopic skills of students who observed a video tutorial followed by a session on mental imagery compared to video tutorial alone on haptic simulators. ⁵⁶ Conversely, Eldred-Evans conducted a randomised-controlled trial of medical students who performed basic laparoscopic skills on a box trainer compared to those who has a 30-min MR training session a week prior to assessment. ⁵⁷ The authors demonstrated the MR-enhanced cohort was more precise and accurate with their surgical movements compared to control. ⁵⁷ Similarly, Stefanidis et al. demonstrated in a randomised-controlled study comparing students who were provided a MR-based curriculum (5 min MR sessions bi-weekly, total eight sessions) had better suturing skills development with co-benefits of reduced levels of stress. ⁵⁸ Furthermore, outside of laparoscopy, Bathalon et al. evaluated the role of MR implemented as a 5-min session on student's performance of surgical cricothyrotomy as per the ATLS guidelines. ⁵⁹ The authors found MR-based intervention in this way improved student's marks in an objective structured clinical exam aimed at evaluating the steps of this procedure as well as the student's fluidity and time. ⁵⁹ These findings, albeit variable, highlight that similar to the clinician environment, MR may be more effective in the presence of a baseline level of experience and expertise. The conflicting findings may also reflect the underlying heterogeneity of studies and the fact that surgical skills examined may reflect a higher level of procedural difficulty, further emphasising the need for more robust and standardised MR-based protocols of skills at expected levels for the medical student in research study designs.

When assessing more relevant skills within the expected scope of competency for medical students as well as junior doctors or interns, the literature suggests MR may derive more benefit. In particular, Sanders et al. in a randomised-controlled trial assessing venepuncture skills with prior MR compared to 30 min of additional physical practice demonstrated MR was equally as effective in improving performance. ¹³ Additionally, Bramson et al. highlight that when MR was compared to additional physical practice for medical students learning lumbar puncture, there was also no difference in performance observed. ²⁰ However, Berger-Estilita et al. and Kuriyama et al. evaluated MR on intravenous cannulation and lung auscultation in randomised-controlled trials, respectively, with both authors demonstrating no significant difference between MR groups and control.^60,61 Similar limitations of the underlying evidence exist, particularly related to the significant heterogeneity of MR-based interventions in addition to the highly variable means of assessment. For educators, this highlights that MR may be a useful adjunct to consolidate skills in a cost-effective and resourceful manner; however, there is a need for further research to define the best practice methods to design, integrate and implement MR-based programmes to achieve the most efficacy in supporting the skills development of medical students.

Insights From Educators and Students

In addition to the potential efficacy of MR-based programmes in supporting the learning of medical students, understanding the perceived value and the experiences of MR-based interventions may also assist educators in recognising ways in which this educational approach may be able to integrate into the medical curricula. From an educator perspective, it is clear from the randomised-controlled studies of Berger-Estilita et al. and Eldred-Evans et al. that the practicality and feasibility of these approaches are highly appealing. Specifically, despite not performing a formal cost-effective analysis, both authors highlight that MR-based practices were much more economical than maintaining other methods of learning such as simulation through low fidelity arm models for intravenous cannulation and box trainers for laparoscopy.^57,60 Furthermore, Shah et al. also highlight that MR-based interventions are much more appealing compared to high-fidelity simulators for ureteroscopic practice in general. ⁶² The authors also suggest that with adequate learning of MR-based skills, students can effectively and in a self-regulated manner apply these skills in their own learning without a mentor, essentially bringing additional costs of learning to zero. ⁶² Despite this, it remains unclear the cost of MR-based programme or curricular and the investment that medical educators afford to providing these opportunities for upskilling to students. Furthermore, in the context of highly variable interventions, it is also likely the costs of these interventions may be variable as well. The evidence at this point highlights the need for additional cost-benefit and cost-effective analysis of these interventions to gain further insights into the practical aspect of implementing MR-based programmes. Additionally, it also remains unclear the perceived value and experience of educators in designing, implementing or conducting these interventions. Understandably, given the intent of the randomised-controlled trials on MR was to understand the efficacy of these interventions, the qualitative experience of educators remains an area that would benefit from further research enquiry.

From the student perspective, overall, it appears that MR-based interventions are appealing for students across the spectrum. For example, at the surgical training level, surgical trainees have highlighted in a qualitative study that MR is a useful adjunct to their clinical and surgical training. ⁵³ At the medical student level, Stefanidis et al. highlight students perceived MR-based modules were effective in improving their subjective performance of laparoscopic skill, particularly with the co-benefit of alleviating stress. ⁵⁸ The authors also highlighted that 92% of the cohort stated they would apply these MR-based skills outside of study, with 85% planning to use these skills in future stressful situations. ⁵⁸ This insight however was derived only from a single cohort of 60 students, highlighting the need for additional qualitative evidence exploring the perceived value and experience of MR based intervention from the student perspective on learning.

Towards Standardised MR in the Medical Curriculum

Evaluation of the literature highlights that MR-based learning strategies are a useful adjunct to support procedural skills learning for medical students. Furthermore, in the landscape of judicious use of education-based resources, the cost-effectiveness of MR compared to other methods including additional procedural skills practice makes the approach appealing from a sustainability and practicality standpoint. Despite this, it is clear from the literature that a standardised and evidence-based approach to integrated MR-assisted procedural learning is yet to be characterised. Therefore, a challenge for educators is to adapt the heterogeneous MR-based protocols into medical student learning within their own jurisdictions and curricula in an efficacious and practical way.

Alluding to the background theories, dual-coding theory in particular assists with guiding fundamental aspects of MR-based frameworks, namely, the emphasis on language and imagery to facilitate skills acquisition. These principles are evident in trials of MR in medical student procedural learning. For example, Sanders et al. utilised a combination of didactic lectures, physical demonstrations and practice for medical students irrespective of whether they were exposed to MR or control to improve surgical skills.^21,55 Additionally, Bramson et al. in their trial assessing MR to assist with medical students learning lumbar puncture utilised instructional videos prior to performing the task itself. ²⁰ These trials highlight that for medical student procedural skills training, MR should be utilised as an adjunct to learning in addition to other modalities of language and imagery including text through lectures or guidelines and imagery through live demonstrations and videos.

For educators, the question then becomes how to effectively implement MR to leverage cognitive simulation as a means to enhance and consolidate skills acquisition. Unfortunately, given the heterogeneity of interventions in the literature, the timing and design of efficacious MR-based practice are poorly characterised. However, as a form of cognitive simulation, best practice approaches to assist with integrating MR into medical student learning may draw upon existing frameworks related to simulation-based education.

The evidence suggests that simulation-based learning exercises should adopt important principles including the use of feedback, deliberate practice, curriculum integration, skills acquisition and maintenance and instructor training. ¹ These principles provide a clearer framework to assist with the development of MR-based learning frameworks. Arora et al. highlight that MR is a skill that can be developed and that with practice, mental imagery and its benefits can be enhanced. ⁴⁴ Given this, MR integration into the medical curriculum requires both consideration into improving delivery of MR learning by educators or facilitators and deliberate practice and development of MR-based skills for learners. Practically, this process would involve stakeholders involved in curriculum and lesson design to train educators on how to effectively teach MR and provide opportunities to develop these skills within lessons. For learners, deliberate practice to consolidate these skills is an imperative. Lastly, a mechanism for feedback focussed on MR technique is another core aspect of skills improvement that relies on engagement by both educators and learners.

Integrating MR in Medical Education: Limitations, Barriers and Insights

Evidence-based integration of MR for medical students remains elusive. Key limitations of this practice include heterogeneity of MR-based interventions in the literature and therefore the quality of the underlying evidence, as well as paradigms of informal use of MR in clinical settings within healthcare. Given this, MR as an additional adjunct to medical student learning remains an area of ongoing research, with best practice methods of design and integration into the medical curriculum remaining elusive. Despite this, the insights and limitations of the underlying evidence may provide avenues to explore in addressing the barriers towards integrating MR-based programmes into medical education practice. For instance, an evident challenge has been the variability in MR-based programmes, leading to downstream issues related to feasibility, generalisability and applicability. The literature suggests that although isolated MR-interventions, such as for 5–30 min prior to skills performance may be beneficial, more sustainable skills development can be gained from adopting a more intensive MR-based curriculum focusing not only on using MR-based skills but also developing MR-based practice as a skill in itself. Given this, educators who are involved in curriculum design and development should consider applying MR-based practice, including an overview of MR theory, tutorials on how to apply MR across varying skills and opportunity for MR-based practice prior to skills performance across multiple sessions.

Notably, given MR-based interventions have been evidently underutilised in medical school education, the evidence highlights a need for additional training for faculty in MR-based theory and practice to be able to effectively deliver this training to students. Furthermore, there are additional underlying costs given that MR-based curriculum remains in its infancy in many jurisdictions. For example, additional written, audio and visual learning resources for both student and faculty are likely to be under developed or non-existent. This in itself poses an additional challenge, particularly related to time and resource constraints. These issues and considerations are global when it comes to incorporating new methodologies into practice, with similarities drawn from institutions who have adopted newer technologies into medical education highlighting the need for initial investment and strategy. ⁶³ For medical educators, the priority in implementing MR-based interventions should focus both on developing a culture and infrastructure that supports MR in addition to training resources and upskilling opportunities for both faculty and students. In addition, evidence from those who have implemented new simulation-based medical education programmes suggests that design and implementation should first follow a process of consultation including both faculty and students. ⁶⁴ This involves discussion between these stakeholders on educational practices, including objectives of the MR programme, the proposed interventions, discourse related to the complexity and fidelity of individual tasks, expectations, desired outcomes and methods of evaluating the efficacy and utility of the intervention.^1,64 Furthermore, buy-in from faculty is required, given the ethical and regulatory environment of implementing novel learning strategies and tools into already established curriculum. ⁶³

Ethical Considerations and Future Directions

Evaluation of studies assessing the role of MR in medical education has highlighted clear limitations of this approach. Practically, despite the reported benefits of cost efficiency of MR, the infancy of MR-based interventions in the medical curriculum calls for an investment of time and resources into developing training, teaching material and programmes for implementation. These factors, in addition to competing interests into other learning modalities such as clinical placements and high-fidelity simulation, also challenge the accessibility and feasibility of MR adoption. The advent of contemporary large language models, such as generative artificial intelligence (AI) tools including ChatGPT, Google Gemini and Perplexity AI, has transformed the landscape of medical and surgical education.^9,65 In particular, the capacity of these tools to efficiently support the development of medical education resources such as tutorials and curriculum when provided with free-text prompts may be an avenue to explore to address the challenges of resource and time commitment in designing initial MR-based pilot programmes. Despite this, the ethical and regulatory considerations of implementing generative AI tools remain, including issues with copyright, data stewardship and verification to ensure these programmes developed with assistance of AI tools remain relevant and meet the desired learning objectives of their respective jurisdiction.

Additionally, ethical considerations should be considered by educators when applying any novel learning approach. In particular, a balance between passive learning strategies such as MR and hands-on deliberate practice is required. This is especially relevant for medical education where there is a need to develop technical skills including procedural skills and clinical examination skills. Curriculum design therefore should consider MR as a supportive adjunct and not a replacement for the learning opportunities already available for deliberate practice of these skills. Furthermore, it is necessary for educators to consider how MR-based interventions may interact in different environments, such as across different regional or cultural contexts. For example, insights from the field of anthropology suggest certain cultures may differ in terms of the vividness and effectiveness of MR. ⁶⁶ A study by Marsella et al. comparing Filipino to Caucasian-Americans demonstrates that the former manifest more vivid mental images. ⁶⁷ Further studies highlight that mental imagery is also influenced by age and sex, therefore highlighting that MR skills are also dependent on sociocultural and demographic factors. ⁶⁸ For educators, considering the unique demographic of their learning cohorts may therefore be another key approach when it comes to designing MR programmes.

Overall, this narrative review highlights the significant potential for MR in medical education in addition to key challenges related to paucity in the evidence. Future prospective research should consider development of robust and standardised frameworks for MR integration for procedural skills training that incorporates pre-procedural resources such as lectures, live demonstrations and videos in addition to the use of MR to consolidate this knowledge prior to performance. Educators in applying MR should also consider methods of developing MR-based practice for students with intent, including through deliberate practice, teaching of MR-based skills and providing feedback on performance with respect to MR. Furthermore, there is a need for more robust evidence to understand the true efficacy of MR-based interventions and the experiences of these for students and faculty. With respect to the former, systematic reviews exploring MR on both technical and non-technical skills development are worth considering. For the latter, robust qualitative studies would be a key area of research to be considered to explore these perspectives. Lastly, given the heterogeneity of MR-based interventions and programmes, a Delphi analysis on MR protocols may be worth considering to establish expert consensus on best practice protocols and designs of MR programmes.

Conclusion

MR remains an under-utilised adjunct to procedural learning for medical students, with lack of standardised approaches to MR-based practice. This review highlights the potential for MR to consolidate procedural skills learning for medical students in a cost-effective manner. However, limitations exist with the heterogeneity of MR-based interventions in the literature. Further research is required to identify evidence-based and standardised frameworks for integrating MR in the medical curriculum.