Supplementary Material for: Feedback from human instructors is superior to guidance by a virtual reality simulator when learning flexible bronchoscopy – a randomized controlled trial.

[Background] Virtual reality (VR) simulators have been applied to bronchoscopy training, providing trainees with useful live feedback and guidance. Therefore, VR guidance could be superior to expert guidance in simulation-based. [Research Question] Does VR simulator guidance outperform guidance from expert instructors for novices navigating the bronchial tree? [Study Design and Methods] A randomized controlled trial was conducted with 36 residents using the EndoSim simulator. The trainees were divided into three groups: VR-guidance group, tutor-guidance group, and control group. They performed for 12 consecutive practice sessions, conducting a full, structured inspection of the bronchial tree, and were evaluated according to: Structured Progress (SP), Diagnostic Completeness (DC), procedure time (PT), and National Aeronautics and Space Administration Task Load Index (NASA-TLX index). [Results] All three groups showed an improvement in SP, DC, PT and NASA-TLX during their 12 procedures (P<.05), without a decrease in performance three weeks later (P>0.05). SP was the only distinguished metric among the three groups. Tutor guidance had a significantly better impact on the novices` SP compared to both VR-guidance (18±0 VS 15.0±5.3, P=.026) and the control group (18±0 VS 15.5±4.5, P=.017 ). Participants in the VR guidance group did not outperform the control group (P=1.00). [Interpretation] Tutor feedback is superior to VR guidance feedback and no feedback. uman supervisor guidance, enhances bronchoscopy quality, and structured progress offers a more nuanced assessment of bronchoscopic navigational skills than diagnostic completeness.