Immersive competence as a source of bias in virtual reality clinical assessment.

Virtual reality (VR) is increasingly used for assessment in educational and clinical settings. However, users' immersive competence (IC)-the ability to navigate and operate VR systems-may introduce bias unrelated to clinical skills or patient functioning. In this randomized controlled trial, 88 medical students received either general IC training, general+specific IC training, or no structured training before completing a VR-based assessment scenario. Multimodal data were collected, including electrodermal activity, cognitive-load ratings, procedural efficiency, and usability barriers. Specific IC training improved performance compared with control (28.3% ± 10.3% vs. 21.2% ± 10.8%, p = 0.010, d = 0.67), moderated by procedural efficiency and increased cognitive load. Prior 3D experience did not predict performance in the control group, likely due to a floor effect, but did in the specific training group. These findings indicate that IC is a causal, modifiable factor in VR-based assessments and should be considered to ensure fair and valid evaluations.