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Implementing Virtual Reality Technology to Teach Medical College Systemic Anatomy: A Pilot Study

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Title: Implementing Virtual Reality Technology to Teach Medical College Systemic Anatomy: A Pilot Study
Language: English
Authors: Meng-Lin Liao (ORCID 0000-0002-2293-319X), Chi-Chuan Yeh, June-Horng Lue, Ming-Fong Chang (ORCID 0000-0002-4522-7669)
Source: Anatomical Sciences Education. 2024 17(4):796-805.
Availability: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
Peer Reviewed: Y
Page Count: 10
Publication Date: 2024
Document Type: Journal Articles
Reports - Research
Education Level: Higher Education
Postsecondary Education
Descriptors: Medical Education, Teaching Methods, Anatomy, Computer Simulation, Video Technology, Medical School Faculty, Teacher Attitudes, Likert Scales, Large Group Instruction, Laboratory Procedures, Motion, Symptoms (Individual Disorders), Visual Perception, Learning Processes, Educational Benefits, Barriers
DOI: 10.1002/ase.2407
ISSN: 1935-9772
1935-9780
Abstract: It can be difficult for some students to learn three-dimensional anatomical structure concepts. While virtual reality (VR) systems have been reported as helpful for learning, there has been scarce research on either VR teaching strategies or the influence of visually induced motion sickness (VIMS) in the context of large anatomy classes (i.e., over 100 students). The study thus aimed to (1) establish a VR anatomy instruction video for a large class; (2) determine how many students experience VIMS when watching a VR anatomy instruction video; (3) evaluate the influence of VIMS on VR anatomy video-based learning; and (4) examine whether a small screen size alleviates VIMS. Laboratory course students viewing a VR anatomy instruction video about the vascular system were invited to participate in the questionnaire survey. Anatomy faculty and staff participated in an experimental trial to determine whether small screen size could alleviate VIMS. The Likert scale survey revealed that students reported the VR strategy as advantageous and appropriate for large classes, but that it cannot replace practical dissection. Of the total participants, 32% reported experiencing VIMS, and 40% of those experiencing VIMS agreed that this could negatively impact their learning through a VR anatomy instruction video. Adjusting the screen size from large to small significantly delayed the onset of VIMS. In conclusion, the VR anatomy instruction video strategy is feasible and helpful for large classes, but educators should consider VIMS when planning their use of this teaching approach.
Abstractor: As Provided
Entry Date: 2024
Accession Number: EJ1426255
Database: ERIC
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  Value: <anid>AN0177613393;[8z8k]01jun.24;2024Jun04.09:22;v2.2.500</anid> <title id="AN0177613393-1">Implementing virtual reality technology to teach medical college systemic anatomy: A pilot study </title> <p>It can be difficult for some students to learn three‐dimensional anatomical structure concepts. While virtual reality (VR) systems have been reported as helpful for learning, there has been scarce research on either VR teaching strategies or the influence of visually induced motion sickness (VIMS) in the context of large anatomy classes (i.e., over 100 students). The study thus aimed to (<reflink idref="bib1" id="ref1">1</reflink>) establish a VR anatomy instruction video for a large class; (<reflink idref="bib2" id="ref2">2</reflink>) determine how many students experience VIMS when watching a VR anatomy instruction video; (<reflink idref="bib3" id="ref3">3</reflink>) evaluate the influence of VIMS on VR anatomy video‐based learning; and (<reflink idref="bib4" id="ref4">4</reflink>) examine whether a small screen size alleviates VIMS. Laboratory course students viewing a VR anatomy instruction video about the vascular system were invited to participate in the questionnaire survey. Anatomy faculty and staff participated in an experimental trial to determine whether small screen size could alleviate VIMS. The Likert scale survey revealed that students reported the VR strategy as advantageous and appropriate for large classes, but that it cannot replace practical dissection. Of the total participants, 32% reported experiencing VIMS, and 40% of those experiencing VIMS agreed that this could negatively impact their learning through a VR anatomy instruction video. Adjusting the screen size from large to small significantly delayed the onset of VIMS. In conclusion, the VR anatomy instruction video strategy is feasible and helpful for large classes, but educators should consider VIMS when planning their use of this teaching approach.</p> <p>Keywords: gross anatomy; screen size; virtual reality; visually induced motion sickness</p> <hd id="AN0177613393-2">INTRODUCTION</hd> <p>Gross anatomy is an ancient, fundamental medical school topic that strives to teach students sufficient anatomical knowledge that they may excel in later clinical subjects. Medical education research has shown that a thorough understanding of human anatomical structures is of great help in clinical diagnosis in orthopedics, clinical training in dentistry, and clinical diagnosis using ultrasound or magnetic resonance imaging.[[<reflink idref="bib1" id="ref5">1</reflink>], [<reflink idref="bib3" id="ref6">3</reflink>]] Nevertheless, the large number of anatomical terms, three‐dimensional (3D) complexity of human structures, and difficulties visualizing them, frequently present medical students with learning obstacles.[[<reflink idref="bib5" id="ref7">5</reflink>]] The COVID‐19 pandemic highlighted that a significant decrease in teaching hours for anatomy instruction can increase student difficulty with learning this subject.[<reflink idref="bib7" id="ref8">7</reflink>]</p> <p>Due to the topic's importance and difficulty, anatomy educators have begun incorporating numerous digital teaching tools to help students become more familiar with anatomical terms, more quickly, outside the laboratory or classroom instruction.[[<reflink idref="bib8" id="ref9">8</reflink>], [<reflink idref="bib10" id="ref10">10</reflink>]] Numerous anatomy education studies have also attempted to transform complex 3D human structures into digital teaching software, including using virtual reality (VR) systems.[<reflink idref="bib11" id="ref11">11</reflink>] The use of VR in anatomy instruction provides two primary benefits. First, observers can freely adjust their observation viewpoint. Second, virtual anatomical structures can be disassembled and flipped for examination.[[<reflink idref="bib11" id="ref12">11</reflink>], [<reflink idref="bib13" id="ref13">13</reflink>]] Hence, medical students' understanding of the complex human structures could be enhanced by supplementing traditional two‐dimensional atlases with 3D spatial representations.</p> <p>Teaching VR‐based anatomy at National Taiwan University (NTU) previously encountered several problems. It was logistically difficult for schools to provide enough VR devices, anatomy education software, and indoor operational space for large classes. In addition, students encountered learning difficulties during VR practice for several reasons, including (<reflink idref="bib1" id="ref14">1</reflink>) limited anatomical knowledge; (<reflink idref="bib2" id="ref15">2</reflink>) lack of experience operating a VR device; and (<reflink idref="bib3" id="ref16">3</reflink>) inability to communicate with instructors or peers. Consequently, anatomical features were observed inaccurately and learning efficiency was inadequate. Many students who watched live broadcasts of their classmates using VR on a large screen reported experiencing visually induced motion sickness (VIMS), which is characterized by symptoms like dizziness, fatigue, and/or nausea.[<reflink idref="bib14" id="ref17">14</reflink>] Therefore, developing suitable VR teaching strategies for large classes, to help students master 3D anatomical concepts, is crucial for anatomy educators.</p> <p>VR, applied in anatomy education, may provide learners with a powerful immersive experience.[[<reflink idref="bib12" id="ref18">12</reflink>], [<reflink idref="bib15" id="ref19">15</reflink>]] However, immersive experiences can be influenced by crucial factors, including vision, hearing, and olfaction.[<reflink idref="bib16" id="ref20">16</reflink>] VIMS has been reported to be a common side effect of virtual environments.[<reflink idref="bib17" id="ref21">17</reflink>] Since screen size has been suggested as a key factor in creating an immersive experience,[[<reflink idref="bib18" id="ref22">18</reflink>]] adjusting screen size may improve VIMS when using VR anatomy instruction videos.</p> <p>To provide students in large classes with high‐quality VR experiences in which to learn anatomy, with limited equipment, the study had four objectives: (<reflink idref="bib1" id="ref23">1</reflink>) to develop a VR anatomy instruction video based on the analysis, design, development, implementation, and evaluation (ADDIE) framework; (<reflink idref="bib2" id="ref24">2</reflink>) to evaluate the acceptability and feasibility of this teaching strategy among gross anatomy students; (<reflink idref="bib3" id="ref25">3</reflink>) to examine the occurrence of VIMS from the VR anatomy instruction video; and (<reflink idref="bib4" id="ref26">4</reflink>) to determine whether VIMS can be alleviated by adjusting the screen size for watching VR anatomy instruction videos. The overarching goal of this research program is to provide valuable resource information to schools interested in implementing VR anatomy education strategies.</p> <hd id="AN0177613393-3">MATERIALS AND METHODS</hd> <p></p> <hd id="AN0177613393-4">NTU gross anatomy courses</hd> <p>NTU gross anatomy courses include systemic anatomy and regional anatomy. Students in the School of Medicine, Department of Dentistry, Department of Forensic Medicine, and the Graduate Institute of Anatomy and Cell Biology all learn systemic anatomy, including the skeletal, cardiovascular, muscular, and nervous systems, annually from September to October.[[<reflink idref="bib20" id="ref27">20</reflink>]] A total of 361 students agreed to participate (IRB approval number: 202012HS015 and 202205HS048), including 181 students during the 2021–2022 academic year and 180 during the 2022–2023 academic year.</p> <hd id="AN0177613393-5">ADDIE model</hd> <p>The ADDIE model has been successfully applied in digital learning.[[<reflink idref="bib22" id="ref28">22</reflink>]] Thus, this process was applied herein (Figure 1) to develop the VR anatomy teaching approach.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/8Z8K/01jun24/ase2407-fig-0001.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="ase2407-fig-0001.jpg" title="1 ADDIE model flow chart. The virtual reality (VR) anatomy instruction video approach used herein was developed and evaluated based on the analysis, design, development, implementation, and evaluation (ADDIE) model." /> </p> <p></p> <hd id="AN0177613393-7">3D Organon VR anatomy feasibility analysis</hd> <p>To analyze which VR anatomy software content was more appropriate for NTU medical students, software by 3D Organon (Medis Media, Australia, QLD) and BodyMap (MAI, USA, VA) was used. Although the 3D Organon software cost was higher, its contents (which include comprehensive labeling and the ability to disassemble objects) were more extensive compared with BodyMap. In addition, previous research demonstrated that the 3D Organon software featured the ability to observe virtual bodies from any angle and depth, to provide an immersive experience, and to disassemble and freely rotate anatomical structures.[<reflink idref="bib12" id="ref29">12</reflink>] Hence, 3D Organon VR Anatomy software was used herein. After discussing the contents of the 3D Organon with other experienced anatomy instructors, the authors determined that systemic anatomy education was more suitable than regional anatomy for VR‐based teaching, and that 3D Organon software was the most appropriate for this study.</p> <p>Two preliminary trials were conducted at the NTU to establish the VR anatomy teaching approach for large classes. In the first trial, an experienced anatomy instructor wearing a VIVE Pro2 VR headset (HTC, Taiwan) operated the VR anatomy system and projected its live images onto a 60‐inch screen, which was viewed by several students. However, some students and anatomy instructors reported the occurrence of VIMS when watching the live broadcast, and a limited number of students could participate in this strategy due to limited operating space. In the second trial, six graduate students enrolled in the anatomy department during the 2020–2021 academic year were invited to wear the VR headset and operate the VR anatomy system in person after the anatomy instructor demonstrated its use. However, this method required a great deal of practice time and incurred the following problems: (<reflink idref="bib1" id="ref30">1</reflink>) The operator was unable to coordinate the viewing angle and operation handle; (<reflink idref="bib2" id="ref31">2</reflink>) the operators' VR viewing angle frequently deviated, preventing them from correctly observing the anatomical structure; and (<reflink idref="bib3" id="ref32">3</reflink>) the operator's frequent, rapid, and large‐angled head rotations caused VIMS among those observing, and prevented high‐quality observation of the on‐screen VR experience. Finally, the limited availability VR equipment and space, the large number of students, and the abovementioned operating problems led to the final strategy herein: recording the instructor's VR anatomy demonstration as a VR anatomy instruction video, which was then played in the laboratory course.</p> <hd id="AN0177613393-8">VR demonstration design</hd> <p>The vascular system was selected to pilot the VR anatomy instruction video because there are marked limitations to plastic models of this system. To reduce unnecessary rotation and record the demonstration smoothly, the anatomical structures of the vascular system were first listed and then identified in 3D Organon software. Finally, the teaching outline and camera script were designed.</p> <hd id="AN0177613393-9">VR anatomy instruction video development</hd> <p>Maintaining consistent perspectives among different recordings is difficult; hence, a "one‐shot" VR anatomy instruction video was created with a camera script. The recording of the 3D Organon VR Anatomy demonstration was conducted via screen recorder 4 (CyberLink). The VR anatomy instruction video displayed only the skeletal and vascular systems in 3D Organon, beginning with the ascending aorta and then the branches. Unique anatomical vessels, such as the internal carotid artery, were viewed from different angles to show their relative positions and unique traveling courses. The final 20‐min VR anatomy instruction video of the vascular system was completed after Power Director 19 (CyberLink) was used to remove all irrelevant images.</p> <hd id="AN0177613393-10">VR anatomy instruction video implementation</hd> <p>The VR anatomy instruction video was played at the beginning of the 2‐h vascular system laboratory. After watching the videos through one of 15 55‐inch or three 65‐inch television screens, 25–28 students per model could view plastic models of the human body and brain and heart vasculatures, and six to seven students per model could view human skeleton specimens to understand the corresponding positions of vessels (all modes and specimens obtained from SOMSO, Germany).</p> <hd id="AN0177613393-11">VR anatomy instruction video evaluation</hd> <p>At the end of the vascular system laboratory course, students were invited to participate in the study by filling out the VR questionnaire, which included six 5‐point Likert scale statements, one yes or no question, and three free‐form text responses (Table S1). Four of the Likert scale questions explored the application of 3D Organon in learning anatomy and the benefits of VR anatomy instruction video; the remaining two addressed the impacts of VIMS during VR anatomy instruction. In addition, the time when VIMS began was recorded on the survey. If the student did not experience VIMS by the end of the video, the beginning time was defined as 20 min for analyses. Except for the scale, the questionnaire was identical during the two academic years. During academic year 2021–2022, the questionnaire used a 10‐point Likert scale response option. In response to student feedback that the 10‐point scale was less user‐friendly, the scale was changed to a 5‐point Likert scale for the 2022–2023 academic year.</p> <p>To analyze combined data from the two academic years, 10‐point Likert scale data from the 2021–2022 academic year were converted to a 5‐point Likert scale by dividing each value by 2 and retaining fractions. A value of four or higher indicated agreement with the topic. The questionnaire's internal consistency was determined using Cronbach's alpha for reliability analysis in SPSS 26 (IBM). Six anatomy instructors and teaching assistants (with 6 ± 4.47 years of experience) also validated the questionnaire (Table S1).</p> <p>The three free‐form text questions were designed to investigate students' perceptions about replacing cadaver dissection with VR anatomy, the influence of VIMS on learning anatomy through VR, and the impact of VR anatomy on peer discussion. The students were encouraged to write comments in response to each topic. Their feedback was analyzed line by line by MF Chang and ML Liao, using an inductive thematic analysis approach. Disagreements were discussed with CC Yeh to reach consensus.</p> <hd id="AN0177613393-12">VR anatomy instruction video via different screen sizes</hd> <p>Fourteen anatomy faculty and staff were invited to participate, to investigate whether VIMS could be relieved by adjusting the screen size. In the first session, participants watched the VR vascular system anatomy instruction video on a 90‐inch projection screen and recorded when VIMS began. Five participants who suffered from VIMS were invited to attend a second session, at least 1 day later. For the second session, the same VR anatomy instruction video was viewed on a 10.2‐inch iPad (9th generation), again recording VIMS onset. As described above, if a participant did not experience VIMS, the beginning time was again defined as 20 min for statistical analyses.</p> <p>For all analyses, <emph>p</emph> < 0.05 was considered statistically significant.</p> <hd id="AN0177613393-13">RESULTS</hd> <p></p> <hd id="AN0177613393-14">Likert scale survey</hd> <p>The survey participants were 217 male, 117 female, and 27 gender‐unspecified students. The response rates were 90.5% and 92.3% during the 2021–2022 and 2022–2023 academic years, respectively. The Cronbach's alpha value was 0.838 for the questions regarding the VR anatomy instruction video effectiveness, and 0.875 for the questions exploring the impact of VIMS on learning, indicating a high level of questionnaire reliability. The Likert scale survey validity was also examined by six experienced anatomical instructors and teaching assistances, reaching high consensus for each statement (see Table S1).</p> <p>The survey questions addressing the application and benefits of 3D Organon VR Anatomy for anatomy instruction (Figure 2) showed that students agreed with the video's benefits for learning gross anatomy and its suitability for large class sizes. However, they disagreed that practical dissection could be replaced by use of the selected software. Further comparison revealed a significant difference in responses regarding replacement with the use of the selected software and benefits of the VR anatomy instruction video (2.450 ± 1.252 vs. 3.680 ± 1.035; <emph>p</emph> < 0.001; Figure 2), indicating that students preferred the traditional dissection methods over the VR anatomy instruction video. Figure 2 depicts the detailed Likert scale survey results regarding the impact of VIMS on learning. Students disagreed that VIMS negatively impacted their VR anatomy instruction video‐based learning or reduced their willingness to use VR to learn anatomy. Therefore, despite VIMS, applying a camera script to record videos for VR anatomy instruction may be a potential strategy for medical student anatomy education.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/8Z8K/01jun24/ase2407-fig-0002.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="ase2407-fig-0002.jpg" title="2 Likert scale survey regarding the virtual reality (VR) anatomy instruction video. Student responses to the VR anatomy instruction video and visually induced motion sickness (VIMS) were analyzed using a 5‐point Likert scale survey. The horizontal bar graph shows means ± standard deviation (SD) of agreement, where 1 = Strongly disagree and 5 = Strongly agree. a: p < 0.05." /> </p> <p></p> <hd id="AN0177613393-16">Variance in responses to VR anatomy instruction video benefits</hd> <p>Understanding the proportion of students who agreed that VR anatomy instruction videos helped them learn may confirm whether this approach is beneficial for learning gross anatomy. Therefore, Likert scale scores of 4 or 5 were defined as agreement. The results indicated that 54.85% of students agreed that the VR anatomy instruction video using the selected software was beneficial for learning gross anatomy; 45.15% of students disagreed (Table 1). Only 31.31% of the students who agreed that VR anatomy instruction video was beneficial also reported that the use of VR anatomy could replace dissection. Among the students who disagreed with the learning benefit of the VR anatomy instruction video, 3.07% concurred that the use of VR anatomy could replace dissection (Table 1). Although 18.56% of students agreed that the use of the VR anatomy could replace dissection, most agreed that the VR anatomy instruction video was beneficial for learning anatomy. A similar pattern was observed in the responses to the question of whether the VR anatomy instruction video was appropriate for classes with more than 100 students. Although 38.78% of students agreed that the VR anatomy instruction video was suitable for large classes, most of these students agreed that the VR anatomy instruction video was beneficial for learning anatomy. To accurately evaluate the efficacy of the VR anatomy instruction video, it is necessary to avoid collecting data from only those students who viewed VR as a beneficial learning tool.</p> <p>1 TABLE Likert scale survey regarding the benefits of the VR anatomy instruction video.</p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="left" /><th align="left">The use of 3D Organon VR anatomy can replace traditional anatomy dissection (agree ≥ 4) [<italic>N</italic> (<italic>N</italic>/<italic>n</italic>)]</th><th align="left">The VR anatomy instruction video using 3D Organon VR anatomy is suitable for large classes (i.e., more than 100 students) (agree ≥ 4) [<italic>N</italic> (<italic>N</italic>/<italic>n</italic>)]</th></tr></thead><tbody valign="top"><tr><td align="left">The VR anatomy instruction video using 3D Organon VR anatomy is beneficial for learning gross anatomy (agree ≥ 4; n = 198)</td><td align="char" char="(">62 (31.31%)</td><td align="char" char="(">110 (55.56%)</td></tr><tr><td align="left">The VR anatomy instruction video using 3D Organon VR anatomy is beneficial for learning gross anatomy (agree < 4; n = 163)</td><td align="char" char="(">5 (3.07%)</td><td align="char" char="(">30 (18.40%)</td></tr><tr><td align="left">Total student number = 361</td><td align="char" char="(">67 (18.56%)</td><td align="char" char="(">140 (38.78%)</td></tr></tbody></table> </ephtml> </p> <hd id="AN0177613393-17">Proportion of students with VIMS when watching the VR anatomy instruction video</hd> <p>After they watched the VR anatomy instruction video for 20 min, 116 students (32.13%) reported having VIMS (Figure 3A). The respective VIMS incidence rates among male (Figure 3B), female (Figure 3C), and gender‐unspecified students were 29.82%, 41.03%, and 11.53%, respectively. The average VIMS onset time was 6.01 (± 4.12) minutes of beginning to watch the video (Figure 3A). There was no significant difference in VIMS rates between male (5.93 ± 4.19; Figure 3B) and female (6.05 ± 4.12; Figure 3C) students. Of note, VIMS was only reported within the first 15 viewing minutes; no students reported VIMS onset after this time. This indicates that VIMS is a marked issue for consideration when using VR anatomy instruction videos.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/8Z8K/01jun24/ase2407-fig-0003.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="ase2407-fig-0003.jpg" title="3 Incidence rate and time to onset of visually induced motion sickness (VIMS). Among all students (A), male students (B) and female students (C) during the 2021–2022 and 2022–2023 academic years, the percentages of students experiencing and not experiencing VIMS are shown in the pie chart, and the VIMS time to onset is shown in the bar chart. Significant differences in time to VIMS onset were observed between students with or without VIMS: all students (A), male students (B), and female students (C). For students who did not experience VIMS, the full video duration (i.e., 20 min) was recorded. a: p < 0.05." /> </p> <p></p> <hd id="AN0177613393-19">Influence of VIMS on learning from the VR anatomy instruction video</hd> <p>Because the Likert scale survey showed that some students disagreed that VIMS had a negative impact on their learning from the VR anatomy instruction video or reduced their willingness to use VR, further analyses were performed regarding the reported influence of VIMS between students with or without VIMS. Forty‐seven (40.52%) of the 116 students who experienced VIMS agreed that it had a negative impact on their learning experience with the VR anatomy instruction video; 52 students (44.8%) agreed that VIMS would decrease their willingness to use VR to learn anatomy in the future (Table 2). These results indicated that more than 40% of students suffering from VIMS were negatively affected by their VR anatomy instruction video‐based learning. Furthermore, among the 245 students without VIMS, 16 (6.53%) and 27 (11.02%) students, respectively, agreed that VIMS would have a negative impact on their learning and decrease their willingness to use VR to learn anatomy (Table 2). Thus, even students who had not personally experienced VIMS may be concerned about the potential negative effects of VR anatomy instruction videos.</p> <p>2 TABLE Likert scale survey regarding the influence of VIMS on learning from the VR anatomy instruction video.</p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="left" /><th align="left">The VIMS had a negative impact on your learning experience of VR anatomy instruction video (agree ≥ 4) [<italic>N</italic> (<italic>N</italic>/<italic>n</italic>%)]</th><th align="left">The VIMS reduced your willingness to use VR to learn anatomy in future (agree ≥ 4) [<italic>N</italic> (<italic>N</italic>/<italic>n</italic>%)]</th></tr></thead><tbody valign="top"><tr><td align="left">Students experiencing VIMS when watching VR anatomy instruction video; n = 116</td><td align="char" char="(">47 (40.52%)</td><td align="char" char="(">52 (44.83%)</td></tr><tr><td align="left">Students without VIMS when watching VR anatomy instruction video; n = 245</td><td align="char" char="(">16 (6.53%)</td><td align="char" char="(">27 (11.02%)</td></tr><tr><td align="left">Total student number = 361</td><td align="char" char="(">63 (17.45%)</td><td align="char" char="(">79 (21.88%)</td></tr></tbody></table> </ephtml> </p> <p>1 Abbreviations: <emph>N</emph>, number of student scoring ≥4 points; VIMS, visually induced motion sickness.</p> <hd id="AN0177613393-20">Free‐form text feedback regarding VR anatomy instruction video</hd> <p>In free‐form text responses, three topics were qualitatively analyzed (Table S2). Regarding the first topic (<emph>use of 3D Organon VR Anatomy can replace traditional anatomical dissection</emph>), many students expressed that the use of VR anatomy might be a supplementary tool to help develop their 3D concept of the human body structure, but cannot replace traditional cadaver dissection because VR anatomy software cannot provide the same level of accuracy in organ size and other perspectives, the realistic representation of connective tissues found in real human bodies, and the importance of physical dissection in medical humanities education. The Likert scale survey results revealed that students acknowledged the utility of the VR anatomy instruction video for learning anatomy but continued to believe that the use of VR anatomy software could not replace traditional cadaver dissection.</p> <p>Regarding the second topic (<emph>impact of VIMS on video‐based VR anatomy instruction</emph>), students indicated that VIMS, including dizziness and nausea, could hinder their ability to concentrate and learn effectively. This feedback indicated that VIMS would negatively affect the over 40% of students suffering from VIMS in terms of their video‐based VR anatomy instruction (Table 2). They also suggested that the VR anatomy instruction video should be divided into multiple shorter segments and that the operator's movement should be as stable as possible. Students further mentioned that using a tablet was less likely to induce VIMS, indicating that screen size may be a factor that can reduce VIMS occurrence.</p> <p>Regarding the third topic (<emph>impact of VR anatomy instruction video on peer discussions of anatomical structures</emph>), most students provided positive feedback. They indicated that watching the same VR anatomy instruction video on a large screen was a feasible, time‐saving instruction method when a limited number of VR hardware devices are available. This fostered a foundation for shared learning and facilitated peer discussions. Based on this feedback, VR anatomy instruction videos may also benefit students through peer discussion.</p> <hd id="AN0177613393-21">Feasible VIMS solution</hd> <p>The incidence of VIMS among anatomy faculty and staff was 35.71%: a rate similar to that among students (Figure 3A). Among the five participants who experienced VIMS and participated in the second section, VIMS started after an average of 6.40 (±3.36) and 14.20 (±6.72) viewing minutes when using a 90‐inch screen or a 10.2‐inch screen, respectively (Figure 4). This difference between the two screen sizes was statistically significant (<emph>p</emph> = 0.008). In addition, VIMS onset was delayed for all participants when using a 10.2‐inch screen. Using a 10.2‐inch tablet may thus mitigate the VIMS caused by watching VR anatomy instruction videos on a large screen, providing a potential solution for future applications.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/8Z8K/01jun24/ase2407-fig-0004.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="ase2407-fig-0004.jpg" title="4 Duration to visually induced motion sickness (VIMS) onset with different screen sizes. Five anatomy faculty and staff who experienced VIMS when watching the VR anatomy instruction video on a 90‐inch projection screen were further invited to watch the video again on a 10.2‐inch tablet screen. Their times to onset of VIMS with the 90‐inch and 10.2‐inch screens were recorded on the scatter plot. There was a significant difference in the time to VIMS onset between the screen sizes. The same participant is labeled with a single color. For participants who did not experience VIMS, the time was recorded as the full video duration (i.e., 20 min). a: p < 0.05." /> </p> <p></p> <hd id="AN0177613393-23">DISCUSSION</hd> <p>Herein, a VR‐based anatomy instruction video strategy was established to teach large classes of medical students, with limited equipment. Several important findings were revealed. First, the application of a VR anatomy instruction video was feasible in classes of more than 100 students. Second, the incidence of VIMS was approximately 30% and was higher among female students than male students. Third, VIMS may negatively affect learning among the students who experience it, reducing their desire to learn anatomy through VR. Fourth, watching VR anatomy instruction videos on a tablet may significantly delay the onset of VIMS. These results illustrate the potential challenges of using VR anatomy instruction videos to teach medical school anatomy and suggest a feasible solution. With limited educational equipment, instructors can still provide students with effective benefits of VR via VR‐based anatomy instruction videos.</p> <hd id="AN0177613393-24">Feasible VR anatomy instruction video strategy for large class sizes with limited equipment</hd> <p>According to the Likert scale survey and free‐form text responses, students agreed that the VR anatomy instruction video was beneficial for learning anatomy and could help them understand complex 3D anatomical structures and systemic anatomy concepts. Due to VR's immersive perspective and ability to disassemble objects, the use of VR in anatomy education may help students understand complex 3D structures, as shown by previous research.[<reflink idref="bib12" id="ref33">12</reflink>] However, students herein disagreed that the use of VR anatomy software could replace the anatomy dissection laboratory, despite recognizing the benefits of the VR anatomy instruction video. Several drawbacks were mentioned in the free‐form text responses, including the lack of a sense of touch, the absence of vivid color markings, the absence of connective tissues, the lack of actual human body size, and overly idealized VR structures. In line with previous research, these factors may contribute to the conclusion that VR anatomy software cannot fully replace traditional anatomy dissection experiences.[[<reflink idref="bib24" id="ref34">24</reflink>]] Consequently, based on the findings herein, a combination of physical and VR teaching methods may be feasible and appropriate for anatomy education.</p> <p>Many universities worldwide teach gross anatomy to classes of more than 100 students.[[<reflink idref="bib20" id="ref35">20</reflink>], [<reflink idref="bib26" id="ref36">26</reflink>], [<reflink idref="bib28" id="ref37">28</reflink>]] This poses challenges for VR education, as it is difficult for institutions to prepare adequate hardware and software resources. Consequently, students must often queue and make appointments to practice with VR equipment. Moreover, individual VR use by students who are not proficient at operating the technology also affects their learning.[<reflink idref="bib29" id="ref38">29</reflink>] Previous research has indicated that students' unsupervised errors and wrong diagnoses during individual VR use may lead to lower‐than‐expected learning outcomes.[<reflink idref="bib24" id="ref39">24</reflink>] The results herein show that students agreed that the VR anatomy instruction video strategy could be used in classes of more than 100 students. They also reported that each student simultaneously experienced a realistic hands‐on learning experience, enhancing the effectiveness of peer discussions. This eliminated wasted time waiting to use limited physical resources and learning VR operations, thus improving the VR learning experience. Previous research has also demonstrated that peer‐to‐peer discussions contribute significantly to understanding gross anatomy.[[<reflink idref="bib20" id="ref40">20</reflink>], [<reflink idref="bib30" id="ref41">30</reflink>]] Therefore, the VR anatomy instruction video strategy described herein may benefit students in large classes with limited VR devices, and may encourage peer discussions to improve anatomy instruction learning outcomes.</p> <hd id="AN0177613393-25">VIMS incidence</hd> <p>Although approximately one‐third of students experienced VIMS during the 20‐min VR anatomy instruction video, which was recorded from a first‐person perspective, this rate was lower compared with a previous study in which about 73% of participants experienced VIMS when watching a video of a bicycle ride recorded from a first‐person perspective.[<reflink idref="bib31" id="ref42">31</reflink>] Herein, the VR anatomy instruction video was recorded using a scripted camera that reduced the amount and speed of the operator's head movements during the recording. Based on their free‐form text feedback, students reported that reducing excessive operator head movements could improve the incidence of VIMS. Since a predesigned camera script has the advantages of both reducing unnecessary head movements and shortening the duration of VR‐based teaching, it may reduce the incidence of VIMS. Hence, preparing a camera script before recording VR instruction videos is recommended.</p> <p>That the occurrence of VIMS was higher among female students herein aligns with previous research on VR gaming,[<reflink idref="bib32" id="ref43">32</reflink>] suggesting that women have a higher likelihood of experiencing discomfort from immersive learning experiences. Although a previous study found that repeated VR operation could alleviate VIMS symptoms,[<reflink idref="bib33" id="ref44">33</reflink>] more than 40% of students with VIMS herein reported that the condition would hinder their ability to learn from, and decrease their willingness to use, VR. Therefore, asking students with VIMS to repeatedly experience VR anatomy instruction videos is impractical. When planning to use VR‐based anatomy instruction videos for anatomy training, educators must consider how to prevent student VIMS during their initial exposure to the VR environment.</p> <hd id="AN0177613393-26">Possible solutions for relieving VIMS</hd> <p>This study found that viewing the VR anatomy instruction video on a small, tablet‐sized screen significantly delayed the onset of VIMS compared with viewing it on a large screen. This may be related to the immersive experience with larger screens. Several studies have demonstrated a close relation between screen size and immersive experience.[[<reflink idref="bib18" id="ref45">18</reflink>]] In their free‐form text feedback, the students also mentioned that using an anatomy app on a tablet might not cause the same degree of VIMS. This may be because an anatomy app showing 3D structures as 2D would reduce streaming lag time. Therefore, using a tablet to watch VR anatomy instruction videos may be a feasible way to alleviate VIMS.</p> <p>Additionally, the average onset of VIMS symptoms was after about six viewing minutes (Figure 3), and the participating students suggested that the VR anatomy instruction video be divided into several segments of shorter durations to reduce VIMS occurrence. Instructors may thus consider uploading videos to an asynchronous online teaching platform within the institutional network, to allow students to play them independently and further mitigate the effects of VIMS on learning.</p> <hd id="AN0177613393-27">Study limitations</hd> <p>The study was not without limitations. First, this pilot study only explored the use of a VR anatomy instruction video for teaching the vascular system; no other systems or regions were investigated. Second, the research design did not include the use of a VR anatomy instruction video on an asynchronous online teaching platform. Doing so exceeded the initial review by the ethics committee, so data collection and analysis for this purpose were impossible. Third, the effectiveness of students independently operating VR devices was not evaluated due to the large number of students and limited VR equipment. Fourth, the sample exclusively consisted of NTU students, possibly limiting generalizability to other universities or countries. These limitations indicate that additional research and investigation are necessary to gain a more comprehensive understanding of the impact of VR on anatomy instruction.</p> <hd id="AN0177613393-28">Future work</hd> <p>The findings herein indicate that developing VR anatomy instruction videos to teach other systemic anatomy units may be valuable. It is also crucial to evaluate the efficacy of uploading VR anatomy instruction videos to an asynchronous online teaching platform, to better describe their potential learning benefits. The effects of adjusting screen size on VIMS could also be further confirmed in the classroom context. Finally, it will be essential to investigate the possibility of integrating VR anatomy instruction videos and other multimedia teaching tools.</p> <hd id="AN0177613393-29">CONCLUSIONS</hd> <p>The results herein demonstrate that VR anatomy instruction videos may help student learning outcomes in large gross anatomy classes, and that a hybrid approach—combining physical and digital teaching methods—may be recommended. Despite the usefulness of this VR strategy, instructors must take VIMS into consideration, as it affects student learning outcomes and willingness to learn anatomy via VR. Furthermore, watching VR anatomy instruction videos on a smaller, tablet‐sized screen may significantly relieve VIMS. These findings provide valuable information for educators who plan to begin using VR‐based anatomy instruction videos.</p> <hd id="AN0177613393-30">ACKNOWLEDGMENTS</hd> <p>The authors thank the students who participated in this study. The authors also appreciate the assistance provided by Yu‐Chin Chen, Yu‐Jen Ko, Pei‐Jung Cheng, Yaw‐Hua Yang, Yu‐Yen Hsiao, Ting‐Yu Chang, Horng‐Tzer Shy, and Shu‐Mei Lai from the Department of Anatomy and Cell Biology, College of Medicine, National Taiwan University, Taipei, Taiwan.</p> <hd id="AN0177613393-31">FUNDING INFORMATION</hd> <p>MFC received funding from National Science and Technology Council (grant number: NSTC 112‐2410‐H‐002‐184); the Ministry of Science and Technology (grant number: MOST 111‐2410‐H‐002‐220); and the Ministry of Education (grant number: PMN1100547). MLL received funding from the Ministry of Science and Technology (grant number: MOST 110‐2511‐H‐002‐020‐MY3).</p> <hd id="AN0177613393-32">CONFLICT OF INTEREST STATEMENT</hd> <p>The authors declare that they have no competing financial interests.</p> <hd id="AN0177613393-33">DATA AVAILABILITY STATEMENT</hd> <p>The data supporting the findings herein are available from the corresponding author upon reasonable request.</p> <hd id="AN0177613393-34">ETHICAL APPROVAL AND CONSENT TO PARTICIPATE</hd> <p>Informed consent was obtained from all study participants. Ethical approval (202012HS015 and 202205HS048) was obtained from the Research Ethics Committee of the National Taiwan University. To protect participant anonymity, no identifying information was collected. All methods were carried out in accordance with relevant guidelines and regulations.</p> <p>GRAPH: Supplementary Table 1.</p> <p>GRAPH: Supplementary Table 2.</p> <ref id="AN0177613393-35"> <title> REFERENCES </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Gupta H, Robinson P. Normal shoulder ultrasound: anatomy and technique. Semin Musculoskelet Radiol. 2015 ; 19 : 203 – 211.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref2" type="bt">2</bibl> <bibtext> Hardy TA. Spinal cord anatomy and localization. Continuum (Minneap Minn). 2021 ; 27 : 12 – 29.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref3" type="bt">3</bibl> <bibtext> Meyer JJ, Obmann MM, Giessler M, Schuldis D, Bruckner AK, Strohm PC, et al. Interprofessional approach for teaching functional knee joint anatomy. 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BMC Med Educ. 2021 ; 21 : 498.</bibtext> </blist> </ref> <aug> <p>By Meng‐Lin Liao; Chi‐Chuan Yeh; June‐Horng Lue and Ming‐Fong Chang</p> <p>Reported by Author; Author; Author; Author</p> <p></p> <p>Meng‐Lin Liao, Ph.D. is an Assistant Professor of the Department of Anatomy and Cell Biology in the College of Medicine at National Taiwan University, Taipei, Taiwan. She teaches gross anatomy, histology, embryology, and neuroanatomy to medical students, and her research interest includes developmental biology and medical education.</p> <p>Chi‐Chuan Yeh, M.D., M.Ed., Ph.D. is a Clinical Assistant Professor of the Department of Surgery at the National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan. Her research interests include model development for training minimally invasive surgery and open surgery, as well as surgical and medical education.</p> <p>June‐Horng Lue, Ph.D. is a Professor of the Department of Anatomy and Cell Biology in the College of Medicine at National Taiwan University, Taipei, Taiwan. He teaches gross anatomy, histology, embryology, and neuroanatomy to medical students.</p> <p>Ming‐Fong Chang, Ph.D. is an Assistant Professor of the Department of Anatomy and Cell Biology in the College of Medicine at National Taiwan University, Taipei, Taiwan. 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  Group: Ti
  Data: Implementing Virtual Reality Technology to Teach Medical College Systemic Anatomy: A Pilot Study
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  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Meng-Lin+Liao%22">Meng-Lin Liao</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-2293-319X">0000-0002-2293-319X</externalLink>)<br /><searchLink fieldCode="AR" term="%22Chi-Chuan+Yeh%22">Chi-Chuan Yeh</searchLink><br /><searchLink fieldCode="AR" term="%22June-Horng+Lue%22">June-Horng Lue</searchLink><br /><searchLink fieldCode="AR" term="%22Ming-Fong+Chang%22">Ming-Fong Chang</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-4522-7669">0000-0002-4522-7669</externalLink>)
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  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Anatomical+Sciences+Education%22"><i>Anatomical Sciences Education</i></searchLink>. 2024 17(4):796-805.
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  Data: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 10
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2024
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
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  Label: Education Level
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  Data: <searchLink fieldCode="EL" term="%22Higher+Education%22">Higher Education</searchLink><br /><searchLink fieldCode="EL" term="%22Postsecondary+Education%22">Postsecondary Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Medical+Education%22">Medical Education</searchLink><br /><searchLink fieldCode="DE" term="%22Teaching+Methods%22">Teaching Methods</searchLink><br /><searchLink fieldCode="DE" term="%22Anatomy%22">Anatomy</searchLink><br /><searchLink fieldCode="DE" term="%22Computer+Simulation%22">Computer Simulation</searchLink><br /><searchLink fieldCode="DE" term="%22Video+Technology%22">Video Technology</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+School+Faculty%22">Medical School Faculty</searchLink><br /><searchLink fieldCode="DE" term="%22Teacher+Attitudes%22">Teacher Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Likert+Scales%22">Likert Scales</searchLink><br /><searchLink fieldCode="DE" term="%22Large+Group+Instruction%22">Large Group Instruction</searchLink><br /><searchLink fieldCode="DE" term="%22Laboratory+Procedures%22">Laboratory Procedures</searchLink><br /><searchLink fieldCode="DE" term="%22Motion%22">Motion</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Visual+Perception%22">Visual Perception</searchLink><br /><searchLink fieldCode="DE" term="%22Learning+Processes%22">Learning Processes</searchLink><br /><searchLink fieldCode="DE" term="%22Educational+Benefits%22">Educational Benefits</searchLink><br /><searchLink fieldCode="DE" term="%22Barriers%22">Barriers</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1002/ase.2407
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1935-9772<br />1935-9780
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: It can be difficult for some students to learn three-dimensional anatomical structure concepts. While virtual reality (VR) systems have been reported as helpful for learning, there has been scarce research on either VR teaching strategies or the influence of visually induced motion sickness (VIMS) in the context of large anatomy classes (i.e., over 100 students). The study thus aimed to (1) establish a VR anatomy instruction video for a large class; (2) determine how many students experience VIMS when watching a VR anatomy instruction video; (3) evaluate the influence of VIMS on VR anatomy video-based learning; and (4) examine whether a small screen size alleviates VIMS. Laboratory course students viewing a VR anatomy instruction video about the vascular system were invited to participate in the questionnaire survey. Anatomy faculty and staff participated in an experimental trial to determine whether small screen size could alleviate VIMS. The Likert scale survey revealed that students reported the VR strategy as advantageous and appropriate for large classes, but that it cannot replace practical dissection. Of the total participants, 32% reported experiencing VIMS, and 40% of those experiencing VIMS agreed that this could negatively impact their learning through a VR anatomy instruction video. Adjusting the screen size from large to small significantly delayed the onset of VIMS. In conclusion, the VR anatomy instruction video strategy is feasible and helpful for large classes, but educators should consider VIMS when planning their use of this teaching approach.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2024
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1426255
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1426255
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  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1002/ase.2407
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 10
        StartPage: 796
    Subjects:
      – SubjectFull: Medical Education
        Type: general
      – SubjectFull: Teaching Methods
        Type: general
      – SubjectFull: Anatomy
        Type: general
      – SubjectFull: Computer Simulation
        Type: general
      – SubjectFull: Video Technology
        Type: general
      – SubjectFull: Medical School Faculty
        Type: general
      – SubjectFull: Teacher Attitudes
        Type: general
      – SubjectFull: Likert Scales
        Type: general
      – SubjectFull: Large Group Instruction
        Type: general
      – SubjectFull: Laboratory Procedures
        Type: general
      – SubjectFull: Motion
        Type: general
      – SubjectFull: Symptoms (Individual Disorders)
        Type: general
      – SubjectFull: Visual Perception
        Type: general
      – SubjectFull: Learning Processes
        Type: general
      – SubjectFull: Educational Benefits
        Type: general
      – SubjectFull: Barriers
        Type: general
    Titles:
      – TitleFull: Implementing Virtual Reality Technology to Teach Medical College Systemic Anatomy: A Pilot Study
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Meng-Lin Liao
      – PersonEntity:
          Name:
            NameFull: Chi-Chuan Yeh
      – PersonEntity:
          Name:
            NameFull: June-Horng Lue
      – PersonEntity:
          Name:
            NameFull: Ming-Fong Chang
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 06
              Type: published
              Y: 2024
          Identifiers:
            – Type: issn-print
              Value: 1935-9772
            – Type: issn-electronic
              Value: 1935-9780
          Numbering:
            – Type: volume
              Value: 17
            – Type: issue
              Value: 4
          Titles:
            – TitleFull: Anatomical Sciences Education
              Type: main
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