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Virtual Escape Rooms in Anatomy Education: Case Studies from Two Institutions

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Title: Virtual Escape Rooms in Anatomy Education: Case Studies from Two Institutions
Language: English
Authors: Aaron W. Beger (ORCID 0000-0001-8545-7656), Sarah Hannan, Riya Patel, Eva M. Sweeney (ORCID 0000-0002-6412-4518)
Source: Advances in Physiology Education. 2025 49(3):621-632.
Availability: American Physiological Society. 9650 Rockville Pike, Bethesda, MD 20814-3991. Tel: 301-634-7164; Fax: 301-634-7241; e-mail: webmaster@the-aps.org; Web site: https://www.physiology.org/journal/advances
Peer Reviewed: Y
Page Count: 12
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Education Level: Higher Education
Postsecondary Education
Descriptors: Anatomy, Computer Simulation, Gamification, Foreign Countries, Learning Activities, Medical Education, Medical Students, Instructional Effectiveness, In Person Learning, Distance Education, Group Activities, Individual Activities, Instructional Design, Student Attitudes
Geographic Terms: United Kingdom (Belfast), Virginia
DOI: 10.1152/advan.00248.2024
ISSN: 1043-4046
1522-1229
Abstract: Virtual escape rooms (ERs) require learners to solve puzzles and answer riddles while trying to "escape" a digital room. Although the educational merit of such gamified learning activities continues to be realized, guides on the development of ERs are lacking, as well as student perceptions on how, if, and where they should be integrated into medical curricula. Therefore, the aim of this study was to describe the experiences of building anatomy-themed virtual ERs of differing formats at two separate institutions, Queen's University Belfast (QUB) and Edward Via College of Osteopathic Medicine (VCOM), focusing on abdominal and upper limb anatomy, respectively. Google Workspace applications served as the primary platform. Three-dimensional (3-D) models were built with photogrammetry techniques or Virtual Human Dissector software (www.toltech.net) and integrated into the ER. Of 69 students and staff invited at QUB, 9 (13%) participated in the in-person virtual ER in teams of two or three (7 medical students, 2 anatomy instructors). Of 27 VCOM medical students invited, 8 (30%) agreed to participate and individually completed VCOM's virtual ER remotely. Anonymous surveys and a focus group revealed the ERs to be enjoyable and engaging and that they encouraged participants to think about material in a new way while helping them to identify knowledge gaps. Strengths and weaknesses of different designs (linear vs. nonlinear), delivery methods (in person vs. remote), and grouping of participants (team based vs. individual) were realized and discussed, revealing opportunities for optimizing the experience. Future studies would benefit from increasing sample sizes to assess the learning gain of such activities.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1475523
Database: ERIC
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  Value: <anid>AN0187950983;apu01sep.25;2025Sep16.05:05;v2.2.500</anid> <title id="AN0187950983-1">Virtual escape rooms in anatomy education: case studies from two institutions </title> <p>Virtual escape rooms (ERs) require learners to solve puzzles and answer riddles while trying to "escape" a digital room. Although the educational merit of such gamified learning activities continues to be realized, guides on the development of ERs are lacking, as well as student perceptions on how, if, and where they should be integrated into medical curricula. Therefore, the aim of this study was to describe the experiences of building anatomy-themed virtual ERs of differing formats at two separate institutions, Queen's University Belfast (QUB) and Edward Via College of Osteopathic Medicine (VCOM), focusing on abdominal and upper limb anatomy, respectively. Google Workspace applications served as the primary platform. Three-dimensional (3-D) models were built with photogrammetry techniques or Virtual Human Dissector software (<ulink href="http://www.toltech.net">www.toltech.net</ulink>) and integrated into the ER. Of 69 students and staff invited at QUB, 9 (13%) participated in the in-person virtual ER in teams of two or three (7 medical students, 2 anatomy instructors). Of 27 VCOM medical students invited, 8 (30%) agreed to participate and individually completed VCOM's virtual ER remotely. Anonymous surveys and a focus group revealed the ERs to be enjoyable and engaging and that they encouraged participants to think about material in a new way while helping them to identify knowledge gaps. Strengths and weaknesses of different designs (linear vs. nonlinear), delivery methods (in person vs. remote), and grouping of participants (team based vs. individual) were realized and discussed, revealing opportunities for optimizing the experience. Future studies would benefit from increasing sample sizes to assess the learning gain of such activities. NEW & NOTEWORTHY: Virtual escape rooms (ERs) offer an innovative way to expose students to educational material in a creative, engaging way, particularly when they incorporate three-dimensional (3-D) models. Activities can be readily built with Google Workspace. Offering this activity to teams in a physical setting may promote collaboration and maximize the educational utility, whereas having learners complete it remotely on an individual basis may be more convenient, allowing them to fit it in their study schedule at their own convenience.</p> <p>Keywords: anatomy education; artificial intelligence; escape room; gamified learning</p> <hd id="AN0187950983-2">INTRODUCTION</hd> <p>Gamified learning is a growing trend in medical education in which gaming elements are integrated into a learning environment ([<reflink idref="bib1" id="ref1">1</reflink>]). One popular format is the escape room (ER), which requires participants to answer questions, solve puzzles, and decipher riddles before "escaping" a room within a given time limit. In doing so, they are able to build skills related to leadership, teamwork, and critical thinking while engaging with educational material in a different way ([<reflink idref="bib2" id="ref2">2</reflink>]).</p> <p>In-person ER activities have demonstrated an increase in workplace social capital for first-year internal medicine residents, indicated by increased cooperation in developing and applying new ideas and feelings of understanding and acceptance in the weeks following the escape room experience ([<reflink idref="bib2" id="ref3">2</reflink>]). Furthermore, preclinical medical students expressed an increase in confidence in performing basic elements of a physical exam ([<reflink idref="bib3" id="ref4">3</reflink>]) as well as a significant increase in pretest/posttest scores ([<reflink idref="bib4" id="ref5">4</reflink>]) following in-person ER activities. ERs have been described as accurate simulations of work in the emergency department by emergency medicine residents, particularly the feelings of comanaging stressful situations, settling differences of opinion, and the need for providing regular status updates ([<reflink idref="bib5" id="ref6">5</reflink>]). Similarly, internal medicine residents found that an in-person ER promoted interpersonal communication and medical knowledge ([<reflink idref="bib6" id="ref7">6</reflink>]). An in-person ER that was performed by teams of seven or eight intern residents from a mix of specialties was also found to help improve confidence in ability to recognize patient safety hazards ([<reflink idref="bib7" id="ref8">7</reflink>]).</p> <p>The development of virtual ERs reflects the expanse of remote learning that was accelerated during the COVID-19 pandemic, though their use in academia is not as well described as in-person activities. Researchers have found virtual ERs to be received positively by graduate biochemistry students ([<reflink idref="bib8" id="ref9">8</reflink>]), to improve learning performance, problem-solving skills, and critical thinking skills among maternity nursing students ([<reflink idref="bib9" id="ref10">9</reflink>]), and to demonstrate a challenging way to consolidate and apply knowledge among cardiovascular physiology graduate students ([<reflink idref="bib10" id="ref11">10</reflink>]). Second-year medical students responded positively after exposure to a virtual ER, indicating their enjoyment with being exposed to complex, team-based, and emotion-provoking challenges that were incorporated into the activity ([<reflink idref="bib11" id="ref12">11</reflink>]). Virtual ERs are typically more cost-effective than their in-person counterparts. They offer scalability and usually require minimal additional intellectual effort after their initial creation. Unlike other virtual gamified learning methods, they do not demand specialized coding skills or extensive technical resources. Virtual platforms also have the added benefit of being able to incorporate three-dimensional (3-D) models, a particularly helpful strategy for visually dependent disciplines like anatomy, which have previously demonstrated educational benefit from such resources ([<reflink idref="bib12" id="ref13">12</reflink>], [<reflink idref="bib13" id="ref14">13</reflink>]).</p> <p>While the benefits of ERs as an educational tool continue to be realized, there is a need for additional description of how best to build a virtual ER, suggestions for their incorporation into the curriculum, as well as a discussion around their strengths and weaknesses. In this study, we aim to present the development, delivery, and evaluation of two virtual ERs focused on anatomy education at two institutions: Queen's University Belfast (QUB) and Edward Via College of Osteopathic Medicine (VCOM). In doing so, we seek to compare these approaches, which differ in regard to design (nonlinear vs. linear), delivery (in person vs. remote), and grouping of participants (team based vs. individual), and discuss the strengths and weaknesses of each.</p> <hd id="AN0187950983-3">MATERIALS AND METHODS</hd> <p>The frameworks for each ER are summarized in Table 1, highlighting the similarities and differences in their development, delivery, and evaluation. Similarities included the use of Google Workspace (https://workspace.google.com/) as the primary platform because of its accessibility, ease of use, and prior demonstration of promoting anatomy learning ([<reflink idref="bib14" id="ref15">14</reflink>], [<reflink idref="bib15" id="ref16">15</reflink>]). Each ER incorporated 3-D models either created with photogrammetry or viewed via Virtual Human Dissector (VHD) software while also integrating histology, pathology, radiology, and clinical elements. Participants for both studies were recruited via convenience sampling, and feedback surveys and a focus group helped elucidate the path forward for how best to include virtual ERs in anatomy curricula. Differences between the activities primarily related to their design (linear vs. nonlinear), delivery (in person vs. remote), and grouping of participants (team based vs. individual).</p> <p>Table 1. Framework comparison of virtual escape room activities at Queen's University Belfast and Edward Via College of Osteopathic Medicine</p> <p> <ephtml> <table><col align="left" span="1" /><col align="left" span="1" /><col align="left" span="1" /><thead><tr><th align="center" rowspan="1" colspan="1" /><th align="center" rowspan="1" colspan="1">QUB</th><th align="center" rowspan="1" colspan="1">VCOM</th></tr></thead><tbody><tr><td rowspan="1" colspan="1">Subjects</td><td rowspan="1" colspan="1">7 medical students and 2 professional staff members</td><td rowspan="1" colspan="1">8 medical students</td></tr><tr><td rowspan="1" colspan="1">Grouping of subjects</td><td rowspan="1" colspan="1">Self-assigned teams of 2 or 3</td><td rowspan="1" colspan="1">Individual</td></tr><tr><td rowspan="1" colspan="1">Location of study</td><td rowspan="1" colspan="1">In anatomy lab</td><td rowspan="1" colspan="1">Remote</td></tr><tr><td rowspan="1" colspan="1">Delivery of ER</td><td rowspan="1" colspan="1">Projected on touchscreens</td><td rowspan="1" colspan="1">Shared link to ER with participants</td></tr><tr><td rowspan="1" colspan="1">Design of ER</td><td rowspan="1" colspan="1">Linearly progress through 3 patient cases</td><td rowspan="1" colspan="1">Nonlinear with 10 hidden questions</td></tr><tr><td rowspan="1" colspan="1">Theme of ER</td><td rowspan="1" colspan="1">Abdominal anatomy</td><td rowspan="1" colspan="1">Upper limb anatomy</td></tr><tr><td rowspan="1" colspan="1">ER time limit</td><td rowspan="1" colspan="1">35 min</td><td rowspan="1" colspan="1">50 min</td></tr></tbody></table> </ephtml> </p> <p>1 ER, escape room; QUB, Queen University Belfast; VCOM, Edward Via College of Osteopathic Medicine.</p> <hd1 id="AN0187950983-4">Ethical Approval</hd1> <p>Studies were separately reviewed and approved by institutional ethical committees at Queens University Belfast (QUB) (reference #MHLS 23_107) and Edward Via College of Osteopathic Medicine (VCOM) (reference #2024-192).</p> <hd1 id="AN0187950983-5"> <emph>Case Study 1</emph>. Abdominal Anatomy at QUB</hd1> <hd1 id="AN0187950983-6">Escape room design.</hd1> <p>The virtual ER scenario featured a junior doctor who must answer questions related to three patients to successfully "escape" a gastroenterology clinic. The game started with a Google Slide showing the consultation room with instructions on how to complete the game. Participants had to click on each patient, which would direct them to a corresponding Google Form with the case and questions. Once they completed each case, they had to decipher a code word. The image of the door on the original Google Slide was linked to a Google Form that required them to input the three codes to complete the game. A video of a 35-min timer (<ulink href="http://www.youtube.com">www.youtube.com</ulink>) was embedded in the slide and started before proceeding with the first patient.</p> <p>Questions aligned with the medical school curriculum. A response validation feature was used in the Google Form, requiring a correct response before participants could progress to the next question. A range of text- and image-based question types were employed (Fig. 1). Puzzel.org was used to create a jigsaw puzzle of a radiological image (Fig. 1<emph>A</emph>), requiring students to click on the website link, solve the puzzle, and identify the indicated structure. Students were also tasked with identifying highlighted structures on zoomed-in regions of 3-D models (Fig. 1<emph>B</emph>) and identifying pathology in images of potted specimens created with 360° photography. Riddles (Fig. 1<emph>C</emph>) and anagrams were generated with the help of the artificial intelligence platform ChatGPT (www.openai.com; version GPT-4o mini). Medical imaging questions (Fig. 1<emph>D</emph>), multiple-choice questions, and tasks based on ordering of anatomical structures (Fig. 1<emph>E</emph>) tested clinical concepts and fundamental anatomical knowledge.</p> <p>PHOTO (COLOR): Figure 1. Question varieties used in Queen University Belfast's abdominal anatomy escape room. A jigsaw puzzle of a radiological image was created with puzzel.org (A). Zoomed-in screenshot of a highlighted structure on posterior abdominal wall (PAW) 3-dimensional (3-D) model (B). Riddles were created with ChatGPT (C). Medical images were used to test clinical concepts (D). Ordering tasks were used to test anatomical knowledge (E). The answers are as follows: main pancreatic duct (A), hepatic portal vein (B), phlebotomy (C), kidney stone in the ureter (D), CIEHBDAFG (E).</p> <p>Photogrammetry was used to generate 3-D models of the posterior abdominal wall and liver with Agisoft Metashape Photoscan Professional (version 1.4.4). This followed a method similar to that described by Struck et al. ([<reflink idref="bib16" id="ref17">16</reflink>]), and further information is available in the Supplemental Material (Supplemental Fig. S1). The 3-D models were exported as 3-D PDF files. To incorporate the 3-D models into the ER questions, a screenshot was taken and cropped and a specific structure was highlighted. This highly cropped image was inserted into the escape room Google Form (Fig. 1<emph>B</emph>). Participants would then have to try and find the corresponding structure in the 3-D PDF and answer the question related to this structure. Screenshots were such that participants were not able to identify the structure without utilizing the 3-D model, thus ensuring interaction with the 3-D model.</p> <p>A different approach (360° photography) was used for the potted pathology specimens because of the nature of the fluid-filled Perspex containers, which would complicate photogrammetric reconstruction because of air bubbles, reflections, and refraction. Pots were placed on a turntable and photographed at 17° intervals with a Nikon COOLPIX P520 camera. A black felt backdrop and a movable diffuse light source (X-ray lightbox) were used to minimize reflection (Supplemental Fig. S2A). The images were inserted as separate slides into a Microsoft PowerPoint presentation. Image backgrounds were removed with the "Remove Background" function so that only the Perspex container and specimen remained (Supplemental Fig. S2B). Slideshow settings were adjusted to "Loop continuously until Esc" so the specimen appeared to rotate as the participants advanced through the PowerPoint presentation. Labels and arrows were added to some slides to provide information to the participants and pose identification questions. A total of four potted specimens were imaged and included in the ER: cholelithiasis depicted in a specimen consisting of a gallbladder, pancreas, and duodenum; a liver showing discoloration due to hemochromatosis; and two kidney sections, one with numerous small renal calculi and the other with a large staghorn calculus. To abide by the laws of the Human Tissue Authority Act 2004, all images of human specimens were password protected and hosted/viewed within the university.</p> <hd1 id="AN0187950983-7">Protocol.</hd1> <p>Queen's University Belfast (QUB) medical students who had completed at least 3 years of their medical degree (<emph>n</emph> = 57) as well as professional staff members (<emph>n</emph> = 12) were invited to participate via email. Of these, seven students (12%) and two staff members (17%) agreed to participate, respectively. Participants gave written informed consent before the session and placed themselves into groups of either two or three before the activity. The two staff members formed a single group.</p> <p>The activity took place in the anatomy laboratory and commenced with the escape room opened on large 65-in. touch screens. PowerPoint presentations with images of potted specimens and 3-D models of cadaveric specimens were left opened on the desktop to reduce loading time. Each group was asked to enter a nonidentifiable group name into the first Google Form and start the embedded 35-min timer before navigating to the first patient. This duration was chosen as it meant that the activity could be easily integrated into practical classes or lecture slots in our medical timetable. Groups were instructed to research topics via the web browser on the touch screen if they were stuck on a question for a long period.</p> <p>Immediately after the activity, participants were invited to provide feedback via an anonymous feedback survey consisting of 25 five-point Likert-scale items and open-ended questions and were also invited to participate in a focus group to discuss their experience.</p> <hd1 id="AN0187950983-8">Evaluation.</hd1> <p>After finishing the ER, all participants completed an anonymous evaluation survey consisting of 25 five-point Likert-scale questions and 2 open-ended questions covering strengths and weaknesses of the activity. To gauge the consistency of each participant's response to questions in the qualitative survey, questions were grouped into themes and Cronbach's alpha was calculated to measure internal consistency of responses. Question group categories included overall satisfaction (<emph>questions 1</emph>, <emph>4–9</emph>, <emph>20</emph>, <emph>25</emph>), 3-D models (<emph>questions 10–15</emph>), potted pathology specimens (<emph>questions 16–19</emph>), and difficulty and time pressure (<emph>questions 2</emph>, <emph>3</emph>, <emph>21–24</emph>).</p> <p>Participants were also invited to discuss their experiences as a focus group. Participants were informed that the session was being recorded and that any information used in the results would be nonidentifiable. The focus group was led by one researcher (S.H.), whose role was to facilitate the discussion with focused but open questions. Transcripts were interpreted and key themes identified with responses from the survey. Ideas or statements repeated within the focus group were recorded along with any extraordinary comments.</p> <hd1 id="AN0187950983-9"> <emph>Case Study 2</emph>. Upper Limb Anatomy at VCOM</hd1> <hd1 id="AN0187950983-10">Escape room design.</hd1> <p>The nonlinear virtual ER was developed as an educational tool to reinforce knowledge of upper limb anatomy and was designed to be used by first-year osteopathic medical students. To create an immersive environment, a photo of VCOM's anatomy laboratory was embedded in Google Slides and served as the main "room" where participants would begin the activity (Fig. 2<emph>A</emph>).</p> <p>PHOTO (COLOR): Figure 2. Setup of upper limb escape room (ER) at Edward Via College of Osteopathic Medicine. Image of anatomy lab was imported into Google Slides and used as main "room" of ER (A). 50-minute timer () was embedded and configured to automatically start playing when in presentation mode (B, pink highlight). Image of clipboard and answer sheet was linked to Google Form in which participants would submit their 10-letter answer to "escape" (B, blue highlight). Ten transparent shapes were randomly placed around the image (B, revealed in yellow highlight), which linked to 10 individual question slides (C). Question slides included links to interactive 3-dimensional (3-D) prosection built in Virtual Human Dissector software (created with permission from Touch of Life Technologies; ), which displayed structures indicated by lettered pins (D). Answer: C5 nerve root, marked by pin N.</p> <p>The building of the ER involved placement of 10 transparent shapes on the main room image (Fig. 2<emph>B</emph>). Ten questions were then created in 10 separate Google Slide presentations, each focusing on specific anatomical structures of the upper limb. Each transparent shape was linked to one of the question slides, so that clicking on the hidden shape in presentation mode would redirect the participant directly to the question slide. Each question slide included a knowledge-based task in the form of either a riddle, a puzzle, or image interpretation, followed by a link to an interactive virtual prosection created and embedded in Virtual Human Dissector (VHD) (Fig. 2<emph>C</emph>). VHD is a subscription-based anatomical educational software program that offers 3-D rendering of real anatomy (Touch of Life Technologies; www.toltech.net), with demonstrated educational value in anatomy curricula ([<reflink idref="bib17" id="ref18">17</reflink>], [<reflink idref="bib18" id="ref19">18</reflink>]). In VHD, customized prosections were created, and lettered pins marked various anatomical structures that were relevant to the corresponding question (Fig. 2<emph>D</emph>). The participant was tasked with locating all 10 items in the ER, solving the corresponding question, and correctly identifying the relevant structure on the linked VHD prosection, noting the letter of the pinned structure.</p> <p>Questions were based on lecture content to ensure relevancy. Riddles were generated with assistance from ChatGPT (www.openai.com; version GPT-4o mini) by using simple prompts (e.g., "write a six-line rhyming riddle on the roots of the brachial plexus"). A jigsaw puzzle of a brachial plexus atlas image (https://puzzel.org/) was accessed from the question slide via a hyperlink, and a crossword puzzle was manually built with the "Shapes" feature in Google Slides. Other questions required the participant to interpret medical imaging, clinical presentations, or diagrams.</p> <p>The ER also included an image of an answer sheet (Fig. 2<emph>B</emph>), which linked to a Google Form. The form included an overview of the escape room, instructions for how to escape, and a field for participants to enter their 10-letter answer. The form was configured to accept only correct submissions by using the "response validation" feature. The form would redirect to a "congratulations" page if they answered correctly or a "try again" page if the answer was incorrect.</p> <hd1 id="AN0187950983-11">Protocol.</hd1> <p>First (OMS-I)- and second (OMS-II)-year osteopathic medical students who served as anatomy interns or anatomy tutors were invited to participate via email (<emph>n</emph> = 27); of these, eight students (30%) agreed to participate. Recruitment for the ER activity was restricted to these groups of peer teachers as they have demonstrated a level of competence and enthusiasm with anatomy content, making them qualified to comment on how similar activities may be integrated into the anatomy curriculum. At the time of the study, OMS-I anatomy tutors had received all upper limb anatomy lectures but not yet taken their exam, whereas OMS-II anatomy tutors/interns were approximately 1 year removed from formal upper limb anatomy instruction but were actively involved in tutoring relevant material to their OMS-I peers.</p> <p>All research activities took place remotely via Zoom (<ulink href="http://www.zoom.com">www.zoom.com</ulink>). All subjects provided informed consent by e-signing a QuestionPro online survey (<ulink href="http://www.questionpro.com">www.questionpro.com</ulink>) before a URL link to the activity was shared via the Zoom chat feature. Minimal details were provided on the nature of the activity, but the use of lecture notes was encouraged, and it was ensured that all participants were on a device with VHD software installed. All subjects were then isolated in Zoom breakout rooms, where they navigated the activity individually. Subjects were instructed to leave the breakout room and return to the main Zoom call after completion of the activity; otherwise the breakout room was set to automatically close and redirect subjects to the main call after 50 min. The duration was chosen based on its alignment with the length of a didactic lecture in the VCOM curriculum. Instructions for completing the anonymous feedback survey immediately followed.</p> <hd1 id="AN0187950983-12">Evaluation.</hd1> <p>Immediately after the activity, a URL link to a QuestionPro anonymous online survey was provided to all subjects via the Zoom chat feature. The survey consisted of 14 five-point Likert-scale questions and 2 open-ended questions. Survey items were based on a previously validated survey ([<reflink idref="bib19" id="ref20">19</reflink>]). To gauge the consistency of each participant's response to questions in the qualitative survey related to the potential utility of the ER as a learning tool, Cronbach's alpha was calculated on items addressing this theme (<emph>questions 1–3</emph>, <emph>5</emph>, <emph>6</emph>, <emph>11</emph>) to measure internal consistency of responses. Internal consistency was not calculated for the remaining items since they addressed disparate themes, and therefore could not be grouped together, or their grouping yielded an insufficient number of items to permit calculation. After all participants finished the survey, a debrief session was conducted to reveal clues and review answers. Descriptive statistics were performed on responses to Likert-scale items in QuestionPro.</p> <hd id="AN0187950983-13">RESULTS</hd> <p>Two distinct virtual ERs were created at the two institutions, one at QUB, which was a linear, in-person, group activity focusing on abdominal anatomy, and one at VCOM, which was a nonlinear, remote, individual ER centered around upper limb anatomy.</p> <hd1 id="AN0187950983-14"> <emph>Case Study 1</emph>. Abdominal Anatomy at QUB</hd1> <hd1 id="AN0187950983-15">Subjects.</hd1> <p>Of the four groups, two completed the game within the 35-min time limit. The groups who had not yet escaped were granted extra time. The average time to complete was 43 min, with the fastest group completing in 27 min.</p> <hd1 id="AN0187950983-16">Feedback survey.</hd1> <p>Results of the 25 Likert items (scaled from 1: "strongly disagree" to 5: "strongly agree") provided by the nine subjects are depicted in Fig. 3. Items related to similar topics were grouped together into categories and are summarized below, including the mean value ( <ephtml> <math display="inline" altimg="eq-00001.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> ) ± standard deviation of responses.</p> <p>PHOTO (COLOR): Figure 3. Likert-scale data from Queen University Belfast (QUB) evaluation survey. The text of each question element is shown on left. Colored bars represent the percentage of respondents selecting each response category in the 5-point Likert scale ("strongly disagree," "disagree," "neither agree nor disagree," "agree," or "strongly agree") (n = 9).</p> <p>Questions relating to the overall satisfaction category consisted of nine items (<emph>questions 1</emph>, <emph>4–9</emph>, <emph>20</emph>, <emph>25</emph>, α = 0.79). All participants agreed or strongly agreed that the ER was enjoyable ( <ephtml> <math display="inline" altimg="eq-00002.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 4.89 ± 0.33), was easy to understand and use ( <ephtml> <math display="inline" altimg="eq-00003.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 4.22 ± 0.44), and encouraged the use of teamwork ( <ephtml> <math display="inline" altimg="eq-00004.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 4.89 ± 0.33) and communication skills ( <ephtml> <math display="inline" altimg="eq-00005.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 4.44 ± 0.53). All subjects also strongly agreed that they enjoyed completing the activity as a group ( <ephtml> <math display="inline" altimg="eq-00006.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 5 ± 0). Most (89%) at least agreed that the ER was well organized ( <ephtml> <math display="inline" altimg="eq-00007.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 4.67 ± 0.71), helped them identify knowledge gaps ( <ephtml> <math display="inline" altimg="eq-00008.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 4.67 ± 0.71), and increased their knowledge of gastrointestinal anatomy ( <ephtml> <math display="inline" altimg="eq-00009.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 4.44 ± 1.01).</p> <p>Question items related to the 3-D models created via photogrammetry included six items (<emph>questions 10–15</emph>, α = 0.66). Most (89%) respondents at least agreed that 3-D models would make a useful addition to anatomy teaching ( <ephtml> <math display="inline" altimg="eq-00010.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 4.44 ± 0.73) and that the image quality of the 3-D models was adequate for identifying structures highlighted ( <ephtml> <math display="inline" altimg="eq-00011.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 4.33 ± 0.71), and all believed that the models would be helpful in the revision of future topics ( <ephtml> <math display="inline" altimg="eq-00012.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 4.67 ± 0.5). When asked whether the 3-D models were easy to use ( <ephtml> <math display="inline" altimg="eq-00013.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 4.22 ± 0.83), two (22%) reported indifference and three (33%) were indifferent or at least agreed that the 3-D models were difficult to orient ( <ephtml> <math display="inline" altimg="eq-00014.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 2.22 ± 1.48). During the ER, two groups required prompts for identifying the hepatic portal vein on the 3-D liver model, which may have contributed to the variance in the responses.</p> <p>Question items related to the images of the two-dimensional (2-D) potted pathology specimens included four items (<emph>questions 16–19</emph>, α = 0.60). Most (89%) participants at least agreed that the images were of good quality ( <ephtml> <math display="inline" altimg="eq-00015.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 4.44 ± 0.73) and would be a useful anatomy resource ( <ephtml> <math display="inline" altimg="eq-00016.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 4.11 ± 0.60), and none felt uncomfortable about the images ( <ephtml> <math display="inline" altimg="eq-00017.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 1.11 ± 0.33). Although seven (77%) indicated that they were able to identify the associated pathology ( <ephtml> <math display="inline" altimg="eq-00018.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 4.00 ± 1.22), difficulty in identifying the pathology was discussed during the focus group. To overcome this, future iterations may benefit from additional labeling to help with orientation and identification of the pathology.</p> <p>Questions related to difficulty and time pressure included six items (<emph>questions 2</emph>, <emph>3</emph>, <emph>21–24</emph>, α = 0.57). Disparate responses related to finding anatomy ( <ephtml> <math display="inline" altimg="eq-00019.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 2.11 ± 0.93) and clinical ( <ephtml> <math display="inline" altimg="eq-00020.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 2.22 ± 1.2) questions too hard may likely be attributed to heterogeneity in the educational level of participants. Only two (22%) participants felt rushed and under pressure ( <ephtml> <math display="inline" altimg="eq-00021.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 2.56 ± 1.13), and five (58%) indicated that they were able to complete the ER in the time allotted ( <ephtml> <math display="inline" altimg="eq-00022.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 3.44 ± 1.42). Free-text comments revealed that participants would have liked to always see the timer on the screen or to have had warning bells for time remaining to encourage them to work faster.</p> <hd1 id="AN0187950983-17">Focus group.</hd1> <p>The seven student participants in the QUB ER agreed to participate in a focus group to discuss their experience. Analysis of the discussion revealed three primary themes.</p> <hd1 id="AN0187950983-18">Theme 1: Motivation and enjoyment.</hd1> <p>Participants generally found the ER to be fun, and they enjoyed the session. One participant noted "An escape room is versatile. Some people can just have fun with it, others can take it more seriously and try and revise and learn from it. Most people should be able to get something out of it." Participants found the competitive nature of the ER motivating, and they all stated that they would take part in an anatomy ER again if given the chance. Participants commented that gamified learning in anatomy creates an incentive to learn and can make learning easier.</p> <p>Participants stated that games such as ER would have been particularly useful in the earlier years of anatomy learning, as expectations from secondary school level to university are often daunting. It has been recognized that many students experience levels of anxiety when exposed to anatomy and cadaveric specimens for the first time ([<reflink idref="bib20" id="ref21">20</reflink>]). One participant commented that lectures and demonstrations can become repetitive after time and having games such as ER would be a great way to "spice things up."</p> <p>One participant commented that using games in anatomy would be more useful as a consolidation tool as opposed to a teaching method, which all other students agreed with. This sentiment was further echoed: "An escape room would be helpful at the end of a topic... and could highlight areas students need to go over and revise."</p> <p>Students also commented on games in anatomy being beneficial, especially given the current issues surrounding anatomy teaching such as bigger classes and reductions in time spent dissecting. Creating games and encouraging teamwork can help ensure that every student is motivated and gets involved during anatomy revision classes.</p> <hd1 id="AN0187950983-19">Theme 2: 3-D virtual models are a useful adjunct.</hd1> <p>All participants agreed that 3-D models are effective as a revision tool in anatomy (Fig. 3); however, all focus group participants stated that being able to see and use cadaveric specimens in teaching remains the gold standard. Some participants found the 3-D specimens hard to orientate and stated that a short demonstration on how to rotate the specimens would have been useful at the beginning of the session rather than having the researcher show them during the ER time. Once some students were shown how to interact with the 3-D model, they claimed it was simple to use and "added an extra flair." This indicates that the way in which ERs are conducted can be easily rectified to include a short tutorial before the beginning of the ER to show students how to operate the software. Collectively, the participants noted the benefit of 3-D virtual images as a revision tool by providing a way to learn and access anatomy resources from home; however, they did not think they should replace prosection/dissection as the main method of teaching when these are available.</p> <hd1 id="AN0187950983-20">Theme 3: Pathological specimens have uncertain benefit.</hd1> <p>Three participants found it hard to identify the pathology in the specimens, with one describing the pots as being "intimidating" as they are often unable to orientate themselves with what they are looking at, and another described the potted specimens as interesting to see but stated that they did not find them necessary or particularly helpful for the case. Another described the potted specimens as being a helpful resource when used alongside other revision material but not on their own and stated that having additional radiological and imaging questions in the ER would have been more beneficial. The addition of labels on the image might have aided students' ability to orientate themselves before asking questions relating to the specimen. The potted specimen containing a liver showing discoloration due to hemochromatosis was particularly hard for participants to decipher. For future sessions a comparable healthy liver could be used alongside the pathological one to help highlight the color difference. All participants agreed on the usefulness of being able to virtually rotate the potted specimen image to better understand what they were surveying.</p> <hd1 id="AN0187950983-21"> <emph>Case Study 2</emph>. Upper Limb Anatomy at VCOM</hd1> <hd1 id="AN0187950983-22">Subjects.</hd1> <p>The cohort was composed of four OMS-I and four OMS-II students. Only one (12.5%) was able to complete the activity within the 50-min time limit.</p> <hd1 id="AN0187950983-23">Feedback survey.</hd1> <p>Results of the 14 Likert items (scaled from 1: "strongly disagree" to 5: "strongly agree") provided by the eight subjects are depicted in Fig. 4. Items were based on a previously validated survey ([<reflink idref="bib19" id="ref22">19</reflink>]), and those related to similar topics are summarized together, including the mean value ( <ephtml> <math display="inline" altimg="eq-00023.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> ) ± standard deviation of responses.</p> <p>PHOTO (COLOR): Figure 4. Likert-scale data from Edward Via College of Osteopathic Medicine (VCOM) evaluation survey. The text of each question element is shown on left. Colored bars represent the percentage of respondents selecting each response category in the 5-point Likert scale ("strongly disagree," "disagree," "neither agree nor disagree," "agree," or "strongly agree") (n = 8).</p> <p>An individual's proclivities for games and gamified learning activities were addressed in <emph>items 4</emph> and <emph>8</emph>. Half of the subjects indicated that they learn better in a game format compared to didactic lecture ( <ephtml> <math display="inline" altimg="eq-00024.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 3.25 ± 1.49), and seven (87.5%) agreed or strongly agreed that they generally enjoy playing games ( <ephtml> <math display="inline" altimg="eq-00025.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 4.38 ± 1.06).</p> <p>Since the activity was being completed individually, statements related to study habits were included to gain insight into the subjects' study preferences when preparing for anatomy summative assessments (<emph>questions 7</emph>, <emph>9</emph>, <emph>10</emph>). A preference for studying for anatomy laboratory practical exams by themselves was denied by half of the subjects ( <ephtml> <math display="inline" altimg="eq-00026.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 2.5 ± 1.20); conversely, the same proportion indicated a preference for studying lecture material solo ( <ephtml> <math display="inline" altimg="eq-00027.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 3.38 ± 1.30). Notably, half of the participants also indicated a preference for assembling information from a variety of sources when learning new material ( <ephtml> <math display="inline" altimg="eq-00028.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 3.25 ± 0.89).</p> <p>Items related to the ER's potential as a learning tool provided insight into the activity's educational value (<emph>questions 1–3</emph>, <emph>5</emph>, <emph>6</emph>, <emph>11</emph>, α = 0.61). All subjects agreed or strongly agreed that the activity encouraged them to think about material in a new way ( <ephtml> <math display="inline" altimg="eq-00029.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 4.5 ± 0.53), and five (62.5%) agreed or strongly agreed that the activity was an effective way to review upper limb anatomy ( <ephtml> <math display="inline" altimg="eq-00030.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 3.75 ± 1.04). Half disagreed that feelings of stress made it difficult for them to focus on learning during the activity ( <ephtml> <math display="inline" altimg="eq-00031.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 2.88 ± 0.99), and seven (87.5%) disagreed that the puzzles and riddles distracted them from learning new material ( <ephtml> <math display="inline" altimg="eq-00032.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 1.88 ± 0.35). When asked "what did you like most about the activity?" all respondents addressed some component of the creative nature of the puzzles and riddles that required them to think about the material in a new, engaging way.</p> <p>Items related to future iterations aimed to determine how future activities should be designed and implemented (<emph>questions 12–14</emph>). The majority of subjects (62.5%) either agreed or strongly agreed that they would prefer to do future ERs as part of a team ( <ephtml> <math display="inline" altimg="eq-00033.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 3.88 ± 1.13) and in a physical setting, rather than remotely ( <ephtml> <math display="inline" altimg="eq-00034.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 3.88 ± 1.13). Importantly, a general desire to retain didactic learning was indicated, as five (62.5%) subjects either disagreed or strongly disagreed that ER activities should replace didactic learning ( <ephtml> <math display="inline" altimg="eq-00035.gif" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mover accent="true"><mtext>x</mtext><mo>¯</mo></mover></mrow></math> </ephtml> = 2.5 ± 1.07). Free-text responses to "what did you like least about the activity" were primarily centered around a lack of instruction upfront and difficulty locating the questions. To address this, future iterations should consider providing clear instructions about what the participant can expect to experience and what elements they will be expected to interact with during the activity.</p> <hd id="AN0187950983-24">DISCUSSION</hd> <p>This article outlines the development, delivery, and evaluation of two anatomically themed virtual ERs at Queens University Belfast (QUB) and Edward Via College of Osteopathic Medicine (VCOM). Although participants generally responded positively to both activities, citing enjoyment in being able to interact with material in new, creative ways, the differing approaches for the two activities regarding design (linear vs. nonlinear), delivery (in person vs. remote), and grouping of participants (team based vs. individual) permit unique discussion on the strengths and weaknesses of each.</p> <hd1 id="AN0187950983-25">Linear vs. Nonlinear Formats</hd1> <p>Linearly formatted ERs require the participant to progress through a series of activities, preventing them from advancing until their current stage is successfully completed, whereas nonlinear formats allow users to pick and choose which puzzle to interact with, requiring no specific sequence for completion. In the QUB ER, participants linearly worked through three patient cases, completing activities as a clinical picture developed, essentially mimicking the development of a patient narrative in clinical practice. Applying newfound knowledge as a patient case develops may inspire learners to construct a deeper understanding of material, which has been supported by improved learning outcomes following exposure to linearly formatted virtual ERs ([<reflink idref="bib21" id="ref23">21</reflink>], [<reflink idref="bib22" id="ref24">22</reflink>]). Educators may therefore opt for a linear format if their primary aim is to promote understanding through the linking of relevant concepts. However, the potential pitfalls of a linear model should also be considered, namely the time investment required to thoughtfully construct a guided evolution of learning and the frustration and discouragement that may arise if a user gets stuck on a question and is unable to progress. To help prevent this, educators may consider incorporating hints or being present to provide clues and answer questions.</p> <p>Conversely, the VCOM ER followed a nonlinear format in which users interacted with 10 activities in whichever sequence they were discovered. This allowed participants to leave and return to an item if they were unsure of the answer, a particularly important feature since the ER was completed on an individual basis. Unlike linear formats, nonlinear ERs allow for several concepts to be tested without the constraint of having to link them, making their construction potentially simpler and more time efficient while promoting their utility as a revision tool. Indeed, nonlinear ERs have been described by users as being enjoyable and an effective way to review material, consolidate knowledge, and apply high-yield concepts ([<reflink idref="bib4" id="ref25">4</reflink>], [<reflink idref="bib23" id="ref26">23</reflink>], [<reflink idref="bib24" id="ref27">24</reflink>]). Notably, however, criticisms of the VCOM ER included difficulty in locating all 10 clues that were hidden in the main image (Fig. 2<emph>A</emph>), revealing a potential weakness in the nonlinear design. Participant suggestions included making the clues more apparent by using highlight or shadowing features during the construction process, which could allow users to spend more time engaging with educational elements versus searching for them.</p> <hd1 id="AN0187950983-26">In-Person vs. Remote Formats</hd1> <p>The QUB ER was projected on touch screens in the anatomy laboratory, offering a format that would accommodate students who prefer in-person activities. Notably, the majority of VCOM subjects indicated a preference for future ERs to be delivered in person after completing their activity remotely (Fig. 4). Being physically present for learning activities has demonstrated higher rates of student satisfaction compared to distance learning ([<reflink idref="bib25" id="ref28">25</reflink>]); however, scalability should also be considered during the design process, since this may be limited for in-person activities depending on the space and resources available.</p> <p>Virtual learning activities completed remotely, similar to VCOM's ER, afford the user flexibility in when and where they can be completed while also promoting scalability. Indeed, during debrief discussions after the VCOM ER, participants commented on the potential benefit of using the activity as a revision tool anywhere within their study schedule. Since learners have indicated that the ER helps them to identify gaps in their knowledge (Fig. 3), it may be beneficial to share the virtual ER with learners and allow them to determine the time point in their individual study schedule when the ER may be most impactful and convenient. Importantly, the majority of VCOM participants indicated a preference for studying for anatomy lecture exams by themselves (Fig. 4), potentially biasing this input. A downside to having users participate in the virtual ER remotely is that they may have difficulty getting any technological issues addressed. Designers may consider deploying their activity with a feedback survey to facilitate submission and tracking of any deficiencies in the user experience.</p> <hd1 id="AN0187950983-27">Team-Based vs. Individual Formats</hd1> <p>QUB offered a linear ER that was completed in a physical setting by small teams. Participants described working in teams as beneficial and reflective of clinical practice, where it is key to communicate effectively with other health professionals. Additional benefits of completing virtual ERs as a team include being able to "talk through [their] thoughts with others and hear their thoughts as well," as indicated by participants of a cardiac physiology virtual ER ([<reflink idref="bib10" id="ref29">10</reflink>]). The use of teams also addresses some of the issues of scalability of in-person ERs: with multiple people around one device, it is more feasible to use ER with large cohorts of medical students. Collaborative, small-group learning has also been shown to increase knowledge and retention ([<reflink idref="bib26" id="ref30">26</reflink>]); thus deploying virtual ERs in a team-based format may optimize its educational utility. The use of teams was further supported by the majority of VCOM participants, who completed their activity remotely on an individual basis but indicated a preference for participating in future ERs as a member of a team (Fig. 4). Conversely, individual formats give the participant autonomy and prevent the scenario of an extroverted teammate driving their experience. This format may also be preferred if the primary aim is having students identify gaps in their knowledge. Individual users may experience frustration if they get stuck on a question, so educators may consider including hints to limit discouragement.</p> <hd1 id="AN0187950983-28">Compliments, Criticisms, and Suggestions</hd1> <p>QUB participants emphasized the value of having a reward structure to entice students to work competitively and proposed that future ERs should have prizes for successful teams. This approach has been supported by other educational ER developers ([<reflink idref="bib23" id="ref31">23</reflink>], [<reflink idref="bib27" id="ref32">27</reflink>]). QUB participants also suggested utilizing the whiteboard function on the touch screens to make the ER more interactive by having to label or draw images. Additionally, QUB participants agreed that questions such as the jigsaw puzzle and solving riddles were more enjoyable than multiple-choice questions and suggested that questions be reformatted to be more interactive. VCOM participants supported this, indicating the creativity and engagement with the riddles and puzzles as being one of the things they liked most about the activity, though they would have appreciated knowing ahead of time that materials such as scrap paper might be helpful for completing activities like the wordsearch and crossword puzzles.</p> <p>Many of the participants were unable to complete the activity within the given time limit. High failure rates could lead to discouragement among users. To avoid this, it may be best to pilot the ER before its distribution to learners as a way to ensure that the timing is realistic and the activity can be feasibly completed.</p> <p>One QUB student mentioned that having all the specimen images in the actual Google Forms cases would have been more beneficial rather than having to switch between multiple tabs on the screen. This was not possible because of the constraints of the Human Tissue Authority Act 2004; it was necessary to password protect these files, which meant we were unable to insert the models into the Google Form.</p> <hd1 id="AN0187950983-29">Pathology Specimens as an Educational Tool</hd1> <p>A benefit to using potted pathology specimens in anatomy teaching is that students can observe rare pathologies that would seldom be seen in clinical practice to support their learning ([<reflink idref="bib28" id="ref33">28</reflink>]). Using potted pathology specimens introduces rare diseases to students and allows them to become familiar with diseases less common in developed countries, or diseases that potentially might reemerge, as well as being valuable for research purposes ([<reflink idref="bib29" id="ref34">29</reflink>]). Others argue that potted specimens pose no real value in anatomy education any more because of the emergence of radiological imaging and scanning. Indeed, a lot of institutions have now moved their potted pathology collections to basements or unused corridors ([<reflink idref="bib30" id="ref35">30</reflink>]).</p> <p>Although participants in the focus group in this study reported the potted pathological specimens as being unfavorable as an addition to the ER, in the evaluation survey respondents strongly agreed or agreed that 2-D potted pathological specimens would make a useful addition to anatomy resources (Fig. 3). These conflicting results raise questions on the educational utility of potted pathology specimens. A recent study by Sutton-Butler et al. ([<reflink idref="bib31" id="ref36">31</reflink>]) analyzing student perspectives on pathological potted wet specimens found that 72/80 (90%) students found the specimens to be useful in teaching and would like to see them being used more. Additionally, having the specimens motivated the students to consider the ethics surrounding body/organ donation through encouraging an ethics discussion. The students also reported the specimens to be useful for identifying anatomical landmarks on the model and preferred seeing real organs as opposed to diagrams or plastic models ([<reflink idref="bib31" id="ref37">31</reflink>]). Disparate results were likely influenced by our small sample size, and testing on a larger group of students would be necessary to better elucidate the perceptions and potential of potted pathology specimens as an educational tool.</p> <hd1 id="AN0187950983-30">Artificial Intelligence</hd1> <p>ChatGPT has received considerable attention in the gaming industry as a potential method of creating interactive virtual laboratory experiences offering students an immersive educational experience ([<reflink idref="bib32" id="ref38">32</reflink>]). Although there is potential for the employment of more artificial intelligence-based applications in medical education, there are some limitations to its use. There is the risk that information provided by artificial intelligence may be misleading or incorrect, therefore questioning the reliability of its use without sufficient quality control. Moreover, artificial intelligence also raises ethical concerns such as discrimination, biases, and confidentiality issues that could have serious consequences for the user if used inappropriately ([<reflink idref="bib33" id="ref39">33</reflink>], [<reflink idref="bib34" id="ref40">34</reflink>]).</p> <hd1 id="AN0187950983-31">Limitations</hd1> <p>The evaluations of the virtual ERs at QUB and VCOM were limited by small sample sizes and sample bias. Seeking feedback from a greater number of learners with more diverse educational backgrounds and anatomical proclivities would provide greater insight into the utility of anatomy-themed virtual ERs.</p> <p>A significant source of bias in this study is the selection bias of participants: as these were both voluntary studies, it is likely that our sample is biased toward students who enjoy games and/or anatomy. This may artificially inflate the perceived overall satisfaction of the students with the activity. To run such a session with a cohort of students as part of the curriculum may be difficult because of time constraints. One approach to mitigate this is to offer the experience of virtual ERs to students so they can complete it as a revision activity in their own time.</p> <p>Some aspects of the ER described in this study require paid software or significant technical knowledge, which could be a limitation for some trying to incorporate ER into their curricula. That said, it is possible to create an ER using simple images and text that can be equally engaging. Another technical limitation of virtual ERs is that, when run remotely, they may lead to student disengagement or frustration if they have insufficient technical capabilities. This can be mitigated by sufficient guidance, encouraging students to complete the ER in groups and providing an avenue for them to seek support.</p> <hd1 id="AN0187950983-32">Conclusions</hd1> <p>Virtual ERs for anatomy education can be readily built using Google Workspace as a platform. Creating 3-D models with photogrammetry or licensed software and incorporating them into the activity can add value to the experience. Linear designs can mimic the development of a patient narrative in clinical practice, whereas nonlinear designs may be simpler to build. ERs that are deployed in person may increase student satisfaction, whereas remote activities may be more scalable. Team-based virtual ERs may be more beneficial for fostering teamwork and collaboration, helping to increase the overall educational utility, whereas individual virtual ERs may be more convenient, allowing learners to participate at a time in their study schedule that works best for them. These factors should be considered when developing and deploying such activities.</p> <hd id="AN0187950983-33">DATA AVAILABILITY</hd> <p>Data will be made available upon reasonable request.</p> <hd id="AN0187950983-34">SUPPLEMENTAL MATERIAL</hd> <p>Supplemental Figs. S1 and S2: https://doi.org/10.6084/m9.figshare.28439900.v1.</p> <hd id="AN0187950983-35">DISCLOSURES</hd> <p>No conflicts of interest, financial or otherwise, are declared by the authors.</p> <hd id="AN0187950983-36">AUTHOR CONTRIBUTIONS</hd> <p>A.W.B., S.H., R.P., and E.M.S. conceived and designed research; performed experiments; analyzed data; interpreted results of experiments; prepared figures; drafted manuscript; edited and revised manuscript; and approved final version of manuscript.</p> <hd1 id="AN0187950983-37">ACKNOWLEDGMENTS</hd1> <p>The authors thank the participants who volunteered to partake in the study.</p> <ref id="AN0187950983-38"> <title> REFERENCES </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Krishnamurthy K, Selvaraj N, Gupta P, Cyriac B, Dhurairaj P, Abdullah A, Krishnapillai A, Lugova H, Haque M, Xie S, Ang ET. Benefits of gamification in medical education. 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  Data: Virtual Escape Rooms in Anatomy Education: Case Studies from Two Institutions
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  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Aaron+W%2E+Beger%22">Aaron W. Beger</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-8545-7656">0000-0001-8545-7656</externalLink>)<br /><searchLink fieldCode="AR" term="%22Sarah+Hannan%22">Sarah Hannan</searchLink><br /><searchLink fieldCode="AR" term="%22Riya+Patel%22">Riya Patel</searchLink><br /><searchLink fieldCode="AR" term="%22Eva+M%2E+Sweeney%22">Eva M. Sweeney</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-6412-4518">0000-0002-6412-4518</externalLink>)
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  Data: <searchLink fieldCode="SO" term="%22Advances+in+Physiology+Education%22"><i>Advances in Physiology Education</i></searchLink>. 2025 49(3):621-632.
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  Data: American Physiological Society. 9650 Rockville Pike, Bethesda, MD 20814-3991. Tel: 301-634-7164; Fax: 301-634-7241; e-mail: webmaster@the-aps.org; Web site: https://www.physiology.org/journal/advances
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  Label: Peer Reviewed
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  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 12
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  Label: Publication Date
  Group: Date
  Data: 2025
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  Data: Journal Articles<br />Reports - Research
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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="%22Anatomy%22">Anatomy</searchLink><br /><searchLink fieldCode="DE" term="%22Computer+Simulation%22">Computer Simulation</searchLink><br /><searchLink fieldCode="DE" term="%22Gamification%22">Gamification</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Learning+Activities%22">Learning Activities</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+Education%22">Medical Education</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+Students%22">Medical Students</searchLink><br /><searchLink fieldCode="DE" term="%22Instructional+Effectiveness%22">Instructional Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22In+Person+Learning%22">In Person Learning</searchLink><br /><searchLink fieldCode="DE" term="%22Distance+Education%22">Distance Education</searchLink><br /><searchLink fieldCode="DE" term="%22Group+Activities%22">Group Activities</searchLink><br /><searchLink fieldCode="DE" term="%22Individual+Activities%22">Individual Activities</searchLink><br /><searchLink fieldCode="DE" term="%22Instructional+Design%22">Instructional Design</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Attitudes%22">Student Attitudes</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22United+Kingdom+%28Belfast%29%22">United Kingdom (Belfast)</searchLink><br /><searchLink fieldCode="DE" term="%22Virginia%22">Virginia</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1152/advan.00248.2024
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  Label: ISSN
  Group: ISSN
  Data: 1043-4046<br />1522-1229
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  Label: Abstract
  Group: Ab
  Data: Virtual escape rooms (ERs) require learners to solve puzzles and answer riddles while trying to "escape" a digital room. Although the educational merit of such gamified learning activities continues to be realized, guides on the development of ERs are lacking, as well as student perceptions on how, if, and where they should be integrated into medical curricula. Therefore, the aim of this study was to describe the experiences of building anatomy-themed virtual ERs of differing formats at two separate institutions, Queen's University Belfast (QUB) and Edward Via College of Osteopathic Medicine (VCOM), focusing on abdominal and upper limb anatomy, respectively. Google Workspace applications served as the primary platform. Three-dimensional (3-D) models were built with photogrammetry techniques or Virtual Human Dissector software (www.toltech.net) and integrated into the ER. Of 69 students and staff invited at QUB, 9 (13%) participated in the in-person virtual ER in teams of two or three (7 medical students, 2 anatomy instructors). Of 27 VCOM medical students invited, 8 (30%) agreed to participate and individually completed VCOM's virtual ER remotely. Anonymous surveys and a focus group revealed the ERs to be enjoyable and engaging and that they encouraged participants to think about material in a new way while helping them to identify knowledge gaps. Strengths and weaknesses of different designs (linear vs. nonlinear), delivery methods (in person vs. remote), and grouping of participants (team based vs. individual) were realized and discussed, revealing opportunities for optimizing the experience. Future studies would benefit from increasing sample sizes to assess the learning gain of such activities.
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  Data: 2025
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    Subjects:
      – SubjectFull: Anatomy
        Type: general
      – SubjectFull: Computer Simulation
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      – SubjectFull: Gamification
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      – SubjectFull: Foreign Countries
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      – SubjectFull: Student Attitudes
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      – SubjectFull: United Kingdom (Belfast)
        Type: general
      – SubjectFull: Virginia
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      – TitleFull: Virtual Escape Rooms in Anatomy Education: Case Studies from Two Institutions
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