“Visualization matters” – Stereoscopic visualization of 3D graphic neuroanatomic models through AnaVu enhances basic recall and radiologic anatomy learning when compared with monoscopy

doi:10.21203/rs.3.rs-3404076/v1

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Research Article

“Visualization matters” – Stereoscopic visualization of 3D graphic neuroanatomic models through AnaVu enhances basic recall and radiologic anatomy learning when compared with monoscopy

https://doi.org/10.21203/rs.3.rs-3404076/v1

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Background

The authors had previouslydeveloped AnaVu, a low-resource 3D visualization tool for stereoscopic projection of 3D models generated from annotated MRI neuroimaging data. However, its utility in neuroanatomical education needs to be quantified,and the students’ perspectives known.

Methods

A three-limb randomized controlled trial with crossover was designed. A sample (n=152) from the 2022 cohort of MBBS students at Government Medical College, Thiruvananthapuram (GMCT), was randomly selected from those who gave informed consent. After a one-hour introductory lecture on brainstem anatomy and a dissection session, students were randomized to three groups (S – stereo; M – Mono and C – Control). S was given a 20-minute demonstration on the brainstem lesson module in AnaVu in stereoscopic mode. M was given the same demonstration, but in monoscopic mode.The C group was taught using white-board drawn diagrams. Pre-intervention and post-intervention tests for four domains (basicrecall, analytical, radiological anatomy and diagram-based questions) were conducted before and after the intervention. Cognitive loads were measured using a pre-validated tool. The crossover part consisted of swapping groups -S, M and C,and they were asked to compare the modes.

Results

For basic recall examinations, there was a statistically significant increase in the pre/post-intervention score difference of the S group when compared to the M group [p=0.03; post hoc analysis, Bonferroni corrections applied] and the C group [p = 0.001; post hoc analysis, Bonferroni corrections applied]. For radiological anatomy examinations, the difference was significantly higher for S compared to C [p < 0.001; post hoc analysis, Bonferroni corrections applied]. Cognitive load scores showed increased mean germane load for S (33.28 ± 5.35) compared with C (28.18 ± 8.17). The qualitative comments indicated general appreciation about stereoscopy and critical points such as inconvenience of wearing goggles, eye strain, and sleepiness. In spite of these comments, out of the S and M swap cohorts, 79/102 preferred S, 13/102 preferred M, and 6/102 preferred both.

Conclusions

Since stereoscopic projection is technically challenging and cost considerations arehigher compared to monoscopic projection, the specific advantages and disadvantages of each are relevant in the Indian medical education scenario.

Anatomy Education

Stereoscopic Projection

Technology Enhanced Learning

Monoscopic Projection

Computer Assisted Learning

Anatomical Visualization

Spatial Learning

Spatial understanding is a vital and clinically important aspect of anatomy learning (1). Despite its profound importance in anatomy, spatial anatomy learning is often underachieved among medical students (2). The most universal, accessible and time-tested method of spatial anatomy learning is cadaveric dissection. Since the 17^th century, dissection has been the mainstay of anatomic training across the world (3). However, dissection is a time-consuming process that requires skill, patience, and motivation from the part of the learner. It is also a semi-destructive process, where parts of the specimen dissected have to be irreversibly destroyed to visualize other deeper structures. This makes revisiting and revising the areas cumbersome. Additionally, the use of formalin as the preserving agent is uncomfortable for many learners due to its inherent irritant nature (4). The dependence on human donors can also limit the use of dissection as a scalable option to learn spatial anatomy, especially for a large student group setting (a typical MBBS cohort in India contains 50-250 students as per National Medical Council regulations).

In addition to cadaveric dissection, there are a number of methods by which spatial anatomy can be taught. This includes high fidelity methods from the digital era created from real cross sectional imaging data, 3D printed models and plastinated models (5, 6) as well as low fidelity methods such as clay/dough models, manikins, body painting, and the use of analogies and gestures (7-9). Fuelled by advances in technology and in medical education, there have been several successful efforts in the last few decades to improve spatial anatomy teaching by incorporating virtual learning environments (10), which include virtual and augmented reality (11-14). There has also been specific interest in using stereoscopic projection of 3-dimensional anatomical models (15, 16), which are sourced either from annotated radiologic data (17) or from anatomic specimens rendered into 3D by photogrammetry (18) or 3D surface scanning (19, 20) methods.

Stereoscopy vs Monoscopy in Anatomy Learning Environments

Stereoscopy

Stereopsis is a binocular sensory phenomenon and is the result of a slight disparity of visual perception of both eyes (21). Stereopsis plays a key role in spatial understanding by providing depth cues for the viewer. Stereopsis is specifically advantageous in traditional anatomy learning environments utilizing dissection lab specimens or manikins, as these are usually within one’s personal space, which is considered as the “zone immediately surrounding the observer’s head, generally within arm’s reach and slightly beyond, which is considered quite personal”(21). Personal space is generally considered to be within a 2 meter radius around the person (21). Some studies have indicated that the learning advantage of a simple physical object (e.g., a dissection specimen, a manikin or an anatomical model of an organ) is mainly due to the stereoscopy offered by it, which highlights the central relevance of stereopsis even in a physical laboratory experience (22).

Stereopsis can be utilized in 3D visualization technologies by presenting two 2D images in a slightly shifted manner to the two eyes, creating the binocular disparity (23, 24). This is known as stereo display. The basic mechanism of a stereo display is the same, where two images – stereo pair – are presented to each eye. The observer’s visual perception interprets the two images through stereopsis. Different methods can be utilized for this purpose, including popular head-mounted display devices such as Oculus Rift™ through virtual reality (25) or Microsoft HoloLens™ through interactive augmented reality (26). These provide excellent stereoscopic imagery and an immersive experience. These methods are limited, however, by the fact that they are suitable for a single or at most a few students and are expensive [a high-end VR hardware, computer and headset costing nearly $3000 (INR ~2.5 Lakhs)] (27). This is not generally suitable (economically and logistically) for a large group teaching setting typically seen in the Indian medical education context (28) or other similar low- and middle-income country settings (29).

The other modes are stereogram, anaglyphic method or usage of polarized glasses (15). Stereogram is a method by which stereoscopic images are located one next to the other. Both eyes are forced to cross (divergent fusing or cross fusing) and create stereopsis (30). This is suitable for static images that can be printed on paper (31) but is not suitable for videos or interactive models. As there is a requirement for a voluntary convergence of the viewer’s eyes for creating stereopsis, this can be uncomfortable. The Anaglyphic method utilizes blue – red 3D glasses to visualize the model but has the disadvantage of having false color representations (15). The method where polarized glasses are used has more advantages in conveying spatial information, as it has the least discomfort in viewing and has no false colors. The main limiting factor is the need for specialized projection systems (stereoscopic projection), as it cannot be diplayed on normal projection systems. This renders adoption of this method difficult in institutions with limited resources.

Although such constraints are a reality, having a stereo display creates an advantage of delivering stereopsis to the Action space– a circular region of radius 2 meters to 30 meters, beyond the personal space of the learner (21). This opens up an avenue to teach a larger audience. Stereoscopic visualization has advantages in any field where spatial anatomical understanding is critical (15), and hence, this can be a potential scalable solution to the problem of teaching spatial anatomy to a large cohort of medical students.

Monoscopy

On the other hand, monoscopy is the presentation of the same image in front of each eye. This is what is seen in a routine projection of images, videos or animations, using classic projectors of a flat screen, which are relatively universally available in academic institutions. Although monoscopic presentations do not give depth perception, some static images (e.g., 3D computer models, artistic renderings in anatomy diagrams) may sometimes offer monoscopic cues for minor depth perception (32). In videos, animations or interactive 3D models, these monoscopic cues may further include perspective projection, shadings, occlusion, motion perspective, and familiar size (21, 30). Hence, if monoscopic projection of 3D models are as effective as having stereoscopic projection systems in anatomy learning environments, then they have economic and practical implications, especially for medical education in India, where student intake is usually high (33).

Indian Medical education and its recent changes

India boasts being the country with the largest number of medical colleges, thus holding a leading role in training healthcare workers in the world. The Indian curriculum was static for many decades. A radical change was brought in 2019 by the National Medical Commission (NMC), with the introduction of the Competency Based Medical Education (CBME) curriculum (34), which includes introduction of early clinical exposure, alignment with other disciplines and horizontal and vertical integration with modules ensuring the students’ achievement of competencies in attitude, ethics and communication (35). The introduction of technologically advanced methods is also a new step taken by the Indian curriculum. Computer Aided Learning (CAL) laboratory is now a minimum standard requirement for the Pharmacology department as per the NMC (36). A 3D virtual anatomy dissection table is mentioned as a desirable requirement by the Department of Anatomy (36). However, 3D visualization is still in its infancy in the Indian medical education system, with the cost factor limiting the implementation of such systems. Dissection, which is the mainstay of anatomy education in India, is also affected by the scarcity of cadavers, which has been reported recently in news media (37-39). This may be due to the relative increase in the number of medical institutions in India, with cadaver availability not sufficient to meet the demands. As these constraints should not affect the quality of medical education in India, it is necessary to explore newer possibilities in anatomy learning and incorporate them into the Indian Medical Education system.

Neuroanatomy education in India

Neuroanatomy is one of the many topics within the subject of anatomy in Phase 1 of the Indian medical curriculum. However, studies indicate that neuroanatomy is considered by learners as both a fascinating and yet a daunting subject when compared with other anatomy topics, such as musculo-sketetal, gastrointestinal, cardiovascular, respiratory and pelvic-reproductive anatomy (40). Learning neuroanatomy requires strong spatial reasoning and abstract mental visualization (41). The complexity of neuroanatomy is partly due to its organization, spatial intricacies and numerous terminologies (42). This complexity of learning neuroanatomy is a significant contributor to ‘Neurophobia’ (43), the fear of learning neural sciences, a term introduced to medical literature in the 1990s. This global phenomenon is multifactorial but has effects even on career choices, which creates a negative impact on neurological healthcare, particularly in India (as per Shelley et al.), which is facing a public health crisis in delivering neurological services, especially in primary care settings, including district and taluk hospitals (44). One of the goals of the Indian anatomy teacher will be to modify the ‘neurophobia’ of students to ‘neurophilia’ (44). There are two main hurdles that anatomists face in neuroanatomy teaching in India. The first is the shrinking time allocation for neuroanatomy (at most 15-20 days of neuroanatomy teaching) in the Indian phase 1 curriculum (42). The second is the problem of students not being able to “mentally convert” the 3-D structures to 2-D structures and vice-versa (42). The examination patterns in India, and hence most of the textbooks in neuroanatomy, demand that students prove their 2D perception, but unfortunately, the emphasis on spatial understanding is not catered to. Spatial understanding will be particularly difficult for students with lower spatial skills (44-46). This dualistic distracting approach (of need to understand the three dimensionality, but assessment of their two-dimensional perspective) often perplexes students (42), and Shelley et al. suggests, using innovative technological solutions to aid the student’s process of creating mental 3-dimensional images from conventional sectional images to enhance teaching-learning effectiveness (44) in the Indian medical education context.

Radiological anatomy in neuroanatomy teaching

Radiological investigations are becoming increasingly routine in healthcare. In this changing scenario, understanding anatomy through radiological images is considered one of the goals in anatomy learning. Integrating radiological anatomy into the anatomical curriculum is one of the solutions to achieve this goal (47). It is suggested that familiarizing students with radiological images earlier on, in their medical education, can specifically improve the student’s ability to learn neuroanatomy in an integrated manner (48) and is suggested as one critical step in eliminating neurophobia. Studies have also indicated that complementing dissection with radiological anatomy helps students develop spatial reasoning skills (49), which are critical as they proceed to clinical learning in further years.

Cognitive loads in instructional design

As per the cognitive load theory (50), an instruction imposes three types of cognitive loads on a learner’s cognitive mechanism – the intrinsic load (IL), the extrinsic load (EL) and the germane load (GL). The IL is influenced by the learner’s prior knowledge and the inherent complexity of the task. Components of instructions that are beneficial generally increase the GL, and features that are not beneficial increase the EL. If IL is optimal (which means the right complexity of the task to the right learner) and EL is low, learners can impose GL and engage in activities that elaborate their knowledge and facilitate learning (51).

AnaVu – An Anatomy Viewing tool

The authors [JS and PH - Engineers based on International Institute of Information Technology, Hyderabad, and Muni Animation, New Delhi; CK, BT, JER and TRK - Radiologists at Sree Chithra Thirunal Institute of Medical Sciences and Technology (SCTIMST) and DGY, AMO and UKG – Anatomy faculty at Government Medical College, Thiruvananthapuram (GMCT)], had previously developed a tool – AnaVu, a scalable solution for projecting stereoscopic images suitable for low resource settings. The tool had a software-graphic interface for the teacher to operate on and hardware for stereoscopic visualization. The MRI images were sourced from a volunteer after ethical approval from the Institutional Ethics Committee of SCTIMST. Different MRI sequences and MR angiogram sequences were acquired. The lesson modules created in the tool have 3D mesh models created from annotated data from T1 weighted magnetic resonance images of the brain (using ITK SNAP for manual annotation (52) and using FreeSurfer for automated annotation (53)). In AnaVu, the mesh models are projected through its hardware component, which consists of two HDMI outputs (Fig 1a) for channelled projection to two projectors stacked one above the other in a metallic projector cage (see Fig 1b), with binocular disparity to simulate stereopsis on a silver screen (Fig 1c). The teacher and the students could visualize the model in the 3D space on the silver screen. The technical details of this projection system can be seen in (54) (Accepted; To be presented).

The graphic user interface of AnaVu was designed in such a way that it has pedagogical advantages. It was a three-panel design with a 3D viewport in its center (see Fig 2), which allowed for selection of an object, a free trackball rotation, zoom in/out, and panning (see Fig 3). In the right panel, there were three canonical section (sagittal, axial and coronal) MRI images (each containing an image stack). The image stack could be surveyed by scrolling in that image/sliding the slider on the right panel. The planes of these sections were also present in the 3D viewport. This gave the teacher and the student the option to understand the correlation between the 3D model and the 2D MRI section (see Fig 2). If the teacher wished to lay focus on the MRI section image, then that could be swapped with the image on the central 3D viewport. This option was created because neuroanatomy is often taught through sections. In the left panel, there were the list of structures, controls and ‘buttons’ for selecting lessons, selecting/deselecting planes, manipulating opacity, and switching to canonical anatomical views (Left/Right, Superior/Inferior, Anterior/Posterior). There were also options to select objects and reduce opacity to “see through” or “within” a structure. (See Fig 3)

There were some considerations taken while annotating brainstem anatomy and nuclei from MRI data with regard to the reference planes (bicommissural plane in MRI and chiasmato commissural plane in routine anatomy sections). We chose the axial planes for the purpose of annotation as the plane parallel to the chiasmato commissural plane, which was perpendicular to the long axis of the brainstem and hence would be ideal to see sections in a neuroanatomy education module. The above problem was circumvented by rotating the source image in an annotation software (ITK SNAP). This made all the axial sections of the brainstem perpendicular to the long axis of the brainstem.

AnaVu also provides a feature to switch between a stereo mode (suitable for the stereoscopic projection system) and a mono mode (suitable for regular projectors), making it suitable for settings where the stereoscopic projection system is not feasible. This gave the teacher the freedom to teach using AnaVu along with a regular PowerPoint presentation or to have a standalone stereoscopic presentation.

The utility of such a tool in anatomical pedagogy is not known in a large group setting. Since 3D graphic models in monoscopy can have some depth cues, it is not known whether that would suffice to improve spatial learning instead of having an expensive stereoscopic projection system. Hence, the possibility of spatial learning of a 3D model projected non-stereoscopically (monoscopy) needs to be understood. For this reason, the AnaVu, which could switch between monoscopy and stereoscopy of the same 3D model, could be used. Moreover, if monoscopic visualization of the 3D model is more or even as effective as stereoscopic visualization of the same model, then the translation of the model into web-based platforms will be useful, as it can be visualized in hand-held devices.

Research question

Specifically, the research questions we explored were as follows:

Is stereoscopic projection having a pedagogical advantage over the monoscopic projection system in anatomy teaching, compared to traditional teaching? If yes, is there any specific domain that is influenced by it?
If monoscopic and stereoscopic models were presented to a student, what would the student prefer?
What were the disadvantages of stereoscopic/monoscopic projection?
How do the students’ perceived cognitive loads vary between the two presentations?

A three-limb randomized controlled trial was designed and submitted before the Institutional Review Board and Human Ethics Committee of Government Medical College, Thiruvananthapuram (GMCT). The HEC gave a letter dated 02.07.2019 stating that the study is exempted from review, based on the 2017 ICMR guidelines, as it is a study assessing educational techniques in medical students.

Sample

The 2022 cohort of 250 MBBS students was informed about the study. An information handout and a consent form were provided, which they had to sign and return if they consented (Supplementary material 1). From those who consented, 152 students were selected using simple random sampling. The random number tables were generated by Microsoft Excel for the study (n =152; Age (mean) – 20.11 years (± 1.61 y); Gender M:F = 60:92).

Topic and justification

The basic anatomy of the brainstem and the main cranial nerve nuclei were taken as the lesson for the study. The rationale for selecting this topic was the following:

It is a relatively smaller area in the brain but is highly clinically relevant. It is also difficult to understand spatially. There are numerous complicated anatomical terms (tectum, tegmentum, mesencephalic nucleus of trigeminal, facial colliculus) in the brainstem, which adds to the difficulty in recalling. The brainstem is classically taught by studying 2-dimensional sections of different levels (e.g., upper midbrain, lower pons, upper medulla). Correlating 2D sections with 3D mental images is quite spatially complex, especially for the internal architecture of the brainstem (41). Correlation of the 2D sectional image with the 3D spatial model is needed to understand the radiological anatomy and interpret lesions in a clinical setting.

Pre-Test and Post-Test

The pre-intervention (Pre-Test) and Post-intervention test (Post-Test) (See Supplementary material 2) were applied before and after the intervention, respectively (Fig 4). The duration of each test was 20 minutes. The questionnaire was designed to incorporate questions from different areas taught in the lecture, dissection and intervention sessions. The maximum possible score was fixed as 35.

The pre-test and post-test had 4 domains (see Supplementary material 2).

Basic recall questions (qn no. 1 – 4) – Maximum possible score was 11
Analytical questions (qn no. 5 – 7) - Maximum possible score was 11
Radiologic anatomy-based questions (qn no. 8 – 11) - Maximum possible score was 8
Diagram-based questions (qn. No. 12 – 13) - Maximum possible score was 5

Perceived Cognitive Load assessment tool

As a better teaching method would show an increased GL and may show decreased EL (see section of cognitive load in Background above), a perceived cognitive load assessment questionnaire tool was used to assess the cognitive loads as reported by the students. This was based on the study by Leppink et al. (51) with a minor adaptation to suit the current teaching experiment, as the original tool was designed for statistics education. This minor adaptation is permitted for further use as per the article by Leppink et al. (see Suggestions for future research and Appendix in (51)). The tool consisted of 10 questions (see Supplementary material 3), with the first three questions (il1, il2 and il3) indicating the intrinsic load (IL); the next three questions (el1, el2 and el3) indicating the extrinsic load (EL); and questions 7-10 (gl1, gl2, gl3 and gl4) indicating the germane load (GL). They were given this instruction in the material “Please respond to each of the questions on the following scale (0 meaning not at all the case and 10 meaning completely the case)”, as per Leppink et al. (51).

Subjective Feedback Questionnaire

A subjective feedback questionnaire that contained 12 questions was used. The first five questions were adapted from the tool used by Codd and Choudhury (55), which was to assess a virtual reality tool for forearm anatomy compared to the traditional method. The next five questions were adapted from the tool used by Maresky et al (56), to assess a virtual reality tool for cardiac anatomy. The last two questions were negatively constructed. A five-point Likert scale was used to obtain student ratings, with 1 indicating “strongly disagree” and 5 indicating “strongly agree”.

Study procedure

The intervention (the educational session) lasted for 2 days (see Fig 3).

On Day 1, the students were given a briefing and then a 20-minute pre-test, which was then followed by an introductory lecture on the brainstem by the second author, A.M.O., for 40-minute duration. They were then given a demonstration of dissection specimen of the brainstem by the second author, A.M.O., for 20 minutes using a document camera.
Based on the first intervention they would receive the next day, the student groups were named S, M and C, representing Stereoscopy (S), Monoscopy (M) and Control (C), respectively. The 152 students were randomized into the three groups by allocating the first 51 of the random numbers (generated earlier for selecting the sample) to S, the next 51 of the random numbers to M and the next 50 to C (see Fig 3). The groups – S [(n=51; age (mean) = 20 y (±2.2); M:F = 33:18)]; M [(n=51; age (mean) = 20.1 y (±1.03); M:F = 32:19)] and C [(n =50; age (mean) = 20.24 (±1.39); M:F = 27:23)] were demographically comparable.
On Day 2,the S, M and C groups assembled at three separate venues.
1. S was given a demonstration of the brainstem lesson module in AnaVu (20 minutes) in stereoscopic projection mode (Fig 5a). The teacher and the students had to wear linearly polarized 3D glasses (goggles) for this session.
2. M was shown a demonstration of the brainstem lesson module in AnaVu (20 minutes) in monoscopic projection mode (Fig 5b). The teacher and the students did not wear any specialized eyewear for this session, as it was using a normal projection system (monoscopic)
3. C was given a demonstration using white/black board-drawn diagrams (20 minutes) (Fig 5c).

Certain steps were taken for the intervention sessions to ensure uniformity in the content being taught in the three groups.
1. A teaching script was prepared earlier to make the teaching content as similar as possible. The content delivery was validated for consistency by six senior students, two in each venue (authors 3-8).
2. The teacher for all the intervention sessions was the first author (D.G.Y.)
3. The time of each session (20 minutes) was monitored and strictly adhered to.
After this, the students were given a post-test and a perceived cognitive load assessment questionnaire (Supplementary material 3) and a subjective feedback form (Supplementary material 4).
A 15-minute break was given.
After this, the students were swapped. The students had to change the venues to attend the respective sessions. The S group moved to the venue where a mono demonstration was given, the M group moved to stereo demonstration, and the C group moved to a stereo demonstration (see bottom of Fig. 4). The timings were coordinated by the senior students (authors 3-8). Participant students were informed that this is essentially a “replay” of the previous session they had but using a different teaching modality (M given Stereo, S given Mono and C given Stereo). They were informed that this was done to allow a comparison of the two methods, know their preference and their perspectives. After the session, they were given a questionnaire for the same (e.g., the SàM swap group was given Supplementary material 5).
Students were thanked for participation, and light refreshments were provided.

Analysis

Pre-test and post-test were evaluated by the authors 3-8 following an answer key, prepared by the authors 1 and 2 and face validated by the senior professors of the Anatomy department. The quantitative data were entered in Microsoft Excel and imported to IBM SPSS version 20 for analysis. ANOVA was performed to detect any statistically significant difference in mean scores among groups. If a significant difference was found on the ANOVA test, post hoc tests with Bonferroni corrections for multiple comparisons were performed to identify the pairs that had a statistically significant difference. Cohen’s d was calculated (M1-M2/SD_pooled) to determine the effect size to measure the quantum of the difference between a pair. The effect sizes were interpreted as small (d = 0.2), medium (d = 0.5) and large (d = 0.8), as per previous reports (57).

The qualitative data were processed using RQDA (R package for Qualitative Data Analysis). First, the data were imported into RQDA, and themes were generated by coding based on the research questions and the key concepts that emerged from the data by two researchers (NKR and UKG) independently to avoid bias. Once the data were coded, RQDA code reports were used to identify the frequency of each code. Text searches were also used to identify specific passages of text that were relevant to the research questions. Finally, the coded data were exported as html files. Graphs were generated using SPSS and GraphPad Prism.

Quantitative analysis

Test scores

The maximum possible score of the pre-test was 35. The total pre-test scores did not differ among groups (S, M and C), as shown by statistical analysis (Table 1, Row 1; p value = 0.947; ANOVA). The age and gender of the groups were also demographically comparable (see study procedure in Methods section above). The maximum possible score of the post-test was also 35. The total post-test scores also did not differ among groups, as shown by statistical analysis (Table 1, Row 2; p = 0.233, ANOVA). The difference between the total post-test and pre-test scores, which indicates the increase/decrease in the students’ understanding, also failed to show a statistically significant difference among groups (Table 1, Row 3; p = 0.226, ANOVA).

Table 1 Table showing total scores secured in Pre/post test.

Test	Stereo Mean (±SD) (Max. possible score for pre/post test – 35)	Mono Mean (±SD) (Max. possible score for pre/post test – 35)	Control Mean (±SD) (Max. possible score for pre/post test – 35)	P value (Test)
Total Pre-test score	1 (±1.12)	0.94 (±0.93)	1 (±1.05)	0.947 (ANOVA)
Total Post-test score	16.98 (±7.18)	15.22 (±7.62)	14.47 (±7.84)	0.233 (ANOVA)
(Post-Test score) – (Pre-Test score)	15.98 (±7.11)	14.28 (±7.54)	13.47 (±7.63)	0.226 (ANOVA)

Domain-specific analysis indicated statistically significant difference among groups in the basic recall domain (Table 2; Row 1; p value = 0.001; ANOVA). The difference was statistically significant between the Stereo and Mono pair [S. Recall_Mean = 5.35 (±2.83) Vs M. Recall_Mean = 3.97 (±2.83); p value = 0.03; post hoc tests, Bonferroni corrections applied] as well as between the Stereo and Control group pair [ S. Recall_Mean = 5.35 (±2.83) Vs C. Recall_Mean = 3.32 (±2.33); p value = 0.001; post hoc tests, Bonferroni corrections applied].

Table 2 Table showing domain-wise analysis of post-test – pre-test (difference) scores. * indicates statistical significance

Test	Stereo Mean (±SD)	Mono Mean (±SD)	Control Mean (±SD)	P value (Test)	Bonferroni corrections/ Post-hoc analysis. P value			(Cohen’s d) Effect size
Basic Recall based questions (Recall)	5.35 (±2.83)	3.97 (±2.83)	3.32 (±2.33)	0.001* (ANOVA)	S,M	0.03*		0.488
					S,C	0.001*		0.783
Analytical based questions (Anal)	3.28 (±2.06)	3.44 (±2.45)	3.74 (±3.05)	0.661 (ANOVA)	N/A			N/A
Radiology based questions (Rad)	4.68 (±1.69)	4.09 (±2.09)	3.14 (±2.02)	<0.001* (ANOVA)	S,C		<0.001*	0.827
					M,C		0.046*	0.462
Diagram based questions (Diag)	2.78 (±1.63)	2.78 (±1.62)	3.27 (±1.50)	0.196	N/A

A statistically significant difference was also noted in radiology-based questions in the test (Table 2; Row 3: p value < 0.001; ANOVA). The difference was statistically significant between the Stereo and Control pair [S. Rad_Mean = 4.68 (±1.69) Vs C. Rad_Mean = 3.14 (±2.02); p value <0.001; post hoc tests, Bonferroni corrections applied] and between the Mono and Control pair [M. Rad_Mean = 4.09 (±2.09) Vs C. Rad_Mean = 3.14 (±2.02); p value = 0.046; post hoc tests, Bonferroni corrections applied]

There was no statistically significant difference in the scores of analytical questions or diagram-based questions (Table 2; Rows 2 and 4).

Cognitive loads

The perceived cognitive loads by the students showed a statistically significant difference among the groups for germane cognitive load (GL) (Table 3, Row 3; p value = 0.001; ANOVA). The difference was statistically significant between the stereo and control pair [S. GL _Mean = 33.28 (± 5.35) Vs C. GL _Mean = 28.18 (± 8.17); p value = 0.002; post hoc tests, Bonferroni corrections applied] and mono and control pair [M. GL _Mean = 32.80 (± 7.91) Vs C. GL _Mean = 28.18 (± 8.17); p value = 0.005; post hoc tests, Bonferroni corrections applied]. There was no statistically significant difference among groups in intrinsic (IL) and extrinsic loads (EL).

Table 3 Table showing perceived cognitive load domains of the three groups. * indicates statistical significance

Cognitive load domain	Stereo Mean (±SD)	Mono Mean (±SD)	Control Mean (±SD)	P value (ANOVA)	Bonferroni corrections/ Post-hoc analysis		(Cohen’s d) Effect size
Intrinsic Load (IL)	16.71 (± 6.13)	16.57 (± 7.72)	17.98 (± 5.40)	0.487
Extrinsic Load (EL)	2.37 (± 3.97)	1.39 ( ± 2.66)	2.80 (± 3.67)	0.122
Germane Load (GL)	33.28 (± 5.35)	32.80 (± 7.91)	28.18 (± 8.17)	0.001*	S,C	0.002*	0.739
Germane Load (GL)	33.28 (± 5.35)	32.80 (± 7.91)	28.18 (± 8.17)	0.001*	M,C	0.005*	0.575

Subjective Feedbacks Questionnaire

The subjective feedback questionnaire mean responses on the 5-point Likert scale are shown in Fig 6 (error bars indicate standard deviation). S and M showed a higher mean response in the first 10 statements. The ones that showed statistically significant differences among the groups (as per ANOVA) are shown with a red star. Two red stars beside the comments (see Fig 5; statement numbers 1, 3, 6, 7, 8, 9 and 10) indicate statistically significant differences for S when compared to C and for M when compared to C. A single star indicates a statistically significant difference for S when compared to C (see Fig 5; Qn 5).

Qualitative analysis

Relevant themes generated about stereo and mono demonstration from pooled comments from S/M demonstration or after an

swap or CàS swap are presented in Table 4. Fourteen themes were generated, which mentioned both general advantages (size comparisons possible, realistic and different perspectives (Theme 4); interesting software features (Theme 3); and better attention (Theme 8), as well as specific advantages for learning radiological anatomy (Theme 7) and sectional anatomy (Theme 9)). There were also specific disadvantages and concerns, such as eye strain (Theme 12), low light ambiences (theme 1), and software glitches, especially the pointer used by the teacher (Theme 10).

Some students even mentioned cost concerns (Theme 11, comment 1) and about whether all teachers would be able to learn this technology (Theme 11, comment 3) as well as whether it would make students rely less on their own spatial sense (Theme 13). Although stereo display gave better spatial understanding, some commented that mono display would still be sufficient (Theme 6). Availability of the software on a web platform or mobile platform was also suggested, mentioning that Mono would be enough for that (Theme 14).

The current study sheds light on the pedagogical advantages of a newer indigenously developed technology for visualizing anatomy in Indian anatomy education scenario and provides insights into the merits and demerits of the technology through the comments of the students.

The pretest scores (Table 1, Row 1) and the demographic data (see Study procedure in Background) of the S, M and C groups indicate comparability of the three groups before the intervention. Although the total test scores were not significantly different for the three groups (Table 1, rows 2 and 3), domain-wise analysis showed significant improvement for the S group compared to the M and C groups in the basic recall test. Recalling terms, orientations, relations, etc., in anatomy is a complicated process. Optimal instructional techniques create a favorable cognitive environment that enhances their ability to recall. Earlier, it was mentioned that stereopsis in the personal space (up to a 2 m radius around a person), as during performing dissection, observing prosections, manipulating a manikin or a physical anatomical model, provides a substantial advantage in perceiving depth and spatial information. Providing stereopsis in the action space (2 m-30 m), as in the case of stereo display (S mode in our experiment), should create such an effect for the large group of students tested here. The statistically significant difference of S. Recall_Mean compared to C. Recall_Mean with a large effect size (Cohen’s d = 0.783) indicates that stereopsis in the action space created by S mode display was effective in providing critical details of depth and spatial information augmenting their ability to recall. This was also highlighted in the students’ comments, where they mentioned that the S mode enabled them to appreciate anatomy better (Table 4: Theme 4, Comments 1–3). The interactive and dynamic interface of AnaVu may also have contributed to the effects of stereoscopy (Table 4: Theme 3, Comments 1–4). Their opinions about understanding size differences and relations were higher for S and M compared to C (see Fig. 6, statements 9 and 10).

This effect of the S mode was better even when compared with the M mode, as indicated by S. Recall_Mean compared to M. Recall_Mean with a moderate effect size (Cohen’s d = 0.488). This may indicate that although there are depth cues in the M mode (perspective projection, shadings, occlusion, motion perspective, familiar size), as discussed earlier, they may not be adequate to create sufficient depth perception to influence anatomical learning. Depth cues were utilized in the design of the interactive 3D viewport of AnaVu. As stereoscopy is a significant part of visual perception that aids in understanding the spatial disposition of the world around us, this finding may indicate the value of stereopsis in anatomical learning and the superiority of stereoscopic visual display in anatomy education compared to monoscopy.

However, from a subjective perspective, students appreciate the M mode. Certain comments from students mentioning that the M mode is sufficient for their learning of spatially complex structures (Table 4: Theme 6, Comments 1–4) may indicate that students subconsciously appreciate the depth cues in the M mode. Considering the fact that stereo display has inconveniences (needs more complex hardware support, darker rooms, and 3D goggles), these subjective advantages of M mode display are relevant. One comment particularly mentions a need for web-based availability of the AnaVu software system and mentions that M mode will be sufficient for that (Theme 14, Comment 1). This indicates that students are particularly leaned to obtain e-learning resources suitable for revision (58) in mobile phones or hand-held devices and may not be that demanding on the mode of visualization for that purpose. As students’ subjective preferences need not always be objectively leading to better learning outcomes, as in the case of many e-learning modalities (59), these responses are relevant.

Another domain that showed a statistically significant advantage was for learning radiological anatomy. As familiarizing anatomy students with radiological anatomy helps them integrate different subjects (47), makes anatomy learning effective (48) and improves spatial reasoning skills (49), the advantage of AnaVu to teach radiological anatomy is twofold. The current CBME curriculum in India envisages vertical integration across basic and clinical disciplines. It also encourages early clinical exposure to first-year medical students (35). In this context, teaching anatomy from stereoscopic models generated from T1 weighted MRI images and displaying the anatomy and the radiological source images in a 3D mode correlatable to the 2D MRI images can be an effective technological solution for bridging the gap between radiological anatomy and gross anatomy. Anatomy and radiology are usually considered complementing disciplines that have an enormous scope for integration. Hence, this tool is a promising approach for radiological anatomy teaching. Considering the fact that S. Rad_Mean Vs C. Rad_Mean had a high effect size (Cohen’s d = 0.827; Table 2, Row 3) and M. Rad_Mean Vs C. Rad_Mean had a moderate effect size (Cohen’s d = 0.462; Table 2, Row 3), using this tool in the S mode or in the M mode is effective for radiological anatomy teaching. Students expressed their appreciation of the tool (in both modes) in understanding radiological anatomy (see theme 7, comments 1–3). One student in the S◊M swap cohort mentioned clearer perception of the MRI in M mode. This may be because, in S mode, the MRI sections appearing as “planes projecting out from the screen” in the stereo space may be uncomfortable for students to visualize, as their eyes have to sequentially converge/diverge and accommodate to focus on nearer and farther structures in the “projecting plane”. In M mode, although the view is the same, the absence of stereopsis/ “projecting planes” may be more comfortable for the eyes, making it easier to survey through the MRI plane.

Students’ perceived cognitive loads had a high effect size (Cohen’s d = 0.739) for S Vs C and a moderate effect size (Cohen’s d = 0.575) for M Vs C. This is reflected in the students’ comments showing increased interest, attention and excitement while learning with AnaVu. This was more with S than with M (See Table 4, Theme 8, Comments 1 and 2). These positive comments are also seen in the students’ subjective feedback questionnaire responses (see Fig. 6, Statements 1 and 3).

Students also appreciated pedagogical aids in the software, such as zooming, panning, and opacity reduction, which provided the opportunity to view specific anatomical details (Table 4; Theme 3, Comments 1–4). Students also mentioned that they appreciate similar teaching methods in the future (Fig. 6; Statement 5). They also mentioned that this mode of learning helped them improve their visuospatial skills (Fig. 6; Statement 8).

Inspite of all these positive opinions, there were specific thoughts on negative aspects of the module in S mode as well as in M mode. Low light ambience, which was needed for the S mode projection, was a hindrance for students interested in taking down notes. Low light also induced disinterest and sleepiness and precluded interaction with the teacher (see Table 4; Theme 1, Comments 1–3). The students had positive and negative reflections on the use of colors in the 3D annotated model. Some students felt the use of colors made it clear (Theme 2, comment 2), while others preferred realistic colors. The use of colors in the 3D model is a consequence of manual or automated segmentation using software tools. This enables the distinction of one structure from the other but at the cost of losing tissue realism. One solution for this problem would be to use surface and texture rendering methods or incorporate other technologies for creating gross anatomy-based 3D graphic models with surface scanning (20) or photogrammetry (18). However, as long as the model is generated from radiologic sources, the 3D models may have less tissue texture realism, but their shape and spatial correlates will be more realistic. The teacher may have to adopt the appropriate technique based on the specific objective of the visualization – spatial anatomy, relations or texture features (19). The students’ comments mentioning that the graphic model looks like “clay models” (Table 4; Theme 11, Comment 1) may have been due to their expectation of seeing texture realism and the apparent disconnect with what they saw in the anatomy dissection session. The student’s observation that anatomy atlas pictures are far more realistic indicates the need to complement such technology with artistic approaches or other modes of visualization.

The major disadvantage of the S mode of display was related to the eyewear. Students had reported discomfort and inconvenience while wearing 3D glasses (Table 4, Theme 12, Comment 3), which was more for those using spectacles (Comment 4). Though students appreciated the better precision in visualization of the S mode of display, many found it a strain for the eyes (Comment 1,2). Students also mentioned certain software issues, particularly that the appearance of the mouse pointer had glitches and may affect the teaching (Table 4; Theme 10, Comments 1 and 2). They also expressed concerns about the utility of the software among teachers and the cost factors (Table 4; Theme 11, Comments 1–3). An interesting speculation by a student was whether using such technology may interfere with their reliance on their own mental spatial abilities (Table 4, Theme 13, Comment 1).

Technological solutions for educational effectiveness are an area where Indian medical education is stepping into and is highly relevant as the NMC has commenced the futuristic CBME curriculum. As the newer e-learning techniques using hand-held devices, web-based platforms and computer-assisted learning modalities are increasingly being relied on (40), the understanding of the relevance of stereopsis (by means of stereo display) in this study will help in developing e-learning and self-learning strategies in anatomical education. The enhancement in basic recall and utility for radiology education using the low-cost AnaVu stereo display may encourage anatomy educationalists to actively seek methods for making students learn anatomy through visualization. The specific disadvantages of the stereo display and the areas where a mono display is effective along with the students’ subjective perspectives can help teachers choose the best visualization method in an informed manner.

S: Stereoscopy

M: Monoscopy

C: Control

3D: Three-Dimensional

2D: Two-Dimensional

IL: Intrinsic Load

EL: Extrinsic Load

GL: Germane Load

CBME: Competency-Based Medical Education

NMC: National Medical Council (of India)

ANOVA: Analysis of Variance

RDQA: R package for Qualitative Data Analysis

SD: Standard Deviation

A part of this study (development of the tool) has been presented in the annual conference of the Anatomical Society of India (Kerala State Chapter) on May 2023.

A part of the results of this study has been accepted for oral/podium presentation at the Asia Pacific International Congress of Anatomy - Australian and New Zealand Association of Clinical Anatomists joint conference (ANZACA – APICA 2023) to be conducted on November – December 2023.

Availability of data and materials

The datasets generated and analyzed during the course of this study are not publicly available due to concerns about the privacy of participants but are available from the corresponding author upon reasonable request.

Acknowledgments

We thank Prof. M.S. Valiathan, National Research Professor and Padma Vibhushan awardee, for being the leading light who gave us the inspiration and the vision to pursue this project. We thank the Science and Engineering Research Board, Department of Science and Technology, Govt. of India, for their constant expert feedbacks and suggestions which has significantly improved the conduct of the project as well as the current study. We thank the staff of the Anatomy Department and the former and the current heads of the Department, Dr Lathikumari (Retired) and Dr Usha Devi KB, whose invaluable support was instrumental for the conduct of the study.

We acknowledge the students of the 2022 cohort for their active participation in the study.

We thank,

Ms. Mythri V (former research scholar, IIIT, Hyderabad) and Ms. Alphin J Thottupattu (former research scholar, IIIT, Hyderabad) for support during the image processing and development of the software.

Dr. Soumya Gopakumar, Assistant Professor of Community Medicine, for her assistance in statistical analysis.

Mr Praveen James, Clinical Engineer, SCTIMST; Ms. Renjima G, Project Technician, Virtual Neuroanatomy project, SCTIMST, for their sincere assistance in the conduct of this project.

Dr. Amogh B Jayakumar for his expert assistance in various parts of conducting the project and writing the manuscript.

Funding Statement

The project was funded by the Science and Engineering Research Board (Grant No. IR/SB/EF/03/2016), Department of Science and Technology, Government of India.

Authors’ contributions

DGY: Annotation of the model, conceptualized and developed the idea, designed the study, performed the anatomy instruction, analyzed and interpreted the data and drafted the manuscript.

AMO: Designed the study, performed the anatomy instruction, interpreted the data and played a role in drafting and critically revising the manuscript.

ASK, SD, MR, NS, NET, NA: Implementation, collection of data and teaching support

NKR: Statistical data analysis and prepared table 4, and figures

BT, JER: MRI image acquisition, annotation of the model, visualization requirement specification and feedback on user-interface of the software tool

UKG: Conceptualization and organization of the study, statistical data analysis

PH: Conceptualisation, design and engineering of AnaVu tool

TRK: Mentor and advisor who oversaw the study with timely, insightful guidance

CK: MRI image acquisition, annotation of the model, visualization requirement specification and feedback on user-interface of the software tool, and supervision of the study.

JS: Primary investigator of the project. Visualization of the model, conceptualization, organization, supervision and overseeing the study.

The authors have read and approved the final manuscript.

Corresponding author: Dr Doris George Yohannan, Assistant Professor of Anatomy, Government Medical College, Thiruvananthapuram

Email: [email protected]

Ethics declarations

Ethics approval and consent to participate

The study was approved by the Human Ethics Committee of Government Medical College, Thiruvananthapuram (GMCT). The HEC gave a letter dated 02.07.2019 stating that the study is exempted from review based on the 2017 ICMR guidelines, as it is a study assessing educational techniques in medical students. Written consent was obtained from the participants by providing an information handout and consent form. The participants were informed about the purpose, nature and procedure of the study as well as the fact that their participation was voluntary. They were assured confidentiality and that the data would be used only for research purposes. They were also informed that when the data will be published their personal details will be kept confidential.

Consent for publication

Not applicable

Competing interests.

The authors declare that they have no competing interests.

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Table 4 is available in the Supplementary Files section

No competing interests reported.

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“Visualization matters” – Stereoscopic visualization of 3D graphic neuroanatomic models through AnaVu enhances basic recall and radiologic anatomy learning when compared with monoscopy

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Abstract

Figures

Background

Stereoscopy vs Monoscopy in Anatomy Learning Environments

Indian Medical education and its recent changes

Neuroanatomy education in India

Radiological anatomy in neuroanatomy teaching

Cognitive loads in instructional design

AnaVu – An Anatomy Viewing tool

Research question

METHODS

Sample

Topic and justification

Pre-Test and Post-Test

Perceived Cognitive Load assessment tool

Subjective Feedback Questionnaire

Study procedure

Analysis

Results

Quantitative analysis

Test scores

Cognitive loads

Subjective Feedbacks Questionnaire

Qualitative analysis

Discussion

Conclusions

Abbreviations

Declarations

References

Table

Additional Declarations

Supplementary Files

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