Effectiveness and Satisfaction of Virtual Dissection on Medical Students: Randomized Controlled Trials Compared to Cadaver Dissection

doi:10.21203/rs.3.rs-4175504/v1

Recent technological advancements have revolutionized medical education, leading to a decline in traditional cadaver dissection. This study aims to investigate the academic performance and satisfaction of students by comparing the effectiveness of virtual and cadaver dissections. This study involved 154 first-year medical students who participated in Human Anatomy and Neuroanatomy laboratories. A curriculum using head-mounted displays (HMDs), life-sized touchscreens, and tablets, was developed. Through crossover randomized controlled trials, students were randomly assigned to virtual (virtual dissection à cadaver dissection) or cadaver (cadaver dissection à virtual dissection) groups. Data collected evaluated academic performance and student satisfaction through quizzes and surveys. In the Human Anatomy laboratory, the cadaver group for each class differed in heart extraction, dissection, and observation. In observation class, the virtual group had a significantly higher quiz score than the cadaver group. In other classes, no significant differences were observed. Compared to the cadaver, satisfaction was significantly higher for HMD (esthetics and immersion), life-size touchscreen (esthetics, understanding of the concept, and spatial ability), and tablets (esthetics, understanding of the concept, spatial ability, and continuous use intention). In the Neuroanatomy laboratory, the virtual group showed significantly higher quiz scores than the cadaver group. Compared to using cadavers, tablets showed a significantly higher satisfaction for esthetics, understanding of the concept, and spatial ability. These findings indicate that virtual dissection can supplement or replace cadaver dissections in medical education. This study is innovative in that it successfully delivered scenario-based virtual content and validated the efficacy in academic performance and satisfaction when using virtual devices compared to handling cadavers.

Trial registration: This research has been registered in the Clinical Research Information Service (CRIS,

https://cris.nih.go.kr/cris/search/detailSearch.do?search_lang=E&focus=reset_12&search_page=L&pageSize=10&page=undefined&seq=26002&status=5&seq_group=26002) with registration number "KCT0009075" and registration date "27/12/2023".

Health sciences/Anatomy

Health sciences/Cardiology

Health sciences/Neurology

Scenario-based virtual content

Virtual dissection

Head-mounted display

Life-sized touchscreen

Tablet

Heart anatomy

Neuroanatomy

Traditional human anatomy education has historically relied on cadavers for studying the human body's structure (Turney 2007; Eizenberg 2015), but alternative methods are emerging due to issues like cadaver scarcity, high costs, formaldehyde exposure, ethical concerns, and pandemic-related challenges (McMenamin et al. 2018; Guttmann, Drake, and Trelease 2004; Washmuth et al. 2020). Recently, universities have decreased anatomy laboratory hours and even removed cadaver-based instruction from some curricula (McLachlan et al. 2004; Leung et al. 2006; Pryde and Black 2006). The coronavirus disease 2019 pandemic has further disrupted anatomy education globally, creating challenges for educators and students (Pather et al. 2020; Edigin et al. 2020; Yun et al. 2022). In response to these challenges, technological advancements and diverse digital resources have played a crucial role in mitigating these disruptions and enabling medical education to continue (Remtulla 2020; Hayat et al. 2021; Sharma and Bhaskar 2020; Owolabi and Bekele 2021). Consequently, medical students are increasingly required to augment or substitute their anatomy education with digital resources due to reduced access to cadavers and time constraints (Clunie et al. 2018).

The concept of Metaverse, which combines “meta” meaning beyond, transcendence, or reality, and “verse” meaning universe or world, has been extensively discussed since 2021. The Metaverse has diverse applications in various fields such as social activities, education, gaming, payments, and medicine (Yang et al. 2022). Virtual reality (VR) holds significant value in medical education, particularly in enhancing technical skills and three-dimensional (3D) visualization in areas like anatomy teaching, surgical training, and cardiopulmonary resuscitation (Pandya and Pandya 2018; Kilmon et al. 2010; Soler et al. 2014). Previous studies have shown that immersive VR enhances learner engagement and practical skills (Radianti et al. 2020; Mansoory et al. 2022). Given the convenience and widespread use of digital education, VR has immense potential as an educational tool for medical students. VR is a broad concept with many different devices and applications. A typical VR simulation system includes a headset, two controllers, and simulation software (Stirling and Moro 2020).

Furthermore, mobile learning (M-learning) devices, such as smartphones and tablets, enable wireless communication, continuous Internet access, and virtual conferencing. They have become popular due to their versatility and multifunctionality. Several studies have indicated that most medical students own these devices, and this trend is increasing (Lau and Kolli 2017; Tran et al. 2014; Kadimo et al. 2018). M-learning can enhance student motivation, a crucial element in self-directed learning (Sharples 2000; Towle and Cottrell 1996). These devices also facilitate the transition from formal to informal or personal to social learning environments, fostering student engagement (Dias and Victor 2022). Previous studies have demonstrated that medical students highly value mobile devices for usability, utility, learning autonomy, and self-efficacy (Kucuk, Baydas Onlu, and Kapakin 2020; Patil et al. 2016; Sha et al. 2012). Mobile learning is perceived to complement traditional learning methods.

Virtual dissection tables such as MDBox™ (Medical IP Co., Ltd., Seoul, Republic of Korea), Anatomage Table™ (Anatomage Inc., San Clara, CA), and Sectra Table™ (Sectra AB, Linkhöping, Sweden) are becoming increasingly adopted by many leading medical schools and institutions worldwide. The Anatomage Table™ is an all-in-one touch-interactive display system, and Sectra™ and Anatomage Tables™ also have a built-in digital imaging and communications in medicine viewer for displaying the computed tomography and magnetic resonance imaging scans (Borgbjerg 2021). These technologies have become more prevalent, and studies supporting the specific use of visualization tables (Shi et al. 2019a; Ward, Wertz, and Mickelsen 2018) and other 3D visualization technologies (Yammine and Violato 2015) have contributed to this trend. These large interactive screens enhance the visualization and accessibility of anatomical structures (Shi et al. 2019b; Bartoletti-Stella et al. 2021; bokuennews 2019). Boscolo-Berto et al. conducted a randomized controlled trial (RCT) with 23 medical students being taught anatomy using either the Anatomage Table™ or textbooks (Boscolo-Berto et al. 2021). Subsequently, both groups performed cadaver dissection. Seventy percent of all students in the group using the Anatomage Table™ said it helped them learn.

3D anatomy software is increasingly used in anatomy education as smartphone and tablet applications gain popularity (Zarcone and Saverino 2022). Novel commercial anatomy applications like Complete Anatomy®, Visible Body®, and Pocket Anatomy® enables students to explore anatomical structures through 3D models, providing flexibility in viewing and manipulation (Lewis et al. 2014; Peterson and Mlynarczyk 2016; Yammine and Violato 2015). As highlighted by Park group paper (Park et al. 2019), most students find 3D anatomy software more effective than traditional two-dimensional atlases (Triepels et al. 2018). Additionally, a study on genital system anatomy by (Bolatli and Kizil 2022) demonstrates that students using mobile applications experienced lower anxiety levels than those involved in cadaver dissection.

Achieving effective digital anatomy education goes beyond just transitioning from cadavers to digital methods; it requires content redesign. Additionally, specialists are needed to supervise the design of digital anatomical scenarios (Wickramasinghe, Thompson, and Xiao 2022). Digital learning scenarios guide learners in a digital environment, requiring careful planning that considers target learners, goals, objectives, intended outcomes, and contexts (Harrington and Simon 2022). In academic and clinical contexts, scenario-based simulations are increasingly used in medical education (Nagle et al. 2009). Scenario-based learning provides students with the opportunity for active engagement and skill-building opportunities for daily living (Yarnall et al. 2007), bridging the gap between theory and practice (Errington 2011; Zilverschoon et al. 2019).

Various studies have investigated students’ preferences for different approaches to learning anatomy (Bandyopadhyay and Biswas 2017; Tayyem et al. 2019; Choi-Lundberg et al. 2016; Cahill and Leonard 1997; Jaiswal et al. 2015). One study found that most students considered traditional anatomy teaching methods ineffective and recommended combining several modalities, notably cadaver dissection and multimedia sessions (Tayyem et al. 2019). According to a study by Rashmi et al., 54.26% of students favored multimedia teaching methods as the best anatomical teaching method (Jaiswal et al. 2015). Several studies emphasize the potential impact of integrating digital technologies in medical education for future learning and assessment (Tabatabai 2020; Weissmann, Useini, and Goldhahn 2021; Austin et al. 2021). These findings reveal that virtual technologies are effective in medical education, enhancing anatomical learning and serving as viable alternatives to traditional cadaveric methods.

The heart and brain are among the most complex medical gross anatomy curriculum. First-year medical students have difficulty understanding the heart’s anatomical structure and positional relationships during cadaver dissection. Heart dissection is challenging owing to the complex 3D interrelations of its parts (Stanford et al. 1994). The heart is positioned within the thorax (Anderson et al. 2013). It is difficult to study the interrelationships of cardiac components and identify individual components in a dissecting laboratory while the organ remains embedded within the mediastinum and encased by the thorax. Neuroanatomy is another challenging subject for many novice students (Allen et al. 2018; Obrero-Gaitan et al. 2021). This requires students to thoroughly understand numerous neuroanatomical structures, vessels, and nerves and their complex spatial relationships (Allen, Eagleson, and de Ribaupierre 2016). A previous study has confirmed that neuroanatomy is among the most difficult subjects (Hall et al. 2018). Therefore, enormous educational needs should be met for the spatial understanding of heart and brain anatomy.

This study aimed to develop scenario-based virtual content and validate students’ academic performance and satisfaction by comparing the effectiveness of virtual and cadaver dissections. We focused on the application of head-mounted displays (HMDs) for VR, life-sized touchscreens, tablets, and related software for heart and brain dissection, possibilities based on current technology, and barriers preventing their widespread adoption in medical education. Our four specific research questions guided this study: (1) Are there differences in student academic achievement when using virtual and traditional cadaver dissections?; (2) Are there differences in students’ satisfaction when using virtual and traditional cadaver dissections?; (3) Are there specific advantages and disadvantages in using a cadaver and the three virtual devices in terms of esthetics, understanding of the concept, reality, spatial ability, immersion, and continuous usage intention?; and (4) Can virtual dissection complement or replace traditional cadaver dissection?

2.1 Sample size

We assumed that 62 ± 11 vs. 68 ± 11 in the mean quiz scores between the cadaver and virtual groups would indicate a meaningful effect. To detect this difference in means with a significance level of 95% and a power of 0.90, we estimated that a total sample size of 142 students would be necessary.

2.2 Participants

The subjects of this study were first-year medical students who took Human Anatomy and Neuroanatomy courses and at least 19 years old on the date of study entry at the Seoul National University College of Medicine (SNUCM), Seoul, Republic of Korea, in 2021. A total of 154 students were enrolled in both courses during that year.

2.3 Curriculum Development

Based on the Analysis, Design, Development, Implementation, and Evaluation (ADDIE) model (Piskurich 2015), we developed and applied an anatomical education curriculum using digital technologies in the five main stages: analysis, design, development, implementation, and evaluation) and evaluated its effectiveness. Table S1 presents the curriculum-development process used in this study.

2.4 Study Design

To ensure a consistent learning experience for all students, we conducted crossover RCTs with two intervention arms: virtual and cadaver groups. Students were randomly assigned to undergo either cadaver dissection followed by virtual dissection or vice versa using a lottery method. Human Anatomy and Neuroanatomy laboratories each lasted for 2 hours. Both the virtual and cadaver dissection laboratories lasted for 50–54 minutes, after which the students took a 3-6-minute Quiz 1 (Q1, primary outcome). The students also took a 3-6-minute Quiz 2 (Q2) and a 6-8-minute survey at the end of the laboratory (Secondary outcome).

2.4.1 Study Design of the “Human Anatomy” Laboratory

A flow diagram of the Human Anatomy laboratory is shown in Fig. 1. The 154 students were randomly divided into three classes: class A (n = 49), class B (n = 52), and class C (n = 53). In each class, the students were randomly assigned to two groups: a virtual group (virtual dissection ◊ cadaver dissection, n = 72) and a cadaver group (cadaver dissection ◊ virtual dissection, n = 82). In the cadaver dissection lab, three situations were presented, contributing to different student experiences: heart extraction (class A), dissection (class B), and observation (class C). Figure S1 illustrates the schedule of the virtual dissection in the Human Anatomy lab using HMD, life-sized touchscreens, and tablets. The three virtual devices were used in the virtual dissection lab for 54 minutes (Figure S1a). Every 18 minutes, these teams rotated and had the opportunity to experience the three technologies. Because three HMDs were available, three students formed a group; each student spent 6 minutes actively using the HMD while observing it for the remaining 12 minutes (Figure S1b). Three tutors were assigned, each responsible for the three students within their groups. When using the life-sized touchscreen, all nine students gathered around it and one tutor was assigned to teach them (Figure S1c). In contrast, each student was provided with a tablet; three tutors were assigned to support and guide approximately nine students in using the tablets (Figure S1d).

2.4.2 Study Design of the “Neuroanatomy” Laboratory

Figure 2 shows the flow diagram of the neuroanatomy lab. All 154 students were randomly allocated to three classes: class A (n = 52), class B (n = 49), and class C (n = 53). Students in each class were randomly divided into two groups: a virtual group (virtual dissection ◊ cadaver dissection, n = 73) and a cadaver group (cadaver dissection ◊ virtual dissection, n = 71). All classes conducted cadaver dissections under the same conditions. In contrast, in the virtual dissection lab, the students exclusively used tablets.

2.5 Devices and Software

Three types of devices were used in this study: Anatomage Table™ (Anatomage, Inc., Santa Clara, California, USA), iPads® (Apple Inc., Cupertino, California, USA), MDBox™ (Medical IP Co., Ltd., Seoul, Republic of Korea) with Oculus Quest 2 HMDs (Meta Platforms, Inc., Menlo Park, California, USA) and two touches. Three anatomy software programs were used: Anatomage™ (Anatomage, Inc., Santa Clara, California, USA), Complete Anatomy® (3D4Medical, San Diego, California, USA) and MDBOX™ (version 1) (Medical IP Co., Ltd., Seoul, Republic of Korea).

2.6 Content Scenario for Virtual Dissection in “Human Anatomy” Laboratory

The contents are organized in a specific order, starting with the coronary artery, followed by the chamber, valve, and conducting system. The tutors prepared virtual content scenarios in advance using an HMD (Figure S2), a life-sized touchscreen (Figure S3), and a tablet (Figure S4). The specific contents explained by the tutor under each topic can be found in Appendix S1. The heart content was stored in the library and accessible through preset tabs in HMD-based (Supplementary video 1), life-sized touchscreen-based (Supplementary video 2), and tablet-based laboratories (Supplementary video 3).

2.7 Content Scenario for Virtual Dissection of “Neuroanatomy” Laboratory

The contents covered various diencephalon and telencephalon structures and structures associated with the third and lateral ventricles. The tutors prepared scenarios for the content in advance using a tablet (Figure S5). Detailed contents explained by the tutor for each topic can be found in Appendix S2. The contents were stored in the library and accessible through preset tabs in the tablet-based laboratories (Supplementary video 4).

2.8 Quiz and Survey

Data were collected from the Q1 and Q2 results to determine if virtual or cadaver dissection laboratory increased academic performance. In addition, an online Google Forms questionnaire asked students about their demographics (gender and age) and satisfaction with the virtual and cadaver dissection laboratories. The satisfaction survey was conducted after revising and supplementing it according to the study purpose by referring to the questions used by Bae and Kwon (Bae and Kwon 2018). Students were asked to evaluate satisfaction with the cadaver, HMD, life-sized touchscreen, and tablet using 5-point Likert-type scale score (1 = very unsatisfied and 5 = very satisfied) on 6 categories with 3 subscales; esthetics (utility, design, and vividness), understanding of the concept (labeling, desired angles, and comprehension), reality (anatomical structures, environment, and real world), spatial ability (facilitated observation, intuitive understanding, and spatial perception), immersion (desire to continue, sense of being in another space, and forget about daily life), and continuance usage intention (re-experience, repetition, and experience in different structures). Appendix S3 presents the questions for each subscale within the categories.

2.9 Statistical Analysis

All statistical analyses were performed using SPSS version 26 (IBM Corp., Armonk, NY, USA). We used the 2-tailed Student’s t-test to assess the differences in quiz scores between the virtual and cadaver groups and considered p < 0.05 statistically significant. In addition, we used one-way ANOVA and Scheffe’s post hoc tests to identify differences between cadavers, HMD, life-sized touchscreens, and tablets.

2.10 Ethical approval

This study was approved by the Institutional Review Board of Seoul National University Hospital (IRB number: C-2103-066-1203). All methods were performed in accordance with relevant guidelines and regulations. Only students who agreed to participate were surveyed and informed consent was obtained from all the participants. Students not participating in this study were also provided equal opportunities for virtual and cadaver dissection laboratories. In addition, informed consent for cadaver donation was obtained from the donor or their next of kin.

3.1 Subject Characteristics of “Human Anatomy” Laboratory

Out of total 158 students, 154 first-year medical students who attended the Human Anatomy laboratory at SNUCM were recruited on April 8, 2021, with 4 students being absent. They completed the Human Anatomy laboratory and responded to the survey. As shown in Table 1, the mean (SD) age of students is 20.8 (1.2) years. Most students were male (69.5%), while 30.5% were female. Students reported having a personal tablet (54.5%) or shared family tablet (6.5%), whereas 39.0% of students reported not having a tablet. Among the 92 students who owned a tablet, most (76.1%) used it for educational purposes, 4.3% for playing games, and 19.6% for watching videos or movies. More than half (59.7%) of the students reported never using VR. The percentage of students using it 2-3 times a week, once a week, or once a day is also small (0.6% each). Among the 62 students with experience using VR technology, most (87.1%) used it to play games, 1.6% used it for educational purposes, 9.7% used it to watch videos or movies, and only 1.6% used it as research participants. Among the students who played VR games, 40 (26.0%) played once a year, 7 (4.5%) played once a month, 1 (0.6%) played 2-3 times a week, 4 (1.9%) played once a week, and 1 (0.6%) played once a day. Additionally, 104 students (67.5%) did not use graphic design software.

3.2 Academic Achievements of “Human Anatomy” Laboratory

In the Human Anatomy Laboratory, the curriculum for the virtual group was consistent across all classes, whereas the cadaver group had different activities in each class (Figure 3): In class C, the virtual group had a significantly higher Q1 score than the cadaver group (p < 0.05), but no significant differences were observed in classes A and B (Figure 3a). When all three classes were combined, the mean Q1 score for the virtual group was slightly higher than that of the cadaver group; however, the difference was not statistically significant (Figure 3b). In Q2, there were no significant differences between the two groups in each class and within each class (Figure 3c) or when all three classes were combined (Figure 3d).

3.3 Survey Results of “Human Anatomy” Laboratory

Of the 154 students, more than half (63%) students reported preferring a virtual dissection laboratory. Of the students preferring cadaver laboratory (37%), 84.2% attributed it to the opportunity to physically interact with anatomical structures, while 15.8% attributed it to the sense of realism it offered. Fifty-five students (56.7%) felt that a tablet-based laboratory was the most helpful in learning anatomical structures, followed by HMD-based learning (29.9%) and life-sized touchscreen-based learning (13%). Students’ satisfaction in responding to the cadavers for dissection and devices for virtual dissection was investigated on a 5-point Likert scale (Figure 4).

Esthetics

Regarding utility and design, life-size touchscreens and tablets showed significantly higher satisfaction than cadavers (Figure 4a). Among the three virtual devices, the tablet resulted in significantly higher satisfaction. However, regarding vividness, the cadavers showed significantly higher satisfaction than the virtual devices.

Understanding of the Concept

With regard to labeling, the three virtual devices showed significantly higher satisfaction than the cadavers (Figure 4b). Moreover, regarding viewing the structure from the desired angle, the life-sized touchscreen and tablet revealed significantly higher satisfaction than the cadaver.

Reality

Regarding the anatomical structures and real world, the cadavers showed significantly higher satisfaction than the three virtual devices (Figure 4c). Similarly, satisfaction with the environment was significantly higher for cadavers than life-sized touchscreens and tablets. Among the three virtual devices, the HMD showed significantly higher satisfaction.

Spatial Ability

Regarding facilitated observations, life-sized touchscreens and tablets showed significantly higher satisfaction than the cadavers (Figure 4d). Additionally, regarding intuitive understanding, the tablet showed significantly higher satisfaction than the cadaver.

Immersion

Regarding the sense of being in another space, the HMD showed significantly higher satisfaction than the cadaver, life-sized touchscreen, and tablet (Figure 4e). However, regarding the desire to continue and forget about daily life, the cadavers showed significantly higher satisfaction than the HMD and life-sized touchscreen, respectively.

Continuous Usage Intention

Overall, the cadavers showed significantly higher satisfaction than the HMD (Figure 4f). Moreover, the tablet resulted in significantly higher satisfaction than the other two virtual devices and cadaver.

3.4 Subject Characteristics of “Neuroanatomy” Laboratory

Out of total 158 students, 154 first-year medical students who attended the Neuroanatomy laboratory at SNUCM were recruited on June 8, 2021, with 4 students being absent. They completed the neuroanatomy laboratory and participated in the survey. As shown in Table 2, the mean (SD) age of students was 21.9 (9.4%). Most of these students were male (70.8%), and only 29.2% were female. Students indicated that they owned a personal (93.5%) or family tablet (1.3%), whereas 8% reported not owning a tablet. Of the 146 students who used a tablet, more than half (59%) used it once per month. In addition, students (70.1%) bought virtual anatomy applications, mainly using Complete Anatomy (56.5%), followed by atlas (9.1%), anatomical learning (3.9%), and 3D anatomy (0.6%). Among the 108 students who bought virtual anatomy applications, 11.7% used them once a day, 12.3% once a week, 32.5% 2-6 times a week, 9.7% 2-3 times a month, and 3.9% once a month.

3.5 Academic Achievements of “Neuroanatomy” Laboratory

The virtual and cadaver groups in the Neuroanatomy laboratory had identical laboratory conditions for all the classes. Scores from Q1 and Q2 were compared to determine statistically significant differences in academic performance between the two groups (Figure 5). The Q1 mean score was statistically significant (p < 0.01)in class A, indicating that the virtual group performed at a significantly higher level than the cadaver group (Figure 5a). Although the virtual group in classes B and C had higher mean scores than the cadaver group, no significant differences were observed. As shown in Figure 5b, the Q1 mean score of all classes was significantly higher in the virtual group than in the cadaver group (p < 0.05). In Q2, we found no statistically significant differences between groups in all classes (Figure 5c) and between the groups (Figure 5d).

3.6 Survey Results of “Neuroanatomy” Laboratory

Of the 154 students, more than half (68.2%) found tablet-based laboratory better in understanding the diencephalon's anatomical structures and positional relationships. The remaining preferred the cadaveric dissection laboratory because of the opportunity to touch the structures (82.3%) and the sense of realism it provided (17.7%). Therefore, we compared the tablet-based and cadaver laboratories during a neuroanatomical course. On a 5-point Likert scale, students' satisfaction with the cadaver and tablet was assessed on a five-point Likert scale, as depicted in Figure 6.

Regarding esthetics (Figure 6a), satisfaction with the utility and design of the tablet was significantly higher, but there was no significant difference in vividness. In terms of understanding the concept (Figure 6b) and spatial ability (Figure 6d) for the three subscales, satisfaction with the tablet was significantly higher, whereas satisfaction with the cadaver was significantly higher for reality (Figure 6c). According to immersion (Figure 6e) and continuous usage intention (Figure 6f), there were no significant differences between the cadavers and tablets on the three subscales.

This study investigated whether virtual dissection could complement or replace cadaver dissection. We developed scenario-based virtual content for Human Anatomy and Neuroanatomy targeting first-year medical students using three virtual devices. Academic performance and satisfaction with virtual content were validated through RCTs. The study results demonstrated that virtual dissection yielded academic achievements superior or equal to those of cadaver dissection. In addition, most students expressed a preference for virtual dissection. Regarding esthetics, understanding concepts, and spatial ability, virtual dissection outperformed cadaver dissection. Among the virtual devices, the tablet showed superior satisfaction in terms of esthetics, understanding of the concept, spatial ability, and intention to continue using the virtual platform. In contrast, the HMD demonstrated superior satisfaction regarding the sense of reality in the environment and immersion, providing a sense of being in another space.

4.1 Study Design

In a recent report on essential competencies for lifelong learning, the European Parliament lists digital competence as one of eight fundamental abilities needed to thrive in a knowledge society (Aminu, Phillips, and Kolanko 2022). In particular, the widespread use of digital technologies and the subsequent increase in the need for digital competence have significantly affected the medical field. Therefore, the key question of this study was how to design a digital educational curriculum following the well-established ADDIE model in the field of instructional design. Our study illustrates how the ADDIE model can help design a curriculum for teaching medical students about the heart and brain. Although several studies have reported the ADDIE model in anatomy education (Cheung 2016; Eansor et al. 2021), none have provided a detailed digital anatomy curriculum. This study is the first to develop detailed virtual content based on the ADDIE model.

This study was the largest RCT conducted in virtual education in Human Anatomy and Neuroanatomy courses. Thus, the sample size was adequate to obtain accurate results. To the best of our knowledge, only a few RCTs on virtual anatomy have involved more than 100 participants (Hu et al. 2020; Can and Toraman 2022; Huang et al. 2018). Previous studies often acknowledged that their sample sizes were relatively small and recommended a cautious interpretation of the findings (Wang et al. 2020; Banerjee et al. 2023).

In the design phase, we selected three devices for virtual dissection. Previous studies have established that virtual devices can be useful supplements for medical students (Chytas et al. 2022; Boscolo-Berto et al. 2021; Bartoletti-Stella et al. 2021). However, no studies have specifically investigated using multiple virtual devices, such as HMDs, life-size touchscreens, and tablets.

In the development and implementation phase, we introduced more structured scenario-based virtual content that focused on various aspects of virtual dissection. The content covered topics such as coronary arteries, heart chambers, valves, and conducting systems. These scenarios were carefully designed to provide students with a comprehensive understanding of the specific areas of each topic during virtual dissection. To enhance the learning experience, we used fade and hide functions and color-coding techniques. In the evaluation phase, we used validated survey tools (Bae and Kwon 2018) and compared the satisfaction levels with virtual devices and cadavers in six categories. However, most studies on virtual dissection laboratory reported creating a satisfaction survey for their pilot study, and not validating the questionnaire used (Duraes et al. 2022; Alasmari 2021; Narnaware and Neumeier 2021).

We believe that our study design is important in teaching students about the heart and brain. The curriculum implemented for the virtual dissection laboratory in both courses was positively received by the medical students and effectively contributed to their academic performance.

4.2 Academic Achievementsof “Human Anatomy” and “Neuroanatomy” Laboratories

This is the first study to investigate students' academic achievement of virtual dissection compared to three cadaver dissection laboratories with different curricula. In most previous RCT studies in virtual anatomy education, all participants assigned to the cadaver dissection group conducted the same curriculum (Hooper et al. 2019).

Differences in the cadaver dissection curriculum could be associated with differences in academic performance. In the Human Anatomy laboratory, the cadaver group for each class followed a different curriculum. The results of the students’ achievement scores on Q1 allowed predict whether virtual dissection could replace cadaver dissection. In classes A and B, in which hearts were extracted and dissected, there was no significant difference in academic performance between the virtual and cadaveric groups. However, in class C, the Q1 mean score of the virtual group was significantly higher than that of the cadaver group (Figure 3a). Therefore, observing a damaged heart during dissection is more challenging when studying anatomical structures than when the heart was extracted, taken out of the body, or dissected. This finding is consistent with those of previous studies (Washmuth et al. 2020; Patel et al. 2015; Anand and Singel 2017). A damaged or cut structure cannot be reconstructed, making it difficult for the students to revisit a completed dissection on a cadaver. Our study showed that the academic performance of the virtual dissection group was comparable to or superior to that of the cadaver dissection group; thus, we believe that virtual dissection can replace cadaver dissection. Nonmedical schools such as nursing, health sciences, and clinical pathology schools do not offer much exposure to actual dissection (Washmuth et al. 2020; Romo-Barrientos et al. 2020); hence, virtual dissection training is expected to be very useful. We also found no significant difference in the Q2 mean score between the cadaver and virtual groups after completing the Human Anatomy laboratory, probably because the students experienced both dissections.

In the Neuroanatomy laboratory, the academic achievement in the virtual laboratory was superior to that in the cadaver laboratory (Fig. 6b). Therefore, the virtual group made superior progress compared with the cadaver group in retaining major anatomical concepts. In addition, this outcome demonstrates the high potential of virtual anatomy education to supplement traditional teaching methods. This is consistent with the advantages of virtual anatomy education in laboratories (Deng et al. 2018; Chan and Pawlina 2015; Moro et al. 2017; Triepels et al. 2020). Owing to ambiguous histological boundaries, the cadaver brain lacks a clear visual distinction between different brain regions. These limitations of the cadaver brain were overcome using visually intuitive virtual content, which improved academic achievement. We believe that virtual dissection can replace traditional hands-on dissection when circumstances prevent medical students from performing cadaveric procedures under optimal conditions.

4.3 Survey Results of “Human Anatomy” Laboratory

We compared satisfaction levels with three virtual devices and cadavers in the Human Anatomy laboratory using validated survey tools (Bae and Kwon 2018) on six categories. This is the first study to provide crucial evidence on designing educational experiences centered on anatomical structures while considering the characteristics and functionalities of devices. Furthermore, this study highlights the advantages and differences in satisfaction associated with various virtual devices. Therefore, it is crucial to carefully evaluate and select appropriate devices that facilitate learning and meet educational objectives.

Among the virtual devices used, HMD showed superior satisfaction with understanding the concept (labeling) and immersion (sense of being in another space) (Figures 4b and 4e). First, regarding understanding the concept, labels on the actual anatomical structures within the virtual environment allowed students to effectively perceive and comprehend these structures. Second, our study revealed high levels of satisfaction associated with a sense of immersion in a different space. Previous studies have reported that sense of immersion enhances the learning experience, increases learners' interest, and improves their overall engagement (Buttussi and Chittaro 2018; Guerra-Tamez 2023). However, contrary to previous findings, our study found lower satisfaction levels regarding re-experiencing, repeating, and experiencing different anatomical structures. It is possible that the design or implementation of the virtual anatomy experience, specifically related to the above components, did not effectively meet students' expectations or needs.

Higher satisfaction levels were observed when using life-sized touchscreen devices than with cadaver dissection in relation to esthetics (utility and design), understanding of the concept (labeling and desired angles), and spatial ability (facilitated observation). First, our study revealed that life-sized touchscreens were significantly more satisfactory in terms of utility and design. Previous studies have also highlighted the importance of user interfaces and experience designs in virtual anatomy content for creating visually appealing, user-friendly learning and teaching tools (Alkhammash et al. 2022; Chickness et al. 2022). The findings reveal that the life-sized touchscreen-based content employed was indeed well-designed and user-friendly. Next, the students expressed higher satisfaction with the tablet-based approach because of two notable features: clear labeling of anatomical structures and flexibility to manipulate and view them from various angles (Figure 4b). According to previous studies, accurately labeling structures is crucial in enhancing learners' understanding and recognition of anatomical components (Pourahmadi et al. 2013; Skulmowski 2022). Moreover, the ability to view anatomical structures from various angles contributes significantly to comprehending anatomical structures (Brito et al. 2022; Ahmed 2023). In terms of spatial ability, the students expressed higher satisfaction with the life-sized touchscreen-based approach because of its ease of observation (Figure 4d). We speculate that a life-sized touchscreen with a larger display area enhances visibility, making observation and understanding more convenient.

In this study, we identified superior satisfaction with using the tablet in terms of esthetics (utility and design), understanding of the concept (labeling, desired angles, and comprehensiveness), spatial ability (facilitated observation), and continuous use intention (repetition) (Figures 4a, 4b, 4d, and 4e). Moreover, similar to the satisfaction level of the life-sized touchscreen, the tablet demonstrated high levels of satisfaction with esthetics (utility and design), spatial ability (facilitated observation), and understanding of the concept (labeling, desired angles, and comprehensiveness). Furthermore, findings on the continuous use intention (Figure 4f) support the notion that tablets positively impact sustained engagement and learning of anatomy (Wilkinson and Barter 2016). Thus, combining esthetic appeal, conceptual understanding, spatial ability, and the desire for continued exploration highlights the potential of tablets as effective educational tools in anatomy.

Despite the high satisfaction with various virtual devices, we also observed that satisfaction with cadavers was significantly higher in certain categories. In terms of vividness, the reality of anatomical structures, environment, and the real world (Figures 4a and 4c), we found the contents in the virtual dissection laboratories less satisfying than those in the cadavers. Previous studies have shown that creating 3D virtual models resembling real cadavers is a major challenge (Lewis et al. 2014; Zilverschoon, Vincken, and Bleys 2017). They attempted to supplement anatomical knowledge by adding details and textures to 3D virtual models (Hanalioglu et al. 2022; Chen et al. 2020).

4.4 Survey Results of “Neuroanatomy” Laboratory

Students stated that the tablet-based laboratory was a more satisfactory cadaver dissection laboratory from the perspectives of esthetics, conceptual understanding, and spatial ability. In addition, from an esthetic point of view, students reported that the tablet-based laboratory helped them understand the anatomical structure and had a better design. This finding is consistent with those of previous studies (Triepels et al. 2020). It has been demonstrated that 3D visualization is superior to conventional approaches for learning anatomy. However, anatomical structures are more realistic in cadavers. If the contents of a tablet-based laboratory are more realistic, the satisfaction level with a tablet-based laboratory can increase. Many studies have reported the development and validation of a 3D atlas (Zilverschoon et al. 2019; Havens, Saulovich, and Saric 2020). Finally, there was no difference in student immersion in tablet-based and cadaver laboratories. In addition, students wanted to experience and repeat the tablet-based laboratory rather than the cadaver laboratory; however, there was no significant difference. Despite higher satisfaction with esthetics, understanding of the concept, and spatial ability, the tablet-based laboratory did not result in higher continuous use intention, probably because of the lower reality satisfaction.

4.5 Limitations

Our study had a few limitations that need to be considered. First, one type of virtual device was insufficient to accommodate all students in the virtual dissection laboratory. Owing to the limited number of HMDs, approximately three students in a group used one in 18 minutes. Therefore, further studies should be conducted in environments with adequate resources. Second, only two anatomical regions were investigated in this study. The expansion of the experiment to other anatomical regions might be interesting and merits consideration in follow-up studies to assess the extent of the generalizability of the anatomical topic. Finally, the participants were restricted to first-year medical students. Whether these findings can be generalized to different grades must be determined.

This study aimed to develop and compare scenario-based virtual dissections with traditional cadaver dissections in medical education. Virtual dissection yielded superior or equal academic achievement and student satisfaction and can be an effective alternative or supplement to cadaver dissection, particularly in specific contexts. Furthermore, the satisfaction scores differed in the virtual group. HMD was preferred for esthetics and immersion, the life-sized touchscreen received higher scores for esthetics, understanding of the concept, and spatial ability, and tablets were favored for esthetics, understanding of the concept, spatial ability, and continuous use intention. The study demonstrates that virtual dissection can offer valuable learning experiences, improve academic performance, and enhance student satisfaction by providing scenario-based virtual content and incorporating advanced technological devices in medical education. Further research and implementation are warranted to fully explore the benefits of virtual dissection in medical curricula and optimize its integration into medical education programs.

Author contributions

YHY contributed to conceptualization, data curation, formal analysis, methodology, investigation, validation, software, supervision, visualization, writing - original draft, and writing - review & editing. HYK, SKJ contributedtoresources, investigation, and writing - review & editing. YMJ, and MJP contributedtoresources, and investigation. DHS contributed to conceptualization, project administration, supervision, formal analysis, validation, and writing - review & editing. HJC contributed to conceptualization, methodology, project administration, supervision, formal analysis, validation, writing - review & editing. All authors approved the final version of the manuscript for submission.

Conflict of interest

The authors have no conflict of interest to disclose.

Availability of data and materials

The datasets generated during and/or analysed during the current study are not publicly available due to ethical concerns. Data are available from the corresponding author for researchers who meet the criteria for access to confidential data.

Funding

This study did not receive any specific grant from funding agencies in the public, commercial, or non-for-profit sectors.

Acknowledgements

We would like to thank the participants who took part in this study.

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Table 1. Demographic characteristics of Human Anatomy survey respondents.

Characteristic	Student, No. (%) First-year medical students (n = 154)^a
Age, mean (SD)	20.8 (1.2)
Gender
Male	107 (69.5)
Female	47 (30.5)
Do you have a tablet?
Personal tablet	84 (54.5)
Shared family tablet	10 (6.5)
Purpose of tablet usage (n=92)*
Education	70 (76.1)
Game	4 (4.3)
Video or movie	18 (19.6)
No	60 (39.0)
Frequency of VR usage
Once a day	1 (0.6)
Once a week	1 (0.6)
2-3 times a week	1 (0.6)
Once a month	4 (2.6)
Once a year	55 (35.7)
What was your experience with VR? (n=62)*
Game	54 (87.1)
Education	1 (1.6)
Video or movie	6 (9.7)
Other^b	1 (1.6)
Never	92 (59.7)
Frequency of VR games based on a first-person perspective
Once a day	1 (0.6)
Once a week	4 (1.9)
2-3 times a week	1 (0.6)
Once a month	7 (4.5)
Once a year	40 (26.0)
Never	101 (65.6)
Frequency of graphic design software usage
Once a day	3 (1.9)
Once a week	3 (1.9)
2-3 times a week	3 (1.9)
Once a month	18 (11.7)
Once a year	23 (14.9)
Never	104 (67.5)

Abbreviation: VR, virtual reality.

^aData are presented as the number (percentage) of survey respondents unless otherwise indicated. ^bOther studies included only research participants. * Only one subgroup of students.

Table 2. Demographic characteristics of Neuroanatomy survey respondents.

Characteristic	Student, No. (%) First year medical students (n = 154)^a
Age, mean (SD)	21.9 (9.4)
Gender
Male	109 (70.8)
Female	45 (29.2)
Do you have a tablet?
Personal tablet	144 (93.5)
Shared family tablet	2 (1.3)
Frequency of tablet usage (n=146)*
Once a day	17 (11%)
Once a week	5 (3.2%)
2-6 times a week	35 (22.7%)
2-3 times a month	6 (3.9%)
Once a month	91(59%)
No	8 (5.2)
Did you buy virtual anatomy applications?
Yes	108 (70.1%)
What is the name of the virtual anatomy application? (n=108)*
Complete Anatomy	87 (56.5%)
Atlas	14 (9.1%)
Anatomy Learning	6 (3.9%)
3D Anatomy	1 (0.6%)
Frequency of virtual anatomy applications usage (n=108)*
Once a day	18 (11.7%)
Once a week	19 (12.3%)
2-6 times a week	50 (32.5%)
2-3 times a month	15 (9.7%)
Once a month	6 (3.9%)
No	46 (29.9%)

^a Data are presented as the number (percentage) of survey respondents unless otherwise indicated. * Only one subgroup of students

No competing interests reported.

Effectiveness and Satisfaction of Virtual Dissection on Medical Students: Randomized Controlled Trials Compared to Cadaver Dissection

Status:

Journal Publication

Version 1

Abstract

Figures

1. Introduction

2. Methods

2.1 Sample size

2.2 Participants

2.3 Curriculum Development

2.4 Study Design

2.4.1 Study Design of the “Human Anatomy” Laboratory

2.4.2 Study Design of the “Neuroanatomy” Laboratory

2.5 Devices and Software

2.6 Content Scenario for Virtual Dissection in “Human Anatomy” Laboratory

2.7 Content Scenario for Virtual Dissection of “Neuroanatomy” Laboratory

2.8 Quiz and Survey

2.9 Statistical Analysis

2.10 Ethical approval

3. Results

4. Discussion

5. Conclusion

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1