Back to table of contents Next article Windows to the BrainFull AccessExtended-Reality Technologies: An Overview of Emerging Applications in Medical Education and Clinical CareWilfredo López-Ojeda, M.S., Ph.D., Robin A. Hurley, M.D.Wilfredo López-OjedaSearch for more papers by this author, M.S., Ph.D., Robin A. HurleySearch for more papers by this author, M.D.Published Online:21 Jul 2021https://doi.org/10.1176/appi.neuropsych.21030067AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Medicine is quickly transforming with computer-assisted extended learning environments and technological augmentations. These advances facilitate the understanding of medical and scientific information, enabling learners, practitioners and researchers to extract and visualize insights from complex basic science and clinical concepts (4). Virtual reality has been employed as a technological supplement to three-dimensional imaging needs in the medical field for the past three decades (10, 11). In addition to virtual reality, augmented reality and mixed reality are emerging imaging technologies progressively being applied as valuable adjunct tools in medical care (e.g., neurosurgery, neurology and psychiatry) and in medical education (5, 10). There are important distinctions and nuances between these three innovative technologies. In virtual reality, the user experiences a full immersion into the virtual world and is completely blinded to the real world or environment (1). This experience occurs with a head-mounted display (digital lenses) wherein a user receives sensory input (i.e., visual and auditory) from the display rather than his or her native surroundings (Figure 1 and Cover). Augmented reality functions as a variant of virtual reality, where the user experiences the real world in real time. In addition, augmented reality allows the user to experience the features of a virtual world with digital information through the aid of a head-mounted display or other display system (i.e., smartphone). Thus, the user is able to interact simultaneously with the real world as well as with virtual objects (12, 13). Mixed reality has been defined as a subcategory of virtual-reality imaging involving the combination of real and virtual environments along the “virtuality continuum,” somewhat connecting the real and virtual worlds. This enables a concurrent and higher level of human-computer connectivity and interaction within a shared environment, utilizing special head-mounted display or mixed-reality devices (7).FIGURE 1 AND COVER. Virtual reality (VR). In VR, the user experiences a full immersion into the virtual world and is completely blinded to the real environment. This occurs with a head-mounted display (digital lenses) in which a user receives sensory input (i.e., visual and auditory) from the display rather than his or her native surroundings (1). VR immersion training is an effective instructional method used in medical school classrooms to teach anatomy and other medical concepts (2, 3). Created under the terms of the Creative Commons Attribution License. Created with BioRender.com.Virtual RealityVirtual-reality immersion training is an effective instructional method used in medical school classrooms to teach anatomy, as well as to help develop empathy in medical and health professions trainees (2, 3, 14, 15). The advantages of virtual-reality systems also extend to clinical training sites, with reported benefits including improvements in patient safety, learning in a low-stakes environment, optimization of time and increasing the overall performance of students (16, 17). A recent systematic review and meta-analysis found that virtual reality improves the knowledge and skills outcomes of health professionals in comparison to other types of digital resources (i.e., Internet) or the more traditional education methods, such as poster boards with markers (18). Health education benefits from the application of this technology by using “avatars” (i.e., digital representations of users, patients, or clinicians). These avatars support clinical and surgical simulations and procedure-focused learning (18).Virtual-reality technology also has significant advantages for patient care and quality-of-life (17, 18). There are emerging applications in multiple medical specialties (Table 1). Virtual-reality immersive experiences are rapidly becoming relevant for psychological, cognitive and physical interventions. Results from a systematic review support the application of virtual reality as a supplemental component in neurorehabilitation programs, with the goal of maximizing a patient’s recovery (19). Virtual reality has been employed as a therapeutic approach to reduce anxiety in phobias (e.g., acrophobia, aerophobia, arachnophobia), in posttraumatic stress disorder, varied anxiety disorders (e.g., social anxiety; obsessive-compulsive disorder; general anxiety disorder), schizophrenia, addiction and utilized to decrease maladaptive behaviors associated with eating disorders and obesity (20–24). Virtual-reality therapeutic application is a suitable option in psychotherapy (due to the high cost limitations and shortage of therapists) and provides a tailored immersive experience to suit the individual’s needs (i.e., patients experiencing challenges interacting with the real world.) (22) A considerable advantage of virtual reality is that patients are aware that the digital environment is computer-generated and unreal; however, their behavioral and somatic responses are very real. Individuals may be more comfortable facing difficult scenarios “virtually” rather than in real life and presumably learning new behaviors transferable to the real world (23). It is also applied as a useful distraction for the reduction of fear and discomfort created by painful or invasive procedures (25).TABLE 1. Use of reality technologies in medicineFieldReality technologiesaVirtual realtyAugmented realityMixed realityMedical education Basic sciences111 Clinical sciences111Medical specialty/practiceb Allergy and immunology110 Anesthesiology111 Dentistry111 Dermatology110 Emergency medicine111 Family medicine1c1c0 Internal medicine111 Medical genetics100 Neurology111 Nuclear medicine111 Obstetrics and gynecology111 Ophthalmology110 Pathology111 Pediatrics111 Orthopedy111 Physical and rehabilitation medicine111 Preventive medicine1d1d0 Psychiatry111 Radiology111 Radiation oncology110 Telemedicine110 Surgery111 Urology111a Zero “0” denotes no reported use of specific reality technology; “1” denotes use of specific reality technology.b Most common subspecialties are included (i.e., cardiology, oncology, and pain medicine).c Mostly geriatric, hospice, and palliative medicine.d Mostly aerospace medicine.TABLE 1. Use of reality technologies in medicineEnlarge tableAugmented RealityAugmented reality provides a level of simplification to the users by employing “virtual-imaging-fetching technology” to incorporate digital information into the real-world environment. Thus, it increases the user’s perception with each interaction (4). This application increases learning of the human body structure and function by decreasing the perceived level of difficulty and by increasing the interest in the naïve learner (26). Augmented reality has been applied to study complex topics such as anatomy and physiology, leading to increased comprehension in third-year biomedical college students (27). Its applicability for undergraduate medical education and training has been a matter of extensive debate and study (28–32). Aside from its undeniable novelty and attractiveness, literature reports are inconclusive regarding the benefits of augmented reality for undergraduate medical education curricula (28, 29, 31). Studies determining learning or knowledge achievement in anatomy and physiology with augmented-reality assisted technology indicate that test performance was not significantly improved (33). However, there is evidence to support that augmented-reality instruction improves the visual-spatial abilities (i.e., ability to mentally manipulate three-dimensional images) of students during anatomy instruction (34). One study noted that changing testing strategies to focus on three-dimensional spatial understanding after augmented-reality instruction could generate better learning outcomes (33). Therefore, augmented reality appears to be a suitable and promising technology to supplement undergraduate medical training and clinical simulations (26, 32, 35, 36). Interestingly, to date, augmented-reality applications have been more integrated into patient care, than in educational settings (12).In patient care (i.e., general surgery and orthopedics), augmented reality can play a significant role in planning surgical interventions and in explaining potential medical complication to patients and their families (12). This innovation helps surgeons to integrate medical images (X-rays, MRI) into clinical procedures; therefore, increasing safety and work productivity, while reducing costs (37). A recent systematic review conducted by Laverdière and colleagues revealed that augmented-reality-based technologies have significant orthopedics application in the operating room involving interactive viewing of radiographic images, intraoperative guidance, and facilitating hands-free real-time access to surgical instrumentation and other resources (38). The advantages of this technology extend to varied other medical specialties and subspecialties (Table 1) (12).In rural areas with limited access to medical providers to deliver appropriate healthcare services, augmented reality posits a new telepresence alternative to current telemedicine technology. Distant learners can actively train and perform intricate medical procedures (i.e., point of care ultrasound, fasciotomies) employing augmented-reality-based telementoring without visual interference, gaining more trust and confidence in their clinical skills (39, 40).With regards to the central and peripheral nervous systems, augmented reality has demonstrated successes in some diseases and conditions (e.g., dementia of the Alzheimer’s type, age-related memory loss, motor impairments, and brain tumors) (5, 41, 42). The cognitive impairments associated with these conditions typically interfere with activities of daily living (e.g., shopping, food, and drink preparation) requiring remembering or complex reasoning (43). Augmented reality provides a level of mental stimulation that positively affects cognitive dysfunction due to dementia and proports to increase quality of life and well-being (43, 44). The accessibility to augmented-reality interventions poses an interesting method to stimulate autobiographical memory (44). In addition, augmented-reality systems have been used effectively in the rehabilitation of upper extremity motor function impairments through the application of adapted augmented-reality games. This is done by engaging and encouraging patients to perform repeated exercises and tasks (45, 46).In neurosurgery, augmented reality is a suitable complement to the basic elements of traditional neuro-navigation. This technology offers real-time clinical and anatomical imaging renderings (5, 6). Three-dimensional holograms can be generated from the MRI of a patient’s brain and tumor and then virtually overlaid onto the patient’s cranium using augmented-reality wearable lenses (Figure 2) (5). Thus, the use of augmented reality can assist and guide the neurosurgical procedure and stereotactic processes (5, 47).FIGURE 2. Augmented reality (AR). AR employs virtual-imaging fetching technology to incorporate digital information into the real-world environment (4). AR is a suitable complement to the basic elements of traditional neuronavigation. This technology offers real-time clinical and anatomical imaging renderings (5, 6). Three-dimensional holograms can be generated from the MRI of a patient’s brain and tumor and then virtually overlaid onto the patient’s cranium using AR wearable lenses (5). Created under the terms of the Creative Commons Attribution License. Created with BioRender.com.Mixed RealityMixed reality is the newest of the extended-reality technologies and at times is difficult to discern from augmented reality due to its technical similarities. However, mixed reality offers a higher level of integration where users can interact with digital elements as if these virtual components are physically present in the real world (48). This technology is becoming a staple for medical education and for many medical disciplines and specialties (Table 1). Mixed reality enhances learners’ understanding of intricate medical concepts (e.g., neuroanatomy, neurologic diseases) of the human body (Figure 3). A compelling study comparing augmented-reality-based to mixed-reality-based anatomy instruction in medical curricula reported advantages for the mixed-reality paradigm (8). The benefits included an increased interaction with exceptional anatomical specimens and models with hyper-realistic rendering and an opportunity for increasing the frequency of learning (8). This new teaching tool is shifting certain aspects of traditional medical pedagogies and curricula from classical two-dimensional pictures and videos to interactive three-dimensional imaging (9). Interestingly, medical students seem open to augmented-reality and mixed-reality technologies to supplement traditional anatomy instruction (i.e., cadaveric dissection), but not as a replacement (8). The advances in mixed-reality simulators are also becoming a fundamental element of physician’s clinical instruction, as they can deliver a risk-free setting for training (49).FIGURE 3. Mixed reality (MR). MR innovation combines the real and virtual environments along the “virtuality continuum,” somewhat connecting the real and virtual worlds. This enables a concurrent and higher level of human-computer connectivity and interaction within a shared environment, utilizing special head-mounted or MR lenses (7). MR enhances learners’ understanding of intricate medical concepts of the human body (e.g., neuroanatomy, neurologic diseases) (8). This new teaching tool is shifting certain aspects of traditional medical pedagogies and curricula from classical two-dimensional pictures and videos to interactive three-dimensional imaging (9). Created under the terms of the Creative Commons Attribution License. Created with BioRender.com.In clinical practice, mixed reality is becoming a trend for viewing and interacting with patient’s radiographic information, including computerized tomography (CT) scans and MRIs (48, 50). It also simplifies the operational flow from the virtual preoperative surgical planning to intraoperative surgical activities (50). Mixed reality offers substantial advances to surgeons, providing structural (anatomy) and application (surgical instruments) at-the-site-guidance during surgical procedures (9). Image renderings (CT, MRI, etc.), can be readily accessed by the surgeon for immediate decision making. These images can also be manipulated and moved around the operating room, using direct voice commands and body gestures (i.e., mid-air hand signals), facilitated by mixed reality’s unique level of digital integration and human interactive capabilities (51, 52).Mixed reality offers important advantages for patients’ education on surgical procedures, by increasing comprehension regarding the intricacies of certain surgical interventions, anesthesia, and medications; thus, resulting in decreased fear and worry (53). In addition, it potentiates constructive patients’ decision making in favor of necessary surgical procedures and reinforces their engagement in treatments (53). Furthermore, mixed reality has proven effective for remote consultations to rural areas lacking access to modern healthcare devices and technologies (9, 39).Extended RealitiesTaken altogether, virtual-, augmented-, and mixed-reality innovations are expanding with new technological applications being disseminated rapidly across multiple medical subspecialties, as noted above (54). There are significant advantages to the use of the reality technologies in medical education (8, 15, 55). However, there are some concerns related to the potential lack of academic skills needed to teach effectively with these technologies, as well as high costs (i.e., hardware and software), physical discomfort and adaptability (i.e., heavy headsets), increased cognitive load, and individual differences in visuospatial and working memory abilities (2, 56–58). In addition, there are other disadvantages associated with the immersive experience of the extended-reality technologies. For example, “cybersickness,” a condition in which the users may experience symptoms similar to motion sickness, though it is not due to movement (59, 60). The symptoms can include headache, dizziness and nausea during or after using any of the extended-reality applications. Essentially, the human brain must integrate real-time multimodal inputs from vision, hearing, vestibular and proprioceptive senses in order to generate the complex, yet riveting, emotions of the virtual experience (61). In addition, current hardware designs are not yet a seamless extension of the user’s senses (i.e., a design that enables physical comfortability, mobility, and functionality over prolonged periods of time). Most virtual-, augmented-, and mixed-reality systems require heavy, bulky, wired-tethering devices with limited battery life (62).Reality technologies encounter other limitations in clinical practice. For example, when augmented-reality digital renderings are overlaid onto a patient’s body in real time, the image transposition must be truthful to the patient’s anatomical orientation. Misalignment inaccuracies may result in faulty training sessions and may lead to unnecessary patient harm (63). There are also important ethical and legal implications that must be taken into consideration when using these types of innovations to either access, store, or transfer patient’s medical information (62). Other ethical concerns have been raised regarding the accidental repercussions when reality technologies supplement or replace traditional practices. An early report from the nineties indicated that virtual-reality technology may set the scenario for the introduction of medical errors, aggravating the symptoms of mental illness or generating new symptoms (64). On the contrary, more recent studies and reviews indicate that virtual reality is being progressively utilized for the diagnosis, assessment, and treatment of mental disorders with a high level of success (22, 60).ConclusionsIn conclusion, all three extended-reality technologies posit great advances for both clinical care and medical education. Their functionality and applicability have the potential for substantial benefits in varied settings across the medical and biomedical sciences. Nonetheless, like all other technological innovations, there are considerable limitations. A mindful introduction will ensure that their use is safe and effective. In addition, more improvements in hardware and software devices are imperative. To this end, a collaborative and integrated approach involving medical professionals, nonphysician staff, scientists, software and hardware developers, graphic artists, informatics experts, engineers and other industry professionals is required to adequately facilitate, evaluate, and record the rapid advances of this field. It is also imperative to have more evidence-based clinical studies to further assess the effectiveness of augmented- and mixed-reality modalities in advancing health professions education and clinical practice.Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center, and Research and Academic Affairs Service Line, W.G. Hefner Veterans Affairs Medical Center, Salisbury, N.C. (López-Ojeda, Hurley); Department of Psychiatry and Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, N.C. (López-Ojeda); Departments of Psychiatry and Radiology, Wake Forest School of Medicine, Winston-Salem, N.C. (Hurley); and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Hurley)Send correspondence to Dr. Hurley ([email protected]).Supported by the Department of Veterans Affairs VISN 6 Mental Illness Research Education and Clinical Center.The authors report no financial relationships with commercial interests.References1 Milgram P, Kishino F: A taxonomy of mixed reality visual displays, 1994. paper/A-Taxonomy-of-Mixed-Reality-Visual-Displays-Milgram-Kishino/f78a31be8874eda176a5244c645289be9f1d4317Google Scholar2 Moro C, Štromberga Z, Raikos A, et al.: The effectiveness of virtual and augmented reality in health sciences and medical anatomy. Anat Sci Educ 2017; 10:549–559Crossref, Medline, Google Scholar3 Izard SG, Juanes JA, García Peñalvo FJ, et al.: Virtual reality as an educational and training tool for medicine. 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Hurley, M.D.3 February 2022 | The Journal of Neuropsychiatry and Clinical Neurosciences, Vol. 34, No. 1 Volume 33Issue 3 Summer 2021Pages A4-177 Metrics KeywordsAugmented RealityVirtual RealityPDF download History Received 12 March 2021 Revised 6 May 2021 Accepted 6 May 2021 Published online 21 July 2021 Published in print 1 July 2021
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