RES E AR C H A R T I C L E Open Access

Can virtual reality improve traditional

anatomy education programmes? A mixed-

methods study on the use of a 3D skull

model

Shi Chen

1,2†

, Jiawei Zhu

3†

, Cheng Cheng

3†

, Zhouxian Pan

, Lingshan Liu

, Jianhua Du

, Xinhua Shen

, Zhen Shen

Huijuan Zhu

, Jihai Liu

2,6

, Hua Yang

2,7

, Chao Ma

and Hui Pan

1,8*

Abstract

Background: Realistic, portable, and scalable lectures, cadaveric models, 2D atlases and computer simulations are

being combined more frequently for teaching anatomy, which result in major increases in user satisfaction.

However, although digital simulations may be more portable, interesting, or motivating than traditional teaching

tools, whether they are superior in terms of student learning remain unclear. This paper presents a study in which

the educational effectiveness of a virtual reality (VR) skull model is compared with that of cadaveric skulls and

atlases. The aim of this study was to compare the results of teaching with VR to results of teaching with traditional

teaching methods by administering objective questionnaires and perception surveys.

Methods: A mixed-methods study with 73 medical students was conducted with three different groups, namely,

the VR group (N = 25), cadaver group (N = 25) and atlas group (N = 23). Anatomical structures were taught through

an introductory lecture and model-based learning. All students completed the pre- and post-intervention tests,

which comprised a theory test and an identification test. The theory test consisted of 18 multiple-cho ice questions,

and the identification test consisted of 25 fill-in-the-blank questions.

Results: The participants i n all three groups had significantly higher total scores on the post-intervention test than on the

pre-intervention test; the post-intervention test score in the VR group was not statistically significantly higher than the

post-intervention test score of the other groups (VR: 30 [IQR: 22–33.5], cadaver: 26 [IQR: 20–31.5], atlas: 28[IQR: 20–33]; p >

0.05). The participants in the VR and cadaver groups provided more positive feedback on their learning models than the

atlas group (VR: 26 [IQR: 19–30], cadaver: 25 [IQR: 19.5–29.5], atlas: 12 [IQR: 9–20]; p <0.001).

(Continued on next page)

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* Correspondence: panhui20111[email protected]

†

Shi Chen, Jiawei Zhu and Cheng Cheng contributed equally to this work.

Department of Endocrinology, Endocrine Key Laboratory of Ministry of

Health, Peking Union Medical College Hospital (PUMCH), Chinese Academe

of Medical Sciences & Peking Union Medical College (CAMS & PUMC), Beijing

100730, China

Medical Department, PUMCH, CAMS & PUMC, Beijing 100730, China

Full list of author information is available at the end of the article

Chen et al. BMC Medical Education (2020) 20:395

https://doi.org/10.1186/s12909-020-02255-6

(Continued from previous page)

Conclusions: The skull virtual learning resource (VLR) was equally efficient as the cadaver skull and atlas in teaching

anatomy structures. Such a model can aid individuals in understanding complex anatomical structures with a higher level

of motivation and tolerable adverse effects.

Keywords: Virtual reality, Anatomy, Medical education

Background

Although anatomy serves as the basis for other medical

courses for medical students [1], universities have de-

creased the hours allocated to anatomy education in

favour of applied clinical work [2]. Medical students

need to supplement their anatomy education with plenty

of traditional resources, including cadaveric dissection,

preserved specimens, and vario us 2-dimensional (2D)

image representations (e.g. textbook illustrations, atlases,

and tomographic scans) [3]. Recent advancements in

computer technology have led to many different forms

of digital anatomy simulations [4]. Among them, virtual

reality (VR) technology is one of the most promising

teaching tools in medical education. VR can be used to

deliver a highly immersive experience through head-

mounted displays (HMDs) and a less immersive experi-

ence through a desktop system [5]. A wide range of vir-

tual learning resources (VLRs) have been developed that

use 3-dimensional (3D) visualization technologies to

supplement and even replace traditional instructional

materials such as cadaver dissections [3]. Users can

interact with vivid imagery for an active and self-

directed learning experience without the limitations of

ethical concerns and donation shortages [ 6, 7] or having

to enter an anatomy laboratory [4]. In a few studies, the

educational value of VLRs has been compared with that

of conventional methods, and the results are generally

inconsistent. When used either alone or to complement

traditional written and online materials, VLRs showed

better or similar effectiveness in terms of enabling stu-

dents to learn anatomy [2, 8–11]. More importantly,

VLRs are rated as more interesting and engaging [8], en-

joyable [8, 9, 11], motivating [8, 12–14] and useful for

understanding spa tial relationships [11, 13, 15] than

traditional tools. There is an inherent appeal in these

newer and more advanced visualizations in addition to

their novelty [4]. However, studies have shown that

compared with cadaver dissection and physical modes,

VLRs are less effective in improving learning outcomes

[16, 17]. The lack of tactile experience is regarded as a

disadvantage.

Although current studies suggest that VLRs cannot re-

place cadaver and physical models, they are perceived as

promising supplementary resources in anatomy educa-

tion. It is therefore important to evaluate the evidence

from different aspects. However, current researches are

largely focused on the comparison between VLRs and

2D textbooks, online materials or physical models.

Petersson et al. [16] and Codd et al. [17] both compared

VLRs with cadaver dissection, but neither study used

VLRs to deliver a highly immersive experience. Recent

studies by Birbara et al. [18] and Shao et al. [10] provide

a fully immersive experience, but neither of the research

groups compared VLRs with cadave r dissection, and the

VLR group used only perception questionnaires. Object-

ive assessments are crucial to evaluating participant s’

performance, in which the identification test is consid-

ered to be a predictor of imp roved learning outcomes

following 3D learning [19, 20]. Therefore, immersive

VLRs and traditiona l teaching modalities, such as ca-

daver dissection and 2D atlases, should be further com-

pared, and the different aspects of the assessments

should also be considered to evalu ate the impact of

VLRs on anatomy education.

Aim and hypothesis

Neurosurgery comprises some of the most challenging

surgical procedures, and mastering the intricacies of cra-

nial anatomy is a career-long endeavour for every neuro-

surgeon [10]. In this study, a coloured and detachable

skull VLR was constructed. The aim of this study was to

compare the results of the skull VLR with the cadaver

skull and a 2D atlas for anatomy education by adminis-

tering objective questionnaires and perception surveys.

Our hypothesis was that the skull VLR and cadaveric

skull groups might have similar performance in the ob-

jective tests, and that students would show a more posi-

tive attitude towards their learning material than the

atlas group.

Materials and method s

3D skull model based on VR technology

The virtual 3D skull model used in this study was con-

structed from computed tomography (CT) scans of a

human skull from the Peking Union Medical College

(PUMC) Anatomy Teaching Collection (Fig. 1). The CT

scans were impo rted into Mimics 17.0 (Materialise NV,

Leuven, Belgium) and con verted into stereolithography

(STL) files. The method used to create a 3D model from

CT scans was previously published by Shui et al. [21].

Several defective structures (ethmoid plate, crista galli,

anterior clinoid process and inferior orbital fissure) on

Chen et al. BMC Medical Education (2020) 20:395 Page 2 of 10

the 3D skull model were modified by using 3D Studio

Max 2016 (Autodesk Inc., San Rafael, CA). In addition,

each bone was isolated from the entire skull and painted

in a different colour (Fig. 2 c & d). The model was then

imported into the Unreal Engine VR platform (Fig. 2a)

through the HTC VIVE software development kit (High

Technology Computer Corporation, Taiwan) and Unreal

Engine 4.15 (Epic Games Inc., Cary, NC), which is com-

patible with HTC VIVE CE (High Technology Computer

Corporation, Taiwan), a VR HMD with a resolution of

2160 × 1200. Users could rotate and scale the model

through handheld controllers. In addition, each cranial

bone could be isolated from all other bones, which al-

lows the user to view an individual selected bone and its

position in space relative to the other bones. When the

isolated structure was placed back in its original pos-

ition, the model was reset.

Participants

Seventy-four clinical undergraduates from PUMC who

had just finished a 2.5-year pre-medical programme at

Tsinghua University were recruited. Thes e students

would begin their undergraduate stage of medicine in

the subsequent 5.5 years, from the basic study of anat-

omy to clinical internships. The anatomy course com-

bines regional and systematic anatomy and requires 144

study hours for each student. Every theoretical lecture is

followed by a cadaver dissection teaching of equ ivalent

time. There are a theoretical test and an identification

test for objective assessment at the end of the course.

The students were randomly divided into three groups,

namely, the skull VLR group (VR group, n = 25), cadav-

eric skull group (cadaver group, n = 25), and 2D atlas

group (atlas group, n = 24). Seventy-three participants

completed the trial, while one participant in the atlas

group dropped out of the study for personal reasons be-

fore the pre-intervention test.

Ethical approval

This study was approved by the Institutional Review

Board of the Institute of Peking Union Medical College

Hospital (PUMCH) (Project No: ZS-1724).

Design

A flowchart of the study design is displayed in Fig. 3. All

participants finished the pre-intervention tests. Then,

they attended a 30-min PowerPoint-based introductory

lecture on cranial anatomy, which included the charac-

teristics of each cranial bone, feature structures and

spatial relationships. The lecture was taught by a teacher

from PUMC whom the students had not met before.

During the lecture, each participant received a single

sheet of pape r with the teaching outline, which could

also be used for note-taking. Afterwards, the three

groups were assigned to three separate rooms for a 30-

min self-directed learning session that used skull VLR,

cadaveric skulls, and 2D atlases. The students in the VR

group received a 2-min instruction about the manipula-

tion of the VR equipment before learning. Study men-

tors were assigned to each room to prevent intragroup

Fig. 1 Photos of the cadaveric skull and skull VLR. a From left to right, the cadaveric skull is shown in the frontal, right, superior and inferior

views. b From left to right, the skull VLR is shown in the frontal, right, superior and inferior views

Chen et al. BMC Medical Education (2020) 20:395 Page 3 of 10

communication and were forbidden to answer questions

related to anatomy. The participants took turns so that

each participant had 7.5 min to manipulate and observe

the model in the first perspective, and they observed the

3D model on the computer screen for the remaining

22.5 min. The participants in the cadaver and atlas

groups also had the same amount of time to hold the ca-

daver skull or atlas, while the other participants could

only observe, without manipulation. To compensate for

the inability to view the teaching outline on paper in the

simulated environment, a projector was used to project

the teaching outline on a screen (Fig. 2b). A post-

intervention test was conducted immediately after the

learning session to evaluate the educational efficacy of

each model. Finally, each participant completed a per-

ception survey.

The pre- and post-intervention tests comprised the

same set of theory tests and identification tests (Supple-

mentary file 1.1 & 1.2). The theory test consisted of 18

multiple-choice questions tha t mainly covered basic

knowledge on the skull. Each correct answer was

awarded 1 point, and the examination lasted 15 min.

The id entification test consisted of 25 fill-in-the-blank

questions on labelled anatomical structures of the skull.

All structures were labelled on the cadaveric skulls. The

participants had 45 s to observe each structure and write

down its name. Each correct answer was awarded 1

point. The content was based on the syllabus from the

PUMC anatomy course, and all the test questions are

available in Supplementary file 1.

To assess the potentia l efficacy of the teaching tools,

in addition to the objective learning efficiency deter-

mined by the test scores, a perception survey was de-

signed (Supplementary file 1.3). The questions were

based on those included in several previous studies con-

ducted to evaluate the efficacy of other 3D models [8,

19, 22]. The perception survey used in this study con-

sisted of five parts that addr essed the participants’ enjoy-

ment, learning efficiency, attitude, intention to use, and

the tool’s authenticity, and a standard five-point Likert

scale was used to quantify the responses (1-strongly dis-

agree, 5-strongly agree with the statement).

Data collection and marking

Demographic information, including each participant’s

age, sex, self-reported VR headset experience and video

game experience, was collected during the trial. The par-

ticipants recorded their group and individual identifica-

tion numbers on the sign-in sheet. The previous grade

point average (GPA) of each participant was obtained

from the grade counsellor. The demographic and group-

ing information were hidden from the test mentor, study

Fig. 2 Photos of the simulation classroom and the skull VLR. a The entire classroom, in which a skull is placed on a table in the front of the

classroom, the other skull is placed on a table in the middle of the classroom, and pictures of the human skeleton are placed in front of the

window. b The skull VLR and projection screen. c The frontal bone separated from the entire skull. d All the bones separated, with the bright

white ball representing the center of the original skull

Chen et al. BMC Medical Education (2020) 20:395 Page 4 of 10

mentor and study staff until the trial was completed. The

study staff scored each answer sheet, and the results were

reviewed by the investigators (Zhu J and Cheng C) twice.

By using the Chen et al.’s[19] mean total scores and the

variance data of the post-intervention test, power calculations

were performed for this study. The calculations revealed that

26 students were required per group (78 students total) to

achieve 80% power to detect a 10% change in the post-

intervention total scores at an alpha level of 0.05.

Statistical analysis

The previous GPA, test scores and perception survey

scores were expressed as medians (interquartile ranges

(IQRs)), and the categorical variables were expressed as

numbers (%). The participants’ ages were expressed as

means (±SDs). A p-value of < 0.05 was considered to in-

dicate statistical significance. Statistical analysis was per-

formed with SPSS 23.0 (IBM Corp, Armonk, NY).

The data distributions were assessed with the

Kolmogorov-Smirnov test. The between-group differences

in the pre- and post-intervention test scores, changes in the

scores, and perception survey scores were assessed with the

Kruskal-Wallis H test because they were found to be non-

normally distributed. If there was a significant difference

with the Kruskal-Wallis H test, the Mann-Whitney U test

was employed for pairwise comparisons. The participants’

ages were compared with ANOVA. The categorical vari-

ables, except for video game experience, were compared

with the chi-square test; video game experience was com-

pared with Fisher’s exact test.

Results

Participant demographics

A total of 73 third-year medical students (39 females,

53.42%) were included in the study (Table 1). Most par-

ticipants were 20 or 21 years old. There were no

Fig. 3 Flowchart of the study design

Chen et al. BMC Medical Education (2020) 20:395 Page 5 of 10

statistically significant differences across the 3 groups in

terms of gender, age, previous GPA in the pre-med

programme at Tsinghua University, VR experience or

video game experience (all p > 0.05).

Comparison of the test score s across groups

The scores for the theory test and identification test

were included in the total scores. The maximum scores

of the theory test, identif ication test, and both tests to-

gether were 18, 25, and 43 points, respectively. A within-

subject analysis showed overall improvement in the test

scores from before to after the intervention, and the

magnitude of improvement was significantly different

across the three groups (p < 0.001). Table 2 displays the

results of the pre- and post-intervention tests.

No statistically significant difference was revealed across

the three groups in the pre-intervention tests (p >0.05for

the total score, theory score, and identification score). In

terms of the post-intervention test, there were no statisti-

cally significant differences across the three groups in ei-

ther the total score or theory score (all p >0.05). The

participants in the VR group performed better in the iden-

tification test than the cadaver and atlas groups (Fig. 4), al-

though with no significance (VR: 15 [IQR: 10–18],

cadaver: 12 [IQR: 8–15.5], atlas: 13 [IQR: 8–18]; p >0.05).

The differences between the pre- and post-

intervention test scores of the individual students were

considered by using the change in scores. Kruskal-Wallis

H analysis revealed that the changes in the scores were

not significantly different across the three groups (p >

0.05 for the changes in the total, theory, and identifica-

tion scores), as shown in Fig. 4.

Results of the perception survey

Comparisons of the results of the perception survey are

shown in Table 3. Overall, the participants in the VR

and cadaver groups found their assigned learning models

to be more enjoyable (VR: 4 [IQR: 3–5], cadaver: 4 [IQR:

3–5], atlas: 2 [IQR: 1–3]; p < 0.001), more interesting

(VR: 4 [IQR: 3–5], cadaver: 4 [IQR: 3–4.5], atlas: 2 [IQR:

1–3]; p < 0.001), more authentic (VR: 4 [IQR: 3–5], ca-

daver: 4 [IQR: 3–5], atlas: 2 [IQR: 1–3]; p < 0.001), and

more efficient for memorization (VR: 3 [IQR: 2–4], ca-

daver: 3 [IQR: 3–4], atlas: 2 [IQR: 1–4]; p < 0.001) and

spatial understanding (VR: 4 [IQR: 4–5], cadaver: 4

[IQR: 3–4.5], atlas: 1 [IQR: 1–3]; p < 0.001). The VR and

cadaver groups reported a higher intention to include

the study material for use in standard anatomy educa-

tion (VR: 3 [IQR: 2–4], cadaver: 4 [IQR: 2.5–4], atlas: 1

[IQR: 1–2]; p < 0.001).

Discomfort during the learning session

During the learning process, discomfort including head-

ache, blurred vision and nausea were evaluated in the

three groups (Supplementary file 2). Although the partici-

pants in the VR group exhibited these adverse effects

more frequently than in the other 2 groups, no significant

difference was found (VR group: 24%, cadaver group: 12%,

atlas group: 8.7%, p > 0.05). Additionally, in the VR group,

the total scores of the post-intervention tests did not vary

in the participants with and without discomfort (30 [IQR:

19.25–32.5] vs. 30 [IQR: 22–34], p >0.05).

Discussion

This is the first study to compare VLR with two different

traditional teaching methods in a randomized controlled

study design, including both objective assessments and

perception surveys, namely, “various question types” in

previous research [19]. The results of the object ive as-

sessment demonstrated that the skull VLR had the same

efficiency as the cadaver skull and atlas in enabling stu-

dents to learn anatomy, despite the relative simplicity of

the model used in this study. The post-intervention identifi-

cation scores were higher in the VR group, although not sig-

nificantly, compared with the other two groups. This result

was consistent with the advantages of VR in stereoscopic

Table 1 Demographic information in the three groups.

Chi-square test.

ANOVA.

Kruskal-Walis H.

Fisher’s Exact test

VR skulls

(N = 25)

Cadaveric skulls

(N = 25)

Atlas

(N = 23)

p-value

Gender [n (%)]

Male 9 (36%) 13 (52%) 12 (52.17%) 0.425

Female 16 (64%) 12 (48%) 11 (47.83%)

Age (Median [IQR]) 21.22 ± 0.69 21.15 ± 0.54 21.19 ± 0.78 0.948

Previous GPA (Median [IQR]) 3.28 [3.14–3.43] 3.30 [3.06–3.47] 3.23 [3.21–3.40] 0.780

VR headset experience [n (%)] 9 (36%) 7 (28%) 7 (30.43%) 0.823

Video game experience [n (%)]

Always 2 (8%) 0 (0%) 1 (4.35%) 0.696

Occasionally 4 (16%) 4 (16%) 2 (8.70%)

Rarely 19 (76%) 21 (84%) 20 (86.95%)

Chen et al. BMC Medical Education (2020) 20:395 Page 6 of 10

Table 2 Pre- and post-intervention tests score in the three groups. Full scores of theory test, identification test, and total score were

18, 25, and 43 points, respectively. The median and quartiles of the total scores were not simply equal to the sum of the theory

score and the identification score.

Kruskal-Walis H

VR skulls

(N = 25)

Cadaveric skulls

(N = 25)

Atlas

(N = 23)

p-value

Pre-intervention score (Median [IQR])

Total 9 [6.5–13] 8 [7–11] 10 [7–14] 0.634

Theory test 7 [5–9] 7 [5–9] 7 [6–10] 0.667

Identification test 3 [1.5–4.5] 2 [0.5–3] 2 [1–5] 0.176

Post-intervention score (Median [IQR])

Total 30 [22–33.5] 26 [20–31.5] 28 [20–33] 0.571

Theory test 15 [12.5–16] 14 [12.5–15.5] 14 [11–16] 0.824

Identification test 15 [10–18] 12 [8–15.5] 13 [8–18] 0.511

Change in score (Median [IQR])

Total 18 [14.5–21.5] 18 [12.5–21.5] 16 [10–20] 0.317

Theory test 7 [5–9] 7 [4.5–10] 6 [3–8] 0.524

Identification test 12 [8–12] 9 [7.5–13.5[ 9 [7–13] 0.278

Fig. 4 Comparison across the three groups in the post-intervention test scores and changes in scores. There were no statistically significant

differences across the three groups in the post-intervention test scores and changes in scores

Chen et al. BMC Medical Education (2020) 20:395 Page 7 of 10

observation and operation, which incorporated the intrinsic

spatial relationships of the anatomical sites studied and may

thus confer a spatial knowledge advantage [11]. The results

of the perception survey in the VR and cadaver groups also

showed a more positive attitude towards the learning models

than the results of the 2D atlas group, which indicated that

the VR and cadaver groups had similar levels of enjoyment,

learning efficacy and authenticity. Novel interventions usually

spark participants’ curiosity and lead to better results [4], and

all participants in the VR group were highly enthusiastic to

promote the use of this skull VLR in anatomy education.

Similarly, previous studies that have compared a 3D VR

model with traditional 2D materials also reported that VR

wasconsideredtobeamoreenjoyableandusefuleduca-

tional tool [8, 11, 23].

Cadavers offer high levels of realism, haptic feedback, and

theopportunitytouserealinstruments and tools, which was

found to be superior to atlas models in several previous stud-

ies [24–26], particularly in surgery [ 27]. In our trial, the

scores of the cadaver skull group showed no statistically sig-

nificant differences from the scores of the atlas group. This

discrepancy might partially result from structural variations

and small damages of the cadaveric skulls and the negative

psychological reactions from participants triggered by the ca-

daveric skulls [28, 29]. In addition, we combined lecture and

model learning to simulate the real learning process. The lec-

tures allowed the participants to learn important information

for the tests and narrowed the differences across the three

groups. Moreover, exposure to the pre-intervention test will

affect performance on an identical post-intervention test

through familiarity with the questions and may also influence

learning during the intervention [30].

3D VLRs, which provide rapid and feedback-based modifi-

cations, offer an opportunity for repetitive practice [23]. An-

other advantage of VLRs is that students can observ e and

receive instant visual feedback based on predefined practical

tasks [31]. Critics have argued that this approach lacks expert

guidance during the learning process, which plays an import-

ant role in forming the basic framework [32]. In fact, teachers

can also assess students’ learning performance and mistakes

through digital reports to further improve students’ skills.

Moreover, the participants in our trial conducted self-

learning in the absence of guidance and gained substantial

progress in learning anatomical knowledge, which is consist-

ent with the results in a previous study [33]. It has been sug-

gested that self-learning in private places is a feasible way to

implement VR simulation learning without constraints of the

place or time provided for learning [33]. In addition, 3D

models are likely to enhance rather than replace lecture-

based teaching by experts [23]. Individuals can first practice

with a VR simulation rather than with cadavers so that they

can repeat the procedures and acquire basic skills before

using expensi ve laboratory facilities [33]. Our study incorpo-

rated a room-scale HMD unit, which was available for the in-

dividuals. With this unit, many more manipulations can be

easily achieved, such as rotating to a suitable view, segment-

ing a single bone and scaling up the model, which makes it a

better tool for understanding difficult anatomical structures.

This HMD unit provides a completely immersive experience

with a high-resolution display, a high refresh rate, and highly

precise, low-latency constellation head tracking.

However, adverse effects caused by the highly immer-

sive experience and the device being positioned in front

of the eyes were regarded as negative aspects of the

VLRs [18]. Adverse effects, including headaches, dizzi-

ness, sore eyes, blurred vision and motion sickness, have

been reported [2, 34, 35 ]. A previous study reported a

high adverse effect rate in a VR group (headaches 25%;

blurred vision 35%) [2], but this rate was lower in our

trial (headaches 20%, blurred vision 4%). It can be in-

ferred that the discomfort caused by the virtual environ-

ment could be relieved with increased resolution and

lower latency. Newer VR designs are being designed to

overcome motion sickness and other VR-associated ad-

verse effects. These designs include grounding the user

by allowing their eyes to fix on a constant object such as

a virtual nose or hand and decoupling the axes of move-

ment from the visual plane [18].

In addition to physical discomfort, the high degree of

immersion in a stereoscopic environment and the novel

Table 3 Results of perception survey in the three groups. Full score of perception survey is 35.

Kruskal-Walis H.

p < 0.05

VR skulls

(N = 25)

Cadaveric skulls

(N = 25)

Atlas

(N = 23)

p-value

Enjoyment Enjoyable 4 [3–5] 4 [3–5] 2 [1–3] < 0.001

c,*

Interest 4 [3–5] 3 [3–4.5] 2 [1–3] < 0.001

c,*

Authenticity 3 [2.5–4] 3 [3–4] 2 [1–3] 0.001

c,*

Learning Efficiency Memorize 3 [2–4] 3 [3–4] 2 [1–4] 0.029

c,*

Spatial 4 [4–5] 4 [3–4.5] 1 [1–3] < 0.001

c,*

Attitude 3 [2–3] 3 [2–4] 1 [1–2] < 0.001

c,*

Intention to use 3 [2–4] 4 [2.5–4] 1 [1–2] < 0.001

c,*

Total 26 [19–30] 25 [19.5–29.5] 12 [9–20] < 0.001

c,*

Chen et al. BMC Medical Education (2020) 20:395 Page 8 of 10

experience of an immersive learning might make the

learning process more mentally taxing [11, 15]. Khot et al.

suggested that the extraneous load of the virtual delivery

modalities might contribute to the worse performance of

students who used these modalities than students who

used physical models [36]. Birbara et al. also found that

students with minimal prior anatomy knowledge in a

stereoscopic cohort had a higher cognitive load [18]. With

no prior knowledge, the participants in our study might

have experienced a greater mental burden, which under-

mined their learning efficiency in the learning session.

Although commercially available and low-cost HMDs

have further enhanced the opportunities for a truly

interactive virtual experience [37], the cost of VLR as a

supplement should be noted. Each set of VR equipment

cost approximately 700 dollars in our study, and it requires

related software, computer hardware and technicians for

its maintenance [38]. Considering the benefits of improved

learning, repeated use, and versatility, VR can reduce the

costs of laboratory material, supervisor staff and even

simulated patients. In general, the cost-benefit trade-off for

these expensive technologies is likely to vary based on

institutional goals and resources [39].

Limitations

Our study had seve ral limitations. First, this is a single-

institution study with a small sample size that included

only 73 participants, which was close to but smaller than

the expected sample size. Further studies with larger

sample sizes are needed to examine a broader spectrum

of medical personnel including resident physicians, nurs-

ing students and related educators. Second, the self-

directed learning session was limited to 30 min in our

study. The participants in the VR group only received a

2-min instruction for the VR equipment manipulation

before the learning session. To reduce the mental bur-

den, prior acquaintance with a virtual environment may

be essential in future study designs. Third, as the pre-

and post-intervention tests were identical, probability

existed that the participants might have purposely fo-

cused on the questions in the pre-intervention tests dur-

ing the 30-min learning session, which may have

influenced their performance in the post-intervention

tests. Longer learning sessions should be considered in

future studies. Finally, this study directly compared VLR

with other resources and only combined VLR with trad-

itional lecture. Further studies are needed to identify the

optimal combination of VLRs with various teaching

methods such as cadaver dissection to fully reflect their

effectiveness as a supplementary aid in medical teaching.

Conclusion

In this study, the skull VLR was equally efficient with cadaver

skull and atlas in teaching anatomy structures. Such a model

can aid individuals in understanding complex anatomical

structures with a high level of motivation and tolerable ad-

verse effects. Advances in 3D digital technology have enabled

the development of more sophisticated and realistic VLRs,

which provide opportunities for its use in traditional anat-

omy teaching settings as a powerful supplement. Future gen-

erations of medical students may benefit from these

technologies at the earliest stages of their learning, from VR

anatomy models to patient-specific VR simulations, as

needed. Additional studies with larger sample sizes are re-

quired not only to evaluate the teaching effectiveness of

VLRs in a more comprehensive frame but also to investigate

the optimal combinations of VLRs with traditional medical

education.

Supplementary information

Supplementary information accompanies this paper at https://doi.org/10.

1186/s12909-020-02255-6.

Additional file 1.

Abbreviations

VR: Virtual Reality; VLR: Virtual Learning Resource; 2D: Two-dimensional;

3D: Three-dimensional; STL: Stereolithography; HMD: Head-mounted Display;

GPA: Grade Point Average

Acknowledgements

The authors appreciate the support from Mr. Zhang Di, Mrs. Li Wenting and

other members in Department of Anatomy in PUMC for provision of

cadaveric materials and test questions, and all participants from third grade

of eight-year program of clinical medicine in PUMC.

Authors’ contributions

S.C. and H.P. conceived and designed the trial. S.C., J.Z. and C.C. drafted the

manuscript. J.Z., C.C., Z.P., L.L., J.D. and X.S. conducted the experiment and

analyzed and interpreted the results. J.L. and Z.S. constructed the model. H.Y.

designed the questionnaires and led the data collection. H.P. and H.Y.

supervised the study. H.Z. and C.M. reviewed and revised the manuscript. All

authors reviewed and approved the final version.

Funding

This work was supported by grants from funds for Young Teachers Training

Program (No.2014zlgc0721), and Education Reform Program

(No.2014zlgc0141) of Peking Union Medical College. There was no financing

from public funds or from third parties.

Availability of data and materials

The datasets used and analysed during the current study are available from

the corresponding author on reasonable request.

Ethics approval and consent to participate

The study was approved by the Institutional Review Board of the Institute of

Peking Union Medical College Hospital (PUMCH) (Project No: ZS-1724), and

written informed consent obtained from all the participants. Study methods

were performed in accordance with approved guidelines.

Consent for publication

Not applicable, no individual person’s data in any form.

Competing interests

The authors declare that they have no competing interests.

Author details

Department of Endocrinology, Endocrine Key Laboratory of Ministry of

Health, Peking Union Medical College Hospital (PUMCH), Chinese Academe

Chen et al. BMC Medical Education (2020) 20:395 Page 9 of 10

of Medical Sciences & Peking Union Medical College (CAMS & PUMC), Beijing

100730, China.

National Virtual Simulation Laboratory Education Center of

Medical Sciences, PUMCH, CAMS & PUMC, Beijing 100730, China.

Eight-year

Program of Clinical Medicine, PUMCH, CAMS & PUMC, Beijing 100730, China.

Department of Human Anatomy, Histology and Embryology, Institute of

Basic Medical Sciences, Neuroscience Center, Chinese Academy of Medical

Sciences, School of Basic Medicine, Peking Union Medical College, Beijing

100005, China.

The State Key Laboratory of Management and Control for

Complex Systems, Institute of Automation, Chinese Automation, Chinese

Academy of Sciences (CASIA), Beijing 100190, China.

Department of

Emergency, PUMCH, CAMS & PUMC, Beijing 100730, China.

Department of

Otolaryngology-Head and Neck Surgery, PUMCH, CAMS & PUMC, Beijing

100730, China.

Medical Department, PUMCH, CAMS & PUMC, Beijing

100730, China.

Received: 8 February 2020 Accepted: 24 September 2020

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