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Using virtual reality in medical education to teach empathy

DOI:10.5195/jmla.2018.518
Authors:
Elizabeth Dyer at University of New England
Elizabeth Dyer
Barbara Swartzlander at University of New England
Barbara Swartzlander
Marilyn R Gugliucci at University of New England College of Osteopathic Medicine (USA)
Marilyn R Gugliucci
  • University of New England College of Osteopathic Medicine (USA)
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Abstract and Figures

Objective: The project adopted technology that teaches medical and other health professions students to be empathetic with older adults, through virtual reality (VR) software that allows them to simulate being a patient with age-related diseases, and to familiarize medical students with information resources related to the health of older adults. Methods: The project uses an application that creates immersive VR experiences for training of the workforce for aging services. Users experience age-related conditions such as macular degeneration and high-frequency hearing loss from the patient's perspective. Librarians and faculty partner to integrate the experience into the curriculum, and students go to the library at their convenience to do the VR assignment. Results: The project successfully introduced an innovative new teaching modality to the medical, physician assistant, physical therapy, and nursing curricula. Results show that VR enhanced students' understanding of age-related health problems and increased their empathy for older adults with vision and hearing loss or Alzheimer's disease. Conclusion: VR immersion training is an effective teaching method to help medical and health professions students develop empathy and is a budding area for library partnerships. As the technology becomes more affordable and accessible, it is important to develop best practices for using VR in the library.
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VIRTUAL PROJECTS
DOI:
dx.doi.org/10.5195/jmla.2018.518
Journal of the Medical Library Association 106 (4) October 2018 jmla.mlanet.org
498
Using virtual reality in medical education to teach
empathy
Elizabeth Dyer, MLIS, AHIP; Barbara J. Swartzlander, MSEd, MLS; Marilyn R. Gugliucci, MA, PhD
See end of article for authors’ affiliations.
Objective: The project adopted technology that teaches medical and other health professions students to be
empathetic with older adults, through virtual reality (VR) software that allows them to simulate being a
patient with age-related diseases, and to familiarize medical students with information resources related to
the health of older adults.
Methods: The project uses an application that creates immersive VR experiences for training of the
workforce for aging services. Users experience age-related conditions such as macular degeneration and
high-frequency hearing loss from the patient’s perspective. Librarians and faculty partner to integrate the
experience into the curriculum, and students go to the library at their convenience to do the VR assignment.
Results: The project successfully introduced an innovative new teaching modality to the medical, physician
assistant, physical therapy, and nursing curricula. Results show that VR enhanced students’ understanding
of age-related health problems and increased their empathy for older adults with vision and hearing loss or
Alzheimer’s disease.
Conclusion: VR immersion training is an effective teaching method to help medical and health professions
students develop empathy and is a budding area for library partnerships. As the technology becomes more
affordable and accessible, it is important to develop best practices for using VR in the library.
The University of New England (UNE) is in the
third year of an educational project that uses virtual
reality (VR) technology to teach empathy to medical
and other health professions students. Funded by
the National Network of Libraries of Medicine New
England Region, the project also familiarizes
students with National Library of Medicine
information resources related to older adult health.
UNE research and teaching librarians collaborate
with faculty from the UNE College of Osteopathic
Medicine on the Biddeford campus and the
Westbrook College of Health Professions on the
Portland campus to implement the project. To date,
more than 600 students from the programs in
medicine, physician assistant, physical therapy, and
nursing have participated.
The project uses software from Embodied Labs
(EL), a new company that creates VR labs for
training the workforce for aging services. The
application is unique in that it puts the learner in the
shoes of the patient to teach about the aging
experience from a first-person perspective. The
“Alfred Lab” teaches about macular degeneration
and hearing loss from the perspective of a seventy-
four-year-old African American man. Other new
labs teach about Alzheimer’s disease and end-of-life
conversations. UNE was the first institution to
license this novel product and has been on the
forefront of testing each module as it is developed
and implementing use with different student
populations.
The planning phase required purchasing
equipment, developing the pre- and post-
assessments that are embedded in the software,
creating the assignment to integrate into the
geriatrics curriculum, and training staff. The authors
tested the project with student library workers as
well as volunteer medical students. First-year
implementation involved 178 first-year medical
students who had a 10-week window to complete
Virtual projects 499
DOI: dx.doi.org/10.5195/jmla.2018.518
jmla.mlanet.org
106 (4) October 2018 Journal of the Medical Library Association
the assignment at the library. The 24-hour library
schedule provided many opportunities for students
to complete the work at a time that was convenient
for them. The second project year expanded the pilot
project to include first-year physician assistant
students. While not part of the planned project,
other programs also participated, due to the great
interest among faculty and students.
Initial grant funding enabled the purchase of 2
VR kits for each campus. Each kit includes an
Alienware laptop, Oculus Rift headset and sensor,
and Leap Motion hand-tracking device with mount
and long USB cable. Optional accessories include
Pelican cases for storage and transport, cable sleeve,
and cleaning wipes. We originally intended students
to check out a kit for in-library use, but we opted to
carve out space for ready-to-go stations to make the
experience as easy as possible (Figure 1). Second-
year funding allowed for 2 more kits, and we chose
desktop stations to see if the technology ran
smoother. Early experiences showed glitchy
connections between the laptop and headset, but
recent experiences show improvement and we saw
no difference in laptop versus desktop function.
Depending on computer configurations, each kit
currently runs from about $2,000–$2,500, with some
item costs trending down.
Software was downloaded from EL and
updated as necessary. Pre- and post-assessments,
initially created in Google Forms, were migrated to
REDCap for better control and security of data.
Faculty and library staff codeveloped assessments
unique to each program. EL accommodated our
requests for program-specific login codes, which
were linked to program-specific assessments. This
enabled easy separation of data by program in
REDCap.
Some limitations of the project include staff time
and space issues. Implementation became a time-
management challenge for library staff who juggled
multiple programs and time frames. The stations
require secure space in the libraries to protect the
equipment when not in use but that is accessible to
students when needed. Library staff also need to
have ready access to information technology staff
who can help maintain and troubleshoot the
technology when problems arise. A valid assessment
tool needs to show that the intervention successfully
improves student learning and empathy.
Figure 1 University of New England virtual reality station
500 Virtual projects
DOI: dx.doi.org/10.5195/jmla.2018.518
Journal of the Medical Library Association 106 (4) October 2018 jmla.mlanet.org
Best practices for using VR in education need to
be developed. For example, some users experience
dizziness or nausea using VR. EL recommends that
time with the headset be limited to about ten
minutes. The “Alfred Lab” fits in this time frame,
but newer modules are longer and broken into parts.
Busy students may forego breaks between parts and
then complain of adverse effects. A challenge to the
project has been keeping the headsets sanitary
between users. We used alcohol-free wipes on the
foam frames that touch the face, but it is unclear
how this affects the integrity of the foam. Oculus
now offers protective liners that can be wiped,
which we plan to use this year on all of our
headsets. The upcoming third year of the project
involves refining logistics to reflect best practices,
testing the newest module against the two that have
already been tried, and using a validated assessment
tool to evaluate the efficacy of the educational
experience.
The technology has been well received by UNE
students and faculty, and has increased the use and
value of UNE Library Services. Students provide
positive feedback about the incorporation of a new
technology tool into their learning. The project has
fostered new faculty-librarian collaborations and
brought students into the library who otherwise
might not have come. Assessment results indicate
that students demonstrate increased understanding
of and empathy with older adults who have age-
related conditions such as macular degeneration and
hearing loss. Research indicates that empathy leads
to better patient care and outcomes and that
educational interventions work [1], so it is
worthwhile to address this subject area in the
curriculum. VR immersion training is an effective
teaching method to help develop empathy and is a
budding area for library partnerships.
ACKNOWLEDGMENT
This project has been funded in whole or in part
with federal funds from the National Library of
Medicine, National Institutes of Health, under
cooperative agreement UG4LM012347-01 with the
University of Massachusetts, Worcester.
REFERENCE
1. Batt-Rawden SA, Chisolm MS, Anton B, Flickinger TE.
Teaching empathy to medical students: an updated,
systematic review. Acad Med. 2013 Aug;88(8):1171–7. DOI:
http://dx.doi.org/10.1097/ACM.0b013e318299f3e3.
AUTHORS’ AFFILIATIONS
Elizabeth Dyer, MLIS, AHIP, edyer@une.edu,
http://orcid.org/0000-0002-5924-1103,
Associate Dean for Library Services and
Research and Teaching Librarian, Abplanalp
Library, University of New England, Portland, ME
04103
Barbara J. Swartzlander, MSEd, MLS,
bswartzlander@une.edu, Research and
Teaching Librarian, Ketchum Library, University of New England,
Biddeford, ME 04005
Marilyn R. Gugliucci, MA, PhD, mgugliucci@une.edu, Professor and
Director of Geriatrics Education Research, Division of Geriatric
Medicine, College of Osteopathic Medicine, University of New
England, Biddeford ME 04005
Received May 2018; accepted June 2018
Articles in this jo urnal are licens ed under a Creative
Commons Attributio n 4.0 Internati onal License.
This journal is published by the University Library System
of the University of Pittsburgh as part of its D-Scribe
Digital Publis hing Program a nd is cosponsored by the
University of Pittsburgh Press.
ISSN 1558-9439 (Online)
... In other words, such a learning experience prepares medical students to take action during the authentic clinical experience. [1][2][3][4] Furthermore, virtual reality has been employed in the demonstration of 3D anatomy, simulation of surgical procedures, teaching empathy to medical students, treatment of phobia or anxiety disorders, rehabilitation of patients, etc. [3][4][5][6][7] ...
... [8][9][10] Steps like promotion of e-learning or employment of technology or implementation of problem-based learning, communication skills training, and simulation-based learning have been adopted to make conventional training more interactive and effective, keeping in mind the principles of adult learning. [6][7][8][9] Virtual reality is a kind of simulation wherein computer-created graphics are employed to produce a realistic world depending on the commands of users. However, considering the possibility of real-time interactivity, this technology aids in changing the input, which then brings about a change in the virtual environment. ...
... Virtual reality is a kind of dynamic and adaptive learning and has been associated with multiple benefits that extend much beyond what is being offered by conventional teaching. [7][8][9] Exposure to virtual reality can help medical students to refine their history taking skills, patient examination skills, improve their abilities to make an evidence based decision for ordering appropriate investigations, aid them in reaching a potential diagnosis and even acquire the skills to effectively treat the patients. [14,16] The learning can be further enhanced by the inclusion of other human factors (viz. ...
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... Numerous benefits of implementing VR in the training of medical professionals have been noted. The literature points to high-immersive technology being equally successful at teaching anatomy to medical students as cadaver and atlas groups (Chen et al., 2020) with the additional effect of increased empathy in medical and other health professions students (Dyer et al., 2018). Evidence also suggests that high-immersive VR is effective in practical applications: Butt et al. (2018) used high-immersive VR to teach urinary catheterization to undergraduate students and reported that the VR group produced equal pass rates similar to those who practiced with a task trainer. ...
... Similar results were obtained by Butt et al. (2018) and Chen et al. (2020). Studies have reported positive cognitive learning outcomes with VR (Bayram & Caliskan, 2019;Chen et al., 2020;Dyer et al., 2018;Hudder et al., 2021;Liu, 2021). A systematic review that compared three learning environments: VR, face-to-face, and traditional simulation with their associated learning outcomes in terms of cognitive, psychomotor, and affective behaviors found that VR was the most effective way to learn cognitive content (Shorey & Ng, 2021). ...
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Guided by constructivist theory, this study examines health professions student learning and engagement in the virtual classroom (VC) setting. Students (N=52) participated in a one-week VC prior to and during the COVID-19 pandemic. After participation, students were surveyed to discern their impressions of the experience, including the administration of a presence questionnaire, a key indicator of virtual environment (VE) efficacy. High student presence scores were significantly correlated with the perception that the VC facilitated learning (r = .573, p = .001). Conversely, students who perceived the course content as challenging were less likely to recommend the VC as a viable alternative learning platform. Furthermore, in terms of presence, undergraduate and graduate students were not significantly different. In summary, health professions students view immersive technologies favorably and may benefit from using such platforms as alternative or supplemental learning tools regardless of their academic level.
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... In total, 14 papers were included in the review, namely, seven quantitative (Little, 2013;Wilkinson et al., 2013;Arzu et al., 2014;Van Schyndel, 2015;Heden and Ahlstrom, 2016;Hincapie et al., 2016;Dyer et al., 2018), five mixed-method (Long et al., 2016;Vogt and Schaffner, 2016;Feldacker et al., 2017;George et al., 2017;Johnston et al., 2018) and two qualitative studies (Todhunter, 2015;Mackay et al., 2017). Ten of these studies focused on the experiences of nurses, one on the experiences of medical doctors, one on the experiences of pharmacy students and two on the experiences of mixtures of nurses and paramedical students. ...
Views and experiences of using advanced technologies in higher education of healthcare professionals: A systematic mixed-method review
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IntroductionWhile it is highly recommended to adopt technology in higher education of healthcare professionals, user experiences have not been widely studied. This review investigates the experience of using technology within healthcare higher education, in an attempt to gather useful insights into how use of such technologies can be improved.Methods Both quantitative and qualitative data was used for this mixed-method review.ResultsThe findings revealed many benefits associated with technology use, which included; improved clinical competency, improved overall quality of education and improved peer networking. However, there were numerous factors which hindered the widespread adoption of advanced technology. These factors included; the high costs involved, a lack of adequate equipment and a lack of understanding in such technology.DiscussionWhile the use of advanced technology for the training of healthcare professionals is generally embraced, it is not without problems. It is necessary for institutions to offer relevant and accessible support to both students and teachers, in order to improve the use of such technology in teaching and learning practice.
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... In another study, medical staff members were trained in empathic interactions with the elderly. The results showed, but without the use of a comparison group, that VR can improve understanding of age-related health problems and increase empathy for older adults [48]. Several studies also used VR to counteract racism by using VR to increase empathy for individuals who have been discriminated [49,50]. ...
Learning about Victims of Holocaust in Virtual Learning about Victims of Holocaust in Virtual Reality: The Main, Mediating and Moderating Effects of Technology, Instructional Method, Flow, Presence, and Prior Knowledge
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The goal of the current study was to investigate the effects of a virtual reality (VR) simulation of Anne Frank’s hiding place on learning. In a 2 × 2 experiment, 132 middle school students learned about the living conditions of Anne Frank, a girl of Jewish heritage during the Second World War, through desktop VR (DVR) and head-mounted display VR (HMD-VR) (media conditions). Approximately half of each group engaged in an explorative vs. an expository learning approach (method condition). The exposition group received instructions on how to explore the hiding place stepwise, whereas the exploration group experienced it autonomously. Next to the main effects of media and methods, the mediating effects of the learning process variables of presence and flow and the moderating effects of contextual variables (e.g., prior technical knowledge) have been analyzed. The results revealed that the HMD-VR led to significantly improved evaluation, and—even if not statistically significant—perspective-taking in Anne, but less knowledge gain compared to DVR. Further results showed that adding instructions and segmentation within the exposition group led to significantly increased knowledge gain compared to the exploration group. For perspective-taking and evaluation, no differences were detected. A significant interaction between media and methods was not found. No moderating effects by contextual variables but mediating effects were observed: For example, the feeling of presence within VR can fully explain the relationships between media and learning. These results support the view that learning processes are crucial for learning in VR and that studies neglecting these learning processes may be confounded. Hence, the results pointed out that media comparison studies are limited because they do not consider the complex interaction structures of media, instructional methods, learning processes, and contextual variables.
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... A review of 178 medical studies showed that using IVR in teaching could effectively improve medical students' understanding of the impacts of gerontological diseases on the daily life of older adults. Moreover, after learning through IVR, the students expressed more feelings of empathy toward older adults with sensory impairments and dementia [50]. Another study showed that IVR teaching can create scenarios that closely resemble those in real health care settings, allowing students to immerse themselves in practicing clinical reasoning and learn how to deal with emergencies, which can boost their ability to make decisions and determine priorities [43]. ...
The Effects of Immersive Virtual Reality Applications on Enhancing the Learning Outcomes of Undergraduate Health Care Students: Systematic Review With Meta-synthesis
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Background: Immersive virtual reality (IVR) applications are gaining popularity in health care education. They provide an uninterrupted, scaled environment capable of simulating the full magnitude of sensory stimuli present in busy health care settings and increase students’ competence and confidence by providing them with accessible and repeatable learning opportunities in a fail-safe environment. Objective: This systematic review aimed to evaluate the effects of IVR teaching on the learning outcomes and experiences of undergraduate health care students compared with other teaching methods. Methods: MEDLINE, Embase, PubMed, and Scopus were searched (last search on May 2022) for randomized controlled trials (RCTs) or quasi-experimental studies published in English between January 2000 and March 2022. The inclusion criteria were studies involving undergraduate students majoring in health care, IVR teaching, and evaluations of students’ learning outcomes and experiences. The methodological validity of the studies was examined using the Joanna Briggs Institute standard critical appraisal instruments for RCTs or quasi-experimental studies. The findings were synthesized without a meta-analysis using vote counting as the synthesis metric. A binomial test with P<.05 was used to test for statistical significance using SPSS (version 28; IBM Corp). The overall quality of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation tool. Results: A total of 17 articles from 16 studies totaling 1787 participants conducted between 2007 and 2021 were included. The undergraduate students in the studies majored in medicine, nursing, rehabilitation, pharmacy, biomedicine, radiography, audiology, or stomatology. The IVR teaching domains included procedural training (13/16, 81%), anatomical knowledge (2/16, 12%), and orientation to the operating room setting (1/16, 6%). The quality of the 75% (12/16) of RCT studies was poor, with unclear descriptions of randomization, allocation concealment, and outcome assessor blinding procedures. The overall risk of bias was relatively low in the 25% (4/16) of quasi-experimental studies. A vote count showed that 60% (9/15; 95% CI 16.3%-67.7%; P=.61) of the studies identified similar learning outcomes between IVR teaching and other teaching approaches regardless of teaching domains. The vote count showed that 62% (8/13) of the studies favored using IVR as a teaching medium. The results of the binomial test (95% CI 34.9%-90%; P=.59) did not show a statistically significant difference. Low-level evidence was identified based on the Grading of Recommendations Assessment, Development, and Evaluation tool. Conclusions: This review found that undergraduate students had positive learning outcomes and experiences after engaging with IVR teaching, although the effects may be similar to those of other forms of virtual reality or conventional teaching methods. Given the identification of risk of bias and low level of the overall evidence, more studies with a larger sample size and robust study design are required to evaluate the effects of IVR teaching.
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... Interestingly, 54% (n=69) of our participants stated that they were unable to put themselves empathically into the situation of the virtual patient. Although empathy can be taught using VR-based teaching [21], there is no data indicating if empathy itself is required for learning in a VR-based environment. Following the empathy-altruism hypothesis, empathy can be seen as a requirement for altruistic action [22] and might thus be a perquisite for learning in patient-centered cases. ...
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Teaching Empathy to Medical Students: An Updates, Systematic Review
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Some research shows that empathy declines during medical school. The authors conducted an updated, systematic review of the literature on empathy-enhancing educational interventions in undergraduate medical education. The authors searched PubMed, EMBASE, PsycINFO, CINAHL, Scopus, and Web of Science (January 1, 2004 through March 19, 2012) using key words related to undergraduate medical education and empathy. They independently selected and reviewed all English-language articles that described an educational intervention designed to promote empathy in medical students, assessing the quality of the quantitative studies using the Medical Education Research Study Quality Instrument (MERSQI). The authors identified and reviewed the full texts of 18 articles (15 quantitative and 3 qualitative studies). Included interventions used one or more of the following-patient narrative and creative arts (n = 7), writing (n = 3), drama (n = 1), communication skills training (n = 4), problem-based learning (n = 1), interprofessional skills training (n = 1), patient interviews (n = 4), experiential learning (n = 2), and empathy-focused training (n = 1). Fifteen articles reported significant increases in empathy. Mean effect size was 0.23. Mean MERSQI score was 10.13 (range 6.5-14). These findings suggest that educational interventions can be effective in maintaining and enhancing empathy in undergraduate medical students. In addition, they highlight the need for multicenter, randomized controlled trials, reporting long-term data to evaluate the longevity of intervention effects. Defining empathy remains problematic, and the authors call for conceptual clarity to aid future research.
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Professor and Director of Geriatrics Education Research, Division of Geriatric Medicine
  • 4005
  • Marilyn R Gugliucci
  • Ma
  • Phd
Marilyn R. Gugliucci, MA, PhD, mgugliucci@une.edu, Professor and Director of Geriatrics Education Research, Division of Geriatric Medicine, College of Osteopathic Medicine, University of New England, Biddeford ME 04005