Medical Education Online

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/zmeo20

Augmented reality in medical education: students’

experiences and learning outcomes

Poshmaal Dhar, Tetyana Rocks, Rasika M Samarasinghe, Garth Stephenson

& Craig Smith

To cite this article: Poshmaal Dhar, Tetyana Rocks, Rasika M Samarasinghe, Garth
Stephenson & Craig Smith (2021) Augmented reality in medical education: students’
experiences and learning outcomes, Medical Education Online, 26:1, 1953953, DOI:
10.1080/10872981.2021.1953953

To link to this article: https://doi.org/10.1080/10872981.2021.1953953

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MEDICAL EDUCATION ONLINE
2021, VOL. 26, 1953953
https://doi.org/10.1080/10872981.2021.1953953

REVIEW ARTICLE

Augmented reality in medical education: students’ experiences and learning

outcomes
Poshmaal Dhara, Tetyana Rocksb, Rasika M Samarasinghea, Garth Stephensona and Craig Smith a

a
Institute for Innovation in Mental and Physical Health and Clinical Translation, School of Medicine, Faculty of Health, Deakin University,
Geelong, Australia; bInstitute for Innovation in Mental and Physical Health and Clinical Translation, Food and Mood Centre, School of
Medicine, Faculty of Health, Deakin University, Geelong, Australia

ABSTRACT ARTICLE HISTORY

Augmented reality (AR) is a relatively new technology that allows for digitally generated Received 29 September
three-dimensional representations to be integrated with real environmental stimuli. AR can 2020
make use of smart phones, tablets, or other devices to achieve a highly stimulating learning Revised 6 July 2021
environment and hands-on immersive experience. The use of AR in industry is becoming Accepted 7 July 2021
widespread with applications being developed for use not just for entertainment and gaming KEYWORDS
but also healthcare, retail and marketing, education, military, travel and tourism, automotive Augmented reality; medical
industry, manufacturing, architecture, and engineering. Due to the distinct learning advan­ education; education
tages that AR offers, such as remote learning and interactive simulations, AR-based teaching technology; online learning;
programs are also increasingly being adopted within medical schools across the world. These learning outcomes
advantages are further highlighted by the current COVID-19 pandemic, which has caused an
even greater shift towards online learning. In this review, we investigate the use of AR in
medical training/education and its effect on students’ experiences and learning outcomes.
This includes the main goals of AR-based learning, such as to simplify the delivery and
enhance the comprehension of complex information. We also describe how AR can enhance
the experiences of medical students, by improving knowledge and understanding, practical
skills and social skills. These concepts are discussed within the context of specific AR medical
training programs, such as HoloHuman, OculAR SIM, and HoloPatient. Finally, we discuss the
challenges of AR in learning and teaching and propose future directions for the use of this
technology in medical education.

Introduction AR is a rapidly developing technology. Due to its

flexibility in integrating physical and virtual environ­
Augmented reality (AR), a type of mixed reality, is
ments, AR-based programs are increasingly used in edu­
a real-world based experience that is enhanced by
cation, including medical education and training. The use
digital objects or information. Barsom, Graafland &
of this technology provides various means of delivering
Schijven (2016) describe augmented reality as “ . . .
learning content and enhancing students’ experiences.
an interactive virtual layer on top of reality’.
Practically, this is usually achieved via a head-set
or tablet-style devise (including smart phones) in
which the digital object is created and is sur­ Brief history of augmented reality use in medical
rounded by the real environment. In addition to education
visual digital stimuli, enhancement of reality in Due to the advantages that AR technology offers, several
education can be also achieved by introducing programs have been successfully implemented in the
auditory, haptic (touch), and even olfactory infor­ field of medicine. Broadly, these can be categorised into
mation or feedback [1]. By presenting only partial two subgroups. The first involves treatment programs
augmentations of the real environment, this mixed which help patients and/or practitioners within
reality allows to precisely control the level of expo­ a hospital or clinical setting, such as therapies, rehabilita­
sure carefully shaping the learning experience. This tion, or surgical procedures. The second includes train­
is different from virtual reality (VR), in which the ing programs which are instead designed to aid teaching
entire environment is digitally created. However, and learning outcomes within the academic university
both AR and VR sit at different ends of the setting [1]. This review will focus on the latter of these
mixed reality continuum, which was acknowledged two categories, and will explore how they have taken
over 25 years ago when this field was first emer­ advantage of key features of this technology to develop
ging [2]. or improve knowledge, learning, and skill outcomes.

CONTACT Craig Smith craig.smith@deakin.edu.au School of Medicine, Institute for Innovation in Mental and Physical Health and Clinical
Translation, Deakin University, Australia
© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
2 P. DHAR ET AL.

Before the use of computers in medical education, databases: PubMed, Google Scholar, and Scopus.
text-books, lectures, cadavers, anatomical models and Keywords including ‘Augmented reality’, ‘Medical
live patients were some of the only pedagogical tools education’, ‘Students experiences’, and ‘Learning out­
available. Basic computer-assisted anatomy programs comes’ were used to search for articles published in
started to appear in the early 1990s [3,4], and were English, and those from the last 10 years were
often accompanied with multimedia approaches such favoured. As this was not a systematic review, author
as the ‘Slice Of Life’ videodiscs that served as a visual discretion was used in selecting appropriateness, and
anatomy encyclopaedia [5]. Continuing advance­ a wider scope of topics is addressed (for an example
ments in hardware allowed for presentation software of a systematic review that addresses a more narrow
such as Microsoft PowerPoint to mostly replace subject topic within this area, see [14]). We also
blackboards and overhead projections in the 1990s conducted a complimentary search of the reference
[6], while the World Wide Web made the Visible lists of key articles.
Human Project [7] and similar programs like the
Visible Embryo Project [8] possible. The mid-1990s
Results
also saw the use of computer-based stereoscopy, in
which slightly offset two dimensional images are dis­ Enhancement of student experiences and
played in each eye to give the illusion of three dimen­ learning outcomes with AR-based medical
sional depth [9]. Although the first head-mounted programs
display was developed in the late 1960s [10], the
AR-based training provides a vast potential to effec­
adoption of VR within medical education has
tively and efficiently prepare medical professionals
required more recent technological advancements
for the real world of practice [15]. Along with offer­
such as the availability of modern head-mounted dis­
ing a safe educational environment and addressing
plays including Google Glass, Microsoft HoloLens,
specific professional skills, AR programs for learning
Oculus Rift VR, and the Samsung Gear VR [11]. AR
in medicine are employed to enhance learners’
has also benefited from recent advancements in
experiences, as described by Salehahmadi and
handheld smartphone and tablet devises, which not
Hajialiasgari [16] (Figure 1).
only improve the power of such programs, but also
AR learning is commonly associated with highly
expand their accessibility out of traditional learning
positive subjective personal experiences, and can be
spaces and into the hands of the learner [12]. This
fun and interesting to use. It is for similar reasons
feature of AR has become particularly important dur­
that AR games such as Pokemon Go have been so
ing the current COVID-19 pandemic, which caused
successful [17]. Moreover, AR can enhance learning
restricted face-to-face access to many university and
delivery, presentation and the utilisation of sensory
other learning spaces [13].
systems, which are three crucial elements of Mayer’s
cognitive theory of multimedia learning [18]. Due to
the high level of digital literacy common amongst
Materials and methods
University students and their familiarity with using
In this narrative review, we conducted an extensive tablets and smartphones, students often report that
literature review using searches within the following they feel confident with adopting AR alternatives to

Figure 1. The main goals of augmented reality in medical education [16].

 MEDICAL EDUCATION ONLINE 3

traditional learning approaches, such as flashcards AR is able to enhance the way in which medical
[19]. The ability to use devices that students already students interact with digital anatomical representa­
own also facilitates self-paced learning, and non- tion at all angles, providing a more immersive experi­
headset VR programs are less likely to cause adverse ence that ultimately aids knowledge and
effects compared to VR while still achieving similar understanding [23].
learning benefits. For example, Moro and colleagues An important advantage of such programs is
showed that an AR structural anatomy program ran that they allow easy manipulation of the digital
on a tablet achieved similar learning outcomes (e.g., subject, so that spatial inter-relationships can be
anatomical knowledge test results) compared to identified and explored in three-dimensional
a headset VR equivalent. Importantly however, the space. In regards to anatomy, this for example
AR tablet version was less prone to adverse effects allows for complicated branching nerve and blood
including general discomfort, headache, dizziness, vessel paths to be examined in isolation, which is
nausea and disorientation, and was also less likely to difficult to do with traditional cadavers as these
cause eye-related problems such as blurred structures lose shape if dissected away from the
vision [20]. surrounding tissue that supports them. Learning
Due to the ability of AR-based learning to support the names for the multitude of anatomical struc­
students’ experiences, not surprisingly, this can also tures is also aided by the ability to select regions/
translate into improved learning outcomes [1]. structures of interest, and access a range of other
Students who successfully complete learning activities information pertaining to them [24].
enhanced by AR programs are more likely to achieve In addition to pure anatomy, understanding how
both enhanced theoretical knowledge and practical anatomy relates to function is a particularly impor­
skills. AR-based learning boosts outcomes in several tant aspect of medical education. This is aided by the
main aspects of training, including professional knowl­ ease at which different anatomical structures can be
edge, cognitive and practical skills, social skills, innova­ added and removed from the digital subject, such as
tion, competence, and creativity [21]. Here, we focus on muscles or underlying skeletal structure including
the effect of AR-based programs on students’ experi­ muscle attachment sites. Furthermore, many AR
ence and learning outcomes in relation to the following (and VR) anatomy programs include functional fea­
three domains of impact: knowledge and understand­ tures where specific muscles can be flexed, in order to
ing, practical skills, and social skills (Figure 2). observe the resulting movement that they control
[25]. This is especially beneficial for understanding
complex systems involving multiple muscle groups
AR enhancement of knowledge and
such as eye movement, which can be accessed easily
understanding
at the student desk or at home (Figure 4). Another
Medical education is associated with an enormous advantage, is that human cadavers and physical mod­
amount of information pertaining to human anatomy els can only logistically represent a limited number of
and bodily function [22]. Learning this information diseased pathologies, and the true range of individual
has been greatly aided with the development of variation is often poorly encapsulated within any
a plethora of digital programs, for example ‘virtual given medical school. In contrast, multiple patholo­
cadavers’ (Figure 3). Rather than being accessed via gies and subtle anatomical variations can be easily
a traditional computer mouse, keyboard and screen, added to virtual representations [26].

Figure 2. Three main domains of medical student experiences and learning outcomes that are enhanced by AR-based programs.
4 P. DHAR ET AL.

Figure 3. The AR app ‘HoloHuman’ showing a virtual cadaver placed on a real examination table. The moderator (shown) is able
to interact with the model and user interface through the use of a HoloLens headset. Structures, organs and systems can be
examines individually or in combination and are fully supported by visual narrative and digital dissection tools (image courtesy
of 3D4 Medical from Elsevier, 2020; https://3d4medical.com/apps/holohuman).

AR enhancement of practical skills that confirmed that teaching practical procedures

It is an expectation that medicine graduates have incul­ such as surgery using AR-based tools contributes to
cated not only extensive and in-depth knowledge about improvements and practical competence in medical
the human body, diseases and associated procedures, teaching and training. These programs can also often
but also communication skills, physical examination aid the performance of the actual surgical procedure
skills, practical skills and clinical skills. While the cur­ itself, and can overlay patient-specific anatomical
rent medical pedagogy and curriculum are undoubtedly information obtained from imaging scans, such as
delivering competency-based medical and healthcare in spinal surgeries [30,31]. Transrectal prostate
professionals, there is still room for improvement in biopsy practice and training can also be aided by
terms of their practical and surgical skills training; and this technology, to help control robot-assisted appa­
face-face patient care and treatment is often limited or ratus [32]. Multiple AR-based programs are already
lacking. Clinical placements have significantly used for kidney surgery and training (and several
improved the students’ practical skills, but a lack of more are likely to be soon adopted), including those
extensive hands-on training can often hamper their to aid patient education [33,34]. Wolf et al describe
ability to master these procedures [27]. Physical models the recent development of an AR program using
often help fill this gap, and these are increasingly Microsoft HoloLens 2, for training the surgical pro­
becoming highly sophisticated and effective. For exam­ cedure of extracorporeal membrane oxygenation can­
ple, a study conducted in the Medical School of the nulation. Compared to conventional training,
University of South Carolina used a Cardiopulmonary medical students that received the AR version exhib­
Patient Simulator called Harvey (i.e., a highly sophisti­ ited a higher level of learning and made fewer proce­
cated manikin), and found that students who were dural errors [35]. Another platform has been
trained for cardiac examination skills using the simula­ developed by Nagayo and colleagues for open surgery
tor performed better (on examinations including the training. The movement of surgical instruments and
USMLE and MCAT) than those trained on standar­ patient anatomy during actual procedures was first
dized manikins or patient models [28]. However, mod­ captured, and then reconstructed within an AR pro­
els such as these can be expensive, and the gram. Trainees are able to manipulate their view to
implementation of new resources to improve practical obtain optimal visual angles, and can pause/rewind
skills is warranted [29]. the procedure in order to focus on particular stages.
AR is beginning to make an important contribu­ Students can also engage in self-practice by manip­
tion to this overall goal, and several cohort studies ulating surgical instruments [36].
 MEDICAL EDUCATION ONLINE 5

Figure 4. The OculAR SIM AR program to aid optometry students (available on multiple devices, such as tablets and
smartphones, subject to licencing conditions). Image courtesy of Apperition (www.appearition.com/deakin-university/), and
Peter Bright,School of Medicine, Deakin University.

In addition to AR, VR-based programs are also the benefits of the Minimally Invasive Surgical
prominently used to improve practical skills and the Trainer VirtualReality (MISTVR) tool indicates that
performance of surgical techniques. For example, it polishes their surgical skills [38]. MISTVR offers
Stanford University introduced the Neurosurgical the added benefits of providing valuable feedback to
Simulation and Virtual Reality Center in 2016, the trainee students, including parameters such as
which provides medical graduates to explore the their handling of the surgical equipment, the duration
structure of the brain and train them to operate of the procedure, and possible errors that could have
[37]. The system has been designed from MRI and been avoided during the virtual surgery. Several
CT scans of real patients, offering trainees with an simulation-based platforms for teaching colonoscopy
opportunity they would only otherwise get while in to healthcare professional are also available, such as
the surgery room. They are also able to investigate GI Mentor™ and EndoVR™ (CAE Healthcare, the old
and operate on a multitude of neurological cases and AccuTouch®, Immersion) [39]. Hysteroscopy has also
on virtual cadavers, providing them a real-time been taught for many years using a VR- platform
experience of the surgical room and how to work called EssureSim, which has been found to contribute
under stress and pressure, while being efficient and to improved precision amongst the trainees [40].
skilled. Psychomotor skills of surgeons are considered More recently, VR training was found to be more
key during laparoscopic procedures, and several pro­ effective than the standard guide passive learning tool
grams have been available for a decade or more. For for teaching a complicated tibial shaft fracture surgi­
example, a study conducted on surgeons to evaluate cal technique [41].
6 P. DHAR ET AL.

AR enhancement of social skills review concluded that although simulation-based

Medical training involves extensive learning about training in health education is gaining momentum,
social interactions and human behaviour, as future limited systematic research has been conducted to
practitioners are expected to perform their duties measure the impact of these on students’ learning
across a vast spectrum of health care settings. AR outcomes. The majority of the undertaken research
provides a unique opportunity to prepare the trainees to date assessed feasibility and face validity [42]. This
for complex social situations in a controlled and outcome shows that although some limited studies
managed environment. Moreover, AR supports indicated great usability of AR training to improve
development of inter-professional competencies that a range of social skills, further comparative investiga­
are critical for healthcare professionals. Although tions are required to evaluate how these could be
commonly AR medical training has been viewed as integrated into the world of virtual medical training.
mainly a way to increase knowledge and practical
skills, it also provides valuable scenarios to support Discussion
work-related social skills [42].
Several studies that evaluated the impact of AR Challenges and future directions
in medical training on student experience and Since the first use of AR platforms in orthopaedic
learning outcomes assessed inter-professional social diseases, the adoption of this technology in medical
competencies, focusing mainly on communication education has progressed significantly. One of the
and teamwork. For example, one randomised study major challenges faced by the higher education sector
of 34 medical residents showed that training in is the cost of designing these interactive platforms
a simulated setting to use endoscopy equipped trai­ [48]. This coupled to the lack of availability of
nees with better communication skills compared to resources to meet the needs of growing student num­
students who underwent self-regulated learning bers impedes their utilization in medical education.
[43]. Another study investigated endovascular and Making this digital technology equitable and accessi­
human factor skills by simulating a crisis scenario ble to all students is the biggest hurdle faced by
that required endovascular ruptured aortic aneur­ educators. Another criticism in the use of AR in
ysm repair. The simulation was evaluated by 22 teaching is the limited hardware that is needed, in
participants with maximum scores for enhancing addition to the growing problem of social isolation
teamwork and patient safety, with a close second associated with digital learning [49,50]. Nevertheless,
for enhancing team’s communication skills [44]. these new digital platforms have enabled educators to
Some medical students evaluated non-technical push the boundaries of traditional pedagogies to cre­
skills (stress management such as music in an oper­ ate a student-centric, engaging and enriching the
ating theatre) added to AR training as somewhat learning experience for the students.
destructive and adding to their perceived difficulties With the advancements in the field, a major next
in mastering technical skills [45]. However, when step has been postulated to be the adaptation of AR
a similar stress management situation (telephone textbooks in medical education, which is an idea that
calls during a procedure) was tested amongst 19 was proposed almost a decade ago [51]. In this pro­
junior surgeons, the training value of such stimula­ posal, Yuen (2011) eloquently described how AR
tion was given a mean score of 4.7 out of 5.0. books would allow students to transport themselves
Furthermore, the study results showed that destruc­ into a scenario/situation and learn by immersing
tive and critical scenarios hinder the objective perfor­ themselves in the experience. While the subsequent
mance of the surgeons, suggesting these as a valuable years have seen these books being slowly prescribed
addition to training [46]. in the curriculum at the school level, their incorpora­
Another interesting study that showed the value of tion in teaching healthcare and medicine-based
AR in critical medical training was conducted to courses in higher education is still in its infancy
prepare operating room clinicians (surgeons, anesthe­ [52,53]. However, continued advancements in this
siologists and nurses) to an event of an operating direction could be extremely useful when students
room fire. Forty-nine participants with a range of are learning about topics including human anatomy
clinical experience completed simulation with over and physiology. The ability to read and visualize
two thirds (67%) indicating the preference for AR- content such as brain function and nerve impulses
based training compared to textbook method [47]. (to quote one example) will assist with retention and
Overall, despite the great potential of AR-based deeper understanding of the physiology of the human
programs to deliver complex and highly precisive body. When considering the ability of AR designs to
training that focusses on social skills building in allow multiple users to interact in the same platform,
a vast range of situations, the current evaluation of this will help tackle the issue of isolation that these
these in the literature is lacking. A recent systematic AR platforms may create for learners. It is believed
 MEDICAL EDUCATION ONLINE 7

Figure 5. In the HoloPatient system, volumetric 3D video capture of a standardized patient sitting in a chair being assessed by
a group of medical students. Students can view the patient and interact with the test results panel and real time vital signs
through the use of the Microsoft HoloLens 2. Here the patient describes chest pain associated with myocardial infarction.
Published with permission from GIGXR (www.gigxr.com/applications/holopatient).

that these AR-interfaced books can offer a respite to space anywhere an internet connection can be made.
students from stagnant and dull text-only based As AR technologies progress, making these technol­
learning material that traditional textbooks offer, ogies affordable will be a key focus. Collaborations
making them an exciting tool for both students and between companies, universities and increased fund­
educators. ing for this sector will pave way for newer AR/VR
Mobile learning (m-learning) and wearable technol­ platforms in medical teaching. A classic example is
ogy is a relatively new digital learning platform, that has the Medical Virtuality Lab designed by University of
enormous potential. AR-based learning software could Southern California, Institute for Creative
be provided on students’ personal devices such as Technologies [59]. The primary aim of this institute
mobiles, iPads and tablet computers, or on wearable is to bring individuals and experts from the film and
items such as smart watches, which would make the game industry together with computer and social
adaptation of this technology in medical education far scientists to create and design the platforms for use
more acceptable and cheaper [54,55]. One example of in healthcare education and training.
this concept is the use of Google Glass [56] at the The field of AR offers opportunities for educators
University of California, Irvine School of Medicine, in in the field of medical education to create a rich and
their anatomy courses and hospital rotations [57]. engaging curriculum, offering students the opportu­
Google Glass offers the ease and flexibility of accessing nity to not only learn but experience the learning
course content and patient-related information in content/material as well. The disruption to traditional
a hands-free format, at the same time allowing users to classroom teaching due to COVID-19 has led to
communicate via voice command. Another wearable a rapid adaptation of digital teaching tools globally,
technology that can be potentially used in teaching is highlighting the importance of digital technologies,
the use of monitors that can record the health of patients, including AR to ensure student learning is not ham­
which is communicated to the smart device of the stu­ pered. Optimal utilization and continued usage of
dents, which allows students to detect a disease. For digital learning tools has the potential to reform the
example, The University of Michigan is developing medical education sector.
a vapour sensor that can help monitor the health of
patients with diabetes and lung disease [58]. The use of
virtual patients and case scenarios during problem-based Acknowledgments
learning sessions is another approach that may be highly
beneficial in medical teaching (Figure 5). We thank 3D4 Medical, Apperition, and GIGXR for the
use of images.
Other important potential future uses for AR-
based medical education include teaching programs
for individuals with reading disabilities (a barrier to
traditional textbook-based learning), and in remote Disclosure statement
learning contexts to transport the user into a virtual No potential conflict of interest was reported by the author(s).
8 P. DHAR ET AL.

ORCID [16] Salehahmadi F, Hajialiasgari F. Grand adventure of

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Craig Smith http://orcid.org/0000-0002-2894-2433 J Plast Surg. 2019;8(2):135–145.
[17] Ewell PJ. Catching more than pocket monsters: poke­
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