The Effects of Virtual Reality on Social Dynamics in Medical Pedagogy during COVID-19
Did VR help to support medical education during the pandemic?
Virtual reality (VR) uses technology to immerse a user in a simulated three-dimensional environment. Recently, maturing capabilities and lowered production costs have allowed the medical community to embrace VR for therapeutic and educational purposes. The Coronavirus Disease 2019 (COVID-19) pandemic has drastically reduced social interaction in classrooms, forcing medical pedagogy to quickly adapt and turn to novel ways such as VR to continue operating. However, the social implications of integrating disruptive technologies such as VR into medicine remain unexplored. This essay will explore how VR-augmented pedagogy has the potential to disrupt medical schools’ long-standing and strict social hierarchies in the context of the COVID-19 pandemic by creating completely virtual classrooms. Even after normalcy returns, the effects caused by the pandemic’s sudden impetus for innovation might be applied to other forms of disruptive technology, inviting the possibility of new pedagogical dynamics between medical students and instructors. This essay will first establish the social context of a traditional medical school as a strict social hierarchy. Next, VR’s current capabilities and social implications will be explored and finally examined in the context of COVID-19.
Setting the Stage
Saunders’ (2010) observations of an educational hierarchy within a CT suite demonstrate traditional social structures in medical pedagogy. In the late 1990s, Saunders observed that this social structure manifested itself in four levels of varying seniority, namely junior medical students, residents, more experienced fellows, and the most senior attending radiologists (147). Indicators of a person’s hierarchal level took the forms of tangible artifacts such as official qualifications and years of experience or implicit arrangements such as seating arrangements around a mechanical viewbox (148). The overseeing attending radiologist tended to place themselves at a distance from the viewbox, allowing students to examine the films inside the viewbox more closely. The social hierarchy also manifested itself in the division of labor within a CT suite. Akin to how school principals typically do not teach students directly, attending radiologists tended to provide general guidance during viewbox sessions and conferences instead of detailed instructions. The rotation structure in a CT suite resulted in fellows being responsible for much of the residents’ radiological education (149). Junior residents demonstrated their lower hierarchal level by being responsible for tedious tasks such as manually arranging viewbox films (154). Additionally, stricter guidelines for documentation formats indicated a higher level of guidance and showed how students at lower hierarchal levels lacked experience (154). Hence, Saunders firmly established a rigid social hierarchy between instructors and students in a medical context.
Saunders argued that CT suite pedagogy was effectively modeled on a master-apprentice relationship (145). Although this model is not entirely identical to how feudal apprentices were attached to a single master for their entire education (146), radiology residents underwent a large amount of shadowing and close collaboration with their mentor, staying faithful to the spirit of apprenticeship (149). Saunders observed that radiology residents received instruction in a variety of forms. Some pedagogical methods may be familiar from earlier education, such as rote learning of book knowledge (146). Other types may seem more niche, such as gaining mechanical expertise by mimicry. For instance, the nuances of the supposedly menial task of arranging viewbox films teach muscle memory and increase a student’s speed and accuracy (153). Other forms of instruction included frequent conferences where radiologists would share progress updates and occasionally test the residents’ knowledge in the form of “hotseat conferences” which cultivated soft skills such as competence under pressure and presentation skills while reviewing didactic knowledge (147).
To Saunders, a clear manifestation of the master-apprentice relationship in the CT suite was how educators and students interacted. Saunders noted how interactions between instructors and residents routinely involved inexperienced students making rookie mistakes and subsequently receiving constructive, albeit harsh feedback (147). Saunders’ observations largely centered on how “abductive” knowledge was taught, which involved honing one’s intuition to make educated guesses based on the available information (157)[1]. Saunders documented the exchanges between the attending radiologists and residents during a viewbox session (158). From the interactions, Saunders clearly illustrated how the attending controlled the lesson’s narrative at all times by dropping hints to nudge students towards the correct observations while holding back enough information to force students into independently making the final abductive leap in logic. When students inevitably made errors, the attending would chastise them, point out the mistakes while setting the students up for another try at exercising their abductive instincts. The attending’s ability to confidently steer the course of such interactions demonstrates the large gap in expertise and seniority between educators and students, showing the clear separation between hierarchal levels.
Outside of Saunders’ CT suite, the idea of a strict social hierarchy that manifests itself explicitly and implicitly throughout the education process can be applied more generally to pedagogy in medical schools. Similar to radiology, medical schools use didactic lectures to teach anatomy and biology. Furthermore, Saunders noted that “Learning to read CT scans is part of the process of learning to read medical images in general.” (146) Hence, it is highly likely that the types of learning employed within a CT suite also appear in other medical fields, even if the exact equipment or sociological arrangements might differ. For example, surgical training heavily involves tacit physical knowledge gained through observation of senior surgeons, as surgeons need to have highly developed fine motor skills before successfully conducting an operation (Li et al., 2017, p. 43). Tutorial lessons, where students can seek clarifications regarding their work and receive feedback, demonstrate master-apprentice dynamics during interactions that help to hone one’s intellectual instincts. However, the degree of collaboration might not be as close as that between radiology residents and fellows. Medical students also undergo internships, exhibiting apprenticeship characteristics such as close collaboration and learning through observations by shadowing practicing physicians. Therefore, Saunders’ observed social structure also applies to general medical pedagogy.
Technological advances over time can influence the physical settings of Saunders’ observed social structure. Even though life in Saunders’ CT suite revolved around the mechanical viewbox, the exact social configurations he observed no longer exist due to digitalization (161). Saunders noted that the suite configurations he witnessed during the digital revolution’s infancy might be unrecognizable to today’s neophyte radiologists (163). Notably, many of the practical skills involved in reading CT images have shifted from mechanical skills to increasingly digital skills. The social dynamics Saunders observed may also be applied across time to present medical educations and its technological configurations, even if the applications are not identical to Saunders’ CT suite.
Virtual Reality and Medical Education
While the world described by Saunders has since digitized, he anticipated the importance of digitalization to medical education by emphasizing the need to reflect current technological trends by updating social observations (Saunders, 2010, p. 163). More than two decades after Saunders first recorded his observations in the CT suite, this suggestion is more relevant than ever as disruptive technologies become ubiquitous and influence established social structures. In particular, cutting-edge virtual reality can influence Saunders’ observed social hierarchy even though it seems radically different from the mechanical viewbox.
Current VR technology can provide an immersive educational experience. Typically, VR setups for medical education use a head-mounted display (HMD) and laptop to run the program (Pottle, 2019, p. 182). The HMD is key to VR’s immersiveness as it blocks out the outside world by filling up the user’s field of vision with generated images, allowing the user to feel as if they are in the world depicted by the VR program. Users can manipulate virtual objects with handheld controllers, providing an element of interactivity to the virtual environment. Nowadays, VR technology has matured sufficiently to be safe, easy, and cost-efficient to use (182). VR programs track the user’s orientation and hand positions, giving the user some spatial awareness which is especially useful in simulating practical operations. Providing the user with a sense of self-perception helps alleviate the common disorientation and nausea caused by older VR programs (Pax and Hamilton, 2018, 405). Many VR programs are ready to use out of the box with their usage difficulty comparable to that of a computer game, a familiar device to today’s digitally savvy students. The equipment needed to run VR software is also relatively easy to use and readily available to consumers (Pottle, 2019, p. 182). VR headsets can be as simple as a cardboard phone holder mounted to the user’s head, assuming the user owns a phone powerful enough to feature VR support. Hence, VR technology nowadays might have the ability to simulate a classroom due to its immersive capabilities and accessible availability to students.
VR has shown effectiveness in augmenting educational experiences in medicine. In surgical education, Li et al. (2017) observed that VR simulations performed better as anatomical models than other simulation models such as animal substitutes and videos (3869). VR programs provided high interactivity and realism, simulating actual human cadavers more effectively (3870). Furthermore, it is possible to repeat simulations to measure progress compared to past performances, similar to how VR games allow you to replay levels (3870). The ability to repeat simulations multiple times is particularly noteworthy as physical training options cannot do so due to limited resources and potentially high running costs of many simulations (Pottle, 2019, p. 182). Automatically measured metrics for measuring performance such as surgical speed, accuracy, and correctness result in immediate student feedback (Li et al., 2017, p. 3870). Li et al. concluded that VR’s ability to realistically simulate anatomical models coupled with its suite of educational features allowed students who underwent VR training to perform more quickly and accurately than counterparts who underwent traditional surgical training (3873). The study also noted that current VR software could not fully replicate surgical nuances and biological variation in physical specimens. However, upgrading VR software to support randomized anatomical models and improving haptic feedback in VR hardware may resolve this. Therefore, VR technology can enhance medical education by providing an effective way to simulate anatomical models.
VR’s ability to enable virtual classrooms in medical pedagogy has the potential to decentralize the classroom as the center of learning. Pottle (2019) asserted that portable VR classrooms, which have all the resources students need, can release students from physical classroom constraints and promote self-directed learning (184). Students can keep learning without being limited by time and geographical boundaries, such as commuting time to and from laboratories and school opening hours. By empowering students to undergo rigorous practical education anywhere, medical pedagogy can occur without an actual physical location. For instance, didactic instruction can occur via video or assigned readings, while laboratory lessons occur in VR. Session data from these VR assignments allow instructors to capture and replay a student’s performance, allowing for more opportunities to give detailed feedback and instruction remotely. Hence, VR enables medical education to bypass the need for an actual classroom venue to impart physical skills.
The prospect of wholly virtual classrooms with reduced interaction between educators and students could unravel Saunders’ proposed model of strict social hierarchy. Saunders’ medical education model strongly emphasized collaboration between educators and students, evidenced by numerous student-teacher interactions observed in the CT suite (Saunders, 2010, p. 158). In particular, subtlety and spontaneity in these interactions illustrated the master-apprentice relationship Saunders’ observed. Furthermore, Saunders stressed the importance of a central education hub for congregation and communication, such as the CT suite’s mechanical viewbox. By delegating the bulk of education to simulators and computers, there is a risk of losing the human touch, close collaboration, and shared environment characteristic of master-apprentice relationships (162).
VR integration may upend Saunders’ observed social hierarchy by inverting and redirecting information flow between educators to students. An exploration of how scientific images influenced social dynamics by Burri and Dumit (2008) asserted that evolving imaging methods could shift the balance of knowledge due to differences in the ability to adapt between senior and junior roles (304). Saunders’ observations support this assertion by showing that junior roles tended to adapt to new technologies more quickly than their seniors, occasionally reversing the top-down flow of information within social hierarchies by educating their instructors to use these new technologies (Saunders, 2010, p. 162). Hence, the learning curve in adapting to disruptive technologies such as VR can affect interactions between hierarchal levels by changing the flow of knowledge between educators and students.
The difficulty in creating VR resources might reduce the autonomy instructors have in planning lessons. Burri and Dumit (2008) explored how generating, using, and distributing scientific images initiated social dynamics between scientists, showing that the act of producing, analyzing, and communicating scientific pictures impacted social dynamics by requiring additional collaboration (300). For instance, creating scientific facsimiles is a vocation of its own as technical knowledge is needed to know the best methods for creating usable images, such as knowing which part of the body to capture a CT scan to gain valuable insights (302). However, existing hierarchical structures and chains of command result in particular social configurations such as experienced laboratory technicians instructing inexperienced scientists on capturing images, simply because the technician lacked the official qualifications to make technical judgments despite their experience (302). The lack of technical knowledge means that educators need to rely on technical experts to design VR simulations, implying that teachers have reduced control over their lesson plans since they would have to account for the design and constraints of VR classrooms.
Finally, VR could further disrupt Saunders’ strict hierarchy of senior instructors educating inexperienced students by removing the need for such instructors. Including VR as a novel visual aid may result in additional peer-to-peer learning instead of inter-level education from Saunders’ model. Pottle (2019) noted a case study in the University of Oxford where peer-to-peer learning in VR occurred with minimal instructor intervention (184), which seems to strongly contradict Saunders’ assertion of the instructor as the driving force behind classroom interactions. Increased peer-to-peer learning, together with previously proposed changes to Saunders’ social structure, demonstrates how VR has reduced the importance of classroom instructors by blurring the lines between hierarchal levels. Therefore, virtual classrooms in VR could fundamentally change classroom dynamics by removing traditional instructors.
Pandemic-era Problems and Pedagogy
Some may argue that VR’s integration into medical education will not drastically modify Saunders’ strict social hierarchy in medical pedagogy. VR tends to serve as a complement to traditional teaching methods and not a replacement. Pottle (2019) specifically noted that VR was especially valuable in blended learning in flipped classroom scenarios where students learn the lesson’s content before gathering for discussions in physical classrooms (184). Therefore, technological aids might augment close communication between educators and students but will not change their nature. However, strict social distancing to prevent the coronavirus’ spread has severely impacted traditional models’ sustainability. As medical schools quickly adapted to the sudden impetus for virtual learning, new classroom arrangements manifested with new social dynamics between students and teachers.
Adapting to the COVID-19 pandemic, medical schools shifted most of their operations online and adapted numerous methods to maintain student engagement. Most medical schools utilized available online resources such as learning management systems and free lectures to substitute typical seminars and homework assignments (Tabatabai, 2020, p. 141). A case study by Almarzooq et al. (2020) about virtual learning in graduate medical school during COVID-19 detailed how the Brigham and Women’s Hospital Fellowship in Cardiovascular Medicine implemented a virtual learning environment using methods such as Microsoft Teams (2635). The article provided anecdotal evidence of how virtual methods can be effectively implemented in medical education, even during times as challenging and rapidly evolving as the COVID-19 pandemic (2637). However, it noted that virtual learning could not fully replace real-life learning but could be augmented using current virtual reality simulations (2637). Bari (2021) observed that virtual learning has distinct drawbacks, such as disengagement or “Zoom fatigue” due to limitations in communicating via video calls. The loss of many non-verbal cues through body language is also a significant problem for educators. As such, there is room to improve pandemic-era virtual learning systems using VR.
Virtual reality was deployed in medical education during the pandemic to a certain extent. A 2020 study by De Ponti et al. attempted to determine the effectiveness of virtual reality simulations in instructing medical students about clinical situations during the pandemic when the ability to conduct in-person classes was severely impacted (2). The results revealed that most students surveyed found that the virtual reality training methodology was helpful, realistic, and a potential complement to traditional apprenticeship sessions (4). However, technical difficulties might have hindered some students’ learning (5). Hence, despite the presence of minor issues, VR can augment medical pedagogy.
Expanding on the uses of VR in the context of the pandemic’s social distancing requirements, the concept of virtual classrooms should be explored. Pottle (2019) raised the intriguing possibility of “multiplayer VR” scenarios that could someday blend current VR teaching aids with levels of collaboration that only occurred in physical settings previously (184). Pottle proposed the idea of live sessions where medical educators and students from all corners of the world could work together on the same problem in the same virtual environment (184). Despite sounding far-fetched, the idea of VR-enabled video communication is not as peculiar as one might think. Advances in network technology such as 5G networks would mean that large-scale support for VR-enabled communication could happen soon. More devices might support VR communication programs, bringing the possibility of VR-augmented communication for virtual classrooms closer to reality.
The idea of virtual classrooms would help to resolve some of the communication limitations of video calls and reconcile the seemingly contradictory notions of close collaboration and wholly virtual learning by creating a learning hub in virtual reality. After overcoming the initial hurdles regarding the technological learning curve, Saunders’ social hierarchy will likely remain unchanged. Even though the bulk of didactic learning is no longer directly from instructors, meaningful and close collaborations in the virtual classroom can preserve the vital parts of Saunders’ proposed master-apprentice relationship like practice under observation. The top-down flow of knowledge between hierarchal levels may remain since the wealth of medical knowledge possessed by medical instructors far exceeds their lack of expertise in operating virtual learning tools. Therefore, even after unleashing VR technology’s potential for virtual classrooms, Saunders’ social hierarchy is very likely to remain relevant even if the central learning venue is no longer a physical one. However, the experiences from learning during the pandemic are likely to linger in the form of increased discussions between students and instructors as equals and increased levels of peer-to-peer learning.
In conclusion, the physical and personal decentralization of current virtual reality simulations has disrupted Saunders’ model of a strict social hierarchy in medical pedagogy. However, future improvements in VR’s capabilities raise the intriguing prospect of virtual classrooms that preserve Saunders’ model of collaboration while leveraging on the potential of VR-augmented education. As VR becomes increasingly common in medical education, more questions may be raised concerning the optimal amount of VR integration to medical pedagogy once normalcy returns and physical lessons resume. A future discussion on this topic could explore how medical schools apply the lessons learned from VR to integrating other forms of disruptive technology into medical pedagogy. For example, artificial intelligence could create virtual instructors by augmenting existing VR software, causing analyzable changes to social dynamics in medical education by potentially removing the need for human educators.
Footnotes
[1] Defined by the American philosopher Charles Sanders Pierce, abductive reasoning uses conjecture to judge if an observation adheres to a previously established set of rules (Saunders, 2010, p. 154). Saunders noted that abduction is similar to deduction and induction but differs in terms of process and results (154). In the CT suite, abductive reasoning determined if an observation contained sufficient characteristics to be diagnosed as symptoms of a particular disease. The abductive element occurred when logical leaps made connections to compensate for missing attributes, which is usually the case as no two specimens are alike (156).
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