The future of medical education?

KU School of Medicine is integrating augmented reality as part of the curriculum

Student using a virtual reality headset to view a body organ

The doors had barely opened in the University of Kansas Medical Center’s new state-of-the-art Health Education Building in the summer of 2017 when doctor-educators at the KU School of Medicine had begun exploring new teaching technologies that could enhance the medical education provided to the physicians of tomorrow.

Augmented and virtual reality (AR/VR), once the exclusive realm of goggle-wearing gamers and high-fidelity videophiles, are rapidly becoming a part of health care education, along with another new technology, point-of-care ultrasound (POCUS). To keep pace with the fast-growing technology race sweeping through medical education, Jared Staab, D.O., assistant professor in the KU Department of Anesthesiology, in partnership with Bradley Jackson, M.D., assistant professor in the Department of Emergency Medicine, is working on a grant to introduce and evaluate the use of AR and POCUS in the School of Medicine.

“We are in a dynamic era in health care when you can blink and the medical knowledge almost doubles,” said Staab, who recently led an enrichment course with the first five students to use the technology, “You know you have a good product when everyone who puts on the VR goggles and steps into augmented reality becomes speechless, and their face is overtaken with a smile.”

From video games to game-chamgers

Perhaps the technology with the greatest potential to become a part of medical education comes from the video gaming world in the form of augmented reality – an environment created by merging real-world video with computer-generated imagery. Many in this current generation of medical students already have firsthand experience with virtual/augmented reality headsets. They are already comfortable donning VR headsets and being thrust into virtual worlds where blisteringly fast race cars fly by or wandering through strange worlds fending off enemy attacks. So it follows that these students come to medical school ready to embrace the integration of their generation’s technology with time-tested medical knowledge and techniques.

“Before the augmented reality ultrasound session, I would have discounted the benefit of AR for medical education,” said Ben Harstine, a second-year student at the KU School of Medicine. “I would have thought it was a little gimmicky. But after using AR to learn ultrasound, I immediately saw the benefits. I learned more about internal anatomy and visualizing structures with ultrasound in two hours than I had in two years of medical school looking at still images.”

In the training, Staab is pairing CAE Healthcare’s Vimedix Augmented Reality simulator with Microsoft’s HoloLens headsets to blend real world scenarios with visual elements generated by a computer program. The device interacts via a special ultrasound probe with a medical manikin torso and head. The HoloLens lets students peer inside the body, break out a portion, levitate it above the body and then maneuver it for closer examination.

For example, students can remove a three-dimensional heart from within the chest and then watch it beat from every angle while looking for abnormalities or pathologies. Then, by digitally expanding the organ in AR, they can then go inside each beating chamber, experiencing the dynamic workings of a live heart in ways a cadaver lab can’t provide.

“Augmented reality is an amazing tool that allows an unparalleled experience in learning the special relationship of structures within the human body,” Staab said. “When you put on the headset you hear the heartbeat in your ears, and then you open your eyes and see organs in 3D with a beating heart and breathing lungs. You can literally put your head inside a beating heart and look through the valves as they open and close. It’s a truly awesome experience than cannot be replicated anywhere else.”

“Using AR, I was able to take the information that I knew from textbooks and the cadaver lab and combine it with the superimposed ultra-sonographic imagery,” said Harstine. “The AR accelerated the process of learning, not only when I used it, but even more so as I watched my classmates and their use of the technology.”

Out of harm’s way

AR brings greater safety to the table as well. By allowing students to perform procedures as quickly or slowly as needed, or as many times as necessary, AR affords them a safe environment to learn. This way, for example, they know precisely what is happening the first time they push a catheter into a vein in real life.

One of the limiting factors for teaching medical procedures has always been the confined space around the body where students can stand to see clearly what is happening. That’s not the case with AR. With everyone wearing a HoloLens plugged into the closed network, an entire class has the same bird’s-eye view of what is going on. The technology also has the potential to be shared long distance with the KU School of Medicine campuses in Salina and Wichita.

“I remember my first central venous catheter placement,” Staab said. “I had read about it in a book, and I passed my anatomy class in medical school, but sticking someone’s neck without guidance and without practice is intimidating. AR allows you to take a simulated body, expand it to a very large size, make it levitate above the body and dissect it in real time over and over in many different cuts and angles while simultaneously being able to relate anatomical structures in 3D.”

Plans are already in the works for AR to go beyond the lab and into the surgical suite. One of the chief shortfalls for medical training is not being able to practice procedures enough times to become proficient. In a joint venture, the departments of anesthesiology, cardiology and cardiothoracic surgery will be demonstrating a procedural simulator that allows learners to perform complex cardiac procedures in a 2D simulation using AR.

Revolutionizing ultrasound

Another education tool the KU School of Medicine is embracing is point-of-care ultrasound (POCUS) training. POCUS has the potential to save billions of dollars on an annual basis across health systems and has the capacity to revolutionize patient care, decrease complications and limit pain and suffering.

On the surface, POCUS appears as simple as most plug-and-play smart technology. Users plug a specially designed ultrasound sensor into the USB port of a cellphone or smart tablet and then employ an application, complete with cloud storage, to scan whatever part of a patient needs to be examined.

However simple the plug-and-play premise might seem in concept, it takes a health care professional specially trained in the use of mobile diagnostic technology to correctly use the device. With its small size, affordable price tag ($2,000 plus a monthly fee), and smart-device compatibility, the Butterfly iQ chosen for testing at KU Medical Center is revolutionizing the marketplace, while at times pushing aside larger, more expensive and less convenient diagnostic tools.

The device is particularly useful in critical situations where every second counts. Physicians trained in POCUS can perform limited examinations at the bedside, bypassing the need to move the patient to a lab or wait for comprehensive exams when answers to binary questions in the critically ill are all that is needed. Beyond the advantages of price, speed and simplicity, the iQ doesn’t expose patients to ionizing radiation. Another plus is that POCUS provides real-time guidance for bedside procedures where precision is a must.

A few studies have even found that medical students using POCUS often surpassed board-certified doctors using standard exam techniques when it comes to detecting pathologies and certain physical exam findings.

“We used to do (procedures) based on anatomical relationships we learned in gross dissection in cadaver labs,” Staab said. “We would stick needles into chests, and blood vessels, and legs, and close to nerves. We were good at it, but once we started using ultrasound at the bedside, there was no going back. What was once a blind guess with potential complications of sticking the wrong structure, can now be guided in real time by point-of-care ultrasound.”

Shaping a new frontier

This influx of next-gen teaching tools could potentially position KU Medical Center as a player in shaping the future of medical education. But no matter how close simulation gets to reality, it can’t replace the tactile sense of touching a human hand, the stresses of managing critically ill patients, the feeling of exhaustion at the end of a multi-hour shift or the enrichment of wisdom passed down from earlier generation. The key is striking a balance between what can be learned through augmented reality and simulation with the skills that can only be taught through hands-on physical examinations, solving the medical mysteries of standardized patients, or working with human bodies in the cadaver lab.

“Currently, in learning anatomy for instance, we mainly learn from two-dimensional diagrams and words but then must construct the 3-D image mentally,” said Daniel Ratzlaff, a second-year KU School of Medicine student from Moundridge, Kansas. “That is supplemented with anatomy lab and examining cadavers, which is great, and I think necessary to see an actual body. But also, it’s not always clear what exactly we're looking at. By visualizing an actual, accurate 3-D model of anatomy, augmented reality would help us understand anatomy more accurately and quickly.”

The potential for these new teaching tools is so strong that other departments are already beating down Staab’s door asking to be coupled to the technology train. From undergraduate to graduate medical education, there is great interest. To expand the program’s reach, Staab with Jackson’s help, has applied for a Medical Alumni Innovative Teaching Fund (MAITF) grant from the School of Medicine to bring POCUS to all three campuses, plus fund a pilot study exploring the viability and student attitudes regarding AR and POCUS.

With these new technologies starting to emerge in medical schools across the country, some early adopters have gone beyond simply sticking a toe in the waters of change and have plunged headfirst into the deep end. Staab said POCUS has become an integral part of the curriculum in several schools, including the University of California–Irvine, which puts its medical students through 70 hours of POCUS training. He quickly added, however, that the footprint is much smaller for schools using AR as a teaching tool. With continued support, KU Medical Center is well-positioned to be an industry leader.

“This has the potential to revolutionize learning while doing so in a way that does not put patients in harm’s way,” Staab said. “Simulation in ultrasound, anatomy and image-guided procedures will give our medical students, residents and fellows the ability to get as close to real life as possible. The best is yet to come and the possibilities are endless.”