Major global events, such as the COVID-19 outbreak, geopolitical tensions and natural disasters have recently created unparalleled challenges in medical education, with the urgent need for a paradigm shift in the teaching of human anatomy [1-3]. Most universities had to transition from traditional in-person teaching methods, to remote learning strategies and virtual platforms as a stopgap, with a few retaining the latter strategies as a component of hybrid teaching models [4-6].

During the COVID-19 pandemic, social distancing protocols severely restricted traditional in-person laboratory-based teaching, where use of three-dimensional (3D) plastic models, museum specimens, plastinates, and cadaveric dissection, were not only critical to the multi-dimensional understanding of the human body, but also essential for the completion of the anatomy learning experience [4, 7, 8]. Although lectures were effectively delivered using the online platform, finding suitable alternatives to replace laboratory-based learning, particularly cadaveric dissection, which is considered to be the gold standard of teaching and learning anatomy, had been quite challenging [9-12]. While reports highlight the increased usage of static images, digital libraries, blended approaches, and dissecting videos, few strategies have enhanced the 3D understanding of anatomy [2, 4, 13]. The global impact of the pandemic, the drastic decrease in cadaveric body donations, and the fear that the pandemic may linger or resurge encouraged anatomy educators to innovate and incorporate novel instructional methods to unlock the didactics of digital technology so that the best educational experience may be delivered [4, 10, 14-16].

In the midst of unprecedented times, adaptability, innovativeness, and multi-modal digital approaches have become key attributes to overcome hurdles and provide alternate instructional strategies in anatomy education. Among the advances in digital technology in medical education, virtual reality (VR) has emerged as a promising tool that is capable of delivering an immersive 3D experience to visualize the spatial relationship of anatomical structures [17-20]. The VR learning resource not only supplements, but also enhances the anatomy learning experience by enabling the student and instructor alike to interact with advanced visualizations and vivid 3D imagery of the human body in a virtual environment [17, 21]. Despite being an effective, increasingly viable option, that is readily available, the uptake of VR technology in anatomy teaching is still very limited [19, 22]. Therefore, this study aimed to investigate the capacity of VR to support distance learning of anatomy during inevitable situations such as the pandemic.

The mapping of learning objectives to instructional strategies and learning resources before and during the COVID-19 pandemic are shown in Table 1.

Over the last few decades anatomy education has seen huge strides from the traditional blackboard teaching to the use of cutting-edge 3D digital technology and virtual platforms [23]. VR technology offers a unique opportunity to revolutionize the field of remote education, particularly in disciplines like anatomy. As traditional classroom settings were replaced with remote learning environments during unprecedented times, such as the COVID-19 pandemic, VR provided an alternate, yet viable solution, to maintain the quality of education while overcoming physical limitations [24].

In this study, learning objectives, instructional strategies, and learning resources before and during the COVID-19 pandemic were mapped (Table 1). The learning objectives remained the same before and during the pandemic, emphasizing the fact that the fundamental goals of the educational sessions did not change. This consistency is essential to ensure that students continue to achieve the intended learning outcomes regardless of the mode of instruction. Students agreed that these lessons achieved the session learning objectives and augmented their learning experiences. With reference to Table 1, the VR-integrated lessons entailed diverse instructional strategies (i.e., direct, interactive, indirect, and independent) and several teaching resources (i.e., slides, image library, in- and post-class formative assessments, VR-recorded videos with live voice over, and dissection videos) as compared to pre-pandemic anatomy instruction. In fact, this facilitated the introduction of interactive and independent instructional strategies into the learning design of VR-integrated lessons. Despite being delivered via the online distance learning platform, these instructional strategies extend beyond knowledge-based approaches as they also foster the soft competencies required to shape the future-ready doctor.

The questionnaire had a response rate of 63% (33 out of 52 students). As the Cronbach’s alpha was higher than the accepted threshold of 0.7, internal consistency was considered to be excellent. This indicates a high level of internal consistency in the construct and items in the questionnaire, which enhances the reliability of the study findings [25].

In comparison to previous studies, that investigate the potential of VR as a complemental active learning tool under normal circumstances, this study focused on the consumption of VR content and the resultant perspective of the content receiver (i.e., the student) during unprecedented times. Elements linked to the use of VR by the content creator (i.e., the instructor) are not reflected upon. Although students did not have direct access to the VR headset’s affordances (e.g., immersion and controllers), they still had the opportunity to be active in the acquisition of knowledge through the recorded 360-degree videos. This allowed students to study the anatomy through a personalized tailored-approach and provided some degree of freedom to navigate within the content using the mouse, thereby fostering principles of active learning.

The VR recordings provided students access to high-quality 3D videos to overcome the limitations of in-person lab access to specimens or models during the pandemic. This ensured continuity in learning without students having to be physically present in the lab, thus promoting safety and adherence to public health guidelines. The addition of live voiceover to VR recordings engaged students by providing real-time explanations, commentary, and guidance. This personalized approach helped to keep students focused and encourage active participation in the learning process, leading to improved retention and understanding of anatomical concepts. The voiceover videos were uploaded to the student learning management portal, and hence could be accessed and reviewed at any time, allowing students to learn at their own pace and revisit difficult concepts as needed. This flexibility also accommodates diverse learning styles and preferences, empowering students to take control of their learning experience [26]. By simulating realistic anatomical structures and functions in a virtual environment, students can engage with the subject matter more deeply, leading to better comprehension and retention of anatomical knowledge [27].

The integration of VR into anatomy lessons has shown significant promise in enhancing spatial learning abilities and improving understanding of 3D anatomy. This innovative approach allows students to immerse themselves in a virtual environment where they can interact with anatomical structures in a more realistic and dynamic manner [28]. An analysis of the usefulness of VR in our study is depicted in Table 2. Eighty percent of participants found that use of VR in anatomy helped improve spatial awareness and better retention of anatomical relationships, a finding similarly reported by Brown et al. (2023) [29] who stated that by allowing students to manipulate virtual objects and explore anatomical structures from multiple perspectives, VR helps to reinforce spatial concepts and facilitate deeper understanding. Almost 70% of students agree that VR was instrumental in facilitating and solidifying their theoretical understanding of the subject, with almost 50% of participants wanting to continue using VR even if the instruction becomes onsite. VR allows students to explore 3D anatomy in great detail leveraging native functionalities of the operating systems, which may not be easily accessible in traditional classroom settings. With VR, students can remotely access anatomical structures from anywhere with an internet connection, allowing for flexible learning schedules and eliminating geographical constraints [30]. VR enables students to grasp the complexities of 3D anatomy more effectively. Unlike 2D illustrations or cadaveric specimens, VR simulations also provide a lifelike representation of anatomical structures, allowing students to visualize organs and their spatial relationships with digital clarity [31]. VR platforms often incorporate interactive elements such as manipulation of virtual anatomical structures, quizzes, and scenario-based learning modules. These features enable personalized learning experiences where students can explore anatomy at their own pace, reinforce concepts through practice, and receive immediate feedback, enhancing overall learning outcomes. This interactivity can increase knowledge retention and skill development [32]. Around 72% in our questionnaire survey form agreed that VR anatomy lessons address the session learning objectives similar to/or even better than static images and other teaching videos.

Cadaveric dissections, considered by many to be the gold standard in instructional methods in the learning of anatomy offer students direct interaction with the human body, allowing them to touch, feel, and manipulate tissues and organs [33]. Students can observe the actual variations in human anatomy, such as differences in organ size, shape, and location, which enhances their understanding of anatomical structures [34]. Collaborative dissections often require students to work in teams, fostering communication and teamwork skills as they navigate through the intricacies of human anatomy together [35]. However, in instructor-oriented approaches, instructors typically complete the dissection of anatomical structures, while students observe and participate under supervision [36]. Cadaveric dissections often follow a structured sequence, starting with basic anatomical regions and progressing to more complex systems, allowing students to build upon their knowledge progressively [37]. Dissections provide an opportunity for students to learn and apply anatomical terminology in a real-world context, reinforcing their understanding of anatomical relationships [38]. However, VR allows students to interact with 3D models of anatomical structures in a highly immersive environment, providing a sense of presence and engagement [39]. VR platforms often offer customizable scenarios and simulations, enabling students to explore different anatomical variations and pathological conditions that may not be readily available in cadaveric specimens [40]. VR simulations allow students to engage in realistic scenarios, such as surgical procedures or anatomical exploration, without the constraints of time and resources associated with cadaveric dissections [39].

While comparing the effectiveness of VR to traditional learning methods such as cadaveric dissection, the participants of our study state that VR shows superior performance while identifying anatomical landmarks and understanding anatomical relationships compared to traditional learning methods, a finding similar to a study done by Wang et al. [41]. Thus, students report that VR offers a unique and authentic experience. Around 60.6% participants in our survey agreed that VR in anatomy lessons has proven beneficial for “anytime-anywhere” learning, instead of the traditional “lab-based learning” method. VR platform self-paced learning modules, allow students to explore anatomical structures at their own speed and revisit concepts as needed [42]. Though 72% of participants agree that VR in anatomy lessons addresses the session learning objectives similar to/or even better than static images and other teaching videos, only 24% agree that it is similar or better than cadaveric dissection, thus preferring cadaveric dissection to VR. Only 12% agree (and 70% disagree) that VR is more beneficial to cadaveric dissection. This re-emphasizes the fact that student understanding of human anatomy through cadaveric dissection far exceeds use of static images, videos, and VR. However, the usefulness of VR as a suitable alternative for distance learning in inevitable circumstances like the COVID-19 pandemic is proven beyond doubt.

Virtual demonstrations allow learners to observe and engage with simulated environments or scenarios, providing learning opportunities that might not be feasible in traditional classroom settings [31]. Interactive discussions in VR environments enable learners to engage with instructors and peers in real-time, despite physical distance. Virtual classrooms equipped with avatars and spatial audio facilitate natural communication and collaboration, fostering meaningful exchanges of ideas and perspectives. Such interactive discussions can promote other cognitive skills such as critical thinking, problem-solving, and social interaction, essential components of effective learning experiences [43].

Though VR has its own usefulness, existing researches have highlighted many challenges which can prevent educators and universities to fully adopt VR [44]. It is still unclear how to effectively integrate VR into daily teaching strategies. Though when thinking of VR, the hardware comes to mind first, it is software applications that must be aligned with and deliver the course learning objectives that are the most difficult to find or create. The cost of integrating VR is another practical barrier [45]. Though the cost of VR headsets has dropped significantly in the last five years, VR applications remain expensive and very often rely on yearly subscription. The major cost lies in the training and acquisition of new skills by the instructors in addition to the time required for the training and implementation of new content into regular teaching material. Finally, instructors as well as support staff might lack personal technological skills that can slow down or limit the use of VR [46].