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Subspecialties Technology and innovation, Training and education, Histology, Pathologists’ assistants

(Virtual) Reality Check

At a Glance

  • Virtual reality (VR) encompasses a broad spectrum of simulated experiences and is gaining popularity as technology advances
  • It has the potential to make medical education safer, more affordable, more accessible, and more readily adaptable to change
  • We propose a 2D and 3D VR project that supplements traditional surgical pathology teaching methods
  • VR gross dissection libraries like the one we have initiated could become a cornerstone in standardizing surgical pathology practice

Defining virtual reality (VR) is akin to defining art. With either one, it’s controversial to confine a diverse range of human expression to just one concrete idea. The widespread perception of VR is one of simulated, lifelike artificial environments – but that doesn’t reflect the spectrum of experiences available today, which range from passive encounters with three-dimensional videos to entirely digital environments manipulated by interactive devices. There’s even augmented reality, which supplements our view of the real world with a layer of computer-generated content. Why the recent proliferation of variability and versatility in VR? We’ve built newer and more capable technologies (compact high-resolution displays, motion sensing, voice control, even gaze tracking) – and more importantly, processing power for mobile devices has become increasingly affordable. That means big-name manufacturers are racing to dominate the market with their own VR platforms. Google, Microsoft, Samsung, HTC, Sony and even Facebook have thrown their hats into the ring, and have flooded the market with low-cost headsets ultimately driving adoption. A recent report from Goldman Sachs presented a base case scenario estimating US$80 billion in revenue from VR/AR hardware and software by 2025, with healthcare contributing US$5.1 billion (1). VR is the next big computing platform – not just for entertainment, but for retail, education, and even medicine.

Medicine’s digital makeover

VR itself is not new to the medical field, but the explosion of affordable, capable equipment is. Recent articles have highlighted the technology’s possibilities in patient care, including phantom limb pain management (2), post-traumatic stress disorder psychotherapy (3), 3D visualization for colonoscopy studies (4), and even as a “warmup” to improve performance in the surgical suite (5). The teaching and training benefits are easy to see; residents in multiple medical and surgical fields have used VR to acquire new skills at minimal cost and with no risk to patient safety (6–8). But despite its utility in other specialties, VR adoption in surgical pathology practice and education has been surprisingly slow.

Why does gross specimen processing need an update? Proper examination of surgical tissue is fundamental to patient care, especially in tumor identification and staging. Cancer diagnosis and treatment require a multidisciplinary approach involving surgery, radiology, oncology, and – last, but not least – pathology, which objectively supports clinical decisions. Although cancer identification has improved over the years, a highly skilled pathologist may still ultimately mean the difference between appropriate care and potentially dangerous treatment. Especially as we increase our comprehension of just how heterogeneous cancer is, it becomes more and more important to ensure efficient, standardized education for our residents and pathologists’ assistants.

Enhancing education

Last July, we were faced with the month-long challenge of passing on as many of our “senior resident” skills as possible to our incoming first-year pathology residents. In doing so, we noticed a few shortcomings in the teaching process. First, trainees typically enter the hectic environment of the working laboratory with minimal prior exposure to surgical pathology – and yet they’re expected to swiftly reach a high level of autonomy in performing tasks that require medical knowledge, fine motor skills, and keen attention to detail. Second, the level of responsibility should increase as trainees demonstrate proficiency, but that often doesn’t translate into reality because of high workloads, limited instructor availability, or the push for decreased turnaround times. Third, the traditional resources for gross specimen processing include text-based instruction and two-dimensional diagrams – but our work itself is inherently visual and 3D. We noticed how time-consuming it was becoming for junior residents to diligently review and re-review manuals of surgical pathology procedures that simply weren’t making the grade.

After contemplating these issues, we decided our trainees needed a modern solution. It needed to be innovative and progressive, while still capable of effectively teaching the fundamentals of gross specimen examination: orientation, description, dissection, and sampling. From our shared interest in informatics, we drew the inspiration to use VR – a logical choice because it’s safe, inexpensive, enjoyable, and has proven benefits in motor skill learning (9). We had the added benefit of being able to tap into New York City’s growing VR community, which offered a wealth of insight and collaboration from other creative minds like independent software developers and 360° video producers.

What we created was an instructional library viewable on both 2D and 3D platforms (see Sidebar “How to Build a Virtual Reality Environment for Pathology”). The content was designed as a passive, immersive environment with audio voice-overs that provide instruction and highlight clinically relevant aspects of different specimen types. Off-the-shelf products, including a stereo camera system, metal mounts, and a smartphone, were used to strategically capture video from the prosector’s point of view. During filming, specimens were placed on a white surface alongside a fixed ruler that provides the viewer with an approximate scale in every frame. We chose our cases with consideration for the most commonly encountered specimen types at our institution, so that we could offer our trainees an experience as close as possible to “real life.”

How to Build a Virtual Reality Environment for Pathology

  • Footage from each camcorder was shot in high definition (1080p) at 60 frames per second.
  • Raw files were converted to head-tracking-capable stereoscopic 3D, with adjustments to horizontal and vertical convergence to obtain the desired depth of field.
  • Post-production editing included contrast and color level adjustments, speed modifications, voice-over audio, and complementary multilingual subtitles.
  • Videos were exported at a 16:9 aspect ratio.
  • Study participants watched the 2D format on a desktop monitor, and the 3D format using a smartphone-based, head-mounted display.

When filming was complete, we asked nine junior residents to watch the content in both 2D and 3D viewing formats (see Figure 1) and provide feedback on the experience. We knew that some viewers of 3D media may develop simulator sickness – a type of motion sickness characterized by visual discomfort, drowsiness, disorientation, nausea and possible vomiting – but a questionnaire completed at regular intervals during the study told us that none of the participants developed significant symptoms. After the experiment, our residents provided positive opinions of the tested videos. All of them said that they would use a gross processing video library to prepare for examining a new specimen type, and most reported that they were more confident in gross specimen processing after trying our simulation. A majority also said that the 3D aspect improved the viewing experience. Overall, although this was a proof-of-concept experiment with preliminary content, it’s a promising beginning (10).

Figure 1. Examples of virtual specimen examination seen in 2D (top) and stereoscopic 3D (bottom) viewing formats.

#pathologyVR

We have started to use the metadata tag #pathologyVR across social networks to make it easier for users to see who’s discussing the subject and find relevant information. To learn more about our project, or to find 2D and stereoscopic 3D samples*, visit our pathology and VR interest website at pathologyvr.org

*To view the stereoscopic 3D content, you’ll need a head-mounted display or stereoscopic glasses.

The future (of VR) is so bright, we gotta wear shades

Thanks to technological advances, increasing popularity, and ease of use, we anticipate that VR will be a key component in teaching the next generation of physicians. Ultimately, it will enable safer, cheaper, more accessible, and more adaptable medical education. And where better to begin than with surgical pathology? It’s a highly visual discipline, and by building on the strengths of traditional teaching methods, our dynamic approach allows viewers to appreciate the procedural actions involved in specimen processing. To improve it further, our main focus is on continuing to develop the gross video library until it includes all of the specimen types a trainee might encounter in an anatomic pathology laboratory. Although it’s an ambitious endeavor, it has the potential to educate not only pathology residents, but also medical students, pathologists’ assistants, and surgical residents and fellows. Impressive claims, perhaps – but our goal, and the reason we developed our VR system, is to maximize efficient and meaningful education in surgical pathology so that our patients can receive better care.

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  1. H Bellini et al., “Virtual and augmented reality: understanding the race for the next Computing Platform”, Profiles in Innovation-Goldman Sachs Group, Inc., ( 2016). Available at: bit.ly/1Y90UGA. Accessed June 7, 2016.
  2. BN Perry et al., “Virtual reality therapies for phantom limb pain”, Eur J Pain, 18, 897–899 (2014). PMID: 25045000.
  3. BO Rothbaum et al., “A randomized, double-blind evaluation of D-cycloserine or alprazolam combined with virtual reality exposure therapy for posttraumatic stress disorder in Iraq and Afghanistan War veterans”, Am J Psychiatry, 171, 640–648 (2014). PMID: 24743802.
  4. K Mirhosseini et al., “Benefits of 3D immersion for virtual colonoscopy”, 3DVis (3DVis), 2014 IEEE VIS International Workshop on, 75–79 (2014).
  5. TS Lendvay et al., “Virtual reality robotic surgery warm-up improves task performance in a dry laboratory environment: a prospective randomized controlled study”, J Am Coll Surg, 216, 1181–1192 (2013). PMID: 23583618.
  6. K Gurusamy et al., “Systematic review of randomized controlled trials on the effectiveness of virtual reality training for laparoscopic surgery”, Br J Surg, 95, 1088–1097 (2008). PMID: 18690637.
  7. AG Gallagher, CU Cates, “Approval of virtual reality training for carotid stenting: what this means for procedural-based medicine”, JAMA, 292, 3024–3026 (2004). PMID: 15613672.
  8. LB Gerson, J Van Dam, “A prospective randomized trial comparing a virtual reality simulator to bedside teaching for training in sigmoidoscopy”, Endoscopy, 35, 569–575 (2003). PMID: 12822091.
  9. G Wulf et al., “Motor skill learning and performance: a review of influential factors”, Med Educ, 44, 75–84 (2010). PMID: 20078758.
  10. E Madrigal et al., “Introducing a virtual reality experience in anatomic pathology education”, Am J Clin Pathol, 146, 462–468 (2016). PMID: 27594429.

About the Author

Shyam Prajapati and Emilio Madrigal

Shyam Prajapati is a resident physician in Anatomic & Clinical Pathology at The Mount Sinai Health System in Manhattan, New York, USA, with an interest in hematopathology and clinical informatics.

Emilio Madrigal is a Cuban-born resident physician in Anatomic & Clinical Pathology at The Mount Sinai Health System in Manhattan, New York, USA, with an interest in surgical pathology and clinical informatics.

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