Abstract
To test whether immersion leads to better learning outcomes compared to non-immersive displays in medical education, this pilot study investigates the impact of presenting 360° video in head-mounted display (HMD) headsets versus desktop computer-based two-dimensional (2D) displays on physical examination performance. Nineteen medical students were randomized into either a 360° video via HMD or a computer-based 2D training intervention group to learn the presentation of a physical examination. Prior research has found that a learner’s spatial ability predicted training outcomes in immersive environments, such that those with lower spatial ability benefited from immersive training more than those with higher spatial ability. To account for baseline spatial reasoning ability that might contribute to learner differences, all participants completed a measure of spatial reasoning, the paper folding test (PFT), prior to training. Following the training intervention, participants were evaluated on their ability to perform the instructed physical examination steps. There was no significant difference in performance between the 360° video and computer-based training groups (p = 0.267, d = 0.41). Additionally, spatial ability was not a significant predictor of performance, with the PFT score explaining only 9.4% of the variability in physical examination scores. These findings suggest that 360° video via HMD does not confer a significant advantage over computer-based training in this context, indicating that this type of immersion was not beneficial for learning to perform physical exams.
Introduction
Research Questions:
Can 360° video immersion help students to learn a physical exam compared to computer-based training?
Does 360° video immersion provide more benefit to students with poor spatial ability than computer-based training?
Medical education programs are increasingly using immersive training, including 360° video and virtual reality (VR), for simulation-based learning. 1 Immersive simulation allows students to experience a wide array of complex as well as simple medical scenarios and tasks. 2 As immersive technologies, classified as “extended reality” (XR), become more prevalent, it is important to consider for which contexts is immersion advantageous over other non-immersive simulation modalities. 3 This study compares the use of immersive 360° video presented in head mounted display (HMD) headsets versus 2D video displayed on computer monitors for learning physical examination skills and whether those benefits are dependent on the learner’s spatial ability. Table 1 compares the similarities and differences of 2D video, immersive 360° video, and VR on the characteristics of type of environment, typical display, typical field of view (FOV), perceived depth, degrees of freedom (DOF), and level of interactivity. Watching traditional, two-dimensional (2D) videos with anatomical information on a non-immersive, flat computer monitor with limited FOV may hinder a student’s ability to learn, particularly when it comes to performing a physical examination. To address this, this study immersed students in a physical exam room via 360° video in an HMD, where a professor demonstrated and taught students how to properly conduct an examination, compared to students in a computer-based display condition who watched the same lesson on a computer monitor. Of note, the immersive experience was limited to a passive 360° video viewed in an HMD, in which the participant experienced just 3 degrees of freedom (“3 DOF”), and could not move around or interact with the environment in 6 degrees of freedom (“6 DOF”) as is typical of interactive VR environments. Despite this limitation, 360° videos viewed in an HMD headset have been suggested to reduce cognitive load and facilitate task learning. 4
Comparison of 2D Video, Immersive 360° Video, and Virtual Reality
Background
Recent evidence has shown that musculoskeletal physical examination skills have been declining among undergraduate medical students. 5 There are several potential causes for this, with the biggest reasons being that there are limited resources available to properly teach students in person, as many patients and physicians are unavailable. 5 Clinical skills involving the psycho-motor domain are inherently difficult to teach in lectures or textbooks alone. There is yet to be a sufficient model that can break down complex clinical skills in practice with limited instructor resources. Such physical examination tests require complex psycho-motor skills that employ various stimuli (auditory, visual, and tactile). Bed-side teaching has been demonstrated to exhibit enhanced learning and is considered the gold standard for teaching physical examination. However, this method is limited due to scheduling and availability constraints considering large numbers of students. Thus, there is a need to find a second method that can provide an integrative and structured learning experience. This is where immersive, virtual simulation training can provide an effective route to teach students without the presence of a patient or instructor. The use of a step-by-step immersive video can save the time of having to perform examinations live and can act to supplement bedside training. A multisensory approach has been suggested to yield optimal outcomes in training students to recognize and retain visuo-spatial information. Current research has also suggested that multimodal teaching methods lead to superior results in learning musculoskeletal physical examinations. 6 It seems that by utilizing different methods of training, such as video-based learning, hands-on practice, and simulated patients, students are able to better apply their practical and theoretical knowledge. Thus, by incorporating immersive simulation methods, we can expect an extra element to be added to the traditional medical curriculum in a positive way. This pilot study sought to investigate the feasibility of integrating immersive 360° videos into the medical school curriculum, including assessing learning outcomes and student experience with the technology compared to traditional computer-based displays.
Immersive simulation in undergraduate medical education
The integration of immersive simulation into undergraduate and medical education has demonstrated significant benefits in some contexts but is not without its limitations. Samadbeik et al. 8 identify numerous advantages and challenges associated with incorporating VR and other types of immersive simulation into medical group training, including high operational costs, the need for specialized training to use headsets, and the potential for extended training durations. Nevertheless, when implemented effectively, immersive simulation learning holds considerable promise for medical education. XR simulations (i.e., VR, augmented reality, mixed reality) with varying degrees of interactivity enabled higher simulation fidelity while maintaining a lower cognitive load,9,10 making immersive simulations particularly well-suited for real-world applications. Furthermore, learning surgical techniques on immersive simulators has been shown to reduce operating times, enhance accuracy, and minimize errors, 8 highlighting the multifaceted uses of XR in a medical space. It should be noted that the level of interactivity and DOF in the immersive simulations were not specified in many of the reviews, and the effects of interactivity vs. immersion should be further explored. 3
Learning physical exam
Physical examinations (PE) are the cornerstone of clinical diagnosis and decision-making. Across the vast spectrum of medical specialties, physicians and healthcare professionals must conduct PE. Significant training and experience with PE are critical for medical education. Traditional training requires students to rely on limited access to professors and brief, constrained opportunities to practice with patients. Using immersive 360° video, students can repeatedly observe instructors and/or clinical scenarios to augment limited face-to-face interactions. Increased visuospatial immersion in a psychomotor task allows for deeper engagement and a better understanding of what is being learned. A prime example is physical exam processes. Implementing immersive simulation provides cost-effective and repeatable high-quality training to medical students. 360° video provides access to high-quality training environments, removing barriers caused by traditional lecture-based learning. 2 The enhanced visuospatial immersion offered by 360° video may foster better comprehension of the spatial and tactile relationships required for PE, supporting the integration of cognitive, spatial, and psychomotor skills. As Gutiérrez et al. found, 11 there is a positive effect of immersion in learning. Overall, the evidence for 360° video as a tool for developing procedural skills like physical examination remains inconclusive, and this study aims to bridge that gap.
Effects of visuospatial ability
When discussing immersive 360° video’s role in providing an enhanced learning experience, visuospatial ability may be a moderating variable at play. The overall impact of immersion and other characteristics unique to immersive simulations (e.g., interactivity) on spatial ability has yet to be determined. 3 One study explored how several factors, such as depth cues (i.e., stereopsis), may influence learning in deep neck anatomy. Visuospatial ability was shown to provide the greatest correlation with correct answers in the post-test with cognitive load, strategy type, and stereopsis showing little to no correlation with test scores. 12 Those with higher spatial ability outperformed those with lower spatial ability in both the VR and non-VR groups. With visuospatial ability suggesting granting learners an edge in spatial tasks, the question should be, how can immersive simulation be utilized to help students with lower spatial ability bridge the gap between those with higher spatial ability?
Visuospatial ability and its relevance for medical education have already been studied in the context of gross anatomy and students’ performance on practical anatomy exams. Physical exam is another domain of medical education where high spatial ability could give certain students an advantage. However, it remains to be seen how this cognitive skill interfaces with the immersive technology during learning. Will students with lower spatial ability gain more of an advantage from using immersive displays as opposed to 2D video, or will students with higher spatial ability push even further ahead?
Methods
Study design
This study was a pilot experimental study designed to assess the impact on physical examination skill acquisition of immersive 360° video via HMD compared to traditional 2D video presented on a computer monitor display. Participants were randomly assigned to either the 360° video or 2D computer condition through a coin flip, ensuring equal allocation. The study aimed to evaluate whether 360° video provided a significant advantage in learning musculoskeletal physical examination skills, particularly for students with varying levels of spatial ability.
Participants
Eligibility criteria
Participants included undergraduate pre-health students and first-year medical students from the University of South Florida. Inclusion criteria required students to have an interest in healthcare and be either junior or senior undergraduates or M1 medical students. Exclusion criteria included prior extensive clinical experience or performing PE.
Recruitment
Participants were recruited through university email lists and student organization announcements. A total of 19 students completed the pilot study.
Setting and timeframe
The study took place at the Center for Advanced Medical Learning and Simulation at the University of South Florida. Data collection was conducted over approximately one calendar school year, ensuring all participants underwent identical procedures.
Randomization and allocation
Participants were randomly assigned to one of two conditions:
2D Computer Condition—Watched a pre-recorded 10-min physical exam instructional video on a standard computer monitor (Dell computer with a 27” Acer monitor, 1920p × 1080p resolution, 75 Hz refresh rate). The video was recorded on an Insta360 camera in 360 degrees, and the entire 360° scene was displayed on the 2D computer monitor for viewing. Participants could not manipulate the video by zooming or dragging with the mouse. They listened to the audio via headphones and could adjust the volume as needed. Immersive 360° video condition—Watched the same 10-min instructional video in an HMD headset (Meta Quest 2). The headset showed an immersive 360° video within which the participant could look around from one spot and experienced 3 DOF. Of note, participants could not move around within the environment, change perspective, or interact with the environment.
The randomization sequence was determined using a simple coin flip upon participant arrival. The allocation was not concealed, as participants were immediately made aware of their group assignment upon setup.
Field of view considerations
In the 2D computer condition, the entire 360° scene was visible on a static 27” computer monitor (∼53° horizontal FOV), limiting peripheral engagement.
In contrast, the immersive 360° video condition used a Meta Quest 2 headset, allowing participants to look around freely (∼90°–120° horizontal FOV), enhancing spatial presence and realism. This FOV was closer to the natural human visual range (∼200° horizontal, ∼135° vertical).
Using 360° video aimed to simulate authentic clinical environments. The same 360° video was used in both conditions so that none of the content would differ, and the only difference would be the DOF of the viewer, the FOV, and the method of viewing the video. The broader FOV in the immersive 360° video condition was expected to provide more visuospatial information in a realistic manner (i.e., closer to human FOV) and therefore improve retention of the procedural content.
Training
On the day of the study, participants were randomly assigned to one of two conditions: Observation of a recorded 360° video of an upper extremity physical exam conducted by a medical school professor on a 2D display computer monitor or within an HMD headset. Students did not receive hands-on practice before evaluation; they only observed the procedure being performed correctly.
Evaluation
Approximately 15 min after training, participants were assessed on their ability to perform the physical exam. Each trainee performed the physical exam once, demonstrating the steps observed in their assigned video. Performance was video recorded and later evaluated using a standardized checklist outlining the steps demonstrated in the video.
Spatial ability
Before training, participants completed a paper folding test (PFT), a validated measure of spatial visualization ability. Scores on this test were used to examine the relationship between spatial ability and performance in the training conditions.
Objectives
This study aimed to determine:
Whether immersive 360° video improves students’ ability to learn a physical exam compared to traditional 2D computer video-based learning. Whether students with lower spatial ability benefit more from 360° video compared to students with higher spatial ability.
Hypotheses
Primary Hypothesis: Participants in the 360° video group will demonstrate better physical exam performance compared to those in the 2D computer group. Secondary Hypothesis: Participants with lower spatial ability will experience greater benefits from 360° video compared to those with higher spatial ability.
Intervention
Participants observed an upper extremity physical exam being performed by an instructor in their assigned condition (360° video or 2D computer). No hands-on practice was allowed prior to evaluation. Following the instructional period, participants completed a 15-min practical assessment, where they performed the physical exam on an examiner while being video recorded.
Outcome measures
The study assessed three primary outcomes:
Physical exam performance—Participants’ ability to perform the physical exam was assessed using a standardized checklist based on proper procedural steps. Spatial ability—Assessed using the PFT, a validated measure of visuospatial skills. Technology usability—Measured using the System Usability Scale (SUS) to evaluate user experience with the HMD technology.
Data collection methods
Demographics survey: Collected participant background information, including academic level and prior VR experience. Physical exam checklist: Each participant’s performance was graded using a validated checklist with scores recorded. PFT: Participants completed a timed, 3-min worksheet to determine their spatial visualization ability. Usability survey: Participants completed the SUS to assess their subjective experience with the headset and immersion level.
Sample size and study validity
A total of 19 participants (10 in the 360° video group, 9 in the 2D computer group). Given the small sample size, results were interpreted as preliminary, with findings guiding future research with a larger cohort. Inter-rater reliability of the physical exam scores was assessed using the intraclass correlation coefficient (ICC) to ensure consistency between evaluators.
Ethical considerations
The study was approved by the University of South Florida Institutional Review Board under Study ID STUDY005857. Participants provided informed consent before participation, with assurances of confidentiality and voluntary withdrawal at any time. No personally identifiable data were retained beyond analysis.
Participant flow diagram
A participant flow diagram is included in Figure 1, detailing the study phases:
Participant Flow Diagram.
Enrollment: 19 participants screened and included.
Allocation: Randomly assigned to 360° video (n = 10) or 2D computer (n = 9).
Lesson & Assessment: Participants watched their assigned lesson, then completed the Physical Exam Performance Test.
Follow-up: All participants completed the study; no dropouts.
Analysis: All 19 participants were included in the final analysis.
Results
Statistical methods
Since there were two scorers for the subjects’ physical examination score, an average fixed raters ICC was calculated, where values below 0.5 indicate poor reliability, between 0.5 and 0.75 moderate reliability, between 0.75 and 0.9 good reliability, and above 0.9 indicates excellent reliability. The ICC was calculated to be 0.965, indicating excellent agreement between the raters. For the primary outcome, involving whether or not the 360° video group scored higher on the physical examination than the 2D computer group, the 19 subjects were divided into 2 groups based on whether or not they received the training via 360° video or computer. There were 9 subjects in the 2D computer group and 10 subjects in the 360° video group. The physical exam scores for each group were plotted and were found not to follow a normal distribution, so a Mann–Whitney U-test was performed instead of a t-test to account for nonparametric data. The threshold for significance was defined as p = 0.05. For the secondary outcome, involving whether or not 360° video helped those with poor spatial ability compared to 2D computer display, the participant size of 19 was too small to divide the participants into 4 groups by low and high spatial ability (which should be considered with a larger population size). Instead, the paper folding score of the participants was added as an additional covariate.
Outcomes
When comparing the 2D-trained and the 360° video-trained groups, there was no significant difference between the two groups (p value = 0.267), suggesting that neither group outperformed each other. When the scores were limited to the shoulder portion of the physical examination, which was the initial portion of the test, there was still no significant correlation (p value 0.263). Next, the secondary outcomes were assessed (Table 2). The Pearson correlation coefficient between paper folding score and physical examination score was 0.2716, suggesting a weak relationship between the two variables. When paper folding scores were added as a covariate to the 2D computer or 360° video condition, the R-squared of the relationship was 9.4%. With the model explaining only 9.4% of the variability in physical examination, this indicates that neither the 360° video experience nor spatial ability as measured by paper folding scores had a notable effect on PE scores.
Collected Data Including Group, Score on Physical Exam Post Training, Paper Folding Test (PFT) Score, and PFT Score High (6+) Versus Low (<6). I = Immersive 360 Video; 2D = 2D Computer Display; PE = Physical Exam Score
Discussion
Student experiences with immersive technology
The usability of immersive technology in medical education is an important consideration, as introducing new technology should enhance, rather than hinder, the learning experience. Participants in this study completed a usability survey to provide feedback on their interaction with the HMD system. While the results did not demonstrate a significant advantage of 360° video over 2D computer video learning, subjective feedback from participants provided insights into how students perceived the technology. Table 3 shows the averages for each of the 10 items rated by participants, comparing the two conditions (360° video vs. 2D). Each item was rated from 1 (strongly disagree) to 5 (strongly agree). Note that the questionnaire employs alternating question polarity, such that the odd-numbered items indicate better usability, and the even-numbered items indicate worse usability. Out of the 19 questionnaires, there was no missing data, and all answers used the standard 1–5 Likert scale. The final calculation for the SUS is as follows: the contribution of each odd-numbered item is the scale position minus 1, the contribution of each even-numbered item is 5 minus the scale position, and the sum of all of these contributions is multiplied by 2.5. As a result, a questionnaire of alternating 5′s and 1’s would yield a final score of 100.
Usability Scores for Each of the 10 Items of the System Usability Scale (SUS), Averaged Among Participants, and Compared Between 360° Video and 2D Computer Conditions
According to Table 4, the average SUS for the 360° video group was 72.75 compared to the average of 79.72 for the 2D group. The 2D group had a higher average across all 5 odd-numbered questions and also outperformed the 360° video group in all but one even-numbered question. However, a Mann–Whitney U test to compare scores between the two groups yielded a p value of 0.25, indicating that the participants’ self-reported usability ratings did not differ meaningfully between the two interface types. This suggested that 360° video had comparable usability to a 2D computer.
Average and Standard Deviation of System Usability Scale for the 360° Video and 2D Computer Conditions
Finally, both the 2D condition and the 360° video condition both outperformed the benchmark for average usability. According to a curved grading scale where a 50th percentile usability score is a 68, both interfaces were above this SUS = 68 threshold. 13 Despite the 2D computer condition aligning with an A-grade and the 360° video condition with a B-grade, the nonsignificant Mann–Whitney result prevents treating these as statistically distinct letter categories. In addition, according to an item-level analysis against the benchmark, the 2D video condition surpassed the SUS = 68 threshold for all questions but 4 and 8, while the 360° video surpassed the SUS = 68 threshold for all but questions 4, 7, and 8. Overall, the SUS data suggests that while 360° video may not have provided a significant performance advantage, it was not significantly different than the 2D computer condition in terms of usability and accessibility. Both conditions also exceeded the SUS = 68 benchmark for an average user experience, although they did not meet the threshold across all 10 items, and neither met the SUS = 80 benchmark for an above-average user experience.
Future iterations of this study may explore qualitative aspects of student engagement, ease of use, and whether increased exposure to 360° video impacts overall usability perceptions over time. Additionally, modifications to 360° video content delivery and interface design could help optimize student learning experiences.
Limitations and future research
Several limitations should be considered when interpreting the findings of this study:
Lack of Interactivity: The 360° video condition experienced a 360° video within the headset and was able to look around the scene with 3 DOF. However, one of the main advantages of VR is the ability to move around within and interact with the environment.7 Our method was passive and likely limited the immersion of the experience and potentially limited procedural learning gains. Future research should explore if students learning physical exam in an environment with 6 DOF (where they could participate in the administration of the exam or see the instruction at different angles, for example) might improve the scores on subsequent testing. This method would take the most advantage of the technology but posed technological challenges for this preliminary study. Small sample size—With only 19 participants, the study lacked sufficient power to detect subtle differences between the 360° video and 2D computer groups. A larger sample would improve statistical robustness. Short-term assessment—Participants were evaluated immediately after training, meaning the study did not assess long-term retention of physical exam skills. Future research could incorporate delayed post-tests to measure skill retention over time. Lack of hands-on practice—Participants were only able to observe the physical exam but did not receive hands-on training before evaluation. This may not accurately reflect real-world medical learning, where students typically engage in both observation and hands-on practice. Limited generalizability—The study was conducted with undergraduate pre-health and first-year medical students at a single institution. Results may not generalize to more advanced learners or practicing clinicians. Technology adaptation curve—Some participants may have been unfamiliar with HMD technology, potentially affecting their comfort level and learning experience. Future studies should consider a pre-training HMD acclimation phase to ensure all participants have equal familiarity with the immersive technology. Potential variability in evaluations—Although a standardized checklist was used, minor subjectivity in scoring could have influenced results. Implementing blinded evaluators or automated assessment tools could help minimize bias in future studies.
Future research should consider increasing sample size, incorporating longitudinal assessments, and integrating objective performance tracking methods to enhance validity. Additionally, exploring different types of interactions (e.g., interactive VR simulations rather than passive observation) may yield more meaningful results.
Generalizability
This study was conducted with students in early stages of medical training, meaning results may not extend to more experienced learners or different educational settings. Additionally, the HMD system used in this study represents just one implementation of immersive technology. Future research could compare different immersive platforms, learning environments, or even hybrid approaches that combine immersive technology with traditional instruction.
Interpretation
Although the study did not yield significant differences between immersive 360° video and 2D computer learning conditions, these findings do not diminish the potential value of immersive technology in medical education. As a pilot study, this research provides foundational insights into the feasibility of 360° video for physical exam training and highlights key areas for future investigation. While spatial ability, as measured by the PFT, did not significantly influence performance outcomes, future studies may benefit from exploring alternative cognitive predictors of immersive learning effectiveness.
Ultimately, immersive technology remains a promising tool in medical education, but further research is needed to determine its optimal role in skill acquisition and long-term knowledge retention. This study contributes to the growing body of literature examining the integration of immersive technology into medical training, providing a basis for more refined studies in the future.
Conclusion
This study investigated the role of immersive 360° video-based learning compared to 2D computer video instruction in medical education. While no significant differences were found between the groups, the study serves as a starting point for further research on immersive learning technologies. The findings highlight the importance of larger sample sizes, longitudinal assessments, and interactive VR applications to better understand immersive technology’s role in skill acquisition. Importantly, these results pertain specifically to passive 360° video and do not rule out potential benefits of interactivity in VR. The study helps to identify the limits of immersive video for psychomotor skill acquisition, such as medical students learning to conduct physical exams. Future research should continue refining 360° video-based training methods to maximize its effectiveness and assess its long-term impact on medical education.
Authors’ Contributions
R.S.: Conceptualization, investigation, methodology, administration, resources, supervision, writing (original), writing (editing); M.B.: Data curation, formal analysis, investigation, validation, writing (original), writing (editing); A.R.: Investigation, writing (original); H.B.: Investigation, writing (original); A.G.: Investigation, writing (original); B.L.: Investigation, writing (original); S.B.: Conceptualization, methodology, administration, resources, supervision.
Footnotes
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.