The status of virtual simulation experiments in medical education in China: based on the national virtual simulation experiment teaching Center (iLAB-X)

ABSTRACT

Background

Virtual simulation experiments have been rapidly applied to medical education curricula in recent years. China constructed a national virtual simulation experimental teaching center (iLAB-X), and this platform covered almost all of the virtual simulation experiment curricula of domestic colleges or universities. We aimed to comprehensively assess the characteristics and usages of virtual simulation experiments in medical education based on iLAB-X.

Methods

A total of 480 virtual simulation experiment courses had been constructed on iLAB-X (https://www.ilab-x.com/) by December 20, 2022, and the curriculum level, type and design were all searched in this platform. We also conducted an evaluation of curriculum usage and online tests, including the page view, frequency of participation, number of participants, duration of experimental learning and passing rate of the experimental test.

Results

The national and provincial high-quality virtual simulation experiment curricula accounted for 33.5% (161/480) and 35.8% (172/480), respectively. The curricula were mainly set as basic practice experiments (46.5%) and synthetic designing experiments (48.8%). Significantly, forensic medicine (100%), public health and preventive medicine (83%) and basic medical sciences (66%) focused on synthetic design experiments. In terms of usage experiments, the average duration of experimental learning was 25 minutes per course, and the average number of participants was just 1257. The average passing (score ≥60) rate of online tests was 80.6%, but the average rate of score ≥ 85 was only 58.5%. In particular, the average page views, the number of participants, the duration of learning and the test passing rate of clinical medicine were relatively low.

Conclusions

The curriculum design features, construction level and utilization rate varied in different medical majors. Virtual simulation experiments are particularly underutilized in clinical medicine. There is a long way for virtual simulation experiments to go to become a supplement or alternative for traditional medical education in the future.

KEYWORDS:

• Virtual simulation experiments
• medical education
• iLAB-X
• online education
• online education

Background

The virtual simulation-based educational approach is an emerging interactive pedagogical strategy using computer-generated virtual simulation technology that immerses learners in a setting with real-world sensory perceptions and allows a series of practices and feedback in this digital world [1]. The utilization of virtual simulation in experimental teaching has become increasingly prevalent and is considered a significant reform in higher education [2,3], which emerges from the integration of cutting-edge virtual simulation technology and a paradigm shift towards student-centered learning [4,5].

The traditional approach to medical education typically involves theoretical learning as a foundation, followed by the acquisition of clinical skills and experiences through direct patient contact during clinical practice. Recently, virtual stimulation experiments have recently become a mainstream resource for undergraduate or graduate medical education in technical skills. Virtual stimulation experiments have been widely used in surgical trainings, radiology education, anatomy teaching, nursing skills, biochemistry and molecular techniques [6–9]. For example, previous studies confirmed that virtual stimulation was preferred methods of complex neurosurgical training which allowed learner to practice at their convenience and gained feedback during training [10–12]. The virtual stimulation simulation-based training served as a valuable complement to realistic training methods involving patients or cadavers, and facilitated a more refined comprehension of the intricate spatial relationship between eloquent tissue and a surgical target [10]. The aphorism of training of the surgeon proposed by Halsted in 1904 that ‘see one, do one, teach one’ is being transformed into ‘see one, repeat virtual stimulation, real practice’ [13]. Meanwhile, the visualization and interactive experimental procedure largely stimulated the learners’ study motivation and initiative [3,14]. A wide array of studies also confirmed the benefits of virtual stimulation-based medical training in skills development and patient safety [15–18]. A systematic review summarized that prior stimulation-based laparoscopic surgery learning enhanced the effectiveness of learning outcomes, including theoretical knowledge understanding, task completion time, operational skill process and therapeutic effect, when compared with nonvirtual stimulation trainings [18]. Furthermore, Wu et al. (2022) conducted a comprehensive review of 92 high-quality papers on virtual simulation in undergraduate medical education, with Europe contributing to 41 articles, followed by North America with 30 articles and Asia with 18 articles [19]. Above virtual simulation experiments were primarily applied to undergraduate medical education for surgical procedural training, emergency and pediatric emergency medicine, basic medical sciences as well as medical radiation and imaging [19]. Generally, the virtual stimulation-based education model lived up to the mastery of medical experiment learning and systematic assessment of medical professional trainings.

Virtual simulation laboratory platforms have been promising supplements or even alternatives to apprentice-like training models in medical schools. Currently, numerous commercial and non-commercial platforms enable medical educational institutions to develop and share their virtual simulation experiment curricula. The Second Life, launched by Linden Lab™ in 2003, has evolved into a prominent international virtual simulation platform for medical education [20,21]. The University of Southern California Standard Patient Studio platform has developed a freeware virtual patient community, which facilitates realistic and emotionally expressive interactions. The platform has been introduced to numerous medical universities and colleges across the United States [22]. In addition, Oxford Medical Simulation, a British company, delivers award-winning virtual reality medical and nursing simulation which could offer undergraduate students an immersive experience in a virtual clinical environment [^23]. Similarly, virtual simulation experiment teaching was rapidly introduced into Chinese higher education and became a focus of educational informatization reform (Supplementary Figure S1). In 2010, the Ministry of Education (MOE) of People’s Republic of China highlighted the construction requirements of virtual simulation experiment teaching [24]. Subsequently, the MOE launched the construction of National Virtual Simulation Experiment Teaching Centers in 2013 [25]. By December 2022, 3,363 virtual simulation experiments had been launched at the Chinese National Virtual Simulation Experiment Teaching Center (iLAB-X, https://www.ilab-x.com/), including 480 medical experiments. These medical virtual simulation experiment curricula covered basic medical sciences, clinical medicine, nursing sciences, traditional Chinese medicine, forensic medicine, pharmaceutical sciences, medical technology and public health and preventive medicine.

The China Medical University (CMU) carried out a pilot of the ‘Virtual-Actual Combined’ teaching approach in 2017, and they reported that virtual stimulation platforms facilitated the mastery of the experimental principles and operations of biochemistry and molecular techniques [9]. Concurrently, Sun Yat-sen University assessed the teaching effectiveness of pulpotomy after adding a virtual simulation experimental platform, and as expected, the new method of instruction exceeded the conventional experimental teaching method without virtual simulation experimental training [3]. The open virtual simulation experiment platform allowed students to preview and review lessons actively and created a repeatable, noninvasive, experimental learning environment that was not location or time-bound, which accelerated the utilization of virtual simulation experiment systems of medicine. Specifically, the coronavirus disease 2019 (COVID-19) pandemic brought a tremendous shock to traditional medical education, and online education became a priority during this urgent situation, which accelerated the utilization of virtual simulation experiment systems of medicine [26–28].

Collectively, the virtual simulation experiment learning mode provided better practice insights into real-world operational skills and was frequently applied to medical experiments. The Chinese iLAB-X had integrated the national intelligent laboratories from 2,672 domestic universities, and the participants exceeded 13 million. In this study, we aimed to comprehensively evaluate the course usage of virtual simulation experiments in medical education based on this experimental platform in China.

Method

The characteristics of iLAB-X

iLAB-X was an integrated experiment cloud platform for virtual simulation teaching in China, and the platform provided completed curriculum management support. Registration is free for all undergraduate and graduate learners. The registration process for the platform mandates that university students provide accurate information regarding their current educational background, including school name and student number. The social learners are only required to provide their province and industry information. The virtual simulation experiments of this platform align with the primary curriculum of medical and nursing schools, and course modules are accessible to all learners nationwide. Certified instructors could release virtual simulation experiments and manage courses through curriculum arrangement, teaching administration, learning quality assessment and academic performance certification. Therefore, we collected all usage data of medical virtual simulation experiments and classified the experimental courses according to medical specialty.

The type of virtual simulation experiment courses in medical education

A total of 480 virtual simulation experiment courses had been constructed on iLAB-X by 20 December 2022, involving basic medical sciences, clinical medicine, nursing sciences, traditional Chinese medicine, forensic medicine, pharmaceutical sciences, medical technology and public health and preventive medicine. The experimental courses were certified as high-quality national curricula, high-quality provincial curricula or others according to the curriculum construction standards of the MOE of China and each province. The curriculum types included basic professional courses, core professional courses, public courses and so on. The experimental course design was divided into basic practice, synthetic design and research and exploration experiment types. Basic practice experiment refers to a process of verification, demonstration, and fundamental operation that involves relatively simple content aimed at cultivating students’ basic experimental skills. Synthetic design and research experiment refers to an experimental approach that integrates multiple knowledge points or courses within a subject, or combines two or more experimental methods. This aims to facilitate students in establishing connections and systematizing their understanding of the subject matter. The exploration experiment is heuristic experimental teaching, which involves conducting experiments, making observations, engaging in discussions and analysis, and drawing final conclusions. The knowledge points of virtual simulation experiment are designed based on the course standard and course outline, and the knowledge points are presented and counted on iLAB-X platform.

Evaluation of curriculum usage and online tests

The experimental course usage and assessment data were uploaded to the iLAB-X platform via the interface docking of iLAB-X. However, the learner usage data of 146 virtual simulation experiments launched before 2019 cannot be uploaded to the iLAB-X platform due to the update of the platform’s data interface. Therefore, we conducted an evaluation of curriculum usage and online tests, including the page views, frequency of participation, number of participants, duration of experiments and passing rate of experiment tests, based on the remaining 334 courses. The platform will administer a final test on the virtual simulation experiment course upon its completion. The passing rate for each experiment course was determined by dividing the number of individuals who pass the final test by the total number of participants who take it.

Statistical analysis

The data regarding the current utilization of virtual simulation experiment courses was extracted from iLAB-X (https://www.ilab-x.com/), and sorted out using Excel spreadsheet. The usage status, including the distribution of curriculum level, curriculum design, curriculum type, and results of online tests, was presented using descriptive statistics in terms of absolute numbers (n) or percentages (%). The average covered courses and average knowledge points per virtual simulation experiment were calculated based on the total number of courses, the total knowledge points, and total number of virtual simulation experiments. The data analyses were conducted using SPSS 24.0 software, and the subsequent data visualization was performed utilizing the drawing function in Excel software.

Results

Status of medical virtual simulation experiments on iLAB-X

There were 480 virtual simulation experiments in medicine constructed on iLAB, and the top three majors represented were basic medical sciences (25.8%), clinical medicine (20.4%) and public health and preventive medicine (12.3%) when ranked by the number of experiment curriculums (Figure 1). Among these online virtual simulation experiment curricula, the high-quality national curricula and high-quality provincial curricula accounted for 33.5% (161/480) and 35.8% (172/480), respectively. Interestingly, more than half of the virtual simulation experiments of clinical medicine were high-quality national curricula. This may be related to the country’s special attention to the development of clinical medicine (Figure 2). Other medical majors, such as basic medical sciences, public health and preventive medicine, nursing sciences and medical technology, were dominated by the number of high-quality provincial curricula (Figure 2). These results revealed the uneven construction quantity and quality of virtual simulation experiment courses among different medical majors.

Figure 1. The percentage of virtual simulation experiments in different medical majors.

Figure 2. The frequency distributions of high-quality national and provincial virtual simulation experiment curricula among medical majors.

The number of knowledge points involved in virtual simulation experiment courses varied greatly with different medicine specialties, among which the public health and preventive medicine and nursing sciences covered the most average knowledge points, followed by the basic medical sciences (Figure 3). However, the average amount of knowledge of clinical medicine was the lowest when compared to other medical majors (Figure 3). This phenomenon might be related to the characteristics of clinical medicine, which is closely associated with the real safety of humans. Therefore, there was less knowledge presented in clinical medical experiment courses, but at a higher degree of refinement, which was consistent with the high-quality construction of virtual simulation experiments in clinical medicine, as mentioned above.

Figure 3. The average knowledge points and covered course of virtual simulation experiments.

According to the experimental design, the virtual simulation experiments were mainly set as basic practice experiments (46.5%) and synthetic designing experiments (48.8%), but the exploration experiment course accounted for only 4.7% (Supplementary Table S1). Significantly, forensic medicine (100%), public health and preventive medicine (83%) and basic medical sciences (66%) focused on synthetic designing experiments (Figure 4). In particular, the virtual simulation experiments of forensic medicine were primarily built based on real cases, and these experiments aimed to cultivate students’ abilities of scene investigation, logical reasoning and analysis and judgment (Supplementary Figure S2). Similarly, the public health and preventive medicine particularly attached importance to synthetic designing experiments involved in the emergency response of major public health events, including infection with a virus, hazardous chemical leaks, collective bromatoxism, major natural disasters, and occupational diseases (Supplementary Figure S3). Immersive scenes were set up in these virtual stimulation experiments to develop emergency monitoring, emergency rescue and media communication skills. Conversely, 86% of the virtual simulation experiments of clinical medicine belong to the basic practice type, including a large number of clinical diagnosis and treatment skills training (Figure 4). In terms of the course type, most of the virtual simulation experiments of basic medical sciences (85%), clinical medicine (69%), traditional Chinese medicine (60%) and public health and preventive medicine (53%) were foundation courses (Figure 5). However, the experiments of nursing sciences (70%), forensic medicine (67%), pharmaceutical sciences (56%) and medical technology (53%) were mainly based on professional courses. The remarkable differences in the distribution of experimental design types and course types in these majors also reflect that virtual simulation experiments cater to the practical needs of distinct medical majors.

Figure 4. The percentage of basic practice experiments and synthetic design experiments of virtual simulation experiments.

Figure 5. The percentage of foundation courses and professional courses of virtual simulation experiments.

The evaluation of curriculum usage of virtual simulation experiments

We assessed the open application of virtual simulation experiments of medicine from page views, the total frequencies of the experiment training, the number of participants, the average duration of the experiment, the experiment completion rate and the passing rate of the experiment assessment. Surprisingly, the average number of views of virtual simulation experiments in forensic medicine was 77,506, which is distinctly higher than that of other majors, which might be related to the fewer online virtual simulation experiments in forensic medicine (Figure 6a). The user participation in the virtual simulation experiment also presented several differences among distinct majors (Figure 6b). For example, the virtual simulation experiments in basic medical sciences showed a relatively high average frequency of experiment participation and a larger average number of participants of 4446 and 1806, respectively. Analogously, the average frequency of experiment participation and the average number of participants were 3903 and 1666 in the public health and preventive medicine fields, respectively. However, the lowest usage of virtual simulation experiments occurred in clinical medicine. In terms of learning duration, the average duration of experiments was 25 minutes per course (Supplementary Table S1), and the pharmaceutical sciences was the longest at 31 minutes, followed by public health and preventive medicine, public health, forensic medicine (27.9 minutes) and nursing sciences (27.8 minutes). The shortest average duration of the virtual simulation experiment was clinical medicine and medical technology (Figure 6c). The learners could participate in an online test at the end of the experimental course. The average passing rate (score ≥60) of all medical virtual simulation experiments was up to 80%, and the average rate of score ≥ 85 was 58.5% (Supplementary Table S1). The average online-test status of different medical majors is shown in Figure 6d.

Figure 6. Evaluation of curriculum usage of virtual simulation experiments (a) The average page views of virtual simulation experiments. (b) The average number of participants and frequency of participation in virtual simulation experiments. (c) The average duration of virtual simulation experiment learning. (d) The results of the online test of virtual simulation experiments.

Discussion

Virtual simulation teaching and learning have constantly increased in medical education in the past decade, becoming the starting point of various medical practices and being widely integrated in traditional professional training [19,29,30]. The Chinese iLAB-X (www.ilab-x.com) is a national public virtual simulation experiment teaching platform that gathers virtual simulation experiments in all disciplines and majors of domestic colleges and universities. This platform directly serves undergraduate and graduate education. Therefore, virtual simulation experiments on iLAB-X are implemented more frequently in China’s medical experiment teaching. Accordingly, we comprehensively displayed the current status and learning effectiveness of virtual simulation experiments in different medical areas, including basic medical sciences, nursing sciences, traditional Chinese medicine, clinical medicine, forensic medicine, pharmaceutical sciences, medical technology and public health and preventive medicine. A previous parallel-design randomized controlled trial compared the learning outcome of tendon repair method between virtual simulation teaching group and control groups, and the finding showed that students learning via the integration of virtual simulation and practical class had significantly better scores than those learning via the traditional method (integration of lectures and practical class) with respect to the tendon repair technique [31]. Another randomized controlled trial about cardiopulmonary resuscitation (CPR) also suggested that the learners of intervention group (receiving virtual simulation basic life support (BLS) course and a basic skill training) had higher overall learning gain outcomes when compared to those in control groups (receiving classic BLS-course and a basic skill training) [32]. In addition, the Chinese People’s Liberation Army Medical University conducted a randomized controlled trial in 2022, where 18 undergraduate students majoring in pharmacy were randomly assigned to intervention group (virtual simulation experiment and traditional experimental teaching) and control group (only traditional experimental teaching). The experimental learning content of the two groups involved the classic biotechnology pharmaceutical experiment known as ‘Hybridoma technology for monoclonal antibody preparation’. The intervention group completed the virtual stimulation experiments course from iLAB-X platform. The average score of students in the intervention group was significantly higher (93.78 ± 1.41) compared to that of the control group (75.94 ± 00.00). Furthermore, students in the intervention group subjectively believed that online virtual stimulation experiment teaching reduced the difficulty associated with learning experimental principles and skills, while also expressing interest in this method of instruction. They also displayed sufficient confidence in their mastery of experimental skills [33].

However, the characteristics of curriculum designs and applications of virtual simulation experiments were disparate in different medical majors. Several previous studies have elucidated many efficient roles of virtual simulation training in clinical medicine. Compared with real clinical operations, virtual simulation experiments can establish a series of ethically safe environments without jeopardizing any patients or animals [19,29]. These scenes were conducive to repeated practice of professional skills and better preclinical preparation and promoted the learners’ abilities of critical thinking or clinical judgments [34,35]. In this study, the number of virtual simulation experiment projects in clinical medicine ranked second among the medical majors, accounting for more than one-fifth of the total. Meanwhile, most of the clinical virtual simulation experiment courses belonged to high-quality national courses. These trends represented the rapid development and transformation of clinical experiment teaching in China. A recent review synthesized 92 published papers on the utilization of virtual simulation experiments in undergraduate medical education, with over half of the studies reporting its application in clinical medical training [19]. Specially, the virtual simulation experiments were popular in various surgical skill training, emergency, and pediatric emergency, and the findings overwhelmingly indicate that the implementation of virtual simulation experiment teaching significantly enhances the acquisition of clinical skills [36–39]. The virtual simulation experiment projects of clinical medicine exhibited unique characteristics. For example, the average coverage of knowledge points per course was the lowest, and the curriculum design and curriculum type were mainly basic practice experiments and foundation courses, respectively. However, the types of synthetic design experiments and research exploration experiments were relatively low. These results were consistent with previous studies that undergraduate students urgently acquired basic clinical technique skills training to prepare for further clinical practice, such as time in motion, flow of operation, and knowledge of the procedure [31,40]. Virtual simulation experiments could allow students to preview before class and practice after class through the combination of online and offline learning models to cultivate students’ basic skills and independent learning ability. However, the virtual simulation experiment projects of clinical medicine on iLAB-X seemed were not fully implemented or promoted, and the average page views, average number of participants, average duration of learning and average passing rate of clinical medicine virtual simulation experiments were relatively low. These results indicated that the actual application effect of virtual simulation experiments in clinical medicine was separated from the high attention of China’s MOE. Professional clinical medicine skills seemed to be mainly taught via the apprenticeship teaching model, while ignoring the potential major role of virtual simulation experiment courses. Future clinical medical education reform should attach greater importance to the role of virtual simulation experiment projects. In addition to the construction of high-quality virtual simulation experiments, colleges and universities should highlight the effective application of these courses.

In contrast, there were just fifty-nine virtual simulation experiment courses of public health and preventive medicine, among which only seven were national high-quality courses. However, these virtual simulation experiment courses were better applied to experiment teaching and in line with professional requirements. The synthetic design experiments exceeded 80% and were mainly applied in training for various public health emergencies. The average number of participants in virtual simulation experiments was highest in public health and preventive medicine. These analyses were consistent with the current emphasis on public health safety and urgent training in response capacity of public health emergencies due to the COVID-19 pandemic in the past three years [41].

The other virtual simulation experiments with a large average number of participants belonged to basic medical sciences, pharmaceutical science, medical technology and forensic science fields. In particular, the basic medical sciences had the largest number of virtual simulation experiment projects and the most average participants in the area of medicine. Among these online virtual simulation experiments, 66% were synthetic design experiments involving human anatomy, physiology, pathology, pathological physiology, pathogeny biology, human parasitology, medical microbiology, molecular diagnosis et al. The basic medical sciences were considered the cornerstone or core component for all medical education. Virtual simulation experiments have been rapidly applied in medical education since 2020 [19,42]. Previous studies reported that the vivid and dynamic imagery of virtual simulation experiments help students learn more efficiently in anatomy [43,44] neurophysiology [45] and cardiac electrophysiology [46].

On the other hand, the virtual simulation experiments in forensic medicine were relatively inadequate, and recently, there were only 12 curricula. All these curricula of forensic medicine in iLAB-X were synthetically designed according to real cases. Current virtual simulation trainings in forensic medicine are devoted to effectively reconstructing accident or crime scenes, and learners are trained in scene investigation, high-order thinking and logical reasoning in these immersive environments [47,48]. The virtual simulation experiments of medical technology on iLAB-X were mainly focused on medical radiation and imaging, laboratory diagnosis and dental laboratory technology. In particular, virtual simulation training has been widely used in computerized tomography (CT), magnetic resonance imaging (MRI), and ultrasound practices in undergraduate medical education, and virtual simulation experiments have been demonstrated to be valuable and effective learning resources [49–51]. Moreover, virtual simulation experiments have also been developed as alternatives to practical nursing education and have effectively promoted nursing neurophysiologyperformance [52,53].

In this study, we first evaluate the usage states of virtual simulation experiment courses of medical education based on the iLAB-X platform. However, the data for this study was derived from the utilization of virtual simulation experiment courses offered by the iLAB-X platform, including the page views, frequency of participation, number of participants, duration of experiments and passing rate of experiment tests. It remains unclear to what extent learners’ practical experimental skills and theoretical knowledge improved following their engagement with these virtual simulation courses, as well as whether the acquisition of virtual simulation experiment knowledge facilitated a shift in learning approaches and skill enhancement, ultimately impacting final experimental outcome. Future comparative study is warranted to set intervention group (virtual simulation experiment and traditional experiment teaching) and control group (lecture and traditional experiment teaching), and then to evaluate the actual learning behavior and learning result of virtual simulation experiments among learners. Moreover, the development of virtual simulation experiment courses in China is still at its preliminary stage, and there are quality variations across modules and specialties. The quality of virtual simulation experiment courses in medical specialties will be continuously enhanced based on the requirements of various disciplines and feedback from early-stage teaching effectiveness.

In conclusion, the Chinese iLAB-X was an effective national integrated platform for virtual simulation experiments. The virtual simulation experiments were rapidly constructed in colleges/universities and gradually applied to medical education. The curriculum design features, construction level and utilization rate varied in different medical majors. Virtual simulation experiments are particularly underutilized in clinical medicine. There is a long way to go for virtual simulation experiments to become a supplement or alternative for traditional medical education in the future.

Authors’ contribution

Lindan Ji and Jin Xu conceived and designed the research. Jin Xu, Lindan Ji and Hui Zhu contributed to the analysis and interpretation of data and drafting the initial manuscripts. Penghao Wang, Hongyi Liu, Tao Chen and Zhijia Zhao contributed to retrieve and extract all data. All co-authors have given final approval of the submitted version. Lindan Ji is the guarantor of this work and has full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Availability of data and materials

The data of the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

All data were publicly available on the iLAB-X (https://www.ilab-x.com/) platform. This study was exempt from the Ningbo University Medical Science Research Ethics Committee.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10872981.2023.2272387.

Additional information

Funding

This research was supported by the Higher Education Teaching Reform Research Program in Zhejiang Province [No. jg20180073].