Visualization Technology in Medical Education

We are usingthree-dimensional, visualization technology to enhance the learningprocess of medical students as they acquire the knowledge and skillsnecessary for clinical evaluation and treatment of themusculoskeletal system.

Visualization technologyoffers the possibility of profoundly changing the way in whichstudents assimilate and process new information by giving them theability to interactively explore biomechanical components of thehuman body and to investigate the effects that changes in physicalproperties can have upon functionality. These materials, designed toserve as an adjunct to teaching strategies that faculty are currentlyusing, are available to students on campus through the KobiljakResource Center at Michigan State University (MSU) College ofOsteopathic Medicine and via the Internet to individuals and groupswho are physically removed from the MSU campus.

Development of MedicalInformatics

Medical informatics is arapidly developing scientific discipline that addresses the use oftechnology for optimizing storage, retrieval and management ofinformation required for problem solving and decision making. Insteadof thinking of technology as a curse that makes life more complex, welike to think of it as a blessing that makes the complexities of lifemore manageable. The Medical Informatics Advisory Panel( the Association of American Medical Colleges has identified fivemajor roles played by physicians &emdash; Life-long Learner,Clinician, Educator/Communicator, Researcher and Manager &emdash; inwhich medical informatics plays a vital part. Our project addressestwo of these: As a life-long learner, a physician needs to keepabreast of advances and to retain proficiency within his or her fieldof medicine; As an Educator/Communicator, the physician needs to bean effective teacher of students and communicator withpatients.

The Internet hasfacilitated the dissemination of scientific information throughoutthe world. One of the more notable projects on the Internet is theNational Library of Medicine's (NLM) Visible Human Project(,a collection of online digital images of complete male and femalecadavers for use in medical research. The Internet also providesmedical educators with an opportunity to deliver interactivetechnology to a target audience both locally and over largedistances. Unfortunately, the simple presentation of information isnot a sufficient condition for learning to occur. Effective learningtools must engage the student, causing them to assimilate newinformation and to construct meaning from it in terms of what theyalready know. While computer-based learning modules (CBLMs) offerdistinct advantages over material in printed form, commercialsoftware has not specifically addressed the unique needs of anosteopathic medical student to visualize and understand concepts thatare space/time dependent.

Historically,visualization technology has been used in two separate and distinctenvironments. The scientific and engineering community has used it toconvey information to a viewer. The entertainment industry has usedit to engage a viewer. The perceived utility of visualizationtechniques took a quantum leap forward when the entertainmentindustry realized that computers could be used to create specialeffects in movies. Shortly after that, the scientific communityrealized that there was potential for not only presenting informationbut also for holding a viewer's attention while it was beingpresented.

Unfortunately, untilrecently, the cost of hardware and software required to develop anddeliver a sophisticated visualization application placed these toolsbeyond the reach of the average educator. But now, as computationalspeed continues to increase and cost continues to drop, what we couldonly dream of doing in the mid-1980s has now become reality. An imagethat once took 20 minutes to render can now be visualized in afraction of a second. In addition, three-dimensional data models arereadily available (,and authoring software ( never been easier to use. This means that educators can focus oncontent rather than being consumed with the mechanics of the deliverysystem.

Establishing Three-DimensionalModels

Computers have not beenproven to be superior to lectures and/or textbooks in transmittingpurely factual information. Consequently, we have purposely avoidedan application that can be addressed using two-dimensional, staticmedia such as the printed page. Computer-based, interactive learningis known to make the educational process more enjoyable for studentsand has been shown to increase long-term retention ofmaterials,[1,2,3] especially when verbal and visualinformation is presented simultaneously.[4]

Our strategy has been toexploit the number-crunching power of computers to generaterepresentations of three-dimensional structures in areas that aredifficult to understand without the aid of animation and/orsimulation and to use the Internet to provide access to thesematerials both on campus and at distance locations. In order to fullyengage the student, we use a combination of two or more of thefollowing: text, graphics, images, video, audio, animation andsimulation. Animated "gif" files are used for free-runninganimations; Java-based programs are used for those instances where aninteractive animation and/or simulation is desired; Quick Time videoand audio is used for laboratory demonstrations. Our instructionalmodules work with computers that are readily available to mostmedical students. The software is designed to execute on a 133 MHzPentium PC computer with 32 Mbytes of RAM memory, 16 bit color at 800x 600 resolution, 100 Mbytes of free disk space, a sound card, anEthernet card and a CD-ROM player. For purely pragmatic reasons, wehave elected to use Internet Explorer 4.0 ( for theuser interface and either Windows 95 or NT 4.0 as the preferredoperating system. For those users off campus who may not have accessto a high-speed Internet connection, the preferred modality ofdistribution is a CD-ROM.

Figure 1. Type I coupled motion of the lumbar spine &emdash; posterior view of L1-L4.

Learning Motion WithAnimation

Osteopathic physicians arein general agreement on the importance of identifying motionabnormalities in their patients and then treating to restore normal,pain-free motion.[5] A detailed knowledge of anatomy andkinematics is an essential component of this process. While basicmorphology can be learned from a textbook, the impact that structurehas upon function is difficult to appreciate using static media. Bymerging morphologic and kinematic data into a computer-generated,three-dimensional animation model, we are able to enhance a student'sability to visualize the detrimental impact that pathology can haveupon an individual's ability to perform normal activities withoutexperiencing pain.[6,7]

Coupled motion is a termused to describe a predictable secondary motion that occurs as aresult of some primary motion. Turning a bolt (the primary motion)causes it to move in or out (the secondary motion) of a threadedhole. One of the more important examples of coupled motion occurs inthe lumbar spine where rotation is coupled with sidebending as aconsequence of the physical configuration of thevertebrae.[8,9] These motion patterns are complex and noteasily visualized with static pictures, but they represent a part ofthe body that needs to function correctly if painful conditions areto be avoided. Figure 1 shows three frames representing normalcoupled motion of the lumbar spine. The left panel represents fullright passive rotation; the center panel represents the neutralposition; and the right panel represents full left passive rotation.Notice that rotation to the left results in coupled sidebending tothe right and that rotation to the right results in coupledsidebending to the left. It is difficult to really appreciate thefunctional interaction of the individual bones when looking at thisstatic set of three images. However, if you go to our Web site( view the animated sequence, you can immediately appreciate howstudent comprehension is enhanced through motion.


Students typically usematerials like these: a) as an advanced organizer to acquire basicconcepts; b) as a supplement to lecture materials; c) as a tool forreview. It has been found that when materials are viewed beforeclass, time spent in class is better used to synthesize informationrather than merely to obtain facts. Like most medical schools whorely upon community-based resources for clerkship and graduatemedical education, MSUCOM ( a responsibility to support its trainees (through distancelearning opportunities) and trainers (through faculty development).Given the appropriate hardware and software, computers providestudents with the ability to access information from a wide range ofsources 24 hours per day. This is especially beneficial for hospitalstaff who have varying work schedules, time restrictions andgeographic constraints.

Visualization technologyis just one component within the discipline of medical informaticsthat will contribute to efficient utilization of the growing pool ofbiomedical information for problem solving and decision making. Wepredict that the use of interactive, three-dimensional visualizationtechnology will facilitate student understanding of static anddynamic relationships among physical components of themusculoskeletal system and will contribute to ongoing efforts todevelop and maintain physician, faculty and student expertise inareas that are uniquely osteopathic.


This study has beensupported in part by Research Grant #95-05-405 from the AmericanOsteopathic Association, Chicago, Illinois.

Richard Hallgren is aprofessor in the Department of Physical Medicine and Rehabilitationat Michigan State University College of Osteopathic Medicine(MSUCOM). His areas of interest include distance learning in medicaleducation and chronic pain syndromes associated with whiplash-typeinjuries.

E-mail: [email protected]

Sherman Gorbis is anassociate professor in the Department of Osteopathic ManipulativeMedicine (OMM) at Michigan State University College of OsteopathicMedicine. He is the director of the Robert C. Ward, DO, FAAOResidency in OMM at MSUCOM. His interests include the integration ofOsteopathic Principles into MSUCOM's curriculum and the treatment ofhospitalized patients with OMM.


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  3. Jaffe, C., Lynch, P., Smeulder, S. (1989), "Hypermedia Techniques for Diagnostic Imaging Instruction: Videodisk Echocardiography Encyclopedia," Radiology, 171, pp. 475-480.
  4. Mayer, R. (1997), "Multimedia Learning: Are We Asking the Right Questions?" Educational Psychologist, 32(1), pp. 1-19.
  5. Greenman, P. (1989), Principles of Manual Medicine, Baltimore, MD: Williams & Wilkins.
  6. Hallgren, R., Reynolds, H., Soutas-Little, R., Hubbard, R., Rechtien, J. (1988), "Three-Dimensional Analysis and Display of Sequential Position Data in the Lumbar Spine," Journal of Clinical Engineering, 13(1), pp. 51-57.
  7. Hallgren, R., Reynolds, H. (1992), "Computer Display of Multidimensional Biomedical Data," Journal of Clinical Engineering, 17(3), pp. 235-243.
  8. Panjabi, M., Oxland, T., Takata, K., G'el, V., Duranceau, J., Krag, M. (1993), "Articular Facets of the Human Spine," Spine, 18(10), pp. 1298-1310.
  9. Holmes, A., Wang, C., Han, Z., Dang, G. (1994), "The Range and Nature of Flexion-Extension Motion in the Cervical Spine," Spine, 19(22), pp. 2505-2510.

This article originally appeared in the 01/01/1999 issue of THE Journal.