Received: 25 June 2024 | Revised: 11 November 2024 | Accepted: 30 November 2024

DOI: 10.1002/aet2.11058

ORIGINAL ARTICLE

Metaverse technologies in acute care medical education: A

scoping review

Justine Lau MD1 | Nicholas Dunn MD1 | Marianna Qu MD2 | Rebecca Preyra MD3 |
Teresa M. Chan MD, MHPE, MBA1,4,5

1
Michael G. DeGroote School of Medicine,
Faculty of Health Sciences, McMaster Abstract
University, Hamilton, Ontario, Canada
Background: The concept of the metaverse is a virtual world that immerses users,
2
School of Medicine, Faculty of Health
Sciences, Queen's University, Kingston,
allowing them to interact with the digital environment. Due to metaverse's utility in
Ontario, Canada collaborative and immersive simulation, it can be advantageous for medical education
3
Faculty of Science, Western University, in high-­stakes care settings such as emergency, critical, and acute care. Consequently,
London, Ontario, Canada
4 there has been a growth in educational metaverse use, which has yet to be character-
McMaster Education, Research,
Innovation, and Theory (MERIT) Program, ized alongside other simulation modalities literature. This scoping review aims to pro-
Faculty of Health Sciences, Hamilton,
vide a comprehensive overview of all research describing metaverse use in education
Ontario, Canada
5
School of Medicine, Toronto for emergency, critical, and acute care.
Metropolitan University, Brampton, Methods: We used Arksey and O'Malley's framework with the Levac et al. modifi-
Ontario, Canada
cations to conduct a scoping review by searching these five databases (MEDLINE,
Correspondence EMBASE, ERIC, Web of Science, and Education Source). The framework comprises
Teresa M. Chan, Toronto Metropolitan
University, 350 Victoria St., Toronto, ON six steps: (1) identifying the research question; (2) identifying relevant literature; (3)
M5B 2K3, Canada. study selection; (4) data extraction; (5) collating, summarizing, and reporting data; and
Email: tchanmd@[Link]
(6) consultation with key informants. Relevant themes and trends were extracted and
mapped for reporting.
Results: The search yielded 8175 citations, which ultimately led to data extraction
from 65 articles. Studies evaluated metaverse programs for the learning and assess-
ment of both technical skills (management of code blue, sepsis, stroke, etc.) and non-
technical skills (e.g., interprofessional collaboration, communication, critical decision
making). Barriers to metaverse implementation include technical challenges and dif-
ficulty evaluating educational effectiveness.
Conclusions: The results of this scoping review highlight the current applications of
metaverse as an educational tool, its identified strengths and weaknesses, and fur-
ther comparison between metaverse and other educational modalities such as high-­
fidelity simulation. This work provides direction for future primary and secondary
research that can aid educational programmers and curriculum planners in maximizing
metaverse potential in emergency, critical, and acute medical education.

Presented at the International Congress on Academic Medicine, Vancouver, BC, Canada, April 2024.

Supervising Editor: Adaira Landry

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction
in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2025 The Author(s). AEM Education and Training published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.

AEM Educ Train. 2025;9:e11058.  [Link]/journal/aet2 | 1 of 12

[Link]
2 of 12 | METAVERSE TECHNOLOGIES IN ACUTE CARE MEDICAL EDUCATION

I NTRO D U C TI O N purposes.1 It has been implemented into different technologies such

as head-­mounted displays in VR and 2D computer applications;
With the rise of simulation in medical education, we have seen some of the most common examples of the metaverse technologies
its vast benefits for trainees in the development of both techni- include commercial games such as Fortnite and Roblox.10 Besides
1
cal and nontechnical skills. In the scenarios of emergency care these games, the metaverse concept has also gained traction as a
(e.g., first few moments and initial intake of patients in the ED), technology with possible utility in improving medical education.11–13
acute medicine (e.g., first few hours to days of inpatient treat- The metaverse concept encapsulates multiple forms of virtual
ment), and critical care (e.g., intensive care level care provided at training environments, the most popular of which is VR, but also
any point in a patient's hospital stay), simulation has proven to be includes augmented reality (AR), lifelogging, and mirror worlds.14 It
an essential educational modality. Simulation-­related educational has been previously defined by others, and for reference we have
modalities allow students to encounter new experiences in a real- created Figure 1, which depicts our interpretation of the framework
istic yet reproducible and zero-­r isk learning environment.1 Some most recently proposed by Wu and Ho.14
of these scenarios may be dangerous or rare, making simulation While metaverse technologies have a role in the education of
2
even more important. Today, almost all medical programs imple- various medical specialties, it could be particularly advantageous in
ment in-­p erson simulation as a component of their curriculum3; emergency medicine, critical care, and acute care.15 The high-­acuity
in fact, schools are often expected by accreditation programs in- nature of these specialties can make student involvement danger-
cluding Committee on Accreditation of Canadian Medical Schools ous for the patient, learner, and collaborating health care provid-
(CACMS) and Liaison Committee on Medical Education (LCME) ers.16–18 The ability to perform a variety of life-­saving procedural
in the United States to remediate gaps in patient encounters by skills with competence is a requirement in these phases of medical
mechanisms such as simulation.4,5 However, being in person often care and their affiliated training programs (e.g., internal medicine,
requires increased resources including personnel, clinical space, acute care surgery, emergency medicine, critical care).19 Moreover,
manikins, medical equipment, etc., all of which make consistent students must apply nonprocedural skills such as quick decision-­
in-­p erson simulation less accessible. 6 Additionally, the limitations making skills, stress tolerance, and situational awareness to partici-
of in-­p erson activities due to the COVID-­19 pandemic greatly im- pate safely during these emergencies. 20 However, these procedural
pacted clinical training in medicine and highlighted the need for and nonprocedural skills are difficult to develop without repeated
7
realistic and flexible educational methods for virtual learning. practice which is not always feasible, accessible, or safe in clinical
Should a similar event occur, medical programs must be pre- settings.16,17 In addition, these specialties require significant team-
8
pared with alternatives including virtual methods of teaching. work and interprofessional involvement which can be difficult to
Ultimately, all these components make in-­
p erson simulation a practice due to the logistics of gathering many individuals. 21 Due to
complex teaching modality to implement in medical education. As the unique needs and challenges that education in these specialties
a result, it is evident that alternative simulation tools are needed; presents, various modalities of metaverse technologies have been
one solution that has been proposed includes these metaverse implemented in these medical domains through serious games, vir-
technologies. tual patients, and situational management.
The term “metaverse” first appeared in 1992 as defined in Neal Given the vast array of metaverse applications in the education
Stephenson's novel Snow Crash.9 He used the term to describe a vir- of acute care, emergency, and critical care specialties and the rapid
tual reality (VR)-­based online world in which users can escape from technological development, establishing a scholarly mapping of key
society. In these worlds, individuals are represented by avatars where literature at the intersection of the metaverse concept and acute care
they can interact with each other and the virtual environment in real education would be of great importance. As a result, this scoping re-
time. Since then, the term “metaverse” has grown significantly as view aims to collect the abundance of novel findings and map them
numerous digital environments have been programmed for various alongside past studies to characterize the usage within metaverse as

F I G U R E 1 A depiction of the proposed

framework for the metaverse inspired by
the work of Wu and Ho14 and adapted by
our team.
LAU et al. | 3 of 12

an educational tool within these specialties. This will allow us to not criteria. These criteria were influenced by the work of Wu and Ho14
only determine the common themes and pertinent findings in literature with our inclusion of certain elements of AR, VR, lifelogging, and
but also discern knowledge gaps requiring further research. Scoping mirror worlds, within our specified criteria to include non–emergency
reviews have been conducted on various technologies in high-­acuity medicine acute care settings. We also applied an education-­relevant
medicine, but they have yet to focus directly on the metaverse con- lens to our scoping review, which differs from the previous work
cept in the education of these three specialties. Ultimately, this scoping of Wu and Ho.14 A preliminary search was performed in MEDLINE
review aims to have a more focused view by providing a comprehen- to check the appropriateness of keywords and MeSH terms. We
sive synthesis of all research describing metaverse usage education in conducted our search on March 29, 2023, in MEDLINE, EMBASE,
these three specialties to recapitulate the copious emerging evidence. ERIC, and Web of Science databases, and our initial screening
included all citations from these databases from their initiation until
this date. The titles and abstracts of retrieved studies were also
M E TH O D S assessed for additional keywords to be added to the final search
strategy. For example, the term “virtual simulation” was added to the
This scoping literature review was conducted to understand the range search strategy to include studies that used the metaverse concept
and nature of publications related to educational use of the metaverse but did not specify the specific form. The first 200 results retrieved
concept in acute, emergency, and critical care medicine. Scoping on Google Scholar were added to the search strategy on March 29,
review methodology was chosen to determine “the scope or coverage 2023 (however, due to the proprietary nature of the Google Scholar
of a body of literature on a given topic and give a clear indication of search algorithm, further data are not available). Furthermore, the
the volume of literature and studies available as well as an overview reference lists of review articles found to be relevant during the
(broad or detailed) of its focus.”22 Scoping reviews mainly align with database search were screened to ensure the inclusion of any missed
a subjectivist epistemology that rejects the idea of a single objective articles. These database searches were selected to comprehensively
23
truth. Throughout the review process, the authorship group select studies discussing the educational use of the metaverse
developed an interpretation of the topic that is shaped by individual concept in acute, emergency, and critical care settings.
and group experiences and knowledge.23 We completed this study in With consultation from librarians at McMaster University, Queen's
adherence with the framework of Arksey and O'Malley24 framework University, and the University of Ottawa, the final search strategy was
for scoping reviews with modifications offered by Levac et al.25 All constructed which can be found in the Appendix S1. No limits related
reporting for this paper aimed to fulfill the Preferred Reporting Items to date range were applied; however, non-­English studies were ex-
for Systematic reviews and Meta-­Analyses extension for Scoping cluded from our study. All references were imported into the review
Reviews (PRISMA-­ScR) reporting guideline. A review protocol software Covidence.27 The references from various databases were
approved by institutional review board was not required as this study combined and duplicate studies were removed based on title and
design only referred to secondary anonymized information, and no abstract.
identifiable information was generated.26

Step 3: Study selection

Step 1: Identifying the research question
The authorship team participated in multiple calibration exercises to
We focused on the following questions that were generated through determine inclusion criteria. We iteratively reviewed articles to discuss
iterative discussion among our research team and molded by our relevance to research questions until a consensus was reached.
findings in the literature in emergency, critical, and acute care: (1) We decided to focus on articles that included using metaverse
What are the current applications of metaverse medical education technologies as an educational tool for medical students, residents, or
and training? (2) What benefits and limitations have been identified fellows in acute, emergency, and critical care medicine. The metaverse
in using metaverse medical education and training? (3) Which concept application must include an immersive, collaborative, and
modalities of metaverse are being employed in medical education simultaneous virtual world where multiple users can interact with
training? (4) What are the barriers to implementing metaverse in each other. We excluded studies specifically involving disciplines
medical education and training? or educational settings other than acute, emergency, or critical
care medicine, including those involving disaster medicine, military
medicine, prehospital medicine, or operating room–specific surgical
Step 2: Identifying relevant studies skills. We also excluded studies applying metaverse for noneducational
purposes, those where only one user could be accommodated, and
Based on our research questions, a preliminary search was designed non-­English studies. Books were excluded from this review.
to combine medical subject heading terms and keywords. Four To ensure that all relevant results were included, papers men-
authors (JL, ND, MQ, TMC) were involved in the development and tioning the use of metaverse in general medical education or gen-
refinement of the study's search terms and inclusion and exclusion eral surgical training were considered in the first stage of screening;
4 of 12 | METAVERSE TECHNOLOGIES IN ACUTE CARE MEDICAL EDUCATION

however, these papers could not have any specific mention of irrel- consulted two researchers who are involved in the development
evant specialties or surgical skills that could only be performed in an of metaverse technologies for medical education; we discussed the
operating room. The screening process for study selection consisted challenges they have faced both financially and technologically to
of two stages; first, a title and abstract review that was then fol- create these innovative modalities. They also shared the various
lowed by full-­text screening. Two independent reviewers screened directions they foresaw the metaverse concept proceeding within
articles for eligibility in both stages. All conflicts were discussed by medical education. Moreover, we welcomed feedback on our project
the two reviewers for resolution; if no consensus was reached, a throughout the conference. Any further analyses suggested by the
third reviewer resolved the conflict. experts were incorporated into our final manuscript discussion
sections.

Step 4: Data extraction

R E S U LT S
A data extraction form was created to be completed by the reviewers
using Google Sheets. To answer our research questions, the form Our initial search retrieved 8173 potential citations after duplicates
was structured to include study type; publication time; study were removed, which based on our criteria were reduced to
participants; types of metaverse programs; targeted skills; advantages 787 articles for full-­text review. Our independent review of the
and disadvantages; unique features; and applications in emergency remaining articles resulted in a final number of 65 articles included
28
medicine, critical care, and acute care. The Cook et al. framework in the review (see Figure 2). Compared with the findings of Wu and
for types of scholarship (description, justification, and clarification) was Ho,14 we had fewer included studies as we excluded any applications
used to construct our extraction tool. The data extraction form was of the metaverse concept that were noneducational as well as those
revised to include additional information as necessary throughout the that did not include medical learners.
process. The data extraction tool was iteratively improved by the team. The highest proportion of publications were from North
The final list of studies for extraction was equally divided among the America (n = 30), with similar amounts from Europe (n = 12) and
authors, with each person being responsible for including or excluding Asia (n = 10). There were publications from many jurisdictions
the study as well as extracting relevant information from included (Middle East [n = 3], Australia/New Zealand [n = 3], South America
studies. The studies that were categorized as “maybe include” were [n = 2], Africa [n = 1]) and some that were not geographically an-
reviewed by multiple authors (JL, ND, MQ, RP) for a final decision. chored (n = 10).
Informed by the Best Evidence in Medical Education data extraction
tool, and in alignment with our research question, we iteratively
designed a data extraction sheet in Google Sheets.29 After a calibration Prevalence over time
exercise, reviewers (JL, ND, MQ, RP) independently extracted relevant
data from included studies after both stages of screening. If conflicts Publications featuring the use of metaverse in acute, emergency, and
arose, the two reviewers had a discussion to resolve it. If necessary, a critical care medical education have increased in the past 5 years,
third reviewer resolved the conflict. All included studies were uploaded especially since 2020 (Figure 3).
onto the reference manager Zotero.30

Specialties of origin
Step 5: Collating, summarizing, and reporting the data
Most publications were anchored in emergency medicine (n = 39),
Extracted data were reviewed and collated and thematic analysis was followed by critical care (n = 15) and acute care (n = 7). Publications
conducted by four authors (JL, ND, MQ, RP), guided by the framework that were either not anchored in a particular specialty (n = 3) or
31
of Kiger and Varpio framework to systematically develop and organize from other specialties (n = 3) were included if topics applicable
themes. Team discussions were held to discuss the data and themes to acute, emergency, or critical care medical education were
to determine how to best present the findings. A final description of included.
the themes and subthemes was agreed upon by our entire group of
authors after the analysis via consensus discussion.
Populations discussed

Step 6: Stakeholder consultation Medical students were most discussed, with equal participation
from preclerkship (n = 4) and clerkship students (n = 4); however,
This scoping review was presented at an international academic the majority of these studies (n = 35) did not specify medical stu-
medicine conference to an audience including researchers dent training level. Residents and fellows were also heavily fea-
specializing in simulation for medical education. Additionally, we tured (n = 38). Some studies did not specify trainee level (n = 12).
LAU et al. | 5 of 12

F I G U R E 2 Prisma flow diagram of

article search and selection process.

F I G U R E 3 Number of articles
discussing use of the metaverse in medical
education of emergency medicine, critical
care, and acute care. Given that our article
search was performed at the end of March
2023, we multiplied the number of articles
published in 2023 at that time by four
to provide an estimated 2023 year-­end
projection.

Types of scholarship emergency, and critical care medical education. Another promi-
nent scholarship type (n = 22) was descriptive, with justification
The bulk of included publications (n = 28) were conceptual (n = 12) and clarification studies (n = 1) being the least common
pieces describing the use of the metaverse concept in acute, (see Figure 4).
6 of 12 | METAVERSE TECHNOLOGIES IN ACUTE CARE MEDICAL EDUCATION

F I G U R E 4 Type of scholarship utilized in included articles. Definition of scholarship type includes conceptual pieces such as editorial
pieces, commentaries, and narrative reviews; description study of systems such as articles describing specific programs that have been
developed; description study of a phenomenon which focuses on observation of an intervention, with no reported comparisons; justification
study that compares efficacy of a newer intervention with a previous one; and clarification study that employs all steps of the scientific
method to create and test theories.

Data sources

Qualitative surveys were the most common data source (n = 28), followed
by objective observations and tests (n = 14), and literature reviews (n = 13).

Empirical studies

Randomized control trials were the most used experimental design

(n = 10), followed by nonrandomized pre-­ and posttest intervention
analysis (n = 7). The remaining empirical studies employed other
experimental designs such as single-­group analysis with repeated
measures (n = 2) and multiple groups with the same intervention F I G U R E 5 Types of metaverse identified in included articles.
(n = 1) and compared outcomes between two groups (n = 1).

(n = 48), which was repeatedly emphasized due to the abil-

Forms of the metaverse ity to include multiple users simultaneously and to capture in-
dividual performance within group activities. Other included
More than half (n = 54) of relevant publications discussed or used themes were communication (n = 41), clinical reasoning (n = 40),
VR, with the remainder being split primarily between AR (n = 18), procedural skills (n = 35), interprofessional collaboration (n = 26),
screen-­based metaverse (n = 17), and mixed reality (n = 10). Other stress management (n = 22), leadership (n = 20), and empathy
forms of metaverse discussed include extended reality (n = 5), mirror (n = 5).
worlds (n = 2), and lifelogging (n = 1; see Figure 5 for a visual depic- Moreover, many of these articles also focused on specific topics
tion). There were no discernible patterns between applications spe- in medicine. The most prevalent topics covered were CPR and ACLS
cific to each form of the metaverse concept. (n = 27) and trauma protocols (n = 21), due to the ability to re-­create
and practice management of critical but less commonly seen clinical
scenarios. Similarly, education of pediatric life support also applied
Major themes and specific topics identified the metaverse concept (n = 4). Other more commonly seen clinical
circumstances were covered including sepsis (n = 6), shock (n = 6), re-
Reviewed articles identified a wide range of themes highlighted spiratory emergencies (n = 5), diabetic emergencies (n = 3), and triage
in medical education. The most common theme was teamwork (n = 3; Table 1).
LAU et al. | 7 of 12

TA B L E 1 Topics and themes identified

Number of Number of
in applications of the metaverse in
Topic studies Themes studies
emergency, acute, and critical care
education. CPR and ACLS 27 Teamwork 48
Trauma 21 Communication 41
Sepsis 6 Clinical reasoning 40
Shock 6 Procedural skills 35
Respiratory emergencies 5 Interprofessional 26
collaboration
Pediatric life support 4 Stress management 22
Diabetic emergencies 3 Leadership 20
Triage 3 Empathy 5
Altered mental status 3

Abbreviations: ACLS, advanced cardiac life support; CPR, cardiopulmonary resuscitation.

Benefits and limitations of the metaverse concept DISCUSSION

Our included publications emphasized a multitude of benefits for In this scoping review, we have provided a comprehensive over-
metaverse technologies. The most frequently mentioned advantage view of metaverse technologies’ utility in emergency medicine,
was the flexibility of time and place (n = 31). Other common advan- acute care, and critical care. Our literature screen identified 65 rel-
tages include being cost-­effective (n = 20), having a high degree of evant studies that were ultimately included in this review. Of these
experimental control (n = 19), and interactive (n = 18), and creating a studies, 58.2% (n = 39) of them focused on emergency medicine,
low-­stakes learning method (n = 17). Additional advantages include a 22.4% (n = 15) focused on critical care, and 10.4% (n = 7) focused
variety of applications (n = 13), multiuser features (n = 13), data genera- on acute care. Various modalities of metaverse were included with
tion (n = 9), immediate feedback (n = 8), and ease of operation (n = 3). the most common being VR (n = 54), AR (n = 18), and screen-­based
Moreover, various limitations of the metaverse concept were media (n = 17). The results of this study suggest that the metaverse
also highlighted in the included articles. The most prevalent limita- concept holds various applications in the medical education of
tions mentioned include high start-­up costs (n = 10) and poor fidelity emergency, critical, and acute medicine. The identified benefits
(n = 8). Other repeated limitations that were raised such as develop- and limitations of the metaverse mostly align with the extensive
mental difficulties (n = 7), technological issues (n = 6), learning curves literature on simulation-­based education, especially in regard to
for metaverse use (n = 6), loss of haptic feedback (n = 6), insufficient providing a low-­s takes learning opportunity that encourages col-
research (n = 6), lack of infrastructure (n = 6), and physical discomfort laboration.41,42 While various benefits of the metaverse were iden-
(n = 6). Lastly, another limitation that was less commonly mentioned tified, the most highlighted advantage was flexibility. Moreover,
is the lack of face-­to-­face interaction (n = 3). Surprisingly, access to the most identified limitation of the metaverse was the high start-
simulation technology was not listed as a limitation in any of the ­up cost. Despite the early stages of metaverse integration into
present studies we found (Table 2). medical education, the metaverse often showed similar or better
learning outcomes and student satisfaction relative to alternative
learning methods.
Comparisons between the metaverse concept and
other modes of education
The emergence of the metaverse
Ten of the included studies were randomized controlled trials, com-
paring the educational effectiveness of metaverse technologies Broadly speaking, this scoping review reflects the growth of schol-
against other modes of education including in-­person physical simu- arly work in the metaverse in medical education of emergency,
lation with high-­fidelity human patient simulators (n = 3),32–34 with- critical, and acute medicine for the past two decades. However,
35,36 37
out mannequins (n = 2), and with a mannequin (n = 1) as well as literature in this domain shows that the past 5 years, in particu-
nonmetaverse computer learning (n = 2)38,39 and paper-­based learn- lar, have exhibited significant development; this is no coincidence
ing methods (n = 1).40 Across these studies, six primary outcomes when considering the COVID-­19 pandemic's influence on virtual
were assessed: performance/skills (n = 8), learner satisfaction and modalities of learning.43 Although all specialties in medicine were
experience (n = 7), knowledge (n = 3), learner confidence and attitude affected, emergency, critical, and acute medicine had uniquely un-
(n = 3), cost and time efficiency (n = 2), and feedback effectiveness predictable circumstances during these times.44 While challenging,
(n = 1). Outcome comparisons for these educational methods can be these unprecedented events further instigated the expansion of the
found in Figure 6. metaverse into medical education of these specialties. With some of
8 of 12 | METAVERSE TECHNOLOGIES IN ACUTE CARE MEDICAL EDUCATION

TA B L E 2 Advantages and limitations of metaverse use in medical education of emergency, acute, and critical care.

Advantages Limitations

Number of
Theme studies Theme Number of studies

Flexibility: Applications in various educational 30 High start-­up cost: Significant expenses incurred 10
contexts, and accommodation of learner for development
participation in different environments
Cost-­effective: Low financial burden compared 20 Poor fidelity: Difficulty to accurately simulate the 8
to other educational modalities nuanced and dynamic nature of clinical events
Experimental control: More reproducible 19 Complex development: Programming of 7
training compared to other modalities application features is intricate
Interactive: Designed for collaboration 18 Technological difficulties: Challenges with 6
between learners equipment including failure of software and
hardware
Low-­stakes training: Low-­pressure simulated 17 Physical discomfort: Unwanted symptoms 6
environment secondary to use of equipment
Multi-­user: Allows for real-­time participation 12 Insufficient research: Lack of evidence to guide 6
between and among learners development of interventions
Data generation: Large amounts of data 9 Lack of infrastructure: Insufficient frameworks 6
production from computerized activity tracking and policies in place to implement these
interventions
Immediate feedback: Synchronous response to 7 Learning curve: Novelty of the intervention can 6
learner actions make it difficult to understand and use initially
Easy to use: Low barriers to initiating use 3 Lack of haptic feedback: Physical stimuli of 6
among educators and learners pressure and motion are difficult to replicate with
technology
No face-­to-­face interaction: Lack of physical 6
proximity to colleagues

F I G U R E 6 Comparing learning
outcomes between the metaverse and
other educational methods. Comparator
educational methods include in-­person
physical simulation with high-­fidelity
human patient simulators (n = 3), without
mannequins (n = 2), and with a mannequin
(n = 1). Nonsimulation educational tools
included nonmetaverse computer learning
(n = 2) and paper-­based learning methods
(n = 1).

the highest rates of COVID-­19 exposure in the emergency depart- despite a non–face-­to-­face platform that protects against disease
ment and intensive care unit, many medical learners were unable transmission.48
to complete clinical rotations to prevent disease exposure.45 In re-
sponse to the need for social distancing, there was a rapid shift in the
medical education landscape toward virtual learning.46 As a result, it Flexibility as an educational tool
is unsurprising that the metaverse's advantage of flexibility was capi-
talized upon for virtual learning.47 This flexibility allowed students Even as the pandemic resolves, the flexibility that the metaverse
to continue having immersive and interactive learning experiences environment provides is still crucial to improving medical education
LAU et al. | 9 of 12

in acute, emergency, and critical care medicine. A core component experience in realistic practice settings.48,57 Experiential learning
of simulation as a training tool is its ability to build collaboration is particularly beneficial for emergency, critical, and acute care
and teamwork in various situations.49 The collaborative nature of learners, where performing under pressure is commonplace.47,58
some metaverse technologies is essential to this aspect of medical Traditional educational frameworks often fail to emulate the
education as multiuser functions allow for interactivity between high-­paced dynamics of emergency room flows.47,59 This can be
students. 50 The collaboration within a metaverse environment especially beneficial for nontechnical skills—such as leadership,
is emphasized when considering the pertinent medical topics of communication, teamwork, and decision making—often most vul-
emergency, critical, and acute care highlighted in reviewed articles; nerable to the impacts of stress.14 These abilities are paramount
these topics include CPR, trauma, shock, and other medical emer- in acute care settings, where patient care efficacy often hinges on
51,52
gencies that require significant provider collaboration. More the synergistic function of health care teams. 56 Literature shows
specifically, medical education has emphasized teamwork not just that creating a 3D environment further increases immersion to
between physicians, but also in an interprofessional manner with create a more realistic simulation for students. 60 To assess non-
allied health care workers including nurses, social workers, oc- technical skills such as stress management, research has shown
53
cupational therapists, and physiotherapists. This is particularly that VR delivery results in increased arousal as shown by increased
relevant to medical specialties of emergency, critical, and acute heart rate when compared to 2D displays. 61 Furthermore, VR mo-
care as interprofessional teams must effectively communicate dalities were found to be more engaging for students, which is
with each other in time-­s ensitive and precarious situations. 51,54 also significant for increasing interest that can be more difficult
However, implementation of interprofessional simulations can be in virtual learning spaces. 61 Accordingly, most included studies in
challenging given that these disciplines may hold teaching in dif- this scoping review used VR, rather than 2D screen displays, as a
ferent locations and on different schedules. 55 In particular, there platform for a metaverse environment.
may be a role for use of the metaverse environment to provide Finally, opportunities to practice skills required for high-­
risk
reliable simulation training in resource-­limited settings. These set- or rare medical emergencies—typically only taught or practiced in
tings may not have the infrastructure to maintain high-­quality in-­ the context of real patient presentations—can be replicated in a
person simulation, and thus, metaverse technologies may provide metaverse environment without the risk of patient harm. This ed-
a feasible method with which simulation education can be pursued ucational environment allows students to practice risky maneuvers
for rural trainees. As a result, even without the contexts of social typically taken over by more experienced attendings, make mistakes
distancing, the flexibility of the metaverse concept continues to without fear of causing harm, and learn from previous inaccuracies.
be beneficial for allowing individuals to collaborate through inter- This enhances the level of preparedness across learners, reducing
professional simulations despite being from different disciplines. medical errors and improving patient outcomes.
This unique advantage of the metaverse was frequently high-
lighted in the reviewed articles as interprofessional collaboration
was a common theme. Financial barriers to initiating metaverse use

A salient theme emerging from our scoping review involves the sig-
Utility for procedural training nificant start-­up costs associated with integration. The creation of
versus nonprocedural skills immersive, interactive environments that accurately mimic real-­life
medical scenarios rely on sophisticated and often expensive cutting-­
One important pattern discussed across the literature surrounds edge technology. Costs of integration—including hardware and
metaverse technologies’ potential to cultivate procedural training software development, educational content procurement, and infra-
and nonprocedural skills. This may be accredited to various unique structure setup—present a notable barrier to widespread adoption.
characteristics which bypass the inherent limitations of traditional While these upfront expenses are sizable, it is imperative to weigh
educational methods. them against potential long-­term benefits—ranging from improved
First, traditional simulations often limit the number of practice at- educational outcomes to broader access to training.62 Early invest-
tempts per learner due to resource constraints and latency time be- ment may set up future reductions in costs as traditional training
tween cycles for set-­up of actual task trainers.56 In contrast, virtual methods, such as in-­person simulations and cadaveric dissections,
settings allow simultaneous engagement in repeated practice cycles are resource-­intensive.56 Potential solutions exist, including strate-
56
with quick, unlimited resets. Training can be tailored to individuals as gic partnerships with governmental bodies or technological firms,
learners repeat specific skills, and continued development may allow leveraging existing technological infrastructure, and innovative
practice in asynchronous settings.48,57,58 This is especially helpful for models of funding. However, due to a current scarcity of high-­quality
procedural skills, where mastery is highly predicated on practice time. papers evaluating the cost–benefit of metaverse integration, likely,
Second, many metaverse environment's capacity to simulate these options will likely only be explored once there is more defini-
complex, high-­stakes medical scenarios allows students to gain tive evidence available.
10 of 12 | METAVERSE TECHNOLOGIES IN ACUTE CARE MEDICAL EDUCATION

Next steps: Gaps and opportunities LI M ITATI O N S

This scoping review demonstrates the educational utility of Several limitations exist within our study. First, our sampling strategy,
metaverse technologies within certain contexts within emergency, while designed to gather all relevant studies within the field, may
acute, and critical care medical education. Given its relatively re- have inadvertently missed some citations. We also excluded non-­
cent gain in popularity, there are important limitations within the English papers. Had we included them and used translation software,
field that should be addressed, namely, the lack of prospective we might have found additional studies aligning with our criteria;
comparison between various metaverse technologies and other however, we were cognizant that these papers may have required
commonly used educational modalities as well as methods to off- some subtlety of language that would not have been amenable to
set commonly cited limitations of metaverse use including poor this type of direct translation. Possibly, there were also education
fidelity and high cost. applications of metaverse technologies that were excluded as
Of the 65 included studies, only 10 were randomized and pro- our search criteria were only inclusive of studies focused on the
spective. With such varied educational applications within these education of medical learners and not continuing medical education.
practice settings, comparisons of the metaverse technologies with This may have resulted from grouping various forms of metaverse
well-­studied modalities such as high-­fidelity simulation with manne- technology under the same umbrella, which was done intentionally
quins, across a greater variety of learning outcomes would be bene- due to the limited literature for each form. Additionally, our team did
ficial in distinguishing areas of strength and weakness of metaverse not assess articles for quality and impact, as we intended to include
use. This evidence could then be used to guide curriculum devel- rather than exclude them to create a fulsome scope of the field.
opment, applying the metaverse concept to contexts and learning Additionally, data about the effectiveness of metaverse technol-
topics for which it outperforms other modalities. ogies as an educational tool compared to traditional methods such as
Despite the cited educational benefits of metaverse technolo- high-­fidelity simulation are limited due to the number of experimen-
gies, the reported disadvantages of its use may impede necessary tal studies and the heterogeneity among them. The significant het-
research in the field, in particular, concerns of high start-­up cost erogeneity of the included studies such as setting, level of trainee,
and poor fidelity. Much of these concerns are similar to the work and assessed outcomes also limits conclusions drawn about the ex-
done in the simulation literature, and we imagine those working tent of its application in various educational settings.
with metaverse-­related technologies for education can borrow and/ Finally, conclusions drawn from this study are limited by the na-
or infer heavily from the rich literature that has emerged regard- ture of the review design. With a scoping review methodology, we
ing simulation-­based education. Interinstitutional collaboration is intended to map the body of literature24 on educational applications
needed to limit such drawbacks and to mitigate costs associated of the metaverse concept in acute, emergency, and critical care med-
with creating metaverse technology and infrastructure. For exam- icine, not to identify best practices or ideal use cases. We intend for
ple, residency programs with common educational outcomes and in- this article to lay the groundwork for future studies on the topic.
terest in using metaverse technologies may benefit from cocreating
metaverse curricular components and the infrastructure necessary
to maintain such activities. CO N C LU S I O N S
Finally, there is a paucity of data that looks at individual differ-
ences in groups around accessibility and biology that may be tied Overall, this review revealed that the current state of knowledge
to certain types of metaverse applications. For instance, there have about the use of metaverse in emergency medicine, critical care,
been reports of gender bias within the VR literature outside of med- and acute hospital medicine education has room to expand and be
icine.63 Similarly, there may be affordances of metaverse environ- further explored. Only a fraction of the existing body of literature
ments for those with differences in physical abilities (e.g., rotational/ directly compares the educational use of the metaverse to other
spatial abilities, visual abilities or disabilities) regarding participation. simulation modalities. From the comparative studies that have been
Some additional implications of the metaverse concept include completed, the metaverse performed equally or better compared to
examining the interactivity and teamwork within these alternative various nonmetaverse education modalities. Much of the existing lit-
environments, as well as in the practice and assessment of acute erature is rooted in narratives, commentaries, and opinion pieces. To
care skills. In particular, the reproducibility of clinical scenarios could better characterize ideal use cases of the metaverse, there is a need
be applied in the setting of learner remediation, with metaverse sim- for more extensive empirical studies comparing asynchronous edu-
ulations being tailored to the unique needs of the learner. We also cational outcomes of different metaverse forms to traditional simu-
are excited about the prospect of what artificial intelligence (AI) and lation modalities within acute, emergency, and critical care medical
generative AI might bring to metaverse environments—especially education.
in the form of nonplayable characters/avatars with which human
participants may interact. The advancement of further haptic feed- AU T H O R C O N T R I B U T I O N S
back technologies may also assist in procedural-­related metaverse Justine Lau, Nicholas Dunn, and Marianna Qu led all elements of
applications. this study including design, focus group facilitation, analysis and
LAU et al. | 11 of 12

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