Medical students’ experiences of mixed-reality-based anatomy instruction in a non-cadaveric curriculum: a qualitative case study

Abstract

Background

Anatomy education requires students to understand complex three-dimensional relationships, yet traditional resources such as textbooks and static images may not fully support spatial learning for all learners, particularly in reduced- or non-cadaveric curricula. Mixed-reality technologies, including the HoloAnatomy application delivered through Microsoft HoloLens 2, have emerged as promising instructional supplements for anatomy education. However, qualitative research examining how students experience these tools within non-cadaveric curricula remains limited.

Objective

This study explored first-year medical students’ perceptions of HoloAnatomy mixed-reality-based anatomy instruction within a non-cadaveric osteopathic medical curriculum, with attention to perceived benefits, challenges, engagement, spatial understanding, and knowledge recall.

Methods

We conducted semi-structured interviews with 12 volunteer first-year medical students from an eligible cohort of 160 students at a single osteopathic medical school in California. All participants had completed nine months of required, non-cadaveric anatomy laboratory sessions that integrated faculty-led instruction, Microsoft PowerPoint slide presentations, and HoloAnatomy mixed-reality instruction delivered through Microsoft HoloLens 2. Interviews were audio-recorded, transcribed, de-identified, and returned to participants for verification. Data were analyzed in NVivo using Braun and Clarke’s six-phase framework for thematic analysis.

Results

Students perceived the mixed-reality sessions as especially valuable for three-dimensional visualization, spatial orientation, collaborative learning, and review of anatomical structures. However, they also identified important limitations, including technical instability, physical discomfort, limited anatomical realism, and restricted ability to manipulate the models. Overall, students viewed HoloAnatomy delivered through HoloLens 2 as a useful supplement to anatomy learning rather than a replacement for other instructional approaches.

Conclusions

The HoloAnatomy mixed-reality experience may enrich anatomy education most effectively when used as a supplementary instructional tool within a multimodal curriculum. Continued refinement of the technology, stronger technical infrastructure, and careful curricular integration may further enhance its perceived educational value in medical anatomy teaching.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12909-026-09881-6.

Introduction

Anatomy education has traditionally relied on cadaveric dissection, textbooks, and two-dimensional images as core modalities for learning human structure [1, 2]. Although cadaveric dissection remains one of the most established approaches for helping students understand three-dimensional anatomical relationships, it can be difficult for some schools to sustain because of the financial, infrastructural, safety, and logistical demands required to establish and maintain a traditional cadaveric laboratory [1, 2]. As a result, some medical schools have adopted reduced-cadaver or non-cadaveric curricula and have increasingly sought alternative instructional approaches to support anatomy learning [1].

In this context, immersive technologies such as the HoloAnatomy application delivered through Microsoft HoloLens 2 have attracted growing attention as potential tools for anatomy education, particularly for helping students visualize complex spatial relationships [3–5]. In this manuscript, augmented and mixed reality are used to describe technologies that overlay or anchor digital three-dimensional anatomical models within the learner’s physical environment, allowing interaction with virtual content while maintaining awareness of the real-world setting. Virtual reality, in contrast, refers to fully simulated digital environments in which anatomical models are viewed and manipulated within a computer-generated space that replaces the user’s view of the physical environment.

Prior research suggests that augmented reality, mixed reality, and related immersive technologies may support three-dimensional understanding, learner engagement, and student satisfaction in anatomy education. However, evidence regarding objective learning outcomes and long-term knowledge retention remains variable [4, 6–9]. Recent state-of-the-art updates further emphasize that the educational value of immersive technologies is shaped by several factors, including technological capability, instructional design, learning efficiency, implementation strategy, and the platform’s ability to represent anatomical complexity and structural diversity [10–12].

Despite growing interest in immersive anatomy technologies, few qualitative studies have examined how students experience HoloAnatomy-supported instruction through Microsoft HoloLens 2 in curricula where cadaveric dissection is not the primary instructional mode [3, 6]. This gap is important because students’ perceived educational value of these tools may be shaped by visualization, realism, usability, collaborative interaction, assessment alignment, and the broader curricular context in which the technology is implemented.

The present study was conducted at a California osteopathic medical school where first-year medical students learned anatomy in a curriculum that did not use cadaveric dissection as a formal instructional model. This setting was especially relevant because students encountered HoloAnatomy as part of a non-cadaveric anatomy curriculum rather than as an occasional supplement to cadaveric instruction.

This study was informed by Situated Learning Theory, which conceptualizes learning as shaped by participation, context, and social interaction [13, 14]. This framework sensitized the analysis to students’ descriptions of shared viewing, instructor guidance, collaborative meaning-making, and context-dependent engagement while learning anatomy through HoloLens 2 [3, 6, 13, 14].

The purpose of this qualitative case study was to examine first-year medical students’ perceptions of HoloAnatomy instruction delivered through Microsoft HoloLens 2 at a single osteopathic medical school in California. Specifically, the study explored the perceived benefits and challenges of using HoloLens 2 for anatomy learning, including its perceived influence on engagement, spatial understanding, and knowledge recall. The following research questions guided the study:

1. What benefits and challenges do students experience when using HoloAnatomy delivered through HoloLens 2 in anatomy learning?

2. How do students perceive HoloAnatomy delivered through HoloLens 2 as influencing engagement, spatial understanding, and knowledge recall?

Methods

Study design and setting

This study was conducted at California Health Sciences University College of Osteopathic Medicine, where the HoloAnatomy software platform, developed by Case Western Reserve University, was implemented using Microsoft HoloLens 2 headsets. We used a qualitative case study design to examine students’ experiences with mixed-reality-based anatomy instruction within this bounded educational setting (Fig. 1) [15, 16]. This approach was appropriate because the study aimed to explore learners’ perceptions, interpretations, and meaning-making within a specific curricular context, rather than to measure predefined outcomes quantitatively [15, 17]. Interview data from this bounded case were analyzed in NVivo version 13 (2020) using Braun and Clarke’s six-phase framework for thematic analysis.

Fig. 1.

Overview of the qualitative study framework. The figure summarizes the study process from volunteer recruitment from a defined eligible cohort through final thematic interpretation, including participant enrollment, semi-structured interviews, transcription and de-identification of interview data, iterative coding in NVivo, and theme development using Braun and Clarke’s thematic analysis approach

Curricular context and mixed-reality intervention

During year 1 at California Health Sciences University College of Osteopathic Medicine, anatomy is taught within an integrated, organ-system-based osteopathic medical curriculum using a non-cadaveric instructional model. Foundational anatomy content is delivered through faculty-led Interactive Learning Sessions (ILS), which are active laboratory-based sessions designed to develop spatial understanding, reinforce clinical correlations, and promote application of anatomical knowledge. These sessions complement other curricular formats, including team-based learning, designated study assignments, clinically integrated sessions, simulation-based activities, and other applied learning experiences.

Interactive Learning Sessions occur during scheduled laboratory time and integrate mixed-reality visualization with anatomical models, digital diagrams, histological images, and radiologic images. The mixed-reality component is incorporated as a mandatory, face-to-face, biweekly anatomy activity using HoloAnatomy software delivered through Microsoft HoloLens 2 devices. Across the nine-month OMS-I academic year, students complete 79 Interactive Learning Sessions, each lasting 110 min. Of these, 55 sessions incorporate HoloAnatomy-supported gross anatomy, three-dimensional spatial anatomy, surface anatomy, neurovascular or organ relationships, imaging-linked anatomy, or anatomy review. The remaining sessions primarily address histology, cytology, embryology-only content, pathology, physiology, laboratory medicine, or other non-HoloLens activities. The full curricular sequence and classification of HoloAnatomy-supported sessions are provided in Supplementary Table 1, with system-level counts summarized in Supplementary Table 2.

Each student is assigned an individual Microsoft HoloLens 2 device for use during on-campus sessions and self-directed study. During HoloAnatomy-supported sessions, faculty guide students through synchronized three-dimensional anatomical models, identify structures using a projected faculty view and pointer, and emphasize spatial relationships and clinically relevant correlations. Students view holographic anatomical structures in the classroom space while following faculty-guided explanations and discussing structures with peers. Guided instruction alternates with designated periods of self-directed exploration, during which students review three-dimensional models and apply concepts through board-style questions during class and self-study.

This structure positions HoloAnatomy as an adjunct to, rather than a replacement for, faculty-led anatomy instruction. Within the first-year active-learning laboratory framework, the mixed-reality intervention was intended to support foundational anatomy learning, three-dimensional spatial orientation, and clinically oriented anatomical reasoning across the organ-system curriculum. The supplementary materials document which ILS sessions used HoloAnatomy support. A representative image of the HoloAnatomy learning environment is provided in Supplementary Material 3.

Ethical considerations

This study was approved by the California Health Sciences University Institutional Review Board (IRB approval no. 2025-041). Before participation, all students received information about the study aims, procedures, voluntary nature of participation, and confidentiality protections and provided written informed consent.

Participants and recruitment

Participants were first-year medical students at California Health Sciences University College of Osteopathic Medicine who had used HoloAnatomy through Microsoft HoloLens 2 during the anatomy curriculum for approximately nine months. The eligible cohort consisted of 160 Class of 2028 students, all of whom had been exposed to the same curriculum. Because the study focused on learner experiences with mixed-reality anatomy instruction, the eligible population was purposively defined as students with direct experience using the technology.

Recruitment occurred through the Class of 2028 institutional email listserv and GroupMe class communication channels, following the workflow outlined in Fig. 1. Twelve students responded and volunteered to participate. No students who scheduled interviews subsequently declined participation, and no interviewed students were excluded from the final analysis. Sampling is therefore best characterized as volunteer sampling from a purposively defined, homogeneous cohort [18, 19].

Participant characteristics were collected to contextualize the sample and support interpretation of the findings in relation to learner background and prior exposure to immersive technologies (Table 1). Prior exposure to augmented or mixed reality was low among participants. Individual-level data on prior undergraduate anatomy coursework, cadaveric exposure, and other premedical anatomy experiences were not collected; these factors were therefore treated as unmeasured contextual variables.

Table 1.

Participant characteristics

Characteristic	Description
Final analytic sample	12 first-year medical students
Age range	24–28 years
Gender distribution	7 female, 5 male
Prior AR/VR experience	All participants reported low prior exposure
Prior anatomy/cadaveric experience	Not formally collected at participant level; treated as an unmeasured contextual variable

Participant characteristics are presented to contextualize the analytic sample

Prior AR/VR experience was self-reported and was generally described as low by all participants

AR/VR  Augmented reality/virtual reality

Given the focused research question, homogeneous participant group, and depth of the interview data, the sample was considered appropriate for an exploratory qualitative case study of this scope, consistent with information power and meaning saturation principles [20–22].

Data collection

Data were collected through semi-structured interviews designed to elicit students’ perceptions, experiences, and interpretations of learning with HoloLens 2 in anatomy instruction. The interview guide included open-ended prompts about perceived benefits, challenges, physical comfort, technical issues, collaboration, spatial understanding, review, recall, assessment preparation, and suggestions for improvement (Supplementary Material 1). All interviews were conducted virtually via Zoom by the student-researcher team, audio-recorded, transcribed verbatim, and de-identified before analysis. Verbatim transcripts were returned to participants through secure institutional email for optional accuracy review. Eight participants actively engaged in this member-checking process and confirmed that the transcripts reflected their perspectives without requesting substantive changes.

Researcher role and reflexivity

Primary qualitative interviews were conducted by the student co-authors, who were OMS-II students with a near-peer relationship to participants but held no responsibility for participant grading, evaluation, or course assessment. This near-peer position was intended to support rapport and conversational openness, while the absence of grading authority helped reduce perceived pressure to provide favorable responses. To further minimize potential power dynamics, the lead author/principal investigator and anatomy faculty did not conduct the live interviews.

JL, an EdD-trained qualitative researcher, designed the study and provided methodological oversight, including maintenance of the audit trail, review of analytic decisions, and verification of theme development. EK and SS conducted the interviews and contributed to initial coding and theme development. SG provided anatomy education context and critically reviewed the developing analysis. Interview transcripts were imported into NVivo 13 qualitative data analysis software, which was used to store, organize, code, and cross-reference text segments during independent and collaborative thematic analysis.

Reflexive memos were maintained throughout data processing to document investigator assumptions, analytic decisions, and potential sources of bias. Particular attention was given to assumptions related to the novelty of mixed-reality technology, expectations regarding its educational value, and the influence of the near-peer relationship between interviewers and participants. These reflexive practices supported transparency, helped bracket investigator preconceptions, and strengthened the credibility of the thematic analysis [23–25].

Data analysis and rigor

Interview transcripts were imported into NVivo 13 (2020) to support data organization, coding, and retrieval of text segments. Data were analyzed using Braun and Clarke’s six-phase framework for thematic analysis [26, 27]. The research team first became familiar with the dataset through repeated transcript reading and memo writing. EK and SS then generated initial codes line by line to identify meaningful text segments, recurring patterns, and early analytic insights.

Codes were compared across transcripts and grouped into candidate themes through iterative discussion among the analytic team. JL provided methodological oversight and reviewed analytic decisions, while SG contributed anatomy education context and helped assess the relevance of emerging interpretations to the curricular setting. Candidate themes were reviewed against the full dataset, refined through team discussion, defined, named, and synthesized into the final analytic narrative.

Several strategies were used to strengthen analytic rigor. The team maintained reflexive memos and an audit trail documenting coding decisions, theme development, and revisions during analysis. Divergent and negative cases were retained rather than excluded; for example, responses reflecting neutral engagement, discomfort with the device, limited perceived educational advantage, or concerns about anatomical realism were used to refine and qualify the final themes. This process improve a balanced interpretation of the data and helped ensure that the final themes reflected both positive and critical learner experiences.

Trustworthiness

Several established strategies supported trustworthiness. Sample adequacy was supported by the study’s focused aim, relatively homogeneous participant group, and detailed interview data [20–22]. Participants were invited to review their transcripts for accuracy, and eight participants completed this process [28]. The research team maintained an audit trail documenting recruitment, data management, coding decisions, theme refinement, and manuscript development to enhance transparency and dependability [29, 30]. Reflexive memoing was used throughout the study to make assumptions, expectations, and interpretive positions more explicit and to support confirmability [24, 31].

Results

Thematic analysis identified five interrelated themes describing students’ perceptions of the educational value and limitations of the HoloAnatomy mixed-reality experience, as conceptually outlined in Fig. 2. Across the dataset, students described HoloAnatomy as particularly useful for engagement, collaborative learning, three-dimensional visualization, and review of gross anatomical structures. At the same time, they identified important limitations, including technical instability, physical discomfort, limited anatomical realism, and restricted learner control. Taken together, the themes suggest that students perceived HoloAnatomy delivered through HoloLens 2 as educationally valuable primarily when it made anatomy more spatially understandable and when its use was supported by effective facilitation, learner control, and reliable implementation. Representative quotations illustrating each theme are provided in Table 2.

Fig. 2.

Thematic map of students’ perceptions of HoloAnatomy-based anatomy instruction. The figure illustrates the five interrelated themes identified through thematic analysis. Together, the themes suggest that students perceived HoloAnatomy delivered through HoloLens 2 as most educationally valuable when it supported spatial understanding, collaborative learning, and review of anatomical material, while its value remained shaped by realism, usability, learner control, and curricular integration

Table 2.

Themes, thematic summaries, and representative quotations

Theme	Thematic summary	Representative quotation
Students perceived that HoloLens increased engagement, but immersion was fragile	HoloLens was often experienced as engaging and motivating, but this benefit was vulnerable to discomfort and technical disruption.	“Sometimes if it wouldn’t work, it was kind of stressful seeing others’ HoloLens working while yours glitched or lagged, so you’re not getting the same smooth experience.”
The technology supported shared, instructor-guided learning	Students valued HoloLens as a collaborative and instructor-guided learning tool that allowed shared attention to anatomical structures.	“The fact that the professors could kind of point things out to us. We see exactly what they’re referring to … That collaborative thing was a part of HoloLens that I didn’t find anywhere else.”
Students reported that HoloLens made anatomy spatially intelligible but not fully realistic	Students found HoloLens useful for appreciating three-dimensional relationships, while also recognizing that the models lacked the realism of actual anatomy.	“What I really like about the HoloLens is you can actually see the 3D version of it—turn it around, look at it from the side, or from a view that isn’t in books or online.”
Students perceived benefits for review and recall, but not as a stand-alone learning solution	HoloLens was viewed as helpful for reinforcing and revisiting material, but not as sufficient on its own.	“Being able to interact with it helps me remember stuff a little bit more than just looking at a static image.”
Educational value depended on usability, learner control, and curricular integration	Students viewed HoloLens as most effective when used in a well-supported hybrid model with sufficient learner control and reliable implementation.	“I think a hybrid format would be ideal. Still have the lab, but use HoloLens as a supplement.”

Representative quotations are provided to illustrate the range and character of each theme identified through thematic analysis. Quotations are reproduced verbatim

Theme 1: students perceived that HoloLens increased engagement, but immersion was fragile

Students described varied responses to HoloLens, ranging from heightened engagement to frustration and relative neutrality. Many participants reported that the novelty and immersive quality of the technology made anatomy learning more interesting than static images or conventional study resources. Being able to rotate structures, zoom in, and examine anatomy in three dimensions was often experienced as exciting and attention-holding. For some students, this benefit extended beyond formal teaching sessions, particularly when HoloLens could be used independently for review before examinations. As one participant explained, “It is a lot more convenient than, say, going to a cadaver lab. … If I want to review something, I can just put it back on real fast and take a look at it.”

At the same time, the motivational value of HoloLens was not stable across all users or sessions. Several students described engagement as contingent on whether the device functioned smoothly and could be worn comfortably. Eye strain, headaches, nausea, and difficulty wearing the headset over glasses reduced the sense of immersion for some participants. Others described technical issues such as lagging, glitching, or difficulty positioning holograms as stressful and demotivating. One participant noted, “Sometimes if it wouldn’t work, it was kind of stressful seeing others’ HoloLens working while yours glitched or lagged, so you’re not getting the same smooth experience.” A smaller subset of students expressed more neutral views, suggesting that their engagement depended less on the device itself than on the quality of the teaching session in which it was used. Overall, students viewed HoloLens as capable of increasing engagement, but only when technological reliability and physical tolerability allowed immersion to be sustained.

Theme 2: the technology supported shared, instructor-guided learning

Students frequently described HoloLens as shaping the learning experience not only through visualization but also through collaboration and guided interaction. Many participants emphasized the value of shared viewing, particularly when instructors used pointer tools to direct attention to specific structures within the holographic environment. These moments were perceived as memorable because they synchronized what students were seeing with what faculty were explaining, helping them connect anatomical structures to classroom discussion in real time. One participant remarked, “The fact that the professors could kind of point things out to us. We see exactly what they’re referring to … That collaborative thing was a part of HoloLens that I didn’t find anywhere else.”

Participants also described HoloLens sessions as more interactive than solitary study with textbooks or two-dimensional images. Shared discussion with peers and instructors appeared to enhance attention and reinforce understanding, especially when students were oriented to the same anatomical view. However, these collaborative benefits were not experienced uniformly. Some students suggested that HoloLens worked better in smaller groups than in larger sessions, especially when devices malfunctioned or when visibility and coordination were inconsistent. Others felt that while the technology assisted class discussion, it did not directly mirror their course examinations. Because formal anatomy assessment was not conducted through live HoloLens identification tasks, some participants judged the value of HoloLens by how well the experience translated to written questions, static images, diagrams, and physical model-based assessment formats. Even so, the data suggest that a substantial part of the technology’s educational value lay in its ability to support coordinated, socially mediated learning rather than individual visualization alone.

Theme 3: students reported that HoloLens made anatomy spatially intelligible but not fully realistic

One of the clearest patterns in the data was that students viewed HoloLens as particularly helpful for understanding anatomical relationships in three dimensions. Participants repeatedly described the holograms as useful for appreciating orientation, scale, layering, and the relative positioning of structures. The ability to examine anatomy from multiple angles, isolate parts of interest, and in some instances feel as though they could “step inside” structures helped students form conceptual models that were difficult to achieve through two-dimensional resources alone. As one participant explained, “What I really like about the HoloLens is you can actually see the 3D version of it—turn it around, look at it from the side, or from a view that isn’t in books or online.” Another participant summarized this benefit succinctly: “I guess it has enhanced my spatial awareness.”

However, students drew a consistent distinction between spatial usefulness and anatomical realism. Although HoloLens supported conceptualization and orientation, many participants felt that the holograms were too simplified, too brightly colored, or too “cartoon-like” to approximate real anatomy closely. For some, this limited the technology’s usefulness for translating classroom learning into more realistic anatomical understanding. One participant commented, “Something about the cartoony way it was pictured out was difficult for me to wrap my head around.” Others emphasized that holograms lacked tactile qualities, natural anatomical variation, and the material complexity associated with cadaveric specimens. This distinction emerged as a central tension in the findings: students valued HoloLens for making anatomy spatially intelligible but did not consider that advantage equivalent to anatomical realism.

Theme 4: students perceived benefits for review and recall, but not as a stand-alone learning solution

Many students believed that HoloLens supported memory and review of anatomical structures. Participants often linked perceived recall benefits to interactivity, visual immersion, and the opportunity to revisit structures repeatedly in three dimensions. For some, the life-sized display and ability to examine internal layers helped make anatomical information more memorable than static textbook images. As one participant explained, “Being able to interact with it helps me remember stuff a little bit more than just looking at a static image.” Students who used HoloLens outside of class often described it as particularly helpful for pre-examination review.

At the same time, students did not generally describe HoloLens as sufficient on its own. A smaller group reported little clear advantage over conventional digital anatomy tools, and several participants suggested that HoloLens worked best when combined with other resources. In this sense, the perceived value of HoloLens for recall was typically framed as supplementary rather than comprehensive. Students viewed the device as something that could reinforce or revisit learning, rather than replace broader anatomy study. The findings therefore suggest that perceived memory support was closely tied to how HoloLens was integrated into students’ broader study practices rather than to the technology as a stand-alone instructional solution.

Theme 5: educational value depended on usability, learner control, and curricular integration

Students consistently linked the perceived educational effectiveness of HoloLens to the quality, reliability, and flexibility of its implementation. Restricted manipulation emerged as a prominent concern. Participants wanted greater control over rotation, zooming, layer removal, and direct interaction with structures. Teacher-controlled viewing modes were sometimes experienced as helpful for guided instruction, but at other times as limiting because they reduced learner autonomy. Technical barriers were also common. Because the curriculum used an established HoloAnatomy platform, student frustrations regarding lagging, glitching, and synchronization appeared to reflect local hardware constraints, network reliability, device ergonomics, and implementation conditions rather than only the underlying anatomy content. One participant noted that reliance on Wi-Fi could make the experience feel “kind of unfair” when connectivity was unstable.

Students also proposed a range of changes that they believed would improve educational effectiveness. Suggestions included a free-play mode with fuller manipulation, more natural and cadaver-like representations, improved ergonomics, stronger software reliability, and clearer technical support. Several participants additionally recommended pedagogical enhancements such as more practice time, advance materials, improved labeling, audio guidance, note-taking functions, and interactive quizzes embedded within the HoloLens environment. Most notably, students repeatedly recommended a hybrid instructional model in which HoloLens would supplement rather than replace traditional anatomy resources. One participant summarized this view directly: “I think a hybrid format would be ideal. Still have the lab, but use HoloLens as a supplement.” Another emphasized the unique value of actual specimens: “You’re able to distinguish by touching the actual specimen … the HoloLens doesn’t let you do that. And I think the only way to really get around that is to incorporate cadavers in some way.” Overall, students viewed the effectiveness of HoloLens as dependent not only on the technology itself, but also on how it was implemented, supported, and positioned within the curriculum.

Discussion

This qualitative case study examined first-year medical students’ perceptions of HoloAnatomy-based instruction within a non-cadaveric osteopathic medical curriculum. Overall, students described HoloAnatomy delivered through Microsoft HoloLens 2 as a valuable tool for three-dimensional visualization, spatial orientation, collaboration, and review. However, they also identified limitations related to technical instability, physical discomfort, restricted manipulation, and limited anatomical realism. Taken together, the findings suggest that students valued HoloAnatomy most for making spatial relationships visible and discussable, but did not view it as a sufficient replacement for other forms of anatomy learning. This pattern is consistent with the broader anatomy education literature, which generally positions immersive technologies as complementary to, rather than substitutes for, established instructional modalities [1, 32, 33].

A central finding was the distinction students made between spatial understanding and anatomical realism. Participants credited HoloAnatomy with helping them understand scale, orientation, layering, and relationships between structures in ways that were difficult to achieve through two-dimensional resources alone. This aligns with prior literature suggesting that augmented and mixed reality tools may be especially useful for spatial learning and three-dimensional conceptualization in anatomy education [32–36]. At the same time, students reported that the holograms lacked the texture, variability, and authenticity of real anatomy, often describing them as simplified or “cartoon-like.” This distinction suggests that from the students perspective, the educational value of HoloAnatomy may lie less in reproducing anatomical fidelity and more in helping learners organize anatomy conceptually and spatially. In other words, the technology appears to support how anatomy is mentally represented, even when it does not fully reproduce how anatomy materially appears. This interpretation is consistent with prior work suggesting that immersive visualization can support mental model construction and relational understanding of anatomical structures [37, 38].

The findings also highlight the social dimension of learning with HoloAnatomy. Students described some of the most meaningful learning moments as those involving shared viewing, instructor-guided pointing, and group discussion around common structures. Interpreted through Situated Learning Theory, HoloAnatomy functioned not only as a visualization tool but also as a medium for guided participation and shared meaning-making [13, 14]. Its value therefore depended not only on what individual students could see, but also on how that visual experience was coordinated with faculty explanation and peer interaction. This is important because discussions of immersive anatomy technology often emphasize visual novelty while underemphasizing the instructional and collaborative conditions that make the technology educationally productive. Emerging work on augmented and mixed reality in anatomy education similarly suggests that immersive visualization is strengthened when embedded in shared instructional activity rather than used as an isolated individual experience [3, 6].

Students also perceived HoloAnatomy as helpful for engagement and review, although these findings should be interpreted as subjective perceptions rather than objective learning outcomes. Many participants described the experience as memorable and valued the opportunity for convenient review outside the classroom. However, this study did not measure examination performance, long-term retention, or clinical transfer. Rather, it suggests that students perceived HoloAnatomy as a supportive cognitive scaffold when the technology was stable and accessible. This distinction is important because outcome-based studies of immersive anatomy tools have produced mixed findings, with some reporting improved retention or performance and others showing more modest or context-dependent benefits [4, 8, 9, 39].

The findings further suggest that the educational value of HoloAnatomy depends heavily on implementation. Technical instability, unreliable internet access, software limitations, physical discomfort, and restricted learner control were not minor inconveniences; they directly shaped how students judged the usefulness of the tool. In educational settings, even a theoretically strong technology may be perceived as having limited impact if learners cannot use it comfortably, manipulate structures freely, or rely on it functioning consistently. Students’ requests for free-play functionality, improved ergonomics, clearer labeling, stronger technical support, and embedded active-learning features indicate that usability and curricular design are inseparable from educational effectiveness. This interpretation is supported by prior studies suggesting that the impact of augmented and mixed reality in anatomy education depends not only on the technology itself, but also on delivery reliability, learner interaction, and instructional integration [5–7, 33]. Therefore, the key question is not simply whether HoloAnatomy can support anatomy learning, but under what conditions and with which design features it does so most effectively.

Finally, students consistently positioned HoloAnatomy as an adjunct rather than a replacement. Even within a non-cadaveric curriculum, participants described its most effective role as part of a broader, multimodal learning environment. HoloAnatomy was valued for spatial visualization, guided collaboration, and review, but not for tactile realism or full anatomical authenticity. The strongest curricular implication, therefore, is not that HoloAnatomy should replace traditional anatomy teaching, but that it may be most effective when integrated with other modalities that address the limitations of holographic representation. This conclusion is consistent with broader anatomy education literature supporting immersive technologies as targeted supplements within multimodal instructional designs rather than as stand-alone replacements [1, 32, 33, 36].

Limitations

Several limitations must be acknowledged. This study was conducted at a single osteopathic medical school with a small sample of twelve volunteering first-year students, which limits immediate transferability. Because participants were recruited from a purposively defined cohort and participation was voluntary, selection bias is possible; students with particularly positive or negative views of mixed-reality anatomy instruction may have been more likely to participate. Response bias is also possible, as participants may have framed their comments in ways they perceived as socially acceptable or aligned with institutional expectations. Participants’ prior undergraduate anatomy experiences, including prior exposure to cadaveric dissection or formal anatomy coursework, were not formally recorded. This is important because students with prior donor-based anatomy experience may evaluate realism and tactile limitations differently from students whose prior exposure was mostly textbook- or image-based. The study also mapped student perceptions rather than objective learning outcomes, long-term retention data, or direct clinical transfer. In addition, the peer relationship between interviewers and participants may have supported candor while also shaping disclosure or response framing, a dynamic previously described in peer interviewing research in medical education [40]. Finally, the findings reflect experiences with a specific software-hardware platform, namely HoloAnatomy software delivered through Microsoft HoloLens 2, at a particular time point and may change as immersive technologies continue to evolve.

Future research

Future research should build on these findings in several ways. Comparative work across cadaveric, hybrid, and non-cadaveric curricula may help clarify where mixed reality offers its greatest educational value. Longitudinal studies are needed to determine whether perceived gains in engagement, review, and spatial understanding translate into measurable improvements in retention or clinically relevant anatomical reasoning over time. Additional studies should compare immersive platforms, including HoloAnatomy delivered through Microsoft HoloLens 2 versus Meta Quest 3, to determine how differences in display quality, field of view, ergonomics, learner control, collaborative functionality, cost, accessibility, and technical reliability affect educational value [10, 11, 41–43]. Future platform development should also examine how immersive anatomy environments represent anatomical variation, structural diversity, and inclusive models of the human body, because these features may influence both perceived realism and educational relevance [12]. Such work would help move the field beyond broad enthusiasm for immersive technology toward a more precise understanding of how, when, and why these tools contribute meaningfully to anatomy education [16, 33, 41].

Conclusions

This study provides qualitative insight into first-year medical students’ perceptions of HoloAnatomy software delivered through Microsoft HoloLens 2 within a curriculum in which cadaveric anatomy was not part of the formal instructional model. Students perceived the platform as beneficial for engagement, collaboration, spatial understanding, and review of anatomy content, while also identifying limitations related to anatomical realism, comfort, technical reliability, learner control, and perceived transfer to assessment performance. Overall, the findings suggest that students viewed HoloAnatomy as most useful when used as a supplementary instructional tool within a thoughtfully designed multimodal anatomy curriculum. Continued refinement of the technology, stronger technical infrastructure, and careful curricular integration may further enhance its perceived educational value in medical anatomy teaching.

Authors’ contributions

J.L, S.S, E.K, and S.S prepared manuscript and all figures and main manuscript text.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The qualitative datasets generated and analyzed during the current study are not publicly available due to participant privacy. The data are available from the corresponding author on reasonable request. The authors would like to thank the 12 medical students who participated in the semi structured interviews for this study. Due to the small size and potentially identifiable nature of this participant group, the qualitative datasets are not hosted in a public repository to ensure the prioritization of participant confidentiality.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the ethical principles outlined in the Belmont Report. Ethical approval was granted by the California Health Sciences University Institutional Review Board (IRB approval no. 2025-041). Informed consent was obtained from all individual participants included in the study.

Consent for publication

Written consent for publication was obtained for the identifiable individuals shown in the supplementary image. Institutional permission to use the photograph was also obtained from California Health Sciences University.

Competing interests

The authors declare no competing interests.