1. 10
Research DOI: 10.1308/rcsbull.2015.10
Technology in health:
wearables, augmented
reality and virtual reality
If the app fits, wear it.
Oliver Trampleasure JOB TITLE AND AFFILIATION
Ali Jawad JOB TITLE AND AFFILIATION
Victoria Buckle JOB TITLE AND AFFILIATION
Shafi Ahmed JOB TITLE AND AFFILIATION
T
echnology has permeated almost every
facet of life – aiding us in communi-
cation, removing the need to perform
menial tasks and facilitating greater achieve-
ments. In the past 50 years surgery has seen
the introduction of interventional radiology,
laparoscopic procedures and various other
applications. As consumers embrace tech-
nology that they can carry around with them
regularly, there are opportunities to improve
health monitoring. Yet medical students
and surgical trainees share a broadly similar
experience with their predecessors of 100
years ago. An increase in global need and a
training infrastructure at capacity are two
important factors contributing to a shortage
of surgeons, leaving 4.8 billion without
adequate cover.1
There has been a sharp rise in the creation
and use of health apps designed for the mo-
bile platform, which is largely market-led and
without sound clinical oversight or evidence.
More recently ‘smartwatches’ and other
wearable devices have entered the consumer
market, gaining momentum with the public
and providing new opportunities to easily
monitor health or encourage adherence to
treatment protocols.
Education is appropriately delivered in a
tried-and-tested manner and, although this
has clear benefits, there is increasing strain
on surgical education at both undergraduate
and postgraduate levels. The use of smart
wearables and augmented reality is showing
great promise in its capacity to effectively
transfer a traditional educational programme
into a digital format, thereby allowing
high-quality education to be delivered to
large numbers of students across the globe
and, in time, reducing the shortfall.

2. 11
Research
WEARABLE TECHNOLOGY
As technology decreases in size, it becomes
reasonable to expect patients to keep a phone
or a similar device with them. In recent
years there has been a sharp increase in the
number of wearable devices, such as Sam-
sung Gear Watches, Apple Watch, heart rate
monitors, etc.
Health applications on mobiles have
become incredibly popular, allowing patients
an easy way of tracking various elements of
their health. Predominantly independent
of clinical oversight, there have been some
inroads into using such applications to share
almost real-time information from a patient
with their clinician or provide accurate
tracking of observations. Gamification is
often used within these applications, but
has been shown to lack adequate adherence
to professional guidelines or industry
standards2
and the vast majority lack an
appropriate evidence base.3
Smartwatches
provide an opportunity to regularly track
patient observations without having an
impact on patients’ lives, and clinicians can
also use them as a multi-purpose device in
the community to accurately quantify signs
such as tremors.4
In the educational sector there are a
number of projects attempting to deliver
traditional question banks online, and gam-
ification is already in use during face-to-face
teaching.5,6
Touch Surgery is an application
that allows users to learn the steps of a
surgical procedure by selecting the correct
instrument and then following a series of
finger movements on the screen – this is
the most advanced gamification project
that benefits from a wide reach owing to its
smartphone compatibility. Educationally, the
project effectively familiarises trainees with
the steps of an operation,7
but fails to provide
a high-fidelity environment that could
replace the face-to-face element of training.
Wearable eyewear, such as Google Glass,
has been used in various industries as a tool
to perform a hands-free checklist, including
in operating theatres.8
The marked improve-
ment seen with the adoption of the WHO
Checklist suggests a device that requires
adherence to a check–response protocol
would likely improve outcomes further.
Google Glass allows this without hindrance
to the surgeon, while facilitating automated
recording. Reporting of checklists into the
patient record – or a theoretical ‘black-box’
recording of surgeries – could dramatically
simplify investigations into culpability,
which in turn could reduce the financial pen-
alties or insurance premiums for organisa-
tions. Further uses of Google Glass currently
being investigated include remote evaluation
of organs for transplant9
and telementoring.
Although initially experiments have been
successful in undergraduate education,10
oth-
er preliminary studies have found that the
video quality is inadequate for some post-
graduate surgical mentoring.11
Teletoxicology
using Google Glass has preliminarily been
shown to be useful and have a direct impact
on clinical treatment,12
whereas devices with
higher-quality video have been successfully
used for neurosurgical telementoring.13
Point-of-view videos from smartglasses
are facilitating better understanding of
clinical and communication skills in un-
dergraduate students. Virtual Medics have
created a communication and reflection
tool that, in preliminary testing, students
have found beneficial – primarily owing to
the ability to view their actions from the
patient’s point of view.14
Currently under
investigation are uses within postgraduate
trauma training by London’s Air Ambulance,
remote suturing teaching, and combining
point-of-view videos with interactive content
to create virtual cases.15
Point-of-view videos
are well-received and can add value,16,17
but
they require a supportive framework to
ensure appropriate impact and do not add
value in all cases.18
AUGMENTED REALITY
The potential of augmented reality is con-
siderable but the practical applications are
yet to be incorporated into the day-to-day
healthcare ecosystem. Various companies
have worked with smartphones (combining
the use of the camera and screen to provide

3. 12
Research DOI: 10.1308/rcsbull.2015.12
a handheld augmentation), but the sharp
increase in the availability of smartglasses
allows for a hands-free implementation that
will be more practical to the clinician.
Common uses of augmented reality
involve added interaction or animation to
traditionally static material – for instance, a
three-dimensional heart model that appears
when viewing an anatomy station covering
cardiovascular material. Interactivity has
a commonly accepted benefit to digital
education,19,20
but the implementation of
augmented reality is currently limited
by a development cycle that is long when
compared with traditional material. These
implementations are more appropriate for
mobile devices as the hardware requirements
exceed those of most smartglasses, although
this should change soon with the next
generation of devices.
Clinical applications of smartglasses are
still limited, but the potential has been publi-
cised with proof-of-concept videos and some
commercial clinical implementations from
various providers.21,22,23
Practical deployment
of systems that allow for voice commands to
bring up the latest patient observations and
locations, or a notification warning the clini-
cian about a change in a patient’s condition,
are yet to be fully integrated throughout a
hospital site. There is a considerable difficul-
ty in creating a system that is able to cope
with the variation between different sites in
patient record system, patient tracking sys-
tem, theatre bookings, observation machines
and the needs of different specialties or staff.
Progress will be considerably easier once
industry standards are implemented and all
devices are replaced, likely through natural
wastage than wholesale upgrades.
Education has adopted the use of aug-
mented eyewear more readily, likely owing
to the less complicated user needs and the
relative lack of repercussions. In 2014 Virtual
Medics performed the first augmented
reality teaching session using Google Glass
– Shafi Ahmed performed a right hemi-
colectomy to a worldwide audience of more
than 13,000 people. The surgical field was
streamed live while students’ questions were
displayed on the screen in his line of sight.
This was received well by students – 65%
preferring this to being unscrubbed in thea-
tre, while 70% preferred being scrubbed.10
Increased interactivity between educator
and student provides the opportunity to
deliver a comprehensive digital education to
large numbers of students anywhere in the
world. High-quality digital education has
been shown to equal traditional education
methods,24
and in developed educational
settings it could add value.25,26
Rural areas
with educational structures in their infancy
– or lacking local skillsets – could benefit
from digital education and telementoring
as a solution to a training gap that hinders
retention.27,28
VIRTUAL REALITY
Virtual reality is a modality that has
the greatest potential, but also holds the
greatest technical challenges. Gamification
of a snowball fight to provide relief to burns
victims and VR’s uses in physiotherapy have
shown measurable improvements in clinical
outcomes,29
although costs of implemen-
tation may not be worthwhile.30
The aim
within surgical training should be to create
a high-fidelity virtual environment that a
trainee could have realistic tactile interac-
tion with in real-time.
Creating an accurate virtual environment
has both software and hardware challenges.
Various companies have created accurate
macroscopic representations of the internal
anatomy for specific uses in surgical trainers,
but the physiological effects of moving or
cutting anatomical structures have not been
modelled within a ‘whole-body’ simulation.
Hardware exists that would manage the level
of computation required but the affordability
of the final training device would likely
hinder adoption.
Haptic feedback is well established in
situations where a surgeon interacts with
laparoscopic instruments or robotics but
the benefit of virtual reality is question-
able in these fields, owing to the static
camera-controlled point of view – open
surgical procedures would be the area in
which virtual reality could have considerable
impact. Developing a ‘glove’ for a consumer
to receive haptic feedback on virtual tactile
interactions is underway with initial suc-
cess,31,32
but a glove of suitable sensitivity for
surgical training holds greater challenges.
Individual hand movements and pressure
points are in development but mimicking the
complexity of the human hand by combining
these will be challenging – although with
time a more holistic haptic experience will
be possible.
Technical challenges limit the fidelity of
the virtual environment and considerable
investment is required to match the realism
of airline or laparoscopic simulators – it is
easier to build a complete cockpit than allow
pilots to interact virtually with their controls.
There are promising projects that are able to
digitally insert your hand movements into a
virtual environment33
and others specialising
in accurate virtual reconstruction of an
environment34
that could provide education-
al benefits in other fields while supporting
further development of surgical applications.
CONCLUSIONS
Wearable technology will continue to see
wider adoption by the consumer market and
likely enter the clinical environment to aid
with real-time observations. Augmented re-
the potential
for the pooling
of experience
and delivery
of high-quality
education to
remote areas is
considerable

4. 13
ResearchDOI: 10.1308/rcsbull.2015.13
ality provides exciting opportunities for use
by clinicians; impro ving adherence to check-
lists is a reality now and can directly improve
outcomes. Realistic implementations in the
near future would include improvements to
the communication between staff in a clini-
cal setting, teleconsultation opportunities to
bring the specialist to the community patient
and eventually live overlays of imaging
during surgical procedures. Virtual reality
will continue to progress in line with the
current increase in interest and investment –
leading to development of clinical-use cases
in time and likely building upon progress
from commercial consumer products by the
entertainment industry.
As a profession we have some responsi-
bility to embrace this wider digitalisation
to ensure that the consumer is receiving
accurate and evidence-based advice to
maximise clinical outcomes. The rise in
health-app usage is a demonstration of public
interest and provides an opportunity for
the proactive clinician. On the global stage
technology is allowing a level of interactivity
between educators and students that has
previously not been possible – the potential
for the pooling of experience and delivery
of high-quality education to remote areas is
considerable. Global digital health education
with interactivity facilitated by augment-
ed-reality smartglasses currently provides
the most effective balance between feasibility
and immediate impact. With coordination of
a global faculty, the surgical profession could
embrace this technology as one element
of the solution to the worldwide shortage,
rather than as an educational luxury.
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