When I say … extended reality

Technology-enhanced learning has transformed many aspects of health professions education. From early skills labs to high-fidelity mannequins, simulation-based medical education has progressively incorporated tools that allow learners to practice in safe, controlled environments. More recently, advances in computing, visualization and wearable devices have enabled immersive simulations that merge physical and digital worlds.1 These innovations are not simply about replacing traditional methods but about broadening the possibilities of medical training by expanding where, how and with whom learning can occur, especially when access to real patients or procedures is limited. The term extended reality (XR) is an umbrella encompassing virtual reality (VR), augmented reality (AR) and mixed reality (MR)—used individually or in combination.2 VR fully immerses users in a computer-generated environment, blocking out the real world by engaging multiple senses such as sight, sound, and touch.3 AR overlays digital information, such as images, animations, or data, onto the real world, enabling simultaneous interaction with both.4 It can project anatomical structures, procedural guidance, or patient data directly into the learner's environment, enhancing spatial understanding without removing the user from the physical setting. MR goes a step further, allowing physical and digital elements to interact in real time.5 Learners might manipulate holographic anatomical structures while using tangible instruments, with both virtual and real objects responding to each other's movements. Imagine a training room with a real stretcher, a holographic patient model, and a holographic defibrillator, with the learner and the virtual tools responding to each other's movements. MR enables collaborative, interactive experiences, such as a team examining a shared holographic patient from multiple perspectives. These modalities enable high-dimensional learning experiences: immersive, interactive, and often emotionally resonant. More importantly, XR extends not only visual experience, but also allows learners to feel ‘there’ even when they are not physically present. It can simulate clinical complexity, replicate social dynamics, or reproduce procedural nuance without risk and allows learners to experience perspectives that would otherwise be inaccessible.6 XR's immersive nature also engages emotional and social aspects of learning. That has implications for design choices and cultural assumptions. For example, what bodies are represented in holograms? Whose language is programmed into virtual patients? Who gets to decide what is ‘realistic’ or ‘immersive’? As XR becomes more embedded in clinical training, these questions are not peripheral; they are central. Without intentionality, XR risks reproducing bias, amplifying inequity, and obscuring rather than illuminating power relations within medical education. In practice, XR has demonstrated value across a range of educational settings, from undergraduate anatomy and procedural training to continuing professional development. By recreating elements of the face-to-face learning environment, such as realistic spatial cues, interactive feedback, and opportunities for repeated practice, XR can support the development of technical and non-technical skills, enhance spatial understanding, and foster learner engagement and satisfaction.6 XR is particularly valuable for skills training and maintenance, supporting both procedural competence and non-technical skills such as teamwork, communication, and situational awareness.7 For example, a review demonstrated that the use of different technologies, including XR, has increased learners' technical skill, communication, and team coordination.8 Imagine students observing cardiac catheterization from within the heart. Trainees can rehearse difficult conversations with virtual patients who respond in real time to verbal and non-verbal cues. Residents can overlay patient-specific imaging onto a real patient before a procedure. A learner practicing in a virtual emergency room may not just rehearse the correct steps for resuscitation; they may feel the urgency, make decisions under pressure, and reflect on their own emotional responses.9 Importantly, it should be seen as a complement to skilled facilitation, structured feedback, and the relational depth of human educators. Beyond technical skill, XR engages the affective and social dimensions of learning, fostering empathy, decision-making under pressure, and reflection on one's own responses.10 It also supports the development of clinical reasoning, adaptive expertise, and interprofessional collaboration by situating learners in realistic, context-rich environments where they must integrate knowledge, skills, and judgement.11 XR can facilitate deliberate practice with immediate feedback, encourage self-directed exploration of clinical scenarios, and promote the transfer of learning from simulated to real-world settings. For example, research in clinical and social neuroscience has also demonstrated that XR can amplify empathy, foster psychological presence, and even help patients and clinicians experience embodied perspectives outside their own.10 But XR is not a panacea. For successful implementation, XR must be anchored in well-defined learning objectives and sound instructional design. Technologies deployed without alignment to educational goals risk becoming distractions, visually impressive but pedagogically hollow. Overly gamified or uncritical uses of XR can turn simulation into spectacle and also exclude learners with disabilities, motion sensitivity, or limited access to equipment. While learners often report increased engagement using VR, some also experience disorientation or simulator sickness that limits session duration.12 This is especially concerning for students with vestibular disorders who were unable to fully participate in head-mounted XR simulations, underscoring the importance of offering alternative access routes.13 There are also risks in conflating innovation with improvement. While XR has clear potential, it should not be seen as a replacement for skilled facilitation, structured feedback, or the relational depth of human educators. XR can complement, but not substitute, the reflective, dialogic processes that underpin transformative learning. Its effectiveness depends on how it is used, for whom, and toward what ends. Institutions may face significant upfront and ongoing expenses. A single head-mounted display can cost hundreds to thousands of dollars, often requiring additional licenses and software updates.7 Additionally, XR requires technical support staff, device maintenance, and integration and/or expansion of existing information technology infrastructure. However, XR can also improve access and cost-effectiveness by reducing the need for travel, specialized facilities, high-fidelity mannequins or cadavers, and by enabling repeatable, self-paced practice.6 So, when I say extended reality, we do not just mean ‘more reality.’ We mean new realities, carefully designed to reimagine the spaces, interactions, and possibilities of health professions education. XR challenges traditional spatial and temporal constraints. It enables immersive rehearsal, contextualized learning, and embodied empathy. But it also requires critical engagement. Not just with what it adds, but with what it displaces. Not only what it makes possible, but also what it risks rendering invisible. Customizable avatars allow representation of diverse races, genders, and cultural backgrounds, supporting culturally sensitive learning. Captioning and audio description features can increase accessibility for learners with hearing or visual impairments. Adjustable settings for sensory load, such as reducing motion intensity or brightness, can help learners prone to simulator sickness. Designing for inclusivity not only broadens participation but also models the cultural competence expected in clinical practice. XR also needs to be understood as one component of the broader digital health education ecosystem. For example, AI-based tutoring systems offer adaptive feedback in ways XR currently does not, while mobile learning apps provide flexible, low-cost access to microlearning resources. XR may also support the training of healthcare professionals in remote areas by enabling immersive participation without the need for travel, reducing geographic inequities in access to advanced training. In this sense, XR complements other innovations such as telesimulation, which connects distributed learners to live simulation centers, and traditional mannequin-based simulation, which still provides irreplaceable tactile and psychomotor practice. Looking ahead, the integration of AI with XR may create adaptive, personalized learning environments that adjust scenarios in real time to a learner's performance. For example, a virtual patient could not only respond realistically to communication but also adapt its complexity based on the learner's demonstrated skill level. This convergence of XR and AI holds promise for scalable, individualized medical education, particularly in remote or resource-limited settings. Situating XR alongside these other technologies helps educators make deliberate choices about when immersion truly adds value. Ultimately, extended reality is not only about enhancing the fidelity of our simulations, but also about broadening the horizons of our imagination. To use XR wisely in health professions education is to design not only for presence, but for perspective, not only for immersion, but for insight. If we can hold onto that vision, XR might indeed extend more than reality; it might extend our capacity to teach, learn, and care. We declare that none of the authors have any conflict of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.