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Keywords:

  • Computer assisted instruction;
  • medical education;
  • microscopy;
  • pathology

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. MATERIAL AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Background and aims: Laboratory education on pathology for undergraduate medical student has traditionally been conducted by using analog microscopy on glass slides with standard pathological cases. Virtual microscopy was recently introduced as an alternative to conventional microscopy, but there are issues surrounding its in the educational context. Methods: We introduced virtual microscopy in a pathology laboratory class, as an addition to analog microscopy. One hundred and sixty first year-medical students were surveyed using preformed or free questions after use of both virtual and conventional microscopy. Results: Many advantages were noticed and students strongly favored virtual microscopy. Most students reported that use of the virtual microscope can significantly improve performance and learning efficiency. The three most significant advantages of virtual microscopy were freedom from optical stress, better image quality and time saving. Less advantageous points were inconvenient slide selection, less vivid feeling of examining and that the technique was not useful for finding artifacts such as foreign bodies. Although they could save time by using virtual microscopy, more students remained longer in the laboratory room when they used virtual microscopy. Conclusion: Virtual microscopy was accepted by students as an excellent tool to facilitate learning. We believe that virtual microscope is an excellent tool for pathology laboratory education.


INTRODUCTION

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. MATERIAL AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Pathology education for the medical student is an important step in bridging basic science and clinical medicine1,2. Laboratory sessions for pathology education consist of conventional microscopy of glass slides of tissue samples of typical diseases, animal experiments, laboratory practices for the immunologic and molecular diagnosis and some discussion sessions covering basic and applied pathology practices. Conventional microscopy of glass slides of tissue samples is the most important and classical method in laboratory education. However, conventional microscopy of glass slides is time consuming and sometimes boring, not only for the student but also for the teaching faculty. The quantity and diversity of area to be taught in pathology requires more efficient ways of instructing students in this classical field of medical education3,4.

Virtual microscopy is a method of viewing highly magnified digital images of tissue sections, stored in a multi-resolution file format5. This method was introduced as a tool for telepathology6 or as an alternative means of data storage. Development of broadband technology and technology for compressing files and networking made early virtual microscopy into a practical technology.

There are several modifications to virtual microscopy technology that make it practical for educational purposes.6–10 Virtual microscopy files can be downloaded to each faculty computer or accessed through a web browser. The files can simulate glass slides under a real microscope.

MATERIAL AND METHODS

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. MATERIAL AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Students and online survey for this study

One hundred and sixty first year-medical students were surveyed for their response on eleven key questions after use of virtual and conventional microscopy. Students had already been taught to use analog microscopy during their histology course. Every student had a personal computer or notebook computer. The medical campus, including laboratory rooms, was equipped with wireless network and local area network facilities.

The survey was carried out online after the semester. Eleven questions were asked and free answer opinions were available. Simple comparison of their responses was carried out.

Virtual microscopic slide acquisition

We used Aperio's ScanScope System11 (Aperio Technologies, Vista, CA, USA) and Olyvia of Olympus Soft Imaging Solutions12 (Olympus Corporation, Tokyo, Japan) which comprise scanner and management software systems. The integrated systems deliver digital slide creation, viewing, management, and analysis capabilities for digital pathology applications.

The scanner system captured multiple small regions of a microscope slide, using a traditional charged-couple device camera. Image tiles were then aligned to create a large contiguous digital image (mosaic) of an entire slide. Line scanning is the key methodology to image tiling. File sizes varied from 0.14 GB (in gastrofiberscopic biopsies) to 12.3 GB for larger tissue blocks.

The Digital Slide Information Management Software – Scanscope and Olyvia – is integrated with the scanner system and delivers viewing, editing, annotating, sharing, workflow management, and analytical capabilities.

Virtual microscopy operation

The virtual microscopy files were uploaded to our computer system and students downloaded their files to their personal computers before the laboratory session. To reduce the downloading time, CD-ROM was available as an alternative to the online network. Students observed slide files using the digital slide information management software through their personal computers. Glass slides were also supplied and students were free to use either the analogue or digital method. One professor and two assistant teachers assisted students and respond their queries.

RESULTS

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. MATERIAL AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

One hundred and forty two students (88.8%), of a possible 160 who participated in the laboratory class using virtual microscopy, responded to the questionnaire. Responses on eleven preformed questions from students are summarized in Table 1.

Table 1.  Comparison of student responses to eleven queries on preference between virtual and conventional microscopy
QuestionAnswer (n= 142)
Traditional MicroscopyAbout SameVirtual Microscopy
Which was less stressful to eyes?315124
Which had better image quality?315124
Which took less time to find lesions?89125
Which was better for searching lesions?115126
Which was better for changing magnitude?115125
Which was easier to use?1014118
Which had better focus?1210120
Which was better for group discussion?1216114
Which was easier to switch to another slide?1416112
Which was more enjoyable?232890
Which was better to find artifacts?204675

Virtual and analog microscope operating skills

Students considered themselves to be skillful in conventional microscopy operating techniques. They also felt comfortable using the virtual microscopy system, although it was the fist class in which they had used it. Therefore, students did not report experiencing difficulty using either type of microscopy.

Efficiency of virtual microscopy

Virtual microscopy was the more efficient tool for 78.0% of students. Analog microscopy way considered more efficient by 5.7% of students, and 16.3% students were neutral.

Time saving in the laboratory

Virtual microscopy saved time in the laboratory for 20% of students, while 33% considered conventional microscopy to be less time consuming. The remaining 36% of students were neutral on time saved between the methods. It should be noted that the number of slides students were required to examine differed between the two groups (see Discussion).

An advantage of virtual microscopy noted by students was the freedom it allowed them to determine where and when they could study. However, 60% of students preferred regular laboratory time in which to study, allowing them to enjoy the guidance of teaching staff and the group discussion.

Preference of students

Most students preferred virtual microscopy to conventional microscope, with 96% the method to their junior classmates as a laboratory tool in pathology.

Other advantages of virtual microscopy

The three most significant advantages of virtual microscopy were freedom from optical stress, better image quality and time saving. Less advantageous points were inconvenient slide selection, less vivid feeling of examining and that the technique was not useful for finding artifacts such as foreign bodies. More importantly, however, most students reported that use of the virtual microscope significantly improve their performance and learning efficiency.

DISCUSSION

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. MATERIAL AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Microscopic examination of tissue specimens is an important modality for medical education in the pathology laboratory which also includes human diagnostic pathology, the animal experiment, the genomic or immunologic laboratory, and clinical case discussion1,2. The traditional examination of glass slides using analog microscopy requires access to high quality microscopes, a number of sets of glass slides for distribution and a number of teaching staff for individual assistance and education6. Further, training students to use light microscopes is time consuming, difficult and not cost-effective as only a small number will go on to be professional pathologists requiring these skills7.

Using information technology in the pathology laboratory is an alternative to classical medical education, but institutions have hesitated to introduce virtual microscopy. We studied staff and student compliance with the virtual microscopy system. We also evaluated how the current use of information technology in education affects students' acceptance of these technologies, because the success of computer aided education is closely related to student attitude towards new technologies.

In Korea, there were at least four medical schools who had adopted, or who were in the process of adopting, virtual microscopy for pathology education in 2006. Kwandong University was the first to adopt the system in 2004, Ajou University, Korea University and Seoul National University adopted the system from 200613. This report does not cover the experiences of all those universities, but rather evaluates the effectiveness of the virtual microscopy system from the instructors' and students' perspectives.

When using the virtual microscopy system, instructors are able to hand out exactly the same slide file to all students. It is costly to make a sufficient number of glass slides with a variety of pathologies, and they are fragile and difficult to maintain. Instructors cannot guarantee the same quality of slide samples for hundreds of students. With the virtual microscopy system, only one good sample is necessary to make a virtual slide file; this same file can be distributed to all students, without degrading the slide, saving instructor's time and reducing costs.

From the students' point of view, the most important aspect of virtual microscopy is its effect on the efficiency on their learning. While we do not have a universal criterion to quantify learning efficacy, several line of evidence show better results for students and faculties using virtual microscopy. Krippendorf et al.14 analyzed students' test scores to compare the efficiency of virtual microscopy and traditional microscopy. Test scores of the students in 2004, who used the virtual microscopy, were compared with the scores of students in 2000–2003, who used traditional microscopy. The authors concluded that virtual microscopy was more efficient, however their evidence was weak; three midterm exams were analyzed but in only one midterm did the two groups show a statistically significant difference in results. Confounding factors for Krippendorf et al. may have been the degree of difficulty of the exams analyzed (which had to differ from year to year, but be of a constant degree of difficulty, which is complex to achieve), and the variable abilities of each year group of students.

There are several controversial responses in our study. More students replied that virtual microscopy laboratory sessions took more time, but that their time could be more efficiently used virtual microscopy. There was a consensus that viewing skills for either method of microscopy were not problem for students. An unexpected response was that virtual images are considered to have better resolution than analog microscopy (Table 1). This response indicates that glass slides for analog microscopy were not in good condition, having been used for several years.

There are some points which fall short of the authors' initial expectation. One unexpected response was that the group discussion of virtual microscopy got fewer positive responses. Because virtual images can be viewed via large computer screens, the authors expected group discussions to have been facilitated by the display. This may be because the Korean students surveyed were not accustomed to discussing their finding with colleagues. If the instructors assigned more group discussions, students may have taken advantage of the large screen display available when using virtual microscopy.

Another unexpected response was that students found virtual microscopy not much easier to switch to another slide. This is despite the fact that the computer multi-tasking system has the benefit of file selection and switching. The poor responses were mainly the result of the current software not being stable enough, or computer networks not being fast enough to process high-resolution image data. However, computer technology is continuously developing and the software and hardware problems experienced here will likely be solved in the near future.

In general, students preferred virtual microscopy to traditional microscopy. It is expected in the future that clinicians will need to be skillful in handling digital images for their research and collaboration with pathologists. Thus, pathologic histology education will be increasingly prioritizing virtual microscopy over traditional microscopy.

REFERENCES

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. MATERIAL AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES