Evaluation of usage of virtual microscopy for the study of histology in the medical,dental, and veterinary undergraduate programs of a UK University

This article describes the introduction of a virtual microscope (VM) that has allowed preclinical histology teaching to be fashioned to better suit the needs of approximately 900 undergraduate students per year studying medicine, dentistry, or veterinary science at the University of Bristol, United Kingdom. Features of the VM implementation include: (1) the facility for students and teachers to make annotations on the digital slides; (2) in‐house development of VM‐based quizzes that are used for both formative and summative assessments; (3) archiving of teaching materials generated each year, enabling students to access their personalized learning resources throughout their programs; and (4) retention of light microscopy capability alongside the VM. Student feedback on the VM is particularly positive about its ease of use, the value of the annotation tool, the quizzes, and the accessibility of all components off‐campus. Analysis of login data indicates considerable, although variable, use of the VM by students outside timetabled teaching. The median number of annual logins per student account for every course exceeded the number of timetabled histology classes for that course (1.6–3.5 times). The total number of annual student logins across all cohorts increased from approximately 9,000 in the year 2007–2008 to 22,000 in the year 2010–2011. The implementation of the VM has improved teaching and learning in practical classes within the histology laboratory and facilitated consolidation and revision of material outside the laboratory. Discussion is provided of some novel strategies that capitalize on the benefits of introducing a VM, as well as strategies adopted to overcome some potential challenges. Anat Sci Educ 7: 389–398. © 2013 American Association of Anatomists.     

Evaluation of virtual microscopy in medical histology teaching

Histology stands as a major discipline in the life science curricula, and the practice of teaching it is based on theoretical didactic strategies along with practical training. Traditionally, students achieve practical competence in this subject by learning optical microscopy. Today, students can use newer information and communication technologies in the study of digital microscopic images. A virtual microscopy program was recently introduced at Ghent University. Since little empirical evidence is available concerning the impact of virtual microscopy (VM) versus optical microscopy (OM) on the acquisition of histology knowledge, this study was set up in the Faculty of Medicine and Health Sciences. A pretest‐post test and cross‐over design was adopted. In the first phase, the experiment yielded two groups in a total population of 199 students, Group 1 performing the practical sessions with OM versus Group 2 performing the same sessions with VM. In the second phase, the research subjects switched conditions. The prior knowledge level of all research subjects was assessed with a pretest. Knowledge acquisition was measured with a post test after each phase (T1 and T2). Analysis of covariance was carried out to study the differential gain in knowledge at T1 and T2, considering the possible differences in prior knowledge at the start of the study. The results pointed to non‐significant differences at T1 and at T2. This supports the assumption that the acquisition of the histology knowledge is independent of the microscopy representation mode (VM versus OM) of the learning material. The conclusion that VM is equivalent to OM offers new directions in view of ongoing innovations in medical education technology. Anat Sci Educ 6: 307–315. © 2013 American Association of Anatomists.     

Development and evaluation of an interactive electronic laboratory manual for cooperative learning of medical histology

This article describes the development of an interactive computer‐based laboratory manual, created to facilitate the teaching and learning of medical histology. The overarching goal of developing the manual is to facilitate self‐directed group interactivities that actively engage students during laboratory sessions. The design of the manual includes guided instruction for students to navigate virtual slides, exercises for students to monitor learning, and cases to provide clinical relevance. At the end of the laboratory activities, student groups can generate a laboratory report that may be used to provide formative feedback. The instructional value of the manual was evaluated by a questionnaire containing both closed‐ended and open‐ended items. Closed‐ended items using a five‐point Likert‐scale assessed the format and navigation, instructional contents, group process, and learning process. Open‐ended items assessed student's perception on the effectiveness of the manual in facilitating their learning. After implementation for two consecutive years, student evaluation of the manual was highly positive and indicated that it facilitated their learning by reinforcing and clarifying classroom sessions, improved their understanding, facilitated active and cooperative learning, and supported self‐monitoring of their learning. Anat Sci Educ 6: 342–350. © 2013 American Association of Anatomists.     

HistoViewer: An interactive e‐learning platform facilitating group and peer group learning

Understanding tissue architecture and the morphological characteristics of cells is a central prerequisite to comprehending the basis of physiological tissue function in healthy individuals and relating this to disease states. Traditionally, medical curricula include courses where students examine glass slides of cytological or tissue samples under a light microscope. However, it is challenging to implement group and peer group learning in these courses and to give students sufficient time to study specimens. An increasing number of medical schools have thus started to implement digital slide viewers, so‐called virtual microscopes, in histology and histopathology. These websites are mostly based on standard commercial software and offer limited adaptation to the special needs of first‐year students. An e‐learning platform has therefore been developed for use in cytology and histology courses. This virtual microscopy tool is coupled to a central database in which students can label and store the positions of individual structures for later repetition. As learning in pairs and peer groups has been shown to provide a high learning outcome, identified structures can be shared and discussed with students' peers or faculty via a built‐in communication module. This website has the possibility of opening an arbitrary number of frames which all can actively be moved and changed in magnification to enable the comparison of specimens and thus encourage a more global understanding of related tissues. HistoViewer is thus suggested as an e‐learning tool combining several modern teaching concepts. © 2013 American Association of Anatomists.     

Optical versus virtual: teaching assistant perceptions of the use of virtual microscopy in an undergraduate human anatomy course

Many studies that evaluate the introduction of technology in the classroom focus on student performance and student evaluations. This study focuses on instructor evaluation of the introduction of virtual microscopy into an undergraduate anatomy class. Semi-structured interviews were conducted with graduate teaching assistants (TA) and analyzed through qualitative methods. This analysis showed that the teaching assistants found the virtual microscope to be an advantageous change in the classroom. They cite the ease of use of the virtual microscope, access to histology outside of designated laboratory time, and increasing student collaboration in class as the primary advantages. The teaching assistants also discuss principal areas where the use of the virtual microscope can be improved from a pedagogical standpoint, including requiring students to spend more time working on histology in class.     

Active learning: A small group histology laboratory exercise in a whole class setting utilizing virtual slides and peer education

Histology laboratory instruction is moving away from the sole use of the traditional combination of light microscopes and glass slides in favor of virtual microscopy and virtual slides. At the same time, medical curricula are changing so as to reduce scheduled time for basic science instruction as well as focusing on student‐centered learning approaches such as small group active learning and peer‐instruction. It is important that medical schools resist the temptation to respond to this conjunction of events by turning histology into a self‐study activity. This article describes a lymphoid histology laboratory exercise, occurring in a specially equipped Learning Studio housing an entire medical class that utilizes virtual slides in the context of small group active learning and peer instruction. Anat Sci Educ © 2012 American Association of Anatomists.     

Using color and grayscale images to teach histology to color‐deficient medical students

Examination of histologic and histopathologic microscopic sections relies upon differential colors provided by staining techniques, such as hematoxylin and eosin, to delineate normal tissue components and to identify pathologic alterations in these components. Given the prevalence of color deficiency (commonly called “color blindness”) in the general population, it is likely that this reliance upon color differentiation poses a significant obstacle for several medical students beginning a course of study that includes examination of histologic slides. In the past, first‐year medical students at Michigan State University who identified themselves as color deficient were encouraged to use color transparency overlays or tinted contact lenses to filter out problematic colors. Recently, however, we have offered such students a computer monitor adjusted to grayscale for in‐lab work, as well as grayscale copies of color photomicrographs for examination purposes. Grayscale images emphasize the texture of tissues and the contrasts between tissues as the students learn histologic architecture. Using this approach, color‐deficient students have quickly learned to compensate for their deficiency by focusing on cell and tissue structure rather than on color variation. Based upon our experience with color‐deficient students, we believe that grayscale photomicrographs may also prove instructional for students with normal (trichromatic) color vision, by encouraging them to consider structural characteristics of cells and tissues that may otherwise be overshadowed by stain colors. Anat Sci Ed 2:84–88, 2009. © 2009 American Association of Anatomists.     

A prospective,randomized crossover study comparing direct inspection by light microscopy versus projected images for teaching of hematopathology to medical students

Instruction in hematopathology at Mayo Medical School has evolved from instructor‐guided direct inspection under the light microscope (laboratory method), to photomicrographs of glass slides with classroom projection (projection method). These methods have not been compared directly to date. Forty‐one second‐year medical students participated in this pilot study, a prospective, randomized, crossover study measuring educational performance during a hematology pathophysiology course. The students were randomized to one of two groups. All students received the same didactic lectures in the classroom and subsequent case‐based review of peripheral blood smears using either laboratory or projection methods, on day one with a crossover to the other method on day two. Pre‐ and post‐test examinations centered on morphology recognition measured educational performance on each day, followed by a questionnaire identifying the student's favored method. There was no significant difference in the pre‐test and post‐test scores between the two teaching methods (rank‐sum P = 0.43). Students overwhelmingly preferred the projection method and perceived it as superior (76%), although post‐test scores were not significantly different. Student's recommended method was split with 50% favoring the projection method, 43% favoring a combined approach, and 23% noting logistical challenges to the laboratory. In this study, the laboratory and projection method were equivalent in terms of educational performance for hematopathology among medicals students. A classroom‐based approach such as the projection method is favored, given the large class sizes in undergraduate medical education, as well as the ergonomic challenges and additional resources required for large group instruction in a laboratory setting. Anat Sci Educ 7: 130–134. © 2013 American Association of Anatomists.     

An evaluation of outcomes following the replacement of traditional histology laboratories with self‐study modules

Changes in medical school curricula often require educators to develop teaching strategies that decrease contact hours while maintaining effective pedagogical methods. When faced with this challenge, faculty at the University of Cincinnati College of Medicine converted the majority of in‐person histology laboratory sessions to self‐study modules that utilize multiple audiovisual modalities and a virtual microscope platform. Outcomes related to this shift were investigated through performance on in‐house examinations, results of the United States Medical Licensing Examination^® (USMLE^®) Step 1 Examination, and student feedback. Medical School College Admissions Test^® (MCAT^®) scores were used as a covariate when comparing in‐house examinations. Results revealed no significant change in performance on in‐house examinations when the content being assessed was controlled (F(2, 506) = 0.676, P = 0.51). A significant improvement in overall practical examination grade averages was associated with the self‐study modules (F(6, 1164) = 10.213, P < 0.01), but gradual changes in examination content may explain this finding. The histology and cell biology portion of USMLE Step 1 Examination remained consistent throughout the time period that was investigated. Student feedback regarding the self‐study modules was positive and suggested that features such as instructor narrated videos were an important component of the self‐study modules because they helped recreate the experience of in‐person laboratory sessions. Positive outcomes from the student perspective and no drop in examination performance suggests that utilizing self‐study modules for histology laboratory content may be an option for educators faced with the challenge of reducing contact hours without eliminating content. Anat Sci Educ 10: 276–285. © 2016 American Association of Anatomists.     

A “Do‐It‐Yourself” interactive bone structure module: Development and evaluation of an online teaching resource

A stand‐alone online teaching module was developed to cover an area of musculoskeletal anatomy (structure of bone) found to be difficult by students. The material presented in the module was not formally presented in any other way, thus providing additional time for other curriculum components, but it was assessed in the final examination. The module was developed using “in‐house” software designed for academics with minimal computer experience. The efficacy and effectiveness of the module was gauged via student surveys, testing student knowledge before and after module introduction, and analysis of final examination results. At least 74% of the class used the module and student responses were positive regarding module usability (navigation, interaction) and utility (learning support). Learning effectiveness was demonstrated by large significant improvements in the post‐presentation test scores for “users” compared with “non‐users” and by the percentage of correct responses to relevant multiple choice questions in the final examination. Performance on relevant short answer questions in the final examination was, on average, comparable to that for other components. Though limited by study structure, it was concluded that the module produced learning outcomes equivalent to those generated by more traditional teaching methods. This “Do‐It‐Yourself” e‐learning approach may be particularly useful for meeting specific course needs not catered for by commercial applications or where there are cost limitations for generation of online learning material. The specific approaches used in the study can assist in development of effective online resources in anatomy. Anat Sci Educ 6: 107–113. © 2012 American Association of Anatomists.     

Improved learning efficiency and increased student collaboration through use of virtual microscopy in the teaching of human pathology

The implementation of virtual microscopy in the teaching of pathology at the Bloomington, Indiana extension of the Indiana University School of Medicine permitted the assessment of student attitudes, use and academic performance with respect to this new technology. A gradual and integrated approach allowed the parallel assessment with respect to both the virtual and optical microscopes. Student survey data indicated that the virtual imaging technology was enthusiastically received, and aggregate grade comparisons with the previous classes showed no decrease in content mastery. Survey questions assessing a variety of parameters reveal improved time and resource utilization, as well as increased student collaboration. Even so, 50% of the respondents indicated having both optical and virtual microscopes available was preferable. Anat Sci Ed 1:240–246, 2008. © 2008 American Association of Anatomists.     

A Web-Based Virtual Microscopy Platform for Improving Academic Performance in Histology and Pathology Laboratory Courses: A Pilot Study

Virtual microscopy (VM) has been utilized to improve students' learning experience in microscope laboratory sessions, but minimal attention has been given to determining how to use VM more effectively. The study examined the influence of VM on academic performance and teacher and student perceptions and compared laboratory test scores before and after VM incorporation. A total of 662 third-year students studying histology and 651 fourth-year students studying pathology were divided into two groups. The light microscopy (LM) group used a light microscope in 2014 and 2015, while the LM + VM group used the VM platform and a light microscope in 2016 and 2017. Four factors positively predict laboratory scores (R square, 0.323; P < 0.001): (i) the pathology course and test-enhanced learning, (ii) the VM platform and experience, (iii) medical students and lecture scores, and (iv) female students. The LM + VM group exhibited less score variability on laboratory examinations relative to their mean than the LM group. The LM + VM group was also associated with fewer failing grades (F grade; odds ratio, 0.336; P < 0.001) and higher scores (A grade; odds ratio, 2.084; P < 0.001) after controlling for sex, school, course, and lecture grades. The positive effect of the VM platform on laboratory test grades was associated with prior experience using the VM platform and was synergistic with more interim tests. Both teachers and students agreed that the VM platform enhanced laboratory learning. The incorporation of the VM platform in the context of test-enhanced learning may help more students to master microscopic laboratory content.     

Evaluating a technology supported interactive response system during the laboratory section of a histology course

Monitoring of student learning through systematic formative assessment is important for adjusting pedagogical strategies. However, traditional formative assessments, such as quizzes and written assignments, may not be sufficiently timely for making adjustments to a learning process. Technology supported formative assessment tools assess student knowledge, allow for immediate feedback, facilitate classroom dialogues, and have the potential to modify student learning strategies. As an attempt to integrate technology supported formative assessment in the laboratory section of an upper‐level histology course, the interactive application Learning Catalytics^TM, a cloud‐based assessment system, was used. This study conducted during the 2015 Histology courses at Cornell University concluded that this application is helpful for identifying student misconceptions “on‐the‐go,” engaging otherwise marginalized students, and forming a new communication venue between students and instructors. There was no overall difference between grades from topics that used the application and grades from those that did not, and students reported that it only slightly helped improve their understanding of the topic (3.8 ± 0.99 on a five‐point Likert scale). However, they highly recommended using it (4.2 ± 0.71). The major limitation was regarding the image display and graphical resolution of this application. Even though students embrace the use of technology, 39% reported benefits of having the traditional light microscope available. This cohort of students led instructors to conclude that the newest tools are not always better, but rather can complement traditional instruction methods. Anat Sci Educ 10: 328–338. © 2016 American Association of Anatomists.     

More technology,better learning resources,better learning? Lessons from adopting virtual microscopy in undergraduate medical education

The adoption of virtual microscopy at the University of Turku, Finland, created a unique real‐world laboratory for exploring ways of reforming the learning environment. The purpose of this study was to evaluate the students' reactions and the impact of a set of measures designed to boost an experimental group's understanding of abnormal histology through an emphasis on knowledge of normal cells and tissues. The set of measures included (1) digital resources to review normal structures and an entrance examination for enforcement, (2) digital course slides highlighting normal and abnormal tissues, and (3) self‐diagnostic quizzes. The performance of historical controls was used as a baseline, as previous students had never been exposed to the above‐mentioned measures. The students' understanding of normal histology was assessed in the beginning of the module to determine the impact of the first set of measures, whereas that of abnormal histology was assessed at the end of the module to determine the impact of the whole set of measures. The students' reactions to the instructional measures were assessed by course evaluation data. Additionally, four students were interviewed. Results confirmed that the experimental group significantly outperformed the historical controls in understanding normal histology. The students held favorable opinions on the idea of emphasizing normal structures. However, with regards to abnormal histology, the historical controls outperformed the experimental group. In conclusion, allowing students access to high‐quality digitized materials and boosting prerequisite skills are clearly not sufficient to boost final competence. Instead, the solution may lie in making students externally accountable for their learning throughout their training. Anat Sci Educ 6: 73–80. © 2012 American Association of Anatomists.     

The development and assessment of an online microscopic anatomy laboratory course

Increasing enrollment in post‐secondary institutions across North America, along with an increase in popularity of and demand for distance education is pressuring institutions to offer a greater number and variety of courses online. A fully online laboratory course in microscopic anatomy (histology) which can be taught simultaneously with a face‐to‐face (F2F) version of the same course has been developed. This full year course was offered in the Fall/Winter (FW) terms in both F2F and online formats. To ensure that the online course was of the same quality as the F2F format, a number of performance indicators were evaluated. The same course, offered exclusively online during the summer with a compressed time frame, was also evaluated. Senior undergraduate students self‐selected which version of the course they would enroll in. Course assessment outcomes were compared while incoming grades were used as a predictor for course performance. There were no significant differences between the incoming grades for the F2F FW and Online FW courses; similarly, there were no significant differences between outcomes for these formats. There were significant differences between the incoming grades of the F2F FW and Summer Online students. However, there were no significant differences among any of the outcomes for any of the formats offered. Incoming grades were strong, significant predictors of course performance for both formats. These results indicate that an online laboratory course in microscopic anatomy is an effective format for delivering histology course content, therefore giving students greater options for course selections. Anat Sci Educ 6: 246–256. © 2013 American Association of Anatomists.     

The translucent cadaver: An evaluation of the use of full body digital x-ray images and drawings in surface anatomy education

It has been noted by staff at the Faculty of Health Sciences, Stellenbosch University that medical students neglect the study of surface anatomy during dissection. This study reports on the novel use of Lodox® Statscan® images in anatomical education, particularly the teaching of surface anatomy. Full body digital X‐ray images (Lodox Statscan) of each cadaver (n = 40) were provided to second year medical students. During dissection students were asked to visualize landmarks, organs, and structures on the digital X‐ray and their cadaver, as well as palpate these landmarks and structures on themselves, their colleagues, and the cadaver. To stimulate student engagement with surface anatomy, dissection groups were required to draw both the normal and actual position of organs on a laminated image provided. The accuracy of the drawings was subsequently assessed and students were further assessed by means of practical identification tests. In addition, students were asked to complete an anonymous questionnaire. A response rate of 79% was obtained for the student questionnaire. From the questionnaire it was gathered that students found the digital X‐ray images beneficial for viewing most systems' organs, except for the pelvic organs. Although it appears that students still struggle with the study of surface anatomy, most students believed that the digital X‐rays were beneficial to their studies and supported their continued use in the future. Anat Sci Educ. © 2012 American Association of Anatomists.     

Interactive radiological anatomy eLearning solution for first year medical students: Development,integration, and impact on learning

A technology enhanced learning and teaching (TELT) solution, radiological anatomy (RA) eLearning, composed of a range of identification‐based and guided learning activities related to normal and pathological X‐ray images, was devised for the Year 1 nervous and locomotor course at the Faculty of Medicine, University of Southampton. Its effectiveness was evaluated using a questionnaire, pre‐ and post‐tests, focus groups, summative assessment, and tracking data. Since introduced in 2009, a total of 781 students have used RA eLearning, and among them 167 Year 1 students in 2011, of whom 116 participated in the evaluation study. Students enjoyed learning (77%) with RA eLearning, found it was easy to use (81%) and actively engaged them in their learning (75%), all of which were associated to the usability, learning design of the TELT solution and its integration in the curriculum; 80% of students reported RA eLearning helped their revision of anatomy and 69% stated that it facilitated their application of anatomy in a clinical context, both of which were associated with the benefits offered by the learning and activities design. At the end of course summative assessment, student knowledge of RA eLearning relevant topics (mean 80%; SD ±16) was significantly better as compared to topics not relevant to RA eLearning (mean 63%; SD ±15) (mean difference 18%; 95% CI 15% to 20%; P < 0.001). A well designed and integrated TELT solution can be an efficient method for facilitating the application, integration, and contextualization of anatomy and radiology to create a blended learning environment. Anat Sci Educ 7: 350–360. © 2013 American Association of Anatomists.     

Building virtual models by postprocessing radiology images: A guide for anatomy faculty

Radiology and radiologists are recognized as increasingly valuable resources for the teaching and learning of anatomy. State‐of‐the‐art radiology department workstations with industry‐standard software applications can provide exquisite demonstrations of anatomy, pathology, and more recently, physiology. Similar advances in personal computers and increasingly available software can allow anatomy departments and their students to build their own three‐dimensional virtual models. Appropriate selection of a data‐set, followed by processing and presentation are the key steps in creating virtual models. The construction, presentation, clinical application, and educational potential of postprocessed imaging techniques including multiplanar reformats, minimum intensity projections, segmentation, volume‐rendering, surface‐rendering, fly‐throughs, virtual endoscopy, angiography, and cine‐loops are reviewed using examples created with only a personal computer and freeware software. Although only static images are presented in this article, further material is available online within the electronic version of this article. Through the use of basic and advanced image reconstruction and also paying attention to optimized presentation and integration, anatomy courses can be strengthened with appropriate radiological material. There are several key advantages for the anatomy department, which is equipped with the ability to produce virtual models using radiology images: (1) Opportunities to present anatomy using state‐of‐the‐art technology as an adjunct to current practices, (2) a means to forge an improved relationship with the local radiology department, and (3) the ability to create material locally, which is integrated with the local curriculum avoiding the problem of information overload when using the internet or other commercially available resources. Anat Sci Educ 3:261–266, 2010. © 2010 American Association of Anatomists.     

The “flipped classroom” approach: Stimulating positive learning attitudes and improving mastery of histology among medical students

Traditional medical education methodologies have been dramatically impacted by the introduction of new teaching approaches over the past few decades. In particular, the “flipped classroom” format has drawn a great deal of attention. However, evidence regarding the effectiveness of the flipped model remains limited due to a lack of outcome‐based studies. In the present study, a pilot histology curriculum of the organ systems was implemented among 24 Traditional Chinese Medicine (TCM) students in a flipped classroom format at Jinan University. As a control, another 87 TCM students followed a conventional histology curriculum. The academic performance of the two groups was compared. In addition, a questionnaire was administered to the flipped classroom group. The test scores for the flipped classroom participants were found to be significantly higher compared to non‐participants in the control group. These results suggest that students may benefit from using the flipped classroom format. Follow‐up questionnaires also revealed that most of the flipped classroom participants undertook relatively more earnest preparations before class and were actively involved in classroom learning activities. The teachers were also found to have more class time for leading discussions and delivering quizzes rather than repeating rote didactics. Consequently, the increased teaching and learning activities contributed to a better performance among the flipped classroom group. This pilot study suggests that a flipped classroom approach can be used to improve histology education among medical students. However, future studies employing randomization, larger numbers of students, and more precise tracking methods are needed before definitive conclusions can be drawn. Anat Sci Educ 10: 317–327. © 2016 American Association of Anatomists.