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THE ANATOMICAL RECORD (NEW ANAT.

) 265:10 14, 2001

ARTICLE

Comparison of a Virtual Microscope Laboratory


to a Regular Microscope Laboratory for
Teaching Histology
TONYA HARRIS, TIMOTHY LEAVEN, PAUL HEIDGER, CLARENCE KREITER, JAMES DUNCAN, AND FRED DICK*

Emerging technology now exists to digitize a gigabyte of information from a glass slide, save it in a highly compressed
file format, and deliver it over the web. By accessing these images with a standard web browser and viewer plug-in,
a computer can emulate a real microscope and glass slide. Using this new technology, the immediate aims of our
project were to digitize the glass slides from urinary tract, male genital, and endocrine units and implement them in
the Spring 2000 Histology course at the University of Iowa, and to carry out a formative evaluation of the virtual slides
of these three units in a side-by-side comparison with the regular microscope laboratory. The methods and results
of this paper will describe the technology employed to create the virtual slides, and the formative evaluation carried
out in the course. Anat Rec (New Anat) 265:10 14, 2001. 2001 Wiley-Liss, Inc.

KEY WORDS: histology; microscopy; computer-assisted learning; education, medical; instruction

The recent trend in histology educa- Lehmann et al., 1999; Mars and digitize the entire information of a
tion has been to incorporate comput- McLean, 1996; Spitzer and Whitlock, histologic slide at high power (40),
ers into both instruction and indepen- 1998; Trelease et al., 2000). The move- save it in a highly compressed file for-
dent student study (Cotter, 1997a,b; ment from glass slides and the micro- mat, and deliver it over the web. By
Evans et al., 2000; Lee et al., 1997; scope to computer images is being accessing these images with a web
driven by the fact that computers, in browser and viewer plug-in, a com-
addition to many other positive at- puter can nearly perfectly emulate a
This project was made possible by the
joint efforts of members of the College tributes, are a very efficient way for real microscope. Using this new tech-
of Medicine at the University of Iowa.
students to learn visual material. Al- nology, the immediate aims of our
Ms. Harris, a second year medical stu-
project were to:
dent, was supported by the NIH Sum- though some medical schools are
mer Research Fellowship Program for
Medical Students. Mr. Leaven, MA, of abandoning the microscope in favor (1) Digitize the glass slides from uri-
the Pathology Dept. created the HTML of computer programs, there may be nary tract, male genital, and endo-
design. Dr. Heidger of the Dept. of Anat- concerns regarding the use of this crine units and implement them
omy and Cell Biology directs the Histol-
ogy section of the Human Organ Sys- technology alone. Most computer pro- as a Virtual Microscope Labora-
tems course and Dr. Dick of the grams are limited to static images tory in the Spring 2000 Histology
Pathology Dept. directs the Pathology course at the University of Iowa.
course. Dr. Kreiter is a member of the that do not functionally resemble the
Office of Consultation and Research in microscope in that they do not allow (2) Carry out a formative evaluation
Medical Education and assisted with
students to explore relationships by of these three units by compar-
the evaluation. Mr. Duncan, MLIS, di-
rects the Information Commons com- moving the tissue and changing mag- ing the Virtual Microscope Lab-
puter laboratories at the Hardin Library oratory to the regular micro-
for the Health Sciences.
nification, independently identify
scope laboratory.
Grant sponsor: The National Library of structures, and discover relationships.
Medicine Information Systems; Grant Static images in textbooks and on the The methods and results of this pa-
sponsor: The University of Iowa Student
Computer Fee Allocation; Grant spon- computer screen certainly have a role per will describe the technology em-
sor: The University of Iowa College of in augmenting the laboratory experi- ployed to create the virtual slides, and
Medicine Educational Development ence. However, many anatomy and the formative evaluation carried out
Funds; Grant sponsor: The NIH Summer
Research Fellowship Program for Med- pathology educators believe that view- in the course.
ical Students. ing slides of human tissue under the
*Correspondence to: Fred R. Dick MD,
100 Medical Laboratories, Room 1198,
microscope (analogous to performing DIGITIZATION OF SLIDES AND
University of Iowa, Iowa City, IA 52242. a gross dissection) adds a totally dif-
E-mail: fred-dick@uiowa.edu DISTRIBUTION
ferent dimension to learning that is
Received 17 October 2000; Accepted 29
November 2000 not afforded by still images. The 19 slides evaluated in this study
Emerging technology now exists to came from the endocrine, urinary

2001 Wiley-Liss, Inc.


ARTICLE THE ANATOMICAL RECORD (NEW ANAT.) 11

ing higher resolution fields, the server


only brings into RAM the portion of the
image being viewed on the computer
monitor (http://www.webtools.com/story/
multimedia/TLS19981119S0099).
The total computing time per slide
ranged from 23 h; however when au-
tomatic capture starts the operator is
free for 1.5 to 2 h. Once digitized and
saved in fpx format, the images were
placed on the College of Medicine NT
server. MGI server software, delivers
the fpx files to the web in standard
HTML frames. Currently only Win-
dows platform with Internet Explorer
or Netscape is available for delivering
fpx files.

VIRTUAL MICROSCOPE
LABORATORY
The Virtual Microscope Laboratory
web site consists of the syllabus, table
Figure 1. A screen shot of a Virtual Microscope Laboratory web page. The upper left frame of contents, virtual slides, gross im-
contains a whole mount of the slide. In the lower left frame is the text of the laboratory ages for gross microscopic correla-
syllabus and additional links. Using the navigational tools at the bottom of the right frame, tion, and links to additional histology
the student can manipulate the virtual slide through six levels of magnification (1.25, 2.5,
5, 10, 20, and 40), starting at the level of the whole mount, as well as click and drag
web sites. It is accessible by students
the slide in an x-y axis through the entire surface of the slide, at any magnification. A 40 in any of the University of Iowa com-
view of thyroid and parathyroid is illustrated. puting centers or cable modem on a
password-protected intranet. The vir-
tract, and male genital tract units in The tiff image was then saved in a
tual slides appear in a 590 590 pixel
the University of Iowa Histology highly compressed FlashPix image file
html frame on an 800 600 screen. A
course study sets. format (fpx) using MGI software (http://
free viewer plug-in for viewing the vir-
A Leica DMR microscope, Ludl mo- www.mgisoft.com), which resulted in a
tual slides can be downloaded from
torized stage with auto-focus, Optron- fpx file of up to 125 megabytes per slide.
the home page of the Virtual Labora-
ics videocamera, and Pentium III Conceptually, the fpx format is a pyra-
tory or from the MGI site. The viewer
computer with two gigabytes of RAM midal stack of replicas of a jpg-com-
plug-in navigational tools allow the
and Windows 2000 were used to digi-
user to zoom in or out through six
tize the slides. Up to 1,200 (30 40)
levels of magnification (1.25, 2.5,
contiguous 40 microscopic fields Emerging technology 5, 10, 20, and 40) and click and
(640 480 pixels at 300 pixels per
now exists to digitize the drag the slide in an x-y axis through
inch with 24-bit color depth) were
the entire surface of the virtual slide
captured automatically and tiled to- entire information of a while being viewed at any magnifica-
gether with a 35-pixel overlap into a
seamless montage (approximately histologic slide at high tion. To the left of the virtual slide is a
200 590 frame that contains a whole
18,000 18,000 pixels). This resulted power (40), save it in a mount of the slide and text from the
in a tagged image file format file (tiff)
of approximately one gigabyte for
highly compressed file Histology laboratory syllabus. Thus,
the Virtual Microscope Laboratory
each slide. MicroBrightField Virtual format, and deliver it with associated slides and syllabus
Slice software coordinated the activi-
ties of the stage, auto-focus, video-
over the web. has similar content to that available to
students in the regular microscope
capture, and automatic tiling of the
laboratory, but with added capability
images (http://www.microbrightfield.
pressed image with a full-sized, full res- to correlate gross images, and link to
com). The 1,200 fields capture up to .9
olution image at the base and a small, other web sites. An example of the
.9 cm. of the tissue of each glass
low-resolution replica at the top of the appearance of a web page is shown in
slide. If more than .9 .9 cm. of tissue
pyramid. A zoom function changes Figure 1.
were needed to demonstrate the key
portions of the specimen, a second file magnification by 2-fold with each click
INCORPORATION INTO THE
with additional fields was captured. of the mouse by jumping from one layer
in the stack to the next. A click and drag COURSE
The tiff files were then opened in
Adobe Photoshop, edited for back- function permits scanning of each layer The web address of the Virtual Micro-
ground color, and cropped if needed. of the stack in an x-y-axis. When view- scope Laboratory, with three units
12 THE ANATOMICAL RECORD (NEW ANAT.) ARTICLE

TABLE 1. Evaluation form used for the survey

Please use the following scale to evaluate the Regular Microscope vs. Virtual Microscope Laboratories.
1 Strongly Agree 2 Agree 3 Neutral 4 Disagree 5 Strongly Disagree
Regular Microscope Laboratory vs. Virtual Microscope Laboratory
Please Note: 1 excellent rating 5 poor rating
1. The method was an efficient use of my 1 2 3 4 5 1 2 3 4 5
time.
2. Directions for use of the Microscope 1 2 3 4 5 1 2 3 4 5
were clear.
3. Microscopic images were clear. 1 2 3 4 5 1 2 3 4 5
4. Navigation of the slides with the 1 2 3 4 5 1 2 3 4 5
microscope was easy.
5. The method optimized the information 1 2 3 4 5 1 2 3 4 5
I needed to learn histology.
6. The microscope was sufficiently 1 2 3 4 5 1 2 3 4 5
accessible.
Please provide specific comments about each microscope laboratory:
1. How would you improve each microscope laboratory?
2. What would you keep the same about each microscope laboratory?
3. Other comments about the microscope laboratories.
How much time did you spend using the Virtual Microscope Laboratory?
1 hr 1 hr 2 hr 2 hr

completed, was given to the students, Some of the respondents did not code were evaluated separately, item one
and they were instructed in the use of a response to all questions on the sur- (The method was an efficient use of my
the web browser plug-in. They were vey; thus, analyses of items were con- time), and item six (The microscope
told that the content was the same as ducted with fewer than 39 responses. was sufficiently accessible) displayed
in the regular laboratory slide boxes The first six items of the evaluation highly significant differences between
and syllabus. Students still attended were designed to compare student the two modes of presentation, with
the regular microscope laboratory, perceptions of different aspects of the Virtual Microscope Laboratory
but they were able to access the Vir- performance of the regular micro- more preferred. For the remaining
tual Microscope Laboratory at any scope laboratory with the Virtual Mi- four items (Directions for use of the
time of day or night on campus, or via
croscope Laboratory. Table 2 displays microscope were clear; Microscopic im-
cable modem from home.
the means (M) and standard devia- ages were clear; Navigation of the slides
tions (SDs) for student responses to with the microscope was easy; The
EVALUATION each item and the total score. For all method optimized the information I
The formative evaluation of the three six of the evaluation items, the mean needed to learn histology) students felt
units was performed during the rating for the virtual microscope was that the virtual microscope was at
Spring 2000 Histology course at the more favorable compared with the least as good as the regular micro-
University of Iowa College of Medi- traditional microscope laboratory. scope, but the difference in responses
cine. The evaluation form shown in Paired two-tailed t-tests were con- was not significant.
Table 1 {Table 1} was distributed to ducted on the differences between the Written responses on the second
158 students via the web at the end of responses for each of the six matched part of the evaluation form were sup-
the course. Since this was a formative questions (regular vs. virtual) and the portive of the virtual microscope. Stu-
evaluation, and the use of the Virtual total. Across the characteristics mea- dents commented that they greatly
Microscope Laboratory was not man- sured by the six items, the Virtual Mi- appreciated the virtual microscope
datory, filling out the evaluation was croscope Laboratory was rated higher lab and thought that the virtual his-
voluntary. Thirty-nine students re- than the regular microscope labora- tology laboratory is great as an addi-
sponded for a return rate of 25%. tory (t 2.03, P .05). When items tion to the regular lab. Some students

TABLE 2. Summary of responses to survey questions 1 6

Type of Item 1 Item 2 Item 3 Item 4 Item 5 Item 6


Laboratory (n 29) (n 29) (n 29) (n 28) (n 29) (n 28) Total
Regular M 3.41 M 2.31 M 2.72 M 2.78 M 3.21 M 2.93 M 17.28
microscope SD 1.09 SD 1.39 SD 1.44 SD 1.42 SD 1.18 SD 1.36 SD 5.60
Virtual M 2.34 M 2.24 M 2.41 M 2.45 M 2.41 M 2.21 M 14.00
microscope SD 1.49 SD 1.50 SD 1.40 SD 1.57 SD 1.43 SD 1.64 SD 8.37
ARTICLE THE ANATOMICAL RECORD (NEW ANAT.) 13

didnt think it should replace the reg- Microscope Laboratory vs. the regular and examination scores will be com-
ular lab. Others stated that the move microscope laboratory. Regular mi- pared with the previous years results.
around and zoom in/out function is croscope laboratories were open dur-
like looking at the real microscope. ing the day, but the additional acces- Development of a Public
Many students wanted to make sure sibility of the Virtual Microscope
Laboratory after hours was taken ad- Domain Set of Virtual Slides
the virtual scope could be reached
from everywhere, including off cam- vantage of by students, especially pre- We have received funding from a Na-
pus. Furthermore, some students ceding practical examinations. In ad- tional Library of Medicine Informa-
commented that they were hoping to dition, students rated the quality of tion Systems Grant to develop a pub-
images and navigation of the virtual lic domain Database of Microscopic
use the virtual microscope laboratory
microscope equal to or better than a Anatomy using the technology de-
to replace spending hours in the mi-
real microscope. Virtual slides are al- scribed in this study. Our long-term
croscope lab, searching aimlessly; we
ways in focus with ideal condenser aim is to develop a comprehensive set
could sit while a histology professor
and light adjustment, thus decreasing
points out the important features, of high-quality peer-reviewed digital
the student time and some of the frus-
zooming in and out across the slide, replicas of slides that, when com-
tration in operating a real micro-
and this virtual process can be so pleted, will be extensively used by
scope.
much more productive for students, course directors to augment or re-
Based on this positive information,
and more stimulating also. Others we plan to carry out laboratory ses- place glass slides and microscopes.
said: I do see the need for some ex- sions next year in two venues. One Because the glass slides from our
perience with the real microscope. will be in a laboratory equipped only course are mostly commercially pur-
Additionally, a few students noted with computer work-stations and a chased, they cannot be put in the pub-
that the Virtual Microscope Labora- lic domain. Thus, we will be asking
tory was quite helpful, however, histology instructors around the world
without an instructor there, it was dif- to contribute to this Database. A Vir-
ficult to find many of the structures. Students gave tual Slide Box of Histology, which con-
Some students wanted more informa- tains some of the slides contributed to
tion in the virtual microscope labora- significantly higher the Database from our institution, can
tory such as arrows to structures that ratings to the be accessed at http:www.medicine.
were difficult for an inexperienced uiowa.edu/pathology/nlm_histology.
viewer to locate and a mechanism to accessibility and This web site also contains the MGI
quiz our progress. Nearly all of the efficiency of the Virtual viewer plug-in site.
students who responded to the evalu- This public domain Database, when
ation indicated that they had used the
Microscope Laboratory completed, will consist of approxi-
Virtual Microscope Laboratory more vs. the regular mately 150 digitized high-resolution
than 2 hours. virtual microscopic slides of every
In addition to student evaluation, stu-
microscope laboratory. adult human organ and tissue. We are
dent use of the Virtual Microscope Lab- saving the virtual slides in native tiff
oratory was tracked on the University of format so that they may be converted
computer projector for faculty dem- to other file formats: fpx, jpg, jpg
Iowa web server using a Microsoft
FlashStats program. This program tab- onstrations. The other venue will be in 2000. Additionally, the Database will
ulates the number of times an URL is a laboratory equipped with multi- contain images of gross organs and
accessed. Hits on the home page of the headed microscopes, plus a computer gross anatomy images from the Visi-
Virtual Microscope Laboratory were projector for faculty demonstrations. ble Human data set downloaded from
tabulated by day and by time of day. After introductory sessions to ac- the Visible Human Slice Server
Student use peaked at 12:30 pm and quaint students with the real and vir- (http://visiblehuman.epfl.ch/) (Spitzer
again at 9:00 pm, dropping off from tual laboratories, the class will be al- and Whitlock, 1998; see also Bacro et
1:00 am until 6:00 am. The frequency of lowed to attend either venue during al., 2000). These gross images will al-
hits by day went up markedly in prox- regularly scheduled laboratory time low students to make gross-micro-
imity to examinations. with an instructor present. Students scopic correlations.
will also have the opportunity to use The end user will be able to use the
any modality outside of scheduled virtual slides in this public domain
DISCUSSION class time; however, the real micro- Database in several ways.
Based on the limited formative evalu- scope laboratory will only be open (1) The URL can be accessed by stu-
ation carried out in this study, a Vir- weekdays 8 am to 5 pm, Tues/Thurs/ dents and used as a virtual slide
tual Microscope Laboratory appears Fri and 8 am to 8 pm, Mon/Wed. At box for histology courses.
to be a viable addition to, if not a the end of the course, all students will (2) Faculty can project the slides in
potential replacement for, real micro- be required to fill out a subjective eval- laboratories or lecture halls.
scopes and glass slides. Students gave uation form, attendance in the two (3) Faculty can capture and down-
significantly higher ratings to the ac- venues will be tabulated, computer load images from any field at any
cessibility and efficiency of the Virtual use outside of class will be tracked, magnification on the virtual slide
14 THE ANATOMICAL RECORD (NEW ANAT.) ARTICLE

for use in PowerPoint presenta- 40. As technology advances, we esti- croscope laboratories, especially if
tions, educational software pro- mate the acquisition time will de- microscopic morphology can be effec-
grams, or for conversion to 2 2 crease by half and processing capabil- tively taught via computer. We believe
color slides. ity will increase, so that up to 4 square the Virtual Microscope Laboratory
(4) Histology faculty can access the centimeters of a histologic slide can and the emerging technology de-
URL of individual slides (in fpx be captured and delivered in the near scribed in this project assists with the
format) and create their own vir- future. Computer technology is ad- transformation in a way that will
tual slide box or virtual labora- vancing at an exponential rate. What maintain many of the educational ad-
tory. might seem technically impractical vantages inherent in using a real mi-
(5) We will be able to provide the today may seem technically trivial in croscope and glass slides.
original tiff or fpx image files, via three years.
tape or DVD, to those who want LITERATURE CITED
to manipulate and serve the im- Should Physicians Know How
ages themselves. Bacro T, Gilbertson B, Coultas J. 2000.
to Use a Microscope? Web delivery of anatomy clips using a
We believe the Database will allow CD-ROM. Anat Rec (New Anat) 261:78
It can be argued that medical students 82.
faculty to develop teaching strategies
need to learn how to use an actual Cotter JR. 1997a. Computer-assisted in-
that promote self-directed learning by struction for the medical histology
microscope. Most practicing physi-
students outside of structured labora- course at SUNY at Buffalo. Acad Med
cians do not use the microscope, es-
tories. Access to microscopic slides 72:S124 126.
pecially to look at histologic slides; Cotter JR. 1997b. Histology on the World
via computer will allow students the
however, many primary care physi- Wide Web: A digest of resources for stu-
flexibility of studying at any computer
cians in office practice will use the dents and teachers. Medical Teacher 19:
on campus or in the future at home 180 184.
microscope to look at gram stains,
when cable modem or DVDs become Evans JA, Wagner U, Santos CM, Hennin-
urine sediments, and blood smears.
commonplace (e.g., see Bacro et al., hausen L. 2000. The interactive web-
We believe this set of students should based histology atlas system. Oncogene
2000). Independent student group
learn to use the microscope in the 19:989 991.
learning will be promoted because Lee CSC, Rutecki GW, Whittier FC, Clarett
context of learning to look at those
computer monitors can be viewed by MR, Jarjoura D. 1997. A comparison of
specimens. The goal of microscopic
multiple participants. These potential interactive computerized medical educa-
anatomy and pathology education is tion software with more traditional
outcomes are all consistent with
to teach students normal and abnor- teaching format. Teach Learn Med
emerging educational goals in medi-
mal human structure, not how to use 9:111115.
cal and dental curricula. Lehmann HP, Freedman JA, Massad J,
the microscope. With all that said, we
The capability to create seamless Dintzis RZ. 1999. An ethnographic, con-
still believe it is important to intro-
digitized facsimiles of entire histo- trolled study if the use of a computer-
duce the students to microscopes and based histology atlas during a laboratory
logic specimens is just emerging.
glass slides at the beginning of their course. J Am Med Inform Assoc 6:38 52.
Although digitization of a smaller Mars M, McLean M. 1996. Students per-
histology education, so they have a
portion of a slide, such as with Quick- ceptions of a multimedia computer-
concept and appreciation of the
Time VR (Trelease et al., 2000), may aided instruction resource in histology.
source of the tissue and the images S Afr Med J 86:1098 1002.
currently be more practical, we be-
that appear on the computer screen. Spitzer VM, Whitlock DG. 1998. The Visi-
lieve there is an educational advan-
ble Human Dataset: the anatomical plat-
tage to visualization of the entire spec- form for human simulation. Anat Rec
imen at low power, coupled with the
CONCLUSION
(New Anat) 253:49 57.
ability to zoom into any portion of the The transformation to teaching histol- Trelease RB, Nieder GL, Dorup J, Hansen
slide at 40. The current capability of ogy on the computer may be inevita- MS. 2000. Going virtual with QuickTime
VR: new methods and standardized tools
the technology described in this study ble. In the future, institutions will not for interactive dynamic visualization of
is to capture only about 1 square cen- be able to support multi-purpose com- anatomical structures. Anat Rec (New
timeter of the surface of a slide at puter learning centers plus large mi- Anat) 261:64 77.