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-
tion has been to incorporate comput-
ers into both instruction and indepen-
dent student study (Cotter, 1997a,b;
Evans et al., 2000; Lee et al., 1997;
This project was made possible by the
joint efforts of members of the College
of Medicine at the University of Iowa.
Ms. Harris, a second year medical stu-
dent, was supported by the NIH Sum-
mer Research Fellowship Program for
Medical Students. Mr. Leaven, MA, of
the Pathology Dept. created the HTML
design. Dr. Heidger of the Dept. of Anat-
omy and Cell Biology directs the Histol-
ogy section of the Human Organ Sys-
tems course and Dr. Dick of the
Pathology Dept. directs the Pathology
course. Dr. Kreiter is a member of the
Office of Consultation and Research in
Medical Education and assisted with
the evaluation. Mr. Duncan, MLIS, di-
rects the Information Commons com-
puter laboratories at the Hardin Library
for the Health Sciences.
Grant sponsor: The National Library of
Medicine Information Systems; Grant
sponsor: The University of Iowa Student
Computer Fee Allocation; Grant spon-
sor: The University of Iowa College of
Medicine Educational Development
Funds; Grant sponsor: The NIH Summer
Research Fellowship Program for Med-
ical Students.
*Correspondence to: Fred R. Dick MD,
100 Medical Laboratories, Room 1198,
University of Iowa, Iowa City, IA 52242.
E-mail: fred-dick@uiowa.edu
Received 17 October 2000; Accepted 29
November 2000
Lehmann et al., 1999; Mars and
McLean, 1996; Spitzer and Whitlock,
1998; Trelease et al., 2000). The move-
ment from glass slides and the micro-
scope to computer images is being
driven by the fact that computers, in
addition to many other positive at-
tributes, are a very efficient way for
students to learn visual material. Al-
though some medical schools are
abandoning the microscope in favor
of computer programs, there may be
concerns regarding the use of this
technology alone. Most computer pro-
grams are limited to static images
that do not functionally resemble the
microscope in that they do not allow
students to explore relationships by
moving the tissue and changing mag-
nification, independently identify
structures, and discover relationships.
Static images in textbooks and on the
computer screen certainly have a role
in augmenting the laboratory experi-
ence. However, many anatomy and
pathology educators believe that view-
ing slides of human tissue under the
microscope (analogous to performing
a gross dissection) adds a totally dif-
ferent dimension to learning that is
not afforded by still images.
Emerging technology now exists to
digitize the entire information of a
histologic slide at high power (40),
save it in a highly compressed file for-
mat, and deliver it over the web. By
accessing these images with a web
browser and viewer plug-in, a com-
puter can nearly perfectly emulate a
real microscope. Using this new tech-
nology, the immediate aims of our
project were to:
(1) Digitize the glass slides from uri-
nary tract, male genital, and endo-
crine units and implement them
as a Virtual Microscope Labora-
tory in the Spring 2000 Histology
course at the University of Iowa.
(2) Carry out a formative evaluation
of these three units by compar-
ing the Virtual Microscope Lab-
oratory to the regular micro-
scope laboratory.
The methods and results of this pa-
per will describe the technology em-
ployed to create the virtual slides, and
the formative evaluation carried out
in the course.
DIGITIZATION OF SLIDES AND
DISTRIBUTION
The 19 slides evaluated in this study
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,
and they were instructed in the use of
the web browser plug-in. They were
told that the content was the same as
in the regular laboratory slide boxes
and syllabus. Students still attended
the regular microscope laboratory,
but they were able to access the Vir-
tual Microscope Laboratory at any
time of day or night on campus, or via
cable modem from home.
EVALUATION
The formative evaluation of the three
units was performed during the
Spring 2000 Histology course at the
University of Iowa College of Medi-
cine. The evaluation form shown in
Table 1 {Table 1} was distributed to
158 students via the web at the end of
the course. Since this was a formative
evaluation, and the use of the Virtual
Microscope Laboratory was not man-
datory, filling out the evaluation was
voluntary. Thirty-nine students re-
sponded for a return rate of 25%.
Some of the respondents did not code
a response to all questions on the sur-
vey; thus, analyses of items were con-
ducted with fewer than 39 responses.
The first six items of the evaluation
were designed to compare student
perceptions of different aspects of
performance of the regular micro-
scope laboratory with the Virtual Mi-
croscope Laboratory. Table 2 displays
the means (M) and standard devia-
tions (SDs) for student responses to
each item and the total score. For all
six of the evaluation items, the mean
rating for the virtual microscope was
more favorable compared with the
traditional microscope laboratory.
Paired two-tailed t-tests were con-
ducted on the differences between the
responses for each of the six matched
questions (regular vs. virtual) and the
total. Across the characteristics mea-
sured by the six items, the Virtual Mi-
croscope Laboratory was rated higher
than the regular microscope labora-
tory (t 2.03, P .05). When items
were evaluated separately, item one
(The method was an efficient use of my
time), and item six (The microscope
was sufficiently accessible) displayed
highly significant differences between
the two modes of presentation, with
the Virtual Microscope Laboratory
more preferred. For the remaining
four items (Directions for use of the
microscope were clear; Microscopic im-
ages were clear; Navigation of the slides
with the microscope was easy; The
method optimized the information I
needed to learn histology) students felt
that the virtual microscope was at
least as good as the regular micro-
scope, but the difference in responses
was not significant.
Written responses on the second
part of the evaluation form were sup-
portive of the virtual microscope. Stu-
dents commented that they greatly
appreciated the virtual microscope
lab and thought that the virtual his-
tology laboratory is great as an addi-
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
didnt think it should replace the reg-
ular lab. Others stated that the move
around and zoom in/out function is
like looking at the real microscope.
Many students wanted to make sure
the virtual scope could be reached
from everywhere, including off cam-
pus. Furthermore, some students
commented that they were hoping to
use the virtual microscope laboratory
to replace spending hours in the mi-
croscope lab, searching aimlessly; we
could sit while a histology professor
points out the important features,
zooming in and out across the slide,
and this virtual process can be so
much more productive for students,
and more stimulating also. Others
said: I do see the need for some ex-
perience with the real microscope.
Additionally, a few students noted
that the Virtual Microscope Labora-
tory was quite helpful, however,
without an instructor there, it was dif-
ficult to find many of the structures.
Some students wanted more informa-
tion in the virtual microscope labora-
tory such as arrows to structures that
were difficult for an inexperienced
viewer to locate and a mechanism to
quiz our progress. Nearly all of the
students who responded to the evalu-
ation indicated that they had used the
Virtual Microscope Laboratory more
than 2 hours.
In addition to student evaluation, stu-
dent use of the Virtual Microscope Lab-
oratory was tracked on the University of
Iowa web server using a Microsoft
FlashStats program. This program tab-
ulates the number of times an URL is
accessed. Hits on the home page of the
Virtual Microscope Laboratory were
tabulated by day and by time of day.
Student use peaked at 12:30 pm and
again at 9:00 pm, dropping off from
1:00 am until 6:00 am. The frequency of
hits by day went up markedly in prox-
imity to examinations.
DISCUSSION
Based on the limited formative evalu-
ation carried out in this study, a Vir-
tual Microscope Laboratory appears
to be a viable addition to, if not a
potential replacement for, real micro-
scopes and glass slides. Students gave
significantly higher ratings to the ac-
cessibility and efficiency of the Virtual
THE ANATOMICAL RECORD (NEW ANAT.) 13
Microscope Laboratory vs. the regular
microscope laboratory. Regular mi-
croscope laboratories were open dur-
ing the day, but the additional acces-
sibility of the Virtual Microscope
Laboratory after hours was taken ad-
vantage of by students, especially pre-
ceding practical examinations. In ad-
dition, students rated the quality of
images and navigation of the virtual
microscope equal to or better than a
real microscope. Virtual slides are al-
ways in focus with ideal condenser
and light adjustment, thus decreasing
the student time and some of the frus-
tration in operating a real micro-
scope.
Based on this positive information,
we plan to carry out laboratory ses-
sions next year in two venues. One
will be in a laboratory equipped only
with computer work-stations and a
Students gave
significantly higher
ratings to the
accessibility and
efficiency of the Virtual
Microscope Laboratory
vs. the regular
microscope laboratory.
computer projector for faculty dem-
onstrations. The other venue will be in
a laboratory equipped with multi-
headed microscopes, plus a computer
projector for faculty demonstrations.
After introductory sessions to ac-
quaint students with the real and vir-
tual laboratories, the class will be al-
lowed to attend either venue during
regularly scheduled laboratory time
with an instructor present. Students
will also have the opportunity to use
any modality outside of scheduled
class time; however, the real micro-
scope laboratory will only be open
weekdays 8 am to 5 pm, Tues/Thurs/
Fri and 8 am to 8 pm, Mon/Wed. At
the end of the course, all students will
be required to fill out a subjective eval-
uation form, attendance in the two
venues will be tabulated, computer
use outside of class will be tracked,
and examination scores will be com-
pared with the previous years results.
Development of a Public
Domain Set of Virtual Slides
We have received funding from a Na-
tional Library of Medicine Informa-
tion Systems Grant to develop a pub-
lic domain Database of Microscopic
Anatomy using the technology de-
scribed in this study. Our long-term
aim is to develop a comprehensive set
of high-quality peer-reviewed digital
replicas of slides that, when com-
pleted, will be extensively used by
course directors to augment or re-
place glass slides and microscopes.
Because the glass slides from our
course are mostly commercially pur-
chased, they cannot be put in the pub-
lic domain. Thus, we will be asking
histology instructors around the world
to contribute to this Database. A Vir-
tual Slide Box of Histology, which con-
tains some of the slides contributed to
the Database from our institution, can
be accessed at http:www.medicine.
uiowa.edu/pathology/nlm_histology.
This web site also contains the MGI
viewer plug-in site.
This public domain Database, when
completed, will consist of approxi-
mately 150 digitized high-resolution
virtual microscopic slides of every
adult human organ and tissue. We are
saving the virtual slides in native tiff
format so that they may be converted
to other file formats: fpx, jpg, jpg
2000. Additionally, the Database will
contain images of gross organs and
gross anatomy images from the Visi-
ble Human data set downloaded from
the Visible Human Slice Server
(http://visiblehuman.epfl.ch/) (Spitzer
and Whitlock, 1998; see also Bacro et
al., 2000). These gross images will al-
low students to make gross-micro-
scopic correlations.
The end user will be able to use the
virtual slides in this public domain
Database in several ways.
(1) The URL can be accessed by stu-
dents and used as a virtual slide
box for histology courses.
(2) Faculty can project the slides in
laboratories or lecture halls.
(3) Faculty can capture and down-
load images from any field at any
magnification on the virtual slide
14 THE ANATOMICAL RECORD (NEW ANAT.)
for use in PowerPoint presenta-
tions, educational software pro-
grams, or for conversion to 2 2
color slides.
(4) Histology faculty can access the
URL of individual slides (in fpx
format) and create their own vir-
tual slide box or virtual labora-
tory.
(5) We will be able to provide the
original tiff or fpx image files, via
tape or DVD, to those who want
to manipulate and serve the im-
ages themselves.
We believe the Database will allow
faculty to develop teaching strategies
that promote self-directed learning by
students outside of structured labora-
tories. Access to microscopic slides
via computer will allow students the
flexibility of studying at any computer
on campus or in the future at home
when cable modem or DVDs become
commonplace (e.g., see Bacro et al.,
2000). Independent student group
learning will be promoted because
computer monitors can be viewed by
multiple participants. These potential
outcomes are all consistent with
emerging educational goals in medi-
cal and dental curricula.
The capability to create seamless
digitized facsimiles of entire histo-
logic specimens is just emerging.
Although digitization of a smaller
portion of a slide, such as with Quick-
Time VR (Trelease et al., 2000), may
currently be more practical, we be-
lieve there is an educational advan-
tage to visualization of the entire spec-
imen at low power, coupled with the
ability to zoom into any portion of the
slide at 40. The current capability of
the technology described in this study
is to capture only about 1 square cen-
timeter of the surface of a slide at
40. As technology advances, we esti-
mate the acquisition time will de-
crease by half and processing capabil-
ity will increase, so that up to 4 square
centimeters of a histologic slide can
be captured and delivered in the near
future. Computer technology is ad-
vancing at an exponential rate. What
might seem technically impractical
today may seem technically trivial in
three years.
Should Physicians Know How
to Use a Microscope?
It can be argued that medical students
need to learn how to use an actual
microscope. Most practicing physi-
cians do not use the microscope, es-
pecially to look at histologic slides;
however, many primary care physi-
cians in office practice will use the
microscope to look at gram stains,
urine sediments, and blood smears.
We believe this set of students should
learn to use the microscope in the
context of learning to look at those
specimens. The goal of microscopic
anatomy and pathology education is
to teach students normal and abnor-
mal human structure, not how to use
the microscope. With all that said, we
still believe it is important to intro-
duce the students to microscopes and
glass slides at the beginning of their
histology education, so they have a
concept and appreciation of the
source of the tissue and the images
that appear on the computer screen.
CONCLUSION
The transformation to teaching histol-
ogy on the computer may be inevita-
ble. In the future, institutions will not
be able to support multi-purpose com-
puter learning centers plus large mi-
ARTICLE
croscope laboratories, especially if
microscopic morphology can be effec-
tively taught via computer. We believe
the Virtual Microscope Laboratory
and the emerging technology de-
scribed in this project assists with the
transformation in a way that will
maintain many of the educational ad-
vantages inherent in using a real mi-
croscope and glass slides.
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