Comparing the use of virtual and conventional light microscopy in practical sessions: Virtual reality in Tabuk University.

Virtual microscopy has an established role in medical practice and education across all medical disciplines. It provides economical and pedagogical advantages, albeit with some shortcomings. We randomly assigned two groups of second-year medical students from the University of Tabuk in KSA to use either conventional light or virtual microscopy practical sessions. The students' perceptions were assessed by written and practical exams. Students in the virtual microscopy group performed better than those in the light microscopy group in both practical and written exams, as reflected by their more-uniform performance and less-scattered grades. The virtual microscopy group had the advantage of optional online off-campus access to study materials, which they spent an average of 2.5 h reviewing. Virtual microscopy is a valid educational tool that can augment conventional microscopy in pathology practical sessions, and its application is convenient for both students and staff.

RCT Entities:   Population Interventions Outcomes

Introduction

Light microscopy practical sessions are a fundamental tool in medical and biological education. Long before the availability of colour-printed textbooks and the advent of PCs and portable electronic devices, the best method by which students learned about histological, biological and pathological entities was by viewing specimens through light microscopes.

Students' conventional light microscope (LM) usage skills and etiquette are poor, and they need time to master LM. Unfortunately, they do not receive adequate exposure to LM before medical school, and the time dedicated to basic medical-science practical sessions in integrated training systems is insufficient (typically 4 h per module).

Virtual microscopy is defined in Wikipedia as “a method of posting microscope images on, and transmitting them over, computer networks”.

The University of Cairo considered launching the first digital pathology unit in the Middle East and started building an undergraduate and post-graduate digital archive in 2003.

The justification behind using virtual microscopes is both economical and pedagogical.

Virtual slides became an integral part of telepathology practice, both for consultation and educational purposes, including the potential usage of whole-mount slides.

Virtual microscopic technologies entail a platform composed of hardware and its accompanying software. The concept is simple, albeit technically advanced: a high-resolution camera takes several pictures of tissue slides, and with the aid of a massive processing power, hundreds of pictures are collaged to a single image of enormous size, reaching 5–20 gigabytes. The process involves pre- and post-image processing, compression, transmission and visualization.

Currently, these robust scanning virtual microscopes are small and do not need a dedicated location in a lab. The price of these machines dropped dramatically for basic models, and universities do not need to purchase their own, as they can rent access to online databases, or they can send their own slides for scanning by other universities.

The software is designed to render a simple mirror of reality. It provides on-screen slide annotation and measurement along with basic magnification buttons (×4, ×10, ×40 and ×100) (Picture 1). The web-based archive can be accessed off-campus at the students' convenience, as long as the student has internet access.

Vendors often exhaust the tissue sections for the sake of profit, and multiple levels are attained, many of which are neither ideal nor uniform.

Materials and Methods

We randomly assigned two groups of students (20 students in each group) from the second-year at the University of Tabuk in KSA in the Faculty of Medicine. These students have the same average level of knowledge and skills.

The learning objectives for the practical sessions are chosen from the syllabus for second-year students, which covers the general pathology section of the Abnormal Human Morphology module. The first group participated in a classic light microscopy session (LM), and the second group participated in a virtual microscopy session (VM). The space, study material content, and number of tutors were matched. The two groups answered 10 short multiple choice questions (MCQs), followed by a 5-question objective structured practical examination (OSPE) one week later after the sessions.

In the stem of the MCQs, we provided students with clinical case scenarios with snapshots from histopathological slides from the VM database for both groups. The time allowed for the MCQs exam was 15 min. The OSPE consisted of 5 stations that were allowed 90 s each for 9 min of total time, including one rest station. The format consisted of either LM or VM slides for the LM and the VM groups, respectively, and the questions were to provide histological description and diagnosis. The MCQs and the OSPE were invigilated by 6 staff members, and the students were spread out 2 m apart during the exams.

Students' apprehension of knowledge and skills via LM and VM was compared through a t-test. Student exposure time to off-campus study materials in the VM was assessed through a feedback questionnaire, and lab-time access in the LM groups was assessed through staff observations. The data were analysed statistically with the aid of SPSS and Microsoft Excel software.

Results

Twenty students were assigned to each group. In the conventional LM group, the average scores for the written exam and the OSPE were 78 and 76, respectively, and the average written and OSPE scores for the VM group were 88 and 90, respectively.

The range of the scores for the LM group was 33 and 28 for the MCQs and OSPE, and the range was 15 for both in the VM group. The minimum score for the MCQs was 59 for the LM group and 79 for the VM group, and the maximum score was 92 and 94, respectively; the OSPE minimum score for the LM group was 60, and that for the VM group was 81; the maximum scores were 88 and 96, respectively.

The dispersion of the scores for the conventional light microscopy sessions was 2–3 times the standard deviation of the virtual microscopy group (Table 1).

Correlation and cross-tabulation between the LM and VM groups showed statistically significant differences between the students' performances in both MCQs and OSPE (P = 0.000) in favour of VM.

The VM group spent an average of 2.5 h off campus reviewing study materials; two students did not access the VM materials, and one student maximally spent 5 h reviewing the VM materials (Figure 1).

Discussion

This is the first study regarding the utilization of the VM in pathology and basic-science education in Saudi Arabian universities. Launching a new teaching methodology requires testing the methodology's validity and learning outcomes. This pilot study evaluated the acceptance of the VM and its learning outcomes compared with the conventional LM. The students' performances in our study in the VM group were better than those of the conventional LM group. Tutors appreciate more interest and enthusiasm during the sessions in the VM groups than in the LM groups.

In a study in Germany, students appreciated the “Whole Slide Imaging functionality, points of interest, auxiliary informational texts, and annotations”. A research group from the US found superior performance by VM students in a haematology course. Research from China found VM “to be an effective and efficient educational strategy”. Another study from China showed only statistically significant differences in the case analysis and the identification of structure in favour of VM, but performance in MCQs and short assay questions was negligible. The potential advantages of VM include active student engagement in sessions with one or up to three students per PC, increased depth and breadth of coverage of learning objectives, and the practicability of self-directed learning. Some researchers have found that students' performances are comparable to their previous performances regardless of the learning method assigned.

VM has its own drawbacks, including the neglect of LM skills and frequent technical troubleshooting. The virtual microscopic slides require an enormous amount of computer memory for storage, and the use of free internet resources requires a fast internet speed. We have chosen a timeframe for the session after consulting the IT office to determine the most convenient timeframe that affords the highest available bandwidth. The difference in student performance between the two groups may be attributed to students' off-campus access to the VM slides, as the links were provided to students during the session. Other researchers stated that students found the off-campus use of VM slides convenient. The feedback from the VM group indicated that 90% of students reviewed the VM slides off campus at least once before the exam. The average time spent by VM students accessing VM review materials was 2.5 h. In the LM group, students could book a time to access the study materials on campus, but none of them came to any such appointments.

Students gained skills for the use of the VM materials swiftly, which ameliorated any familiarity bias regarding the use of the microscope in the LM group. This notion reflected the shallow learning curve for the VM group. In contrast, in our own experience the LM group's skills and etiquette had a steep learning curve, and often valuable time during the sessions was dedicated to adjusting the microscopes' fields, power and focus. The students' feedback reflected the ease of use and the functionality of the virtual microscope as an educational tool. The duration of the sessions can be reduced, or students can spend extra time in validating the skills attained. Students showed more-uniform performance in the VM group than the LM group, which was reflected by the smaller standard deviation and the narrow range of scores in both MCQs and OSPE. The current trend is to validate electronic learning methods in a control environment that eliminates bias and infatuation; the current trend also entails an ongoing validation of simulation-based education. The classic LM enthusiast argues against the use of simulators, claiming that they can fundamentally alter the essence of medical education, and in contrast, technology aficionados may be infatuated with new inventions and be too quick to adopt new technologies without validating them. This can cripple students' abilities to adapt and deal with real-life situations.

Collier et al. surveyed teaching assistants for their acceptance of VM use as a teaching tool for undergraduate students in histology. The researchers measured acceptance by analysing the teaching assistants' responses to a list of 14 questions. They advocated the use of VM besides providing the students with access to LM. Some researchers affirmed that VM “can effectively replace the traditional methods of learning pathology”. The impact of using VM is a reduction in expenses while maintaining educational outcomes.

Students appreciated the ease of using VM vs. LM and found the former more interactive and that continuous feedback from tutors minimizes boredom and knowledge gaps. Two students in the VM group failed to access the VM study materials off campus. Debriefing revealed drawbacks such as slow domiciliary internet connection and technical troubleshooting. These shortcomings can be solved by providing on-campus Wi-Fi hotspots in libraries and reading classrooms, and the technical troubles can be alleviated through continuous auditing and through training for staff and students. We advocate the use of both LM and VM methods as educational tools in academic teaching, as they both have merits. This trend reflects the current popular attitude that stresses blending both approaches. The establishment of a VM atlas requires three steps: the digitalization of conventional slides (a single slide is sufficient for generating a representative digital image), the use of its advantages and its off-campus availability. Although free-access atlases on the web could be used pending the completion of the project, collaboration between multiple universities can hasten the process.

The limitations of this study include the small number of students in the samples and the fact that it was restricted to male students. Female students' participation may add another perspective to this study. Furthermore, the timeframe was short, and the material taught was relatively brief; a more elaborate curriculum-wide study is warranted.

Conclusion

The students' performances in both MCQs and OSPE in VM was better than in LM. Grades are more uniform, and their scatter shows less dispersion for the VM group than the for LM group.

The VM stands as a credible supplementary tool for practical sessions that can augment the LM as educational tools.

The feasibility of accessing the VM study material and resources off-campus increases the exposure time for the study materials.

Conflict of interest

The author has no conflict of interest to declare.

Authors' contributions

The Author has formulated the concept and design, collected the data, analyzed and presented the results. The author drafted, revised and approved the manuscript before submission. The author agreed and complies with the terms and guidelines of the publisher regarding penalties and sanctions upon detection of plagiarism.