Enhancing Learning Objectives by use of simple Virtual Microscopic slides in Cellular physiology and Histology; Impact and attitude

Teaching In The Laboratory

Enhancing learning objectives by use of simple virtual microscopic slidesin cellular physiology and histology: impact and attitudes

Godson Emeka Anyanwu,1 Augustine Uchechukwu Agu,1 and Ugochukwu Bond Anyaehie2

1Department of Anatomy, College of Medicine, University of Nigeria, Enugu; and 2Department of Physiology, Collegeof Medicine, University of Nigeria, Enugu, Nigeria

Submitted 20 January 2012; accepted in final form 12 April 2012

Anyanwu GE, Agu AU, Anyaehie UB. Enhancing learning ob-jectives by use of simple virtual microscopic slides in cellular phys-iology and histology: impact and attitudes. Adv Physiol Educ 36:158–163, 2012; doi:10.1152/advan.00008.2012.—The impact andperception of students on the use of a simple, low technology-drivenversion of a virtual microscope in teaching and assessments in cellularphysiology and histology were studied. Its impact on the time andresources of the faculty were also assessed. Simple virtual slidesand conventional microscopes were used to conduct the sameexaminations for the same students. Students performed signifi-cantly better in the examination with the virtual slide and alsoshowed a significantly higher preference for virtual slides. Thetime and cost implications of conducting examinations using thesimple virtual slides were reduced by �1,400%. The results reem-phasize the need for the design and adoption of simple sustainabletechnological innovations in developing countries to bridge gaps inpurposeful learning environments.

virtual reality; teaching and learning strategies; PowerPoint-mediatedcommunication; virtual microscopy

THE CUMBERSOME PROCESS and limitations associated with the view-ing of traditional microscopes and the problems of archiving,movement, and replacement of glass slides have become a chal-lenge in the teaching of histology and cellular physiology and alsothe assessment of student performance. These challenges are welldocumented (17, 20, 24). Therefore, many universities have ad-opted various approaches to this (4, 7, 10), with the most currentbeing virtual microscopy (8, 12, 13, 16, 19). The use of virtualmicroscopy has been popularized in institutions with robust econ-omies, and its advantages have been well researched (4, 5, 7, 8).A virtual slide is a digitally captured glass slide that is composedof high-resolution images that can be viewed, panned, andzoomed on a computer screen.

In histology and cellular physiology education, virtual mi-croscopy has been associated with the elimination of the skillbarrier for students overwhelmed with the material and inter-pretation of specimens using a microscope (17), teaching largegroups of students (5), resolution of problems associated withslide variability (17), and maintenance of high-quality slidesfor all students (4). Today, several advanced and highly ex-pensive technologies are being used in the creation of thesevirtual slides, some of which are area-scanning and line-scanning systems.

Teaching and learning in developing countries have beencharacterized by the problem of an overpopulation of students

(1). Classroom facilities, laboratories, equipment, reagents,teaching materials, and personnel are usually inadequate. Inour institution, the histology and cellular physiology laboratorytakes care of three groups of students from three differentfaculties: medicine and surgery students from the Faculty ofMedicine, dentistry students from the Faculty of Dentistry, andmedical laboratory students from the Faculty of Health Sci-ences. Coordination of lectures, practical, tutorials, and exam-inations has become increasingly difficult. Students are brokeninto small groups during practical sessions to enable adequateexposure to the available microscopes and slides. Inadver-tently, this increases the number of hours and energy spent inteaching. This has resulted to heavy expenditures in the de-partment incurred through producing and constantly replacingworn out glass slides and purchasing, repairing, and replacingmicroscopes.

Topmost in the options considered in our search for a wayout of the present challenges was the use of virtual microscopy.As good as this option appeared, its adoption in our system didnot seem immediate as a result of the cost of creating andmaintaining virtual slides, which is well beyond the limitedbudget available to the faculty (a typical situation for mostuniversities in developing nations). With our inability to pro-duce the normal conventional virtual microscopy, our focuswas redirected toward creating a simple, low technology-driven version of a virtual microscope (SLTDVM) that wouldbe able to ensure the availability of standard slides in variousstain preparations, multiple sections of the various parts of thetissue, and at various magnifications.

We hypothesized that a cheap replication of the advantagesof the conventional virtual slides in our environment wouldimprove the overall quality of our practical examinationthrough reductions in time and energy input and improvementsin visual clarity of the slides. This virtual slide could be set upin the class with a projection apparatus, and each image couldbe commonly treated by the lecturer, thereby avoiding theproblem where each student’s interpretation of the details ofeach image was subject to what was viewed in each micro-scope. Students could also store these virtual slides in theircomputers and study them anytime and anywhere. They couldalso simply connect to the departmental website for theirindividual studies. These virtual slides also take care of prob-lems associated with physical bulk of the glass slides andmicroscopes as well as storage and accessibility. With theseproperties in view, we also hypothesized that the simple virtualslides would be perceived as better learning material than thetraditional microscope. The virtual slides were designed to givean exciting approach to histology and cellular physiologycourses, which would increase students’ interest and participa-

Address for reprint requests and other correspondence: G. E. Anyanwu,Dept. of Anatomy, College of Medicine, Univ. of Nigeria, Enugu Campus,Enugu, Nigeria (e-mail: [email protected]).

Adv Physiol Educ 36: 158–163, 2012;doi:10.1152/advan.00008.2012.

158 1043-4046/12 Copyright © 2012 The American Physiological Society

tion in the courses. By their features, they would also stimulatepeer review of slides at the students’ comfort and convenience.With these in consideration, we also hypothesized that studentswould perceive it as measure that would encourage groupinteractions toward enhancing their knowledge of the courseswith lesser difficulty.

MATERIALS AND METHODS

Preparation of the SLTDVM. Photomicrographic images of varioustissues (in different sections, with different stains and preparations,and at various magnifications) in the curriculum were made using anOlympus BH-2 BHS research microscope. Additional images weredownloaded from histol.chuvashia.com and histol.narod.ru after duepermission was granted. These scanned images were annotated andcompiled into a file using PowerPoint software. The images weregrouped according to systems and topics. They were compiled in sucha way that the desired slides could be projected on the screen duringlectures, practical sessions, tutorials, and examinations. Various im-ages of each tissue, in different magnifications with different stainsand focused areas, made up the different sections of the file. Electronmicroscopic images that were usually unavailable in the laboratorydue to our inability to own an electron microscope were also madeavailable in these virtual slides for some of the tissues. Unlike ourtraditional microscopy box with an average of 100 slides, a file of thisSLTDVM is made up of �250 virtual slides. Some samples of theseslides are shown in Fig. 1. As an initial step to the introduction of thisnew program, we decided to assess its academic quality, student

perceptions, and the difference its adoption made in the operations ofthe department in terms of time and manpower need during practicalexaminations. We also aimed to determine the perception of visuallyimpaired students to the adoption of this program and its effect onstudent performance in practical histology examinations.

Participants. A total of 280 undergraduate medical students of theFaculty of Medical Sciences of the University of Nigeria (EnuguCampus) participated in this study.

Procedures. Students had been exposed to two semesters of theundergraduate histology curriculum for their medical program throughdidactic teachings and practical sessions. The practical sessions werecarried out using light microscopes with a minimum of six students toa microscope. Notice of a histology practical examination was givento the students 2 wk ahead of time. Twenty slides drawn from topicsacross the curriculum were selected for the assessment. Each slide hadtwo questions, which ranged from the identification of whole slide,focused areas of the slide, and statement of functions.

The examination was done in two phases for the same set ofstudents. The first phase involved the use of a conventional micro-scope. Twenty light microscopes were mounted with the selectedslides on different bench stations. The assessment was conductedusing the traditional steeple-chase examination method. One minutewas assigned for viewing and answering of questions of each slide.

In the second phase of the examination, virtual slides from ourSLTDVM, which were same with the 20 traditional microscopicslides used in the first phase of the examination, were used. The samehistological stains, magnification, focused areas of slides, and questionsused in the first phase of the examination were repeated in these virtual

Fig. 1. 1 Samples of slides from the bone section of the virtual slide file as well as samples of slides used in the virtual slide examination.

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159ENHANCING LEARNING OBJECTIVES USING SIMPLE VIRTUAL SLIDES

Advances in Physiology Education • VOL 36 • JUNE 2012

slides. Students were not made aware that they were repeating the sameexamination. They were informed that the second phase of the examina-tion was a continuation of the first part. The sequence of the slides wasalso consciously juggled to loose similarity with the first part of theexam. The slides and questions were then projected onto the screenusing an electronic projector (Acer XD1170D). All students answeredthe questions at the same time. One minute was allowed before thetransition to the next slide.

Both examinations were carried out the same day. Questionnaireswere distributed to the students to complete. Student performance inboth methods was assessed independently by the authors. The samemarking schemes were used for both methods, and the examiners wereblind to the group to which the scripts belonged. Repeat students anddirect entry students were excluded from this study. This study wasapproved by the Ethics Committee of the department.

Statistical analysis. The data generated from the assessment, withstudent responses to the questionnaires, were analyzed using SPSS(version 15.0).

RESULTS

Of the 280 students that qualified to do this study, only thedata of 265 students that completed the study were analyzed.The examination using virtual slides lasted for only 20 min,whereas the conventional microscopy examination lasted for285 min. The performance of the students was significantlyhigher in the virtual slide examination (P � 0.001), with themean percentage score in the virtual slide examination being52.3 � 18.2 and that for the traditional slide examination being48.7 � 16.8. The 5th, 50th, and 95th percentile scores in thevirtual slide examination were 23.8, 52.5, and 83.1, respec-tively, whereas those for the traditional slide examination were20.6, 47.5, and 76.9, respectively. Table 1 shows studentresponses to the questionnaire. The mean scores of the differ-ent groups of respondents in both methods are also included.

Table 1. Summary of the distribution of student responses to the questionnaire and mean attendence scores in the examinations

Frequency, %

Mean Scores

VSexamination, %

Traditional slideexamination, %

Do you think you would understand histology better using VS rather than microscopes?Yes 67.7 53.1 � 17 48.8 � 17No 25.3 48.9 � 19 47.7 � 16Not sure 7.0 57.1 � 17 55.1 � 14

Do you have any problem with the present way of learning histology slides using microscopes only?Yes 78.7 51.8 � 18 47.9 � 16No 21.3 53.9 � 19 52.2 � 17

Do you think a combination of both methods will enhance learning?Yes 84.8 53.2 � 18 49.4 � 17No 11.7 48.1 � 11 46.6 � 14Not sure 3.5 42.0 � 19 44.4 � 18

Do you think you stand better chances of passing a histology practical examination if the VS areprojected using PowerPoint?

Yes 72.8 54.9 � 18 49.1 � 16No 13.6 45.3 � 19 48.5 � 17Not sure 13.6 48.1 � 14 51.1 � 17

Which of the below would you prefer? (choose only one)A. Do both teaching and examination with projected VS alone. 15.2 49.4 � 21 45.6 � 14B. Do both teaching and examination with microscopes alone. 3.9 45.0 � 11 48.8 � 18C. Teach with microscopes but examine with projected VS. 3.1 57.8 � 12 52.3 � 17D. Teach with projected VS but use microscopes to examine. 1.7 57.0833 40.0 � 4E. Use both methods for teaching but examine with projected VS. 52.4 55.6650 50.1 � 17F. Use both methods for teaching but conduct examine with microscopes. 23.6 47.080 48.9 � 17

Do you think the time conserved using PowerPoint to do examinations is any additional advantage?Yes 66.5 55.8 � 18 50.6 � 16No 23.3 45.7 � 16 46.7 � 17Not sure 10.1 46.4 � 13 43.3 � 17

Do you think the energy preserved using projected VS to conduct the examination can affect yourability to perform better?

Yes 70.7 52.5 � 18 49.4 � 17No 19.2 52.5 � 19 46.4 � 17Not sure 10.0 51.4 � 18 50.1 � 17

Do you think using these VS at home will increase your ability to revise your work and do more privatestudies?

Yes 79.7 55.1 � 17 48.0 � 17No 15.5 51.9 � 19 47.7 � 15Not sure 4.8 54.1 � 17 52.1 � 13

Do you think learning with VS will encourage peer tutorials?Yes 85.0 58.5 � 18 49.7 � 14No 11.6 47.5 � 17 47.3 � 15Not sure 3.4 46.1 � 15 52.1 � 16

In which of the two methods was it easier to identify structures?Traditional slides 28.8 46.4 � 17 47.7 � 18VS 71.2 54.9 � 18 49.6 � 16

Values are means � SE. VS, virtual slides. Significance was determined by a paired-sample t-test (significant at P � 0.01 and P � 0.05).

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An overview of these responses showed that the studentsstrongly supported the inclusion of use of SLTDVM in thehistology and cellular physiology laboratory. Table 1 alsoshows a comparison of the various views of the students withtheir academic performance. Irrespective of the views, theacademic output was better with the virtual slides (P � 0.01and P � 0.05).

To assess the impact of the two methods on the academicperformance of visually impaired students, students with clin-ically diagnosed cases of visual impairment were separated,and this accounted for 27.2% (72 students) of the studentsample. Table 2 shows a summary of the comparative scores ofstudents with and without eye problems in the two methods.While the scores of these students were still significantly betterwith the virtual slides (P � 0.05), the difference between thosewith eye problem and those without in both methods was notsignificant.

DISCUSSION

Most of the challenges highlighted in our histology andcellular physiology laboratory have also been noted in manyother institutions (4, 5, 17, 22). While many institutions indeveloped countries have adopted the use of virtual micros-copy (4, 5, 12), some authors have viewed this trend withreservations, expressing fear of the complete loss of traditionalmicroscopy skills to virtual microscopy (6, 21, 23).

The invention of the microscope in 1590 opened up the fieldof cytology and histology. From this period until now, so manytechnological advancements have been noted in the teachingand practice of this course. The invention of projectors at thebeginning of 20th century, for the first time, made it possible toproject microscopic specimens onto screens (27); this has alsobeen extensively explored in other fields of learning (2, 3). Theadvent of photomicrographs also led to further appreciation ofthese microscopic structures without viewing directly from themicroscope. By the late 1980s, digital tiles (the earliest tech-nology for obtaining multiple macroscopic fields of view) wereintroduced (26, 30), and digital slides were developed (17).With notable advancements in computer technology and thedevelopment of software that can scan and copy glass slideimages, digital slides gave rise to virtual microscopy (11, 29).Today, various forms of virtual microscopy are available (8,14, 17).

In our study, �78% of the participants agreed that they werehaving problems with the present method of studying histologythrough traditional microscopy. This same view has been notedamong students in various parts of the world (4, 12, 15, 16).Such dissatisfaction could arise from reasons such as theinability of students to afford personal microscopes (whichwould ensure a review of these slides during their privatestudying hours), the insufficiency of glass slides, problemsassociated with moving microscopes around, difficulty of ac-quiring microscopy skills, etc.

The results of this study show a high preference for learninghistology and cellular physiology with virtual slides (67%),although a large number of students (84%) also desired thecombination of both methods. Irrespective of the preferences,students performed better using the virtual slides. The essentialroles that peer tutoring, revision, and personal studies play inenhancing learning are well documented (25, 28). The SLTDVMpresented in this work has the advantage of being readilyavailable, affordable, and convenient to use. These qualitiesallow the creation of an academic environment and practicesthat support peer tutoring, personal revision, and studies. Anyinnovation that accentuates these aspects of learning should beencouraged in the system and further explored. The gooddisposition of the students to the introduction of this form ofvirtual slide in the teaching and examination of histology,coupled with the better performance of students in the same,shows that virtual slides irrespective of the level of technolog-ical advancement incorporated is a tool to improve teachingand examination in histology, cellular physiology, pathology,histopathology, and other related fields. This is most needed indeveloping countries to address the prevailing issues of a highstudent-to-lecturer ratio, inadequate number of technical staffand facilities, low budget for funding laboratories, and otherendemic problems peculiar to medical training in low-incomenations (1). The virtual slide collections also made it possiblefor the department to present views of electron microscopicimages of structures to the students, even though we do nothave a single electron microscope.

The time spent in conducting the traditional slide examina-tion (which is also a reflection of the energy input) was �5 h,whereas the virtual slide examination was done in �0.5 h. Thisis a �1,400% reduction in energy and time. The numbers ofstudents involved in these practical examinations (traditional slideexamination) usually determine the duration. During the secondMBBS/BDS examinations for Medicine and Dentistry students,the department mounts practical histology examination for thesetwo faculties, and because of the number of students involved,members of staff and students will usually spend �10 h inrunning the steeple-chase examination. While running theseexaminations, students’ movements during the hours of wait-ing for their turns are usually regimented, and, most often, theweariness of such long hours, as noted in this work, affects thestudent’s performance negatively. This weariness does notaffect the students alone but also the staff. Expectedly, �70%of the students felt that they could do better if spared this longwait, and 66% also agreed that being mentally and physicallyrefreshed before writing the examination was an additionaladvantage. We do not need to wait until we acquire high-resolution digital images stored in a multiresolution file formatwith microscope simulators to save our staff and students thiswhole situation and trauma.

Table 2. Comparative scores of participants with andwithout diagnosed eye problems in the assessment with VSand traditional microscopic methods

StatisticalParameters

VS Scores, %Traditional Microscope

Scores, %

With eyeproblems

Without eyeproblems

With eyeproblems

Without eyeproblems

Mean 52.7 52.5 47.6 49.6Median 51.3 53.8 46.3 48.8Mode 33.8 58.8 15.0 47.5SD 20.1 17.2 19.4 15.4Percentile

5th 23.0 24.6 15.0 25.050th 51.3 53.8 46.3 48.895th 86.3 82.9 81.0 74.3

Significance was determined by a paired-sample t-test (at P � 0.05).

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Advances in Physiology Education • VOL 36 • JUNE 2012

The identification of structures using our simple virtualslides projected onto the screen was noted by the majority ofthe students to be much easier. This view was substantiated bytheir performance and in other researches (4, 10, 13). Consid-ering that the students studied these tissues using the conven-tional microscope, it would have been expected that theirperformances in the traditional slide examination should bemuch better, which was not the case. This is an indication thatuse of the virtual slides may be a much better teaching methodthan traditional slides.

Further evidence of this improved learning outcome usingvirtual slides is shown in Table 3. By using our SLTDVM inconducting histology examination, we were able to bridge thegap between the candidates with eye problems and thosewithout. This was shown by the insignificant difference be-tween the means of the candidates with and without eyeproblems in the virtual slide examination (P � 0.05). This was notthe same for the traditional slide examination. The percentage ofstudents (27.2%) diagnosed with visual impairment indicate agood proportion of the class that could suffer disadvantages ifvisual conditions of the slides are not improved. For most of theeye defects noted in this study, student performances were betterin the projected simple virtual slides. Our SLTDVM can reducethe problems of insufficiency of both microscope and glass slideson the part of both students and the department. The problemwhere students imagine and try to figure out structures taught onthe board or structures being viewed in the slide of the lightmicroscope are eliminated. This is because the lecturer is able topoint out all the details of the tissue in question using oneprojected virtual slide for everybody. Students can relate with thelecturer and with one another based on what has been commonlypresented to them on the screen, thereby fostering much-desiredteam-based learning (10).

Conclusions. In summary, this system is a step toward theachievement of curriculum reform in medical schools world-wide, which is focused on a reduction in contact hours, de-compression of crowded programs, increased emphasis onindependent learning, development of interpersonal skills, andproblem solving (9, 31). Acknowledged is the fact that oursimple virtual slide cannot be rated to be as good, effective, andefficient as conventional virtual microscopy, but we still ap-preciate the difference this little innovation can make to bothstaff and students in the teaching of histology and cellularphysiology in our environment. Encouraged by this success,we recommend this to schools that may be in similar situations.This study also shows that a good number of the students arestill interested in conventional microscopes; therefore, whilewe promote the convenience and efficacy of our simple virtualslide and its introduction to schools, we do not advise the totaldiscontinuation of the use of the traditional microscope. Werecommend its adoption as a supplementary measure in theteaching of histology, as a result of the importance of acquiringthe skills and practical knowledge of microscopy.

ACKNOWLEDGMENTS

The authors deeply appreciate and acknowledge Andrei Gunin and crew forgranting permission to use the photomicrographs in their web link (histol.chuvashia.com; histol.narod.ru) to achieve this educational goal.

DISCLOSURES

No conflicts of interest, financial or otherwise, are declared by the author(s).

AUTHOR CONTRIBUTIONS

G.E.A. conception and design of research; G.E.A. and A.U.A. performedexperiments; G.E.A. analyzed data; G.E.A., A.U.A., and U.B.A. interpreted resultsof experiments; G.E.A. prepared figures; G.E.A. and U.B.A. approved finalversion of manuscript; A.U.A. drafted manuscript; U.B.A. edited and revisedmanuscript.

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