Experience with Virtual Slides at Stanford Medical School: Perspective of a Medical Educator Andrew Connolly, MD, PhD Director of Medical School Laboratories.

Experience with Virtual Slides at Stanford Experience with Virtual Slides at Stanford Medical School:Medical School:

Perspective of a Medical EducatorPerspective of a Medical Educator

Andrew Connolly, MD, PhDAndrew Connolly, MD, PhDDirector of Medical School LaboratoriesDirector of Medical School LaboratoriesStanford University School of MedicineStanford University School of Medicine

Medical School Medical School NewNew Curriculum: Curriculum:Integrated, Flexible, Broad, ProlongedIntegrated, Flexible, Broad, Prolonged

1)1) Started in 2004 at Stanford. Similar to the trend at Started in 2004 at Stanford. Similar to the trend at many med schools. many med schools.

2)2) IntegratedIntegrated curriculum with organ system approach curriculum with organ system approach teaching anatomy, histology, physiology, pathology, teaching anatomy, histology, physiology, pathology, and clinical practice all together. More efficient for and clinical practice all together. More efficient for more material.more material.

3)3) FlexibleFlexible: Most students take 5 years and individually : Most students take 5 years and individually tailor their curriculum. We want more diversity of tailor their curriculum. We want more diversity of outcome. Digital curriculum lends more flexibility.outcome. Digital curriculum lends more flexibility.

4)4) BroadBroad: All students are required to develop an : All students are required to develop an individual scholarly concentration and perform individual scholarly concentration and perform research.research.

5)5) ProlongedProlonged: Didactics extend into 3rd and 4th year : Didactics extend into 3rd and 4th year Emphasize life-long learning, CME. (rumors of the Emphasize life-long learning, CME. (rumors of the Boards exam changing to one later Gateway exam).Boards exam changing to one later Gateway exam).

Medical School New Curriculum:Medical School New Curriculum:IssuesIssues

• Integrated curriculum has less time available for basic Integrated curriculum has less time available for basic science. Relevance is critically evaluated for all basic science. Relevance is critically evaluated for all basic science training. Quality has to be excellent.science training. Quality has to be excellent.

• Integrated curriculum is actually less flexible for Integrated curriculum is actually less flexible for course selections for students. Need to counteract course selections for students. Need to counteract this with new methods.this with new methods.

• More use of M.D. instructors. Efficiency is key.More use of M.D. instructors. Efficiency is key.

• Our target audiences of students are accustomed to Our target audiences of students are accustomed to digital media.digital media.

Stanford Medical StudentsStanford Medical Students1)1) Lectures attended by only 30/86 med students on Lectures attended by only 30/86 med students on

average. Most of the rest view the lecture on webcast average. Most of the rest view the lecture on webcast later, with pause and speed control, the hardcopy of later, with pause and speed control, the hardcopy of notes and Powerpoint in front of them.notes and Powerpoint in front of them.

2)2) The web has become the primary source of The web has become the primary source of information. Only 50% of students buy the required information. Only 50% of students buy the required textbook. The others go to the electronic version textbook. The others go to the electronic version online. online.

3)3) Case-based small group session attendance is Case-based small group session attendance is mandatory, and this has become the only live mandatory, and this has become the only live experience for many of them in the first two years. We experience for many of them in the first two years. We are trying to increase active learning settings, and are trying to increase active learning settings, and emphasize communication and professionalism.emphasize communication and professionalism.

4)4) Very interactive through digital means.Very interactive through digital means.

Students’ Multimedia ApproachStudents’ Multimedia Approach

Benefits of Virtual Slides in Med SchoolBenefits of Virtual Slides in Med School

1)1) The slides are uniform, high quality, easily The slides are uniform, high quality, easily distributed and can be linked to other digital distributed and can be linked to other digital content.content.

2)2) Able to distribute the material to the Able to distribute the material to the students in a flexible curriculum over students in a flexible curriculum over several years.several years.

3)3) Increasing efficiency of instruction. Many Increasing efficiency of instruction. Many busy expert M.D. instructors are being used busy expert M.D. instructors are being used in integrated curriculum. Team-based in integrated curriculum. Team-based learning can benefit from virtual slides.learning can benefit from virtual slides.

4)4) Ability to share materials between schools.Ability to share materials between schools.

Problems of Virtual Slides in Med SchoolProblems of Virtual Slides in Med School

1)1) Technical support required and technical Technical support required and technical difficulties arise. (Should lessen with time)difficulties arise. (Should lessen with time)

2)2) Decreased proficiency of students with Decreased proficiency of students with microscopes. (problem?)microscopes. (problem?)

3)3) Digital shortcuts in problem-based learning Digital shortcuts in problem-based learning and improper sharing. (The rules need to and improper sharing. (The rules need to be clear; switching cases among med be clear; switching cases among med schools will help)schools will help)

4)4) Unclear effects on interpersonal skills. Unclear effects on interpersonal skills. What are the new group settings? Effects What are the new group settings? Effects of email, IM, iChat, video conferencing, of email, IM, iChat, video conferencing, social networking sites.social networking sites.

Most popular sites for Pathology studyMost popular sites for Pathology study

1)1) Course Content website (Blackboard)Course Content website (Blackboard)• Learning Objectives.Learning Objectives.• Syllabus. Handouts.Syllabus. Handouts.

• Problem sets.Problem sets.

2)2) Online Textbooks (must be free)Online Textbooks (must be free)

3)3) Google (and hunt for best resource)Google (and hunt for best resource)

4)4) WikipediaWikipedia

5)5) Instant Message a friend online.Instant Message a friend online.

6)6) Webpath (suggested by Course)Webpath (suggested by Course)

7)7) Iowa Virtual Slidebox (suggested by Course)Iowa Virtual Slidebox (suggested by Course)

Our library: The digital resource hubOur library: The digital resource hub

Robbins onlineRobbins online

Students prefer to browse and get frustrated with online Students prefer to browse and get frustrated with online materials that aren’t immediate, free, and without login.materials that aren’t immediate, free, and without login.

Our Educational Uses of Virtual SlidesOur Educational Uses of Virtual Slides1)1) Course website with 24/7 access to histology & Course website with 24/7 access to histology &

histopathology slides with associated digital content.histopathology slides with associated digital content.

2)2) Use of virtual slide unknowns for problem-based learning Use of virtual slide unknowns for problem-based learning and exams.and exams.

3)3) Recorded narrated movies (in Camtasia or Captivate) of Recorded narrated movies (in Camtasia or Captivate) of expert tour of virtual slides usually of ImageScope expert tour of virtual slides usually of ImageScope window.window.

4)4) Team-based learning using sharing of slides between Team-based learning using sharing of slides between laptops and central projector (SynchronEyes).laptops and central projector (SynchronEyes).

5)5) Use of virtual slides extended to Pathology post-graduate Use of virtual slides extended to Pathology post-graduate medical education (residents) and assessment.medical education (residents) and assessment.

6)6) Use of virtual slides in CME courses run by our Use of virtual slides in CME courses run by our Pathology Department.Pathology Department.

Team-based LearningTeam-based Learning

Modern Lab SpaceModern Lab Space

Stanford Virtual Slide ProjectStanford Virtual Slide Project

Assets: Assets: 1)1) An Aperio T2 ScanScope robotic slide scanner at An Aperio T2 ScanScope robotic slide scanner at

the Palo Alto VA Hospital.the Palo Alto VA Hospital.2)2) Some tech-savvy pathologists and students.Some tech-savvy pathologists and students.

Problems: Problems: 1)1) Modest support from the educational technology Modest support from the educational technology

folks. We bought and support our own server (and folks. We bought and support our own server (and now use it for much post-graduate training).now use it for much post-graduate training).

2)2) Very time-consuming during start up. Sharing Very time-consuming during start up. Sharing materials among schools should make this easier.materials among schools should make this easier.

The Virtual Slide DetailsThe Virtual Slide Details1)1) Glass slides are selected that are suitable. (Some Glass slides are selected that are suitable. (Some

don’t work due to slide thickness, coverslip don’t work due to slide thickness, coverslip aberrations, air bubbles, poor tissue prep)aberrations, air bubbles, poor tissue prep)

2)2) Scanning is performed using Scanning is performed using 40x40x objective in objective in SVSJPEG (1inch x 3/4 inch; 100,000 x 75,000 SVSJPEG (1inch x 3/4 inch; 100,000 x 75,000 pixels; 500 MB for many)pixels; 500 MB for many)

3)3) SVSJPEG files are converted to easily served SVSJPEG files are converted to easily served folders of JPEGs:folders of JPEGs:

• CWS format (with Digital Slide Studio) or CWS format (with Digital Slide Studio) or • Zoomify conversion of .svs (SVSJPEG) renamed .tifZoomify conversion of .svs (SVSJPEG) renamed .tif

4)4) Our server running Apache uses HTML files to Our server running Apache uses HTML files to allow the user to see virtual slides either in a allow the user to see virtual slides either in a browser window (via FlashPlayer) or as a browser window (via FlashPlayer) or as a connection to the ImageScope client software.connection to the ImageScope client software.

5)5) Slides are very fast on campus (with Gigabit Slides are very fast on campus (with Gigabit networking) and slow off campus. Students can’t networking) and slow off campus. Students can’t resist downloading whole slides with ImageScope.resist downloading whole slides with ImageScope.

The ServerThe Server1)1) Typical Dell PowerEdge Server with internal hard drives Typical Dell PowerEdge Server with internal hard drives

and attached rack of hard drives.and attached rack of hard drives.2)2) Performance helped by:Performance helped by:

• More memory (>8GB)More memory (>8GB)• Preloading of INI files to memory.Preloading of INI files to memory.• Fast internal SCSI drives with cache of most commonly used Fast internal SCSI drives with cache of most commonly used

slides.slides.• Switch to Linux and XFS file system.Switch to Linux and XFS file system.

3)3) Troubles:Troubles:• Networking issues: Security, bandwidth, firewall, style.Networking issues: Security, bandwidth, firewall, style.• Image loading speed slowed mostly by clients’ connection Image loading speed slowed mostly by clients’ connection

speed. speed. • Inconvenience of Linux for server-side applications (requiring us Inconvenience of Linux for server-side applications (requiring us

to run Windows with VMware)to run Windows with VMware)

4)4) Questions:Questions:• CWS vs. Zoomify system of JPEGs?CWS vs. Zoomify system of JPEGs?• Linux vs. Windows server?Linux vs. Windows server?• Flash vs. Java vs. Client software?Flash vs. Java vs. Client software?• Scalability and capacity?Scalability and capacity?

Organ System PagesOrgan System Pages

Virtual Slides FolderVirtual Slides Folder

Disease PagesDisease Pages

Virtual Slide Guide PagesVirtual Slide Guide Pages

Browser (Flash)-based Virtual SlidesBrowser (Flash)-based Virtual Slides

Client Software-based Virtual SlidesClient Software-based Virtual Slides

Section thickness: Section thickness: Depends on what you want to showDepends on what you want to show

Gland: 5 micronsGland: 2 microns Gland: 12 microns

Urge to improve slide composition: Urge to improve slide composition: Due to better low power, more links, sharingDue to better low power, more links, sharing

Need for HIPAA compliance in Education:Need for HIPAA compliance in Education:

1)1) No patient names or identifiersNo patient names or identifiers

2)2) No surgical pathology numbers.No surgical pathology numbers.

3)3) Beware of names of files or enclosed data in Beware of names of files or enclosed data in image files.image files.

Copyright Issues in Linked Material:Copyright Issues in Linked Material:

1)1) Beware of copyright material for web pages made Beware of copyright material for web pages made available broadly. Follow the $.available broadly. Follow the $.

Virtual Slide CollectionsVirtual Slide CollectionsSlide Collections:Slide Collections:1)1) Medical School: 300 slides with disease Medical School: 300 slides with disease

descriptions and multimedia links.descriptions and multimedia links.2)2) Surgical Pathology Cases: 400 slides with 360 Surgical Pathology Cases: 400 slides with 360

gross photos. As unknown or known cases.gross photos. As unknown or known cases.3)3) South Bay Pathology Society: Advanced cases for South Bay Pathology Society: Advanced cases for

practicing pathologists (600 slides). As unknown practicing pathologists (600 slides). As unknown or known.or known.

4)4) Subspecialties: Eye pathology (80 cases), Subspecialties: Eye pathology (80 cases), Neuropathology (120 cases), Dermatopathology Neuropathology (120 cases), Dermatopathology (100 cases).(100 cases).

5)5) General Biology slides for K-12.General Biology slides for K-12.

Future PlansFuture Plans

1)1) Finish medical student pages, including Finish medical student pages, including more non-copyright gross photographs and more non-copyright gross photographs and radiographs (Gen Y kleptomania).radiographs (Gen Y kleptomania).

2)2) Optimize speed for web-based viewing. Optimize speed for web-based viewing.

3)3) Open up site to outside Stanford Open up site to outside Stanford (capacity?).(capacity?).

4) Share virtual slides and software with other 4) Share virtual slides and software with other schools (CWS or Zoomify?).schools (CWS or Zoomify?).

AcknowledgementsAcknowledgements

StanfordStanford

Don Regula, MDDon Regula, MD

Brian Tobin, BSBrian Tobin, BS

Jenny Wilson, SMS-VJenny Wilson, SMS-V

Aperio Technical SupportAperio Technical Support