2015, Volume 31, Number 3, Page(s) 175-180
Transition to Virtual Microscopy in Medical Undergraduate Pathology Education: First Experience of Turkey in Dokuz Eylül University Hospital
Özgül SAĞOL1, Kutsal YÖRÜKOĞLU1, Banu LEBE1, Merih Güray DURAK1, Çağnur ULUKUŞ1, Burçin TUNA1, Berna MUSAL2, Tülay CANDA1, Erdener ÖZER1
1Department of Pathology, Dokuz Eylül University Faculty of Medicine, İZMİR, TURKEY
2Department of Medical Education, Dokuz Eylül University Faculty of Medicine, İZMİR, TURKEY
Keywords: Virtual systems, Pathology, Problem based learning, Microscope, Medical education
Pathology education includes an important visual part
supporting a wide range of theoretical knowledge. However, the use
of traditional microscopes in pathology education has declined over
the last decade and there is a lack of interest for microscopy. Virtual
microscopy, which was first described in 1985 and has experienced
a revolution since 2000, is an alternative technique to conventional
microscopy, in which microscopic slides are scanned to form digital
images and stored in the web. The aim of this study was to evaluate
the use of virtual microscopy in practical pathology sessions and its
effects on our students and undergraduate education at our faculty.
Material and Method: Second and third year medical students who
were used to conventional microscopes were included in the study.
The practical sessions were carried out via virtual slides and the
effect of the new technique was investigated by a scale at the end of
each session. Academic staff from the pathology department joined
sessions to promote discussion and respond to questions. Student
ratings were analysed statistically.
Results: The evaluation of the ratings showed that the students
were easily adapted to the use of virtual microscopy. They found
it user-friendly and thought that the opportunity of viewing slides
at home was advantageous. Collaboration between students and
interactive discussions was also improved with this technique.
Conclusion: It was concluded that the use of virtual microscopy could
contribute to the pathology education of our students.
Pathology education, which is a highly visual subject,
is partly based on histological examination of diseased
tissues. This practical part is important because it helps
students understand the basic concepts as well as the
mechanisms of diseases. Analysing tissue and searching
for clues of diagnosis improve the students’ approach to
the disease, simulating clinical examination of a patient1
. Additionally, the students can imagine how the tissue
is processed and what the daily work of a pathologist looks
The microscope has been the most widely used instrument
in pathology education. However, some recent studies
have demonstrated a decrease in the use of traditional
microscopes in medical schools, mainly as a result of
current developments in the curriculum as well as some
disadvantages of the technique itself4. The quality of
educational microscopes used in many faculties is often
poor and the cost of the new technology microscopes is quite
high. Thus, adapting the laboratory to evolving technology
and increasing the number of medical school students is
costly. Maintenance of an adequate slide collection is also
difficult and creates a huge increase in laboratory work as
hundreds of slides are selected, cut, stained and sorted.
Moreover, the slides have to be changed regularly because
of fading of the dye or slide damage. Variability between
sections in the slide collection often cause confusion among
students and affects the success of teaching process. In
addition, a large reserve of tissue is needed while preparing
a slide set for the whole class. Cytological samples, small
biopsies and special areas in biopsies such as transition
of dysplastic epithelium to invasive cancer are generally
difficult to reproduce in large numbers of consecutive slides
and therefore difficult to demonstrate to all students3,4.
To standardize sections and the representative areas that
the students are supposed to see is not possible with light
microscopy sections. Finding sufficient laboratory time for
slide review during a busy curriculum is also a problem.
The use of the microscopes is often limited to the working
hours of the faculty, requiring the students to be physically
at school for self study5.
Medical students frequently complain about difficulties
in finding lesions while examining histologic slides by
microscopes. These difficulties mainly originate from lack
of orientation of the organ and the lesion that they need
to learn. Since very low power magnification that makes
an overview easier is not available in student microscopes,
getting oriented to the whole slide is quite difficult. Thus,
there is usually need for demonstration on a projection screen in a classroom setting. Even after demonstration,
students may hardly correlate what they see on the
microscope with the demonstrated lesion. Unfortunately,
being unable to put annotations on each slide other than
crude dotting, limits students’ proper orientation to the
There has been a change towards using microphotographs
in practical sessions because of the mentioned difficulties..
However, this has not been a satisfactory solution
especially for the orientation problem. Virtual microscopy
or digital slide technology, which serves as a simulator of
microscopy, provides an effective solution for this problem.
The experience of the medical schools that partially or
completely integrated the virtual microscope technology
into their histology and pathology curricula has previously
been reported. Learning with this technique was accepted
by students at a high rate in most of these studies6-16.
Experience with the integration of this technology to active
learning curricula is more limited17. Virtual microscopy
has not only been reported to improve the student learning
process, but it has also been shown in several studies to
improve their collaboration skills, communication abilities
and self-confidence12. Due to the mentioned reasons, we
have decided that transition to virtual microscopy is needed
in our curriculum and have planned this study.
This project was carried out with two groups of students who
were in their second and third year of medical education at
Dokuz Eylul University Hospital. Problem-based learning
is applied during the first three years at our institution.
A total of 188 second and 163 third year students, who
had already become adapted to individual single headed
monocular microscopes (since they had practical histology
sessions in their first year) participated in the study. Two
practical sessions were selected from each second and third
year curricula. The topics of the practical sessions were as
1. Viral hepatitis (Second year, gastrointestinal system,
nutrition and metabolism block )
2. Atherosclerosis (Second year, cardiovascular system
3. Neoplasia (Third year, neoplasia block)
4. Viral dermatosis (Third year, skin and locomotor system
The slides that were intended to be taught in these practical
sessions were selected from pathology archives by the
responsible instructor. Normal tissues were also selected in order to remind students the normal histology of the related
organ. The slides were scanned with a slide scanner (Mirax
Midi, 3DHistech, with a Hitachi 3CCD camera) with a 20X
objective and the high resolution images were uploaded to
the server. Annotations including squares, arrows or shapes
with numbers, pointing to the microscopic features, were
placed on each tissue. The slides were viewed with Mirax
Viewer software that was downloaded for free from the
web. All students had free access to the digital slides (Figure
1). They could access the slides at the http://22.214.171.124/
mirax web site from any computer with an internet
connection. A tutor guide was prepared and given to all
students before the practical session, describing how to
access the digital slides and how to interpret the sections.
Scientific knowledge about the disease, description of
annotations, and the learning objectives were also included
in these guides. The first practical session for second
year medical students focused on the pathology of viral
hepatitis and cirrhosis. The students were first given a
detailed theoretical lecture on the elementary microscopic
findings of chronic viral hepatitis and cirrhosis via a
Powerpoint presentation, the day before the practical
session. Other practical sessions were carried out the same
way. The students were given information about the virtual microscopy technique and how they would use the Mirax
Viewer program in the computer laboratory at the end of
the first lecture in each class.
Click Here to Zoom
|Figure 1: A virtual
slide of a cirrhotic
liver section, with
The computer laboratory included 80 computers with
internet access and installed Mirax Viewer program in 3
rooms. At least one tutor in each laboratory supervised the
learning process. Two students or more shared a computer
when needed. The students were allowed to work in larger
groups for interactive discussions. At the beginning of
the practical session, the students were given a guide
introducing the Mirax Viewer program, step by step. This
guide also included the list of microscopic features they were
supposed to learn during the session. The students were
asked to match these microscopic findings in the list with
annotation numbers on each slide. In the neoplasia practical
session, a powerpoint presentation with clinical histories
and macroscopic photographs were also downloaded to the
desktops for students to view before working on the virtual
images. Scales with 10 questions were distributed to students
at the end of each session. The scale included ratings of the
virtual slide sessions, from 1 to 5 ( 5: I Strongly agree, 4: I
agree, 3: I have no idea, 2: I disagree, 3: I strongly disagree).
In the scale used in this study, some questions allowed the students to make comparisons between traditional
microscopes and virtual slides, as they had experience
previously on how to use traditional microscopes in their
histology sessions. Unfortunately, both techniques could
not be used at the same time for the purpose of comparison
because of the laboratory conditions and timing issues. A
total of 248 students participated in the survey. The student
ratings were analysed statistically by SPSS 15.0 software.
The scale used in this study is given in Table I.
Click Here to Zoom
|Table I: Scale used to evaluate the students’ satisfaction . (5: I Strongly agree, 4: I agree, 3: I have no idea, 2: I disagree, 1: I strongly
The results of the students ratings are given in Table II
The reliability analysis of the scale used in this study
showed that the mean Cronbach Alpha value was 0.90.
The students were well adapted to the virtual microscopy
technique. They found it user-friendly, practical, easier to use and also found the opportunity to view slides at home
advantageous. They appreciated the image quality. Most
of them agreed that virtual slides could replace or be used
in combination with traditional microscopes. They liked
viewing slides in collaboration with their friends and this
improved their understanding of the histopathology. They
never complained about sharing their computers with one
or two friends. Being able to view the normal histologic
slides as well as the pathologic samples for comparison
also contributed to their learning. In spite of the fact that
they were able to discuss their findings with their friends,
and the histopathology of the lesions were given as lectures
before the practical sessions, they still requested the
supervising of a tutor. The ability to view the slides at home
did not decrease their attendance to practical sessions.
They followed the instructions given as handouts and tried to match the lesions shown by annotations with the
given pathological findings in the handouts. The matching
exercise improved group discussions at the end of the
lesson as the students tried to compare their results with
each other and with the tutors. At the end of each block, the
students attended practical exams that were integrated with
other disciplines such as microbiology, parasitology and
pharmacology. In these exams, microphotographs taken
from the virtual slides that had been viewed in the practical
sessions were used in pathology questions. The comparison
between the grades of previous and current exams could
not be made definitely as the components of the exams
Click Here to Zoom
|Table II: Student ratings as percentage. (5: I Strongly agree, 4: I agree, 3: I have no idea, 2: I disagree, 1: I strongly disagree)
Virtual microscopy, also known as digital slide technology
(DST) or whole slide imaging, is a way of creating dynamic
images from glass slide specimens, which are viewed and
manipulated by using computer-based technology, closely
mimicking traditional light microscopy12,13,18
examining the virtual slides, the user can change the field
of view by panning in the x-y axis and zooming from one
magnification to another, just as viewing a glass slide with a
traditional optical microscope. Development of digitalized
slides had begun in 1985, when multiple microscopic views
(digital tiles) had been taken via motorized microscopic
stages and virtual slides had been created by a digital
montage. Then in the late 1990s, virtual slide preparation
with a slide scanner was described. Integration with
annotations, which increased the educational value of
virtual slides was developed in 20014
Virtual microscopy has been used in many fields of
pathology. Recently, some institutions have even integrated
this technology to their daily diagnostic practice. Actually,
the majority of the literature reports no significant difference
in diagnostic abilities with virtual slides in comparison to
glass slides12,14. Others use virtual slides for research,
consultation, teaching and other academic purposes.
Currently there is increasing evidence in the literature that
many medical faculties prefer using virtual slides in their
In the early 1990s, pathology education had mostly relied on
lectures and laboratories built on traditional microscopes.
However, the recent curricular reform with the integrated
approach has decreased the time allocated to pathology and
other basic sciences because of the need to adapt clinical
issues in the first two years of medical education. Problembased
or self-directed study has replaced the didactic
teaching with lectures and laboratories. There is a tendency to believe that practicing physicians other than pathologists
do not need to know how to use a microscope. The rate of
glass slide use in teaching histopathology was reported to be
as high as 85% in 1997 by Kumar et al. In a survey presented
at Association of Pathology Chairs in 2007 in the US, only
45% of medical schools had studied histopathology in their
curricula and among these only 18% had used glass slides
Problem-based learning has been used in the first three
years at Dokuz Eylul University Faculty of Medicine
since 1996. Problem-based learning sessions have been
integrated with theoretical lectures and practical lessons as
well as independent study times for students. As a part of
this active model of learning, practical pathology sessions
on some selected important topics were integrated within
the curriculum. However, the practical sessions had to be
integrated with other disciplines such as microbiology and
parasitology because of the limited partition of pathology
among our integrated curriculum. These integrated
practical sessions required large laboratories other than
The use of glass slides had nearly been given up at Dokuz
Eylul University in the first 3 years of medical education
with transition to problem-based learning in 1996.
Since then, histopathology had been taught by using
digital microphotographs used in posters or Powerpoint
presentations, prepared for the students’ self-study during
practical sessions. With that method, exploring a section,
finding normal and pathologic structures independently, as
well as discovering relationships within the same tissue was
impossible. In spite of the labels on the photographs, the
students were not able to orientate the morphologic findings
they saw on the pictures. The tutors generally had poor
feedback at the end of each practical session. Additionally,
there was a need for more residents and instructors
supervising, because the students required detailed
explanations to understand the microscopic findings on
the microphotographs. Thus, the practical sessions became
lectures instead of an active learning experience.
As a result of the decision of transition to virtual slides in
our faculty, many advantages of virtual slides compared to
glass slides have been reported. First of all, the virtual slides
can be viewed anytime and anywhere a computer and an
Internet connection is available. The quality of images is
standard and there is no need for focusing, proper condenser
adjustment, and lighting that cannot be performed easily
by the students on traditional microscopes. Technical
competence in viewing is easier to manage when compared
to traditional microscopes. The very low power overview allows students to better recognize relationships of normal
tissues to pathologic lesions. A thumbnail and location box
in the viewer program allows students to remain oriented
to the whole slide while viewing at high magnification. In
addition, labeling the tissue with annotations, integrating
descriptions, case scenarios, and gross and radiological
images is also possible and improves understanding. The
storage of the virtual slides is easier, when enough server
space is provided4,5. Computer screen allows student
collaboration and group discussions, and these have been
confirmed by our own students as well.
The improvement of learning while practicing specific skills
by the use of simulation-based tools such as phlebotomy
or resuscitation models is the main purpose in medical
education19. Similar to these simulation-based techniques
used in medical education, virtual slides have already taken
their place within the learning process in pathology. For
the first time in Turkey, we experienced an improvement in
pathology education in our institution with this technique.
Therefore, we think that this technology is applicable to
medical school curricula, which will otherwise turn out
to be completely theoretical and devoid of visuality while
teaching basic aspects of medicine.
SOURCE OF FUNDING
This research was supported by Dokuz Eylül University
Research Foundation Grant. Grant Number: 2008. KB.
CONFLICT OF INTEREST
The authors declare no conflict of interests.
1) Braun MW, Kearns KD. Improved learning efficiency and
increased student collaboration through use of virtual microscopy
in the teaching of human pathology. Anat Sci Educ. 2008;1:240-6.
2) Coleman R. Can histology and pathology be taught without
microscopes? The advantages and disadvantages of virtual
histology. Acta Histochemica. 2009;111:1-4.
3) M erk M, Knuechel R, Perez-Bouza A. Web-based virtual
microscopy at the RWTH Aachen University: Didactic concept,
methods and analysis of acceptance by the students. Ann Anat.
4) Dee FR. Virtual microscopy in pathology education. Hum Pathol.
5) Foster K. Medical education in the digital age: Digital whole slide
imaging as a learning tool. J Pathol Inform. 2010;1. pii: 14.
6) Kumar KR, Velan GM, Korell SO, Kandara M, Dee FR, Wake D.
Virtual microscopy for learning and assessment in pathology. J
7) Heidger PM, Dee FR, Consoer D, Leaven T, Duncan J, Kreiter C.
Integrated approach to teaching and testing in histology with real
and virtual imaging. Anat Rec. 2002;269:107-12.
8) Blake C, Lavoie HA, Millette CF. Teaching medical histology at
the University of South Carolina School of Medicine: Transition
to virtual slides and virtual microscopes. Anat Rec B New Anat.
9) Krippendorf BB, Lough J. Complete and rapid switch from light
microscopy to virtual microscopy for teaching medical histology.
Anat Rec B New Anat. 2005;285:19-25.
10) Kim MH, Park Y, Seo D, Lim YJ, Kim D, Kim CW, Kim WH.
Virtual microscopy as a practical alternative to conventional
microscopy in pathology education. Basic Appl Pathol. 2008;1:
11) McBride JM, Prayson RA. Development of a synergistic casebased
microanatomy curriculum. Anat Sci Educ. 2008;1:102-5.
12) Weinstein RS. Innovations in medical imaging and virtual
microscopy. Hum Pathol. 2005;36;317-9.
13) Scoville SA, Buskirk TD. Traditional and virtual microscopy
compared experimentally in a classroom setting. Clin Anat.
14) Kumar RK, Freeman B, Velan GM, De Permentier PJ. Integrating
histology and histopathology teaching in practical classes using
virtual slides. Anat Rec B New Anat. 2006;289:128-33.
15) Hamilton PW, Wang Y, McCullough SJ. Virtual microscopy
and digital pathology in training and education. APMIS.
16) Dee FR, Meyerholz DK. Teaching medical pathology in the
twenty-first century: Virtual microscopy applications. J Vet Med
17) Bloodgood RA. Active learning: A small group histology
laboratory exercise in a whole class setting utilizing virtual slides
and peer education. Anat Sci Educ. 2012;5:367-73.
18) Weinstein RS, Graham AR, Richter LC, Barker GP, Krupinski EA,
Lopez AM, Erps KA, Bhattacharyya AK, Yagi Y, Gilbertson JR.
Overview of telepathology, virtual microscopy, and whole slide
imaging: Prospects for the future. Hum Pathol. 2009;40:1057-69.
19) Nelson D, Ziv A, Bandali KS. Going glass to digital: Virtual
microscopy as a simulation-based revolution in pathology and
laboratory science. J Clin Pathol. 2012;65:877-81.