A new tool to support interactive and collaborative education
in histopathology
Johanna Elms*
BEST Network, School of Medical Sciences, University of New South Wales, Australia
Email: j.elms@unsw.edu.au
Stephanie Dowdell*
BEST Network, School of Medical Sciences, University of New South Wales, Australia
Simone Van Es
School of Medical Sciences, University of New South Wales, Australia
Betty Kan
School of Medical Sciences, University of New South Wales, Australia
Nicholas Hawkins
School of Medical Sciences, University of New South Wales, Australia
*These authors contributed equally to this paper
For the past century, the discipline of pathology has used microscopic images of diseased
tissue to allow students in biomedicine to develop an understanding of disease and disease
processes. Technological advances in digital display of these images is rapidly
transforming this field, and demanding a re-evaluation of traditional pedagogy. The
Biomedical Skills and Education (BEST) Network, a collaborative group of university
academics, has developed Slice, an annotation tool and image repository that enables
students working individually to interact with digital histology slides and share annotations
to facilitate discussion.
We evaluated aspects of Slice as part of the Rational Use of Investigations course (RUI) at
UNSW Australia. RUI is an elective for senior medical students that develops skills in the
use and interpretation of medical investigations. A cohort of 16 students enrolled in the
RUI course were divided into two groups, that undertook a traditional multi-header
microscope teaching session or a lesson using the Slice online annotation tool. At two
points during the course, both groups were given a 10-minute formative assessment.
Results indicated that the group who had completed the Slice lesson performed better in
recognising morphological features relevant to diagnosis. These results are supported by
the finding that all students wanted more virtual annotation tools to aid histopathology
learning and agreed that Slice allowed collaboration with peers and educators. This small
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study indicates that online tools that engage students through peer and teacher collaboration
in class can improve student learning outcomes in histopathology.
Keywords: Histopathology, Online Learning, Biomedical Education
Introduction
The last decade has seen increasing use of digitised images of glass microscope slides (whole
slide images [WSI], virtual microscopy) instead of traditional microscopes in the teaching of the
microscopic appearances of normal (histology) and diseased (histopathology) tissues (Hamilton
et al, 2012). UNSW Australia has used a digital slide repository for over a decade (Kumar et al,
2004), and like many institutions worldwide (Dee et al, 2003; Kumar et al, 2004; Lee, 2005;
Kumar et al, 2006; Triola and Holloway, 2011; Hamilton et al, 2012), whole slide images are at
the core of the study of both histology and histopathology in our school.
In 2012, four institutions (UNSW Australia, University of Queensland, University of Melbourne
and James Cook University) along with the education technology company, Smart Sparrow
formed the Biomedical, Education, Skills and Training (BEST) Network (www.best.edu.au) in
order to developed collaborative teaching resources and technology for the biomedical sciences.
Slice is a cloud-based image repository that was formed as a key component of the network, and
is capable of hosting and delivering large (typically up to 4GB) whole slide images via the
internet to any site worldwide.
In the discipline of histopathology, teaching is traditionally performed around a multi-header
microscope, where up to eight individuals use separate eyepieces to view the same glass slide.
The navigation of that slide is controlled by one individual operating the main microscope –
typically the teacher. That person also typically controls a lighted “pointer” that they can move
around the field of view to highlight features on the slide to their students.
The Slice platform offers the potential to significantly alter training in the discipline of
histopathology, because it can replicate and potentially extend the experience of the multiheader
session. Using Slice, students and teachers have the ability to mark and describe regions of
interest on whole slide images (Figure 1). These annotations are captured on layers separate to
the actual image, and can be shared easily between students and teachers.
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Figure 1: Use of annotations by a student to elaborate and share knowledge.
This screen grab shows a high power view of a duodenal biopsy in the central viewer window. A student
has identified a particular cell type at the request of the teacher, and has made notes regarding its
function.
This ability to annotate images in real time provides a significant improvement on the traditional
light pointer, and because the annotations remain permanently associated with the image, they
can be viewed at a later date by student or teacher. Likewise, virtual imaging frees students from
technical issues of focus and spatial disorientation that are common with the use of the
multiheader microscope. For these reasons, we speculated that student learning of
histopathological features on slides may be improved by use of the Slice tool.
Final year medical students at UNSW Australia with an interest in pathology are given the
opportunity to undertake a eight week course designed to develop basic interpretive skills in the
field of diagnostic histopathology. The ‘Rational Use of Investigation’ (RUI) course is casebased. Under the supervision of a pathologist, students work in teams to interpret microscope
slides of diseased tissue, along with clinical information from that case, to form a diagnosis and
report their findings to the class. Multiheader microscope sessions have been an important part of
the course, in which students get direct training and feedback from their teacher regarding the
identification and interpretation of morphological features in tissue sections relevant to their
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case. Thus the RUI course provided an opportunity to assess the ability of the Slice tool to
replicate or extend the learning experience provided by traditional multiheader sessions.
Methods
User Group
All students enrolled in the RUI course at UNSW in 2014 (n=16) agreed to participate in this
study, and provided informed consent to do so (UNSW HREC # HC13197). The students were
then allocated to two groups of eight, based on alphabetical order of their surname.
Technology
The Slice image bank and annotation tool developed by the BEST Network allows users to:

View histopathology slides online (www.best.edu.au/slice) and to navigate around those
slides in a manner similar to using a conventional microscope, including pan and zoom.
 Annotate the virtual slide by placing pins or drawing polygons to select a region on a
private layer.
 Add textual information about the region of the image associated with a pin or polygon.
 Share the specific annotated image and zoom level via a link (URL) provided by the
platform.
Glass slides that were to be used in multiheader sessions were digitised so that comparable
images were used in both multiheader and Slice (virtual microscopy) sessions.
Deployment
The two groups of students were allocated to either a Slice annotation lesson or a histopathology
teaching lesson on the multi-header microscope. A total of 24 different virtual slides were used
over four teaching sessions. The same slides were used for both Slice and multiheader classes.
The groups interchanged between learning activities in each teaching session so that all users had
access to both teaching methods. While generally students had the opportunity to view slides in
both the real and virtual sessions, some slides were identified beforehand by teachers as cases
that would be used for assessment in this trial. Access to those slides was controlled, so that
students only saw them in either the real or virtual settings, based on their group, and students
were not aware these would be the “assessment” slides. For those slides, teachers in both the real
and virtual sessions had agreed on the key elements that should be taught to their students, and
that those elements would form the basis of the subsequent evaluation. The duration of teaching
on those slides was also agreed to prior to the teaching sessions. In this way, we sought to
minimise bias introduced by differences in emphasis between teachers.
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The multiheader microscope session was led by a pathologist guiding students through the slides
with all users visualising the same histopathology slide and discussing the various points of
interest. Students were asked questions to gauge understanding throughout the session.
During the computer-based Slice lessons, users had access to the Slice image bank through
private log-ins and were able to utilise the annotation tool. An anatomical pathologist guided
students through the session using the lead computer before students used the Slice annotation
tool to mark and describe regions of interest. Students could paste links to their annotations to a
discussion board on the Moodle learning management system. The pathologist then used the
Moodle interface to access and discuss the students’ work in real-time by projecting the
annotations via the lead computer for the class. Feedback was given in verbal or written form via
these classes or online discussion on Moodle.
Evaluation
The evaluation of learning outcomes using the two different teaching modalities was additional
to the students’ summative course assessment. Therefore only two data collection points
occurred, at weeks 3 and 5 of the course. A short, formative assessment with 5 questions based
on a selected “assessment” images from the Slice repository was given to both groups to evaluate
whether there were differences in the comprehension of key morphological features in a selected
case. In both instances, the assessment related to a previously selected case that had been
recently (<60min) discussed with the teacher, either around the multiheader microscope or using
the Slice viewing tool. The nature of the teaching format (multiheader or Slice) on which each
student group had received prior teaching about the assessment image varied between the two
assessment time points. This served to control for any a priori differences in ability between the
groups. Students were not aware of which case would be assessed. After the assessment, data
regarding the student experience of the different learning modalities was also collected by a short
questionnaire. All assessment responses were evaluated by one teacher (NH).
Results
Formative assessments
Both assessments were completed by all 16 students. Results showed that the average mark for
students who completed the Slice lesson first was higher for both exams (Figure 2), although the
relatively small numbers meant that this difference was not statistically significant.
5
100
90
80
Percent correct
70
60
50
Slice
40
MH
30
20
10
Cohort 1
Cohort 2
Cohort 1
Cohort 2
0
Assessment 1
Assessment 2
Assessment Number
Figure 2: Assessment results for student groups.
Students undertook an interactive Slice Annotation lesson (Slice), or a multi-header microscope lesson
(MH) and were given a 10 minute exam with 5 questions at the end of the lesson on one slide from that
session. Both groups received the same assessment, which asked them to identify histopathological
features relevant to the case. Data for the student groups shows the average percentage of correct
responses for each assessment (mean +/- standard deviation). Performance following the multiheader
session was less irrespective of the student cohort exposed to that teaching modality.
Student evaluation survey
Following the completion of each concept quiz, students voluntarily evaluated their experience
of the two teaching methods. Students stated that the use of Slice and the annotation tool added
to their understanding of the subject matter, reporting that the ability to receive feedback
regarding areas of misconception was particularly valuable for learning. The questions and
results are summarised below Table 1 and 2.
Table 1: Student responses to Questionnaire 2.
Item
SD* D
A
SA
Favourable
to Slice
(%)†
6
I was comfortable using Slice
0
0
5
5
100
It was easier to discuss slides in class using the
multiheader than when using Slice
Being able to annotate images in Slice assisted my
learning
I found sharing annotations in class helped my
understanding of the slides
I received better feedback on my understanding of
the slides in the multi-header session than in the
Slice session
I was comfortable using the multiheader
1
5
3
1
60
4
6
100
6
4
100
6
3
1
60
3
6
1
30
4
6
100
8
2
100
I was more comfortable using Slice than the multiheader
The functionality of Slice (viewing, annotation,
sharing images) helped me learn about the slides
* Multiple choice responses to the questions were either: Disagree (D), Agree (A) or Strongly Agree (SA).
† Percentage of the 11 respondents who were favourable to the Slice tool.
Table 2: Student responses to Questionnaire 2.
Item
D*
A
SA
Favourable to
Slice (%)†
Slice allowed me to collaborate with my classmates
0
7
4
100
Slice allowed me to collaborate with my lecturer
0
4
7
100
Using the annotation software improved my digital
or online skills
I have received feedback in the Slice class that
helped me in my assessments
Using Slice in class made the lesson more interesting
than the multiheader microscope
I liked using Slice
3
5
3
73
3
6
2
73
1
2
8
91
3
8
100
The annotation tool was easy to use
7
4
100
I would like more virtual annotation tools in my
learning
5
6
100
* Multiple choice responses to the questions were either: Disagree (D), Agree (A) or Strongly Agree (SA).
† Percentage of the 11 respondents who were favourable to the Slice tool.
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Discussion
Here we have used the functionalities of the Slice image bank and annotate tool to enhance
learning in the context of small group teaching in histopathology. Evaluation of student
performance at two separate time points showed a trend towards better student performance after
lessons using the Slice tools compared to the multi-header microscope session. Interestingly, for
at least one of the assessments the performance of students was relatively poor for both
modalities, though this may reflect issues in standard setting rather than pedagogy per se.
Questionnaire data revealed that students related their understanding and exam performance to
use of the Slice annotation tool and the ability to gain feedback by sharing their annotations in
Slice with peers and teacher. Over two thirds of students preferred the feedback they received on
Slice to that of the multiheader session, and the majority of students found it easier to discuss
slides in class using Slice.
Several aspects of the study design reported here require further consideration. While the small
class size for the RUI course lends itself to use of multiheader microscopes as a teaching
modality, as is typical of postgraduate pathology training, it necessarily limits the power of the
study to achieve statistically significant results. The trends seen in this current study thus require
replication with a larger student base. Despite its small size, our study has the clear advantage of
offering a direct comparison of student performance between the two learning modalities, based
on the same slides and students. Others who have postulated an increase in performance by
students who learn using virtual microscopy have often done so on the basis of indirect
comparison with historical controls from previous years or on different student cohorts
(Krippendorf and Lough, 2005).
Another consideration in the study design was the allocation of students to test groups on the
basis of alphabetical order of surname. No consideration was given to prior performance in their
degree, prior experience in histopathological assessment, nor interest in the discipline. However,
variation in group performance was unlikely to reflect inherent differences in the two cohorts,
since results were better for the group that had been exposed to the assessment case through the
Slice tool, even though that group varied between assessments.
Microscopes remain integral to the work of a range of disciplines, including diagnostic
histopathology and microbiology. Thus a potential downside for the use of virtual microscopy
solutions in undergraduate training is the potential lack of microscopy skills amongst graduates.
In reporting on another interactive virtual slide platform, Wang et al (2012) noted that only 11%
of their study cohort were concerned about this lack of microscopy skills. In the current study,
over 90% of our students valued time on the Slice sessions more than the multi-header
microscope, suggesting again that lack of practical microscopy skills is not a major concern for
students. It is likely that the university sector will become increasingly reliant on online
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microscopy tools, both because of the benefits they bring to student experience and
comprehension, and because of their resource efficiency. Disciplines which regard microscopy
as a key skill, such as pathology, will increasingly need to provide formal training for entry level
professionals, in order to address this emerging skills deficit.
While nearly all students in the current study were comfortable with both the Slice and multiheader sessions, the large majority found Slice interactive lessons both more interesting and
more facile than multiheader microscope sessions. In a similar study at Queens University
Belfast in 2006 (Hamilton et al., 2012), 88% of students said they would prefer to use virtual
microscopy over traditional microscopy in the classroom. Student’s digital literacy and previous
exposure to virtual slide platforms may have influenced these results, thus future studies will
need to assess the impact of student digital literacy on assessment outcomes. However, the
positive response of students to virtual microscopy interactive lessons shows that not only is
there educational value in incorporating virtual microscopy tools in student assessment, but that
students want and enjoy this experience.
While the focus of this study was on improving recognition of key morphological features of
disease, it is also noteworthy that all students in this study also agreed that Slice allowed them to
collaborate with classmates and teachers. It is possible that this improved collaboration was a
key driver to more effective learning. Certainly, planned further developments of the Slice tool
will build on the implicit benefit of the online space by enhancing the capacity to for studentstudent and student teacher collaboration around learning from images. It is likely that benefits
seen here in the context of training in histopathology may be generalisable to all disciplines in
which interpretation of image data is a fundamental professional skill.
Acknowledgements
The authors wish to acknowledge the support of Diane Vukelic and the BEST Network in
making the Slice image bank available for this trial.
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Copyright © 2015 Elms, J., Dowdell, S., Van Es, S., Kan, B., Hawkins, N. The authors assign to HERDSA and
educational non-profit institutions a non-exclusive license to use this document for personal use and in courses of
instruction provided that the article is used in full and this copyright statement is reproduced. The authors also grant a
non-exclusive license to HERDSA to publish this document in full on the World Wide Web (prime site and mirrors)
and within the portable electronic format HERDSA 2015 conference proceedings. Any other usage is prohibited
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