Biomedical Visualisation: Volume 16 ‒ Digital Visualisation in Biomedical Education (Advances in Experimental Medicine and Biology, 1421) 3031303784, 9783031303784

Table of contents :
Preface: Visualisation in Biomedical Education
Contents
About the Editors
Part I: Communicating Visualisation
1: Science Communication and Biomedical Visualization: Two Sides of the Same Coin
1.1 A Few Historical Cases of Biomedical Visualization in the United States
1.2 Science Communication and the Knowledge Deficit Model
1.3 Biomedical Visualization Through a Science Communication Lens
1.4 When to Train Scientists in Science Communication?
References
2: Putting the Cart Before the Horse? Developing a Blended Anatomy Curriculum Supplemented by Cadaveric Anatomy
2.1 Context: The Creation of a Cadaveric and Non-cadaveric Lab in a New Medical School
2.2 Designing the Anatomy Resources (Non-cadaveric) Laboratory
2.3 Selection of TEL Resources for the Anatomy Resources Laboratory
2.3.1 Virtual Dissection Tools
2.3.1.1 Virtual Human Dissector
2.3.1.2 Visualisation Tables
2.3.2 Digital and Physical Anatomical Models
2.3.2.1 Complete Anatomy
2.3.2.2 Anatomical Models
2.3.3 Portable Ultrasound and Radiology
2.4 Curriculum Delivery and Session Delivery
2.5 Experiences with Digital Visualisation Approaches
2.5.1 Supporting Educators with TEL Resources
2.5.2 Use of Key Views
2.5.3 Use of Colour and Translucency
2.5.4 Cross-Sectional Tools
2.5.5 Virtual Dissection and Virtual Construction
2.5.6 Ultrasound and Radiology
2.5.7 COVID-19 Pandemic Resilience
2.6 Completion of the Build Project and Integration of Cadaveric Anatomy
2.7 Design and Integration of Cadaveric Anatomy (Student Perspective)
References
Part II: Innovating Visualisation
3: The Third Dimension: 3D Printed Replicas and Other Alternatives to Cadaver-Based Learning
3.1 Introduction
3.1.1 Capturing 3D form Through the Ages
3.2 The Limitations and Problems with Dissection of Human Cadavers
3.2.1 Alternatives to Cadavers for Anatomy Learning and Teaching
3.3 The Development of 3D Printed Anatomical Replicas and their Deployment in Teaching
3.4 Creation of 3D Printed Replicas of Pathology Specimens
3.5 Comparison of 3D Printed Replicas to Plastinated Specimens as Learning Resources
3.6 Comparison of 3D Prints to Plastic Models
3.7 Limitations of 3D Printed Replicas
3.7.1 The Value of 3D Printing and Associated Technologies in Medical Student and Biomedical Science Student Research Projects
3.7.2 3D Printing as Technology to Create Medical Simulation Devices
3.7.3 Technology Enhanced-Learning and Moving into the Virtual World
3.8 Conclusions and a Forward Vision
References
4: Evaluating a Photogrammetry-Based Video for Undergraduate Anatomy Education
4.1 Introduction
4.1.1 Aims and Objectives
4.2 Material and Methods
4.2.1 Model Creation
4.2.2 Video Creation and Editing
4.2.3 Evaluation
4.2.4 Ethical Assessment
4.3 Results
4.4 Discussion
4.4.1 Photogrammetry-Based Videos
4.4.2 Voice-Over and Captions
4.4.3 Video Length and Rotation Speed
4.4.4 Font Type
4.4.5 Text and Background Colour
4.4.6 Limitations
4.4.7 Future Work
4.5 Conclusions
References
5: Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real
5.1 Introduction
5.1.1 The Traditional Way of Teaching Histology and Pathology in a Laboratory Setting
5.1.2 Virtual Microscopy Arrives on the Scene
5.1.3 Traditional Light Microscopy and Virtual Microscopy, Companions or Adversaries?
5.2 The Use of Virtual Microscopy for Biomedical Education and Clinical Applications in Different Regions of the World
5.2.1 Adoption of Virtual Microscopy for Biomedical Education in North America, Europe, and Australia
5.2.1.1 Adoption of Virtual Microscopy for Biomedical Education in Eastern Europe
5.2.2 Adoption of Virtual Microscopy for Biomedical Education in Africa
5.2.2.1 Adoption of Virtual Microscopy for Biomedical Education in Ghana and Other Sub-Saharan African Countries
5.2.2.2 Adoption of Virtual Microscopy for Biomedical Education in North African Countries
5.2.2.3 Adoption of Virtual Microscopy for Biomedical Education in South Africa
5.2.3 Adoption of Virtual Microscopy for Biomedical Education in South Asia
5.2.3.1 Adoption of Virtual Microscopy for Biomedical Education in India and Other Countries of the Indian Subcontinent
5.2.3.2 Adoption of Virtual Microscopy for Biomedical Education in Middle Eastern Countries
5.2.3.3 Adoption of Virtual Microscopy for Biomedical Education in South-Eastern Asian Countries
5.2.4 Adoption of Virtual Microscopy for Biomedical Education in China and Other East Asian Countries
5.2.4.1 Adoption of Virtual Microscopy for Biomedical Education in China
5.2.4.2 Adoption of Virtual Microscopy for Biomedical Education in South Korea and Japan
5.2.5 Adoption of Virtual Microscopy for Biomedical Education in South America
5.2.5.1 Adoption of Virtual Microscopy for Biomedical Education in Brazil
5.2.5.2 Adoption of Virtual Microscopy for Biomedical Education in Other South American Countries
5.3 Summary and Conclusions: Virtual Microscopy Is Here to Stay
References
6: Online, Interactive, Digital Visualisation Resources that Enhance Histology Education
6.1 Introduction
6.1.1 Histology Visualisation: The Basics of Tissue Preparation
6.1.2 Staining Procedures Visualise Cell and Tissue Components
6.1.3 Specific Structures Can Be Visualised Using a Variety of Techniques
6.2 Histology Education
6.3 Use of Technology in Teaching and Learning
6.3.1 Online Learning Platforms in Education
6.3.2 Virtual Microscopy: An Online Education Platform
6.3.3 Virtual Microscopy Is Cost Effective and Facilitates Student Engagement
6.3.3.1 An Online Virtual Microscopy Learning and Teaching Platform with Annotations and Student Engagement
6.4 Aims and Objectives
6.5 Development of an Online Interactive Histology Atlas
6.5.1 How It All Started
6.5.2 The Concept of a Completely Online Histology Course
6.6 Meyer´s Histology
6.6.1 Meyer´s Histology Online Interactive Atlas Including Virtual Microscopy: A Descriptive Example
6.6.2 Mastery Learning
6.7 Quantitative Evaluation of Meyer´s Histology Online Interactive Atlas
6.7.1 Discussion of Quantitative Survey
6.8 Engaging and Interactive Animation/Models of Histological Structures Are Now Available
6.8.1 The Transition from the Gross Anatomy Structure to Histological Details Is an Essential Learning Objective
6.9 Video Descriptions of Human Cells, Tissues, and Organs
6.10 Online Visualisation of Histology Lectures with Functionalities that Engage Students and Promote Self-directed Learning
6.10.1 How the Histology Lectures Were Created by `Lecturio.com´
6.10.2 A Description of Features of the Histology Lectures Were Created by Lecturio.com
6.10.3 Evaluations
6.11 Students and Histology Teachers Have Worldwide Access to Meyer´s Histology Resources
6.11.1 How Do Students and Histology Teachers Access Meyer´s Histology Resources?
6.12 A Histology Course Can Be Presented Completely Online for Engaging Students and Promoting Self-directed Learning
6.12.1 An Example of a Successful Online Histology Course: Course Syllabus and Schedule
6.12.2 An Example of a Successful Online Histology Course: Directives to Students
6.12.3 An Example of a Successful Online Histology Course: A Learning Module
6.12.4 An Example of a Successful Online Histology Course: Students´ Assessments
6.12.5 An Example of a Successful Online Histology Course: Student Evaluations of the Course
6.13 3D Printers: Possible Uses in Histology Visualisation?
6.14 Conclusion
References
7: Leading Transformation in Medical Education Through Extended Reality
7.1 The Definition and Current State of Extended Reality Technologies
7.2 What Can Extended Reality Offer to Medical Education?
7.3 The Application of Extended Reality in Postgraduate Teaching and Medical/Surgical Training
7.4 Widening the Access to Medical Education in Low-Middle Income Countries: Is Extended Reality the Answer?
7.4.1 Subtitle 5: Key Considerations in Embedding Extended Reality Within a Medical Education Setting Curriculum
7.4.2 Subtitle 6: The Limitations and Future of Extended Reality Within Medical Education
References
8: Visualisation Approaches in Technology-Enhanced Medical Simulation Learning: Current Evidence and Future Directions
8.1 Introduction
8.2 Methods
8.2.1 Search Strategy
8.2.2 Inclusion Criteria
8.2.3 Exclusion Criteria
8.2.4 Data Extraction
8.2.5 Risk of Bias Assessment
8.3 Results
8.3.1 Results of the Systematic Search
8.3.2 Methodological Considerations of Investigating Approaches to Visualisation
8.3.3 Visualisation Approaches to Clinical Simulation by Technology-Enhanced Learning Modality
8.3.3.1 Offline and Online Computer-Based Modules and Applications
8.3.3.2 Serious Games and Other Educational Modalities
8.3.4 Risk of Bias Assessment
8.4 Discussion
8.4.1 Current Recommendations
8.4.2 Quality of Available Evidence
8.4.3 Future Directions
8.5 Conclusion
References
9: Visualisation Through Participatory/Interactive Theatre for the Health Sciences
9.1 Introduction
9.2 Definition of PIT
9.3 PIT Technique: Simultaneous Dramaturgy
9.4 PIT Technique: Forum Theatre
9.5 Essential Components of PIT Techniques
9.6 The Construction of a PIT Story: Visualisation Through Storytelling
9.7 Structure: The Milieu
9.8 Structure: The Idea
9.9 Structure: The Character
9.10 Structure: The Event
9.11 The Conflict
9.12 Working with Actors in a PIT: Making the Story Visible
9.13 Leading a PIT: Assisting the Audience to See the Unseen
9.14 Participant Safety
9.15 Working with Actors
9.16 Self-check Measures
9.17 Working with Different Audiences: Learning to Visualise
9.18 Educational Theory: Transformative Learning and Visualisation PIT
9.19 Conclusion
References

Citation preview

Advances in Experimental Medicine and Biology 1421

Scott Border Paul M. Rea Iain D. Keenan   Editors

Biomedical Visualisation Volume 16 ‒ Digital Visualisation in Biomedical Education

Advances in Experimental Medicine and Biology Volume 1421 Series Editors Wim E. Crusio, Institut de Neurosciences Cognitives et Intégratives d’Aquitaine, CNRS and University of Bordeaux, Pessac Cedex, France Haidong Dong, Departments of Urology and Immunology, Mayo Clinic, Rochester, MN, USA Heinfried H. Radeke, Institute of Pharmacology and Toxicology, Clinic of the Goethe University Frankfurt Main, Frankfurt am Main, Hessen, Germany Nima Rezaei , Research Center for Immunodeficiencies, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran Ortrud Steinlein, Institute of Human Genetics, LMU University Hospital, Munich, Germany Junjie Xiao, Cardiac Regeneration and Ageing Lab, Institute of Cardiovascular Sciences, School of Life Science, Shanghai University, Shanghai, China

Advances in Experimental Medicine and Biology provides a platform for scientific contributions in the main disciplines of the biomedicine and the life sciences. This series publishes thematic volumes on contemporary research in the areas of microbiology, immunology, neurosciences, biochemistry, biomedical engineering, genetics, physiology, and cancer research. Covering emerging topics and techniques in basic and clinical science, it brings together clinicians and researchers from various fields. Advances in Experimental Medicine and Biology has been publishing exceptional works in the field for over 40 years, and is indexed in SCOPUS, Medline (PubMed), EMBASE, BIOSIS, Reaxys, EMBiology, the Chemical Abstracts Service (CAS), and Pathway Studio. 2021 Impact Factor: 3.650 (no longer indexed in SCIE as of 2022)

Scott Border • Paul M. Rea • Iain D. Keenan Editors

Biomedical Visualisation Volume 16 – Digital Visualisation in Biomedical Education

Editors Scott Border School of Life Sciences University of Glasgow Glasgow, UK

Paul M. Rea Anatomy Facility, School of Medicine, Dentistry and Nursing, College of Medical, Veterinary and Life Sciences University of Glasgow Glasgow, UK

Iain D. Keenan School of Medicine Newcastle University Newcastle upon Tyne, UK

ISSN 0065-2598 ISSN 2214-8019 (electronic) Advances in Experimental Medicine and Biology ISBN 978-3-031-30378-4 ISBN 978-3-031-30379-1 (eBook) https://doi.org/10.1007/978-3-031-30379-1 # The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface: Visualisation in Biomedical Education

In education, the term ‘visualisation’ can refer to both the presentation of information and concepts via visual means, and to the cognitive process performed by learners when creating mental images of previously observed objects. Medicine, medical sciences, and healthcare education all involve inherently visual topics and often require learners to understand key concepts in three dimensions. Consequently, it is important that appropriate modalities are used to support learning in these disciplines. Furthermore, alongside the continuing development of modern technology-enhanced learning resources, rapidly changing student expectations, and the increasingly blended delivery of post-pandemic curricula, educators have turned to new and existing digital visualisation approaches to support both in-person and asynchronous learning. It is important to note that biomedical education can extend beyond specific learning technologies and university degree programmes. As such, this volume begins with two chapters that highlight broader considerations. The opening chapter addresses the visual communication of complex biomedical concepts to wide audiences for the purposes of public health, an important contemporary issue that has been emphasised in the pandemic era. This is followed by a chapter that sets the scene of curricular integration by providing a description of and the development of a new facility for delivering blended, technology-enhanced learning. Subsequently, recent developments in digital visualisation technologies are described and explored, with the history and underpinnings of a wide variety of three-dimensional learning approaches considered. In doing so, a range of subject disciplines, which are delivered within the education and training of medical and healthcare professionals, are addressed. Three-dimensional anatomical models, 3D printing technologies, and photogrammetry videos in anatomy education are initially explored, followed by a summary of histology approaches from around the world, and the description of a specific digital histology resource. Extended reality (comprising virtual, augmented, and mixed reality) and virtual simulation approaches are then outlined within the context of medical education. Regardless of the tools used, the art of effective teaching is achieved through high-quality communication. Subject level experts are frequently expected to communicate complex scientific ideas to non-specialist audiences, including the public. We live in an age where misinformation can be spread v

vi

Preface: Visualisation in Biomedical Education

easily, and the visualisation of important healthcare strategies can be supported through infographics to support and create impactful take-home messages. Lay audiences relate well to storytelling, and the process of visualising a narrative of biological processes can lead to enhanced understanding. The final chapter describes a particularly innovative visualisation approach involving participatory and interactive theatrical techniques. This approach, referred to as forum theatre, is based on the principle that everyday healthcare experiences of service users are recognised as fundamental in equipping emergent practitioners with key aspects of knowledge that are required to maintain and improve high-quality care services. This approach is being used in nursing education and has led to enhanced student understanding of individual experiences and increased respect for individual differences. This volume provides important insights into a range of effective learning approaches and will have implications for educators and practitioners seeking to expand their repertoire of technology-enhanced digital learning approaches for communication, curriculum development, and designing safe real-world learning opportunities. The work presented here provides careful consideration of several key areas and advocates for the tailored application or inclusion of three-dimensional and visual disciplines in medical and healthcare education. Newcastle upon Tyne, UK Glasgow, UK

Iain D. Keenan Scott Border

Contents

Part I 1

2

Science Communication and Biomedical Visualization: Two Sides of the Same Coin . . . . . . . . . . . . . . . . . . . . . . . . . . . Jason M. Organ and Adam M. Taylor Putting the Cart Before the Horse? Developing a Blended Anatomy Curriculum Supplemented by Cadaveric Anatomy . . E. Donald, K. Dulohery, M. Khamuani, H. Miles, J. Nott, D. Patten, and A. Roberts

Part II 3

4

5

Communicating Visualisation 3

15

Innovating Visualisation

The Third Dimension: 3D Printed Replicas and Other Alternatives to Cadaver-Based Learning . . . . . . . . . . . . . . . . . Paul G. McMenamin Evaluating a Photogrammetry-Based Video for Undergraduate Anatomy Education . . . . . . . . . . . . . . . . . . . . . Irene Gianotto, Alexander Coutts, Laura Pérez-Pachón, and Flora Gröning Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real . . . . . . . . . . . . . . . . . . . . . . . . . . . Michael Hortsch, Nii Koney-Kwaku Koney, Aswathy Maria Oommen, Doris George Yohannan, Yan Li, Ana Caroline Rocha de Melo Leite, and Virgínia Cláudia Carneiro Girão-Carmona

39

63

79

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education . . . . . . . . . . . . . . . . . . . . . . . . . 125 Geoffrey T. Meyer

7

Leading Transformation in Medical Education Through Extended Reality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Arian Arjomandi Rad, Hariharan Subbiah Ponniah, Viraj Shah, Sukanya Nanchahal, Robert Vardanyan, George Miller, and Johann Malawana

vii

viii

Contents

8

Visualisation Approaches in Technology-Enhanced Medical Simulation Learning: Current Evidence and Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Aleksander Dawidziuk, George Miller, and Johann Malawana

9

Visualisation Through Participatory/Interactive Theatre for the Health Sciences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 James Wilson

About the Editors

Scott Border , BSc (Hons), PhD, N.T.F., F.A.S., S.F.H.E.A., is Head of Anatomy within the College of Medical, Veterinary and Life Sciences at the University of Glasgow. Professor Border trained as a behavioural neuroscientist, with an interest in the neural correlates of learning and memory. Having taught gross anatomy to medical students for 16 years (mainly focusing on clinical neuroanatomy and head and neck anatomy) at Southampton, he is now leading anatomy education at the University of Glasgow. His main areas of interest focus on innovative approaches to anatomy education. Working with students as partners in anatomical education is a major investment of his time, and this work has been recognised with a National Teaching Fellowship from Advance H.E in 2019. Paul M. Rea Paul is Professor of Digital and Anatomical Education at the University of Glasgow. He is Director of Innovation, Engagement and Enterprise within the School of Medicine, Dentistry and Nursing. He is also a Senate Assessor for Student Conduct and Council Member on Senate and coordinates the day-to-day running of the Body Donor Program and is a Licensed Teacher of Anatomy, licensed by the Scottish Parliament. He is qualified with a medical degree (MBChB), an MSc (by research) in craniofacial anatomy/surgery, a PhD in neuroscience, the Diploma in Forensic Medical Science (DipFMS), and an MEd with Merit (Learning and Teaching in Higher Education). He is a Senior Fellow of the Higher Education Academy, professional member of the Institute of Medical Illustrators (MIMI), and a registered medical illustrator with the Academy for Healthcare Science. Paul has published widely and presented at many national and international meetings, including invited talks. He has been the lead editor for Biomedical Visualisation over 12 published volumes and is the founding editor for this book series. This has resulted in almost 90,000 downloads across these volumes, with contributions from over 400 different authors, across approximately 100 institutions from 19 countries across the globe. He is Associate Editor for the European Journal of Anatomy and has reviewed for 25 different journals/publishers. He is the Public Engagement and Outreach lead for anatomy coordinating collaborative projects with the Glasgow Science Centre, NHS, and Royal College of Physicians and Surgeons of Glasgow. Paul is

ix

x

also a STEM ambassador and has visited numerous schools to undertake outreach work. His research involves a long-standing strategic partnership with the School of Simulation and Visualisation, the Glasgow School of Art. This has led to multi-million-pound investment in creating world-leading 3D digital datasets to be used in undergraduate and postgraduate teaching to enhance learning and assessment. This successful collaboration resulted in the creation of the world’s first taught MSc Medical Visualisation and Human Anatomy combining anatomy and digital technologies. The Institute of Medical Illustrators also accredits it. It has created college-wide, industry, multi-institutional, and NHS research linked projects for students. Iain D. Keenan, BSc, (Hons.), PhD, M.Med.Ed., S.F.H.E.A., N.T.F., F.A.S., is Senior Lecturer in Anatomy within the School of Medicine, Newcastle University, UK. Iain has been interested in the visualisation of threedimensional morphology since his PhD training and post-doctoral fellowships in developmental biology. Iain has since taught gross anatomy, histology, and embryology for medical, dental, and physician associates and medical sciences and healthcare degree programmes at Newcastle University for more than 11 years. Iain has numerous leadership and mentoring roles in educational research and scholarship at Newcastle University and leads a programme of pedagogic research with student partners, colleagues, and international collaborators. His research involves development and investigation of digital visualisation and art-based learning activities. His innovative approaches support student observation and understanding of challenging three-dimensional and spatial concepts in anatomy. He has previously authored five chapters in the Biomedical Visualisation series, and his wideranging contributions to anatomical education have been recognised in the award of a National Teaching Fellowship (2020) and Fellowship of the Anatomical Society (2021).

About the Editors

Part I Communicating Visualisation

1

Science Communication and Biomedical Visualization: Two Sides of the Same Coin Jason M. Organ and Adam M. Taylor

Abstract

Biomedical visualization has a long history as a tool for education around public health. However, recent advances in our understanding of how to be more effective at communicating complex scientific ideas to a public audience necessitate a re-examination of approaches to biomedical visualization. Scientific knowledge has expanded dramatically in the twenty-first century, as has its availability beyond the scientific arena. This chapter briefly discusses the historical approaches in biomedical visualization from the perspective of Western public health. It also outlines the approach that biomedical visualization should take according to best practices in effective science communication. Keywords

SciComm · Knowledge deficit model · Communication · Visual media · Public engagement J. M. Organ (✉) Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA Department of Communication Studies, Indiana University Purdue University, Indianapolis, IN, USA e-mail: [email protected] A. M. Taylor Lancaster Medical School, Faculty of Health and Medicine, Lancaster University, Lancaster, UK

Science and technology are cornerstones of knowledge-based societies and economies of the twenty-first century, and yet both are constantly changing in real time in response to incremental changes in our understanding of nature and our place in it. As scientific fields become more complex and the pace of science quickens, a problem that has persisted since the beginning of scientific inquiry continues to grow: scientists are generally poor at communicating their findings with the public. When public understanding of science in a community is low, the public loses confidence in science and evidence-based decision-making, which creates an environment for misinformation1 and disinformation to thrive (Peretti-Watel et al. 2015). All of this is problematic when societies and economies are intricately tied to information derived from science. But scientists have only slowly recognized the importance of clear communication with the public, and this has taken a tremendous toll on public trust in science. Take the COVID-19 pandemic, for example, and the public discourse in the United States. Communication breakdowns between scientists, public health officials, policymakers, and the public have been ubiquitous and continual (Jaiswal et al. 2020): what does the science show about the efficacy of masks, what are the most effective 1

Misinformation is information that is unintentionally incorrect, whereas disinformation is intentionally incorrect.

# The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Border et al. (eds.), Biomedical Visualisation, Advances in Experimental Medicine and Biology 1421, https://doi.org/10.1007/978-3-031-30379-1_1

3

4

testing protocols for managing communities, are lockdowns effective at combating the spread of viral disease, how safe are the vaccines and the new messenger RNA vaccine technology, and— most profoundly—why do the evidence-based conclusions of science keep changing? The lack of clear messaging from scientists and elected officials played a role in more than one million American COVID-19 deaths (and counting), aggregated by the Johns Hopkins University Coronavirus Resource Center (coronavirus.jhu. edu). One of the big issues facing science communication is that any science is a constantly evolving journey of building knowledge to better inform our interface with the world. This in part explains why evidence-based conclusions of science keep changing, but in the midst of a global pandemic they can often change at a rate that exceeds the public ability to assimilate themselves with this new information and what it might mean. Overall this results in a decline in public trust (Kreps and Kriner 2020). Similarly challenging is the availability of scientific information on social media and the Internet, not just to the public, but also to the media, vastly changing the way peer-reviewed, and even pre-peer-reviewed (pre-print) science is communicated. Most of the process of communicating relies on there being two arenas of communication; scientific and public, with scientists wanting to engage the public in the public arena. This model has its origins in the early 1980s, but even in the early 2010s and today this is still being seen as the common approach. This is despite the availability of information online merging the scientific and public arena making information much more readily available (Peters 2013). Despite this increased availability of information, there is also work to do to increase the synergy of scientists and journalists working together to disseminate information, rather than acting like strangers with different languages and messages in their agendas (Peters 2013). Scientists have increased the utilization of repositories to make more of their early work, prior to peer review, available in the form of pre-prints, in the hope of getting constructive

J. M. Organ and A. M. Taylor

feedback from their scientific peers to strengthen their research output. These online facilities can reduce the ability of scientists to refine the final message that is being communicated to the public from their data and the media often communicates this to a much wider audience in a much shorter time than previously. The interest in this more widely available scientific data, particularly in the COVID-19 pandemic, has led to an increase in academics, public, and media engagement with these resources such that COVID-19-related pre-prints were accessed much more frequently than non-COVID-19 (Fraser et al. 2021). The most notable example of this is hydroxychloroquine, which was touted as a treatment from its publication in a pre-print, resulting in increased off-label prescriptions as well as increased internet searches (Caulfield et al. 2021; Liu et al. 2020; Vaduganathan et al. 2020). Another consideration is the way that science is visualized and communicated today, is very different to 50 years ago, perhaps even as recently as 5 years ago. In 2016, the Pew Research Center highlighted that most Americans still get their news through TV, but in younger generations (18–49 years) those numbers swing significantly in favor of getting news via online platforms (Mitchell et al. 2016). In 2021, Pew Research Centre went further to show that one-third of Americans regularly access news on Facebook, with others obtaining news from other social media platforms (Walker and Matsa 2021). This rapid communication of science and other news has meant that scientists have had to adapt how their data is presented. Gone are the interviewstyle TV and radio clips, but replaced with infographics and short sentences about the impact or significance of the science (Lee and Lee 2022; Lee et al. 2022). This rapid delivery of information has become more personalized rather than being to a mass audience, the personalized “feel” to what is communicated is reinforced by algorithms on social media platforms that can reinforce by delivering similar content that aligns with beliefs and opinions that are already expressed or felt by the viewer (Cinelli et al. 2021; Ohme 2021).

1

Science Communication and Biomedical Visualization: Two Sides of the Same Coin

Over the last decade, the National Academy of Sciences, Engineering, and Medicine (NASEM) has been sounding the call for scientists to develop more effective ways to communicate complex scientific information with a diversity of public, nonspecialist audiences. These calls have resulted in several special NASEM publications on the science of science communication, each of which explicitly notes the importance of science communication research and application (NASEM 2012, 2014; National Academies of Sciences 2017). Several universities—like University of Edinburgh, University of British Columbia, and Stony Brook University, through its Alan Alda Center for Communicating Science, for example—have answered the NASEM call by developing advanced degrees and certificate programs in science communication, and by providing important experiential learning experiences in effective ways to facilitate “courageous conversations” rooted in empathy. Likewise, several medical schools, including Northwestern University (Watson 2011), Indiana University School of Medicine (Hoffmann-Longtin et al. 2018), Stony Brook University (Kaplan-Liss et al. 2018), and Midwestern University (Muldoon 2022) use applied improvisational theater techniques to teach clinical care providers how to communicate more effectively within their teams and with greater empathy toward their patients. And most recently, scientific organizations have taken up the mantel of providing their members with professional development opportunities in science communication, including the American Association for the Advancement of Science (O’Malley et al. 2021) and the American Association for Anatomy (Longtin et al. 2022). The objective of this chapter is to discuss the importance of using an effective science communication strategy in biomedical visualization. To do this, we will explore the goals of science communication and approaches, both historically and currently, to enhance public understanding of science. We will also explore what biomedical visualization through an explicit science communication rhetorical frame should include.

1.1

5

A Few Historical Cases of Biomedical Visualization in the United States

Biomedical visualization has a long history of communicating important scientific concepts to nonspecialist audiences in the United States. In the second half of the nineteenth century, public health communications were often depicted as political or editorial cartoons to address concerns about public nuisances and dirty streets, quarantine and immigration, and food purity and adulteration (Hansen 1997). These cartoons, published in such venerated outlets as Harper’s Weekly and The New York Times, were not, however, designed to change perception in response to a public health concern. Instead, they were meant to lambaste various aspects of public life and were elitist in nature (Hansen 1997)—they were meant as political and editorial commentary. During World War II, biomedical visualization as a means of science communication began targeted approaches to change public understanding, but mostly in the context of military communications within the ranks. The US Army enlisted the help of Theodor Geisel—better known as “Dr. Seuss”—as well as several other well-known storytellers and illustrators to produce a series of top-secret cartoons featuring a character called Private Snafu—SNAFU coming from the unofficial military acronym for Situation Normal: All Fouled Up!.2 Private Snafu was voiced by Mel Blanc, best known as the voice of Bugs Bunny, Daffy Duck, Porky Pig, and Barney Flintstone. The goal of these cartoons was to help enlisted soldiers with weak literacy skills learn important details about security, proper sanitation habits, and other relevant subjects (Nel 2007). The US Navy followed suit in 1945 with its own film (part animation and part live action) aimed at educating sailors about Staphylococcus and Streptococcus bacteria (Klein 2011). Both science communication and biomedical visualzation campaigns were focused

2

Or Situation Normal: All F—ked Up!

6

J. M. Organ and A. M. Taylor

on military personnel and were not intended for public audience. In the 1950s and 1960s, when vaccines were developed to prevent poliomyelitis, mass vaccination campaigns directed at American civilians were instituted and were highly successful. The strategies included making vaccines available at an array of public locations like railway stations, bus stops, and markets, and included house-tohouse immunizations where teams of vaccinators visited each dwelling or household to identify candidates for vaccination (Sutter and Maher 2006). Public trust in science was high at that point in our history, which made it easier to convince individuals to take a vaccine. But times have changed and American skepticism toward science is high (Funk and Rainie 2015). New approaches are necessary to earn the trust of the American public, which has been a significant challenge for the rollout of COVID-19 vaccines developed rapidly and with a newer mRNA technology—the vaccine campaigns, modelled after those used for the poliomyelitis rollout have been less successful. The question is, why?

1.2

Science Communication and the Knowledge Deficit Model

The goal of science communication is to communicate complex information with an audience of nonspecialists (Longtin et al. 2022). Scientists are trained to seek answers using the scientific method. When better data are presented that overturn previous experiments or paradigms in science, scientists are trained to accept them and alter conclusions based upon them. The public does not solve problems and seek unknown answers in the same way that scientists are trained, and therefore traditional means of disseminating the results of scientific inquiry are not effective when communicating with the public. Unfortunately, science communicators historically have utilized an approach to public communication called the Knowledge (or Information) Deficit Model of communication (Brown 2009; Simis et al. 2016), and they have

been largely ineffective at facilitating public understanding. The Knowledge Deficit Model supposes that a deficit in scientific knowledge among the public can be overcome by providing the public with more and better information (Brown 2009), and then the public will use that information to make better decisions rooted in scientific evidence. We have seen this repeatedly of late regarding the development and distribution of COVID-19 vaccines, including ones built upon newer mRNA technology. There were massive campaigns to educate the public about how COVID-19 vaccines work, how they work differently from more traditional vaccines, and what vaccine efficacy looks like. Media outlets flooded the discourse with scientific explanations in an effort to bring the public up to speed and provide them with the information needed to make important decisions about vaccination—i.e., using the Knowledge Deficit Model. Biomedical visualization played an important role in this regard as infographics were generated by public health agencies to educate the public. Yet, according to the Johns Hopkins Coronavirus Resource Center as of June 2022, only 67% of Americans have been vaccinated (Hopkins CRC: https://coronavi rus.jhu.edu/vaccines/international), suggesting that the Knowledge Deficit Model of science communication around COVID vaccine hesitancy was not entirely effective. Nevertheless, it persists. Simis et al. (2016) proposed several reasons that the Knowledge Deficit Model continues to persist in the science communication toolkit: it follows naturally from the hypothetico-deductive reasoning that scientists are trained to use in hypothesis testing, the model is a product of institutional structures of graduate science education—scientists are largely not trained to communicate using any other model since it is effective when communicating with other scientists—it is a product of scientists’ attitudes toward “the public,” and finally because it has been historically effective in influencing public policy. Simis et al. (2016) argue for better science communication training for scientists as part of

1

Science Communication and Biomedical Visualization: Two Sides of the Same Coin

graduate training, echoing the calls in the NASEM publications for the same. On a different side of the coin, social science research has clearly demonstrated the importance for science communicators in understanding their target audience. Perhaps just as important as the ideas outlined by Simis et al. (2016) about why the Knowledge Deficit Model dominates the science communication landscape, Kahan (2012) demonstrates that even those who have an above-average understanding of science do not necessarily hold evidence-based opinions about controversial topics like climate change, fracking, or private gun possession (Kahan 2012; Simis et al. 2016). Kahan argues instead that beliefs are shaped by the social groups we associate with: political or religious affiliations, occupations, and sexual or gender identity, for example. Because we often belong to multiple social groups, our beliefs are shaped by our intersecting social identities. And when we are confronted with scientific evidence that appears to attack our social groups’ beliefs, we often become defensive and consider the evidence encountered to be flawed. This is especially true and can lead to a strengthening of our social group convictions (Kahan 2012, 2013). This is unlikely to be a surprise to anyone reading this chapter, as we have seen it play out in the United States and other countries regarding COVID-19 vaccine hesitancy.

1.3

Biomedical Visualization Through a Science Communication Lens

With all of this as backdrop, effective biomedical visualization must communicate complex health information to a wide public audience while avoiding these science communication pitfalls. The most effective way to connect with a public audience is to tell a story, and so biomedical visualization needs to incorporate a storytelling approach to communication. The human brain has evolved in remarkable ways since our earliest ancestors walked upright for the first time over

7

6 million years ago in East Africa (Aiello and Dean 1990). One of the major adaptations our brains have evolved is the capacity to understand story. Storytelling is a universal human trait, and our brains are naturally adapted to learn from stories better than through other modes of information delivery (Boyd 2009). Stories help us makes sense of complex information and to make meaning from it, and they provide guidelines for how we should understand, think about, and act in response to recurring, familiar situations. It is crucial, then, that biomedical visualizations adopt a storytelling perspective if they are to be effective because of widespread and complex skepticism among the American public toward scientific integrity (Funk et al. 2019). Storytelling or narratives have been utilized across multiple scientific subject areas from climate change to colorectal cancer (Howarth 2017; Neil et al. 2022). These narratives present an effective way of providing an engaging arena to convey information to an audience, as well as integrating with the audience’s societal context(s). This kind of arena helps the audience to give relatable meaning to the science. The societal context is incredibly important in science communication, particularly when the information is presented in a local context, enabling this to be viewed in a direct way that is often visually relatable to the audience and the potential impact of what is being presented. The effectiveness of storytelling in climate change is a prime example of the importance of presenting the local context for the audience to relate to, it has been shown that films and news can cause a change in opinion, but after a short time, these opinions shift back to baseline or original belief (Happer and Philo 2016; Howell 2014; Reyes-García et al. 2016). The importance of longer-term action comes from communication of stories that place the importance of people taking action in response to the issues they face, rather than just recognizing there is an issue (Sabherwal and Shreedhar 2022). While presenting action and local context is important, there is also the factor of relatability or more broadly credibility, which links in some respect to locality, but may also be more aligned

8

with relatability to the individual or entity that is presenting the science. This credibility helps to build dialogue, which is incredibly important in science communication. Dialogue represents a key tool in any scientist’s toolkit to help understand opinion, plan further research application, and drive progress. This bidirectional communication moves away from the flawed assumption that scientific knowledge and worldview are dominant, valuing experiential and cultural knowledge on a par. This bidirectional communication enables researchers to understand the point of view of patients in health research, for example. The importance of this bidirectional flow enables scientists to be viewed as unbiased, trying to build a narrative with the audience, rather than for them. The bidirectional flow also enables the end users/public to build their own picture of how they relate to and where they feel they fit into the story. Many researchers of a given disease or disorder are unlikely to suffer from the condition they work on; hence scientists may have substantial scientific knowledge but the impacts and usefulness of this on a patient may be useless if the science is not perceived to make any positive change on the way of life of the end-user, in this case, the patient. An important example of this in action was the introduction and availability of cochlear implants to correct deafness in young children. This resulted in a strong response from the deaf community who see deaf children as perfectly healthly and are part of a culture and society that saw no reason to operate on children (Lane and Bahan 1998). This shows the relatability of those people communicating science and the importance of engaging in a dialogue with all stakeholders in the relevant scientific area. This dialogue builds a platform where scientists and laypersons are equal in terms of sharing, receiving, and processing information. The inclusivity of laypersons and the relatability of scientists has to help take steps toward correcting the distrust that society has for science (Kabat 2017). This distrust is not a new phenomenon, when early scientists communicated their findings related to germ theory, an anticontagion movement countered this and grew in popularity. Similarly, Galileo, whose work demonstrated that

J. M. Organ and A. M. Taylor

the earth orbited the sun, not the other way around, saw him convicted on a strong suspicion of heresy. He communicated his scientific findings, which were in direct contradiction with what the Catholic church believed was the celestial functioning at the time. In both of these instances, the communication of science was from experts, who are now held as scientists of the highest regard, their communication was through the recognized formal channels at the time, yet some experts and many outside the sphere of expertise doubted the credibility of the science being presented. In Galileo’s case, going against the church may have been significant enough to generate opposition from those who believed in the church and higher powers and that their views should not be questioned. So whilst, expertise and trust are important and are clear issues that need to be overcome in science communication, there is also the question of trustworthiness. Can the audience trust what is being discussed, does the communicator have an agenda which means that what they are presenting represents their employer/funder of their research which may have gains to be made out of the success of this work? This problem stems, potentially, from scientists not communicating enough negative studies, i.e., those which do not show something as significant, which can potentially be viewed as having a biased agenda. In storytelling, there is also the incorporation of awe, which can bring an additional dimension that can cause a shift in the audiences’ worldview or opinion (Keltner and Haidt 2003). This display of awe as an emotion from the audience has the potential to enhance the interest in the science being communicated. Fortunately, these tools are widely available to help science communicators and biomedical visualization practitioners use the power of storytelling in their work. One of the best-known tools for helping storytellers develop their stories is Kenn Adams’ Story Spine, first created in 1991 and adopted by theater professionals worldwide (Adams 2007). This famous story template can be seen in many of the most popular stories in movies, literature,

1

Science Communication and Biomedical Visualization: Two Sides of the Same Coin

television, and so forth, and provides a familiar five-part structure that an audience can anticipate as the details of the story are told: Beginning, First Significant Event, Middle, Climax, and End. In the Beginning, the world of the story is introduced, and the main character’s routine is established. The Beginning brings the story to the First Significant Event, where the main character breaks their routine. This leads to the Middle, where there are dire consequences for having broken the routine and it is unclear whether the main character will persevere in the end. During the Climax, the main character embarks upon success or failure, until finally in the End, the main character either succeeds or fails and a new routine is established (Adams 2007). Since 2017, I (author J.M.O) have been teaching scientists how to become more effective at communicating their work with an audience of nonspecialists. Most of this work is rooted in my training at the Alda Center for Communicating Science and the programs we built at Indiana University (IU) and the American Association for Anatomy using the Alda Center as a model. As such, most of the work we do at IU is rooted in applied improvisational theater techniques (Hoffmann-Longtin et al. 2018; Longtin et al. 2022). We use Adams’ Story Spine regularly in our sessions, but we also use another exercise— 1000 Words is Worth a Picture—to teach participants about the importance of using details that connect emotionally with the audience. The Picture exercise is described below. 1000 Words Are Worth a Picture The exercise begins with the facilitator holding up a picture frame with a blank image (Fig. 1.1). The facilitator explains that the photograph in the frame is one of the most important pictures they have and why. Then, they describe the photograph in vivid, colorful detail, focusing on the emotions behind the photograph, to draw the audience in. As an example, I typically use this description as I facilitate this exercise: I’m excited to share this photograph with you today because it is one of my favorites and it means so much to me. As you can see, this is a picture of me and a woman—my sister—standing in a crowd of

9

tens of thousands of other concertgoers wearing tie-dyed t-shirts and glowstick necklaces. Here I am, wearing my beloved sweatshirt from my alma mater, the University of Missouri, and you can see the silly smile on my face that demonstrates I was having a blast. You will also notice the not so happy look on my sister’s face, even though we were in one of our happy places. You see, the concert festival we were attending had on-site camping included in the ticket price and we had met a bunch of my college friends from all over the country to celebrate New Year’s Eve 1999 with our favorite band, Phish, and 100,000 of our closest friends. I had secured the tickets, food, travel accommodations from over 1500 miles away, and everything else we would need to have the time of our lives. My sister had one job: pack the tent. She managed to pack the tent, alright. But she left the tent poles on the floor of the living room at our parents’ house in Kansas and so we had nowhere to sleep but in our car for the entirety of the three-day festival. The reality of the situation had finally sunk in for my sister just as this photograph was snapped, and that’s why she isn’t smiling. My sister and I aren’t as close as we used to be—and it has nothing to do with the tent poles! But I love this picture because it reminds me how close we used to be and that makes me so happy.

After describing my favorite photograph, as the facilitator, I ask the participants what they remember about the picture. Inevitably, what is remembered most is the smile on my face and the dejected look on my sister’s face. They remember the story about the tent poles and how my sister and I are not as close as we used to be. They remember the colorful, vivid details of the story because those are the parts that connect with them emotionally. The purpose of this exercise is to tell the story of the photograph and to connect it to data visualization—there is a story in every single graph or figure that scientists present. It is up to the presenter, or biomedical visualization specialist, to connect that story to the audience in a way that they will remember the details and the story behind them. For storytelling to be effective as a means of science communication and biomedical visualization, we must adopt the central tenet of communication theory that teaches a sophisticated understanding that the audience is a co-creator of meaning in the communication process (Pearce 1989). Effective communication practice should

10

J. M. Organ and A. M. Taylor

Fig. 1.1 A picture frame with a blank picture for use in the 1000 Words Are Worth a Picture exercise

account for the needs of the audience, thereby treating communication as a process of meaning-making rather than solely dissemination of information (Pearce 1989)—the Knowledge Deficit Model does not work and has flawed assumptions that scientific knowledge is dominant over other forms of knowledge (Jasanoff 2011). And therefore, it is crucial for scientists to learn about effective communication approaches, which repeatedly stress that everyone requires these skills and can acquire them with proper training and practice (Longtin et al. 2022; Tallapragada 2018). In a recent contribution to PLOS SciComm, the science communication blog of the Public Library of Science open access journal family, Elshafie and Kostman detail their process for creating visually compelling and empathetic infographics to explain how the COVID-19 mRNA vaccines operate (Elshafie and Kostman 2021). They took a simple message “the vaccine takes something from the virus and helps your body use it to protect itself from the virus,” and workshopped several approaches to conveying that information via biomedical visualization. The result can be seen in Fig. 1.2, with the take home message that images meant to communicate complex scientific information with the public do not need to be dull to be credible, they do not need to be

illustrated in the style of a comic book to be interesting, and the power of color is undeniable: some color combinations are effective for drawing attention, while others are not; the key is to find the colors that elicit an emotional reaction so that the audience is part of the communication process.

1.4

When to Train Scientists in Science Communication?

The growing evidence base for the importance of science communication and its integral part in visualization of data to inform wider audience lends itself to question; when should training be offered to scientists in how to effectively communicate their science and what visual aids are most optimal for conveying their message? Undergraduate students often commence their studies with knowledge that is closer to the “layperson” than they will be in the rest of their scientific career, as they progress through their undergraduate, postgraduate, and postdoctoral studies, their subject expertise grows. With the position of “less” expert knowledge at an early point in their career, it would make the most sense to train and impart the importance of the effective (visual) communication of science at this time,

1

Science Communication and Biomedical Visualization: Two Sides of the Same Coin

11

Fig. 1.2 Infographic depicting how the COVID-19 mRNA vaccines work. Reprinted with permission from PLOS SciComm under the CC BY 4.0 license, from Elshafie and Kostman (2021)

but this is potentially in contrast to the level of knowledge and expertise that they may have in relation to the science subject to be communicated, so teaching the general skills and theory of science communication should be a core skill in any scientific subject. Studies of undergraduate students in an environmental sciences course demonstrated that students were already on their way to being effective communicators, students utilized visual resources to communicate and engage their audience (Shivni et al. 2021). In postgraduate study, it is well acknowledged that there is a gap in the science communication tools of these students and there is a challenge of trying to find time to offer training as part of their program and also that there is a lack of trained staff within institutions to offer any training (Kuehne et al. 2014). Science communication to laypersons is fairly commonplace in grant funding submissions nowadays, representing a necessary pathway to demonstrate transparency to the general public whose tax money funds science. Similarly, in reporting the results of clinical trials, writing lay summaries for the public to understand the outcome of trials is commonplace (Barnes and

Patrick 2019; Sedgwick et al. 2021). The skills learnt throughout undergraduate to principal investigator career steps will continue to be useful to scientists in sharing science beyond their area of expertise. While there is variety in science communication training across the scientific arena, we need to ensure that what is delivered is effective and fit for purpose, rather than just offering training as a tick box exercise. Recent efforts to develop a scale to measure effectiveness have been undertaken and offers the potential for a level of competencies or expectations to be delivered in search of more effective science communicators (Rodgers et al. 2020). Biomedical visualization, if it is going to operate under the principles of effective science communication, needs empathetic voices that attend to the needs of the target audience. Without these voices, misinformation and disinformation can quickly overtake the public discourse, needs expert and empathetic voices. And without these voices communicating science with the public and especially with policymakers (Longtin et al. 2022), fields like healthcare, public health, and climate science have been overrun with

12

conspiracy theories and misinformation. The American public—whose tax dollars fund federal research grants—are left wondering what and who to believe about science and public health. Biomedical visualization that attunes to their needs will be effective in assuring that the public is not left behind.

References Adams K (2007) How to improvise a full-length play. Allworth Press, New York Aiello L, Dean C (1990) An introduction to human evolutionary anatomy. Academic Press, New York Barnes A, Patrick S (2019) Lay summaries of clinical study results: an overview. Pharmaceut Med 33(4): 261–268. https://doi.org/10.1007/s40290-019-00285-0 Boyd B (2009) On the origin of stories: evolution, cognition, and fiction. Harvard University Press, Cambridge, MA Brown S (2009) The new deficit model. Nat Nanotechnol 4:609–611 Caulfield T, Bubela T, Kimmelman J, Ravitsky V (2021) Let’s do better: public representations of COVID-19 science. FACETS 6:403–423. https://doi.org/10.1139/ facets-2021-0018 Cinelli M, De Francisci Morales G, Galeazzi A, Quattrociocchi W, Starnini M (2021) The echo chamber effect on social media. Proc Natl Acad Sci 118(9): e2023301118. https://doi.org/10.1073/pnas. 2023301118 Elshafie SJ, Kostman MP (2021) Can science be simple? Distilling complexity into engaging images. Available at: https://scicomm.plos.org/2021/07/31/ can-science-be-simple-distilling-complexity-intoengaging-images/ Fraser N, Brierley L, Dey G, Polka JK, Pálfy M, Nanni F, Coates JA (2021) The evolving role of preprints in the dissemination of COVID-19 research and their impact on the science communication landscape. PLoS Biol 19(4):e3000959. https://doi.org/10.1371/journal.pbio. 3000959 Funk C, Rainie L (2015) Public and scientists’ views on science and society. Pew Research Center. https:// www.pewresearch.org/science/2015/01/29/publicand-scientists-views-on-science-and-society/. Accessed 7 June 2022 Funk C, Hefferon M, Kennedy B, Johnson C (2019) Trust and mistrust in Americans’ views of scientific experts Hansen B (1997) The image and advocacy of public health in American caricature and cartoons from 1860 to 1900. Am J Public Health 87:1798–1807 Happer C, Philo G (2016) New approaches to understanding the role of the news media in the formation of public attitudes and behaviours on climate change.

J. M. Organ and A. M. Taylor Eur J Commun 31(2):136–151. https://doi.org/10. 1177/0267323115612213 Hoffmann-Longtin K, Organ JM, Helphinstine JV, Reinoso DR, Morgan ZS, Weinstein E (2018) Teaching advocacy communication to pediatric residents: the efficacy of applied improvisational theater (AIT) as an instructional tool. Commun Educ 67(4):438–459. https://doi.org/10.1080/03634523.2018.1503314 Howarth C (2017) Informing decision making on climate change and low carbon futures: framing narratives around the United Kingdom’s fifth carbon budget. Energy Res Soc Sci 31:295–302. https://doi.org/10. 1016/j.erss.2017.06.011 Howell RA (2014) Investigating the long-term impacts of climate change communications on individuals’ attitudes and behavior. Environ Behav 46(1):70–101. https://doi.org/10.1177/0013916512452428 Jaiswal J, LoSchiavo C, Perlman DC (2020) Disinformation, misinformation and inequality-driven mistrust in the time of COVID-19: lessons unlearned from AIDS denialism. AIDS Behav 24(10):2776–2780. https://doi. org/10.1007/s10461-020-02925-y Jasanoff S (2011) Constitutional moments in governing science and technology. Sci Eng Ethics 17(4): 621–638. https://doi.org/10.1007/s11948-011-9302-2 Kabat GC (2017) Taking distrust of science seriously: to overcome public distrust in science, scientists need to stop pretending that there is a scientific consensus on controversial issues when there is not. EMBO Rep 18(7):1052–1055. https://doi.org/10.15252/embr. 201744294 Kahan D (2012) Why we are poles apart on climate change. Nature 488(7411):255–255. https://doi.org/ 10.1038/488255a Kahan DM (2013) Social science. A risky science communication environment for vaccines. Science 342(6154):53–54. https://doi.org/10.1126/science. 1245724 Kaplan-Liss E, Lantz-Gefroh V, Bass E, Killebrew D, Panzio N, Savi C, O’Connell C (2018) Teaching medical students to communicate with empathy and clarity using improvisation. Acad Med 93:440–443 Keltner D, Haidt J (2003) Approaching awe, a moral, spiritual, and aesthetic emotion. Cognit Emot 17:297– 314. https://doi.org/10.1080/02699930302297 Klein T (2011) Woody abstracted: film experiments in the cartoons of Shamus Culhane. Animation 6(1):39–53 Kreps SE, Kriner DL (2020) Model uncertainty, political contestation, and public trust in science: evidence from the COVID-19 pandemic. Sci Adv 6(43):eabd4563. https://doi.org/10.1126/sciadv.abd4563 Kuehne LM, Twardochleb LA, Fritschie KJ, Mims MC, Lawrence DJ, Gibson PP, Stewart-Koster B, Olden JD (2014) Practical science communication strategies for graduate students. Conserv Biol 28(5):1225–1235. https://doi.org/10.1111/cobi.12305 Lane H, Bahan B (1998) Article commentary: ethics of cochlear implantation in young children: a review and reply from a Deaf-World perspective. Otolaryngol

1

Science Communication and Biomedical Visualization: Two Sides of the Same Coin

Head Neck Surg 119(4):297–313. https://doi.org/10. 1016/s0194-5998(98)70070-1 Lee N, Lee S (2022) Visualizing science: the impact of infographics on free recall, elaboration, and attitude change for genetically modified foods news. Public Underst Sci 31(2):168–178. https://doi.org/10.1177/ 09636625211034651 Lee SH, Pandya RK, Hussain JS, Lau RJ, Chambers EAB, Geng A, Jin BX, Zhou O, Wu T, Barr L, Junop M (2022) Perceptions of using infographics for scientific communication on social media for COVID-19 topics: a survey study. J Visual Commun Med 45(2):105–113. https://doi.org/10.1080/17453054.2021.2020625 Liu M, Caputi TL, Dredze M, Kesselheim AS, Ayers JW (2020) Internet searches for unproven COVID-19 therapies in the United States. JAMA Intern Med 180(8):1116–111 8. h ttp s://doi.org/10.1001/ jamainternmed.2020.1764 Longtin K, Wisner R, Organ JM (2022) It is essential to connect: evaluating a science communication boot camp. Anat Rec 305(4):992–999. https://doi.org/10. 1002/ar.24894 Mitchell A, Gottfried J, Barthel M, Shearer E (2016) The modern consumer news. Available at: https://www. pewresearch.org/journalism/2016/07/07/pathways-tonews/. Accessed 12 Sept 2022 Muldoon KM (2022) Improving communication about diversity, equity, and inclusion in health professions education. Anat Rec 305:1000–1018 NASEM (2012) The science of science communication I: summary of a colloquium. The National Academies Press, Washington, DC NASEM (2014) The science of science communication II: summary of a colloquium.The. National Academies Press, Washington, DC National Academies of Sciences, Engineering, and Medicine (NASEM) (2017) Communicating science effectively: a research agenda. The National Academies Press, Washington, DC Neil JM, Parker ND, Levites Strekalova YA, Duke K, George T, Krieger JL (2022) Communicating risk to promote colorectal cancer screening: a multi-method study to test tailored versus targeted message strategies. Health Educ Res 37(2):79–93. https://doi. org/10.1093/her/cyac002 Nel P (2007) Children’s literature goes to war: Dr. Seuss, PD Eastman, Munro Leaf, and the private SNAFU films. J Pop Cult 40:468–487 Ohme J (2021) Algorithmic social media use and its relationship to attitude reinforcement and issue-specific political participation—The case of the 2015 European immigration movements. J Inf Technol Politics 18(1):36–54. https://doi.org/10.1080/19331681. 2020.1805085 O’Malley RC, Slattery JP, Baxter CL, Hinman K (2021) Science engagement with faith communities: respecting identity, culture and worldview. JCOM 20:C11 Pearce S (1989) Communication and the human condition. SIU Press, Carbondale

13

Peretti-Watel P, Larson HJ, Ward JK, Schulz WS, Verger P (2015) Vaccine hesitancy: clarifying a theoretical framework for an ambiguous notion. PLoS Curr 7. https://doi.org/10.1371/currents.outbreaks. 6844c80ff9f5b273f34c91f71b7fc289 Peters HP (2013) Gap between science and media revisited: scientists as public communicators. Proc Natl Acad Sci U S A 110(Suppl 3):14102–14109. https://doi.org/10.1073/pnas.1212745110 Reyes-García V, Fernández-Llamazares Á, Guèze M, Garcés A, Mallo M, Vila-Gómez M, Vilaseca M (2016) Local indicators of climate change: the potential contribution of local knowledge to climate research. Wiley Interdiscip Rev Clim Chang 7(1):109–124. https://doi.org/10.1002/wcc.374 Rodgers S, Wang Z, Schultz JC (2020) A scale to measure science communication training effectiveness. Sci Commun 42(1):90–111. https://doi.org/10.1177/ 1075547020903057 Sabherwal A, Shreedhar G (2022) Stories of intentional action mobilise climate policy support and action intentions. Sci Rep 12(1):1179. https://doi.org/10. 1038/s41598-021-04392-4 Sedgwick C, Belmonte L, Margolis A, Shafer PO, Pitterle J, Gidal BE (2021) Extending the reach of science—talk in plain language. Epilepsy Behav Rep 16:100493. https://doi.org/10.1016/j.ebr.2021.100493 Shivni R, Cline C, Newport M, Yuan S, Bergan-Roller HE (2021) Establishing a baseline of science communication skills in an undergraduate environmental science course. Int J STEM Educ 8(1):47. https://doi.org/10. 1186/s40594-021-00304-0 Simis MJ, Madden H, Cacciatore MA, Yeo SK (2016) The lure of rationality: why does the deficit model persist in science communication? Public Underst Sci 25(4): 400–414. https://doi.org/10.1177/0963662516629749 Sutter RW, Maher C (2006) Mass vaccination campaigns for polio eradication: an essential strategy for success. In: Plotkin SA (ed) Mass vaccination: global aspects—progress and obstacles. Current topics in microbiology and immunology, vol 304. Springer, Berlin Tallapragada M (2018) A new research agenda: instructional practices of activists mobilizing for science. Commun Educ 67(4):467–472. https://doi.org/10. 1080/03634523.2018.1502460 Vaduganathan M, van Meijgaard J, Mehra MR, Joseph J, O’Donnell CJ, Warraich HJ (2020) Prescription Fill patterns for commonly used drugs during the COVID-19 pandemic in the United States. JAMA 323(24):2524–2526. https://doi.org/10.1001/jama. 2020.9184 Walker M, Matsa KE (2021) News consumption across social media in 2021. Available at: https://www. pewresearch.org/journalism/2021/09/20/news-con sumption-across-social-media-in-2021/. Accessed 12 Sept 2022 Watson K (2011) Serious play: teaching medical skills with improvisational theater techniques. Acad Med 86(10):1260–1265

2

Putting the Cart Before the Horse? Developing a Blended Anatomy Curriculum Supplemented by Cadaveric Anatomy E. Donald, K. Dulohery, M. Khamuani, H. Miles, J. Nott, D. Patten, and A. Roberts

Abstract

Cadaveric anatomy is frequently described as the gold standard for anatomy education. Increasingly and especially following the COVID-19 pandemic, there is acceptance that a blended approach for anatomy curriculum delivery is optimal for learners. Setting up a new UK Medical School in 2019 necessitated building a new cadaveric anatomy facility. To enable anatomy curriculum delivery during the construction period (2019–2021), a technology-enhanced learning (TEL) anatomy curriculum was developed, as well as an anatomy laboratory suitable for TEL. Development of a TEL anatomy curriculum with the later inclusion of cadaveric anatomy is unusual since the typical model is to supplement cadaveric anatomy with TEL approaches. TEL solutions that provide digital visualisation of anatomy may support learners by reducing cognitive load. Examples include using colour and/or translucency features to

E. Donald · K. Dulohery · M. Khamuani · H. Miles · J. Nott · D. Patten (✉) · A. Roberts School of Medicine, University of Sunderland, Sunderland, United Kingdom e-mail: [email protected]; Kate. [email protected]; Munesh. [email protected]; Harry.Miles@sunderland. ac.uk; [email protected]; Debs. [email protected]; [email protected]. uk

highlight and signpost pertinent anatomy and constructing virtual anatomical models in real time, rather than dissection. Radiology and portable ultrasound provide clinically contextualised visualisations of anatomy; the latter offers a haptic learning experience too. A TEL anatomy laboratory can provide interactive learning experiences for engagement and outreach activities for young school children, where cadaveric anatomy is not suitable. Keywords

Technology-enhanced learning · Digital visualisation · Cadaveric anatomy · Clinical imaging · Laboratory design

2.1

Context: The Creation of a Cadaveric and Non-cadaveric Lab in a New Medical School

In 2018, the University of Sunderland was chosen to host one of the five new medical schools established to address the shortage of doctors in the United Kingdom (UK) (Rimmer 2018). All five new medical schools were required to partner with a mature and established medical school for the purpose of mentorship. The University of Sunderland School of Medicine is located within the Faculty of Health Sciences and Wellbeing, which already delivered a wide range of healthcare education programmes. Therefore,

# The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Border et al. (eds.), Biomedical Visualisation, Advances in Experimental Medicine and Biology 1421, https://doi.org/10.1007/978-3-031-30379-1_2

15

16

medicine was a natural complement to the existing suite of degree courses. The University has a strong commitment to widening participation (WP) and social inclusivity and the School of Medicine set ambitious targets to recruit both local and WP students: the pioneer cohort comprised 50 students, with cohorts of 100 students in subsequent years of programme delivery. Whilst the faculty was recognised for its excellent teaching facilities, including its use of fully immersive simulation, an anatomy laboratory was required to support the delivery of the medical programme. Sunderland partnered with an established medical school that delivered a spiral problem-based learning (PBL) curriculum, with vertical themes running throughout the 5-years of the course. The anatomy component of the curriculum was also spiral, regional, and dissection-based, such that students revisited regional anatomy throughout years one to three, with an increase in clinical application as students progressed. To replicate the curriculum of our partner institute, the University of Sunderland committed to the design and construction of a new cadaveric anatomy facility within the first 3 years of the opening of the School of Medicine. Prior to the construction of our new cadaveric lab, there was a need to deliver our own interpretation of the partner medical school cadaveric anatomy curriculum using alternative visualisation techniques. The starting point for curriculum design was a detailed analysis of the intended-learning outcomes (ILOs) and a commitment to be faithful to the partner medical school anatomy curriculum. This comprised facilitation of hands-on, interactive, small group teaching sessions and ensuring alignment of anatomy teaching with the overall PBL curriculum. However, the method of ILO delivery permitted educators the opportunity to further enhance the preparedness of our students for clinical practice. We highlighted clinical imaging, including ultrasound, as a key component of our delivery. In conjunction, we sought local surgeons, radiologists, and sonographers to support our objectives.

E. Donald et al.

Our approach required the establishment of a new technology-based anatomy laboratory, termed the Anatomy Resources Laboratory. This chapter will focus on the digital visualisation resources and approaches we used to mimic cadaveric teaching, and to facilitate understanding of clinical imaging, including ultrasound. We aim to share our experiences as a new medical school and to provide guidance to others who are about to embark on a similar journey.

2.2

Designing the Anatomy Resources (Non-cadaveric) Laboratory

The modern anatomical laboratory has bespoke design requirements that extend beyond infrastructural components such as lab size, suitable lighting, or ventilation (Wessels et al. 2020). Designing a learning environment not only encompasses the physical space, but also interpersonal and intrapersonal components, as well as pedagogical and technological elements, all of which will influence student behaviour and learning (Cleveland and Kvan 2015). Furthermore, the laboratory space should be able to cater to traditional and novel educational strategies and must be designed robustly to be able to respond to changing educational pedagogies and innovations (Cleveland and Kvan 2015; Macchi et al. 2014). These design concepts must also link with teaching session design, in terms of interactions between staff and students, as well as the teaching strategies employed (Lamb and Shraiky 2013). The design brief for the new Anatomy Resources Laboratory was to create a flexible learning space, which would accommodate small group teaching across a range of learning approaches including technology-enhanced learning, anatomical models, ‘talk and chalk’, portable ultrasound and body painting. A circuit of activities for students to rotate through was envisaged. In this regard, movable chairs and tables were included to facilitate a wide range of small group teaching approaches. Round tables were selected for students to interact easily

2

Putting the Cart Before the Horse? Developing a Blended Anatomy Curriculum. . .

17

Fig. 2.1 Original floorplan of the anatomy laboratory

with each other. Additionally, individual study pods were created by way of 12 computer stations to be used by students during sessions or for independent study (see Fig. 2.1 and https:// virtualtours.sunderland.ac.uk/360sV2/index. html?360=1610023&iframeCleared=true ). The computers purchased were the highest specification required to run all of the selected software packages and were paired with large interactive touchscreen display screens to permit students an intuitive interaction with anatomy software, since rotation and resizing of digital anatomy models are likely to be less challenging when using a touchscreen device. Standard audiovisual equipment was included to enable projection onto a screen (2.4 m × 1.6 m) from a range of

devices. Lockers for the secure storage of student belongings were installed outside of the laboratory. To facilitate the integration of ultrasound into our curriculum, a changing room for human volunteer ultrasound models was included alongside a store for ultrasound machines and portable examination couches. A moveable partition was included to enable separation of the room into two spaces for activities such as body painting and ultrasound scanning. Window blinds were also fitted to preserve modesty and allow comfort for students and/or patient volunteers for body painting and ultrasound scanning. Dimmable lighting was added to support the optimal display of ultrasound screens and projected ultrasound images. Wall shelving was included in the laboratory for

18

E. Donald et al.

Fig. 2.2 Anatomical models (Somso® models from Adam, Rouilly, Sittingbourne, UK) shelved so as to permit ready access to students and staff, and to create an appealing visual display

the display of anatomical models to create visual appeal and to physically signpost the space to learners and educators (Fig. 2.2). Overall, the design of the room provided a learning environment that was adaptable for collaborative and self-directed work, as well as didactic teaching for small and large groups. Additionally, the absence of cadaveric resources and the visual appeal of the laboratory enabled anatomy to be included as a key element of widening participation events for school children and in undergraduate recruitment activities.

2.3

Selection of TEL Resources for the Anatomy Resources Laboratory

The University of Sunderland was committed to providing the best anatomy learning experience possible whilst the new cadaveric anatomy

laboratory was being designed and constructed. They recognised the significance of highresolution digital models in a modern anatomy curriculum, alongside cadaveric teaching. The institution, therefore, provided capital funding for a full range of anatomical models and software packages for anatomy learning, as well as a visualisation table and portable ultrasound equipment. There is no single ‘gold standard’ accepted for anatomical education that can meet the needs of a full anatomical curriculum. Instead, integrating complementary multimodal resources can be of great benefit to the student cohort (Estai and Bunt 2016; Khalil et al. 2018). Additionally, Wilson et al. (2017, 2018) performed a systematic review, which stated that across all the included studies (dissection, prosections, models, and digital resources), there was no significant difference in overall performance in knowledge exams regardless of teaching modality. However, the

2

Putting the Cart Before the Horse? Developing a Blended Anatomy Curriculum. . .

quality of TEL studies within the literature has also been questioned and another systematic review highlighted that TEL studies may not always provide robust data on their impact within anatomical education (Clunie et al. 2018). Thus, any conclusions must be interpreted with great caution and educators should also critically analyse the specific applications of each resource against the intentionality of what is required for curriculum delivery (Wilson et al. 2018). Thus, we explored what this meant in the context of our curriculum. Biggs’ theory of constructive alignment (Biggs 1996) was a key driver in the selection of our learning resources, learning activities and assessments, and informed the design of the laboratory. As we had received our ILOs from our partner institution, we had to ensure that our teaching opportunities were both feasible and engaging and aligned with our assessment strategy (Biggs and Tang 2015). Furthermore, we applied Gagné’s principles of instructional design to our curriculum (Gagné et al. 1992). We provided a variety of features to meet learner needs including interactivity, accessibility, formative assessment, and opportunities for selfdirected learning. Our central tenet when selecting resources was to permit a constructivist approach in line with their PBL curriculum. PBL requires students to work collaboratively in small groups and as independent learners, and we endeavoured to equip our students with resources to fit both of these requirements. With regards to three-dimensional (3D) visualisation tools, we wanted to select resources to ensure we could deliver (a) an accurate 3D representation of the human body and (b) clinical imaging modalities to allow for learning both within and outside of the classroom. Upon analysis, there was not a one-size-fits all resource to deliver the curriculum. Furthermore, we recognised that multiple learning preferences exist within a cohort of students, and that it is useful to use a multimodal design that offers our students multiple ways to learn anatomy (DiLullo 2020).

19

Here, we provide a descriptive account of how we integrated TEL including Anatomage (Anatomage Inc. a Delaware corporation, Santa Clare, USA), Virtual Human Dissector (VHD; VH Dissector 6.0.1, Touch of Life Technologies, Inc, Aurora, Colorado, USA), Complete Anatomy (Complete Anatomy, 3D4Medical, San Diego, USA), and portable ultrasound. Other authors have explored the scholarly basis for the integration of TEL approaches in anatomy curricula (Keenan and Ben Awadh 2019) and so this aspect will not be explored here. Where possible, an evidence base is given for the approaches used.

2.3.1

Virtual Dissection Tools

2.3.1.1 Virtual Human Dissector VHD is a versatile software package that has been developed by the National Library of Medicine’s Visible Human Project (National Library of Medicine 2004). Students find interpretation of crosssectional anatomy (CSA) challenging; this is likely due to either the teaching methods employed, inherent spatial abilities of individuals, and/or time spent learning anatomy (Ben Awadh et al. 2022). Modern diagnostic medicine relies routinely on the interpretation of two-dimensional (2D) clinical images such as magnetic resonance imaging (MRI) and computed tomography (CT) scans, so early mastery of interpretation skills is important for undergraduates (Radiology 2011). VHD comprises a complete, detailed 3D representation of an entire male and a partial female human body reconstructed from labelled photographs of thin (at intervals of between 0.3 and 1 mm), serial transverse cryosections of each gelatin-embedded cadaver (Visible Human Project Factsheet 2004). With a mouse click or using touchscreen technologies, whole organ systems or individual structures can be removed and replaced from the 3D view to highlight pertinent anatomical relationships. VHD allows the user to examine structures or entire organ systems simultaneously in both 3D and 2D views and it also allows the user to reconstruct 3D structures by selecting the structures on the 2D view.

20

E. Donald et al.

Fig. 2.3 Screenshots taken from VHD (VH Dissector 6.0.1, Touch of Life Technologies, Inc, Aurora, Colorado, USA) which show an anterior view of the lungs and

corresponding cross-sectional anatomy at the level of the highlighted plane of section; note the use of textbook colour-coding of arteries and veins

Luursema et al. (2006), state that simultaneous referencing between 3D and 2D visualisations of anatomy may assist students in developing a 3D mental map of the body and may facilitate CSA interpretation (Fig. 2.3). Donnelly et al. used a cross-over design to investigate the utility of VHD in aiding crosssectional image interpretation and found that student test scores improved significantly ( p < 0.05) following 20 min of self-directed learning using VHD, and that this method was comparable in student outcomes to teaching approaches using prosections (Donnelly et al. 2009). Deng et al. found that alongside testing outcomes, student satisfaction also increased following the adoption of digital virtual simulation software, such as VHD, into the curriculum, suggesting that such methods improve the efficiency of anatomical teaching (Deng et al. 2018). Houser and Kondrashov surveyed medical students on the utility of a multimodal anatomy curriculum and reported that students perceived VHD (in combination with ultrasound and cadaveric dissection) aided the interpretation of radiological images (Houser and Kondrashov 2018).

Version 6.0.1 of VHD permits the creation of oblique planes that are useful for contextualising the scanning planes required for point-of-care ultrasound (POCUS). Probe positioning to obtain standardised echocardiography views, for example is particularly challenging for students (Dieden et al. 2019). We created cross-sectional reference images in VHD alongside ultrasound scanning activities to enable students to anchor the ultrasound images they obtain within a whole section of the body, and we believe that this is a novel application of VHD (Fig. 2.4). Based on our experiences and the studies described above, we determined that VHD could help learners to relate their understanding of 3D anatomical structures to 2D representations of anatomy. We purchased VHD licenses for the 12 computers in the laboratory (as well as instructor licenses) to enable students to work through guided learning activities as part of anatomy classes.

2.3.1.2 Visualisation Tables Visualisation tables have been in existence for almost 20 years and have been shown to provide

2

Putting the Cart Before the Horse? Developing a Blended Anatomy Curriculum. . .

Fig. 2.4 Screenshots taken from VHD (VH Dissector 6.0.1, Touch of Life Technologies, Inc, Aurora, Colorado, USA) where the resultant blue plane of section on the 3D figure is reoriented by manipulation of the coronal and sagittal planes to map to the ultrasound plane for a 4-chambered view of the heart. In the upper image the bony landmarks and skin are included to reference the correct plane for probe orientation and in the lower images skin translucency is used with highlighting to reference the plane through the heart. The 4-chambered view shown in VHD maps to the apical 4-chamber view of the heart. Image by Patrick J. Lynch and C. Carl Jaffe, distributed under a CC-BY 2.5 license

21

22

interactive TEL experiences for learners (Custer and Michael 2015; Clunie et al. 2018). The two market leaders at the time were Anatomage and Sectra (Sectra AB, Linköping, Sweden). The literature on the utility of these tables was scant at the time of purchase, in 2018, but both tables were trialed and considered as a significant element of the anatomy learning experience since they allowed virtual dissection for a small group learning experience. Sectra AB is a medical imaging company (sectra.com). In our experience, the Sectra Visualisation Table (VT) provides an excellent, interactive experience for clinical imaging along with access to VHD for anatomy teaching and this has been previously described by Ben Awadh et al. (2022). In our opinion, Anatomage, provided more utility as an anatomy teaching tool, with clinical imaging included as an adjunct. Some of the Anatomage functionality we used is now discussed. Anatomage provides four fully segmented datasets from both male and female donors of Asian and Caucasian ethnicity; high-resolution regional anatomy datasets are also provided. These can be selected through the ‘Gross Anatomy’ menu. The Table also permits sectioning in axial, sagittal, and coronal planes, as well as diagonal planes. The depth of sectioning can be controlled by using a slider bar. Segmented anatomy is fully indexed to enable the creation of customised digital models (termed ‘pre-sets’) and a pre-authored Anatomage Curriculum Menu provides over 400 ready-made pre-sets. Segmented anatomy is indexed to a set of corresponding histological sections, which permits integration between gross and histological anatomy. Anatomage also carries a large collection of CT, MRI, and 4D regional scans within the ‘Case Library’ menu, which illustrate normal anatomy and anatomical variations, pathology, embryology, trauma, and disease. These clinical images support clinical anatomy teaching and can be used to link anatomy teaching to PBL cases. The Anatomage Table (AT) is also equipped with a feature called ‘Quiz Mode’ which offers a range of formative assessment opportunities for

E. Donald et al.

students. A ‘Game’ mode allows students to compete for points. Gamifying education using friendly competition is a way of motivating and engaging students (Ahmed et al. 2015; Worm and Buch 2014). Other Anatomage tools include the ability to add colour or translucency to structures. Colour can be used to signpost pertinent anatomical structures and translucency to reference between deep and superficial structures. We considered cognitive load theory (Van Merriënboer and Sweller 2010) to differentiate between the functionality of Sectra and Anatomage. Anatomage allows the user to manage intrinsic cognitive load by using the ‘simple to complex’ approach, where structures can be easily constructed allowing the learner to progress from basic to advanced level. Similarly, it is conceivable that the colour-coding feature within Anatomage may reduce extraneous cognitive load for learners. Ultimately, decreasing the cognitive load on students and can keep them more engaged throughout the session structures (Khalil et al. 2018; Van Nuland et al. 2017). Previous work has identified that students perceive that Anatomage enhances active learning and that the interactivity of Anatomage facilitates understanding of anatomical relationships and body systems (Fyfe et al. 2018; Alasmari 2021). Learners also value the creation of pre-sets which can be captured and stored for personal study (Martín et al. 2018). Taken together, we identified Anatomage as a comprehensive and diverse solution for our curriculum delivery.

2.3.2

Digital and Physical Anatomical Models

2.3.2.1 Complete Anatomy Complete Anatomy (CA) software (3D4Medical Elsevier, Amsterdam, Netherlands) is accessible as an app on most devices, such as Mac, Windows, and smartphones. The app allows content to be downloaded for off-line availability, thus increasing its accessibility and inclusivity for students. CA uses 3D renderings of human

2

Putting the Cart Before the Horse? Developing a Blended Anatomy Curriculum. . .

23

Fig. 2.5 Screenshot taken from Complete Anatomy (CA; Complete Anatomy, 3D4Medical, San Diego, USA) to demonstrate some of its functions. Using CA, it is possible

to fade specific structures so that underlying ones can be more easily visualised

anatomy, which permit the creation of bespoke digital anatomical models either before or during class in real time. In addition, the App was purchased for its comprehensive range of pre-authored content. This content includes gross and microscopic anatomy models, crosssections, and radiological images as well as instructional videos. CA provides access to over 1500 videos on different anatomical regions in the body, which educators can signpost to students for independent asynchronous learning before attending any lab session or small group tutorial (Harmon et al. 2021). For additional functionalities present within the app, some screenshots from the software can be seen in Figs. 2.5 and 2.6. It has been reported previously that visually appealing educational resources can encourage student engagement (Sandars and Lafferty 2010). It was noted that the CA app had high visual appeal and it was envisaged that this would promote students to engage with the content. Similarly, other authors have highlighted the importance of easy navigation of an educational resource, as it increases the chances of knowledge gain for the learner (Van Nuland et al. 2017). CA

can be easily accessed by students on their devices both at home and in the classroom without extensive support or training from educators. We envisaged that CA would provide an excellent platform to allow transitions between a technology-enhanced or hybrid learning curriculum and a cadaveric anatomy curriculum, which aligns with previous work in this area (Havens et al. 2020). CA was highly valued by students and educators, and it was quickly integrated into anatomy teaching across the faculty. The widespread use of CA across several faculty programmes meant that CA met the criteria for centralised library funding. To overcome the limitation of having a personal device to access CA, University of Sunderland students can also access CA on desktop computers and laptops in the university library. This educational platform is currently being used by over 350 universities worldwide including several different institutions in the United Kingdom; its usage has increased during the switch to online learning during the COVID19 pandemic (Attardi et al. 2022; Longhurst et al. 2020).

24

E. Donald et al.

Fig. 2.6 Screenshot taken from Complete Anatomy (CA; Complete Anatomy, 3D4Medical, San Diego, USA) to demonstrate some of its functions. Using CA, it is possible

to label structures of interest and to highlight specific regions and/or osteological features in different colours

2.3.2.2 Anatomical Models Notwithstanding the increasing availability of digital visualisation tools available to anatomists, most anatomy departments routinely provide and use plastic anatomical models to support student learning. There is debate in the literature around the relative efficacy of 3D visualisation approaches compared to physical models (Yammine and Violato 2015). For example, recently Wainman et al. (2018) found that in terms of learner gain, physical models surpassed 3D visualisation approaches due to the stereoscopic vision afforded by physical models. These findings have implications for the use of digital technology in spatial learning. We therefore provided a full range of anatomical models (Somso® models from Adam, Rouilly, Sittingbourne, UK) to allow students to see spatial relationships in 3D space, whilst also providing a haptic experience that cannot be gleaned from digital anatomical models. When not used in teaching, the models were shelved in the lab, which had the benefit of physically signposting the space to learners and educators (Fig. 2.2).

2.3.3

Portable Ultrasound and Radiology

POCUS comprises a short ultrasound examination of the patient at the bedside that answers a focussed clinical question such as ‘is there visible sliding motion of the visceral pleural membrane against the parietal pleural membrane?’ The use of POCUS for medical diagnosis continues to expand in almost all medical specialties largely because diagnosis is rapid, more accurate, and cost-effective, leading to shorter stays in hospitals (Hashim et al. 2021; Smallwood and Dachsel 2018). POCUS has particular utility in Emergency Medicine and has been incorporated within the UK emergency medicine curriculum since 2010 (The Royal College of Emergency Medicine 2015). The increasingly widespread use of POCUS is now influencing medical curriculum development worldwide. Ultrasound curricula are most developed in the USA, but several UK medical schools have incorporated ultrasound scanning in their anatomy curricula (Hoppmann et al. 2011, 2015), in order to prepare medical

2

Putting the Cart Before the Horse? Developing a Blended Anatomy Curriculum. . .

graduates for their inevitable encounters with POCUS. There is no accepted standard ultrasound curriculum. However, there are several considerations when integrating ultrasound teaching into undergraduate medical education, such as time available, resources, and expertise (Celebi et al. 2019). Most recently, authors have suggested that there is a need for a standardised, integrated ultrasound curriculum to ensure effective training and safe practice of POCUS (Hashim et al. 2021). Ultrasound scanning is a skill and mastery of this skill requires practice. We recognised that we needed to purchase sufficient portable ultrasound equipment to enable students to have frequent opportunities to scan and to have sufficient time allocated to scanning within classes. We therefore purchased six handheld GE (GE Ultrasound, GE Healthcare, UK) V Scan devices and one GE Logic machine. We later increased ultrasound provision with three GE Versana machines. We designed the learning environment to provide privacy for ultrasound models and to enable the visualisation of sonoanatomy on both individual machines and large screen projections (Patten et al. 2010). For successful integration of ultrasound, it is important to work with educators who have appropriate clinical expertise, such as sonographers, radiologists, and clinicians (Birrane et al. 2018). We engaged with sonographers to deliver ultrasound teaching and to train anatomy educators. Sonographers also acted as role models and contributed to the delivery of our hidden curriculum, and we employed simulated patients for scanning. These experiences influence medical students in acquiring values and attitudes that contribute to professionalism and how they should behave in a clinical setting. They also contribute to developing communication skills and how students should interact with patients in a clinical setting (Hafferty and O’Donnell 2015). We prefaced the ultrasound scanning sessions with body painting activities to ensure students could locate surface landmarks for ultrasound probe positioning. In keeping with our previous experiences, the literature demonstrates that students find

25

ultrasound sessions engaging (Griksaitis et al. 2014; Patten 2015) and that scanning can improve medical students’ practice of clinical examination (Tshibwabwa et al. 2007). In planning our ultrasound activities, we also considered the educational value of our sessions (Galusko et al. 2018). For successful integration of ultrasound, there is a requirement for clear ILOs, knowledge of surface anatomy, and of the relevant gross anatomy. Ultrasound may not be useful as a replacement for gross anatomical teaching, but rather as an application of existing student knowledge (Wakefield et al. 2018). Therefore, we carefully curated the ILOs from our partner institution that would be most suitable for ultrasound. We have previously highlighted our intention to include clinical imaging of anatomy within our curriculum. In a recent white paper, the European Society of Radiology (Radiology 2011) proposed a curriculum framework for undergraduate learning in radiology and made recommendations for radiologists to be involved in the teaching programme. To deliver authentic and current teaching in radiology, we included radiologists as educators within our department.

2.4

Curriculum Delivery and Session Delivery

Once the laboratory was established and all resources were in place, individual anatomy practical classes were planned. A station format was chosen to facilitate small group teaching (n ~ 6–8 students) where small groups would cycle around four activities. The predominant four-station format was AT, VHD, anatomical models, and another activity (such as clinical imaging, ultrasound, body painting, or another art-based learning approach). Teaching approaches varied depending on the educator and the resource being used, yet what was consistent was the ability for all students to engage by asking and answering questions, actively taking notes, or interacting with the digital and physical resources. For each practical session, learning resources and activities were selected to complement ILOs. CA models were authored, and anatomical

26

E. Donald et al.

models (Somso® models from Adam, Rouilly, Sittingbourne, UK) were allocated as required. The AT was pre-loaded with curriculum ‘presets/screens’ that were useful for some practical sessions. Since the intention was to deliver an element of dissection for students, Tutor Guides were authored for each session to enable a scripted, but real-time demonstration of virtual dissection on the Table. Similarly, guides were authored to facilitate virtual dissection using VHD software on the laboratory computers in real time.

2.5 2.5.1

Experiences with Digital Visualisation Approaches Supporting Educators with TEL Resources

Educators learned how to use the AT through onsite training, webinars, and peer teaching. Pre-authored curricular content was available on the AT and was used on occasion in class. As we became more familiar with the AT features, we found that our approach to using it evolved. Clinical educators, who had largely learnt anatomy through cadaveric specimens, also delivered some real-time virtual dissection on the AT. Since they had limited opportunities to learn how to operate the AT, it was paramount that they were supported to navigate the AT quickly and without difficulty so as not to waste teaching time. To address this, a series of pre-sets were created for each class along with an accompanying Tutor Guide (as described above), which illustrated a stepwise dissection and construction of the anatomy. Tutors could simply load each pre-set as required and this was found to be an efficient way to progress through a dissection or construction in class. Tutor guides were illustrated with screenshots of the pre-sets (Fig. 2.7). Similarly, we routinely created CA screens for use in class by students and/or educators. As we became more familiar with the Anatomage and VHD features, we were able to optimise and finesse the deployment of these resources.

Fig. 2.7 Anterior view of the liver, gallbladder, pancreas, spleen, and duodenum using Anatomage (Anatomage Inc. Santa Clare, USA, Anatomage Table EDU; the 3D rendering of the cadaver data is from Anatomage Table). Note the use of colour-coding to signpost the disposition of these organs, and the use of translucency to reference the subcostal location of the liver and spleen without impeding view

2.5.2

Use of Key Views

Garg et al. (2001) use the term ‘key views’ to describe the typical viewpoints of anatomical illustrations in standard atlases, for example most anatomical atlases will show anterior and posterior views of carpal bones. There is evidence to show that students are better at recalling anatomy initially when it is presented in a key view and that student-controlled manipulation of viewpoints improves spatial and factual learning (Garg et al. 2001; Yammine and Violato 2015). Therefore, when using digital representations of anatomy we routinely presented the first image as a key view (as seen in textbooks, for example anterior, and posterior; as exemplified on the AT Fig. 2.7). Pre-sets in key views were later re-oriented/rotated on the Table as required to highlight anatomical structures and their relationships. Thus, the real-time classroom experiences using digital representations

2

Putting the Cart Before the Horse? Developing a Blended Anatomy Curriculum. . .

permitted multiple views to be observed, which should improve factual learning and spatial orientation.

2.5.3

Use of Colour and Translucency

Other digital models such as Primal Pictures (Primal Pictures, 3D anatomy Software) include the facility to colour-code and/ or add translucency to anatomical structures, and this is also a feature of Anatomage and VHD. From our collective experiences of teaching with embalmed cadaveric specimens, we knew that students routinely struggled to differentiate between neurovascular structures which appeared very similar in colour. We therefore routinely highlighted neurovasculature in all VHD (Fig. 2.8) and Anatomage pre-sets (Fig. 2.9) to explicitly reference standardised textbook depictions of anatomy. The rationale here was to cue prior student knowledge (from independent study before class) during their interactions with digital representations of anatomy in class to facilitate

Fig. 2.8 Anterior 3D view of posterior mediastinal structures with an axial section using VHD (VH Dissector 6.0.1, Touch of Life Technologies, Inc,

27

information organisation whilst minimising cognitive effort (Heo and Chow 2005). We also used colour-coding to emphasise/ explain anatomical relationships for AT (Figs. 2.8 and 2.9). For example, colour-coding the groups of limb muscles to aid conceptualisation of functional muscle compartments. Identification of anatomical structures using this method has also been linked to reducing cognitive load for medical students (O’Byrne et al. 2008), and in body painting colour has been reported to aid memorisation of anatomical structures (Finn 2018). We found that the translucency feature of Anatomage was particularly useful for enabling visualisation of deeper structures whilst simultaneously referencing more superficial structures. The translucency feature can enable visualisation of the ribs without obscuring the underlying liver and spleen (Fig. 2.7). Students can rotate the model and appreciate proximity of these organs with their adjacent ribs. This translucency feature was especially useful when teaching neuroanatomy (Fig. 2.9b) since it permitted a visualisation of deeper brain structures in reference to the outer

Aurora, Colorado, USA, www.toltech.net); note the use of colour-coding to signpost the major arteries, veins, and nerves

28

E. Donald et al.

Fig. 2.9 (a) Anterior view of the lower limbs with associated neurovasculature; note the use of colour-coding to signpost the major arteries, veins, and nerves and the colour-coding of muscles to highlight functional compartments of muscles. (b) Posterior view of the brain; note the use of colour-coding to signpost the components of the ventricular system and basal ganglia, and the use of translucency to reference the surrounding cerebral cortex. (c) Anterior view of the left lower limb with associated neurovasculature; note the use of colourcoding to signpost the major arteries, veins, and nerves and

the use of the ‘no clip’ function to highlight the course of the neurovasculature between the individual muscles. Images (a), (b), and (c) are taken from Anatomage (Anatomage Inc. Santa Clare, USA, Anatomage Table EDU; the 3D rendering of the cadaver data is from Anatomage Table). (d) Anterior 3D view of the thorax using VHD (VH Dissector 6.0.1, Touch of Life Technologies, Inc, Aurora, Colorado, USA, www. toltech.net); note the use of skin translucency to permit referencing of bony landmarks beneath the skin surface

cortical regions. Translucency capability in VHD was restricted to the skin which was useful in teaching surface anatomy. Reduced skin opacity permits bony landmarks to be referenced to surface features (Fig. 2.9d).

directed students to URL bookmarks of VHD digital models with which to interact. Students were then required to navigate to specific crosssectional slices, to colour-code structures, and to navigate up and down through adjacent crosssectional images to appreciate the course and changing profile of anatomical structures. Student feedback (personal communication with students) indicated that this activity was not highly valued. Students focussed on working through the instructions instead of the cross-sectional anatomy and did not appreciate the anatomy or achieve the ILOs. We created accompanying video guides demonstrating the activity along with the written guide, and students very much appreciated the guided instructions. We found

2.5.4

Cross-Sectional Tools

The preferred resource for teaching crosssectional anatomy was VHD, for the reasons described above. To support learner gain (Donnelly et al. 2009), we created detailed, illustrated instructional guides for students to use with VHD as part of a self-directed activity in class, using the class computers. The guides

2

Putting the Cart Before the Horse? Developing a Blended Anatomy Curriculum. . .

that this focus on cross-sectional anatomy aided student understanding in radiology teaching. To support active student engagement, and in keeping with principles of instructional design, radiologists routinely engaged students in formative assessment of their knowledge of crosssectional anatomy. Anatomage also provides the facility for crosssectional anatomy teaching. A ‘no-clip’ tool is a novel feature, which permits selected structures to be preserved during dissection. This feature enables the course of neurovascular structures within the limbs to be visualised when anatomy is viewed as a cross-sectional dissection (Fig. 2.9c).

2.5.5

Virtual Dissection and Virtual Construction

Digital dissection tools allow for deconstructive approaches where students can remove layers or structures to visually observe what lies beneath. However, they also permit novel methods of learning, such as a constructive approach whereby students can construct a region digitally. We hypothesised that a constructive approach would enable students to build up the complexity of a region and would elicit greater learner gains than a deconstructive approach, where anatomical structures are sequentially removed (Fig. 2.10), starting with the osteology in the top left (a) and proceeding to add in the relevant anatomical details b–f), and thus students start with a complex model which may impact on cognitive load. As the literature is limited with regards to the data on the efficacy of technology-enhanced approaches to increase learner gain (Clunie et al. 2018), we decided to test this parameter. We investigated learner gain between these two different methods of teaching brachial and lumbosacral nerve plexuses (deconstructive and constructive) using the AT (n = 50, year 1 medical students). Ethical approval for this study was granted by the University of Sunderland (ref. no. 008189). We performed a pre-test, an immediate post-test, and delayed post-testing either 6 weeks (lumbosacral plexus) or 12 weeks

29

(brachial plexus) after the initial teaching. These different time points are attributed to curricular restrictions. For both plexuses, there was a significant increase in test score after the teaching session ( p < 0.001) (two-way mixed ANOVA). For the lumbosacral plexus, a significant increase remained for the retention test for both teaching methods ( p < 0.05) (Table 2.1). These results suggest that both methods are beneficial for learning and indicate that educators can utilise both approaches for teaching nerve plexuses. However, we are yet to explore other regions such as neuroanatomy. Additionally, as retention still significantly increased after 6 weeks but not after 12 weeks, this indicates that spaced repetition testing may be useful to integrate (Donker et al. 2022). We have a formative assessment hosted on Canvas (Instructure Global, London, U.K.), our virtual learning environment, after each session to which we can easily integrate questions from previous weeks.

2.5.6

Ultrasound and Radiology

We included ultrasound activities throughout years one to three of the anatomy curriculum at the University of Sunderland. We supported sonographers to develop instructional videos in ultrasound physics and machine operation and these were developed into an ultrasound module on our virtual learning environment for students to access before ultrasound sessions. This is a work in progress as we continue to add video content to this module. Year one activities introduced students to ultrasound as an imaging modality including image interpretation and the aspects of safe scanning as we have previously outlined (Patten 2015). Thereafter in years two and three, scanning activities were aligned to emergency medicine POCUS procedures to highlight clinical relevance and to address curriculum spirality. For example, we used a Heartworks TTE Mobile ultrasound simulator (MedaPhor Ltd.) to demonstrate cardiac tamponade for year 2 students to build upon their experiences in year 1. The availability of plentiful equipment enabled students to

30

E. Donald et al.

Fig. 2.10 Screenshots of pre-sets from approach to teaching the lumbosacral Anatomage (Anatomage Inc. Santa Anatomage Table EDU; the 3D rendering

a constructive plexus using Clare, USA, of the cadaver

data is from Anatomage Table) starting with the osteology in the top left (a) and proceeding to add in the relevant anatomical details (b–f)

engage in regular scanning activities in small groups with sufficient scanning time. Simulated patients were employed so that students were not asked to volunteer as the patient. To maximise the learning opportunity, students were instructed to observe each other scanning, and to note the repeated instructions of the sonographer and the probe position. We recorded ultrasound scanning activities whilst the class was in progress to capture the sonographer instructions, which were subsequently used for staff training. With respect to our inclusion of radiology in our anatomy curriculum, and to ensure a

sustainable model and continued engagement with radiologists, we worked in partnership with our National Health Service Trust Radiology Directorate to reach out to radiology trainees across our region. The use of trainees ensures currency of disciplinary knowledge and trainees provided learning resources and feedback to our students. We supported the trainees in their professional development by providing formal teaching observations as evidence for e-portfolio records and Annual Review of Competence Progression panels; this mutually beneficial model

Table 2.1 Percentage score obtained in pre-test, post-test (directly after teaching session), or retention test (6 or 12 weeks) Lumbosacral Constructive Lumbosacral Deconstructive Brachial Constructive Brachial Deconstructive p < 0.01 and *p < 0.05

**

Pre-test 55.2% ±3.0 SEM

Post-test 76.6% ±3.3 SEM**

Retention test 72.4% ±3.1 SEM*

51.1% ±3.5 SEM 41.8% ±3.3 SEM

75.6% ±3.8 SEM** 59.1% ±3.9 SEM**

66.6% ±3.7 SEM* 48.8% ±3.6 SEM

40.8% ±3.1 SEM

60.5% ±3.6 SEM**

46.4% ±3.3 SEM

2

Putting the Cart Before the Horse? Developing a Blended Anatomy Curriculum. . .

has enabled delivery of a spiral strand of radiology throughout our curriculum.

2.5.7

COVID-19 Pandemic Resilience

The predominant TEL focus of our curriculum enabled a smooth transition to online learning during the COVID-19 pandemic. Most medical schools worldwide had to rapidly adapt their teaching approaches and switch to online learning (Brassett et al. 2020; Longhurst et al. 2020; Grafton-Clarke et al. 2022). Although our curriculum was designed to be delivered face-to-face in the Anatomy Resource Laboratory, we were easily able to convert our delivery to online synchronous sessions because we were able to access Anatomage, VHD, and Complete Anatomy from our own personal devices. We used the software to demonstrate and explain anatomy and we simply shared computer screens in real time over Microsoft Teams (Microsoft Corporation, USA). Furthermore, as students had access to Complete Anatomy on their own devices, we were able to design active learning tasks as well as designate pre-authored content for them as either pre-work or revision. Whilst our TEL approaches afforded a robust and rapid adjustment to curriculum delivery during the COVID-19 pandemic, we agree with previous authors (Franchi 2020), that technology alone cannot enhance the understanding of 3D anatomical concepts and that a tactile experience (such as interaction with cadavers) is required (Böckers et al. 2021). We are committed to delivery of a blended anatomy curriculum incorporating a combination of digital and traditional anatomy resources into teaching sessions to improve student outcomes (Byrnes et al. 2021).

2.6

Laboratory’, and the existing ‘Anatomy Resources Laboratory’. A translucent glass wall separates the two laboratories to permit simultaneous oversight of both learning environments and the wall can be switched to opaque for privacy and separation of the learning spaces when required. This enables both laboratories to be timetabled concurrently for different groups of learners (Fig. 2.11). The cadaveric laboratory is furnished with stainless steel trollies and laboratory stools for small group learning. Standard AV provision is included along with wall-mounted flat screen monitors and a ceiling-mounted WolfVision VZ-C6 Visualiser. The visualiser permits realtime and pre-recorded demonstrations of cadaveric specimens to be displayed on the flat screen monitors for the whole cohort. A ‘Quiet Room’ has also been created, which will provide a reception area for visitors and for those students who need to take time out from the anatomy laboratory, offering a restful and tranquil place for quiet counselling and contemplation. Artwork is therefore an important feature in this room, and in keeping with our broad interpretation of anatomy visualisation, glass, and ceramic work has been commissioned for this room. The University offered a competitive award to students enrolled on the Masters in Visual Practice (Glass and Ceramics). Some of the work is complete and is in place (Fig. 2.12) and other works are in progress. The next stage of curriculum development offers anatomy educators the opportunity to iteratively blend cadaveric and non-cadaveric elements across our spiral PBL medical curriculum whilst remaining faithful to our commitment to deliver hands-on, interactive, small group teaching sessions and to ensure alignment of anatomy teaching to the overall PBL curriculum.

Completion of the Build Project 2.7 and Integration of Cadaveric Anatomy

Construction of the new cadaveric anatomy facility is completed and is currently in use. A key feature of the facility is the provision of two adjoining laboratories, both the new ‘Cadaveric

31

Design and Integration of Cadaveric Anatomy (Student Perspective)

Integrating cadaveric anatomy into an already established curriculum raises pertinent questions that revolve around how and when to incorporate

32

E. Donald et al.

Fig. 2.11 The ‘Anatomy Resources Laboratory’ with anatomical models (Somso® models from Adam, Rouilly, Sittingbourne, UK) Anatomage table (Anatomage Inc.

Santa Clare, USA) and translucent wall, allowing oversight into the Sir James Knott Cadaveric Laboratory

this resource. Specifically, how do we blend cadaveric anatomy with our current resources and when in their training should students be introduced to cadaveric anatomy? Whilst there are reports of institutions reintegrating cadaveric anatomy after it being removed from educational programmes, there is little data on how to incorporate this resource into a curriculum where students have solely used non-cadaveric material (Wilson et al. 2018). Our students are key stakeholders in our anatomy curriculum and their insight is invaluable. As such, we have been exploring student perceptions of how and when to integrate cadaveric anatomy into a technology-enhanced curriculum. Data has largely been collected using focus groups, which have been analysed using reflexive thematic analysis. Emerging themes from the unpublished data demonstrate that students would value the combination of digital models and cadaveric anatomy, as our students believe that these resources will

complement each other. Digital models should be prioritised in education in the early years, as the ability to colour and label structures provide clarity that reduces focus on extraneous information, reducing cognitive load (Van Merriënboer and Sweller 2010). Access to digital models on student devices allows for flexible learning away from the classroom. However, students find that the technology is difficult to use, which inhibits learning and independent use, and so it is paramount that training is integrated into taught sessions. Our students identified cadaveric anatomy as the natural progression in a spiral curriculum. Cadaveric anatomy provides a sense of ‘real’ anatomy, an opportunity to learn haptically, understand anatomical variation, and observe pathology, which our students believe will provide greater confidence in their clinical skills and knowledge (Wilson et al. 2018). Despite having a wealth of accurate digital models at their fingertips, our students believe that having

2

Putting the Cart Before the Horse? Developing a Blended Anatomy Curriculum. . .

33

Acknowledgements The new Anatomy Centre has been established with the help of generous funding from the Sir James Knott Trust and the Garfield Weston Foundation.

References

Fig. 2.12 Art installation ‘Deus’ designed by Rodrigues Goncalves, one of the student enrolled on the Masters in Visual Practice (Glass and Ceramics) course at the University of Sunderland. This piece is already in place in the Quiet Room of the anatomy facility. Image supplied by and used with permission from Rodrigues Goncalves

something real to study is paramount to conceptualising 3D anatomy and relationships. Therefore, in this exciting time of curriculum development, we are obliged to identify and evaluate strategies to allow for these approaches to complement each other, rather than leaving one method on the shelf. We aim to identify an optimal blend of cadaveric and non-cadaveric learning resources and approaches in order to maximise learner gain in all aspects of our integrated spiral anatomy curriculum. We anticipate that we will be able to share our findings on the optimum time to introduce cadaveric anatomy and which learning resources can maximise learner gain in various aspects of gross anatomy and clinical image interpretation, including ultrasound.

Ahmed M, Sherwani Y, Al-Jibury O et al (2015) Gamification in medical education. Med Educ Online 20:29536 Alasmari W (2021) Medical students’ feedback of applying the virtual dissection table (anatomage) in learning anatomy: a cross-sectional descriptive Study. Adv Med Educ Pract 12:1303–1307 Attardi SM, Harmon DJ, Barremkala M et al (2022) An analysis of anatomy education before and during Covid-19: August–December 2020. Anat Sci Educ 15:5–26 Ben Awadh A, Clark J, Clowry G (2022) Multimodal three-dimensional visualization enhances novice learner interpretation of basic cross-sectional anatomy. Anat Sci Educ 15:127–142 Biggs J (1996) Enhancing teaching through constructive alignment. High Educ 32:347–364 Biggs J, Tang C (2015) Constructive alignment: an outcomes-based approach to teaching anatomy. Teaching anatomy. Springer, Cham Birrane J, Misran H, Creaney M et al (2018) A scoping review of ultrasound teaching in undergraduate medical education. Med Sci Educ 28:45–56 Böckers A, Claassen H, Haastert-Talini K et al (2021) Teaching anatomy under COVID-19 conditions at German universities: recommendations of the teaching commission of the anatomical society. Ann Anat 234: 151669 Brassett C, Cosker T, Davies DC et al (2020) COVID-19 and anatomy: stimulus and initial response. J Anat 237: 393–403 Byrnes KG, Kiely PA, Dunne CP et al (2021) Communication, collaboration and contagion: “virtualisation” of anatomy during COVID-19. Clin Anat 34:82–89 CelebI N, Griewatz J, Malek NP et al (2019) Development and implementation of a comprehensive ultrasound curriculum for undergraduate medical students—a feasibility study. BMC Med Educ 19:1–8 Cleveland B, Kvan T (2015) Designing learning spaces for interprofessional education in the anatomical sciences. Anat Sci Educ 8:371–380 Clunie L, Morris NP, Joynes VCT et al (2018) How comprehensive are research studies investigating the efficacy of technology-enhanced learning resources in anatomy education? A systematic review. Anat Sci Educ 11:303–319 Custer TM, Michael K (2015) The utilization of the anatomage virtual dissection table in the education of imaging science students. Journal of Tomogr Simul 1:1

34 Deng X, Zhou G, Xiao B et al (2018) Effectiveness evaluation of digital virtual simulation application in teaching of gross anatomy. Ann Anat 218:276–282 Dieden A, Carlson E, Gudmundsson P (2019) Learning echocardiography- what are the challenges and what may favour learning? A qualitative study BMC Med Educ 19:212 Dilullo C (2020) Learners of a new generation. In: Chan LK, Pawlina W (eds) Teaching anatomy: a practical guide. Springer International, Cham Donker SCM, Vorstenbosch MATM, Gerhardus MJT et al (2022) Retrieval practice and spaced learning: preventing loss of knowledge in Dutch medical sciences students in an ecologically valid setting. BMC Med Educ 22:65 Donnelly L, Patten D, White P et al (2009) Virtual human dissector as a learning tool for studying cross-sectional anatomy. Med Teach 31:553–555 Estai M, Bunt S (2016) Best teaching practices in anatomy education: a critical review. Ann Anat Anat Anz 208: 151–157 Finn GM (2018) Current perspectives on the role of body painting in medical education. Adv Med Educ Pract 9: 701–706 Franchi T (2020) The impact of the Covid-19 pandemic on current anatomy education and future careers: a student’s perspective. Anat Sci Educ 13:312 Fyfe S, Fyfe G, Dye D et al (2018) The Anatomage table: differences in student ratings between initial implementation and established use. Focus on Health Professional Education 19:41–52 Gagné RM, Briggs LJ, Wager WW (1992) Principles of instructional design. Harcourt Brace Jovanovich, Orlando Galusko V, Bodger O, Rees E et al (2018) Hand-held ultrasonography: an opportunity for “hands-on” teaching of medicine [version 1]. MedEdPublish 7:103 Garg A, Norman G, Sperotable L (2001) How medical students learn spatial anatomy. Lancet 357:363–364 Grafton-Clarke C, Uraiby H, Gordon M et al (2022) Pivot to online learning for adapting or continuing workplace-based clinical learning in medical education following the COVID-19 pandemic: a BEME systematic review: BEME Guide No. 70. Med Teach 44:227– 243 Griksaitis MJ, Scott MP, Finn GM (2014) Twelve tips for teaching with ultrasound in the undergraduate curriculum. Med Teach 36:19–24 Hafferty FW, O’Donnell JF (2015) The hidden curriculum in health professional education. Dartmouth College Press, Hanover Harmon DJ, Attardi SM, Barremkala M et al (2021) An analysis of anatomy education before and during Covid-19: May–August 2020. Anat Sci Educ 14:132– 147 Hashim A, Tahir MJ, Ullah I et al (2021) The utility of point of care ultrasonography (POCUS). Ann Med Surg 71:102982–102982

E. Donald et al. Havens KL, Saulovich NA, Saric KJ (2020) A case report about anatomy applications for a physical therapy hybrid online curriculum. J Med Libr Assoc 108: 295–303 Heartworks TTE Mobile. Available: https://www. intelligentultrasound.com/2017/09/28/bringing-ultra sound-into-simulation-with-the-new-heartworks-ttemobile/ Heo M, Chow A (2005) The impact of computer augmented online learning and assessment tool. J Educ Technol Soc 8:113–125 Hoppmann RA, Rao VV, Poston MB et al (2011) An integrated ultrasound curriculum (iUSC) for medical students: 4-year experience. Crit Ultrasound J 3:1–12 Hoppmann RA, Rao VV, Bell F et al (2015) The evolution of an integrated ultrasound curriculum (iUSC) for medical students: 9-year experience. Crit Ultrasound J 7:18 Houser JJ, Kondrashov P (2018) Gross anatomy education today: the integration of traditional and innovative methodologies. Mo Med 115:61–65 Keenan ID, Ben Awadh A (2019) Integrating 3D visualisation technologies in undergraduate anatomy education. In: Rea PM (ed) Biomedical visualisation, vol 1. Springer International, Cham Khalil MK, Abdel Meguid EM, Elkhider IA (2018) Teaching of anatomical sciences: a blended learning approach. Clin Anat 31:323–329 Lamb G, Shraiky J (2013) Designing for competence: spaces that enhance collaboration readiness in healthcare. J Interprof Care 27(Suppl 2):14–23 Longhurst GJ, Stone DM, Dulohery K et al (2020) Strength, weakness, opportunity, threat (SWOT) analysis of the adaptations to anatomical education in the United Kingdom and republic of Ireland in response to the Covid-19 pandemic. Anat Sci Educ 13:301–311 Luursema JM, Verwey WB, Kommers PAM et al (2006) Optimizing conditions for computer-assisted anatomical learning. Interact Comput 18:1123–1138 Macchi V, Porzionato A, Stecco C et al (2014) Evolution of the anatomical theatre in Padova. Anat Sci Educ 7: 487–493 Martín JG, Mora CD, Henche SA (2018) Possibilities for the use of Anatomage (the anatomical real body-size table) for teaching and learning anatomy with the students. Biomed J Sci Tech Res 4:94 National Library of Medicine (2004) The visible human project factsheet. Available: http://www.nlm.nih.gov/ pubs/factsheets/visible_human.html. Accessed Feb 2008 O’Byrne PJ, Patry A, Carnegie JA (2008) The development of interactive online learning tools for the study of Anatomy. Med Teach 30:e260–e271 Patten D (2015) Using ultrasound to teach anatomy in the undergraduate medical curriculum: an evaluation of the experiences of tutors and medical students. Ultrasound 23:18–28 Patten D, Donnelly L, Richards S (2010) Studying living anatomy: the use of portable ultrasound in the undergraduate medical curriculum. Int J Clin 4:72–76

2

Putting the Cart Before the Horse? Developing a Blended Anatomy Curriculum. . .

Radiology ESO (2011) Undergraduate education in radiology. A white paper by the European Society of Radiology. Insights Imaging 2:363–374 Rimmer A (2018) Five medical schools are created in England in bid to increase home grown doctors. BMJ 360:k1328 Royal College of Emergency Medicine (2015) Curriculum and assessment systems for training in emergency medicine. August 2015 Curriculum. Available: https://rcem.ac.uk/curriculum/ Sandars J, Lafferty N (2010) Twelve Tips on usability testing to develop effective e-learning in medical education. Med Teach 32:956–960 Smallwood N, Dachsel M (2018) Point-of-care ultrasound (POCUS): unnecessary gadgetry or evidence-based medicine? Clin Med (Lond) 18:219–224 Tshibwabwa ET, Groves HM, Levine MA (2007) Teaching musculoskeletal ultrasound in the undergraduate medical curriculum. Med Educ 41:517–518 Van Merriënboer JJG, Sweller J (2010) Cognitive load theory in health professional education: design principles and strategies. Med Educ 44:85–93 Van Nuland SE, Eagleson R, Roger SKA (2017) Educational software usability: artifact or design? Anat Sci Educ 10:190–199 Wainman B, Wolak L, Pukas G et al (2018) The superiority of three-dimensional physical models to two-dimensional computer presentations in anatomy learning. Med Educ 52:1138–1146 Wakefield RJ, Weerasinghe A, Tung P et al (2018) The development of a pragmatic, clinically driven ultrasound curriculum in a UK medical school. Med Teach 40:600–606 Wessels Q, Taylor AM, Jacobson C (2020) Designing anatomy teaching spaces to meet the needs of today’s learner. In: Chan LK, Pawlina W (eds) Teaching anatomy: a practical guide. Springer International, Cham Wilson A, Miller C, Klein B et al (2017) A 50 year review and meta-analysis of anatomy laboratory pedagogies. FASEB J 31:392.1 Wilson AB, Miller CH, Klein BA et al (2018) A metaanalysis of anatomy laboratory pedagogies. Clin Anat 31:122–133 Worm BS, Buch SV (2014) Does competition work as a motivating factor in e-learning? A randomized controlled trial. PLoS One 9:e85434 Yammine K, Violato C (2015) A meta-analysis of the educational effectiveness of three-dimensional

35

visualization technologies in teaching anatomy. Anat Sci Educ 8:525–538

E. Donald, BSc, MSc, Lecturer in Anatomy within the School of Medicine at the University of Sunderland with a background in human anatomy and evolution. Research interests include anatomy pedagogy and technology enhanced learning. K. Dulohery, BSc, PG Cert, MSc, PhD, FHEA, Senior Lecturer in Anatomy within the School of Medicine at the University of Sunderland. Research interests include anatomy pedagogy, curriculum development and technologyenhanced learning. M. Khamuani, BDS, MSc, MMedSci, FHEA, Lecturer in Histology and Anatomy at the University of Sunderland, School of Medicine with a background in dentistry and anatomy education. Research interests include anatomy pedagogy and technology enhanced learning. H. Miles, BSc, MSc, FHEA, Lecturer in Anatomy within the School of Medicine at the University of Sunderland with a background in biomedical science and human anatomy. Research interests include anatomy pedagogy and technology enhanced learning. J. Nott, BSc, PG Cert, MSc, PhD, FHEA, Senior Lecturer in Anatomy within the School of Medicine at the University of Sunderland with an interest in translational anatomy, technology-enhanced learning, and assessment in medical education. D. Patten, BSc, PG Cert, PhD, FHEA, Professor in Anatomy within the School of Medicine at the University of Sunderland. Research interests include anatomy pedagogy, curriculum development and technology-enhanced learning. A. Roberts, BSc, MSc, FHEA, Lecturer in Anatomy within the School of Medicine at the University of Sunderland with a background in clinical sciences and human anatomy. Research interests include anatomy pedagogy and technology enhanced learning.

Part II Innovating Visualisation

3

The Third Dimension: 3D Printed Replicas and Other Alternatives to Cadaver-Based Learning Paul G. McMenamin

Abstract

Capturing the ‘third dimension’ of complex human form or anatomy has been an objective of artists and anatomists from the renaissance in the fifteenth and sixteenth centuries onwards. Many of these drawings, paintings, and sculptures have had a profound influence on medical teaching and the learning resources we took for granted until around 40 years ago. Since then, the teaching of human anatomy has undergone significant change, especially in respect of the technologies available to augment or replace traditional cadaver-based dissection instruction. Whilst resources such as atlases, wall charts, plastic models, and images from the Internet have been around for many decades, institutions looking to reduce the reliance on dissection-based teaching in medical or health professional training programmes have in more recent times increasingly had access to a range of other options for classroom-based instruction. These include

digital resources and software programmes and plastinated specimens, although the latter come with a range of ethical and cost considerations. However, the urge to recapitulate the ‘third dimension’ of anatomy has seen the recent advent of novel resources in the form of 3D printed replicas. These 3D printed replicas of normal human anatomy dissections are based on a combination of radiographic imaging and surface scanning that captures critical 3D anatomical information. The final 3D files can either be augmented with false colour or made to closely resemble traditional prosections prior to printing. This chapter details the journey we and others have taken in the search for the ‘third dimension’. The future of a haptically identical, anatomically accurate replica of human cadaver specimens for surgical and medical training is nearly upon us. Indeed, the need for hard copy replicas may eventually be superseded by the opportunities afforded by virtual reality (VR) and augmented reality (AR). Keywords

Supplementary Information: The online version contains supplementary material available at https://doi. org/10.1007/978-3-031-30379-1_3.

Anatomy · Replicas · Medical education · 3D printing · Additive manufacturing · Cadavers · Augmented reality · Virtual reality

P. G. McMenamin (✉) Faculty of Medicine, Nursing and Health Sciences, Department of Anatomy and Developmental Biology, Monash University, Melbourne, VIC, Australia e-mail: [email protected] # The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Border et al. (eds.), Biomedical Visualisation, Advances in Experimental Medicine and Biology 1421, https://doi.org/10.1007/978-3-031-30379-1_3

39

40

3.1 3.1.1

P. G. McMenamin

Introduction Capturing 3D form Through the Ages

It is difficult to envisage from the lofty technological heights of the twenty-first century the shift in thinking about medicine around the time of the renaissance in the late fifteenth and early sixteenth centuries, which was brought on by a clearer understanding of human anatomy. An understanding of diseases and their causes was almost non-existent, partly because of the lack of understanding of normal anatomy and physiology. In this world, there were no textbooks or printed illustrations to guide the learner or practitioner. The ‘five systems drawings’ of Galen were retained by the teachers and were copied by students. Not only were they very crude, diagrammatic, and inaccurate but they lacked any attempt to portray depth or the ‘third dimension’. Johannes and Gregorius de Gregoriis, printers from Venice, produced the first ever illustrated medical textbooks, Fasciculus Medicinae in 1491 (1st edition) and later 1495 in Fasciculo de Medicinae in Volgare, but they merely reproduced ancient diagrams. The first clear evidence that someone may be trying to impart a three-dimensional perspective to illustrations of human form was possibly Antonio Pollaiuolo in Florence 20 years earlier (1470). Pollaiuolo produced a classic piece of artwork using copperplate engraving (an intricate and demanding method of print reproduction, which was not to be used by scientists for at least another century) depicting a scene of 10 naked warriors in battle. The artwork clearly suggests that Pollaiuollo had studied the surface anatomy of the body in motion and had possibly even dissected some human cadavers (see reviews, McMenamin 2022; Rifkin 2006). The next major figure who sought to capture 3D form was Leonardo DaVinci (1452–1519). He was a prime example of an artist becoming a scholar in human anatomy with the purpose of enhancing his art. We know he studied human and comparative anatomy, and may have

dissected human cadavers in public, which was becoming a common form of ‘entertainment’ in the renaissance period. It is quite clear from his many richly annotated illustrations that he was an either highly skilled dissector himself or had the assistance of skilled dissectors. For example, his drawings of limb anatomy, from various perspectives are akin to a 3D panoramic series (Fig. 3.1a). The work was revolutionary and demonstrated how through such knowledge he able was to bring an understanding of anatomy to his other famous artworks. His use of shading to portray depth and three-dimensional perspective, known as ‘sfumato’, was pioneering. Leonardo’s work would have made more of an impact on art and indeed on medicine if his drawings and observations had been shared amongst his contemporaries, however, that was not his goal. Many of his works were essentially unpublished and lay unseen for another 150–400 years or more (see Dr. Peter Abraham’s account, YouTube video; https://www.youtube.com/ watch?v=h9de37e9hXs). Michelangelo (1475–1564) is regarded by many to be the greatest artist of his time. It is clear from his work that he appreciated the need to study human anatomy in order to improve his skills in sculpture and painting. For example, one need only look at the relief marble piece (The Madonna of the Stairs [1490–1492]) which he created when he was merely 15–17 years old, The Pieta, when he was 23 years old (Fig. 3.1b), or David, the giant when he was around 26–28 years old, to appreciate his level of knowledge. He also made many diagrammatic illustrations of human anatomy and imparted a threedimensional form to them with his artistic skills (Fig. 3.1c). Raphael (Raffaello Senzio, 1483–1520) also had a significant impact on the art and anatomy worlds and was clearly influenced by Michelangelo and Vesalius. That Raphael studied human anatomy is evident by his harmonic drawings of naked bodies and simulations of crucifixions. Raphael and Michelangelo were artists first and foremost and anatomists second. Namely, their studies of

3

The Third Dimension: 3D Printed Replicas and Other Alternatives to Cadaver-Based Learning

41

Fig. 3.1 (a) One of DaVinci’s drawings of the upper limb shows his efforts to portray the anatomy from different perspectives almost like a rotating series. This is regarded by many as the first attempt to capture the ‘third dimension’ or 3D form. (b) Michaelangelo’s famous sculpture

‘The Pieta’ was created when he was around 23 years old. (c) One of Michaelangelo’s drawings of cadaver dissections. Note the shading and artistic method of capturing depth and 3D form

anatomy were a means of improving their artistic depiction of human form that had depth perspective—namely that ‘third dimension’ (Rifkin et al. 2006). Vesalius (1514–1564), often considered the ‘grandfather’ of human anatomy, dissected a great many bodies as evidenced by his thousands of illustrations in his famous De Humani Corporis fabrica published in 1543. His most defining works were the careful illustrations of the musculoskeletal system in which he (or in fact the artists whom he employed) not only tried to portray the fascicular pattern of muscles but also their 3D form. Whilst anatomically accurate, he, like many artists/anatomists around that time, frequently included unrelated subject matter in illustrations, such as architecture and rural scenery. Some of the more unusual trends of anatomical art, which clearly appear very strange in the context of modern moral frameworks, continued once the pioneering work of those described above had wrestled art and medicine from the grasp and control of the church and societal constraints (McMenamin 2021). Kemp (2010, 2011), in erudite reviews, points out that eventually in the seventeenth to eighteenth centuries there was a trend away from very elaborate artistic portrayal of the human form in

dramatic and heroic poses to more illustrative realistic or ‘non-style’ of anatomical drawings typified by William Cheselden, William Hunter, and both John and Charles Bell. These illustrations were the forerunners to Gray’s Anatomy and other traditional modern anatomy and surgical illustrations. That trend of ‘nonstyle’ diagrammatic representations of the 3D form of the human body was to dominate the medical, surgical, and scientific textbooks that were part of the essential home study toolkit of every student or trainee in medicine and other allied health professions for over 200 years (Kemp 2010, 2011). Until recently, the real appreciation of 3D form and relations of anatomical structures to one another in the human body was to remain the domain of the dissection room during the majority of those 200 years.

3.2

The Limitations and Problems with Dissection of Human Cadavers

The nature and value of the principal resource traditionally used in the teaching of human anatomy within medical and allied health curricula, namely cadavers, have brought unique sets of

42

issues with them, when compared to the resources used in other basic pre- and paraclinical sciences. Standring (2016) has recently given a very comprehensive account of the history of anatomy and dissection. Readers are directed to this work for a more detailed treatise on the history of this traditional learning method. There is still an ongoing discussion, however, about the role of cadaver dissection in modern medical undergraduate training (Heetun 2009; Korf et al. 2008; Parker 2002; Winkelmann 2007), which was recently explored in a debate at the Association of Medical Education in Europe (AMEE) conference 2017 (McMenamin et al. 2017). For the purposes of that Oxbridgestyle debate, protagonists took positions for and against exposure to cadavers in medical education. Some have argued consistently that dissection is the cornerstone of medical anatomy learning (Moxham 2014), despite a lack of empirical evidence (Wilson et al. 2018). In the AMEE debate, there was extensive discussion of the plethora of other learning resources that are now available compared to a mere 30–40 years ago. It is one of these resources, 3D printed replicas, that shall be the focus of the remainder of this chapter. First of all, we must consider what factors have fuelled the search for alternatives to cadavers. Teaching hours for ‘gross anatomy’ are reported to have fallen in USA medical schools from around 250 h in 1973 to around 130 h in 2017 (McBride and Drake 2018). Of course, not all of that time is used for practical dissection, as most courses traditionally comprise a mixture of didactic teaching and laboratory sessions, which could include, but not be exclusively composed of, dissection. Indeed, some institutions in the UK, Europe, and the USA have either abandoned dissection-based learning (McLachlan et al. 2004; McLachlan and de Bere 2004) or rely on combinations of prosection with more targeted dissection (Drake et al. 2009). Most Western countries now have integrated curricula where traditional pre- and paraclinical discipline boundaries are blurred and the principle approach is problem-based (Wyer 2019) or case-based learning (Thistlethwaite et al. 2012).

P. G. McMenamin

Having a human cadaver laboratory comes with a series of considerations that are taking on greater importance in modern medical schools and allied health professional colleges. Firstly, there are significant financial considerations in maintaining a cadaver laboratory, including the costs of administrating a body donor bequest programme and the cost of maintaining and staffing a modern safe anatomy laboratory with appropriate embalming and storage facilities (Raja and Sultana 2012). Secondly, there are cultural and perceived ethical considerations that hinder the practice of students dissecting the human body in many countries (Jones 2012). The need for careful administration of body bequest programmes and societal acceptance of its value for medical education are also an impediment to running a cadaver-based anatomy teaching programme in some settings. Many countries still have practices such as use of unclaimed bodies or euthanised individuals judged to be criminals, which whilst illegal in many developed countries, are still practiced in several countries (Hildebrandt 2008; Tomasini 2008). Recently, Winkelmann and colleagues (Habicht et al. 2018) surveyed 165 countries with medical schools, of which 71 replied. In 22 (32%) of the 68 countries that use cadavers for anatomy teaching, body donation was the exclusive source of cadavers. However, in the majority, unclaimed bodies were the main (26%) or exclusive (31%) source. These authors noted that some countries import cadavers from abroad, mainly from the USA or India. They identified one country in which the bodies of executed persons are given to anatomy departments. These practices do nothing to enhance the profession of anatomists and reputation of anatomy schools in general. Whilst some bequest programmes in countries such as Australia or those in Europe and the UK, with a Christian-Judaist background, are considered by many as the exemplars of regulated practices supported by strong government legislation. This is due to the infamous historical events of body snatching, such as those of Burke and Hare in Edinburgh (Magee 2001). However, to the present day, some state, federal, and government controls are less well developed than one may

3

The Third Dimension: 3D Printed Replicas and Other Alternatives to Cadaver-Based Learning

assume. Despite its reputation as a leader in medical research, and as a leader in the Western world generally, the USA still has some questionable laws, as many recent scandals involving the public paying to witness the dissection of a cadaver, testifies. The widow of the donor in a recently publicised scandal was unaware that a group called ‘Med Ed Labs’ from Las Vegas who procured the cadaver for $10,000 (US$) for an organisation called ‘Death Science’, would use the body for non-research, non-educational purposes. It was in fact used for a commercial venture with members of the public paying up to $500 per person to attend the dissection virtually or in person in a Portland hotel (ABC News 2021). One final practical issue that is perhaps yet to fully play out in being a barrier to cadaver-based anatomy teaching, is the growing awareness of formaldehyde as a carcinogenic agent (IARC 2006) (The Australian National Industrial Chemical Notification and Assessment Scheme, [NICNAS] 2006). In a recent draft discussion document there is a proposal, in some states in Australia at least (Safe Work Australia 2017), to decrease the current tolerance levels of formaldehyde, from 1 to 0.1 ppm TWA (Time Weighted Average) and STEL (Short Term Exposure Limit) from 2 to 0.3 ppm (NICNAS 2006; Safe Work Australia NSW 2017). These changes may have a significant effect on the practice of embalmed cadaver dissection. Formaldehyde is an irritant at 0.5 ppm, and dangerous to life and health at 20 ppm and above (National Institute for Occupational Safety and Health [NIOSH]), with proven links to nasopharyngeal cancers in humans (International Agency for Research on Cancer [IARC] 2006). In some USA labs, the safety levels are 0.3 ppm, whilst in the UK it is TWA of 2 ppm and STEL of 3 ppm. In Sweden and Germany, the maximum permissible indoor level is 0.1 ppm. Commercially available embalming solutions contain formaldehyde at 4–5% concentration, with 2% methanol and 6% isopropanol (Schmid et al. 2014). In poorly ventilated dissection rooms during large classes, where major body cavities are being opened or where specimens are being

43

removed from storage tanks for class use, the levels in the laboratory may exceed limits. This is especially true in the environment immediately above the body (‘personal breathing space’) where we have observed much higher levels (personal observation of the author). Laboratory sessions can typically last 2 h for students, whilst teaching staff, and even more so technical staff, are likely to be exposed for much longer periods. It is imperative therefore that measures are taken to reduce the levels of formaldehyde exposure. The changing awareness of the dangers of formaldehyde has driven a push for downdraft tables and improved quality air handling in anatomy facilities. Although other embalming fluids are available (Hayashi et al. 2016) issues of deterioration over time and fungal growth do occur, especially in more humid climates. Whilst dissection of fresh frozen cadavers is extensively used in surgical training workshops (Chai 2019) or in physician training (McBride and Drake 2011) only a few universities choose to use them for undergraduates (Song and Jo 2021). However, fresh frozen un-embalmed cadavers are not a viable option for large undergraduate teaching of medical or allied health professional programmes, due to the short handling time of fresh material, the length of teaching programmes (over 1–2 years in many countries) and also the practicalities of other health and safety issues such as exposure of students to mycobacterium, Hepatitis B, Hepatitis C, prions, and HIV (Demiryürek et al. 2002).

3.2.1

Alternatives to Cadavers for Anatomy Learning and Teaching

The concept of replacing cadavers with realistic replicas is not new. The highly intricate wax models created largely in the eighteenth century by Clemente Susini are still available for viewing at La Specola in Florence and Calgiari, Italy and other museums in Budapest and Vienna (Fig. 3.2a, b). Similar reproductions created by Maison Tramond in Paris were sold around the world in the nineteenth century (Fig. 3.2c). The

44

P. G. McMenamin

Fig. 3.2 (a, b) The highly intricate wax models created largely in the eighteenth century by Clemente Susini are still available for viewing at La Specola in Florence and

Calgiari, Italy and other museums in Budapest and Vienna. (c) Vasseur-Tramond wax model (Pastor et al. 2016)

first attempt to visualise the ‘third dimension’ of human anatomy using photographic techniques was in the 1950s and 1960s when Gruber and Bassett created a stereoscopic atlas of human anatomy. Dr. Gruber, the inventor of ‘View-Master’, in collaboration with Dr. Bassett, an anatomist at Stanford University created a large range of stereographic images that could be viewed either by an individual with the handheld binocular viewer or by an audience using a stereo projector and polarised glasses. The dissections were of high quality and were popular for some time. The Stereoscopic Atlas of Human Anatomy (Bassett 1962) consisted of 221 View-Master Reels with 1547 colour stereo views of dissections of most body regions. Each stereo view was accompanied by a black and white labelled drawing and explanatory text. In more recent times, many anatomy departments in medical schools, and indeed individual students, have sought alternatives or adjuncts to cadaver-based instruction using alternative techniques including plastination (von Hagens 1979) (Fig. 3.3a), three-dimensional (3D) imaging (Estevez et al. 2010), and body painting (McMenamin 2008) (Fig. 3.3b). However, even more recently, digital radiographic visualisation tables, virtual reality (VR), augmented reality (AR), many available on

handheld devices, have given educators and students an even wider choice of learning aids (Uruthiralingam and Rea 2020; Keenan and Ben Awadh 2019). These are discussed later in the chapter. These alternatives have taken on even greater significance during the last few years due to restrictions on face-to-face classes due to the COVID-19 pandemic where students have largely been learning from home (Pather et al. 2020). These recent conditions are especially demanding for the discipline of anatomy where visualisation, haptic feedback, and the entire dissection room experience have been traditionally held sacred as the most superior way to learn human anatomy (Moxham 2014) because it exposes students to 3D relations and anatomical variations in a real body. However, more recently, it has been appreciated that dissection not only provides an integration of visual and kinaesthetic elements, but it also imbibes in students a range of psychosocial skills and behaviours that arise from collaborative learning and the use of a real donor body. It has been proposed that all of these factors contribute to the formation of professional identity in medicine (Evans et al. 2018). This aspect of the debate is refreshing, as for so long discussion has focussed on the notion that anatomy could only be learned ‘properly’ by dissection (Moxham 2014). That never-ending debate failed

3

The Third Dimension: 3D Printed Replicas and Other Alternatives to Cadaver-Based Learning

45

Fig. 3.3 (a) Plastinated specimen (From https://www.vonhagens-plastination.com), (b) Mature students participating in a body painting class (McMenamin 2008)

to acknowledge that only a fraction of medical undergraduates will ever perform any sort of surgery, and furthermore, that there is currently a lack of scientific empirical evidence of its superiority as a learning resource and method of learning human anatomy (Wilson et al. 2018).

3.3

The Development of 3D Printed Anatomical Replicas and their Deployment in Teaching

Additive manufacturing, more commonly described as 3D printing, is now a critical part of the iterative design process in engineering, producing physical models or prototypes quickly, easily, and inexpensively from computer-aided

design (CAD) and other digital data. In the medical and healthcare arena, 3D printing technology has already impacted surgery (Chae et al. 2015; Abla and Lawton 2015; Stramiello et al. 2020), and other disciplines by allowing the production of bespoke prefabricated models for pre-surgical planning and the creation of patient-specific prostheses, or as patient educational tools (Rengier et al. 2010; Aimar et al. 2019; Morgan et al. 2020; Park et al. 2021). At Monash University, Melbourne, Australia, we were faced with a shortage of prosections for teaching large numbers of students in multiple classes, an absence of our own body bequest programme, the high cost of sourcing cadavers from other institutions and a paucity of trained skilled prosectors. In this situation, we sought alternatives to ‘wet’ prosections. The solution,

46

P. G. McMenamin

Fig. 3.4 A summary of the latter stages of 3D print reproductions. (a) Digitally rendered surface contour map of an original prosection of the head and neck; (b) after false colouration; and (c) the final 3D printed replica

described in our highly cited first study, was to create 3D printed replicas of anatomy prosections (McMenamin et al. 2014). At that time, we chose to predominantly use 3D rendered files based on CT or MRI imaging of cadaver prosections (Fig. 3.4a) which were then digitally false coloured (Fig. 3.4b). To this end, we chose a traditional colour palette used in anatomy textbooks (arteries = red; veins = blue; nerves = yellow etc.) (Fig. 3.4c). The decision on colouration was based on three main factors. Firstly, the grey and brown tones of embalmed cadaver specimens were visually unattractive as 3D prints (Fig. 3.5a) compared to a false coloured 3D print (Fig. 3.5b). Secondly, the quality of 3D surface scanners available at that time did not sufficiently capture high-fidelity surface topographical detail or colour in specimens, which meant the prints based on that form of data acquisition approach were not ideal. Lastly, we thought that a colour coding similar to textbook diagrams and atlases would help students learn anatomy more effectively, whereas a mixture of greys and browns would not allow inexperienced students to distinguish nerves, vessels, ligaments, and other structures from one another. Since this first published study describing the method of 3D printed normal adult human anatomy replicas, which we termed ‘Series 1’ (www.

3danatomyseries.com) (McMenamin et al. 2014), we went on to create 3D printed replicas of various stages of human foetal development (Fig. 3.6a) (Young et al. 2019). This series was based on material from an archived collection in our institution for which there was no known provenance. They dated back to the 1950s and 1960s when many institutions collected fetal material from tertiary obstetric teaching hospitals, possibly without the ethical controls that exist in the modern era (Fourniquet et al. 2019). The creation of accurate replicas using our expertise in 3D scanning and printing workflow allowed us to incorporate the 3D prints of fetal material into our teaching resources. However, with cognisance of ethical implications, we have not sought to make these available to other institutions or commercial partners. Upon completion of scanning the specimens, they were respectfully cremated, and the ashes were interned at a local cemetery with a plaque acknowledging the contribution this material had made to student education. To our knowledge, the only study of a similar nature has used histological and modern microscopic imaging data sets to create 3D printable stages of early human embryonic material that are made available for other educators (Azkue 2021). Whilst the deployment and integration of 3D printed replicas of adult human anatomy were

3

The Third Dimension: 3D Printed Replicas and Other Alternatives to Cadaver-Based Learning

47

Fig. 3.5 (a) 3D printed reproduction of a hand based on surface scanning only showing the grey and brown tones typical of a prosection; (b) a 3D printed replica to demonstrate the value of false colouring to aid in student learning

successful in our classes, we thought it important in light of the often raised issue that ‘simply because technologies are innovative and appealing does not necessarily mean they are more effective for learning than existing approaches’ (Keenan and Ben Awadh 2019) that we test the hypothesis that 3D printed replicas had parity in education outcomes to conventional wet cadaver prosections. To this end, we conducted a randomised double-blind controlled trial (RDBCT) with undergraduate medical student participants, in which we chose an area of anatomy (cardiac anatomy) in which the participating students had no previous teaching (Lim et al. 2016). The creators of the Monash 3D printed series 1 were not involved in the design or implementation of the trial for fear of perceived bias. Following a pre-test, examining baseline cardiac anatomy knowledge, participants were randomly assigned to three groups who underwent self-

directed learning sessions using either cadaveric materials (n = 18), 3D printed replicas (n = 16), or a combination of cadaveric materials/3D prints (combined group, n = 18). Participants were then subjected to a post-test created by a third party. Fifty-two participants completed the trial. Pre-test scores were not significantly different between the groups; however, post-test scores were significantly higher for 3D prints group compared to the cadaveric materials or combined materials groups (mean of 60.83% vs. 44.81% and 44.62%). This RDBCT trial suggested that use of 3D prints did not disadvantage students relative to cadaveric materials, but indeed the data actually revealed that 3D prints may confer certain benefits to anatomy learning (Lim et al. 2016). The explanation could be multifactorial, but at a personal level we have observed that students have no hesitancy about handling the 3D printed replicas compared to cadaveric

48

P. G. McMenamin

material, a factor we believe led to a better educational outcome. Our findings of parity or improved outcomes in trials of the effectiveness of 3D prints in teaching have been supported by several independent studies using either our own Monash Series 1 (Garas et al. 2018), single material copies of largely osteology specimens (Smith et al. 2018) or multi-material and multi-coloured 3D printed models (Mogali et al. 2018). Evaluation studies of student perceptions in these and other studies (Backhouse et al. 2019) support our contention that 3D printed replicas not only provide valuable supplemental material to cadaverbased teaching such as prosections, but indeed may act as an actual valuable alternative in circumstances where deployment of real human material is not possible for various reasons. In our Monash Series 1, the colour coding was intended to aid student learning, and thus like 2D atlases the anatomy colouration scheme represented a ‘caricature’ of real anatomy. We based our decision to do this on the grounds that even prosections from embalmed cadavers did not mimic the appearance of fresh living human tissue, as perhaps seen in the operating theatre, and were therefore not any more realistic than our chosen colouration scheme. However, after taking cognisance of some feedback from users that the colour scheme perhaps too closely resembled conventionally manufactured plastic models, we decided to create a hybrid series (Monash 3D Printed Series 1.1) that blended the colouration seen in prosections with a slight colour augmentation to highlight critical anatomical features (Fig. 3.6b, c). The fidelity achieved in this series was possible because new scanning and printer technology (see below) made this a viable option. Such technology was not available 6 or more years previously.

3.4

Creation of 3D Printed Replicas of Pathology Specimens

Monash University had an archive of over 1500 pathology specimens stored in the anatomy facility that were not being used, as the discipline of pathology no longer has a central campus

presence at the institution. The discipline is now taught using digital resources online on various clinical campuses. With advances in the quality and resolution of 3D scanners combined with the high quality of UV-curable resin 3D printers now commercially available, our group decided to create 3D printed replicas of some selected human pathology specimens (‘Monash 3D Printed Series 2’) (Fig. 3.7) (McMenamin et al. 2021). Our experiences in 3D image data acquisition and 3D printing equipped us with the technical skills and resources to overcome some of the challenges of accurately recreating and replicating colour, fine detail, and 3D form. These elements were necessary to make printing of pathology specimens of sufficient quality and value to students in this discipline, where colour and detail are critical to correct diagnosis. This series will be commercially available from 2022 onwards. We are not aware of any other similar studies that have reproduced pathology specimens.

3.5

Comparison of 3D Printed Replicas to Plastinated Specimens as Learning Resources

In our previous study (McMenamin et al. 2014), we discussed the many obvious advantages of 3D printed reproductions of normal prosected anatomical specimens over plastinated cadaver specimens. Plastination became popular in medical education several decades ago as an alternative to conventional ‘wet’ human cadaveric material following the description of the method of infiltration of specimens with silicone, epoxy, and polyester-copolymers (von Hagens 1979). The method is laborious and requires removal of water, replacement with solvents (requires large volumes), and subsequent exchange of solvents with polymers under vacuum and at sub-zero (20 °C and below) temperatures in large freezers. It can take up to 6 months to produce one specimen. Plastinated specimens can accurately demonstrate important anatomical features if the dissections are of suitable quality. They have a

3

The Third Dimension: 3D Printed Replicas and Other Alternatives to Cadaver-Based Learning

49

Fig. 3.6 (a) 3D printed replicas of human foetuses at various stages from Monash University’s archived foetal collection as described in Young et al. (2019). (b) and (c) Example of a 3D printed replica of a torso from ‘Monash

3D Printed Series 1.1’ in which a mixture of surface scanning and moderate colour augmentation is used to capture a more ‘cadaver-like’ appearance

good shelf-life if cared for, but can deteriorate over time (Fruhstorfer et al. 2011). When comparing plastinates to 3D prints as educational resources, a number of issues arise. Firstly, with 3D printing, it is worth noting that it

is possible to rapidly reproduce an indefinite number of copies of the same prosection, making them ideal for ensuring equity of access to learning resources in large classes, whereas each plastinated specimen is a unique dissection that

50

P. G. McMenamin

Fig. 3.7 Three examples of 3D prints of pathology specimens (see McMenamin et al. 2021)

had to be created. As a side note, an unintended benefit, that had not been anticipated in 2014, is that teaching with multiple copies of 3D printed anatomical replicas allows for social distancing in the new COVID-19 era. Secondly, plastinated specimens still require cadavers sourced from local body donor bequest programmes, and many institutions do not have such access. Thirdly, plastination involves considerable infrastructure costs if appropriate health and safety issues are properly addressed. The most critical of these is due to the large volumes of flammable solvents involved. Once prepared, they do suffer wear and tear, and replacement involves considerable time and labour costs. Lastly, plastinated specimens in many jurisdictions are still classified, correctly in the author’s view, as human tissue and thus require facilities approved and licensed to handle cadaveric material. In contrast, 3D prints can be deployed in any teaching environment, for example in peripheral or rural medical school locations, or indeed any non-licenced learning environments. They can also be replaced relatively easily if damaged. Criticisms that 3D printed replicas are false coloured can also be levelled at plastinated specimens to some degree. Neither approach entirely reproduces the colouration of conventional embalmed cadavers or indeed fresh living material, such as would be

experienced in a surgical setting. Plastinates, like single material 3D prints, do not have the haptic qualities of embalmed or fresh human material, an issue raised by at least one study (Fruhstorfer et al. 2011). With the differences raised above in mind, the scientific question arises—are plastinates more effective for learning than 3D printed replicas? In an interesting study examining the value of 3D printed replicas in teaching, Mogali et al. (2021) created 3D printed replicas of existing plastinates using segmented digital communications and imaging in medicine (DICOM) data. They sought to compare the effects on learning in a study designed similar to our own (Lim et al. 2016). This latest study was an extension of an earlier published pilot study (Mogali et al. 2018). In the most recent investigation, they chose cardiac anatomy (as in our own study) and neck anatomy as their regions of interest. The 3D prints were produced in a multi-material printer with hard and soft substrates (consisting of a basic set of primary colours). The only difference between the plastinates and the 3D prints was therefore the tactile quality and substrates, not the anatomy per se. Not surprisingly, they found no difference in pre- and post-test results between the two groups. Mogali and colleagues noted that the 3D prints were much more cost effective than

3

The Third Dimension: 3D Printed Replicas and Other Alternatives to Cadaver-Based Learning

plastinates, although the authors did not appear to factor in the labour and purchase costs of the top-of-the-range multi-material printer they used, which can cost >US$100,000. The issue of cost-effectiveness arises when one considers another study that utilised surface scanning and 3D printing technology to create copies of osteology specimens (Smith et al. 2018). This seems a curious choice of subject material, as conventional plastic models of skeletal material are widely available and are relatively inexpensive (>US$100). The issues raised about plastinated specimens or indeed 3D prints, regarding cost could also be applied to ‘wet’ cadaveric prosections. Namely, one has to factor in the cost of creation and dissection, storage, wear and tear, laboratory technician salaries, and the need for the specimens to be restricted to registered or licenced anatomical teaching facilities.

3.6

Comparison of 3D Prints to Plastic Models

The conventionally manufactured plastic models of normal anatomy that are in common use in high schools, doctors’ surgeries and many allied health professional training establishments. are mass produced copies of a ‘hypothetical’ or ‘caricatured’ anatomical specimens that typically lack important anatomical details. Whilst the manufacturing process (plastic injection moulding) is less expensive than either 3D printed replicas or plastinates and they may be adequate for patient education, however, they are not ideal for teaching detailed topographical anatomy typically required in medical and other allied health professional courses.

3.7

Limitations of 3D Printed Replicas

There are of course some limitations to 3D printed replicas of human anatomy specimens. Firstly, the output is only as good as the input: therefore, it is imperative that high quality

51

dissected specimens that illustrate as many features as possible without being overly complex be chosen for replication and 3D printing. The specimens have to be amenable to either highresolution CT scanning or surface scanning, or both, and must possess the ability to be reproduced accurately by 3D printing. Specimens with features such as nerves and vessels that are suspended without support structures will be difficult to print and may be fragile. Deep recesses in the specimen can prove challenging when removing support material. One current limitation of our 3D printed replica series is the lack of pliability or similar haptic properties when compared to real specimens. We have tried to resolve this problem (Ratinam et al. 2019) by employing multi-material printers, but the results were found to be unsuitable as current technology does not allow for subtle colour tones to be combined with variations in ‘shore hardness’. The soft materials (‘Tango’, Stratasys Ltd) were very friable and the colour range in these materials was limited. The colour range in hard media (‘Vero’ Stratasys) was comparable to less expensive UV-curable inkjet printers, but that offered no advantage of simulating haptic properties. On the whole, replicas printed in Tango materials were found not to be suitably resilient for repeated handling in student classes. This generation of multi-material printers are extremely expensive which means that each individual print can also be very expensive (>US $2000 in production costs alone for a multimaterial hand for example). Again, when others have carried out price comparisons, they have tended to not include labour, purchase or replacement costs, or the costs of maintenance contracts. It is for these reasons that we chose high-quality multi-colour powder-based stereolithographic (SLA) printers. A 3D Systems (formerly Z Corporation) Z650 gypsum powder-based printer (3D Systems, Rock Hill, SC, USA) was used in our initial studies. It uses combinations of coloured binders to print with a claimed palette of 390,000 colours, similar to a conventional ink jet printer. The Z650 has a large build tray (254 × 381 × 203 mm3) with a build speed of 28 mm/h, which makes it a suitable size for

52

P. G. McMenamin

printing many human anatomical specimens. A hand model (Fig. 3.5b) took around 3 h to print with a slice thickness of 0.1 mm. A plastic powder-based SLA printer (Projet 4500) was next chosen as the next generation of printer as gypsum prints from the Z650 were friable and suffered damage if poorly handled. However, over time, we found the fidelity of these powder printers to be insufficient, for example to capture the colour detail required for quality reproductions of pathology specimens where visual details are so critical to the utility of the replica (McMenamin et al. 2021). To resolve this, we purchased a full colour UV-curable inkjet printer (Mimaki 3DUJ -553, Nagano, Japan). This printer has a resolution and layer thickness of 42 microns and 600 dpi down to 22 microns and 1270 dpi depending on the printing mode chosen. We found this sufficiently depicted the colour accuracy and geometry of the original specimen (Fig. 3.7a–c). There are many much cheaper options in the 3D printer market, such as ABS or PLA plastic filament printers but these only print in a single colour of hard plastic which in our view offers very poor realism. Indeed, the final 3D prints resemble inexpensive plastic children’s toys.

summer scholarships that allow them to carry out short 6–8 week projects in our department. Several of our published works in the field of medical applications of 3D printing have resulted from these short projects. Project students have acted as conduits between anatomists and the clinicians and surgeons, who are often unaware of the expertise in 3D data acquisition, radiographic data segmentation, and 3D printing that exists at Monash University Department of Anatomy and Developmental Biology. Examples of this work include creation of surgical simulation devices (Nagassa et al. 2019; Lioufas et al. 2016) or models for pre-surgical planning (Bennett et al. 2018). Other students have chosen more extensive Honours or PhD research projects which involve 3D printing (Ratinam et al. 2019). There are now many commercial operators, such as ‘Materialise’, who offer digital segmentation and 3D printing services for pre-surgical planning. However, there are also several software applications that are open-source or inexpensive (Virzì et al. 2020).

3.7.1

Surgical training has been beset with issues of access to materials that mimic the surgical experience and many training programmes rely on the apprenticeship model within the operating theatre, with the guidance of an expert surgeon who supervises the trainees. This tends to slow down procedures and exposes patients to greater risks (Khan et al. 2019). The need for simulation, not only in surgery but also in many medical procedures, has therefore been recognised for many decades and has involved the use of ex vivo or live animal organs and tissues (da Luz et al. 2015), human cadavers (Chai et al. 2019), and manufactured replicas or mannikins (Dutta and Krummel 2006; Shaharan and Neary 2014). It is only recently that 3D printing has been realised as a valuable technology for the creation of anatomically accurate and realistic simulation devices, and the reader is directed to

The Value of 3D Printing and Associated Technologies in Medical Student and Biomedical Science Student Research Projects

Medical students and biomedical science students are highly intelligent and motivated cohorts of students, who may not be able or willing to engage in an entire year of research such as an Honours degree, but are often willing to engage in short-term projects that utilise modern technology and software. We have found that when students learn that the 3D prints that they use in anatomy classes are created ‘in house’, they are often very keen to engage in any way they can. This is particularly true when they reach the clinical years of their studies, and choose co-supervised surgery/anatomy electives, or are awarded

3.7.2

3D Printing as Technology to Create Medical Simulation Devices

3

The Third Dimension: 3D Printed Replicas and Other Alternatives to Cadaver-Based Learning

53

Fig. 3.8 (a) Model of one internal carotid (from carotid canal to division into anterior and middle cerebral) being filled with artificial blood. (b, c) Ballistic gel moulded

supratentorial portion of the brain model containing lateral ventricles (yellow) as viewed from below and above

recent reviews (Chae et al. 2015; Chao et al. 2017). Our laboratory liaison with clinicians and surgeons, to identify specific needs for accurate and realistic simulators, has led to the creation of 3D printed or hybrid devices (various material casting based on 3D printed moulds) such as a paediatric anaesthetic simulator (Weatherall et al. 2021), neurovascular simulation models (Nagassa et al. 2019) (Fig. 3.8), and a cleft palate repair simulator (Lioufas et al. 2016).

3.7.3

Technology Enhanced-Learning and Moving into the Virtual World

Clearly, one of the challenges of a modern educator in the discipline of anatomy is to aid medical and allied health students in their understanding and learning of 3D concepts. This is particularly relevant to interpretation of 2D radiographic images of patients, especially in the last 20–30 years where computed tomography (CT) and magnetic resonance imaging (MRI) have become routine diagnostic tools. It thus behooves the modern anatomy education institution to integrate any available technology which will aid students on this challenging journey (Sugand et al. 2010).

54

P. G. McMenamin

Fig. 3.9 (a) Image of a Sectra table in vertical position (b) Image of Series 1 data with description on Sectra table

However, there is a debate that many technologyenhanced learning (TEL) approaches are introduced without proper and careful scholarly consideration of the evidence of their effectiveness, in part because their value seems selfevident but also because students readily engage with new technology just as they do in the other domains of their life (Keenan and Ben Awadh 2019). So, what are the tools available that could potentially aid learners in understanding the ‘third dimension’ of human anatomy? Advances in computer technology and the speed of connectivity have seen access to modern radiographic DICOM data become available to anatomy educators in the form of visualisation tables (Sectra [https://medical.sectra.com] (Ben Awadh et al. 2022) and Anatomage [https:// www.anatomage.com/table/]) (Ward et al. 2018). These devices allow students and teachers to gather around a table (or screen in case of Sectra whose tables readily tilt to a vertical format) (Fig. 3.9a). These ‘tables’ are touch screens and allow complex interactions with 2D and 3D data. To some extent, the viewing of human anatomical images in life size and the ability to digitally ‘slice and dice’ or study various layers can in some sense replicate part of the dissection table group learning environment and experience (Keenan and Ben Awadh 2019). The Sectra education

portal has digital learning resources, including access to picture-archiving and communication system (PACS) imaging software linked to clinical cases, digital versions of ‘Monash Series 1’ and an accompanying anatomy curriculum (Fig. 3.9b). It also has a license for the TolTech VR Dissector software (TolTech, Aurora, CO, USA) (https://www.toltech.net/products/vh-dis sector) based on the virtual human project (Spitzer and Scherzinger 2006). A full description of the manner in which these visualisation tables can be used to augment teaching is explored by Keenan and Ben Awadh (2022). These authors also discuss the use of another means of 3D visualisation, the ‘Alioscopy 3D Display screen’ which uses a unique patented lenticular lens array bonded to an LCD screen to give the viewer an autostereoscopic view that does not require polarised glasses. Viewers must be in small groups and be within a 50° viewing angle on either side of the screen to obtain the 3D effect. Until recently, to the author’s knowledge, there have been no trials comparing complex threedimensional spatial relationships in crosssectional and radiological images on visualisation devices compared to hard copy images. However, recently Ben Awadh and Keenan (2022) published a study that examined a novel learning approach which combined visualisation tablebased thoracic cross-sections and digital models

3

The Third Dimension: 3D Printed Replicas and Other Alternatives to Cadaver-Based Learning

with a 3D printed heart. They used a mixedmethod experimental and survey approach to investigate student perceptions of these challenging anatomical areas and compared the multimodal intervention to a two-dimensional crosssection control group. Pre-and post-testing of student perceptions who used the intervention during their first anatomy class at medical school revealed significant increases (P < 0.001) in thoracic cross-sectional anatomy interpretation performance when compared to the subsequent abdominal control activity (used 2D images alone). Whilst this study was not comparing visualisation tables alone (namely students in the experimental group had a 3D printed heart as a further learning resource), their study did clearly suggest that 3D visualisation has an obvious place in medical student anatomy programmes. A more recent way of experiencing the ‘third dimension’ can be achieved by the use of Virtual Reality (VR). VR can be defined as a realistic and immersive simulation of a three-dimensional environment, created using interactive software and hardware, and experienced or controlled by movement of the body or thought of as an immersive, interactive experience generated by a computer, which seems real to the user. The first attempts at using headsets for immersive experiences were already being trialed in the 1960s, although the term VR was not coined until the 1980s. However, the concept of VR entered the public consciousness with the release of two popular movies, ‘The Lawnmower Man’ and ‘The Matrix’. The use of VR is now commonplace and has impacted the gaming sector, entertainment industry, education sector, travel, and property and construction industries. VR-based simulation training has been long established in aeronautics training and is becoming more widely used in medical and allied health training and education (Huang et al. 2018; Bielsa 2021; Khan et al. 2019). Sales of VR headsets are predicted to exceed 14M per annum by 2024 (https://www.statista.com/statistics/677096/vrheadsets-worldwide/). In our laboratory at Monash University, we created our own VR experience using the 3D data that had been gathered for the purposes of

55

3D printing. A simulated laboratory was designed to mimic the anatomy facility and virtual specimens were placed on ‘shelves’ and could be lifted and placed on a central viewing platform for manipulation (Fig. 3.10a, b). Students or staff select a virtual specimen (with or without labels) and manipulate it in space (using a virtual cube) (Fig. 3.11a–c). The license for this VR application has recently been granted to Touch of Life Technologies (TolTech, Aurora, CO, USA) who will incorporate it into their new VR application in ‘VH Dissector’. Is VR or 3D simulation the way of the future in anatomy education (or clinical training) in the same way it has become integral in for example aviation training? A recent literature review of the use of VR and augmented reality (AR) in anatomy education (Uruthiralingam and Rea 2020) found that of 56 articles related to VR, 45 were for; eight were neutral; and three were against the use of this technology. It seems certain, from this juncture in history at least, that as this technology becomes more widely available it will be one more adjunct (in some cases) or a potential alternative to cadaver-based learning materials. Augmented reality (AR) is a new technology which allows the user to superimpose virtual objects onto physical objects in real space and allows individuals to interact with both simultaneously. With AR, the user is not completely immersed in a digital environment as it enables them to still see real-world objects overlaid with digital input (i.e., augmenting the reality that actually exists). There are several available highquality AR Apps suitable for tablet devices or mobile phones such as 3D4Medical (Elsevier, Amsterdam, Netherlands) and VisibleBody (Boston, Mass, USA). AR may be preferred by some users as there are reports of some people feeling motion sickness symptoms and postural instability when using VR goggles (LaViola 2000; Moro et al. 2017). Virtual reality sickness is different from motion sickness in that it can be caused by the visually induced perception of self-motion. Real self-motion is not needed and oculomotor signs are not usually present (Stanney et al. 1997). An important advantage of AR over physical models and cross-sections in learning anatomy,

56

P. G. McMenamin

Fig. 3.10 The real (a) and virtual (b) lab from our pilot VR laboratory

is that AR offers the opportunity to study the anatomy of a structure thoroughly by virtually disassembling and reassembling anatomical parts. A recent trial by Moro et al. (2017) to assess whether learning structural anatomy (in this case skull anatomy) utilising VR or AR is as effective as tablet-based (TB) applications, and whether these modes allowed enhanced student learning, engagement and performance, found no significant differences between mean assessment scores in VR, AR, or TB. They reported symptoms of motion sickness in 25–40% of people using VR, but despite this, they concluded both VR and AR are as valuable for teaching anatomy as tablet devices, but have the added advantage of

increased learner immersion and engagement and thus may be valuable to supplement lesson content in anatomical education. Until very recently, a conclusive answer regarding whether AR was a more effective means of learning than traditional methods remained pending. A recent systematic review and meta-analysis of AR and anatomy education by Bölek et al. (2021) found five articles for meta-analysis totaling 508 participants (240 participants in the AR groups; 268 participants in the control groups). They concluded that there was no significant difference (P = 0.732) in anatomical test scores between the AR group and the control group. Sub-analysis on the use of AR versus the use of

3

The Third Dimension: 3D Printed Replicas and Other Alternatives to Cadaver-Based Learning

57

Fig. 3.11 (a) Students interecting with cerebral vasculature in VR platform. (b) An example of a labelled shoulder specimen in VR

traditional 2D teaching methods showed a significant disadvantage when using AR. Because of the implications of earlier studies regarding differences in modalities of learning in student populations, the authors performed a metaregression analysis, which revealed no significant correlation between mean difference in test results and spatial abilities (as assessed by mental rotations test scores). The authors, therefore, concluded that this meta-analysis showed insufficient evidence to conclude that AR significantly impacts learning and that outcomes are significantly impacted by student spatial abilities. The small number of published studies suitable for meta-analysis indicated to the authors that there was a need for more well-designed, randomisedcontrolled trials on AR in anatomy education research (Bölek et al. 2021). In our laboratory, we have had only limited experience with AR. The Monash ARnatomy app is built on top of Unity. Unity is a game engine that is often used to build video games and 3D animated movies. The AR image marker mechanism is built with a Unity plugin called Vuforia. Vuforia is an augmented reality software development kit for mobile devices that enables the creation of augmented reality applications. It uses computer vision technology to recognise

and track planar images and 3D objects in real time. The app is designed to utilise the phone camera to pick up particular image markers. Once the image marker is detected, the algorithm will overlay a 3D hand model on top of the image marker within the phone screen (Fig. 3.12). Whilst it was clearly engaging for students to use, we wished to address the question of the real educational value of this AR teaching aid versus conventional 2D learning. Therefore, we recently performed a RDBCT, similar to our study of 3D prints in classroom situations (Lim et al. 2016). We compared students, who were naïve to this region, in their learning of hand anatomy during the period of one weekend. The control group used their own chosen resources (including textbooks and web-based resources), whilst the experimental group had access to our ‘AR Hand Anatomy’ app. Neither group had access to cadaveric material. Preliminary analysis suggested there was no significant difference (P = 0.929) in pre- and post-trial assessment results between the two groups, (Unpublished observations). A feedback analysis is currently underway to try to address student perceptions of the ‘AR Hand Anatomy’ App. Student satisfaction with learning modalities is an important factor, but as all experienced

58

P. G. McMenamin

Fig. 3.12 The ‘Hand AR’ App was developed by the author in collaboration with Monash University’s ‘Virtual and Augmented Reality Services’ (VARS) Unit and

Academic and Data Technology Services (ADTS), Faculty of Information Technology. For video demonstration, see Supplementary Video 3.1

anatomy educators know, dissection of a cadaver is certainly not to all students’ taste as a learning tool. There is evidence that female students experienced greater anxiety than male students upon first exposure to cadavers and self-identified non-white, non-Christian students experienced sustained anxiety (Wisenden et al. 2018). Thus, it behooves us as educators to explore other options for learning that are available to aid students in their journey to discover the that elusive ‘third dimension’ of human anatomy which we know can be a significant challenge to learning and understanding this discipline.

outlined and reviewed, as these areas are becoming more pertinent, as shown by recent research on health risks. The benefits and limitations of 3D printed replicas of human anatomy are compared and reviewed in turn with cadaver prosections, plastinates, and traditional plastic models. Where possible, this comparison is performed in the context of the few scientifically based evaluations available. Other resources or technologyenhanced learning such as visualisation tables and VR and AR, with which we have experience, and that are being increasingly used in anatomy education as adjuncts to learning with cadavers, or as an alternative. Such approaches have been described and the evidence for their effectiveness has been reviewed alongside factors such as cost. The case is made that if real human prosections or cadaver dissection opportunities are not available to students, but there are opportunities to enrich the teaching resources, then the recently developed 3D printed replicas of human anatomy developed by us and others can offer novel, accurate, and effective solutions. As we move forward it is clear that students in the 2020s onwards have a plethora of resources compared to just 50 years ago. The author can only hope that this chapter motivates educators and students in the discipline of anatomy alike to experiment with various resources and teaching methods, as we have.

3.8

Conclusions and a Forward Vision

In the current chapter, the author has tried to capture the history from the renaissance to the present of the ages old dilemma of illustrating 3D form, the ‘third dimension’, of human anatomy for the purposes of medical and allied health student education. The issues that face educators who have difficulties accessing cadaveric material and why such challenges are very real in various cultural, geographical, and economic settings have been discussed. The issues of safety and exposure to formaldehyde have also been

3

The Third Dimension: 3D Printed Replicas and Other Alternatives to Cadaver-Based Learning

This new world of resources can only but help us all appreciate and grasp that mysterious and elusive ‘third dimension’. Acknowledgments I would like to acknowledge the staff at 3DID (3D Innovation and Design) laboratory in the Department of Anatomy and Developmental Biology, including the Director, Assoc. Prof. Justin Adams, and the staff Michelle Quayle and Lucy Costello. Prof John Bertram was head of department during the birth of the 3D printing projects and gave unwavering support and encouragement for which the group is extremely grateful. Dr. Colin McHenry was also instrumental in the initiation of the idea of 3D printing. Conflict of Interest Monash University has a royaltybased commercial licence with various commercial entities for the distribution of Monash 3D Printed Anatomy Series. These royalties are distributed according to Monash policies.

References ABC News (2021). https://abcnews.go.com/US/ wireStory/death-science-calls-cadavers-public-dissec tion-educational-80999161 Abla AA, Lawton MT (2015) Three-dimensional hollow intracranial aneurysm models and their potential role for teaching, simulation, and training. World Neurosurg 83:35–36 Abrahams P. YouTube lecture on Leonardo da Vinci. https://www.youtube.com/watch?v=h9de37e9hXs& l i s t = PLU2WOdHkTddBwCHTrVZ9siRfrFeDOGyvS& index=1&t=15s Aimar A, Palermo A, Innocenti B (2019) The role of 3d printing in medical applications: a state of the art. J Healthc Eng 21:5340616 Azkue JJ (2021) External surface anatomy of the postfolding human embryo: computer-aided, threedimensional reconstruction of printable digital specimens. J Anat 239:1438–1451 Backhouse S, Taylor D, Armitage JA (2019) Is this mine to keep? three-dimensional printing enables active, personalized learning in anatomy. Anat Sci Educ 12: 518–528 Bassett DL (1962) A stereoscopic atlas of anatomy. Sawyer’s, Williams and Wilkins Company, Portland, OR, Baltimore Ben Awadh A, Clark J, Clowry G, Keenan ID (2022) Multimodal three-dimensional visualization enhances novice learner interpretation of basic cross-sectional anatomy. Anat Sci Educ 15:127–142 Bennett D, McMenamin P, Pacilli M, Clarnette T, Nataraja RM (2018) Novel application of additive manufacturing techniques for paediatric choledochal malformations. J Paediatr Child Health 54:807–809

59

Bielsa VF (2021) Virtual reality simulation in plastic surgery training. Literature review. J Plast Reconstr Aesthet Surg 74:2372–2378 Bölek KA, De Jong G, Henssen D (2021) The effectiveness of the use of augmented reality in anatomy education: a systematic review and meta-analysis. Sci Rep 11:15292 Chae MP, Rozen WM, McMenamin PG, Findlay MW, Spychal RT, Hunter-Smith DJ (2015) Emerging applications of bedside 3d printing in plastic surgery. Front Surg 2:1–14 Chai DQ, Naunton-Morgan R, Hamdorf J (2019) Fresh frozen cadaver workshops for general surgical training. ANZ J Surg 89:1428–1431 Chao I, Young J, Coles-Black J, Chuen J, Weinberg L, Rachbuch C (2017) The application of threedimensional printing technology in anaesthesia: a systematic review. Anaesthesia 72:641–650 da Luz LT, Nascimento B, Tien H, Kim MJ, Nathens AB, Vlachos S, Glassberg E (2015) Current use of live tissue training in trauma: a descriptive systematic review. Can J Surg 58:S125–S134 Demiryürek D, Bayramoğlu A, Ustaçelebi S (2002) Infective agents in fixed human cadavers: a brief review and suggested guidelines. Anat Rec 269: 194–197 Drake RL, McBride JM, Lachman N, Pawlina W (2009) Medical education in the anatomical sciences: the winds of change continue to blow. Anat Sci Educ 2: 253–259 Dutta S, Krummel TM (2006) Simulation: a new frontier in surgical education. Adv Surg 40:249–263 Estevez ME, Lindgren KA, Bergethon PR (2010) A novel three-dimensional tool for teaching human neuroanatomy. Anat Sci Educ 3:309–317 Evans DJR, Pawlina W, Lachman N (2018) Human skills for human[istic] anatomy: an emphasis on nontraditional discipline-independent skills. Anat Sci Educ 11:221–224 Fruhstorfer BH, Palmer J, Brydges S, Abrahams PH (2011) The use of plastinated prosections for teaching anatomy—the view of medical students on the value of this learning resource’. Clin Anat 24:246–252 Garas M, Vaccarezza M, Newland G, McVayDoornbusch K, Hasani J (2018) 3D-Printed specimens as a valuable tool in anatomy education: a pilot study. Ann Anat 219:57–64 Habicht JL, Kiessling C, Winkelmann A (2018) Bodies for anatomy education in medical schools: an overview of the sources of cadavers worldwide. Acad Med 93: 1293–1300 Hayashi S, Naito M, Kawata S, Qu N, Hatayama N, Hirai S, Itoh M (2016) History and future of human cadaver preservation for surgical training: from formalin to saturated salt solution method. Anat Sci Int J 91: 1–7 Heetun M (2009) Anatomy dissection: a valuable surgical training tool. Br J Hosp Med (Lond) 70:540 Hildebrandt S (2008) Capital punishment and anatomy: history and ethics of an ongoing association. Clin Anat 21:5–14

60 Huang TK, Yang CH, Hsieh YH, Wang JC, Hung CC (2018) Augmented reality (AR) and virtual reality (VR) applied in dentistry. Kaohsiung J Med Sci 34: 243–248 International Agency for Research on Cancer (IARC) (2006) Monographs on the evaluation of carcinogenic risks to humans, volume 88 (2006), formaldehyde, 2-butoxyethanol and 1-tert-butoxypropan2-ol. http:// monographs.iarc.fr/E NG/Monographs/vol88/ index.php Jones G (2012) Resurrecting unclaimed bodies. Clin Anat 25:674–675 Keenan ID, Ben Awadh A (2019) Integrating 3D visualisation technologies in undergraduate anatomy education. Adv Exp Med Biol 1120:39–53 Kemp M (2010) Renaissance humanism to Henry Gray. J Anat 216:192–208 Kemp M (2011) Leonardo (Rev edn.). Oxford University Press, Oxford Khan R, Plahouras J, Johnston BC, Scaffidi MA, Grover SC, Walsh CM (2019) Virtual reality simulation training in endoscopy: a Cochrane review and metaanalysis. Endoscopy 51:653–664 Korf HW, Wicht H, Snipes RL, Timmermans JP, Paulsen F, Rune G, Baumgart-Vogt E (2008) The dissection course—necessary and indispensable for teaching anatomy to medical students. Ann Anat 190: 16–22 LaViola JJ (2000) A discussion of cybersickness in virtual environments. ACM SIGCHI Bull 32:47–56 Lim KH, Loo ZY, Goldie SJ, Adams JW, McMenamin PG (2016) Use of 3D printed models in medical education: a randomized control trial comparing 3D prints versus cadaveric materials for learning external cardiac anatomy. Anat Sci Educ 9:213–221 Lioufas PL, Quayle MR, Leong JC, McMenamin PG (2016) 3D printed models of cleft palate pathology for surgical education. Plast Reconstr Surg Glob Open 4:e1029. eCollection Magee R (2001) Art macabre: resurrectionists and anatomists. ANZ J Surg 71:377–380 McBride JM, Drake RL (2011) Student-directed fresh tissue anatomy course for physician assistants. Anat Sci Educ 4:264–268 McBride JM, Drake RL (2018) National survey on anatomical sciences in medical education. Anat Sci Educ 11:7–14 McLachlan JC, De Bere SR (2004) How we teach anatomy without cadavers. Clin Teach 1:49–52 McLachlan JC, Bligh J, Bradley P, Searle J (2004) Teaching anatomy without cadavers. Med Educ 38:418–424 McMenamin PG (2008) Body painting as a tool in clinical anatomy teaching. Anat Sci Educ 1:139–144 McMenamin PG (2022) Art and anatomy in the renaissance: are the lessons still relevant today. ANZ J Surg 92:34–45 McMenamin PG, Quayle MR, McHenry CR, Adams JW (2014) The production of anatomical teaching

P. G. McMenamin resources using three-dimensional (3D) printing technology. Anat Sci Educ 7:479–486 McMenamin PG, McLachlan J, Wilson A, McBride JM, Pickering J, Evans DJR, Winkelmann A (2017) Do we really need cadavers anymore to learn anatomy in undergraduate medicine? Med Teach 40:1020–1029 McMenamin PG, Hussey D, Chin D, Alam W, Quayle MR, Coupland SE, Adams JW (2021) The reproduction of human pathology specimens using threedimensional (3D) printing technology for teaching purposes. Med Teach 43:189–197 Mogali SR, Yeong WY, Tan HKJ, Tan GJS, Abrahams PH, Zary N, Low-Beer N, Ferenczi MA (2018) Evaluation by medical students of the educational value of multi-material and multi-colored three-dimensional printed models of the upper limb for anatomical education. Anat Sci Educ 11:54–64 Mogali SR, Chandrasekaran R, Radzi S, Peh ZK, Tan GJS, Rajalingam P, Yee YW (2021) Investigating the effectiveness of three-dimensionally printed anatomical models compared with plastinated human specimens in learning cardiac and neck anatomy: a randomized crossover study Anat. Sci Educ 15(6):1007–1017. https://doi.org/10.1002/ase.2128 Morgan C, Khatri C, Hanna SA, Ashrafian H, Sarraf KM (2020) Use of three-dimensional printing in preoperative planning in orthopaedic trauma surgery: a systematic review and meta-analysis. World J Orthop 11:57– 67 Moro C, Štromberga Z, Raikos A, Stirling A (2017) The effectiveness of virtual and augmented reality in health sciences and medical anatomy. Anat Sci Educ 10:549– 559 Moxham B (2014) Symposium on anatomical education. J Anat 224:255 Nagassa RG, McMenamin PG, Adams JW, Quayle MR, Rosenfeld JV (2019) Advanced 3D printed model of middle cerebral artery aneurysms for neurosurgery simulation. 3D Print Med 5:11 National Industrial Chemicals Notification and Assessment Scheme (NICNAS) (2006) Formaldehyde information sheets. Attorney General’s Department, Canberra, ACT, 2600. http://www.nicnas.gov.au/ communications/publications/information-sheets/ existing-chemical-info-sheets Park JW, Kang HG, Kim JH, Kim HS (2021) The application of 3D-printing technology in pelvic bone tumor surgery. J Orthop Sci 26:276–283 Parker LM (2002) ‘Anatomical dissection: why are we cutting it out? Dissection in undergraduate teaching. ANZ J Surg 72:910–912 Pastor JF, Gutiérrez B, Montes R, Ballestriero JM (2016) Uncovered secret of a Vasseur-Tramond wax model. J Anat 228:184–189 Pather N, Blyth P, Chapman JA, Dayal MR, Flack NA, Fogg QA, Green RA, Hulme AK, Johnson IP, Meyer AJ, Morley JW, Shortland PJ, Štrkalj G, Štrkalj M, Valter K, Webb AL, Woodley SJ, Lazarus MD (2020) Forced disruption of anatomy education in

3

The Third Dimension: 3D Printed Replicas and Other Alternatives to Cadaver-Based Learning

Australia and New Zealand: an acute response to the Covid-19 pandemic. Anat Sci Educ 13:284–297 Raja DS, Sultana B (2012) Potential health hazards for students exposed to formaldehyde in the gross anatomy laboratory. J Environ Health 74:36–40 Ratinam R, Quayle M, Crock J, Lazarus M, Fogg Q, McMenamin PG (2019) Challenges in creating dissectible anatomical 3D prints for surgical teaching. J Anat 234:419–437 Rengier F, Mehndiratta A, von Tengg-Kobligk H, Zechmann CM, Unterhinninghofen R, Kauczor HU, Giesel FL (2010) 3D printing based on imaging data: review of medical applications’. Int J Comput Assist Radiol Surg 5:335–341 Rifkin BA, Ackerman MJ, Folkenberg J (2006) Human anatomy: depicting the body from the renaissance to the present day. Thames and Hudson, London Safe Work Australia (2017) Workplace exposure standards for airborne contaminants. http://www. safeworkaustralia.gov.au/sites/swa/about/publications/ pages/ workplace-exposure-standards Shaharan S, Neary P (2014) Evaluation of surgical training in the era of simulation. World J Gastrointest Endosc 6: 436–447 Smith CF, Tollemache N, Covill D, Johnston M (2018) Take away body parts! An investigation into the use of 3D-printed anatomical models in undergraduate anatomy education. Anat Sci Educ 2018(11):44–53 Song YK, Jo DH (2021) Current and potential use of fresh frozen cadaver in surgical training and anatomical education. Anat Sci Educ 15(5):957–969. https://doi.org/ 10.1002/ase.2138 Spitzer VM, Scherzinger AL (2006) Virtual anatomy: an anatomist’s playground. Clin Anat 19:192–203 Standring S (2016) A brief history of topographical anatomy. J Anat 229(1):32–62 Stanney KM, Kennedy RS, Drexler JM (1997) Cybersickness is not simulator sickness. Proc Hum Factors Ergon Soc Annu Meet 41:1138–1142 Stramiello JA, Saddawi-Konefka R, Ryan J, Brigger MT (2020) The role of 3D printing in pediatric airway obstruction: a systematic review. Int J Pediatr Otorhinolaryngol 132:109923 Sugand K, Abrahams P, Khurana A (2010) The anatomy of anatomy: a review for its modernization. Anat Sci Educ 3:83–93

61

Thistlethwaite JE, Davies D, Ekeocha S, Kidd JM, MacDougall C, Matthews P, Purkis J, Clay D (2012) ‘The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Med Teach 34:e421–e444 Tomasini F (2008) Research on the recently dead: an historical and ethical examination. Br Med Bull 85: 7–16 Uruthiralingam U, Rea PM (2020) Augmented and virtual reality in anatomical education—a systematic review. Adv Exp Med Biol 1235:89–101 Virzì A, Muller CO, Marret JB, Mille E, Berteloot L, Grévent D, Boddaert N, Gori P, Sarnacki S, Bloch I (2020) Comprehensive review of 3d segmentation software tools for MRI usable for pelvic surgery planning. J Digit Imaging 33:99–110 von Hagens G (1979) Impregnation of soft biological specimens with thermosetting resins and elastomers. Anat Rec 194:247–255 Ward TM, Wertz CI, Mickelsen W (2018) Anatomage table enhances radiologic technology education. Radiol Technol 89:304–306. Erratum in: Radiol Technol. 2018 May; 89:428–430 Weatherall AD, Rogerson MD, Quayle MR, Cooper MG, McMenamin PG, Adams JW (2021) A novel 3-dimensional printing fabrication approach for the production of pediatric airway models. Anesth Analg 133:1251–1259 Winkelmann A (2007) Anatomical dissection as a teaching method in medical school: a review of the evidence. Med Educ 2007 Jan; 41(1):15–22 Wilson AB, Miller CH, Klein BA, Taylor MA, Goodwin M, Boyle EK, Brown K, Hoppe C, Lazarus M (2018) A meta-analysis of anatomy laboratory pedagogies. Clin Anat 31:122–133 Wisenden PA, Budke KJ, Klemetson CJ, Kurtti TR, Patel CM, Schwantz TL, Wisenden BD (2018) Emotional response of undergraduates to cadaver dissection. Clin Anat 31:224–230 Wyer PC (2019) Evidence-based medicine and problem based learning a critical re-evaluation. Adv Health Sci Educ Theory Pract 24:865–878 Young JC, Quayle MR, Adams JW, Bertram JW, McMenamin PG (2019) Three-dimensional printing of archived human fetal material for teaching purposes. Anat Sci Educ 12:90–96

4

Evaluating a Photogrammetry-Based Video for Undergraduate Anatomy Education Irene Gianotto, Alexander Coutts, Laura Pérez-Pachón and Flora Gröning

Abstract

Modern anatomy education has benefitted from the development of a wide range of digital 3D resources in the past decades, but the impact of the COVID-19 pandemic has sparked an additional demand for high-quality online learning resources. Photogrammetry provides a low-cost technique for departments to create their own photo-realistic 3D models of cadaveric specimens. However, to ensure accessibility, the design of the resulting learning resources should be carefully considered. We aimed to address this by creating a video based on a photogrammetry model of a cadaveric human lung. Students evaluated three different versions of this video in a Likert-type online survey. Most responding students found this type of video useful for their learning and helpful for the identification of anatomical structures in real cadaveric specimens. Respondents also showed a preference for specific design features such as a short video length, white text on black background, and the presence of captions. The positive student feedback is promising for the future development of photogrammetry-based videos

I. Gianotto · A. Coutts · L. Pérez-Pachón · F. Gröning (✉) School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK e-mail: [email protected]; [email protected]. uk; [email protected]; [email protected]

,

for anatomy education and this study has provided pilot data to improve the accessibility of such videos. Keywords

Gross anatomy education · Blended learning · 3D photogrammetry · Video creation · Accessibility · Learning disabilities

4.1

Introduction

Traditional human anatomy education has relied on the use of cadavers for centuries, and cadaverbased approaches are still the foundation of anatomy teaching in many medical schools. However, due to technological developments in the past decades, traditional cadaver-based teaching is increasingly supplemented by digital learning resources (Guimarães et al. 2017; Yammine and Violato 2014). As anatomy requires the understanding of 3D spatial relationships, developments in 3D visualisation technology have made a particular impact and a wide range of digital 3D learning resources is now available for anatomy education (Keenan and Ben Awadh 2019; Murgitroyd et al. 2015). In addition to commercial 3D anatomy atlases, there is a growing number of free anatomical 3D models available online on platforms such as Sketchfab (Sketchfab Inc., New York, USA, https://

# The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Border et al. (eds.), Biomedical Visualisation, Advances in Experimental Medicine and Biology 1421, https://doi.org/10.1007/978-3-031-30379-1_4

63

64

sketchfab.com). Thanks to the availability of free or low-cost 3D image processing software such as 3D Slicer (Slicer Community, https://www.slicer. org) or Blender (Blender Foundation, Amsterdam, Netherlands, https://www.blender. org), the in-house development of 3D content has also become feasible for departments with small budgets. Unlike cadaveric specimens, digital 3D models are not confined to the anatomy lab. Therefore, they can provide a useful alternative when access to cadaveric specimens is limited or not possible (e.g., during self-study for the preparation or revision of practical classes or during lockdowns resulting from the COVID-19 pandemic). Many anatomy departments had to put their in-person classes on hold and move their teaching online to minimise infection risks (Brassett et al. 2020; Pather et al. 2020). Therefore, educators and students had to adjust their teaching and learning very quickly to cope with the reduction or lack of in-person classes and direct interaction with cadaveric specimens. This has led to an unprecedented demand for highquality digital anatomy resources across the world, and it can be expected that this demand will remain high if institutions continue to promote a blended learning approach (Bonk and Graham 2006; Garrison and Kanuka 2004; Nathaniel et al. 2021). Beyond the obvious benefit of digital 3D anatomy resources in situations of limited access to cadaveric specimens, there has been some debate on the impact of these resources on learning. As 3D visualisation technology is still a fairly new tool in anatomy education, published data on its effects on student learning are currently limited and occasionally conflicting (Keenan and Ben Awadh 2019). For example, several studies have found some improvement in student performance after students used digital 3D models, but the improvement was not significant (Brewer et al. 2012; Keedy et al. 2011), whereas other studies showed that students using digital 3D models achieved significantly better test results than control groups (Ben Awadh et al. 2022; Glittenberg and Binder 2006; Nicholson et al. 2006). In contrast to this, Wainman et al. (2018) found that

I. Gianotto et al.

digital 3D models shown on a 2D screen were less effective for student learning than traditional physical models. Indeed, a systematic review by Clunie et al. (2018) suggested that the available research on technology-enhanced learning in anatomy is not yet at a level to provide strong causative evidence for the impact on student learning. Common 3D imaging techniques used for anatomy education include computed tomography (CT) and magnetic resonance imaging (MRI). A new and less common approach is 3D photogrammetry, which, in the context of gross anatomy, is a virtual 3D reconstruction based on overlapping photos taken from different viewing angles around a specimen. This technique has the advantage of creating photo-realistic 3D models, thus potentially facilitating the identification of anatomical structures in cadaveric specimens. Other advantages include its high portability, non-invasiveness and low costs compared to more traditional 3D imaging techniques (Evin et al. 2016; Struck et al. 2019). Studies have shown that photogrammetry can produce accurate 3D models of dissected cadaveric specimens and bones (De Benedictis et al. 2018; Evin et al. 2016; Petriceks et al. 2018). However, as this imaging technique has been introduced to anatomy education only recently, data on the impact of 3D photogrammetry on teaching and learning are limited. A few studies have evaluated the usefulness of 3D photogrammetry models for students and staff and have reported very positive feedback (Burk and Johnson 2019; Petriceks et al. 2018; Wesencraft and Clancy 2019). Petriceks et al. (2018) collected feedback from anatomy staff. Wesencraft and Clancy (2019) conducted an evaluation with a small group of postgraduate students (n = 7). Burk and Johnson (2019) performed an evaluation with the largest sample size to date (n = 413). Most students who responded to their survey (74%) found 3D photogrammetry models useful, in this case a digitised plastic model and a dissected cadaveric specimen. It should be noted though that no distinction was made between the two models in the survey so that we do not know student views on the digitised cadaveric specimen

4

Evaluating a Photogrammetry-Based Video for Undergraduate Anatomy Education

compared to the digitised plastic model. For example, it would be interesting to see if students find photo-realistic models of cadaveric specimens more helpful for the identification of structures in real specimens than models with simplified colours such as traditional plastic models. These data would be particularly relevant for the use of 3D photogrammetry models as supporting learning resources for dissection- and prosection-based anatomy teaching. 3D photogrammetry models can be used for anatomy education mainly in two different ways: Either they are embedded in a platform or file that allows students to interact with the 3D models (e.g. rotate and zoom in on details) or the 3D models are animated to produce educational videos. Resources that allow students to interact with the 3D model can be created using existing online platforms such as Sketchfab (but this might not be an option for sensitive image data of human cadaveric specimens), or they can be created using a game engine (Wesencraft and Clancy 2019), which requires special expertise and resources. Alternatively, 3D PDFs or PowerPoint files with embedded 3D models can be created. In contrast, the creation of videos requires software to animate the 3D model and video editing software. Both types of resources (interactive 3D models and videos based on animated 3D models) have advantages and disadvantages, and which type is more preferable for a specific project will depend on the expertise and facilities available in a department. In addition, local policies for data security will play an important role in the decision. One of the largest public online repositories of videos, including educational videos, is YouTube (Google LLC, Mountain View, USA, https:// www.youtube.com). This commercial platform has become a popular source of information for students. A large number of available videos and a wide range of topics help students find what they are looking for and the concise nature of the videos, which are typically only a few minutes long, allows students to get an overview of a topic quickly. Barry et al. (2016) showed that the majority of students employ free online platforms when they struggle with anatomy content, with

65

YouTube found to be their main source of anatomy videos. In addition, short videos have been shown to be beneficial for student engagement (Guo et al. 2014). These findings suggest that a format similar to short anatomy clips on YouTube could be a good choice for in-house video productions. When implementing online and digital resources in their teaching, educators should ensure web accessibility to provide equal access and opportunities for their students. Web accessibility means that online resources and tools are designed and developed so that people with disabilities can use them (Web Accessibility Initiative 2021). Therefore, web accessibility concerns the removal of barriers for disabled students when they use digital resources. This includes a wide range of disabilities such as visual, auditory, cognitive, physical speech, language, learning, and neurological disabilities (World Wide Web Consortium 2021). However, accessibility is not only relevant for students with disabilities, but it can also remove or reduce barriers resulting from the student’s economic situation or geographic location (Baldwin and Ching 2021). There are several published guidelines for accessible online learning resources available (see Baldwin and Ching (2021) for a recent review of the main guidelines). One major internationally recognised set of recommendations is the Web Content Accessibility Guidelines (WCAG), published by the World Wide Web Consortium (W3C), the main international standards organisation for the Internet. The latest version of the WCAG, which is scheduled to be finalised in 2022, is WCAG 2.2 (World Wide Web Consortium 2021). Examples of WCAG recommendations include providing text alternatives for any non-text content and captions for audio content, or ensuring a sufficient contrast between text and background. Universities are increasingly aware of accessibility issues and have adopted new policies to address these. For example, it is now common practice that captions are added to lecture recordings. Although universities publish accessibility guidelines for their staff and/or provide

66

I. Gianotto et al.

staff training, educators might still feel confused and overwhelmed. Linder et al. (2015), who conducted a national study on online accessibility in US Higher Education institutions, found that few educators at these institutions felt equipped to produce accessible online content. Therefore, it seems worthwhile to raise further awareness amongst educators and discuss how certain design features can affect the accessibility of online learning resources. There is a growing number of evaluation frameworks available that can be used to evaluate digital learning resources. Kirkpatrick’s model is probably the most widely known framework (Kirkpatrick and Kirkpatrick 2006), but there are also frameworks that have been specifically designed for technology-enhanced learning (Cook and Ellaway 2015; Pickering and Joynes 2016). Cook and Ellaway (2015) identified seven data collection activities (e.g., needs analysis, usability, reusability, student experience, learning outcomes and cost analysis), whilst Pickering and Joynes (2016) proposed a four-stage evaluation process (i.e., evaluation of need, learner satisfaction and gain, learner impact, and institutional impact). Both frameworks share key features such as a needs analysis and the consideration of student experience and learning outcomes and both provide guidance on how to evaluate technology-enhanced learning comprehensively. However, it might not always be feasible or desirable for educators to conduct such a comprehensive evaluation including all stages. In that case, a less comprehensive evaluation, which includes only some of the elements of these frameworks, might still provide some valuable data and insights, especially in the early stages of a project.

4.1.1

this evaluation were to improve the quality and accessibility of educational videos produced in-house and engage students in the production and optimisation process. Achieving these aims involved collecting student suggestions for video content at the beginning of the project, followed by a student-led video production using a 3D photogrammetry model of a cadaveric human lung. Three different versions of the video were created to evaluate the accessibility of individual design features. The evaluation involved collecting student feedback using an online Likert-type and free-text questionnaire. This approach was intended to produce valuable pilot data that could provide the basis for a more in-depth analysis of individual video design elements, in order to improve accessibility and achieve benefits for student learning. The following research questions were considered: (1) How do undergraduate Biomedical Sciences students perceive the impact of our created photogrammetry-based video on their anatomy learning?; (2) How do these students perceive the accessibility of individual video design features such as font type and colour?; (3) What improvements of the video design do these students suggest?; and (4) Which topics do these students suggest for future videos? Based on previous findings (Barry et al. 2016; Burk and Johnson 2019; Wesencraft and Clancy 2019), it is anticipated that students will have positive perceptions about short photogrammetry-based videos. Regarding the accessibility of individual video design features, we expect that student preferences are in line with the main guidelines for web content such as WCAG 2.2 (World Wide Web Consortium 2021).

Aims and Objectives

4.2 The main aim of this project was to design and create high-quality video content to enhance prosection-based human anatomy teaching at the University of Aberdeen. A second aim was to evaluate the newly created video in terms of its perceived usefulness for learning and the accessibility of the video design. The ultimate goals of

4.2.1

Material and Methods Model Creation

We selected a digital 3D model of a human cadaveric right lung from our departmental database. This model had been created using photogrammetry after gaining approval from the

4

Evaluating a Photogrammetry-Based Video for Undergraduate Anatomy Education

Licensed Teachers of Anatomy at the University of Aberdeen. Figure 4.1 provides an overview of the main work steps. For the image acquisition, the specimen was placed on a turntable, and a high-resolution digital single lens reflex (DSLR) camera was used to capture images of the specimen from different

angles to achieve 360° coverage. The camera was placed 1 m away from the model, and a black felt background was used to minimise reflections and to allow for easier postprocessing. A tripod was set to three different height levels and 16 photos were taken at each level as the specimen was rotated. During this procedure, care was taken to keep the rotation of the turntable constant between each of the 16 photos. The specimen was then moved to two additional positions to expose parts of the specimens that were not visible in the original position and the image acquisition was repeated. This resulted in a total of 144 photos. Photoshop CC 2018 (Adobe Inc., San Jose, USA) was used to mask the background of each photo so that only the specimen was visible. This prevented a possible interference of background features with the 3D reconstruction process. The masked photos were then saved as TIFF files. The images were imported into Photoscan Professional 2018 (Agisoft LLC, St. Peterburg, Russia) and aligned using the Photoscan automatic alignment tool. This was followed by an automatic optimisation of the alignment. Based on the aligned images, a 3D dense point cloud was created. The ‘free-form selection’ tool was used to select and remove any anomalous points outside the dense point cloud. After this correction, a mesh was generated, and surface texture was added to the model. This procedure was repeated for each chunk (i.e., each set of photos that were taken of the specimen in a specific position). Using landmarks in overlapping areas, the chunks were aligned and merged. Thus, a closed 3D model was created. The final model was exported as an OBJ file.

4.2.2

Fig. 4.1 Summary of the workflow applied in this project. A 3D photogrammetry model of a human right lung was created based on overlapping photos. After animating this model, a video was created including additional audiovisual information. Students evaluated three slightly different versions of this video via an online survey

67

Video Creation and Editing

The video content was selected based on suggestions from second year Biomedical Science students at the University of Aberdeen (n = 33). The students were contacted via a Messenger chat group (Meta Platforms Inc., Menlo Park, USA) and asked to name the anatomy topics that they found most challenging to

68

learn. Student suggestions included videos on lung and heart anatomy, vasculature of the abdomen, muscles of the back, peritoneal folds, spinal nerves, and innervation of the lower limb and the general areas of head and neck. Since a photogrammetry model of the right lung was already available, we decided to focus on this structure. The video was planned to be a mix of both, visual 3D animations created in 3DsMax 2021 (Autodesk Inc., San Rafael, USA) and a recorded voice-over. The script for the video was created in advance of the animation of the 3D model. The video script consisted of the voice-over text and guidance on the planned visual information. This included information on the rotation of the animated lung model; the view of the lung (anterior, posterior, medial); the zoom factor for the visualisation of the model; and the outlining of selected structures such as the lobes of the lung. The script also included estimated frame numbers and the text appearing on the screen. The voice-over was recorded based on the text in the script and was then used to generate the estimated frame numbers. To record the voiceover, the Voice Memos app for iOS (Apple Inc., Cupertino, USA) was employed and a headset was used to reduce background noise. The 3D photogrammetry model was animated using 3DsMax 2021. A free-form camera was used to frame the model correctly and the animation was carried out using key frames. The key frames allowed for smooth and controlled movement of the model. The guide frames from the script were used in conjunction with the frames in 3DsMax so that the timing of the voice-over matched the length and timing of the animations. After completing the animation, the video was exported as a universal AVI file with 30 frames per second (FPS). Premiere Pro CC (Adobe Inc., San Jose, USA) was then used to combine the voice-over with the animation of the 3D model created in 3DsMax. The use of Premiere Pro CC allowed for the animations to be precisely timed with the voiceover by cutting selected frames from the video and copying and pasting sections to increase the animation’s length or cutting some sections

I. Gianotto et al.

shorter. The final video was exported as an AVI file with 30 FPS. After Effects (Adobe Inc., San Jose, USA) was used to add credits, labels, and the logo of the University of Aberdeen to the video. To indicate the borders of each lobe of the lung, those borders were manually delineated using a graphics tablet. Text layers were created for the text labels of anatomical structures and for the video credits. A consistent format (i.e., text position and colour as well as font type and size) was used throughout the video. Three versions of the same video were created, varying the font type and text colour. The original video used white Arial font (Version 1); the second version used white Cambria font (Version 2); and the third version used red Arial font (Version 3). A black background was chosen for all three versions. The video for each version was rendered and exported in AVI format. These videos were then uploaded to Panopto (Panopto Inc., Seattle, USA) and captions were added using the Panopto automatic captioning tool. Manual correction of the automatically generated captions was performed where necessary. The final captioned videos were then embedded into the University of Aberdeen virtual learning environment MyAberdeen, which is based on Blackboard Learn (Blackboard Inc., Reston, USA). Each video had a length of 1 min and 18 s.

4.2.3

Evaluation

A survey with five-point Likert-type items (Table 4.1) was created using Google Forms (Google LLC, Mountain View, USA, https:// docs.google.com/forms) to obtain student views on the effectiveness of the video for their learning (based on a questionnaire created by Gröning et al. 2020) and the accessibility of the different versions of the video. The aspects evaluated included: the usefulness of the video as a whole and the usefulness of individual design features (i.e., voice-over and captions, length of the video, text colour, font type and rotation speed). Items 1–8 referred to all versions of the video, whereas item 9 was repeated for each

4

Evaluating a Photogrammetry-Based Video for Undergraduate Anatomy Education

69

Table 4.1 Questionnaire items administered using a five-point Likert-type scale Questionnaire item 1. This video helps me identify structures in cadaveric specimens. 2. Having more videos of this type would help my learning. 3. The voice-over helps me understand the video content. 4. The voice-over is distracting. 5. The captions help me understand the video content. 6. The short (bite-sized) format of this video makes it more likely that I watch it. 7. A slower rotation would make it easier for me to identify structures. 8. The black background helps me focus on the video content. 9. The text is easy to read.

version of the video. The survey also included a text field for comments with the instruction: “Please give us any additional comments (e.g. suggestions to improve the video or ideas for future videos)”. Participation in this survey was voluntary and anonymous. The survey did not collect any demographic or personal data that could allow the identification of participants. The questionnaire was completed by 19 undergraduate second year Biomedical Sciences students at the University of Aberdeen who were studying lung anatomy as part of an introductory anatomy course. This course is the first of two compulsory gross anatomy courses for students in the BSc/MSci Biomedical Sciences degree programmes at the University of Aberdeen. The course consists of weekly practical classes with prosected cadaveric specimens, live online tutorials, and recorded lectures. For the practical classes, a student-directed learning approach is applied. It requires students to prepare well for every class and to learn primarily by self-directed means during the practical classes, assisted by a worksheet and demonstrators. When completing the questionnaire, the students had covered the following course content: “Introduction to anatomical terms”; “Introduction to bones, joints, and muscles”; “Nerves and the back”; “Upper limb”; “Lower limb”; “Thoracic wall”; “Lungs and pleura”. The mean and standard deviation of responses to each Likert-type item were calculated using the following values for the five options: Strongly disagree = 1, disagree = 2, neutral = 3, agree = 4, and strongly agree = 5. The means and standard deviations were then plotted using bar charts.

Given the small number of students who filled in the survey, no additional statistical analysis of the data was performed. The collection of both quantitative and qualitative data and the consideration of potential biases are consistent with a post-positive theoretical stance. However, we did not quantify the reliability and validity of the questionnaire items and we did not perform a semiquantitative thematic analysis of the free-text data.

4.2.4

Ethical Assessment

The Licensed Teachers of Anatomy at the University of Aberdeen approved the use of the human cadaveric right lung for the creation of photogrammetry-based learning resources. The School of Medicine, Medical Sciences and Nutrition Ethics Review board at the University of Aberdeen confirmed that this study falls in the category of service evaluation with no requirement for an ethical opinion.

4.3

Results

The results of our survey are summarised in Figs. 4.2 and 4.3. The first three statements of the survey received a very high level of agreement (Fig. 4.2). Of the 19 students that completed the survey, 18 students agreed (options 4 and 5) that the video was helpful in identifying structures in cadaveric specimens (4.63 ± 0.96) and thought that more videos of this type would be helpful for their learning (4.74 ± 0.93). The same number of

70

I. Gianotto et al.

Fig. 4.2 Student perceptions of the photogrammetrybased video and selected video design features (n = 19). Blue bars represent the mean responses for each survey

item and the error bars show ± one standard deviation. Likert-type scale: 1 = strongly disagree, 5 = strongly agree

students (18) found the voice-over helpful in understanding the video content (options 4 and 5, 4.68 ± 0.95). This result was mirrored by the responses to the opposite statement “The voiceover is distracting”, to which 18 students disagreed (options 1 and 2, 1.53 ± 0.96). When asked about captions, most participants (16) agreed (options 4 and 5) that those helped with understanding the video content (4.37 ± 1.07). The short, bite-sized length of the video was seen very positively by most students, as 17 students agreed (options 4 and 5) that they would be more likely to watch videos of this

length (4.37 ± 1.12). Only two students disagreed with this statement (options 1 and 2). However, when asked about the rotation speed of the model, the student responses were more mixed. Five students agreed (option 4) that a slower rotation would make it easier to identify the anatomical structures, but most students (10) neither agreed nor disagreed (option 3) and some (4) disagreed (options 1 and 2) with this statement (3.00 ± 0.82). The responses also showed a strong approval of the black background. Most students (18) agreed (options 4 and 5) that the black

Fig. 4.3 Student perceptions of the readability of the text in the three different versions of the video (n = 19). Blue bars represent the mean responses for each survey item and the error bars show ± one standard deviation. Likert-type scale: 1 = strongly disagree, 5 = strongly agree

4

Evaluating a Photogrammetry-Based Video for Undergraduate Anatomy Education

background helps them to focus on the content of the video (4.53 ± 0.96). Regarding the different font types (Fig. 4.3), most students agreed (options 4 and 5) that the text was easy to read in both fonts, Arial as well as Cambria (Arial: 18 students agreed; Cambria: 16 students agreed, 4.42 ± 0.96). However, altering the text colour from white to red had a large effect on readability of the text. Most students (9) found the text in red Arial font (Version 3) difficult to read (options 1 and 2). Only four students agreed (options 4 and 5) that the red text on black background was easy to read (2.68 ± 1.34). Responses to the request for comments (including suggestions to improve the video or ideas for future videos) at the end of the survey reiterated some of the responses to the Likert-type items. Three comments showed a preference for the white text in Arial font (Version 1), whilst only one comment expressed a preference for white text in Cambria font (Version 2). Two students commented that the red text (Version 3) feels “negative”, “angry” and “aggressive”. Suggestions to improve the videos included: (1) highlighting all key areas (e.g., drawing a line to highlight the length of each fissure and the hilum area) as it was done for the lobes of the lung; (2) colour coding text labels and highlighted areas; and (3) keeping the lobes highlighted when showing the posterior view of the lung. Suggestions for future videos included: (1) heart anatomy; (2) a follow-up video on the left lung; and (3) videos on spatial relations of structures in the thorax (e.g., the location of the lungs in relation to other structures or impressions of structures on the lung surface). One comment suggested videos of this type for most structures studied in the course. In general, the comments reiterated the positive feedback seen in the Likert-type responses: e.g. “Well done!”, “Loved it! Super useful with detail and not too long”, “I cannot really think of any suggestion so I will just say good job!”, “all good”, “It is a great video and very helpful for learning, thank you for making it!”, “Good job!”, “It was very helpful for the assessment and very easy to understand”, “The format of the first video was ideal for me and wouldn’t change anything

71

about it”, “Good video! It helped a lot!”, “more short videos please”.

4.4

Discussion

This project aimed to create a new video for human anatomy education using a 3D photogrammetry model of a cadaveric human lung and to evaluate this video in terms of its perceived usefulness for learning and accessibility of the video design. As three slightly different versions of the video were used in the evaluation, some pilot data on the accessibility of individual design features could be collected.

4.4.1

Photogrammetry-Based Videos

The survey responses showed that most students found the video helpful for the identification of structures in cadaveric specimens and agreed that more videos of this type would help their learning. This finding corroborates the results of similar previous student evaluations of photogrammetry models for anatomy education (Burk and Johnson 2019; Wesencraft and Clancy 2019). It is important to note though that in these previous studies, students evaluated interactive versions of the 3D models rather than videos of animated models. Therefore, the results of this study are not directly comparable. However, all three evaluations (i.e. those by Burk and Johnson (2019) and Wesencraft and Clancy (2019) as well as this study) highlight the potential of 3D photogrammetry models to enhance the student experience as the models are perceived as very useful, either in the form of videos or embedded in a platform that allows direct interaction with the 3D models. Unlike previous evaluations of photogrammetry models for anatomy education (Burk and Johnson 2019; Wesencraft and Clancy 2019), this study also asked students specifically if they found that the video helps them to identify structures in cadaveric specimens. The high level of agreement with this statement is probably not surprising considering the photo-realistic

72

I. Gianotto et al.

nature of the model. Compared to textbook diagrams or plastic models with simplified colours, structures in photogrammetry models look much more similar to those in prosections, which might facilitate the transfer of identification skills from the digital model to the real specimen. The high level of appreciation of these resources should also be seen in the context of anatomy teaching at the University of Aberdeen, where interactions with prosections in practical classes are the focus of each practical class and most questions in assessments refer to pinned structures in prosections.

4.4.2

Dallas et al. (2016) found that undergraduate students who were exposed to captions scored significantly better in subsequent assessments. Commonly used lecture recording and video streaming software such as Panopto or Camtasia (TechSmith Corp., Okemos, USA) include an auto-captioning tool. Alternatively, separate software can be used to add captions. However, manual editing of the automatically generated captions is usually required. As a consequence, captioning can be a time-consuming task, but the student responses in this study and previous research (Dallas et al. 2016) show that this additional effort is justified to improve accessibility.

Voice-Over and Captions 4.4.3

A large majority of the respondents found the voice-over helpful for understanding the video content and disagreed that the voice-over was distracting. This is useful feedback as our previous photogrammetry-based videos did not include a voice-over and relied solely on visuals (i.e., text labels for key structures in the model). Based on the responses to this survey, it seems that the additional effort of scripting and recording a voice-over is appreciated by the students. The presence of a voice-over is also in line with recommendations to use both auditory and visual channels to convey complementary information and to match modality to content, meaning that the appropriate channel should be chosen for each type of information instead of ‘overloading’ a channel with information, which would impede learning (Brame 2016). In our video, the voiceover allowed us to explain key aspects of lung anatomy during the animation without increasing the number of text labels on the screen. A large majority of the responding students also found that the captions helped them to understand the video content. This finding supports current WCAG guidelines (W3C 2021) and university policies that require educators to add captions to lecture recordings and other educational videos. In addition, there is evidence that captions do not only benefit students with disabilities and second language learners, but also the general student population. For example,

Video Length and Rotation Speed

Most respondents agreed that the short, bite-sized length of the video (i.e. less than 2 min) increases the likelihood that they would watch the video and they were also content with the speed of the model rotation. Only a small minority of the students thought that a slower rotation would make it easier to identify structures in the model. Student satisfaction with the rotation speed of the model is most probably due to the fact that the rotation speed was optimised based on our previous evaluation of a similar video (Gröning et al. 2020). In that evaluation, over 40% of the students found the rotation too fast. In subsequent video productions, we therefore used a slower rotation speed. Student preferences for short, bite-sized videos are in line with common guidelines and empirical data. In recommendations for effective educational videos, Brame (2016) argued that the most important guideline for maximising student attention is to keep videos short. Guo et al. (2014) analysed a large dataset of almost seven million video sessions watched by students on massive open online courses (MOOCs) and found that students watched a whole video if it was less than 6 min long, but median engagement time dropped to about 50 and 20% for 9–12 min videos and 12–40 min videos, respectively. Even for those longer videos, the maximum median

4

Evaluating a Photogrammetry-Based Video for Undergraduate Anatomy Education

engagement was 6 min. It should be noted that these observations from MOOCs might not be directly applicable to the students in this study as the latter attended a compulsory anatomy course that used a blended learning approach. However, the findings by Guo et al. (2014) as well as the responses to our survey suggest that short, bite-sized videos are a good choice for student engagement and experience.

4.4.4

Font Type

Most students agreed that the text was easy to read in both the sans serif font Arial as well as the serif font Cambria. There was only a slight preference for Arial (i.e., a difference of two respondents), but our small sample size is insufficient to determine if there is indeed a preference for one of these fonts. A serif font, such as Cambria or Times New Roman, is characterised by adornments and extra strokes at the ends of the letter, which create a more decorative look (Table 4.2). Sans serif fonts, such as Arial or Verdana, are lacking these decorative elements and are made of simple and clean lines. There are three main reasons why serifs are believed to affect readability: first, serifs are believed to increase letter discriminability; second, they are thought to provide an accentuation to the ends of strokes that may help readers to read faster and reduce fatigue; and third, the horizontal serifs along the font baseline might help readers to read faster and more efficiently by guiding the horizontal movement of the eyes (Arditi and Cho 2005; De Lange et al. 1993; Rubinstein 1988). Contrary to this, studies have Table 4.2 Examples of serif and sans serif fonts Cambria (serif) Times New Roman (serif) Arial (sans serif) Verdana (sans serif)

73

shown that readers prefer sans serif fonts when consuming digital content (Boyarski et al. 1998; Reynolds 1979), but despite this preference, there are several experimental studies (e.g. Ali et al. 2013; Arditi and Cho 2005; De Lange et al. 1993) that did not find any significant difference in readability between serif and sans serif fonts. Ali et al. (2013) explained this result as being associated with improved screen technology. In the past, serif fonts were thought to be less suitable for computer screens due to low screen resolution, but as most computer screens today can display all types of fonts clearly, the rendering of serif fonts has greatly improved. Even though it is interesting to study the readability of different fonts in the general population, the effect of font types on readability is particularly relevant for students with disabilities such as dyslexia and impaired vision. Associations for people with dyslexia tend to recommend sans serif fonts (Evett and Brown 2005). Although such recommendations do not usually cite the scientific evidence on which they are based, there are several studies that have tried to determine the most accessible fonts for readers with dyslexia. For example, Kuster et al. (2017) found a preference for Arial in children with dyslexia, and Rello and Baeza-Yates (2016) showed that sans serif fonts increased onscreen reading performance in readers with dyslexia. Empirical evidence, therefore, supports the recommendation that sans serif fonts should be used for online learning resources to improve accessibility.

4.4.5

Text and Background Colour

Most students agreed that the black background was useful to focus on the content of the video and found the white text easier to read than the red text. This finding is in line with common accessibility guidance. The WCAG (World Wide Web Consortium 2021) uses contrast ratio as a measure of the difference in perceived luminance or brightness between two colours, which ranges from 1:1 (e.g. white text on white background) to 21:1 (e.g. white text on black background). The

74

I. Gianotto et al.

WCAG recommends that visual presentations of text have a contrast ratio of at least 7:1 unless it is large-scale text, where a lower contrast ratio is acceptable. As white text on black background has a very high contrast ratio of 21:1, it fulfils the WCAG guidelines even for small text. The exact contrast ratio of red text on black background depends on the type of red, but even bright red gives a contrast ratio below 7:1 and is thus less accessible than white text on black background. This recommendation is supported by empirical studies that have shown that a high contrast between text and background colours increases readability (e.g. Hall and Hanna 2004). In addition to the lower contrast ratio of red text on black background, the WCAG (World Wide Web Consortium 2021) advises specifically against the use of predominantly long wavelength colours (e.g. red) against darker colours (e.g. black) for those who have protanopia, which is a type of colour blindness. The use of red text on black background should, therefore, be avoided in the design of online learning resources. Two students commented on the emotional effect of the red text in version 3 of the video using the terms “negative”, “angry” and “aggressive”. Their perception is in line with findings of psychological studies. For example, Moller et al. (2009) showed that people tend to associate red with negative emotions and danger as it is the colour of fire, blood, and anger. Fetterman et al. (2012) also found a robust association between red and anger in their study participants. These student comments show that the choice of certain design features might trigger unintended emotional reactions and that these might also be worth considering in the design of digital learning resources.

4.4.6

Limitations

This is a pilot study that included only a small sample of one specific group of students (i.e., second year undergraduate students studying Biomedical Sciences at the University of Aberdeen). Results are likely to differ for a larger and more

diverse sample. It is also worth noting that these students are part of a single institution. Therefore, our findings may not be applicable to other schools or educational systems. In addition, only one video based on one cadaveric specimen was evaluated in this study. Although the positive feedback is consistent with the responses collected in our evaluation of a similar video using a different model (Gröning et al. 2020), it is possible that a wider range of models from other anatomical regions and varying surface textures could lead to different responses. Participants were made aware that their responses were anonymous and that none of the questions asked for data that could be potentially used to identify individuals. However, it is possible that responses were still influenced by a courtesy bias (i.e., that respondents had the tendency to be courteous towards those who produced the video). The respondents knew the project supervisor and the project students who produced the video and conducted the evaluation from personal interactions during practical classes. This might have increased the likelihood of the participants to evaluate the video more favourably. The tool used to evaluate our video was a survey and, therefore, we can consider only student preferences and perceptions. Consequently, our study was limited to the lower levels of relevant evaluation frameworks (Cook and Ellaway 2015; Kirkpatrick and Kirkpatrick 2006; Pickering and Joynes 2016). We did not test student performance and thus the actual effects of the video and its different versions on student learning. Perceived learning cannot be used as a measure of actual learning (Deslauriers et al. 2019), where the term ‘actual learning’ reflects a change in knowledge and is identified by rigorous measurement of learning (Bacon 2016). Moreover, no personal data were collected in the survey. Therefore, we do not know whether some of the students who participated in the survey had disabilities, such as dyslexia or impaired vision. Overall, this study should be seen as a pilot study to obtain preliminary data on how our video is perceived by students and how we could improve it.

4

Evaluating a Photogrammetry-Based Video for Undergraduate Anatomy Education

4.4.7

Future Work

Future studies could benefit from a larger sample that includes students from different subjects, levels, and institutions. Studies could also evaluate a range of models from different anatomical regions and with varying surface features. In addition to a survey, effects on student performance could be studied in a randomised controlled intervention study. It would also be informative to compare students with common learning disabilities (e.g. dyslexia, attention-deficit/hyperactivity disorder (ADHD) and auditory or visual processing disorders) and students without a disability. Future studies on the use of short videos for anatomy education could also explore different ways of student engagement with these videos. This could be inspired by previous work on the use of social media in anatomy education. Social media platforms have already been used successfully for anatomy teaching as they allow the exchange of ideas and resources between users and facilitate self-reflection (Guimarães et al. 2017). For example, anatomy educators have set up Facebook pages (Meta Platforms Inc., Menlo Park, USA, https://facebook.com) to support student learning (Jaffar 2012, 2014; Pickering and Bickerdike 2017). Jaffar and Eladl (2016) found that discussion and engagement were directly proportional to student performance (i.e., students who actively engaged in discussions performed better than those whose engagement was limited to a single ‘like’ or comment). Hennessy et al. (2016) created a Twitter hashtag (Twitter Inc., San Francisco, USA, https://twitter.com) to help student learning and observed that this tool increased effectiveness and speed of communication between students and educators, but they found no or a negligible correlation between contribution or viewing frequency and examination scores. However, the hashtag not only helped and encouraged students to engage with each other and the material, but it also provided a platform where students could share their worries, thus raising morale and reducing anxieties through the establishment of a support network. Based

75

on these experiments, it could be explored if commenting tools improve student engagement with videos. These tools are not only available on commercial social media platforms but also in commonly used virtual learning environments. Therefore, they could also be applied to videos containing models of human cadaveric specimens, where strict access management is required (e.g., exclusive access for students on a specific course after the students have signed a code of conduct). As this is an evolving field and the demand for high-quality online learning resources has significantly increased as a result of the COVID-19 pandemic, it seems timely to conduct more studies on how to improve the educational value and accessibility of photogrammetry-based videos for anatomy education.

4.5

Conclusions

This project achieved its main aim of designing and creating high-quality video content to enhance prosection-based human anatomy teaching at the University of Aberdeen. It successfully included student suggestions in the early planning stage of the video and the findings of the evaluation indicate that our photogrammetry-based video was very well received by students. A large majority of the survey respondents found this type of video useful for their learning and helpful for the identification of anatomical structures in real cadaveric specimens. These responses suggest that videos using animated photogrammetry models could enhance dissection- or prosection-based anatomy teaching, especially when access to real specimens is not possible (e.g., during self-study for the preparation or revision of practical classes). The photorealistic appearance of these models is likely to be a major factor why students find that these models facilitate the identification of structures in cadaveric specimens. The survey results also provided some insights into student preferences regarding individual design features of the video (e.g., video length, text colour, font type and the presence or absence

76

of captions). Overall, the responses are in line with common accessibility guidelines and previous studies. Some features require additional effort and time (e.g., the recording of a voiceover and the addition of captions), but the responses show that this additional work is worthwhile as students perceive these features as helpful. Overall, the positive student feedback is promising for the future development of photogrammetry-based videos for anatomy education. This study has provided some valuable pilot data that could provide the basis for a more in-depth exploration and analysis of individual video design elements to improve accessibility and maximise the benefits of learning. Acknowledgements The authors are deeply grateful to the individuals who facilitate anatomy teaching at the University of Aberdeen with their generous body donations. The use of a human cadaveric specimen for the creation of a 3D photogrammetry model and video was approved by the Licensed Teachers of Anatomy at the University of Aberdeen. We would also like to thank the anatomy technicians at the University of Aberdeen for their support. We are grateful to Ronja Struck, Sara Cordoni, and Sofia Aliotta for image acquisition and 3D reconstruction work and we would like to thank the students who provided feedback on the video. This work was supported by a HotStart Studentship awarded to A. Coutts by the University of Aberdeen Development Trust. L. Pérez-Pachón was funded by the Roland Sutton Academic Trust (0053/R/17) and an Elphinstone PhD Scholarship from the University of Aberdeen.

References Ali AZM, Wahid R, Samsudin K, Idris M (2013) Reading on the computer screen: does font type has effects on web text readability? Int Educ Stud 6:26–35. https:// doi.org/10.5539/ies.v6n3p26 Arditi A, Cho J (2005) Serifs and font legibility. Vis Res 45:2926–2933. https://doi.org/10.1016/j.visres.2005. 06.013 Bacon DR (2016) Reporting actual and perceived student learning in education research. J Mark Educ 38:3–6. https://doi.org/10.1177/0273475316636732 Baldwin SJ, Ching YH (2021) Accessibility in online courses: a review of national and statewide evaluation instruments. TechTrends 65:731–742. https://doi.org/ 10.1007/s11528-021-00624-6 Barry SD, Marzouk F, Chulak-Oglu K, Bennet D, Tierney P, O’Keeffee GW (2016) Anatomy education

I. Gianotto et al. for the YouTube generation. Anat Sci Educ 9:90–96. https://doi.org/10.1002/ase.1550 Ben Awadh A, Clark J, Clowry G, Keenan ID (2022) Multimodal three-dimensional visualization enhances novice learner interpretation of basic cross-sectional anatomy. Anat Sci Educ 15:127–142. https://doi.org/ 10.1002/ase.2045 Bonk JC, Graham CR (2006) Blended learning systems: definition, current trends and future directions. In: Graham CR, Bonk CJ (eds) The handbook of blended learning: global perspectives, local designs. Pfeiffer Publishing, San Francisco, CA, pp 3–21 Boyarski D, Neuwirth C, Forlizzi J, Regli S (1998) A study of fonts designed for screen display. In: Karat CM, Lund A, Coutaz J, Karat J (eds) Proceedings of the SIGCHI conference on human factors in computing systems—CHI ‘98, pp 87–94. https://doi.org/10.1145/ 274644.274658 Brame CJ (2016) Effective educational videos: principles and guidelines for maximizing student learning from video content. CBE Life Sci Educ 15:1–6. https://doi. org/10.1187/cbe.16-03-0125 Brassett C, Cosker T, Davies DC, Dockery P, Gillingwater TH, Lee TC, Milz S, Parson SH, Quondamatteo F, Wilkinson T (2020) COVID-19 and anatomy: stimulus and initial response. J Anat 237:393–403. https://doi. org/10.1111/joa.13274 Brewer DN, Wilson TD, Eagleson R, De Ribaupierre S (2012) Evaluation of neuroanatomical training using a 3D visual reality model. In: Westwood JD, Westwood SW, Li F-T, Haluck RS, Robb RA, Senger S, Vosburgh KG (eds) Medicine meets virtual reality 19. IOS Press Ebooks, Amsterdam, pp 85–91. https://doi. org/10.3233/978-1-61499-022-2-85 Burk ZJ, Johnson CS (2019) Method for production of 3D interactive models using photogrammetry for use in human anatomy education. HAPS Educ 23:457–463. https://doi.org/10.21692/haps.2019.016 Clunie L, Morris NP, Joynes VCT, Pickering JD (2018) How comprehensive are research studies investigating the efficacy of technology-enhanced learning resources in anatomy education? A systematic review. Anat Sci Educ 11:303–319. https://doi.org/10.1002/ase.1762 Cook DA, Ellaway RH (2015) Evaluating technologyenhanced learning: a comprehensive framework. Med Teach 37:961–970. https://doi.org/10.3109/ 0142159X.2015.1009024 Dallas B, McCarthy A, Long G (2016) Examining the educational benefits of and attitudes toward closedcaptioning among undergraduate students. J Scholar Teach Learn 16:56–71. https://doi.org/10.14434/ josotl.v16i2.19267 De Benedictis A, Nocerino E, Menna F, Remondino F, Barbareschi M, Rozzanigo U, Corsini F, Olivetti E, Marras CE, Chioffi F, Avesani P (2018) Photogrammetry of the human brain: a novel method for threedimensional quantitative exploration of the structural connectivity in neurosurgery and neurosciences. World

4

Evaluating a Photogrammetry-Based Video for Undergraduate Anatomy Education

Neurosurg 115:279–291. https://doi.org/10.1016/j. wneu.2018.04.036 De Lange RW, Esterhuizen HL, Beatty D (1993) Performance differences between Times and Helvetica in a reading task. Electron Publ 6:241–248 Deslauriers L, McCarty LS, Miller K, Callaghan K, Kestin G (2019) Measuring actual learning versus feeling of learning in response to being actively engaged in the classroom. Proc Natl Acad Sci USA 116:19251– 19257. https://doi.org/10.1073/pnas.1821936116 Evett L, Brown D (2005) Text formats and web design for visually impaired and dyslexic readers-clear text for all. Interact Comput 17:453–472. https://doi.org/10. 1016/j.intcom.2005.04.001 Evin A, Souter T, Hulme-Beaman A, Ameen C, Allen R, Viacava P, Larson G, Cucchi T, Dobney K (2016) The use of close-range photogrammetry in zooarchaeology: creating accurate 3D models of wolf crania to study dog domestication. J Archaeol Sci Rep 9:87–93. https://doi.org/10.1016/j.jasrep.2016.06.028 Fetterman AK, Robinson MD, Meier BP (2012) Anger as “seeing red”: evidence for a perceptual association. Cogn Emot 26:1445–1458. https://doi.org/10.1080/ 02699931.2012.673477 Garrison D, Kanuka H (2004) Blended learning: uncovering its transformative potential in higher education. Internet High Educ 7:95–105. https://doi.org/ 10.1016/j.iheduc.2004.02.001 Glittenberg C, Binder S (2006) Using 3D computer simulations to enhance ophthalmic training. Ophthalmic Physiol Opt 26:40–49. https://doi.org/10.1111/j. 1475-1313.2005.00358.x Gröning F, Aliotta S, Struck R, Pérez-Pachón L (2020) Using 3D photogrammetry to enhance the teaching of human anatomy: an evaluation. In: Proceedings of the 19th International federation of associations of anatomists Congress, London. 9–11 Aug 2019. J Anat 236:95–96. https://doi.org/10.1111/joa.13163 Guimarães B, Dourado L, Tsisar S, Diniz JM, Madeira MD, Ferreira MA (2017) Rethinking anatomy: how to overcome challenges of medical education’s evolution. Acta Medica Port 30:134. https://doi.org/10.20344/ amp.8404 Guo PJ, Kim J, Robin R (2014) How video production affects student engagement: an empirical study of MOOC videos. In: L@S 2014: proceedings of the First ACM conference on learning @ Scale, Atlanta, Georgia, 4–5 March 2014, pp 41–50. https://doi.org/ 10.1145/2556325.2566239 Hall RH, Hanna P (2004) The impact of web page textbackground colour combinations on readability, retention, aesthetics and behavioural intention. Behav Inform Technol 3:183–195. https://doi.org/10.1080/ 01449290410001669932 Hennessy C, Kirkpatrick E, Smith C, Border S (2016) Social media and anatomy education: using Twitter to enhance the student learning experience in anatomy. Anat Sci Educ 9:505–515. https://doi.org/10.1002/ase. 1610

77

Jaffar A (2012) YouTube: an emerging tool in anatomy education. Anat Sci Educ 5:158–164. https://doi.org/ 10.1002/ase.1268 Jaffar A (2014) Exploring the use of a Facebook page in anatomy education. Anat Sci Educ 7:199–208. https:// doi.org/10.1002/ase.1404 Jaffar A, Eladl M (2016) Engagement patterns of high and low academic performers on Facebook anatomy pages. J Med Educ Curric Dev 3:1–6. https://doi.org/10.4137/ JMECD.S36646 Keedy AW, Durack JC, Sandhu P, Chen EM, O’Sullivan PS, Breiman RS (2011) Comparison of traditional methods with 3D computer models in the instruction of hepatobiliary anatomy. Anat Sci Educ 4:84–91. https://doi.org/10.1002/ase.212 Keenan ID, Ben Awadh A (2019) Integrating 3D visualisation technologies in undergraduate anatomy education. In: Rea P (ed) Biomedical visualisation. Advances in experimental medicine and biology, vol 1120. Springer, Heidelberg, pp 39–53. https://doi.org/ 10.1007/978-3-030-06070-1_4 Kirkpatrick DL, Kirkpatrick JD (2006) Evaluating training programs: the four levels, 3rd edn. Berrett-Koehlar, San Francisco, CA Kuster SM, van Weerdenburg M, Gompel M, Bosman AMT (2017) Dyslexie font does not benefit reading in children with or without dyslexia. Ann Dyslexia 68: 25–42. https://doi.org/10.1007/s11881-017-0154-6 Linder KE, Fontaine-Rainen DL, Behling K (2015) Whose job is it? Key challenges and future directions for online accessibility in US institutions of higher education. Open Learn 30:21–34. https://doi.org/10.1080/ 02680513.2015.1007859 Moller AC, Elliot AJ, Maier MA (2009) Basic hue-meaning associations. Emotion 9:898–902. https://doi.org/10.1037/a0017811 Murgitroyd E, Madurska M, Gonzalez J, Watson A (2015) 3D digital anatomy modelling – practical or pretty? Surgeon 13:177–180. https://doi.org/10.1016/j.surge. 2014.10.007 Nathaniel TI, Goodwin RL, Fowler L, McPhail B, Black AC Jr (2021) An adaptive blended learning model for the implementation of an integrated medical neuroscience course during the Covid-19 pandemic. Anat Sci Educ 14:699–710. https://doi.org/10.1002/ase.2097 Nicholson DT, Chalk C, Funnell WRJ, Daniel S (2006) Can virtual reality improve anatomy education? A randomised controlled study of a computer-generated three-dimensional anatomical ear model. Med Educ 40:1081–1087. https://doi.org/10.1111/j.1365-2929. 2006.02611.x Pather N, Blyth P, Chapman JA, Dayal MR, Flack NA, Fogg QA, Green RA, Hulme AK, Johnson IP, Meyer AJ, Morley JW, Shortland PJ, Štrkalj G, Štrkalj M, Valter K, Webb AL, Woodley SJ, Lazarus MD (2020) Forced disruption of anatomy education in Australia and New Zealand: an acute response to the Covid-19 pandemic. Anat Sci Educ 13:284–300. https://doi.org/10.1002/ase.1968

78 Petriceks AH, Peterson AS, Angeles M, Brown WP, Srivastava S (2018) Photogrammetry of human specimens: an innovation in anatomy education. J Med Educ Curric Dev 5:1–10. https://doi.org/10. 1177/2382120518799356 Pickering J, Bickerdike S (2017) Medical student use of Facebook to support preparation for anatomy assessments. Anat Sci Educ 10:205–214. https://doi. org/10.1002/ase.1663 Pickering JD, Joynes VK (2016) A holistic model for evaluating the impact of individual technologyenhanced learning resources. Med Teach 38:1242– 1247. https://doi.org/10.1080/0142159X.2016. 1210112 Rello L, Baeza-Yates R (2016) The effect of font type on screen readability by people with dyslexia. ACM Trans Access Comput 8:1–33. https://doi.org/10.1145/ 2897736 Reynolds L (1979) Progress in documentation: legibility studies: their relevance to present-day documentation methods. J Doc 35:307–340. https://doi.org/10.1108/ eb026686 Rubinstein R (1988) Digital typography: an introduction to type and composition for computer system design. Addison Wesley, Boston, MA Struck R, Cordoni S, Aliotta S, Pérez-Pachón L, Gröning F (2019) Application of photogrammetry in biomedical science. In: Rea P (ed) Biomedical Visualisation. Advances in experimental medicine and biology, vol 1120. Springer, Heidelberg, pp 121–130. https://doi. org/10.1007/978-3-030-06070-1_10 Wainman B, Wolak L, Pukas G, Zheng E, Norman GR (2018) The superiority of three-dimensional physical models to two-dimensional computer presentations in anatomy learning. Med Educ 52:1138–1146. https:// doi.org/10.1111/medu.13683 Web Accessibility Initiative (2021) Introduction to web accessibility. Available at: https://www.w3.org/WAI/ fundamentals/accessibility-intro/. Accessed 12 Feb 2022 Wesencraft KM, Clancy JA (2019) Using photogrammetry to create a realistic 3D anatomy learning aid with unity

I. Gianotto et al. game engine. In: Rea P (ed) Biomedical visualisation. Advances in experimental medicine and biology, vol 1205. Springer, Heidelberg, pp 93–104. https://doi.org/ 10.1007/978-3-030-31904-5_7 World Wide Web Consortium (2021) Web content accessibility guidelines (WCAG) 2.2. Available via https:// www.w3.org/TR/WCAG22/. Accessed 12 Feb 2022 Yammine K, Violato C (2014) A meta-analysis of the educational effectiveness of three-dimensional visualization technologies in teaching anatomy. Anat Sci Educ 8:525–538. https://doi.org/10.1002/ase.1510

Irene Gianotto is a third year student on the BSc (Honours) Biomedical Sciences (Anatomy) programme at the University of Aberdeen. Alexander Coutts is a fourth year student on the BSc (Honours) Biomedical Sciences (Anatomy) programme at the University of Aberdeen. Laura Pérez-Pachón, BSc, MSc, PhD, is an Associate Medical Writer. She completed her doctoral research project at the School of Medicine, Medical Sciences, and Nutrition at the University of Aberdeen. Her thesis is titled: “Augmented reality to guide free flap surgery: a study of the accuracy of novel holographic headsets and their potential to be implemented in clinical practice”. Flora Gröning, MA, PhD, FHEA, is a Senior Lecturer in Anatomy within the School of Medicine, Medical Sciences and Nutrition at the University of Aberdeen. She is also the coordinator of the BSc/MSci Anatomy degree programme at the University of Aberdeen. Her interests include structure–function relationships in connective tissues and the application of 3D digital visualisation and mechanical modelling in musculoskeletal research and anatomy education.

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real Michael Hortsch, Nii Koney-Kwaku Koney, Aswathy Maria Oommen, Doris George Yohannan, Yan Li, Ana Caroline Rocha de Melo Leite, and Virgínia Cláudia Carneiro Girão-Carmona Abstract

For the last two centuries, the scholarly education of histology and pathology has been based on technology, initially on the availability of low-cost, high-quality light microscopes, and more recently on the introduction of computers and e-learning

M. Hortsch (✉) Departments of Cell and Developmental Biology and of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA e-mail: [email protected] N. K.-K. Koney Department of Anatomy, University of Ghana Medical School, University of Ghana, Korle Bu, Accra, Ghana e-mail: [email protected] A. M. Oommen · D. G. Yohannan Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India Kerala University of Health Sciences, Thrissur, Kerala, India Y. Li Department of Anatomy, Histology and Embryology, Fudan University, Shanghai, China e-mail: [email protected] A. C. R. de Melo Leite University of International Integration of the AfroBrazilian Lusophony, Redenção, Brazil e-mail: [email protected] V. C. C. Girão-Carmona Department of Morphology, Federal University of Ceará, Fortaleza, Brazil e-mail: [email protected]

approaches to biomedical education. Consequently, virtual microscopy (VM) is replacing glass slides and the traditional light microscope as the main instruments of instruction in histology and pathology laboratories. However, as with most educational changes, there are advantages and disadvantages associated with a new technology. The use of VM for the teaching of histology and pathology requires an extensive infrastructure and the availability of computing devices to all learners, both posing a considerable financial strain on schools and students. Furthermore, there may be valid reasons for practicing healthcare professionals to maintain competency in using light microscopes. In addition, some educators may be reluctant to embrace new technologies. These are some of the reasons why the introduction of VM as an integral part of histology and pathology instruction has been globally uneven. This paper compares the teaching of histology and pathology using traditional or VM in five different countries and their adjacent regions, representing developed, as well as developing areas of the globe. We identify general and local roadblocks to the introduction of this still-emerging didactic technology and outline solutions for overcoming these barriers.

# The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Border et al. (eds.), Biomedical Visualisation, Advances in Experimental Medicine and Biology 1421, https://doi.org/10.1007/978-3-031-30379-1_5

79

80

M. Hortsch et al.

Keywords

Virtual microscopy · Histology · Medical education · Pathology · Technology-enhanced instruction

5.1

Introduction

Histology, also known as microanatomy, describes the cellular composition and structure of biological organisms at the microscopic level. As this dimension is not accessible to the naked human eye, histology and its clinical counterpart pathology require microscopy, a technological approach that has only been available for the last 400 years (Bennett 1956; Hussein et al. 2015; Chapman et al. 2020). Early microscopes were limited in their magnifying ability and image quality (Van Zuylen 1981) and histology only became established as its own scientific field, independent of gross anatomy, over the last two centuries after more powerful and higher-quality microscopes became available to researchers, clinicians, and learners (Chapman et al. 2020). Together with the development of fixation and staining protocols (Titford 2005, 2006; Coleman 2006; Alturkistani et al. 2015), these advances enabled a detailed structural investigation of living organisms at the microscopic scale and resulted in the cell theory of life as formulated by Theodor Schwann and others in the first half of the nineteenth century (Schwann 1838; Mazzarello 1999). These technical and theoretical advancements were followed by the identification of specialized cell types, their molecular products, and a classification of various tissue types that form the organs and organ systems of multicellular organisms including humans (Griffith 1864; Bohm et al. 1904; Young et al. 2013; Mescher 2018; Lowrie 2020; Pawlina and Ross 2018; Gartner 2020). As the cellular structure of organs and tissues relate to their functions (physiology) and defines the location of biological reactions (biochemistry), histology has been a fundamental academic focus for students of the biomedical sciences for more than one and a half centuries

(Anonymous 1875; Hussein et al. 2015; Chapman et al. 2020). Histology is also foundational for the understanding of pathological or disease processes (pathology). Therefore, most medical, dental, as well as veterinary curricula incorporate a histology course or component in their preclinical phase (Bracegirdle 1977; MacPherson and Brueckner 2003; Sims et al. 2007; Farah and Maybury 2009a; Stewart et al. 2014; McBride and Drake 2018). The teaching of histology usually involves two distinct elements, the first being a presentation of the nomenclature and the scientific facts to the learners, commonly in the form of lectures or a self-learning approach using textbooks and other self-learning resources. The second phase of histology instruction encompasses the application of the learned material in a laboratory-style setting with students studying micrographic images (Painter 1994; Koury et al. 2019; Drake et al. 2002). These two components of classic histology education have different but connected learning objectives. The first didactic component involves a basic memorization of histological terms and components, as well as their associated structures and functions. The laboratory component requires students to apply this knowledge to histological preparations and to analyze and interpret tissue or cell images. This second phase usually involves higher-level learning processes as defined by Bloom’s taxonomy (Zaidi et al. 2017). Thus, the two phases of classical histology instruction are complementary, and both are required for a full mastery of histology by a learner.

5.1.1

The Traditional Way of Teaching Histology and Pathology in a Laboratory Setting

The traditional way of teaching histology in a laboratory setting involves light microscopes and glass slides, also called traditional microscopy (TM) (Fig. 5.1) (Anonymous 1875; Orth 1878; Huber 1892, 1900; Cotter 2001; Schaffer 1920). However, glass slides are prone to breakage and over time often fade and degrade in

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

81

Fig. 5.1 Shown is one of two boxes containing glass slides that every University of Michigan medical and dental student used to receive for the duration of the histology course/component together with a basic optical microscope. The University of Michigan virtual slide

website (UMMS 2021) became fully operational for the 2005–2006 academic year and in subsequent years, very few students chose to check out a loan glass slide collection and a microscope (Hortsch 2013)

quality. As histology glass slides are sometimes difficult to replace and expensive if bought from a commercial supplier, students at schools with a limited budget are often forced to use inferior quality specimens or must prepare their own slides for the learning of histology. Also, the purchase of a quality light microscope for each student and microscope maintenance is often difficult for institutions in less affluent areas of the world. Consequently, groups of learners often share a single microscope and glass slide set. These restrictions limit each student’s time to learn from the glass slide material. On the positive side, histology instruction with light microscopes and glass slides are usually supervised by experienced instructors which allows students to ask questions and verify their analyses of the specimens. Also, histology laboratory sessions normally start with a short lecturestyle presentation by a histology or pathology

teacher, which introduces students to the slide material and makes their subsequent analysis more efficient. As each student or student group observes a slightly different set of slides, students can exchange glass slides and get a better idea of the normal variability of biological specimens. One other advantage of the classical histology laboratory approach is that students learn the basic skills of operating a light microscope. Such skills are sometimes needed for other biomedical subjects like pathology and microbiology and potentially later when practicing medicine in specific clinical situations. Again, there appears to be a difference between physicians in affluent countries versus their colleagues in developing countries where high-tech medical laboratories and services are less available, and a practicing physician may still need to perform his/her own microscopic analysis (Rosai 2007; Pratt 2009;

82

M. Hortsch et al.

Maybury and Farah 2009; Kuo and Leo 2019; Hortsch 2015).

5.1.2

Virtual Microscopy Arrives on the Scene

In the late twentieth century, with rapid advances in computer technologies such as personal computers, increased digital storage capacity; the internet; and an expanding interconnectivity of digital devices; it became possible to store, manipulate, and use high-resolution digital images. These developments laid the foundation for what is now known as virtual or sometimes digital microscopy (Gu and Ogilvie 2005; Krenacs et al. 2010). Besides the above-listed computing devices and technologies, virtual microscopy (VM) also requires specialized microscopes with an automatic motorized stage, a high-resolution digital camera, and dedicated software to generate, store, handle, and view large digital image files (Gu and Ogilvie 2005, Krenacs et al. 2010). Soon after VM became a usable technology, several commercial companies started to offer VM equipment and software for sale (Garcia Rojo et al. 2009, 2006), with the Aperio ImageScope (now Leica Biosystems, Wetzlar, Germany) becoming a widely used system during the early days of VM (Staniszewski 2009). Over the last 20 years, a variety of additional options became available with a wide price range. However, the introduction of VM at any school is still an expensive endeavor and depends on a functional technological infrastructure, as well as adequate human and financial support. In addition, the VM image file formats are often proprietary and specialized viewer software is necessary to view or convert them into other formats, impeding easy sharing of resources and image files between users (Staniszewski 2009; Glatz-Krieger et al. 2006; Tuominen and Isola 2009). Finally, students must purchase or have access to computers at their schools. Most institutions, even in the developed parts of the world, rarely provide personal computers to each student.

With the appearance of new hardware computing devices, specifically laptops, computer tablets, and smartphones, VM software has evolved, and virtual slide images are now viewable using these devices at any time and at any location that provides a stable internet connection. In addition, VM is not the only e-learning modality that is now used by students for their histology and pathology education. Supplemental e-learning resources include e-books (Pawlina and Ross 2018; Young et al. 2013); websites (see Table 5.1); e-learning platforms and course management systems (Broudo and Walsh 2002; Sander and Golas 2013; Drees et al. 2020); gamebased approaches (Felszeghy et al. 2019); question databases (Hortsch 2016); social media (Maske et al. 2018; Essig et al. 2020); podcasts (Beylefeld et al. 2008); online tutorials (Rosenberg et al. 2006); Massive Open Online Courses (MOOCs) (Multon et al. 2018; Zhang et al. 2018); mobile applications (Hortsch 2016; Ostrin and Duschenkov 2016); and more. Again, most of these new learning strategies and resources have been developed by educators in relatively few wealthy countries. Today’s generation of students appreciates having a choice of different learning resources. However, without proper guidance by educators, this multitude of learning resources places the responsibility of developing a successful learning strategy onto the learner. The creation of a VM image collection begins with dye-stained histology or pathology glass slides that are scanned at high resolution with a specialized microscope-camera setup and converted into large image computer files, often exceeding 1 Gigabyte in size (Gu and Ogilvie 2005; Krenacs et al. 2010). The VM image files are then stored on external computer servers and are accessed and displayed using a compatible viewer software that is usually located on the user’s computer/tablet/smartphone or is part of a website that is compatible with the user’s browser software. Individual users can open image files of their choice and zoom in or out (thereby changing magnification) and pan over various areas of the slide to select regions of interest for further study (Fig. 5.2). Similar to Google Earth (Gorelick et al.

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

83

Table 5.1 Freely accessible VM histology and pathology websites Name of Website (sorted alphabetically) URL of website Features: Virtual slides (scalable light microscopy images), digital images (not scalable light microscopy images), EMs (electron micrographs), laboratory manual, quiz questions, pathology slides/images Cell Image Library (The American Association for Cell Biology) http://www.cellimagelibrary.org/home Features: Variety of light microscope and EM digital and virtual images, including animations and movies. Wide range of imaging technologies, cell types, and organisms Histologic (University of Alabama at Birmingham School of Medicine) https://peir.path.uab.edu/wiki/Histologic Features: Virtual histology slides with some diagrams and labeled digital images, and laboratory manual Histology @Yale (Yale University) http://medcell.med.yale.edu/histology/histology.php Features: Virtual histology slides and digital images (with optional annotation), EMs, laboratory manual, quiz questions, and labeled digital pathology images Histology Guide (Drs. Sorensen and Brelje) https://histologyguide.com Features: Virtual histology slides, EMs (with optional color coding and labels), laboratory manual, and quiz questions Histology Lab Manual (Columbia University) https://histologylab.ctl.columbia.edu Features: Virtual histology slides, digital images, EMs, laboratory manual, and quiz questions Michigan Histology and Virtual Microscopy Learning Resources (University of Michigan) https://histology.sites.uofmhosting.net Features: Virtual histology slides, digital images, labeled EMs, laboratory manual, and quiz questions Medical Histology and Virtual Microscopy Resources (Duke University Medical School) https://histology.oit.duke.edu Features: Virtual histology slides and pathology correlates, laboratory manual, unknown virtual slides with identifying answers Slides for Junqueira’s Basic Histology (Indiana University School of Medicine) http://medsci.indiana.edu/junqueira/virtual/junqueira.htm Features: Virtual histology slides from the Junqueira textbook University of Colorado Virtual Histology Lab http://leeshistology.com Features: Virtual histology slides, quiz access requires an account University of Michigan Virtual Slide Box (Department of Pathology) https://www.pathology.med.umich.edu/slides/ Features: Virtual pathology slides with diagnosis (searchable) Virtual Histology (Loyola University, Chicago) http://zoomify.lumc.edu Features: Virtual histology slides, and EMs Virtual Pathology at the University of Leeds https://www.virtualpathology.leeds.ac.uk/slides/ Features: Case-based virtual pathology slides (searchable) This list of open histology and pathology websites is not complete, nor comprehensive and only reflects websites that were functional at the time this manuscript was written. Only English language websites are listed that contain virtual image slides (scalable) and are freely accessible without registration, password, or additional software downloads

2017), this does not require the complete download of the large image file, but only of smaller digital information packages representing a limited area of the original slide at a selected magnification. As most traditional light microscopes usually only have one head (mono-headed versus multiheaded microscopes), only one user can observe a specimen at a given time, which makes sharing

observations with instructors and classmates cumbersome. VM opened the door to utilizing the histology laboratory as a group learning exercise, a popular didactic approach with medical educators in today’s teaching environment (Fig. 5.3) (Koles et al. 2010; Abdelkhalek et al. 2010; Prober and Norden 2021). With VM, multiple users can concurrently access the same image file with their individual devices or share

84

M. Hortsch et al.

Fig 5.2 The figure shows an example of a virtual microscopy slide (Slide #168 from the University of Michigan virtual slide collection in the Virtual Microscopy Database). The top panel depicts an H&E-stained section from the small intestine at low magnification. The lower

panel shows a subsection of the same slide depicting an intestinal villus at the highest possible magnification (40×). Users can view any region of the slide at a magnification of their choice (up to 40×)

the view of an image displayed on a computer monitor or a larger screen projection. These options facilitate team-based learning strategies in the histology or pathology laboratory (Dickerson and Kubasko 2007; Goldberg and

Dintzis 2007; Braun and Kearns 2008; Triola and Holloway 2011; Sander and Golas 2013). The VM concept has also been adapted to electron micrographs. Algorithms and equipment have been developed to merge regular high-resolution digital electron microscopy

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

85

Fig. 5.3 Histology laboratory session in the Fall term of 2010 at the University of Michigan Medical School. Dr. Welsh is helping two first year medical students to navigate the online virtual slide collection on their laptop computers

(EM) images into large virtual EM (VEM) files (Kaynig et al. 2010; Lee and Mak 2011; Mione et al. 2011; Faas et al. 2012). However, VEM is currently mostly used for specific research and pathology applications and has not been widely adopted for education (Ravelli et al. 2013; Sawai et al. 2013a; Sokol et al. 2015; Dittmayer et al. 2018). Most VM websites with EM images offer regular digitized Transmission Electron Microscopy (TEM) or Scanning Electron Microscopy (SEM) images without any real magnification ability (Table 5.1). VM can be used in different ways in the educational setting, often as a supplement to regular light microscopy. However, at many schools VM has become the primary mode of image analysis and is increasingly replacing TM altogether (McBride and Drake 2018). During its early days as an educational tool or when the technological foundation for its use in the laboratory by all students is missing, VM is often used in a

lecture-style presentation by teachers to demonstrate histological and pathological structures and concepts (Romer and Suster 2003; Higazi 2011; Yohannan et al. 2019). So far, VM has seen its widest educational use for medical, dental, and veterinary histology and pathology. However, it has also been used to teach cell biology, botany, and microbiology (specifically parasitology) (Linder et al. 2008; Mione et al. 2011; AlcalaCanto et al. 2012; Bonser et al. 2013; Brockman et al. 2020) and for basic research applications (Conway et al. 2008; Wienert et al. 2012).

5.1.3

Traditional Light Microscopy and Virtual Microscopy, Companions or Adversaries?

The overall structure of instructor-guided histology laboratory instruction with VM is surprisingly similar to laboratory sessions that use TM

86

(Lehmann et al. 1999; Holaday et al. 2013). Regardless of the technology, scheduled histology laboratory sessions are usually 2–3 h in length. Normally, an instructor introduces the image material for the topic of the day in a short, lecture-style presentation or video before students make their own observations either using microscopes and glass slides or computers and virtual slides. Students may follow instructions provided by a laboratory manual, either printed or posted online (Huber 1892, 1900; Michaels et al. 2005; UMMS 2021). However, as virtual slides are accessible from computer servers or websites, students can sometimes complete their histology laboratory segments independent of scheduled hours and teacher support, which is an option that many students value. Another important difference between VM versus TM instruction is that only high-quality specimens are selected for digitization. Consequently, all students have equal access to the best histological or pathological slide material. However, it has the limitation that learners no longer experience the variability of biological material and appreciate slide-to-slide variations (Xu 2013). Overall, the impact of VM on histology learning success appears to be positive, but questions remain. Many factors influence students’ knowledge and proficiency in the fields of histology and pathology (Selvig et al. 2015; Ariana et al. 2016; Zureick et al. 2018; Meng et al. 2021). Several published reports suggested that VM is at the least an effective and equivalent teaching and learning tool when compared to TM instruction (Scoville and Buskirk 2007; Rosas et al. 2012; Mione et al. 2013; Brown et al. 2016) with many other studies reporting that VM instruction results in improvements of learning outcomes (Krippendorf and Lough 2005; Husmann et al. 2009; Higazi 2011; Brueggeman et al. 2012; Shastri et al. 2016; Wilson et al. 2016; McDaniel et al. 2018; Kuo and Leo 2019). Similar findings were published for the use of VM in pathology education and its clinical applications (Marchevsky et al. 2003a; Gagnon et al. 2004; Koch et al. 2009; Farah and Maybury 2009b; Ozluk et al. 2012; Brick et al.

M. Hortsch et al.

2013; Ordi et al. 2015; Hanna et al. 2017; Borowsky et al. 2020). Although TM and VM laboratory instructions have much in common and serve the same educational goals, VM offers several additional educational options, and most importantly, more flexibility for educators and learners (Table 5.2) (Ostrin and Dushenkov 2017). In addition, most students quickly embrace the use of electronic technologies in the classroom (Holaday et al. 2013; Wilson et al. 2016; Felszeghy et al. 2017; Simok et al. 2019; Tauber et al. 2019).

5.2

The Use of Virtual Microscopy for Biomedical Education and Clinical Applications in Different Regions of the World

The technical foundations for VM were first developed in the late twentieth century, mainly in North America and Europe and the first adaptations of using digital images (not yet completely virtual/scalable) for the teaching of histology and pathology were reported shortly before the turn of the millennium (McEnery et al. 1995; Mars and McLean 1996; Cotter 1997a, b, 2001; Lehmann et al. 1999; Trelease et al. 2000). Starting in 2000, these initial applications of electronic technology were followed by reports about the use of fully scalable VM images for education and clinical applications (Felten et al. 1999; Harris et al. 2001; Heidger et al. 2002; Romer and Suster 2003; Dee et al. 2003; Kumar et al. 2004, 2006; Lee 2005; Krippendorf and Lough 2005; Boutonnat et al. 2006; Dee and Meyerholz 2007; Mills et al. 2007; Scoville and Buskirk 2007; Kim et al. 2008; Stewart et al. 2008; Husmann et al. 2009; Dee 2009; Farah and Maybury 2009b). Considering the expense and technical requirements for using these new technologies as general educational tools (Paulsen et al. 2010), it is not surprising that VM was first adopted in the most affluent and technologically advanced countries. Schools and universities in developing parts of the world

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

87

Table 5.2 Advantages of and roadblocks to using VM in histology and pathology education Advantages of Using VM for Histology and Pathology Instruction • VM provides a reliable resource that supplies the same set of images to every student • High-quality image files can be obtained from many national and international sources • New technologies often motivate learners to engage with the material • VM enables online histology and pathology instruction • VM is compatible with distance learning and students can participate from any location that has an Internet connection • Students can work on assignments and can review material at any time • VM requires fewer experienced instructors per student • Once established, VM is cheap to maintain, negating the need for expensive microscope service and the replacement of broken glass slides • VM makes better use of limited instruction time in a time-restricted curriculum • VM facilitates group learning and flipped classroom approaches • VM allows for easy integration of histology with clinical applications (pathology) • VM is the technical foundation of telemedicine/telepathology Roadblocks for Using VM in Histology and Pathology Education • VM is dependent on a reliable technological infrastructure • The production of virtual slides requires expensive equipment • Lack of funding and support by universities and schools is often encountered • VM usage requires tech-savvy teachers and learners • Students’ access to VM material often depends on personal devices and fast Internet access, creating uneven learning opportunities for individual learners • Curricular restrictions and traditional assessment methods discourage VM usage • Resistance can be encountered by students and educators who want to maintain traditional teaching methods • Students no longer learn how to operate an optical microscope • Lack of slide/image variability limits students’ learning experience • Many VM resources are only available in English

are often using the traditional methods of teaching histology to the present day. Besides technological and financial inequities, educators in these countries are encountering different roadblocks that hinder the introduction and use of VM at their educational institutions (curricular impediments, language problems, availability of quality e-learning material for histology, Internet access or slow connection speed; need for teaching with real microscopes, and resistance by students and teachers to change the instructional modus) (Table 5.2). The following sections explore the current state of VM usage for histology and pathology education, and also for clinical applications (telepathology) in five different countries and their neighboring regions located on four different continents. These descriptions represent areas of different levels of technological development and economic affluence. Each subchapter outlines how far the introduction of VM has advanced and how this educational technology has changed histology education. The authors also address factors

that have enabled or hindered these changes with their views on how this new technology may benefit their students and colleagues.

5.2.1

Adoption of Virtual Microscopy for Biomedical Education in North America, Europe, and Australia

The industrialized regions of the globe, specifically Europe and North America, have a long history of teaching histology and pathology with light microscopes and glass slides, and histology laboratory sessions have been part of medical and dental curricula for more than one and a half centuries (Anonymous 1875; Orth 1878; Schaffer 1920; Tuchman 1993; Cotter 2001). Originally, students participating in a histology course received a light microscope on loan, as well as a laboratory manual (Huber 1892, 1900). These early manuals contained detailed staining instructions, indicating that at least for some

88

specimens, students had to complete the last steps of preparing glass slides for observation. As early histology textbooks lacked photographic images (Kölliker 1867; Orth 1878; Bohm et al. 1904; Schaffer 1920), students were required to draw their observations onto the empty pages of their laboratory manuals (Huber 1892, 1900; Cotter 2001). This educational approach of artistically reproducing microscope observations has been shown to improve student understanding of histological structures and to have a positive impact on learning (Cogdell et al. 2012; Kotze and Mole 2015; Balemans et al. 2016; Cracolici et al. 2019). This didactic approach is still commonly used in developing countries but rarely in developed countries (Yohannan et al. 2019). The necessity for learners to prepare their own histological slides for observation was abandoned some time ago and students were provided with loan collections of permanent histological glass slides (Fig. 5.1). However, even large student collections often remained incomplete and usually were of variable quality. Because glass slides are prone to breakage and fading over time, the need for constantly replacing slides together with the regular maintenance of light microscopes posed a significant expense, even for well-funded schools in wealthy countries (Krippendorf and Lough 2005). Consequently, histology instructors and school administrators were receptive to alternative and supposedly cheaper modes of histology laboratory instruction. During the last quarter of the twentieth century, personal computers became available to teachers and learners in the developed parts of the world and claimed an increasingly important role in the educational field (Bork and Franklin 1979; Abdulla et al. 1983). This development when combined with the invention of the Internet and increased general interconnectivity of computer networks with servers contributed to the creation of VM. However, due to limited computer capabilities, the initial use of computers for the teaching of histology, pathology, and other anatomical sciences were often restricted to static microscope images (Chapman et al. 1992; Painter 1994; Cotter 1997a, 2001; Lei et al. 2005; Evans et al. 2000). These static digital images without

M. Hortsch et al.

magnification ability are still used and provide the backbone of today’s electronic histology textbooks (e-books) often replacing their printed paper counterparts (Pawlina and Ross 2018; Mescher 2018). With the Internet still being relatively new and less accepted for educational applications, students were sometimes provided a CD-ROM (Compact Disk-Read Only Memory) with a collection of digital images as a supplementary learning resource (McMillan 2001; MacPherson and Brueckner 2003; Lei et al. 2005). However, with VM image file sizes exceeding the capacity of CD-ROMs and with the demise of CD-ROM technology, this was only a temporary solution for providing digital images to histology learners. Overall, static images without the options to change objectives for increased magnification and to focus on different areas of a glass slide are an incomplete substitute for traditional microscopy. Many of the initial obstacles to the adoption of VM were technical in nature. Software strategies were required to record and handle large image files. This was solved by breaking the image up into small fragments or tiles and stitching these smaller image fragments electronically together (Silage and Gil 1985; Westerkamp and Gahm 1993; Appleton et al. 2005; Kayser and Kayser 2013). Over time, computer server space became larger and cheaper, resolving another problem for the development of VM, and personal computers and access to the internet became available at institutions of higher learning in most industrialized countries, specifically North American, Europe, Australia, and a few nations located on other continents (e.g., Japan, South Korea, Singapore, Israel, and South Africa). Published reports from these countries about the use of VM for the teaching of histology and pathology appeared shortly after the turn of the millennium (Harris et al. 2001; Heidger et al. 2002; Romer and Suster 2003; Dee et al. 2003; Kumar et al. 2004, 2006; Lee 2005; Krippendorf and Lough 2005; Boutonnat et al. 2006; Dee and Meyerholz 2007; Stewart et al. 2008; Husmann et al. 2009; Dee 2009; Farah and Maybury 2009a, b; Scoville and Buskirk 2007; Kim et al. 2008; Paulsen et al. 2010). Concomitantly, VM was also adopted for a

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

variety of clinical applications (Steinberg and Ali 2001; Lundin et al. 2004; Gagnon et al. 2004; Koch et al. 2009; Lopez et al. 2009; Marchevsky et al. 2003b, 2006; Weinstein et al. 2009). These early reports about VM all originated from several European and North American countries and from Australia, with only one report in the above list coming from South Korea (Kim et al. 2008). Over the last 20 years, VM became the predominant educational modus in most developed countries (McBride and Drake 2018), not only for the teaching of medical histology and pathology, but also for the instruction of dental and veterinary students (Sims et al. 2007; Mills et al. 2007; Weaker and Herbert 2009; Rosas et al. 2012; Gatumu et al. 2014; Stewart et al. 2014; Fernandes et al. 2018). In the early years, VM and digital images were often used to supplement traditional histology/ pathology laboratory sessions (Painter 1994; Harris et al. 2001; Dee et al. 2003; Raja 2010) and some instructors and students initially expressed skepticism about the new technology being equivalent to classical light microscopy with glass slides (Cotter 1997a; Harris et al. 2001; Donnelly et al. 2012; Rosas et al. 2012). After VM became the main instructional modus for histology, this attitude changed, and VM was embraced by teachers and learners from a range of different countries (Heidger et al. 2002; Krippendorf and Lough 2005; Boutonnat et al. 2006; Mills et al. 2007; Weaker and Herbert 2009; Husmann et al. 2009; Fonyad et al. 2010; Merk et al. 2010; Collier et al. 2012; Gatumu et al. 2014; Rodrigues-Fernandes et al. 2020). When given a choice, today’s students will rarely select TM over VM for the learning of histology and pathology (Schmidt 2013; Hortsch 2013). Many schools that have adopted VM no longer offer the option of loaning a light microscope and glass slide collection (Weaker and Herbert 2009; Johnson et al. 2015; Vainer et al. 2017; Gribbin et al. 2022). In 2017, 67% of US medical schools taught histology exclusively with VM, 10% with only TM, 10% with a combination of both, and

89

13% with static images (McBride and Drake 2018). A second major change in the teaching of histology occurred in parallel with the implementation of VM. Previously, histology was taught in stand-alone courses, independent of other biomedical subjects. Over the last 20 years, many medical and dental schools have incorporated histology education into an integrated curriculum design (Blake et al. 2003; Drake et al. 2009; Barbeau et al. 2013; Yen et al. 2014). In 2017, 98% of US medical schools taught histology partially or fully integrated into their curriculum (McBride and Drake 2018). This integrated curriculum arrangement allows for a better coordination with the other basic sciences, especially gross anatomy, physiology, and biochemistry, in addition to pathology, which constitutes the clinical counterpart of histology. A third major change in histology/pathology education that is in part linked to the introduction of VM enabled the conversion of the histology laboratory segment into an online learning event (Gadbury-Amyot et al. 2013; Barbeau et al. 2013; Yen et al. 2014; Thompson and Lowrie 2017). With recorded lectures and virtual histology slides available online, students can choose to either attend live lectures and laboratory sessions or study the material at a time and location of their own choosing. When given this choice, most medical students prefer the recorded or online options (Holaday et al. 2013; Zureick et al. 2018). As a downside of this strategy, instructors are not available to answer questions, give guidance, and verify students’ identifications, an opportunity that is positively correlated with better examination results for histology (Selvig et al. 2015). There are complex and manifold reasons why students prefer recorded histology lectures and online histology laboratory assignments without teacher guidance, thereby risking lower examination scores (Zureick et al. 2018; Gribbin et al. 2022). Online histology instruction is mainly an active and self-directed learning process, which is a current popular learning paradigm among medical educators and curriculum

90

developers (Schmidt et al. 2011; Bloodgood 2012; Khalil et al. 2013; Jurjus et al. 2018). However, this approach makes it difficult for instructors to identify students who struggle with the material and who may score poorly in summative examinations (Hortsch and Mangrulkar 2015). The development of three-dimensional (3D) VM image sets and their use for histology and pathology education or clinical applications is an ongoing process. The lack of focal depth is a significant limitation of VM images. They display a one-pixel thick two-dimensional representation of the tissue. In contrast, using the fine focus knob of a light microscope, limited 3D exploration of the tissue section is possible. With increased computing power and file storage space, it became possible to combine multiple whole slide images at different planes of focus into genuine 3D image sets (Kalinski et al. 2008; Saalfeld et al. 2009; Eberle et al. 2014; Sieben et al. 2017; Pichat et al. 2018). 3D VM may support histology learners in their understanding of complicated tissue and cell structures (Roth et al. 2015), but its value in teaching general histology and pathology has not been ascertained. Some reports have been published on the application of 3D VM as a useful diagnostic tool for specific histopathological situations (Dee and Meyerholz 2007; Farahani et al. 2017), but it is still too early to pass judgment on whether 3D VM provides significant advantages over the current 2D VM version. Over the last 70 years, less and less time has been scheduled in medical curricula for the teaching of the basic sciences and for histology education in particular (Painter 1994; Hightower et al. 1999; Drake et al. 2009; McBride and Drake 2018). The introduction of VM as a new educational tool for histology and pathology was in part motivated by the assumption that it provides a more efficient way of teaching these subjects (Bloodgood and Ogilvie 2006; Kumar et al. 2006; Collier et al. 2012; Thompson and Lowrie 2017). Few schools in developed countries maintain histology laboratory sessions that are solely based on TM (McBride and Drake 2018), and many schools are abandoning in-person histology and pathology laboratory sessions altogether in

M. Hortsch et al.

favor of online exercises (Gadbury-Amyot et al. 2013; Barbeau et al. 2013; Yen et al. 2014; Thompson and Lowrie 2017; Gribbin et al. 2022). More recently, this reduction of the preclinical phase of medical education has continued (O’Connor Grochowski et al. 2007; Scudder et al. 2019) with some programmes cutting time for histology laboratory sessions completely from their curriculum (Daniel et al. 2020). It is not surprising that medical student histology knowledge and examination results have decreased when one of the two main didactic components of histology education is removed (Gribbin et al. 2022). This should be an alarming development as many human diseases are cellular in nature and histological knowledge is a positive predictor of students’ academic performance in pathology (Nivala et al. 2013). In summary, VM has become the prevalent technology to teach histology and pathology in most technologically developed parts of the world. However, with less scheduled time available for histology education in general, the histology laboratory component is curtailed, pushed online, or abolished altogether (McBride and Drake 2018; Gribbin et al. 2022). Most likely, it will be the clinical applications of VM (telepathology) (Kumar and Dunn 2009; Ghaznavi et al. 2013; Farahani et al. 2015; Boyce 2017) combined with advances in artificial intelligence and deep learning strategies that will claim an increased role in modern medicine (Gertych et al. 2015; Howard et al. 2021; Mikula et al. 2007; Vali-Betts et al. 2021; James et al. 2021).

5.2.1.1

Adoption of Virtual Microscopy for Biomedical Education in Eastern Europe The introduction of new teaching resources and strategies at the university level has been rather uneven in Eastern European countries that were formerly part of the Warsaw Pact alliance. Several of these countries are home to some of the oldest universities in Europe, where notable early researchers laid the foundation for histology as an independent foundational science, such as Charles University in Prague, Czech Republic,

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

and Jagiellonian University in Krakow, Poland. After the breakup of the Soviet Union, Eastern European countries took very different political and economic paths. Reviewing the published literature, VM was adopted very early in some Eastern European countries, specifically in Poland (Slodkowska et al. 2008; Staniszewski 2009; Lundin et al. 2009; Szymas and Lundin 2011; Filipiak et al. 2011), Hungary (Molnar et al. 2003; Ficsor et al. 2006; Cserneky et al. 2009; Fonyad et al. 2010), the Czech Republic (Krajčí et al. 2011; Pospíšilová et al. 2013; Tauber et al. 2019, 2021a, b, c; Kolinko et al. 2022), and also the Baltic states (Lithuania, Latvia, and Estonia) (Laurinavicius et al. 2012; Laurinavicius and Raslavicus 2012). In contrast, reports about the use of VM in other countries of that region are more recent, such as those from Russia (Djangirova et al. 2015; Kruglova et al. 2019; Beresneva et al. 2019), Ukraine (Zayachkivska 2018; Bulyk and Kushniryk 2020; Popko et al. 2021), Belarus (Kunkevich and Lozinskaya 2019), and Serbia (Capo et al. 2017). The use of VM for clinical pathology rather than education often appeared to be the driving force for the initial use of this technology.

5.2.2

5.2.2.1

Adoption of Virtual Microscopy for Biomedical Education in Africa

Adoption of Virtual Microscopy for Biomedical Education in Ghana and Other Sub-Saharan African Countries Africa’s colonial past has shaped most of its educational and medical systems (Monekosso 2014). After African countries gained independence, internal struggles, wars, and natural disasters impeded the creation of a functional health care system and of modern educational organizations. More recently, many new medical schools were founded in several African regions, but economic factors and inadequate funding have often prevented the adaptation of new technologies (Monekosso 2014). In addition, the health burden

91

in Africa is very high and there is a great need for increasing the number of well-educated medical professionals (Kent and Burch 2011; Chen et al. 2012). There is also a significant ‘brain drain’ situation, in which physicians are leaving Africa for countries where they are better compensated (Hagopian et al. 2004; Mullan et al. 2011). The shortage of educators at African medical schools is significant for both the basic sciences, as well as for clinical specialties (Mullan et al. 2011). The intake of medical students at the University of Ghana has increased significantly in the recent past, mostly to meet the rising demand for physicians in Ghana and other African countries. Currently, the University of Ghana admits two cohorts of medical students per academic year, about 230 students directly from high school and about 70 post-baccalaureate students. Thus, the average medical school class size has increased from 65 students in the 1990s to about 300 students during the 2020–2021 academic year. Other students from the School of Allied Health Sciences and students in some master’s programmes also receive histology instruction, which increased the total number of histology learners. Unfortunately, this increase in student enrollment was not accompanied by a corresponding increase in space, equipment, and other resources. Like most schools in other sub-Saharan countries, Ghanaian universities and colleges have long relied on a synchronous face-to-face mode of teaching. The University of Ghana Medical School Anatomy Department offers a variety of laboratory-based courses that include histology instruction. In most African universities, histology is accepted as a fundamental course for medical education. Nevertheless, many Ghanaian institutions, including the University of Ghana Medical School, reduced the time allocated for the study of histology when they adopted a modular curricular system. This problem is not unique to Ghana or Africa and appears to be a worldwide phenomenon (Kramer et al. 2008; McBride and Drake 2018). Due to the reasons outlined later in this section, at most African medical schools, histology laboratory sessions are taught using traditional

92

light microscopes and glass slides (Kramer et al. 2008). However, the microscopes used for histology laboratory instruction at the University of Ghana and many other African medical schools are old and often malfunctioning, and many microscopic slides are broken. In addition, the ratio of students per microscope for the University of Ghana medical students has shifted from the initial ratio of 1:1 to the current ratio of five students sharing one microscope. This factor greatly reduces the amount of time each student has available to observe and learn from the histology glass slides. These conditions have adversely affected students’ learning experiences. The technological infrastructure at most African universities lags behind when compared to schools in other developing global regions (Williams et al. 2010) and this has led to the slow adaptation of modern educational technologies in Africa. Many African universities display academic inertia and are reluctant to invest in these resources, specifically in equipment and subscriptions to digital platforms that are needed to integrate modern technologies into the teaching process. The adage “if it ain’t broke, don’t fix it” may be another reason why many African universities have not embraced advanced technologies despite the benefits these technologies would bring to their educational systems. In summary, the hesitance to adopt these new teaching and learning technologies can be attributed to economic, practical, and administrative constraints, roadblocks that are also present in other developing countries (Mars and McLean 1996; Yohannan et al. 2019). The worldwide COVID-19 pandemic forced many universities to use online alternatives to in-person learning. Synchronous lectures were delivered via platforms including Microsoft Teams (Microsoft, Redmond, WA, USA), Sakai (Sakai 2021), and Zoom (Zoom Video Communication, San Jose, CA, USA), or recorded lectures were offered to learners asynchronously (Dhawan 2020; Evans et al. 2020; Darici et al. 2021; Zalat et al. 2021). However, the speed with which these new modes of teaching were implemented was challenging for African educators and students. The transition to online

M. Hortsch et al.

learning required new teaching styles and methods of classroom management, and was complicated by poor internet connectivity in most of Africa (Zalat et al. 2021). At the University of Ghana, the switch to online histology lectures was not accompanied by a transition to VM laboratory instruction. To adhere to COVID19 protocols, fewer students were allowed into the histology laboratory session, which accordingly reduced their overall time for learning using a light microscope. Nevertheless, the COVID-19 pandemic has initiated some experimental online learning opportunities for histology, which has greatly improved the quality of images available to African students. Free histology internet sites such as the University of Michigan and the Histology Guide websites (Table 5.1) were recommended to histology learners at the University of Ghana. However, these sites don’t always cater to specific local curricular needs. As students require access to computer stations and may have to pay for internet access, based on informal student feedback, student engagement with these online histology resources was low. Some learners also struggled to adapt to online learning platforms as they had no previous experiences with such learning modalities. The University of Ghana Medical School and other medical schools in Africa have acquired Anatomage tables, an interactive high-tech 3D anatomy and physiology learning device (Anatomage, Santa Clara, CA, USA) (Allen et al. 2019). The table has a histology component with virtual slides. At the University of Ghana Medical School, students are given access to Anatomage tables for studying both histology and gross anatomy (Fig. 5.4). However, the use of the Anatomage table for histology has some challenges as the histology content is limited and inadequate, and the slides are not labeled. In addition, one Anatomage table can only accommodate up to 10 students at a given time (Fig. 5.4). As the University of Ghana has over 300 histology learners and only two Anatomage tables, students’ time at these devices is very limited, negating one of the intended advantages of the Anatomage device, which was to provide

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

93

Fig. 5.4 Dr. Koney is using the histology function of the Anatomage table to teach histology to a group of medical students at the University of Ghana

students with unlimited access to digital materials. New medical schools are being established in many African countries that are recovering from wars and rebuilding their economies, specifically Liberia, Rwanda, and Sierra Leone (Monekosso 2014). Schools in these countries are more likely to adopt new technologies for their medical school teaching. However, it will take concerted efforts to introduce e-learning strategies into the African teaching and learning environment (Eke 2010). The importance and advantages of adopting modern teaching technologies are well known and some countries like Nigeria have used them to improve teaching quality resulting in a higher academic success rate (Anyanwu et al. 2012). However, the lack of infrastructure and other general resources pose a roadblock to the use of VM as a teaching approach for histology on the African continent. Also, the use of light microscopes has advantages, especially for

physicians who are going to be trained in pathology and laboratory sciences or who will practice in rural areas without pathological support services. Nevertheless, considering the current conditions of histology instruction at most African medical schools, and the advantages of VM, African universities have no alternative other than to adopt this educational technology. Although mostly on a trial basis, VM has already been adopted for telepathology, and in a few cases for histology education, in some African countries (Awaldelkarim et al. 2010; Malami 2011; Ayad 2011, 2013; Michelo et al. 2017; Bacha et al. 2020).

5.2.2.2

Adoption of Virtual Microscopy for Biomedical Education in North African Countries Compared to the sub-Saharan region of the African continent, the situation of VM use for histology and pathology instruction and pathological

94

clinical services is different in African countries bordering the Mediterranean Sea. Starting in 2008, several reports were published about the use of VM for education and clinical pathology in the countries of Maghreb and Egypt. The first such report was about the application of VM for telepathology at the Italian Hospital in Cairo, which was the result of a collaboration with clinical centers in Italy, the UK, and the USA (Ayad and Sicurello 2008). This pilot project gave rise to the establishment of a virtual telepathology center at Cairo University (Ayad 2011, 2013; Ayad and Yagi 2012) and the wider use of VM for pathology education in Egypt. More recently, a study from the University of Tunis in collaboration with several university hospitals in Tunisia found that VM was equivalent to TM for the teaching of pathology and cytology to medical internship students (Bacha et al. 2020).

Adoption of Virtual Microscopy for Biomedical Education in South Africa As outlined above, histology is still being taught in most sub-Saharan African countries with light microscopes and glass slides (Kramer et al. 2008). The major exception is South African universities, some of which have adopted VM as an educational resource for histology and pathology teaching (Fig. 5.5). Histology teachers in South Africa expressed early interest in using e-learning approaches for educational purposes (Mars and McLean 1996). A survey conducted in 2000 at the University of Pretoria indicated that medical and dental students were interested in the use of VM for learning histology (Richards et al. 2000). Only veterinary students viewed the use of light microscopes as indispensable for their education. The introduction of VM at South African schools was complemented by the adaptation of other e-learning modalities, such as histology websites and podcasts (McLean 2001; Beylefeld et al. 2008). There have also been considerable efforts at South African medical schools to use mobile devices, such as computer tablets, for instruction (Lazarus et al. 2017). At many South African universities, TM and VM are now

M. Hortsch et al.

concurrently used for histology and pathology instruction. Figure 5.5 shows a 2016 photo depicting a histology laboratory session at Nelson Mandela University in Port Elizabeth, South Africa. Students used light microscopes and glass slides in parallel with VM images on their laptops or computer tablets. Also, the clinical application of VM for telepathology is more advanced in South Africa than in the rest of Africa (Banach et al. 2008). However, there are considerable inequities in the general use of e-learning resources within South Africa and for a large section of South African society such resources are not readily accessible (Letseka et al. 2018; Jantjies 2020). In addition, although the availability of modern teaching and learning technology is higher in South Africa than in most other African countries, educators are often reluctant or unable to effectively integrate these technologies into their teaching (Chigona and Dagada 2011).

5.2.2.3

5.2.3

5.2.3.1

Adoption of Virtual Microscopy for Biomedical Education in South Asia

Adoption of Virtual Microscopy for Biomedical Education in India and Other Countries of the Indian Subcontinent India is a world leader in the education of medical professionals, as well as the number of medical schools in a single country (Supe and Burdick 2006; Sood 2008). The Indian medical education system has its roots in India’s colonial past (Lam and Lam 2009) and has unfortunately been static for many decades (Supe and Burdick 2006). In 2019, the National Medical Commission (NMC) of India introduced a new Competency-Based Medical Education (CBME) curriculum (Basheer 2019; Rege 2020). Some of the highlights of the new curriculum are the introduction of vertical (for Anatomy, Surgery, Radiology) and horizontal (for Anatomy, Physiology, Biochemistry) integration, as well as early clinical exposure for preclinical students. Histology training remains a major component of the medical

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

95

Fig. 5.5 This 2016 photo shows students at Nelson Mandela University in Port Elizabeth, South Africa, using a combination of virtual and traditional microscopy in a histology laboratory session (Photo courtesy of Dr. N. Wickens)

curriculum (NMC 2018), as well as for dental, nursing, and many other paramedical educational programmes. The authors of this segment (D.G.Y. and A.M. O.) are affiliated with the Government Medical College at Thiruvananthapuram (GMCT) situated in the state of Kerala, India. At their institution, 60 instructional hours are dedicated to medical histology education. The theoretical component of histology is taught using conventional lectures (15 h for general histology and 20 h for organ system-based histology). The practical component is taught using traditional optical microscopes and glass tissue slides. In 2018, the

authors received a copy of the University of Michigan virtual slide collection and used it for testing how VM can be integrated into the Indian system of teaching histology (Yohannan et al. 2019). However, a major barrier to integration was the reluctance of histology teaching colleagues to use this new learning technology (Yohannan et al. 2019). In addition, even a large virtual slide collection such as the one from the University of Michigan does not contain all specimens that are needed for teaching histology at GMCT and requires supplementation with additional virtual slides from other sources including the Virtual Microscope Database

96

M. Hortsch et al.

(VMD) (Lee et al. 2018). Currently, VM slides are used by educators in a demonstration mode on a large display screen, which is simultaneously viewed by groups of approximately 30 students (Fig. 5.6, upper panel). A similar approach is used at some neighboring institutions in the Indian State of Kerala that have adopted VM for education, for example at the Sree Gokulam Medical College & Research Foundation (Chimmalgi

2018). In laboratory sessions, students study glass slides with traditional light microscopes (Fig. 5.6, lower panel). They are required to draw diagrams of their observations into their histology notebooks using purple and pink pencils, respectively, which represent the dyes of regular hematoxylin and eosin (H&E) stained tissues. These drawings are assessed by instructors. The traditional glass slide collection

Fig. 5.6 The upper panel shows Dr. Oommen using a projected virtual microscopy image for introducing a histology topic to a group of undergraduate (MBBS) and postgraduate (MD Anatomy) students at the Government

Medical College, Thiruvananthapuram in India. Subsequently, these students use their light microscopes to investigate similar glass slides (lower panel)

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

is periodically reviewed by a histology subcommittee in the department. Broken or faded slides are replaced with specimens derived from postgraduate research work in the department, or from cadaveric donors. A smaller number of slides are taken from animal species, as replacing them with human tissues would be challenging (Biswas et al. 2017). Additional slides in the GMCT collection were purchased from other colleges. Consequently, the ongoing replacement of glass slides can be a work-intensive and expensive endeavor. Histology assessments at GMCT and other medical schools in India consist of practical and theoretical components and microscope skills are tested using only TM. As VM is not part of the evaluation process for histology at Indian universities, students are less motivated to use this technology for their own learning. Several publications from India on the use of VM for histology education recommend it as an add-on to the current traditional method (Chandra 2013, 2014; Sekhri 2013; Shastri et al. 2016). Two other Indian studies focused on learning outcomes and indicated that VM in combination with TM is superior to TM alone for the teaching of histology (Yohannan et al. 2019) and histopathology education (Nauhria and Ramdass 2019). Two studies on dental histology education in India provided similar results (Raja 2010; Hande et al. 2017). That Indian students learn about the use of virtual images has important clinical implications when they will provide healthcare in India’s rural communities where they might have to rely on telepathology. A telepathology network using static digital images has been used between a rural cancer center hospital (Nargis Dutt Memorial Cancer Hospital) located at Barshi and a highlevel tertiary care cancer referral center (Tata Memorial Hospital) located in Mumbai, both in the Indian state of Maharashtra, but separated by 370 km (Desai et al. 2004). There are significant hurdles to the introduction of VM in Indian schools. First, India has a diverse sociocultural structure, with rigid and static conventions. This system, together with a lack of access and awareness may discourage educators to use innovative teaching methods. A

97

2019 study conducted in Tripura, a northeastern Indian state, listed ‘talk’, ‘chalk and board,’ overhead projectors, and PowerPoint (Microsoft, Redmond, WA, USA) presentations as audiovisual aids to evaluate student preferences of learning resources (Das et al. 2019). Though the authors highlighted the importance of VM and smart boards in histology laboratories, they judged these approaches as too advanced for implementation into the teaching of histology and pathology at Indian medical colleges. Second, the practical laboratory sessions and the assessment system that emphasize using TM and the exercise of drawing histology diagrams are probably one of the major hurdles for educators and students to accept VM. Student motivation is often limited to identifying tissues and cells and drawing diagrams. Only a few students and educators aim for a fuller understanding of cell and tissue structure and function and their clinical importance and relevance. Another significant hurdle is the lack of infrastructure and economic constraints for setting up VM facilities at Indian educational institutions. The NMC-endorsed curriculum makes no mention of technology-enhanced learning for anatomical education (Basheer 2019, Rege 2020). Overall, there are limited computer resources available for individuals or groups of students in Indian histology laboratories. Many Indian institutions lack a high-speed Internet connection, or access is restricted to online classes. Local server facilities with connected computers are rarely found, which limits the use of VM for offline demonstrations (Chimmalgi 2018; Yohannan et al. 2019). Most medical students are also unable to connect their devices to personal or institutional Wi-Fi networks. Educators, who wish to update their teaching may be required to develop their own homegrown, low-tech approaches for VM by using optical microscopes and household items (Nasimudeen 2016) or Foldscope microscope kits (Foldscope Instruments, Palo Alto, CA, USA) as low-cost alternatives to optical microscopes (Cybulski et al. 2014) combining these with smartphone and screen mirroring devices (Prakash and Prakash 2019). Another publication reports a

98

whole slide digital image approach using an image montaging feature of Adobe Photoshop (Adobe Inc., San Jose, CA, USA) and a trinocular microscope for oral and dental pathology (Banavar et al. 2016). Few institutes in India, such as the All India Institute of Medical Sciences (AIIMS 2021), have a well-established e-learning infrastructure, including digital microanatomy laboratories (Potaliya et al. 2017; AIIMS 2021). One electronic device that is ubiquitously available to students in India is the smartphone. However, smartphones may be of limited use for VM due to small screen sizes. These barriers to the effective use of VM for histology education in India will hopefully disappear as time progresses and the technological infrastructure at Indian universities improves (Dhir et al. 2017).

5.2.3.2

Adoption of Virtual Microscopy for Biomedical Education in Middle Eastern Countries Several countries in the Middle East are not only more affluent but also more technologically advanced with a well-supported educational system (Reis et al. 2017; Hamdy et al. 2010a, b). In 2011, the University of Michigan Virtual Slide collection was shared with several universities in Israel (Tel Aviv University and Hebrew University in Jerusalem) and these institutions have used VM for education ever since. Starting in 2012, the faculty of medicine at the Technion Institute of Technology in Haifa, Israel, scanned and digitized around 450 high-quality glass slides and made them available to their students (Coleman 2013). The Ben Gurion University in Beer Sheva, Israel, also provided student access to VM slides, which have efficiently supported pathology education during the COVID-19 pandemic (Samueli et al. 2020). Similarly, universities in most countries on the Arabian Peninsula are actively using VM for both biomedical education and clinical applications. Students at Qassim University in Saudi Arabia preferred a combination of VM and TM for learning pathology (Alkhamiss 2019). A comparison of VM with TM also resulted in a high preference for VM by students learning oral histology and pathology at King Saud University in

M. Hortsch et al.

Riyadh, Saudi Arabia (Alotaibi and Alqahtani 2016). The same study also reported that students using VM achieved higher examination scores and advocated that VM completely replace TM. Similar conclusions were published by the University of Tabuk, Saudi Arabia for pathology education (Foad 2017). More recently, two educators from the College of Medicine at Taif University, Saudi Arabia, reported the positive impact of VM on medical histology education when they shifted to distance learning during the COVID-19 pandemic (Amer and Nemenqani 2020). They found that VM was not only an effective teaching technology but also served their online assessment needs. VM also proved to be a highly effective teaching strategy when integrated into the histopathology curriculum at Mohammad Bin Rashid University in Dubai, United Arab Emirates (UAE) (Lakhtakia 2021). The existing VM infrastructure allowed for a rapid shift to distance learning at this University during the COVID-19 pandemic (Du Plessis et al. 2021). In collaboration with the Cleveland Clinic Laboratories in Ohio, USA, a clinical application of VM was reported for the development of an ePathology service at the Cleveland Clinic Abu Dhabi, UAE (Nahal et al. 2018). A telepathology system was also successfully implemented at Kuwait University in Jabriya, Kuwait (Buabbas et al. 2021). However, users at that school expressed dissatisfaction with a lack of technical support, indicating that the introduction of VM needs to happen in an appropriate supporting context. Dr. May Al-Habib from Al-Nahrain College of Medicine in Bagdad, Iraq received a copy of the Michigan Virtual Slide collection in 2012. She primarily used VM in a demonstration modus to teach her students at her school and reported that VM provides a reliable resource for her courses and that students find VM easy to use, especially as Internet connectivity improved in Iraq (Fig. 5.7) (personal communication). Two papers from neighboring Iran also reported that VM has been a successful approach for telepathology (Abdirad and Ghaderi-Sohi 2009) and for histology education at Guilan University in Rasht, Iran (Golchai et al. 2012).

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

99

Fig. 5.7 In this 2016 photo Dr. Al-Habib uses a VM image from the University of Michigan Histology slide collection to demonstrate and discuss the histological

structure of an organ with her students at Al-Nahrain College of Medicine in Bagdad, Iraq (Photo courtesy of Dr. M. Al-Habib)

These successes contrast with the use of digital technologies in other parts of Central Asia where resource limitations prevented implementation of VM and restricted usage to static telepathology. There have been limited advances instigated by educators based within the Central Asian countries of Georgia, Armenia, Azerbaijan, Kazakhstan, Turkmenistan, Uzbekistan, Tajikistan, and the Kyrghyz Republic with respect to the use of modern technologies for education and medicine since these nations gained independence after the dissolution of the USSR (Gajewski and Atkins 2011). With North Atlantic Treaty Organization (NATO) support, a satellite-based system, “the Virtual Silk Highway,” was established to improve internet access in these countries for the support of telemedicine and telepathology services (Gajewski and Atkins 2011). A successful application of telemedicine in Afghanistan involved a collaboration of dermatopathologists at Emory University in the USA with an academic teaching hospital in Kabul (Ismail et al. 2018).

5.2.3.3

Adoption of Virtual Microscopy for Biomedical Education in South-Eastern Asian Countries The state of VM use for medical education in many South-Eastern Asian countries mirrors the situation described for India, specifically concerning technological limitations and the barriers to the reform of antiquated school and university systems. One exception may be Singapore, an affluent city-state in the region, where several academics expressed early enthusiasm for the educational and clinical potential of VM (Eng 2004; Shanmugaratnam 2007; Racoceanu et al. 2011). In Singapore, VM is primarily used for pathology and has been successfully integrated into the normal workflow at the laboratory of Singapore General Hospital (Cheng et al. 2016). Recent work has reported that most medical colleges in Thailand still use TM for the teaching of histopathology (Laohawetwanit 2020). However, due to the COVID-19 pandemic, there has

100

been a shift toward the scholarly use of VM (Kantasiripitak and Laohawetwanit 2021). A study from the Chulabhorn International College of Medicine of Thanmasat University in Pathum Thani, Thailand, has used clinical vignettes along with VM slides, and reported improved post-test student performance (Laohawetwanit 2020). In addition, students rated VM as very useful for their learning. Two other studies from Thailand also indicated that initial attempts of incorporating VM into histology and pathology education were successful (Choomchuay 2011; Titipungal 2015). A study from Malaysia indicated that students’ perceived that their competence in histology was positively influenced when VM was used as a teaching tool (Simok et al. 2019). An experimental analysis conducted at the Penang International Dental College in Penang, Malaysia, showed that a hybrid teaching model using both VM and TM was preferred, and the academic performance of students was dependent on the media formats that were used to present the content (Telang et al. 2016). A recent survey about the anatomy learning environment at Universiti Putra Malaysia in Seri Kembangan, Malaysia, reported that students viewed learning resources for the anatomical sciences as suboptimal (Yen et al. 2021). As most Malaysian universities had no virtual teaching components in their curriculum structure and were unprepared to use VM technology effectively, this created challenges during the COVID-19 pandemic for the teaching of anatomy and histology (Tg Muda et al. 2021). A study conducted at the Islamic University of Indonesia in Yogyakarta investigated how students evaluated a combination of case-based learning with VM in comparison to TM (Fidianingsih and Wijaya 2015). The authors reported that case-based learning and VM were well-received by their students and presented an equally effective method to TM for teaching histology to first year medical students. Thus, the published literature indicates that VM has been used in many South-East Asian countries. However, it has not reached a high level of consistent and widespread application.

M. Hortsch et al.

5.2.4

5.2.4.1

Adoption of Virtual Microscopy for Biomedical Education in China and Other East Asian Countries

Adoption of Virtual Microscopy for Biomedical Education in China Although new student-centered methods are increasingly being used, histology instruction in mainland China had a predominantly teachercentered format in the past (Cheng et al. 2020). The histology curriculum commonly consists of a lecture-based and a laboratory component with a 1:1 ratio of contact hours. A survey approach identified that 64% of Chinese medical schools reported a total of 71–90 contact hours for histology and embryology, with histology instruction accounting for at least 80% of that time. At Fudan University, the institution of this segment’s author (Y.L.), histology remains a stand-alone course for medical students. The medical schedule includes 56.25 contact hours for histology, with a 2:3 ratio of lecture to laboratory hours. During laboratory sessions, both a light microscope with a box of 73 glass slides and one computer tablet are available to each student (Fig. 5.8). An interactive communication system connects students and teachers. In addition, VM is offered as a supplement to provide self-directed learning opportunities. In 2008, the introduction of VM for the teaching of histology began in mainland China at Huazhong University of Science and Technology (Ye et al. 2008; Li 2016). In 2016, the number of mainland Chinese institutes using VM had risen to at least 14 (Li 2016). A national survey in 2018 showed that this number had further increased to 34, with 76% of these universities using VM exclusively for histology laboratories and another 24% using a mixed approach of both TM and VM (Cheng et al. 2020). Recently, the COVID-19 pandemic resulted in 51 medical institutes using VM for practical histology sessions, which accounted for 65% of all 78 surveyed medical schools in China (Cheng et al. 2021). This trend indicates an increasing value recognition and

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

101

Fig. 5.8 Medical students participating in a histology laboratory course at Fudan University, Shanghai, in China use a combination of virtual and traditional microscopy

popularity of VM in the Chinese medical education system. The introduction of VM had a positive impact on medical education in China. Currently, there are over 40 published articles reporting on its usage for teaching histology in China. These publications can be found by searching PubMed and three Chinese databases (WanFang Data, CNKI and VIP). It should be noted that the term “digital slide” is used more often in Chinese articles rather than “VM” or “virtual slide.” VM has also been used at Chinese schools for flipped classroom approaches (Cheng et al. 2017; Zhang et al. 2020), problem-based learning (Tian et al. 2014), and for remote online learning (Zhong et al. 2021), all of which differ from the traditional Chinese teaching paradigm. These developments suggest that VM is helpful for teachers at Chinese schools, who wish to try new teaching approaches, and that VM provides Chinese students with a productive learning experience. Several publications originating from Chinese universities report on combining digital slides with other teaching techniques or resources. One article outlines the use of an advanced monitoring method for collecting data about virtual slide viewing strategies by students (Ni et al. 2019).

The results revealed which slides or portions of slides were intensively viewed by students while learning histology. Other studies investigated the use of VM to increase the test efficiency in histology examinations (Xing et al. 2019; Liu et al. 2021). VM has also been combined with screen recording software allowing instructors to produce voice-annotated videos, clarifying key areas on the slides, and reducing student cognitive load (Fu et al. 2013; Li et al. 2018). Lastly, the integration of digital slide snapshots into social media posts on Tencent QQ and WeChat (Tencent Holding Limited, Shenzhen, China) increased effective communication between students and instructors (Song et al. 2021). In addition to these applications of VM, a collection of virtual slides was compiled into a physical textbook containing 840 histological images derived from more than 330 digital slides, and with explanations in Chinese and English (Dong et al. 2015). This textbook provides an important histology learning resource for students in China, especially at institutions without VM resources. These additional uses of VM as a teaching tool in China demonstrate how VM possesses several important advantages when compared to TM (Table 5.2).

102

Most Chinese students value the use of VM, especially the flexibility to study histology at their own pace, the ease of use, and an increase in effective engagement with the material (Cheng et al. 2020). The advent of VM also introduced Chinese students to online assignments (Xing et al. 2019). Similar to histology learners in other developing countries, Chinese students used to draw pictures of their light microscope observations of tissues and cells with red and blue pencils. Because students completed these drawing assignments in class, this activity took valuable time away from their analysis of the slide preparations. Using VM, students can concentrate on investigating histological slides without being distracted by other tasks. After class, students will take screenshots of virtual slides and add annotations to generate an electronic report, which is delivered online to their teachers. Using this approach students collaborate and integrate their captured images into a comprehensive personalized electronic histology atlas. This process provides a helpful strategy for students to review the required course material (Li et al. 2019). There are three major reasons that VM has become a major learning resource for medical education in China. First, a shortage of technical support staff, coupled with the rapid increase in the number of undergraduate students due to enrollment expansion, has resulted in a severe shortage of glass slides available to students (Cheng et al. 2020). At Fudan University, the number of technicians has dwindled from five to one during a 20-year period and no new glass slides have been added to the educational collections for more than a decade. Second, recent improvements in the educational infrastructure at Chinese medical schools have made VM an appealing alternative to glass slides. Third, the original Chinese teacher-centered medical curriculum has proven to be inadequate to accommodate the exponential increase of scientific knowledge and resulted in insufficient time for teaching new scientific concepts. Therefore, medical education reform in China has become an urgent and important issue. In the future, the

M. Hortsch et al.

need for earlier clinical exposure will likely further reduce the time dedicated for instruction of the basic biomedical sciences. There are also some obstacles to the wider acceptance and use of VM in China. First, most VM image file collections represent only one staining method and many image files have limited information about the tissue and its origin. As H&E remains the primary staining method for histological specimens, other slide staining methods, especially immunohistochemistry (IHC), are usually underrepresented in VM image collections or are lacking altogether. In addition, a majority of VM collections have only 100 virtual slides or less, resulting in a lack of specimen diversity. A second obstacle is the lack of a national resource database for VM image files in China. VM files are usually owned by institutions or teachers and are inaccessible to other educators or students as they are stored within secure password-protected databases. Third, some teachers are still reluctant to use VM as an educational tool, arguing that the use of VM results in the loss of microscope skills (Xu 2013). However, students requiring such skills will usually learn them when needed, for example, in a research laboratory or clinical setting. Fourth, Chinese students learn with an examination-oriented mindset (Lam and Lam 2009). Thus, the examination modus, VM or TM, will directly affect the acceptance and use of VM. At present, only a few universities have implemented a VM-based online assessment modus. Finally, slow Internet speeds at some Chinese institutions limit or prevent access to histology e-learning materials based in other countries, such as the University of Michigan Histology website (UMMS 2021). In 2008, the Kaohsiung Medical University in Taiwan established a VM system for oral and maxillofacial pathology education (Chen et al. 2008). The authors reported that students favored VM over TM. A Kaohsiung Medical University virtual slide collection is now freely available from the Virtual Microscopy Database (VMD) (Lee et al. 2018). Two studies from National Taiwan University reported that the VM platform

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

improved undergraduates’ academic performance in histology and pathology courses (Lee et al. 2020; Chang et al. 2021). Some advantages and drawbacks of the VM system were noted and mirrored those reported from mainland China (Lee et al. 2020). In addition, VM also supports continuing education of medical professionals in Taiwan, specifically pathologists and cytotechnologists (Hang et al. 2015). Some educators from Taiwan reported further improvements in the use of VM, such as simultaneously displays on the same computer screen and the use of comparative image presentations to support more efficient user knowledge acquisition (Chen et al. 2015).

5.2.4.2

Adoption of Virtual Microscopy for Biomedical Education in South Korea and Japan In South Korea, a pre-VM report on 29 medical colleges showed that the structure of anatomy curricula in Korea was similar to that in Japan, but different from that used in the United States, particularly in the ratio of lecture to laboratory hours (Lee and Baik 1990). In 2004, VM was first adopted at Kwandong University and proved to be a good alternative to TM for pathology education (Song et al. 2006; Kim et al. 2008). Students also expressed a preference for VM over TM. The three most significant advantages of VM were reported to be freedom from optical stress, higher-quality images, and time savings. Limited slide selection and the lack of opportunity to operate a light microscope were named as disadvantages. One publication reported about a neuro-atlas of the spinal cord and brain stem that was developed from virtual slides to help students and researchers learn about the human nervous system (Song et al. 2010). Another paper from Korea reported that the combination of highthroughput multiplex IHC methods and whole slide imaging made in situ single-cell characterization and analysis more efficient, providing an advanced analysis of the cell composition in a tissue microenvironment (Koh et al. 2020). Recently, Korea released recommendations for

103

pathologic practice using digital pathology, which will provide an important standard for future pathologic diagnosis (Chong et al. 2020). In Japan, authors from Nippon Medical School in Tokyo published a report in 2008 on a VM teaching tool that depicted human full-term placentas (Takizawa et al. 2008). Two years later, Tohoku Bunka Gakuen University in Sendai began using virtual slides for histology education (Yamanaka 2010). In addition, several papers mentioned the use of VM for pathology education and clinical practice in Japan (Yamanaka 2010; Itoh and Ogi 2017). The authors of these papers listed similar advantages of VM as other early adopters. Mentioned disadvantages were a lack of depth perception, few images scanned at high magnification with oil and 100× objectives, and technical difficulties due to large image file sizes. More recently, a textbook entitled “Histology of Virtual Slides” was published in Japan (Komao 2020). Currently, VM is well accepted for education at Japanese medical schools. The use of VM is also important for telepathology in Japan (Sawai 2009; Nakayama et al. 2012; Sawai et al. 2013b; Toyoda and Eda 2014). Since 2015, the Japanese Society of Pathology has issued two guidelines and three technical standards for digital pathology systems (Chong et al. 2020). In addition to educational and diagnostic uses, VM has also been used in Japan for morphometric analysis in several research projects (Itoh and Ogi 2017; Kaneko et al. 2019; Kawaguchi and Masuda 2020). Park et al. reported on OpenTein, a VM image database of stem cell-derived teratomas (Park et al. 2016) and Uesugi et al. used three-dimensional VM reconstructions to study age-related human renal microvascular changes (Uesugi et al. 2016). In general, VM is now widely used in most East Asian countries. Teachers and students value VM as an effective learning tool. It is anticipated that VM will continue to replace light microscopy in medical education and pathological diagnosis in this region of the world.

104

5.2.5

M. Hortsch et al.

Adoption of Virtual Microscopy for Biomedical Education in South America

Adoption of Virtual Microscopy for Biomedical Education in Brazil In Brazil, digital technologies are rarely used for the teaching of histology and histopathology. Some universities cover the subject of histology using theoretical concepts and clinical cases in combination with static images. However, by definition, static histology images do not allow learners to scan and progressively magnify sections of a histological slide. Pre-pandemic teaching of histology at the Morphology Department at the Federal University of Ceará (UFC) in Fortaleza, Brazil, consisted of theoretical classes that were followed by laboratory sessions using traditional optical microscopes. At the beginning of laboratory sessions, histological slides were projected with the aid of a light microscope connected to an image projector (Fig. 5.9). This allowed students to become acquainted with the slide material. Subsequently, students studied similar slides with their loan light microscopes under the

supervision of an instructor. These practical classes depended on the physical availability of optical microscopes and teaching collections of histological glass slides. The COVID-19 pandemic resulted in the closure of university campuses worldwide, including those within the Brazilian system. This forced the use of remote digital teaching alternatives for all subjects. This new teaching paradigm was challenging for Brazilian medical education (Carvalho et al. 2020), specifically for histology and histopathology instruction that were previously taught using TM. Social distancing demanded teaching strategies that were independent of microscope usage, and it became necessary to use digital didactic resources for the teaching and learning of histology at UFC. The Google Classroom platform (Alphabet Inc., Mountain View, CA, USA) was adopted to organize the supporting educational material (e.g., notes, slides, video classes, and study programmes) (Google 2022). Google Meet (Alphabet Inc., Mountain View, CA, USA) was used for online conferences and discussions of the subject material. Unlike other countries, Brazilian universities lack open websites with material to teach histology using VM (Dos Santos et al.

Fig. 5.9 Pre-pandemic practical histology classes at the Federal University of Ceará (UFC) used traditional optical microscopy. On the left, Dr. Girão-Carmona shows a

histological image from a microscope that is connected to a projector. On the right, students are exploring similar glass slides using light microscopes

5.2.5.1

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

105

2021). As an alternative strategy, VM platforms in languages other than Portuguese were adopted for histology teaching. Consequently, the absence of VM resources in Portuguese was a problem for some Brazilian students with limited English language knowledge. On the positive side, students were offered access to digital material via video conference on-screen in real time and were provided with a collaborative environment for discussions with instructors (Fig. 5.10). Although these digital tools were helpful during the COVID-19 pandemic, students were often left to study histological slides independently, without instructor support. Despite the global increase of digital technologies in medical education (Guze 2015), the use of VM for education is a very new development in Brazil (Dos Santos et al. 2021).

The use of VM was an important milestone for the Morphology Department of UFC as it was the first time that this type of resource was used for histology instruction. A survey about VM that was offered to UFC students after they returned to classroom lessons revealed that almost all students used the Histology Guide website (V.G., unpublished results) (Sorensen and Brelje 2021). They specifically appreciated the easy access, the quality of the images, the ability to zoom in and out, and the autonomy it provides to learners. On the negative side, surveyed students mentioned the platform language (English) that impeded an easy understanding of the subject, incompatibility with smartphones, and general problems with insufficient internet connections. Consequently, a majority of UFC students

Fig. 5.10 Dr. Girão-Carmona teaching a video conference session at the Federal University of Ceará (UFC) during the COVID-19 pandemic. Upper panel is a

screenshot using a static image, lower panel is a VM image from the Histology Guide online website (Table 5.1) (Sorensen and Brelje 2021)

106

advocated a continuing use of optical microscopes for histology instruction. At the University of the International Integration of Afro-Brazilian Lusophony (UNILAB) (also a federal university in the State of Ceará), prior to the onset of the COVID-19 pandemic, projected photographs of slides from the institutional collection were used to introduce a histology topic before the start of laboratory sessions. Students were encouraged to discuss the topic with instructors to expand their understanding of the material before viewing histological glass slides with optical microscopes. Microscope laboratories were available to students for studying the slides at other times and a review session with test quizzes under supervision of an instructor was offered, covering both didactic as well as laboratory aspects of the topic. During the pandemic, histology laboratory classes at UNILAB were taught synchronously and online using static pictures and a US-based VM website (Sorensen and Brelje 2021). The limited quality of Internet connections and the unfamiliarity with a virtual learning platform were major problems that required multiple adaptations from both teachers and learners. To support these didactic changes in histology and histopathology teaching at UNILAB and UFC, training in digital information and communication technologies, further improvements to the computer infrastructure, and the implementation and adoption of additional e-learning strategies will be necessary. Despite the adversities caused by the pandemic, these didactic experiences confirmed that digital technologies can deliver high-quality education to Brazilian health science students (Barteit et al. 2020). The use of VM technology extends to clinical applications when medical specialists located at different sites need to collaborate online for establishing a patient’s diagnosis. Digital analysis by a group of pathologists at the Medical Faculty of the University of Buenos Aires in Argentina of pathological images began in 1990 (Nessi De Aviñón and Bengtsson 1990). In 1994, Brazilian pathologists and a group of Paraguayan colleagues independently reported similar uses of digital pathology images (Zandona

M. Hortsch et al.

et al. 1994; Rojo 2015). A report from Peru about the use of telepathology followed in 2001 (AriasStella et al. 2001). However, the use of digital pictures for telepathology did not progress as quickly as in North America and European countries, mainly due to a lack of financial support, trained staff, and the absence of a physical infrastructure (Paltas Quimis 2020). VM is more widely used in Brazil for teaching and clinical applications of oral histopathology (Fonseca et al. 2015; Araujo et al. 2018; Fernandes et al. 2018). A comparison between TM and VM for dental student instruction of oral pathology at the Federal University of Pernambuco in Recife, Brazil has been published (Fernandes et al. 2018). Most students viewed VM as the superior teaching technology and they performed better on examinations using virtual versus conventional glass slides. Similar results were reported by odontology teachers at the State University of Campinas (UNICAMP) in Campinas, Brazil, when evaluating the transition from TM to VM in their oral pathology course (Fonseca et al. 2015). The authors reported that equal access to digitized material and optimization of class time allowed for more discussions about the pathology images. Because health science students rarely use microscopes in the practice of medicine, teaching the use of a conventional optical microscope is no longer a high priority (Kumar et al. 2004; Braun and Kearns 2008; Saco et al. 2016). In contrast, other educators have reported that 56% of surveyed students stated that conventional microscopy should not be eliminated (Fonseca et al. 2015). These findings suggest that universities in Brazil and other South American countries will require flexibility when changing histology and pathology education from traditional teaching methods to modern e-learning technologies such as VM (Pachame and Portiansky 2017; Joaquim et al. 2022).

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

5.2.5.2

Adoption of Virtual Microscopy for Biomedical Education in Other South American Countries The current use of VM for medical education and clinical applications at UFC and UNILAB, as well as barriers to implementation are similar to those at other South American universities. In Chile, VM has been used for dental education at several universities, including University of the Andes in Santiago (Becerra et al. 2015), Universidad Austral de Chile in Valdivia (Rosas et al. 2012), and University of the Americas in Providencia (Muñoz 2018). When the COVID-19 pandemic arose in Chile in 2020, health science students at the University of Chile in Santiago were able to continue their histology education using VM, which had originally been introduced as a supplement to TM (Rojas et al. 2020). During the COVID-19 pandemic, educators and students at the Universidad Central de Venezuela used the virtual images on the Michigan Histology website for histology instruction (Dr. M. De Lima Eljuri, personal communication) (UMMS 2021). Students at the Health Science Faculty of the University of Carabobo in Venezuela used VM in their pre-pandemic histology courses (Rodriguez 2014) and medical students at the University of Santander in Columbia for pathology education (Diaz-Perez et al. 2014). Sometimes the need for technology upgrades has resulted in collaborative efforts between institutions from different countries. For example, a VM learning tool was developed at the Medical School at University of São Paulo (USP) in Brazil in collaboration with the Medical School of the University of Chile (Dos Santos et al. 2021). In this study, first year medical students at USP considered VM easier to navigate, more efficient, and easier to use when compared to TM. Even though the implementation of VM technology is still at a very early stage in South American countries, the evidence suggests that the introduction of this technology as an educational tool is a desirable and achievable goal for the entire continent. The high acquisition costs of VM slide scanners are still a significant obstacle,

107

especially for Brazilian public universities. Additionally, the high-resolution images used for VM require ample data server storage space, as well as a high-speed Internet connection system, both still lacking at many places in South America (Saco et al. 2016). The high costs of setting up a functional VM system may be the most important factor that slows down the wider use of VM on the South American continent.

5.3

Summary and Conclusions: Virtual Microscopy Is Here to Stay

The use of VM comes with several advantages, as well as limitations (Table 5.2). Most reports in the literature agree that VM is a step forward in histology education and for the clinical practice of pathology. The use of VM often resulted in higher student motivation to engage in the learning process (Wilson et al. 2019; Felszeghy et al. 2017; Simok et al. 2019; Tauber et al. 2019), with equivalent or improved learning outcomes when compared to TM (Scoville and Buskirk 2007; Husmann et al. 2009; Higazi 2011; Mione et al. 2013; Kuo and Leo 2019). VM also provides a more flexible and time-efficient method to teach histology and pathology in the context of modern educational concepts like student-centered, self-directed, and team-based learning. Global implementation and adaptation of VM have generally followed a stepwise progression. Initially, educators often use VM in a demonstration mode within lecture-style presentations (Figs. 5.4, 5.6, 5.7, and 5.9). When using VM in a histology or pathology teaching laboratory, virtual images are initially offered in combination with TM (Figs. 5.5 and 5.8). Eventually this approach may result in a complete replacement of TM instruction (Fig. 5.3). Depending on the local situation and curricular requirements, the order of implementation may vary, and some incremental steps may be bypassed. Ultimately, teacher-guided laboratory sessions may become optional or obsolete, with students performing histology laboratory exercises independently and

108

asynchronously. Unfortunately, this loss of teacher-guided laboratory instruction has a potential negative impact on learning success and may result in diminished student abilities in the correct analysis and interpretation of micrographic images (Selvig et al. 2015; Gribbin et al. 2022). As outlined here, the introduction of an instructional technology such as VM incurs both general and unique challenges. Overall, the introduction and use of e-learning approaches for teaching histology and pathology are dependent on the economic affluence of the institution and global region. Certain advantages are present in technology-advanced countries in North America, Europe, and in Australia, where new learning technologies have typically been developed and initially implemented. In developing countries, the introduction of new technologies is often viewed as a strategy to reach the same level as industrialized global regions (Frehywot et al. 2013; Barteit et al. 2020). Furthermore, the educators, university administrators, and students sometimes resist the introduction of new teaching and learning modalities (Yohannan et al. 2019). However, after an introductory period, students tend to embrace VM as their preferred method of learning histology and pathology (Wilson et al. 2019, Felszeghy et al. 2017, Simok et al. 2019, Tauber et al. 2019). Importantly, the introduction of VM for teaching and clinical use is dependent on a functioning technological infrastructure, as well as experienced support staff. These requirements exist at the level of both the institution and the individual student. In developing countries, many students do not have the financial means to purchase their own personal computer or tablet device and institutions are unable to provide such devices for each learner. Even in highly industrialized countries, societal inequities may result in similar situations. The COVID-19 pandemic required rapid, profound, and global changes in the format of histology and pathology education. Social distancing requirements and temporary closure of institutions uncovered global inequities, but also served as a catalyst for change by enabling the introduction of VM for histology and pathology education. As outlined here, individual

M. Hortsch et al.

institutions identified a variety of different solutions for continuing histology education, which were often based on local or international VM online resources. Publications originating from a range of countries and universities have reported successful adaptations of VM for the teaching of histology and pathology during the COVID-19 pandemic (Amer and Nemenqani 2020; Sensu et al. 2020; Caruso 2021; Cheng et al. 2021; Darici et al. 2021; Guiter et al. 2021). One solution that was adopted by some schools during the COVID-19 pandemic was the use of openly accessible VM websites (Table 5.1, Figs. 5.10 and 5.11). Although many of these websites are organized to serve the educational needs of the host institution, they contain large numbers of high-quality virtual images and include additional features such as laboratory instructions and formative assessments (Table 5.1). However, such resources may not always be directly applicable or relevant to external institutions and educational programmes. Secondly, use of these resources is typically dependent on rapid and stable internet connections, a luxury that not all educational institutions and students possess. Another drawback is that most of these websites are written in English, making their use problematic for schools in countries where English is not the primary language and/or the main language of instruction. Open VM resources in languages other than English are rare or non-existent. That virtual image files can easily be copied and shared between instructors, on websites, and by databases is a major advantage of VM (Ducut et al. 2010; Travis 2015; Egevad et al. 2017; Lee et al. 2018), allowing teachers and learners worldwide easy access to high-quality image material from other institutions. However, this still requires that the necessary hardware and software infrastructure to manipulate and view VM images is locally available. Several national and international collaborations to develop and/or share VM images have been described here. These examples may serve as an inspiration for schools and educators in developing countries. They illustrate how to obtain and implement VM teaching material for local instruction. One database that allows

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

109

Fig. 5.11 Several websites offer internet access to highquality virtual histology images for free without password protection or the need to register (Table 5.1). Shown is the

homepage of the University of Michigan Histology website (UMMS 2021) (which features 269 virtual light micrographs and 140 labeled EM images

for the free download of virtual histology and pathology image files is the Virtual Microscopy Database (VMD) (VMD 2022) (Fig. 5.12). The VMD contains over 3500 light and electron microscopy image files, most showing normal histology, and is organized in over 20 collections from universities located on 6 different continents (Lee et al. 2018). These images are available under an Attribution-NonCommercialShareAlike Creative Commons license (CC BYNC-SA 4.0) to educators and researchers regardless of their location. Users must first register to obtain full access to the VMD image material. The VMD is not organized to serve students directly and students will not be accepted as users. Rather, the VMD serves as a repository and resource for educators to obtain high-quality image material for their own educational uses. In

addition, some commercial sites offer histology and pathology image material for sale, and other virtual image databases have been reported in the published literature, most offering pathology images (Lundin et al. 2004, 2009; Teodorovic et al. 2006; Rossner et al. 2012; Khushi et al. 2013; Egevad et al. 2017). As mentioned above, the first use of VM in developing countries is often not for educational, but rather for clinical purposes. VM facilitates connections between rural clinical sites and pathological specialists at larger urban health centers or universities. This provides an opportunity to improve health care in developing countries and sometimes has been a driving force for the implementation of VM technology (Fontelo et al. 2005; Gongora Jara and Barcelo 2008; Pagni et al. 2011; Nelson et al. 2012; Sareen 2017). This

110

M. Hortsch et al.

Fig. 5.12 Homepage of the Virtual Microscopy Database (VMD) (VMD 2022), a free repository of VM image collections from over 20 different universities (Lee et al. 2018). This resource is not designed for direct student use

but provides educators and researchers with a large selection of virtual image files for research or educational purposes

parallels the development in more industrialized regions of the world where an increasing number of pathological analyses of patient specimens are now being processed electronically. A common theme driving the implementation of VM for education in many countries is the reduction of time dedicated for the teaching of the basic sciences including histology (Hightower et al. 1999; Drake et al. 2009; McBride and Drake 2018). VM technology provides an option for placing histology/pathology laboratory education online and serves as a platform for individualized, teacher-independent learning, an appealing prospect for many medical curriculum administrators. However, without expert support during histology laboratory sessions, student understanding of tissue and organ structure-function relationship may suffer, resulting in reduced learning performance and summative assessment scores (Selvig et al. 2015, Gribbin et al. 2022). The global use of VM for histology and pathology education is an ongoing and inevitable process. The ultimate outcome of how this technology will be used in different geographical

regions is still unknown, but in the future most students of the biomedical sciences will encounter VM during their educational training and/or their clinical work. Acknowledgments We would like to thank Dr. May Al-Habib (Al-Nahrain College of Medicine, Bagdad, Iraq) and Dr. Nicolas Wickens (Nelson Mandela University, Port Elizabeth, South Africa) for allowing us to use their photos depicting histology instruction at their schools and Dr. Margarita De Lima Eljuri for communicating how VM was used for histology education during the COVID19 pandemic at her school, the Universidad Central de Venezuela. We are also grateful to Dr. Mike Welsh (formerly University of Michigan, USA) for giving us permission to use a photograph of him teaching medical students histology at the University of Michigan and to Dr. Sarah Hortsch (University of Michigan, USA) for suggesting many improvements to our manuscript draft.

References Abdelkhalek N, Hussein A, Gibbs T, Hamdy H (2010) Using team-based learning to prepare medical students for future problem-based learning. Med Teach 32:123– 129

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

Abdirad A, Ghaderi-Sohi S (2009) Telepathology in Iran. In: Kumar S, Dunn BE (eds) Telepathology. Springer, Berlin Abdulla AM, Watkins LO, Henke JS, Weitz FI, Frank MJ (1983) Classroom use of personal computers in medical education: a practical approach. Med Educ 17:229– 232 AIIMS (2021) Department of Anatomy, All Indian Institute of Medical Sciences [Online]. New Delhi. Available: http://anatomy.aiims.ac.in/. Accessed 9 Dec 2021 Alcala-Canto Y, Ibarra-Velarde F, Vera-Montenegro Y, Alberti-Navarro A (2012) Virtual microscopy for studying veterinary parasitology. Comp Parasitol 79: 138–142 Alkhamiss AS (2019) Impact of virtual pathology teaching method on the education of medical students at Qassim University—Saudi Arabia. Jouf Univ Med J 6:35–44 Allen MA, Kirkpatrick N, Agosto ER (2019) Anatomage Table 6. J Electron Resour Med Libr 16:59–66 Alotaibi O, Alqahtani D (2016) Measuring dental students’ preference: a comparison of light microscopy and virtual microscopy as teaching tools in oral histology and pathology. Saudi Dent J 28:169–173 Alturkistani HA, Tashkandi FM, Mohammedsaleh ZM (2015) Histological stains: a literature review and case study. Glob J Health Sci 8:72–79 Amer MG, Nemenqani DM (2020) Successful use of virtual microscopy in the assessment of practical histology during pandemic COVID-19: a descriptive study. J Microsc Ultrastruct 8:156–161 Anonymous (1875) The teaching of histology. Br Foreign Med Chir Rev 56:327–339 Anyanwu GE, Agu AU, Anyaehie UB (2012) Enhancing learning objectives by use of simple virtual microscopic slides in cellular physiology and histology: impact and attitudes. Adv Physiol Educ 36:158–163 Appleton B, Bradleu A, Wildermoth M (2005) Towards optimal image stitching for virtual microscopy. Digital image computing: techniques and applications (DICTA’05). IEEE Xplore, Queensland Araujo ALD, Amaral-Silva GK, Fonseca FP, Palmier NR, Lopes MA, Speight PM, De Almeida OP, Vargas PA, Santos-Silva AR (2018) Validation of digital microscopy in the histopathological diagnoses of oral diseases. Virchows Arch 473:321–327 Ariana A, Amin M, Pakneshan S, Dolan-Evans E, Lam AK (2016) Integration of traditional and e-learning methods to improve learning outcomes for dental students in histopathology. J Dent Educ 80:1140–1148 Arias-Stella J, Arias-Stella Castillo J, Huamanciza Y, Meza Aznaran LA (2001) First consultation of diagnóstica telehistopatología made in Peru [in Spanish]. Folia Dermatol Peru 12:35–40 Awaldelkarim KD, Mohamedani AA, Barberis M (2010) Role of pathology in sub-Saharan Africa: an example from Sudan. Pathol Lab Med Int 2:49–57 Ayad E (2011) Virtual telepathology in Egypt, applications of WSI in Cairo University. Diagn Pathol 6(Suppl 1):S1

111

Ayad E (2013) E-education for medical students using WSI in Egypt. Diagn Pathol 8:S39 Ayad E, Sicurello F (2008) Telepathology in emerging countries pilot project between Italy and Egypt. Diagn Pathol 3(Suppl 1):S2 Ayad E, Yagi Y (2012) Virtual microscopy beyond the pyramids, applications of WSI in Cairo University for E-education & telepathology. Anal Cell Pathol 35:93– 95 Bacha D, Ferjaoui W, Charfi L, Rejaibi S, Gharbi L, Ben Slama S, Nijim L, Lahmar A (2020) The interest of virtual microscopy as a means of simulation learning in pathological anatomy and cytology. Oncol Radiother 14:23–29 Balemans MCM, Kooloos JGM, Donders ART, Van Der Zee CEEM (2016) Actual drawing of histological images improves knowledge retention. Anat Sci Educ 9:60–70 Banach L, Stepien A, Schneider J, Wichrzycka-Lancaster E (2008) Dynamic active telepathology over National Health Laboratory service network, South Africa: feasibility study using Nikon Coolscope. Diagn Pathol 3 (Suppl 1):S3 Banavar SR, Chippagiri P, Pandurangappa R, Annavajjula S, Rajashekaraiah PB (2016) Image montaging for creating a virtual pathology slide: an innovative and economical tool to obtain a whole slide image. Anal Cell Pathol (Amst) 2016:9084909 Barbeau ML, Johnson M, Gibson C, Rogers KA (2013) The development and assessment of an online microscopic anatomy laboratory course. Anat Sci Educ 6: 246–256 Barteit S, Guzek D, Jahn A, Bärnighausen T, Jorge MM, Neuhann F (2020) Evaluation of e-learning for medical education in low- and middle-income countries: a systematic review. Comput Educ 145:103726 Basheer A (2019) Competency-based medical education in India: are we ready? J Curr Res Sci Med 5:1–3 Becerra D, Grob M, Assadi JL, Astorga C, Tricio J, Memelli R, Silva C, Sabag N (2015) Academic achievement and perception of two teaching methods in histology: light and digital microscopy. Pilot study. Int J Morphol 36:811–816 Bennett HS (1956) The role of histology in medical education and biological thinking. Anat Rec 125:327–354 Beresneva OY, Sazonov SV, Denisenko SA (2019) The whole slide imaging at the department of histology, cytology and embryology USMU [in Russian]. Bulletin of the Ural State Medical University, pp 33–35 Beylefeld AA, Hugo AP, Geyer HJ (2008) More learning and less teaching? Students’ perceptions of a histology podcast. S Afr J High Educ 22:948–956 Biswas S, Sharma S, Chakraborty S (2017) Students’ perception of present teaching method of histology— a study from Eastern part of India. Natl J Integr Res Med 8:61–65 Blake CA, Lavoie HA, Millette CF (2003) Teaching medical histology at the University of South Carolina School of Medicine: transition to virtual slides and

112 virtual microscopes. Anat Rec B New Anat 275:196– 206 Bloodgood RA (2012) Active learning: a small group histology laboratory exercise in a whole class setting utilizing virtual slides and peer education. Anat Sci Educ 5:367–373 Bloodgood RA, Ogilvie RW (2006) Trends in histology laboratory teaching in United States medical schools. Anat Rec B New Anat 289:169–175 Bohm AA, Von Davidoff M, Huber GC (1904) A textbook of histology including microscopic technic. Saunders & Company, Philadelphia, WB Bonser SP, De Permentier P, Green J, Velan GM, Adam P, Kumar RK (2013) Engaging students by emphasising botanical concepts over techniques: innovative practical exercises using virtual microscopy. J Biol Educ 47: 123–127 Bork A, Franklin S (1979) Personal computers in learning. Educ Technol 19:7–12 Borowsky AD, Glassy EF, Wallace WD, Kallichanda NS, Behling CA, Miller DV, Oswal HN, Feddersen RM, Bakhtar OR, Mendoza AE, Molden DP, Saffer HL, Wixom CR, Albro JE, Cessna MH, Hall BJ, Lloyd IE, Bishop JW, Darrow MA, Gui D, Jen KY, Walby JAS, Bauer SM, Cortez DA, Gandhi P, Rodgers MM, Rodriguez RA, Martin DR, McConnell TG, Reynolds SJ, Spigel JH, Stepenaskie SA, Viktorova E, Magari R, Wharton KA, Qiu J, Bauer TW (2020) Digital whole slide imaging compared with light microscopy for primary diagnosis in surgical pathology. Arch Pathol Lab Med 144:1245–1253 Boutonnat J, Paulin C, Faure C, Colle PE, Ronot X, Seigneurin D (2006) A pilot study in two French medical schools for teaching histology using virtual microscopy. Morphologie 90:21–25 Boyce BF (2017) An update on the validation of whole slide imaging systems following FDA approval of a system for a routine pathology diagnostic service in the United States. Biotech Histochem 92:381–389 Bracegirdle B (1977) The history of histology: a brief survey of sources. Hist Sci 15:77–101 Braun MW, Kearns KD (2008) Improved learning efficiency and increased student collaboration through use of virtual microscopy in the teaching of human pathology. Anat Sci Educ 1:240–246 Brick KE, Sluzevich JC, Cappel MA, Dicaudo DJ, Comfere NI, Wieland CN (2013) Comparison of virtual microscopy and glass slide microscopy among dermatology residents during a simulated in-training examination. J Cutan Pathol 40:807–811 Brockman RM, Taylor JM, Segars LW, Selke V, Taylor TAH (2020) Student perceptions of online and in-person microbiology laboratory experiences in undergraduate medical education. Med Educ Online 25:1710324 Broudo M, Walsh C (2002) MEDICOL: online learning in medicine and dentistry. Acad Med 77:926–927 Brown PJ, Fews D, Bell NJ (2016) Teaching veterinary histopathology: a comparison of microscopy and digital slides. J Vet Med Educ 43:13–20

M. Hortsch et al. Brueggeman MS, Swinehart C, Yue MJ, ConwayKlaassen JM, Wiesner SM (2012) Implementing virtual microscopy improves outcomes in a hematology morphology course. Clin Lab Sci 25:149–155 Buabbas AJ, Mohammad T, Ayed AK, Mallah H, Al-Shawaf H, Khalfan AM (2021) Evaluating the success of the tele-pathology system in governmental hospitals in Kuwait: an explanatory sequential mixed methods design. BMC Med Inform Decis Mak 21:229 Bulyk RY, Kushniryk OV (2020) Use of visualization tools in the educational process. Clin Exp Pathol 19: 156–160 Capo I, Andrejic Visnjic B, Miljković D, Popović M, IlicSabo J, Amidzic J, Fejsa Levakov A, Djolai MA, Lalosevic D (2017) Virtual microscopy in histology and pathology education at the Faculty of Medicine, University of Novi Sad. Med Pregl 70:371–376 Caruso MC (2021) Virtual microscopy and other technologies for teaching histology during Covid-19. Anat Sci Educ 14:19–21 Carvalho VO, Conceicao LSR, Gois MB Jr (2020) COVID-19 pandemic: beyond medical education in Brazil. J Card Surg 35:1170–1171 Chandra M (2013) Virtual microscopy—technology of the new millenium. J Odontol Res 1:1–3 Chandra M (2014) Digital pathology slides in medical education. Indian J Dermatopathol Diagn Dermatol 1: 17–20 Chang JY, Lin TC, Wang LH, Cheng FC, Chiang CP (2021) Comparison of virtual microscopy and real microscopy for learning oral pathology laboratory course among dental students. J Dent Sci 16:840–845 Chapman CM, Miller JG, Bush LC, Bruenger JA, Wysor WJ, Meininger ET, Wolf FM, Fischer TV, Beaudoin AR, Burkel WE, MacCallum DK, Fisher DL, Carlson BM (1992) ATLAS-plus: multimedia instruction in embryology, gross anatomy, and histology. Proc Annu Symp Comput Appl Med Care:712–716 Chapman JA, Lee LMJ, Swailes NT (2020) From scope to screen: the evolution of histology education. Adv Exp Med Biol 1260:75–107 Chen YK, Hsue SS, Lin DC, Wang WC, Chen JY, Lin CC, Lin LM (2008) An application of virtual microscopy in the teaching of an oral and maxillofacial pathology laboratory course. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 105:342–347 Chen C, Buch E, Wassermann T, Frehywot S, Mullan F, Omaswa F, Greysen SR, Kolars JC, Dovlo D, El Gali Abu Bakr DE, Haileamlak A, Koumare AK, OlapadeOlaopa EO (2012) A survey of sub-Saharan African medical schools. Hum Resour Health 10:4 Chen L-S, Lay Y-J, Yang C-C, Chang S-H (2015) A virtual microscope system for histology learning in education. In: 8th International Conference on Ubi-Media Computing (UMEDIA). IEEE Xplore, Colombo Cheng CL, Azhar R, Sng SH, Chua YQ, Hwang JS, Chin JP, Seah WK, Loke JC, Ang RH, Tan PH (2016) Enabling digital pathology in the diagnostic setting:

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

navigating through the implementation journey in an academic medical centre. J Clin Pathol 69:784–792 Cheng X, Ka Ho Lee K, Chang EY, Yang X (2017) The “flipped classroom” approach: stimulating positive learning attitudes and improving mastery of histology among medical students. Anat Sci Educ 10:317–327 Cheng X, Chan LK, Li H, Yang X (2020) Histology and embryology education in China: the current situation and changes over the past 20 years. Anat Sci Educ 13: 759–768 Cheng X, Chan LK, Cai H, Zhou D, Yang X (2021) Adaptions and perceptions on histology and embryology teaching practice in China during the Covid-19 pandemic. Transl Res Anat 24:1–10 Chigona A, Dagada R (2011) Adoption and use of E-learning at tertiary level in South Africa: a qualitative analysis. In: Barton SM, Hedberg J, Suzuki K (eds) Global learn Asia Pacific 2011—global conference on learning and technology. Association for the Advancement of Computing in Education (AACE), Melbourne, pp 93–101 Chimmalgi M (2018) Off-line virtual microscopy in teaching histology to the undergraduate medical students: do the benefits correlate with the learning style preferences? J Anat Soc India 67:186–192 Chong Y, Kim DC, Jung CK, Kim DC, Song SY, Joo HJ, Yi SY, Medical Informatics Study Group of the Korean Society of Pathologists (2020) Recommendations for pathologic practice using digital pathology: consensus report of the Korean Society of Pathologists. J Pathol Transl Med 54:437–452 Choomchuay N (2011) An application of virtual microscopy in the pathology laboratory teaching for undergraduate medical student. Master of Science, Chulalongkorn University, Bangkok Cogdell B, Torsney B, Stewart K, Smith RA (2012) Technological and traditional drawing approaches encourage active engagement in histology classes for science undergraduates. Biosci Educ 19:1–15 Coleman R (2006) The long-term contribution of dyes and stains to histology and histopathology. Acta Histochem 108:81–83 Coleman R (2013) The advantages of virtual microscopy for teaching histology. Ital J Anat Embryol 118:58 Collier L, Dunham S, Braun MW, O’Loughlin VD (2012) Optical versus virtual: teaching assistant perceptions of the use of virtual microscopy in an undergraduate human anatomy course. Anat Sci Educ 5:10–19 Conway C, Dobson L, O’Grady A, Kay E, Costello S, O’Shea D (2008) Virtual microscopy as an enabler of automated/quantitative assessment of protein expression in TMAs. Histochem Cell Biol 130: 447–463 Cotter JR (1997a) Computer-assisted instruction for the medical histology course at SUNY at Buffalo. Acad Med 72:S124–S126 Cotter JR (1997b) Histology on the World Wide Web: a digest of resources for students and teachers. Med Teach 19:180–184

113

Cotter JR (2001) Laboratory instruction in histology at the University at Buffalo: recent replacement of microscope exercises with computer applications. Anat Rec 265:212–221 Cracolici V, Judd R, Golden D, Cipriani NA (2019) Art as a learning tool: medical student perspectives on implementing visual art into histology education. Cureus 11:e5207 Cserneky M, Szende B, Fonyad L, Krenacs T (2009) Telepathology in Hungary. In: Kumar S, Dunn BE (eds) Telepathology. Springer, Berlin Cybulski JS, Clements J, Prakash M (2014) Foldscope: origami-based paper microscope. PLoS One 9:e98781 Daniel M, Monrad SU, Weir S, Kolars JC, Mangrulkar RS (2020) University of Michigan Medical School. Acad Med 95:S249–S253 Darici D, Reissner C, Brockhaus J, Missler M (2021) Implementation of a fully digital histology course in the anatomical teaching curriculum during COVID-19 pandemic. Ann Anat 236:151718 Das S, Saha N, Chakraborty T, Shil A (2019) Perception of students on histology learning method. IOSR J Dent Med Sci 18:11–18 Dee FR (2009) Virtual microscopy in pathology education. Hum Pathol 40:1112–1121 Dee FR, Meyerholz DK (2007) Teaching medical pathology in the twenty-first century: virtual microscopy applications. J Vet Med Educ 34:431–436 Dee FR, Lehman JM, Consoer D, Leaven T, Cohen MB (2003) Implementation of virtual microscope slides in the annual pathobiology of cancer workshop laboratory. Hum Pathol 34:430–436 Desai S, Patil R, Kothari A, Shet T, Kane S, Borges A, Chinoy R (2004) Static telepathology consultation service between Tata Memorial Centre, Mumbai and Nargis Dutt Memorial Charitable Hospital, Barshi, Solapur, Maharashtra: an analysis of the first 100 cases. Indian J Pathol Microbiol 47:480–485 Dhawan S (2020) Online learning: a panacea in the time of COVID-19 crisis. J Educ Technol Syst 49:5–22 Dhir SK, Verma D, Batta M, Mishra D (2017) E-learning in medical education in India. Indian Pediatr 54:871– 877 Diaz-Perez JA, Raju S, Echeverri JH (2014) Evaluation of a teaching strategy based on integration of clinical subjects, virtual autopsy, pathology museum, and digital microscopy for medical students. J Pathol Inform 5:25 Dickerson J, Kubasko D (2007) Digital microscopes: enhancing collaboration and engagement in science classrooms with information technologies. Contemp Issues Technol Teach Educ 7:279–292 Dittmayer C, Völcker E, Wacker I, Schröder RR, Bachmann S (2018) Modern field emission scanning electron microscopy provides new perspectives for imaging kidney ultrastructure. Kidney Int 94:625–631 Djangirova TV, Shabalova IP, Pronichev AN, Polyakov EV (2015) The virtual cytologic slides for external evaluation of quality of implementation of cytologic analyses

114 in clinical diagnostic laboratories: possibilities and perspectives [in Russian]. Klin Lab Diagn 60:29–32 Dong W, Ma B, Li H (2015) Color atlas of digitalized sections in human histology [in Chinese]. Xi’an Jiaotong University Press, Xi’an Donnelly AD, Mukherjee MS, Lyden ER, Radio SJ (2012) Virtual microscopy in cytotechnology education: application of knowledge from virtual to glass. Cytojournal 9:12 Dos Santos FS, Osako MK, Perdona GDC, Alves MG, Sales KU (2021) Virtual microscopy as a learning tool in Brazilian medical education. Anat Sci Educ 14: 408–416 Drake RL, Lowrie DJ Jr, Prewitt CM (2002) Survey of gross anatomy, microscopic anatomy, neuroscience, and embryology courses in medical school curricula in the United States. Anat Rec 269:118–122 Drake RL, McBride JM, Lachman N, Pawlina W (2009) Medical education in the anatomical sciences: the winds of change continue to blow. Anat Sci Educ 2: 253–259 Drees C, Ghebremedhin E, Hansen M (2020) Development of an interactive e-learning software “Histologie für Mediziner” for medical histology courses and its overall impact on learning outcomes and motivation. GMS. J Med Educ 37:Doc35 Du Plessis SS, Otaki F, Zaher S, Zary N, Inuwa I, Lakhtakia R (2021) Taking a leap of faith: a study of abruptly transitioning an undergraduate medical education program to distance-learning owing to the COVID-19 pandemic. JMIR Med Educ 7:e27010 Ducut E, Liu F, Avila JM, Encinas MA, Diwa M, Fontelo P (2010) Virtual microscopy in a developing country: a collaborative approach to building an image library. J eHealth Technol Appl 8:112–115 Eberle FC, Kanyildiz M, Schnabl SM, Schulz C, Hafner HM, Adam P, Breuninger H (2014) Three dimensional (3D) histology in daily routine: practical implementation and its evaluation. J Dtsch Dermatol Ges 12:1028– 1035 Egevad L, Cheville J, Evans AJ, Hornblad J, Kench JG, Kristiansen G, Leite KRM, Magi-Galluzzi C, Pan CC, Samaratunga H, Srigley JR, True L, Zhou M, Clements M, Delahunt B, Panel IPIE (2017) Pathology Imagebase—a reference image database for standardization of pathology. Histopathology 71: 677–685 Eke HN (2010) The perspective of e-learning and libraries in Africa: challenges and opportunities. Libr Rev 59: 274–290 Eng KH (2004) National University of Singapore hosts successful conference. Clin Teach 1:42–43 Essig J, Watts M, Beck Dallaghan GL, Gilliland KO (2020) InstaHisto: utilizing instagram as a medium for disseminating visual educational resources. Med Sci Educ 30:1035–1042 Evans JA, Wagner U, Santos CM, Hennighausen L (2000) The interactive web-based histology atlas system. Oncogene 19:989–991

M. Hortsch et al. Evans DJR, Bay BH, Wilson TD, Smith CF, Lachman N, Pawlina W (2020) Going virtual to support anatomy education: a STOPGAP in the midst of the Covid-19 pandemic. Anat Sci Educ 13:279–283 Faas FG, Avramut MC, Van Den Berg BM, Mommaas AM, Koster AJ, Ravelli RB (2012) Virtual nanoscopy: generation of ultra-large high resolution electron microscopy maps. J Cell Biol 198:457–469 Farah CS, Maybury TS (2009a) The e-evolution of microscopy in dental education. J Dent Educ 73:942–949 Farah CS, Maybury TS (2009b) Implementing digital technology to enhance student learning of pathology. Eur J Dent Educ 13:172–178 Farahani N, Parwani AV, Pantanowitz L (2015) Whole slide imaging in pathology: advantages, limitations, and emerging perspectives. Path Lab Med Int 7:23–33 Farahani N, Braun A, Jutt D, Huffman T, Reder N, Liu Z, Yagi Y, Pantanowitz L (2017) Three-dimensional imaging and scanning: current and future applications for pathology. J Pathol Inform 8:36 Felszeghy S, Pasonen-Seppänen S, Koskela A, Mahonen A (2017) Student-focused virtual histology education: do new scenarios and digital technology matter? MedEdPublish:1–19 Felszeghy S, Pasonen-Seppanen S, Koskela A, Nieminen P, Harkonen K, Paldanius KMA, Gabbouj S, Ketola K, Hiltunen M, Lundin M, Haapaniemi T, Sointu E, Bauman EB, Gilbert GE, Morton D, Mahonen A (2019) Using online gamebased platforms to improve student performance and engagement in histology teaching. BMC Med Educ 19: 273 Felten CL, Strauss JS, Okada DH, Marchevsky AM (1999) Virtual microscopy: high resolution digital photomicrography as a tool for light microscopy simulation. Hum Pathol 30:477–483 Fernandes CIR, Bonan RF, Bonan PRF, Leonel A, Carvalho EJA, De Castro JFL, Perez DEC (2018) Dental students’ perceptions and performance in use of conventional and virtual microscopy in oral pathology. J Dent Educ 82:883–890 Ficsor L, Varga V, Berczi L, Miheller P, Tagscherer A, Wu ML, Tulassay Z, Molnar B (2006) Automated virtual microscopy of gastric biopsies. Cytometry B Clin Cytom 70:423–431 Fidianingsih I, Wijaya DP (2015). Case-based learning and simple virtual microscopic slides in teaching histology to first year medical students. In: 12th Asia Pacific Medical Education Conference (APMEC). Singapore Filipiak K, Malinska A, Krupa D, Zabel M (2011) Innovative methods of archiving, presentation and providing access to histological sections. Adv Cell Biol 3:41–54 Foad AFA (2017) Comparing the use of virtual and conventional light microscopy in practical sessions: virtual reality in Tabuk University. J Taibah Univ Med Sci 12: 183–186 Fonseca FP, Santos-Silva AR, Lopes MA, Almeida OP, Vargas PA (2015) Transition from glass to digital slide

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

microscopy in the teaching of oral pathology in a Brazilian dental school. Med Oral Patol Oral Cir Bucal 20:e17–e22 Fontelo P, Dinino E, Johansen K, Khan A, Ackerman M (2005) Virtual microscopy: potential applications in medical education and telemedicine in countries with developing economies. In: HICSS 2005—38th Hawaii International Conference on System Sciences, IEEE Computer Society, Big Island, HI, pp 1–7 Fonyad L, Gerely L, Cserneky M, Molnar B, Matolcsy A (2010) Shifting gears higher—digital slides in graduate education—4 years experience at Semmelweis University. Diagn Pathol 5:73 Frehywot S, Vovides Y, Talib Z, Mikhail N, Ross H, Wohltjen H, Bedada S, Korhumel K, Koumare AK, Scott J (2013) E-learning in medical education in resource constrained low- and middle-income countries. Hum Resour Health 11:4 Fu B, Lin S, Zhong N, Niu H, Zhang Y, Lan Y (2013) Construction of autonomous learning material database for histological experiments based on digital sectioning [in Chinese]. China Med Educ Technol 6:672–674 Gadbury-Amyot CC, Singh AH, Overman PR (2013) Teaching with technology: learning outcomes for a combined dental and dental hygiene online hybrid oral histology course. J Dent Educ 77:732–743 Gagnon M, Inhorn S, Hancock J, Keller B, Carpenter D, Merlin T, Hearn T, Thompson P, Whalen R (2004) Comparison of cytology proficiency testing: glass slides vs. virtual slides. Acta Cytol 48:788–794 Gajewski J, Atkins S (2011) Telemedicine on the virtual silk highway: a project to improve pathology diagnosis. Proc Asia Pac Adv Netw 31:1–11 Garcia Rojo M, Garcia GB, Mateos CP, Garcia JG, Vicente MC (2006) Critical comparison of 31 commercially available digital slide systems in pathology. Int J Surg Pathol 14:285–305 Garcia Rojo M, Punys V, Slodkowska J, Schrader T, Daniel C, Blobel B (2009) Digital pathology in Europe: coordinating patient care and research efforts. Stud Health Technol Inform 150:997–1001 Gartner LP (2020) Textbook of histology. Elsevier Gatumu MK, MacMillan FM, Langton PD, Headley PM, Harris JR (2014) Evaluation of usage of virtual microscopy for the study of histology in the medical, dental, and veterinary undergraduate programs of a UK University. Anat Sci Educ 7:389–398 Gertych A, Ing N, Ma Z, Fuchs TJ, Salman S, Mohanty S, Bhele S, Velasquez-Vacca A, Amin MB, Knudsen BS (2015) Machine learning approaches to analyze histological images of tissues from radical prostatectomies. Comput Med Imaging Graph 46(Pt 2):197–208 Ghaznavi F, Evans A, Madabhushi A, Feldman M (2013) Digital imaging in pathology: whole-slide imaging and beyond. Annu Rev Pathol 8:331–359 Glatz-Krieger K, Spornitz U, Spatz A, Mihatsch MJ, Glatz D (2006) Factors to keep in mind when introducing virtual microscopy. Virchows Arch 448:248–255

115

Golchai B, Nazari N, Hassani F, Bahadori MH (2012) Computer-based E-teaching(virtual Medical Teaching) or traditional teaching: a comparison between medical and dentistry students. Proc Soc Behav Sci 47:2080– 2083 Goldberg HR, Dintzis R (2007) The positive impact of team-based virtual microscopy on student learning in physiology and histology. Adv Physiol Educ 31:261– 265 Gongora Jara H, Barcelo HA (2008) Telepathology and continuous education: important tools for pathologists of developing countries. Diagn Pathol 3(Suppl 1):S24 Google (2022) Google classroom [Online]. Google, Mountain View, CA. Available: https://edu.google. com/intl/ALL_us/products/classroom/. Accessed 18 Jan 2022 Gorelick N, Hancher M, Dixon M, Ilyushchenko S, Thau D, Moore R (2017) Google earth engine: planetary-scale geospatial analysis for everyone. Remote Sens Environ 202:18–27 Gribbin W, Wilson EA, McTaggart S, Hortsch M (2022) Histology education in an integrated, time-restricted medical curriculum: academic outcomes and students’ study adaptations. Anat Sci Educ 15:1–14 Griffith JW (1864) An elementary text-book of the microscope; including a description of the methods of preparing and mounting objects, etc. John Van Voorst, Paternoster Row, London Gu J, Ogilvie RW (2005) Virtual microscopy and virtual slides in teaching, diagnosis, and research. Taylor & Francis, Boca Raton Guiter GE, Sapia S, Wright AI, Hutchins GGA, Arayssi T (2021) Development of a remote online collaborative medical school pathology curriculum with clinical correlations, across several international sites, through the Covid-19 pandemic. Med Sci Educ 31:1–8 Guze PA (2015) Using technology to meet the challenges of medical education. Trans Am Clin Climatol Assoc 126:260–270 Hagopian A, Thompson MJ, Fordyce M, Johnson KE, Hart LG (2004) The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain. Hum Resour Health 2:17 Hamdy H, Telmesani AW, Al Wardy N, Abdel-Khalek N, Carruthers G, Hassan F, Kassab S, Abu-Hijleh M, Al-Roomi K, O’Malley K, El Din Ahmed MG, Raj GA, Rao GM, Sheikh K (2010a) Undergraduate medical education in the Gulf Cooperation Council: a multicountries study (Part 1). Med Teach 32:219–224 Hamdy H, Telmesani AW, Wardy NA, Abdel-Khalek N, Carruthers G, Hassan F, Kassab S, Abu-Hijleh M, Al-Roomi K, O’Malley K, El Din Ahmed MG, Raj GA, Rao GM, Sheikh J (2010b) Undergraduate medical education in the Gulf Cooperation Council: a multicountries study (part 2). Med Teach 32:290–295 Hande AH, Lohe VK, Chaudhary MS, Gawande MN, Patil SK, Zade PR (2017) Impact of virtual microscopy with

116 conventional microscopy on student learning in dental histology. Dent Res J (Isfahan) 14:111–116 Hang JF, Liang WY, Hsu CY, Lai CR (2015) Integrating a web-based whole-slide imaging system and online questionnaires in a national cytopathology peer comparison educational program in Taiwan. Acta Cytol 59: 278–283 Hanna MG, Monaco SE, Cuda J, Xing J, Ahmed I, Pantanowitz L (2017) Comparison of glass slides and various digital-slide modalities for cytopathology screening and interpretation. Cancer Cytopathol 125: 701–709 Harris T, Leaven T, Heidger P, Kreiter C, Duncan J, Dick F (2001) Comparison of a virtual microscope laboratory to a regular microscope laboratory for teaching histology. Anat Rec 265:10–14 Heidger PM Jr, Dee F, Consoer D, Leaven T, Duncan J, Kreiter C (2002) Integrated approach to teaching and testing in histology with real and virtual imaging. Anat Rec 269:107–112 Higazi TB (2011) Use of interactive live digital imaging to enhance histology learning in introductory level anatomy and physiology classes. Anat Sci Educ 4:78–83 Hightower JA, Boockfor FR, Blake CA, Millette CF (1999) The standard medical microscopic anatomy course: histology circa 1998. Anat Rec 257:96–101 Holaday L, Selvig D, Purkiss J, Hortsch M (2013) Preference of interactive electronic versus traditional learning resources by University of Michigan medical students during the first year histology component. Med Sci Educ 23:607–619 Hortsch M (2013) Virtual biology: teaching histology in the age of Facebook. FASEB J 27:411–413 Hortsch M (2015) “How we learn may not always be good for us”—do new electronic teaching approaches always result in better learning outcomes? Med Teach 37:507–509 Hortsch M (2016) Taking a SecondLook™ at a timeefficient self-review resource. Med Sci Educ 26:3–4 Hortsch M, Mangrulkar RS (2015) When students struggle with gross anatomy and histology: a strategy for monitoring, reviewing, and promoting student academic success in an integrated preclinical medical curriculum. Anat Sci Educ 8:478–483 Howard FM, Dolezal J, Kochanny S, Schulte J, Chen H, Heij L, Huo D, Nanda R, Olopade OI, Kather JN, Cipriani N, Grossman RL, Pearson AT (2021) The impact of site-specific digital histology signatures on deep learning model accuracy and bias. Nat Commun 12:4423 Huber GC (1892) Directions for work in histological laboratory. George Wahr (republished by the University of Michigan Library), Ann Arbor Huber GC (1900) Laboratory work in histology. George Wahr (republished by the University of Michigan Library), Ann Arbor Husmann PR, O’Loughlin VD, Braun MW (2009) Quantitative and qualitative changes in teaching histology

M. Hortsch et al. by means of virtual microscopy in an introductory course in human anatomy. Anat Sci Educ 2:218–226 Hussein IH, Raad M, Safa R, Jurjus R, Jurjus A (2015) Once upon a microscopic slide: the story of histology. J Cytol Histol 6:377 Ismail A, McMichael JR, Stoff BK (2018) Utility of international store-and-forward teledermatopathology among a cohort of mostly female patients at a tertiary referral center in Afghanistan. Int J Womens Dermatol 4:83–86 Itoh K, Ogi H (2017) Virtual microscopy system in global applications and challenges [in Japanese]. J Kyoto Prefect Univ Med 126:829–836 James CA, Wheelock KM, Woolliscroft JO (2021) Machine learning: the next paradigm shift in medical education. Acad Med 96:954–957 Jantjies M (2020) How South Africa can address digital inequalities in e-learning [Online]. The Conversation. Available: https://www.phephaufunde.org.za/wp-con tent/uploads/2020/09/How-South-Africa-can-addressdigital-inequalities-in-e-learning-The-Conversation. pdf. Accessed 6 Jan 2022 Joaquim DC, Hortsch M, Da Silva ASR, David PB, De Melo Leite ACR, Girao-Carmona VCC (2022) Digital information and communication technologies on histology learning: what to expect? An integrative review. Anat Histol Embryol 51:180–188 Johnson S, Purkiss J, Holaday L, Selvig D, Hortsch M (2015) Learning histology—dental and medical students’ study strategies. Eur J Dent Educ 19:65–73 Jurjus RA, Butera G, Krum JM, Davis MM, Mills A, Latham PS (2018) Design of an online histology and pathology atlas for medical students: an instructional aid to self-directed learning. Med Sci Educ 28:101–110 Kalinski T, Zwonitzer R, Sel S, Evert M, Guenther T, Hofmann H, Bernarding J, Roessner A (2008) Virtual 3D microscopy using multiplane whole slide images in diagnostic pathology. Am J Clin Pathol 130:259–264 Kaneko M, Konishi E, Ukimura O (2019) A practice of research using virtual slides [in Japanese]. J Kyoto Prefect Univ Med 128:595–604 Kantasiripitak C, Laohawetwanit T (2021) Embracing online virtual microscopy and web conferencing for pathology residents in Thailand: a paradigm shift in pathology education in the midst of COVID-19 pandemic. Asian Med J Altern Med 21:145–150 Kawaguchi J, Masuda T (2020) Quantitative measurement of steatosis in liver biopsy specimens using virtual microscopy [in Japanese]. J Iwate Med Assoc 72:21– 29 Kaynig V, Fischer B, Muller E, Buhmann JM (2010) Fully automatic stitching and distortion correction of transmission electron microscope images. J Struct Biol 171: 163–173 Kayser G, Kayser K (2013) Quantitative pathology in virtual microscopy: history, applications, perspectives. Acta Histochem 115:527–532

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

Kent A, Burch VC (2011) Are we addressing the health sciences education needs of sub-Saharan Africa? Med Educ 45:966–968 Khalil MK, Kirkley DL, Kibble JD (2013) Development and evaluation of an interactive electronic laboratory manual for cooperative learning of medical histology. Anat Sci Educ 6:342–350 Khushi M, Edwards G, De Marcos DA, Carpenter JE, Graham JD, Clarke CL (2013) Open source tools for management and archiving of digital microscopy data to allow integration with patient pathology and treatment information. Diagn Pathol 8:22 Kim MH, Park YS, Seo D, Lim YJ, Kim D-I, Kim CW, Kim WH (2008) Virtual microscopy as a practical alternative to conventional microscopy in pathology education. Basic Appl Pathol 1:46–48 Koch LH, Lampros JN, Delong LK, Chen SC, Woosley JT, Hood AF (2009) Randomized comparison of virtual microscopy and traditional glass microscopy in diagnostic accuracy among dermatology and pathology residents. Hum Pathol 40:662–667 Koh J, Kwak Y, Kim J, Kim WH (2020) High-throughput multiplex immunohistochemical imaging of the tumor and its microenvironment. Cancer Res Treat 52: 98–108 Koles PG, Stolfi A, Borges NJ, Nelson S, Parmelee DX (2010) The impact of team-based learning on medical students’ academic performance. Acad Med 85: 1739–1745 Kolinko Y, Maleckova A, Kochova P, Grajciarova M, Blassova T, Kural T, Trailin A, Cervenkova L, Havrankova J, Vistejnova L, Tonarova P, Moulisova V, Jirik M, Zavadakova A, Tichanek F, Liska V, Kralickova M, Witter K, Tonar Z (2022) Using virtual microscopy for the development of sampling strategies in quantitative histology and designbased stereology. Anat Histol Embryol 51:3–22 Kölliker A (1867) Handbuch der Gewebelehre des Menschen für Aerzte und Studirende [in German]. Wilhelm Engelmann, Leipzig Komao S (2020) Histology of virtual slides [in Japanese]. Japan, Yodosha Company Limited Kotze SH, Mole CG (2015) Making large class basic histology lectures more interactive: the use of drawalong mapping techniques and associated educational activities. Anat Sci Educ 8:463–470 Koury HF, Leonard CJ, Carry PM, Lee LMJ (2019) An expert derived feedforward histology module improves pattern recognition efficiency in novice students. Anat Sci Educ 12:645–654 Krajčí D, Pospíšilová E, Černochová D (2011) Methods of application of virtual slides in modern histology practical teaching. MEFANET 2011 5th international conference of Czech and Slovak faculties of medicine, focused on e-learning and medical informatics in the education of medical disciplines. MEFANET, Brno Kramer B, Pather N, Ihunwo AO (2008) Anatomy: spotlight on Africa. Anat Sci Educ 1:111–118

117

Krenacs T, Zsakovics I, Micsik T, Fonyad L, Varga SV, Ficsor L, Kiszler G, Molnar B (2010) Digital microscopy—the upcoming revolution in histopathology teaching, diagnostics, research and quality assurance. In: Méndez-Vilas A, Diaz J (eds) Microscopy: science, technology, applications and education. Badajoz, FORMATEX Krippendorf BB, Lough J (2005) Complete and rapid switch from light microscopy to virtual microscopy for teaching medical histology. Anat Rec B New Anat 285:19–25 Kruglova IA, Zinoviev SV, Utkin OV, Denisenko AN, Ilyinskaya OE, Moskvichev MA (2019) Digital image in the practice of a cytologist: experimental study [in Russian]. Russ Clin Lab Diagn 64:649–653 Kumar S, Dunn BE (eds) (2009) Telepathology. Springer, Berlin Kumar RK, Velan GM, Korell SO, Kandara M, Dee FR, Wakefield D (2004) Virtual microscopy for learning and assessment in pathology. J Pathol 204: 613–618 Kumar RK, Freeman B, Velan GM, De Permentier PJ (2006) Integrating histology and histopathology teaching in practical classes using virtual slides. Anat Rec B New Anat 289:128–133 Kunkevich A, Lozinskaya O (2019) Development of an interactive methological guide on histology using computer technologies in the SEI BSU. IX international scientific conference for young scientists, graduates, master and PhD students. Republic of Belarus, Minsk Kuo KH, Leo JM (2019) Optical versus virtual microscope for medical education: a systematic review. Anat Sci Educ 12:678–685 Lakhtakia R (2021) Virtual microscopy in undergraduate pathology education: an early transformative experience in clinical reasoning. Sultan Qaboos Univ Med J 21:428–435 Lam TP, Lam YYB (2009) Medical education reform: the Asian experience. Acad Med 84:1313–1317 Laohawetwanit T (2020) The use of virtual pathology in teaching medical students: first experience of a medical school in Thailand. MedEdPublish 9:1–10 Laurinavicius A, Raslavicus P (2012) Consequences of “going digital” for pathology professionals—entering the cloud. Stud Health Technol Inform 179:62–67 Laurinavicius A, Laurinaviciene A, Dasevicius D, Elie N, Plancoulaine B, Bor C, Herlin P (2012) Digital image analysis in pathology: benefits and obligation. Anal Cell Pathol (Amst) 35:75–78 Lazarus L, Sookrajh R, Satyapal KS (2017) Tablet technology in medical education in South Africa: a mixed methods study. BMJ Open 7:e013871 Lee SH (2005) Virtual microscopy: applications to hematology education and training. Hematology 10(Suppl 1):151–153 Lee W, Baik S (1990) Analysis of anatomy curicula of twenty-nine medical colleges in Korea [in Korean]. Korean J Med Educ 2:42–50

118 Lee KC, Mak LS (2011) Virtual electron microscopy: a simple implementation creating a new paradigm in ultrastructural examination. Int J Surg Pathol 19:570– 575 Lee LMJ, Goldman HM, Hortsch M (2018) The virtual microscopy database-sharing digital microscope images for research and education. Anat Sci Educ 11: 510–515 Lee BC, Hsieh ST, Chang YL, Tseng FY, Lin YJ, Chen YL, Wang SH, Chang YF, Ho YL, Ni YH, Chang SC (2020) A web-based virtual microscopy platform for improving academic performance in histology and pathology laboratory courses: a pilot study. Anat Sci Educ 13:743–758 Lehmann HP, Freedman JA, Massad J, Dintzis RZ (1999) An ethnographic, controlled study of the use of a computer-based histology atlas during a laboratory course. J Am Med Inform Assoc 6:38–52 Lei LW, Winn W, Scott C, Farr A (2005) Evaluation of computer-assisted instruction in histology: effect of interaction on learning outcome. Anat Rec B New Anat 284:28–34 Letseka M, Letseka MM, Pitsoe V (2018) The challenges of e-learning in South Africa. In: Sinecen M (ed) Trends in e-learning. IntechOpen, London Li Y (2016) Implementation and thoughts of virtual microscopy system in teaching histology at home and abroad [in Chinese]. Basic Med Educ 18:651–653 Li Y, Zhong J, Liu C, Guo Q et al (2018) The application of digital slide based virtual human histology experiment teaching [in Chinese]. Chin J Histochem Cytochem 27:500–502 Li Y, Wang F, Zheng H, Liu L, Zhou G (2019) Application of student-centered strategies in histology laboratory course [in Chinese]. Basic Med Educ 21:858–860 Linder E, Lundin M, Thors C, Lebbad M, WinieckaKrusnell J, Helin H, Leiva B, Isola J, Lundin J (2008) Web-based virtual microscopy for parasitology: a novel tool for education and quality assurance. PLoS Negl Trop Dis 2:e315 Liu S, Bing L, Li L, Ma B, Wang F, Szhang Y, Hao A, Guo Y (2021) Application and experience of computer examination system for morphology based on virtual slide library [in Chinese]. Chin J Anat 44:65–67 Lopez AM, Graham AR, Barker GP, Richter LC, Krupinski EA, Lian F, Grasso LL, Miller A, Kreykes LN, Henderson JT, Bhattacharyya AK, Weinstein RS (2009) Virtual slide telepathology enables an innovative telehealth rapid breast care clinic. Hum Pathol 40: 1082–1091 Lowrie DJ (2020) Histology: an essential textbook. Thieme Publisher, New York Lundin M, Lundin J, Helin H, Isola J (2004) A digital atlas of breast histopathology: an application of web based virtual microscopy. J Clin Pathol 57:1288–1291 Lundin M, Szymas J, Linder E, Beck H, De Wilde P, Van Krieken H, Garcia Rojo M, Moreno I, Ariza A, Tuzlali S, Dervisoglu S, Helin H, Lehto VP, Lundin J (2009) A European network for virtual microscopy—

M. Hortsch et al. design, implementation and evaluation of performance. Virchows Arch 454:421–429 MacPherson BR, Brueckner JK (2003) Enhancing the dental histology curriculum using computer technology. J Dent Educ 67:359–365 Malami SA (2011) Recent advances in telepathology in the developing world. In: Graschew G, Roelofs TA (eds) Advances in telemedicine: applications in various medical disciplines and geographical regions. Intech Open Access Publisher Marchevsky AM, Relan A, Baillie S (2003a) Selfinstructional “virtual pathology” laboratories using web-based technology enhance medical school teaching of pathology. Hum Pathol 34:423–429 Marchevsky AM, Wan Y, Thomas P, Krishnan L, EvansSimon H, Haber H (2003b) Virtual microscopy as a tool for proficiency testing in cytopathology: a model using multiple digital images of Papanicolaou tests. Arch Pathol Lab Med 127:1320–1324 Marchevsky AM, Khurana R, Thomas P, Scharre K, Farias P, Bose S (2006) The use of virtual microscopy for proficiency testing in gynecologic cytopathology: a feasibility study using ScanScope. Arch Pathol Lab Med 130:349–355 Mars M, McLean M (1996) Students’ perceptions of a multimedia computer-aided instruction resource in histology. S Afr Med J 86:1098–1102 Maske SS, Kamble PH, Kataria SK, Raichandani L, Dhankar R (2018) Feasibility, effectiveness, and students’ attitude toward using WhatsApp in histology teaching and learning. J Educ Health Promot 7:158 Maybury T, Farah CS (2009) Perspective: electronic systems of knowledge in the world of virtual microscopy. Acad Med 84:1244–1249 Mazzarello P (1999) A unifying concept: the history of cell theory. Nat Cell Biol 1:E13–E15 McBride JM, Drake RL (2018) National survey on anatomical sciences in medical education. Anat Sci Educ 11:7–14 McDaniel MJ, Russell GB, Crandall SJ (2018) Innovative strategies for clinical microscopy instruction: virtual versus light microscopy. J Physician Assist Educ 29: 109–114 McEnery KW, Roth SM, Kelley LK, Hirsch KR, Menton DN, Kelly EA (1995) A method for interactive medical instruction utilizing the World Wide Web. Proc Annu Symp Comput Appl Med Care:502–507 McLean M (2001) Web pages: an effective method of providing CAI resource material in histology. Med Teach 23:263–269 McMillan PJ (2001) Exhibits facilitate histology laboratory instruction: student evaluation of learning resources. Anat Rec 265:222–227 Meng J, Love R, Rude S, Martzen MR (2021) Enhancing student learning by integrating anatomy in pathology teaching. Med Sci Educ 31:1283–1286 Merk M, Knuechel R, Perez-Bouza A (2010) Web-based virtual microscopy at the RWTH Aachen University:

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

didactic concept, methods and analysis of acceptance by the students. Ann Anat 192:383–387 Mescher AL (2018) Junqueira’s basic histology. McGraw Hill—Lange Michaels JE, Allred K, Bruns C, Lim W, Lowrie DJ Jr, Hedgren W (2005) Virtual laboratory manual for microscopic anatomy. Anat Rec B New Anat 284:17– 21 Michelo C, Zulu JM, Simuyemba M, Andrews B, Katubulushi M, Chi B, Njelesani E, Vwalika B, Bowa K, Maimbolwa M, Chipeta J, Goma F, Nzala S, Banda S, Mudenda J, Ahmed Y, Hachambwa L, Wilson C, Vermund S, Mulla Y (2017) Strengthening and expanding the capacity of health worker education in Zambia. Pan Afr Med J 27: 92 Mikula S, Trotts I, Stone JM, Jones EG (2007) Internetenabled high-resolution brain mapping and virtual microscopy. NeuroImage 35:9–15 Mills PC, Bradley AP, Woodall PF, Wildermoth M (2007) Teaching histology to first-year veterinary science students using virtual microscopy and traditional microscopy: a comparison of student responses. J Vet Med Educ 34:177–182 Mione S, Bacher K, Thierens H, Cornelissen M (2011) Virtual electron microscopy in cell biology. Microsc Res Tech 74:251–256 Mione S, Valcke M, Cornelissen M (2013) Evaluation of virtual microscopy in medical histology teaching. Anat Sci Educ 6:307–315 Molnar B, Berczi L, Diczhazy C, Tagscherer A, Varga SV, Szende B, Tulassay Z (2003) Digital slide and virtual microscopy based routine and telepathology evaluation of routine gastrointestinal biopsy specimens. J Clin Pathol 56:433–438 Monekosso GL (2014) A brief history of medical education in sub-Saharan Africa. Acad Med 89:S11–S15 Mullan F, Frehywot S, Omaswa F, Buch E, Chen C, Greysen SR, Wassermann T, Abubakr DE, Awases M, Boelen C, Diomande MJ, Dovlo D, Ferro J, Haileamlak A, Iputo J, Jacobs M, Koumare AK, Mipando M, Monekosso GL, Olapade-Olaopa EO, Rugarabamu P, Sewankambo NK, Ross H, Ayas H, Chale SB, Cyprien S, Cohen J, Haile-MariamT, Hamburger E, Jolley L, Kolars JC, Kombe G, Neusy AJ (2011) Medical schools in sub-Saharan Africa. Lancet 377:1113–1121 Multon S, Pesesse L, Weatherspoon A, Florquin S, van de Poel J-F, Martin P, Vincke G, Hoyoux R, Maree R, Verpoorten D, Bonnet P, Quatresooz P, Defaweux V (2018) Un « Massive Open Online Course » (MOOC) sur des travaux pratiques en histologie : un objectif, un outil, un public varié ! Retour sur une première expérience [in French]. Ann Pathol 38:76–84 Muñoz MS (2018) Uso de laboratorios virtuales para la enseñanza de la histoembriología humana en la carrera de Enfermería de la Universidad de las Américas [in Spanish]. Rev Educ Las Am 7:56–72

119

Nahal A, Batac CMO, Slaw RJ, Bauer TW (2018) Setting up an ePathology service at Cleveland clinic Abu Dhabi: joint collaboration with Cleveland Clinic, United States. Arch Pathol Lab Med 142:1216–1222 Nakayama I, Matsumura T, Kamataki A, Uzuki M, Saito K, Hobbs J, Akasaka T, Sawai T (2012) Development of a teledermatopathology consultation system using virtual slides. Diagn Pathol 7:177 Nasimudeen R (2016) Cheap device to capture images/ videos with mobile cameras/point and shoot cameras [Online]. Kozhikode, Kerala. https://www.youtube. com/watch?v=WbpSQCUPy18. Accessed 28 Nov 2021 Nauhria S, Ramdass P (2019) Randomized cross-over study and a qualitative analysis comparing virtual microscopy and light microscopy for learning undergraduate histopathology. Indian J Pathol Microbiol 62: 84–90 Nelson D, Ziv A, Bandali KS (2012) Going glass to digital: virtual microscopy as a simulation-based revolution in pathology and laboratory science. J Clin Pathol 65:877–881 Nessi De Aviñón AC, Bengtsson MC (1990) The mouse spleen white pulp response to continuous hypoxia. A digital image processing analysis. Acta Physiol Pharm Latinoam 40:309–318 Ni H, Wu M, Jiang J, Xu S, Li L, Wang Y, Li S, Xiong J (2019) Research on the present situation of histology teaching based on digital slides and the function of in-depth teaching feedback [in Chinese]. Basic Med Educ 21:983–985 Nivala M, Lehtinen E, Helle L, Kronqvist P, Paranko J, Saljo R (2013) Histological knowledge as a predictor of medical students’ performance in diagnostic pathology. Anat Sci Educ 6:361–367 NMC (2018) Competency based undergraduate curriculum for the Indian medical graduate [Online]. Medical Council of India. Available: https://www.nmc.org.in/ wp-content/uploads/2020/01/UG-Curriculum-Vol-I. pdf. Accessed 28 Nov 2021 O’Connor Grochowski C, Halperin EC, Buckley EG (2007) A curricular model for the training of physician scientists: the evolution of the Duke University School of Medicine curriculum. Acad Med 82:375–382 Ordi O, Bombi JA, Martinez A, Ramirez J, Alos L, Saco A, Ribalta T, Fernandez PL, Campo E, Ordi J (2015) Virtual microscopy in the undergraduate teaching of pathology. J Pathol Inform 6:1 Orth J (1878) Cursus der Normalen Histologie zur Einführung in den Gebrauch des Mikroskopes sowie in das Practische Stadium der Gewebelehre [in German]. August Hischwald, Berlin Ostrin Z, Duschenkov V (2016) The pedagogical value of mobile devices and content-specific application software in the A&P laboratory. HAPS Educ 20:97–103 Ostrin Z, Dushenkov V (2017) Pulling the plug on microscopes in the anatomy and physiology laboratory. HAPS Educ 21:112–118

120 Ozluk Y, Blanco PL, Mengel M, Solez K, Halloran PF, Sis B (2012) Superiority of virtual microscopy versus light microscopy in transplantation pathology. Clin Transpl 26:336–344 Pachame AV, Portiansky EL (2017) Virtual microscopy: a new technological tool for teaching histology and pathology. Analecta Vet 37:28–32 Pagni F, Bono F, Di Bella C, Faravelli A, Cappellini A (2011) Virtual surgical pathology in underdeveloped countries: the Zambia Project. Arch Pathol Lab Med 135:215–219 Painter SD (1994) Microanatomy courses in U.S. and Canadian medical schools, 1991–92. Acad Med 69: 143–147 Paltas Quimis EL (2020) Digitization of laboratory samples in the area of cytology in Latin America: a systematic mapping [in Spanish]. Universidad Politecnica Salesiana Sede Quito Park SJ, Komiyama Y, Suemori H, Umezawa A, Nakai K (2016) OpenTein: a database of digital whole-slide images of stem cell-derived teratomas. Nucleic Acids Res 44:D1000–D1004 Paulsen FP, Eichhorn M, Brauer L (2010) Virtual microscopy-The future of teaching histology in the medical curriculum? Ann Anat 192:378–382 Pawlina W, Ross MH (2018) Histology—a text and atlas. LWW, Wolters Kluwer Health Pichat J, Iglesias JE, Yousry T, Ourselin S, Modat M (2018) A survey of methods for 3D histology reconstruction. Med Image Anal 46:73–105 Popko S, Aksamytieva M, Yevtushenko V (2021) Experience of application of modern innovative teaching methods in higher medical school studying the discipline “Histology, cytology and embryology”. In: II International Multidisciplinary Scientific and Theoretical Conference. European Scientific Platform, Athens, pp 38–40 Pospíšilová E, Černochová D, Lichnovská R, Erdösová B, Krajčí D (2013) Application and evaluation of teaching practical histology with the use of virtual microscopy. Diagn Pathol 8:S7 Potaliya P, Dixit SG, Ghatak S (2017) Impact of teambased virtual microscopy on student learning in histology. Experimental Biology 2017 Meeting. FASEB J, Chicago Prakash R, Prakash K (2019) Virtual microscopy made economical and effortless using the Foldscope and a smartphone with screen mirroring. J Oral Maxillofac Pathol 23:292–294 Pratt RL (2009) Are we throwing histology out with the microscope? A look at histology from the physician’s perspective. Anat Sci Educ 2:205–209 Prober CG, Norden JG (2021) Learning alone or learning together: is it time to reevaluate teacher and learner responsibilities? Acad Med 96:170–172 Racoceanu D, Loménie N, Roux L (2011) Cognitive virtual microscopy: a cognition-driven visual explorer for

M. Hortsch et al. histopathology—the MICO ANR TecSan 2010 initiative. BMC Proc 5:P77 Raja S (2010) Virtual microscopy as a teaching tool adjuvant to traditional microscopy. Med Educ 44:1126 Ravelli RB, Kalicharan RD, Avramut MC, Sjollema KA, Pronk JW, Dijk F, Koster AJ, Visser JT, Faas FG, Giepmans BN (2013) Destruction of tissue, cells and organelles in type 1 diabetic rats presented at macromolecular resolution. Sci Rep 3:1804 Rege N (2020) Towards competency-based learning in medical education: building evidence in India. J Postgrad Med 66:9–10 Reis S, Glick SM, Urkin J, Gilbey P (2017) The medical education system in Israel. Lancet 389:2570–2574 Richards PA, Richards PD, Coetzee HL, Soley JT (2000) The optical microscope—en route to extinction? J Audiov Media Med 23:113–118 Rodrigues-Fernandes CI, Speight PM, Khurram SA, Araujo ALD, Perez D, Fonseca FP, Lopes MA, De Almeida OP, Vargas PA, Santos-Silva AR (2020) The use of digital microscopy as a teaching method for human pathology: a systematic review. Virchows Arch 477:475–486 Rodriguez CLV (2014) Teaching methodologies for meaningful histology learning [in Spanish]. Rev Digit Univ 15:1–16 Rojas M, Cuevas F, Smok C, Roa I, Conei D, Prieto R, Del Sol M (2020) Studying embryonic and fetal development with the virtual microscope! in the times of Covid-19 [in Spanish]. Int J Morphol 38:1296–1301 Rojo MG (2015) Historia de la Telepatología en Latinoamérica [in Spanish]. Rev Asoc Iberoam Telesal Telemed 2:1–8 Romer DJ, Suster S (2003) Use of virtual microscopy for didactic live-audience presentation in anatomic pathology. Ann Diagn Pathol 7:67–72 Rosai J (2007) Why microscopy will remain a cornerstone of surgical pathology. Lab Investig 87:403–408 Rosas C, Rubi R, Donoso M, Uribe S (2012) Dental students’ evaluations of an interactive histology software. J Dent Educ 76:1491–1496 Rosenberg H, Kermalli J, Freeman E, Tenenbaum H, Locker D, Cohen H (2006) Effectiveness of an electronic histology tutorial for first-year dental students and improvement in “normalized” test scores. J Dent Educ 70:1339–1345 Rossner M, Rossner F, Zwonitzer R, Suss T, Hofmann H, Roessner A, Kalinski T (2012) Pathowiki. A free expert database for pathology. Pathologe 33:124–128 Roth JA, Wilson TD, Sandig M (2015) The development of a virtual 3D model of the renal corpuscle from serial histological sections for E-learning environments. Anat Sci Educ 8:574–583 Saalfeld S, Cardona A, Hartenstein V, Tomancak P (2009) CATMAID: collaborative annotation toolkit for massive amounts of image data. Bioinformatics 25:1984– 1986

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

Saco A, Bombi JA, Garcia A, Ramirez J, Ordi J (2016) Current status of whole-slide imaging in education. Pathobiology 83:79–88 Sakai (2021). Available: https://www.sakailms.org. Accessed 9 Mar 2022 Samueli B, Sror N, Jotkowitz A, Taragin B (2020) Remote pathology education during the COVID-19 era: crisis converted to opportunity. Ann Diagn Pathol 49: 151612 Sander B, Golas MM (2013) HistoViewer: an interactive e-learning platform facilitating group and peer group learning. Anat Sci Educ 6:182–190 Sareen R (2017) Telepathology in developing countries—the cloud with silver lining. Health Care Curr Rev 5:1–3 Sawai T (2009) Telepathology in Japan. In: Kumar S, Dunn BE (eds) Telepathology. Springer, Berlin Sawai T, Kamataki A, Uzuki M, Ishida K, Hanasaka T, Ochi K, Hashimoto T, Kubo T, Morikawa A, Ochi T, Tohyama K (2013a) Serial block-face scanning electron microscopy combined with double-axis electron beam tomography provides new insight into cellular relationships. Microscopy (Oxf) 62:317–320 Sawai T, Uzuki M, Miura Y, Kamataki A, Matsumura T, Saito K, Kurose A, Osamura YR, Yoshimi N, Kanno H, Moriya T, Ishida Y, Satoh Y, Nakao M, Ogawa E, Matsuo S, Kasai H, Kumagai K, Motoda T, Hopson N (2013b) World’s first telepathology experiments employing WINDS ultrahigh-speed internet satellite, nicknamed “KIZUNA”. J Pathol Inform 4:24 Schaffer J (1920) Vorlesungen über Histologie und Histogenese nebst Bemerkungen über Histotechnik und das Mikroskop [in German]. Wilhelm Engelmann, Leipzig Schmidt P (2013) Digital learning programs—competition for the classical microscope? GMS Z Med Ausbild 30: Doc8 Schmidt C, Reinehr M, Leucht O, Behrendt N, Geiler S, Britsch S (2011) MyMiCROscope: intelligent virtual microscopy in a blended learning model at Ulm University. Ann Anat 193:395–402 Schwann T (1838) Ueber die Analogie in der Structur und dem Wachsthum der Thiere und Pflanzen [in German]. Neue Notizen aus dem Gebiete der Natur- und Heilkunde, 5, Jan: 33–36; 1838; Feb:25–29; 1838; Apr: 21–23 Scoville SA, Buskirk TD (2007) Traditional and virtual microscopy compared experimentally in a classroom setting. Clin Anat 20:565–570 Scudder DR, Sherry AD, Jarrett RTSF, Kuhn AW, Fleming AE (2019) Fundamental curriculum change with 1-year pre-clerkship phase and effect on stress associated with residency specialty selection. Med Sci Educ 29:1033–1042 Sekhri K (2013) Technology-assisted education: virtual microscopy—a step towards revolution in medical education. J Res Med Educ Ethics 3:23–28

121

Selvig D, Holaday LW, Purkiss J, Hortsch M (2015) Correlating students’ educational background, study habits, and resource usage with learning success in medical histology. Anat Sci Educ 8:1–11 Sensu S, Teke O, Demirci M, Kutlu S, Genc BN, Ayalti S, Gurbuz YS, Erdogan N (2020) Telepathology in medical education: integration of digital microscopy in distance pathology education during COVID-19 pandemic. J Med Sci Clin Res 8:536–543 Shanmugaratnam K (2007) Happenings in histopathology—a post-World War II perspective. Ann Acad Med Singap 36:691–697 Shastri D, Anand A, Ravichandran D, Samraj T (2016) Virtual microscopy: here to stay? Natl J Basic Med Sci 6:35–38 Sieben A, Oparka R, Erolin C (2017) Histology in 3D: development of an online interactive student resource on epithelium. J Vis Commun Med 40:58–65 Silage DA, Gil J (1985) Digital image tiles: a method for the processing of large sections. J Microsc 138:221– 227 Simok AA, Hadie SNH, Abdul Manan H, Yusoff MSB, Mohd Noor NF, Asari MA, Kasim F (2019) The impact of virtual microscopy on medical students’ intrinsic motivation. Educ Med J 11:47–59 Sims MH, Mendis-Handagama C, Moore RN (2007) Virtual microscopy in a veterinary curriculum. J Vet Med Educ 34:416–422 Slodkowska J, Chyczewski L, Wojciechowski M (2008) Virtual slides: application in pulmonary pathology consultations. Folia Histochem Cytobiol 46:121–124 Sokol E, Kramer D, Diercks GFH, Kuipers J, Jonkman MF, Pas HH, Giepmans BNG (2015) Large-scale electron microscopy maps of patient skin and mucosa provide insight into pathogenesis of blistering diseases. J Invest Dermatol 135:1763–1770 Song JS, Yi SY, Oh HE (2006) Experimental production and implementation of the pathology laboratory teaching material using virtual microscope. Korean J Med Educ 18:193–201 Song D-Y, Oh S-P, Lee J-H, Yu H-N, Woo R-S, Lee M-Y, Baik T-K (2010) Development of human neuro-digital slides and neuro-atlas for neuroscience tutorial I (spinal cord and brain stem) [in Korean]. Korean J Phys Anthropol 23:177–186 Song Y, Ding Y, Ren X, Liu B, Ma H (2021) Experience in on-line teaching and examining of histological experiments based on digital slices, Rain Class and QQ Group Class [in Chinese]. Chin J Histochem Cytochem 30:102–106 Sood R (2008) Medical education in India. Med Teach 30: 585–591 Sorensen RL, Brelje TC (2021) Histology guide [Online]. Available: https://histologyguide.com. Accessed 3 Dec 2021 Staniszewski W (2009) Virtual microscopy, data management and image analysis in Aperio ScanScope system. Folia Histochem Cytobiol 47:699–701

122 Steinberg DM, Ali SZ (2001) Application of virtual microscopy in clinical cytopathology. Diagn Cytopathol 25:389–396 Stewart J 3rd, Bevans-Wilkins K, Bhattacharya A, Ye C, Miyazaki K, Kurtycz DF (2008) Virtual microscopy: an educator’s tool for the enhancement of cytotechnology students’ locator skills. Diagn Cytopathol 36:363– 368 Stewart SM, Dowers KL, Cerda JR, Schoenfeld-Tacher RM, Kogan LR (2014) Microscope use in clinical veterinary practice and potential implications for veterinary school curricula. J Vet Med Educ 41:331–336 Supe A, Burdick WP (2006) Challenges and issues in medical education in India. Acad Med 81:1076–1080 Szymas J, Lundin M (2011) Five years of experience teaching pathology to dental students using the WebMicroscope. Diagn Pathol 6(Suppl 1):S13 Takizawa T, Goto T, Ishibashi O, Luo S-S, Ishikawa T, Mori M, Ishikawa G, Takeshita T, Takizawa T (2008) Virtual microscopy of human full-term placenta: a new teaching tool for anatomy education [in Japanese]. J Med Assoc Nippon Med School 4:170–171 Tauber Z, Cizkova K, Lichnovska R, Lacey H, Erdosova B, Zizka R, Kamarad V (2019) Evaluation of the effectiveness of the presentation of virtual histology slides by students during classes. Are there any differences in approach between dentistry and general medicine students? Eur J Dent Educ 23:119–126 Tauber Z, Lacey H, Lichnovska R, Erdosova B, Zizka R, Sedy J, Cizkova K (2021a) Students preparedness, learning habits and the greatest difficulties in studying Histology in the digital era: a comparison between students of general and dental schools. Eur J Dent Educ 25:371–376 Tauber Z, Lichnovska R, Erdosova B, Zizka R, Cizkova K (2021b) Modernized didactic techniques and their impact on the teaching of histology by means of virtual microscopy. Interdiscip J Virtual Learn Med Sci 12: 162–168 Tauber Z, Lichnovska R, Erdosova B, Zizka R, Cizkova K (2021c) Teaching histology in the age of virtual microscopy and e-resources: is a tailored approach to domestic and international students warranted? Interdiscip J Virtual Learn Med Sci 12:97–105 Telang A, Jong N, Dalen JV (2016) Media matter: the effect of medium of presentation on student’s recognition of histopathology. J Clin Diagn Res 10:JC01– JC05 Teodorovic I, Isabelle M, Carbone A, Passioukov A, Lejeune S, Jamine D, Therasse P, Gloghini A, Dinjens WN, Lam KH, Oomen MH, Spatz A, Ratcliffe C, Knox K, Mager R, Kerr D, Pezzella F, Van Damme B, Van De Vijver M, Van Boven H, Morente MM, Alonso S, Kerjaschki D, Pammer J, LopezGuerrero JA, Llombart Bosch A, Van Veen EB, Oosterhuis JW, Riegman PH (2006) TuBaFrost 6: virtual microscopy in virtual tumour banking. Eur J Cancer 42:3110–3116

M. Hortsch et al. Tg Muda TFM, Rushaidhi M, Choy KW, Dhamodharan J, Abdul Ghafar N, Wong KH, Abas R, Teoh SL, Hadie SNH (2021) Anatomy teaching and learning in Malaysia during the COVID-19 pandemic. Educ Med J 13:71–81 Thompson AR, Lowrie DJ Jr (2017) An evaluation of outcomes following the replacement of traditional histology laboratories with self-study modules. Anat Sci Educ 10:276–285 Tian Y, Xiao W, Li C, Liu Y, Qin M, Wu Y, Xiao L, Li H (2014) Virtual microscopy system at Chinese medical university: an assisted teaching platform for promoting active learning and problem-solving skills. BMC Med Educ 14:74 Titford M (2005) The long history of hematoxylin. Biotech Histochem 80:73–78 Titford M (2006) A short history of histopathology technique. J Histotechnol 29:99–110 Titipungal T (2015) Virtual microscopy fosters higher learning capability for medical students over optical microscopy in a pathology laboratory course. Proceedings of the association for medical education in Europe. AMEE, Glascow Toyoda Y, Eda H (2014) A survey of the current situation of pathologists and development of a consultation network using virtual slides [in Japanese]. Off J Jpn Prim Care Assoc 37:244–248 Travis LD (2015) Histology resources. J Electron Resour Med Libr 12:126–133 Trelease RB, Nieder GL, Dorup J, Hansen MS (2000) Going virtual with quicktime VR: new methods and standardized tools for interactive dynamic visualization of anatomical structures. Anat Rec 261:64–77 Triola MM, Holloway WJ (2011) Enhanced virtual microscopy for collaborative education. BMC Med Educ 11:4 Tuchman AM (1993) Science, medicine and the state in Germany, the case of Baden, 1815–1871. Oxford University Press, New York Tuominen VJ, Isola J (2009) The application of JPEG2000 in virtual microscopy. J Digit Imaging 22:250–258 Uesugi N, Shimazu Y, Kikuchi K, Nagata M (2016) Age-related renal microvascular changes: evaluation by three-dimensional digital imaging of the human renal microcirculation using virtual microscopy. Int J Mol Sci 17:1831 UMMS (2021) University of Michigan Histology Website [Online]. Available: http://histology.medicine.umich. edu/. Accessed 26 Jan 2022 Vainer B, Mortensen NW, Poulsen SS, Sorensen AH, Olsen J, Saxild HH, Johansen FF (2017) Turning microscopy in the medical curriculum digital: experiences from the faculty of health and medical sciences at University of Copenhagen. J Pathol Inform 8:11 Vali-Betts E, Krause KJ, Dubrovsky A, Olson K, Graff JP, Mitra A, Datta-Mitra A, Beck K, Tsirigos A, Loomis C, Neto AG, Adler E, Rashidi HH (2021) Effects of image quantity and image source variation

5

Virtual Microscopy Goes Global: The Images Are Virtual and the Problems Are Real

on machine learning histology differential diagnosis models. J Pathol Inform 12:5 Van Zuylen J (1981) The microscopes of Antoni van Leeuwenhoek. J Microsc 121:309–328 VMD (2022) Virtual microscopy database [Online]. American Association for Anatomy. Available: https://www.virtualmicroscopydatabase.org. Accessed 11 Mar 2022 Weaker FJ, Herbert DC (2009) Transition of a dental histology course from light to virtual microscopy. J Dent Educ 73:1213–1221 Weinstein RS, Graham AR, Richter LC, Barker GP, Krupinski EA, Lopez AM, Erps KA, Bhattacharyya AK, Yagi Y, Gilbertson JR (2009) Overview of telepathology, virtual microscopy, and whole slide imaging: prospects for the future. Hum Pathol 40: 1057–1069 Westerkamp D, Gahm T (1993) Non-distorted assemblage of the digital images of adjacent fields in histological sections. Anal Cell Pathol 5:235–247 Wienert S, Heim D, Saeger K, Stenzinger A, Beil M, Hufnagl P, Dietel M, Denkert C, Klauschen F (2012) Detection and segmentation of cell nuclei in virtual microscopy images: a minimum-model approach. Sci Rep 2:503 Williams CD, Pitchforth EL, O’Callaghan C (2010) Computers, the Internet and medical education in Africa. Med Educ 44:485–488 Wilson AB, Taylor MA, Klein BA, Sugrue MK, Whipple EC, Brokaw JJ (2016) Meta-analysis and review of learner performance and preference: virtual versus optical microscopy. Med Educ 50:428–440 Wilson AB, Brown KM, Misch J, Miller CH, Klein BA, Taylor MA, Goodwin M, Boyle EK, Hoppe C, Lazarus MD (2019) Breaking with tradition: a scoping metaanalysis analyzing the effects of student-centered learning and computer-aided instruction on student performance in anatomy. Anat Sci Educ 12:61–73 Xing W, Mei C, Feng R (2019) Construction and application of digital slide network teaching system in histology courses. In: Long S, Dhillon BS (eds) 18th international conference on man-machine-environment system engineering, 2019. Springer Nature, Singapore, pp 195–200 Xu CJ (2013) Is virtual microscopy really better for histology teaching? Anat Sci Educ 6:138 Yamanaka N (2010) A new approach in the education of histology by application of the virtual microscope [in Japanese]. Rehabilitation science: memoirs of the Tohoku Bunka Gakuen University Faculty of Medical Science & Welfare, Department of Rehabilitation 6: 51–56 Ye C, Li H, Yang S (2008) Application of digital slides in morphology experimental teaching [in Chinese]. Basic Med Educ 10:497–499 Yen P-Y, Hollar MR, Griffy H, Lee LMJ (2014) Students’ expectations of an online histology course: a qualitative study. Med Sci Educ 24:75–82

123

Yen SGS, Jalani SAM, Rushlan MAA, Hadie SNH, Minhat HS, Abas R (2021) Anatomy education environment among pre-clinical medical students in Universiti Putra Malaysia using anatomy education environment measurement inventory. Educ Med J 13: 21–29 Yohannan DG, Oommen AM, Umesan KG, Raveendran VL, Sreedhar LSL, Anish TSN, Hortsch M, Krishnapillai R (2019) Overcoming barriers in a traditional medical education system by the stepwise, evidence-based introduction of a modern learning technology. Med Sci Educ 29:803–817 Young B, O’Dowd G, Woodford P (2013) Wheater’s functional histology. Elsevier Churchill Livingstone, Philadelphia Zaidi NB, Hwang C, Scott S, Stallard S, Purkiss J, Hortsch M (2017) Climbing Bloom’s taxonomy pyramid: lessons from a graduate histology course. Anat Sci Educ 10:456–464 Zalat MM, Hamed MS, Bolbol SA (2021) The experiences, challenges, and acceptance of e-learning as a tool for teaching during the COVID-19 pandemic among university medical staff. PLoS One 16: e0248758 Zandona C, Budel V, Larsimont D, Petein M, Gasperin P, Pasteels JL, Kiss, R. (1994) Digital cell image analysis of Feulgen-stained nuclei from human papillary, medullary, colloid, lobular and comedocarcinomas of the breast. Anticancer Res 14:2173–2182 Zayachkivska O (2018) Digital technology in teaching medical students [in Ukrainian]. Pratsі NTSH Med Sci 52:57–64 Zhang H, Liu D, Lang W, Zhang M, Yao H, Wang Y, Lian J, Sun L (2018) The application of flipped class based on MOOC in the teaching of histology and embryology [in Chinese]. J Med Educ Res 17:1126– 1129 Zhang W, Li S, Song X, Liang Y (2020) The practice and evaluation of the introduction of flipped teaching in histology laboratory course [in Chinese]. Basic Med Educ 22:729–733 Zhong Y, Sun W, Zhou L, Tang M, Zhang W, Xu J, Jiang Y, Liu L, Xu Y (2021) Application of remote online learning in oral histopathology teaching in China. Med Oral Patol Oral Cir Bucal 26:e533–e540 Zureick AH, Burk-Rafel J, Purkiss JA, Hortsch M (2018) The interrupted learner: how distractions during live and video lectures influence learning outcomes. Anat Sci Educ 11:366–376

Michael Hortsch, PhD, is a Professor of Cell and Developmental Biology and of Learning Health Sciences at the University of Michigan Medical School in Ann Arbor, MI, USA. He has been teaching histology to his students at the University of Michigan for over 30 years. His research addresses the use of e-learning modalities by educators and learners.

124

M. Hortsch et al.

Nii Koney-Kwaku Koney, PhD, is a Lecturer at the University of Ghana Medical School, Korle Bu, Ghana. He has been involved in anatomy education since 2010 and is interested in introducing virtual microscopy to augment the traditional teaching of histology in Ghana. His research activities involve the use of technology in African medical education.

Yan Li, PhD, is an Associate Professor in the Department of Anatomy, Histology and Embryology, School of Basic Medical Science at Fudan University in Shanghai, China. She has taught histology and embryology for 22 years. Her goal is to improve teaching and student learning experiences with the help of new teaching strategies and technologies.

Aswathy Maria Oommen, MBBS, MS, is an Assistant Professor in Anatomy at Government Medical College Thiruvananthapuram, Kerala, India. She has been teaching medical students for 20 years. Her main interests are to improve the standards of medical education and to motivate her students.

Ana Caroline Leite, PhD, is a Professor of Pathology at the University of International Integration of AfroBrazilian Lusophony in Redenção, CE, Brazil. She has been teaching pathology for almost 10 years. Her research addresses the use of digital resources for teaching histology and pathology.

Doris George Yohannan, MBBS, MD, is an Assistant Professor in the Department of Anatomy at the Government Medical College Thiruvananthapuram, Kerala, India. He has taught anatomy to medical students for 10 years. His interests are focused on teaching neuroanatomy and clinically oriented anatomy, and on the introduction of modern technologies for medical education.

Virgínia Girão-Carmona, PhD, is a Professor of Histology and Embryology at the Federal University of Ceará in Fortaleza, CE, Brazil. She has been teaching histology for almost 20 years. Her research covers the use of virtual technologies for teaching histology.

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education Geoffrey T. Meyer

Abstract

Teaching histology is expensive, particularly in some universities with limited or ageing resources such as microscope equipment and inadequate histological slide collections. Increasing numbers of student enrolments have required duplications of laboratory classes. Such practical classes are staff intensive and so teaching hours are increased. Technology can now solve many of these issues but perhaps, more importantly, can also cater to the self-directed and independent learning needs of today’s learners. This chapter will describe and evaluate distinct innovations available on a global scale, utilising both technology-enhanced and interactive learning strategies to revolutionise histology teaching via successful online delivery of learning resources. Histology students can access these innovations to maximise their learning and enable them to complete all learning outcomes away from the traditional classroom environment (i.e., online). Most appropriately, all of these innovations address and help solve cognitive challenges that students experience in histology learning. Lecture recording platforms with engaging functionalities have enabled students to view G. T. Meyer (✉) School of Human Sciences, The University of Western Australia, Perth, WA, Australia e-mail: [email protected]

lectures online. Using new innovative histology resources has eliminated the need for students to attend practical histology laboratory sessions. Instead, students can now study histology successfully and enjoyably in their own time. Learners can interact with unlimited numbers of high-quality images and click on hyperlinked text to identify key features of histological structures. Students can now use virtual microscopy to view digitised histological sections (virtual microscopy) at increasing levels of magnification. Consequently, there is no requirement for academic staff to be present when directing students through their learning objectives, which therefore eliminates formal, scheduled practical classes. The learning platforms offer a variety of formative assessment formats. On completion of a quiz, instant feedback can be provided for students, which makes histology learning efficient and can significantly improve student performance in examinations. However, there remains the issue that threedimensional (3D) interpretation from traditional two-dimensional (2D) representations of cell, tissue, and organ structure can be cognitively challenging for many students. The popularity of using animations and 3D reconstructions to help learners understand and remember information has greatly increased since the advent of powerful graphics-oriented computers. This technology allows animations to be produced much more

# The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Border et al. (eds.), Biomedical Visualisation, Advances in Experimental Medicine and Biology 1421, https://doi.org/10.1007/978-3-031-30379-1_6

125

126

G. T. Meyer

easily and cheaply than in previous years, whilst Cinema 4D technology has enhanced a new paradigm shift in teaching histology. 3D reconstruction and animations can meet the educational need and solve the dilemma. Keywords

Histology · Online learning · Histology atlas · Virtual microscopy · Anatomy · Microanatomy · Histology lectures · Histology videos · Histology quizzes

6.1

Introduction

Histology, also called microscopic anatomy or microanatomy, is the study of the microscopic structure of the body’s cells, tissues, and organs. Traditionally, histologists use light microscopes, transmission and scanning electron microscopes, and even atomic force microscopes to provide details of cell, tissue, and organ structure (Table 6.1). However, this is not without first employing various preparative techniques and many diverse ‘visualisation’ methods to identify the desired histological structures. There are several types of microscopes, each having their own unique designs and lens structures. The purpose of this chapter is not to describe the functional peculiarities of each type of microscope which are well described (Mescher 2013; Ovalle et al. 2013; Ross and Pawlina 2016; Lowe et al. 2018; Gartner and Lee 2022), however, the specific cell or tissue structure that some types of microscopes reveal is included in Table 6.1. A more in-depth understanding of the structure and function of cells, tissues, and organs can also be provided using other techniques (Mescher 2013; Ovalle et al. 2013; Ross and Pawlina 2016; Lowe et al. 2018; Gartner and Lee 2022) such as: • Histochemistry and cytochemistry. • Immunocytochemistry and hybridisation techniques. • Autoradiography. • Organ and tissue culture.

• Cell and organ separation by differential centrifugation. • Specialised microscopic techniques and microscopes. Since these methods are so diverse, this chapter will focus on histology visualisation for teaching and learning. In traditional histology courses, this has typically involved examining tissue and organ slices using a light microscope, or images obtained from electron microscopy. However, recent innovative technologies have transformed histology teaching and learning away from the lecture theatre and laboratory practical classroom to a completely online environment.

6.1.1

Histology Visualisation: The Basics of Tissue Preparation

Before the histological structure of any tissue can be examined using traditional light microscopy, small slices of tissue must be processed to preserve the structure (fixation) and embedded within a medium (e.g., paraffin), so that thin slices of tissue can be cut using a microtome or a cryostat (that can section frozen tissues) and mounted on a glass slide. Fixatives do not preserve all cell or tissue components, so specific fixatives are employed to stabilise and preserve the desired components. Cryofixation involves rapidly cooling tissue samples (so no crystals form) to the temperature of liquid nitrogen (-196 °C) or below and is commonly used to prepare specimens for electron microscopy and immunocytochemistry. Chemical fixatives harden tissues, which is required for effective microtome or cryostat sectioning. Fixatives generally preserve tissues and cells by irreversibly cross-linking proteins. The most widely used fixative for light microscopy is 10% neutral buffered formalin, or 4% formaldehyde in phosphate buffered saline. However, these fixatives do not react with lipids, which are then removed during alcohol dehydration procedures. To retain membrane structures, special fixatives or even frozen tissues are used

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

127

Table 6.1 Examples of microscope types and what they reveal about cell or tissue structure Type of microscope Light microscope Phase-contrast microscope

Dark-field microscope

Fluorescence microscope

Confocal scanning microscope Polarising microscope

Transmission electron microscope Scanning electron microscope Atomic force microscope Virtual microscope

Characteristic feature/s Stained preparations of tissues are examined by passing light through the tissue section. This is the microscope commonly used for routine histological analyses Light changes speed when it passes through structures of different refractive indices. Dark or light parts of the image correspond to dense or less dense portions of the cell or tissue. Used to examine living cells and tissues, e.g., tissue culture or unstained semi-thin sections of plastic-embedded tissue. The interference microscope and the differential interference microscope are two modifications of the phase contrast microscope No direct light from the light source is gathered by the objective lens—only light scattered or diffracted by structures within the specimen passes through the objective lens. Used to examine autoradiographs, urine for crystals of uric acid or oxalate, and for demonstrating specific bacteria, e.g., spirochetes Certain molecules fluoresce under ultraviolet light, so the fluorescent microscope is used to detect naturally occurring fluorescent molecules, e.g., vitamin A and some neurotransmitters. But, more widely used to detect antigens or antibodies in immunocytochemical staining procedures Only a very thin plane of the section is seen in focus at any one time. A computer can assemble several focussed planes and reconstruct a specimen into a three-dimensional image Uses a polarising filter (polariser) placed between the light source and the specimen, and another (analyser) placed between the objective lens and the observer. Permits structures constructed of highly organised molecules to be visualised, e.g., striated (voluntary/ skeletal) muscle Uses a beam of electrons rather than a beam of light, which allows greater resolution or details of structures The electron beam does not pass through the specimen but reflects or emits electrons from the thin metal coating previously applied to the specimen. Shows the surface view of structures Studies surface topography at molecular and atomic resolution A digital procedure that replaces the viewing of histological sections on glass slides using a light microscope

Mescher (2013), Ovalle et al. (2013), Ross and Pawlina (2016), Lowe et al. (2018), and Gartner and Lee (2022)

for the binding or retention of phospholipids. For electron microscopy, the most used chemical fixative is glutaraldehyde, usually as a 2.5% solution in phosphate buffered saline. Other fixatives used for electron microscopy are osmium tetroxide or uranyl acetate. Both these fixatives retain the integrity of membrane structures. Osmium is a heavy metal that binds to phospholipids. Uranyl ions also bind to phospholipids.

6.1.2

Staining Procedures Visualise Cell and Tissue Components

Biological structures consist of an assortment of molecules such as amino acids and proteins, lipids, matrix components, and collections of fibrous proteins embedded within proteoglycan-

rich ground substances and proteinaceous fibres, e.g. collagen and elastin. Because all tissue components have a similar optical density, stains, or dyes, e.g. haematoxylin and eosin (H&E), are frequently used in histology to enhance contrast of tissue components. H&E staining is frequently used in histology to examine thin tissue sections and distinguishes basic tissue components, e.g., the cell nucleus from the cell cytoplasm, connective tissue elements, and other extracellular substances (Fig. 6.1). Many different fixative and staining procedures are adopted to visualise specific components. Stains may highlight muscle fibres, connective tissue fibres, elastic components, basement membranes, and may distinguish different blood cells in a blood smear, and some organelles within cells. Histology textbooks

128

G. T. Meyer

Fig. 6.1 Typical haematoxylin and eosin (H&E) staining used in histology. Haematoxylin stains cell nuclei purple/ blue (1); eosin stains cytoplasm, connective tissue, and other extracellular substances pink or red (2). Captured with permission from Meyer’s Histology Online Interactive Atlas; https://www.histology-online.com

(Mescher 2013; Ovalle et al. 2013; Ross and Pawlina 2016; Lowe et al. 2018; Gartner and Lee 2022) provide details of commonly used stains and the specific cell or tissue components they highlight.

6.1.3

Specific Structures Can Be Visualised Using a Variety of Techniques

Histochemistry, cytochemistry, and immunocytochemistry are the branches of histology and cell biology that concern localisation of cellular components and identification of the biochemical content of cells using several histological staining methods. Such approaches may be based on the specific binding of a visible dye, or the binding of a fluorescent dye and labelled antibody to a specific cell component or enzyme.

6.2

Histology Education

Histology courses typically focus on student understanding of how the microscopic structure of cells, tissues, and organs correlate with the functions of these body components. Histology is normally integrated with the study of gross anatomy, physiology, and embryology and is the

basis for the practice of clinical pathology. Histology is presented in basic science education programmes within medical and dental curricula, and is a component of many allied health, biomedical, and biological science courses. Histology textbooks, e.g., (Mescher 2013; Ovalle et al. 2013; Ross and Pawlina 2016; Lowe et al. 2018; Gartner and Lee 2022) are the traditional reference for learning histology. Histology is an image-intensive discipline, as most learning is completed by viewing either image of histological sections or by examining histological sections of tissues and organs using a microscope. Traditionally, learning a histology curriculum requires students attending lectures and formal laboratory classes that are supervised by academic staff. During the classes, students typically view histological sections using an optical (light) microscope. With increasing numbers of student enrolments in courses requiring histology instruction, multiple laboratory classes are required, since most schools typically only have 50–80 microscopes and class slide collections. These learning resources are accompanied by images of cell and tissue structure revealed using transmission and scanning electron microscopes or atomic force microscopes. The need for multiple classes increases teaching hours of academic and other support staff. Histology instruction is therefore expensive to provide, and over the past two decades universities have continually strived to revolutionise the teaching and learning of histology using state-of-the-art technologies and interactive learning strategies to maximise student learning outcomes whilst maximising cost-effectiveness. New innovative technologies allow learners to visualise histology anywhere, at any time, and allow flexible selfdirected learning through social media, live streaming, and virtual reality (Chapman et al. 2020).

6.3

Use of Technology in Teaching and Learning

Over the past two decades, developments in technology have progressed at unprecedented rates.

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

This exponential change has resulted in a huge discontinuity between the current student generation, Generation Z, and previous generations (Prensky 2001). Generation Z grew up with the rapid evolution and dissemination of technology, and as a result of this, the majority of students now incorporate this technology seamlessly into their lifestyle (Selwyn 2009; Herro et al. 2013). The current student population possesses unprecedented skills that influence their learning, and impact on teaching delivery. Educating within this climate of extreme and complex change is now the norm (Healey et al. 2014). It is exceedingly important that the evolution of the student generation is evaluated and addressed in order to determine more effective strategies for twentyfirst century teaching and learning (Black 2010). In an attempt to develop university courses to meet the demands of students, many systems have shifted to include online technology, such as Learning Management Systems, for delivery platforms (Álvarez et al. 2013). However, as online learning platforms become more popular, it is required that strategies are put in place to ensure the students remain engaged in the education process (Kember et al. 2010). A great deal of research has been published regarding the integration of online learning platforms into the education system (Panigrahi et al. 2018; Liu et al. 2020), however, researchers are yet to extensively explore the effect this may have on student engagement in course work. Extensive research is also lacking with respect to the effectiveness of education systems that have shifted from laboratory based, practical teaching, to a total online delivery (Allen and Seaman 2010).

6.3.1

Online Learning Platforms in Education

Online learning platforms are used extensively in tertiary education systems worldwide to support student learning and improve course delivery (Islam 2013). The technical design and formatting of online learning platforms determine the effectiveness of student engagement and course

129

involvement (Lim et al. 2007; Dixson 2012; Dewan et al. 2019). If a learning platform is easy to navigate, this may assist in student learning as well as enhancing collaboration and peer involvement. A reduction in the time students spend learning the functionalities of an online platform increases the amount of time they are able and willing to spend on learning content (Lim et al. 2007). Another study in 2013 further argued this idea, supporting the notion that student engagement can be greatly enhanced if operating systems are appropriately designed (Deng and Tavares 2013). A separate, earlier study in 2007 had identified that online learning platforms can assist in student learning through enhancing student engagement in a course (Liaw et al. 2007). One hundred and sixty-eight students were surveyed, and through analysis of student responses, researchers concluded that online learning platforms are likely to improve student problem solving and critical thinking skills through enhancing student engagement (Liaw et al. 2007). Furthermore, a prior study discussed the potential for online learning platforms to enhance student engagement through increasing selfdirected learning in a course (Leidner and Jarvenpaa 1995). Self-directed learning provides students with a greater sense of responsibility and autonomy and this is seen to improve grade mark results (Healey et al. 2014). A later study confirms that online platforms are a brilliant tool for providing students with increased opportunities for self-directed learning (Liu et al. 2010). Self-directed learning is argued to enhance student learning, as it is proposed that students gain a better understanding when they actively teach themselves (Augustin 2014); it is therefore implied that online platforms can subsequently enhance student learning and grade outcomes through providing students with self-directed learning opportunities in a curriculum. Faster dissemination of information is another proposed benefit of online learning platforms. A faster exchange of information provides students with a greater sense of satisfaction in their learning. In my own teaching experience, it is

130

especially important for Generation Z students to seek instant gratification. Interaction between students and educators, and from peer to peer (Walser et al. 2017; Hall et al. 2018; Elmansouri et al. 2020; Messerer et al. 2021), not only enhances the sense of community and peer interaction (important factors in increasing student engagement) it also allows for the instant dispersal of information on demand. A fast exchange of information can assist with learning as students are motivated by their ability to achieve instant results whilst interacting with peers and teachers (Cho et al. 2007). As a result of the research performed regarding the growth of technology in education, it can be determined that there are some fundamental aspects that need to be included in online learning platforms. In order to fulfill the goal of increasing student engagement, learning platforms need to have a simplistic, navigable interface (Berge 2002; Lim et al. 2007; Deng and Tavares 2013); increase potential for self-directed learning (Liu et al. 2010); facilitate communication between peers (Herman 2012); and allow for instant exchange and dissemination of course information (Cho et al. 2007). Educational strategies are now moving more and more towards online delivery of course content, in a deliberate response to the COVID-19 pandemic. Presenting a histology course completely online requires high-quality interactive and engaging learning resources to successfully deliver the content. Additionally, learning tools should be included to guide the learner in confidently navigating through histological sections and viewing histological characteristics of each tissue/organ when using virtual microscopy. Mastery learning (mastering each learning component before moving onto the next) can be provided by extensive, interactive review quizzes (Rueshle et al. 1999). A Learning Management System (LMS) or Virtual Learning Environment (VLE) should be chosen that will deliver these resources on a user-friendly platform that includes interactive discussion forums and other

G. T. Meyer

features to engage the learners with their peers and the histology instructors online.

6.3.2

Virtual Microscopy: An Online Education Platform

A cost-effective initiative has been to transfer histology teaching and learning to computerbased technologies, such as virtual microscopes (Kumar et al. 2004; Paulsen et al. 2010). Virtual microscopy is a digital process that provides a realistic alternative to the viewing of glass mounted slides with the aid of a light microscope. Using digital scanners, histological sections can be digitised and stored as virtual slides within a picture archive (e.g. the ScanScope XT and the ScanScope OS System by Aperio; https://www. leicabiosystems.com). The digitisation is done at high resolutions so that multiple magnifications, which correspond to the objective lenses on a light microscope (typically ×4, ×10, ×20, ×40, and ×100), can be selected by clicking on the desired magnification. Additionally, the magnification can be gradually adjusted using the keyboard or mouse wheel. At any given magnification the entire slide can be moved, as if using a light microscope, by clicking on the slide and simultaneously moving the mouse. Virtual microscopy allows greater ease of access to the material, which can provide a more flexible study approach for students. Increased accessibility is provided when virtual microscopy material can be accessed remotely outside the laboratory, at anytime, anywhere, provided students have an appropriate device on which to view it. Other features enable students to simultaneously access and view the same histological sections at exactly the same time (Blake et al. 2003; Krippendorf and Lough 2005; Becker 2006; Glatz-Krieger et al. 2006; Pinder et al. 2008). This supports a more equitable learning experience for all students and permits teachers to demonstrate and explain a structure or feature to many students at the same time, without the need

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

for costly video-equipped microscopes or screens. Further advantages of virtual microscopy include the user-friendly interface, i.e. a web browser rather than a microscope), and the ability to have multiple windows open at once so that structures can be compared whilst studying (Harris et al. 2001; Blake et al. 2003; Krippendorf and Lough 2005; Becker 2006; Deniz and Cakir 2006; Braun and Kearns 2008; Pinder et al. 2008). It has also been noted that virtual microscopy reduces the effects of motion sickness and eye fatigue experienced by many students when using light microscopes (Braun and Kearns 2008).

6.3.3

Virtual Microscopy Is Cost Effective and Facilitates Student Engagement

Virtual microscopy is not only effective in facilitating student engagement, but also in lowering costs associated with traditional microscopy in a university course. Microscope maintenance can be costly, however, use of virtual microscopy reduces expenses directed towards maintenance (Raja 2010). Another practical advantage of virtual microscopy is the ability of the platform to reach a large student body. This provides a huge economical advantage, by enabling large numbers of students to access the same application simultaneously (Helle et al. 2011). Previous studies have found virtual microscopy to be an effective technique that facilitates student engagement in histological, medical, and pathological-based courses (Harris et al. 2001; Blake et al. 2003; Chen et al. 2008; Foster 2010; Higazi 2011; Pantanowitz et al. 2012; Kogan et al. 2014; Ordi et al. 2004). However, there is still room for further research into systems and functionalities that will address all areas of student engagement (Healey et al. 2014), and, as a result, increase student grade mark outcomes. There is increasing demand for students of today to meet high industry standards and be competitive when entering the workforce in professional medical and science areas. Thus, it is required that

131

virtual microscopy platforms are enhanced in order to increase facilitation of collaboration, peer-assisted learning, student autonomy, instant information dissemination, and active course engagement to the greatest extent possible (Berge 2002; Cho et al. 2007; Helle et al. 2011). This will increase student engagement in histology-based courses, lead to increased grade averages (Raja 2010), and subsequently produce students who are more adept in their understanding of the curriculum.

6.3.3.1

An Online Virtual Microscopy Learning and Teaching Platform with Annotations and Student Engagement Chapman et al. (2020) provide an extensive list of virtual microscopy sites with free access available for use in histology education. One popular online, virtual microscopy facility is Slice, which promotes extensive visualisations of histology. Slice (https://www.best.edu.au/slice) is an online image-based learning and teaching platform for viewing, annotating, and interacting with images, as well as sharing knowledge with colleagues and students. In late 2020, the BEST (Biomedical Education Skills and Training) Network welcomed OpenLearning (https://www. openlearning.com) as their new technology partner. In 2021, improvements were made across the platform and tools, particularly in Slice, their image-based online learning and teaching platform. Slice has the following functionalities (Table 6.2).

6.4

Aims and Objectives

Histology teaching has undergone substantial changes over the past two decades for several reasons. A major transformation concerns the advent of innovative technologies to deliver a more cost-effective histology education to students in medical, dental, and allied health/biomedical courses in tertiary education institutions worldwide. This chapter will focus on the author’s journey, personal reflections, and student feedback in the creation and development of

132

G. T. Meyer

Table 6.2 Seven functionalities of Slice image-based online learning and teaching platform 1. Access to a huge library of images including whole slide images 2. Upload teaching images

3. Organise images and share with others

4. LTI integration

5. Teach microscopy online

6. Annotate and add descriptions to images

7. Run group activities and review misconceptions

This library hosts over 21,700 images, including over 6000 virtual slides covering a variety of disciplines including histology, pathology, veterinary science, radiology, botany, and zoology The Slice facility can accept contributions of a wide variety of file types including many virtual slide formats such as svs, tiff, qptiff, and mrxs. The images are catalogued with information that makes them easily searchable and recognises the copyright owner and contributor Academics or administrators can select images and create collections that mimic classes or course structures. Collections are folders that members can curate to organise images and layers for personal reference or for use as part of a course. Collections are private with a link to make it easy to share groups of images with other academic and student members Academics or administrators can set up single sign on with Blackboard, Moodle, and Canvas to automatically register students for access to SLICE and provide faster access to embedded Slice images, annotation layers, and Collections Academics or administrators can view and interact with online images including virtual slides and transform microscopy classes by supplementing or replacing physical microscope sessions with Slice. Users can navigate tissue sections, zooming in/out and panning across Academics or administrators can create annotations highlighting features for use in class or to share with colleagues or students. Annotations are highlighted areas of an image with/without descriptions. All members can make and save annotations on any image, at any time. Annotation layers are all in context of the location of the feature on the image and can be edited at any time. Annotation layers are private until the URL is shared Students can view images and make their own notes on images in classes or in their own time, enhancing their learning. Student members can create annotation layers to create their own study notes and revision materials and access them at any time or ask questions about content being taught, by sharing with their tutors or lecturers privately Making annotations can be a group activity. Collaborative annotation facilitates both small group annotation layers where members work collaboratively to mark up an image. Large group activities can be run where participants can attempt an exercise individually and then receive feedback on whether they have correctly identified features. Collaborative layers provide teachers with insight into participant understanding Academics or administrators can engage students with collaborative annotation activities to work together on in class. Academics or administrators can gain insight into student understanding by reviewing their annotations. Annotations form heatmaps that highlight misconceptions

extensive, innovative ‘Meyer’s Histology’ resources provided at https://www.histologyonline.com and https://www.meyershistology. com. These resources are accessed by students and histology teachers worldwide and have enabled the complete online delivery of histology courses that have replaced traditional ‘en-face’ histology teaching. Here, a detailed description of these resources will be outlined and the educational context, pedagogic and logistical challenges, and benefits, of creating Meyer’s

Histology will be explored. These descriptions are provided with the aim of guiding other histology teachers contemplating the creation of their own histology teaching resources.

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

6.5 6.5.1

Development of an Online Interactive Histology Atlas How It All Started

At the University of Western Australia (UWA), my department was rather unique compared to many schools of anatomy worldwide. The department was part of a medical and dental school but also a member of the Faculty of Science. The department’s teaching was focused on the preclinical delivery of anatomy (including neuroanatomy) and histology to medical and dental undergraduate students, but also offered teaching units in human evolution, human genetics, human reproduction, neurobiology, anatomy (including neuroanatomy) and histology, which students completed towards a Bachelor of Science degree majoring in Anatomy and Human Biology. Hence, the department was originally named the ‘Department of Anatomy and Human Biology’. Following structural changes within the university and further expansions of teaching courses, it is now named the ‘School of Human Sciences’. In 1997, the department predicted that the teaching of histology would require an expensive outlay due to increasing numbers of students, which in turn required duplications of laboratory classes for several different histology courses, and increased staff workloads. The department possessed limited numbers of microscopes and inadequate histological slide collections. At the same time, computer-based learning was gaining momentum and the preference was to purchase computers that had a more universal student usage for all teaching courses, rather than allocate significant funds to purchase new microscopes and produce more slide collections. Technology and a shift to computer-based learning came to the rescue to solve the emerging problems in teaching histology, but also catered to the emerging pedagogies directed at the self-directed and independent learning needs of students. As the main teacher of histology in the department, I took responsibility to create a computeraided learning platform that could alleviate some of the issues with the teaching of histology

133

(as described above). The initial aim was to reduce the number of staff members required to attend laboratory practical classes and so allow them to allocate more time to their research endeavours. The first version of a computer-based resource contained the original student histology laboratory manual supplemented with extensive images. It was delivered via computers stationed adjacent to the student microscopes in the histology classroom, which also served as a computer-aided learning laboratory for students enrolled in other teaching units. Within 2 years, it was also transferred to a web-based resource and students could view the resource away from the histology teaching classroom. The original basic template of the web-based resource was created by a colleague (Werner Henning) who had the skills to write the HTML language, and this project was funded by a grant from the Department of Anatomy and Human Biology. Werner was also a biologist, not just an IT specialist, and so he understood the content and the academic aims of the resource which made the task easier. It was then a simple matter for me to copy the codes, etc. for each histological item and paste them into the correct sequence to assemble the atlas. Creating an index of all histological components characterising human tissues and organs was the initial step. Almost 1070 such items were listed in the index. Writing the interactive web-based content and assembling it into the platform was extremely time consuming. Although much of the content was copied from a previously used laboratory manual, a lot more descriptive content was added, particularly the directives to locate the histological structures at increasing magnifications, i.e., simulating using a microscope. Also, acquiring an extensive database of images was time consuming. First, a near as possible perfect histological slide of each tissue or organ was selected, then the images were taken of the various histological components at increasing magnifications. For the atlas content, four images of the same histological structure were photographed, but in different locations in the histological slide where possible. One image (usually the best image) was to be included in the

134

atlas, and another was used in a formal lecture presentation (e.g., ‘en face’ to my histology classes at UWA or later, via Lecturio https://www. lecturio.com). The remaining two images were used in a review quiz and in a formal examination. Some histological features were imaged when they were identified in the section cut transversely, obliquely, and longitudinally, e.g., blood vessels and other tubular structures, muscle, and nerve fibres. This was not a task you could allocate to a student to complete, nor could you ask a member of the technical staff to complete this, as they had other time commitments supporting the research laboratories throughout the department. However, in the initial stages of the development of the content, students were asked during laboratory classes that, if they thought they had identified a particularly good example of a histological structure, to alert me. I would then note the slide box, slide number and histological item, and at a later stage would take the required photographs. The first version of the resource was called the ‘Interactive Histology Atlas and Laboratory Practical Assistant’. At the same time, I was fortunate enough to form a collaborative teaching arrangement with Professors John Campbell (now deceased, 2021) and Michael Hall, both at the University of California Los Angeles (UCLA). Both Professor Campbell and Professor Hall assisted in my histology teaching commitments at UWA, and in turn, I travelled to UCLA and helped with their teaching of histology to UCLA Dental Students. These two academics helped me write the content and would advise me on many aspects of the creation of the resource. It was the histology slide collections from UCLA that form much of the virtual microscope collection in the resource today. This initial paradigm shift in the delivery of a laboratory practical session, whereby labelled images, and clear directives on where to locate relevant histological features within a histological section, did reduce the need for many staff to attend and assist student enquiries or with their inability to find structures during their microscope examination of the tissue sections. In fact,

G. T. Meyer

many students completed many of the learning objectives away from the histology classroom, and a few only attended laboratory sessions for much shorter periods to view histological sections to confirm their learning outcomes, so the need for allocating laboratory schedules was much reduced. This freed up time for other teaching units/classes to then utilise the computers in this classroom. I did miss the interactivity with the students, and this was the main reason why I allocated a 1 h slot each week to be in the classroom to answer questions, etc. However, the attendance at these sessions dwindled mostly in parallel with continually reviewing the descriptive content and including answers to the typical questions often asked during the laboratory sessions. This innovation formed the basis for me being awarded a UWA Teaching Award and then in 1999 an Australian University Teaching Award in the category ‘Flexible Delivery/Learning’.

6.5.2

The Concept of a Completely Online Histology Course

The realisation that the practical learning of histology (i.e., a traditional laboratory practical session) could now be successfully completed in an online learning environment given the use of the ‘Interactive Histology Atlas and Laboratory Practical Assistant’ prompted the thought that perhaps the histology course itself (not just the laboratory practical component) could be transferred to a completely online platform. Further improvements to the content of the resource over a 5-year period were accompanied by several independent, quantitative surveys and analyses of the success of students being able to successfully identify histological sections when competing in a traditional practical examination. The results confirmed that even if students studied their practical histology learning in a completely online environment, they could still attend the histology classroom at the end of the course, sit at 40 microscope stations, and readily identify histological sections of 40 different tissues and organs, that

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

135

Table 6.3 Four resources necessary to present a histology course completely online 1. Descriptive videos

2. 3D anatomy and 3D microanatomy images

3. Histology lectures 4. An online learning platform, i.e. a Learning Management System (LMS)

Describes histological characteristics of all human cells, tissues, and organs to replace, and increase the content in, a laboratory guide/ manual Better relate the histological structures to their gross anatomy locations in the body Provides a 3D view of histological structures that are limited when viewing a 2D histological section Provided on a professional platform with functionalities to promote a user-friendly interface Presents all resources in a user-friendly manner

are the usual format of any traditional practical histology examination. These analyses were included in a successful 2009 Australian Learning and Teaching Council (ALTC) Fellowship Grant and a 2011 ALTC Project Grant to pursue the transfer of histology teaching to a completely online format. The project’s aim was firstly to upgrade the online interactive atlas. The atlas had a virtual microscopy facility embedded with a database of over 300 scanned histological sections that would normally be contained (as glass slides) within a traditional histology class slide collection; and extensive review quizzes were added. Secondly, the four resources created (Table 6.3) were identified as being essential to completely transferring teaching of histology to an online environment:

6.6

Meyer’s Histology

Meyer’s Histology (https://www.histologyonline.com) and (https://www.meyershistology. com) was created to continue to revolutionise the teaching and learning of histology using the ‘state-of-the-art’ technologies currently available and interactive learning strategies to maximise student learning outcomes. Currently, two separate websites are currently required. The LMS used for providing extensive descriptive videos on histology (https://www.meyershistology.com) is ‘Thinkific’ via Thinkific Labs Inc. Canada (https://thinkific.com) but as yet, there is no functionality on this platform to link to the interactive atlas content and virtual microscopy functionality

at (https://www.histology-online.com). It is anticipated that this will be soon resolved. Nevertheless, links from both sites enable users to access all content very easily. The reader is strongly encouraged to visit each website to view all the web-based interactive features provided within each learning resource, although brief descriptions of these features are described in the sections that follow. Most websites provide a preview opportunity. Quantitative evaluations of the histology learning resources are provided initially from a survey completed by a histology class in 2014 (Sect. 6.7) and are also supported by ongoing student evaluations (2014–present).

6.6.1

Meyer’s Histology Online Interactive Atlas Including Virtual Microscopy: A Descriptive Example

A new template was designed by innovative web designers at GTP iCommerce Pty Ltd, Australia (https://www.gtp-icommerce.com), and larger images (700 × 500 pixels) replaced the smaller 500 × 440 pixel images. A more flexible quiz facility was included, and a database of scanned histological sections enabled an inbuilt virtual microscope functionality to replace the ‘virtual microscope’ of only still images. One of the great benefits is that the website design has flexibility, which allows me, or a website administrator, to add a new image, new or additional scanned histological sections, or new content at any time. The index can be extended, although is

136

G. T. Meyer

Table 6.4 Meyer’s histology online interactive atlas—The frontpage and table of contents

Frontpage features 1. Chapter 1: Cells and Basic Tissues 2. Chapter 2: Organ Systems 3. Each topic has a ‘+’ icon alongside indicating it can be opened out to a tree of all histological features that characterise the cell, tissue, or organ being studied 4. A ‘Search Site’ function enables the user to locate any histological structure within the extensive index

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

now complete in terms of traditional histology curricula in most medical/dental schools and biological/biomedical science departments. An extensive histology curriculum is presented that covers accredited histology curricula taught in medical schools, dental schools, and allied health sciences programmes worldwide. The Frontpage and Table of Contents are best summarised in point form below with each point 1–4 labelled in Table 6.4; content is presented in a logical sequence and in two separate ‘Chapters 1 and 2’: An example of the content for a particular topic in Meyer’s Histology is best summarised in point form below with each point 1–4 labelled on the image in Table 6.5. Unique functionalities of Meyer’s Histology are best summarised in point form below with each point 1–5 labelled on the image in Table 6.6. Opening the link of the histological section, e.g. ‘Esophagus (H&E)’, takes the viewer to a virtual scanned section of the oesophagus (Fig. 6.2). With a good internet connection, the section is loaded almost instantly. Hovering the ‘mouse pointer’ over the section loads a thumbnail at the top left-hand side of the viewing frame (not shown) and a magnification zoom facility that opens at the baseline (not shown). Magnification can be increased (Fig. 6.3) until the viewer can locate a similar image to the original image and the histological feature presented in the atlas. Viewers are encouraged to scan around the histological section and find other examples of the histological feature. This functionality differs from other websites in that it contains clear directives on how to locate histological features when using virtual microscopy and replaces the need to attend a traditional histology laboratory class which is a cost-saving for many universities and colleges worldwide. The last item in the ‘tree’ is a quiz (Fig. 6.4). A database of around 50 multiple-choice questions (MCQs) and ‘roll down’ questions are loaded for each topic. To encourage multiple attempts at the quiz, and so reinforce the learning, only 25 questions are randomly selected from the database for each attempt.

6.6.2

137

Mastery Learning

Many platforms offer a variety of quiz formats. On completion of a quiz there is an option for instant feedback to students, making histology learning efficient and rewarding, and have significantly improved students’ grades/marks in examinations. Online formative assessments are perceived as tools that promote self-directed learning, improved knowledge, and tailor learning for individual learning needs and preferences (Nagandla et al. 2018). Formative assessments are presented within the resource in different formats. Table 6.7 illustrates an example of a quiz question from extensive quizzes now provided by (https:// www.meyershistology.com). There are over 1500 quiz questions. Again, quizzes are contained within the typical topics presented in a histology curriculum. In the example of a series of quiz questions on ‘The Mammalian Cell’ (Table 6.7), questions are chosen from a database contained within appropriate subheadings. Unique components of these quizzes are best summarised in point form with each point 1–4 labelled on the upper image in Table 6.7. The interactive descriptions of histological structures and direct links to the virtual microscopy sections meet an essential requirement for delivering online course content in an interactive and engaging manner (Rueshle et al. 1999). Mastery learning (mastering each learning component before moving onto the next) was provided by extensive, interactive review quizzes (Rueshle et al. 1999). One of the oldest, traditional histology learning resources was the histology textbook. Histology visualisations were included in textbooks, but the number of descriptive images that could be included in a textbook was very limited due to the cost of colour printing. Now, any web-based instructive document avoids that limitation. However, the descriptive text within textbooks can provide valuable knowledge and, with a close alignment of content, can serve as an effective accompaniment to web-based images.

138

G. T. Meyer

Table 6.5 An example of the content for a particular topic, e.g. ‘Epithelium’ in Meyer’s Histology

Typical content for each topic 1. When the ‘tree’ icon is opened, for example ‘Epithelium’, all histological features that characterise the tissue ‘Epithelium’ are listed 2. In some instances, a particular histological feature, e.g., ‘Transitional epithelium’ will be accompanied by a ‘+’ icon indicating there is a sub-family or sub-tree of structures to study 3. The Front page of each topic has a typical descriptive image and the ‘Learning outcomes’ are listed 4. The last entry in the ‘tree’ is a link to an extensive quiz for the user to confirm their understanding of the topic

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

139

Table 6.6 An example of the functional components for each topic, e.g., ‘Stratified squamous (non-keratinised; thick) epithelium’ in Meyer’s Histology

Functional components for each topic 1. Opening a histological characteristic or structure listed, e.g. ‘Stratified squamous (non-keratinised; thick) epithelium’ loads a high-resolution image that shows the pertinent histological details of the structure listed 2. Descriptive text explains the histological details and relevant histological features are hyperlinked 3. The hyperlink loads an identifying label on the image. This interactivity engages the student in the learning process 4. The label will disappear if another hypertexted feature is opened or when the viewer refreshes the image 5. Most images with descriptive, interactive text have an accompanying link at the bottom of the page to view a histological section using virtual microscopy. A typical organ, e.g. ‘Esophagus’, with the stain used, illustrating the histological feature, in this example ‘Stratified squamous (non-keratinised; thick) epithelium’, has a short text directive and usually an arrow indicating when to look within the section to study the histological feature

140

G. T. Meyer

Fig. 6.2 Meyer’s Histology Online Interactive Atlas: Virtual Microscopy Platform. The scanned section of the ‘Upper Esophagus (Human; H&E)’ is adequately labelled (1). At the low magnification, the viewer can see where the

6.7

Quantitative Evaluation of Meyer’s Histology Online Interactive Atlas

A research study was implemented in 2014 to evaluate the potential benefit of using Meyer’s Histology Online Interactive Atlas with virtual microscopy as a teaching method for learning ‘practical’ histology online (e.g., identifying tissue types and the microanatomy of organs). Learner microscope manipulation and skill acquisition were not assessed. Specifically, this study conducted an empirical evaluation of an online histology course by focusing on student perceptions and attitudes in the course. The study hypothesised that students would have positive perceptions and attitudes towards the online course, therefore providing support for the

most appropriate place within the section (2) is best to view the histological feature being described, based on the directive provided in the previous link/image

adoption of an online course instead of a traditional course approach. Undergraduate students enrolled in a histology course ‘Human Organs and Systems’ in 2014, at the University of Western Australia, completed the online survey (N = 193). Human ethics approval was obtained from the University of Western Australia (Reference number: RA/4/1/ 7150). The survey contained 33 questions. A summary of some aspects of the 2014 student survey is provided in Table 6.8.

6.7.1

Discussion of Quantitative Survey

The above survey performed at the University of Western Australia in 2014 aimed to evaluate student opinions of the online histology learning

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

141

Fig. 6.3 Meyer’s Histology Online Interactive Atlas— Virtual Microscopy Platform. The virtual microscopy platform enables the user to increase magnification using the

magnifier (1) to locate any histological structure within the histological section, e.g., stratified squamous (non-keratinised; thick) epithelium (2)

resources and their perceptions, attitudes, and performance in completing a completely online histology course. This was also done to establish if optical microscopy could be successfully replaced by virtual microscopy in an online course format. The main reasons for converting the university’s histology instructional practices from optical microscopy to virtual microscopy included the reduction of cost by reducing laboratory contact hours (Bloodgood and Ogilvie 2006; Bergman et al. 2008; Dee 2009; Drake et al. 2009), but also to update the curriculum and provide students with more flexible histology instruction and encourage self-directed learning skills. With virtual microscopy gaining more support and acceptance as an instructional tool in morphological sciences, it was important to evaluate it from the student’s perspective. Virtual

microscopy is steadily replacing the longestablished reign of optic microscopy in the biomedical sciences (Dee 2009; Lundin et al. 2009; Merk et al. 2010; Paulsen et al. 2010; Helle et al. 2011). Overall, student appraisal of the Meyer’s Histology resources was found to be very positive, as over 85% of students reported their experience of the unit to be useful and user friendly, and over 75% of the students reported the unit to be engaging. Additionally, it was found that experience with the unit promoted self-directed learning (75% agreed), in addition to an improvement in self-reported personal learning strategies (65% agreed). This suggests that not only was the Meyer’s Histology online learning environment perceived very favourably, but that it fostered student self-directed learning and personal

142

G. T. Meyer

Fig. 6.4 Meyer’s Histology Online Interactive Atlas. An extensive quiz, e.g. ‘Epithelium quiz’ is available at the end of each topic (1)

learning strategies for most students. The survey suggested that students have very positive

attitudes and perceptions towards the online teaching of histology. Responses confirmed that

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

143

Table 6.7 An example of the unique components for quizzes in Meyer’s Histology

Unique components of quizzes 1. The database of questions on ‘Cell Organelle Structure’ contains 20 questions. There is also the option of having questions randomly selected from any of the total of 106 questions from the 6 subheadings 2. There are two formats used to load the question and answers 3. After the question stem there is the option to have more than one answer correct. Although, after the question stem there is also the option to have only one answer correct (upper image) 4. Immediate feedback is provided, which can also be accompanied by an explanation of the corrects answer/s. Sometimes the question stem can be very short and simple (upper image) but often the stem contains reinforcing learning content before the question is asked (lower image)

the learning platform and histology resources, particularly interactive descriptions of histological structures and direct links to the virtual microscopy sections, meets essential requirements for delivering online course content in an interactive and engaging manner (Rueshle et al. 1999). Individual students’ examination

performances markedly improved in the years after the online format was introduced in 2014.

144

G. T. Meyer

Table 6.8 A summary of some aspects of the 2014 student survey Attitudes and perceptions Quality of resources in the Online Interactive Atlas

Self-directed learning

Virtual microscopy

Descriptive videos

Online lecture or ‘en-face’ lectures Online or traditional laboratory session Was ‘Mastery learning’ effective?

6.8

80% of students had very positive attitudes and perceptions towards the complete online teaching of histology Between 80% and 90% agreed images used were high quality and at appropriate magnifications; the accompanying descriptive text was very informative; labels clearly indicated the key histological features being viewed in the image and it was easy to open the virtual microscopy link to access the histological sections 78% agreed the online course in histology encouraged users to become a selfdirected learner. Sixty-seven percent agreed the ‘self-directed learning’ approach in this histology course improved users’ personal learning strategies and/or introduced them to new ways to learn Between 75 and 85% agreed the virtual microscopy functionality included viewing histological sections of very high quality and was an enjoyable learning experience Between 68 and 86% agreed presentations were concise and easy to listen to; images used were of a very high quality; descriptions of histological structures were very clear and where appropriate related to function; annotations were used to identify all relevant histological characteristics being referred to and the time length of each video was appropriate, i.e., not too long or not too short Over 86% of the students preferred viewing innovative online lectures rather than attending ‘en-face’ lectures 72% preferred to complete their histology course completely online rather than attend traditional lectures and practical laboratory sessions 85% agreed that completing weekly quizzes improved their examination scores. More than 45% attained a final mark of 80% or higher each year from 2014–2018 compared to only 20% of the student cohort before the introduction of online learning

Engaging and Interactive Animation/Models of Histological Structures Are Now Available

The goal mentioned in Sect. 6.5.2 was to create resources that were identified as being essential to transfer teaching histology completely to an online environment. Completing the online interactive atlas including virtual microscopy and review quizzes has been described above. The next need was incorporating 3D anatomy and 3D microanatomy images into the atlas to better translate a traditional 2D view of any tissue or organ into its real 3D structure but also, to relate histological structures to their gross anatomy locations in the body. 3D4Medical from Elsevier is the creator of ‘Complete Anatomy’ (https://www.3d4medical. com), one of the world’s most advanced 3D anatomy platforms. Students can investigate the minute detail of human anatomy in incredible 3D. In terms of histology, they have created 3D

microanatomy models that add a useful learning resource for enabling the student to relate gross anatomy more easily to microscopic structure. Figure 6.5 shows a 3D model of the lung

Fig. 6.5 3D4Medical from Elsevier (https://www. 3d4medical.com) microanatomy model of the pulmonary acinus (used with permission in Meyer’s Histology Online Interactive Atlas)

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

(pulmonary) acinus albeit this 3D feature is lost in this printed image.

6.8.1

The Transition from the Gross Anatomy Structure to Histological Details Is an Essential Learning Objective

Histology students have little understanding of the relevance of learning microscopic anatomy unless they can relate what they identify under the microscope with the tissue they see at the gross anatomy level. Histology visualisation is a more complete learning tool when coupled with the gross anatomy locations of various histological structures. This paradigm shift is often difficult for students unless the relevant gross anatomy features are revealed in a step-by-step process. During 2022, the online, interactive histology atlas (https://www.histology-online.com) will incorporate appropriate images of the 3D models to present a gross anatomy view (e.g., of the duodenum), then details of histological characteristics (Fig. 6.6).

6.9

Video Descriptions of Human Cells, Tissues, and Organs

The next need to transfer teaching histology completely to an online environment was to create extensive descriptive videos describing histological characteristics of all human cells, tissues, and organs to replace a traditional laboratory guide/manual. Videos are becoming an essential tool in education. Any search on the internet reveals many videos available describing histological content/ knowledge. It is often unclear though if videos are structured to serve as an online lecture, or as an online version of the traditional ‘pre-lab’ many histology educators presents prior to students commencing a formal practical laboratory session. Meyer’s Histology (https://www. meyershistology.com) provides extensive video descriptions of all the histological features of

145

human cells, and basic tissues and extensive video descriptions of all the histological features of human organs. The platform contains over 170 video presentations. Unique functionalities of these videos are illustrated in Fig. 6.7. Histology videos were recorded using Camtasia 2021 Screen Recorder and Video Editor developed by TechSmith Corporation, USA (https://www.techsmith.com). Using ‘Camtasia 2021 Screen Recorder and Video Editor’ made it simple to record and create professional looking histology videos. I spent several months preparing all the video content for each of the ‘Histology of Cells and Basic Tissues’ and ‘Histology of Human Organs’. The first task was to write a description of each histological feature that was the topic of the video, including assembling all the images required for the video presentations. Images were selected by viewing a database of histological sections using virtual microscopy that are available in the Meyer’s Histology Online, Interactive Atlas. Once the descriptive text was finalised, I recorded a clear presentation of the description on the Camtasia platform. At least two copies of the original audio recordings were retained. The original recording was labelled ‘the working copy’. At the appropriate timeline in this ‘working copy’, images were inserted, and appropriate annotations added, which were usually arrows indicating the histological features referred to in the audio. Similar, to the histology lectures created by Lecturio GmbH, Leipzig, Germany (Sect. 6.10), the recordings are presented to viewers as mini lectures so the content of each cell, tissue, or organ was covered in detail. One of the most recent innovations in 2021/22 with these videos, that separates them from other videos available on the internet currently, is the use of virtual microscopy to locate and demonstrate histological features rather than using still images. This was the reason for retaining copies of the original audio recordings so that at any later time additional (or new) images could be added, or the histological structures could be presented using a virtual microscopy facility.

146

Fig. 6.6 Using images of anatomical models (with permission from 3D4Medical from Elsevier; https://www. 3d4medical.com), a low magnification image of the digestive system is presented, and the duodenum is identified (highlighted in green colour) as the first part of the small intestine (top left panel). The student views the duodenum in relation to the stomach and the large intestine as well as surrounding organs such as the pancreas, liver, and gallbladder. One might systematically dissect the anterior abdomen to reveal the duodenum by removing the anterolateral part of the peritoneum, omental apron, transverse colon, posterior part of the peritoneum, and layers of the wall of the duodenum (top right panel). At each stage

G. T. Meyer

of the virtual dissection, descriptive text of the anatomical structure highlighted (i.e. in green colour in the images) appears in the image panel on the left-hand side, e.g. ‘Transverse Colon (Anterior)’ (top left panel), ‘Circular Muscular Layer of Small Intestine (Duodenum; Posterior)’ (top right panel), ‘Mucosa of Small Intestine (Duodenum; Posterior)’ (lower left panel). Then a very low microscopic image of a histological section through the duodenum is presented (lower right panel) to link to the gross anatomy structures before then providing a detailed examination of the mucosa of the duodenum at increasing magnification in the atlas content to reveal the histological characteristics of that organ

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

Fig. 6.7 Extensive video descriptions of cells, tissues, and organs. For example, ‘The Mammalian Cell’ (1; top panel) is divided into short videos of up to 8 mins duration (2; top panel) and each topic starts with an ‘Introduction and Learning Overview’ (3; top panel). When the viewer

147

listens to the audio whilst watching the screen, histological features mentioned are viewed using virtual microscopy (in the updated version, due 2022) and are indicated by annotations such as labels and arrows (lower panel)

148

6.10

G. T. Meyer

Online Visualisation of Histology Lectures with Functionalities that Engage Students and Promote Self-directed Learning

To successfully transfer histology teaching to a completely online environment, a further requirement was to record histology lectures on a professional platform with functionalities to promote a user-friendly interface. More than ever before, lecture-style videos are becoming an essential tool in education. Education Institutions need to deliver learning online, within the campus environment and in a hybrid blended format. Students can access recorded lectures posted on their student Learning Management System (LMS). The simplest and most common video resource can be created by the histology teacher on their own computer and loaded onto a local server, perhaps using ‘YouTube’ (https://www.youtube.com). These lectures are mostly limited to an audio recording, often without complete annotations on PowerPoint slides. In most cases, the lecturer is not visible, albeit sometimes confined to a small ‘window’ at the bottom of the screen. There are several online video or live streaming platforms available for remote learning (Table 6.9). Histology lectures by myself have been visualised on a specialised learning platform. ‘Lecturio.com’ (https://www.lecturio.com) is one of the most popular lecture platforms available for delivering medical education. Lecturio’s mission as stated, ‘is to provide students and faculty with the best learning tools, proven effective by learning science’. Lecturio has ‘created a high-quality digital medical education resource,

which is affordable, adaptive, and personalised’. Lecturio designed their platform ‘with the needs of learners and faculty in mind, combined with the latest state-of-the-art learning technology and comprehensive monitoring and assessment features’.

6.10.1

How the Histology Lectures Were Created by ‘Lecturio.com’

I recorded histology lectures in the studios of Lecturio in Leipzig, Germany. Before arriving in Leipzig, I had spent several months preparing all the lecture content including all the PowerPoint presentations and all the images required for the lecture presentations. One of the features about the lectures (explained below) is that once the full lecture is recorded, they are then presented to users as mini lectures. So, the length of the lecture topic was not confined to a traditional 45 min lecture that would normally be delivered ‘en-face’ in university lecture theatres. This gave the presenter an opportunity to include the content of each lecture topic in much more detail. In the Lecturio studio, the presenter stands about 4 m in front of a computer screen which projects the PowerPoint slides. The presenter has a microphone discretely positioned and does not read from lecture notes but presents the lecture as he/she would in a traditional lecture theater. A camera is fitted within the computer screen to record the presenter. Throughout the lecture, there is a person present in the studio carefully listening to the presentation. If they do not understand a certain segment of the lecture, or the presentation slide or image is not clear, they will

Table 6.9 List of six online video or live streaming platforms available for remote learning Video or live streaming platforms YouTube Echo360 Camtasia Dacast Muvi Panopto

Platform URL https://www.youtube.com https://echo360.com https://www.techsmith.com https://www.dacasr.com https://www.muvi.com https://www.panopto.com

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

stop the lecture and ask the presenter to clarify this a bit more or amend the PowerPoint slide. The lecture then continues. Should the lecturer make an error or has any other reason to stop the lecture, they were able to do so and continue the lecture when ready. The lecture is then edited and prepared for publishing by the recording staff. The series of histology lectures was completed in 10 days. Usually, three lectures were completed per day, but often parts of lectures were also re-recorded, if necessary, each day.

6.10.2

A Description of Features of the Histology Lectures Were Created by Lecturio.com

As mentioned above, instead of presenting a traditional 45-min (or more) lecture, with several subject headings or objectives, a traditional lecture’s content is divided into short mini lectures of each major heading for the viewer’s convenience, to watch in short intervals during the week at times that suit them. The feedback from students is that ‘this is a better way for me to absorb and understand the content as it is delivered in small packages’. ‘I like to be able to listen to the topics in small bundles of information that I can select whilst travelling on public transport!’ In total, there are 94 lecture videos covering ‘Histology-Types of Tissues’ which includes a large section of mini lectures on the ‘Mammalian Cell’ and 103 lecture videos covering ‘HistologyOrgan Systems’. Each mini lecture is usually between 2 and 6 min duration. Unique features of the Lecturio lecture platform are described in Table 6.10.

6.10.3

149

complete medical curriculum and promotes the resources to ‘Study medicine from anywhere’.

6.11

Students and Histology Teachers Have Worldwide Access to Meyer’s Histology Resources

To gain access to the histology lectures, viewers need to login via the ‘Lecturio.com’ website. Access to these lectures is available to individual students or more commonly via subscription by the student’s university. Access to all other resources is via links to a membership management tool. The online interactive atlas resource platform (https://www. histology-online.com) was coupled with ‘aMember Pro’, a web-based membership management tool (https://www.amember.com) that allowed student subscriptions, enabling students from other universities all over the world to access the resource. The marketing of the resources is essential to provide an income to maintain the website, storage of large, scanned images, and a reliable (but economical) web-based membership management tool. But also, there need to be funds to finance the updating of software and any website changes etc. that require an IT/web designer. At one stage, I approached a couple of reputable publishing companies to offer the product but found that quite frustrating. There was no appreciation of the online teaching and learning advantages of the resource as an e-learning resource, and the publishers wanted to disassemble the content and publish it as a standard printed atlas, which eliminates all the interactive components and benefits of the resource.

Evaluations 6.11.1

The listed comments from users worldwide (with permission from Lecturio.com) are provided in Table 6.11. Besides offering a complete ‘Histology’ lecture series, the Lecturio platform provides a

How Do Students and Histology Teachers Access Meyer’s Histology Resources?

Students can subscribe individually for a very small fee. Over 80 universities in Australia and overseas have subscribed via their university

150

G. T. Meyer

Table 6.10 ‘Lecturio.com’ histology lecture platform

Unique features of the Lecturio lecture platform 1. A PowerPoint slide appears with content to be described by the presenter 2. The lecturer is visible for about 60% of the length of the presentation. Students comment ‘Seeing the lecturer at close up range was a much more engaging experience for me as I could see his expressions and so his personality and sense of humour were better received/evident’ 3. Each mini lecture is usually between 2 and 6 min duration. It is possible to pause and/or repeat any part of the presentation 4. The speed of the audio presentation can be increased or decreased. This is particularly important when adjusting to the lecturer’s accent 5. Each mini lecture has an icon to open and translate the lecture into 24 of the most used languages 6. The learning objectives are verbally presented but also listed as a side panel on the platform 7. At certain points in the lecture an MCQ quiz question would ‘pop-up’ to test the knowledge gained by the user after viewing a specific explanation of content, the quiz questions are answered with an indication of confidence and drive a spaced retrieval algorithm aiming to assist the learner with long-term mastery. This is turn produces valuable formative assessment data for the educator 8. The viewer has the option of deferring access to quiz questions until the mini lecture is completed. Student comment ‘Completing the quizzes engaged me in the content being presented’ 9. A full transcript of the lecturer’s presentation is available 10. PowerPoint slides can be viewed and/or copied to a personal word document library 11. A discussion forum is an important part of the learning platform for every mini lecture. Viewers can post a question about the content—perhaps clarify some issues they may have. A response by the lecturer is usually posted within 24 h 12. Several descriptive articles are pertinent to understanding the topic can be opened directly from links on the platform 13. A support facility enables the user to ‘chat’ with a member of the Lecturio support team The lecture ‘theatre’ video presentation of a histology course shows an accompanying PowerPoint display of teaching slides with the usual variety of annotations and enables the user to view the lecturer closely

library acquisition funds, or directly from departmental funds, to enable their students to access the resource. Normally, the histology

course director/lecturer contacts me via email regarding a fee for access for their students. In some instances, there is no fee charged, e.g., for

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

151

Table 6.11 Student evaluations of the histology lectures delivered via ‘Lecturio.com’

developing nations characterized by a population with low and middle incomes, and other socioeconomic indicators. When a university wishes to subscribe, the histology teacher or university library acquisitions manager is provided with a coupon code that all students and staff use when registering to bypass the normal payment channel. Students must register with their university email account. Most importantly, the coupon code is valid for 4 years. This allows the student to use the resource even after their histology course may have finished. Normally a degree course or postgraduate medical/dental course extends over 4 years so this allows the student

to refer to the histology resources if needed in later years of their study programme. When the system is operative there are very few problems as it can be viewed on most browsers. A demonstration video on the website explains the functionalities and how to use the resource. The extensive descriptive videos and extensive review quizzes (https://www.meyershistology. com) are available through the ‘Thinkific 2021’ platform (https://www.thinkific.com). This platform enables educators to create professional digital learning products for any kind of audience with a user-friendly course builder, and no coding or technical expertise is required.

152

6.12

G. T. Meyer

A Histology Course Can Be Presented Completely Online for Engaging Students and Promoting Self-directed Learning

Even before the COVID-19 pandemic, formal courses were offered online. Massive Open Online Courses (MOOCs) enrol massive numbers of students at any one time. There are at least 10 MOOC platforms that currently operate with a proven track record, and many more are being developed (Table 6.12). None of these platforms offer an extensive course in histology that is equivalent to a histology curriculum presented at major medical and dental schools worldwide and other courses in Biomedical Sciences and Allied Health. However, as described above, numerous websites offer some histology instruction in the form of videos etc.

6.12.1

An Example of a Successful Online Histology Course: Course Syllabus and Schedule

The various resources listed (Sect. 6.5.2) that were needed to offer a histology course completely online were created over a period of several years and continue to be upgraded. It would be dismissive if it was not emphasised that this was an enormous academic undertaking. From 2014 onwards, histology courses at the University of Western Australia were provided

completely online using all the resources from the Meyer’s Histology platforms described above. This was an example of an online histology course facilitated or supervised locally by a histology teacher. However, two complete online courses in Histology started in 2015 at the University of California, Los Angeles Extension (UCLA Extension; https://www.uclaextension. edu) and were facilitated or supervised by me on the other side of the world, in an almost totally opposite time zone! Both courses are offered at least twice each year but often an extra course is offered during the summer term. They have been offered each year since 2015. The UCLA Extension courses were ‘Histology for the Health Sciences: Basic Tissues of the Body’ and ‘Histology for the Health Sciences: Organ Systems’. The curriculum was based on the same curriculum offered in most Medical, Dental, and Allied Health courses worldwide. The teaching approach and course design (for both UCLA Extension Courses) in histology outlined below are based on my experiences with different approaches over many years and after extensive feedback from the students, i.e., the users. One histology course is described here as a guide to any educators contemplating designing an online course. During the design and delivery of the course, the advice from UCLA Extension Canvas and Learning Support or UCLA Instructional Designers was much appreciated. The Canvas Learning Management Platform (https://www.instructure.com) delivers the UCLA Extension Courses.

Table 6.12 List of at least 10 Massive Open Online Courses (MOOCs) platforms Best online course platforms Canvas network Cognitive Class Coursera edX FutureLearn iversity Kadenze Khan Academy Udacity Udemy

Platform URL https://www.instructure.com https://cognitiveclass.ai https://www.coursera.org https://www.edx.org https://www.futurelearn.com https://iversity.org/en https://www.kadenze.com https://www.khanacademy.org https://www.udacity.com https://www.udemy.com

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

The course described here is ‘Histology for the Health Sciences: Basic Tissues of the Body’, but the other course ‘Histology for the Health Sciences: Organ Systems’ is similarly presented on the Canvas LMS. This Online Learning Platform and Learning Management System fulfilled the requirements for the online delivery of the courses described (see Sect. 6.5.2). The teaching schedule outlines the topics presented over a 10 week teaching term (Fig. 6.8).

6.12.2

An Example of a Successful Online Histology Course: Directives to Students

A series of instructions or directives welcoming students and institutional contact details, a detailed explanation about how to access and use Online Lectures, Meyer’s Histology Online Interactive Atlas (including virtual microscopy), and extensive descriptive videos are provided in the first Module (Fig. 6.9) ‘Getting started for the beginning of this course, i.e., Week 1 (20th September 2021)’. A detailed explanation ‘Advice when completing your Weekly Graded Quizzes’ can also be found in this first Module (Fig. 6.9). Students are very focussed on success and so the quizzes/ examinations are always on their minds. It was important to reinforce (from what is also contained within the ‘Course Syllabus’ document) details about the format of quizzes, their educational value, etc.

6.12.3

An Example of a Successful Online Histology Course: A Learning Module

The course is divided into modules containing various topics. The example in Table 6.13 is the module on ‘The Mammalian Cell’. Each module contains learning tools (or week’s learning tasks) recommended that students complete in the order listed.

6.12.4

153

An Example of a Successful Online Histology Course: Students’ Assessments

Each Weekly Graded Quiz is worth 5%. The total of 8 Quizzes is worth 40%. Each weekly graded quiz opens from 12:01 am Saturday (at the end of the week) to 11:59 pm Friday (the following week); i.e., for 7 days. Students can take the quiz at any time during that period. Each weekly graded quiz will only cover the topics presented during that week. Most questions have an automated marking system which is activated after the quiz is completed. After each attempt, the student receives instant feedback on the questions correctly answered. When the quiz closes, all responses are reviewed, as often a students’ entry in a ‘written’ answer may differ from the automated bank of answers. Minor spelling errors are tolerated. When the quiz closes and all responses are reviewed and marks amended (if necessary), which is completed within 24 h, the quiz is re-opened so students can see the correct answers. Each weekly quiz contains 20 questions randomly selected from a database containing around 40–50 questions. Students are not supervised when completing these weekly graded quizzes, but the expectation is that students will not have time to consult notes, etc. when completing the questions in the allotted time (i.e., 18 min). The purpose of the quizzes is: 1. To guide students to achieve the ‘Learning outcomes’ and so are an important and very useful learning tool rather than simply an assessment. The knowledge gained by completing quizzes each week will adequately prepare students for the midterm and final examinations. 2. Being required to complete a short, graded quiz each week will ensure the student completes topics on a regular basis and not ‘cram’ before the midterm and final examinations.

154

Fig. 6.8 Online histology course ‘Histology for the Health Sciences: Basic Tissues of the Body’ schedule

G. T. Meyer

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

155

Fig. 6.9 Introductory module with directives on how to access histology learning resources

Emphasis is for students to engage with the histological sections of human tissues and organs using virtual microscopy and view relevant histological characteristics of these organs. This will facilitate students achieving the skills required to recognise normal and abnormal structures within tissues and organs. The midterm examination is worth 25% and only examines material presented in Weeks 1–4. The final examination is worth 35% and only examines material presented in Weeks 6–9. To accommodate people’s work schedules, both the midterm and the final examinations open from 6 am on Saturday of the exam week and close 11.59 pm the following Monday. Both the midterm examination and the final examination are supervised by ‘ProctorU’ (https://www.proctoru. com). ProctorU is a leading provider of remote proctoring and integrity safeguards for online testing and includes trained human test proctors.

Students have expressed no issues with this proctoring system.

6.12.5

An Example of a Successful Online Histology Course: Student Evaluations of the Course

Evaluations are completed by students at the end of each course. Typical examples of student comments below (presented to me as the Instructor from the UCLA Extension Student office) are from histology courses completed in 2020 and 2021: • The instructor is prompt in resolving issues and the material is very interesting and organised. • Very satisfied. Course lectures were easy to follow, and professor was great.

156

G. T. Meyer

Table 6.13 A typical learning module, e.g. ‘The Mammalian Cell’ embedded in the LMS is best summarised in point form

A typical learning module embedded in the LMS, e.g. ‘The Mammalian Cell’ 1. ‘Learning tasks’ are detailed. These include directives to accessing 1 or 2 Online histology lectures (providing learning content/knowledge about a specific topic). An Online Interactive Atlas, providing learning content/knowledge about the different cells and tissues of a specific topic. Histological sections of cells and tissues are to view using virtual microscopy 2. PowerPoint slides to accompany the online lectures are provided 3. There is a link to open Histology Lectures (delivered via ‘Lecturio.com’) 4. There is a link to open Meyer’s Histology Online Interactive Atlas with the Virtual Microscopy facility 5. Extensive short video descriptions. These are the last series of learning resources listed as they serve to not only provide extensive content, but also reinforce and summarise content provided in the other learning resources 6. A link to ask questions 7. A graded quiz

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

• This course was challenging and required a lot of study time. • I am a predental student and learning to view histological slides before dental school can get me a head start. • When I first started the course, I didn’t think I would be able to identify and know all the information, but now I have a good base knowledge of histology. • Professor Meyer was great! His lectures were clear and understandable. • The weekly quizzes were a great way to test the weekly knowledge and the interactive atlas was super helpful in learning what the structures look like and a refresher of their functions. • Yes! I learned a lot that I will be able to use in the future. • The professor was well organised and gave lots of resources to learn the material. • Honestly, Dr. Meyer was an incredible professor. His slides were excellent. The Lecturio lectures were excellent and well-paced. The grading was fair. Meyer’s histology is a great resource. This has had to be one of the most enjoyable online classes I have ever taken. It was absolutely excellent, and I learned so much. • I LOVE classes with Professor Meyer!! • Dr. Geoffrey Meyer responds to student’s emails promptly. He very much cares for his students and is willing to help as much as possible. He challenges his students with his materials/exams, but he also accommodates his students to have the best learning experiences. • Great resources to learn and although it was a challenging course, we had more than enough resources to be able to understand the content clearly and thoroughly. • This course will not only help me in future science courses but also in post-grad school. • Great professor, very caring, very informed, very easy to listen to for the lectures. • Would have loved to have him for a class in person.

157

• Wonderful structure and materials for the course. • Instructor was extremely helpful, organised, and understanding. • Professor was very understanding and responsive when we had a question considering the rigour and the dense material of the class. But I learned a lot of great skills from it. • I thoroughly enjoyed this histology course! The content was engaging and challenging. I retained material that will assist me with dental school. • Although I did not get to interact with Dr. Meyer due to my own time constraint, Dr. Meyer was very accessible throughout the course and gave us encouragement that although this material can be challenging but it is definitely possible to do well. • Although this is an online course, the lecture materials were well-put together and the online histology resources were a great addition.

6.13

3D Printers: Possible Uses in Histology Visualisation?

In many medical and dental schools worldwide, the trend seems to be a reduction in the dissection-based teaching of both anatomy and medical pathology (McMenamin et al. 2021). The teaching of medical pathology has undergone significant change in the last 40 years with less focus being placed on the ability of students to describe the gross anatomical pathology of specimens (McMenamin et al. 2021). Financial considerations involved in employing staff to maintain bottled specimens, space constraints in student laboratories, and concerns with health and safety of staff and have meant that many institutions have decommissioned their pathology collections. Surface scanning coupled with computed tomography (CT) scanning and 3D printing has enabled the digital archiving of gross pathological specimens and the production of reproductions or replicas of preserved human anatomical pathology specimens. With modern

158

G. T. Meyer

ultraviolet (UV) curable resin printing technology, it is possible to achieve photographic quality accurate replicas comparable to the original specimens in many aspects. Accurate 3D reproductions of human pathology specimens offer many advantages over traditional bottled specimens including the capacity to generate multiple copies and their use in any educational setting, giving access to a broader range of potential learners and users (McMenamin et al. 2021). Australian scientists from Monash University have 3D printed realistic body parts (www. 3danatomyseries.com), to allow doctors in training to learn about the human body and anatomy without the use of real cadavers. Their collection of highly accurate normal human anatomy models has been generated directly from either radiographic data or actual cadaveric specimens using advanced imaging techniques and state-ofthe-art 3D printing technology. One other group has created 3D printed replicas of human pathology specimens (Mahmoud and Bennett 2015). These authors used photogrammetry and ink-jet powder-based printers to conclude that 3D printing of human anatomic pathology specimens was possible and may prove valuable in education, medical training, clinical research, and clinicopathological correlation at multidisciplinary team meetings. At the present time though, there are no reports or examples of histological structures being created using similar technologies, but perhaps there will be in the future.

6.14

Conclusion

Visualisation is a key component to understanding the histology (microanatomy) of the human body. Technologies have evolved over centuries to identify components of cells, tissues, and organs. Now various techniques can even identify molecular components of biological membranes and other unique components that make up cell structure and participate in the specific functions of each cell type. With the increasing ability to diagnose disease processes (and in their early stages), using

biological markers at the molecular level from a blood test or biopsy sample, who knows if there is any future in histology education in an everchanging medical/dental curriculum? However, its importance will always remain as a basic science in allied health or biological/biomedical science curricula, and will remain essential to further investigating how cells, tissues, and organs function and develop pathological changes. What is the next step in histology education? Evidence in this chapter has shown conclusively that online teaching of histology is successful, and significantly reduces (almost eliminates) the cost of teaching histology curricula in individual institutions. Perhaps it will not be long before these institutions recommend their students complete a common online histology course available globally, with their learning facilitated by their university teacher and accredited by the student’s institution. Acknowledgements The author would like to thank the UWA students who participated in the 2014 survey. The author is also grateful for the advice and assistance of Professor John Campbell PhD (deceased) and Professor Michael Hall PhD both from UCLA in creating the unique learning resources. A University of Western Australia Teaching Fellowship, Australian Award for University Teaching, Australian Learning and Teaching Council Grant 00910-63001003, and Australian Learning and Teaching Council Fellowship ID11-1990 to the author provided financial support for the creation of all the resources used. Conflicts of Interest Geoffrey T. Meyer is the creator of all resources delivered by https://www.histology-online. com and https://www.meyershistology.com and a Co-Director of Histology-Online Pty Ltd that distributes these resources. Students can subscribe individually for a very small fee, i.e. only about USD$14. Many universities subscribe (for a small fee) via their university library acquisition funds to enable their students to access the resources for 4 years. In some instances, no fee is charged, e.g. for developing nations characterised by a population with low and middle incomes, and other socio-economic indicators. This marketing of the resources is ‘non-profit’ and essentially to provide an income to maintain the website, storage of large, scanned images, and a reliable (but economical) web-based membership management tool. Also, funds finance updating of software and any website changes etc. which require a web designer or IT specialist.

6

Online, Interactive, Digital Visualisation Resources that Enhance Histology Education

References Allen IE, Seaman J (2010) Learning on demand: online education in the United States. 2009. ERIC Álvarez A, Martín M, Fernández-Castro I, Urretavizcaya M (2013) Blending traditional teaching methods with learning environments: experience, cyclical evaluation process and impact with MAgAdI. Comput Educ 68: 129–140 Augustin M (2014) How to learn effectively in medical school: test yourself, learn actively, and repeat in intervals. Yale J Biol Med 87(2):207–212 Becker JH (2006) Virtual microscopes in podiatric medical education. J Am Podiatr Med Assoc 96:518–524 Berge ZL (2002) Active, interactive, and reflective elearning. Q Rev Dist Educ 3(2):181–190 Bergman EM, Prince KJAH, Drukker J, van der Vleuten CPM, Scherpbier AJJA (2008) How much anatomy is enough? Anat Sci Educ 1:184–188 Black A (2010) Gen Y: who they are and how they learn. Educ Horiz 88:92–101 Blake CA, Lavoie HA, Millette CF (2003) Teaching medical histology at the University of South Carolina School of Medicine: transition to virtual slides and virtual microscopes. Anat Rec B New Anat 275(1): 196–206 Bloodgood RA, Ogilvie RW (2006) Trends in histology laboratory teaching in United States medical schools. Anat Rec 289B:169–175 Braun MW, Kearns KD (2008) Improved learning efficiency and increased student collaboration through use of virtual microscopy in the teaching of human pathology. Anat Sci Educ 1:240–246 Chapman J, Lee L, Swailes N (2020) From scope to screen: the evolution of histology education. In: Biomedical visualisation. Advances in experimental medicine and biology, p 1320 Chen YK, Hsue SS, Lin DC, Wang WC, Chen JY, Lin CC, Lin LM (2008) An application of virtual microscopy in the teaching of an oral and maxillofacial pathology laboratory course. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol 105(3):342–347 Cho H, Gay G, Davidson B, Ingraffea A (2007) Social networks, communication styles, and learning performance in a CSCL community. Comput Educ 49(2): 309–329 Dee FR (2009) Virtual microscopy in pathology education. Hum Pathol 40:1112–1121 Deng L, Tavares NJ (2013) From Moodle to Facebook: exploring students’ motivation and experiences in online communities. Comput Educ 68:167–176 Deniz H, Cakir H (2006) Design principles for computerassisted instruction in histology education: an exploratory study. J Sci Educ Technol 15:1–10 Dewan MAA, Murshed M, Lin F (2019) Engagement detection in online learning: a review. Smart Learn Environ 6:1 Dixson MD (2012) Creating effective student engagement in online courses: what do students find engaging? J Scholarsh Teach Learn 10(2):1–13

159

Drake RL, McBride JM, Lachman N, Pawlina W (2009) Medical education in the anatomical sciences: the winds of change continue to blow. Anat Sci Educ 2: 253–259 Elmansouri A, Murray O, Hall S, Border S (2020) TEL methods used for the learning of clinical neuroanatomy. Biomed Visual 10(4):43–73 Foster K (2010) Medical education in the digital age: digital whole slide imaging as an e-learning tool. J Pathol Inform 1(1):14 Gartner LP, Lee MJ (2022) Gartner & Hiatt’s atlas and text of histology, 8th edn. Wolters Kluwer, Philadelphia Glatz-Krieger K, Spornitz U, Spatz A, Mihatsch MJ, Glatz D (2006) Factors to keep in mind when introducing virtual microscopy. Virchows Arch 448:248–255 Hall S, Harrison CH, Stephens J, Andrade MG, Seaby EG, Parton W, McElligott S, Myers MA, Elmansouri A, Ahn M, Parrott R, Smith CF, Border S (2018) The benefits of being a near-peer teacher. Clin Teach 15(5):403–407 Harris T, Leaven T, Heidger P, Kreiter C, Duncan J, Dick F (2001) Comparison of a virtual microscope laboratory to a regular microscope laboratory for teaching histology. Anat Rec 265(1):10–14 Healey M, Flint A, Harrington K (2014) Engagement through partnership: students as partners in learning and teaching in higher education. Higher Education Academy, York Helle L, Nivala M, Kronqvist P, Gegenfurtner A, Björk P, Säljö R (2011) Traditional microscopy instruction versus process-oriented virtual microscopy instruction: a naturalistic experiment with control group. Diagn Pathol 6(Suppl 1):S8–S8 Herman GL (2012) Designing contributing student pedagogies to promote students’ intrinsic motivation to learn. Comput Sci Educ 22(4):369–388 Herro D, Kiger D, Owens C (2013) Mobile technology: case-based suggestions for classroom integration and teacher educators. J Digit Learn Teach Educ 30(1): 30–40 Higazi TB (2011) Use of interactive live digital imaging to enhance histology learning in introductory level anatomy and physiology classes. Anat Sci Educ 4(2):78–83 Islam AKMN (2013) Investigating e-learning system usage outcomes in the university context. Comput Educ 69:87–399 Kember D, McNaught C, Chong FCY, Lam P, Cheng KF (2010) Understanding the ways in which design features of educational websites impact upon student learning outcomes in blended learning environments. Comput Educ 55(3):1183–1192 Kogan LR, Dowers KL, Cerda JR, Schoenfeld-Tacher RM, Stewart SM (2014) Virtual microscopy: a useful tool for meeting evolving challenges in the veterinary medical curriculum. J Sci Educ Technol 23(6): 756–762 Krippendorf BB, Lough J (2005) Complete and rapid switch from light microscopy to virtual microscopy for teaching medical histology. Anat Rec 285B:19–25

160 Kumar RK, Velan GM, Korell SO, Kandara M, Dee FR, Wakefield D (2004) Virtual microscopy for learning and assessment in pathology. J Pathol 204:613–618 Leidner DE, Jarvenpaa SL (1995) The use of information technology to enhance management school education: a theoretical view. MIS Q 19:265–291 Liaw SS, Huang HM, Chen GD (2007) An activitytheoretical approach to investigate learners’ factors toward e-learning systems. Comput Hum Behav 23(4):1906–1920 Lim H, Lee SG, Nam K (2007) Validating E-learning factors affecting training effectiveness. Int J Inf Manag 27(1):22–35 Liu Y, Li H, Carlsson C (2010) Factors driving the adoption of m-learning: an empirical study. Comput Educ 55(3):1211–1219 Liu ZY, Lomovtseva N, Korobeynikova E (2020) Online learning platforms: reconstructing modern higher education. Int J Emerg Technol Learn (iJET) 15(13):4–21 Lowe JS, Anderson PG, Anderson SI (2018) Stevens & Lowe’s human histology, 5th edn. Elsevier Health Sciences, Philadelphia Lundin M, Szymas J, Linder E, Beck H, de Wilde P, van Krieken H, Rojo MG, Moreno I, Ariza A, Tuzlali S, Dervisoglu S, Helin H, Lehto V, Lundin J (2009) A European network for virtual microscopy—design, implementation and evaluation of performance. Virchows Arch 454:421–429 Mahmoud A, Bennett M (2015) Introducing 3-dimensional printing of a human anatomic pathology specimen: potential benefits for undergraduate and postgraduate education and anatomic pathology practice. Arch Pathol Lab Med 139(8):1048–1051 McMenamin PG, Hussey D, Chin D, Alam W, Quayle MR, Coupland SE, Adams JW (2021) The reproduction of human pathology specimens using threedimensional (3D) printing technology for teaching purposes. Med Teach 43:189–197 Merk M, Knuechel R, Perez-Bouza A (2010) Web-based virtual microscopy at the RWTH Aachen University: didactic concept, methods and analysis of acceptance by the students. Ann Anat Anat Anz 192:383–387 Mescher A (2013) Junqueira’s basic histology: text and atlas, 13th edn. McGraw-Hill Education, New York Messerer DAC, Kraft SF, Horneffer A, Messerer LAS, Böckers TM, Böckers A (2021) What factors motivate male and female Generation Z students to become engaged as peer teachers? A mixed-method study among medical and dental students in the gross anatomy course. Anat Sci Educ 10:1–13 Nagandla K, Sulaiha S, Nalliah S (2018) Online formative assessments; exploring their value. J Adv Med Educ Prof 6(2):51–57 Ordi O, Bombí JA, Martínez A, Ramírez J, Alòs L, Saco A, Ribalta T, Fernández PL, Ortiz MGR, Hoyos JRC, López MGR (2004) The social networks of

G. T. Meyer academic performance in a student context of poverty in Mexico. Soc Networks 26(2):175–188 Ovalle WK, Nahirney PC, Netter FH (2013) Netter’s essential histology. Clinical key 2012. Elsevier Saunders, Philadelphia Panigrahi R, Srivastava PR, Sharma D (2018) Online learning: adoption, continuance, and learning outcome—a review of literature. Int J Inf Manag 43: 1–14 Pantanowitz L, Szymas J, Yagi Y, Wilbur D (2012) Whole slide imaging for educational purposes. J Pathol Inform 3:46 Paulsen FP, Eichhorn M, Bräuer L (2010) Virtual microscopy—the future of teaching histology in the medical curriculum? Ann Anat Anat Anz 192:378–382 Pinder KE, Ford JC, Ovalle WK (2008) A new paradigm for teaching Histology laboratories in Canada’s first distributed medical school. Anat Sci Educ 1:95–101 Prensky M (2001) Digital natives, digital immigrants. Cross currents: cultures, communities, technologies Raja S (2010) Virtual microscopy as a teaching tool adjuvant to traditional microscopy. Med Educ 44(11): 1126–1126 Ross MH, Pawlina W (2016) Histology: a text and atlas. Wolters Kluwer Health, Philadelphia Rueshle S, Dorman M, Evans P, Kirkwood J, McDonald J, Worden J (1999) Critical elements: designing for online teaching. ASCILITE 99 Selwyn N (2009) The digital native—myth and reality. ASLIB Proc 61(4):364–379 Walser J, Horneffer A, Oechsner W, Huber-Lang M, Gerhardt-Szep S, Boeckers A (2017) Quantitative and qualitative analysis of student tutors as near-peer teachers in the gross anatomy course. Ann Anat 210: 147–154

Geoffrey T. Meyer , BSc (Hons), PhD, FRSB, is a Professor and Senior Honorary Research Fellow in the School of Human Sciences, at the University of Western Australia (UWA). He has been teaching anatomy (including neuroanatomy) and histology for over 40 years. During that time, he has received several teaching awards including a UWA Excellence in Innovation in Teaching Award, an International Excellence in Innovation in Teaching, Learning, and Technology Award and was an Australian University Teaching Award Winner. He has received a UWA Teaching Fellowship and was awarded a prestigious ALTC (Australian Learning and Teaching Council) Fellowship. Professor Meyer is a Fellow of the Royal Society of Biology (FRSB) and a member of the International Federation of National Teaching Fellows (IFNTF). He is the immediate Past-Coordinator for Histology on the Federative International Program for Anatomical Terminologies (FIPAT) of the International Federation of Associations of Anatomists (IFAA).

7

Leading Transformation in Medical Education Through Extended Reality Arian Arjomandi Rad, Hariharan Subbiah Ponniah, Viraj Shah, Sukanya Nanchahal, Robert Vardanyan, George Miller, and Johann Malawana

Abstract

Extended reality (XR) has exponentially developed over the past decades to incorporate technology whereby users can visualise, explore, and interact with 3-dimensionalgenerated computer environments, and superimpose virtual reality (VR) onto real-world environments, thus displaying information and data on various levels of the realityvirtuality continuum. In the context of medicine, VR tools allow for anatomical assessment and diagnosis, surgical training through A. Arjomandi Rad Medical Sciences Division, University of Oxford, Oxford, UK

lifelike procedural simulations, planning of surgeries and biopsies, intraprocedural guidance, and medical education. The following chapter aims to provide an overview of the currently available evidence and perspectives on the application of XR within medical education. It will focus on undergraduate and postgraduate teaching, medical education within Low-Middle Income Countries, key practical steps in implementing a successful XR programme, and the limitations and future of extended reality within medical education. Keywords

Extended reality · Virtual reality · Augmented reality · Medical education

The Healthcare Leadership Academy, London, UK H. Subbiah Ponniah · V. Shah · S. Nanchahal Faculty of Medicine, Department of Medicine, Imperial College London, London, UK e-mail: [email protected]; [email protected]; sukanya. [email protected] R. Vardanyan The Healthcare Leadership Academy, London, UK Faculty of Medicine, Department of Medicine, Imperial College London, London, UK e-mail: [email protected] G. Miller · J. Malawana (✉) The Healthcare Leadership Academy, London, UK University of Central Lancashire Medical School, Preston, UK e-mail: [email protected]; johann@medics. academy; [email protected]

7.1

The Definition and Current State of Extended Reality Technologies

Before exploring its core content, we will clarify some key terminology which will be utilised throughout this chapter. Virtual Reality (VR) involves using computer modelling to create an immersive, 3-dimensional, virtual environment which can be explored by the user. In contrast, Augmented Reality (AR) involves enhancing the user’s real-world environment by overlaying digital information in the form of sound, images, or other sensory stimuli. Mixed

# The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Border et al. (eds.), Biomedical Visualisation, Advances in Experimental Medicine and Biology 1421, https://doi.org/10.1007/978-3-031-30379-1_7

161

162

A. Arjomandi Rad et al.

Fig. 7.1 Schematic display of extended realities. (a) Virtual reality: digital space is completely separated from the environment. (b) Augmented reality: digital space is integrated into the users’ natural environment. (c) Mixed

reality: the user is able to stay in his natural environment and still interact with the digital information. Adapted with permission from authors, Arjomandi Rad et al. (2021)

Reality (MR) combines elements of both VR and AR by enabling virtual objects to interact with the user’s real environment. Extended Reality (XR) serves as an umbrella term encompassing VR, AR, and MR. The COVID-19 pandemic has accelerated the acceptability of digital technology within medicine as highlighted in the literature reviewed by Budd et al. (2020), however, this trend is one which has been developing for some time. The use of telemedicine for video consulting has become commonplace and these advances are further cementing the place of XR technologies within medical practice. The advantages XR offers to medical practice are largely centred around its ability to visualise anatomy in 3-dimensions and therefore is particularly highly utilised within surgery. Andrews et al. reviewed existing literature (Andrews et al. 2019) and suggested the existing state of XR within medical practice can be summarised into two main categories. Firstly, XR technology can be used during diagnosis and pre-procedural planning. In these circumstances VR is often the preferred means of XR. In addition, XR also has intraprocedural applications, again, often in the form of displaying patient anatomy during the

procedure. In contrast, for its intraprocedural application, AR is often the preferred form of XR as it does not obscure the healthcare professional’s view during the procedure. These applications of XR within medicine practice are particularly utilised in the field of interventional cardiology. Within a narrative literature review, Logeswaran et al. found that the use of XR within medical education is not yet routine, although there have been several pilot programmes that have been trialled (Logeswaran et al. 2021a). Similar to the role of XR within clinical practice, these applications of XR within medical education have largely been focussed on supplementing anatomy and skills-based teaching although other uses have also been explored. This is likely due to the potential XR holds in terms of 3D visualisation of structures (Fig. 7.1).

7.2

What Can Extended Reality Offer to Medical Education?

XR certainly has a great deal to offer to medical education for students, educators, and administrators, the literature surrounding which

7

Leading Transformation in Medical Education Through Extended Reality

has been surmised by Zweifach and Triola (2019a). Most medical schools use cadaveric specimens as their primary method of delivering anatomy teaching. However, cadavers have significant associated costs with their use. XR, although likely providing a substantial upfront cost, has the opportunity to reduce long-term costs of anatomy education by serving as an alternative or adjunct to cadaveric teaching. An additional shortcoming of the existing reliance on cadavers for anatomy teaching is that it limits students’ access to educational opportunities. Students do not get to spend a great deal of time in the dissecting room which, for many, is their only opportunity to explore anatomy in 3-dimensions. Therefore, XR can serve as a valuable supplement to conventional cadaveric-based teaching by providing an opportunity for students to interact with the human body outside of the dissecting room. In addition, XR has some educational features which cannot be achieved with cadaveric-based teaching. During dissection, or when using prosections, anatomical structures often get damaged or obscured and are therefore less readily accessible to see and study. XR overcomes this shortcoming by enabling students to, for example, remove layers of tissue one at a time to gain a better visualisation of the anatomy, which is not dependent on the quality of dissection of their cadaver. Furthermore, following a systematic review of existing literature, Barteit et al. (2021) found the use of XR to teach anatomy to be more engaging and motivating than traditional teaching methods such as books or atlases. Increased student engagement with a subject is likely to correlate with improved understanding and competence, and therefore any medium that promotes increased learner engagement has inherent value. In addition, a randomised control study with 57 participants (Nicholson et al. 2006) found students who utilised a 3D computer-generated anatomical ear model to perform significantly better in a postintervention quiz than those who undertook an online tutorial alone. This further emphasises the added value XR in particular has to anatomical teaching as opposed to existing teaching methods.

163

Stepping away from the value of XR to anatomical teaching, XR also has significant potential for procedural and surgical skills acquisition. It is common knowledge that mastery of any skill involves a great deal of practice, which often involves making errors in the initial phases of learning. However, unlike many other fields, practical skills in medicine can have dangerous consequences if performed incorrectly. Therefore, when surgical or procedural skills teaching is undertaken in a clinical environment, a balance must be struck between the degree to which a trainee is allowed to practice their skills and the safety of the patient. This can often result in surgical trainees feeling less prepared and confident in their practical technique. XR offers a way to bridge this gap by providing a safe and interactive platform for trainees to develop their practical clinical skills without compromising patient safety. Most importantly, XR enables students to make mistakes, which are undoubtedly valuable learning opportunities, but without the same consequences which would be faced in a clinical setting. This is likely to improve the confidence and perceived preparedness of surgical trainees for performing practical skills, and VR training has been shown to reduce surgical times and improve performance in a number of different specialities (Pinter et al. 2020). To emphasise these points, a randomised clinical trial with 18 participants utilising immersive virtual reality simulation of orthopaedic surgical procedures also found training using the VR model to improve trainees efficiency and quality of surgical skill acquisition. Beyond enabling students to develop the practical skills themselves, using XR also enables a high-pressure environment to be simulated if desired, which can allow students to develop their ability to think on the spot and perform tasks under stressful circumstances. Furthermore, XR has benefits for medical education beyond those aspects focussing on practical skills or 3-dimensional visualisation. XR has also been found to be valuable for improving medical students’ interpersonal skills. Simulation with XR has been used to provide an immersive experience of the environment of patients suffering from long-term conditions, e.g.,

164

A. Arjomandi Rad et al.

Fig. 7.2 XR use within the operating theatre. Adapted with permission by authors (Arjomandi Rad et al. 2021)

Alzheimer’s disease (Barteit et al. 2021), which was shown to nurture students’ empathy by exposing them to the patient’s point of view and typical lifestyle. In addition, XR-based virtual patients can also be utilised by medical students for history taking, or to simulate difficult conversations, which in turn can improve students’ communication skills and therefore their clinical practice (Fig. 7.2). XR can also improve learning opportunities for medical students. Particularly since the COVID-19 pandemic, the number of students able to be present on a ward round at one time has been restricted. Even without social distancing rules, having too many students on a ward round can be intimidating for patients and provides less opportunity for students to actively participate. In 2020, Imperial College London conducted a proof-of-concept study trialling the use of MR technology to enable 11 fourth year medical students to participate in ward rounds remotely (Bala et al. 2021). The MR technology also enabled clinicians to superimpose imaging

and test results onto the patient’s environment for students to view whilst simultaneously listening to the clinician’s conversation with the patient. By using XR in such a manner, multiple students can engage with an experience at one time, which also fosters a collaborative learning environment.

7.3

The Application of Extended Reality in Postgraduate Teaching and Medical/Surgical Training

The benefits of application of XR technology are arguably the most significant in the field of surgery, in particular, surgical training. Traditionally, the surgical training model has always been compared to one of an apprentice model, with the trainee learning the skills from an experienced mentor. A trainee surgeon’s path to mastering surgical procedures usually requires extensive learning and often involves working at highvolume medical centres. These centres provide

7

Leading Transformation in Medical Education Through Extended Reality

numerous opportunities for hands-on experience, allowing trainees to hone their skills in a broad variety of procedures across different surgical specialties and subspecialties. This hands-on experience is vital for successfully graduating from their training program. Furthermore, in a field that is often the vanguard of medical innovation, even the more experienced surgeon will require training to obtain proficiency in new procedures or techniques to be the safest clinician possible. The use of XR technology thus far has certainly exponentiated access to surgical training outside of the operating theatre, with the ability to revise and practise new and old techniques, with significantly less consequences, and not limited by the range or complexity of procedures that are often only viable in centres with high case loads. The use of VR has been shown to reduce procedural times; improve accuracy; results in fewer complications; and has improved surgeon and patient satisfaction; all contributing to a more cost-effective model for training the next generation of surgeons whilst upholding the highest standards of care offered to patients (Mao et al. 2021). The use of XR has not only improved proficiency for individual clinicians, but also for teams. The use of VR has enabled group simulation encompassing various roles alongside the primary surgeon, including the vital role of scrub nurses, improving coordination between various team members. The benefits of upskilling and training of the wider surgical team alongside the primary surgeon are often most evident when looking at surgical trainees in the early stages of their training, as well as complicated cases requiring complex preparation and assembly of various array of instruments (Edwards et al. 2021). It must be noted that whilst VR surgical simulation is not a like-for-like replacement of a real operation experience, it certainly provides the ability to complement the current surgical training model by laying a foundation for the practical transition of the knowledge from textbooks and 2-dimensional resources. By incorporating features such as tactile feedback, a degree of imitation of the real procedure can be achieved, thus helping build the psychomotor skills outside

165

the operating theatre and helping expedite the overall time to proficiency in the technique (Li et al. 2017). Whilst VR has mainly been used for surgical simulations, AR has been employed to provide real-time assistance during surgery. The development of headset models, alongside developments in telecommunication, has greatly expanded the use of telementoring and teleconsultation. These methods facilitate guidance from an expert surgeon to the operating surgeon in real time, despite not being there in person, thus enabling the sharing of techniques and knowledge without being limited by location of the operating table, with the ability to annotate and highlight key stages to guide the surgeon through the procedure (Subbiah Ponniah et al. 2021). This is particularly useful during surgery out of hours, which is often manned by more junior members of the team and thus enables sharing in real time a view of a complicated case to more senior staff, thus enabling better assessment of injuries and patient monitoring (Salehahmadi and Hajialiasgari 2019). The use of AR also enables visualisation of internal anatomy, which can be superimposed onto the patient, enabling the visualisation of key structures more easily than with traditional intraoperative imaging modalities such as fluoroscopy that typically produce 2D images and involve radiation exposure (Salehahmadi and Hajialiasgari 2019; Khor et al. 2016). AR has also been employed in preoperative planning, which can provide a more accurate forecast of the final result, particularly in aesthetic and craniofacial surgery where appearance is of great importance (Salehahmadi and Hajialiasgari 2019). XR technology has revolutionised the way surgical teaching is conducted by enabling surgeons to broadcast real time as well as record and catalogue their procedures, along with stageby-stage commentary and technical notes, creating a decentralised bank of surgical teaching materials (Khor et al. 2016). This decentralisation allows for greater flexibility in learning and sharing expertise with a wider range of people than was previously possible with the traditional apprentice model, and provides trainees with a more comprehensive understanding and exposure

166

A. Arjomandi Rad et al.

to the variety of surgical techniques used around the world to supplement their clinical training.

7.4

Widening the Access to Medical Education in Low-Middle Income Countries: Is Extended Reality the Answer?

Extended reality, on the surface, presents many solutions to challenges faced by low- and middleincome countries (LMICs) in gaining equitable access to medical education. Delving deeper, many LMICs are often limited by a ‘pointblank’ lack of access to sufficiently skilled healthcare personnel that are capable of training, enriching, and developing the next generation of clinicians. Indeed, the World Health Organisation’s Global Strategy Report on Human Resources for Health envisions an estimated needs-based shortage of 14.5 million aggregated doctors, nurses, and midwives in nations below the Sustainable Development Goal (SDG) index threshold to exist by 2030 (WHO 2022). This has often been attributed to the ‘brain drain’ phenomenon, whereby commonly the most-skilled and knowledgeable academics seek to leave their respective countries in search of better educational opportunities provided in more specialist settings, such as those that exist within the ecosystems of highincome countries (HICs). This theory was postulated by Dohlman et al. in a review that examined the drivers of this common effect (Dohlman et al. 2019). Upon leaving, academics take with them a vast amount of expertise relating to several elemental areas of medical education within LMICs and this understanding is consequentially not passed to trainees via the traditional training model. In essence, a vicious cycle is constructed that prevents accumulation of specialist knowledge within an LMIC-based centre over time, which stunts innovation and development (Karan et al. 2016). In addition, the climate surrounding accessible educational opportunities in LMICs is notably dynamic and such opportunities remain sparsely

distributed (Graetz et al. 2019). The principles of delivery of medical education in resource-poor settings do not always seek to facilitate what may constitute effective learning methods, rather the didactic delivery of content outright is prioritised (Celletti et al. 2013). This further limits the level of competency that trainees may be able to ascend to and poses important challenges, as aforementioned, as these individuals would often not possess sufficient training to provide care within high-risk regions (where it is in greatest demand globally). This further perpetuates the cycle outlined above. From the perspective of promoting global health equity, the introduction of XR presents a remarkable opportunity to level the playing field. For example, a surgeon training in Mozambique may receive access to the exact same virtual experience as a surgeon training in the United States. XR is not merely a transferable format but is incomparably consistent and allows an opportunity to reduce disparities within training opportunities both internationally and nationally within LMICs (Logeswaran et al. 2021b). In conjunction with this, it is not dependent on the availability of specific personnel or resources outside the specific mode of technology utilised. This makes it a suitable long-term, reliable, and sustainable approach. Its role would likely pivot towards supplementing practical and procedural skills-based or case-based teaching as opposed to knowledge-based teaching where the immediate role of XR within LMICs seems to be less profound and impactful (Cecilio-Fernandes et al. 2020). As aforementioned, XR could play a particularly poignant role in improving surgical education in LMICs where access to a mentor to guide one through a relevant technique and its minutiae is not only an aid but also a prerequisite. It is therefore not surprising that the majority of trials of its use in LMICs have been surgically oriented. Proximie (Proximie Ltd, London, U.K.), the company behind an innovative technology system pioneered to allow surgeons to virtually scrub into operations, has piloted a range of novel and exciting initiatives within this growing sector, following a call to action as a subsequent of the

7

Leading Transformation in Medical Education Through Extended Reality

COVID-19 pandemic. This has seen them examine the concept of virtual augmented reality telesurgery. Using Proximie, remote mentors have manipulated physical equipment in a LMIC-based operating room and hence virtually guided trainees within those settings towards performing specific procedures, which have been well-described in a case report of its application in a training context for reconstructive hand surgery in Gaza by Greenfield et al. (2018). Mechanistically, its foundation lies in the use of cross-audiovisual communication embedded in a cloud-based augmented reality system where live images are used to create a remote visual field that a remote surgeon can ‘virtually’ act upon. The benefits of such a system in viably increasing accessibility towards training opportunities, reducing global surgical inequalities, and addressing worldwide patient need are clear, although they must be weighed against any potential drawbacks. The technology’s effectiveness for increasingly complex surgical cases tangential to the common pitfalls of international communication in healthcare including covert cultural and time differences must be considered. Other technologies including virtual interactive presence and augmented reality (VIPAR) have also been well-described as methods of promoting equity in global surgical education in the literature. In the United States and Vietnamese telecollaboration case, the VIPAR tool uses mobile devices to allow a remote mentor to convey audiovisual information in real time across cases, in addition to virtually gesturing to anatomical features of relevance in training cases (Davis et al. 2016). As promising as some of these cases are, fundamentally XR in its current state is not a financially viable innovation for LMICs. It is incredibly expensive and it is not feasible for many medical education units in LMICs to adopt en-masse (Muinga and Paton 2019) although, it is to be said that a full-scale costanalysis is yet to occur. XR also requires a level of set-up and maintenance that makes it accessible to only a few specialist groups within LMICs, as the expertise needed to conduct this may be

167

either absent or scarce. This may contribute further to regional divides in the quality of health care within any individual LMIC. Many healthcare systems in LMICs simply do not have the infrastructure to support XR natively and would be forced into hierarchising more cost-effective teaching methods as a result (Joos et al. 2021). That is not to say that, with some tweaking and refining, XR will not play an assumed normality within medical education in LMICs in the future. If future approaches could take a frugal eye and adopt XR into resources already present in LMICs, XR may play a potentially revolutionary role. However, this point is still a distant one. It is worth considering the extent to which XR may further reinforce a global divide in accessibility within medical training in the short term and actively hinder, rather than advance, the WHO mission to achieving global health equity. Yet, given the dynamic climate of geopolitics, this is not an easy question to answer.

7.4.1

Subtitle 5: Key Considerations in Embedding Extended Reality Within a Medical Education Setting Curriculum

The adoption of XR technologies within the medical school and training programmes for healthcare practitioners at all levels could have tremendous potential in enhancing the learning experience in a clinically safe environment. An XR-based curriculum for medical education in a medical school would refer to the use of virtual and augmented reality technologies to enhance the learning experience of medical students. The programme would aim to provide students with hands-on, immersive simulations of medical procedures and surgeries, as well as interactive 3D anatomy lessons, and other medical scenarios that may be difficult to replicate in real life. By using XR technology, students would be able to practice procedures in a safe and controlled environment, receive immediate feedback on their performance, and develop important diagnostic and treatment skills. This programme could also

168

provide a valuable supplement to traditional lecture-based teaching and increase the overall effectiveness and engagement of medical education. When planning on implementing an extended reality curriculum within a healthcare teaching setting some important considerations have to be made, especially to ensure a costeffective programme with high levels of adoption both from faculty and students. Indeed, the execution should take place on three major fronts: organisational, faculty, and students. Firstly, it is important to understand that whilst both faculty and students represent the key components of medical education, a multi-level organisational involvement is key to ensure the success of any XR programme (Zweifach and Triola 2019b). The following should take into particular consideration the cost of implementation and cost-effectiveness of an XR programme, its long-term sustainability, the human resources needed, and most importantly the additional educational value provided. In fact, being able to objectively demonstrate both a financial and educational return of investment will be a key initial step. Demonstrating the added value of an XR could be gained from studies conducted and published at other institutions or from the direct implementation of a pilot programme. Whilst developing a pilot programme would include some initial costs, it would provide a more realistic overview of the potential expenses relevant to the institution. Indeed, factors such as the size of the organisation, the number of students, and funding available will vary amongst institutions, making it difficult to generalise costing from published studies. Furthermore, numerous medical schools around the world still use cadaveric dissections for the purpose of teaching anatomy to students. Whilst the practical aspect offered by anatomical dissection has been shown to be a valuable learning experience, the costs associated with running and maintaining anatomy facilities have also been shown to be potentially extremely elevated (Kovacs et al. 2018). Despite the upfront cost brought by the purchase of XR equipment, in the long-term these devices could prove significantly cost-effective for institutions.

A. Arjomandi Rad et al.

Secondly, early faculty involvement in the initial stages of XR-based curricula will not only ensure increased engagement with this technology, but will also guarantee the delivery of continuously cutting-edge medical education tailored to the learning pace and style of students. Indeed, students in all areas of healthcare practice are usually constantly tested for both their practical and theoretical clinical knowledge through standardised tests. A unique feature of XR would be the continuous tracking of student progress, therefore allowing faculty to continuously enhance their teaching, in order to fill in the gaps in knowledge of students. Therefore, XR would enable the provision of personalised feedback to students, not only at assessment stage, but throughout their learning experience (Arjomandi Rad et al. 2022). Standardising practical assessments, which could be carried out through simulated patients increases the objectivity of exam evaluations, taking away the subjective opinion or experiences of examiners and any potential bias present. Thirdly, and not least, it is important to consider the individual experience of the students. Ultimately, educational institutions have the common objective of educating the next generation of healthcare practitioners ensuring the highest standards of competence and patient safety. The establishment of an XR-based curriculum should be tailored to the needs and requirements of students at each individual institution, without being generalised. Knowledge about optimal use of the technology and time should be provided for the students to gain confidence with new XR systems, without overwhelming students by immediately transitioning to XR-mediated examinations (De Ponti et al. 2020). Students with special educational needs, such as dyslexia, dyscalculia, or dysgraphia and attention-deficit hyperactivity disorder, should also be included in the initial stages to ensure an inclusiveness and equal learning environment for everyone. Considerations should also be made to ensure an adequate degree of exposure and interaction with XR-enhanced learning at medical school. For instance, simply arranging two sessions during a whole academic year might in fact not be of any

7

Leading Transformation in Medical Education Through Extended Reality

substantial benefit to the learning experience of students. Whether to choose structured on unstructured teaching should also be considered. The goal of structured teaching with XR technology is to provide students with a consistent and comprehensive learning experience that covers all relevant concepts and skills in a logical and organised manner. On the other hand, non-structured teaching in the context of XR technology in medical education involves a more flexible and informal approach to education. This may involve providing students the freedom to explore and experiment with the XR simulations on their own, allowing them to learn at their own pace and in a manner that best suits their learning needs. This type of teaching can help to foster student independence and critical thinking skills, as they discover new ideas and concepts on their own. The choice between structured and non-structured teaching with XR technology will depend on the goals of the educator and the learning needs of the students. Some subjects may require a more structured approach, whilst others may benefit from a more flexible and non-structured approach. The key is to find the right balance between structure and flexibility to provide students with an engaging and effective learning experience. Furthermore, students or trainees could also be provided with their own XR system to enable a constant learning both inside and outside the hospital or university setting. There are several advantages to providing medical students with their own XR set for their education: Increased accessibility: Having their own XR set would allow students to access the virtual and augmented reality simulations at any time, both inside and outside of the hospital or university setting. This would allow them to practice and reinforce what they have learned, even when they are not in a structured teaching session. Improved learning outcomes: Providing students with their own XR set would allow them to have a constant and personalised learning experience, which can help to improve their skills and knowledge. They can repeat simulations and

169

procedures as many times as they need to, until they feel confident and competent in performing them. Convenience: By having their own XR set, students would not have to compete for access to limited XR systems during structured teaching sessions. This would allow for more efficient use of class time, as students can come prepared and ready to practice and apply what they have learned. Increased motivation: Owning their own XR set can increase student motivation and engagement, as they are able to take control of their own learning experience. They can explore and experiment with the simulations on their own, which can help to foster creativity and independent thinking. Overall, providing medical students with their own XR set can greatly enhance their educational experience, allowing them to have a constant and personalised learning experience that improves their skills and knowledge.

7.4.2

Subtitle 6: The Limitations and Future of Extended Reality Within Medical Education

Whilst it is easy to take an exclusive look at some of the boundless successes of XR in medical education that we have established, we must not forget that it is still a technology in its relative infancy and hence it is prone to its own teething problems. Many iterations of XR are still plagued by technological shortcomings that need to be urgently addressed prior to wider implementation, as identified in a narrative review conducted by Herur-Raman et al. (2021). Most prominently, greater refinement in the mechanisms of haptic feedback and tracking must be sought. Precision and accuracy are of upmost importance for any tool designed to mimic or simulate a practical clinical technique and, as already described, there may be grave consequences for patient safety if this is not achieved (Coles et al. 2011). A multitude of current applications, specifically those applied in gross anatomy education, use

170

hand- and finger-tracking, which is a less favourable approach to tactile feedback on account of providing a less realistic simulation. As a result, many current modes of XR cannot be feasibly applied to train and practise intricate and fidelitous procedures, which inherently excludes a substantial proportion of clinical skills (McGrath et al. 2018). Furthermore, in order for users to navigate XR for extended periods of time (as would be realistic for simulating longer cases or interactions), the concept of cybersickness represents a significant obstacle. Cybersickness is a discomforting phenomenon suggested to affect from 20–95% of users upon prolonged exposure to either augmented or virtual reality (Stanney 2021). In essence, it is an equivalent to ‘motion sickness’ comprising headaches, nausea, and other emetic responses. Current literature surrounding the extent of the phenomenon is rather vague, and this in itself warrants further analysis prior to adoption of any form of XR in medical education. On a logistical level, many of the principal barriers to XR’s application within medical education revolve around cost, maintenance, and practicalities. It is no secret that XR is notoriously expensive (Zweifach and Triola 2019a)—it requires multiple components that must all meet optimal performance criteria such as the hardware of the system itself as well as associated costs including ensuring high-quality display screen resolution, fast network speeds, and reliable graphics. This must be considered in tandem with the associated running costs. The pool of individuals with the skill required to programme XR systems as well as oversee their maintenance and troubleshoot errors is limited (Kourtesis et al. 2019). In addition, medical education units and programme directors must spend considerable time planning, designing, and implementing an XR curriculum. In an atmosphere where senior medical educators may already be sceptical or averse to such novel innovations based on comparisons to the way they were trained, cumbersome practicalities akin to this may spark further faculty resistance (Dixon-Woods et al. 2011). An often-overlooked area within innovation in medical education is the concept of generational

A. Arjomandi Rad et al.

difference and consideration of a diverse group of stakeholders for the implementation of any one technology, an area brought to notable attention again at the advent of the COVID-19 pandemic and its shift towards a majority technology-based ecosystem of conducting educational and professional activity (with many of the consequential remnants of this effect still in place). Whilst younger students may theoretically feel more at ease with approaching XR-based innovations, many educators may struggle with acquiring the technological literacy and IT skills to feel the same way (Antón-Sancho et al. 2022). Furthermore, any XR technologies must be considered in the context of digital fatigue (the phenomenon whereby exhaustion, poor mental health, and burnout result from overuse of technology). Most recently, a Shahrvini et al. study reported that 18% of study respondents cited digital fatigue as a drawback of following a remote curriculum during COVID-19 (Shahrvini et al. 2021). Whilst many methods of medical education have already shifted to technology-driven delivery, we must think deeply on a holistic level about whether transforming yet even more aspects of medical education is truly in congruence with leading a sustainable lifestyle. This leaves us with some clear future directions that may precede the mass application of XR in medical education. It is paramount that a set of guidelines surrounding XR in medical education is absent and is something that ought to be created. This could provide a framework that medical education programmes use as a springboard for implementing XR locally and would solve the problem of navigating the vagueness and lack of transparency of the XR world. Significant work is already underway to undertake costeffectiveness analyses and economic evaluations of XR tools and, moreover, recent prototypes have shown promise in developing economical solutions, as well as solutions to minimise associated health risks (including cybersickness) as seen in the commercial Oculus (Meta, Menlo Park, California, U.S.A.) range (Palmisano et al. 2020). Additionally, as more institutions begin the process of amicability towards XR tools, there is wider scope for future evaluative research

7

Leading Transformation in Medical Education Through Extended Reality

to understand the true performance of XR in context (Baniasadi et al. 2020).

References Andrews C, Southworth MK, Silva JNA, Silva JR (2019) Extended reality in medical practice. Curr Treat Options Cardiovasc Med 21(4):18. [cited 2021 Nov 18]. Available from http://www.pmc/articles/ PMC6919549/ Antón-Sancho Á, Fernández-Arias P, Vergara D (2022) Virtual reality in health science education: professors’ perceptions. Multimodal Technol Interact 6(12):110. https://doi.org/10.3390/mti6120110 Arjomandi Rad A, Vardanyan R, Lopuszko A, Alt C, Stoffels I, Schmack B, Ruhparwar A, Zhigalov K, Zubarevich A, Weymann A (2021) Virtual and augmented reality in cardiac surgery. Braz J Cardiovasc Surg 37(1):123–127 Arjomandi Rad A, Vardanyan R, Thavarajasingam SG, Zubarevich A, Van den Eynde J, Sá MP, Zhigalov K, Sardari Nia P, Ruhparwar A, Weymann A (2022) Extended, virtual and augmented reality in thoracic surgery: a systematic review. Interact Cardiovasc Thorac Surg 34(2):201–211 Bala L, Kinross J, Martin G, Koizia LJ, Kooner AS, Shimshon GJ et al (2021) A remote access mixed reality teaching ward round. Clin Teach 18(4): 386–390. [cited 2021 Nov 21]. Available from https://onlinelibrary.wiley.com/doi/full/10.1111/tct. 13338 Baniasadi T, Ayyoubzadeh SM, Mohammadzadeh N (2020) Challenges and practical considerations in applying virtual reality in medical education and treatment. Oman Med J 35(3):e125. [cited 2022 Jan 23]. Available from http://www.pmc/articles/ PMC7232669/ Barteit S, Lanfermann L, Bärnighausen T, Neuhann F, Beiersmann C (2021) Augmented, mixed, and virtual reality-based head-mounted devices for medical education: systematic review. JMIR Serious Games 9(3): e29080. [cited 2021 Nov 19]. Available from http:// www.pmc/articles/PMC8299342/ Budd J, Miller BS, Manning EM, Lampos V, Zhuang M, Edelstein M et al (2020) Digital technologies in the public-health response to COVID-19. Nat Med 26: 1183–1192 Cecilio-Fernandes D, Parisi MCR, Santos TM, Sandars J (2020) The COVID-19 pandemic and the challenge of using technology for medical education in low and middle income countries. MedEdPublish 9:74 Celletti F, Buch E, Samb B (2013) Oxford textbook of medical education. In: Walsh K (ed) Oxford textbook of medical education, vol 1, 1st edn. Oxford University Press, Oxford Coles TR, Meglan D, John NW (2011) The role of haptics in medical training simulators: a survey of the state of

171

the art. IEEE Trans Haptics 4(1):51–66. [cited 2022 Jan 23]. Available from https://pubmed.ncbi.nlm.nih. gov/26962955/ Davis MC, Can DD, Pindrik J, Rocque BG, Johnston JM (2016) Virtual interactive presence in global surgical education: international collaboration through augmented reality. World Neurosurg 86:103–111. [cited 2022 Jan 23]. Available from https://pubmed.ncbi.nlm. nih.gov/26342783/ De Ponti R, Marazzato J, Maresca AM, Rovera F, Carcano G, Ferrario MM (2020) Pre-graduation medical training including virtual reality during COVID-19 pandemic: a report on students’ perception. BMC Med Educ 20(1):1–7 Dixon-Woods M, Amalberti R, Goodman S, Bergman B, Glasziou P (2011) Problems and promises of innovation: why healthcare needs to rethink its love/ hate relationship with the new. BMJ Qual Saf 20(Suppl 1):i47–i51. [cited 2022 Jan 23]. Available from https:// pubmed.ncbi.nlm.nih.gov/21450771/ Dohlman L, Dimeglio M, Hajj J, Laudanski K (2019) Global brain drain: how can the Maslow theory of motivation improve our understanding of physician migration? Int J Environ Res Public Health 16(7): 1182. [cited 2022 Jan 23]. Available from http:// www.pmc/articles/PMC6479547/ Edwards TC, Patel A, Szyszka B, Coombs AW, Liddle AD, Kucheria R et al (2021) Immersive virtual reality enables technical skill acquisition for scrub nurses in complex revision total knee arthroplasty. Arch Orthop Trauma Surg 141(12):2313–2321. https://doi.org/10. 1007/s00402-021-04050-4 Graetz N, Woyczynski L, Wilson KF, Hall JB, Abate KH, Abd-Allah F et al (2019) Mapping disparities in education across low- and middle-income countries. Nature 577(7789):235–238. [cited 2022 Jan 23]. Available from https://www.nature.com/articles/ s41586-019-1872-1 Greenfield MJ, Luck J, Billingsley ML, Heyes R, Smith OJ, Mosahebi A et al (2018) Demonstration of the effectiveness of augmented reality telesurgery in complex hand reconstruction in Gaza. Plast Reconstr Surg Glob Open 6(3):e1708. [cited 2022 Jan 23]. Available from http://www.pmc/articles/PMC5908501/ Herur-Raman A, Almeida ND, Greenleaf W, Williams D, Karshenas A, Sherman JH (2021) Next-generation simulation—integrating extended reality technology into medical education. Front Virtual Real 2:115 Joos E, Zivkovic I, Shariff F (2021) Virtual learning in global surgery: current strategies and adaptation for the COVID-19 pandemic. Int J Surg Glob Health 4(1): e42–e42. [cited 2022 Jan 23]. Available from https:// journals.lww.com/ijsgh/Fulltext/2021/01010/Virtual_ learning_in_global_surgery__current.2.aspx Karan A, DeUgarte D, Barry M (2016) Medical “brain drain” and health care worker shortages: How should international training programs respond? AMA J Ethics 18(7):665–675

172 Khor WS, Baker B, Amin K, Chan A, Patel K, Wong J (2016) Augmented and virtual reality in surgery-the digital surgical environment: applications, limitations and legal pitfalls. Ann Transl Med 4(23):454. Available from https://pubmed.ncbi.nlm.nih.gov/28090510 Kourtesis P, Collina S, Doumas LAA, MacPherson SE (2019) Technological competence is a pre-condition for effective implementation of virtual reality head mounted displays in human neuroscience: a technological review and meta-analysis. Front Human Neurosci 13:342. [cited 2022 Jan 23]. Available from http:// www.pmc/articles/PMC6783565/ Kovacs G, Levitan R, Sandeski R (2018) Clinical cadavers as a simulation resource for procedural learning. AEM Educ Train 2(3):239–247 Li L, Yu F, Shi D, Shi J, Tian Z, Yang J et al (2017) Application of virtual reality technology in clinical medicine. Am J Transl Res 9(9):3867–3880. Available from https://pubmed.ncbi.nlm.nih.gov/28979666 Logeswaran A, Munsch C, Chong YJ, Ralph N, McCrossnan J (2021a) The role of extended reality technology in healthcare education: Towards a learner-centred approach. Future Healthc J 8(1):e79– e84 Logeswaran A, Munsch C, Chong YJ, Ralph N, McCrossnan J (2021b) The role of extended reality technology in healthcare education: Towards a learner-centred approach. Future Healthc J 8(1):e79– e84. [cited 2022 Jan 23]. Available from https://www. rcpjournals.org/content/futurehosp/8/1/e79 Mao RQ, Lan L, Kay J, Lohre R, Ayeni OR, Goel DP et al (2021) Immersive virtual reality for surgical training: a systematic review. J Surg Res 268:40–58. Available from https://www.sciencedirect.com/science/article/ pii/S0022480421004169 McGrath JL, Taekman JM, Dev P, Danforth DR, Mohan D, Kman N et al (2018) Using virtual reality simulation environments to assess competence for emergency medicine learners. Acad Emerg Med 25(2):186–195. [cited 2022 Jan 23]. Available from https://pubmed.ncbi.nlm.nih.gov/28888070/ Muinga N, Paton C (2019) Virtual reality for medical and nursing training in low- and middle-income countries. Pathways for Prosperity Commission Background Paper Series (25):1–10. [cited 2022 Jan 23]. Available from www.pathwayscommission.bsg.ox.ac.uk Nicholson DT, Chalk C, Funnell WRJ, Daniel SJ (2006) Can virtual reality improve anatomy education? A randomised controlled study of a computer-generated three-dimensional anatomical ear model. Med Educ 40(11):1081–1087. [cited 2022 Jan 21]. Available from https://pubmed.ncbi.nlm.nih.gov/17054617/ Palmisano S, Allison RS, Kim J (2020) Cybersickness in head-mounted displays is caused by differences in the user’s virtual and physical head pose. Front Virtual Real 1:24 Pinter C, Lasso A, Choueib S, Asselin M, Fillion-Robin JC, Vimort JB et al (2020) SlicerVR for medical intervention training and planning in immersive virtual

A. Arjomandi Rad et al. reality. IEEE Trans Med Robot Bionics 2(2):108. [cited 2021 Nov 20]. Available from http://www. pmc/articles/PMC7977740/ Salehahmadi F, Hajialiasgari F (2019) Grand adventure of augmented reality in landscape of surgery. World J Plast Surg 8(2):135–145. Available from https:// pubmed.ncbi.nlm.nih.gov/31309050 Shahrvini B, Baxter SL, Coffey CS, MacDonald BV, Lander L (2021) Pre-clinical remote undergraduate medical education during the COVID-19 pandemic: a survey study. BMC Med Educ 21(1):1–13. [cited 2022 Jan 23]. Available from https://bmcmededuc. biomedcentral.com/articles/10.1186/s12909-02002445-2 Stanney KM (2021) Cybersickness in virtual reality versus augmented reality. Front Res Topic. [cited 2022 Jan 23]. Available from https://www.frontiersin.org/ research-topics/12692/cybersickness-in-virtual-realityversus-augmented-reality Subbiah Ponniah H, Shah V, Arjomandi Rad A, Vardanyan R, Miller G, Malawana J (2021) Theatres without borders: a systematic review of the use of intraoperative telemedicine in low- and middle-income countries (LMICs). BMJ Innov 7(4):657. Available from http://innovations.bmj.com/content/7/4/657. abstract WHO (2022) Global strategy on human resources for health: workforce 2030 [cited 2022 Jan 23]. Available from https://apps.who.int/iris/handle/10665/250368 Zweifach SM, Triola MM (2019a) Extended reality in medical education: driving adoption through provider-centered design. Digit Biomark 3(1):14. [cited 2021 Nov 18]. Available from http://www. pmc/articles/PMC7015382/ Zweifach SM, Triola MM (2019b) Extended reality in medical education: driving adoption through provider-centered design. Digit Biomark 3(1):14–21

Arian Arjomandi Rad is an academic foundation doctor at the University of Oxford, Clinical Academic Graduate School (OUCAGS). He recently graduated from Imperial College London, with a degree in Medicine and Surgery, and a degree in Management. He is also a PhD candidate in Cardiothoracic Surgery at the University of Maastricht, School for Cardiovascular Diseases. He has a strong academic interest in Cardiothoracic Surgery, and over his short career has achieved over 50 peer-reviewed publications, 40 presentations, and national/International conferences and received 13 academic awards/prizes, including The Diana Legacy Award for his research and volunteering activities. He is the current Associate Research Director at the Healthcare Leadership Academic (HLA) and the Chair of the HLA Research Masterclass. Hariharan Subbiah Ponniah is a fifth year medical student at Imperial College School of Medicine. He has a passion for Trauma and Orthopaedics, focusing on surgical innovation and education. Hariharan has demonstrated

7

Leading Transformation in Medical Education Through Extended Reality

his commitment to his field as Co-Chair of the Imperial College Surgical Society, one of the largest and most active undergraduate medical societies in the country. He also serves on the RSM Student Section as a council representative. He has maintained a high academic standard, with distinctions in pre-clinical and clinical exams, placement on the Dean’s List and a prize for his BSc in Surgical Design, Technology, and Innovation. Viraj Shah is a fourth year medical student at Imperial College London, currently undertaking an intercalated degree in Healthcare Management at Imperial Business School. He holds a particular passion for innovation, leadership, and research with interests spanning the intersection of surgery, medical technology, and digital health. Viraj’s research has been presented internationally, awarded multiple prizes, and published in several academic journals. Viraj is currently a HLA scholar and serves as the Research Lead at PRASSA—the UK’s plastic surgery student association. He is currently working on projects with teams at Imperial College, King’s College, and Johns Hopkins in the machine learning space. Sukanya Nanchahal is a fourth year medical student pursuing an intercalated BSc in Pharmacology at Imperial College London. At present, she is also serving as President of the Imperial College Surgical Society and regional ambassador for the Association of Surgeons in Training. She has particular interests in surgery, medical education, and widening participation initiatives, having undertaken multiple related projects within these fields. She is the proud recipient of numerous medical school prizes and scholarships, including gold medals in her third year clinical and written examinations. Robert Vardanyan is a doctor who graduated from Imperial College London with a degree in Medicine and Surgery, and a degree in Management from the Imperial Business School. He also holds a Diploma in the Philosophy of Medicine (DPMSA) with a strong interest in

173

surgical bioethics. His academic and clinical interest is in Neurosurgery and has extensively published in the field, as well as presented his work at national and international conferences. His academic expertise includes costeffectiveness analyses, clinical observational studies, and review research on surgical therapies and experimental science. He has also participated in an international randomised controlled trial within Neurosurgery both in an observer and site investigative role. His professional memberships lie within surgical and global health organisations and he is a serving member of several board committees that focus on coordinating humanitarian and philanthropic work internationally. George Miller is an Imperial Public Health Registrar and Emergency Medicine Doctor. As Director-General, he takes responsibility for the HLA Scholars’ programme, as well as chairing the HLA Research Collaborative. He is also an Honorary University Lecturer, a Fellow of the Institute of Leadership and Management, lead for the Intermediate Leadership Programme and a Senior Project Manager at Medics. Academy. He was one of the top scoring applicants for the AFP, CST, and Public Health Training across the country, and has since presented national courses on ‘Success in Medical School’, ‘Preparing for the AFP’, and ‘Preparing for the PSA’. He is currently conducting policy research at the Department of Social Policy and Intervention, University of Oxford. Johann Malawana is a former Obstetrician and Gynaecologist and now a Senior Clinical Fellow at the School of Medicine at the University of Central Lancashire, the CEO of Medics. Academy and the Managing Director of the Healthcare Leadership Academy. He holds or has held a variety of Board level roles across the public sector, regulators, and the private and charity sectors. His Academic interest is in the role of technology in Healthcare Education Delivery and Digital Health.

8

Visualisation Approaches in Technology-Enhanced Medical Simulation Learning: Current Evidence and Future Directions Aleksander Dawidziuk, George Miller, and Johann Malawana

Abstract

Technology-enhanced learning (TEL) has been proposed as an approach to minimise the healthcare workforce shortage preventing universal healthcare coverage. Simulationbased medical education is a well-established teaching method. Little is known about effective strategies to translate in-person medical simulation teaching into a virtual world. This work aimed to review the literature on approaches to visualisation in technologyenhanced medical simulation. A systematic search strategy was optimised using three databases: Embase, MEDLINE, and APA PsycInfo. Additional papers were identified through cross-referencing. The last date of this search was 3 January 2022. The articles were analysed qualitatively. The risk of bias was assessed using ROBINS-I and RoB 2 tools. The search yielded 656 results with 9 additional papers identified through crossreferencing. Following deduplication and exclusions, 23 articles were included in a A. Dawidziuk The Healthcare Leadership Academy Research Collaborative, London, UK Royal Free London NHS Foundation Trust, London, UK G. Miller · J. Malawana (✉) The Healthcare Leadership Academy Research Collaborative, London, UK University of Central Lancashire, Preston, UK e-mail: [email protected]

qualitative synthesis of evidence. Offline and online computer-based modules with virtual patient cases or practical skills simulations were identified as the most prevalent clinical simulation teaching modalities. Visualisation approaches included text, images, animations, videos, and 3D environments. Significant heterogeneity of study designs with a moderate risk of bias was established. Based on the current data, the virtual patient scenarios should use natural language input interfaces enriched with video and voice recordings, 3D animations, and short text descriptions to make the patient management experience more lifelike and increase knowledge retention. However, there is no agreed framework for assessing the pedagogical value of these innovations. High-quality randomised controlled trials of TEL-based clinical simulation are essential to advance the field. Keywords

Visualisation · Technology-enhanced learning · TEL · Medical education · Medical simulation

8.1

Introduction

The global shortfall of healthcare workers is estimated to reach 18 million by 2030 (World Health Organization 2017). The need to increase

# The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Border et al. (eds.), Biomedical Visualisation, Advances in Experimental Medicine and Biology 1421, https://doi.org/10.1007/978-3-031-30379-1_8

175

176

the numbers of qualifying healthcare professionals is especially pressing in low-andmiddle-income countries (LMICs) (Frenk et al. 2010). Digital health education has been identified as one of the approaches to addressing the continuously growing challenge of providing universal health coverage (Cook et al. 2008; Car et al. 2019). In recent years, an emergence of technologyenhanced learning (TEL) adoption in both undergraduate and postgraduate settings could be observed (Nicoll et al. 2018). TEL is increasingly presented as a way of delivering enhanced educational experience allowing for continued professional development essential for ensuring highquality healthcare services. Digital education has also been found to increase medical school faculty effectiveness and efficiency in delivering education in LMICs (Frehywot et al. 2013). Multiple modalities have been used to deliver digital education for health professionals including online and offline computer-based digital education, serious gaming and gamification interventions, massive open online courses, virtual learning environments, virtual reality, digital psychomotor skills trainers, and mobile digital education (Car et al. 2019). However, some of these approaches are expensive and cannot be implemented in resource-scarce areas to improve medical education delivery globally. Finding the most effective low-cost interventions, based on widespread possession of personal technology devices (including personal computers, laptops, tablets, and smartphones), is essential for universal implementation (Sandars 2015). Simulation-based medical education (SBME) is a well-established method of medical teaching which has recently become central to shaping future healthcare professionals (McGaghie et al. 2010). Technology-enhanced medical simulation has also been trialled at multiple institutions, for example by introducing virtual patient case descriptions into e-learning modules (Hege et al. 2016). Yet, little is known about how to translate in-person SBME sessions into a virtual environment to achieve the best teaching results. To gain further insight into this area, it is important to

A. Dawidziuk et al.

establish good practices for visualising simulated healthcare services, patients, and procedures. Previous attempts have been made to evaluate particular aspects of visualisation in general healthcare education (e.g., medical computer animation or three-dimensional (3D) visualisation) (Ruiz et al. 2009; Ghanbarzadeh et al. 2014). However, most of the analysed papers described the use of visuals in pre-clinical teaching, especially focusing on the 3D representation of human anatomy and physiology. In this way, a knowledge gap encompassing the use of visual aid in technology-enhanced clinical simulation learning has been identified. Hence, this work aimed to systematically review and appraise the literature covering the effectiveness of different approaches to the visualisation of health education content used for technology-enhanced medical simulation learning.

8.2 8.2.1

Methods Search Strategy

To identify the body of literature relevant to this review, a search strategy was optimised using three databases: Embase (1947–2022), MEDLINE (1946–2022), and APA PsycInfo (1806–2022). The following combination of search terms was used to find the relevant references: (“simulation”) AND (“technologyenhanced learning” OR “technology-enhanced education” OR “digital learning” OR “digital education” OR “e-learning” OR “e-education”) AND (“healthcare” OR “health” OR “medicine” OR “medical” OR “clinical”) AND (“visualisation” OR “visualization” OR “visual” OR “graphic” OR “graphical” OR “imagery”). The search results were limited to works in the English language and studies conducted on human subjects. Finally, the references were deduplicated. The last date of this literature search was 3 January 2022. The focus of the review was to evaluate the approaches to visualisation for effective technology-enhanced clinical simulation that

8

Visualisation Approaches in Technology-Enhanced Medical Simulation. . .

could be introduced at a global scale as a step towards reaching universal health coverage. Hence, appropriate inclusion and exclusion criteria were defined.

8.2.2

Inclusion Criteria

1. An article on the use of visualisation in technology-enhanced clinical simulation in undergraduate or postgraduate healthcare education. 2. An original research article presenting new data or a methodological paper.

8.2.3

Exclusion Criteria

1. Blended learning modalities combining TEL and in-person teaching. 2. Use of a physical simulator device (e.g. robotic surgery simulator or manikin). 3. Use of a fully immersive virtual reality or augmented reality technology requiring special technology. 4. TEL used in teaching pre-clinical subjects including anatomy and physiology.

8.2.4

Data Extraction

The data extraction categories for the studies included in the final review were the number of subjects (N ), study design, characteristics of the participant population, clinical subject, technology-enhanced learning modality, visualisation approaches used, and key findings of the paper.

8.2.5

177

as they do not describe any interventions. The risk of bias was visualised using a designated tool (robvis) (McGuinness and Higgins 2021). The evidence in this review is reported in line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines (Liberati et al. 2009).

8.3 8.3.1

Results Results of the Systematic Search

The systematic search yielded 656 results with 9 additional papers identified through crossreferencing, producing a total of 665 records. Eleven duplicates were found and removed, leaving 654 records for the title and abstract screening. Five hundred forty seven of these were deemed irrelevant to the aims of this work. The remaining 107 articles were assessed in full. Eighty four of them were excluded due to lack of clinical simulation teaching (n = 49), use of a physical simulator (n = 10), no investigation of visualisation approaches (n = 9), use of fully immersive virtual or augmented reality (n = 9), opinion articles (n = 5), and no use of technology-enhanced learning (n = 2). Following all the exclusions, 23 articles were included in a qualitative synthesis. Figure 8.1 presents exclusions throughout each of the stages of the systematic review. A summary of the key characteristics and findings of all the included papers is presented in Table 8.1.

8.3.2

Methodological Considerations of Investigating Approaches to Visualisation

Risk of Bias Assessment

The risk of bias was assessed using validated tools. ROBINS-I scoring was used to assess non-randomised interventions (Sterne et al. 2016). RoB 2 tool was applied to randomised study designs (Sterne et al. 2019). The risk of bias in methodological papers was not assessed

Five categories of paper types have been identified. Nine of these were single-group correlation studies which either compared knowledge of the participants pre- to post-intervention or collected qualitative (focus groups, semistructured interviews) and quantitative data (Likert scales, test results) assessing the subjects’

178

A. Dawidziuk et al.

Fig. 8.1 PRISMA diagram detailing exclusions throughout the stages of the review (Liberati et al. 2009)

perceptions of the intervention following teaching delivery (Lim et al. 2005; Ahmed et al. 2009; Alvarez and Dal Sasso 2011; Van Der Spek et al. 2011; Andrade et al. 2012; Kleinert et al. 2015; Isreb et al. 2020; Sihombing et al. 2021). Ten papers presented randomised designs which were either randomised controlled trials (n = 4) where a traditional teaching method (e.g. a live lecture or reading a textbook) was used as a control or compared different approaches to technology-enhanced clinical simulation side by side (n = 6) (Friedman et al. 1991; Clark et al. 2000; Hu et al. 2009; Maier et al. 2013; Davids et al. 2014; Tolsgaard et al. 2016; Berger et al. 2018; Schmitz et al. 2018; Boucheix et al. 2018; Koka et al. 2020). One publication described a controlled intervention with no randomisation to groups (Mehrabi et al. 2000). Lastly, three of the included references were methodological papers

with no new data (Lax et al. 2011; Horstmann et al. 2012; Leung et al. 2013). A breakdown of study types is depicted in Fig. 8.2. Most of the papers reviewed presented approaches to content visualisation in computerbased learning modules (six offline and nine online) (Friedman et al. 1991; Mehrabi et al. 2000; Clark et al. 2000; Lim et al. 2005; Hu et al. 2009; Ahmed et al. 2009; Alvarez and Dal Sasso 2011; Lax et al. 2011; Horstmann et al. 2012; Maier et al. 2013; Leung et al. 2013; Schmitz et al. 2018; Isreb et al. 2020; Nelson and Knudtson 2020; Koka et al. 2020). Three online computer-based applications and three serious games were also included (Van Der Spek et al. 2011; Andrade et al. 2012; Davids et al. 2014; Kleinert et al. 2015; Tolsgaard et al. 2016; Berger et al. 2018). Lastly, one video demonstration and one online objective structured

Single-group correlation

Single-group correlation

Randomised controlled trial Single-group correlation

24

20

53

Lim et al. (2005)

Ahmed et al. (2009) Hu et al. (2009)

Van Der Spek et al. (2011)

Methods paper

Single-group correlation

–

10

14

Controlled trial

150

Mehrabi et al. (2000)

Alvarez and Dal Sasso (2011) Lax et al. (2011)

Randomised controlled trial

423

Clark et al. (2000)

Study design Randomised 3 group trial

N 72

References Friedman et al. (1991)

Emergency physicians

Triage in crisis management

Pain education

Nursing (acute pain cases)

Nursing students

Interprofessional resource

Dentistry

Minor skin surgery

Regional anaesthesia

Orthopaedics

CPR

Subject Medicine (cases)

Dental students

Plastic surgery trainees

Medical trainees

Medical students

Medical students

Population Medical students

Online computerbased module Serious game

Offline computerbased module Offline computerbased module Online computerbased module

Offline computerbased module

Offline computerbased module

Offline computerbased module

TEL modality Offline computerbased module

Videos, interactive exercises with feedback, illustrative commentary with visual and voice-over explanations 3D artificial environment

Simulated patient interface with a list of questions and answers

3D multimedia images for dental practice

Photos, illustrations, and videos of skin lesions, list of treatment options

A series of 3D animation clips (2–8 s) organised in a PowerPoint presentation

Tutorial involving patient cases with options to flip through pages, perform free and guided searches and use a structured interview

Moving and still images, sounds, links to a glossary of terms, notepad, and videos are available at all times

Visualisation approaches Three simulation formats (pedagogic, high-fidelity, problem solving)

Table 8.1 A summary table presenting key characteristics and findings of the studies included in the review

The article presents a detail description to inform understanding of educational innovation design Serious games offer promise in medical education. However, gaming is a complex task and serious games need the designs to facilitate players deal with complexity (continued)

Key findings Students derive more benefit from constructing requests in natural language rather than choosing from a list, especially at higher training levels The programme was an effective theoretical resource, multiple completions allowed for better retention of knowledge Video clips and animations combine theory and practice Computer-based intervention improved motivation saved time and helped with memory retention Methodological errors resulted from difficulty in conveying angles and depth in 3D animations Most effective for trainees with some practical experience Bright colour scheme improved readability. Bullet points are superior to text in paragraphs 3D materials improved understanding of theory before attending skills laboratory Simulation deemed realistic by the students

8 Visualisation Approaches in Technology-Enhanced Medical Simulation. . . 179

Randomised 2 groups trial

Single-group correlation

Randomised 2 groups trial

Randomised controlled trial Randomised 3 groups trial

Randomised 3 groups trial

82

62

45

117

67

Davids et al. (2014)

Kleinert et al. (2015)

Tolsgaard et al. (2016)

Berger et al. (2018) Boucheix et al. (2018) Schmitz et al. (2018)

43

Randomised 2 groups trial

Methods paper

–

207

Methods paper

–

Horstmann et al. (2012) Leung et al. (2013)

Maier et al. (2013)

Study design Single-group correlation

N 30

References Andrade et al. (2012)

Table 8.1 (continued)

Medical students

Breaking bad news

Catheter insertion

Pharmacy (cases)

Pharmacy students

Nursing students

Medicine (cases)

Surgery (cases)

Medicine (cases)

Paediatrics

Emergency medicine

Urology (patient cases)

Subject Geriatric home safety assessment

Medical students

Medical students

Medical trainees, fellows

Medical students

–

–

Population Medical students, geriatric medicine trainees

Online computerbased module

Video demonstration

Online computerbased application Online computerbased application Serious game

Online computerbased module Online computerbased application

Online computerbased module Online computerbased module

TEL modality Serious game

Different viewpoints face-to-face, over-the-shoulder and alternating views Three content presentations text, video and video with hints

3D pharmacy cases (multiple choice options, recorded voices)

Constructing and solving virtual patient cases (text and images)

“Look-and-learn” worked example cases, interactive cases with treatment simulation; immediate feedback via on-screen text messages and animations Immersive 3D virtual patient simulator with additional tables, images, and videos; patient responses as text

Video and picture-based exercises, virtual patients

Full multimedia case illustrations (patient answers as text, examination as multimedia) Flash-based presentations with interactive content, simulations, web links, PDF articles, and assessments

Visualisation approaches 3D artificial environment (home interior)

Video with hints prepared students best for breaking bad news

The study showed that the application can be introduced in different countries with only minor changes Learners in mixed viewpoint group outperformed those in other groups

Text in bullet points preferable to paragraphs. Too many objects on the screen led to ignoring graphics or text. Optimising usability improves persistence in e-learning Ability to select all the investigations motivated students to use all available results instead of choosing the optimal tests No effect of constructing vs. solving cases knowledge gains. Constructing longer than solving cases

Key findings Minimal to no difficulty in navigating the virtual house. Visual spatial must be considered when designing 3D virtual environments Integrated authoring tools facilitated creation of multiple virtual patient cases for student education Modules are easily created using commercially available software The modules significantly reduce the time required to give lectures Spaced activation of virtual patient cases led to a more balanced usage

180 A. Dawidziuk et al.

Single-group correlation

Single-group correlation

24

35

Nelson and Knudtson (2020) Sihombing et al. (2021)

Urology resident candidates

O&G residents

Paramedics

Surgical trainees, consultants

Urology

Colposcopy

Stroke assessment

Laparoscopic cholecystectomy

Online computerbased module Online OSCE

Online computerbased module Online computerbased module

Interactive learning platform including interactive games and images of abnormalities Online clinical case stations presented using MS Word and PowerPoint over ZOOM

Interactive slides with text, illustrations and tasks vs. instructional video

Sketch images, real life hazards video clips (2D, 3D) Better understanding of key concepts with e-learning vs. video Paramedics watching video performed better in task—module should contain video extracts Visual patterns with tests improve learning in colposcopy, especially if skills are first being developed. Online had comparable results with face-to-face exams Technical difficulties affected the delivery of exam

Online module more informative than textbooks

2D two-dimensional, 3D three-dimensional, BLS basic life support, CPR cardiopulmonary resuscitation, O&G Obstetrics and Gynaecology, OSCE objective structured clinical examination, N number of subjects, TEL technology-enhanced learning

Randomised controlled trial

39

Koka et al. (2020)

Single-group correlation

33

Isreb et al. (2020)

8 Visualisation Approaches in Technology-Enhanced Medical Simulation. . . 181

182

A. Dawidziuk et al.

Fig. 8.2 A bar chart presenting study formats used to investigate approaches to visualisation in technology-enhanced clinical simulation learning

clinical examination were reviewed (Boucheix et al. 2018; Sihombing et al. 2021). TEL modalities analysed are summarised in Fig. 8.3. Most of the original studies involved healthcare (medical, nursing, dental, pharmacy) students (n = 13) (Friedman et al. 1991; Mehrabi et al. 2000; Clark et al. 2000; Hu et al. 2009; Alvarez and Dal Sasso 2011; Andrade et al. 2012; Maier et al. 2013; Kleinert et al. 2015; Tolsgaard et al. 2016; Berger et al. 2018; Schmitz et al. 2018; Boucheix et al. 2018; Sihombing et al. 2021). Medical and surgical trainees were subjects in six studies (Lim et al. 2005; Ahmed et al. 2009; Andrade et al. 2012; Davids et al. 2014; Isreb et al. 2020; Nelson and Knudtson 2020). Fully qualified doctors and other fully trained healthcare professionals participated in only three of all the studies (Van Der Spek et al. 2011; Isreb et al. 2020; Koka et al. 2020).

8.3.3

8.3.3.1

Visualisation Approaches to Clinical Simulation by Technology-Enhanced Learning Modality

Offline and Online Computer-Based Modules and Applications The first attempts to investigate different approaches to developing simulated clinical

digital education modules were made in the early 1990s. At the time, the modules were offline and disseminated using CD-ROM (compact disc read-only memory) discs. The earliest work identified by this review investigated simulated patient cases with branched design scenarios in which students could use questions to obtain medical history as well as request examination findings to reach the diagnosis (Friedman et al. 1991). Through using different simulation formats including pedagogic, high-fidelity, and problem-solving, it was found that medical students derive more educational benefit from using natural language input to request information, rather than choosing from a list of questions and investigation options. The finding was especially true for students at higher training levels. Other offline computer-based modules focused on the simulation of practical procedures including cardiopulmonary resuscitation (CPR), fracture management, regional anaesthetic block, and skin minor surgery procedures rather than virtual patient cases (Mehrabi et al. 2000; Clark et al. 2000; Lim et al. 2005; Ahmed et al. 2009). In a large sample CPR study, it was reported that a module composed of moving and still images with sounds as well as links to a glossary of terms, notepad and video clips, available on the screen throughout the module allowed for better theoretical knowledge retention than a classic tutorial with a manikin (Clark et al. 2000). Similar

8

Visualisation Approaches in Technology-Enhanced Medical Simulation. . .

183

Fig. 8.3 A bar chart presenting technology-enhanced learning modalities in which visualisation approaches to clinical simulation were investigated (OSCE—Objective Structured Clinical Examination)

findings in teaching fracture management to medical students were reported (Mehrabi et al. 2000). Using patient cases with options to flip through the pages, perform free and guided information searches, and use structured patient interview questions improved students’ motivation and helped memory retention when compared with an in-person lecture. To teach regional interscalene brachial plexus block, a series of 3D animation clips lasting from 2 to 8 s organised in a Microsoft PowerPoint presentation was used (Lim et al. 2005). The module was found to be effective, especially for medicine and anaesthetics trainees with some previous practical experience. However, some of the angles and depth of injections were difficult to convey using animations which led to methodological errors during the final technique assessment. Additionally, plastic surgery trainees who completed an offline module composed of photos, illustrations, and videos of skin lesions with a panel of alternative minor skin surgery options to choose from reported that pages with bright colour schemes improved readability and that text in bullet points was superior in paragraphs for understanding (Ahmed et al. 2009). Additionally, an offline computer-based module composed of 3D multimedia images was delivered to dental

students (Hu et al. 2009). Similarly to the abovementioned studies, the authors identified the value of digital learning for improving the understanding of theoretical aspects of practical dentistry procedures before attending skills laboratory sessions. In the 2010s, a shift from offline to online computer-based modules could be observed with the improvement of the internet connection speed. Also, more virtual patient case modules were identified. The initial attempts identified were simple interfaces, like a screen with a list of questions to choose from to reveal patient answers necessary to assess acute pain for nursing students’ teaching (Alvarez and Dal Sasso 2011). More complex simulated patient systems involved videos, interactive exercises with formative feedback and illustrative commentary with visual and voice-over explanations such as the design described by Lax and colleagues for a pain education interprofessional resource (Lax et al. 2011). With the advent of integrated authoring tools for e-learning modules, more virtual patient cases for student education involving fully graphical multimedia case illustrations (patient responses and findings as a mix of text and multimedia) could be implemented (Horstmann et al. 2012). It was also reported

184

that using this type of commercially available software to create digital content significantly reduced the amount of time that would be needed to deliver traditional in-person teaching (Leung et al. 2013). At the same time, the activation of virtual patients in time was investigated (Maier et al. 2013). Spaced activation of virtual patient cases (video-based patient exercises) was associated with a more balanced usage pattern and a lower peak of simulated sessions right before the exam. In a study involving both “look-and-learn” worked cases and interactive cases with feedback via on-screen text messages and animations, the previous observation of the superiority of text in bullet points over paragraphs has been repeated (Davids et al. 2014). Most of the patient cases allowed students to choose any investigations they would like to request. Kleinert and colleagues found that students who used their immersive virtual 3D surgical patient simulator tended to request all the investigations available before making the diagnosis instead of choosing the optimal combination, which would emulate real practice conditions better (Kleinert et al. 2015). Another work on virtual patient cases composed of text and images aimed to compare the educational impact of constructing and solving cases (Tolsgaard et al. 2016). It concluded that there was no additional educational benefit coming from constructing cases but at the same time constructing cases took students much longer than solving them. Different presentation methods of the same content were also investigated in “breaking bad news” tasks (Schmitz et al. 2018). A textual description of the patient encounter was compared to a video alone and a video with additional written hints. The last of these three modalities was deemed most effective for preparing medical students for difficult patient conversations. Additionally, an e-learning module composed of interactive slides with text descriptions, illustrations, and tasks developed for paramedics to teach them stroke assessment resulted in a better theoretical understanding of key concepts when compared to a traditional instructional video (Koka et al. 2020).

A. Dawidziuk et al.

However, the paramedics who watched the video performed better in some aspects of the practical task, hence potentially combining the module with video fragments would make the most effective resource. Continuing the theme of practical skills, a work by Nelson and Knudtson on colposcopy teaching found that an interactive online platform resulted in the best effects in obstetrics and gynaecology residents when the skills were first developed, confirming that digital clinical simulation is an effective intervention before practising skills on models or in the clinical setting (Nelson and Knudtson 2020).

8.3.3.2

Serious Games and Other Educational Modalities Serious games have been identified as a promising clinical simulation modality for medical education. 3D artificial environments have been trialled for developing triage skills in crisis management scenarios by fully qualified emergency physicians (Van Der Spek et al. 2011). Another attempt of using a computer game for medical simulation was a fully virtual geriatric home safety assessment (Andrade et al. 2012). The participants (medical students and geriatric medicine trainees) reported minimal to no difficulty in navigating the virtual house. Yet, it was also noted that in the future, educators must account for the visuospatial ability of the students when designing learning tasks in 3D virtual environments. A serious game was also developed for pharmacy students in Belgium and Switzerland to emulate client interactions in a community pharmacy (Berger et al. 2018). The programme with multiple action choice options and pre-recorded voices showed that a serious game can be introduced in multiple countries with only minor changes. More specific research into demonstration videos used for simulation teaching of clinical practical procedures was also undertaken (Boucheix et al. 2018). Different views used for recording a catheter insertion instructional video for nursing students (face-to-face, over-the-shoulder, and alternating views) were compared. The work concluded that more alternating views allow

8

Visualisation Approaches in Technology-Enhanced Medical Simulation. . .

for better visualisation of the procedure and lead to improved learning outcomes. Lastly, during the COVID-19 pandemic, online objective structured clinical examinations were introduced with simulated patient scenarios using additional materials displayed in Microsoft Word and PowerPoint (Microsoft Corp., Redmond, Washinton, U.S.A) shared over Zoom teleconferencing software (Zoom Video Communications Inc., San Jose, California, U.S.A.) (Sihombing et al. 2021). This online examination had a comparable result to the previous face-to-face attempts. However, there were some technical difficulties with exam delivery even though it was trialled before. They may be inherently associated with any live digital health education delivery.

8.3.4

Risk of Bias Assessment

The risk of bias in non-randomised studies was assessed using the ROBINS-I tool (Sterne et al. 2016). The bias domains assessed were confounding, selection of participants, classification of interventions, deviations from intended interventions, missing data, measurement of outcomes, and selection of reported results. The results of the ROBINS-I risk assessment are presented in Fig. 8.4. Out of 10 papers assessed, two were affected by a serious risk of bias, five by a moderate risk, and three by low risk. The main sources of concern were the selection of participants and missing data. Figure 8.5 displays the risk of bias assessment in randomised studies conducted using the RoB 2 scoring tool (Sterne et al. 2019). The domains assessed were the randomisation process, deviations from the intended intervention, missing outcome data, measurement of the outcome, and selection of the reported result. Of ten studies analysed, there were some concerns regarding seven references, mainly in the missing data category. Three of the works included in this review were methodological papers and the risk of bias was not assessed due to their non-experimental

185

nature (Lax et al. 2011; Horstmann et al. 2012; Leung et al. 2013).

8.4 8.4.1

Discussion Current Recommendations

A systematic search of evidence on the effective use of visualisation approaches to technologyenhanced clinical simulation yielded a heterogenous group of papers published over the last 30 years. The works investigated numerous TEL interventions assessed using multiple randomised and non-randomised study designs. The differences in the body of evidence suggest that a variety of research directions have been pursued in this field. This observation coincides with the findings of other systematic reviews on the topic of digital health education which note that a more systematic research direction and approach are needed for the effective synthesis of evidence (Car et al. 2019; Kononowicz et al. 2019). Nonetheless, despite a plethora of various research questions related to the use of technology in clinical simulation teaching identified, the reviewed literature allows for observing some overarching trends. Delivery of virtual patient cases through technology-enhanced modules and applications was the most common type of educational simulation reviewed (Friedman et al. 1991; Alvarez and Dal Sasso 2011; Horstmann et al. 2012; Maier et al. 2013; Davids et al. 2014; Kleinert et al. 2015; Tolsgaard et al. 2016; Berger et al. 2018). Multiple valuable suggestions for the effective creation of future TEL-based patient scenarios can be inferred from the results of these works. Firstly, a natural language input, which could emulate real clinical practice, instead of a choice from a list of pre-defined medical history questions and investigations, should be used when creating new scenario interfaces (Friedman et al. 1991). Moreover, the number of choices should be limited to encourage more efficient and cost-effective patient management (Friedman et al. 1991). The interactivity of the

186

A. Dawidziuk et al.

Fig. 8.4 A visual display of the ROBINS-I risk of bias assessment of non-randomised studies included in the review (n = 10) created using robvis software (Sterne et al. 2016; McGuinness and Higgins 2021)

platforms should be further promoted through immediate onscreen feedback following case completion (Lax et al. 2011; Davids et al. 2014). Lastly, to make the simulated patients more immersive, voice and video responses should be embedded in the scenarios instead of using plain text (Kleinert et al. 2015; Berger et al. 2018). To present simulated examination findings in a lifelike manner, real recordings could be more useful than just using descriptions (Koka et al. 2020). The evidence also contains findings about some of the most rudimentary aspects of content visualisation which can be useful for developing any technology-enhanced clinical simulation materials. Text in bullet point format with a bright colour scheme was suggested to facilitate learning (Ahmed et al. 2009). Moreover, the use of 3D

animations (Lim et al. 2005; Hu et al. 2009; Isreb et al. 2020) allows for better visualisation of practical procedures. If videos are used instead of animations, they should be recorded from multiple viewpoints to provide the most reliable spatial representation of procedural steps (Boucheix et al. 2018). Lastly, annotating videos with hints or salient points should be used to improve retention (Schmitz et al. 2018). Some general observations regarding the sequence of introducing TEL solutions within the medical education modules can also be noted. Several studies indicated that digital learning modules and applications aimed at supporting clinical practical procedures teaching bring the best educational benefit when delivered before the in-person sessions in skills laboratories

8

Visualisation Approaches in Technology-Enhanced Medical Simulation. . .

187

Fig. 8.5 A visual display of the RoB 2 risk of bias assessment of randomised studies included in the review (n = 10) created using robvis software (Sterne et al. 2019; McGuinness and Higgins 2021)

or the clinical areas (Hu et al. 2009; Nelson and Knudtson 2020). Moreover, spaced activation of online content rather than releasing all modules at once leads to more balanced usage (Maier et al. 2013). It was also confirmed that multiple completions of technology-enhanced virtual modules improve knowledge retention (Clark et al. 2000). Based on these findings, future TEL-based clinical simulation modules should be delivered in advance of any in-person teaching sessions with more advanced modules divided into smaller sections released sequentially and allowing multiple attempts. Serious computer games offer a lot of promise (Van Der Spek et al. 2011; Andrade et al. 2012; Berger et al. 2018). However, gaming is a complex task and serious games need their designs to facilitate how players deal with complexity (Van

Der Spek et al. 2011). Even though creating a multifaceted virtual environment may resemble real clinical practice, it might distract students or trainees and in consequence, slow down the educational effort.

8.4.2

Quality of Available Evidence

Overall, the studies included in this review were prone to bias, which was shown by the ROBINS-I and RoB 2 assessments. In many works, the sample sizes were small, and participants were completing extracurricular or university modules during which new virtual interventions were trialled instead of being recruited to participate in standalone studies. Additionally, in longitudinal studies, in which there was a time gap

188

A. Dawidziuk et al.

between pre- and post-intervention assessments, loss of follow-up resulting in attrition bias was often reported. All of these limitations reduce the applicability of the recommendations listed in the previous section to certain populations and educational settings. Lastly, at the moment, there is no established methodology for evaluating and reporting technology-enhanced simulation in clinical education, making it difficult to comment on the selection of outcomes and presentation of data.

8.4.3

Future Directions

This review has shown the growing popularity of virtual patient scenarios delivered using online computer-based modules. This trend is likely to continue with the increasing availability of software allowing quick and easy development of new cases. Technology-enhanced learning modalities reviewed in the work are all computer-based teaching interventions. However, recently, sales of smartphones have surpassed that of all other technological devices including personal computers, laptops, and tablets, especially in resource-limited LMICs (Iqbal and Bhatti 2020). Endeavours should be made to encourage the development of new smartphone-based simulation modules to increase their uptake globally. New studies assessing the use of visuals in these applications would be needed to establish best practices. Even though serious games provide a highly immersive clinical environment, they might not become more popular until their development becomes less resource intensive. Even though multiple applications of TEL-based clinical simulation are researched, there is no standardised evaluation framework for these innovations. Reaching a consensus on how to reliably assess the pedagogical value of technology-enhanced clinical simulation interventions, whether it would be measured through testing, student satisfaction rating or cost-effectiveness analysis, is essential for the progress of the field. This topic also requires a more comprehensive and structured research strategy. More

longitudinal studies with low loss of follow-up rates are needed to evaluate the long-term effects of virtual clinical. The subject populations should include multiple groups of healthcare students and professionals of different grades in order to identify how to prioritise new virtual content development and introduction into curricula. To determine the most efficient visualisation approaches, multiple intervention groups will be needed within study designs in order to explore the interface features responsible for communication with simulated patients, clinical decisionmaking when choosing management options, and knowledge retention following the sessions.

8.5

Conclusion

The body of evidence on visualisation in technology-enhanced clinical simulation is dominated by online computer-based modules based on simulated patient cases. Based on the current data, the virtual patient scenarios should be based on natural language input interfaces enriched with video and voice recordings, 3D animations, and short text descriptions to make the patient management experience more lifelike and increase knowledge retention. However, the applicability of current evidence is limited to particular populations and settings. There is also no agreed framework for assessing the pedagogical value of these innovations. Hence, to advance the field, it is essential to conduct a small number of high-quality randomised controlled trials evaluating the long-term effects of different approaches to TEL-based clinical simulation in a pre-determined agreed manner. Conflict of Interest Statements No conflict of interest to declare.

References Ahmed JS, Coughlan J, Edwards M, Morar SS (2009) User interface evaluation of a multimedia CD-ROM for teaching minor skin surgery. Behav Inf Technol 28: 269–279. https://doi.org/10.1080/ 01449290701579868

8

Visualisation Approaches in Technology-Enhanced Medical Simulation. . .

Alvarez AG, Dal Sasso GTM (2011) Virtual learning object for the simulated evaluation of acute pain in nursing students. Rev Lat Am Enfermagem 19:229– 237. https://doi.org/10.1590/ s0104-11692011000200002 Andrade AD, Cifuentes P, Mintzer MJ et al (2012) Simulating geriatric home safety assessments in a three-dimensional virtual world. Gerontol Geriatr Educ 33:233–252. https://doi.org/10.1080/02701960. 2011.611553 Berger J, Bawab N, De Mooij J et al (2018) An open randomized controlled study comparing an online text-based scenario and a serious game by Belgian and Swiss pharmacy students. Curr Pharm Teach Learn 10:267–276. https://doi.org/10.1016/J.CPTL. 2017.11.002 Boucheix JM, Gauthier P, Fontaine JB, Jaffeux S (2018) Mixed camera viewpoints improve learning medical hand procedure from video in nurse training? Comput Human Behav 89:418–429. https://doi.org/10.1016/J. CHB.2018.01.017 Car J, Carlstedt-Duke J, Tudor Car L et al (2019) Digital education in health professions: the need for overarching evidence synthesis. J Med Internet Res 21(2): e12913. https://doi.org/10.2196/12913 Clark LJR, Watson J, Cobbe SM et al (2000) CPR ‘98: a practical multimedia computer-based guide to cardiopulmonary resuscitation for medical students. Resuscitation 44:109–117. https://doi.org/10.1016/S03009572(99)00171-9 Cook DA, Levinson AJ, Garside S et al (2008) Internetbased learning in the health professions: a metaanalysis. JAMA 300:1181–1196. https://doi.org/10. 1001/JAMA.300.10.1181 Davids MR, Chikte UME, Halperin ML (2014) Effect of improving the usability of an e-learning resource: a randomized trial. Adv Physiol Educ 38:155–160. https://doi.org/10.1152/ADVAN.00119.2013 Frehywot S, Vovides Y, Talib Z et al (2013) E-learning in medical education in resource constrained low- and middle-income countries. Hum Resour Health 11:1–15 Frenk J, Chen L, Bhutta ZA et al (2010) Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 376:1923–1958. https://doi.org/10. 1016/S0140-6736(10)61854-5 Friedman CP, France CL, Drossman DD (1991) A randomized comparison of alternative formats for clinical simulations. Med Decis Mak 11:265–272. https:// doi.org/10.1177/0272989X9101100404 Ghanbarzadeh R, Ghapanchi AH, Blumenstein M, TalaeiKhoei A (2014) A decade of research on the use of three-dimensional virtual worlds in health care: a systematic literature review. J Med Internet Res 16(2):e47. https://doi.org/10.2196/JMIR.3097 Hege I, Kononowicz AA, Tolks D et al (2016) A qualitative analysis of virtual patient descriptions in healthcare education based on a systematic literature

189

review. BMC Med Educ 16:1–11. https://doi.org/10. 1186/S12909-016-0655-8/FIGURES/3 Horstmann M, Horstmann C, Renninger M (2012) Case creation and e-learning in a web-based virtual department of urology using the INMEDEA simulator. Nephrourol Mon 4:356–360. https://doi.org/10.5812/ kowsar.22517006.1503 Hu J, Yu H, Shao J et al (2009) Effects of dental 3D multimedia system on the performance of junior dental students in preclinical practice: a report from China. Adv Health Sci Educ Theory Pract 14:123–133. https://doi.org/10.10 07/S 10459-00 7-9096-9/ TABLES/4 Iqbal S, Bhatti ZA (2020) A qualitative exploration of teachers’ perspective on smartphones usage in higher education in developing countries. Int J Educ Technol High Educ 17:1–16. https://doi.org/10.1186/S41239020-00203-4/TABLES/7 Isreb S, Attwood S, Hesselgreaves H et al (2020) The development of an online standalone cognitive hazard training for laparoscopic cholecystectomy: a feasibility study. J Surg Educ 77:1–8. https://doi.org/10.1016/J. JSURG.2019.09.002 Kleinert R, Heiermann N, Plum PS et al (2015) Web-based immersive virtual patient simulators: positive effect on clinical reasoning in medical education. J Med Internet Res 17(11):e263. https://doi.org/10.2196/JMIR.5035 Koka A, Suppan L, Cottet P et al (2020) Teaching the national institutes of health stroke scale to paramedics (e-learning vs video): randomized controlled trial. J Med Internet Res 22(6):e18358. https://doi.org/10. 2196/18358 Kononowicz AA, Woodham LA, Edelbring S et al (2019) Virtual patient simulations in health professions education: systematic review and meta-analysis by the digital health education collaboration. J Med Internet Res 21(7):e14676. https://doi.org/10.2196/14676 Lax L, Watt-Watson J, Lui M et al (2011) Innovation and design of a web-based pain education interprofessional resource. Pain Res Manag 16:427–432. https://doi.org/ 10.1155/2011/359079 Leung C, Bernard A, Kman NE (2013) Emergency medicine e-learning: articulating the facts, moving to the future. Acad Emerg Med 20:S342–S343. https://doi. org/10.1111/acem.12118 Liberati A, Altman DG, Tetzlaff J et al (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 62:e1–e34. https://doi.org/10.1016/J. JCLINEPI.2009.06.006 Lim MW, Burt G, Rutter SV (2005) Use of threedimensional animation for regional anaesthesia teaching: application to interscalene brachial plexus blockade{. Br J Anaesth 94:372–377. https://doi.org/10. 1093/BJA/AEI060 Maier EM, Hege I, Muntau AC et al (2013) What are effects of a spaced activation of virtual patients in a

190 pediatric course? BMC Med Educ 13:1–6. https://doi. org/10.1186/1472-6920-13-45/TABLES/2 McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ (2010) A critical review of simulation-based medical education research: 2003–2009. Med Educ 44:50–63. https://doi.org/10.1111/J.1365-2923.2009.03547.X McGuinness LA, Higgins JPT (2021) Risk-of-bias VISualization (robvis): an R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods 12:55–61. https://doi.org/10.1002/jrsm.1411 Mehrabi A, Glückstein C, Benner A et al (2000) A new way for surgical education—development and evaluation of a computer-based training module. Comput Biol Med 30:97–109. https://doi.org/10.1016/S00104825(99)00024-4 Nelson EL, Knudtson JF (2020) Interactive learning modules with visual feedback improve resident learning in colposcopy. J Low Genit Tract Dis 24: 215. https://doi.org/10.1097/LGT.0000000000000515 Nicoll P, MacRury S, Van Woerden HC, Smyth K (2018) Evaluation of technology-enhanced learning programs for health care professionals: systematic review. J Med Internet Res 20(4):e131. https://doi.org/10.2196/JMIR. 9085 Ruiz JG, Cook DA, Levinson AJ (2009) Computer animations in medical education: a critical literature review. Med Educ 43:838–846. https://doi.org/10. 1111/J.1365-2923.2009.03429.X Sandars J (2015) The challenge of cost-effective technology-enhanced learning for medical education. Educ Prim Care 22:66–69. https://doi.org/10.1080/ 14739879.2011.11493970 Schmitz FM, Schnabel KP, Bauer D et al (2018) The learning effects of different presentations of worked examples on medical students’ breaking-bad-news skills: a randomized and blinded field trial. Patient Educ Couns 101:1439–1451. https://doi.org/10.1016/ J.PEC.2018.02.013 Sihombing AT, Taher A, Rodjani A et al (2021) Assessing the online objective structured clinical examinations in urology qualifying exam for urology residents in Indonesia during COVID-19 time. MethodsX 8: 101316. https://doi.org/10.1016/J.MEX.2021.101316 Sterne JA, Hernán MA, Reeves BC et al (2016) ROBINSI: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 355:i4919. https://doi. org/10.1136/BMJ.I4919

A. Dawidziuk et al. Sterne JAC, Savović J, Page MJ et al (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 366:l4898. https://doi.org/10.1136/BMJ. L4898 Tolsgaard MG, Jepsen RMHG, Rasmussen MB et al (2016) The effect of constructing versus solving virtual patient cases on transfer of learning: a randomized trial. Perspect Med Educ 5:33–38. https://doi.org/10.1007/ S40037-015-0242-4/FIGURES/2 Van Der Spek ED, Wouters P, Van Oostendorp H (2011) Code red: triage or cognition-based design rules enhancing decision making training in a game environment. Br J Educ Technol 42:441–455. https://doi.org/ 10.1111/J.1467-8535.2009.01021.X World Health Organization (2017) Dublin declaration on human resources for health: building the health workforce of the future

Aleksander Dawidziuk is a foundation programme doctor at Royal Free London NHS Foundation Trust. He graduated from Imperial College School of Medicine and intercalated in Biomedical Engineering. He held the role of the President of the Students Section at The Royal Society of Medicine. He has a keen interest in healthcare transformation and has published on digital healthcare, surgical innovation, and medical technology. He was a scholar in The Healthcare Leadership Academy London 2020 cohort. Since completing his scholarship, he has been researching healthcare leadership, medical education, and technology-enhanced learning. George Miller Chairs the Healthcare Leadership Academy Executive Committee. He is a fellow of the Institute of Leadership and Management, an honorary clinical lecturer, and a clinician in London. Johann Malawana is a former Obstetrician and Gynaecologist and now a Senior Clinical Fellow at the School of Medicine at the University of Central Lancashire, the CEO of Medics.Academy and the Managing Director of the Healthcare Leadership Academy. He holds or has held a variety of board-level roles across the public sector, regulators, the private and charity sectors. His academic interest is in the role of technology in Healthcare Education Delivery and Digital Health.

9

Visualisation Through Participatory/Interactive Theatre for the Health Sciences James Wilson

Abstract

This chapter provides an overview of the use of participatory/interactive theatre (PIT) techniques to enhance visualisation in the teaching and learning of healthcare students. The chapter explores the foundations of learning through visualisation and participatory/interactive theatre. This includes a narrative on the definition of a PIT, two commonly utilised techniques with examples from healthcare education, followed by a focus on the granular construction methods needing to be considered when putting together a PIT. Keywords

Visualisation · Simulation · Interactive theatre · Transformative learning · Psychological safety · Education

9.1

Introduction

In the teaching of students studying the complete range of professions in healthcare, educators are constantly striving to create learning that is meaningful and that sparks curiosity in the student cohorts. For learning to be ‘seen’, it is essential to create an environment that facilitates learning.

This chapter will focus on the components to be considered in the design and delivery of visually engaging learning experiences utilising methods of participatory/interactive theatre (PIT) methods. The roots of utilising PIT are embedded within many larger bodies of work in the drama and theatre literature. PIT chiefly aims to produce an immersive synergy between participants witnessing a scenario, which could be in the form of a play or theatrical production, and then through the use of a facilitator, introduce a technique that provides participants with the opportunity to engage/shape/change the scenario. If new to PIT, then the techniques available to teachers can present as a wide array of styles, techniques, and variations, which can be overwhelming. The options available for any teacher, whether a novice or expert in designing and delivering PIT methods can be intimidating and exciting in equal measure. For the purpose of this chapter, the specific techniques that will be exemplified will include: simultaneous dramaturgy, forum theatre, and digital interactive theatre. This chapter aims to provide a brief overview of PIT methods and how they have been applied in healthcare education, along with an accompanying narrative on the component parts that assist in the design and delivery of a visually engaging learning experience.

J. Wilson (✉) University of Chichester, Chichester, UK e-mail: [email protected] # The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Border et al. (eds.), Biomedical Visualisation, Advances in Experimental Medicine and Biology 1421, https://doi.org/10.1007/978-3-031-30379-1_9

191

192

9.2

J. Wilson

Definition of PIT

The commonly referred to forerunners to the practice of PIT include J.L. Moreno, Bertolt Brecht, Jerzy Grotowski, and Augusto Boal. Each of them sought to involve the audience in performance in different ways compared with traditional theatrical performances. What they shared was an interest in engaging their audiences in the work of theatre. However, each paved the way for the formation of a novel participatory/ interactive technique. It would be both logical and advantageous if there was an all-inclusive definition for PIT because it would lead to higher levels of uptake and traction. The fewer the number of educators who understand PIT, the more difficult it will be to convince others in education of its purpose and value. There are literary and interpretive challenges in defining PIT due to the wide range of theatre practices that fall within its domain and the dizzying array of terms used to describe techniques. PIT covers a plethora of dramatic practices such as applied theatre, community theatre, theatre for development, and theatre of the oppressed, to name only a few. Each individual theatre practice describes a performative style that aims to engage individuals in an audience in ways that are participatory in scope and seek to illuminate learning by presenting material that is immersive and visually engaging. PIT sits within the label of ‘theatre in education’ and arguably there is a paucity of training/qualifications available to educators to upskill and comfortably design and deliver a PIT. As an example, a group of educators being tasked with creating a scenario about clinical practice with a vague brief that the subject can be anything they choose will likely descend into a mix of befuddlement and discord with such broad, unspecific instructions. On the other hand, if educators are provided with structured criteria with key steps to follow then this could unlock a world of possibilities. Theatre, which derives from the Greek word ‘theatron’ meaning ‘the seeing place’ or ‘place for viewing’, denotes that a theatre event is some type of performance or ritual that can be

observed. A PIT, very simply put, is an application of theatre that has an interactive technique inserted which facilitates audience involvement. A PIT project will begin by presenting a rehearsed scenario using actors. The story brought to life in dramatic form will have been created to have resonance and relevance to the observing audience. At the conclusion of the presented scenario, there is an opportunity provided for open dialogue between the audience and a skilled facilitator. As a follow on from the dialogue, the lead facilitator will preside over the insertion of an appropriate technique that allows the audience to interact in some way with the scenario. The interaction mechanisms provide audiences with opportunities to be involved in a scenario and view it from a different lens or make changes through facilitation. PIT may include specific techniques such as simultaneous dramaturgy or forum theatre which will be explored in more detail.

9.3

PIT Technique: Simultaneous Dramaturgy

The origin of simultaneous dramaturgy can be found in the collected works of the theatre director. Simultaneous dramaturgy sits in a library of collected theatrical techniques, which Boal carefully catalogued and utilised over his many years practicing theatre. It contains a collection of theatre games which included examples such as image theatre (Grant 2017), newspaper theatre (Boland and Cameron 2005), legislative theatre (Boal 2005), rainbow of desire (Boal 2013), invisible theatre (Burstow 2008), and forum theatre (Boal 2002). During a simultaneous dramaturgy session, there is a prepared story performed as a theatrical play, which would be shown twice to an audience. In the replay, the dramatic action would be paused at pre-planned points by the facilitator. The facilitator would enter onto the stage and open dialogue with the audience about the issues faced by the actor at the paused point in the play. During the dialogue about the challenges faced by the actor, the facilitator would also ask the

9

Visualisation Through Participatory/Interactive Theatre for the Health Sciences

audience to verbally suggest different actions that the actors could apply to the situation (Boal 2002). On receiving the audience’s instructions, the actors would improvise the suggestions with the intention of moving the play in a new direction. The objective of simultaneous dramaturgy is to facilitate the ‘co-deconstruction’ of the play, which permits the audience to direct the changes using the actors as their tools. This method facilitates the opportunity for the audience to observe and create imagined changes and collectively reflect (Boal 2002). An important differentiation between simultaneous dramaturgy and other interactive techniques is that the space between the action on the stage and the audience is occupied by the facilitator who directs the actors on receipt of an audience member’s advice. Simultaneous dramaturgy permits interaction by the audience offering words of coaching for the main actor to enact. The following narrative example is based on a real clinical situation: Martin, a second-year student nurse is waiting to be called into the practice assessor’s office for a review of his placement. He is visibly nervous. He shares with the audience through the facilitator dialoguing with him that he has been underperforming on his placement and is expecting a rough ride from his practice assessor. The practice assessor appears and ushers Martin into the ‘office’ (a table with two chairs in the stage area). The practice assessor begins by asking Martin how he feels he is performing on placement, their demeanour is firm and short. Martin attempts to minimise the damage by maintaining a line that all is well with him. The practice assessor is not buying it and they begin unloading onto Martin reports of his underperformance. Laced within the reports, the practice assessor persistently asks if Martin is okay? At the fourth attempt to crack Martin, the practice assessor changes tack by slowing and softening their voice before uttering “Are you really okay, you can tell me, what’s going on?” Martin takes his time, it is written on his face the dilemma to open up or not—can he trust this practice assessor with his intimate personal information? Martin shares that he has been to see his GP recently and been diagnosed with mild depression. . .without missing a beat, the practice assessor visibly sits back in the chair in a ‘gotcha’ moment and interjects “I just knew there was something wrong. . .”

193

The practice assessor sends the student off the ward muttering all sorts of reasons like “how irresponsible’it is being on the ward whilst taking anti-depressants” and that “It’s putting patients at’risk” and that “Martin should go off sick to sort out his head!” Martin’s protests grow weaker, and he slowly picks up his things and leaves the ward. Martin is overwhelmed by the callous treatment, lack of empathy, and that his dream of becoming a nurse has been severely hampered by mentioning his battle with a mental illness.

The scenario in the example above depicted the effect of a person in authority and their stigmatising treatment of a subordinate following the disclosure of a mental illness. In simultaneous dramaturgy, the scenario was played through until the end without any interruption. The facilitator then entered into dialogue with the audience to gain their impressions, cathartic outpouring, and ascertain a sense of what the two actors could have done differently. The scenario was then replayed to the audience (one-half of the audience took charge of Martin and the other half guided the practice assessor). At moments of the facilitators choosing, they paused the scenario and asked the audience to make suggestions about how their actor could have engaged differently with the situation. Questions are posed to the audience through the facilitator, such as: ‘Should Martin disclose his mental illness?’; ‘should the practice assessor be more supportive of Martin?’; ‘was the practice assessor right to send Martin home?’; ‘how can someone who discloses a mental illness be supported in the workplace?’ It is left to the audience to decide the flow, frequency, and self-judgement of effectiveness of their interventions. As time runs out on the session, actors are de-rolled and allowed to share the experience of playing their characters. The session is concluded by the facilitator who wraps up using the principles of debriefing by agreeing with the audience on the learning points from the session.

9.4

PIT Technique: Forum Theatre

Forum theatre evolved from an unplanned situation during a large theatrical event being led by

194

Augusto Boal in the 1960s who was utilising simultaneous dramaturgy. Babbage (2004) explains how forum theatre occurred by chance during a simultaneous dramaturgy performance that was being facilitated by Boal. The play was tackling the issue of adultery and it had been paused at a moment when the wife protagonist had found out about her antagonist husband’s affair with another woman. As per the rules explained beforehand for simultaneous dramaturgy, the audiences were invited to provide verbal suggestions about how the wife should respond to the revelation. A female member of the audience became highly agitated at the actor playing the wife as she was unhappy at the actress being repeatedly unable to accurately depict her suggestion, which was to ‘Give him a good talking to’. In a moment of frustration, the female audience member stood up and made her way towards the stage, audibly demanding to replace the useless actress playing the wife on the stage and show everyone what she was meaning. The request was granted by Boal (although the encouraging and applauding 400-strong audience getting behind the female made it impossible for him to refuse!). In a twist to the story, Boal (2013) explained what happened next involved her verbal suggestion of ‘Give him a good talking to’ which consisted of (somehow) acquiring a broom handle on the way to the stage and resulted in her silently but firmly giving the actor playing the husband a sound beating! The actions of the female audience member were the first recorded case for Boal (2002) where someone from the audience transitioned from being a spectator (witnessing without input) into becoming a ‘spect-actor’ (taking action and showing alternatives) whilst stressing the incongruence between the audience members’ internal thoughts, the difficulty in articulating the internal thoughts into meaning for another person (the wife actor on the stage in this case) to follow and the resulting demonstration of the thought (‘Give him a good talking to’ translated in to violently hitting the actor with a stick). Forum Theatre (FT) is a deceptively simple formula and can lull an enthusiastic yet uninformed educator into a ‘chutzpa trap’ with its

J. Wilson

alluring and seemingly easy format. In the preparation phase, a ‘scenario of relevance’ to the audience is selected, written, and rehearsed with actors prior to a session. During the FT session, a facilitator with a specific ruleset (also known as a ‘joker’) will guide the audience through the proceedings. The joker first invites the audience to watch the struggle between a protagonist and one or more antagonists played by actors in the scenario. The scenario is played through once, uninterrupted, until it reaches an unsatisfactory or unresolved ending. At the conclusion of the first run through of the scenario, the joker will lead a discussion asking the audience about the main problem issues they identified in the play and ask them to suggest alternative solutions. After dialoguing with the audience and storing a bank of solutions, the joker will explain the spectactor mechanism before showing the original scenario presented a second time by the actors. The spect-actor mechanism allows a watching spectator to stop the action at any time and take the place of an existing performer to try out a new idea Babbage (2004). The spect-actor mechanism provides the audience the opportunity to have the control to stop/pause the action. When an audience member shouts ‘stop’, the agreed understanding of the ruleset is that the audience member has an idea they would like to try and the joker invites them on the stage to replace the protagonist so that they can demonstrate/show an alternative tactic that could result in a more satisfactory conclusion. This cycle repeats until the audience is satisfied or the session time runs out (Boal 2002). The neologism ‘spect-actor’ is the name Boal gave to the mechanism within a forum theatre which encourages members of the audience to enter the forum theatre at a moment of their choosing, enacting, and proposing solutions to a situation with committed action. It is the antithesis of the ‘spectator’ which is described as a passive role where the audience silently witness/observe a play without speaking, interrupting, or acting (Babbage 2004). In further exploration of the ‘spect-actor’ phenomenon, it is the unwritten rule and common practice in the commercial/traditional theatre that the stage is the restricted domain of the actors.

9

Visualisation Through Participatory/Interactive Theatre for the Health Sciences

The stage is a deliberate space designed to create a divide that should not be crossed by audience members (Prentki and Preston 2009). Yet in the Boal (2002) experience of simultaneous dramaturgy, this convention was being breached by a frustrated female audience member who succumb to her own internal desire to ‘show’ everyone what was going on inside her mind. In essence, she wanted to ‘show’ her intervention instead of being limited by the language of ‘tell’. In providing permission for audience members to enter on to the stage is a technique that is unique to forum theatre as it gives the audience a chance to ‘enter’ into the play, and take on the role of a character, even if only for a moment. Equally, ‘exiting’ the stage at any time is also in the gift of the spect-actor and provides safe access back to the safety of their own chair back within the audience. The scene opens with an apparently stressed nurse on the phone. The nurse is carping to the recipient (who is unseen) about the working conditions of the generic healthcare environment they are in (staff shortages, sick patients, and in need of gin!). The introduction of the nurse character paints the picture of an individual slowly burning out and an entrenched compassion fatigue. The nurse ends the call and walks to the door of the classroom. On the other side of the door is Mr. Smart, an old man with Alzheimer’s, who is being admitted to the healthcare environment by the nurse. The nurse character has been primed to enact almost every socially malignant act and unload them onto Mr. Smart. As the scene progresses, one malign act after another is revealed and the disempowering and shrinking effect on Mr. Smart becomes apparent to the audience. At the conclusion of the scene, Mr. Smart is fumbling in his pockets and becoming more visibly irate, his language expression problems combined with his growing anxiety prevent him from being able to verbally communicate his needs or what he is seeking. He stands up and begins wandering around the room, much to the disdain of the nurse, who is now feeling that they need to move onto the next task but Mr. Smart’s ‘challenging behaviour’ is needing a firm hand. Mr. Smart is incomprehensibly speaking to the audience and making all sorts of self-patting gestures. The nurse weakly attempts to calm Mr. Smart before resorting to grabbing his arm and marching him to the chair, where he is literally flung into. The nurse exasperatedly speaks to Mr. Smart ‘Is this how it’s going to be with you?’ The nurse removes the hands from their hips and

195

exits the scene stating they will be ‘back in a minute with a cup of tea’ (earlier in the scene we find out that Mr. Smart prefers coffee). The audience is then left to observe the image of Mr. Smart in the chair. Frightened. Alone.

Similar to simultaneous dramaturgy, the audience would first watch the example above played out in full without interruption. This allows the material to be worked with to be presented to the audience and they can internally begin to consider what could be done differently. The facilitator would dialogue with the audience, gathering what they observed as problems and requesting suggestions on how the scenario could be made better for Mr. Smart if the nurse acted in a more compassionate manner. There is often anger from the audience towards the nurse character. The character of the nurse can be explored and revealed to the audience by inserting a ‘hot seat’ technique, which allows the nurse to share aspects of their back story and the reason behind their behaviour. After the facilitator has completed the discussion with the audience, the forum theatre commences by inviting members of the audience to enter the stage as a spect-actor and make meaningful changes to the scene.

9.5

Essential Components of PIT Techniques

So far, this chapter has only explored two of a large number of PIT techniques available. In the production of a visually engaging pedagogical session, the techniques of simultaneous dramaturgy and forum theatre rely on four key pillars to produce an immersive PIT that promotes deep learning. The four key pillars and a discussion about them follow: 1. 2. 3. 4.

The construction of the PIT Story Working with actors in a PIT Leading a PIT Working with different audiences

196

9.6

J. Wilson

The Construction of a PIT Story: Visualisation Through Storytelling

Human life is centred around storytelling and communication as it takes centre stage in our day-to-day life. We are literally moving stories waiting to be told, and it is why storytelling is perhaps one of the greatest means of impact. If reflected on for a moment, there will be a realisation of how many stories have been consumed even without your permission. The passive content of stories shapes personal impressions, perceptions, and beliefs whilst becoming an inner narrative or your unlived experience. Stories matter to our individual and collective existence because they impact our shared experiences. Within education, there is a need to be more deliberate about the stories that we tell. Stories are narratives that pass as currency and influence those around you. Narratives matter, stories matter, and there is no other way to say this. For story or scenario writing, determining focus is the first ‘pre-writing’ step followed by adding a structure. When deciding what the story will be about, the goal is to understand and synthesise material in order to convey a message, promote a concept or tell a story. When finding focus, some writers cannot see the story through the trees of their material and then mistakenly believe that the focus is the same as the topic. They also may not realise how important it is to ‘sum up’ their story in a simple conversational sentence early in the process (e.g., an old man with dementia is admitted to the clinical unit and is assessed by a callous nurse). There is an art form in the design of stories becoming scenarios. To make visually engaging scenes come alive, attention is paid to the ingredients of the scenario. For the scenario, storytelling and story-writing is a realm of literature which can inform the structure. The structural elements of storytelling can be determined using several writing techniques, here are four structures: milieu, idea, character, and event.

Whilst each is present in every story, there is generally one that dominates the others.

9.7

Structure: The Milieu

The milieu is the world, the society, the conditions, the family, all the elements that come up during the ‘world-creation’ phase. Every story has a milieu, but when a story is structured around one, the milieu is the thing the storyteller cares about most. For instance, if producing an interactive theatre about a healthcare student entering their first ever clinical placement, the point of the story is for the participating students to engage in witnessing several differing clinical environments and comparing the cultures of staff that was encountered. In milieu stories, there is little value in writing about the main characters’ childhood and upbringing because the real story begins when the student arrives on placement. When writing a milieu story, the beginning point is obvious (when the character arrives) and the ending is just as plain (when they leave). Milieu-focused stories are effective when seen through the viewpoint of the arriving character, as the engaged audience will experience the emotions, surprise (and terrible) things that stories about healthcare can expose learners to observe.

9.8

Structure: The Idea

The idea story is all about the process of seeking and discovering new information through the eyes of characters who are driven to make the discoveries. The structure is straightforward: The idea story begins by raising a question; it ends when the question is answered. An example of an idea story is the ‘mystery’ that follows this structure. The story begins when a crime takes place. The question we ask is, ‘who did it and why?’ The story ends when the identity and motive of the criminal are revealed. Within healthcare, mystery-based stories would include presenting students with the question ‘what condition could the main protagonist be experiencing

9

Visualisation Through Participatory/Interactive Theatre for the Health Sciences

and what informs your thinking?’ In speculative fiction, a similar structure can be applied to explore leadership/management scenarios. The story begins with a question such as ‘Why are all the staff leaving the department through resignation when they are such a highly regarded team?’ When writing an idea story, begin as close as possible to the point where the question is first raised, and end as soon as possible after the question is answered.

9.9

Structure: The Character

The character story focuses on the transformation of a character’s role in the community that matters most to them. In one sense, the story is almost always ‘about’ one or more characters. In most stories, though, the tale is not about the character’s character; that is the story is not about ‘who’ the character is. The structure of a character story is as simple as any of the others. The story begins at the moment when the main character becomes their most unhappy, impatient, or angriest within their present role that they begin the process of change which ends when the character either settles into a new role (happily or not) or gives up the struggle and remains in the old role (happily or not). Character stories link well with interactive techniques such as Forum Theatre (discussed later), as the audience has an opportunity to make changes in the characters’ life and enact solutions that attempt to resolve problems (or not).

9.10

Structure: The Event

The event story highlights that something is out of order with the norms expected in a healthcare world. In classic healthcare situations, this can include the appearance of a monster (the arrival of a bully), the breaking of an oath (an area told that it would be spared austerity measures receiving the news that their service is being re-provisioned), the impact of service changes (transformation effects of clinical commissioning groups to integrated care systems), or the

197

reappearance of a unpopular, powerful adversary who was thought to be gone (someone with a history of abusing staff arrives back in the healthcare environment). In all cases, a previous order, a ‘golden age’ has been disrupted and the healthcare arena has been plunged into flux or a more perilous place. The event story ends at the point when there a new order is established or, more rarely, when the old order is restored or, the audiences have been victorious in making significant changes. The interactive theatre story begins not at the point when the care environment becomes disordered, but rather at the point when the character whose actions are most crucial to establishing the new order becomes involved in the struggle. A story depicting the arrival of a bully does not begin with their entrance into the health care environment but when the main character becomes involved in the struggle to remove the monstrous intimidator and re-establish balance. The event story does not begin with a prologue recounting all the history of a healthcare area up to the point where the bully appears. It begins, instead, by establishing the situation and then thrusting the events onto the main character, explaining no more of the world to the audience than is needed to know right at the beginning. In essence, the audience learns the rest of the events bit by bit, as the information is revealed to the audience. As a tip in writing event stories, It is the viewpoint character, not a narrator, who is the audience’s guide. Begin small in event scenarios, and only gradually expand an audience’s vision to include the whole picture. The four structures discussed above can be enhanced by weaving in the scenario drivers below and tie-up the delivery of a visceral scene for an audience.

9.11

The Conflict

All PIT is about conflict. The collision, or the clash of conscious wills of the actors in the achievement of their goals. The means actors deploy to meet their goals will often be objective and subjective, concrete, and abstract (concrete facts that have ideological significance. The

198

J. Wilson

actors are required to hold a necessary understanding of what the actor wants, and they are primed to relentlessly pursue their goals. Managing the will of a character must be socially necessary to be believable as casual or whimsical desires will not connect with a healthcare audience. Jane and John sit opposite each other in a small office space. John is ‘tidy-blind’ and his side of the desk is a chaotic mess of files and scattered paper. Jane is hyper-organised with a clear desk. Throughout the scene, the audience observe John being vocal, taking calls loudly with his desk overflowing onto the other side. The audience watch Jane, fume, grow visibly annoyed, and repeatedly slide John’s rubbish back over to his side. Jane eventually cannot take any more and loudly complains to John about his inconsiderate behaviour. John blasts back that she is ‘an insufferable cold fish lacking in any personality’. Their manager arrives to offer mediation in the situation. . .the facilitator enters to announce that the audience are going to help the manager navigate this hot/cold conflict.

9.12

Working with Actors in a PIT: Making the Story Visible

The relationship between facilitator and actor is one of the most sacred in producing a PIT. Together they are collaborating on a project that is bigger than either one of them. Although the facilitator is responsible for balancing relationships with all the team members, the relationship between a facilitator and actor presents unique opportunities and challenges. When acting for PIT in healthcare, the facilitator (often taking on the role of a director) will need to understand each cast member’s comfort in the acting parts they are taking on. When an audience member enters the stage, the actor must be able to draw upon the character that they are playing in order to respond authentically. Challenges: Example: Dr. Mann was leading a routine consultation with Andrew. During the questioning of Andrew, the audience revealed that Andrew had unwittingly admitted to committing a child sex offence. An audience member bravely took over the Dr. Mann character and confronted Andrew

with the situation and that he was going have to call the police. The actor playing Andrew, sat up as if he had just been asked if he would like a cup of tea and nodding simply said ‘oh, alright then’. The facilitator was stunned at the actor’s total lack of response to being labelled as a paedophile! The scene continued to fizzle as the actor playing Andrew went along with whatever the audience wanted. No fight. No sense of shame, shock, or alarm. No conflict. An overly easy and unrealistic victory for the audience.

Actors have to be able to inhabit a scene and through rehearsal beforehand, embody their character so that the audience meets the right level of resistance that they could expect from the myriad of characters that exist in the world.

9.13

Leading a PIT: Assisting the Audience to See the Unseen

The generic definition of a facilitator is ‘a person or thing that makes an action or process easy or easier’. A broad definition that conceals the nuance of roles, responsibilities, and conduct required by a lead facilitator of a PIT. Within a PIT, the lead facilitator performs a contemporary and innovative function yet applies a set of rules that borrows from other familiar roles such as a theatre director or a drama teacher. The lead facilitator’s skill-set will include maintaining safety, working with actors, and self-check measures to ensure a PIT session runs smoothly.

9.14

Participant Safety

In PIT sessions, psychological safety is ideally created and maintained throughout the learning experience by the facilitator. Strategies include demonstrating respect for learners, ensuring transparency in the learning process, inviting questions, encouraging a commitment to curiosity and respect, and valuing different perspectives along with clarifying roles and expectations. PIT sessions are designed to facilitate the application of knowledge to a clinical setting and stimulate

9

Visualisation Through Participatory/Interactive Theatre for the Health Sciences

critical thinking. The exploration of complex situations may result in participants making mistakes whilst testing out solutions and facilitators must be attuned to mitigate against contextual factors where participants may experience anxiety. Each learner experiences psychological safety differently based on experiences and perceptions of the event. It is a facilitator’s responsibility to ensure that emotional or psychological safety is indemnified within a session. Participants want to feel safe, and this requires a facilitator mitigating for creating the right mood or feeling of being comfortable within the learning space. From the perspective of a participant in a PIT, facilitators should avoid at all costs coercing participants to show vulnerability and then having it dissected or worse, disrespected within a session. The onus is on the facilitator to ensure the right atmosphere is created. Students experiencing psychological safety express reduced levels of anxiety which leads to higher student engagement in processing emotions, thinking reflectively, and openly discussing perspectives. Skilled facilitators are key in providing and maintaining a psychologically safe environment where participants perceive a PIT as constructive yet supportive, not critical, destructive, or embarrassing.

9.15

Working with Actors

The facilitator role will include leading the actors within a PIT. It is a collaborative process from prep to wrap. When working with actors on a PIT, keep these tips in mind: It is essential to know who you are working with and complete independent research if you have never worked with a specific actor before. It pays dividends to understand how they like to work as this will spark a relationship of trust and mutual understanding. Include the actors in your process. If they are open to it, ask your actors if they would like to look at your briefing notes or learning outcomes. Allowing involvement facilitates a team approach and better serves your vision.

199

Create a calm and respectful environment. Assure the actors that this is a journey and that you will be accompanying them every step of the way. Self-check regularly if there is an inner need to raise your voice on set. Doing so will create unnecessary tension that is not conducive to creativity. Be prepared but be flexible; have a plan for how you want the story to be displayed but be able to be spontaneous and play to the strengths of the actors. At the same time and conversely, it is not sensible to be amenable to every suggestion since this invites a ‘free-for-all’ and diverts from the overall vision. Give your actors space to work. Communicate your ideas in pre-production, talk through things before a scene starts, and give notes afterward. But when the scene is rolling, let the actor be in control—let an actor do a complete scene before speaking up. Be direct. If you want an actor to do something differently, tell them. Be kind but also be candid and honest about what you want. Some first-time facilitators can often be too timid when it comes to handling actors. Actors actively want feedback and guidance. Remember the shared goal, which is making an actor’s performance as good as it can be so that it tells the story in the best way possible. Be aware of your actors’ needs. Depending on the material being covered, there may be a need to lighten the mood, or give the actor time to step away from the character momentarily. Offer regular time-outs so that everyone feels fresh and energised about the work. Listen to your actors’ instincts. If a scenario is not making sense and the actor is having trouble remembering it, then consider a rewrite. The writing process must be just as integrated as any other element of PIT. Many actors in a DIT will be volunteers or fall under the category of ‘non-actors’. It is important to respect and trust that by being volunteers wanting to be involved, they will absorb feedback, guidance, and benefit from the collaborative process of making a PIT. Finally, watch the work of other facilitators. Observe how they handle different PIT sessions

200

J. Wilson

and actors. They will have their own style, ask different questions of an audience and deploy their own PIT techniques. In studying how good facilitators elicit both a good performance from their actors and an engaged response from an audience means that you can borrow the same techniques for your own sessions.

9.16

Self-check Measures

During PIT sessions, facilitators will behave differently, and their own personalities should be encouraged to come through so that personal styles can be adopted. Self-check measures are rules which are almost obligatory in a PIT. The physical stance of the facilitator is extremely important. A facilitator who allows their own timidity, indecision, or doubts to show through will have a demobilising effect on the audience and the actors. Behaviour breeds behaviour and a confused or tired image of a facilitator will have a detrimental effect on the PIT. Facilitators should avoid actions that could manipulate the audience. It is possible for personal interpretations of events to overpower their dialogue. It installs a ‘Socratic’, interrogative or open question approach in a facilitator and responding only to the audience contributions and shutting off personal views. The facilitator should reassure the audience that they are making the decisions. Facilitators decide nothing and whilst they are present to spell out the rules of the PIT, there is an acceptance that there may be a need to change the focus if deemed necessary for the study of the proposed subject. When working with actors on stage during a PIT session, the facilitator is required to simultaneously support but also set boundaries for them. An actor may be struggling to remember a particular segment of the scenario, but a quick exchange of glances between facilitator and actor can communicate the fragility of the situation. It means that concentration levels within the performing group should be maintained to ensure that vital moments are not missed when actors need support. Conversely, if an actor breaks

character and/or begins to become more vocal than the facilitator, then a gentle hand on the shoulder of that actor and a quick word in an ear can mitigate any blurring of roles presented to an audience. Facilitation of a PIT is considered as one of the most challenging roles to undertake as they are often on their own. The reactive nature of managing the various moving parts of a PIT can leave an individual drained of energy and as the lonely facilitator, it is vital that reflection and self-care is provided.

9.17

Working with Different Audiences: Learning to Visualise

A common fear amongst facilitators is facing an audience who will not engage. There are several reasons behind why an audience may unilaterally decide to disinvest in a PIT session. First up, is that the actor character being depicted in the PIT must be witnessed by the audience to be making attempt to struggle or fight against the challenging situation. Audience members are more likely to identify and render assistance to a protagonist when they are not merely laying down and accepting their lot. A nurse and a patient were having a stand-off at a doorway. The patient had been sectioned under the mental health act and was wanting to leave. The nurse was stopping the patient from leaving. The nurse was behaving like a true ogre, standing over the patient with their voice getting louder with every sentence. The escalation reached a crisis when the nurse place a hand on the patient to turn them away from the door. The patient (in slow motion for the purpose of theatre) smacked the nurse and caused them to fall onto the floor. When the facilitator asked for assistance, nobody wished to save the nurse character because ‘The nurse deserved everything they got!’

Secondly, not all situations have solutions. It can be difficult to wrestle with an audience (especially if they are new to PIT) who crave the desire to have the secret unlocking answer to a scenariobased clinical problem being revealed to them before the end of the session. In some cases, the

9

Visualisation Through Participatory/Interactive Theatre for the Health Sciences

honest and realistic truth is that there is no magic solution and that is a part of clinical practice experiences. Thirdly, the actors playing the part of the antagonist can take on contrasting traits which can demotivate student involvement. Two such examples are dubbed the ‘couch potato’ and the ‘brick wall’. The couch potato does not react to new elements introduced by the audience interventions and therefore does not portray realistic responses. For an example of a couch potato, re-visit the earlier example where one of the audience members, in the role of a spect-actor, accused the actor character of being a paedophile. Much to everyone’s surprise and the facilitators’ dismay, the actor merely shrugged their shoulders in response and gave no protest in accepting the accusation. The brick wall, by contrast, is the actor that plays to win at all costs. The actor will appear to morph their character to deliberately overcome an audience intervention. An example of brick wall was during a PIT about a bullying manager. One spect-actor after another was swatted aside and despatched by the bullying manager who adopted differing tactics to the original character they played for every encounter. The audience response to the couch potato and brick wall is to disinvest in the PIT, either because it is so unrealistic to life or unbeatable that they may as well stop trying. Fourthly, if any of the four pillars are missing then a PIT will likely collapse. For example, even with a strong story, an experienced facilitator and an energised audience, if an actor is unprepared and reads their lines monotonously, whilst holding a script, then the bubble is irrecoverably burst. Fifthly, there is the question of audience resonance. Resonance is concerned with how much an individual audience member connects with the material being depicted via the PIT. There are three narratives of resonance that an audience member may experience: • High resonance—‘I have committed an act just like the one being depicted in the PIT’. The audience member recognises language, thought processes, or behaviour that is being depicted by the actor in the play.

201

• Medium resonance—‘I have not committed such an act, but I have seen others acting like that in another environment’. The PIT scenario triggers an audience member’s memory and a person from their history is recreated in their mind. • Low resonance—‘I have done or not seen such an act like the one being depicted in the PIT, but I can imagine that there are people in the world who could undertake such an act’. An audience member may not have had exposure to a set of traits being played by an actor in the PIT but can be validated by others that it is real and worthy of taking note of the ideas being posited in preparation for when they do come across them. • Bad resonance—‘I simply don’t recognise what I am seeing’. An audience member will disconnect from the scenario. If the depiction is severely bad, then there is a potential for creating something that could be received as insulting. Presenting a negative visualisation of a PIT to an audience leads to future consequences for all who contribute. Audiences sigh when a PIT appears on a timetable and are given the same status as ‘role play’. The pool of willing actors will also dry up through dissatisfaction and disassociate themselves from any future projects. Facilitators who have ‘face-planted’ in a session bear a psychological scar and have no hesitation in heaving PIT into a metaphorical skip.

9.18

Educational Theory: Transformative Learning and Visualisation PIT

The default presumption in adult education is that participants are hardwired to be active, engaged, and curious learners. When we find students in the opposite state of not being curious or actively disengaged in learning then it is because something has turned the switch off. Learning is an individual challenge and complex for many reasons and can be accomplished via a mix of

202

approaches. The flexibility of the human brain to respond to differing stimuli means that a single approach to teaching will not suffice. For example, healthcare teaching relies heavily on the traditional lecture as a primary teaching method and although there are advances in active lecturing techniques, learning through the senses is lost when visual and kinaesthetic learning is underutilised, which can impact on engagement. Transformative learning first emerged on the academic landscape in the 1970s and was originally developed by Jack Mezirow (1978), who compiled the theory based on his study of adult women who returned to the classroom after an extended absence. His research reported that women had experienced significant changes in the way they viewed the world and their ways of being. The research findings suggested these experiences might be similar to the experiences of other adult learners as opposed to the more common learning theories adopted for teaching children. Transformative learning is a dedicated ‘adult’ learning theory. All transformative learning begins with an individual recognising a disorienting dilemma which is a sense of puzzlement internally at an external situation and can trigger feelings of discomfort with a personally held view about the world. PIT sessions are specifically designed to create disorientating dilemmas by reflecting the types of people, behaviours and decisions a healthcare professional may encounter. An individual experiencing a disorientating dilemma has the option to critically reflect on personal assumptions, attitudes, and beliefs or maintain their own status quo. Following a critical reflection and dialogical discourse with others, transformative learning then urges informed action (praxis) which links to ‘learning by doing’ and mechanistically linked to the ‘spect-actor’ in a PIT. New perspectives can then be incorporated into an individual’s frame of reference (Mezirow 1997; Taylor 2008). Transformative learning is fundamentally based on learning that is understood to be a process of using whatever an individual’s prior interpretation to construe a new or revised ‘interpretation of a meaning’ of one’s experience

J. Wilson

that serves as a guide for future action (Mezirow 2003). PIT sessions offer the opportunity for a participant to challenge a held view about the world whilst it is filtered through their own personal frame of reference. A frame of reference is composed of two dimensions. Firstly, as a ‘meaning perspective’ which is a habit of mind consisting of broad, generalised orientation predispositions. Secondly is a ‘meaning scheme’ which is constituted by a cluster of specific beliefs, feelings, attitudes, and value judgements that accompany and shape an interpretation. Individual actions are guided by beliefs. In short, world view beliefs can be challenged through the presentation of a disorientating dilemma and invite the participant to rinse a frame of reference through a process of critical reflection on their assumptions. According to Mezirow (1998), learning occurs by enlarging existing meaning schemes, learning new meaning schemes, or transforming meaning perspectives with transformations being either epochal or incremental. The transformative learning approach was designed by Mezirow (1978) who proposed that learners undergo a change in perspective (perspective transformation) as a result of their experiences. Transformative learning is the process of effecting change in a frame of reference. Adults acquire coherent bodies of experience, associations, concepts, values, feelings, conditioned responses, and frames of reference that define their life world. Frames of reference are the structures of assumptions through which we understand our experiences (Cranton and Hoggan 2012). Frames of reference selectively shape and demarcate expectations, perceptions, cognition, and feelings which set a ‘line of action’. Once set, there is an instinctive move from one specific activity (mental or behavioural) to another. There is a strong tendency to reject ideas that fail to fit our preconceptions, labelling those ideas as unworthy of consideration aberrations, nonsense, irrelevant, weird, or mistaken. When circumstances permit, transformative learners move towards a frame of reference that is more inclusive, discriminating,

9

Visualisation Through Participatory/Interactive Theatre for the Health Sciences

self-reflective, and integrative of experience (Taylor 2008). The underlying themes around PIT show strong associations with the features of transformative learning which can be presented as live action in a classroom whilst simultaneously facilitating the opportunity for people to critically examine their habitual expectations, revise them, and act on the revised point of view (Calleja 2014). PIT can also link with problem-solving properties as Mezirow (1997) states that transformative learning can assist by defining a problem or by redefining or reframing the problem. This type of learning has direct relevance to the attributes of the transferable skills that are increasingly being sought in graduates (Marzano 2007).

9.19

Conclusion

In the design, delivery, and evaluation of learning of a PIT, there is a requirement to pay attention to the unity of elements that must be considered, constructed, and maintained. Novice or naïve facilitators who deploy PIT techniques without first considering personal competence or the complexities involved can unwittingly transcend into a psychologically unsafe learning space. The effects of a poor experience will leave its emotional mark on both facilitator and participant alike. It is essential to carefully craft early sorties into PIT with care and attention to critical components such as the reality of the story, the competence of the facilitator, the investment of the actors and the psychological safety of the participants/audience members. PIT sessions that align with learning theories such as transformative learning ensure that participants enter into sessions with an open mind, an open heart, and a willingness to be involved.

203

References Babbage F (2004) Augusto Boal. Routledge, London Boal A (2002) Games for actors and non-actors. Routledge, London Boal A (2005) Legislative theatre, 1st edn. Taylor and Francis, Florence Boal A (2013) The rainbow of desire, 1st edn. Taylor and Francis, Florence Boland G, Cameron D (2005) Newspaper theatre: applying performance-based learning to journalism education. In: Stockwell S, Isakhan MB (eds) JEA2005: journalism and the public. Griffith University, Brisbane, pp 1–20. Journalism Education Association (JEA) Conference, Australia, 29/11/05 Burstow B (2008) Invisible theatre, ethics, and the adult educator. Int J Lifelong Educ 27(3):273–288. https:// doi.org/10.1080/02601370802047775 Calleja C (2014) Jack Mezirow’s conceptualisation of adult transformative learning: a review. J Adult Contin Educ 20(1):117–136 Cranton P, Hoggan CD (2012) Evaluating transformative learning. In: Taylor EW, Cranton P (eds) The handbook of transformative learning: theory, research, and practice, Jossey-Bass higher and adult education series. Wiley, San Francisco, CA, pp 520–535 Grant D (2017) Feeling for meaning: the making and understanding of image theatre. Res Drama Educ 22(2):186–201 Marzano RJ (2007) The art and science of teaching: a comprehensive framework for effective instruction. Association for Supervision and Curriculum Development, Alexandra, VA Mezirow J (1978) Perspective transformation. Adult Educ 28(2):100–110 Mezirow J (1997) Transformative learning: theory to practice. In: New directions for adult and continuing education, vol 1997, no 74, pp 5–12 Mezirow J (1998) On critical reflection. Adult Educ Q 48(3):185–198 Mezirow J (2003) Transformative learning as discourse. J Transform Educ 1(1):58–63 Prentki T, Preston S (eds) (2009) The applied theatre reader, 1st edn. Routledge, London Taylor EW (2008) Transformative learning theory. New Dir Adult Contin Educ 119:5–15