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Annals of Anatomy
journal homepage: www.elsevier.de/aanat
Department of Anatomy and Cell Biology, Martin-Luther-University of Halle-Wittenberg, Groe Steinstrae 52, D-06097 Halle, Saale, Germany
Department of Anatomy II, Friedrich-Alexander-University Erlangen-Nrnberg, Universittsstr. 19, D-91054 Erlangen, Germany
a r t i c l e
i n f o
Keywords:
Virtual histology
Virtual education
Telemedicine
s u m m a r y
Conventional continuing education in microscopic anatomy, histopathology, hematology and microbiology has hitherto been carried out using numerous sets of sectioned tissue specimens in a microscopy
laboratory. In comparison, after digitalization of the sections it would be possible to access teaching
specimens via virtual microscopy and the internet at any time and place. This would make it possible
to put innumerable new learning scenarios into practice. The present article elucidates the advantages
of virtual microscopy in histology instruction and presents a concept of how virtual microscopy could
be introduced into the teaching of microscopic anatomy in several steps. Initially, the presently existing
microscopic teaching specimens would be digitalized and made available on-line without restriction.
In a second step, instruction would be shifted to an emphasis on virtual microscopy, utilizing all of the
advantages offered by the technique. In a third step, the microscopic contents could be networked with
other anatomical, radiological and clinical content on-line, thus opening new learning perspectives for
students of human and dental medicine as well as those of medically related courses of study. The advantages and disadvantages of such a concept as well as some possibly arising consequences are discussed
in the following.
2010 Elsevier GmbH. All rights reserved.
Corresponding author at: Department of Anatomy II, Friedrich-AlexanderUniversity Erlangen-Nrnberg, Universittsstr. 19, D-91054 Erlangen, Germany.
Tel.: +49 9131 852 2865; fax: +49 9131 852 2862.
E-mail address: friedrich.paulsen@anatomie2.med.uni-erlangen.de
(F.P. Paulsen).
0940-9602/$ see front matter 2010 Elsevier GmbH. All rights reserved.
doi:10.1016/j.aanat.2010.09.008
379
Fig. 1. (a) Microscope made by Ernst Leitz in Wetzlar, ca. 1910, Original equipment of the Institute of Anatomy and Cell Biology of the Martin Luther University in HalleWittenberg, Germany, then known as the Botanical Institute of Halle. (b) Microscope made by Leica, ca. 2000, Institute of Anatomy II, Friedrich Alexander University of
Erlangen-Nuremberg, Germany.
tual slides are large les and special programs, known as virtual
microscopes, are necessary for their visualization. These programs
use special streaming technologies allowing demonstration without time lag. The digitalized sections are transferred with software
making it possible to click on the respective section (virtual specimen box) and thus activate the specic les. After activation, the
section appears in a small window inset showing its appearance
on the slide without magnication thus providing an orientation
guide (so-called navigator eld), while at the same time it is initially shown as an overview on the remainder of the screen. Various
magnications corresponding to the objective sizes of a conventional microscope can now be clicked on using a menu bar. Beyond
this, the size can be gradually changed via mousewheel or keyboard (zooming). At any given size, one can, by pressing the mouse
key and simultaneously pulling the mouse, move the entire section
as if moving a slide under a conventional microscope. At higher
magnications, a crosshair aids in identifying the currently viewed
position in the section. Via a further button, information on the
respective section can be accessed (e.g. stain, gure legend, etc.).
Using the menu commands, it is possible to click on a list of relevant
supplementary information (e.g. related specimens which could
facilitate understanding, clinically associated illustrative materials,
additional antibody markings, electron microscopic pictures, etc.).
The vanguard role in the use of this new technology has been
taken by the pathologists, who have already gathered a great deal
of experience using it (Steinberg and Syed, 2001; Dee et al., 2003,
2007; Grant, 2003; Romer, 2003; Gagnon et al., 2004; Kumar et
al., 2004, 2006; Lundin et al., 2004; Helina et al., 2005; Lee, 2005;
Dee, 2006, 2009; Glatz-Krieger et al., 2006; Marchevsky et al., 2006;
Ward, 2006; Glatz et al., 2007; Dee and Meyerholz, 2007; Simms
et al., 2007; Kalinski et al., 2008; Kim et al., 2008; Sinn et al., 2008;
Stewart et al., 2008, Taylor et al., 2008; Lpez et al., 2009). In the
present issue, Merk et al. (2010) present a report on experiences in
a histopathology course at the RWTH Aachen using a didactic concept based on Web-based virtual microscopy as well as an analysis
of its acceptance by students. There are, however, other anatomical
institutes which have used virtual microscopy over a longer period,
even some in Germany (e.g. The University of Iowa, USA; University of Basel, Switzerland; University of the Saarland). The virtual
presentations of these universities can be accessed without cost via
380
http://www.path.uiowa.edu/virtualslidebox/
http://vmic.unibas.ch/patho/topo/index.html
http://wwwalt.med-rz.uniklinik-saarland.de/
med fak/anatomie/bock/vmic.htm
At some other universities (e.g. the Christian Albrecht University of Kiel, Germany), the sections used for teaching histology
as well as supplementary electron microscopic preparations have
already been digitalized. However, these les are only accessible
via password and can be used exclusively by participants of the
microscopy course or by faculty members of the respective university. These presentations, whether freely accessible or not, have
in common that the use of virtual microscopy is provided only in
the form of supplementary educational material and has not yet
been implemented as an independent training concept for teaching
microscopic anatomy.
The goal of this article is to present a concept through which
virtual microscopy may be fully integrated into the teaching of
anatomy as well as being made available to the user as freely accessible supplementary educational material. Up to the present, this
was only possible within the framework of the very limited socalled free microscopy hours in the microscopy lab outside of the
ofcial course periods.
3. Concept for the conversion to virtual microscopy
At most German universities the number of human and dental medical students is much greater than the number of available
microscopy places. For this reason, two (as e.g. in Erlangen, Halle,
Kiel) or more (as e.g. in Tbingen, where there are 100 microscopy
places for 400 students) courses of microscopic anatomy are usually
offered in parallel. This makes the coordination of a period for free
microscopy, during which students have the opportunity to study
the specimens outside of regular course hours, a true challenge.
The integration of virtual microscopy into the concept of teaching histology cannot completely neglect the use of conventional
light microscopy as, in the future, the profession of the physician or medical scientist will continue to require the knowledge
of how to use a microscope. For this reason, students should continue to be instructed in the use of good binocular microscopes in
small groups as is usual practice today at most universities. The
remaining course time would be spent working with the virtual
microscope. The microscopy lab spaces must be equipped for the
use of virtual microscopy. Ideally the number of workplaces should
match the number of students to be trained. At the very least, every
present microscopy workplace should also be equipped for virtual
microscopy. In the latter case, this would admittedly mean that the
course would still have to be offered two or three times or even
more frequently in parallel. A given workplace would require only
a minimally equipped computer terminal with monitor and mouse.
Future courses of microscopic anatomy could be held at these worksites. Outside of regular course hours, the students would have
the opportunity to study all preparations using virtual microscopy.
Assuming an internet access, students would have the opportunity
to view the virtual specimens independently of place or time, e.g.
out of the opening hours of the institute, during vacation periods
and from any place, even from mobile phones.
4. Innovative content, demonstration of sustainability and
transferability as well as additional benets to be expected
from such a concept
4.1. Advantages
Conventional continuing education in microscopic anatomy,
histopathology, hematology and microbiology has hitherto been
carried out using numerous sets of sectioned tissue specimens in a
381
382
2009). Once any given institute has performed its complete course
of histology using virtual microscopy for the rst time, it will
become apparent whether other universities will follow suit. In
Germany, concrete plans for the implementation of such a concept
are in progress in Mnster and Erlangen. Beyond the universities
which already have such plans, there are further anatomical institutes planning to provide virtual microscopy at least in the form of a
supplementary option. Beyond this, it may be realistically assumed
that medical book publishers will gradually couple their histology textbooks with supplementary digital materials. Lucrative third
party funds, as e.g. from virtual institutes of higher learning such as
those already working in Baden-Wrttemberg, Bavaria and Hessen,
will further boost the creation of such virtual educational offerings
at universities and institutions of higher learning. This development will additionally strengthen and accelerate the process of
conversion from conventional to virtual microscopy.
The knowledge gained within the framework of such a concept
and further developments in the eld of communications technology could make a contribution to the fact that in future the
microscopy course may no longer take place in the solid buildings of the university (microscopy labs), but rather be offered at
a given time via the internet. Every student would sit at home
at his computer or whatever may be available at that time (consider the Ipad)and log in via a password. An instructor would
hold the lesson from his computer, discussing in detail a relevant
specimen using a built in microphone in the computer (e.g. Skype).
Meanwhile, it would even be possible to see the teacher in a small
corner of the monitor (so desired). Questions from the students
would be transmitted to a tutor who would also be participating
via his computer. This scenario offers the possibility of instructing
a large number of students all at the same time. The costs for a
microscopy lab could be dispensed with and the amount of staff
necessary would be minimal. Whether such a vision is desirable,
is a moot point at the present time. On the other hand, transmitting lectures alternatively via camera from one room to another in
which the lecturer is not even present, in order to deal with oversized student cohorts is surely an even poorer solution. Concerns
that virtual microscopy may provoke a reduction in staff number in
the anatomical institutes does not appear to be a realistic threat. A
more serious problem, rooted in the global budget restrictions and
poorer payment of the university staff, will be nding appropriate,
highly qualied personnel.
Acknowledgment
We thank Marco Gsswein for the preparation of photographs.
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