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Annals of Anatomy 193 (2011) 395– 402

Contents lists available at ScienceDirect

Annals of Anatomy

jo ur n al ho mepage: www.elsev ier .de /aanat

ducation

yMiCROscope—Intelligent virtual microscopy in a blended learning model atlm University

. Schmidta,∗, M. Reinehra,1, O. Leuchtb, N. Behrendtb, S. Geilerc, S. Britscha,∗

Institute of Molecular and Cellular Anatomy, Ulm University, Albert-Einstein-Allee 11, 89081 Ulm, GermanyNet-Base, Computer and Network-Technology, Zinkmattenstrasse 6, 79108 Freiburg, GermanyDepartment of Teaching Evaluation, Ulm University, Albert-Einstein-Allee 11c, 89081 Ulm, Germany

r t i c l e i n f o

rticle history:eceived 11 January 2011eceived in revised form 28 February 2011ccepted 29 April 2011

eywords:

s u m m a r y

The growing diversity among students and the rapid increase in new technologies entering the systemof higher education, demand reconsideration of traditional learning methods. To improve the individualstudent’s learning situation we developed and integrated a novel virtual microscope, MyMiCROscope,into a face-to-face approach for teaching microscopic anatomy. The intelligent virtual microscope hasnot only enabled self-directed learning of the students at their individual learning speed independentof time and place but also offered new possibilities to interact with the user because it implements

yMiCROscopeicroscopic anatomy

ntelligent virtual microscopyntelligent virtual slideslended learningelf-directed learning

systematic annotations accessible from different operational levels. Furthermore the alteration of a soleinstructor-led course into a blended learning model resulted in a change of the learning behaviour of thestudents: group work and social interactions were facilitated.

The results of this study show the advantages that intelligent virtual microscopy incorporates for self-directed learning and that blended learning in undergraduate medical education is able to fulfil the

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individual needs of the st

. Introduction

The integration of face-to-face learning experiences with onlinexperiences affiliating the strengths of traditional and modernearning settings is designated as blended learning (Driscoll, 2002;arrison and Kanuka, 2004). Blended learning has been defined

n a variety of ways in the current specialized literature (Driscoll,002; Fox, 2002; Kerres and De Witt, 2003; Garrison and Kanuka,004; Mortera-Gutierrez, 2006; Osguthorpe and Graham, 2003).ccording to Garrison and Kanuka (2004), it is important to under-tand, that “blended learning has to be distinguished from otherorms of learning that incorporate online opportunities. The realest of blended learning is the effective integration of the two

ain components (face-to-face instruction and internet technol-gy) such that we are not just adding on to the existing dominantpproach or method”. Initial studies with blended learning have

eported promising results. Student achievement and satisfactionave been equal to or superior to traditional courses (Dziubant al., 2004). Blended approaches are able to improve learning out-

∗ Corresponding authors. Tel.: +4973150023101; fax: +4973150023102.E-mail addresses: corina.schmidt@uni-ulm.de (C. Schmidt), stefan.britsch@uni-

lm.de (S. Britsch).1 Present address: Institute of Pathology, Kantonsspital Winterthur, Brauerstr. 15,H-8401 Winterthur, Switzerland.

940-9602/$ – see front matter © 2011 Elsevier GmbH. All rights reserved.oi:10.1016/j.aanat.2011.04.009

ts and support social interactions without disregarding practical skills.© 2011 Elsevier GmbH. All rights reserved.

comes for students veritably (Twigg, 2003; Garnham and Kaleta,2002) and on average have higher success and lower withdrawalrates (Dziuban and Moskal, 2001; Dziuban et al., 2004; Twigg,2003). Our major goal was to facilitate learning experiences andself-directed learning for medical students, therefore a blendedlearning model instead of an exclusive instructor-led approachto teach microscopic anatomy was introduced. This methodicalchange was performed in two steps: First, development of anintelligent virtual microscope, MyMiCROscope, and, second, reor-ganization of the traditional course of microscopic anatomy toimplement the new e-learning tool. The development of an intel-ligent virtual microscope requires the identification of qualitystandards virtual microscopes must today exhibit (Harris et al.,2001; Glatz-Krieger et al., 2003, 2006; Merk et al., 2010; Paulsenet al., 2010 and references cited therein) and the specification of fea-tures essential to support learning outcomes. One of these featuresin MyMiCROscope is the implementation of “intelligent virtualslides”, defined as continuously zoomable, high quality picturesimplementing important information given through systematicannotations, which are accessible from different operational lev-els.

The evaluation of MyMiCROscope supported a high acceptance

of the blended learning model. A total of 97% of the volunteeringstudents asserted that they would recommend MyMiCROscope and94% would like to use it as self-directed e-learning tool for prepa-ration for the first oral exam. Comments of the students endorse

396 C. Schmidt et al. / Annals of Anatomy 193 (2011) 395– 402

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Fig. 1. Screenshot of the slide gallery view after choosing

he fact that they do not want MyMiCROscope to replace the tradi-ional instructor-led course where they use the light microscopes toxamine the histological slides, but that they want it as an effective,otivating complement to the course, forming part of a blended-

earning concept.The present study supports the fact that the combination of

nstructor-led teaching methods in microscopic anatomy withntelligent virtual microscopy in a blended learning approach suc-eeds in fulfilling individual learning needs in higher educationithout losing professional skills.

. Material and methods

.1. Digitizing histological slides and system structure

Scans of the histological slides were taken using MIRAX MIDICarl Zeiss) with a Plan-Apochromat 20×/0.8 objective operatedy MIRAX Control software. The virtual slides were converted intohe sis-format (Arivis). Hosting and organization of the slides isdopted through the mirax@net-base platform (http://www.net-ase.de/Net-Base.1.0.html) consisting of three major components:1) the scalable, red hat based storage system comprises two redun-

ant web-servers connected with two redundant load-balancers.2) The LAMP-based, specifically adapted content managementystem (CMS; TYPO3) for the administration of the virtual slides.dditional slide-information and the user access-rights are stored

th course day (“Kurstag 5 ) of the Ulmer histology course.

in a MySQL database. (3) The Apache-module for backend-rendering of the slides. A special javascript-framework is used tovisualize the slides in web-browsers. This “webview” (Arivis) is par-tially controlled by the CMS using a special XML-based API. Thevirtual slides can be viewed with every up to date browser withoutfurther plugins.

2.2. User surface and content of MyMiCROscope(http://mirax.net-base.de/UK-Ulm.mymi.0.html)

After the password-restricted login the self-explanatory usersurface of MyMiCROscope directs the user to the Ulmer courseof microscopic anatomy. MyMiCROscope includes all histologicalslides of the Ulmer course of microscopic anatomy as intelligentvirtual slides. Each course day is presented as a slide gallery view(Fig. 1). The single slide view offers a continuously zoomable,high-resolution picture with integrated systematic annotations.Annotations define visual designations of different shape andcolour within a virtual slide and corresponding text information.The user is able to choose between showing and hiding single anno-tations/groups of annotations in the picture. In the single slide viewthe annotations in MyMiCROscope are additionally compiled as

a list subdivided into three sections: organization, common andspecial annotations (Fig. 2). Choosing an annotation from the dis-played list or within the intelligent virtual slide zooms the pictureto the correct magnification, in which the annotation was made.

C. Schmidt et al. / Annals of Anatomy 193 (2011) 395– 402 397

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ig. 2. Screenshot of the single slide view offering on the left-hand side a navigaetween showing and hiding single annotations/groups of annotations in the pict“Gliederung”), common (“allgemein”) and specific (“speziell”) annotations.

he symbol designating the chosen annotation is displayed with

bounding box and the corresponding text information (Fig. 3).y applying this tool the user is able to explore an intelligentirtual slide step by step adjusted to the level of individual knowl-dge.

ig. 3. Screenshot after choosing the annotation “Perichondrium” via double-click fromnnotation was made. The symbol designating the chosen annotation is displayed with a

toolbar, a continuous zoom function and annotations. The user is able to choosee annotations are compiled as a list subdivided into three sections: organization

Furthermore, a measuring tool enables the user to get an impres-

sion of the true size of a chosen structure and a print screen functionenables the possibility to archive and print structures of inter-est.

the offered list. The picture is zoomed to the correct magnification, in which the bounding box and corresponding text information.

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.3. Implementation of MyMiCROscope into the course oficroscopic anatomy (blended learning concept)

MyMiCROscope includes all histological course slides as intelli-ent virtual slides in a chronologic order analogous to the courseurriculum. To integrate MyMiCROscope into the program of theourse of microscopic anatomy a revision of the course script andeconceptualization of the course was accomplished.

.4. Evaluation of MyMiCROscope

.4.1. Student groups and efficiency controlDuring the summer term 2010 three different groups of stu-

ents (human, dental, and molecular medicine) between the firstnd third year of medical education participated in the course oficroscopic anatomy. Because of the number of students (447 stu-

ents) three parallel courses were organized. The distribution ofhe three different groups of students (human, dental, and molecu-ar medicine) over 3 parallel courses of histology was randomised.n each course every student received a box containing 100 histo-ogical slides and a corresponding course script. In addition to theegular course times, the students were allowed to have optionalccess to light microscopes and histological slides once a week for

h.The efficiency control during each course of microscopic

natomy is subdivided into three parts: (1) the intermediate examontaining multiple choice questions about general histology, (2)he practical exam where the students have to identify two histo-ogical specimens with the help of the light microscope, draw andxplain them, and (3) the final exam containing multiple choiceuestions about special histology.

.4.2. Evaluation sheetThe selection of the questions used in the evaluation sheet was

ased on the criteria for qualitative assessment of e-learning soft-are published on behalf of the Federal Ministry of Education,

cience and Culture (Gottfried et al., 2002). At the beginning ofay 2010 the test version of MyMiCROscope was ready for use.

n July 2010 the evaluation sheet with 37 statements regardinghe assessment of MyMiCROscope was filled out by the studentsn a voluntary and anonymous basis (369/447). Statements giveno the students were assigned to five main categories: (1) user-riendliness and administration, (2) content and structure, (3)andling and usability, (4) pedagogic and didactic benefit, and (5)enefit for academic studies.

The different statements were rated by the students on a scaleanging from false (=1) to true (=6) according to their distinctmpression. At the very beginning of the evaluation sheet the stu-ents were asked to give information about which course of studieshey belong to and when they have begun to study. At the very endf the evaluation sheet the students were asked to provide an over-ll grade for MyMiCROscope on a scale ranging from very good (=1)o very bad (=6) and were given the opportunity to write free com-

ents about what they would improve or what they liked the mostegarding MyMiCROscope.

Statements:(1) User-friendliness and administration:

1.1 The activation of the programme works well.1.2 System requirements and restrictions are defined.1.3 The design of the user surface is pleasant.1.4 Control bars and their function are easy to handle.1.5 The navigation in MyMiCROscope is clearly arranged and

coherent.1.6 The access to the tutorials is unproblematic.1.7 The system works quickly and reliably.1.8 There is comprehensible instruction.1.9 The compendium with the course days is useful.

omy 193 (2011) 395– 402

1.10 There is a possibility to get rapid error-feedback.(2) Content and structure:

2.1 The content is clearly structured.2.2 Accompanying material, e.g. course script with helpful

questions exists.2.3 The tutorials can be reiterated at the users ease.2.4 The content is correct.2.5 The sequence of the tutorial is variable.

(3) Handling and usability:3.1 The access to the different features is easy and direct.3.2 Retention and printing of individual pictures at different

magnifications are possible.3.3 The annotations are comprehensible.

(4) Pedagogic and didactic benefit:4.1 MyMiCROscope is motivating.4.2 MyMiCROscope helps me to learn more efficiently.4.3 MyMiCROscope enables me to learn in a pleasant atmosphere.4.4 MyMiCROscope enhances my sense of achievement because it

improves the recognition of structures and consolidates myknowledge.

4.5 The learning-content is coherent and distinct.(5) Benefit for academic studies:

5.1 Pictures are of high quality and useful for learning without thehelp of an instructor.

5.2 MyMiCROscope is useful for the preparation of exams.5.3 MyMiCROscope includes consolidated text information.5.4 Even the inexperienced user is able to find and learn structures

in a virtual slide.5.5 The subdivision of the annotations enables a structured

exploration of the slides.5.6 The use of the measuring tool enables a better understanding

of the true size of the structures.5.7 MyMiCROscope enables me to consolidate my knowledge.5.8 MyMiCROscope helps me to improve my performance in

microscopic anatomy.5.9 The virtual slides are consistent with the glass slides used in

the course.5.10 MyMiCROscope enables self-directed learning.5.11 I do not want to miss MyMiCROscope as learning aid.5.12 I will recommend MyMiCROscope.5.13 I want to use MyMiCROscope for preparation for the first oral

exam.

2.4.3. Statistical analysis of the dataA total of 369 from 447 students participating in the course

of microscopic anatomy volunteered in the evaluation. All eval-uation sheets were analyzed, including incomplete replies. Theprogram used for the statistical analysis was EvaSys EducationSurvey Automation Suite (Electric Paper). With this program thearithmetical average (aa) and standard deviation (SD) were calcu-lated for every given statement and main category, and visualizedvia a histogram and profile line.

3. Results

3.1. MyMiCROscope in a blended learning model in the course ofmicroscopic anatomy

MyMiCROscope was developed to facilitate learning experi-ences and to support self-directed learning of medical students in ablended learning concept aimed at improvement in their learningoutcomes. MyMiCROscope includes all histological course slidesas intelligent virtual slides thereby enabling self-directed studyingindependent of time and place. To integrate MyMiCROscope intothe program of the course of microscopic anatomy a reorganiza-tion of the course-curriculum was accomplished. Histological slidesfundamental for comprehension stayed in the regular course andwere discussed there intensely with the students. Supplemental

slides were taken out of the regular course and used for self-directed learning with MyMiCROscope with the help of integratedquestions. With this blended learning approach, similar theoreti-cal basics were constituted during the course and the transfer of

C. Schmidt et al. / Annals of Anatomy 193 (2011) 395– 402 399

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Fig. 4. Graphic representation of the results of the stu

his knowledge enabled through the self-directed learning withyMiCROscope.Students used MyMiCROscope for the preparation of the course

nd exams very regularly. During May 2010 and August 2010ore than 10,000 password-restricted logins took place. Com-ents on MyMiCROscope made by the students during the course

ime showed that they appreciated the new possibility to view andeview the slides at any time at their own pace and to have thehance even to explore unknown slides with the help of the system-tic annotations on their own. They took snapshots of virtual slidesnd amended their individual course scripts with these images. Aew learning behaviour appeared: to prepare themselves for theourse or exams groups of students discussed virtual slides at thecreen of their laptops and studied together.

.2. Results of the survey of MyMiCROscope

A total of 82.5% of the students participating in the course oficroscopic anatomy volunteered in the evaluation. At the date

f the survey 74.9% of the volunteering students studied humanedicine, 13.1% dental medicine and 12.0% molecular medicine.

rom this collective, 71.4% of the students were in the second, 20.8%n the fourth, 5.6% in the fifth and 1.7% in the sixth semester. Rangingn a scale from bad (=1) to good (=6) the main categories admin-stration and user friendliness obtained 5.2, content and structure

survey for category 4, pedagogic and didactic benefit.

5.6, handling and usability 5.4, pedagogic and didactic benefit 5.4,and benefit for academic studies 5.5 from 6 possible points. There-fore, the global indicator as mean value for the five categories scores5.4 points.

In the following the results of the single statements for the maincategories 4 and 5 will be given. As described before the differ-ent statements were rated by the students on a scale ranging fromfalse (=1) to true (=6) according to their distinct impression. Eachpercentage mentioned below is the sum of the student contingentchoosing the points score 5 and 6 of the specified scale.

The results of category 4 (pedagogic and didactic benefit) sup-ported that 87.7% of the students valued MyMiCROscope as amotivating learning tool. In all, 92.3% of them stated that it helpedthem to learn more efficiently and 86.8% corroborated that itenabled them to do this in a pleasant atmosphere. A total of 89.5% ofthe students were persuaded that MyMiCROscope enhanced theirsense of achievements and 93.0% felt confident that the learning-content was coherent and distinct (Fig. 4).

The results of category 5 (benefit for academic studies) revealedthat 93.7% of the students endorsed that the pictures in MyMi-CROscope are of high quality and 94% affirmed the aptitude of

MyMiCROscope for the preparation of exams. In all, 85.2% con-firmed that MyMiCROscope included consolidated text informationand 80.7% thought that the inexperienced user would also be com-fortable in working with this e-learning tool. Even 90.3% of the

400 C. Schmidt et al. / Annals of Anatomy 193 (2011) 395– 402

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Fig. 5. Graphic representation of the results of the st

tudents appreciated the subdivision of annotations to enable thetructured exploration of the slides and 77.5% thought that the

sage of the measure tool in MyMiCROscope was useful for obtain-

ng a better understanding of the real size of histological structures. total of 96.7% of the volunteering students confirmed that MyMi-ROscope enabled them to consolidate their knowledge and 97.0%

survey for category 5, benefit for academic studies.

supported that it helped them to improve their performance inmicroscopic anatomy. Even 96.1% confirmed that the virtual slides

were representative for the course of microscopic anatomy atUlm University and 95.6% assessed that MyMiCROscope enabledself-directed learning. Of responders, 71.2% did not want to missMyMiCROscope as learning aid and 97.6% affirmed that they would

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ecommend MyMiCROscope. Even 93.7% of the students empha-ized that they wanted to use MyMiCROscope for preparation forhe first oral exam (Fig. 5).

Thus, the results of the evaluation showed a very high accep-ance of MyMiCROscope by the students. The overall grade for

yMiCROscope was given 1.3 (1 = very good, 6 = very bad). Fur-hermore, the students wrote about 50 pages of free commentsSupplementary data). The majority of the students favoured therouping of the slides related to the course days and the annota-ions within the slides, which were subdivided into different levels.hey saw MyMiCROscope as a useful, new e-learning tool support-ng their own learning outcome in microscopic anatomy by offeringhem control over content, learning sequence, pace of learning, andhe free choice of time and place. It is important to highlight thathe students did not want MyMiCROscope to replace the tradi-ional instructor-led course where they use the light microscopeso examine the histological slides but they wanted it as an effec-ive, motivating complement to the course, being part of a blendedearning concept. To improve the usability of the program also inontext of exams or as basis for other clinical disciplines they pro-osed an additional general classification of the slides into topicsnd the possibility to quiz themselves to check their own level ofnowledge.

. Discussion

In August 2009 we began to develop an intelligent virtual micro-cope. We aimed to achieve a virtual microscope with Ulm-specificourse slides, self-explanatory user surface, high quality and freelyoomable pictures including systematic annotations. Given themportance of such annotations we wanted them to be zoomable,ble to be switched off/on, adaptable to irregular histologicaltructures within the picture, and last but not least easy to findor the user. Even the inexperienced user should be given thepportunity to find these annotations just by means of a mouse-lick on an annotated structure of the virtual slide itself or on oneenomination of a given list of histological terms. In May 2010 therst test version of an intelligent virtual microscope implement-

ng these features, MyMiCROscope, was introduced in the coursef microscopic anatomy. The important advantage of this virtualicroscope compared to other available ones are the integrated

ystematic annotations accessible from different operational lev-ls thereby allowing a handling adapted to the knowledge of theser. This opens a form of interaction between student and pro-ram explaining the fact that about 90% of the students affirm thatyMiCROscope motivates them to learn and enhances their sense

f achievements. The described approach implementing intelligentirtual slides in a blended model to teach microscopic anatomyid not involve any reduction in staff or contact time or theeplacement of light microscopes. Our goal was to improve theocus and efficiency of student–instructor interactions by provid-ng an innovative, flexible learning tool. MyMiCROscope alloweds to divide the learning content of the histology course in twonequally weighted sections, the broad instructor-led and themaller self-directed part. Thus, the benefits of having MyMiCRO-cope were split. First, instructors had more time for explaininghereby strengthening face-to-face teaching, and the students moreime for drawing and studying the fundamental histological slidesith the help of light microscopes in the course; second the stu-ents had additional opportunities for the study of appropriateourse and supplemental slides at their earliest convenience inde-

endent of face-to-face teaching and availability of microscopes.he feedback given by the students directly during the courseimes, with multiple e-mails and especially in the evaluation of

yMiCROscope was very encouraging. The students acknowledged

omy 193 (2011) 395– 402 401

MyMiCROscope as a motivating and new e-learning tool support-ing their own learning outcome in microscopic anatomy by offeringthem control over content, learning sequence, pace of learning, andthe free choice of time and place. They awarded the test version ofMyMiCROscope an overall grade of 1.3 on a scale of 1 (=very good) to6 (=very bad), thereby showing the relevance this program reachedfor their individual study of microscopic anatomy.

About 97% of the students in our course felt confidentthat MyMiCROscope supports their consolidation of knowledgeand improves their performance in microscopic anatomy. Wehave compared student outcomes with the changed curriculum(blended learning) to previous years (exclusive instructor-ledapproach). Interestingly we observe an improvement in the out-comes for students studying dental medicine (data not shown). Inorder to get statistically valid data for all three groups of students(human, dental, and molecular medicine) this will require furtherobservation. Various studies document that blended approachescontribute to improved learning outcomes for students (Twigg,2003; Garnham and Kaleta, 2002) and on average have highersuccess and lower withdrawal rates (Dziuban and Moskal, 2001;Dziuban et al., 2004; Twigg, 2003). The significance in reduction ofwithdrawal rates, e.g. for medical students is growing in consider-ation of the fact that a lack of specialists in the health professionshas become a problem for society nowadays. Complete replace-ment of traditional methods with e-learning models does notnecessarily show an improvement in the learning outcomes of thestudents or the consolidation of their knowledge (Boeker and Klar,2006). The dissatisfaction of students having mainly online settingsthereby suffering from lack of face-to-face interactions could evenbe addressed with blended learning approaches (Osguthorpe andGraham, 2003). Blended models can help to bring the students inthe focus of learning by enabling them new options to schedule thecoursework. The sustained time flexibility, the chance to controlthe content, pace and location of their learning boost their level ofsatisfaction regarding blended learning. Even students having mul-tiple responsibilities such as work or family commitments are ableto schedule their learning load better (Aycook et al., 2002; Garnhamand Kaleta, 2002). With the capacity to activate both self-regulatedand interpersonal learners, blended learning was also found tobe effective in addressing diverse learning styles (Bielawski andMetcalf, 2003).

With the implementation of MyMiCROscope we observed achange in the learning behaviour of our students. They workedin groups discussing virtual slides together in front of the lap-top. The use of MyMiCROscope advanced social interactions amongthe students, which are in their part important to consolidationof knowledge (Brown and Palincsar, 1989; Cohen, 1994; Dolmanset al., 2005; Regehr and Norman, 1996). Studies showed that a well-planned blended learning approach is able to change the natureof in-class sessions: the student’s behaviour shifted from a con-suming into a more active role and the collaboration among thestudents improved (Blake et al., 2003; Braun and Kearns, 2008),even a stronger sense of community was induced (Rovai and Jordan,2004). Interestingly, the majority of our students, who have beendescribed as so-called “millenials” (born 1981–1994) in the liter-ature (Oblinger, 2003), exhibit characteristics that may explain tosome extent the change of their learning behaviour: “Their learn-ing preferences tend toward teamwork, structure and the use oftechnology. Their strengths include multitasking, goal orientationand a collaborative style” (Oblinger, 2003).

The intelligent virtual microscope, MyMiCROscope has provento be a motivating e-learning tool supporting self-directed learn-

ing in a blended learning approach in microscopic anatomy atthe Ulm University. Future perspectives of MyMiCROscope willinclude a complete and systematic atlas of histology and an inno-vative quiz tool. The implementation of MyMiCROscope in new

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earning approaches is under development and will be reportedlsewhere.

cknowledgements

The authors wish to thank Peter Krämer (Zeiss) for the sup-ort to initiate this study. We thank Markus Rödling (Net-Base)nd Christian Götze (Arivis) for the IT-support; Thomas Betz (Zeiss)nd Renate Burgemeister (Zeiss) for the excellent scanning of theistological slides. We thank Stefanie Wiest (Department of Teach-

ng, Ulm University) for critical reading and our colleagues Siglindeartwig and Christoph Wiegreffe (Institute of Molecular and Cel-

ular Anatomy, Ulm University) for valuable discussions. We alsohank the students of the Medical Faculty at Ulm University forolunteering the evaluation and valuable feedback during the testhase of MyMiCROscope.

ppendix A. Supplementary data

Supplementary data associated with this article can be found, inhe online version, at doi:10.1016/j.aanat.2011.04.009.

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