Diagnostic cytopathology, the study and diagnosis of disease at the cellular level, is an essential part of clinical decision-making. Creating and validating high quality digital teaching materials for both medical students and medical specialist trainees, in this subject area, is consequently important for equity of learning and standardisation of assessment. To address this issue, digital educational materials in cytopathology were created in the form of whole slide images (WSI), hosted on Slice, and this large suite of WSI was then utilised to create 25 virtual microscopy adaptive tutorials (VMATs) using the Smart Sparrow Adaptive eLearning Platform1.
To formally evaluate the efficacy, perceived efficiency and acceptability of WSI and VMATs for learning cytopathology, two randomised cross-over trials were conducted to:
Results revealed measurable and perceived benefits of WSI and VMATs for pathology trainees, as well as medical students. High levels of user acceptability were demonstrated as well as learning benefits at least equal in effectiveness to conventional methods with the advantage of much greater accessibility. Efficacy, efficiency and equity of learning provided by WSI and VMATs were prominent themes in evaluation surveys completed by pathology trainees. For medical students, use of VMATs resulted in significantly improved diagnostic accuracy for fine needle aspirates. Medical students' perceptions of VMATs were positive, particularly regarding immediate feedback, interactivity and equity. One important point to arise from user (ranging from medical student to senior specialist trainee) feedback was that the same subject matter could be used for all levels of training but the complexity of the interactive tutorial and accompanying adaptive feedback needed to be tailored to the existing level of training and knowledge of the user. Therefore, this technology was shown to be effective, efficient and acceptable at different stages of medical training.
From a practical perspective, the preparation of effective educational content, to accompany each whole slide image within the VMAT, required diagnostic expertise and understanding of potential misconceptions, in order to build a storyboard of content and adaptive feedback associated with trap states (incorrect responses that indicate misconceptions). The average development time for each VMAT ranged from 15 to 40 hours; this was dependent on the complexity of both the educational content and the layering of interaction within the VMATs.
The key driver to assess this technology arose from the need for equitable access to high quality instructive clinical material across diverse training environments, including those studying and/or working in regional and remote areas, and to achieve better standardisation of assessment. Educational technology is rapidly advancing, and medical students, pathology trainees and specialists will have increasingly higher expectations about how they should be able to engage with educational resources.
To conclude, WSI are becoming part of the specialty examination process in Anatomical Pathology in Australasia, and are incorporated into certifying and proficiency examinations in the United States4 and Europe5. Worldwide, the diagnostic workflow is increasingly incorporating digital technology. Consequently, verification of educational interventions using digital technologies was an important undertaking.
References1. Van Es SL, Pryor WM, Belinson Z, Salisbury EL, Velan GM. Cytopathology whole slide images and virtual microscopy adaptive tutorials: A software pilot. J Pathol Inform 2015; 6 (54) http://dx.doi.org/10.4103/2153-3539.166016.2. Van Es SL, Kumar RK, Pryor WP, Salisbury EL, Velan GM. Cytopathology whole slide images and adaptive tutorials for postgraduate Pathology trainees: a randomized crossover trial. Hum Pathol 2015; 46 (9):1297-305 http://dx.doi.org/10.1016/j.humpath.2015.05.009.3. Van Es SL, Kumar RK, Pryor WM, Salisbury EL, Velan GM. Cytopathology whole slide images and adaptive tutorials for senior medical students: A randomized crossover trial,. Diagn Pathol 2016;11(1) http://dx.doi.org/10.1186/s13000-016-0452-z.4. Weinstein RS. Innovations in medical imaging and virtual microscopy. Hum Pathol 2005;36(4):317-9.5. van den Tweel JG, Bosman FT. The use of virtual slides in the EUROPALS examination. Diagn Pathol 2011;6 (Suppl 1):S23.
Dr Simone Van Es (MBBS, FRCPA, PhD (Digital Pathology), Grad Dip Med, Cert FPA, Anatomical Pathologist and Lecturer in Pathology) was recently awarded her PhD in Digital Pathology. Her project involved creating and evaluating digital resources in the field of cytopathology and histopathology. She conducted a pilot study and two trials, involving RCPA anatomical pathology trainees and UNSW medical students.