Medical Science Educator (2019) 29:803–817

https://doi.org/10.1007/s40670-019-00759-5

ORIGINAL RESEARCH

Overcoming Barriers in a Traditional Medical Education System

by the Stepwise, Evidence-Based Introduction of a Modern
Learning Technology
Doris George Yohannan 1 & Aswathy Maria Oommen 1 & Kannanvilakom Govindapillai Umesan 1 &
Vandana Latha Raveendran 1 & Latha Sreedhar Lakshmi Sreedhar 1 & Thekkumkara Surendran Nair Anish 2 &
Michael Hortsch 3,4 & Renuka Krishnapillai 1

Published online: 1 July 2019

# International Association of Medical Science Educators 2019

Abstract
Introduction Histology teaching in India and in other developing countries has not changed much over the past decades and has
not joined the global movement of using virtual microscopy (VM). Many factors may have contributed to this academic inertia—
including curricular requirements for traditional microscopy (TM) skills, assessments that are heavily based on TM, and unfa-
miliarity with modern technology among faculty, as well as infrastructural shortcomings. This study is aimed at overcoming these
roadblocks by using a blended approach combining VM with TM in a tradition-centered curricular setting.
Methods For validation of this approach, the authors conducted a non-randomized controlled trial with a crossover design on first
year medical students at the Government Medical College, Thiruvananthapuram, India. Examination scores and responses of a
student group taught with VM as an adjunct to TM were compared with a student group taught with TM only.
Results The test group had significantly better results when compared to the control group for knowledge-based tests (p = 0.012;
analysis of co-variance) and for an unannounced visual-based test conducted 1 month later (p = 0.001; Mann-Whitney U test).
Feedback collected from students showed highly favorable responses to the use of VM for teaching histology.
Conclusion This study should encourage Indian medical colleges and schools in other developing countries to start using VM as a
supplementary approach for their histology education programs. Furthermore, as the Medical Council of India recommends the
introduction of new competency-based integrated curriculum in India starting in 2019, the use of VM may facilitate more
effective learning in the new scenario.
Trial Registration CTRI/2018/04/012928

Keywords Histology education . Indian medical education . Virtual microscopy . Competency-based medical education . Low-
and middle-income countries . Technology-enhanced learning

Electronic supplementary material The online version of this article Introduction

(https://doi.org/10.1007/s40670-019-00759-5) contains supplementary
material, which is available to authorized users.
The introduction of modern didactic approaches and e-
* Doris George Yohannan learning technologies that is transforming medical education
dorisgeorge54@gmail.com in North America and Europe has mostly bypassed the under-
developed and developing parts of the world [1–5]. The med-
1
Department of Anatomy, Government Medical College,
ical education system in countries like India is often rigid and
Thiruvananthapuram, Kerala, India based on traditional methods of instruction [6]. This lack of
2
Department of Community Medicine, Government Medical College,
change has been attributed to economic constraints, as well as
Thiruvananthapuram, Kerala, India resistance by the educational establishment to modifications
3
Department of Cell and Developmental Biology, University of
of the status quo. New approaches are needed in countries like
Michigan Medical School, Ann Arbor, MI, USA India to catch up with the more industrialized countries at the
4
Department of Learning Health Sciences, University of Michigan
technological as well as educational level. As described in this
Medical School, Ann Arbor, MI, USA manuscript, the authors suggest a stepwise model of
804
introducing an advanced e-learning technology, virtual mi-
croscopy, into the histology component of a representative
Indian medical school curriculum.
The Indian medical education system is one of the biggest
in the world [7–9]. It produces physicians, who serve India, as
well as many other countries, including the USA and the UK
[10]. This implies that changes in the Indian medical educa-
tion will have a global impact [10]. However, the medical
curriculum in India has not changed much over the past
20 years [11]. The curriculum is deeply rooted in the tradition-
al Western model of medical education and is teacher-cen-
tered, discipline-specific, and lecture-based, similar to many
other countries in Asia and Africa [5]. Solanki and Kashyap
[9] describe the Indian medical curriculum as “static and tra-
ditional” and the assessment system as “poor,” relying heavily
on conventional didactic methods like large classroom lec-
tures and usually lacking innovative approaches. The
Medical Council of India (MCI) regulates the entire medical
education of the country [10]. The MCI prescribes the overall
curriculum with the details of teaching and assessment being
left to the individual universities [6]. Any significant reforms
in the curriculum must be approved by the MCI [6, 10]. The
MCI accreditation process values classroom, laboratory facil-
ities, human resources, and conventional equipment and in-
struments with less consideration for the quality of medical
education, teaching methods, or its outcomes [10, 12].
Recently, the MCI has announced the implementation of
the new competency-based undergraduate curriculum for the
Indian medical graduate starting in August 2019 [13–16]. The
new curriculum is supposed to encourage integrated education
by de-emphasizing compartmentalization of various disci-
plines. The new system will demand the basic subjects like
histology to be taught in a contemporary, integrated, function-
ally, and clinically relevant manner using newer teaching
methods [7, 17]. However, at present, the teaching approach
and technique used for histology are inadequate to deliver the
content effectively. Hence, there is a void between the demand
of the upcoming curriculum and the current state of medical
education in India.
Limitations in Teaching Histology in India and Other
Developing Countries
Worldwide, histology is an important component of health
professional training. It teaches medical students the cellular
and tissue architecture of the human body, enabling them to
correlate microstructure with functional aspects. Historically,
histology has been taught using optical microscopes and
stained tissue glass slides [18, 19]. In India, as well as in many
other resource-constrained countries, traditional microscopy
(TM) still remains the popular modus of teaching histology
[20, 21]. However, maintaining quality glass slides and mi-
croscopes creates a considerable financial strain. If
Med.Sci.Educ. (2019) 29:803–817
maintenance and replacement of slides is not done on a regular
basis, faculty and students often have to use sub-standard
quality learning resources. In addition, poor faculty to student
ratio may also affect the teacher-student interaction [2, 22].
Histology education is also threatened by the universal trend
of allocating less time in the preclinical curriculum to teaching
microanatomy [23, 24]. Many students end up memorizing
visual information without seeing the features that they need
to analyze for a deeper functional insight. As a result, they
may remain grossly ignorant of the importance of microanat-
omy for understanding health and disease.
In addition, Indian students are encouraged to study the slides
individually with minimal opportunity for group learning.
Material for self-study or review outside the classroom is usually
not provided. Laptop/computers or internet connection and Wi-
Fi are not available in the histology laboratory, nor are they
permitted. The use of e-learning and blended learning in medical
education is very minimal in India [4], with none available for
histology. Facilities in the histology laboratories of most medical
colleges are limited to the minimum requirements mandated by
the MCI, which includes laboratory area, seating for students,
microscopes, reagents, and equipment for preparing slides [12].
Practical skills that are taught are confined to mere identification
of slides and drawing of diagrams. Problem-based learning for
teaching anatomy or histology is not generally used or at best is
in its infancy [8, 25]. Assessments are also in a traditional format,
including brief answer questions. Analytical or skills assessment
is rarely performed [6]. Nevertheless, there have been encourag-
ing sporadic attempts in India to modify the traditional methods
of teaching histology and gross anatomy [26, 27].
Virtual Microscopy in the Indian Medical Curriculum
Setting
Virtual microscopy (VM) is a technique where histological
tissue slides are electronically scanned at high resolution and
combined into high-quality digital files which can be explored
using a computer with a digital viewer program [28, 29].
Many of the problems faced by the use of TM are alleviated
to some extent by the introduction of VM. However, from a
global perspective, the impact of VM is rather uneven. The
merits of this technology are well-documented [18, 29–33]
and are mostly enjoyed in developed countries. Digitizing
slides into high-quality digital files involves high costs and
requires technical expertise [34], which limits the introduction
of VM at institutions in developing countries. Though some
medical schools, for example, the University of Michigan [35]
and the University of Iowa [36], have shared their virtual slide
file collections, the considerable size of the VM files, and the
requirements for high-speed Internet access, local Wi-Fi, and
the availability of computers for all learners remain road-
blocks in developing countries [3]. The introduction of the
Virtual Microscopy Database (VMD) by the American
Med.Sci.Educ. (2019) 29:803–817
Association of Anatomists has opened the door for new op-
portunities to advance histology and pathology education
worldwide [34, 37]. This has brought histology teaching using
VM one step closer to reality in both developing and under-
developed countries.
The impact of including VM-based instruction into a cur-
riculum as traditional as the Indian system is not well-docu-
mented. This information is critical to ensure that this new
instructional method is sensitive to the curricular needs of
the Indian medical education context [38], ensuring its feasi-
bility and effectiveness. Although limited studies based on the
use of some form of digital histology have been published [21,
39–41], to the best knowledge of the authors, fully functional
VM-enabled histology laboratories and teaching modules are
currently not used at any medical college in India. Instituting
this new technology at Indian medical schools faces several
major hurdles. The first obstacle is to introduce VM into an
environment that stresses the use of TM. Also, the assessment
system depends heavily on students’ experience of using op-
tical microscopes and on drawing diagrams. The second hur-
dle is the technical and financial difficulty of setting up virtual
histology laboratories. The procurement of funds to install the
necessary infrastructure may be out of reach for many emerg-
ing medical colleges in India and other developing countries.
Moreover, several faculty, teaching assistants, and administra-
tors are unfamiliar with this technology and are hesitant and
resistant to installing costly computer equipment in histology
laboratories.
These types of curricular and infrastructural impediments
and prejudices preclude a complete one-step transition from
the traditional histology laboratory teaching to VM instruction
as has happened at many Western medical schools [32, 42,
43]. It should also be noted that many Indian medical gradu-
ates are committed to serving the poor and underprivileged in
remote locations of the country where doctors need to handle
or supervise the use of microscopes. Therefore, operating a
regular optical microscope is still a desirable skill in the Indian
academic and professional setting and should not be
abandoned.
Taking all these factors into account, the authors hypothe-
sized that a blended approach of using both VM and TM that
is based on scientific evidence may be an appropriate method
of introducing this new technology at an Indian medical col-
lege, at least during the initial phase of medical student edu-
cation. VM can be seen as a supplementary teaching tool, with
TM remaining the predominant learning modus in the histol-
ogy laboratory. The aim of this study, which was designed by
Government Medical College, Thiruvananthapuram (GMCT)
faculty in cooperation with a faculty member of the University
of Michigan Medical School in the United States (M.H.), was
to test the effectiveness of adding VM demonstrations along
with TM in teaching histology to first year medical students at
GMCT and to validate this approach.
805
Materials and Methods
Ethical Issues and Consent
This study was approved by the Human Ethics
Committee (HEC)/Institutional Review Board of
GMCT: HEC.No.04/14/2018/MCT dated 23.02.2018.
This study was also registered under the Clinical Trial
Registry of India (as per the direction of the HEC,
GMCT): CTRI/2018/04/012928. Written and informed
consent was obtained from all study participants. They
were clearly informed that there is no compulsion at all
to take part in the study.
Histology Syllabus, Study Material, and Assessment
at the Kerala University of Health Sciences
In the state of Kerala, the Kerala University of Health Sciences
(KUHS) conducts the graduate medical education, Bachelor
of Medicine and Bachelor of Surgery (MBBS) course at the
33 affiliated medical colleges, including the Government
Medical College at Thiruvananthapuram (GMCT), the school
where the study was conducted.
As per the syllabus of the KUHS [44], the theoretical as-
pects of histology are taught using didactic lectures (15 lecture
hours for general histology and approximately 20 lecture
hours for organ system histology). The practical aspects of
histology are taught using optical microscopes and tissue
slides (60 h). The study material suggested by the KUHS
University is Textbook of Human Histology by Inderbir
Singh [45]. The reference textbooks are Di Fiore’s Atlas of
Histology [46], Bailey’s Textbook of Histology [47], and
Textbook of Human Histology by Gunasegaran [48]. Six hun-
dred fifty teaching hours are reserved for the anatomical sci-
ences and histology is taught as a sub-component of anatomy
during the first year (phase 1) of MBBS course.
Assessment of a student’s knowledge of anatomy en-
compasses an assessment of gross anatomy, embryology,
histology, and genetics. The major share of marks (80%
of the total) for the assessment is determined by “external”
or university-based examinations, conducted uniformly in
all medical colleges affiliated to the university. “Internal”
or medical college-based examinations determine the re-
maining 20% of marks [10, 12]. These examinations are
summative and comprise theoretical as well as practical
skill assessment. The total marks required for a pass is
50% of the maximum marks. Students need to pass the
phase 1 examination to proceed to phase 2 of MBBS.
Mark distribution for anatomy assessment as prescribed
by the KUHS [44] is added as Supplementary Material
S1. Out of the total marks for anatomy assessment, the
histology component comprises roughly 35% (practical)
and 10% (theory).
806
Teaching Schedule for Histology at Government
Medical College in Thiruvananthapuram
Histology teaching at GMCT is subdivided into short topics
featuring two or three slides (e.g., testis and epididymis; fun-
dus and pylorus of the stomach). The chronologic sequence of
taught slide topics at GMCT is
& General histology: epithelium, connective tissue, carti-
lage, bone, muscle, nervous tissue, blood vessels, lym-
phoid tissues, skin, placenta, umbilical cord, mammary
gland.
& Systemic histology: respiratory system, endocrine system,
central nervous system, cornea, retina, salivary glands,
tongue, gastro-intestinal tract, liver, gall bladder, urinary
system and male and female reproductive system.
Practical sessions are conducted every week (for a batch of
50 students per day, covering 200 students in 4 batches from
Monday to Thursday). Seating, microscopes, and light sources
are present to accommodate 50 students at a time. A preview
lecture introduces the topic about 1 week before a scheduled
practical session. During each practical session, the best TM
slides are projected using a slide projector system (MICAPS
Microscope Camera, Pro HDMI 1080 CC with HDMI output)
and an instructor summarizes the salient features of each slide
using chalkboard-drawn diagrams. Subsequently, students
study tissue sections using a traditional optical microscope.
A pair of slide sets, with best fields focused, is kept as a
common demonstration for all students (referred to as demon-
stration slides). Based on their observations, students draw
diagrams in their practical record books, which are evaluated
by a faculty member.
Fig. 1 Virtual microscopy (VM)
demonstration conducted with a
test group. The first author is
demonstrating VM on a computer
display interface
Med.Sci.Educ. (2019) 29:803–817
Virtual Microscopy
Virtual images were obtained from two external sources. The
first source was a virtual slide collection generously provided
on an external hard drive by the University of Michigan, USA.
Additional slides were sourced from various other collections
through the Virtual Microscopy Database [37]. The selected
image files were viewed using the Aperio Imagescope, ver-
sion 12.3 program from Leica Biosystems [49]. These images
were shared with groups of 50 students by displaying them on
a 55-in. full-HD high-quality LED display television (Model
LH-55 DM300 DX, Panasonic Corporation, Kadoma, Osaka,
Japan) available in the GMCT anatomy laboratory (Fig. 1).
Study Methodology and Student Demographics
The study was conducted as a non-randomized controlled trial
with crossover design (Fig. 2). The performance of the control
group, exposed to only traditional microscopy (TM), was
compared with that of the test group, who were exposed to a
virtual microscopy (VM) demonstration session followed by
the regular TM session. The performance was assessed with a
series of tests.
The study population consisted of 200 first year medical
students from the 2017 MBBS admission cohort at GMCT.
The mean age of the study participants was 19.4 (SD ± 1.48)
years. The student cohort consisted of 100 (50%) male and
100 (50%) female students. Every year, GMCT admits 200
first year medical students. This particular year incidentally
had equal number of male and female students.
Students were assigned by their name in alphabetic order
into four batches—A (roll numbers 1–50), B (51–100), C
(101–150), and D (151–200). This allowed smaller group
Med.Sci.Educ. (2019) 29:803–817
Fig. 2 Flowchart showing the design of the study
teaching. The batches were comparable in age, gender, and
academic performance (Supplementary Material S2). The in-
tervention was conducted during a 2-week period (testing
window) in the latter half of the second semester of the first
year MBBS course. The easier topic, colon and appendix, was
taught in the first week and the more challenging topic, liver
and gall bladder, was taught in the second week. Students had
already completed general histology and a number of systemic
histology laboratory sessions. Therefore, they had a good ex-
perience of histology by the time the study was conducted. For
the first week, batches B and D were in the test group and
batches A and C were in the control group. For the second
week, the batches were swapped—A and C were in the test
group and batches B and D were in the control group (Fig. 2).
Students who missed any practical session during the testing
window period were excluded from the knowledge-based test
807
(KBT) analysis of that week and visual-based test (VBT) con-
ducted 1 month later. Non-responders and partial responders
were also excluded from the analyses (see Tables 1 and 2).
Knowledge-Based Tests and Intervention Procedure
One week before the practical session, all 200 students
attended a preview lecture, which introduced the topic.
During the practical session, the investigators conducted a
pre-intervention KBT using a paper questionnaire with
multiple-choice questions (Supplementary Material S3 and
S4). Subsequently, the students were given the intervention,
either TM or VM + TM, according to the control or test group
to which they were assigned (Fig. 2).
For the test group, during the VM session, the instructor
conducted a short teaching session with demonstration of the
selected virtual slides (Fig. 1). For the first week VM session,
the virtual slide specimens that were demonstrated were two
for colon and one for appendix. For the second week VM
session, the virtual specimens demonstrated were liver (1
H&E stained, 1 Masson’s trichrome-stained slide, and 1 elec-
tron microscopy (EM) slide to demonstrate space of Disse,
Kupffer cell, liver sinusoids, bile canaliculi) and gall bladder
(1 slide). After the VM session, the test group was also
instructed on how to draw the diagrams, using a chalkboard.
Subsequently, they participated in the TM session.
For the control group, a short teaching session was con-
ducted using TM slides projected using a slide projector sys-
tem (MICAPS Microscope Camera, Pro HDMI 1080 CC with
HDMI output). They were also instructed using a chalkboard
on how to draw diagrams. Subsequently, they attended the
regular TM session.
Some deliberate steps were taken to make the two group
teaching sessions similar, except for the use of VM. The teach-
ing sessions in both the test group and the control group were
of 15 min each. Both sessions were performed by the lead
investigator. A script containing specific points to be taught
was followed by the lead investigator for both the sessions to
avoid any bias in the content. Content consistency was
reviewed by two independent co-investigators (A.M.O,
K.G.U.) before and during the session. The only difference
between the two types of sessions was the inclusion or ab-
sence of the VM demonstration.
During the practical TM session, the students had to view
histological glass slides using microscopes and produce draw-
ings of their observations, which were evaluated by a faculty
member. After the practical session, the same paper question-
naire was given as a post-intervention KBT to assess the stu-
dents’ knowledge (Supplementary Material S3 and S4). A
survey form was also provided to the students with ten state-
ments which they had to rate using a five-point Likert scale
(Supplementary Material S5). The first five statements ad-
dressed histology and TM sessions and had to be answered
808 Med.Sci.Educ. (2019) 29:803–817

Table 1 Pre-intervention and post-intervention scores of knowledge-based test with results of statistical analyses

Pre-intervention KBT Post-intervention KBT Paired t test comparing ANCOVA test comparing
Mean % score (± SD) Mean % score (± SD) pre-intervention with post-intervention KBT of
N N post-intervention KBT test with control group

Control group (TM only) 59.1 ± 20.4 82.5 ± 16.2 p < 0.001 p = 0.012
186a 186a
Test group (VM + TM) 58.3 ± 20.9 85.2 ± 12.8 p < 0.001
187a 187a

KBT knowledge-based test, SD standard deviation, N number of participants, TM traditional microscopy, VM virtual microscopy, ANCOVA analysis of
co-variance
a
Absent students and non-responders of KBT were excluded

by control and test groups. The next five statements, which simulate the traditional assessment system followed in India,
had to be answered by the test group participants only, rated which mainly tests didactic knowledge and fact memorization
the VM sessions. Bartlett’s test of sphericity was significant [6, 51]. The maximum score for the KBT (pre-and post-inter-
(Bartlett’s index = 369; p < 0.001) and the Kaiser-Meyer- vention) was 10 points.
Olkin (KMO) measure of sampling adequacy was 0.74, both
indicating that factor analysis may be done on the data.
Visual-Based Tests
Principal component analysis (with varimax rotation) yielded
two factors with eigenvalue more than 1. These factors could
Without prior notice, a visual-based test (VBT), to assess stu-
account for 48% of the variance in the ten variables. The
dents’ long-term visual and analytical skills, was performed
survey was designed by the principal investigator (D.G.Y)
1 month after the original training session. This test was de-
and two co-investigators (A.M.O. and K.G.U) based loosely
signed to assess higher levels of histology learning as defined
on two surveys from international publications [42, 50]. These
by Bloom’s taxonomy [52]. Histological images combined
were reviewed, edited, and refined multiple times by an expert
with open-ended questions were projected onto a screen for
panel consisting of 2 professors of anatomy (who have been
students to analyze and answer. The questions were aimed at
undergraduate and postgraduate examiners for anatomy for
assessing more practical aspects of histological image
various universities in India) and 3 associate professors of
interpretation—like how well students were able to describe
anatomy, using the Delphi technique. The questions were thus
a given field of an image and identify a structure and its func-
tailored for the academic environment in Indian medical edu-
tional significance (Supplementary Material S6). The maxi-
cation. It included questions on producing drawings, collabo-
mum score for the VBT was 21 points each for colon/
ration, and ability to identify detail. The internal reliability was
appendix and for liver/gall bladder.
tested and was found to be good (Cronbach’s alpha = 0.82).
Comments were also collected under two categories: com-
ments on the histology and TM sessions and comments about Scoring
VM.
The same sequence was repeated for the second topic after The answer key and scoring pattern of pre- and post-
the test and control groups were swapped (Fig. 2). Both the intervention KBT and VBT were set by the principal investi-
pre- and post-intervention KBT questions were identical and gator and two co-investigators. The scoring of the answer
designed to assess students’ didactic knowledge. This was to sheets was done by four faculty members who were not part

Table 2 Scores of visual-based test with results of statistical analyses

Cumulative VBT score Mann-Whitney U test comparing cumulative

Mean % score (± SD) VBT of test group with control group
N

Control group (TM only) 37.29 ± 17.62 p = 0.001

158a
Test group (VM + TM) 43.57 ± 18.57
162a

VBT visual-based test, SD standard deviation, N number of participants, TM traditional microscopy, VM virtual microscopy
a
Absent students during intervention and/or VBT were excluded
Med.Sci.Educ. (2019) 29:803–817
of the study and they were blinded regarding the test limb to
which the student was assigned.
Statistical Analysis of Data
Pre-intervention KBT and post-intervention KBT scores were
analyzed using paired t tests to evaluate whether the differ-
ences observed were statistically significant. As both scores
were of the same person before and after the intervention, with
a one to one relation, a paired t test was considered most
appropriate to evaluate the effect of the intervention. The
threshold for statistical significance, p value was set at 0.05.
The scores of post-intervention KBT in test and control groups
were compared using an analysis of co-variance test to ac-
count for the influence of the uncontrolled independent
variables.
A Kolmogorov-Smirnov test revealed that the VBT scores
were not normally distributed and hence a non-parametric test
was considered appropriate for comparing these scores. An
independent sample Mann-Whitney U test was conducted on
the VBT scores to compare test and control group. The SPSS
statistical package, version 20 for Windows (IBM
Corporation, Armonk NY), and the GraphPad Prism, version
7 (GraphPad Software, San Diego CA) software program,
were used respectively for statistical analysis and graph
generation.
Results
Cumulatively, 93.3% (373/400) of students attended the KBT
and filled out the survey forms. Eighty percent (320/400) of
students participated in the VBT conducted 1 month later.
(Please note that the denominator is cumulative over
2 weeks—200 × 2 = 400; as the entire sample size was
swapped during the 2-week duration.) The KBT and VBT
(scores) were analyzed quantitatively and the survey re-
sponses and open comments were analyzed using qualitative
methods.
Knowledge-Based Test and Visual-Based Test Scores
KBT scores improved with both types of interventions
(Table 1). A paired t test indicated that the histology knowl-
edge of the students of both control and test groups signifi-
cantly improved, regardless of their experimental group as-
signment (p < 0.001; Table 1). VM + TM yielded a signifi-
cantly better learning outcome than the TM only modality.
Analysis of co-variance test compared the two instructional
procedures by taking into account the influence of the uncon-
trolled independent variables (pre-intervention scores, batch
faculty, and clustering of good performers or poor
performers in a group) that may have influenced the post-
809
intervention KBT scores. It found significant difference be-
tween the test and control groups (p = 0.012; Table 1), though
with a small effect size (Cohen’s d = 0.19). There was a sig-
nificant improvement in the VBT score of the test group when
compared to the control group (p = 0.001; Mann-Whitney U
test) with a medium effect size (Cohen’s d = 0.35) (Table 2).
Survey Responses on Histology and Traditional
Microscopy
Of the 200 students, 180 returned the survey sheets after the
first week intervention, whereas after the second week inter-
vention, 193 students responded. Combining the two, 373
responses were obtained. Nearly half of the students (48.4%)
agreed that histology is understood well by them, the rest were
either neutral (34.2%) or disagreed (17.1%). When students
were asked whether drawing the histological images helped
them to remember the features of the slides, 76.2% agreed.
When they were asked whether they could identify all struc-
tures they had learned using TM, a majority of 61.1% an-
swered “NO.” A good proportion of students (48.4%) report-
ed that it was difficult for them to point out specific histolog-
ical features and discuss them with peers or faculty, while
using TM alone. Only 38 students (10.1%) agreed that TM
could clarify histological concepts (Fig. 3).
Survey Responses on Virtual Microscopy
Nearly all students responded, “YES” (98.9%), when asked
whether VM made them understand histology better than TM.
When students were asked whether VM enabled them to use
traditional microscopy better, 85.1% said “YES,” 11.6% were
neutral, and 6% disagreed. To the question whether they could
point to a specific detail of a virtual slide and discuss it with
peers or faculty, 88.3% of students responded positively.
Students were also asked to comment on the statement—“I
feel I can draw diagrams better after I saw virtual microsco-
py”—88.9% agreed, 10% were neutral. Almost 9 out of 10
students agreed that they preferred VM for viewing a histolo-
gy slide (Fig. 3).
Response on the Learning Experience of That Day
Students’ opinions about how they felt about that day’s learn-
ing experience were also collected using a 5-point Likert-
based response scale (see page 2 of Supplementary Material
S5). The mean ± standard deviations of the responses of the
students were 4.48 ± 0.53 for the test group and 3.73 ± 0.64
for the control group. [When determining the mean, the rating
scale was 1 = very poor; 2 = poor; 3 = neither good nor poor; 4
= good; 5 = very good; n is 186 (control) and 187 (test); the
numbers were cumulative of 2 weeks.]
810 Med.Sci.Educ. (2019) 29:803–817

Fig. 3 Student responses of the

10 questions presented to them in
a survey questionnaire. The first 5
questions addressed histology and
traditional microscopy. The next 5
questions addressed virtual
microscopy. The responses are
illustrated on a bar graph with
bars representing mean values (±
SD). The mean values are typed
in figures. Number of responses,
n = 373 for statements 1 through 5
(control and test group
participants); 187 for statements 6
through 10 (test group
participants only)

Students’ Perspectives seemed to like were “zooming of slides,” clarity, orientation

Students were asked to provide open, non-compulsory com-
ments on histology and TM, as well as virtual microscopy. For
the analysis of the survey responses, grounded theory using
“list and sort” method was applied to generate several themes
from their responses (Tables 3 and 4).
Many students did favor the use of TM (theme 1 in
Table 3), though some admitted that it was difficult to com-
prehend. Variability of the glass slides was something per-
ceived as good by many students (theme 1 in Table 3).
Many students commented on difficulties with using tradition-
al slides, including slide and microscope quality (theme 2 in
Table 3). One student suggested to provide accurate slide pic-
tures for revision whenever needed (theme 3). In theme 4, a
few students suggested issues they had with TM slides while
drawing histology diagrams (slides and pictures seem to be
totally different). One student suggested displaying the slides
that are used by the department to conduct examinations
(theme 5). A student suggested allotting more time for practi-
cal histology. Another student suggested combining the theory
and laboratory sessions (theme 6).
There was an overwhelming response from the students
favoring the use of VM. The features of VM which they
of tissue, more memorable for a longer time, detail, high res-
olution, and hence better understanding (theme 1 in Table 4).
Many students suggested to include VM demonstrations for
all laboratory sessions. One student commented that drawing
histology diagrams seemed easier (theme 2 in Table 4). A few
students requested to conduct VM demonstrations of the
slides that had already been taught earlier in the academic year
(theme 3). One student expressed concern whether examina-
tions conducted by the university will have slides of this high
quality (theme 4). Four students mentioned the need for get-
ting access to VM slides for their individual review. They
suggested adding labels and annotations for this purpose
(theme 5). A few commented that VM could be included in
the preview lecture as well (theme 6). Two students suggested
a blended learning approach with a centralized VM display
and individual glass slides with TM for concurrent study
(theme 7).
Discussion
Over the past decades, the effectiveness of VM for teaching
histology has been demonstrated in many published reports
Med.Sci.Educ. (2019) 29:803–817
Table 3 Students’ responses
about histology and traditional Theme
microscopy (TM)
1. Favoring TM
2. Issues with traditional
slides
3. Need material for review
4. Concern about “drawing
diagrams”
5. Concern about
examinations
6. Change pattern of
laboratory schedule
TM traditional microscopy
[18, 22, 32, 33]. The primary aim of this project was not to
corroborate this evidence or to assess the benefits of VM over
TM. Rather, this work was undertaken to demonstrate the
feasibility of a stepwise strategy for introducing VM into the
educational environment of a developing country where a
traditional teaching and assessment system has been prevalent
for many years. Bleakley et al. argue that reflection is neces-
sary for ensuring that a new teaching method is suited for the
curricular background of a developing country, rather than
blindly adopting it under the assumption that “metropolitan
West is best” [38]. It is not surprising that the introduction of
VM will raise challenges, doubts, arguments, and cynical at-
titudes among many faculty members and the university lead-
ership, who are used to a more traditional style of teaching
histology. Based on the results of this study (test results, sur-
vey responses, and open comments) and their personal expe-
riences, the authors would like to discuss some of these chal-
lenges and propose a way forward for anatomy teachers in
India and other developing countries where similar roadblocks
811
Histology and traditional microscopy
• “The histology demonstration is conducted in such a way that we can understand the
slide. The demonstration is fine”
• “Histology demonstrations are not bad but very difficult to comprehend”
• “Slides of different quality were shown which were good.”
• “It was overall good”
• “The histology class was good. But if the virtual microscopy was included as in the
previous class we could have learned more. The last class with virtual microscopy was
way far better than this class.” (This student was in test group in 1st week and control
group in 2nd week)
• “Structures cannot be well distinguished in these traditional slides”
• “The slides we receive are quite different than those used for demonstrations.”
• “Provide better slides with most structures seen intact”
• “Slides that are given to us individually to focus under our own microscopes are of very
poor quality. In the slide of appendix, we could not even see lymphocytes. So the
quality of these slides should be improved.”
• “Slides that are given should be improved in quality”
• “Microscopes should be changed.”
• “Cannot identify the slides properly. Eg: Appendix slide in light microscope was similar
to that of large intestine. The lymphatic follicles were not seen clearly”
• “It would be better if teachers help the students build a 3D picture of the structure in their
mind”
• “Provide pictures/pdf of accurate microscopic slides to memorize/revise whenever
needed”
• “Sometime there is contradiction in what we are drawing and seeing. We are drawing
according to how our predecessor [peer who attended the practical before] has drawn.
Staining difficult to understand.”
• “Usual histology demonstrations are not much helpful to draw the diagram and
reference to a textbook is required”
• “Slides do not clearly convey idea of all the structures that we draw in diagrams”
• “Slides and the diagram in the record appears to be totally different”
• “Projection of examination slides would be better”
• “If the theory is taken during laboratory session, it will help a lot, because it will be
followed by seeing the slide and drawing the section. It will help us to learn properly”
• “Need a little more time.”
to innovation exist to overcome the resistance against the use
of e-learning technologies and to successfully introduce novel
educational approaches into a tradition-centered education
system.
The Challenges of Creating a Virtual Slide Collection
in a Resource-Constrained Environment
The standard technology for developing virtual slide
files, whole slide imaging, is exceedingly expensive
[34] and therefore out of reach for most institutions in
developing countries. In these countries, the need for
VM slides can be best addressed by collaborative part-
nerships, where digitization of slides is done in devel-
oped countries and then shared with medical schools in
developing countries [2]. Faculty members in resource-
constrained countries may also consider collaborations
to develop their own low-cost methods for digitizing
histology and pathology slides from their laboratories.
812 Med.Sci.Educ. (2019) 29:803–817

Table 4 Students’ responses about virtual microscopy (VM)

Theme Virtual microscopy

1. Favoring VM demonstrations • “100% satisfied with virtual microscopy.”

2. Drawing diagrams easier
3. Need to show topics already covered • “Can you please provide this [VM] for the previous histology classes also as a revision”
also in VM
4. About examinations
5. Need annotated VM slides for
individual review
6. Include VM in preview lecture
7. Blended learning
8. Issues with physical arrangements
• “Very helpful, far better than traditional microscopy”
• “The images will hopefully be in my memory for a longer time”
• “Zooming the slides makes the things to be better understood by the students.”
• “It [VM] helped me a lot to understand the basic histology
• “Great move! Better understanding.”
• “Should show virtual microscopy in all classes”
• “The structure can be seen much more clearly than traditional microscopy”
• “An excellent method of teaching as well as learning.”
“Please continue the virtual microscopy sessions, if possible. Extremely helpful. As the slides are very detailed, even the
smallest structure can be seen and understood easily”
• “Virtual microscopy gives the precise idea about a tissue, its orientation and a detailed idea about each cell. Traditional
microscopy used to give only a vague idea. It would be useful if this technology is done permanently in the histology
laboratory.”
• “A clear and high resolution demonstration. Is very helpful. Thank you.”
• “Seems very helpful and easier to understand. Drawing seems easier.”
• “Very good. Should have implemented it earlier for a better idea about histology “
• “Please show the already taken slides also. Really helpful”
• “I kindly request you to show other slides also in virtual microscopy”
• “Even though virtual microscopy helps to identify structures with layers distinctly and clearly, I am worried about exams
that whether such clarity be ensured then”
• “Labeled slides will be good to revise”
• “Virtual histology would be much more handy for individual revision if there were automated labeling for cells with brief
description when asked for”
• “Labeling of the parts is needed. Short details about the slide can be included”
• “If the structures are marked on the slide, it will be more helpful. Like, when the pointer moves to a particular cell and it
shows name of the cell and few details about it.”
• “It would be good if virtual histology is included in class-room preview lecture slides as well as in coming histology classes”
• “Can be used along with the lecture class”
• “I feel it would be better if the virtual histology slide are shown in preview class so that the minute details could be well seen
while taking the theory”
• “Rather than using the total duration of the class for drawing the slides, the first 15–20 min could be used along with a
centralized display of virtual microscopy along with individual slides to compare and understand the structure clearly (if
possible)”
• “Traditional and virtual microscopic techniques can be intermixed”
• “Learning with a lot of background noise is very difficult. Rather than a very open anatomy dissection hall, demonstration
room preferred. Sound clarity was very less and hard to understand. Need better audio system.”
• “A better sound system could be helpful. Placing the screen a little bit higher”
(A clear display system was available only in the anatomy dissection hall during the study. At present the demonstrations are
conducted in the histology laboratory.)

VM virtual microscopy

This approach has been effectively implemented by
some schools to create VM collections of their own
[3, 22, 42]. Whereas a Brazilian study reported the cre-
ation of digitized histology slides from its own histolo-
gy laboratory [53], other reports from Cambodia and the
Philippines relied on collaborative assistance from other
international institutions (Australia and the USA, respec-
tively) [3, 54]. The present work is also the result of a
collaborative effort between GMCT and an established
US university, the University of Michigan. These col-
laborations not only promote the exchange of ideas and
provide resources, but also expose the partners from the
developing countries to the advanced standards of med-
ical education used in the more developed parts of the
world. As an alternative, online databases for VM im-
ages, such as the Virtual Microscopy Database (VMD),
also address this need [34, 37] and some of the images
used in this study were retrieved from the VMD.
The Limited Availability of an Advanced Information
Technology Infrastructure
The lack of an advanced technology-driven teaching environ-
ment may not pose a roadblock in most developed countries,
but is undoubtedly a significant hurdle in the Indian system
and for most universities in other developing and under-
developed countries [55]. Probably the most significant chal-
lenge is to make computers available in laboratories [55] for
individual access by students and ideally also off-campus with
a high-speed internet connection, so that students can access
the VM slides whenever and wherever they desire. The stu-
dents’ survey responses in the current study mention this issue
(see theme 3 in Table 3 and theme 5 in Table 4). When the
University of South Carolina made a full transition to a VM-
based histology teaching in 2001, it was supported by the
establishment of a technology-enhanced curriculum where
students were required to purchase their own laptops [42]. A
Med.Sci.Educ. (2019) 29:803–817
wireless network was installed covering the entire campus and
histology examinations also made use of VM slides [42].
None of these changes are currently feasible for most Indian
medical colleges. Moreover, students admitted to Indian med-
ical colleges usually come from diverse economic strata and
the purchase of individually owned computers is economical-
ly out of reach for a majority of them.
In addition, a dedicated support unit, which handles informa-
tion technology (IT) for academics, is nonexistent at most med-
ical colleges in India. Therefore, the authors propose a compro-
mise of adopting a long-term, stepwise strategy, which initially
involves a faculty-guided VM demonstration to groups of stu-
dents. After the procurement of servers, IT support, and com-
puter facilities in histology laboratories, this might lead to a
small group “self-learning system,” where 4–5 students can
learn to manipulate VM slides at a shared computer station.
Globally, some institutions, mostly in developed countries,
have transitioned to virtual microscopy in one step, whereas
others have implemented a more gradual transition [56].
Although e-learning and computer-assisted learning is gener-
ally lagging behind in low- and middle-income countries [4],
over the last decades, there have been encouraging reports
from countries like Argentina [1], Brazil [53], and Cambodia
[54] about the use of modern technologies for medical educa-
tion, including one about using digital microscopy for teach-
ing pathology [3].
Should Virtual Microscopy Completely Replace
Traditional Microscopes?
Pratt pondered this interesting question in her paper [57], con-
cluding that a blended approach of teaching histology would
be most apt in the scenario of her medical school—the West
Virginia School of Osteopathic Medicine, USA. She stated
that the aims of histology education should have a focus on
enabling the student to interpret histological images and cor-
relate cellular structure with physiological function. Her report
also indicates that excluding TM completely from histology
has the danger of making physicians less equipped for medical
practice, especially in rural areas. Based on her survey report,
the West Virginia School of Osteopathic Medicine adopted a
blended approach by supplementing traditional microscopes
with virtual microscopy, which can be accessed by all preclin-
ical students with their laptops [57].
In addition, there are other arguments against the complete
elimination of TM. According to a recent survey among histo-
pathologists in the USA and Canada, where VM is very popular,
many respondents were not in favor of using VM over TM for
actual histopathological diagnosis [58]. Some studies on the
pedagogical advantage of the VM-only format have also raised
concerns. At the University of Turku, Finland, a comparison
between the students using VM (experimental group) and TM
(historical controls) reported superior results for VM when
813
learning normal histology and in contrast superior results for
TM when learning abnormal or pathological histology [59].
Wilson et al. in their meta-analysis also reported that the use
of VM images had a small positive impact on students’ histol-
ogy performance when compared to TM [33].
Considering the needs in developing countries like India
and opting to replace TM completely, a blended approach
similar to that used in the current study may provide a more
balanced compromise. Blended learning will utilize the ad-
vantages of VM-enabled instruction (initial phase) or VM-
enabled small group learning (later phase), while retaining
the opportunity to learn operating optical microscopes and
the analysis of histological glass slides.
Does It Make Sense to Introduce Virtual Microscopy
into the Indian Educational System?
Taking the needs of the current Indian curriculum and health
care system into consideration, the authors had hypothesized
that adding VM demonstrations would improve the histology
performance of students in several aspects. As outlined in this
manuscript, a number of improvements in students’ academic
performance were documented or noticed by the teaching staff.
Students used the traditional microscopes much better and
identified structures on their own. This suggests a synergetic
effect of the two teaching modalities resulting in an improved
learning outcome. In their responses (statement 8 in Fig. 3),
students felt that the VM demonstrations also helped them to
better communicate with peers and faculty about specific re-
gions of a slide. This suggests an increased interest in the
subject and in small group learning. A similar observation
was reported in a previous study [50].
An overview thumbnail image was available in the VM
slide viewing software, which provided orientation for stu-
dents, when viewing a slide at high magnification [18, 32]
and making the navigation to a particular region of interest
easier. This aspect is important when learning histology and is
difficult when using TM. Students in the present study men-
tioned that “zooming” and navigation of the VM slides in-
stantly conveyed its orientation (theme 1 in Table 4).
Some students felt that drawing histology diagrams was
easier after the VM demonstration (theme 2 in Table 4;
statement 9 in Fig. 3). As mentioned earlier, the creation of
histology drawings is an essential part of the assessment sys-
tem in India. Students’ survey responses indicate that drawing
histology diagrams helped them to remember the material
better (statement 2 in Fig. 3), which has been mentioned by
previous studies [60–62]. Students appreciated the details of
the slides, their clarity, and felt that they would retain the
content for a longer time (theme 1 in Table 4). The authors
suspect that the higher quality of the selected VM images may
be an important factor in this student response.
814
During the 2nd week of the study, the authors used an
electron microscopy VM slide for teaching the ultra-
structure of the liver (space of Disse, Kupffer cells, bile can-
aliculi) to the test group. Currently, at the authors’ institution,
there are no opportunities of using electron microscopy im-
ages or histology slides with special staining methods (e.g.,
immuno-histochemistry, chrome alum-phloxine stain for the
endocrine pancreas). VM can help with introducing these al-
ternative imaging approaches.
Though not supported by direct observations in the present
study, the authors foresee some additional advantages of
implementing VM in the Indian system. With a more devel-
oped IT infrastructure, VM will allow students better access of
viewing of high-quality images. In the current system, there is
no ability for students to review slides unless the faculty offers
such an opportunity. At the authors’ institution, this is only
provided briefly before scheduled examinations. There is an
obvious demand for access of histological image material for
review purposes at the students’ own convenience (theme 3 in
Table 3; theme 5 in Table 4). Studies at schools where VM
technology is ubiquitously available have shown that many
students access VM slides outside of lab hours [19, 63]. A
recent study indicated an increased access of VM slides by
students, specifically during the week before the scheduled
examination [64].
As India joins other Asian countries in modernizing its
medical curriculum by converting it to an integrated format
[5, 13, 65], VM also has the potential of supporting students’
learning success. Correlating histology with allied disciplines
like histopathology has been shown to enhance students’ un-
derstanding how normal and abnormal tissue structures are
related to their functionality and will help linking concepts
between different disciplines [18, 30, 66]. This will help in
orienting histology education to a case-based and clinical ap-
proach in future.
Can Virtual Microscopy Also Affect Students’
Performance in Traditional Histology Examinations?
Considering the dependence on traditional microscopy for the
histology assessment at Indian medical schools, it was a gen-
uine area of concern that a VM experience might have no or a
negative impact on students’ examination performance.
However, the higher KBT scores (p = 0.012; analysis of co-
variance) and the higher VBT scores (p = 0.001; Mann-
Whitney U test) for the test group indicate that even a 2-
week “short span” of VM demonstration was able to create a
small (KBT) and a medium (VBT) statistically significant rise
in performance scores. The performance improved not only
for the KBT, which assessed basic-level didactic questions,
but also for analytically and visually oriented questions in
VBT. The 2017 MBBS admission cohort passed their first
year MBBS examinations (phase 1) and GMCT students had
Med.Sci.Educ. (2019) 29:803–817
the highest pass proportion (94%) for a single medical college
at the entire KUHS University consisting of 33 medical col-
leges. It would be unreasonable to attribute this success to the
short 2-week trial session, but the limited introduction of VM
apparently did not harm students’ performance in this exam-
ination. The high quality of the VM image material might also
have been helpful in raising students’ understanding of the
tissue/organ structure-function relationship.
Most studies describing improvements of students’ aca-
demic performance when including VM originated from the
USA, Europe, China, and Australia [33, 67]. Only three pa-
pers report on the experimental use of VM for histology edu-
cation in India, two on dental histology and one on medical
histology, all reporting improved scores for learners using VM
compared to TM [39–41]. A recent publication by Juneja and
Juneja stressed the need for using VM in teaching dental pa-
thology at Indian dental schools and discussed the barriers of
making this transition, including the lack of acceptance by
senior pathology faculty [20]. The decision whether to adopt
VM for the teaching of histology and pathology should be
made based on scientific evidence and with the understanding
that this choice may affect the education of future generations
of physicians.
Educating Indian Faculty, University Leadership,
Curriculum Experts, and Policy Makers
Probably the most significant barrier besides economic strains
and technological shortcomings is the obstacle of “unfamiliar-
ity” and “prejudices” towards technology in the Indian medi-
cal education establishment. This problem could be addressed
by VM technical workshops for postgraduate students of anat-
omy and for faculty members and by demonstrating the merits
and limitations of using VM. Curriculum experts at the level
of the MCI and various universities should consider the stra-
tegic and economic feasibility issues of adopting VM as an
adjuvant to TM for all medical colleges in India. By moving
towards a technologically enhanced curriculum, it is hoped
that this will result in more significant changes in the Indian
medical education system. Many (not all) faculty members
involved in the intervention described in this manuscript felt
positive about the use of VM in teaching histology at their
school. One senior faculty member recently said, “I felt really
happy. Though I taught about it many times, it is the first time
I am seeing an intercalated disc in the cardiac muscle.”
Limitations of the Study
This study used only a small number of virtual slides during a
2-week instructional period. The test group and control group
were not randomized. But cross-over design in the methodol-
ogy and analysis of co-variance in the data analysis and a large
sample size should have eliminated confounding factors. The
Med.Sci.Educ. (2019) 29:803–817
responses of students to survey questions were collected twice
in a span of 2 weeks. Individual students may have changed
their answers for some questions during that time frame and
the analyses may not have addressed this possibility. The nov-
elty factor of the VM technology may have also affected the
student scores. Though all possible attempts were made to
equalize academic content for the test and control groups,
there might have been an un-avoidable extra exposure with
study material (virtual slides) for the test group compared to
the control group, which may have also influenced the out-
come. Students were not able to view virtual histology slides
as an alternative to traditional microscopy. This was due to
infrastructural and time limitations.
Conclusions
There is an unfortunate history of a “static” and “traditional”
medical curriculum in India and in many other developing
countries that has been pervasive for many decades [1, 9].
The results of the present study should encourage the Indian
university faculty and leadership to adopt changes more boldly.
Based on the encouraging results of the current study of intro-
ducing VM in a stepwise manner as part of a blended instruc-
tional approach with traditional microscopy, the authors man-
aged to convince the department leadership at GMCT with
support from the majority of faculty to introduce VM demon-
strations for the entire histology component taught to the 2018
MBBS admission cohort. In the future, after the procurement of
an IT infrastructure, the authors envision a progressive conver-
sion to a mostly “virtual histology laboratory.” This approach
can be duplicated at other medical colleges across India and
other developing countries. However, faculty and postgraduate
students also need to be trained on using the virtual slides and
teachers need to understand how a student sees and interprets a
histological image using the new technology.
“Change does not change tradition. It strengthens it.
Change is a challenge and an opportunity, not a threat.”
Prince Philip of England [68]
Acknowledgments The authors would like to thank the students of 2017
MBBS admission cohort at GMCT for taking part in this study. The
authors are grateful to the department and institutional authorities who
provided their support for this work. The authors gratefully acknowledge
Dr. P.S. Indu MD, PhD, Professor and Head of Community Medicine,
GMCT, for her valuable guidance throughout this study. The authors also
thank the postgraduate students in the Department of Anatomy, GMCT,
for their enormous support during the course of this study. The authors are
indebted to the editor and anonymous reviewers for their insightful com-
ments which were extremely helpful in revising and improving the orig-
inal manuscript.
Funding This study was funded by the State Board of Medical Research,
Directorate of Medical Education, Government of Kerala. The grant was
815
issued by the Principal of GMCT: Order No.A2-SBMR (2017-2018)/15/
2182/2017/MCT dated 15.05.2018.
Compliance with Ethical Standards All procedures per-
formed in studies involving human participants were in accordance with
the ethical standards of the institutional and/or national research commit-
tee and with the 1964 Helsinki declaration and its later amendments or
comparable ethical standards.
Conflict of Interest The authors declare that there is no conflict of
interest.
References
1. Carrera LI, Tellez TE, D'ottavio AE. Implementing a problem-
based learning curriculum in an Argentinean medical school: im-
plications for developing countries. Acad Med. 2003;78(8):798–
801.
2. Fontelo P, DiNino E, Johansen K, Khan A, Ackerman M, editors.
Virtual microscopy: potential applications in medical education and
telemedicine in countries with developing economies. System
Sciences, 2005. HICSS'05. Proceedings of the 38th Annual
Hawaii International Conference on; 2005: IEEE.
3. Fontelo P, Faustorilla J, Gavino A, Marcelo A. Digital pathology–
implementation challenges in low-resource countries. Anal Cell
Pathol. 2012;35(1):31–6.
4. Frehywot S, Vovides Y, Talib Z, Mikhail N, Ross H, Wohltjen H,
et al. E-learning in medical education in resource constrained low-
and middle-income countries. Hum Resour Health. 2013;11(1):4.
5. Lam TP, Lam YYB. Medical education reform: the Asian experi-
ence. Acad Med. 2009;84(9):1313–7.
6. Sood R. Medical education in India. Med Teach. 2008;30(6):585–
91.
7. MCI. Vision 2015. Medical Council of India, New Delhi. 2011.
https://old.mciindia.org/tools/announcement/MCI_booklet.pdf.
Accessed 20 Jan 2019.
8. Jacob TG. History of teaching anatomy in India: from ancient to
modern times. Anat Sci Educ. 2013;6(5):351–8.
9. Solanki A, Kashyap S. Medical education in India: current chal-
lenges and the way forward. Med Teach. 2014;36(12):1027–31.
10. Supe A, Burdick WP. Challenges and issues in medical education in
India. Acad Med. 2006;81(12):1076–80.
11. MCI. Regulations on graduate medical education, 1997 (Amended
up to May 2018). New Delhi, India; 1997. https://old.mciindia.org/
Rules-and-Regulation/GME_REGULATIONS.pdf. Accessed 20
Jan 2019.
12. MCI. Minimum standard requirements for the medical college for
200 admissions annually. Regulations, 1999 (Amended – up to
January 2018). New Delhi, India. 1999. https://old.mciindia.org//
for-colleges/STANDARD-FOR-200.pdf. Accessed 21 Jan 2019.
13. Modi JN, Gupta P, Singh T. Competency-based medical education,
entrustment and assessment. Indian Pediatr. 2015;52(5):413–20.
14. Herur A, Kolagi S. Competency-based medical education: need of
the hour: let’s do our bit…!! BLDE Univ J Health Sci. 2016;1(1):
59.
15. InformationDesk. Medical Council of India. Competency based
undergraduate curriculum for the Indian Medical Graduate. 2018.
https://old.mciindia.org/InformationDesk/ForColleges/
UGCurriculum.aspx. Accessed 20 Jan 2019.
16. Raju P. A new competency based curriculum for MBBS will be
introduced from 2019–20 In: The Financial Express | The Indian
Express [P] Ltd. The Indian Express [P] Ltd.; 2018. http://www.
expressbpd.com/healthcare/policy/a-new-competency-based-
816
curriculum-for-mbbs-will-be-introduced-from-2019-20/399595/.
Accessed 23 Jan 2019.
17. MCI. Competency based undergraduate curriculum for the Indian
medical graduate, vol. 1. 1st ed. New Delhi: India; 2018.
18. Paulsen FP, Eichhorn M, Bräuer L. Virtual microscopy—the future
of teaching histology in the medical curriculum? Ann Anat.
2010;192(6):378–82.
19. Triola MM, Holloway WJ. Enhanced virtual microscopy for col-
laborative education. BMC Med Educ. 2011;11(1):4.
20. Juneja S, Juneja M. Virtual digital pathology: the future is near.
Indian J Pathol Microbiol. 2017;60(2):306–7.
21. Shastri D, Anand A, Ravichandran D, Samraj T. Virtual microsco-
py: here to stay? Nat J Basic Med Sci. 2016;6(1):35–8.
22. Tian Y, Xiao W, Li C, Liu Y, Qin M, Wu Y, et al. Virtual microscopy
system at Chinese medical university: an assisted teaching platform
for promoting active learning and problem-solving skills. BMC
Med Educ. 2014;14(1):74.
23. Bloodgood RA, Ogilvie RW. Trends in histology laboratory teach-
ing in United States medical schools. Anat Rec. 2006;289B(5):
169–75.
24. Drake RL, McBride JM, Pawlina W. An update on the status of
anatomical sciences education in United States medical schools.
Anat Sci Educ. 2014;7(4):321–5.
25. Nayak S, Ramnarayan K, Somayaji N, Bairy KL. Teaching anato-
my in a problem-based learning (PBL) curriculum. Neuroanatomy.
2006;5:2–3.
26. Koshi R, Holla SJ, Chandi G. Introduction to histology through the
use of familiar objects: innovative teaching module. Clin Anat.
1997;10(5):333–6.
27. Chimmalgi M. Interactive lecture in the dissection hall:
transforming passive lecture into a dynamic learning experience.
Anat Sci Educ. 2018;12:191–9. https://doi.org/10.1002/ase.1803.
28. Gu J, Ogilvie RW. Virtual microscopy and virtual slides in teaching,
diagnosis, and research. 1st ed. Advances in pathology, microscopy
& molecular morphology. Boca Raton: CRC Press; 2005.
29. Dee FR, Meyerholz DK. Teaching medical pathology in the twenty-
first century: virtual microscopy applications. J Vet Med Educ.
2007;34(4):431–6.
30. Goldberg HR, Dintzis R. The positive impact of team-based virtual
microscopy on student learning in physiology and histology. Adv
Physiol Educ. 2007;31(3):261–5.
31. Dee FR. Virtual microscopy in pathology education. Hum Pathol.
2009;40(8):1112–21.
32. Mione S, Valcke M, Cornelissen M. Evaluation of virtual micros-
copy in medical histology teaching. Anat Sci Educ. 2013;6(5):307–
15.
33. Wilson AB, Taylor MA, Klein BA, Sugrue MK, Whipple EC,
Brokaw JJ. Meta-analysis and review of learner performance and
preference: virtual versus optical microscopy. Med Educ.
2016;50(4):428–40.
34. Lee LMJ, Goldman HM, Hortsch M. The virtual microscopy
database-sharing digital microscope images for research and edu-
cation. Anat Sci Educ. 2018;11:510–5. https://doi.org/10.1002/ase.
1774.
35. Michigan. Michigan histology and virtual microscopy learning re-
sources. Michigan Medical School, University of Michigan. 2018.
http://histology.medicine.umich.edu/full-slide-list. Accessed 22
Jan 2019.
36. Iowa. Iowa Virtual Slidebox. University of Iowa, Department of
Pathology. 2018. http://www.path.uiowa.edu/virtualslidebox/.
Accessed 21 Jan 2019.
37. VMD. Virtual Microscopy Database. American Association of
A n a t o m i s t s , B e t h e s d a , M D . 2 0 1 8 . h t t p : / / w w w.
virtualmicroscopydatabase.org. Accessed 22 Jan 2019.
38. Bleakley A, Brice J, Bligh J. Thinking the post-colonial in medical
education. Med Educ. 2008;42(3):266–70.
Med.Sci.Educ. (2019) 29:803–817
39. Raja S. Virtual microscopy as a teaching tool adjuvant to traditional
microscopy. Med Educ. 2010;44(11):1126.
40. Hande AH, Lohe VK, Chaudhary MS, Gawande MN, Patil SK,
Zade PR. Impact of virtual microscopy with conventional micros-
copy on student learning in dental histology. Dent Res J (Isfahan).
2017;14(2):111.
41. Chimmalgi M. 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. 2018;67(2):186–
92.
42. Blake CA, Lavoie HA, Millette CF. Teaching medical histology at
the University of South Carolina School of Medicine: transition to
virtual slides and virtual microscopes. Anat Rec. 2003;275B(1):
196–206.
43. Ostrin Z, Dushenkov V. Pulling the plug on microscopes in the
anatomy and physiology laboratory. HAPS Educ. 2017;21(2):
112–8. https://doi.org/10.21692/haps.2017.024.
44. KUHS. Syllabus for courses affiliated to the Kerala University of
Health Sciences. Bachelor of Medicine and Bachelor of Surgery.
Thrissur, Kerala, India. 2016. http://14.139.185.154/kuhs/images/
kerala/kuhs/syllabus/syllabus_new/medicine/ug/new_mbbs_16-
05-2018.pdf. Accessed 23 Jan 2019.
45. Vasudeva N, Mishra S. Inderbir Singh’s textbook of human histol-
ogy. 7th ed. New Delhi: Jaypee Brothers, Medical Publishers Pvt.
Limited; 2014.
46. Eroschenko VP. DiFiore’s atlas of histology with functional corre-
lations. 12th ed. Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins; 2013.
47. Copenhaver WM, Kelly DE, Wood RL. Bailey’s textbook of his-
tology. 17th ed. Baltimore: Williams & Wilkins; 1978.
48. Gunasegaran JP. Textbook of histology and practical guide. 2nd ed.
Gurgaon: Elsevier Health Sciences; 2014.
49. Leica. Aperio ImageScope. Leica Biosystems. 2018. https://www.
leicabiosystems.com/digital-pathology/manage/aperio-
imagescope/. Accessed 19 Jan 2019.
50. Braun MW, Kearns KD. Improved learning efficiency and in-
creased student collaboration through use of virtual microscopy in
the teaching of human pathology. Anat Sci Educ. 2008;1(6):240–6.
51. Sood R, Adkoli B. Medical education in India—problems and pros-
pects. J Indian Acad Clin Med. 2000;1(3):210–2.
52. Zaidi NB, Hwang C, Scott S, Stallard S, Purkiss J, Hortsch M.
Climbing Bloom’s taxonomy pyramid: lessons from a graduate
histology course. Anat Sci Educ. 2017;10(5):456–64.
53. Fonseca F-P, Santos-Silva A-R, Lopes M-A, de Almeida O-P,
Vargas P-A. Transition from glass to digital slide microscopy in
the teaching of oral pathology in a Brazilian dental school. Med
Oral Patol Oral Cir Bucal. 2015;20(1):e17.
54. Hayes JA, Ivanusic JJ, le Roux CM, Hatzopoulos K, Gonsalvez D,
Hong S, et al. Collaborative development of anatomy workshops
for medical and dental students in Cambodia. Anat Sci Educ.
2011;4(5):280–4.
55. Gukas ID. Global paradigm shift in medical education: issues of
concern for Africa. Med Teach. 2007;29(9–10):887–92.
56. Weaker FJ, Herbert DC. Transition of a dental histology course
from light to virtual microscopy. J Dent Educ. 2009;73(10):1213–
21.
57. Pratt RL. Are we throwing histology out with the microscope? A
look at histology from the physician’s perspective. Anat Sci Educ.
2009;2(5):205–9.
58. Nwizu NN, Owosho A, Ogbureke KUE. Emerging paradigm of
virtual-microscopy for histopathology diagnosis: survey of US
and Canadian oral pathology trainees. BDJ Open. 2017;3:17013.
https://doi.org/10.1038/bdjopen.2017.13.
59. Helle L, Nivala M, Kronqvist P. More technology, better learning
resources, better learning? Lessons from adopting virtual
Med.Sci.Educ. (2019) 29:803–817
microscopy in undergraduate medical education. Anat Sci Educ.
2013;6(2):73–80.
60. Balemans M, Kooloos JG, Donders ART, der Zee V, Catharina E.
Actual drawing of histological images improves knowledge reten-
tion. Anat Sci Educ. 2016;9(1):60–70.
61. Greene SJ. The use and effectiveness of interactive progressive
drawing in anatomy education. Anat Sci Educ. 2018;11:445–60.
https://doi.org/10.1002/ase.1784.
62. Reid S, Shapiro L, Louw G. How haptics and drawing enhance the
learning of anatomy. Anat Sci Educ. 2018;12:164–72. https://doi.
org/10.1002/ase.1807.
63. Ordi O, Bombí JA, Martínez A, Ramírez J, Alòs L, Saco A, et al.
Virtual microscopy in the undergraduate teaching of pathology. J
Pathol Inform. 2015;6:1.
64. Saco A, Bombi JA, Garcia A, Ramírez J, Ordi J. Current status of
whole-slide imaging in education. Pathobiology. 2016;83(2–3):79–
88.
817
65. Khalid B. The current status of medical education in the Gulf
Cooperation Council countries. Ann Saudi Med. 2008;28(2):83–8.
66. Kumar RK, Freeman B, Velan GM, De Permentier PJ. Integrating
histology and histopathology teaching in practical classes using
virtual slides. Anat Rec. 2006;289B(4):128–33.
67. Krippendorf BB, Lough J. Complete and rapid switch from light
microscopy to virtual microscopy for teaching medical histology.
Anat Rec. 2005;285B(1):19–25.
68. Hurley MH, Hanley D. Correctional administration and change
management. 1st ed. Boca Raton: CRC Press; 2010.
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