A Comparison Between Virtual and Conventional Microscopes in Health Science Education

Virtual microscopes are computer or web-based programs that enable users to visualize digital slides and mimic the experience of using a real light microscope. Traditional light microscopes have always been an essential teaching tool in health science education to observe and learn cell and tissue structures. However, studies comparing virtual and real light microscopes in education reported learners’ satisfaction with virtual microscopes regarding their usability, image quality, efficiency, and availability. Although the use of virtual or web-based microscopy is increasing, there is no equivalent decrease in the number of schools utilizing traditional microscopes. We conducted a scoping review to investigate the comparative impact of conventional and virtual microscopes on different aspects of learning. We report a relative effect of virtual and light microscopy on student performance, long-term knowledge retention, and satisfaction. Our results show that virtual microscopy is superior to traditional microscopes as a teaching tool in health science education. Further studies are needed on different learning components to guide the best use of virtual microscopy as a sole teaching tool for health care education.


Introduction
Traditional light microscopes have always been used for teaching tissue structures and microanatomy in health science education.Recent advancements in whole-slide imaging, virtual microscopes, digital slide viewers, and similar technologies show an immense possibility in education, with a potential to entirely substitute traditional light microscopes in many disciplines of health science education (Saco et al., 2016;Triola & Holloway, 2011).Virtual or web-based microscope refers to a computer or web-based program that enables users to mimic the experience of using a real light microscope.A virtual microscope allows users to view, navigate, and manipulate digital slides acquired from a camera-equipped microscope or a commercial digital slide scanning system (Triola & Holloway, 2011).The popularity and use of virtual microscopes are increasing throughout health professional education, especially in histology and pathology (Bloodgood & Ogilvie, 2006;Glatz-Krieger et al., 2006;Paulsen et al., 2010;Sharmin et al., 2021).Virtual microscopes improve the overall in-class teaching environment (Blake et al., 2003;Bloodgood & Ogilvie, 2006;Cotter, 2001;Kumar et al., 2004).Studies comparing virtual and real light microscopes in education found equal satisfaction from learners with the quality of image and usability while garnering greater satisfaction with the efficiency of learning and availability (Harris et al., 2001;Heidger et al., 2002;Kumar et al., 2004;Mills et al., 2007).Students' academic performances are improved or unaffected by virtual microscopy (Harris et al., 2001;Helle et al., 2013;Kumar et al., 2004).
One of the critical advantages of a web-based or virtual microscope over a traditional light microscope is its ubiquitous availability (Triola & Holloway, 2011).This technology allows users to view digital slides anytime and at any place in the world, outside the classroom.The traditional method of teaching microanatomy and tissue structure relies on a limited number of light microscopes and glass slides, which does not allow simultaneous observation by multiple learners, prevents interactive in-class discussions.As per Capela et al. (2010), these limitations attenuate student motivation.Virtual microscopes enable multiple users to view the digital slides on a larger screen, promoting interactive discussion and team-based learning (Triola & Holloway, 2011).Digital slides and virtual microscopes can also be excellent resources for teaching.Instructors can pre-annotate slides outside class time and embed digital slides or links to specific views in teaching notes (Harris et al., 2011).
Although virtual microscopes and other computer-based slide-viewers provide access to many great-quality rare slides, they require computers, active Internet, or other smart devices, which may not be readily available to everyone.Although the use of virtual or web-based microscopy is increasing, there is not an equivalent decrease in the number of schools utilizing traditional microscopes for education (Bloodgood & Ogilvie, 2006), indicating that the questions regarding the impact of virtual microscopes in all aspects of learning are yet to be answered.
In this context, we aim to investigate the current scenario of virtual microscopy in health professional education, with a specific focus on the comparative impact of traditional and virtual microscopes in different aspects of learning.Our research question is: How do virtual microscopes compare with conventional microscopes in health science education?

Data Sources
Both medical and allied health databases were searched systematically to include all health professional education programs at the graduate and undergraduate levels.PubMed, The Cumulative Index to Nursing and Allied Health Literature (CINAHL) database, Excerpta Medica dataBASE (EMBASE), Cochrane, and Web of Science were searched systematically.Search terms were: virtual histology, virtual microscopy, and web-based microscopy combined with education, teaching, and learning.The details of search terms and search results are listed in Table 1.

Study Selection
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to conduct the scoping review (Moher et al., 2009).Figure 1 represents the flow diagram of the study selection.Articles written in English and published in the last 10 years were included.To answer our research question, we included studies solely focused on health professional education.We excluded articles published before 2010, focused on non-health professional education, or applied virtual microscopy for diagnostic or clinical uses.We also excluded articles that are reviews, commentary, opinions, or technical descriptions.According to our established inclusion criteria, articles were screened based on titles and/or abstracts by two independent reviewers in the first round of review.In the second round, the two reviewers examined the full texts of the selected articles.After each review cycle, the disagreements between the first two reviewers were resolved by the third reviewer.Details of the inclusion and exclusion criteria are listed in Table 2.

Data Extraction
The data from the 13 articles were extracted and organized (Table 3).The results relevant to the research question were then synthesized.

Results
The initial search included 1,112 non-duplicate records from both medical and educational databases.The first screening phase by title and abstract retrieved 55 articles for fulltext review.Forty-two reports were excluded in the second phase for not matching our research question or not conducting a comparative evaluation between virtual and conventional microscopes for education.Duplicates and conference proceedings were also excluded in this phase (Figure 1).After the two-phase screening, 13 articles were eligible for data extraction.All the qualified articles conducted a comparative assessment between traditional and virtual microscopes to teach health professional education.
All the studies included in our review divided research participants into either two or all of the following groups: Groups using conventional microscopes Groups using virtual microscopes Groups using both traditional and virtual microscopes Twelve studies evaluated students' performance and knowledge attainment.Knowledge acquisition was assessed and compared between the groups from scores in formal board exams (Nauhria et al., 2019), online, multiple-choice, laboratory exams, identification tests (Lee et al., 2020), and score improvement from pre-test to post-test (Hande et al., 2017;Mione et al., 2013;Nauhria et al., 2019).Six studies assessed participants' preferences and satisfaction on the Likert scale.Eleven studies took the quantitative, and two studies took the mixed-method approach to collect and analyze data from the participants.Note.Virtual microscope = VM; Light microscope = LM; Conventional microscope = CM

Population Demographic of the Studies
The population included in the studies comprises students of medicine (5 studies), dentistry (2 studies), medicine and dentistry combined (1 study), biomedical sciences (1 study), veterinary (2 studies), and medical laboratory sciences (2 studies).The population is from the United States, United Kingdom, Belgium, Chile, China, Grenada, India, Saudi Arabia, Spain, Taiwan, and Turkey.An overview of the year the article was published and the demographic distribution of the population is shown in Figure 2. Virtual microscopy was applied to teach general histology (4 studies), pathology (4 studies), both histology and pathology (1 study), cytology (1 study), dental histology (1 study), and hematology (2 studies).

Effect of the Virtual Microscope on Student Performance
Assessing the differences between pre-test and post-test scores is frequently used to evaluate students' performance.Pre-test-post-test design involves collecting pre-test measures of the outcome of interest before administering some treatment, followed by a post-test on the same measure after treatment or intervention occurs.Pre-test-post-test designs can be applied in experimental and quasi-experimental educational research and used with or without control groups (Salkind, 2010).Mione et al. (2013) divided students into the light microscope and virtual microscope groups.The authors compared the differences in pre-and post-test scores between the groups.No significant differences were reported between pre-test and post-test scores among the student groups (2013).
On the other hand, Hande et al. (2017) divided students into three groups who were learning either with conventional microscopes (Group A), virtual microscopes (Group B), or both (Group C).Comparing the difference between pre-test and post-test scores among groups showed significant differences.Handle et al. discovered that the students who used both the light and virtual microscopes demonstrated the most significant improvement in their post-test scores compared to the pre-test, followed by the groups who used only virtual microscopes as their learning tool.The student group who used only conventional light microscopes showed the slightest difference between their pre-and post-test scores (2017).
Student performances in the formal academic examinations were also recorded to compare groups studying with conventional or virtual microscopes.Lee et al. (2020) divided students into two groups where one group used only light microscopes, and the other group used both light and virtual microscopes for learning histology and pathology.The group of students who used light and virtual microscopes performed better with less score variability on their laboratory examinations than the group who used only light microscopes.In a cross-over study, Nauhria et al. (2019) randomized participants either to the virtual microscopy or the light microscopy group then compared their mean scores in standardized exams.Students who used virtual microscopy scored significantly higher in the national board exam than those who used light microscopy.The authors also conducted pre-and post-test comparisons, where the students from the virtual microscopy group showed significant improvement in their post-test scores compared to the light microscopy group.Ordi et al. (2015) used an online test to comparatively evaluate the skill acquired by two student groups.One group used light microscopes, and the other used virtual microscopes for learning pathology.The study found no significant differences in students' performance between the groups.Similarly, no significant differences were reported by Brueggeman et al. (2012) concerning group mean scores for the midterm laboratory exam, final laboratory exam, or the course total.However, in the study by Foad (2016), students from the virtual microscopy group performed better than those in the light microscopy group in practical and written exams.Compared to the conventional microscope group, students using virtual microscopes scored higher in multiple-choice questions, short essays, case analyses, and cognitive tests, which measured their abilities to diagnose tissue structures from histological slides (Daniela et al., 2018;Tian et al., 2014).
In summary, 10 out of 12 studies found that students learning with virtual microscopes performed better in knowledge acquisition tests, including post-test, national board exam, online, written, multiple-choice, case analysis, and structure identification.The other two studies reported no significant differences in the mean score between groups using virtual or light microscopes (Table 3).

Impact of the Virtual Microscope on Long-Term Knowledge Retention
In a non-experimental comparative study, Solberg (2012) randomly assigned students in a clinical hematology course to use digital slides in virtual microscopes (Group 1) and traditional glass slides in the light microscope (Group 2).To evaluate students' immediate performance, separate microscope stations were set up where the students were asked to identify cellular structures.A delayed performance evaluation was conducted nine weeks after the initial laboratory sessions, similar to the immediate assessment.Students learning with the virtual microscope and digital slides (Group 1) performed better on evaluations immediately following the learning activity and after a considerable time (2012).

Student Preference and Satisfaction
Surveys based on the Likert scale were used to assess student preferences between virtual and conventional microscopes and their overall satisfaction with virtual microscopy and digital slides.In the study by Nauhria et al. (2019), 83% of the students preferred to use a virtual microscope over a light microscope.Student participants showed a high level of satisfaction and found virtual microscopes user-friendly and effective as teaching and learning tools (Daniela et al., 2018;Hande et al., 2017;Ordi et al., 2015;Sagol et al., 2015;Tian et al., 2014).The ability to view slides anywhere and at any time was considered highly advantageous by the participants (Brown et al., 2016;Ordi et al., 2015;Sagol et al., 2015).

Limitations
The goal of our scoping review was to investigate and synthesize a comparative overview of the impact of virtual and light microscopes as a teaching and learning tool for health science education.The eligible studies for our scoping review primarily evaluated student performance in knowledge tests and their satisfaction and preferences.We did not assess the quality of the studies included in our scoping review (Arksey et al., 2005).There is a clear need to conduct further studies to investigate the impact of virtual microscopy on other learning components, including engagement, knowledge retrieval, self-regulated learning, self-efficacy, and motivation.The findings of our review was based on the small number of articles that met our inclusion criteria specifically relevant to our research question.We acknowledge that negative results may have been missed due to publication bias.

Discussion
The use and popularity of virtual microscopes appear to be increasing worldwide across different disciplines of health science education.The vast majority of published literature on virtual microscopes focuses on the technical details of the technology and its sole effect on education.Our scoping review aimed to generate an overview comparing the impact of virtual and light microscopes in health professional education.We included comparative evaluation studies between student groups using conventional and virtual microscopes.
Based on our data extraction, we have summarized the effect of virtual microscopy on student performance, long-term knowledge retention, and satisfaction.The literature included comparative evaluations between groups of learners who used (i) only conventional microscopes, (ii) only virtual microscopes, and (iii) a combination of conventional microscopes.All the articles that assessed student satisfaction with virtual micoscopes reported it at a high level.Ten out of twelve studies reported higher test scores and better performance in knowledge acquisition by the student groups who used virtual microscopes alone or in combination with light microscopes.Two studies reported no significant differences between the light and virtual microscope users regarding group means for the midterm laboratory exam (Brueggeman et al., 2012) and online test (Ordi et al., 2015).These findings indicate that virtual microscopes have either equally good or better effects on students' knowledge acquisition or academic performance compared to light microscopes.In addition to the panning and zooming features, virtual microscopes also offer the ability to highlight areas of interest and create thumbnail views or location boxes for tracking navigation, which positively affects students learning.This technology can also potentially increase students' basic knowledge and problem-solving skills (Tian et al., 2014).
Only one study in our review collected test scores from participants who used virtual microscopes alone or virtual microscopes together with light microscopes (Hande et al., 2017).The study found that students who used both light and virtual microscopes performed significantly better than the group who used only a virtual microscope or only a light microscope as a learning tool.This performance indicates that virtual microscopes can augment traditional light microscopes in enhancing the learning experience and grasp of the subject (2017).
Only 13 studies fulfilled our selection criteria, suggesting that although there is widespread adoption of virtual microscopes as a teaching modality, there are not enough studies exploring the impact of this technology compared to light microscopes.The potential and benefits of virtual microscopes appear evident.However, further studies in this area can guide the best use of this technology to support and enhance active learning, engagement, professional development, problem-solving skills, and satisfaction.

Conclusion
Virtual microscopes are gaining popularity as a teaching tool for microanatomy and pathology.Reportedly, educational institutions are replacing traditional light microscopes with virtual systems to cope with increasing costs, space, and equipment.We conducted a scoping review to identify the relative effect of virtual and light microscopy on student performance, long-term knowledge retention, and satisfaction.All studies included in our review reported virtual microscopy as superior or equal to light microscopes in all aspects of students' learning experiences.Further studies in this area can guide educational institutions and educators to identify the best use of virtual microscopes as a teaching tool.

Figure 2
Figure 2Distribution of Articles Based on Year of Publication and Location of the Population

Table 1
Detail of Search Terms and Search Results

Table 2
Inclusion and Exclusion Criteria

Table 3
Detail of the Studies Included in the Scoping Review