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Each year the American Pathology Chairs meet to discuss matters relating to the discipline of pathology. In July, 1995, the meeting was held in Vail, Colorado in conjunction with meetings of GRIPE, Group for Research in Pathology Education, and PRODS, Pathology Residency Program Directors. The theme of the meeting was 'Educating the Educator.'
In the spring I wrote to all Pathology Chairs in the United States and Canada asking about their experiences or attitudes about computers in pathology education. This booklet is a compendium of materials which were e-mailed, FAXed and/or sent by regular mail.
I have taken the liberty of editing them slightly and they are all printed here without anyone's permission. If I have taken too many liberties, I apologize.
I have tried to identify all participants in these remarks, but I suspect I've left some out. For that I also send my regrets.
I have copied a page from the May 3, 1995, issue of JAMA, which is devoted to and written in great part by students. It addresses the uses of computers in the clinical problem solving situation which constitutes much of the clinical curriculum and the practice of medicine. The tools Mr. Coleman learned by consulting Robbins and Merck presumably derived from his second year course in Pathology and more than caught my eye for any number of reasons, not the least of which is that they represent the culmination of dreams, plans, conversations and projects I've had with Drs. Ramzi Cotran, Vinay Kumar, Stanley Robbins (at the Brigham & Women's), Richard Zorab (at W.B. Saunders), Drs. Robert Berkow and Andrew Fletcher (at Merck & Co. Inc.) and lastly Dr. Alexander Grimwade and Ms. Carol Mackin (at Keyboard Publishing).
I believe this compendium, with its sins of omission and commission, is a good summary of our collective thoughts about computers in pathology education and I believe it provides insights into new avenues ahead.
PROGRAM: EDUCATING THE EDUCATOR
Forces Affecting Medicine and Medical Education
M. Roy Schwarz, MD
Vice President
Scientific, Educational and Practice Standards
American Medical Association
Evaluation. The Role of the NBME in Medical Education
Donald Melnick, MD, Senior VP
National Board of Medical Examiners
Workshop
Pruning The Curriculum. Can Critical Thinking Be Taught?
Histopathology: Glass Slides? Curricular Blind Spots.
Problem Based Learning. Rewarding Educators.
Teaching Clinical Pathology. Should Residents Teach?
The Future of Anatomic Pathology. Managed Care and Pathology.
Pathology as a Career. Using Lab Tests Rationally.
Cost Accounting Education.
Use of Computers in Education
Robert L. Trelstad, MD Professor and Chair
Robert Wood Johnson Medical SchoolI. Practical Issues
Computer Laboratory Pace and Its Design
Access: Physical and Electronic: Who, When, How
Hardware: Networked, Free-Standing, Portable
Software: Commercial, Home-Grown, Shareware
CostsII. Political Issues
University Support
Dean's Office Support
Faculty Support
Control of the Computer Lab(s)
The Library
Management Information ServicesIII. Student Issues
Computer Accessibility and Portability
Affordability of Hardward and Software
Computer Literacy
Study Patterns: Old and New
Library LiteracyIV. Faculty Issues
Computerphilia, Computerphobia
Hardware: Access and Ownership
Software: Authorship, Publication, Intellectual Property, Plagiarism, TheftV. Pedagogic Uses
In Lecture by Faculty In Small-Groups
Independently by Student Literature Searching
Lecture and Class Notes Textbook Reference/Review
Problem Solving Quizzes with Feedback to Textbook Simulations Writing Assignment Management
Notices, E-Mail Image Databases: Analog and DigitalVI. Evaluation
Student Use and Evaluation
Faculty Use and Evaluation
Pre and Post Testing Studies
Acceptance by Licensure and Credentialling OrganizationVII. Future
Internet and Other Communications Resources
Computer Based Certifying Examinations
Continuing Medical Education
Home, Office and Institutional Work Stations
Telepathology in the World of Telemedicine
Computer Workshop
Robert L. Trelstad, MD & David J. Foran, PhD
OrganizersInternet
There will be sessions, both formal and informal for those who want to know and/or see how the Internet operates and, better yet, its extensive collection of teaching materials for pathology. We are grateful to Silicon Graphics, Inc. for providing two Indy workstations which will be used for demonstrations and hands-on exploration. We have planned for both a simulation of the Internet and a direct Internet Linkage (56 KBPS direct connection). The simulation and tele-imaging tools are being provided by the Imaging Program of Robert Wood Johnson Medical School and managed by Dr. David J. Foran.
Image Compression Test
We have developed a new image compression algorithm based on wavelet theory for use with pathology images. We have available a test program where images are compared. This 15 minute test will be available for you to take and the results will be made available to participants by mail. This experiment is being conducted in collaboration with faculty from Rutgers University from the center for Computer Aids to Industrial Productivity (CAIP) and from the Department of Computer Science.
How To Become A More Effective Teacher: A Future View
Richard C. Reynolds, MD
Executive Vice President
Robert Wood Johnson Foundation
The Pathology Curriculum: What Should It Be?
Aubrey J. Hough, MD
Professor and Chair
University of Arkansas for Medical Sciences
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Dr. Donald C. Houghton
Department of Pathology
Oregon Health Sciences University
Portland OR 97201-3098
We have relatively strong University administrative support of clinical biomedical information and computing facilities, but we have only been nibbling at the edges of using computers in medical education (except for library facilities). Predictably, costs in terms of capital, space and technical support are the problems. In general, except for those in the structure-oriented disciplines, the faculty has not been especially vocal in lobbying for a change. We have recently heard that there will be funding for a modest computer center for first and second year students. I don't yet know what the potential scope (size and technical possibilities) of the center will be.
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Dr. Robert Boorstein
Dr. Vittorio Defendi
Department of Pathology
New York University School of Medicine
New York NY 10016
We now use computers in four distinct ways.
1) For general pathology, our laboratory materials, mostly photomicrographs, are available in 11 modules with text and some questions. These are available for self study. They were written by J. Waisman at NYU.
2) For Renal pathology, 3 lectures were eliminated and 2 modules were written by Dr. Gallo. Their use is mandatory. (Although someone could presumably cover the same material in a book.)
3) The Slice of Life and question bank are available for self study.
4) Vanderbilt materials are available for self study. The topic list as it correlates with our course are distributed to the class.
We are collecting a fair amount of student responses on which of these elements students find valuable. We have no real data on whether any of these things are valuable in actually learning. ----------------------
Dr. Robert M. Friedman
Department of Pathology
Uniformed Services University of the Health Sciences
Bethesda MD 20889-4799
We have developed for use on the internet case studies and clincal cases,
the latter for CME. These are at http://wwwpath.USUf2.USUHS.mil
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Dr. Howard M. Reisner
Dr. Joe W. Grisham
Department of Pathology
University of North Carolina School of Medicine
Chapel Hill NC 27599-7525
As Course Director for our second year (systemic) pathology course, I have
become involved in this medical school's "Electronic Syllabus Project"
(ESP) and tried to integrate our department's teaching effort into it. ESP
is an attempt to provide our medical students with all first and second
year course-related syllabus material in an electronic form. Although it
initially grew out of efforts to save trees and cut printing expenses, some
faculty were quick to recognize the potentials of presenting course materials
in an electronic form. A working ESP committee selected Folio VIEWS as an
"authoring environment" over a variety of competing products.
Several factors were important in this choice: 1) There is excellent Mac/Windows
interoperability, 2) The environment provides a full text indexed database
engine. Searching on text is very fast and database size is relatively small,
3) The structure is similar to HTML and has multiple forms of hyperlinking.
It is my understanding that Folio VIEWS produced material can be easily
converted to HTML format for WWW distribution. 4) The layout of Folio VIEWS
is hierarchical. Outlines constructed using all standard word processors
can be directly imported into the authoring environment. 5) Essentially
all graphic formats, animation and sounds can be accommodated. There are
certainly drawbacks to the environment but overall it suits our course material
very well.
Our department has been one of the first to attempt to convert our second year syllabus to the Folio VIEWS format. We were lucky enough to have a talented resident (Dr. David Thomas) who is interested in medical education and neuropathology. In the last two-three months he has produced an excellent version of the neuropath segment of the syllabus as a Folio VIEWS "infobase". This represents about 10% of our second year course. Dr. Thomas has far expanded our original paper syllabus to include appropriate scanned histopath material, supplemental diagrams, radiographic data and some hypertext type links. Our faculty has been most laudatory and we (just barely) managed to test our "beta" version on our current second year class. Although not optimal, we were able to mount the syllabus on the Med School server and it was available to students on 386 level machines in their laboratory rooms. (We developed for 486 machines with 800 X 600 type adapters). There is a very brief survey of opinions of students and a few test questions (dependent on electronic syllabus use) on the neuropath quiz which will be given next week. The infobase is about 16 megs in length and we are hoping to produce a pilot CD-ROM in the next three weeks. Obviously the entire second year syllabus would require some sort of mass storage medium if we choose to distribute it to students for off site use. Currently, we have no intention of distribution via WWW for a variety of reasons (although all or most of the images used are local so copyright is not a problem).
Dr. Thomas is currently working on our (short) first year syllabus (nine sessions on general pathology). We hope to attempt to finish our entire second year syllabus by next April pending fund availability to allow Dr. Thomas to continue the project. In collecting syllabus material for next years class I intend to try and collect images and ideas suitable for inclusion in an electronic form.
My last thoughts on the issue are that: 1) students seem to enjoy the format although we do not yet know how useful it is as an educational tool (although we wish to find out) and 2) It is impossible to OVERESTIMATE the time and resources needed for the project.
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Dr. Gloria J. Delisle
Dr. Paul N. Manley
Department of Microbiology, Immunology & Pathology
Queen's University
Kingston ONT K7L 3N6
Our medical students and residents are using our multimedia interactive
CDROM title "Microbes in Motion" as a stand alone text or supplement
for problem based learning. The CD is 400MB of interactive basic microbiology
with audio, video, animation, text , glossary(with audio), objectives and
quizzes with hyperlinks. The CD-ROM is published by Wm.C. Brown Publishers,
Dubuque Iowa ISBN 0-697-27265-6. We assign medical students problems and
they access the CD-ROM through the learning resources library or purchase
for home use. The material is brought into class on laptops and interactive
session s are used by either projection gun TV or LCD panels and projectors
with full sound. The response has been overwhelming, resulting in awards
for teaching from both the students and faculty.
Clinical pathology residents use the CD-ROM for computer assisted learning. The next title (available July 96) is an interactive CD-ROM on laboratory diagnosis of infectious disease by the same authors (Delisle and Tomalty) and the same publisher (Wm.C. Brown). The clinical material is accessed for the program by a microscope interfaced with a computer to provide digitized images from glass slides, or gross specimens. These images are also used in a lecture or seminar format as required.
The ASM case studies for infectious disease are also useful for residents and undergraduate medical students.
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Dr. John Wurzel
Dr. Henry Simpkins
Department of Pathology & Laboratory Medicine
Temple University Health Sciences Center
Philadelphia PA 19140
INTEGRATION OF COMPUTER BASED LEARNING INTO A MEDICAL SCHOOL PATHOLOGY COURSE
Members of the Department of Pathology and Laboratory Medicine of Temple University Medical School and collaborators have written 30 computer based learning (CBL) lessons based on the department's extensive collection of high resolution digital images. The lessons have been designed to supplement the traditional pathology teaching laboratories that use microscope slides and fixed gross specimens. Since 1991 these lessons have become an integral part of the 200 hour general and systemic pathology required of second year medical students. Students make extensive use of the CBL and value it highly. This discussion includes the following: (1)the purposes of the teaching laboratories (and, therefore, of the corresponding CBL); (2)how CBL is created; (3)how the material fits into the course; (4)the advantages of CBL over traditional laboratories.
The laboratories use patient derived-material to illustrate the major educational points made in the lectures and textbook and to train the students to recognize the morphologic appearances of common disease processes and lesions. Each session centers on a specific theme (e.g., neoplasms of the lung) and uses histopathology sections, gross specimens, and occasionally cytology samples. The CBL lessons have the same themes, but use high resolution digital images derived from photographic representations of the specimens, all in PICT format. The PICT images are linked to text as described below. The technology for creating high resolution images is readily available. Images are scanned from projection slides (currently, using Kodak PhotoCD; originally, the Barneyscan ColorImaging System) and edited with Adobe Photoshop. The department has almost 1800 images, including gross specimens, histology and histopathology sections, cytology smears, special morphologic techniques (ultrastructure, immunohistochemistry), patient photographs, x-rays and other radiology images, electrophoresis patterns, and microbiology specimens. Questions and answers pertaining to the images are created with standard word processing. A series of images and the corresponding questions and answers are compiled to create a lesson on a specific topic. The text and the images are integrated with a software package created by Dr. Steven Erde and his colleagues at Cornell University School of Medicine. Students use the same software to study the lessons. The hardware for student users is an ethernet based network located in the Temple University Health Sciences Center Library. Each of the 16 workstations consists of either a Mac II or Quadra CPU with 8 MB RAM and an 8 bit video display card and a 19" high resolution color monitor.
Implementation of the CBL so that students can use it involves several factors. (1)The course director is intimately involved in the production of the materials; the other factors, in part, follow from this. (2)CBL is designed primarily to enable the students to meet existing course requirements rather than being added on to their already overcrowded schedules. Almost all lessons closely parallel existing laboratories. In fact, many of the projections slides from which the images are scanned and some of the text are teaching materials used in the laboratories. The CBL lessons allow the students to meet the educational objectives given for each of the laboratory sessions. Since examinations are, in part based on the laboratories, the close relationship between the laboratories and the CBL in their topics, objectives, and materials implies that study of the CBL helps the students to meet course requirements. (3)Faculty-supervised sessions using the CBL have replaced 10 hours of traditional laboratories. (4)Course surveys include questions about student use of and satisfaction with CBL.
Evidence from the course surveys indicate that student reaction to CBL has been favorable; in fact, much more favorable than originally anticipated. Data on the use of the CBL is as follows:
Course Year % Enrolled Students % Survey Respondents % Survey Respondents
Using CBL
Answering Survey Using CBL More Than 50 Hours
1991 90% 95% 23%
1992 96% 98% 25%
1993 91% 100% 19%
The students evaluate the quality and utility of CBL on a scale of 1 to 5, with 1 being the lowest (unacceptable) and five being the highest (excellent). Since the results are essentially the same each year, they are pooled, as follows: image quality, 4.51; tool for self-assessment, 4.19; for reinforcing concepts presented in textbook and lectures, 4.55; for teaching morphology, 4.55; ease of use, 4.82. Since the implementation of CBL there has been a marked increase in the students' overall evaluation of the course. Between 1987 and 1990, before CBL, the overall course evaluation ranged from 3.667 to 3.727 (again, on a scale of 1 to 5), since CBL implementation in 1991 the rating has been at least 4.134.
In comparison to the traditional pathology laboratories using microscope slides and fixed organs, CBL has several advantages including: (1)permanent archiving of difficult to obtain or replace teaching specimens; (2)use of the same material for teaching different groups of learners (in our case, dental students and residents also use the material); (3)creation of lessons in subjects for which there are no laboratories; (4)demonstration of material not often available in pathology laboratory format (e.g., forensic specimens); (5)display of many examples of same process or disease; (6) comparison of different types of images (e.g., gross specimen and x-ray) of the same process or disease; (7)use in both faculty-supervised and independent study; (8)ready direction of the student to the key points in the image; (9)access to the material for many hours (about 85 hours per week at Temple Health Sciences Center Library); (10)enthusiastic reception by students; (11) exchange of educational material with faculty at other institutions. Many of these advantages were not anticipated at the onset of the project. In summary, existing technology permits creation of CBL lessons that integrate high resolution images with text. When appropriately integrated into course structure, CBL is well received and very extensively used by students. Integration requires that faculty design of the material so that it allows the students to meet educational goals and objectives of the course. CBL is such a powerful tool for simulating pathology teaching laboratories that it could partly or totally replace them in medical education.
The author thanks John Yelcick, M.D. and Edward Redding for their contributions during the initial phases of the project. Earlier versions of this report were presented at the Health Science Library Consortium Meeting, Philadelphia, PA in April, 1992 and in April, 1994.
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Dr. Chris J. McCarthy
Dr. Robert D. Cardiff
Department of Pathology
University of California, Davis Medical Center
Sacramento CA 95817
EXPERIENCES WITH COMPUTERS IN EDUCATION
HISTORY: One of our earliest attempts to integrate computers in the Pathology curriculum was the use of a question bank developed by GRIPE for examination and self assessment. It was refined through the development of appropriate response feedback and references created by second year pathology students as part of a points-for-question assignment. The question bank existed on an HP-3000 minicomputer and was accessed via monochromatic dumb-terminals. This resource became more valuable as the question bank expanded over a period of several years and when the bank questions were used in actual graded tests. As technology improved and the budget allowed, stand-alone microcomputers began to supplant the minicomputer/server hardware. Question banks created for the minicomputer were transferred into Hypercard stacks which had the ability to link to videodisc images on a second monitor. An early decision was made to support dual platforms in both hardware (IBM-compatible as well as Macintosh) and software to maximize the use of computers by infusing them with many of the earliest commercially available instructional packages as they became available. A number of these commercial packages became integrated into the curriculum of various courses, e.g.: MacDiet, for a self-evaluation exercise in Nutrition; CaseNotes for Biochem, as an evaluated cumulative exercise in Biochemistry; Occupational Case Studies, as a "take-home" assignment in Epidemiology; Assigned modules in Biostatistics, also as homework for Epidemiology; NLM Pathology Videodisc Series, as lecture substitute and corresponding self-evaluation exercise; and various physiologic simulations such as Heart Lab, Model Neuron and ECG on disk have successfully substituted Physiology wet-lab exercises.
CURRENT AND FUTURE EFFORTS
Running parallel with the evolution of hardware technology was the maturation of robust authoring software packages which allowed us to integrate and customize computer resources into specific curricular needs. Programs such as Hypercard, Toolbook, Director and Authorware have been employed on an increasingly frequent basis to provide specific enhancements and adjustments to curricular needs. Among these enhancements, has been a project for the Lab courses in Hematology, Histology and Pathology and others to digitize images used for lab exercises and lab syllabi. The original template used for augmenting the laboratory lessons was authored in Director by UCSD School of Medicine called MedPics. The method was to substitute into MedPics pictures of our actual teaching specimens as used by students in lab, combining the text and lab values from student's lab syllabus to create universally accessible interactive laboratory experiences. These "digital syllabi" not only reinforce the learning as experienced in labs but give students the opportunity to preview labs to make their lab time more efficient. This, in turn, makes faculty teaching more efficient. Surveys of students indicate that development is successful and worth expanding. Efficient time management has always been a high priority of Medical Students. Traditional learning resources remain available in the form of extra texts, old exams, anatomical models, gross specimens and slide sets through the library and learning resource center. In all subjects, there is more information sources than time allows for student's perusal, so the resources which the student spends most time with generally indicates the most efficient information source. "Digital syllabi" are now being used extensively by students in several basic science courses. Usage falls off where computer CPU speed is slow. If a student must wait more than twenty seconds for a digital image to appear, the level of interest and utilization drops off quickly. Recent developments in internet networking via the World Wide Web have opened up vast amounts of learning resources to students which represents tremendous potential as a source of digital information. Where that information can be gathered and controlled by carefully planned linking, the students quickly adopt this information medium as a favorite source. But access speed remains a deterrent to full utilization. Anticipating improvements in access speed as this medium evolves, we have begun porting resource material and developing new resources in HTML format. For the present, speed can be optimized by localizing file access.
SUMMARY: The educational use of computers by students at the U.C. School of Medicine has substantially increased over the past five years as a result of improved technology/speed, the increased availability of locally developed programs tailored to the UCD curriculum, the availability of commercial multimedia authoring systems, the improved level of computer literacy in students and the increased acceptance of the use of this technology by the faculty. The most proliferative utilization of this technology is in the area of visual, interactive tutorials customized to suit individual needs within the curriculum. Of particular approval by students are those digital tutorials which contain, as a subset of their design, a self-testing mode allowing the student to identify his/her weaknesses in a particular subject area.
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Dr. Ann Irwin
Dr. Clive R. Taylor
Department of Pathology & Laboratory Medicine
University of Southern California, Medical School
Los Angeles CA 90033-1054
Dr. David Bailey and Dr. Katsumi Miyai, the Pathology department and core
course chairs, respectively, at UCSD School of Medicine have passed along
to me the letter you sent to Dr. Bailey regarding this summer's path chair
meeting in Vail.
They have expressed an interest in having my office (the Instructional Development Group of the Learning Resources Center) participate in the "Computers in Education" portion of the program. Specifically, we have developed a software program called "MedPics" in conjunction with UCSD's Human Disease course which is currently being pressed to CD-ROM, and is being marketed through Micron BioSystems (Denver, CO). Drs. Bailey and Miyai have asked myself and my colleague, Dr. Helene Hoffman (Assistant Dean for Curriculum and Educational Computing) to demonstrate this educational software in whatever manner would best facilitate your needs (we are the co-developers).
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Jill Conway MD/PhD student in philosophy
Dr. Patricia J. O'Morchoe
Department of Pathology
University of Illinois (Urbana)
Urbana IL 61801
OMPUTER-BASED EDUCATIONAL RESOURCES AT THE UNIVERSITY OF ILLINOIS COLLEGE
OF MEDICINE AT URBANA-CHAMPAIGN
In an effort to supplement the medical school curriculum and take advantage of the growing technological resources, faculty at the University of Illinois College of Medicine at Urbana-Champaign College of Medicine (UICOM-UC) have developed instructional materials for use in undergraduate medical education. This software represents a multi-departmental effort, combining the expertise of the Departments of Pathology, Medical Information Science, and Cell and Structural Biology. First-year students are introduced to computer instruction with the "Talking Atlas of Histology". In the second year, the "Pathology Atlas" and the "Pathology Tutorials" closely follow the curriculum and supplement the lectures.
TALKING ATLAS OF HISTOLOGY
Created by Dr. Richard Mintel, Dr. Peter Ziemkowski, Dr. Aulikki Kokko-Cunningham, and Dr. P.J. O'Morchoe
The "Talking Atlas of Histology" provides students with a better simulation of working at a microscope with an instructor than can be obtained from traditional atlases. The student sits in front of a computer screen and calls up an image without any labels or extraneous information. The student decides which structures are of particular interest, and uses a mouse to click on these. In response, a dialog box pops up on the screen containing the correct identification of the structure, together with the correct pronunciation in 16-bit digital audio. Textual information concerning the structure and its function are delivered at another click of the mouse. The program offers different modes to satisfy a variety of student needs. For example, there is a quiz format where the computer program picks out random structures and asks the student to identify them. The student can also search for a particular structure and it will be highlighted on the screen. The program uses the Macintosh application, Supercard, and runs on any Macintosh computer equipped with a color monitor and 16-bit audio capacity.
The major advantages of this atlas lie in the need for interaction between the student and the program and the availability of the correct pronunciation of important terms at an early stage in training. In addition, the detailed structural and functional information help students relate various concepts in physiology, histology, and anatomy. The atlas is used for learning primary concepts in histology as first-year students, a review of major topics in preparation for the second-year pathology course or the USMLE Step I exam, as well as a quick memory refresher of important concepts in the clinical years.
Student response to the histology atlas has been mixed. While some students appreciate the format and the access to this learning tool, many feel that it response time is too slow to be a really valuable resource. On the other hand, student teaching assistants have found the program of great help prior to leading the laboratory sessions. Planned revisions include improving the speed and updating the content.
PATHOLOGY ATLAS
Created by Dr. Donald R. Thursh (deceased), Dr. Allan Levy, Dr. P.J. O'Morchoe, and Dr. Allan Smith
The "Pathology Atlas" is a collection of several hundred images of gross and microscopic specimens arranged in seven volumes--General Pathology, Cardiovascular Pathology, Pulmonary Pathology, Renal Pathology, Coagulopathies and Hematopoietic Disorders, Skin Pathology, and Endocrine Pathology. Each volume contains slides and legends which are indexed by key words and alphabetically. The extensive legends explain concepts which are often noted on the image with arrows and/or numbers. The atlas was compiled using Hypercard for Macintosh computers.
Partially in response to changing technology and the limitations of a Hypercard format, we are in the process of converting this atlas for use on the World Wide Web (WWW). The images have been modified using Adobe Photoshop and stored as GIF files. An image and its legend constitute one page. The legends, other links, and title are visible on opening the page, with a postage-stamp image that shows the reader a preview of the image. By clicking on the thumb nail image, the user links to a screen-sized image which shows the slide in full detail. The conversion for use on the WWW has been completed for the General Pathology and Cardiovascular Pathology volumes. The remaining volumes should be made available in the fall of 1995. In addition, a Cytopathology volume will be added which will emphasize the correlation between cytopathology specimens and their tissues of origin.
This internet resource was not available to our students last year, so we do not have any information on its value as an educational tool for the pathology course. Student feedback on the Macintosh version indicated that the atlas was not sufficiently integrated with the course curriculum and therefore not extremely useful to students, except as a reference. We are hopeful that this resource may be useful to medical students and physicians outside our own community. We have noted that browsers throughout the world connect to the atlas frequently, and a few comments from users around the world indicate a definite interest in the project.
PATHOLOGY TUTORIALS
Created by Dr. P.J. O'Morchoe, Dr. Allan Levy, Ms. Jill Conway
The Pathology course for M2 students is taught to a large extent by the use of a case-based approach. The small class size (25-30) at UICOM-UC allows the material to be presented in a group discussion format. The case histories and related questions are provided in a written format prior to the lectures. The "Pathology Tutorials" supplement the regular pathology lectures and seminars by providing a computer review of the case histories, slides, questions, and answers. The slides are accompanied by legends which may expand upon the descriptions presented in class. The tutorials, compiled using Hypercard for Macintosh, are easy to use and have on-screen instructions. At this time, students have access to over 1000 slides.
A student selects a lecture from a menu of options and is given a list of case histories. After selecting a case to review, the history is presented, and a series of questions follows. The student is encouraged to think about a particular question. Moving to the next screen provides a brief answer to the question accompanied by the images of the slides used to guide the class discussions with appropriate legends.
Student usage of these tutorials has been encouraging. We have provided a comment feature which allows students to ask questions or make suggestions about the program. Content questions are given to the course director, who may address difficult points or clarify questions in subsequent lectures. There was some concern that class attendance would drop if the lecture material was available on computers, but an appreciable difference in attendance was not noted. Another concern was that the accessibility of material before class would keep students from actively looking up information themselves in preparation for participation. While some students appeared to merely note the answers to questions before the lecture, most appeared to actively engage with the material and use the tutorials for review rather than as a primary source. Providing brief answers in advance is intended to allay the initial apprehension of those students who are unaccustomed to participation in group discussions. During the actual classes, the answers given on the computer are greatly expanded upon. Students also report using these tutorials before the USMLE Step I exam as a study aid.
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Dr. Suzanne Stensaas
Dr. Daniel M. Knowles
Department of Pathology
Cornell Medical College
New York NY 10021
We are in the process of converting all of our hyperpath documents to WWW format for use by anyone, and I would really be excited to be able to show this. Furthermore, Dr. Tom Godwin, involved with Residency training program, is probably coming. He has been one of the principal authors of the work and a teacher at CUMC through the entire history of PathMAC. WE would like to demo together if you can give us some more details.
Cornell's focus is on medical students, computers are not used in Resident education.
The following is a summary of how computers are used as one of many forms of facilitation of pathology education:
1. As a supporting animation (i.e. oncogenes in HyperCell) in lecture on neoplasia.
2. As electronic class notes with images (Hyper Path).
3. As small cases studies with images (PBL, i.e. planalyzer).
4. As an illustrated on-line glossary.
5. As bibliographic reference (i.e. Knowledge Finder, Scientific American Medicine,
Merck Manual).
6. As images for PBL.
7. As images for case based exams (glass slides are also used).
8. As images for discussion in review sessions.
9. As images for discussion in micro labs.
10. As images with cases or questions for self assessment (i.e. Image Quest).
11. As a means of using the GRIPE Test Item Bank (i.e. Test Bank).
12. As a way of organizing weekly materials for listing and launching appropriate software
for the week (Bookslate).
Commentary:
Cornell has a long history of rising images and computers. Beginning in 1985 with Drs. Erde and Alonso, "PathMAC" was initially a WORM videodisc system with a MacPlus. This energetic beginning has continued. PathMAC is no longer used. In its place is the Education Center. The Education Center consists of six rooms, each with a CRT ceiling, mounted projector and five Quadra 700 computers with 21 inch monitors. An Ethernet network and core support for faculty and students to develop software or review material is provided.
In July of 1995 a major remodeling of the old labs will result in the Sanford and Joan Weill Education Center to open in the Fall of 1996. This will stress small group learning (20 small rooms), a state of the art multimedia classroom, ATM network and over 100 power PCs. The Education is part of the Office of Academic Affairs (Dr. Alonso) as is the Office of Academic Computing (Dr. Erde). Dr. Stensaas is the Director of the Education Center and served as the Pathology Course Director from 1991-1995.
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Dr. James R. Newland
Dr. Samuel M. Cohen
Department of Pathology & Microbiology
University of Nebraska Medical Center
Omaha NE 68198-3135
PATHOLOGY LABORATORY REVIEW
What follows is what I have written this year utilizing videodisk technology:
a. Neoplasia Laboratory
b. Pediatric Pathology Laboratory
c. Breast Pathology Laboratory (comprehensive)
d. Female Genital Tract Laboratory
e. Cardiovascular Pathology Laboratory
f. Respiratory Pathology Laboratory
g. Kidney Pathology Laboratory
h. Pathology of the Genitourinary Tract Laboratory
i. Musculoskeletal Laboratory (comprehensive)
j. Urinary Sediment Laboratory (comprehensive)
I wrote the material as shown on the enclosed examples. The comprehensive experiences are the only experience the students have relative to laboratory material in the subject area, and they are tested on it Musculoskeletal and Breast labs. The comprehensive urinary sediment laboratory was prepared using Pat Ward's urinary sediment videodisk. It is for medical students taking a special primary care elective (no exam). The other labs utilize the Slice of Life VI. The comprehensive laboratories were written with objectives, narrative with figures, and questions with feedback. The others were reviews of "wet" laboratories given by our faculty.
The authoring software was AuthorWare Pro (Macintosh platform). Expertise for this was provided by the Learning Resources Center in our McGoogan Library of Medicine. All I had to do was write the scripts. I intend to make all the remaining laboratories comprehensive. Usage by students was light when supplemental and heavy when it was in the examination. "If you test them on it, they will come."
If the CAI is supplemental, there are a few students who will avail themselves of the opportunity. I think it depends upon learning style. The students who have looked at my supplemental stuff have liked it. They also very much liked the musculoskeletal lab that they were required to do in the Learning Resources Center.
I also used the Slice of Life VI videodisk to teach "wet" laboratories on anemia and leukemia/lymphoma. The students seemed to like that, too. After a brief demo using the videodisk, the students would look at slides with their microscopes. Later, they asked me to do a review of the hematology laboratories using the videodisk.
CARDIOVASCULAR PATHOLOGY
This series of figures is designed to accompany the Cardiovascular Pathology Laboratory. Its best use is with the original laboratory exercise. Material presented will follow the order of the laboratory handout. You should have the laboratory handout with you and follow its narrative.
1. Normal Aorta
Figure #1 (4475) is an external and intimal surface view of a normal aorta. Figure #2 (11809) gives a closer look at the intimal surface.
Figure #3 (25755) is a MOVAT stain of the normal abdominal aorta. Figure #4 (14701) is an elastic stain of the aorta with the luminal surface on the right and the adventitial surface on the left. The intima and adventitial collagen stain pale blue, while the elastic fibers in the media stain black.
2. Normal Heart
Figure #1 (3716) consists of anterior right and left oblique projections of the heart. Figure #2 (4472) is a view of the superior surface, while figure #3 (11799) is a posterior view. Figure #4 (3734) is a cut section showing the right side of the heart, and Figure #5 (3800) is a view of the normal left ventricle. Figure #6 (3812) is a coronal section at the level of the ventricles. Figure #7 (3554) is a composite view of an x-ray of the normal chest and a normal heart for comparison.
Figure #8 (11738) is a normal microscopic appearance of myocardium of the left ventricle.
3. Aortic Atherosclerosis
Figures #1 & 2 (11054, 11057) are gross scanning and medium power views of the intimal surface of atherosclerosis of the aorta. Figure #3 (11060) is from a more severe case, while figure #4 (14216) demonstrates even more advanced atherosclerosis.
Figure #5 (28811) is a microscopic view of aortic atherosclerosis, and figure #6 (28808) demonstrates calcification in this process.
4. Coronary Artery Atherosclerosis
Figure #1 (40194) is the gross appearance of a coronary artery with partial occlusion due to atherosclerosis and hemorrhage within a plaque. Figure #2 (53271) demonstrates coronary artery thrombosis in the setting of atherosclerosis.
Figures #3 & 4 (25636, 25638) microscopic views demonstrate early and more advanced coronary atherosclerosis. Figures #5 & 6 (25641, 53266) are both severe coronary atherosclerosis.
5. Myocardial Infarction: Gross Examples
Gross examples of acute and recent myocardial infarctions are figures #1 (6620) with a 3-5 day anteroseptal infarct, figure #2 (6623) with an 11 day inferolateral infarct, and figure #3 (6630) with a circumferential subendocardial infarct. Figure #4 (6731) demonstrates old and recent myocardial infarctions.
Complicated acute myocardial infarctions include figure (6715) with a rupture and hemopericardium and figure #6 (6725) with a ruptured papillary muscle.
Gross examples of healed myocardial infarctions are figures #7 & 8 (6338, 11532).
6. Myocardial Infarction: Microscopic Appearances
Sequence of Histologic Findings in Acute Myocardial Infarction
FIGURE # TIME COMMENTS
1 (6639) <24 hrs infarct in lower 1/2
2 (6642) <24 hrs contraction bands
3 (6645) 1-2 days a few PMNs
4 (6643) 3-5 days heavy PMNs
5 (6657) 5-7 days basophilic interstitial debris
6 (6660) 7-10 days macrophages
7 (6663) 10-14 days early granulation tissue
8 (6666) 2-3 weeks early fibrosis
9 (8746) old infarct scarring
7. Valvular Heart Disease: Rheumatic Heart Disease
Figures #1 and 2 (6862, 6865) denote the clinical features and complications of mitral stenosis. Figure #3 (20284) is a chest x-ray of a patient with mitral stenosis. Figures #4 and 5 (38556, 38569) are external views of a heart with mitral stenosis. Note the left atrial dilatation. Figure #6 (38572) demonstrates a mural thrombus of the left atrium. Figure #7 (3677) shows the fishmouth deformity of mitral stenosis from the ventricular side. Figures #8 and 9 (20579, 46251) are surgical specimens of mitral stenosis. Figure #10 (3419) demonstrates left atrial and left ventricular views of a mitral stenosis surgical specimen. Figure #11 (6845) shows valve thickening and commissural fusion in mitral stenosis.
Figure #12 (53321) is an opened heart with aortic stenosis. Figure #13 (11486) is a closeup view of aortic stenosis, while figure #14 (20556) is a surgical specimen of the same process.
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Dr. James H. Harrison, Jr.
Dr. Robert Lowe
Dr. Michael A. Gerber
Department of Pathology
Dr. Sandor Vigh
Department of Anatomy
Tulane University, School of Medicine
New Orleans LA 70112-1393
EXPERIENCES WITH COMPUTER-AIDED INSTRUCTION IN THE SCHOOL OF MEDICINE
In the semester just completed, the School of Medicine has for the first time used computer-aided instruction (CAI) as a significant part of several major basic science classes. This effort grew out of an informal interaction among several faculty members and was partly experimental. We have learned some important lessons from this experience. We would like to review them with you and to make some recommendations concerning the requirements for expanding CAI use at Tulane Medical School in the future.
Most of this CAI material was developed by Tulane faculty members and was delivered by the Tulane Medical Center World Wide Web server. A range of instructional strategies was used. In Medical Pathology, nine CAI modules replaced lectures and were the sole source (other than the textbook) for this material. In addition, 11 CAI case studies were used in parallel with lectures, to provide practice using the material.
In Medical Histology, over 400 images were placed online for study, and much of this material was available only via the computers. This initial effort led to an inter-institutional collaboration in which Tulane has been provided two extensive sets of human histology glass slides (from the Department of Anatomy, University Medica/School of Pecs, and the Department of Anatomy, Semmelweis University, Budapest, Hungary) for use in our curriculum and for development of an archival site in human histology on the Internet.
In Medical Physiology, part of the Cardiovascular Physiology Section (10 hours of lecture) was placed on the Web server. A mechanism was provided for students to email questions and comments to the instructor and class sessions were converted from lectures to discussions of student responses (captured electronically) to the basic material presented via the computers.
From our experiences with this material, we can make the following observations:
· Development of CAI instructional material by Tulane faculty.
Current Tulane faculty can develop CAI material that is useful in teaching, tailored for our environment, and competitive in quality with commercial packages. World Wide Web technology dramatically reduces the time and computing skill required to develop this material, but development is still very time-consuming. Although much of the developmental work can be done by faculty, staff, or students who are not expert in computing, periodic expert support and criticism is crucial for the success and overall quality of these efforts. This technology can change the way in which material is taught, and has the potential to improve teaching efficiency, but it is doubtful that it will significantly reduce the amount of overall faculty time dedicated to teaching. Eamon Kelly's comments in the recent Report of the President concerning information technology moving faculty to the position of a "guide on the side" are apt in this context. Guiding from the side still takes time, effort and skill.
· Acceptance of CAI material by students.
In general, students responded favorably to these materials. In many cases, students were highly favorable, ranking our CA/among the most rewarding instructional experiences so far in medical training. There were also a few students who did not respond favorably, particularly objecting to replacement of lectures with other teaching methods. We suspect that these students have not been heard from in the past because they were relatively satisfied with the previous instructional approach and skillful at learning in this manner. When we bring new approaches to the curriculum that require new learning skills and strategies, critical comments from these individuals should be expected. We should be sensitive to them and realize that we do deal with a range of personalities and abilities in our student population.
· Preparing the students to use CAI effectively.
lnterestingly, positive and negative perceptions of CA/did not appear to be strongly correlated with the level of computing skill of the students. We did receive comments from some students indicating that they liked the material, but that they needed instruction in basic computer use to get the most out of it. We also found that many students felt "insecure" unless they printed out copies of every document in the instruction sets and took them home. We feel that this behavior stems both from the past conditioning of the students to copy all possibly pertinent documents for later triage, and from inexperience with using computers for/earning. Better orientation to the use of computers and appropriate learning strategies could improve this situation and maximize the benefits of CAl. We feel very strongly that time should be dedicated within the curriculum to preparation of the students in using information technology.
· Student access to the learning material.
Over the past month, use of our World Wide Web server has dramatically increased. The combined load on our two servers in January averaged almost 3800 accesses per day, as compared with a previous high of about 1900 accesses per day in November. The peak day in January for the servers showed over 9900 accesses. This increase corresponds both to a general increase in use of the servers within and outside the Tulane community and to the use of the servers for CAI in several classes simultaneously. Most of the student accesses to the servers came from within the computer teaching lab, but a significant number of students also dialed in from home using Tulane's dial-in PPP lines (see below). It appears that the server and network hardware within the medical school are adequate to handle these levels of access. However, we have identified several other shortcomings in student access to the CAI material that need to be solved.
1. The computer teaching laboratory has major design flaws that limit its usefulness. Many of these were originally pointed out in the discussion of the plans prior to building the lab. Based on our experience, the lab is noisy, too small, and very cramped when any significant number of students come in at one time. There is very little area to place books or notes. The temperature regulation of the room is poor. Blower motors in the ceiling cause significant flickering in the screens of several machines, making them difficult to use for any length of time. In short, it is not an attractive place to concentrate and learn.
2. The IBM machines as originally installed are not appropriately set up for multimedia teaching and continue to have network access problems. They have been essentially useless for CAI this year, except for DOS-based simulations in physiology that do not require network access and which do not use screen graphics. As CAI programs become more sophisticated, these computers will become more of a liability.
3. A number of students have found it useful to access the networked teaching material from their homes, using their own computers and modems, and Tulane's dial-in (PPP) lines. This arrangement works reasonably well, except that the number of lines is limited. Over the two weeks prior to the exams at the end of January, our students flooded the dial-in lines, making it very difficult tot anyone to gain access. There certainly is not enough dial-in capacity for the students to use CAI material routinely from home when instructional packages are in use by several classes. TCS is in the process of providing some additional lines, and will review the need for increased numbers of lines prior to next fall. Our plans need to be part of this review.4. Support within the computing lab continues to be a problem, both for students with quick questions or points of confusion, and for maintenance of the software and machines. Data Systems or another appropriate group needs additional staff that can be dedicated to supporting and developing the lab.
· Assessment and Recommendations.
Overall, our initial efforts in CA/at Tulane have been very successful and our experience suggests that CAI, including material developed on site, can make a positive contribution to our curriculum. The degree of faculty interest in these efforts suggests that a significant amount of CAI development could be initiated over the spring and summer which would lead to a major expansion of CAI use in the next scholastic year. We believe that this would be beneficial to the curriculum and to the perception of Tulane as a modern school of medicine. We have identified a number of limitations that should be addressed before additional significant CAI development is done, however, and we make the following recommendations:
1. The World Wide Web should be adopted as a standard technology for development and delivery of CAI at the School of Medicine, and a unit should be established that can provide expert support for faculty wishing to develop instructional materials.
2. Training in information technology should be instituted next fall in the medical curriculum, either as a component of a current course (e.g., Introduction to Clinical Medicine) or as a new course.
3. Some of the computers (ca. 12) should be moved from the computer teaching lab to another secure location. This will free up some work space and make the conditions in the teaching lab more tolerable. The new location may not need 24 hour access, as the computer lab would still be available after hours. It is possible that a limited number of sites within the medical library might be appropriate.
4. If significant use of CA/is to be pursued, the School of Medicine should set a policy strongly recommending that students purchase their own portable computers and modems when they begin the curriculum and specific models of computers and modems should be recommended. To do otherwise is unfair to students who are not familiar with computers and/or who might spend money on inappropriate computers.
5. To further increase access, ethernet ports should be provided at additional locations, such as medical library carrels. These ports would allow students to bring their own computers to school and plug them into the Tulane network.
6. Additional PPP lines should be provided, either as an addition to the TCS PPP pool or as a new medical center pool. If a new PPP sewer is initiated at the medical center, it should have more than 16 lines. It is strongly recommended that access lines at 28.8 kbps be provided (the current lines are 14-.4 kbps); the higher line speeds will significantly increase the efficiency of transfer of teaching material that contains images.
7. The IBM computers should either be immediately upgraded for full network access and reasonable graphics capability, or we should consider removing all but a few from the computing lab.
8. We should arrange to provide personnel for administering the computing lab. If CA/development progresses as it could, it would be reasonable to have a full-time technical manager as well as after-hours student proctors for the computing lab by next fall.
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| References | Home |
Dr. John G. Thomas
Dr. Ludwig Albornoz
Dr. Mary Ann Sens
Department of Pathology
Byrd Health Science Center
West Virginia University
Morgantown WV 26506
A UNIQUE COMPUTERIZED CLINICAL MICROBIOLOGY WORKSTATION TO ASSIST PATHOLOGY PERSONNEL IN DIAGNOSIS, CONSULTATION AND EDUCATION.
PURPOSE: Algorithms used in decision-tree-analysis were introduced to infectious disease diagnosis in the late 1960's; the first dealt with Bacteroides fraqilis detection in blood cultures. Their use in the clinical microbiology laboratory, however, has not paralleled data and information management or the growing recognition of artificial intelligence (AT) in other scientific disciplines; it was relegated to administrative functions. Presently, there is the fortuitous and timely arrival of three components that necessitates its reevaluation: 1) sophisticated microbiology computer programs; 2) overwhelming amounts of microbiology information and 3) the need for pathology staff to intervene as consultants on a daily basis and assist in microbiology data interpretation. Hence, our objective was to design and implement a computerized Pathology Microbiology Workstation that featured computer assisted diagnostics, consultation and education.
METHODS: An intensive review of the literature was undertaken. Programs and topics "expanded" included the following: medical case histories; computer aided instruction for both general and medical microbiology; and computer aided instruction and laboratory procedures.
A review of the available microbiology software programs was also undertaken focusing on needs of the pathology department, cost, and goals for the microbiology workstation. A ready source included national medical-scientific organization: ASM, ASCP, CAP, and CDC. Computer hardware was chosen that maximized rapid, visual presentation of the various programs. Also several medical institutions were contacted that had previously utilized computerized training for their pathology residents. Finally, a criteria based questionnaire for staff and faculty was constructed to evaluate the useability of the microbiology computerized workstation. Raw scores were tabulated and evaluated.
RESULTS: The computer components of the workstation utilized a 486 DX 2/66 System with a 17" monitor; it included 8 mB RAM and 540 mB HD. Nine microbiology programs were selected that were DOS or Windows based. General topics included: case reviews, antibiotic utilization and cost containment, identifying at-risk patients, diagnosis, and tutorial/education. These were organized and grouped into a scheme of four parallel, but separate pathways that highlighted common features for 1) education, 2) diagnosis, 3) Path Micro daily workflow and 4) technical information. Each was selected using a Windows ICON. For diagnosis, the GIDEON program was most used and most preferred by the pathology residents. For educational and/or tutorial purposes the Gram Stain Educator (GSE) was favored by residents, laboratory staff and medical students. The GSE was integrated into a pathology workshop for 3rd year medical students. Pathology faculty and residents preferred the Path-Micro workflow scheme, because it directed weekend review and simplified data retrieval and consultation when directors were not immediately available. It also maximized collection of reimbursable professional fees.
CONCLUSIONS
1. To date, there is little published information about interactive computerized microbiology workstations in the pathology laboratory. Although the components are present, there is apprehension in microbiology to utilize and maximize sophisticated microbiology programs.
2. The concept of a computerized pathology laboratory microbiology workstation was well-received. Its design of 4 complementary pathways to facilitate rapid review of pertinent medical information for assistance in diagnosis, consultation and/or education was considered beneficial. 3. The staff and residents became more sensitized to data management; for residents, it organized workflow and for pathology staff, weekend coverage. Administratively, it maximized reimbursement by focusing on consultation via the Path Microbiology Pathway.
4. Future goals include expanding the workstation components by integrating with national and international resources, and addressing more fully, artificial intelligence in microbiology; algorithms will be constructed for cost management through decision analysis. It will use a criteria based scheme to evaluate their impact in quality assurance (QA) .
PATHWAY I
This Work Station will be the primary focus of the pathology residency in microbiology and virology and will require the resident to check for unusual or significant results each day; review "send out" results and unusual antibiotic profiles. It will also include the ability to track BMT CMV requests and Influenza virus. Emphasis will include the 10 AM "plate rounds" and 3 PM "serum/virology rounds".
In the future, the resident will need to call up results from the Sunquest system, call up results from Anatomic Pathology and hence correlate CP/AP results. They will also need to enter results and appropriate charges (analogous to Hematology Path Table) for consultation.
PATHWAY II
This will consist of complementary, consultative resources. This will include ready references for antibiotic questions as well as established data bases for antibiograms locally, regionally, and nationally (CDC). This will include programs in three basic categories: 1) GIDEON (Global Infectious Disease and Epidemiology Network); 2) national antibiograms; 3) new artificial-intelligence(AI)-like-programs emphasizing empiric antibiotic therapy/ antifungal therapy/antiviral therapy based on clinical and pharmaceutical parameters (i.e. Pfizer, fluconazol) for at-risk-patients.
This will have as a long term goal (Levels II and III), interaction with WWNet/Internet and WONDER/PC (CDC); this pathway will also be a primary teaching resource for the future outreach programs including the present one-day workshop and the potential virology course that is being eliminated by CDC. This would be theoretically taught in late August and has already received some support/inquiry.
PATHWAY III
This section will emphasize complementary educational components and interactive learning experiences. It will complement traditional methods, i.e. textbooks, etc. Programs already purchased include tutorial programs for the Gram Stain and Anaerobic culturing, a tremendously inventive, educational program for identification of anaerobic bacteria. This will also complement the arrival of the new anaerobic chamber. Computerized cases in Microbiology (American Society for Microbiology) complements the Textbook of same name utilizing a new interactive format.
PATHWAY IV
This section will allow the Technical Specialist, Debby Taniguchi, and others to have word processing capabilities (Level II) and/or data management capabilities (now) for logging and tracking of blood cultures, wound isolates and serum (OB/GYN) storage (which are now done by hand) and the ability to download information from the Vitek and Bactec Systems for future evaluation/summations of culture results. This also includes an ASCP Check Sample Program which allows the user to track unusual isolates for infection control.
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Dr. Janet F. Stanstny
Dr. David S. Wilkinson
Department of Pathology
Virginia Commonwealth University
Medical College of Virginia
Richmond VA 23298-0662
Four computer based tutorials, Pathology of the Ovary, Pathology of the Breast, Pathology of the Myometrium and Endometrium; and Pathology of the Vulva, Vagina and Cervix were developed primarily for t/se by second year medical students, but pathology and OB/GYN residents also utilize them. The tutorials were designed to help the student learn pathology of the female genital tract and male and female breast during the MS-2 Reproductive course. The same information is presented during the classroom lectures. Each tutorial is composed of two sections, a viewer and a quiz The viewer is a series of gross, microscopic and radiographic images with descriptive text which illustrates pathology and disease processes. The quiz is a series of practice exam questions associated with the information presented in the viewer. Instructive feedback for all correct and incorrect responses is provided within the quiz to help the student understand why the response was correct or incorrect. Upon completion of the quiz, the student receives a score .indicating the number of correct responses. The score is for the students information only and not used as part of the course grade. This program has been used at MCV for the past three years. We have evaluated the program through surveys completed at the end of the Reproductive course. The students response has been overall positive. They appreciate the convenience of working on the programs at their own pace and time frame. I have included a copy of our summary of the responses from our survey.
Although these tutorials have not replaced the lectures, two fours laboratories showing gross organs and microscopic glass slides with participation of the students have been replaced by the computer programs. In response to the acceptance of these programs, a new unit is currently being developed on Virginia Commonwealth University
Student reactions to the Question: Suggestions for Improving Computer Based Pathology Tutorials
· The computer path tutorials were excellent:
1) extremely inclusive - all material available such that they could easily stand alone
2) in reviewing with them, one could concentrate on the areas of weakness (certain subtopics, visual images, etc. it is my belief that people learn in different ways. If one assumes the objective is to teach, then any single medium must be flexible enough to accommodate many learning styles. The path tutorials/quizzes are the best d I have seen for this. (For example, some like to see the pictures first, then learn details. Others want the details before the pictures. This is obviously easy with the tutorials. I have no criticisms.
· I would have happily been well prepared for the entire course, had it been in such a format. The visuals intellectually highlight the printed materials, and the quizzes reinforce what is learned. The material can be 'covered at one's own speed. Even the atmosphere is more comfortable. (By the way, I am not a computer literate person. Also, I tend to fall asleep in lecture, so although I attend, I don't always absorb,)
· I thought it was great. I should have skipped the lectures.
· Actually spent my entire study time on the computer because items easy to learn but felt like l learned a lot of useless slides (i.e. that wouldn't have any chance to be tested on)
· Could be the first program that could replace the class
· They are excellent study aids. The graphics were acceptable. The whole program was better than the lectures.
· I thought the tutorials/quizzes were very helpful. It was a good summary of info with visual stimulation. I think two sources of info input (reading the computer and seeing the pictures) is much better than one source (reading the syllabus).
· Your lectures were very clear and summarizing. Thanks! I appreciate all your hard work.
· This was great. l learned well from the computer -I feel it is a great ADDITIONAL tool to supplement lectures and lab. However, it is not a replacement.
· I get more out of lecture, but I think the tutorials were useful adjuncts.
· All the computer should remain supplemental - as good as it is, it can never replace lecture and lab.
· Use them as supplements, rather than substitutes.
· Keep both class lectures and computers to use as a study guide.
· Great design. Keep the lecture! l like the computer, but it should only be used as a supplement!!!
· Keep it for next year; lectures are also very helpful to hear and see the material in broad overview before using the computers.
· I thought they were good. But I would not recommend they replace lecture and lab. great as a supplemental study resource, especially if the material in the computer directly reflects that covered in lecture!
· Go to lecture initially. Use tutorials to review and test yourself. Good learning tool. Only problem was difficulty getting on computer since there are 168 of us and only 21 computer. It was difficult even when it wasn't close to exam time.
· I suggest that you have the tutorials as adjuncts to the lecture and not keep people from attending the lecture. Many people, like me, pick up so much info the first time it is heard and not seen.
· The computer works for me because I can take my time and see the images as often as l like; I think I would have benefited, on the practical, from studying all the tutorials. l would suggest that in the future you keep the programs as optional, but highly recommended. I don't think they should replace the role of lecturer.
· Great program! Very helpful - even better when used with lecture.
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Dr. Lester Wold
Department of Pathology & Laboratory Medicine
Mayo Clinic
Departmentally we have utilized two HyperCard-based teaching modules in medical school and resident education. These were developed in conjunction with Dr. Jannie Woo from State University in New York at Syracuse. I have enclosed some initial comments regarding the orthopedic pathology teaching module, which I developed in conjunction with Dr. Woo. These comments were collected at an American Society of Clinical Pathologists bone tumor and tumor-like condition course, as well as the American Academy of Orthopaedic Surgeons review course. I simply brought the teaching module on my laptop and collected comments from course participants. In addition, I have utilized this teaching module to each orthopedic surgical residents the basics of orthopedic pathology.
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Dr. Rodney A. Schmidt
Dr. Nelson Fausto
Department of Pathology
University of Washington
Seattle WA 98195
We have developed a HyperCard application, which we call "Digital Pathology", that presents digital images and descriptions. Before we wrote this program, we used a set of approximately 200 kodachrome slides which we expected the students to study. Each slide had a short description in the course syllabus. The program takes those images and descriptions and displays them on Power Macintoshes in our library's computer center. Much of the program is simply a digital alternative to kodachrome slide projectors but there are also some nice features for jumping quickly between images and for searching the descriptions for related slides. The program proved to be very popular with the medical students.
We are very happy with this program and will continue to use it. We are currently rewriting some of the codes in order to make it easier to add and delete images. We are also planning to port the program to Supercard for two reasons. First, Supercard has capabilities for annotating images, etc. that HyperCard lacks. Also, Supercard promises a Windows player and in this way we hope to achieve cross-platform capability. The dream is to master a CD ROM with both Macintosh and Windows viewing software as well as a collection of images. This could then be distributed to the medical students. It may also be possible to go directly from HyperCard to HTML.
One of the major disadvantages of prepackaged image programs is that the collection of images that come with the software often do not match up well with course content at a particular school. One of our basic design principals is to make it as easy as possible to add and subtract images from the collection. In this way, it would be relatively "friendly" to instructors at another institution because they could start with a basic collection of images and then tailor the program to suit their own needs.
It would be interesting to demonstrate this program in the afternoon but there are a number of logistical and financial that would have to be answered first.
DIGITAL PATHOLOGY: THE USE OF DIGITAL IMAGES AS A REPLACEMENT FOR KODACHROME SLIDE SETS IN THE STUDY OF PATHOLOGY
Mr. Wheeler
Medical Student
The second year medical school course in ,Systemic Pathology at the University of Washington School of Medicine includes a set of 211 kodachrome slides that students are responsible for on the mid-term and final exam. For the fall of 1994, a computer program called 'Digital Pathology was developed and distributed on 10 Apple 7100/66 Power-Macintoshes in the Health Sciences Library. The program allowed the students to study the slides within a database environment. This study surveyed the students by an evaluation form included with the final exam. Of the 159(94%) students who responded, 86% felt that the Digital Pathology program was a reasonable alternative to the use of kodachrome slides and 60% felt comfortable with using it as the sole source of slide review. Overall, the students found the computer program to be advantageous over the kodachrome slides in 5 out of 6 chosen categories, with the exception of its suitability for group study, which 64% of the class found to he a moderate-major disadvantage.
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Dr. Leonard S. Gottlieb
Department of Pathology & Laboratory Medicine
Boston University School of Medicine
Boston MA 02118
We have offered Keyboard Pathology to students as an adjunct for review of material in General Pathology, for learning systems pathology in association with a pathophysiology course given by the Department of Medicine and for review for Part I of the boards. For General Pathology several lecturers made "Transcripts." The list of "Transcripts" and instructions for using them are included in the course syllabus.
In the annual course evaluations for General Pathology, only about 5% of students report any significant use of the program. Anecdotal reports from students and the staff of the library (where the computers are located) indicate that some students (maybe 10%) use the program for board review. We believe the program is useful, but greater utilization would require more faculty interest and input than we can provide at present. Our teaching is based in the lectures and in small group (12-14 student) laboratory sessions.
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Dr. C. Bruce Alexander
Dr. Peter G. Anderson
Dr. Jay M. McDonald
Department of Pathology
University of Alabama, Birmingham
Birmingham AL 35233-7331
SUMMARY OF OUR APPLICATION OF COMPUTERS TO MEDICAL EDUCATION
The Department of Pathology at the University of Alabama School of Medicine conducts a course in General Pathology from September through December followed by a course in Correlative (systemic) Pathology from January through May.
Three years ago the Department of Pathology, in concert with the School of Medicine, discussed the potential for alternatives to purchasing a microscope for each student. At this time, it was decided instead of purchasing a microscope for each student, the school would purchase a workstation which included a microscope, a video camera and monitor. Subsequent to this, a PC and laser disc player have also been obtained for these workstations.
Traditional lectures and laboratories included the use of Kodachrome sets and glass slides. The above workstations were adapted to provide one lecturer with access to three rooms with forty-sixty students per room. Beginning with the pilot project in the summer of 1992 in Histology, the program then expanded to full use of a microscope, video camera and monitor to replace the standard single microscope per student. This was initially begun in the freshman class and then extended to General Pathology in the Class of '92.
It is the intent of the school to create an expanded computer facility which would:
1. Accommodate required basic science instruction for medicine, dentistry and optometry
2. Have an infrastructure to support appropriate software development
3. Have an organization to serve other instructional needs as well as computerized instruction
4. Accommodate obsolescence by moving from dedicated hardware to hardware purchased by students when sufficient software is available.
We have progressed with this concept and have adopted photo CD's as a mechanism to capture laboratory images. These photo CD's are available to the students 24 hours a day. In addition, two pilot projects, a pulmonary laboratory in the pulmonary correlative disease course for 1995 and in a pilot lecture on pulmonary neoplasia for 1995, index sheets were created to accompany lecture and lab.
In addition, the correlative pathology neuro-pathology laboratories have been adapted for photo CD images per this plan.
We will have further information available regarding the use of photo CD's and the video camera microscope workstations at the University of Alabama School of Medicine at the GRIPE meeting at Vail in July. In addition, examples of the laboratory photo CD sheets may be made available for review if you feel this is useful.
All the students evaluate the courses and laboratories. The transition to the above workstations and photo CD's has received high marks from students in the sample population. This is being reviewed with the Dean of the School of Medicine for greater implementation in the 1995-96 school year. Additional computer applications at UASOM include conversion from standard Kodachrome presentations at lectures to the use of PowerPoint and on-line computer projections for lectures. This is also undergoing evaluation for more extensive use.
Computer assisted images have also been used in examinations by selected faculty. Two laboratories have used the Slice of Life material as reference work. The other images are locally produced.
No inter-active videos are currently being used in the curricula.
Future applications include accessing for third and fourth years, a photo CD data bank of archive materials from the second year pathology courses. As well, plans are underway to fully convert laboratory images to photo CD's with text and with questions. We will represent the Department of Pathology at the Vail GRIPE APC PRODS meeting and are available for further questions. We will also have available examples of the laboratory photo CD's for the pilot project that have been implemented at UAB.
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Dr. Maria Evans
Dr. John F. Townsend
Department of Pathology
University of Missouri
Columbia Medical Center
Columbia MO 65212
1. Computers in Resident Education
a. A general observation, based on meetings I have attended and personal interaction with residents at this and other institutions, is that residents are poorly trained in computer use.
b. Ideally, every resident should have a "laptop" computer or its equivalent. It is a tool that is as important to resident education and professional practice as a microscope. Since economic constraints will, in many cases, result in having to manage with less than the ideal, institutions should provide sufficient access to computers to ensure that every resident has an opportunity to work with them and learn to use them in practice, research, and education.
c. Every resident should, as an absolute minimum, be able to:
i. Use a spread sheet, a word processing program, and a data base program.
ii. Use a computer for literature search.
d. In addition, it would be desirable if residents could use presentation programs such as Power Point or Aldus Persuasion to make a presentation, create 35 mm slides, digitized photos or items from a chart (example - a tracing for a serum protein electrophoresis).
e. Skills could be demonstrated and evaluated by requiring residents to:
i. Analyze quality control and quality assurance data and report their findings and conclusions.
ii. Use data and materials produced by presentation programs in problem solving.
2. It is important that "computer education" does not degenerate into an enervating, time wasting exercise in doing "electronic scut" (typing autopsy reports for example) for the senior staff.
3. Looking into the future, it is reasonable to expect increased interactive uses of computers. Interactive software can be a "tireless teacher" for simulating gross and microscopic pathology skills in anatomic pathology and for working up blood bank and other problems in clinical pathology. There also will be rapid development of information sharing programs such as World Wide Web.
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Dr. Michael Cancro
Dr. Leslie A. Litzky
Dr. Patrice Spitalnik
Dr. Leonard Jarett
Department of Pathology & Laboratory Medicine
University of Pennsylvania School of Medicine
Philadelphia PA 19104-4283
Dr. Patrice Spitalnik
My experience with computer assisted education has been limited to the histology course in the medical school. This program (HARP) was developed by medical students and I helped edit the text and questions that went along with the reproductions of the histological sections. The students find the program useful for studying on their own after they have looked at the slides in class under the microscope. This gives them the opportunity for examination on their own. This is very helpful since the figures and answers are clear and correct. The program is not a substitute for in class learning at this time.
Dr. Michael Cancro
These comments are restricted to the training of medical students.
The University of Pennsylvania School of Medicine has moved substantially in computer aided instruction over the last four years. The medical school teaching facilities now provide ready and ample access to computers. These include the teaching laboratories themselves, where there are 5 to 6 machines per room of 20 students; the medical/graduate student lounge, where an additional 32 machines are available exclusively to medical and PhD students, and the biomedical library, where an additional 48 machines are available, but are open to the entire university community. The classroom and lounge computers are available 24 hours a day to via electronic keying. The machines in both areas are locally networked to an instructional materials file server, as well as to the biomedical library, and to the Internet. This availability was key to generating significant faculty interest for the development of educational software.
Educational software has been developed by Penn faculty and students for several disciplines: Study and review programs are now used in Gross Anatomy, Histology, Embryology, Behavioral Science, and Systemic Pathology. Further, the Histology review program is during laboratory periods an adjunct and guide to microscopy.
In addition, simulations for classroom teaching have been developed and are used in Membrane Physiology, Nerve electrophysiology, Renal Physiology, Respiratory physiology. Finally, entrance to the Internet is used to access national human genetics databases (OMEM) for exams in the genetics course. Finally, a library of instructional software is available from which students may choose to use instructional materials developed by other schools or institutions.
Pathology Teaching:
The department of pathology has supported development of a Computer Assisted pathology program (CAP) that serves as a study aid in our systemic pathology course (PATH 200). This program contains the images used in the teaching sessions and the CPCs, and is organized in an organ block fashion. The program is not used as an adjunct during classroom teaching, but is instead intended as an independent study and review tool lot students. Usage information suggests approximately half of the medical class uses the CAP program for these purposes.
Remarks:
In general, the most critical elements to fostering computers in medical student teaching are: Sufficient hardware availability/accessibility, especially in classrooms; software applications that faculty are willing to underwrite as appropriate study aids for their course; sufficient infrastructure for logistic maintenance of these systems.
The strongest impediments are: Lack of imaginative uses in terms of simulations and information access. Much software (and instructional design) remains electronic page turning with a multi-media bent, but fails to embrace the pedagogic changes that computers and information access promise.
Dr. Leslie A. Litzky
Computer-assisted instruction (CAI) was incorporated into Pathology 200 for the first time in August of 1992, which coincided with my arrival and was first tested in the Pulmonary Pathology section of the course. Prior to my arrival, David EIder had spent several months working with Tom McAleer, a series of work-study students and Ronni Lodato to take her lecture outlines with accompanying kodachromes and digitize the images. An interactive shell was created by the Office of Information Technology which consisted of a split screen with the text of the lecture on one side, and a menu which allowed for the selection of a corresponding figure which could be brought up simultaneously on the second half of the screen. The image itself (which could be a gross photograph, microscopic section, x-ray or schematic diagram) appeared with tabs or arrows. The student could make a diagnosis and then select the tab or arrow and check whether his or her impression had been correct. Additional arrows were placed to direct the student's attention to other anatomic landmarks or diagnostic features. The quality of the images was quite good and many of the students took advantage of the system to review lectures or study for exams which now include a limited number of kodachromes to identify. Additional sections of the course have been added to the point that about 50% of the material is available on the CAl. During this time, computers were added in the laboratories and in the medical library, expanding the number of terminals and allowing laboratory instructors to call up pertinent images during a lab session.
My overall impression of this type of instruction is extremely favorable with certain caveats which I have cited below:
1 ) I personally do not see the CAI replacing the personal interaction of a lecturer or laboratory leader with a small group of medical students. 1 think that there is something unique about this type of learning which not only includes the student's intellectual processing and mastery of the material, but extends to role-modeling for students and the continued intellectual development of the instructor or resident assistant as well. What the CAI does do is allow for more uniformity in terms of the material being presented (every student has the opportunity to see the same set of images and to study them for as long as necessary) and afford those students who are particularly attracted to this type of learning the opportunity to analyze the material from yet another perspective.
2) From a practical point of view, CAI is time-consuming and does require financial support for equipment and personnel. It takes time for the instructor to gather together the lecture materials and kodachromes, as well as to proof the lectures and the annotated images. The instructor must be able to frequently meet with the computer programmer as the program is being developed, which is very difficult to coordinate without a technically competent educator who is able to dedicate a substantial portion of effort to the project. The CAI is not a one time project most of the staff update their lectures each year and change their kodachromes or there is turnover in staff and the new attending will want to reformat the lecture. My lecture on the CAI is now three years old and it is startling to contemplate how much new information or conceptual changes have occurred but these lectures have not been updated because we have been concentrating our resources on completing all of the lectures.3). I have discussed these issues at length with David Elder and we have decided that a new approach is needed. We have decided to use the CAI to create a database of key images. Each instructor will select several classic kodachromes from each lecture which they feel the students should know. These images will be put onto the computer without the accompanying lecture text - which the students have a copy of anyway. By dropping the text, the material will be somewhat less cumbersome to create and to update. The students will understand that these are the images and disease processes that we wish to emphasize.
4) The technology relevant to these programs is in a state of continuous development. It would be highly desirable for our educational efforts to have someone with the initiative, interest and technical expertise to keep up with the new technology - a lot of which is occurring on this campus. There are many computer-assisted educational programs out there which could be evaluated but this takes a great deal of time.
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Dr. Don Witzki
Director of Evaluation and Testing
Dr. Robert Rubeck
Assistant Dean of Academic Affairs in the Office of Education
Dr. Deborah E. Powell
Department of Pathology
University of Kentucky College of Medicine
Lexington KY 40536
We have been utilizing computer-based education for several years in the Department. The College of Medicine, however, will be requiring all students to have a computer beginning with the class entering in the Fall of 1996 and the class entering in the Fall of 1995 are strongly advised (and may actually be required) to have a computer. The school plans to make available to all students software, including CD ROM materials from all of our in-house, generated programs, including the pathology digital lectures. Ultimately we hope to go to computer-based testing for some segment of our course but that is not yet in place although we are getting close. We also hope to have the course syllabus as well as all of the other courses available hopefully within the next year.
In summary, we have been using some computer assisted educational tools at the University of Kentucky for the past two to three years with more emphasis during the past year. We are continuing to investigate other uses for computers in our educational activities.
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Dr. Paul Strausbach
Course Director
Dr. Paul G. Catrou
Pathologist in Charge of Informatics
Dr. H.Thomas Norris
Department of Pathology & Laboratory Medicine
East Carolina University School of Medicine
Greenville NC 27858-4354
Dr. Paul Strausbach
We have limited experience in the use of computers in Pathology education. There are three programs available to our students: 1) The National Library of Medicine Basic Medical Pathology Series; 2) Guide Path; and 3) Keyboard Pathology. None of these are integrated into the course so I would estimate that less than 10% of our students (4 7 students) use them. However, the lecture portions of the NLM Basic Medical Pathology are probably viewed by up to 30% of the students. Guide Path is used by a fair number of our residents for board review. I have not heard of much use of Keyboard Pathology.
Thoughts on Computer Education:
1) Computer instruction has to be incorporated into the body of the course or it will not be heavily used.
2) In-house generated computer teaching will probably be better accepted than commercial packages. This is because the in-house generated programs will be more relevant to the ongoing course.
3) Images have to be of high quality. With hardware and memory getting cheaper, this will be easier.
4) As the computer generation reaches college and medical school, there will be more demand for good interactive computer teaching.
5) Medical students, in general, like to test their knowledge. The more successful computer education probably will be "test driven."
6) Computer education software should probably be introduced as a block; e.g., general pathology, etc. An individual lesson here and there will not gain wide acceptance.
Paul G. Catrou, M.D.
In response to your request to provide information pertaining to the use of computers in education, I feel qualified to respond only to their use in resident training.
Computers are used in two principle areas in the residency training program: 1) as a means to directly assist education, and 2) as tools to perform other pathology related tasks. At this time resources in the first category are limited. The only computer-assisted tool residents have access to, and use, is the ASCP Intellipath® system. However, I do not believe they have any formal required work associated with this resource.
Most of the computer education is provided via real-life experiences using the computer as a tool. There are several computer uses in this category. 1) The Department provides local network access to the literature retrieval system provided by the school's library. 2) When the resident is on call for the clinical pathology service, he is provided with a modem-equipped laptop which provides dial-in capability to the laboratory information system (LIS) as well as a hypertext driven on-call manual. 3) In addition, the Department provides a centrally located personal computer (PC) for word processing and spreadsheet use. 4) Of course the residents use many of the LIS functions in their day-today activities.
Residents can take a one month (or more) elective in Laboratory Informatics. This elective is tailored to the computer literacy of the resident. This elective has been offered for the past two years and has been taken by two residents so far.
Finally, we are in the process of establishing a World Wide Web server, at first to be used locally within the Department, and then to be made available to Internet users as the need arises.
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Dr. Edward C. Klatt
Dr. Carl R. Kjeldsberg
Department of Pathology
University of Utah School of Medicine
Salt Lake City UT 84132
EDUCATIONAL COMPUTING AT THE UNIVERSITY OF UTAH
At the University of Utah extensive use is made of computers in education for both medical students as well as pathology residents. In the first two years of the medical school curriculum, there are computer media for histology, biochemistry, anatomy, and neuroanatomy that are integrated into these courses. The second year pathology course has both a computerized question bank as well as image base that are integrated into the course along with the syllabus and the laboratory exercises and are used extensively by the students. The overall performance by the students has increased in the last 3 years, both on exams given during the courses and on the USMLE steps I and 3, Computer media have not been a substitute for regular lectures and laboratories in the "traditional" type of teaching format, but have greatly supplemented it and allowed for a wider variety of learning experiences.
Computerization, however, has been victimized by its own success, because increasing use of computer media has strained the ability of the University to keep pace with sufficient equipment and networking capabilities. We are now trying to upgrade the computers that the students use and make better use of existing limited space. We are currently working toward greater use of HTML documents from the World Wide Web in medical education, since that will provide a good graphical interface for both Macintosh and PC compatible computers for many more students than can be accommodated in the medical library. We have generated a prototype teaching laboratory called "WebPath" that is available on the World Wide Web via the Internet (http://www-medlib.med.utah.edu/WebPath/webpalh.html).
In the pathology residency program, the residents have been provided with access to both Macintosh and PC compatible computers. There is a video disk player, and the department has obtained the intellipath series. The residents have access to the Internet through the University, and many also can access the Internet at home via a free University connection. Residents utilize computers for preparation of conferences and for publications. Resident projects have included generation of a computerized set of teaching cases in anatomic pathology, research in telemedicine applications, and digital imaging techniques in diagnostic surgical pathology. Use of the laboratory information systems at the University Hospital and the affiliated hospitals in the residency program is incorporated into resident rotations for both anatomic and clinical pathology.
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Dr. Elliott Kagan
Dr. Jeffrey Cossman
Department of Pathology
Georgetown University School of Medicine
3900 Reservoir Road NW
Washington DC 20007
USE OF COMPUTERS IN EDUCATION
In January 1990, we initiated a computer-based learning module for sophomore medical students, named the SuperPATH project. This has been a joint undertaking between the Department of Pathology and the J.V. Dahlgren Medical Library, which was conceived as part of Georgetown University Medical Center's Integrated Academic Information Management System (IAIMS) venture. The SuperPATH project was formulated to assist medical students in the acquisition of an increasing body of medical information in the field of Pathology, and to develop the skills needed for medical problem solving. SuperPATH entails the use of hypertext programming, whereby lecture notes, glossaries, and literature citations are integrated with digitized, full-color images of a spectrum of lesions in gross and microscopic pathology. The digitized images are captured and stored on expandable 500 megabyte hard disks that are accessible through a file server. The system, which is housed in the Biomedical Information Resources Center of the J.V. Dahlgren Medical Library, comprises a series of networked Macintosh work stations using Apple's Macintosh II EtherTalk Interface Card and AppleShare File Server software. Currently, the SuperPATH module has specific computer-based teaching programs on autoimmune diseases, the pneumoconioses, tumors of the central nervous system, and a problem-based learning study of a case of systemic lupus erythematosus.
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Dr. Vinay Kumar
Dr. Herb Hagler
Dr. Errol Friedberg
Department of Pathology
University of Texas Southwestern Medical School
Dallas TX 75235-9072
We changed our Path Course completely this past year. Lectures were reduced drastically and replaced by independent study time and biweekly case discussions. Our faculty created approximately 100 cases covering both general and systemic pathology. Each case (text and images) was made available to the students on Macintosh computers. The dean bought one MacPower PC for every four students. Available to the students were also Keyboard series and the early version of the MedPics program developed by UCSD. The student response to this change was very positive. Considering that this was the first year, we did not experience any major catastrophe. During the development and the execution of this computer and case based curriculum, we were forced to address several questions that relate to teaching Pathology to sophomore medical students. These included both the power and limitations of computers, the pros and cons of case based teaching with respect to faculty effort, student behavior, and the subjective nature of grading. We were also forced to decide what we will teach and what we will not and the potential implications of our decisions on student performance in USMLE Step 1. Can we encourage critical thinking at the expense of reducing the factual content of the course? Obviously our faculty put in a very large effort to develop this course, and they are wondering how much this will count toward their academic advancement. I believe many of these issues have been faced by others that have adopted such curricula. More schools may have to address them as they consider moving away from the traditional models of teaching.
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Dr. Faramarz Naeim fnaeim
Dr. J. Michael McCoy
Dr. Martin A. Pops
Dr. Jonathan Braun
Department of Pathology & Laboratory Medicine
University of California, Los Angeles
Los Angeles CA 90024-1732
NEW WAY TO TEACH COST CONTAINMENT AND PROPER TEST UTILIZATION
The practice of ordering an extensive battery of tests to rule out a long list of possible diagnoses has been passed from faculty to residents, interns, and medical students for many years and has been continually reinforced by increasing malpractice lawsuits. Diagnostic tests are responsible for approximately 25% of the nation's health care costs, and it is possible to reduce their rate of utilization by at least 30% without compromising patient care, a cost reduction of as much as $60 billion/year.(1,2)
MEDCASE, a multimedia software system designed to improve clinical reasoning and to promote cost awareness, was developed by two of the authors (Faramarz Naeim and Farzad Naeim).(3) Each case study was presented with a brief clinical history and physical findings. Students were asked to select one or several possible differential diagnoses and select a number of relevant tests or special procedures in order to narrow down the list of pathophysiologic processes and approach a final diagnosis. To be able to get the results of any test ordered, users were required first to answer why they were ordering the test. Test results were reported as text, graph, figure, or combinations of these. After the initial selection of diagnostic tests, users were then allowed to use the patient management and follow-up sections. Each case had three follow-ups, and each follow- up required additional studies or answers to specific questions. For each case study a budget was allocated.
MEDCASE was introduced to the UCLA second-year medical students in the Pathophysiology of Disease (PPD) course, and a request was made for voluntary student participation to evaluate this program and to work on two case studies. Of the total of 165 medical students, 121 (73%) participated. The majority of the students felt that the program promoted cost awareness (80%), helped them to learn PPD (92%), and was acceptable as a component of the PPD examination (60%). Most of the students (84%) agreed that the demand for providing reason(s) for selecting a test was helpful in obtaining more efficient test utilization. The students were divided into two groups: group A was provided with an allocated budget for each case and group B had an unlimited budget to work the cases up. Although the patterns of test selection were comparable in the two groups, the average dollar amounts per case were more in group B than in group A such that the differences in average patient cost between group A and group B students were $89 (9%) for Case 1 and only $12 (1.5%) for Case 2.
The strong support of the participants for an interactive case study education program that promotes proper test utilization and cost containment is encouraging and opens a new avenue for teaching medical students.
1. Schroeder,S.A., and Cantor,J.C. On Squeezing Billions - Cost Control Fails Again. N.Engl. J. Med. 325(1991):1099-1100.
2. Dranova,D., Shanley,M., and White,W.D. How Fast Are Hospital Prices Really Rising? Med. Care 23(1991):690-696.
3. Naeim,F., McCoy,J.M., and Naiem,F. A Computer-based, Problem Solving Case Study Program to Promote Cost Awareness. Bult. Pathology. Educ. 18(1993):43-54.
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Dr. Patrick C.J. Ward
Department of Pathology & Laboratory Medicine
University of Minnesota, Duluth School of Medicine
Duluth MN 55812-2487
Only 50% of my ex-sophomore medical students answered the survey as of today (presumably because of the stress of preparing for National Boards). I am enclosing all of these because I believe that there are some remarkable truths buried in these surveys regarding the use of laserdiscs for instruction in both histopathology and gross pathology. PathLab: General Pathology is dedicated strictly to principles of general pathology and contains approximately 1500 photomicrographs at various powers. PathLab: Systems Pathology is in preparation and should be published before the end of the year. l
Please feel free to dissect the data, collate, tabulate, and use in any way you see fit for the meetings in Vail. You might call Mike Engebretson to make sure that you get a copy of PathLab: General Pathology to review, available through C.V. Mosby. Sorry I cannot be there. I am subject to altitude sickness.
VIDEODISCS IN PATHOLOGY SURVEY
UNIVERSITY OF MINNESOTA, DULUTH
MAY 1995
1. When You Used PathLab: General Pathology To Prepare For General Pathology, Did You Find It Helpful?
Yes: 23 No: 2
Student 1
I did find PathLab helpful for review of general pathology. Looking back on it I could have made better use of it by reviewing for 10-15 minutes each day rather then trying to get an empty machine the week before a test.
Student 2
Too much time involved on material not covered proportionally on the test. Just way too much reading and too many pictures.
Student 3
Too many slides. Felt rushed to get through. Hard to do ~1000 slides with all the other stuff we have going on and expect to get much out of it.
Student 4
I spent a lot of time using PathLab. I would recommend scheduled lab times where one of you would be available in the lab to ask questions. Also would be helpful to have pathology highlights pointed out on slides. often its hard to tell from the description what is abnormal vs. normal.
Student 5
Very helpful, but in order to get through all the information in a timely fashion, less repetition and half the number of slides would have been adequate.
2. Would You Have Preferred Using A Microscope And A Class Set Of Microscopic Slides'?
Yes: 0 No: 28
Student 1
With the amount of material we are expected to cover on a daily basis I can't imagine that there would have been time to use a microscope. Besides that, there would be no way of knowing when the correct image was in proper view unless there was an instructor always available. I definitely believe that the laserdisc was by far more valuable and time conserving.
Student 2
I would like some use of microscopes, i.e. 1-2 class sessions. When I went out on preceptorship, we used microscopes to look at blood smears, urine samples, vaginal/cervical smears. They don't look like your nice, perfect slides. I'd like to see examples of what commonly is seen in clinical lab specimens.
Student 3
I have used a microscope extensively before medical school. While I believe that a microscope is the tool of choice for the expert, there is not doubt that the videodisc format is a superior method for student study and review.
3. To Review Histopathoiogy Using PathLab: General Pathology, Which Did You Prefer?
Barcode Access: 12 Computer Access: 9 Both: 3
Student 1
Bar-code access was by far my most preferred method. The time savings coupled with the ability to easily skip around the material were the main reasons for this. The computer access was best when viewing material for the first time, but even later in the year I found myself relying solely on the bar-code books.
Student 2
Bar-code pens don't always work--batteries, etc. Computer is quicker and also the words were helpful too.Student 3
Too often the bar-coder didn't work. Thought with the bar-code one could skip up to a certain section easily.
Student 4
For one thing, the bar-codes are often not working. Besides why use the book when its on the computer in front of you. The bar-code book might be good for reference, but that's about it.
Student 5
I used them both for different types of studying. The computer access the first time through and the bar-code access for review and studying for exams.
Student 6
Both are OK, but I liked being able to jump around easier and to have the text on the computer screen.
4. Write A Brief Summary Statement On Your Reaction
To Computerized Histopathology.
Student 1
Computerized histopathology is obviously the wave of the future. I commend all the efforts that have gone into this great undertaking. I would hope that the technology doesn't stop here. It would seem an obvious venture to also produce a CD-ROM version for computerized use. This advancement would allow students to purchase (or rent) copies for their personal use on their home computers. No longer would we be tied to the LRC or Path Lab waiting for a free machine. Also, we would have a valuable reference source constantly within reach.
Other additions that I would like to see would be the inclusion of more gross specimens, especially with the skin material covered by Dr. Ward. While Robbins provided some gross pictures many were in black and white and definitely left me wondering what a specific skin lesion would really look like. I'm sure that the skin lesions discussed in class would have been easier to understand, or learn, if I could have had access to gross pictures with which to make the proper associations.
Complaints? Only that at times there seemed to be voluminous pictures covering the same topic. While using the computer there was no way to bypass these areas of repetitive histological examples.
Student 2
I found it helpful, but not necessary. Because there were very few photomicrographs per exam relative to the huge numbers of potential slides to view, it was easier to look at the book's pictures, concentrate on the rest of the exam, and pray.
Student 3
I'm incredibly grateful. I have from friends at other medical schools who really struggle with slides and scopes. They never know if they're seeing what they're supposed to, etc. They always tell me how lucky I am to go to this 'user friendly' school where path slides are fun! Everyone, everywhere should have it.
Student 4
I feel that computerized histopathology is a great resource and I mention it to all prospective students as one of the schools highlights.
Student 5
I thought that this innovative approach was an excellent educational tool. If you were to specify certain areas to concentrate on for the exams it would be easier to develop lasting knowledge of the important information.
Student 6
I think I looked at more than 1000 slide, more than I would have seen using the microscope. The arrows, highlights, questions & answers were just enough interaction to make the disc very worthwhile. This is the best use of computers in education yet. A huge time-saver.Student 7
I think its such a big improvement over microscopes. It provides so much more than the pictures in Robbins. Its all at your fingertips. The big thing is the time one saves over conventional slides. We don't have a lot of time to spare, so the computers help. I think it exposes us to subjects we normally wouldn't cover that much. Independent study is good. I think the computer histopath puts us ahead of other medical schools in this area.
Student 8
the videodisc offered a very complete and easy to understand method of reviewing not only histopathology, but also basic concepts. I think what would help even more would be a set of case studies at the end where the students can quiz themselves (with answers, of course).
Student 9 (this is Student 3 of Question 2)
I think the videodisc atlas of general pathology is a great step forward for students. One doesn't have to scan a slide to find the pathology of interest. The monitors are generally of good quality and allow groups of student to study together as well as minimizing eye strain for students. I wish that there were some sort of self test feature built in where tissues could be viewed with a predetermined group and after analysis by the student the correct description could be shown.
5. Write A Brief Note On Your Reaction To Dr. Blomberg's Barcode-Accessible Atlas Of Gross Pathology.
Student 1
Loved it. Very good pictures, especially like when key areas ere highlighted on the next screen so I knew what I was seeing. I liked the organization and text. Was great for reviewing materials for the exams as well as explaining the slides.
Student 2
Too often he would describe the micro appearance of a gross section instead of what gross features we should concentrate on. Not too helpful.
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Dr. Susan Koethe, PhD
Dr. Carl Becker
Department of Pathology
Medical College of Wisconsin
Milwaukee, Wisconsin 53226
Our Pathology course runs for the entire second year, August to September. Our curriculum is fairly traditional and we cover a vast amount of the material in Robbins. The format of the course is lecture (ave. of about 5/week), case based learning sessions each Monday for two hours, some gross and microscopic labs, autopsies and each student does a one-on-one clinical pathology experience with their CBL preceptor. We have available for the students three separate question banks. One is a program developed by Dick Komorowski and some of the residents that has about 20-25 questions per section following most of the sections covered in class (some are stronger than others which resulted from the strengths of the program writers). Each answer for each question has an explanation accompanying it. Also, the program includes graphic material associated with many of the questions that enlarges to fill the screen when "clicked on".
We also use the Keyboard Publishing Quiz bank, Text stacks and Video index. Khang Ho our neuropathologist has developed a neuropathology program that the students use extensively. It is a question bank accompanied by pictures. The pictures are many of the same slides he uses in lecture and the students use this program usually close to the neuropath exam for review. This program is also used extensively by Neurology residents.
I encourage students to use the computers early in each unit as a way to become familiar with the vocabulary of the material that is going to be presented and as a preview of coming attractions. My feeling is that early in the unit the students are not as stressed (since the exam seems a long time off) and probably are in a position to take more in. I also urge them to go back to the computers about 2/3 of the way through the unit and this time use them to figure out what they know and don't know. I try to get the students to understand that the question banks are a very good "front-end" learning tool and to encourage them to not view the computers as a final quiz the day before an exam. We do not make available slides that are used in lecture and actually have very few slide based questions on our exams. I try to get the students to use the video index as a way to increase their visual skills in pathology. Some students seem to take to this while others can't be bothered.
We are finalizing a project we began this spring to allow students to dial into our pathology programs from home. There is a lot of enthusiasm among students to have this available. They will not be able to download material but will essentially have access to the screens. By making this available for home use we will save on having to increase the size of our computer lab (as you can see from the comments we continue to have problems with maintenance of the computers-maybe it's too many users) and can use the money for more software. As an aside, one of the students informed me at the end of this year that there was a pirated edition of your Keyboard publishing program in IBM format that he got from someone in Ohio and had copied for all the students in the class with IBMs!
We polled the students at the end of the year about their computer usage. Of 169 respondents, 76% used the MCW path program, 78% used the Neuropath program and 34% used the Keyboard publishing programs. More may have used Keyboard publishing yet not known what it was called. Also, the availability of the pirate edition is not factored in. Of the students who used the programs 68% felt that they contributed to their retention of information and 65% felt that the programs contributed to their ability to integrate and apply the information presented in lecture and reading. Attached are some of the comments we received from the students.
I'm looking forward to seeing the case studies for Pathology that I understand will be available through Keyboard soon. We are considering developing some of our own case studies that will include an E-mail component so students can talk to each other about the cases. I am looking forward to seeing what other people are doing and the demonstrations after your session in Vail.
Student Comments:
· Make it available for home use or over the WWW for access from remote sites.
· Great source to test my understanding of the material and to learn.
· I like to have as many pictures as I can get my hands on, so these were a good source of them. I can't wait to see you guys getting the stuff on-line so that they can be accessed from home.
· There must be a limit to the number of sources one uses to study for a class. There are only 168 hours in a week. It is impossible to study the text plus the lecture notes plus going to class plus doing the computer program plus studying for all your other classes.
· I liked the computer programs but only used them for a couple of units due to lack of time
· The program was fantastic. I took each test after reading each chapter and the corresponding lectures. It really gauged my performance and if I knew the material.
· Just fantastic! Although, the course directors need to get together and find some finances for some new computer equipment or for some continual maintenance. Computers breaking down definitely limited the use of the computer center by the students. I was in there frequently and often times students left because so many computers were down that there were none to be used.
· The programs were excellent, we need more computers though.
· They were good, but I just didn't have enough time.
· They were good and I would stress them to next years class.
· Most were good but I just didn't always have the time to do them
· These computer programs were excellent. They should be recommended to all path students.
· This saved me. I often find it difficult to keep my interest in studying, but the computer program almost made it fun by challenging myself to score well on those mini exams. I also knew then whether or not I would be reasonably well prepared for the exam.
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Dr. Donald J. Innes
Dr. Thomas W. Tillack
Department of Pathology
University of Virginia Health Sciences Center
Charlottesville, Virginia
HEMATOLOGY FOR MEDICAL STUDENTS: LEARNING WITH COMPUTERS
Teaching in medical school is changing. Although the estimated amount of medical knowledge doubles approximately every ten to twenty years, the challenge of medical education is not the volume of information which must be learned, but how the information is organized to facilitate learning and understanding by the student.
As the new tools of computer technology expand into our lives as educators, we need to utilize and evaluate this technology as it applies to medical education. The computer can be an effective tool for presentation and organization of information. The style and immediate interactive nature of computer presented materials appeals to the medical students of the 1990s.
Four modes of computer use will be described and contrasted: 1) Keyboard Pathology, annotated questions bank; 2) Basic Hematology - an integrated text, image and question format; 3) World Wide Web - a system of images and text and access to medical databases throughout the world and 4) the Internet - providing ready communication among students and faculty.
By the end of the second year of medical school, 100% of the class had an active e-mail address. Over 75% of the students used the Keyboard Pathology program more than 80% used the Basic Heme program. Actual use of the Internet and World Wide Web could not readily be evaluated, however was estimated at more than half the class. For most (67%) students the computer programs available for learning hematology were considered a valuable resource in their study. the majority of today's medical students find the computer to be a welcome addition to the learning armamentarium.
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Dr. Jana Raskova
Dr. David J. Foran
Dr. Robert L. Trelstad
Department of Pathology & Laboratory Medicine
Robert Wood Johnson Medical School
Piscataway/New Brunswick, New Jersey 08903
THE ROLE OF COMPUTERS IN A LECTURE-FREE PATHOLOGY COURSE
Jana Raskova, MD
Course Director
Nine years ago we introduced a major change in the format of the Sophomore Pathology Course. Instead of lectures the class was given learning assignments and guaranteed protected curriculum time for study. The assigned material was then reviewed and discussed in small groups, each with a faculty instructor. In response to students' and instructors' comments and experience, this course has undergone some changes and fine tuning. Currently it is based on weekly assignments on specific topics. Each topic is introduced by a general overview (one or two hours) on the first day of the week, followed on other days by a thorough review, analysis and discussion in two types of small groups (16 students per one instructor). One, Path-Talk lasts four hours every week; in an interactive setting the morphologic and pathophysiologic aspects of the assigned topic are discussed. This group also features Journal Club presentation by a student of a recently published, clinically relevant article. The other small group, Case Based Study (which lasts three hours) is based on the analysis of clinical cases, and focuses on the meaning and interpretation of laboratory tests, and on the correlation of abnormal laboratory values with pathophysiology and morphology. In addition we provide several laboratory sessions demonstrating gross specimens, and an optional autopsy experience. The course has been assigned 205 hours over a period of 15 weeks.
This new teaching concept brought a profound change in a student's approach to study. For the first time the student was provided with help and advice on how to seek and find factual information, rather than with the information itself. While freed from required attendance at lectures, students were made responsible for using their time effectively. Students found that they had to be not only prepared but also to be able to express, explain, and defend their understanding of the topic in front of their peers, and of their instructors. In the absence of the classical lecture, it was necessary to identify effective learning resources, appropriate to different study strategies. While a major textbook combined with images remains a corner-stone of a student's preparation, it became obvious that means of self- evaluation were a pressing need. It was, in this context, that the computer entered the scene. This was a very natural development. The earliest experience was with the use of a question bank. At present, the use of questions, both theoretical and image related still enjoys the greatest popularity. Based on our questionnaires and our ongoing discussions with students of the subject of computers in education we have learned that the "question-image-answer-reference" computer format is the one most helpful for their study. In general, our students fall into two groups with respect to the use of computer based problems and questions: most often individual students use "questions-images-answers" after they have studied the subject from the printed text to evaluate their understanding. Other students prefer to tackle the questions first to focus on the topic