"A Hypertext Instruction System to Augment the Teaching of Electron Microscopy in a Pathology Residency Training Program."

Karlene Hewan-Lowe, M.B., B.S.
Emory University School of Medicine, Atlanta, Georgia.
Department of Pathology and Laboratory Medicine
Grady Memorial Hospital
Atlanta, Ga 30335
Ph #: (404) 616-7432.
Fax (404) 525-8158
e-mail: matkohx@gsusgi2.gsu.edu.


J. Morgan Morris, Ph.D.,
G. Scott Owen, Ph.D.
Hypermedia and Visualization Laboratory, Department of Mathematics and Computer Science, Georgia State University, Atlanta, Georgia.

Teaching of electron microscopy (EM) in pathology residency training programs has declined. Most residents in the Emory University pathology residency program rate the current level of EM teaching as either good or fair. Given the time constraints of a residency training program and the decreased emphasis that pathology residency program directors place on teaching EM, we believe that current EM teaching methods can be augmented by the development of an EM hypertext instruction system. Since EM is an ill-structured domain, design principles for the EM hypertext instruction system should incorporate the principles of cognitive flexibility theory as well as the key findings from an analysis of residents' questionnaires. Once the final version of the EM hypertext instruction system is implemented, it will be evaluated to see whether it did augment pathology resident training in EM and how pathology residents interacted with the system and give a notation to case designers.

The Society for Ultrastructural Pathology has expressed concern about the declining status of the teaching of electron microscopy (EM) in pathology residency programs. The society has yet to issue prescriptive methods for addressing this problem. A solution to the decline in status of EM teaching in pathology will not be immediately available since those electron microscopists who teach EM know little about the attitudes of residents to the use of EM in pathology and the attitudes of residents to current EM teaching methods in pathology residency programs. Our impression is that recent advances in molecular biology and immunohistochemical techniques have contributed to the decreased usage of EM as a diagnostic tool in pathology. Pathology residency program directors have responded to the decline in the role of EM as a diagnostic tool by decreasing the time and emphasis that is allotted for teaching ultrastructural pathology. In our opinion, this attitude of pathology residency program directors is short sighted. EM still has a role in the diagnosis of benign and malignant lesions, the validation of tissue immunohistochemical and molecular biology studies, diagnosis of viral infections and the evaluation of renal biopsies. Furthermore, competency in EM is still a requirement for resident certification by the American Board of Pathology. Given the time constraints of the pathology residency training program and the decreased emphasis that is placed on EM training by pathology program directors, we are interested in implementing a hypertext instruction system for EM that we believe can augment the limited amount of formal and informal EM teaching methods that are currently available to pathology residents in the Emory University residency
training program.

In the Emory University (EU) pathology residency training program, formal training in ultrastructural pathology consists of one to two lectures per year (Table 1). The goal of each lecture is to provide the pathology resident with a comprehensive review of diagnostic ultrastructural organelles so that he or she will achieve the level of competency in EM that is required for certification by the American Board of Pathology. Methods of informal instruction in ultrastructural pathology include review of relevant electron micrographs during case sign out and review of electron micrographs during case presentations at the residents' interesting case conference (Table 1). Additional informal EM teaching methods consist of independent study activities; such as review of relevant EM material in general pathology text books, EM textbooks
and atlases as well as journal articles.

Before we began the design of the hypertext EM system, we distributed questionnaires to the pathology residents. The purpose of these questionnaires was to elicit information from the residents about their knowledge of electron microscopy, their attitudes towards existing instruction in EM, their attitudes towards independent study methods in EM and their rating of existing teaching methods of EM. In addition we also wished to gain insight into the level of computer access and computer literacy that the resident body had.

There are thirty two residents enrolled in the EU pathology residency training program. Twenty six of these residents responded to the survey (Fig. 1). The age range of the responders was 26 to 44 years and the average age was 31 years. The summary of the residents' responses are shown in Tables 2 through 6. The key findings that were elicited after tabulating the residents' responses are as follows. The majority of residents state that the study of tissue morphology is their primary reason for learning EM. Most residents have never used an electron microscope. Although the residents are very familiar with EM requisitions, they are only somewhat familiar with other technical aspects of electron microscopy. Many residents are not very familiar with the interpretation of electron micrographs. The residents chose EM case review with a pathologist as the best method for learning EM. Computer-based instruction for EM was rated no worse than EM case presentation, EM lecture, EM material in videotape format and presentation of EM material at a national meeting. Computer-based instruction, access to a teaching set of electron micrographs, EM textbooks and videotape material were all rated as good independent study methods for EM. The residents' perception of the primary use of EM was in the evaluation of renal biopsies. Existing methods of teaching EM were rated as fair by the majority of the residents.

The responses to the residents' questionnaires indicate a favorable attitude towards the use of a computer-based EM information system for independent study of ultrastructure. Our immediate goal is to develop and test a prototype of the EM hypertext system whose design incorporates the key findings of the summary of the residents' questionnaires (Table 7). Another important design consideration is the structure of the EM information base. Electron microscopy is an ill-structured domain (Spiro and Jehng; 1989) because there is non-uniformity across the range of interpretations of electron micrographs; the interpretation of electron micrographs is context dependent and the diagnostic interpretations overlap because of the variable content and morphology of specific ultrastructural organelles in the cells of a variety of lesions. Interpretation of electron micrographs is a fundamental activity of diagnostic electron microscopy that requires cognitive flexibility to integrate additional information provided by light microscopy, immunohistochemistry, histochemistry and molecular biology with the features of a set of electron micrographs so that a rational diagnostic interpretation of a set of electron micrographs can be made. Spiro and Jehng have proposed that the organization of information in an ill-structured domain should be based on the principles of cognitive flexibility theory, a theory with wide applications (Spiro and Jehng; 1989). With a hypertext random access method, the EM information base can be structured so that during random access, information can be rearranged to present different instruction sequences as well as different conceptual perspectives to the resident (Table 8A). The implementation features of the Hypertext EM Tutor are shown in Table8B. Once the final implementation of the system is completed we wish to evaluate whether this EM hypertext system did indeed augment the pathology residents training in EM and how pathology residents interacted with the system.

References

Spiro RJ, Jehng J-C: Cognitive Flexibility and Hypertext: Theory and Technology for the Nonlinear and Multidimensional Traversal of Complex Subject Matter. In: Cognition, Education, and Multimedia: Exploring Ideas in High Technology, edited by D Nix, R Spiro, pp. 163-205. Hillsdale: Lawrence Erlbaum Associates, 1990.

Description of demonstration software

The demonstration software is implemented in Guide (Info Access, Bellevue Washington). The information base for this prototype consists of material related to granular cell tumors. Program design and implementation incorporate the design principles and implementation objectives that are shown in Tables 7 and 8A.
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