Online Medical Undergraduate Education

Online Medical Undergraduate Education Nicholas Harvey

Online Medical Undergraduate Education Introduction The use of computers and the internet has rapidly climbed over the last decade which has been followed by the snowballing implementation of various electronic services identified by the prefix ‘e’. Although they are designed with a view to making life simpler, the so-called ‘technophobe’ feels quite the opposite. However, the technophile generation are filling more and more seats on either side of the teacher’s desk and embracing this new paradigm in education with positive attitudes towards elearning (Sandars & Morrison 2007). But does this mean e-learning strategies should be globally employed? E-learning applications are certainly now engrained in medical curricula (Hege et al. 2007).

There is an argument that computers are too often used to simply present information with little consideration for tried and tested teaching principles routinely employed in traditional education (Eva et al. 2000). Van Merriënboer et al. (2004) concluded that elearning can even be perceived as a backward step in pedagogical terms. However, Harden (2008) is of the opinion that if e-learning is harnessed appropriately, ‘it can enhance the curriculum and help to address problems and challenges currently facing medical educators such as increasing student numbers, changes in medical practice and globalisation’. It is, therefore, important to critically appraise e-teaching strategies because of their ‘disruptive potential’ (Bridges 2000).

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This essay is a brief overview of e-teaching and e-learning focussing on undergraduate medical education from an evidence based perspective. Harden and Hart (2002) expressed concern that a blend of e-learning with face-to-face learning is important in medicine because of the practice-based nature of the subject. The aim of this essay, therefore, is to consider the efficacy of e-learning in the undergraduate medical curriculum to supplement current practices, not a total replacement of facilitator contact. It is important to remember that the technological advances do not change how we learn but aid in ‘removing the constraints on the kinds of learning experiences we can economically and practically create’ (Horton 2001).

Electronic Teaching & Learning The electronic delivery of teaching has several advantages over traditional methods (McKimm, Jollie & Cantillon 2003; Ruiz, Mintzer & Leipzig 2006). With the electronic provision of learning resources, an immediate learner-centred approach is possible with the ‘where, when, what and how’ under the control of each learner. This fourdimensional flexibility empowers the learner to decide on the subject, sequence and pace of the activities. This represents a shift away from Harden’s (2008) analogy of a ‘caged bird’, restricted by his teacher, towards a ‘soaring eagle’ who has freedom of choice and greater responsibilities. Web-based applications also offer the opportunity for shared resources and discussion and have proved a successful way of educating students from different countries and cultures (Evans et al. 2008). It is also worth remembering, however, that students learn in different ways and use of internet resources differ according to personality preference (McNulty et al. 2006).

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In order to be effective, electronic content requires systematic planning and application (Laurillard 2002). This takes time and most teachers feel that planning and implementing a web course is more time-consuming when compared to a traditional course (Christianson, Tiene & Luft 2002). Electronic resources also require different expertise and, as a result, e-courses may be difficult to achieve in small institutions and not all are equally effective (Friedman 1996). Because of these new challenges, in addition to traditional information technology and administration support, new roles have emerged such as education technologists and e-librarians who are able to offer specialist support (Ellaway & Masters 2008).

The worldwide potential of online learning has lead to international collaborations which are able to achieve a high quality online learning experience. The International Virtual Medical School (IVIMEDS) is a prime example of the economies of scale in online medical education (Harden & Hart 2002).

Electronic Teaching & Learning: Where and When? One of the greatest advantages of online resources is their accessibility. Wireless broadband coverage of many public places means the internet is accessible from a laptop in almost any urban area while some content is even accessible for mp3 players, mobile phones and personal digital assistants. The application of this technology has shown to be of benefit for students who can often feel isolated and pressurised whilst on attachments away from their teaching institution (Baker et al. 2001; Wheeler 2002). Unfortunately, noise and interruptions are not conducive to learning (Downs & Crum

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1978; McDonald, Wiczorek & Walker 2004) and may well be common in the environments in which these mobile learning (‘m-learning’) resources can be used.

Because the internet is always available, e-learning also allows students to decide when they want to access a particular resource. While this avoids clashes and supports the development of time management skills and self directed learning it may also be making it possible for students to take on a job whilst at university.

The flexibility, increased availability of computers and familiarity with them has lead to predictions of significant growth in e-learning (Russell & Russell 1999; Oblinger 2001). There is a danger, however, that these advantages may be outweighed by the promotion of individual learning leading to ‘the lonely learner’ syndrome (Harden & Hart 2002).

Electronic Teaching & Learning: What? Without content the technology is useless. In its most basic form, online resources may simply be copies of the syllabus, course objectives, lecture slides and summaries and elibrary content all of which students find helpful (Baker et al. 2001). In fact, in 1956 Freyberg demonstrated that providing students with written summaries of lectures benefitted learning. Currently, online access to the core materials described above is provided in all of the new medical schools in the United Kingdom (Howe et al. 2004).

There are now a plethora of institutional, regional, national and international web based medical resources that are aimed at patients, students and health professionals. As a result internet searches produce vast numbers of results (Haq & Dacre 2003) and the

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quality of the actual information and delivery of it is variable and very difficult to rate objectively (Burd, Chiu & McNaught 2004). It is recognised that a system of identifying reliable and effective resources is required and agencies such as Health On the Net (HON) certify sites according to agreed criteria in an attempt to highlight sites adhering to certain standards (Gaudinat 2006).

Discussion so far has focussed on electronic resources of individual ‘learning objects’ of varied quality with which e-learning may occur. Learning objects can be didactic (text, audio, video, etc) or interactive (tutorials, forums, wikis, etc). Teaching sites are most effective if they implement a pedagogical approach that promotes active learning (McKimm, Jollie & Cantillon 2003). A review of websites by Alur, Fatima & Joseph in 2002 found that only 50% of medical websites promoted any of the components of critical thinking, independent learning, evidence-based learning, and feedback.

The decision of content is of major importance, but in medical education learning outcomes and curricula are the subject of constant scrutiny and refinement and usually nationally and institutionally agreed, respectively (Cumming & Ross 2007; General Medical Council 2003). It is the teaching processes of the defined syllabus that are critical if online education is to be more widely adopted in attaining the described outcomes through active deep e-learning. Ellaway and Masters (2008) described a continuum with content-focussed visual learning environments (VLEs) at one extreme and process-focussed at the other with most courses falling somewhere in-between.

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Electronic Teaching & Learning: How? It has been shown that the digital delivery of didactic teaching is probably as effective and acceptable as a live lecture for instance (Soloman et al. 2004). However, in the arguments above, and indeed in recent years, the emphasis is on how teaching processes can use a participatory, student-centred approach to motivate and promote active and self-directed learning. This, in part, has been driven by the General Medical Council (2003) with the aim of developing professional attitudes and transferable skills to support life-long learning.

Ellaway and Masters (2008) stated that e-learning aspires not only to be flexible, but to be engaging and learner-centred, encouraging interaction, collaboration and communication. Over recent years the evolution of the internet has lead to technologies such as blogs, wikis, podcasts, games and other forms of interaction. These are often referred to under the umbrella term ‘Web 2.0’ because initially internet technology was mainly text-based and did not promote interaction (i.e. ‘Web 1.0’). There is a resulting high interest in the exploitation of Web 2.0 technologies in online education although there is a lack of knowledge and skills regarding their implementation and use (Sandars & Schroter 2007). There are several e-learning management software packages (courseware) available which range from commercial packages such as Blackboard to free ‘open source’ courseware such as Moodle. These VLEs provide a platform to present tailored information and feedback in text, pictures, sound and video. This ability of sophisticated interaction between learners and the online environment has proven very beneficial, especially in terms motivation and reflection in action. Virtual patient

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cases are a good example of this and have proven to be a very effective method of teaching (Smith et al. 2007).

The other revolution, however, is that Web 2.0 technologies can also promote a transformation from simple networks of individuals into complex networks of learners through the use of ‘social software’ (instant messaging, online forums, blogs and wikis). The use of social software amongst young people is very common (Sandars & Schroter 2007) and encourages reflection, mutual support and sharing of information and experiences. An important consideration in implementing social software, however, is a debate highlighted by Ellaway and Masters (2008) that online participation does not necessarily represent e-learning. Therefore, the success of the student centred approach such as small group work including facilitated peer discussions and student delivered content in the physical classroom (Entwistle, Thompson & Tait 1992) does not necessarily translate to its electronic counterpart. Further research is required to fully answer this question.

Small Group Work The trend towards small group work over recent years affords this process more consideration in the context of e-learning in order to achieve the benefits already experienced face to face. The advantages evolve around the principle of participation and interaction in all stages of learning (Crosby 1996) compared to completely independent learning at the other end of the spectrum.

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Small group work is said to encourage participation, problem-solving skills and an awareness of other’s views. It also develops communication skills and encourages the student’s responsibility for their own learning (Crosby 1996). The latter promotes the holy grail of medical education: embracement of a career of life-long learning. Another opportunity of the personal contact in small group work, which cannot be underestimated, is role modelling (McA Ledingham & Crosby 2001).

Student communication and collaborative production of content (e.g. wikis) in VLEs are electronic substitutes for small group work. Peer-to-peer communication tools can be both synchronous (e.g. instant messaging) and asynchronous (e.g. forums) and are central to avoiding the lonely learner syndrome previously described. E-learning has the potential to fall towards the interactive end of the spectrum of teaching processes but, as already mentioned, there is no evidence yet that it can fulfil all of the important criteria. A benefit of e-learning is that it provides virtual interactivity and personalised feedback economically. This is at the expense of loosing true face to face interactions and, therefore, some of the possible benefits of small group work.

Problem Based Learning Since the constructivist potential of problem based learning (PBL) in undergraduate medical education was recognised in a book by Barrows and Tamblyn in 1980 and recommended by the General Medical Council in 1993 it has been increasingly implemented by medical schools. PBL can be thought of as a type of small group work that promotes deep learning of not only knowledge, but generic skills and attitudes (Wood 2003).

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The Web 2.0 technology such as online chat rooms, controlled access and timed release of supporting materials for PBL successfully complement many PBL courses. Entirety online PBL has also been successfully implemented (McConnell 2002; Ronteltap & Eurelings 2002) but this should be left to experienced hands (Ellaway & Masters 2008).

Reflection Schön (1983) described two types of reflection: reflection-in-action and reflection-onaction. Reflection-in-action occurs during a task to help us complete it. Reflection-onaction refers to a process of evaluating ones knowledge-in-action after the event. Grundy (1987) recognised that reflection on experiences is a key component of medical professionalism. Reflective writing refines this process further and promotes the integration of experiences with prior learning or triggers new learning (Eisner 1991). This process is important to undergraduates in addition to doctors because experiential learning is a stimulus for deep learning. Reflection also aids the conversion of implicit learning and tacit knowledge into explicit knowledge which is important when required to communicate this knowledge to patients and peers (Eraut 2000).

The internet blog is a relatively new but very popular internet fashion which utilises Web 2.0 technology (Sandars & Schroter 2007). The name is derived from a contraction of ‘web log’ and the technology is easily available free of charge on websites and is built into many VLEs. Blogs are used almost entirely for documenting reflection-onaction and can be utilised in education for encouraging reflective learning. Entries can

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be private or public, are fully searchable and allow comments so provide learning material for readers in addition to the author.

The Spiral Curriculum In 1960, James Bruner described the concept of a ‘spiral curriculum’ where subjects, topics or themes are continually revisited throughout a course to build a deeper knowledge and understanding. The ability of students to simply revisit electronic resources online at any time supports this process (Masters & Gibbs 2007). Because modern VLEs are not just simple collections of independent resources but highly integrated webs of information, students can very simply revisit learning objects if they identify a gap in their knowledge, skills or attitudes. In this instance the learning objects are referred to as ‘reusable’. For example, a tutorial on colorectal cancer may assume the student has a basic understanding of what cancer is because it was covered in the first year. Automatic linking of key terms (‘cancer’ in this example) will provide a link to a previous tutorial or glossary of terms so that the student can simply and quickly revisit the topic and meet the expected level of knowledge to begin the tutorial. This is a basic example of how a VLE can support a spiral curriculum but more sophisticated methods exist to identify previous learning outcomes that require revisiting such as a pre-tutorial quiz.

Assessment In addition to the use of electronic technology in teaching and learning, it plays an increasing role in both formative and summative assessment. Formative assessment in the form of marks or standard comments can be automatically provided to each user

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instantly. Users also have the ability to compare their performance in each domain or topic area and against a class mean. Areas in need of development may be highlighted and links to further educational activities provided. Results of assessments are also accessible to administrators so that they can assess progress and effectiveness of materials. Summative assessments can be used in much the same way but raise issues of security and heavy dependence on reliability. If enough secure and reliable computers are available in a moderated area there is potential for an extremely efficient examination process with marks available immediately. Electronic examinations also inherently support collaboration in creation and more efficient audit and quality control processes (Ellaway & Masters 2008).

Knowledge, Competence and Performance Assessment With regards to Miller’s pyramid (1990), e-assessment lends itself very well to the ‘knows’ and ‘knows how’ levels in the hierarchy of clinical competence. This may commonly be in the form of multiple choice questions (MCQs) or extended matching questions (EMQs) with most VLEs having the provision for this. Observed structured clinical examinations (OSCEs) are currently widely used to assess the ‘shows how’ echelon of performance (Harden & Gleeson 1979), which in conjunction with knowledge tests are used in an attempt to predict actions in practice.

Electronic assessments of the action levels of competence are less commonly used but show some potential. Implementations range from complete virtual patient cases to a station in an OSCE that utilises electronic content (Waldmann, Gulich & Zeitler 2008; Ellaway & Masters 2008). Virtual reality simulations also exist but are expensive and

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probably unnecessary at the undergraduate level because other acceptable and reliable methods exist (Engum, Jeffries & Fisher 2003).

Portfolio Assessment Stetcher (1998) described the portfolio as a ‘purposeful collection of work’ and can be used both as a learning tool and an assessment aid. In addition to notes, assignments and evidence of achievements of competencies portfolios usually contain reflective accounts for the reasons outlined above. The realisation that the portfolio is the only method of assessing Miller’s ‘does’ level of competence has triggered increased use in undergraduate courses.

With Web 2.0 technology it is very simple to employ web-based portfolios which achieve the same quality of content as paper-based portfolios but improve student motivation and ease of access for facilitators (Driessen et al. 2007). Electronic portfolios can also be self-generating to an extent by automatically logging electronic courses undertaken, quizzes performed, blog entries, etc.

Course Evaluation Evaluation of a course is closely associated with the evaluation of the students through level two (and to some extent, level three) of Kirkpatrick’s evaluation model (1959) and student assessment has already been discussed. The reactions of students (Kirkpatrick’s level one) to e-content can be evaluated by simply forcing each learner to provide feedback before completion of a topic is possible. This supplies more feedback which in theory is more representative. The number of students completing topics and the time

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spent on them is also monitored by VLEs and could be used as an indicator of engagement.

Conclusion Like any change in medical education, it should be brought about for the benefit of the student and/or patient but to the detriment of neither. Regardless of the methods implemented, a medical school curriculum should facilitate active reflective learning and promote life-long learning. As discussed, electronic teaching strategies have massive potential in these realms when blended with its traditional counterpart but each step of implementation requires detailed critical appraisal so that the benefits of traditional models are not lost. We must remember that medical students learn valuable knowledge, skills and attitudes from doctors, allied health professionals and patients in environments that could not be replicated in the electronic form. Above all we must remember that our vocations as doctors evolve around the patient so we must not divorce this association in medical education.

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