Kamin CS, Deterding RD, Wilson B, Armacost M, Breedon T. The development of a collaborative distance learning program to facilitate pediatric problem-based learning.
Med Educ Online [serial online] 1999;4,2. Available . from URL http://www.Med-Ed-Online.org
The Development of a Collaborative Distance Learning Program to Facilitate Pediatric Problem-based Learning Carol S. Kamin, Ed.D*., Robin D. Deterding, M.D*, Brent Wilson, Ph.D†., Michael Armacost, M.A†., Tom Breedon, M.A†., *University of Colorado School of Medicine, †University of Colorado-Denver
Abstract - Introduction. A team of pediatric educators at the University of Colorado School of Medicine teamed with faculty and graduate students from the University of Colorado-Denver to develop a prototype program to support medical students’ learning of national pediatric curricular objectives, regardless of their clinical location and variable patient exposure. Description. This hybrid Web/CD-ROM program allows “virtual” problem-based learning teams composed of four to five students and a faculty member to collaborate asynchronously through a digital video patient case. One prototype case has been developed and funding has been secured to develop a bank of cases to support the national pediatric curriculum. Discussion. Cases delivered by digital video provide a rich medium for visual and auditory cues to patient evaluation, which in turn encourage the development of visual recognition skills needed in clinical practice. Such cases also model appropriate professional behavior and allow students to solve clinical problems in authentic clinical situations.
Medicine has undergone unprecedented changes in this decade. Historically, goals of clinical curricula were achieved in affiliated university hospitals as students learned common problems from treating numerous hospitalized patients under the supervision of a clinical professor. This is no longer possible since patients spend less time in hospital settings, and physicians see more patients in shorter clinic visits. With the emergence of managed care, less than five percent of all patient/physician interactions result in hospitalizations.1 For students to learn and see common patient problems they must now be placed in community-based practices. Medical educators have been reforming medical school curricula with problem-based learning methods since the early seventies,2 but most of these reforms have taken place in the first two years during basic science coursework.3 More recently, national curricular standards for each specialty have been created and adopted by many clinical disciplines. Though the decentralization of clinical education increases exposure to general primary care, it creates difficulty in achieving curricular standards since students see different types of clinical problems depending on the site and there is variability in the quality of clinical teaching. Students in Pediatric Medicine have additional curricular challenges. Pediatric problems are often
1
seasonal; for example croup arises predominately in the fall and infant wheezing, called bronchiolitis, is predominately a winter occurrence. Because of this seasonal nature of pediatrics, the clerkship cannot assure that all students will have an opportunity to learn important pediatric diseases. Also, the Council on Medical Student Education (COMSEP) has reported that other essential competencies such as child abuse, genetic disease, and adolescent issues are not being adequately taught and seen during a limited six to eight week clinical clerkship.4 To respond to these changing conditions, educators at the University of Colorado School of Medicine turned to distance learning technologies. The purpose of this paper is to describe a prototype program and discuss early formative evaluation findings. A multi-campus team, consisting of a pediatrician educator, a medical educator, an instructional design professor, and two graduate students, was formed to conceptualize alternative methods of teaching and content delivery. The team secured funding from the University of Colorado’s President’s Office to develop a program and one innovative video case, delivered via CD-ROM using the Internet to support collaborative problem-solving from a distance. Digitized video cases required students serving in remote regions of the state to collaborate via the World Wide Web and solve realistic clinical problems based on key curriculum objectives
Kamin CS, Deterding RD, Wilson B, Armacost M, Breedon T. The development of a collaborative distance learning program to facilitate pediatric problem-based learning.
Med Educ Online [serial online] 1999;4,2. Available . from URL http://www.Med-Ed-Online.org
that correspond to the National Pediatric Curriculum. A problem-based learning model was used as the primary instructional strategy. We proposed to investigate the usability of video and distancelearning technologies and whether they could supplement the clinical experience of third-year medical students, thereby helping educators adjust to changing conditions in medical education.
The typical PBL case is a paper case that unfolds using a guided design method developed in 1969 at West Virginia University’s Department of Engineering and first instituted in a medical school at Michigan State.9 Case problems become knowledge structures or schemas, to which related medical knowledge can be attached. The case serves as a kind of cognitive scaffolding, allowing greater retention and integration of new knowledge.10 Experienced physicians use these knowledge structures, or illness scripts, as anchor points around which his/her thinking revolves.11
The traditional approach to medical education is based on a hypothetico-deductive approach to medical problems from a biomedical perspective. Less attention is given to peripheral dimensions of family, community, and preventive medicine.5 Physicians must be taught to see the unity among the three perspectives of human beings: as living organisms, as members of society, and as unique persons. Since first instituted in 1969 at McMaster University, problem-based learning (PBL) has been viewed as a powerful tool for addressing many of the problems associated with the traditional curriculum. PBL programs focus on the process of learning as well as its content, leading students to better apply their knowledge to practical situations. Using a student-centered approach, the purpose of PBL is to develop competencies in adapting to change, dealing with problems, reasoning critically, adopting a holistic approach, appreciating the other person’s point of view, collaborating in groups, and self-assessment.6 When learning is perceived as relevant, medical students are motivated to reflect on and be responsible for their own learning. Traditional PBL programs include tutorial groups of 4-8 students and a faculty facilitator. Problems (cases) are presented to the students, providing a framework for them to learn scientific mechanisms in the context of clinical problems and to self-assess by defining the limits of their current knowledge. Group members investigate learning issues independently, and report back to the group. The case provides a vehicle for integrating all parts of the patient problem, including behavioral and psychosocial factors, treatment, and prevention. 7 Information from many disciplines is integrated into the patient case, facilitating recall and transfer of that information to future related cases. The emphasis is on the process of multiple hypothesis generation, inferential or abductive reasoning,8,* and creation of student learning issues to be investigated, rather than the eventual outcome: the patient diagnosis.
2
A study conducted in Maastricht12 concluded that research needed to be conducted on case design, because in spite of the importance of problem effectiveness, “little is known about the criteria by which problems should be designed or improved.” Schmidt found that a well-structured case provided a focus to the process and improved learning regardless of the variability of the facilitator’s skill or expertise.13, 14 Combining PBL and Technology - A number of schools have reported innovative uses of technology in delivering content. Some schools have used digital x-rays and other visual aids that contributed to the realistic nature of cases, with the patient story presented in a textual format.15 Diagnostic Reasoning, a computer-based PBL text case, was developed at Southern Illinois University used on campus by individual learners rather than as a collaborative group.16 Northwestern School of Medicine used electronic discussion groups to support PBL discussions. Students have reported enthusiastic support for these discussion groups,17 but the groups did not connect people working in field settings, nor did they add online images or video to present the case. Outside of a PBL format, Georgetown experimented with a voice-recognition patient simulation in a presentation (large class) format with videodisc technology and found that because of the dramatic video portrayal, students were very involved in the case.19 While other medical schools have experimented with technology and PBL, this prototype provided a unique contribution with the combination of PBL groups, distance technology, and digital video cases delivered via computer. Project Rationale and Design Third-year medical students are in the phase of their education where they are acquiring experience in a supervised but authentic environment. Students
Kamin CS, Deterding RD, Wilson B, Armacost M, Breedon T. The development of a collaborative distance learning program to facilitate pediatric problem-based learning.
Med Educ Online [serial online] 1999;4,2. Available . from URL http://www.Med-Ed-Online.org
are to be exposed to prototypical patient problems, while developing their own style of patient assessment and treatment. Experience in an authentic setting is an important goal of the third-year curriculum. PBL has been used primarily as a teaching strategy during the basic science years with little existing literature about its use during the clinical years.19 PBL could serve as a valuable supplement to clinical teaching as a means of ensuring that students see the variety of conditions necessary to meet course objectives. Through online use of PBL cases, students could collaborate, solving clinical problems and pursuing self-direct learning over the Internet.
per-based. PBL video was obtained using actual patients in the clinical setting with their consent or by using highly scripted simulations of with actors. The video contains interaction between patient and parent, physician and other health care providers when necessary and the quality of it must be sufficient to include subtle attributes of the patient when needed. Digital video is a format usable on a computer. The technology of digital video has only recently improved to the extent that it is considered practical for projects such as this one.
The online cases in our program unfold using digital video rather than text because by the third year of training, students should begin to glean the information in a more realistic fashion. Students should begin to pick up on visual cues from the patient, especially when the patient is too young to explain the presenting problem. Physicians must recognize the visual and auditory cues to accurately diagnosis a child. Pediatric patients provide an additional burden on physicians with their underdeveloped communications skills and inability to provide accurate symptoms and history. Physicians must rely on the subtle signs of a patient in the initial assessment and physical examination.
L.I.V.E. (Learning through Interactive Video Education) denotes our program design for digitized video cases. Following this model, cases are progressively disclosed to students with digital video of patient/physician encounters from a CD-ROM. Multiple groups of 4-5 students at different clinical sites and a faculty facilitator discuss a case and teach each other material they have researched within the discussion section of the program. This blend of technologies requires students to work through the case individually and collaboratively. An important feature is that the distributed learning via the Web allows both students and faculty to participate asynchronously and choose the best time to work through the case. This is a critically important issue for students who dislike leaving patient interactions for scheduled meetings and for faculty who have numerous time demands during their day. Cases are designed using the Guided Design or Progressive Disclosure Model, allowing cases to progressively unfold over time causing students to labor with limited data and identification of individual learning issues.
The video presentation also helps students study the actions of the physician. Using actual videos, students can learn from the modeling of professional behavior and communication in difficult situations. Video provides a rich medium for visual and auditory cues to patient evaluation, through observation of both the patient and the consulting physician. The use of video offers some further advantages that help justify the costs of development. Video typically provides relevance and motivation to the instruction. Most learners prefer a high media to text ratio when working on the computer.20 In addition, video provides contextual anchoring by placing students in realistic situations. Just as the presented problem serves to anchor learning in a concrete case, so the video presentation gives a more concrete anchoring to the case details. With multiple examples this anchoring may facilitate the transfer of learning.21 The use of videotape to present cases is not a novel approach. Videotape is used by some schools to introduce a PBL case, but most cases remain pa-
3
Project Description
Standard program components independent of the case include the weekly schedule with deadlines and instructions about how to proceed through the case, a student page with pictures and e-mails of group members, and a help section (See Figure 1). While student groups change, the remainder of the structure is relatively stable, allowing easy input of new cases as they are developed. Session 1 - The case begins with the student’s assessment of the patient problem, signs, symptoms, and an initial history recorded via digital video from a CD-ROM (See Figure 2). The prototype case presents a child with shaken baby syndrome. After viewing each video clip as often as desired, a student goes to the “Postings” area and types in the facts
Kamin CS, Deterding RD, Wilson B, Armacost M, Breedon T. The development of a collaborative distance learning program to facilitate pediatric problem-based learning.
Med Educ Online [serial online] 1999;4,2. Available . from URL http://www.Med-Ed-Online.org
known about the case, initial hypotheses, and any learning issues or research the student would need to conduct or understand the case better. Once the student hits the Submit button, information is entered into the server database where students may read each other’s work. As students proceed through the case, they may return to the postings to reorder, delete, or enter new information. However, a new record is made in the database for each change so that the instructors may examine the reasoning of students as they progress through the case (See Figure 3).
complete one case per week during the six-week course.
After further history via the second video clip and postings, the student may perform a virtual physical exam (See Figure 4). In this section, students can select a focused examination or do a complete examination that includes video clips, text and still frame images of x-rays or other specialized tests. After completing the physical exam, students are asked to write orders just as they would in a real clinical encounter. Orders include instructions for monitoring laboratory or imaging tests. These orders are also entered in a database record. Finally, students sign up for learning issues that are independently researched between sessions. Between Sessions - After a period of self-study, students access the discussion section to teach each other about their learning issues. They also respond to probes that the facilitator provides the group based on student postings. The role of the facilitator is an important one to assure a meaningful discussion as well as provide cohesiveness to a virtual group. He/she must ask about student reasoning, synthesize discussion points, and encourage students to discuss the case with each other rather than simply report on it. Session Two - Students receive lab results and watch the resolution of the case as the actor/physician manages the patient providing a standardized model of care. Optional video clips of experts provide closure to the case and allow students to compare their reasoning and group discussion with that of experts. Finally, students are asked to complete an on-line evaluation of the case. A Web-based report of the postings of all students was available to the faculty at any point during the case. As additional cases are developed, students will
4
Study Design Our goal was to investigate the feasibility of digital video cases and to determine whether students would collaborate with each other using L.I.V.E. This process of evaluation and improvement of educational programs, known as formative evaluation, had product improvement as its primary purpose. All development projects of this scale require continuing input from end users concerning program quality and effectiveness. At various points in the development process, we conducted sessions with faculty, student and resident volunteers to gather input about the program and the case. The methods used included: expert review, direct observation by the project team who collected information on anecdotal record forms and student attitude surveys. Three content experts reviewed the case to verify its authenticity and accuracy in portraying a realistic clinical situation. Four residents worked through the computerized case individually with two trained observers for each encounter. Two groups of four students worked through the computer case as a face-toface group with trained observers in the room. Of the twelve students and residents, 11 returned evaluations to our office. Observers completed thirty anecdotal records. Lessons Learned We sought input regarding interface, video quality, and group interactions. This on-going feedback guided continued development. Upon case completion, we examined hypotheses and discussions to determine whether the case was too easy or too difficult for students. Attitudes were assessed by survey and observation. Screen Design and Navigation - Direct observation allowed the project team to view design decisions that failed to work well for the students. We discovered items about the case that we neglected to provide such as the age of the patient. We failed to provide enough instructions at the beginning of the program. Examples included the following: 1) some instruction was needed in operating the video controller on the screen; 2) when students used the
Kamin CS, Deterding RD, Wilson B, Armacost M, Breedon T. The development of a collaborative distance learning program to facilitate pediatric problem-based learning.
Med Educ Online [serial online] 1999;4,2. Available . from URL http://www.Med-Ed-Online.org
posting section to log on facts and hypotheses, they were unsure whether they were “allowed” to delete or reorder items; and 3) students wanted to know if they could take notes or replay the video.
through the case with others and seeing how others’ responses were different from my own.” Another said that the video more accurately portrayed how a patient history is obtained than text cases. When observed, students leaned into the computer as the video began and replayed the video several times, appearing very engaged. Residents asked why we were only making these for students and suggested residents would like to learn with them as well.
These suggestions will be incorporated into the program and we continue to learn new ways to make our project better by listening to our students. We will continue to use the formative evaluation process as we develop additional cases, expanding the number of faculty facilitators, and conducting more virtual groups. We expect the program to evolve in an iterative cycle of continuous improvement for the life of the program. Case Level - To ensure the case was not too easy or too difficult for third year students, hypotheses and group discussion were examined. The students did not include NAT (non-accidental trauma) in their differential or hypotheses even when given more information. This group was in the fifth week of the clerkship and had heard a lecture on child abuse the previous week. The lecture allowed students to recount information when prompted. They knew the legal issues, could list the risk factors, but they did not develop skills in applying or integrating this knowledge without the unprompted practice the case provided. First-year residents who worked through the case included NAT in the differential late in the program, but failed to order a CT scan which was critical to diagnosing this patient. Third-year residents had NAT in their differential or hypotheses lists early in the case and did order a CT scan. Third-year residents had seen child abuse cases in the hospital, the interns had rarely seen assessments of these children and students seldom participated in the initial discovery or diagnosis of child abuse because of time constraints or legal issues involved in these cases. These findings indicated that the case was written at the optimum learning level for third year students. It challenged them to apply knowledge in a realistic clinical setting. Given the open structure of the program, we were surprised to find that given a skilled facilitator, the program appeared to have instructional value for learners at different stages of training. The facilitator raised the level of complexity in the discussion based on learner responses. Student Attitudes - When asked what students liked best about the case, one student said “working
5
Technical Issues Networked computers were used to provide access to case presentations and to enable students to share insights and hypotheses collaboratively in asynchronous fashion. While the concept of online delivery was appealing, the costs of development were high. Months were spent reviewing and researching courseware available to avoid the expense of creating a custom-built program. Course authoring tools available were very limited in their interactivity and none provided a problem-based environment that allowed the on-line collaboration desired. Therefore, we created our own program or framework allowing the addition of new cases as they are developed. The program was created in HTML, with cgi scripts written with Allaire’s Cold Fusion to enable the writing and query into the Microsoft Access database residing on a Windows NT server. The most difficult technical challenge was figuring out the navigation between the CD-ROM and the Web. Macintosh computers have a standard letter name for a CD-ROM drive but Windows-based computers do not. Students started the program from a file on the CD-ROM drive; whenever they went to the Web by entering postings in the database, the frames stayed at the top of the page, enabling the return to the CDROM. By starting the program from the CD-ROM, the need to hard code the letter name or location of the CD-ROM drive was eliminated. The video was shot with a Sony DCR-VX1000 digital camera with scenes from multiple angles. In our prototype case, amateur actors volunteered to reenact the authentic case. A baby sedated for a procedure was used to portray a lethargic child. The video was edited in Adobe Premiere and imported into Terran Interactive’s Media Cleaner Pro for compression using a PowerMac 8500 workstation with a Targa 2000 board. The digital video necessitated using CD-ROM delivery because of the large size of the files. We compressed the video with
Kamin CS, Deterding RD, Wilson B, Armacost M, Breedon T. The development of a collaborative distance learning program to facilitate pediatric problem-based learning.
Med Educ Online [serial online] 1999;4,2. Available . from URL http://www.Med-Ed-Online.org
Cinepak at 320 X 240 screen size and flattened files for cross-platform playback. We have added a firewire card and QuickTime 3.0 to our workstation. New cases have been compressed with the new Sorenson codec at 29 frames per second. With new development tools increasingly available and the emergence of DVD-ROMs as a future playback system, all digital videotapes have been archived to take advantage of improved formats as technical standards change.
limits and potential of such technology-supported programs.
Future Development Our desire with this prototype was to move from the notion of the computer as a presenter of information to a system that supported collaborative learning. Therefore, instructional design was focused on integrating group work, problem solving, and faculty mentoring. This prototype project was designed to investigate the use of technology to support learning in a problem-based curriculum. It is believed that the video cases used in conjunction with problem-based learning and collaborative conferencing will create a rich environment for active learning.22 These distance-learning strategies may have important implications for other health care and educational disciplines. Other questions and development issues will be resolved in the near future as we proceed with more detailed investigations on the program’s effectiveness, the impact of video on student learning and attitudes, and the impact of distance learning on the quality of case discussions. We have recently received a three-year grant from the Fund for the Improvement of PostSecondary Improvement (FIPSE) to develop and disseminate a bank of video cases that support the pediatric curriculum. We agreed to develop a template that allows easier authoring and sharing of cases, as well as a program package that can be transported to other Internet servers at other schools. Faculty development will be directed at computer skills and on-line group facilitation skills that are critical to group functioning. We continue to investigate new innovations that support collaboration and realistic presentation of cases and believe additional development in this area is needed. Web and multimedia technologies seem valuable tools in this pedagogical effort. As the project progresses, we expect to better understand the
6
References 1. Shugars DA, O'Neil EH, Bader JD (Eds). Healthy American: practitioners for 2005, an agenda for action for U.S. health professional schools. Durham, NC: The Pew Health Professionals Commission, 1991. 2. Papa FJ & Harasym PH. Medical curriculum reform in North America, 1965 to the present: A cognitive science perspective. Acad Medi 1999, 7(2), 154-164. 3. Neame RLB & Powis DA. Toward independent learning: Curricular design for assisting students to learn how to learn. J of Med Educ 1989; 56(11), 886-93. 4. Olson A, Berkow R, & Woodhead J. The national general pediatric clerkship curriculum: Progress I implementation. Presented at the Annual Meeting of the Association of Medical School Pediatric Department Chairs and Council on Medical Student Education in Pediatrics, 1998, Bar Harbour, Florida. 5. Moore-West M, Regan-Smith M, Dietrich A, & Kollisch, DO. Innovations in medical education: Enhancing humanism through the educational process. In HC Hendrie & C Lloyd (Eds.), Educating competent and humane physicians (pp. 128-174). Indianapolis: Indiana University Press, 1990. 6. Engel CE. Problem-based learning. British Journal of Med Educ 1992; 48(6), 325-9. 7. Barrows H. Problem-based, self-directed learning. Journal of Amer Med Assoc 1983; 250(22), 3077-80. 8. Peirce CS. Application to the carnegie institution for support of research in logic, Memoir 19, On Arguments 1992 [Online link in Ryder (1995)]. 9. Wales CE, Nardi AH, & Stager RA. Emphasizing critical thinking and problem-solving. In L. Curry, J.F. Wergin & Associates (Eds.), Educating Professionals: Responding to new
Kamin CS, Deterding RD, Wilson B, Armacost M, Breedon T. The development of a collaborative distance learning program to facilitate pediatric problem-based learning.
expectations for competence and accountability (pp. 178-226). San Francisco: Jossey-Bass Publishers, 1993. 10. Albanese MA & Mitchell S. Problem-based learning: A review of literature on its outcomes and implementation issues. Acad Med, 1993; 68(1), 52-81.
Med Educ Online [serial online] 1999;4,2. Available . from URL http://www.Med-Ed-Online.org
TIME patient simulation model. Acad Med 1990; 65(5), 327-333. 19. Foley RP, Polson A, Vance J. A review of the literature on problem-based learning in the clinical setting. Teaching and Learning in Med (in press).
11. Schmidt HG, Norman GR, & Boshuizen HPA. A cognitive perspective on medical expertise: Theory and implications. Acad Med 1990; 65(10), 611-621.
20. Santer DM, D’Alessandro MP, Huntley JS, Erkonen WE, & Glavin JR. The multimedia textbook: A revolutionary tool for pediatric education. Arch of Ped Adolescent Med 1994; 148: 711-715.
12. Dolmans DH, Gijselaers WH, Schmidt HG, & van der Meer SB. Problem effectiveness in a course using problem-based learning. Acad Med 1993a; 68(3), 207-13.
21. Tessmer M & Richey RC. The role of context in learning and instructional design. Educational Technology Research and Development 1997; 45(2), pp. 85-155.
13. Schmidt HG. Resolving inconsistencies in tutor expertise research: Does lack of structure cause students to seek tutor guidance? Acad Med 1994; 69(8), 656-662.
22. Grabinger RS. Rich environments for active learning. In D. H. Jonassen (Ed.), Handbook of research for educational communications and technology (pp. 665-692). New York: Simon & Schuster Macmillan, 1996.
14. Gijselaers WH & Schmidt HG (1990). Development and evaluation of a causal model of problem-based learning. In Z.M. Nooman, H.G. Schmidt, and E.S. Ezzat (Eds.), Innovation in medical education: An evaluation of its present status (pp.95-113). New York: Springer Publishing Company.
Correspondence should be addressed to: Carol S. Kamin,Ed.D. TCH, 1056 E. 19th Ave., B158 Denver, CO 80218 E-mail -
[email protected]
15. Smolen AJ. Use of a multimedia clinical data repository in PBL education. Presented at Computers in Healthcare Education Symposium “Re-engineering Healthcare Education” April 1997. Philadelphia, PA. 16. Dorsey JK, Gocey J, Murrell K, Rinderer-Rand H, Hall C, & Myiers JH. Medical student response to an interactive patient simulation program used to supplement child abuse education. Child Abuse & Neglect 1991; 20(10), 973-977. 17. Altman M. (April, 1997). Electronic collaboration and PBL. Presented at Computers in Healthcare Education Symposium “Reengineering Healthcare Education” April 1997; Philadelphia, PA. 18. Harless WG, Duncan RC, Zier MA, Ayers WR, Berman JR, & Pohl HS. A field test of the
7
This work was supported by a grant from the University of Colorado Office of the President – Changing the Learning Paradigm Through Technology Initiative Acknowledgements: The authors would like to acknowledge the assistance of the University of Colorado Office of the President’s grant stated above, without which the development of our prototype would not have been possible. We would also like to acknowledge subsequent funding provided by the Fund for the Improvement of Post-Secondary Education (FIPSE) for the development, evaluation, and dissemination of additional pediatric cases to be used with this program. ___________________________
Kamin CS, Deterding RD, Wilson B, Armacost M, Breedon T. The development of a collaborative distance learning program to facilitate pediatric problem-based learning. *
Abductive reasoning is the kind of reasoning from partial information that professionals typically engage in. This is in contrast to the top-down, formal reasoning of deduction and the reasoning from particulars of induction. Ryder (1995) explained it this way: Philosopher Charles Peirce (1902) coined the term abduction to describe the nature of inquiry. It is the craft of Doyle's Sherlock Holmes or Eco's Brother William. Abduction does not lead to immediate conclusions, but it advances our understanding and allows us to move the inquiry forward. Signs are not data that can be neatly dismissed as true or false; instead, they provide hints and illuminate circumstances (see Shank, 1993). Abduction extracts meaning from ambiguous or indeterminate fields of data. The logic of signs is abductive logic.
8
Med Educ Online [serial online] 1999;4,2. Available . from URL http://www.Med-Ed-Online.org
Kamin CS, Deterding RD, Wilson B, Armacost M, Breedon T. The development of a collaborative distance learning program to facilitate pediatric problem-based learning.
Figure 1. Home Page for L.I.V.E.
9
Med Educ Online [serial online] 1999;4,2. Available . from URL http://www.Med-Ed-Online.org
Kamin CS, Deterding RD, Wilson B, Armacost M, Breedon T. The development of a collaborative distance learning program to facilitate pediatric problem-based learning.
Figure 2. First Video Segment Presented
10
Med Educ Online [serial online] 1999;4,2. Available . from URL http://www.Med-Ed-Online.org
Kamin CS, Deterding RD, Wilson B, Armacost M, Breedon T. The development of a collaborative distance learning program to facilitate pediatric problem-based learning.
Figure 3. Facts, Hypothesis, and Learning Issues
11
Med Educ Online [serial online] 1999;4,2. Available . from URL http://www.Med-Ed-Online.org
Kamin CS, Deterding RD, Wilson B, Armacost M, Breedon T. The development of a collaborative distance learning program to facilitate pediatric problem-based learning.
Figure 4. Physical Examination Page
12
Med Educ Online [serial online] 1999;4,2. Available . from URL http://www.Med-Ed-Online.org
