Lessons learned: developing e-learning to teach ...

Practical Teaching

Lessons learned: developing e-learning to teach physical examination Doug Knutson, Timothy Cain, Larry Hurtubise and Cynthia Kreger, The Ohio State University College of Medicine (OSU COM)

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edical education is changing. Traditionally, the pre-clinical years revolved around the lecture hall. Students, buried under textbooks and notes, looked forward to their clinical years, which gave them their first opportunity to interact with ‘real patients’. While these older techniques still continue, medical students in the twenty-first century are engaging with a profession where ever-advancing technologies put access to information and resources at their

fingertips, and many medical schools are embracing technology to augment and enhance their traditional teaching materials. The term ‘e-learning’ has evolved to describe all types of on-line or off-line computer-based study. Practical and resource considerations have driven medical schools to explore e-learning alternatives, as modern managed healthcare has shifted from the inpatient to the outpatient environment. This change has

made physician preceptors more geographically dispersed, so students have had to follow. In these circumstances, on-line technologies can provide an effective conduit for disseminating educational material among students and preceptors. These and other compelling reasons (outlined by Greenhalgh1 in Box 1) have helped to drive the development and implementation of e-learning resources in medical schools.

Many medical schools are embracing technology

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Content specialists and technical experts spoke different languages

Box 1. Why computer-assisted learning? Computer-assisted learning is inevitable – individual lecturers and departments are already beginning to introduce a wide range of computerbased applications, sometimes in a haphazard way. Planned and co-ordinated development is better than indiscriminate expansion. It is convenient and flexible – courses supported by computer-assisted learning applications may require fewer face-to-face lectures and seminars, and place fewer constraints on staff and students. Unique presentational benefits – computer presentation is particularly suited to subjects that are visually intensive and difficult to conceptualise. And ‘virtual’ cases may reduce the need to use human tissue in learning. Personalised learning – learners can progress at their own pace. Economies of scale – once an application has been developed, the incremental cost of offering it to additional students is relatively small. Competitive advantage – potential applicants may use the quality of information technology to discriminate between medical schools. Source: Adapted from Greenhalgh1.

Medical educators often struggle with the appropriate use of e-learning. Some computerassisted instructional materials are ineffective, but well-designed programs can be especially useful in teaching conceptually difficult subjects, or those topics with significant visual or auditory components. Some disciplines lend themselves naturally to the tools and techniques of the modern digital classroom (for example, anatomy, physiology, pathology, radiology, etc.), while others are more difficult to adapt. One set of skills in particular that has proved challenging to simulate in a web-accessible fashion is the physical examination.

TEACHING PHYSICAL EXAMINATION USING COMPUTER RESOURCES Our institution has created a computer-based, interactive resource to help teach physical examination. Over three years, the project team developed e-learning modules for eight body-system examinations (head and neck; lungs and thorax; cardiovascular system; abdomen; musculoskeletal system; neurological system; male genitalia; and female genitalia). The modules were embedded with media-

rich learning objects that allowed the learner to simulate physical examination experiences prior to actual patient encounters (for example, taking a blood pressure reading, distinguishing between normal and abnormal breath sounds, performing a fundoscopic or otoscopic examination, etc.). In other cases, digital video vignettes were developed and annotated to demonstrate various techniques. When completed, the resulting e-learning resource contained nearly 50 individual learning objects and over 45 video demonstrations. A demonstration of this project can be viewed at http://medicine.osu.edu/exam/. The project team has reflected on the development process, and the lessons learnt are worth sharing.

LESSONS LEARNT Lesson 1: IT people are from Mars, doctors are from Venus On our team, the content specialists and technical experts spoke different languages. The physicians had to work to understand IT language, and vice versa. Even when the physicians thought they understood a phrase or concept, their depth of knowledge was inadequate to truly under-

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stand an application. Table 1 identifies some key terms used by our technical experts in the development process that led to confusion, either in content or in context. The terms are followed by lay definitions and/or explanations that may help medical educators to understand the jargon. Table 2 identifies commonly used acronyms or terms that have different meanings in medical and technical settings. For those developing e-learning materials, expect miscommunication and some difficulty as the team members learn each others’ languages. To avoid frustration, we recommend devoting time at each project meeting to understanding and dealing with this problem. As with any project, recognising and working through communication differences will improve relationships and facilitate a timely project outcome. Lesson 2: Specialisation isn’t unique to medicine Just as neurosurgeons don’t typically deliver babies, so database developers might not have, say, well-honed graphic design skills. Assembling an inter-disciplinary project team with the appropriate mix of necessary skills can be challenging, and is dependent on the project itself. For our project, we wanted an interactive learning experience, complete with text, digital images, animation, sound and video, delivered via the web. Our initial team centred around one individual with skill in illustration, animation and specific expertise in MacromediaTM Flash, but our work came to an abrupt halt when the central team member accepted a technology position in another institution. After searching for someone with a similar skill set, we realised that finding a match was unlikely, and eventually filled the position by employing a multimedia design consultant plus part-timers with specific areas of expertise in illustration and design.

Table 1. Definitions and considerations relevant to e-learning in medical education Learning objects Self-contained, reusable pieces of information. Each educational objective may be taught using one or more learning objects. For example, if a goal of an e-learning tool is to teach auscultation of the heart, a learning object might be the text that outlines the component of each heart sound; another might be an animated, beating heart; another a file containing various examples of normal and abnormal heart sounds; and yet another might be a videotape or illustration of stethoscope placement. All these learning objects may come together on a single web page or module to complete a learning objective.

We recommend starting with an educational technologist

Server A computer or device connected to a local area network (LAN) or to the Internet that allows multiple, distributed users to connect remotely for the purposes of transferring data and files. While in development, an elearning resource may be installed on a development or testing server with a different capacity and abilities from the production server to be used to access the final product. Therefore, when educators pilot the program, problems may be encountered that are very worrying to the educators, but not to the technical specialists. These server problems are less likely to occur when the e-learning materials are deployed on a more robust production server. Streaming Internet technology that allows remote users to begin viewing audio or video files while they are being transferred rather than waiting for the download to complete. Whenever a student begins an on-line learning activity, data is delivered from the server to the student’s computer. In the case of multimedia, digital and audio video can be streamed from a server to enable the learner to begin viewing them before the typically large files have been completely downloaded. The quality of the video image, embedded sound and playback are related directly to the quality of the source material, compression rate, bandwidth of the connection and server processing capabilities. Bandwidth Refers to the volume of data that can be transferred across a network at any given time, typically expressed in bits per second (bps). For example a file of digital video content 20MB in size would take about 6 minutes to download completely using a modem connection (56 kbps), compared to a little over 12 seconds when accessed via a T1 (1.544 Mbps) Internet connection available at most institutions. Compression The process of reducing the size of an electronic resource (for example, data, image, video, audio files) to optimise storage, manipulation and delivery. Compressed files are easier to work with and to deliver remotely. The process of compressing video and image files can have a negative impact on quality for the end-user. Developers must determine the balance between efficient streaming of digital images and video, and level of detail needed to ensure adequate learning.

Table 2. Acronyms with dual meanings Acronym Medical meaning

IT meaning

CAD

Coronary artery disease

Computer-aided design

CF

Cystic fibrosis

Cold fusion

COM

College of Medicine

Component object model

CTS

Carpal tunnel syndrome

Clear to send

DTR

Deep tendon reflex

Data terminal ready

EOM

Extraocular movement

End of message

FTP

Failure to progress

File transfer protocol

HPA

Hypothalamic pituitary axis

High performance addressing

IM

Intramuscular

Instant messaging

IP

Intraperitoneal

Internet protocol

PDA

Patent ductus artreiosus

Personal digital assistant

PROM

Premature rupture of membranes Programmable read-only memory

ROM

Range of motion

For those interested in developing their own e-learning projects, we recommend starting with an educational technologist. In some institutions, this person might have an instructional

Read-only memory

design background, but in others, he or she might be more rigorously trained in computing and information systems. Explaining the in-depth proposal to this person will allow him/her to

identify the necessary team members. This might include a photographer, videographer, illustrator, animator, multimedia designer, and web application developer, depending on the specific objectives of your project. By consulting specialists early, a team can avoid the delays inherent in personnel shifts, which are all too likely to occur in today’s technology market. Lesson 3: Think about return on investment While this lesson seems obvious, it might be difficult to determine. ‘Investment’ may include money paid to developers and consultants, release time for content developers, and the opportunity cost of investing in one project rather than another. ‘Return’ may include money saved by using computer-based instead of faculty resources; income generated by the sale of the end product; the value of the enhanced reputation of the developing institution; and

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Our team actively sought feedback from various specialists and end-users

the value of reaching students who respond better to technology-based training. Some of these benefits may be incalculable. Because these costs and benefits are difficult to measure, educators need to ensure that

the product makes sense from a methodological perspective. If the project does not fill a need, fit into an existing curriculum and have the full support of the managing course director, the developmental costs will be wasted, and the team’s efforts

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may collect e-dust on the e-shelf. Developers should consider both increased efficiency and standardisation of learning. For example, our project included videotapes of physical examination

We learned our lessons the hard way

techniques that allowed students to view the demonstration as if they were in the front seat of a lecture hall. Reproducing this experience with a one-to-one faculty/student ratio would be extremely expensive. As another example, through using our cardiac module we are able to teach students the characteristics of several heart murmurs. This allows each student to hear the sounds, see an animated beating heart

and evaluate the murmur in a standardised setting prior to trying to do this in a clinical setting. Lesson 4: Be forward-thinking Forward thinking includes planning for the optimal distribution of workload. E-learning projects are very different from clinical research projects or other curriculum development projects. The rate-limiting steps for each aspect may be something about which a

physician educator has limited knowledge, or none at all. And many of these projects are the result of grant funding, the continuation of which is largely dependent on the successful and timely completion of the original project. It therefore makes sense to employ the skills of a project manager. Project management may be defined as the ability to apply knowledge, skills and techniques to a broad range of activities to meet the requirements of a particular project.2 This includes specific processes – initiating, planning, executing, monitoring/ controlling and closing; and specific project knowledge areas – project integration, scope, time management, cost management, human resources, communications and risk management, to name just a few. These skills are distinct from those that the physician or technical team members might have. Given even the most ideal conditions, projects stray from timetables and deadlines. Code needs to be rewritten, photo and video shoots scheduled,

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content developed, and problems with any of these elements can push a project off track. The work is not linear, and the rate-limiting steps might be out of the control of any one of the groups involved. A project manager can schedule the work to enable the team to use their time effectively. Being forward-thinking also involves being aware of technological advances expected to occur in the future. Medical knowledge changes almost as rapidly as does technology, and mixing these can be a recipe for obsolescence. Rely on the experts to select technologies and deployment strategies that can be predicted to be in universal use at the project’s endpoint. Determining what the technological future holds can be a guessing game, but the risk can be minimised by consulting your institution’s office of information technology, which can share the results of technology surveys and identify trends in your institution. Additionally, consult your technical team. They keep up with their industry in much the same way as a

physician might keep up with the field of medicine, through reading journals, attending meetings and searching the Internet. Lesson 5: Typos happen Employ a content management system that will maximise efficiency. A content management system is a web application designed to facilitate the creation and updating of the text seen on websites. In the early stages of our project, the technical team was responsible for uploading content. Typographical errors were identified by the content experts, then forwarded to the technical team for correction. To maximise efficiency, our technical team developed a web-enabled tool that permitted the content specialists to log in to a secure website and manage content directly. This saved enormous amounts of time, avoided frustration and gave the physician educators ultimate control of the content. For those unable to develop their own content management system, there are many available from software companies and technology consultant groups.

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Lesson 6: Get feedback early and often Throughout the development process, our team actively sought feedback from various specialists and end-users. The content from each module was reviewed for accuracy as it was developed. Course directors also reviewed the content and the learning method for each module to make sure it was in line with the intended curriculum. Once the team had completed the first e-learning module, we piloted it with a handful of self-selected students and colleagues to gain feedback. This invaluable step was used to retool, restructure and refine plans for additional modules. Each module was piloted in a similar fashion, and as each module was completed, we used a feedback outline developed by our educational and technical specialists to help in formulating other technical projects (see Box 2). Lesson 7: Have a ‘Plan B’ to hand Be ready for system breakdowns. Server problems, power outages and computer ‘crashes’ can wreck the best-laid plans. Our ‘Plan B’

REFERENCES

Box 2. Feedback outline

1. Greenhalgh T. Computer assisted learning in undergraduate medical education. BMJ 2001;322:40–44.

I) Getting started a. Develop objectives b. Develop strategy c. Storyboard student educational experience GET FEEDBACK FROM: course director, colleagues, educational technologist II) Develop a prototype (‘wireframe’)

FURTHER READING

a. Mimic the specific web pages that the student will see

Adams AM. Pedagogical underpinnings of computer-based learning. Journal of Advanced Nursing 2004;46:5–12.

b. Describe technical tools GET FEEDBACK FROM: designers, colleagues, IT office, students

Barker A. Faculty development for teaching online: educational and technological issues. Journal of Continuing Education in Nursing 2003;34:273–278.

III) Develop a module a. Input content b. Develop technology

Ellaway R, Dewhurst D, Cumming A. Managing and supporting medical education with a virtual learning environment: the Edinburgh Electronic Medical Curriculum. Medical Teacher 2003;25:372–380.

c. Test the following: i. Functionality ii. Usability iii. Educational efficacy iv. System requirements GET FEEDBACK FROM: course director, colleagues, technical experts, students

a. Test server performance b. Finalise usability testing and modify c. Develop leaders’ guide and FAQs GET FEEDBACK FROM: course director, colleagues, designers, students V) Deploy

b. Evaluate learning GET FEEDBACK FROM ALL INVOLVED VI) Revise

E-learning is here, and apparently here to stay. It may not be easy

Ward J, Gordon J, Field JM, Lehmann HP. Communication and information technology in medical education. The Lancet 2001;357:792–796. Wiecha JM, Gramling R, Joachim P, Vanderschmidt H. Collaborative e-learning using streaming video and asynchronous discussion boards to teach the cognitive foundation of medical interviewing: a case study. Journal of Medical Internet Research [electronic resource] 2003;5:e13.

a. Evaluate the technical performance

CONCLUSIONS

Hartmann J. An educational program in the medical uses of computers for rural physicians. Medical Reference Services Quarterly 1998;17:25–34. Romiszowksi AJ. How’s the e-learning baby? Factors leading to success or failure of an educational technology innovation. Educational Technology 2004;44:5–27.

IV) Compile modules

involved ensuring that our end product was available via both the web and on CD-ROM. If connection to a server is a vital requirement, then prepare for all eventualities; for example, if the production server is not very robust, allow for multiple access times. Additionally, allow students to work off-line or be able to access information in other formats while problems are being remedied.

2. Project Management Institute. A Guide to the Project Management Body of Knowledge, 3rd edn. Newtown Square, PA: PMI, 2004.

for medical educators to adapt to this pedagogical shift, but changes in medical education, and indeed the whole of healthcare, are driving forces that will not disappear. Our program was completed successfully via an open collaboration between departments and experts with complementary skills. We learned our lessons the hard way – by making mistakes and rebounding from them, but the things we discovered are helping immeasurably as we move into newer and more advanced technical applications and projects.

Webopedia: on-line dictionary and search engine for computer and Internet technology definitions. (http:// www.webopedia.com). Accessed 1 August 2005. Zucker J, Chase H, Molholt P, Bean C, Kahn RM. A comprehensive strategy for designing a web-based medical curriculum. Proceedings: a conference of the American Medical Informatics Association/AMIA Annual Fall Symposium AMIA Fall Symposium. 1996: 41–45.

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