E-learning in Medical Education and Blended Learning Approach

Education in a technological world: communicating current and emerging research and technological efforts
_______________________________________________________________________________________
A. Méndez-Vilas (Ed.)
E-learning in Medical Education and Blended Learning Approach
Dr. A. I. Albarrak
Medical Informatics Unit, Department of Medical Education, College of Medicine, King Saud University,Riyadh, Saudi
Arabia.
Introduction
Education has evolved from a material based process, where the instructor (teacher) focused on presenting information
to students, to a student (learner) centered process where students are able to learn at their own pace. Furthermore, the
student’s role has changed from being a receiver to a being a learner and the instructor’s role has changed to being a
mentor, guiding students to acquire knowledge and improve their learning skills [1]. The focus has shifted from a
teacher-centered model to a learner-centered one, offering stronger learning motivation and interactivity. Interactivity
maintains learner interest and provides a means for personalized learning and reinforcement. Evidence suggests that
e-learning is more efficient in most cases because learners gain knowledge, skills, and attitudes faster than through
traditional instructor-based methods. This efficiency translates into improved motivation and performance. In addition,
the use of e-learning is associated with improved retention rates and efficient use of content [2].
The main goals of medical education are to equip students and graduate clinicians with the necessary medical
knowledge and skills and to provide them with the strategies for their application in practice. The integration of
e-learning into undergraduate, graduate and continuing medical education has a significant impact on the delivery and
performance of medical education [3].
The rapid evolution and growth of information and communications technologies (ICT), and the rapidly changing
health care environment with advances in the biomedical sciences and in the diagnoses and management of diseases,
and the delivery of health care services, have led to the development of new services and applications. Furthermore, the
shift towards competency-based medical education and problem based learning, together with the increasing complexity
and volume of medical content, have increased the demand for continuing education and knowledge updates. These
have, in turn, created demands for new methods and approaches to medical education e.g. online continuing medical
education (CME) and e-learning [3-5].
E-learning can be defined as the use of ICT or the Internet in educational activities. E-learning is also defined as
learning mediated by technology, such as the Intranet, and multi-media based computer applications. E-learning
systems enable students to extend their learning experiences beyond the borders of a classroom by using both online
and offline learning resources. Such activities usually increase the interaction among students and between instructors
and students. Because of the nature of medical education, e-learning systems require specialist design to accommodate
more practical sessions, and more student involvement in medical procedures and operations. To provide medical
students with a productive e-learning experience, an e-learning system should be able to provide students, not only with
access to text books and lecture materials, but with both simulated and real life cases including medical history, lab
results, radiology images and other patient related information. These resources improve the students’ diagnosis and
intervention skills, leverage their learning outcomes and improve their learning capabilities at the same time as
improving their accessibility by utilizing ICT tools [6, 7].
History
The use of computers in medical education has been in continuous development since the early 1960s. Its adoption
however, has been limited by the programming process of entering data through punch cards and the limitations of
relatively primitive computer languages. Although the earliest attempts to apply computer applications in medical
education started in 1961, major developments in computer-assisted instruction occurred in quick succession in the late
1960s at several American medical colleges. Different terms such as “computer-based learning”, “computer assisted
education”, “computer assisted learning; CAL” have been used but the differences were basically semantic. Ohio State
University started a CAL application in 1967 as a one-terminal, one course system. In 1969 the program was
incorporated into the evolving Independent Study Program in the basic medical sciences and was called "TES" (Tutorial
Evaluation System). Production of lessons was to a great extent assisted by the development of the COURSEWRITER
III; a computer program that allowed an instructor to enter text in response to computer guidance without any need for
programming skills. Simultaneously, the Massachusetts General Hospital Laboratory of Computer Science began
developing simulations of clinical encounters. Employing a computer language developed for the purpose and a welldesigned instructional strategy, these simulations became highly sophisticated. By the middle of the 1970s, the
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Massachusetts General Hospital laboratory had developed more than 30 simulations with multiple cases within each
simulation [8].
The University of Illinois developed a different type of simulation model that was termed “CASE” (ComputerAssociated Simulation of the Clinical Encounter). A common feature of these systems was that they ran on mainframe
computers, accessible over telephone lines and with the capacity to time-share. The National Library of Medicine in
1972 sponsored a consortium to share these educational resources, paying the costs of access via a national computer
network. The Massachusetts General Hospital, Ohio State University and the University of Illinois served as hosts.
More than 150 institutions participated in this program. In 1984 an explosion of activity, that continues to date; was
undoubtedly prompted by the advent of the personal computer [8].
Modes of E-Learning
There are many approaches to implementing e-learning systems including distance learning which enables students in
different continents to obtain graduate and post graduate degrees remotely with no need to attend lectures in person [9].
Creating e-learning material involves several components. Once content is developed, it must be managed, delivered,
and standardized. Content comprises all instructional material structured in a meaningful way. Material could be linked
to a specific learning objective as a part of a specified curriculum. Examples of the instructional materials include
tutorials, PowerPoint™ presentation slides of lectures, case-based learning, hypermedia, and web links. Content
management includes all the administrative functions (e.g. storing, indexing, and cataloging) needed to make e-learning
content available to learners. Examples include portals, repositories, digital libraries, learning management systems,
search engines, and e-portfolios [10-12].
Content delivery may be either synchronous or asynchronous. Synchronous delivery refers to real-time, where all
learners receive information and communicate simultaneously. Examples include teleconferencing or
videoconferencing, Internet chat forums, and instant messaging. While in asynchronous delivery, the transmission and
receipt of information do not occur simultaneously, the learners are responsible for pacing their own self-instruction and
learning [13, 14].
A concept related to e-learning prior to the birth of the Internet was multimedia. Multimedia uses two or more media,
such as text, graphics, animation, audio, and video to produce engaging content delivered by computer. A detailed
definition of multimedia is “the combination of various digital media types, such as text, images, sound and video, into
an integrated multi-sensory interactive application or presentation to convey a message or information to an audience”
[15].
Applications of E-learning in Medical education
Due to the advantages of e-learning in medical education i.e. increased accessibility to information, better updating
solutions, personalized training, better distribution, standardization of content, better efficiency in achieving knowledge
and skills, it has been used more frequently in the last decade. The technological advances and the Internet contributed
to the development of the e-learning resources. In addition, repositories and digital libraries for access to e-learning
materials were established. Students greatly appreciate the facilities offered by e-learning (easy access to materials,
navigation, interactivity, friendly interfaces). But they do not consider it as a replacement for the traditional learning
which has its own advantages [16].
E-learning offers opportunities for flexible teaching and learning while enhancing the possibilities for more
individualized and self-directed learning. Technology mediated education modes have been used to overcome
geographic restrictions. Enhanced capacity for interactive teaching and learning is another advantage of e-learning. It is
believed that e-learning is better suited for problem based education, and can also be cost-effective. Studies have
demonstrated that technology mediated learning can provide cost savings for both learners and providers [17].
Technologies used in e-learning can vary from a simple audio-tape or a DVD to sophisticated multi point
videoconferencing facilities supported by simulation and online applications. In fact, international organizations such as
the United Nations (UN) and the World Health Organisation (WHO) have acknowledged e-learning as a useful tool in
addressing education needs in the healthcare sectors in developing countries. The United Nations’ Millennium
Development Goals have articulated the significance of use of ICT to address education and health problems in
developing countries [18, 19].
Integration of e-learning into traditional medical education can be effective in addressing most medical education
challenges [1]. There are various examples of successful integration of e-learning modes in medical programs around
the world. Technology has been effectively used to deliver learning material, enhance communication and
administration; there is also evidence that e-learning has been useful in providing health and medical education [20, 21].
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Preclinical & Clinical applications
The introduction of e-learning tools into medical education has made significant changes in the way medicine is taught.
It has become mandatory for the medical students and teachers to have advanced ICT skills to help them achieve their
goals in learning and practice and to be able to manage and utilize e-learning systems, and to gain more from the online
information and the Internet [4]. Computer applications in medical education have been developed to enhance
traditional education strategies, and to provide new methods of learning. For undergraduate students, asynchronous
delivery of curriculum for self-learning and to augment traditional classroom and lab sessions has been developed.
Computer-based learning can be applied in many ways such as drill-and-practice with immediate evaluation by multiple
choice questions; simulated cases with self-assessment; synchronous videoconferencing for small group teaching;
clinical training where the common “visit rounds” are replaced or supported by patient computer simulated programs;
simulation and animation applications; as well as searching the Internet for medical information; telemedicine;
web-based teaching tools and virtual reality [22-24]. In addition, medical students are provided with appropriate
practice in the form of live cases, clinical procedures, radiology image examinations and diagnosis, patient medical
history review, and other basic medical practices [1].
Continuing Medical Education for health professionals
Health professionals need to regularly update their knowledge of changes and advances in medical sciences,
technologies and techniques. This activity is often called continuing professional education (CPE) or continuing
medical education (CME). The overall use of online CME remains limited [25]. CME is usually acknowledged as an
indispensable part of the working life of physicians and health professionals. The use of the Internet and its related
technologies that augment knowledge and performance can be integrated into CME programs. Compared with
conventional learning, e-learning has the advantage that participants can choose the place and time themselves. Within a
clinical context, the effect of Internet-based CME programs is comparable to traditional CME approaches [26-28].
Internet-based CME is a response to the challenges of globalization and high demands in medical practice. Online
learning has a significant role to play in CME, offering personalized and flexible learning [24]. Core elements in
constructing an e-learning program include a bank of reusable learning objects, a virtual practice, and a set of learning
outcomes and self-assessment activities [28-30]. In the last decade many countries have legislated for the revalidation
and recertification of medical practitioners within their health systems. Two principles underlie CME: professional
development is a process of lifelong learning in practice, and professionals must be able to demonstrate they are
clinically competent in their roles.
Simulation
Virtual world software applications in education have grown rapidly over the past decade as academic institutions
around the globe sign up to develop a presence in those virtual worlds. Examples of virtual world applications are
Second Life (Linden Lab) [31], ProtoSphere™ (ProtonMedia) [32], OLIVE™ (Forterra Systems) [33], the Croquet
Consortium™ [34], and Open Wonderland™ (Open Wonderland Foundation) [35]. In these on-line worlds, users
choose an avatar (or virtual character) and interact in a three Dimension (3D) environment with other on-line users
controlling the character’s movements, actions and voice. Educational institutions, including medical schools and health
organizations, are developing educational activities to be taught to students in this environment. Recently there has been
growing interest by medical and public communities in using Second Life™ for public education, out-reach and
training [36, 37].
Virtual models for e-learning are defined by the European Commission as computer programs that simulate the
action of real devices and systems which help students to improve their theoretical knowledge and practical skills.
According to ToroTroconis M. et al [36], “virtual reality” is a computer simulation that creates an image of a world that
appears to our senses in much the same way as we perceive the real world, or “physical” reality. Virtual reality is a
medium by which people can share ideas and experiences. A virtual patient is defined as a specific type of computer
program that simulates real-life clinical scenarios where learners emulate the roles of health care providers to obtain a
history, conduct a physical examination and make diagnostic and therapeutic decisions [38].
Other virtual patient definitions include a broader range of techniques for medical educational purposes:
 Artificial patients or animal models (computer simulations designed to teach biochemical or physiological
principles on simulated models) [39]
 Human patient simulators (mannequins or interactive models reflecting human appearance, pathology and
physiology)
 Simulated patients (patient information simulated and stored in a database for student use)
 E-patients (use of real patient cases with different names to maintain anonymity, e.g. electronic health record
information)
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Virtual world patients (patient is a virtually generated character — an avatar — living in a virtual world
environment) [40].
Blended learning approach
Blended learning, a fairly new term in education, is an approach that combines e-learning technology with traditional
instructor-based education. The term blended learning may be new, but the concept is familiar to most educators.
Faculty, administrators and learners find that multimedia and e-learning enhances both teaching and learning. There has
been a general trend in education towards the blended learning approach employing both e-learning, and traditional
face-to-face classroom teaching with self-directed learning. This enables medical educators to design programs that use
the most appropriate learning modalities and technologies to stimulate and promote an effective learning process.
Examples includes a lecture supplemented with an online tutorial, a group assignment using a wiki, surgical procedures
(e.g. laparoscopy) via video streaming or the use of virtual online patients and robot technology [41].
Ease of delivery is the most often cited advantage of e-learning; it includes accessibility, easy updating, personalized
instruction, distribution, standardization and accountability. Accessibility refers to the user’s ability to find what is
needed, when it is needed. Improved access to educational materials is crucial, as learning is often an unplanned
experience. As updating electronic content is much easier than updating printed material, e-learning technologies allow
educators to revise and update content simply and quickly. In an e-learning environment, learners have control over the
content, learning sequence, pace of learning, time, and interactions, thereby allowing them to tailor their experience to
meet their learning objectives. Internet applications allow the widespread distribution of digital content to learners
simultaneously anytime and anywhere.
New and advancing technologies provide enormous opportunities for curriculum designers, teachers, students and
patients to engage in exciting and innovative learning experiences. As with any educational intervention, care must be
taken to ensure that the availability of technology enhances learning and is not just technology for technology’s sake. A
limited access to computers and communication technologies, and unreliability and unavailability of information
technologies (IT) infrastructure may mean that medical students have fewer opportunities available to them. The
selective use of e-learning as part of a blended learning curriculum enables medical students to engage with high quality
teachers and doctors around the world in both real time and at asynchronous learning events. As electronic and mobile
technologies become more widely available at reasonable cost, and as governments work collaboratively to address IT
infrastructure challenges, the use of such technologies in both healthcare and education will become more widespread.
The huge benefit of e-learning is that tomorrow‘s doctors will be digital natives, working to care for patients living in
rural and remote areas. These patients will have access to screening, preventive care, medical treatment and
management delivered in new ways by doctors who are familiar and confident in using a range of technologies as part
of their everyday practice [42, 43].
However, students do not see e-learning as replacing traditional instructor-led training but as a complement to it,
forming part of a blended learning strategy. Many universities are now developing full suites of undergraduate and
postgraduate programs in blended curricula that can, in part, be run on-line through asynchronous teaching (using
discussion boards and text based assignments) and synchronous teaching (using instant messaging, real-time audio
tutorials and teleconferencing). Such programs also involve face-to-face and practical sessions, deemed essential for
subjects like medicine, that require learning complex practical, clinical and communication skills underpinned by an
extensive knowledge base.
To complement the traditional teaching, interactive tutorials are developed on a teaching website or what is called a
Virtual Learning Environment (VLE). The VLE can contain, for example, clinical cases which are in a problem-based
learning (PBL) format that closely resemble real-life medical scenarios. Cases mainly cover the common cardiac and
respiratory scenarios, they may also include other common emergencies such as stroke and gastrointestinal hemorrhage.
Links are also available to useful educational sites and current clinical guidelines are provided with each case via
national or international organizations.
VLE or learning content management systems are a multi-user and multi-mode environment where learners may
create, store, retrieve, manage and deliver digital learning content from a central object repository. VLEs such as
Moodle and Blackboard are used to deliver e-learning strategies such as on-line courses to students, who are
geographically separated from the main campus or learning centre [20, 44].
Over the last few years, teaching software has been developed, that allows real-time and interactive learning to take
place in a virtual on-line classroom environment. Examples of virtual classroom teaching software includes Elluminate
Live!™ [45], Wimba™ [46] and DimDim™ [47], which allow the use of video and audio and can record PowerPoint™
slides and sessions on the Internet. Students have the ability to answer and ask questions via real-time text and audio,
and follow the instructor’s pointers on the PowerPoint™ items on the screen. These can contain text or images which
can be manipulated by the instructor or students depending on the pre-set permissions [48].
There is a huge shortage of qualified medical educators worldwide and universities have used virtual classroom
teaching software and learning management systems to involve a network of internationally based on-line faculty in
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course delivery, teaching basic and clinical sciences over the Internet. Employing the latest technology and software,
high quality on-line lectures are delivered to students locally and remotely [49, 50].
Discussion
Traditionally, education has been based on attending classes day after day, listening to a lecturer providing the
necessary course work information, and going through exams to assess knowledge. Education focused on the material
itself rather than the learner. The evolution of the e-learning environments and systems has changed the way medicine is
taught. Medicine, as a complex multidisciplinary field, has been implementing computerized technologies, with
e-learning being a central point of the process in many cases. These technologies include web-based education and
virtual reality (e.g. high fidelity human simulation). Web-based learning (WBL), for instance, can serve to deliver
educational programs efficiently to physicians who may be located far from each other and remote from full-time
medical school faculty [51].
The International Virtual Medical School (IVIMEDS; http:// www.ivimeds.org) and the Virtual Campus of King’s
College of the University of London (http://www.kcl.ac.uk/schools/medicine/about/learning/vc.html/) are examples of
e-learning training at undergraduate, residency, and continuing professional levels. The IVIMEDS consists of more than
30 partners in about 15 countries. They have agreed to share curriculum maps that link learning content and assessment,
learning resources including illustrations, video clips, animated diagrams, medical images, and virtual patients that
simulate authentic, high fidelity patient problems. The Virtual Campus of King’s College offers web-based systems that
provide learning and administrative support to medical, dental, and health sciences students. As more and more
institutions seek cost-effective approaches to optimizing the capacity of e-learning in medical training, there is no doubt
that these virtual universities will have an increasing appeal in the coming years [52].
Mobile health (mHealth) [53] and Moodle [54, 55] are examples of mobile health applications which can be defined
as the practice and delivery of medical and public health services by mobile technology such as mobile communications
devices (mobile phones and PDAs — personal data assistants), computers, communications satellites, and patient
monitors. The rapid rise in mobile phone penetration and the spread of these economical technologies means that these
technologies can be used in countries where physical medical access for rural populations is limited. This allows for an
improved ability to diagnose and track diseases and an increased access to healthcare and health-related information in
rural areas. Tomorrow‘s doctors will need to be aware of and familiar with using a wide range of such devices and
technologies, particularly when working in rural or remote areas of the world.
There is an increasing integration between traditional computer-based technologies and mobile communication
devices. M-learning (or mobile learning) is supported by a growing trend for medical students and young doctors
around the world to purchase the latest mobile smart phones (e.g. iPhone™ and Blackberry™) or PDAs for use in a
hospital or clinical environment with wireless networks, where bulky laptops are not as practical. The availability of
medical software and applications for these devices, such as the e-textbooks (digital copies of medical textbooks),
clinical skills videos (stored as a library for review), medical reference guides (e.g. PubMed), medical calculators (e.g.
for drug dosage, arterial blood gas calculations), medical dictionaries, medical study tools (Netter‘s flashcards,
diagnosis guides, mnemonics guide) and patient database software (track patient information for log books) have made
m-learning into an attractive, easy, flexible and cost effective option [56].
It is apparent that the advances in ICT and the developments in computer ability and e-learning systems can be used
to improve significantly both medical practice and education. Computer applications in medical education have been
developed to enhance traditional educational strategies, and to provide new methods of learning. For undergraduate
students, computer-based learning can be applied in many ways such as drill-and-practice where the material is
presented to a student and evaluation is conducted immediately by multiple choice questions. Discrimination learning,
where the student is asked to differentiate between two apparently similar sets of clinical findings, and clinical training
where the common ground rounds are replaced/supported by patient computer simulated programs; as well as searching
the Internet for medical information are all examples of ICT supported learning. In addition, conventional educational
content types also are still utilized in other areas, such as lecture notes, books, lecture presentations, examination
questions, practicals, scientific papers, graphs, images/videos, and simulators. Other educational content types unique to
medical education are teaching files, virtual patients, evidence based medicine documents, objective standard clinical
examinations, clinical guidelines, anatomical atlases, electronic traces of images, and others [1][57-59].
E-learning is not only great for learners but also for instructors as they can easily update information, it saves them
time and it provides a standard for education programs. In addition, e-learning, when used as a support for a traditional
lesson, can be seen as a tool which provides more effective education for people who have the same basic skills or share
the same background information. Improvements and the widespread use of computers, the Internet and other forms of
communication technologies have increased the use of these tools for educational purposes.
E-learning systems designed for medical education should overcome space limitations and simplify access to medical
information in addition to helping to overcome other medical education challenges. E-learning systems should improve
student involvement in medical procedures and operations, and access to life cases while paying special attention to
handling the privacy and security of patient data.
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