Use of instructional technologies for medical education

Introduction

Medical education is a continuous process reaching from undergraduate study of anatomy to a call with a specialist when facing a difficult case as a practitioner. Learning in medicine is life long learning and needs deliberate practice of desired educational outcomes (Ericsson, Issenberg 2005). It is a field of theoretical and scientific knowledge but also of manual, practical and social skills . Thus in medicine, the educational needs are multiple in form and in level. They reach from quick, just-in time access to content (text or pictures) to sophisticated "fly-through" Virtual Reality systems inspired by military and from first-year medical students to highly specialized practitioners. This page is meant to give an overview of instructional technologies used in medical education today.

Challenges in medical education

Like in other fields, there is an exponential growth of knowledge of the human body, its structures and functions (Issenberg 2001) as well as a rapid development of sophisticated techniques in many application fields. At he same time, changes in medical practice (shorter stays in hospital, more acutely ill patients and limited instructors time) make bedside education, teaching and learning more difficult. Advances in technologies cause a shift from traditional hands-on medical actions towards computer-assisted manipulations and/or imagery, a trend that has to be taken into account for medical teaching and training. These issues can be adressed by the advances in educational technology, along with pedagogical approaches like problem-based learning, that can help educators teaching skills and molding attitudes (Issenberg 2001, Choules. See also Case-based learning, Medicine Blends Computers and PBL.

Medical education research

Today there is lack of scientific founded and sound comparative studies on educational developments in medicine. For example, a meta study about Problem-based learning applications could not be done for lack of high-quality studies (Issenberg 2005). There is a call for higher quality and consensus on basic terms and conditions in medical educational research. Each medical specialty looks only at its own litterature and seldom at other research (eg anaethesiologists look at anaesthesiology litterature etc...), not to speak of research other than in the medical education field (business industry, aviation and military).“There appears to be little awareness of the substantive and methodological breadth and depth of educational science in this field”(of high-fidelity medical simulation) (Issenber 2005). The Best-Evidence Medical Education (BEME) collaboration (Harden et al in Issenberg 2005) involves individuals, universities and organizations committed to promote evidence-based education in medicine. The goals are to produce systematic reviews of medical educational research studies, to disseminate information worldwide to all stakeholders and to create a culture of best evidence medical education. Outcome measurement tools for computer-based educational programs integrated into a curriculum (Issenberg 2005, Huwendiek 2009) as well as evaluation tools for elearning programs (Cook 2005) and virtual patients (Leong 2003)are active field in medical educational research.

Instructional technologies in medical education

Just-in-time learning: Searching for information

Repositories allowing to quickly find text or pictures and latest research findings are important, not only for students but also in practitioners life-long learning. this just-in time learning (Choules) has a set place in medical education. Link to some repositories: Medline of the National Library of Medicine in the US, many search sites that help doctors search in medline: eg for Switzerland univadis tellmed.

Virtual patients and multimedia presentations

Presentations of a patient or a case, in text only in a multimedia format, are a widespread tool in medical education. They are called "virtual patient". (Choules) Multimedia presentations also are used in many ways. They could present as a a video clip showing a particular symptom in image and sound, a flash animation demonstrating a cellular process, or an x-ray with comments on the findings (Choules). These multimedia presentations can be defined as learning objects (Ruiz 2006) that can be found in diverse repositories: Merlot, a site for online teaching and learning materials (not only medical) or the MedEd portal, a free peer-reviewed publication service and repository for medical teaching materials, assessment tools, and faculty development resources. examples of virtual patients sites: virtual patients ranging from text only interactive case presentation to video of a consultation or a web-based patient simulation authoring tool. These presentations can be used in tutorial sessions with small groups of students working on the case.

eLearning: on demand learning

elearning in medicine often includes virtual patients, simulation of a clinical case, but it also can be used for training of "attitude" basics (Choules). Computer-Aided Instruction (CAI) like interactive CD-Rom based software are useful for learning many topics repetitively. They can be used by the students any time at their conveninece as on demand learning. There are hundreds of programs available in many areas and levels. Example of a multimedia computer educational system is UMedic, a curriculum of 15 patient-centered case based programs for education in cardiology.

Simulation and Virtual Reality: meet Harvey!

Simulation in medical education reaches from role playing with real people over physical body simulation dummies(Issenberg 2001) to the virtual reconstruction of a patient's organ for "fly-through" exploration (Satava 1999) or to catastrophy scenarios involving dozens of participant "victims". Harvey is a cardiology simulation dummy and teaching device simulating a patient presenting a blood pressure, pulses and auscultatory findings. Harvey is often used together with UMedic and thus combines a physical simulation installation with a multimedia computer system including computer and video graphics, sound and real-time digitized videos (Issenberg 2001). The development of endoscopic surgery with minimal invasive action started a new field of technical developments around the images and the haptic ("touch") quality of the instruments. Working with a monitor, the surgeon is no longer directly looking at the patient's anatomy, his actions are no longer directly moving the instruments since there is a computer-assisted translation of motion. it is the idea of "...using bits instead of atoms" (Negroponte, from Satava 1999). Imaging technologies like magnetic resonance and computer tomogram or ultrasound develop as well as computer-assisted manipulation of the surgical instruments. This allows not only extremely precise microscopic or stereotactic surgery (eg in brain surgery) but a natural consequence is that the surgeon no longer needs to be directly next to the patient (telepresence surgery).(Satava) All these developments also bring with them the possibility to transmit virtual reality, which also means practicing and learning in a safe and controled environment. One example is the PreOp endoscopic simulator (HT medical systems), allowing to practice different types of endoscopy on a dummy with monitor simulations and haptic feel of the endoscope. Another example is an anastomosis simulator (sewing arteries, intestines or other tubular organs together)measuring hand position, pressure on the instruments and tearing forces on the virtual tissue (Raibert et Al, from Satava).

Synchronous and asynchronous communication - ask the expert

Trainig like elearning can be accompanied by forums, wikis and /or blogs that allow sharing experiences in cases where there is no evidence-based information readily available. For practitioners, specialists advice just in time by phone can be of great help as well as asynchronous media like blogs and forums.(Choules) These technologies also play an important role in integrated or blended learning scenarios.

Formative assessment, evaluation

Simulation Simulation technologies are used in many different fields from flight simulators to managment games, nuclear plant personnel or military training and there is a growing body of evidence that simulation is an effective mechanism for education and evaluation (Tekian et al 1999, from Issenberg 2005).Simulations :

• program learner-specific findings, conditions and scenarios
• provide standardizes experiences for all examinees
• include outcome measures that yield reliable data

(Issenberg 2005). MCQOf course, less exciting tools like well-built MCQ remain an important tool for summative assessment. e-portfolios e-portfolios for formative assessment (see the Learning e-portfolio page) are a useful tool in th medical field (Choules). Virtual patients Virtual Patients can and have been used for examinations or certification. One difficulty is the fact that there are multiple correct scenarios(Choules). Standards There are organizations that aim at setting standards for the quality end evaluation of medical education, like the Outcome project, a long-term initiative by the Accreditation Council for Graduate Medical Education (ACGME).

Pedagogical scenarios

In medical education and specially during the medical sudies, the technologies described above are most effective when purposefully integrated into a curriculum. Existing web-based scenarios cover fields like patient care modules, residents educational modules for anaesthesiology, surgery (including simulations), cardiology (including patient simulators)and others. These programs must follow instructional design principles (Petrusa 1999). An example of a pedagogical scenario is the implementation of a four-year multimedia cardiology computer curriculum at six US medical schools (Petrusa 1999). Integration into a curriculum is one of the essential features for effective use of simulations (Issenberg 2005) and other multimedia computer-based educational programs. It also allows in-context evaluation of the effectiveness of the program. Outcome measurement of integrated computer-based curricula is one of the developing research fields (Petrusa, Issenberg 2005)along with other forms of development of blended learning (Schaffer 2004, Ruiz 2006, Pereira 2007).

Discussion

Instructional technologies in medicine have followed the recent technological developments, from complex 3D fligh-through simulations to role playing , elearning and a wide range of specialized information sources. Today, quantity of learning ressources is less a concern than quality and application of these multiple possibilities. Educational technologies will never replace bedside learning in real-life settings facing real patients (and oneself), but in the context of diminishing ressources in terms of patient contacts, time of trainers and possibilities to practice complex medical acts, they can offer means to build and evaluate meaningful pedagogical scenarios and standardized, safe and forgiving settings for learners of all levels and fields, and reliable assessment of the acquired skills.

References

Choules, A.P., 2007, The use of elearning in medical education: a review of the current situation.

Cook, D.A., 2005, The research we still are not doing: an agenda for the study of computer-based learning.

Ericsson, K.A., 2003, Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains

Huwendiek, S., 2009. Evaluation of curricular integration of virtual patients: development of a student questionnaire and a reviewer checklist within the electronic virtual patient (evip) project.

Issenberg B.S., 2001, Simulation and new learning technologies.

Issenberg B.S., 2005, Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review.

Leong S.L., 2003, Integrating web-based computer cases into a required clerkship: development and evaluation.

Pereira J.A., 2007, Effectiveness of using blended learning strategies for teaching and learning human anatomy.

Petrusa E.R:, Issenberg B.S., 1999, Implementation of a four-year multimedia computer curriculum in cardiology at six medical schools.

Ruiz J.G, 2006, Learning objects in medical education.

Ruiz J.G, 2006, The impact of e-learning in medical education.

Satava, R.M., 1999, Emerging technologies for surgery in the 21st century.

Schiffer K, 2004, Blended learning in medical education: use of an integrating approach with web-based small group modules and didactic instruction for teaching radiologic oncology.

Various links

Best-Evidence Medical Education (BEME)

Electronic virtual patients (evip) programme, european community bank of 320 repurposed and enriched virtual patients, also guidelines and how-to's.

Harvey, the cardiology patient simulator.

ivimed, the international Virtual Medical School, lead by numerous Universities (UK, Canada, USA, Finland...), and offering IMS and authoring tool, eg with virtual patient functions.

Medline of the National Library of Medicine, USA.

Merlot, a site for online teaching and learning materials (not only medical)

Outcome project, a long-term initiative by the Accreditation Council for Graduate Medical Education (ACGME) to ensure and improve the quality of graduate medical education.

PreOp, an endoscopic visual and haptic simulator (HT medical systems).

UMedic, a multimedia computer curriculum for cardiology, is a patient-centered system teaching patient histories, laboratory data and treatment. Can be used in combination with Harvey.

Visible human project, the complete, anatomically detailed, three-dimensional representations of the normal male and female human bodies.