Psychiatric Bulletin (2007) 31: 73-75. doi: 10.1192/pb.bp.106.010819
© 2007 The Royal College of Psychiatrists
Case-based online learning for medical undergraduates
Elizabeth H. Hare, Consultant Psychiatrist
Royal Edinburgh Hospital, Edinburgh EH10 5HF, UK, email:
ehare{at}lpct.scot.nhs.uk
Phillip Evans, Curriculum Development Officer
Edinburgh Medical and Veterinary College
Claire E. McIntosh, Consultant Psychiatrist and Honorary Senior Clinical Teacher
University of Dundee, Bannockburn Hospital, Stirling
Lindsay D. G. Thomson, Senior Lecturer in Forensic Psychiatry
University of Edinburgh
Declaration of interest
None.
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Introduction
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Online learning is a tool for teaching and assessing students but to date
it has been under-utilised in psychiatry. This article outlines the evidence
base for such approaches and gives an illustrative account of developing
modules for medical undergraduates on the topic of alcohol use and misuse.
This may act as a guideline for the development of other psychiatric teaching
modules.
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Computer-assisted learning
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Current medical students have grown up with computers and expect learning
materials to be available electronically. The use of computers in medical
education is a rapidly expanding field, with systems evolving from simple
computer storage of lecture notes to sophisticated web-based multimedia
interactive computer-assisted learning modules. An emerging approach is the
case-based model, where specific clinical problems are presented using audio
and video materials, including laboratory, pathology and radiology findings,
with animations, games, quizzes and immediate feedback on performance to
sustain interest.
Sporadic developments in computer-assisted learning have been made possible
by improvements in information technology and the input of enthusiasts
encouraged by positive responses from students
(Reid et al, 2000).
Reviewing the literature, Greenhalgh
(2001) found that prospective
randomised controlled trials in this field were too few and too varied in
methodology to permit meta-analysis. Nevertheless, such learning packages were
at least as effective as conventional teaching formats, and in some cases
achieved similar results at less cost of student time. However, not all
students are confident or interested in working with computers; moreover the
evidence base for cost-effectiveness is sparse. Psychiatrists have not been
prominent in this field (Letterie,
2003) and may thereby miss a valuable teaching opportunity,
particularly for integrating areas of psychiatry into other fields of
medicine. With increasing student numbers and decreasing numbers of
in-patients, there are few patients for student teaching, and developing banks
of virtual cases can help to address this need.
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Planning
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The development of high quality computer-assisted learning modules requires
a team that includes educators to help plan learning outcomes and methods of
assessment, clinicians to select and provide content, and creative technicians
to optimise visual impact and transform content into a variety of interactive
elements. The team has to meet regularly, to share ideas, check on progress
and maintain the momentum (Huang,
2005). Potential authors will find that looking at the work of
others is a guide to what is possible with today’s technology. For
contributors, the matter of intellectual property must be clear from the
outset and in universities the usual practice is for authors to receive
acknowledgement but not rights to royalties from the use of materials produced
though multimedia departments. Commitment of time is required, although
National Health Service (NHS) employers may well be unlikely to give
consultants extra sessions to do this work. The university may be persuaded to
finance the project, in particular the technician’s time. Given the
already crowded undergraduate curriculum, it is necessary to consult with
those charged with overseeing existing courses so that proposed online
learning modules can be integrated into the curriculum.
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Educational principles
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Educational principles must be given priority and include:
- relevance, reliability and validity of content
- clarity of delivery
- effective use of time
- appropriate assessment.
Medical students are strategic learners who will prioritise content that
will feature in their examinations (Reid
et al, 2005). Each module should address four to six main
learning outcomes which are selected to concentrate on key clinical topics,
particularly where technology can assist students in addressing difficult
concepts. Students should be directed to complete the modules at the relevant
point in the curriculum, and periods should be timetabled when computers with
internet access are available. Students may work individually, although many
prefer to work in pairs or threes, which they find enriches the learning
experience.
For each module, as with any educational activity, the rule of thumb is to
repeat information three times then check for understanding. Students, like
patients, can be switched off both by being told at length what they already
know or by being overwhelmed by too much information. So, having stated the
learning objectives, the minimum requirements should be to establish what the
student already knows, deliver the content and offer at least a final test. A
reference list and printable summary, including the student’s own
assessment of what they learned, may also add value (Cranfield Knowledge
Garden;
http://ollkg.rmcs.cranfield.ac.uk).
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Content
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Case histories
The use of case histories is a well established approach, with the patient
presenting with problems that are investigated: highlighting aspects of basic
science before proceeding to management. Some computer-assisted learning
modules have used the images and stories of real patients with their consent
(D’Alessandro et al,
2004). Clinicians may consider creating their own library, using a
digital camera and keeping a supply of consent forms available. However, there
is no absolute guarantee of online privacy, so to attempt to preserve
anonymity, tools such as Adobe Photoshop can be used to remove identifying
features of patients such as tattoos. Edinburgh University uses volunteer
simulated patients and the modules are held in a secure internet site which
overcomes many of the issues relating to confidentiality.
Technical considerations
As with Microsoft PowerPoint presentations, the content on each screen page
should be pared down; reading large blocks of text is difficult and it is best
to avoid users having to scroll down. Currently, NHS computers block the
‘streaming’ of video material so it may be preferable to use only
still photographs and brief ‘sound bites’ to allow students to run
the modules when on placement.
Interactive elements
To sustain attention and interest, it is preferable to interpolate every
couple of pages of plain text with quizzes, tables, flow charts and animated
diagrams. Students value variety, for example matching names with
processes/diagnoses, using short questions with model answers and answering
multiple-choice questions. It is most useful to give brief explanations of
answers, not simple statements of true or false. The mind is most willing to
take on new material at the point it has discovered it did not know. To
encourage the curious student, relevant internet links can be included, but
these have to be checked regularly to ensure they remain ‘live’.
For the purposes of refining modules during production, it is important to ask
colleagues and students to give feedback.
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Our project–alcohol use and misuse
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Alcohol is still the nation’s favourite drug and an increasing source
of morbidity and mortality among the general population as well as doctors and
students (Royal College of Psychiatrists,
1987; Plant, 2004).
Alcohol use can lead to or complicate presentations in any speciality and so
must be addressed at many points in the medical course. Since the General
Medical Council’s 1993 report, Tomorrow’s Doctors,
medical schools have sought to further integrate clinical and non-clinical
teaching, and interactive computer-based learning has assisted this
process.
E.H.H. became involved in the development of computer-assisted learning
modules after attending a course in medical education at the regional
postgraduate centre, and subsequently identified another interested specialist
registrar (C.E.M.). An analysis of the problems and issues arising from
alcohol misuse suggested that at least a dozen modules were required to cover
the whole range of alcohol-related morbidities in the short and long term.
Moreover, to dispel the stigmatising stereotype that patients with substance
misuse are impervious to medical intervention patients with good outcomes
would be included. We therefore mapped out a virtual soap opera: a series of
case studies based on a group of people who met at a wedding, covering:
- social costs
- alcohol metabolism
- recommended limits and dependence syndrome
- acute intoxication and addicted doctors
- drink driving
- self-harm and brief intervention
- detoxification
- delirium tremens and Wernicke’s and Korsakoff’s syndromes
- hepatitis
- portal hypertension and liver transplantation
- cardiac effects
- pathological jealousy.
This scale of project was made possible by Edinburgh’s pioneers in
the field, who have developed authoring software to assist translating content
into an interactive format.
Progress has been slow largely because of competing priorities for
clinicians and also technicians. However, the two latest modules have been
written by three medical students as selected study components and summer
projects. Plans to match the story lines with the appearance of topics in the
curriculum have been complicated by course reorganisation. Nevertheless, in
the 5 years since the project’s inception, nine modules have been
completed and a further two are well into development. Much time has been
invested but the finished products have tended to restore faith in
multi-disciplinary working. For example, we have developed an interactive
drinking diary that generates feedback on the health risks of different
patterns of drinking, and a diagram of the brain that changes colour when the
student selects the correct anatomical area responsible for the various
symptoms of intoxication (Figs.
1 and
2).
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Evaluation
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Novel educational interventions can be evaluated with as much or as little
rigour as new treatments or service developments
(Morrison, 2003). Evaluation is
essential as part of the production process and ideally should be undertaken
in the longer term to establish the cost-effectiveness of the work. Authors
can view an anonymised list of all answers submitted, which can help to
identify ambiguous questions. Our students are given ‘marks’ as
they progress through the module, but this does not count towards their final
course mark. The computerised nature of online learning can give information
about when, by whom and for how long these programmes are accessed. In the 8
weeks after the formal launch of the first two modules in the second year of
the undergraduate course, 60% of the students accessed the material and spent
a median time of 25 min on each visit. Evaluation of an earlier Edinburgh
series of online learning modules on the respiratory system suggests that
although textbooks and own notes remain popular, computer packages are
particularly valued as revision tools and the students who work through the
material for reasons other than revision are also the high achievers (P.
Warren, personal communication).
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Conclusion
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Even the best computer simulations will never substitute for the experience
of seeing real patients or for traditional textbooks, but they can
nevertheless form an engaging learning experience in psychiatry. They can be
deployed throughout psychiatric education and can assist in integrating
psychiatric teaching with that of other medical specialties.
Computer-delivered modules are popular with students, and although
time-consuming to produce, they can be repeated as often as the student
requires.
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Future plans
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Presentation of our project at the 2005 summer meeting of the Scottish
Division of the College has opened up discussions on sharing the modules with
all Scottish medical schools through the Scottish Deans’ Group. This may
provide an opportunity for evaluating the series as a whole. Similar
techniques are equally applicable to post-graduate education; the Royal
College of Psychiatrists is developing online materials for psychiatrists to
use for their continuing professional development and is actively recruiting
potential authors and reviewers. Anyone interested in contributing should look
on the College CPD online website at
http://www.psychiatrycpd.org.
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Acknowledgments
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We thank Dr Sandy Reid, the pathologist who pioneered online learning at
the University of Edinburgh and Ms Mary Hutchison and Jackie Aim, the
technicians who designed and developed the programme graphics, through
Edinburgh’s Learning Technology Organisation.
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References
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Top
Introduction
Computer-assisted learning
