Rheumatology Advance Access originally published online on March 10, 2006
Rheumatology 2006 45(9):1158-1161; doi:10.1093/rheumatology/kel077
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Development of an interactive learning tool for teaching rheumatology—a simulated clinical case studies program*
Department of Rheumatology, Division of Immunity and Infection, School of Medicine, University of Birmingham, Edgbaston, Birmingham and 1Technology Innovation Centre, University of Central England, Birmingham, UK.
Correspondence to: Dr Stephen P. Young, Department of Rheumatology, Division of Immunity and Infection, The Medical School, University of Birmingham, B15 2TT, UK. E-mail: s.p.young{at}bham.ac.uk
 |
Abstract |
|---|
 Top Abstract IntroductionDiscussionReferences |
|---|
Objectives. To promote independent self-study involving problem solving and decision analysis in the undergraduate medical curriculum, we have developed a series of interactive web-based clinical case studies.
Methods. An initial needs assessment was performed to determine students’ attitudes to e-learning. From these results we designed a series of 30 interactive case studies for delivery from a web-server.
Results. A survey of 59 undergraduate students believed that online teaching resources were a useful supplement to existing teaching and they could see a positive use for e-learning. The interactive case studies program was well received by a broad range of respondents (n=84) of different abilities and backgrounds who felt that the program was realistic and clearly presented in an intuitive manner.
Conclusions. The recent increases in numbers of medical undergraduates, the trend towards student-centred learning and the emphasis on patient-related teaching means a great pressure on teachers and resources in medical schools. The case studies program we have developed was effective and well received by both biomedical and medical students. This approach may provide a way to increase the exposure of students to clinical cases involving interactive diagnostic and treatment procedures, that mimic real-world scenarios, but with fewer resource implications.
KEY WORDS: E-learning, Rheumatology, Clinical case studies, Undergraduate education, Postgraduate education.
|
Introduction |
|---|
|
TopAbstractIntroductionDiscussionReferences |
|---|
Problem solving and decision analysis are essential skills for medical students and practitioners alike. The existing medical curriculum requires that medical students have a large factual knowledge base, and as such teaching has traditionally been through lectures and rote memorization paying little attention to nurturing key problem-solving skills. This discrepancy has been acknowledged in several reports which recommend that there should be a limit on the amount of factual information that students are expected to learn, and that students should be required to be active, independent learners and problem solvers [1, 2]. The Association of American Medical Colleges report put particular emphasis on the need for medical schools to take the lead in the application of information science/computer technology as a way of achieving these aims since computers are intrinsically interactive [3], facilitating the move away from passive learning.
We have taken this premise that technology may assist with the learning process and used it in conjunction with a more traditional approach to clinical teaching, namely short clinical cases studies. This latter method can elicit thought processes which can improve the problem-solving ability in both GPs and medical students when compared with factual knowledge-based questions [4].
We have developed an e-learning program that simulates real world patient scenarios. The users can question the patient in a natural way, examine the patient and their X-rays, and order laboratory tests before attempting a diagnosis and treatment. Our program avoids the ‘drill and practice’ mode of learning that has been a feature of many computer-based instruction programmes [3], and provides a method of teaching problem solving and decision analysis whilst promoting independent learning.
Needs assessment
At the University of Birmingham (UK), clinical rheumatology teaching is delivered to a wide range of students and professionals. With such a diverse learner population, we decided to gauge the response of our students to e-learning. Fifty-seven medical (years 3 and 4) and biomedical (year 3) students were canvassed on their opinions.
One-third of the students felt that e-learning was a good idea and a useful tool. A quarter of students felt that it would only be useful as a supplement to more traditional teaching methods and that face-to-face teaching was preferred.
The students expected a range of resources to be available to them, including previous exam papers and lectures. They were keen to see computer-accessible basic descriptions of the signs and symptoms of rheumatological conditions, media describing particular skills and techniques including clinical pictures of rheumatological ailments and case studies which would allow them to integrate their knowledge and skills.
Many students felt that the ease of accessing online resources was a key determinant in their popularity and that it was important that the program worked smoothly and without fault. Five students out of the 59 questioned said they were not keen on e-learning at all.
Development of an electronic problem-based case studies program
For several years, we have used a standalone electronic clinical case studies program for teaching rheumatology. Over this time we have obtained extensive feedback about its function and the teaching requirements of the students. To make our program more extensible, facilitating the addition of new cases, we redesigned it using newer web and database technologies.
When a user requests the first page they are presented with the option of accessing the user guide or starting the actual program. From the main program, the user can navigate through a series of screens each dealing with a different aspect of clinical information. These include patient case history (Fig. 1) and simulated patient examinations, and they can order investigations, for example, radiology/biochemistry/immunology.
|
As the user collects information on the case, they are guided towards making a diagnosis and treatment regime. As the investigations are performed a pseudo-financial cost is incurred, the level of which is based on real costs of the various procedures charged by the relevant departments within the National Health Service Trust. After the user has completed the case study, they are provided with feedback on their activities, i.e. their expenditure and their prescribed treatment regime. They also take a formative assessment, in the form of multiple-choice questions, so that they can test their knowledge about a particular condition. The layout of the case studies program allows the student to repeat components or tests as the need arises. A key feature is the limit of three suggestions at the diagnosis stage. If an incorrect diagnosis is made, then the user is obliged to undertake further examination or laboratory tests. Immediate feedback on both correct and incorrect diagnoses aids this process.
Cases
There are currently 30 cases available: rheumatoid arthritis (4); lupus (3); Sjögren's syndrome (3); ankylosing spondylitis (2); scleroderma (2); Reiter's disease (2); osteoarthritis (2); juvenile idiopathic arthritis (2) and one each of psoriatic arthritis, polymyositis, amyloidosis, polychondritis, adult-onset Still's disease, lyme disease, gout, giant cell arteritis, Churg–Strauss vasculitis and Wegener's granulomatosus.
Student feedback on the program
A questionnaire was built into the program inviting users to provide feedback. Data from 84 questionnaires were analysed for user satisfaction. For analysis purposes we subdivided the data into two groups. The first contained only undergraduates (31) and the second (non-undergraduates) included postgraduates, healthcare professionals and ‘other’ individuals who may have used the program (53).
The responses to the program were positive (Figs. 2a and b). Both groups agreed that the program was well organized and clear, the cases were of appropriate difficulty (complexity), that it was realistic and that they had learnt from it. Twenty-eight of the undergraduates and 38 non-undergraduates found the program useful enough to reuse in future.
|
Additional comments from undergraduate group included:
- ‘Made subject interesting – Enjoyed completing it!’
- ‘I found this programme extremely useful and interesting, being able to apply the knowledge gained in lectures and also learning as you go along.’
- ‘Very useful. Brings all knowledge from lectures together. Feel we understand it better now. Thank you.’
- ‘I found this programme extremely useful and interesting, being able to apply the knowledge gained in lectures and also learning as you go along.’
Comments from the non-undergraduate group included:
- ‘I am really amazed by the reality of the cases here. Please keep up the good work and please include more common cases that we can see in the hospital or even in the out-patient department or A&E. Thank you.’
- ‘I am an internal medicine registrar from Indonesia. I hope the cases will be added with other diagnosis and complication. This website is very useful for me and my colleagues, thanks a lot. Now I inform this website to my colleagues in Indonesia.’
- ‘My doctor is fantastic but she only has ten minutes per patient and now I know more about rheumatoid arthritis’
- ‘I am an internal medicine registrar from Indonesia. I hope the cases will be added with other diagnosis and complication. This website is very useful for me and my colleagues, thanks a lot. Now I inform this website to my colleagues in Indonesia.’
The pseudo-financial cost incurred throughout the exercise was widely praised by both groups. A small number of respondents said that they would like to see more cases added to increase the range of conditions covered.
Summative assessment
As part of our undergraduate teaching we have used the case studies program as a component of a formal summative assignment. Thirty-six students were asked to produce a brief written report based upon one of the clinical cases. As part of this assessment the students were expected to:
- Apply their investigative skills to diagnose a range of clinical rheumatological conditions.
- Explain the use of a range of clinical and scientific investigations that are required to make a successful diagnosis.
Reports were marked by two independent rheumatologists according to the reporting of the approximately 30 pieces of information or actions relevant to the case, which they were able to find, and the explanation of how these were used in the diagnosis and treatment. Student marks ranged from 55 to 95% with the majority of students gaining 70% or more on their assignment reports. All students achieved both the learning outcomes, indicating the usefulness of the approach used.
|
Discussion |
|---|
|
TopAbstractIntroductionDiscussionReferences |
|---|
Problem-based learning (PBL) is an important educational approach which aims to promote student-centred active learning with focus on questioning, critical thinking and problem solving. This involves the student working out what they need to learn about a particular task and how to apply their knowledge to it. In PBL, information is collected in small sections little by little, synthesizing and building knowledge. However, there is actually no necessity to derive a final solution to the problem, it is the process of learning how to learn which is the important factor [5, 6].
One of the most common forms of PBL used in medicine is the clinical case study. These are often real patient cases which have been transcribed and made anonymous. It has been suggested that these may provide a stronger sense of the patient as a person, thus promoting clinical communication skills, while problem solving may help develop better clinical reasoning skills [7]. Narrative or ‘story-telling’ cases have been used to good effect [8]. Interactive programs have also been gaining popularity [9].
For many years, we have successfully used interactive computer-based training for teaching rheumatology. Our program provides an effective way of maximizing the impact of rheumatology by making the teaching more effective, promoting student-centred learning and enhancing clinical knowledge [10]. The flexibility of our program allows students to use the simulated patients as a platform for experimentation, to try out different ‘what if’ scenarios, as has been reported with other simulation programs [11].
E-learning has found favour because it offers many advantages in educational settings. This is not only because of its ‘reach’ but also because of its inherent capability for non-linear interaction [12, 13]. Students can control the pace and sequence of their instruction and make personally meaningful choices which should help them in their understanding [11].
In our program, we present the information in different categorized screens, for example case history, biochemical data, radiology and interactive pictures of the patient which could be used to simulate a physical examination. At any point the user is in control of how they want to proceed in collecting the information, having the ability to ‘jump’ backwards and forwards to any point in the program. Feedback is provided to the user as they make their choices. There is a library facility with supplementary information to aid the user in their diagnosis and to educate them in aspects of the particular condition.
Interactive programs are designed to stimulate the learning process, if the program is too difficult to use the user spends more time trying to learn how to use the program rather than assimilating the information being presented [14]. All our respondents were happy with the way the program was presented, that is, it was clear and well organized.
All users of our program felt that they had learnt from the experience. Even though our formal feedback data is limited to a total of 84 responses, we were encouraged by the findings. This is due to the fact that the feedback and comments made by the undergraduate group were reflected almost exactly by those of the non-undergraduate group. This somewhat reduces any bias in positive response which could be attributed to the fact that the undergraduates were our own students.
When asked if they would use this program again, 90% of the undergraduates and 72% of the non-undergraduates felt that they would. The lower response in this latter group may have resulted from the fact that outside of our University network, users are only allowed to trial one demonstration clinical case.
Several authors have commented on the potential cost of developing CBT programs [9, 15]. The redesign of our program required the collation of new data (generously provided by our clinical colleagues), developing the website (approximately £5000) and hosting the website. To reduce the burden on resources we developed our program based upon template web pages. The patient data is stored in a database and is dynamically written to the web pages. In doing so, increasing the number of cases requires that the information is typed directly into the database and does not require highly technical skills to re-program the site. Maintenance and administration costs are therefore reduced.
Educational institutes have placed a lot of emphasis on using e-learning. This is because it fits in with the distributed nature of today's learning society and it can support the increasing size of the student population. It is available on demand (24/7); our students confirmed that it would be useful to have resources available over the web, so that they could revisit them in their own time. We have shown that our program is a useful tool at introducing rheumatology to our students. However, we are aware of the findings of the initial needs assessment. These showed that, although one-third of the students thought e-learning was a useful tool, a quarter of them felt that it would only be useful as a supplement to traditional methods of teaching, face-to-face teaching being preferred. Students expect a range of teaching resources to be available to them.
E-learning is a component of, but not a substitute for other forms of teaching, as was emphasized by Haq and Dacre [9]. E-learning is now seen to be a part of a blended educational approach which uses may different methods, that is a mix of e-learning, face-to-face elements and self-paced learning. We have shown that an e-learning tool for teaching rheumatology can fulfil some of the requirements of our students, and is a worthwhile supplement to traditional teaching.
|
Acknowledgments |
|---|
This work was supported in part by grants from the Arthritis Research Campaign, Birmingham Arthritis Appeals Trust and the University of Birmingham, School of Medicine. We are also indebted to many of our clinical colleagues who collaborated in providing the original case data for incorporation into the computer-based cases.
The authors have declared no conflict of interest.
|
Notes |
|---|
* http://webrheum.bham.ac.uk/casestudies
|
References |
|---|
|
TopAbstractIntroductionDiscussionReferences |
|---|
- Physicians for the twenty-first century. (1984) Report of the project panel on the general professional education of the physician and college preparation for medicine. J Med Educ 59:1–208.[Web of Science][Medline]
- General Medical Council. (1993) Tomorrow's doctors: recommendations on undergraduate medical education. (General Medical Council, London).
- Piemme TE. (1988) Computer-assisted learning and evaluation in medicine. JAMA 260:367–72.
[Abstract/Free Full Text] - Schuwirth LW, Verheggen MM, van der Vleuten CP, Boshuizen HP, Dinant GJ. (2001) Do short cases elicit different thinking processes than factual knowledge questions do? Med Educ 35:348–56.[CrossRef][Web of Science][Medline]
- Toohey S. (1999) Designing courses for higher education. (SRHE/OU press, Buckingham).
- Problem based learning: case studies, experiences and practice. (2001) (Kogan PageIn Schwartz P, Mennin S, Webb G (Eds.). , London).
- Bearman M, Cesnik B, Liddell M. (2001) Random comparison of ‘virtual patient’ models in the context of teaching clinical communication skills. Med Educ 35:824–32.[CrossRef][Web of Science][Medline]
- D'Alessandro DM, Lewis TE, D’Alessandro MP. (2004) A pediatric digital storytelling system for third year medical students: the virtual pediatric patients BMC. Med Educ 4:10.
- Haq I and Dacre J. (2003) Computer assisted learning in undergraduate and postgraduate rheumatology education. Rheumatology 42:367–70.
[Abstract/Free Full Text] - Williams C, Aubin S, Harkin P, Cottrell D. (2001) A randomized, controlled, single-blind trial of teaching provided by a computer-based multimedia package versus lecture. Med Educ 35:847–54.[CrossRef][Web of Science][Medline]
- Laurillard D. (1993) Rethinking university teaching: a framework for the effective use of educational technology. (Routledge, London).
- Chen SY and Paul RJ. (2003) Editorial. Individual differences in web-based instruction – an overview. British J Educ Technol 34:385–92.
- Graff M. (2003) Learning from web-based instructional systems and cognitive style. Br J Educ Technol 34:407–18.
- Clarke RC and Meyer RE. (2003) E-learning and the science of instruction: proven guidelines for consumers and designers of multimedia learning. (Wiley and Sons, San Fransisco, Pfeiffer).
- Vivekananda-Schmidt P, Hassell AB, McLean M. (2004) The evaluation of multimedia learning packages in the education of health professionals: experience of a musculoskeletal examination package. Nurse Res 11:43.[Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||