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A Model For Asynchronous Learning Networks In Medical Education

by Sloan-C

ABSTRACT
This study examines the feasibility of online clerkship programs, with a specific emphasis on how to effectively utilize asynchronous learning networks (ALN) in a pediatrics clerkship. A new model of web-based clerkship program is presented, and methodologies for constructing an online clerkship program are discussed. Participant ratings indicate that the online clerkship can be an effective way to enhance anytime, anywhere collaborative learning by medical students. A majority indicated that the experience enriched learning, improved retention, provided additional supports, and allowed students to work at times and places of their own choosing. We describe the potential benefits of the online clerkship to students and suggest additional ways to improve the traditional clerkship.

I. INTRODUCTION

Informatics and computer technology are proceeding at a very rapid pace, resulting in an increased use of computers in the health care industry. Hence it becomes necessary to prepare future physicians to meet the challenges of computer applications in medicine. Physicians and medical students at all levels are required to develop basic skills in the area of medical informatics and related computer technology.

The application of computer technology to medical education has traditionally been referred to as computer-based training (CBT), computer-assisted instruction (CAI) and computer managed instruction (CMI). In addition, computer technology in medical education includes all the activities that are involved in instruction and evaluation, administration of medical education programs, retrieval and storage of clinical information, and integration of computer technology into the medical curriculum.

In certain medical disciplines such as pediatrics, the application of computers has evolved toward interactive-type learning using electronic conferencing and clinical cases [1], [2], [3], [4], [5]. The advantages of the online pediatrics clerkship programs include providing improved and unlimited accessibility of information to students, allowing rapid feedback from faculty members and residents, and enhancing exposure to previous and current clinical cases including uncommon syndromes.

Developers have previously proposed online pediatrics clerkship programs. These programs typically do not provide total instructional components and are limited to syllabi, brief notes, discussions, or clinical cases [1], [2], [3], [4], [5]. Therefore, this study was designed to provide an online third year clerkship in pediatrics and to develop, implement, and evaluate a comprehensive model that includes instructional components for ALNs in medical education.

Objectives
The primary objective of this study is to determine the feasibility of computer technology solutions that will meet the demands of a high quality distributed learning environment relative to a pediatrics clerkship. In addition, an objective is to study the impact of the online clerkship using ALN with pediatrics clerkship directors, chief residents and third year medical students. Finally, this feasibility study discusses the need for flexible access to, and delivery of,online medical education.

Hypotheses
Table 1 presents our hypotheses.

Table 1. Hypotheses About Impact of Online Clerkship Learning by Medical Students.

A. Impact on Students
The online clerkship is a virtual facility for interaction among the members of a class, rather than interaction in a physical space. This virtual facility constitutes an environment that can be designed to facilitate collaborative learning among students, between students and faculty members, among teachers, and between students and other medical professionals. It may also allow participants to achieve independence in acquiring active learning techniques and accomplishing individual self-paced interaction.

In asynchronous learning, students may be required to use reflective thinking prior to answering or discussing issues [6]. They may participate at their own convenience, thereby making the program more applicable in meeting the demands of medical degree programs.

In campus-based undergraduate courses, technology has proven to be capable of providing a means for a rich and collaborative learning environment, thus exceeding the traditional classroom in its ability to connect students and course materials at anytime.

Collaborative learning activities include seminar-style presentations, debates, group projects, case study discussions, simulation and exercises, expert feedback, sharing of solutions to homework problems, and collaborative research plans that can be achieved by computer conferencing. Table 1 presents several related hypotheses about the impact of online clerkship learning by medical students.

B. Impact on Clerkship Director and Chief Residents
It is expected that the added workload will be significant in the developmental stages of online material, with gradual reduction in time and effort expended. Once these stages are completed, the clerkship director will have gained experience and will only be required to update the online material regularly. Thus, workload involved in a mature online clerkship will be comparable to the traditional clerkship. However, the amount of work for the online clerkship director is directly proportional to the number of students due to unlimited time for questions and contributions [6].

The use of a conferencing system avoids repetitious answering of student questions and is a time saver for students and teachers alike [7], [8]. Frequently asked questions (FAQs) can then be created, displayed and used to modify the course materials. Using electronic conferencing, students can answer and respond to each other which should save faculty time in a large class or lecture environment. Online grading of quizzes and assignments could save additional time.

1. Online Course Definition
An online program refers to web-based and collaborative learning where accessibility is not limited in time and place [7], [8]. The primary challenge involved in developing online programs is providing prospective students a clear understanding of the nature, features, and content of online programs. Since online courses and curricula are relatively new, there is considerable variety in the format, length, breadth, and in the quality of programs.

2. The Students
In most U.S. medical schools, students spend the third and fourth years of their training in hospitals or clinics. During this period, students rotate in pediatrics, medicine, obstetrics and gynecology, surgery, neurology and psychiatry clerkships. The Pediatrics clerkship at Vanderbilt University consists of eight weeks during which approximately 18 students are assigned to one of four patient care teams that are supervised by residents. Students collect patient history, perform patient examinations, and suggest treatment plans. In addition, they have clinical case discussions, and approximately thirty hours of lectures and seminars per rotation.

Table 2 shows expectations of students during the eight-week pediatric rotation period.

Table 2. Expectations of Students During the Pediatric Rotation.

In the traditional approach, students may be assigned in clinics, offices or hospitals at locations distant from the main campus. This necessitates long commutes to and from the medical school to attend lectures, seminars, and to get feedback to their clerkship questions. In the absence of online materials, students would be required to have constant sources of reference including books, review articles and handouts. When students are located in various clinics and hospitals, it becomes difficult to coordinate group efforts in problem solving and discussion.

Like any other clinical discipline, exposure to a wide scope of clinical cases and syndromes in pediatrics may be limited during the eight weeks of a traditional clerkship program. For instance, seasonal cases that are common during certain times of the year and other rare cases may not be available during the eight weeks training. Lastly, problems exist in terms of consultation with other specialists away from training locations.

3. Current Online Programs
There are several universities currently using ALN-based education programs [9]. Few, if any, medical schools utilize ALN-based learning in their clerkship programs [3], [10], [11]. At Vanderbilt Medical School, none of the medical disciplines use ALN-based learning in the clinical clerkships. Medical schools currently using online clerkships employ formats that are not comprehensive and are limited to syllabi, brief notes, discussions, or clinical cases. While these are effective ways to improve learning, a need exists to build and test a model for the online clerkship that optimizes learning, enhances multiple collaborative interactions, and facilitates anytime-anywhere learning.

4. Tools
Most of the current limited online clerkship programs are using simple HTML editors and synchronous online discussion software such as Net-meeting [3], [5], [10]. Table 3 presents the hardware and software tools used in this project.

Table 3. Tools Used in Pediatric Clerkship Program.

The system also provides students with on-line materials that include the following:

1. Goal of the pediatrics clerkship program
2. Syllabus
   • Ward team tasks & responsibilities - what students will be doing on the Wards.
   • Ambulatory pediatrics experience - in clinics or a private practice office
   • The core curriculum - the blueprint for learning pediatrics
   • Weekly departmental conferences - schedule for the Department of Pediatrics
   • Learning sessions - discuss cases and learn concepts with faculty members
   • Weekly reading assignments
   • Evaluation and grading process
3. Contents: this curriculum was designed for an eight week core clerkship. Each week includes
   • Weekly Pretest: this can be instantly graded
   • Objectives: a student will be expected to master the objectives during the week
   • Prerequisites: knowledge and skills required before the beginning of the week
   • Reading materials: includes textbooks, web sites, or review articles
   • Assignments: weekly tasks required of each student
   • Clinical problems: these include clinical images, simulation, audio or video
   • Chief's Rounds: chief resident's presentation and conference questions using audio and video
   • Feedback questionnaire: comments to help instructors improve the content of each week
   • What did you learn?: restatement of objectives of the week
   • Post-test: test given at the end of each week for student evaluation
4. Useful links: These are web site links that are highly recommended by faculty members. These consist of a mixture of journals, case simulations, review articles, and search engines. The links are periodically reviewed and updated based on the student feedback.
5. Frequently asked questions: the most frequent and general questions related to the site. A searchable database of FAQ's will be developed after acquiring enough questions.
6. Instructors information: the instructors of the clerkship and their contact information.
7. Feedback: includes feedback forms for students and faculty members for purposes of evaluating the program.
8. Search: keyword search engine within the clerkship Intranet.

II. METHODS

Since this study is intended be a model for an online pediatrics clerkship, data was collected from different sources. The goals of this curriculum in Pediatrics were taken from the general pediatrics core curriculum that represents the consensus of the Council on Medical Student Education in Pediatrics (COMSEP) [10], [12]. COMSEP consists of clerkship directors and a broad range of expertise, from medical students to pediatric department chairs.

Syllabus, contents (weeks 1-8) and useful links were collected from clerkship directors and chief residents. Other materials such as feedback forms and FAQs were developed simultaneously with the clerkship Intranet.

Text material was collected and built in this site using the Microsoft Frontpage98 editor. Chief's Rounds were presented by Power Point and Real Audio. A library was designed to be a database for the faculty presentations, multimedia (case simulations) and Chief's Rounds cases. This database includes previous and current cases and presentations.

To build sets of information, conventional materials (papers, handouts, slides, and presentations) were converted and uploaded in the web server. Software applications necessary to support the interaction and communications processes were prepared and packaged. These applications were finally implemented and tested to ensure that they worked well together. All materials and applications were made available constantly to all students and instructors in the network and PC's labs.

Desired student outcomes and needs were analyzed during the development stage. Weekly feedback questionnaires were designed to accomplish and measure the student outcomes. In addition the main page and secondary pages, including contents, were built and provided complete information about the course.

A. Experiment
The experimental design involved the layout of a model followed by testing of volunteer students, and collection of feedback and surveys from professors. Therefore a model for online clerkship was designed to include goal, syllabus, contents (weeks 1-8), conference, useful links, FAQ's, instructors and search engine. At the end of five and eight weeks, residents and attending physicians evaluated students' performances.

Sixteen students volunteered to test and evaluate the Intranet using the student feedback forms. A questionnaire was developed that measured student perception. Technical training was provided in both individual and group formats for students and instructors. Internet browser (Netscape and Explorer) and conference tutorials were added to the web site to complement the training. An online asynchronous help forum was made available to instructors and students so they could share information and discuss common problems.

Web site protection was achieved by creating usernames and passwords. The conference system was set to achieve maximum security. The following levels of security were selected:

1. Registration required - All users must register before entering a conference by providing name, email address, and a username and password.
2. User Approval required - Registered users must be approved by a conference moderator or administrator before entering a conference.
3. Forced session login - All users must provide a password and username to enter a conference.

Following approval by the system administrator, registered users receive email messages confirming their accounts. This information includes a registration page that should be referred to for accessing the conference, along with a login ID and password.

B. Evaluation Techniques
The primary purpose of this study was to assess student learning during an asynchronous course. To accomplish this, Clerkship Director, Chief Resident and student questionnaires were developed. At the end of the course students, Clerkship Director and Chief Residents were asked to write an evaluation of their experiences with the course addressing specific questions.

1. Student feedback
Questionnaires recorded responses from students, Clerkship Director and Chief Resident based on a five-point scale with 1= Strongly disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, and 5 = Strongly agree. Table 4 shows the ratings requested of students.

Table 4. Ratings Requested of Students.

2. Clerkship Director and Chief Residents feedback
The Clerkship Director and Chief Residents were also asked to evaluate the course and students' performance. Table 5 presents questions given to the director and residents.

Table 5. Evaluation Questions for Clerkship Director and Chief Residents.

C. Results
1. Table 6 presents the student feedback questionnaires (n=10).

Table 6. Results of Student Feedback.

The results of this study show that 100 percent of students agreed or strongly agreed that the online materials were accessible at any time and any place. At least 70 percent of the students agreed that their learning experiences were enriched, collaborative learning skills were improved, and additional support was provided. The results also show that 60 percent of the students thought this improved their retention of factual knowledge. Additionally, 50 percent of students agreed that the faculty members and chief residents were accessible online, and would recommend the online clerkship to their colleagues.

All the students who used the online clerkship preferred to access it between 8 am to 4 p.m. Seventy percent of the students spent 1-6 hours a week, while 30 percent of the students spent 6-12 hours a week. Twenty percent of the students disagreed on the accessibility of faculty members and chief residents, did not get rapid feedback and did not improve collaborative learning skills.

The following statements represent a sampling of student feedback:

• The concept of online coursework and feedback with faculty is one that holds tremendous potential. The current version of this web page has a very nice framework. However, the strength will be in actual factual lessons and information online. There is still only a skeleton of knowledge on the clerkship pages. If its limit will be only to direct our studying or recommend topics for research, then I don't think it will be used by students. But if it will hold online lessons and text and especially quizzes or images for study, then this will be a very valuable addition to the pediatrics rotation and will help bring a central focus to the rotation that will assure that every student learns the core material in pediatrics.

• This is a wonderful way to teach. I wish more of my rotations had similar formats. So many times as third year students, we feel little or no direction. This has been a wonderful resource for me.

• The best part of the program so far is that it provides a structure and deadline for specific topics, forcing me to progress in my studying. It is frustrating, however, that more didactic material is not part of the program itself - the program being only a template for study rather than a comprehensive study resource. Thanks for your hard work.

• I like the idea. It helped me prepare for the exam and better understanding of the material.

• I had no experience with Internet and computer. However, the tutorial that is in the FAQ page helped me a lot.

• This online course gave me a chance to interact with other students.

2. Clerkship Director and Chief Resident Feedback
The Clerkship Director and Chief Resident strongly agreed with improvement of the quality of assignments, clinical cases, and students' performance. The Chief Resident agreed with the concept of using their time more efficiently in the online clerkship, while the Clerkship Director was neutral to the concept. However, they strongly agreed that they would like to do an online clerkship again. None of them disagreed with improvement of assignment quality and students' performance, efficient use of their time and repeating the online clerkship.

The following statements represent a sampling of their feedback:

• Thorough orientation with clearly defined tasks, timelines, and responsibilities for both students and faculty alike. Students should perceive this as a true course with commitments to participate to get a good evaluation.

• Design of an online course requires a lot of front-end planning of goals and objectives. Involvement by students is most helpful. Attention must be paid to measurable outcomes to assess success or failure of these projects. Educational psychologists may also play a role here in designing research projects to test hypotheses for ALN.

III. DISCUSSION

A. Outcomes
Applications of computer instruction in pediatrics have expanded in the last few years. Online clerkship programs may accomplish medical students' interactive learning experiences, collaborative learning skills, self-paced and anytime-anywhere learning.

A model of a comprehensive and interactive online clerkship has been developed, implemented and tested. The results suggest that in general medical students liked the concept of ALNs as a way for delivering medical education.

Based upon student, Clerkship Director and Chief Resident feedback, the results of this study also indicate that anytime-anywhere accessibility is an important factor in online clerkship as evident in the range of preferred training period access times (8 am - 4 p.m.). The online clerkship was a significant addition to the students' training and learning experience. This assertion is supported by the fact that the majority of students agreed whereas none disagreed. The availability of additional support from faculty members and residents is necessary for success in any proposed online clerkship program. This result is clearly exhibited in our study where most of the students indicated their agreement concerning availability of this support.

The online clerkship requires access to faculty members and chief residents by the students. Twenty percent of students were unable to do so due to the commitment of faculty members and residents in other clinical areas. Thus, some students disagreed and some agreed with regards to the rapid feedback.

A high percentage (60%) of students said they improved their retention of factual knowledge due to online materials usage at any time. Students benefited from the conference system where most of them indicated that collaborative learning skills were enhanced and thus at least half of the students would recommend the online clerkship to their colleagues.

Some of the negative feedback may be explained by the fact that some students had no previous experience with asynchronous courses and lacked sufficient computer and internet experience. Therefore, in designing the technological components of the online program, an effort was made to keep the program simple, easy to use, and less intrusive during instruction. This required that the model employ simple software interfaces that would minimize student frustration due to technical difficulties.

Working in teams has become essential in hospitals. With excellent network capabilities, teams of individuals with specific expertise can be easily brought together electronically to rapidly accomplish a task. In medical education, we need to emulate this environment so that students can have preparatory experiences that will mimic the real hospital environments. Therefore the online clerkship program was conceived with these ideas in mind.

The success of online clerkship programs will be dependent on faculty involvement and participation. The Clerkship Director and Chief Residents in our study indicated improvement of students' performance and would like to continue participating in the online program. However, concerns of the faculty members were mainly related to efficient use of their time.

B. Technical issues
Medical students have access to computers in computer labs or in the medical library to access the online clerkship. Both of these locations are OS2-based and thus have older versions of browsers without multimedia capabilities. Thus plug-ins, Java, audio and frames, do not work in some locations. Moreover, using the current medical networks, downloadable files are not an option.

C. Conclusion
A model of an online clerkship program in pediatrics has been developed. Participant ratings indicate that this model enhanced the students' learning experiences, collaborative learning skills and ability to learn any time and any where. Building an online clerkship in pediatrics has been shown to be useful in enhancing the learning experience. We describe a comprehensive model that includes several instructional components.

Using asynchronous discussion forums with sufficient security levels has supported collaborative learning skills. Multimedia applications such as a Presenter plug-in provide a video presentation that supports anytime-anywhere interactive learning. The data indicates that the online clerkship can improve students' performance as compared to the traditional clerkship.

D. Future work
The future of this technology depends on overcoming difficulties related to the increased workload for faculty members in medical education. It will be necessary to provide training for faculty members on how to utilize collaborative learning approaches.

Future areas for development and improvement of online clerkship programs will require several approaches. Instead of using a general username and password to logon to the site, a system of individual username and password needs to be developed. A searchable database of FAQ's and library of cases need to be developed. A step-by-step tutorial for the clerkship web site must also be developed. Real video presentation may complement the Chief Resident's conference once the medical network is upgraded. Since the faculty questions at this time are in essay format, an online test using a web-based database needs to be developed. This will support adaptive and standard testing, along with automatic grading, record keeping, and test administration.

A private one-to-one or a private team group discussion in the conference needs to be added the current conference system. Bugs and access problems need to be solved and re-editing options need to be added. Annotation options for students to write their own comments and notes along with the reading materials or clinical cases need to be developed. With the pending Internet-2 era, applications using animations may also be developed.

We anticipate that these areas of future work will contribute to achieving the vision for integrated technology and learning in medical education.

IV. REFERENCES

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