Computer-assisted learning in undergraduate and postgraduate rheumatology education

I. Haq and J. Dacre

Academic Centre For Medical Education, Royal Free and University College Medical School, University College London, 4th Floor Holborn Union Building, Archway Campus, Highgate Hill, London N19 5LW, UK

Abstract

Computers and the Internet form a large part of our professional and personal lives. There are advantages and disadvantages to computer-assisted learning which will be discussed. An Internet and Medline search was performed to assess the educational content of rheumatology websites and also their effect on learning in the undergraduate and postgraduate setting.

KEY WORDS: Rheumatology, Education, Internet, Computer aided learning.

Introduction

The Internet and World Wide Web play an increasingly large part in our professional and personal lives. With the advent of Continuing Professional Development for consultants and more structured Higher Specialist Training for Registrars, there is a potential to develop computer-assisted learning for all specialities. In 1998, Tench et al. [1] studied 154 websites that contained the word ‘rheumatology’. Forty-three per cent of the sites were not accessible or in non-English languages. Of the 87 remaining websites, 67% originated from medical organizations and 51% were directly aimed at rheumatologists. The remainder were directed at patients only or both patients and health professionals. It was found that few sites had a pure educational or scientific content and that searching for relevant information was time consuming.

This review will consider the potential and current uses of computer-assisted learning in undergraduate and postgraduate rheumatology education, with examples from other medical specialities.

Advantages and disadvantages of computer-assisted learning

Increasing demands on a clinician's time often result in limited time for educational activities. In principle, computer-assisted learning can be done at the individual's convenience and pace, and the same material is available to a large number of people over a wide geographical area, which standardizes the learning experience whenever the learner logs on. Modern computers with multimedia capabilities can provide an interactive learning experience. The development of high-tech computer-assisted learning programmes is labour intensive, requiring appropriate hardware, backup and frequent upgrading. This has traditionally been done by enthusiasts with little educational expertise and is beyond the scope of most full-time clinicians. In addition, a dedicated information technology staff is necessary to provide practical advice and maintenance of the software and hardware. Some people may be less inclined to use electronic resources because of perceived lack of computer literacy. This should become less common as computer skills are now emphasized at all stages of education. At the Royal Free and University College Hospital Medical School, all first year medical students are assessed for their computer skills, and students with advanced skills act as mentors for both other students and clinicians. A study by Church et al. [2] showed that in a survey of 489 medical registrars, 76% had Internet access at work and 30% at home; 24% reported no access. Forty-five per cent thought that an interactive quiz or problem-solving programme would be a useful form of assessment.

Search methodology

To find evidence of current examples of computer-assisted learning in medical education, a search was carried out using Medline and the Internet search engine google.co.uk. Search terms included:

The search displayed 89 000 sites. Five hundred sites were chosen at random. Searching through these sites was laborious and time consuming, and the quality of the educational material provided was variable. Examples of high quality sites are discussed below.

The Arthritis Research Campaign and Royal College of Physicians were also contacted to obtain details of any relevant projects currently available or in development.

Undergraduate computer-assisted learning in rheumatology

Web Course Tools (WebCT) is a commercially available software package which can be adapted for local needs. A website has been developed by Dacre et al. at University College London (www.ucl.ac.uk/webct). There is currently a pilot programme available on the locomotor system. This comprises an introduction to the musculoskeletal system in text with illustrations and videos on how to perform a GALS (gait, arms, legs and spine) screen and regional locomotor examination. There is also a slide archive of physical signs with accompanying explanatory notes. Example multiple choice questions and objective structured clinical examination (OSCE) stations are also provided. This website has been available to all students in the rheumatology firm at the Whittington Hospital since October 2000. Sixty-five students enrolled in the course and the number of times the site was accessed during the firm was available as a ‘hit rate’. Twenty nine filled in a questionnaire on the course. Fifty-five per cent felt they had gained significant knowledge using the materials provided; however, only 12% thought it was much easier than standard teaching. Videos and an image database were found to be most useful. Seventy-nine per cent of respondents felt their information technology skills were adequate for navigating the site.

There was no correlation between the hit rate and score in the end of firm OSCE (r=-0.24) or a correlation between the end of firm and end of year scores (r=+0.24). This may reflect that skills such as communication and examination still cannot be learned fully without ‘on the job practice’ in conjunction with more theoretical learning.

Similar sites have been set up at other universities such as Sheffield and Birmingham, although these are only available via a password. Course lectures are posted on the site as powerpoint presentations, and there are interactive case histories/examinations using a virtual body map. The Arthritis Research Campaign is funding the development of computerized interactive learning programmes for the GALS screen, knee and shoulder examinations.

Two other initiatives may markedly improve the way medical education is delivered at the undergraduate level.

First, the International Virtual Medical school is a collaboration between medical schools throughout the world. The aim is to make further developments in medical education possible that would be beyond the scope of any single institution. One component of their programme involves the development of an e-learning resource bank that can be shared and updated regularly.

Second, the Universities' Collaboration in E-Learning (UCEL) is a collaboration between the medical and nursing schools of Nottingham, East Anglia and Cambridge Universities. Again their aim is to develop and share web-based educational material.

Both these initiatives are not currently available but should include rheumatology as part of their content. It is important that our speciality has a foothold in the development of these new methods of delivering medical education.

Computer-assisted learning in postgraduate medical education

Jenkins et al. [3] have piloted a web-based training programme in reproductive medicine. The course consisted of problem-based case studies. The course materials were also sent by post. Eighteen trainees took part in the course and usefulness of the Internet course was rated at an average of 4.5 (scale 1–5 with 5 being most useful). The identical paper course was rated at 4.0. Overall satisfaction of trainees and trainers was high, but four trainees found the technology a significant bar to participation. Simpson et al. [4] describe a pilot Internet teaching project to support specialist medical training in respiratory medicine in the North East Thames region. The site was used in conjunction with monthly specialist registrar training days. The site included interactive radiology and clinical case history quizzes together with multiple choice questions, a discussion-based journal club and facilities for giving feedback on the site itself and future topics for the monthly training days. The case history and radiology quizzes were most liked by trainees, but the educational impact was not studied directly. Computer use in general increased at the end of the project, with significant increases in the percentage of trainees using computers for accessing emails, the Internet or just curiosity. Problems encountered were those of software failure, lack of Internet access at home or at work and slow download times.

The Royal College of Physicians runs a modular distance learning system called Medical Masterclass. It is aimed at those studying for the MRCP examination, although specialist registrars may also find it useful. Each module covers a separate system, with tutorials in book form. Two CD-ROMs are also supplied containing interactive case histories with video materials and self-assessment. An associated website (www.medical-masterclass.co.uk) contains further self-assessment questions, speciality-specific guidelines and a ‘Literature Watch’.

Computer-assisted learning in postgraduate rheumatology education

The Interactive Rheumatology Tutor [5], designed by Dr Ray Armstrong, uses text, sound and video. Information is given on history, examination and joint/soft tissue injections. Self-assessment with feedback on answers given is also good. The CD-ROM is easy to navigate and fun to use, and is a valuable educational tool for students, general practitioners or allied health professionals in rheumatology, but does not provide the depth of information required for the specialist rheumatologist.

Stefan Schewe has developed a case-based teaching programme—RheumaTutor [6]. Twenty-five cases are available, together with photographs, but unfortunately no pathological images or video/audio clips. Data are given on the patients' demographic details and presenting complaints. Questions are asked using those on a standard list. The same format is used in sections on investigation and treatment. There is no information on physical examination and the long lists of questions that can be asked make navigation difficult. At the moment, the official version is in German, although an English translation is available from the author.

The American College of Rheumatology also produces a rheumatology self-assessment programme and tutorial in rheumatology on CD-ROM. It includes 150 case-based clinical situations in an multiple choice question format with feedback on answers. It is designed to be used by trainees in residency and fellowship programmes, so should be suitable for specialist registrars.

The American College of Rheumatology website also includes a ‘case of the month’. This is a problem-oriented, computer-assisted activity that uses multiple choice questions to direct the user towards a diagnosis and provides feedback on performance. Separate Authorware software from Macromedia is required to view the cases.

Many other medical school and university websites also contain rheumatology educational content. The Yale University Medical Library contains links to other university educational sites, containing case histories, joint injection technique tutorials, image databases and electronic books. The University of Washington contains a radiology teaching file. Brief cases histories are included with one or two radiological images and explanation of the pathological findings.

Medscape.com is a health professional website covering most specialities. It provides access to Medline and other databases and contains a sizeable Continuing Medical Education (CME) section comprising text- and image-based lectures followed by an online multiple choice question test, in which a score of >70% needs to be obtained to obtain CME credits. Clear aims and objectives are given and the exercise should be completed within 1.5 h. Examples of rheumatology CME topics include the role of biologics in optimizing rheumatoid arthritis treatment, and COX-2 inhibitors.

Rheumatology society websites also contain educational materials. The EULAR Data Bank of Images is held at the University of Ancona, Italy [7]. Historical and clinical images are available, with text commentary. The images can be downloaded to create slides for teaching. The historical images are fascinating. How many rheumatologists are aware that the artist Renoir had severe rheumatoid arthritis? Pictorial essays covering such topics as atlanto-axial subluxation in rheumatoid arthritis and nailfold capillaroscopy in scleroderma provide excellent teaching material for rheumatology trainees and consultants. Signing the Guest Book in the ILAR website [8] allows free access to self-assessment exercises and interactive case histories with answers and feedback.

The Arthritis Research Campaign is supporting the development of an interactive rheumatology website—JointZone—and also collaborating in a project using the Database of Individual Patient Experiences website (www.dipex.org) for patients with rheumatoid arthritis. Dipex is a non-profit organization based at the department of Primary Health Care, University of Oxford. Their aim is to promote more balanced encounters between healthcare professionals and patients by providing detailed access to the patient perspective. Hypertension and prostate cancer sections are currently available. Videos of patient experiences, frequently asked questions and a discussion forum are included. The aim of the project is to collect videos of patients with rheumatoid arthritis. This is an exciting development and will be of use to patients, students, specialist registrars and consultants. (See Appendix for a list of web resources.)

The future for computer-assisted learning in postgraduate rheumatology

Undergraduate rheumatology education programmes already exist on the Internet, mostly linked to university websites. However, postgraduate education needs to be more in-depth and should ideally cover practical and theoretical issues. The latter are much easier to develop, for example interactive tutorials/case histories. Practical issues such as joint injection may not be so easy to incorporate. There is also the question of assessment. A new European curriculum is imminent as is the latest rheumatology curriculum from the Royal College of Physicians. It is sensible that the content of any future computer-based training is based on these documents. Any distance learning course such as an MSc may find web resources useful in dissemination of course information, virtual seminars and assessment. At the moment there is no European consensus on an exit examination in rheumatology. This may involve qualitative and quantitative assessments of practice. Other specialities have them in place and it is possible that there will be one in the future in rheumatology. There may also be regular trainee assessments. Any such assessment will cover knowledge, skills and attitudes. Knowledge can be assessed using the Internet via multiple choice question tests or equivalent (extended matching questions). Skills and attitudes would not be appropriate to assess in this way. A major problem of any such computer-based knowledge assessment is probity. It is vital to be sure that the person taking the knowledge test is who he/she says they are. This has been a stumbling block so far in the development of such assessments at the Royal College of Physicians.

Despite all the benefits that computer-assisted learning may bring, no benefit will be seen on a large scale until all clinicians are trained in how to use the new technologies, and all hospitals have computer clusters with reliable and speedy Internet access available for clinical staff. With the arrival of electronic patient records and prescribing, these skills and hardware are going to become essential. Internet-based postgraduate rheumatology education is still in its very early days. It has the potential to provide additional learning resources for trainees and consultants. Other specialities are developing or have developed web-based training and it is important that we in rheumatology are not left behind in this. We also need to be sure that the quality of any content is high and consistent throughout the country. However, there are considerable costs in setting up and maintaining such a programme and these issues need to be addressed. Also, it should be emphasized that computer-assisted learning should be used as an adjunct to traditional clinical teaching methods rather than a replacement.

In summary, computers and the Internet have huge potential to change the way we learn and are assessed in the future. However, many initiatives are still in the development stage and it remains to be seen whether in fact the potential is realized.

Appendix

List of web resources

Notes

Correspondence to: I. Haq. E-mail: i.haq{at}acme.ucl.ac.uk Back

References

  1. Tench CM, Clunie GPR, Dacre J, Peacock A. An insight into rheumatology resources available on the World Wide Web. Br J Rheumatol 1998;37:1233–5.[CrossRef][ISI][Medline]
  2. Church RD, Elves AWS, Inman R, Scriven PM. Using the Internet for postgraduate medical education. Hosp Med 1999;60:370–1.[ISI][Medline]
  3. Jenkins JM, Cook J, Edwards J, Draycott T, Cahill DJ. Medical education with the Internet: a pilot training programme in reproductive medicine. Br J Obstet Gynaecol 2001;108:114–6.[CrossRef][ISI]
  4. Simpson A, Weist A, Reading NG, Roberts CM. A pilot Internet teaching project to support specialist medical training. Hosp Med 1999;60:904–7.[ISI][Medline]
  5. Armstrong R. Interactive rheumatology tutor. Cambridge: Cambridge University Press,1997.
  6. Bernalot Moens HJ. Two interactive rheumatology tutors on CD-ROM. Ann Rheum Dis 2000;59:328–9.[Free Full Text]
  7. Larkin M. Rheumatology moves online for Joint Motion 2000–2010. Lancet 1999;353:1368.[Medline]
  8. Armstrong R, Rasker JJ. www.ilar.org. A source of information for rheumatologists, allied health professionals, medical students and the general public. Ann Rheum Dis 2000;59:241–2.[Free Full Text]
Submitted 3 December 2001; Accepted 16 August 2002





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