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Online Medical Undergraduate Education

Nicholas Harvey

Online Medical Undergraduate Education


The use of computers and the internet has rapidly climbed over the last decade which

has been followed by the snowballing implementation of various electronic services

identified by the prefix ‘e’. Although they are designed with a view to making life

simpler, the so-called ‘technophobe’ feels quite the opposite. However, the

technophile generation are filling more and more seats on either side of the teacher’s

desk and embracing this new paradigm in education with positive attitudes towards e-

learning (Sandars & Morrison 2007). But does this mean e-learning strategies should be

globally employed? E-learning applications are certainly now engrained in medical

curricula (Hege et al. 2007).

There is an argument that computers are too often used to simply present information

with little consideration for tried and tested teaching principles routinely employed in

traditional education (Eva et al. 2000). Van Merriënboer et al. (2004) concluded that e-

learning can even be perceived as a backward step in pedagogical terms. However,

Harden (2008) is of the opinion that if e-learning is harnessed appropriately, ‘it can

enhance the curriculum and help to address problems and challenges currently facing

medical educators such as increasing student numbers, changes in medical practice and

globalisation’. It is, therefore, important to critically appraise e-teaching strategies

because of their ‘disruptive potential’ (Bridges 2000).

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This essay is a brief overview of e-teaching and e-learning focussing on undergraduate

medical education from an evidence based perspective. Harden and Hart (2002)

expressed concern that a blend of e-learning with face-to-face learning is important in

medicine because of the practice-based nature of the subject. The aim of this essay,

therefore, is to consider the efficacy of e-learning in the undergraduate medical

curriculum to supplement current practices, not a total replacement of facilitator contact.

It is important to remember that the technological advances do not change how we learn

but aid in ‘removing the constraints on the kinds of learning experiences we can

economically and practically create’ (Horton 2001).

Electronic Teaching & Learning

The electronic delivery of teaching has several advantages over traditional methods

(McKimm, Jollie & Cantillon 2003; Ruiz, Mintzer & Leipzig 2006). With the electronic

provision of learning resources, an immediate learner-centred approach is possible with

the ‘where, when, what and how’ under the control of each learner. This four-

dimensional flexibility empowers the learner to decide on the subject, sequence and

pace of the activities. This represents a shift away from Harden’s (2008) analogy of a

‘caged bird’, restricted by his teacher, towards a ‘soaring eagle’ who has freedom of

choice and greater responsibilities. Web-based applications also offer the opportunity

for shared resources and discussion and have proved a successful way of educating

students from different countries and cultures (Evans et al. 2008). It is also worth

remembering, however, that students learn in different ways and use of internet

resources differ according to personality preference (McNulty et al. 2006).

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In order to be effective, electronic content requires systematic planning and application

(Laurillard 2002). This takes time and most teachers feel that planning and

implementing a web course is more time-consuming when compared to a traditional

course (Christianson, Tiene & Luft 2002). Electronic resources also require different

expertise and, as a result, e-courses may be difficult to achieve in small institutions and

not all are equally effective (Friedman 1996). Because of these new challenges, in

addition to traditional information technology and administration support, new roles

have emerged such as education technologists and e-librarians who are able to offer

specialist support (Ellaway & Masters 2008).

The worldwide potential of online learning has lead to international collaborations

which are able to achieve a high quality online learning experience. The International

Virtual Medical School (IVIMEDS) is a prime example of the economies of scale in

online medical education (Harden & Hart 2002).

Electronic Teaching & Learning: Where and When?

One of the greatest advantages of online resources is their accessibility. Wireless

broadband coverage of many public places means the internet is accessible from a

laptop in almost any urban area while some content is even accessible for mp3 players,

mobile phones and personal digital assistants. The application of this technology has

shown to be of benefit for students who can often feel isolated and pressurised whilst on

attachments away from their teaching institution (Baker et al. 2001; Wheeler 2002).

Unfortunately, noise and interruptions are not conducive to learning (Downs & Crum

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1978; McDonald, Wiczorek & Walker 2004) and may well be common in the

environments in which these mobile learning (‘m-learning’) resources can be used.

Because the internet is always available, e-learning also allows students to decide when

they want to access a particular resource. While this avoids clashes and supports the

development of time management skills and self directed learning it may also be

making it possible for students to take on a job whilst at university.

The flexibility, increased availability of computers and familiarity with them has lead to

predictions of significant growth in e-learning (Russell & Russell 1999; Oblinger 2001).

There is a danger, however, that these advantages may be outweighed by the promotion

of individual learning leading to ‘the lonely learner’ syndrome (Harden & Hart 2002).

Electronic Teaching & Learning: What?

Without content the technology is useless. In its most basic form, online resources may

simply be copies of the syllabus, course objectives, lecture slides and summaries and e-

library content all of which students find helpful (Baker et al. 2001). In fact, in 1956

Freyberg demonstrated that providing students with written summaries of lectures

benefitted learning. Currently, online access to the core materials described above is

provided in all of the new medical schools in the United Kingdom (Howe et al. 2004).

There are now a plethora of institutional, regional, national and international web based

medical resources that are aimed at patients, students and health professionals. As a

result internet searches produce vast numbers of results (Haq & Dacre 2003) and the

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quality of the actual information and delivery of it is variable and very difficult to rate

objectively (Burd, Chiu & McNaught 2004). It is recognised that a system of identifying

reliable and effective resources is required and agencies such as Health On the Net

(HON) certify sites according to agreed criteria in an attempt to highlight sites adhering

to certain standards (Gaudinat 2006).

Discussion so far has focussed on electronic resources of individual ‘learning objects’ of

varied quality with which e-learning may occur. Learning objects can be didactic (text,

audio, video, etc) or interactive (tutorials, forums, wikis, etc). Teaching sites are most

effective if they implement a pedagogical approach that promotes active learning

(McKimm, Jollie & Cantillon 2003). A review of websites by Alur, Fatima & Joseph in

2002 found that only 50% of medical websites promoted any of the components of

critical thinking, independent learning, evidence-based learning, and feedback.

The decision of content is of major importance, but in medical education learning

outcomes and curricula are the subject of constant scrutiny and refinement and usually

nationally and institutionally agreed, respectively (Cumming & Ross 2007; General

Medical Council 2003). It is the teaching processes of the defined syllabus that are

critical if online education is to be more widely adopted in attaining the described

outcomes through active deep e-learning. Ellaway and Masters (2008) described a

continuum with content-focussed visual learning environments (VLEs) at one extreme

and process-focussed at the other with most courses falling somewhere in-between.

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Electronic Teaching & Learning: How?

It has been shown that the digital delivery of didactic teaching is probably as effective

and acceptable as a live lecture for instance (Soloman et al. 2004). However, in the

arguments above, and indeed in recent years, the emphasis is on how teaching processes

can use a participatory, student-centred approach to motivate and promote active and

self-directed learning. This, in part, has been driven by the General Medical Council

(2003) with the aim of developing professional attitudes and transferable skills to

support life-long learning.

Ellaway and Masters (2008) stated that e-learning aspires not only to be flexible, but to

be engaging and learner-centred, encouraging interaction, collaboration and

communication. Over recent years the evolution of the internet has lead to technologies

such as blogs, wikis, podcasts, games and other forms of interaction. These are often

referred to under the umbrella term ‘Web 2.0’ because initially internet technology was

mainly text-based and did not promote interaction (i.e. ‘Web 1.0’). There is a resulting

high interest in the exploitation of Web 2.0 technologies in online education although

there is a lack of knowledge and skills regarding their implementation and use (Sandars

& Schroter 2007). There are several e-learning management software packages

(courseware) available which range from commercial packages such as Blackboard to

free ‘open source’ courseware such as Moodle. These VLEs provide a platform to

present tailored information and feedback in text, pictures, sound and video. This ability

of sophisticated interaction between learners and the online environment has proven

very beneficial, especially in terms motivation and reflection in action. Virtual patient

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cases are a good example of this and have proven to be a very effective method of

teaching (Smith et al. 2007).

The other revolution, however, is that Web 2.0 technologies can also promote a

transformation from simple networks of individuals into complex networks of learners

through the use of ‘social software’ (instant messaging, online forums, blogs and wikis).

The use of social software amongst young people is very common (Sandars & Schroter

2007) and encourages reflection, mutual support and sharing of information and

experiences. An important consideration in implementing social software, however, is a

debate highlighted by Ellaway and Masters (2008) that online participation does not

necessarily represent e-learning. Therefore, the success of the student centred approach

such as small group work including facilitated peer discussions and student delivered

content in the physical classroom (Entwistle, Thompson & Tait 1992) does not

necessarily translate to its electronic counterpart. Further research is required to fully

answer this question.

Small Group Work

The trend towards small group work over recent years affords this process more

consideration in the context of e-learning in order to achieve the benefits already

experienced face to face. The advantages evolve around the principle of participation

and interaction in all stages of learning (Crosby 1996) compared to completely

independent learning at the other end of the spectrum.

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Small group work is said to encourage participation, problem-solving skills and an

awareness of other’s views. It also develops communication skills and encourages the

student’s responsibility for their own learning (Crosby 1996). The latter promotes the

holy grail of medical education: embracement of a career of life-long learning. Another

opportunity of the personal contact in small group work, which cannot be

underestimated, is role modelling (McA Ledingham & Crosby 2001).

Student communication and collaborative production of content (e.g. wikis) in VLEs are

electronic substitutes for small group work. Peer-to-peer communication tools can be

both synchronous (e.g. instant messaging) and asynchronous (e.g. forums) and are

central to avoiding the lonely learner syndrome previously described. E-learning has the

potential to fall towards the interactive end of the spectrum of teaching processes but,

as already mentioned, there is no evidence yet that it can fulfil all of the important

criteria. A benefit of e-learning is that it provides virtual interactivity and personalised

feedback economically. This is at the expense of loosing true face to face interactions

and, therefore, some of the possible benefits of small group work.

Problem Based Learning

Since the constructivist potential of problem based learning (PBL) in undergraduate

medical education was recognised in a book by Barrows and Tamblyn in 1980 and

recommended by the General Medical Council in 1993 it has been increasingly

implemented by medical schools. PBL can be thought of as a type of small group work

that promotes deep learning of not only knowledge, but generic skills and attitudes

(Wood 2003).

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The Web 2.0 technology such as online chat rooms, controlled access and timed release

of supporting materials for PBL successfully complement many PBL courses. Entirety

online PBL has also been successfully implemented (McConnell 2002; Ronteltap &

Eurelings 2002) but this should be left to experienced hands (Ellaway & Masters 2008).


Schön (1983) described two types of reflection: reflection-in-action and reflection-on-

action. Reflection-in-action occurs during a task to help us complete it. Reflection-on-

action refers to a process of evaluating ones knowledge-in-action after the event.

Grundy (1987) recognised that reflection on experiences is a key component of medical

professionalism. Reflective writing refines this process further and promotes the

integration of experiences with prior learning or triggers new learning (Eisner 1991).

This process is important to undergraduates in addition to doctors because experiential

learning is a stimulus for deep learning. Reflection also aids the conversion of implicit

learning and tacit knowledge into explicit knowledge which is important when required

to communicate this knowledge to patients and peers (Eraut 2000).

The internet blog is a relatively new but very popular internet fashion which utilises

Web 2.0 technology (Sandars & Schroter 2007). The name is derived from a contraction

of ‘web log’ and the technology is easily available free of charge on websites and is

built into many VLEs. Blogs are used almost entirely for documenting reflection-on-

action and can be utilised in education for encouraging reflective learning. Entries can

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be private or public, are fully searchable and allow comments so provide learning

material for readers in addition to the author.

The Spiral Curriculum

In 1960, James Bruner described the concept of a ‘spiral curriculum’ where subjects,

topics or themes are continually revisited throughout a course to build a deeper

knowledge and understanding. The ability of students to simply revisit electronic

resources online at any time supports this process (Masters & Gibbs 2007). Because

modern VLEs are not just simple collections of independent resources but highly

integrated webs of information, students can very simply revisit learning objects if they

identify a gap in their knowledge, skills or attitudes. In this instance the learning objects

are referred to as ‘reusable’. For example, a tutorial on colorectal cancer may assume

the student has a basic understanding of what cancer is because it was covered in the

first year. Automatic linking of key terms (‘cancer’ in this example) will provide a link

to a previous tutorial or glossary of terms so that the student can simply and quickly

revisit the topic and meet the expected level of knowledge to begin the tutorial. This is a

basic example of how a VLE can support a spiral curriculum but more sophisticated

methods exist to identify previous learning outcomes that require revisiting such as a

pre-tutorial quiz.


In addition to the use of electronic technology in teaching and learning, it plays an

increasing role in both formative and summative assessment. Formative assessment in

the form of marks or standard comments can be automatically provided to each user

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instantly. Users also have the ability to compare their performance in each domain or

topic area and against a class mean. Areas in need of development may be highlighted

and links to further educational activities provided. Results of assessments are also

accessible to administrators so that they can assess progress and effectiveness of

materials. Summative assessments can be used in much the same way but raise issues of

security and heavy dependence on reliability. If enough secure and reliable computers

are available in a moderated area there is potential for an extremely efficient

examination process with marks available immediately. Electronic examinations also

inherently support collaboration in creation and more efficient audit and quality control

processes (Ellaway & Masters 2008).

Knowledge, Competence and Performance Assessment

With regards to Miller’s pyramid (1990), e-assessment lends itself very well to the

‘knows’ and ‘knows how’ levels in the hierarchy of clinical competence. This may

commonly be in the form of multiple choice questions (MCQs) or extended matching

questions (EMQs) with most VLEs having the provision for this. Observed structured

clinical examinations (OSCEs) are currently widely used to assess the ‘shows how’

echelon of performance (Harden & Gleeson 1979), which in conjunction with

knowledge tests are used in an attempt to predict actions in practice.

Electronic assessments of the action levels of competence are less commonly used but

show some potential. Implementations range from complete virtual patient cases to a

station in an OSCE that utilises electronic content (Waldmann, Gulich & Zeitler 2008;

Ellaway & Masters 2008). Virtual reality simulations also exist but are expensive and

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probably unnecessary at the undergraduate level because other acceptable and reliable

methods exist (Engum, Jeffries & Fisher 2003).

Portfolio Assessment

Stetcher (1998) described the portfolio as a ‘purposeful collection of work’ and can be

used both as a learning tool and an assessment aid. In addition to notes, assignments and

evidence of achievements of competencies portfolios usually contain reflective accounts

for the reasons outlined above. The realisation that the portfolio is the only method of

assessing Miller’s ‘does’ level of competence has triggered increased use in

undergraduate courses.

With Web 2.0 technology it is very simple to employ web-based portfolios which

achieve the same quality of content as paper-based portfolios but improve student

motivation and ease of access for facilitators (Driessen et al. 2007). Electronic

portfolios can also be self-generating to an extent by automatically logging electronic

courses undertaken, quizzes performed, blog entries, etc.

Course Evaluation

Evaluation of a course is closely associated with the evaluation of the students through

level two (and to some extent, level three) of Kirkpatrick’s evaluation model (1959) and

student assessment has already been discussed. The reactions of students (Kirkpatrick’s

level one) to e-content can be evaluated by simply forcing each learner to provide

feedback before completion of a topic is possible. This supplies more feedback which in

theory is more representative. The number of students completing topics and the time

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spent on them is also monitored by VLEs and could be used as an indicator of



Like any change in medical education, it should be brought about for the benefit of the

student and/or patient but to the detriment of neither. Regardless of the methods

implemented, a medical school curriculum should facilitate active reflective learning

and promote life-long learning. As discussed, electronic teaching strategies have

massive potential in these realms when blended with its traditional counterpart but each

step of implementation requires detailed critical appraisal so that the benefits of

traditional models are not lost. We must remember that medical students learn valuable

knowledge, skills and attitudes from doctors, allied health professionals and patients in

environments that could not be replicated in the electronic form. Above all we must

remember that our vocations as doctors evolve around the patient so we must not

divorce this association in medical education.

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