Impact of a cybertutor in dermatological teaching
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Transcript of Impact of a cybertutor in dermatological teaching
Education
Impact of a cybertutor in dermatological teaching
Mariana Soirefmann1,2, MD, Cristiane Comparin1,2, MD, Juliana Boza1,2, MD,Chao Lung Wen1,2, PhD, and Tania Ferreira Cestari1,2, PhD
1Department of Dermatology, Hospital de
Clinicas de Porto Alegre, Federal University
of Rio Grande do Sul, Brazil, and2Department of Telemedicine, Hospital das
Clinicas de S~ao Paulo, University of S~ao
Paulo, Brazil
Correspondence
Mariana Soirefmann, MD
General Francisco de Paula Cidade
556/ 202 C
Porto Alegre
Brazil, 91330440
91330440
Brazil
E-mail: [email protected]
Conflict of interest disclosures: none.
Abstract
Background The potential value of multimedia programs as an accessory instrument for
medical education has already been demonstrated in several areas. However, most of
them lack adequate validation. The authors proposed this study in order to develop and
evaluate a computer multimedia program, aiming at providing a more attractive and state
of the art learning tool in dermatology.
Methods The cybertutor was developed containing clinical cases, self-education classes,
and short video presentations. In order to evaluate its impact, 50 undergraduate students
attending the third year of Medical School at UFRGS were randomized into two groups:
group 1 was submitted to a multimedia program on a specific dermatological subject –
parasite infestations, and group 2 to standard classes on the same subject. Both classes
were taught by an experienced teacher, on the same subject and at the same time. In the
end, the level of knowledge acquisition for the two groups was evaluated by a multiple
choice test.
Results The average of correct answers was 11.16 (SD = 1.625) in group 1 and 11.96
(SD = 1.645) in group 2. There were no statistically significant differences between the two
groups (P = 0.09). The majority (80%) of the students who attended the cybertutor group
showed interest in taking part in similar activities.
Conclusions According to this study, multimedia programs may be used for
undergraduate education in Dermatology as a complementary educational tool. Contact
with an instructor is still considered to be important and should be offered simultaneously.
Introduction
Undergraduate medical school curriculum is often basedon principles that were established in the early 18th cen-tury. Formal lectures and practical learning at outpatientunits or at patients’ bedsides were and still are part of thecurriculum of most medical schools.1 However, this edu-cational model is being questioned for several reasons,which include decrease in knowledge retention and stu-dent interest, financial constraints on educational pro-grams, emphasis on memorization of concepts rather thanon intuition and rationality, and decrease in time avail-able for faculty members, which are not only involved inteaching medical students and residents but also in per-forming clinical work and/or research.2–6
In late 1984, the General Professional Education of thePhysician report recommended a thorough revision of themedical curriculum. Its authors have suggested, amongother things, that medical curricula should be revised to relyless on classroom lectures and more on independent study
and problem solving in order to increase active learning andraise the level of knowledge retention amongst students.7
Moreover, over the past decade, medical care deliveryhas shifted from an inpatient to an outpatient model.Therefore, medical students are often required to com-plete community rotations in an ambulatory setting toachieve learning goals. Many of these students completetheir rotations at distant sites, making it difficult to returnto campus to attend required lectures.8
In order to allow all these changes in medical curricu-lum, advances in technology were crucial. Current devel-opments in information technology and in video andphotographic equipment have allowed the transmission ofimages with a resolution similar to that of color slides.9
Moreover, published studies have shown that the accu-racy of digital images is about 85%, confirming thatimages could be considered reasonably accuratewhen comparing with real patient observation.10 Finally,web-based learning is becoming increasingly popular ininstitutions of higher education.8
International Journal of Dermatology 2013, 52, 722–727 ª 2013 The International Society of Dermatology
722
Although the potential value of multimedia programs asan accessory instrument for medical education has alreadybeen demonstrated in several areas,2,11 most of these pro-grams have not yet been validated. Bearing that in mind, wehave proposed this study aiming at evaluating the impact ofa computer-aided learning program as an optional tool toteach dermatology to undergraduate medical students.Moreover, we have intended to verify if students exposed tothis particular multimedia program would have a similarlevel of knowledge compared with traditional expositiveteaching in order to properly validate this method.
Materials and methods
Prospective, double-blind, randomized clinical trials (RCTs) with
undergraduate students in the third year of Medical School at
the Federal University of Rio Grande do Sul – UFRGS.
Students who have not attended dermatology classes were also
invited to participate.
Sample size was based on a previous study of Seabra et al.2
A power analysis indicated that through the analysis of a
sample of 50 subjects, it would be possible to detect a two-
point difference in average with a power of 80%, P < 0.05 for a
one-tailed t-test.
The project was submitted and approved by the Institutional
Ethics Committee (IEC), and all volunteers have signed a Term
of Free and Informed Consent and have given their
authorization for image use.
Equipment
A Sony digital camera Cybershot® (5.1 megapixels) was used
to photograph dermatological lesions, under Informed Consent;
a desktop microcomputer with Windows XP was used to save
and process digital images; Adobe Acrobat Dreamweaver
Software was used as tools to create the website that had the
capacity to upload digital images to the clinical form; Web
Servers based on Windows, with MS-SQL database and ASP e
ASP Net applicatives; Tandberg videoconference equipment
with ISDN/IP transmissions to online interaction, if necessary.
Study development
The study was divided into two parts: the first one was the
development of a multimedia computer program, called
cybertutor; the second part consisted of an evaluation of this
new educational tool in Dermatology.
Part 1
The development of the cybertutor was performed at the
Telemedicine and Applied Photobiology Laboratory from the
Research Center of Hospital de Cl�ınicas of Porto Alegre, HCPA
(UFRGS), with technical support from the Telemedicine
Department of the University of S~ao Paulo (USP). It is an
interactive multimedia program.
The cybertutor is a software that was developed using
Microsoft’s .net platform (ASP) and utilizes a databank based on
MS-SQL. Access is restricted and can occur only by inserting a
pin number. Authorized users possess a pin number, and users
are categorized according to their profile, thus safeguarding the
privacy and the identity of the patients listed (only the doctor who
is treating a given patient has access to a given patient’s
complete name, while other doctors are only able to visualize the
initial letters of the first and last names of the patient).
The software was developed by a team of system analysts
from the course of telemedicine of the FM-USP (Faculdade de
Medicina da Universidade de S~ao Paulo/Medical School of the
University of S~ao Paulo) under the coordination of a professor
and researcher of the telemedicine course.
The standard patient’s clinical information file was created
having the most relevant data of a standard dermatology clinical
information file as a model. The cybertour clinical information
file can support up to five digital images or MP4 videos
alongside a description of the lesion portrayed. Besides that,
the clinical information files were where the electronic clinical
files were developed containing CID’s databank, a record of all
medicines available as well as a list of the interactions between
different types of drugs.
The contents of the cybertutor include the following.
1 Thirty clinical cases: after IEC approval and having obtained
informed consent, typical cases of the most common
dermatological disorders were selected among patients
attending the Dermatological Unit of HCPA. The dermatological
disorders included were: eczema, atopic dermatitis, irritant
contact dermatitis, allergic contact dermatitis, virus infections,
bacterial infections, superficial fungus infections, parasitic
infections, psoriasis, acne, rosacea, non-melanoma skin cancer,
melanoma, melasma, alopecia areata, androgenetic alopecia,
urticaria, lichen planus, pruritus, and prurigo.
Relevant clinical data as well as pictures of the
corresponding disease were included using the Adobe Acrobat
Dreamweaver software. Four single-choice questions were
posed for each clinical case. The choices for answers were
commented, whether they were correct or not, using both
explanations about differential diagnosis and therapeutic options
available. Additionally, updated references about each disorder
were obtained from Medline and Cochrane databases and also
from dermatology textbooks.
2 Self-education classes: five theoretical classes were prepared
as PowerPoint presentations. The choice was based on the
updated curriculum of UFRGS, which is made up of the
following courses: terminology in dermatology and primary
lesions; parasite infestations; superficial fungal infections;
cutaneous manifestations from systemic diseases; cutaneous
neoplasm and eczemas.
3 Short video presentations covering the most frequent
dermatological procedures, such as skin punch biopsies,
shavings, simple excisions, and local anesthesia.
ª 2013 The International Society of Dermatology International Journal of Dermatology 2013, 52, 722–727
Soirefmann, Comparin, Boza, et al. Impact of a cybertutor in dermatological teaching Education 723
Part 2
Evaluation of the impact of a computer-aided learning program,
using a multimedia presentation on parasite infestations in
dermatology as a model, in order to compare knowledge
retention and students’ interest when exposed to either
cybertutor or traditional classes.
The impact of the cybertutor in dermatological teaching was
measured by an RCT. Fifty students in the third year of
medical school at UFRGS that had not yet undergone
dermatology rotation were randomized into two groups: group 1
had free access to a multimedia program of Infestations in
Dermatology (Figs. 1 and 2); and group 2 attended a standard
lecture on the same subject, at the same time. The standard
lecture was prepared and presented by a dermatology teacher
who was not involved in the development of the cybertutor. To
guarantee the consistency of both presentations, the same
class plan, including the main topics to be covered, was
followed by both teachers, the one who prepared the cybertutor
presentation and the other who prepared the thought class.
Both dermatology teachers had the same level of expertise and
teaching experience. At the end, the level of knowledge
acquisition for the two groups was evaluated by a multiple-
choice test, containing 15 questions, prepared by another
blinded instructor. Immediately after exposure, students who
attended the cybertutor also answered a six-statement
questionnaire, based on the Likert scale, about their subjective
feelings on computer teaching method, including their opinion
about digital lecture format as an adequate replacement for live
lectures.
Results
Complete data were available for 25 students who com-pleted the digital lectures and 25 students who attendedthe live lectures. Samples were quite similar, and therewas no significant statistical difference regarding averageage, as presented in Table 1.The objective evaluation showed no statistically signifi-
cant difference between the grades of the two groups(P = 0.09). The average of correct answers was 11.16
Figure 1 Self-education classes: dermatological infestations
International Journal of Dermatology 2013, 52, 722–727 ª 2013 The International Society of Dermatology
Education Impact of a cybertutor in dermatological teaching Soirefmann, Comparin, Boza, et al.724
(SD = 1.625) in group 1 and 11.96 (SD = 1.645) ingroup 2. These data are also presented in Table 1.Students’ personal opinions about which teaching
methods were found best are presented in Table 2. Morethan 80% of the students considered the cybertutor asfriendly and educational. In addition, more than 60% ofthe students considered this multimedia program a pleas-ant activity. Eighty percent of the students manifestedinterest in participating in similar activities in other medi-cal topics in the future. However, most of them believed
that it did not entirely replace the instructor, emphasizingthe relevance of the professor and student interaction.
Discussion
The process of education has evolved over time in acontinuing effort to meet the needs of our society.12
While traditional methods and practices of formal edu-cation (including lectures with writing boards, learner-transcribed notes, and heavy reliance on printed materi-als) are still effective for some courses, there are deficien-cies when they are applied to the learning and teaching ofscience and technology, both on a local institution andglobal basis.12
In this context, the use of multimedia programs inmedical education would have some advantages overtraditional teaching methods.2,13 Multimedia technologiesallow professors to save time as they enable the presenta-tion of new texts, graphs, and audio and video record-ings. These elements can be changed, added, or deletedinstantly, allowing both students and doctors to research
Figure 2 Dermatological infestations: sarcoptes scabiei
Table 1 Characteristics of the sample and test results
Group 1 Group 2
Teaching method Multimedia program Standard lecture
No. students 25 25
Average age (years) 22.6 22.64
Average of correct answers
(%)a11.16 (74.4) 11.96 (79.73)
aTotal of 15 questions.
ª 2013 The International Society of Dermatology International Journal of Dermatology 2013, 52, 722–727
Soirefmann, Comparin, Boza, et al. Impact of a cybertutor in dermatological teaching Education 725
on a constantly updatable learning tool.2,14 In addition,students may potentially increase the time they devote totheir studies once the educational content is available forconstant or repeated practice and can be examined oraccessed whenever students may deem necessary.13,15 Fur-ther advantages of multimedia programs are the ability tointeract with students and to receive immediate feedbackso that they can learn what their weak points are andthus learn from their mistakes much quicker than theywould usually be able to.13
Shaikh et al. studied the efficacy and feasibility of mul-timedia programs for pediatric medical education. Therewas significant improvement (mean improvement 22%,P < 0.002) in competency in five out of the six areasassessed. In addition, 88% of trainees were very satisfiedwith the teaching methodology (� 5 on a 7-point scale),and 86% were very likely to apply the information intheir future practice.16
In an effort to address the concern of internal validityof the present study, the material presented in the derma-tological tutorial was identical to the material covered inthe traditional lecture.13 Regarding results, we observedthat students who used the computer-aided multimediaprogram obtained 74.4% right answers, while those whotook the class answered 79.7% of the questions correctly.The difference between the groups was not statisticallysignificant or clinically relevant. Therefore, the use ofmultimedia programs as a complementary tool for derma-
tological teaching allows students to have at least thesame learning performance and level of cognition as thosewho attend traditional lectures. These findings were alsoobserved in studies that used multimedia programs forteaching other medical specialties, such as neuroanatomy,surgical technique, and general urology.2,17,18
The majority of students who took part on the electro-nic cybertutor group agreed that this multimedia programis educational but said that it does not replace professors.These findings were also observed in other papers thathave already been published. Hong et al. publishedthat the use of computers and the Internet is a usefuland effective way to teach dermatology.19 Moreover,Potomkova et al. found out that medical Web-based tuto-rials represent an effective educational tool supportingself-directed learning.20
Despite the increased use of multimedia programs inmedical education, barriers still remain to the widespreadimplementation of this methodology. One of the mainbarriers is the lack of evidence of computer-aided learningprogram effectiveness as an educational tool. In addition,a possibility for future research would be an improvedevaluation of the long-term retention of computer-aidedlearning program vs other teaching methodologies.Finally, long-term retention of knowledge is a very impor-tant consideration, as the majority of medical students’exposure to dermatology is in the first three years of med-ical school.13
Final considerations
Multimedia computer-assisted training programs providea more stimulating and realistic training environment thatapproaches the reality of the patient and doctor relation-ships, as it happens in real life.Within the limits of this study, the computer-aided
learning program is at least as effective as traditionallecture teaching of dermatological infestations to medicalstudents. Therefore, multimedia programs may be used forundergraduate education in dermatology as a complemen-tary educational tool. It is important to emphasize that thedirect contact with an instructor is still considered to beimportant and should be concomitantly offered to stu-dents. The instructor may act as a distant tutor, while thestudents have a more active attitude in the learning pro-cess, exploring the information available and selecting themost important for their knowledge acquisition.Regarding dermatological teaching at our institution,
we plan to utilize multimedia computer-assisted trainingprograms blended with traditional teaching methods toengage different learning styles and effectively increasestudent contact time with dermatological material duringspecific dermatology instruction and throughout medicaltraining and careers.
Table 2 Cybertutor group: students opinions on multimediaprogram based on Likert scale
Question
number
Disagree
fully (%)
Disagree
partially
(%)
Neutral
(%)
Agree
partially
(%)
Agree
fully
(%)
1. The program
is user friendly
4 0 0 32 64
2. The program is
pleasant to
use
4 4 24 32 36
3. The program
produced
immediate
memorization
0 20 32 44 4
4. The program is
educational
0 0 12 32 56
5. I would like to
have a similar
program for
other topics
0 12 8 44 36
6. Programs
similar to
this one can
replace the
teacher
40 40 8 8 4
International Journal of Dermatology 2013, 52, 722–727 ª 2013 The International Society of Dermatology
Education Impact of a cybertutor in dermatological teaching Soirefmann, Comparin, Boza, et al.726
The importance of multimedia programs in medicaleducation will most likely move beyond the scope ofundergraduate medical education. In the future, multi-media programs in medical education may become oneof the major methods of teaching graduate medical stu-dents as well as continuing medical education for pri-mary care physicians, dermatologists, and otherphysicians as well.
Acknowledgments
This work was supported by the Telemedicine Depart-ment of the University of S~ao Paulo (USP) and the Tele-medicine and Applied Photobiology Laboratory from theResearch Center of HCPA, UFRGS.
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ª 2013 The International Society of Dermatology International Journal of Dermatology 2013, 52, 722–727
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