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Conventional teaching remains effective in teaching medical biochemistry in BPKIHS, Nepal, although students enjoy supplementary computer teaching
Biochemistry and Molecular Biology Education 29 (2001) 137–141
Article
Conventional teaching remains effective in teaching medical biochemistry in BPKIHS, Nepal, although students enjoy supplementary computer teaching B.C. Konera,*, M. Lamsalb, B.D. Banerjeec, N. Baralb a
Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry-6, India b Department of Biochemistry, B.P. Koirala Institute of Health Sciences, Dharan, Nepal c UCMS, Shahdara, Delhi, India
Abstract A computer program down loaded from the Internet was used as a tutorial to teach the structure–function relationship of MHC molecule to MBBS students of BPKIHS, a medical college in Nepal. The computer-aided teaching session, with a facilitator from the biochemistry faculty, was found to be more interesting to the students although learning outcomes were not enhanced by comparison to sessions using only conventional tools. A non-subject expert presenting the computer tutorial failed to generate interest in the topic, and the achievement of learning objectives by the students was inferior. We conclude that the interaction with a biochemistry subject expert was crucial for success in our use of computer-aided teaching sessions on the structure–function relationship of proteins. The results are discussed with attention to the role of computer-aided instruction in medical colleges in a developing country (Nepal). r 2001 IUBMB. Published by Elsevier Science Ltd. All rights reserved. Keywords: Computer-aided learning; Facilitator; Subject expert; MHC; Structure–function relationship
1. Introduction The use of computers in teaching is increasing globally, although in developing countries the use of computers in medical education is still limited because of paucity of resources, lack of awareness and trained personnel. Many educational computer programs on biochemistry and medical topics are available either commercially or free from the Internet. Many programs are evaluated, although there is no uniformity and universally accepted method for such evaluation [1]. Studies show that computer programs are equally or more effective than conventional tools [2–4], although reports to the contrary are also available [5,6]. Of course, the effectiveness will depend on quality, type and appropriate selection of programs that can fulfill the educational objectives of a curriculum. Until 1994, Nepal had only one medical college and approximately 1700 doctors to serve nearly 20,000,000 population. Recently, six medical colleges have opened *Corresponding author. Tel.: +91-413-372380-9 Ext. 553; Fax: +91-413-372067. E-mail address: [email protected] (B.C. Koner).
in Nepal raising the number to seven including the oldest one in the capital city, Katmandu. B. P. Koirala Institute of Health Sciences (BPKIHS) is a medical institute (recently upgraded to a medical university) situated in Dharan, Nepal (a developing country in the Indian subcontinent). It is set up by an Indo-Nepal collaboration project with financial, technical and skilled human resource assistance from the Government of India. It is situated in the small foothills township of Dharan (population: 110, 316; longitude: 871280 ; latitude: 261480 ; altitude: 305–610 m) in the Sunsari district in the eastern part of Nepal [7]. The Institute discourages rote learning and gives emphasis to reasoning skill in order to give a holistic view of health to the students [8]. It has an innovative undergraduate medical curriculum that is thoroughly integrated, partially problem based and incorporates the organ system approach which is intended to follow the SPICES model [9,10].1 To achieve its teaching goals, different teaching– learning tools e.g., SIS (structured interactive session), UNCLE (unconventional learning exercise), CLIP/CBL 1 The first version of MBBS curriculum of B.P. Koirala Institute of Health Sciences, Ghopa, Dharan, Nepal, 1996.
1470-8175/01/$20.00 r 2001 IUBMB. Published by Elsevier Science Ltd. All rights reserved. PII: S 1 4 7 0 - 8 1 7 5 ( 0 1 ) 0 0 0 4 7 - 9
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B.C. Koner et al. / Biochemistry and Molecular Biology Education 29 (2001) 137–141
(clinical posting/case based learning) and FIP (field posting) have been adopted [10]. The term SIS originated from BPKIHS [10,11] (see footnote 1) and is a modified form of lecture where more time is given for interaction with the students. This is more suitable for groups of 30–50 students. This is student centered, teacher controlled and highly structured having definite objectives. The students are kept active throughout the session, which is not possible for traditional didactic lectures (nearly a monologue). Hence SIS is considered more effective. Structure–function relationships of proteins are emphasized in our medical curriculum because it helps in the conceptualization and understanding of the biochemical basis, pathophysiological process and clinical interferences in many diseases, e.g. inborn errors of metabolism, haemoglobinopathies, cancers, etc. Besides enzymes and haemoglobinopathies, the major histocompatibility complex (MHC) is a topic through which concept of structure–function relationships in proteins can be reinforced to the undergraduate medical students. A web site made for lecture or self-paced learning, is freely available from the internet [12] that depicts MHC structure and how MHC molecules take part in presenting antigen epitopes to T-lymphocytes. In view of the above, the present study was conducted in BPKIHS to explore: (a) if the learning of structure–function relationship of MHC in an SIS employing a computer presentation program is better than that in an SIS using conventional tools, e.g. OHP slides and blackboard, (b) what role a biochemistry faculty member as facilitator can play in a computer-aided SIS (particularly when the program can be used for both self-paced learning and lecture presentation), (c) if computer-assisted teaching/learning sessions can save time and (d) the student’s opinion/perception about computeraided SIS (CA-SIS) on MHC structure and function. The broad objective of the study was to explore the impact and perspective of computer-aided learning on medical students in Nepal.
2. Methods 2.1. The computer program The web site on MHC (Feb 19, 1998; version 0.9) created by Eric Martz and group is made for lecture or self-paced study [12]. Running the program requires installation of Chime and Netscape navigator 3.01 or 4.01 or later. The program depicts the structure– function relationship of MHC with the help of computer graphics and presents detail of the structures from different sides and different forms (space filling model,
ribbon model, etc.). Rotation or enlarging options are included in the Chime menu. The program was downloaded and used in the ‘computer-aided structured interactive session’ (CA-SIS) by projecting on a big screen through an LCD projector. Before the study, a four member expert team approved the web site as suitable for use with a biochemistry class on MHC in the ‘immunology’ module for the phase I MBBS curriculum at BPKIHS. 2.2. The study design First and second year MBBS students, who mainly take pre- and para-clinical subjects with some input from clinical departments, were incorporated in the study. For the first year students, the class taken during the study was integral to the course, but the scores were not incorporated in the final assessment. The students were randomized and assigned into two groups, taking account of academic standing to balance the ability spread. Group A (n ¼ 20) was exposed to SIS with conventional tools with the facilitator being a faculty member from Biochemistry. Group B (n ¼ 20) was exposed to computer-aided SIS with the facilitator being a computer expert who had no knowledge about the biochemistry subject, or MHC, but was familiar with the Chime menu and operation of the program. The second year students were also divided similarly into two groups: group C (n ¼ 10) and group D (n ¼ 11). The group C was taught as for group A, but the group D attended CA-SIS where the downloaded program of the web site was used as the tool and the facilitator was a faculty member from Biochemistry. For the second year students, the class was optional and not integral to the course, because they had already attended a related ‘blood and immunology’ module in first year. Forty students out of 50 from the first year took part in the study. The attendance was 21 out of 40 for the second year class. The poor percentage of attendance in the class for the second year groups was because the class was optional for them, and they were busy with study for their current module. They might also have thought that the class would only be repetition because the ‘blood and immunology’ module was over for them and the students knew that the score would not be added to the final assessment. The objectives of the class were kept the same for all the groups. However, a Biochemistry faculty member took the classes for groups A, C and D and interaction in SIS was encouraged. The time taken for the sessions in each group was noted. All students were pre-tested with MCQs (n ¼ 10) on immunology to rule out any difference in academic standing of the test groups (group B & D) from the respective controls (groups A & C). The post-test questions (MCQ, n ¼ 10) were different from those in the pre-test. The MCQs of the post-test
B.C. Koner et al. / Biochemistry and Molecular Biology Education 29 (2001) 137–141
examined whether the learning objectives of the class were achieved by the students. Some studies employ the same questions for both pre- and post-tests, but the present study used different question sets to assess new learning, rather than measure improvement in responses to known questions. After the post-test, groups A & C were asked to attend a computer-aided SIS (as taken for group D) and groups B & D attended the same SIS as taken for group A &C. Then the students were asked to write their comments on (a) the web site, (b) their liking /disliking about CA-SIS, (c) which they felt better and easier between CA-SIS and SIS using conventional tools for understanding the topic, (d) if they wanted CA-SIS any more in future and (e) free comments and suggestions, if any. 2.3. Statistical analysis The pre-test and post-test scores were expressed as mean and standard deviation and compared by a MannWhitney ‘U’ test with corresponding control groups. A p value of less than 0.05 was considered as the level of significance.
3. Results The pre-test and post-test scores are shown in Table 1. The pre-test score reveals that the academic standing of the test groups (B & D) is comparable to their respective controls (groups A & C) as the differences in scores between the groups are not statistically significant. The post-test scores revealed that the performance of the first year students attending CA-SIS was significantly inferior to their counterpart attending SIS using conventional tools. The pre- and post-test performance of the two groups of the second year students were not different statistically. The times in class for CA-SIS
139
were 37 and 42 min for the first and second year groups, respectively, and those for SIS with conventional tools were 40 and 38 min for the respective controls. Based on these times, computer use was not seen as a means to save time in teaching. A majority of the students in all groups felt that understanding of the topic was better and easier in CA-SIS, except for group B. Eighty percent of group B students opined that understanding was better in SIS using conventional tools. However, all the students in all the groups wanted such CA-SIS again in future, and all liked the CA-SIS and the web site.
4. Discussion The use of computers has increased in teaching medical sciences as well as in running hospitals in developed countries. Computer literacy and awareness about medical informatics by health professional is claimed to increase the effectiveness of health systems [13,14] and the GMC and Association of American Medical College’s GPEP report of 1993 has given stress to computer literacy among medical students [15,16]. The computer is considered as an effective learning tool for delivering knowledge as well as to develop problem solving skills [17]. The objective assessment of the present study clearly demonstrates that CA-SIS is less effective in comparison to SIS with conventional tools and that CA-SIS on structure–function relationship of MHC molecules became effective only when a biochemistry subject expert was the facilitator and the students had an opportunity to interact with a subject expert during the session. Due to lack of infrastructure, it was not possible to provide computer terminals to individual students to evaluate the effectiveness of self-paced learning using the same computer program. The application of computers in medical education in the developing countries is not widespread, but is gradually increasing. The educational setup, mental
Table 1 Pre and post-test scores (mean7SD) and subjective response of batches exposed to computer-aided SIS (CA-SIS) and SIS using conventional tools on structure–function relationship of MHC molecule Groupsa
Pre-test score
Post-test score
Group n ¼ 20 Group n ¼ 20 Group n ¼ 10 Group n ¼ 11
A 1st year conventional SIS
7.6571.60
5.872.12
90%
B 1st year computer SIS
6.8071.88
3.371.52b
20%
C 2nd year conventional SIS
6.8071.69
7.271.62
100%
D 2nd year computer SIS
7.0072.14
6.7271.62
100%
Subjective responseF% claiming that computer SIS achieved better understanding
a Group A=1st year students exposed to SIS with conventional tools the facilitator being a subject expert; Group B=1st year students exposed to computer assisted SIS the facilitator being a computer expert; Group C=2nd year students exposed to SIS with conventional tools the facilitator being a subject expert and Group D=2nd year students exposed to computer assisted SIS the facilitator being a subject expert. b po0:05 in comparison to group A.
140
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make-up and aptitude of the students and teachers and the attitude of administrative authorities towards novel experimental teaching are different in developing countries, so the effect and impact of computer-aided teaching might be different as compared to that seen in the developed countries. There are hardly any published reports from developing countries evaluating the effect of computers in teaching. In our study, the performance of the students after attending a CA-SIS or a SIS using conventional tools on the same topic was not significantly different. This raises the question of whether undergraduate students should be encouraged to own a computer when equally effective alternative teaching is available. Others have raised the same question [6]. However, it is more difficult to address the issue of computer use in developing countries where resources are less and the resource management is very poor. Learning is not only an intellectual process but also involves emotion. The overwhelming subjective response of the students in favor of CAL indicates that the learning in CAL session might be more effective in terms of long-term memory and problem-solving skill development. The present study evaluated only immediate recall capacity of the students. The overwhelming response in favor of CAL might be because it was novel for the students, thereby creating a false belief about the superiority of the use of advanced technology in teaching. A more objective assessment will only be possible when the students have been repeatedly exposed to computer-aided teaching sessions. At present, there are 43 computers in BPKIHS and all the teaching departments have at least one Desk-top PC connected via LAN to the internet through VSAT. In total, 30 PCs are used by academic departments for both academic and administrative work. Other computers are used for the administrative and accounting purposes of the Institute. None of the BPKIHS students have their own computer, not because none of them can afford it, but because they hardly feel any need to own a computer at present. The students’ access to the Institute’s computers and internet facilities are very limited. They are allowed to use computers and the internet under the supervision of faculty members only when they have a specific need, such as to prepare research projects or seminar presentations at the end of PBLs. However, they are free to search Medline in the library by making a prior appointment. We used only two computers for the present studyFone belonging to the Department of Biochemistry and other to the Medical Education Department. The computer from the Medical Education Department was connected to a LCD projector in a seminar room where all the CA-SIS was conducted. The problems are that within a limited financial capacity, the Institute has to give priority to the development of many other fundamental areas. Only a limited number of
faculty members have enough computer knowledge to improve the computer support and develop computer programs suitable for the Institute’s curriculum to fulfill the learning need of BPKIHS students. It would be desirable for the medical students of Nepal to have free access to computers and information available from the internet; however, most of the software is from the developed countries and might not be suitable for the BPKIHS curriculum. There are no responsible authorities that have control over these web sites on medical topics to check their worth and truth. We also have the reservations that free use of the internet may dehumanize the practice of medicine and change the societal values in a developing country like Nepal.
Acknowledgements Dr.B.C.Koner was in Nepal while conducting the study, on deputation to BPKIHS, Nepal from Govt. of India. The authors acknowledge Mr. D. Dahal, the computer expert of BPKIHS for his help in performing the study. The authors are thankful to the journal reviewer for valuable suggestions to revise the manuscript.
References [1] L. Hardin, T.B. Patrick, Content review of medical education software assessment, Med. Teacher 20 (3) (1998) 207–211. [2] M. O’corner, R. McGraw, L. Killen, D. Reich, A computer-based self-directed training module for basic suturing (1), Med. Teacher 20 (3) (1998) 203–206. [3] L.W. Desch, M.T. Esquivel, S.K. Anderson, Comparison of a computer tutorial with other methods for teaching well-newborn care, Am. J. Dis. Child. 145 (11) (1991) 1255–1258. [4] P. Devitt, D. Cehic, E. Palmer, Computer in medical education 2. Use of a computer package to supplement the clinical experience in a surgical clerkship: an objective evaluation, Aust. NZ J. Surg. 68 (6) (1998) 428–431. [5] D.A. Rogers, G. Regehr, K.A. Yeh, T.R. Howdieshell, Computer-assisted learning versus a lecture and feedback seminar for teaching a basic surgical technical skill, Am. J. Surg. 175 (5) (1998) 508–510. [6] R.J. McAuley, Requiring students to computers: question for consideration, Acad. Med. 73 (6) (1998) 669–673. [7] www.bpkihs.edu. [8] S. Koirala, N. Kumar, M. Upadhyay, Institutional goal and phylosophy of B. P. Koirala Institute of Health Sciences, Ghopa, Dharan, J. Inst. Med. 16 (1) (1994) 1–4. [9] R.M. Harden, S. Sowder, W.R. Dunn, Educational strategies in curriculum development: the spices model, Med. Educ. 18 (3) (1984) 284–297. [10] R. Singh, P. Gupta, K. Singh, S. Koirala, Undergraduate pediatric education at BPKIHS integrated with an innovative curriculum, Indian Pediatr. 36 (1) (1999) 43–50. [11] R. Bijlani, The MBBS programme of BPKIHS, Vision (BPKIHS) (1995) 8–10. [12] E. Martz, 1998, www.umass.edu/microbio/chime/mhc/index/htm.
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[16] T. Koschmann, Medical education and computer literacy: learning about, through and with computers, Acad. Med. 70 (9) (1995) 818–821. [17] P. Devitt, E. Palmer, Computer in medical education 1: evaluation of a problem-oriented learning package, Aust. NZ J. Surg. 68 (4) (1998) 284–287.
Article
Conventional teaching remains effective in teaching medical biochemistry in BPKIHS, Nepal, although students enjoy supplementary computer teaching B.C. Konera,*, M. Lamsalb, B.D. Banerjeec, N. Baralb a
Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry-6, India b Department of Biochemistry, B.P. Koirala Institute of Health Sciences, Dharan, Nepal c UCMS, Shahdara, Delhi, India
Abstract A computer program down loaded from the Internet was used as a tutorial to teach the structure–function relationship of MHC molecule to MBBS students of BPKIHS, a medical college in Nepal. The computer-aided teaching session, with a facilitator from the biochemistry faculty, was found to be more interesting to the students although learning outcomes were not enhanced by comparison to sessions using only conventional tools. A non-subject expert presenting the computer tutorial failed to generate interest in the topic, and the achievement of learning objectives by the students was inferior. We conclude that the interaction with a biochemistry subject expert was crucial for success in our use of computer-aided teaching sessions on the structure–function relationship of proteins. The results are discussed with attention to the role of computer-aided instruction in medical colleges in a developing country (Nepal). r 2001 IUBMB. Published by Elsevier Science Ltd. All rights reserved. Keywords: Computer-aided learning; Facilitator; Subject expert; MHC; Structure–function relationship
1. Introduction The use of computers in teaching is increasing globally, although in developing countries the use of computers in medical education is still limited because of paucity of resources, lack of awareness and trained personnel. Many educational computer programs on biochemistry and medical topics are available either commercially or free from the Internet. Many programs are evaluated, although there is no uniformity and universally accepted method for such evaluation [1]. Studies show that computer programs are equally or more effective than conventional tools [2–4], although reports to the contrary are also available [5,6]. Of course, the effectiveness will depend on quality, type and appropriate selection of programs that can fulfill the educational objectives of a curriculum. Until 1994, Nepal had only one medical college and approximately 1700 doctors to serve nearly 20,000,000 population. Recently, six medical colleges have opened *Corresponding author. Tel.: +91-413-372380-9 Ext. 553; Fax: +91-413-372067. E-mail address: [email protected] (B.C. Koner).
in Nepal raising the number to seven including the oldest one in the capital city, Katmandu. B. P. Koirala Institute of Health Sciences (BPKIHS) is a medical institute (recently upgraded to a medical university) situated in Dharan, Nepal (a developing country in the Indian subcontinent). It is set up by an Indo-Nepal collaboration project with financial, technical and skilled human resource assistance from the Government of India. It is situated in the small foothills township of Dharan (population: 110, 316; longitude: 871280 ; latitude: 261480 ; altitude: 305–610 m) in the Sunsari district in the eastern part of Nepal [7]. The Institute discourages rote learning and gives emphasis to reasoning skill in order to give a holistic view of health to the students [8]. It has an innovative undergraduate medical curriculum that is thoroughly integrated, partially problem based and incorporates the organ system approach which is intended to follow the SPICES model [9,10].1 To achieve its teaching goals, different teaching– learning tools e.g., SIS (structured interactive session), UNCLE (unconventional learning exercise), CLIP/CBL 1 The first version of MBBS curriculum of B.P. Koirala Institute of Health Sciences, Ghopa, Dharan, Nepal, 1996.
1470-8175/01/$20.00 r 2001 IUBMB. Published by Elsevier Science Ltd. All rights reserved. PII: S 1 4 7 0 - 8 1 7 5 ( 0 1 ) 0 0 0 4 7 - 9
138
B.C. Koner et al. / Biochemistry and Molecular Biology Education 29 (2001) 137–141
(clinical posting/case based learning) and FIP (field posting) have been adopted [10]. The term SIS originated from BPKIHS [10,11] (see footnote 1) and is a modified form of lecture where more time is given for interaction with the students. This is more suitable for groups of 30–50 students. This is student centered, teacher controlled and highly structured having definite objectives. The students are kept active throughout the session, which is not possible for traditional didactic lectures (nearly a monologue). Hence SIS is considered more effective. Structure–function relationships of proteins are emphasized in our medical curriculum because it helps in the conceptualization and understanding of the biochemical basis, pathophysiological process and clinical interferences in many diseases, e.g. inborn errors of metabolism, haemoglobinopathies, cancers, etc. Besides enzymes and haemoglobinopathies, the major histocompatibility complex (MHC) is a topic through which concept of structure–function relationships in proteins can be reinforced to the undergraduate medical students. A web site made for lecture or self-paced learning, is freely available from the internet [12] that depicts MHC structure and how MHC molecules take part in presenting antigen epitopes to T-lymphocytes. In view of the above, the present study was conducted in BPKIHS to explore: (a) if the learning of structure–function relationship of MHC in an SIS employing a computer presentation program is better than that in an SIS using conventional tools, e.g. OHP slides and blackboard, (b) what role a biochemistry faculty member as facilitator can play in a computer-aided SIS (particularly when the program can be used for both self-paced learning and lecture presentation), (c) if computer-assisted teaching/learning sessions can save time and (d) the student’s opinion/perception about computeraided SIS (CA-SIS) on MHC structure and function. The broad objective of the study was to explore the impact and perspective of computer-aided learning on medical students in Nepal.
2. Methods 2.1. The computer program The web site on MHC (Feb 19, 1998; version 0.9) created by Eric Martz and group is made for lecture or self-paced study [12]. Running the program requires installation of Chime and Netscape navigator 3.01 or 4.01 or later. The program depicts the structure– function relationship of MHC with the help of computer graphics and presents detail of the structures from different sides and different forms (space filling model,
ribbon model, etc.). Rotation or enlarging options are included in the Chime menu. The program was downloaded and used in the ‘computer-aided structured interactive session’ (CA-SIS) by projecting on a big screen through an LCD projector. Before the study, a four member expert team approved the web site as suitable for use with a biochemistry class on MHC in the ‘immunology’ module for the phase I MBBS curriculum at BPKIHS. 2.2. The study design First and second year MBBS students, who mainly take pre- and para-clinical subjects with some input from clinical departments, were incorporated in the study. For the first year students, the class taken during the study was integral to the course, but the scores were not incorporated in the final assessment. The students were randomized and assigned into two groups, taking account of academic standing to balance the ability spread. Group A (n ¼ 20) was exposed to SIS with conventional tools with the facilitator being a faculty member from Biochemistry. Group B (n ¼ 20) was exposed to computer-aided SIS with the facilitator being a computer expert who had no knowledge about the biochemistry subject, or MHC, but was familiar with the Chime menu and operation of the program. The second year students were also divided similarly into two groups: group C (n ¼ 10) and group D (n ¼ 11). The group C was taught as for group A, but the group D attended CA-SIS where the downloaded program of the web site was used as the tool and the facilitator was a faculty member from Biochemistry. For the second year students, the class was optional and not integral to the course, because they had already attended a related ‘blood and immunology’ module in first year. Forty students out of 50 from the first year took part in the study. The attendance was 21 out of 40 for the second year class. The poor percentage of attendance in the class for the second year groups was because the class was optional for them, and they were busy with study for their current module. They might also have thought that the class would only be repetition because the ‘blood and immunology’ module was over for them and the students knew that the score would not be added to the final assessment. The objectives of the class were kept the same for all the groups. However, a Biochemistry faculty member took the classes for groups A, C and D and interaction in SIS was encouraged. The time taken for the sessions in each group was noted. All students were pre-tested with MCQs (n ¼ 10) on immunology to rule out any difference in academic standing of the test groups (group B & D) from the respective controls (groups A & C). The post-test questions (MCQ, n ¼ 10) were different from those in the pre-test. The MCQs of the post-test
B.C. Koner et al. / Biochemistry and Molecular Biology Education 29 (2001) 137–141
examined whether the learning objectives of the class were achieved by the students. Some studies employ the same questions for both pre- and post-tests, but the present study used different question sets to assess new learning, rather than measure improvement in responses to known questions. After the post-test, groups A & C were asked to attend a computer-aided SIS (as taken for group D) and groups B & D attended the same SIS as taken for group A &C. Then the students were asked to write their comments on (a) the web site, (b) their liking /disliking about CA-SIS, (c) which they felt better and easier between CA-SIS and SIS using conventional tools for understanding the topic, (d) if they wanted CA-SIS any more in future and (e) free comments and suggestions, if any. 2.3. Statistical analysis The pre-test and post-test scores were expressed as mean and standard deviation and compared by a MannWhitney ‘U’ test with corresponding control groups. A p value of less than 0.05 was considered as the level of significance.
3. Results The pre-test and post-test scores are shown in Table 1. The pre-test score reveals that the academic standing of the test groups (B & D) is comparable to their respective controls (groups A & C) as the differences in scores between the groups are not statistically significant. The post-test scores revealed that the performance of the first year students attending CA-SIS was significantly inferior to their counterpart attending SIS using conventional tools. The pre- and post-test performance of the two groups of the second year students were not different statistically. The times in class for CA-SIS
139
were 37 and 42 min for the first and second year groups, respectively, and those for SIS with conventional tools were 40 and 38 min for the respective controls. Based on these times, computer use was not seen as a means to save time in teaching. A majority of the students in all groups felt that understanding of the topic was better and easier in CA-SIS, except for group B. Eighty percent of group B students opined that understanding was better in SIS using conventional tools. However, all the students in all the groups wanted such CA-SIS again in future, and all liked the CA-SIS and the web site.
4. Discussion The use of computers has increased in teaching medical sciences as well as in running hospitals in developed countries. Computer literacy and awareness about medical informatics by health professional is claimed to increase the effectiveness of health systems [13,14] and the GMC and Association of American Medical College’s GPEP report of 1993 has given stress to computer literacy among medical students [15,16]. The computer is considered as an effective learning tool for delivering knowledge as well as to develop problem solving skills [17]. The objective assessment of the present study clearly demonstrates that CA-SIS is less effective in comparison to SIS with conventional tools and that CA-SIS on structure–function relationship of MHC molecules became effective only when a biochemistry subject expert was the facilitator and the students had an opportunity to interact with a subject expert during the session. Due to lack of infrastructure, it was not possible to provide computer terminals to individual students to evaluate the effectiveness of self-paced learning using the same computer program. The application of computers in medical education in the developing countries is not widespread, but is gradually increasing. The educational setup, mental
Table 1 Pre and post-test scores (mean7SD) and subjective response of batches exposed to computer-aided SIS (CA-SIS) and SIS using conventional tools on structure–function relationship of MHC molecule Groupsa
Pre-test score
Post-test score
Group n ¼ 20 Group n ¼ 20 Group n ¼ 10 Group n ¼ 11
A 1st year conventional SIS
7.6571.60
5.872.12
90%
B 1st year computer SIS
6.8071.88
3.371.52b
20%
C 2nd year conventional SIS
6.8071.69
7.271.62
100%
D 2nd year computer SIS
7.0072.14
6.7271.62
100%
Subjective responseF% claiming that computer SIS achieved better understanding
a Group A=1st year students exposed to SIS with conventional tools the facilitator being a subject expert; Group B=1st year students exposed to computer assisted SIS the facilitator being a computer expert; Group C=2nd year students exposed to SIS with conventional tools the facilitator being a subject expert and Group D=2nd year students exposed to computer assisted SIS the facilitator being a subject expert. b po0:05 in comparison to group A.
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make-up and aptitude of the students and teachers and the attitude of administrative authorities towards novel experimental teaching are different in developing countries, so the effect and impact of computer-aided teaching might be different as compared to that seen in the developed countries. There are hardly any published reports from developing countries evaluating the effect of computers in teaching. In our study, the performance of the students after attending a CA-SIS or a SIS using conventional tools on the same topic was not significantly different. This raises the question of whether undergraduate students should be encouraged to own a computer when equally effective alternative teaching is available. Others have raised the same question [6]. However, it is more difficult to address the issue of computer use in developing countries where resources are less and the resource management is very poor. Learning is not only an intellectual process but also involves emotion. The overwhelming subjective response of the students in favor of CAL indicates that the learning in CAL session might be more effective in terms of long-term memory and problem-solving skill development. The present study evaluated only immediate recall capacity of the students. The overwhelming response in favor of CAL might be because it was novel for the students, thereby creating a false belief about the superiority of the use of advanced technology in teaching. A more objective assessment will only be possible when the students have been repeatedly exposed to computer-aided teaching sessions. At present, there are 43 computers in BPKIHS and all the teaching departments have at least one Desk-top PC connected via LAN to the internet through VSAT. In total, 30 PCs are used by academic departments for both academic and administrative work. Other computers are used for the administrative and accounting purposes of the Institute. None of the BPKIHS students have their own computer, not because none of them can afford it, but because they hardly feel any need to own a computer at present. The students’ access to the Institute’s computers and internet facilities are very limited. They are allowed to use computers and the internet under the supervision of faculty members only when they have a specific need, such as to prepare research projects or seminar presentations at the end of PBLs. However, they are free to search Medline in the library by making a prior appointment. We used only two computers for the present studyFone belonging to the Department of Biochemistry and other to the Medical Education Department. The computer from the Medical Education Department was connected to a LCD projector in a seminar room where all the CA-SIS was conducted. The problems are that within a limited financial capacity, the Institute has to give priority to the development of many other fundamental areas. Only a limited number of
faculty members have enough computer knowledge to improve the computer support and develop computer programs suitable for the Institute’s curriculum to fulfill the learning need of BPKIHS students. It would be desirable for the medical students of Nepal to have free access to computers and information available from the internet; however, most of the software is from the developed countries and might not be suitable for the BPKIHS curriculum. There are no responsible authorities that have control over these web sites on medical topics to check their worth and truth. We also have the reservations that free use of the internet may dehumanize the practice of medicine and change the societal values in a developing country like Nepal.
Acknowledgements Dr.B.C.Koner was in Nepal while conducting the study, on deputation to BPKIHS, Nepal from Govt. of India. The authors acknowledge Mr. D. Dahal, the computer expert of BPKIHS for his help in performing the study. The authors are thankful to the journal reviewer for valuable suggestions to revise the manuscript.
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