Introduction of e-learning in dental radiology reveals significantly improved results in final examination

Journal of Cranio-Maxillo-Facial Surgery 39 (2011) 40e48

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Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com

Introduction of e-learning in dental radiology reveals significantly improved results in final examination Sandra Meckfessel a, *, Constantin Stühmer a, Kai-Hendrik Bormann a, Thomas Kupka b, Marianne Behrends b, Herbert Matthies b, Bernhard Vaske c, Meike Stiesch d, Nils-Claudius Gellrich a, Martin Rücker a a

Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany Peter L. Reichertz Institute for Medical Informatics, Hannover Medical School, Hannover, Germany Institute of Biometry, Hannover Medical School, Hannover, Germany d Department of Dental Prosthetics, Hannover Medical School, Hannover, Germany b c

a r t i c l e i n f o

a b s t r a c t

Article history: Paper received 27 March 2009 Accepted 10 March 2010

Purpose: Because a traditionally instructed dental radiology lecture course is very time-consuming and labour-intensive, online courseware, including an interactive-learning module, was implemented to support the lectures. The purpose of this study was to evaluate the perceptions of students who have worked with web-based courseware as well as the effect on their results in final examinations. Materials and methods: Users (n3þ4 ¼ 138) had access to the e-program from any networked computer at any time. Two groups (n3 ¼ 71, n4 ¼ 67) had to pass a final exam after using the e-course. Results were compared with two groups (n1 ¼ 42, n2 ¼ 48) who had studied the same content by attending traditional lectures. In addition a survey of the students was statistically evaluated. Results: Most of the respondents reported a positive attitude towards e-learning and would have appreciated more access to computer-assisted instruction. Two years after initiating the e-course the failure rate in the final examination dropped significantly, from 40% to less than 2%. Conclusions: The very positive response to the e-program and improved test scores demonstrated the effectiveness of our e-course as a learning aid. Interactive modules in step with clinical practice provided learning that is not achieved by traditional teaching methods alone. To what extent staff savings are possible is part of a further study. Ó 2010 European Association for Cranio-Maxillo-Facial Surgery.

Keywords: E-learning Education Radiology Online courseware Content Management System

1. Introduction During the twentieth century many new technologies were introduced in the hope that they would improve educational standards. Unfortunately none of them lived up to their initial promise to revolutionise teaching and to act as a replacement for textbooks. Neither the invention of the radio nor the television leads to lasting improvements in education. The radio was supposed to become common in schools and to bring “the services of the finest teachers and inspirations of the greatest leaders” into the classrooms (Darrow, 2008). Even the television, which combined the motion picture with the widespread presence of the

* Corresponding author. Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany. Tel.: þ49 511 532 4766; fax: þ49 511 532 4740. E-mail addresses: [email protected], sandra.meckfessel@ gmx.de (S. Meckfessel).

radio, did not enhance teaching and was only used infrequently in schools (Cuban, 1986). In the 1960s the computer entered the education field as a new learning tool, again with the promise that it would revolutionise education (Mayer, 2001). The earliest computer-based learning programmes utilised computer-assisted instructions (CAI). These were based on a question-and-answer game that was supposed to initiate the memorisation of correct answers. A well-known example is the “teaching machine” invented by B.F. Skinner, founder of the learning theory of behaviourism (Skinner, 1954). Later programmes recorded the errors made by the user and adjusted to the individual user’s needs by repeating similar questions. The introduction of systems based on DOS software marked the beginning of authentic multimedia learning as the use of graphics opens up a variety of chances to improve education (Liaskos and Diomidus, 2002). Multimedia learning encompasses all forms of learning that use digital media to present and distribute learning materials. E-learning, computer-based learning and online-learning are used

1010-5182/$ e see front matter Ó 2010 European Association for Cranio-Maxillo-Facial Surgery. doi:10.1016/j.jcms.2010.03.008

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synonymously (Kerres, 2001). E-learning encourages self-explanation and takes place as an individual or group activity without direct contact with the teacher (Romiszowski, 2003). Online courseware is supposed to provide the student with individualised teaching based on their individual needs. The student can choose the time and place to learn, taking advantage of more flexibility and variety. At the end of the 1990s, the Internet found its way into everyday life, for both occupational and recreational use and led to a revival of interest in multimedia learning. As an emerging source, the World Wide Web seems to offer new opportunities to enhance education, but has it entered the education field as much as it has other parts of life? New students are so used to the new digital media that they take the use of e-courses for granted and this has encouraged academics to incorporate the technology into their teaching. In the medical education sector the utilisation of computers as a learning tool has advanced relatively slowly. The “chalk and talkprinciple” is a widespread, proven teaching method of teaching in the medical sector (Qayumi et al., 2004). Even though information and guidelines exist to enable educators to develop an online multimedia module, it remains a challenge for medical lecturers to design e-programs and incorporate them into their conventional teaching. This can be a problem for educators in the medical sector, because they have not usually been trained in didactics. Some aspects of the psychology of learning can improve developing individual online multimedia modules. In CAI two kinds of active-learning are interesting: behavioural and cognitive activity. In short, behaviourism describes reaction as a consequence of an impulse. Positive or negative effects to the reaction have an impact on the frequency with that the reaction occurs (Skinner, 1954). This principle is applicable to quizzes within the e-learning module. When giving a correct answer, the learner would be rewarded and keep the right answer in mind (Rutherford, 2000). The learner builds fragmented knowledge resulting in good retention but with poor transfer performance (Bransford and Brown, 2000). Cognitive-learning can be considered as an interior perception and recognition of information, in contrast to external conditioning caused by behavioural activity. When working with interactive modules, the student is cognitively involved because he or she is actively trying to make sense of the presentation. Self-explanation is a cognitive performance that encourages students in activelearning and ensures that students attend to the material while effectively monitoring their evolving understanding (Chi et al., 1989). The learner builds organised and integrated knowledge, resulting in good retention and good transfer performance (Bransford and Brown, 2000). It is therefore recommended that an interactive module is integrated in online courseware when explaining themes that are difficult to understand. In 2006 the Department of Oral and Maxillofacial Surgery of the Hannover Medical School, in collaboration with the computing faculty, introduced an online course, called “Medical Schoolbook”, for undergraduate dental students attending the dental radiology lecture in their third year of study. After one semester of dental radiology, the students have to pass a final examination to acquire authorisation to take X-rays. During this semester the student is asked to become familiar with theory and practice of dental radiology. The “Medical Schoolbook” is designed to assist the clinical teaching and to support the lectures by offering additional didactic edited text as well as an interactive-learning module. The interactive module is a lifelike visual animation without audible feedback. The user gains virtual practical experience and learns effortlessly. This learning experience is not achievable using conventional teaching methods. The combination of e-learning and in-school teaching is called “blended learning” as it combines the efficacy and flexibility of web-based learning with the social aspects of faceto-face communication in a lecture (Reinmann-Rothmeier, 2003).

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The purpose of this study was to clarify to what extent webbased multimedia learning is accepted and appreciated by the student body and to evaluate the effect on the results in subsequent exams. In addition this survey illustrates what requirements need to be considered for reasonable online courses and how preconditions are accomplished for establishing e-learning as an essential part in medical education. In addition, we consider if it is expedient to define standardised guidelines for developing online courseware or if it is preferable to design an e-program individually for each course. 2. Material and methods Over a two-year period a questionnaire was distributed to the students at the end of the lecture course to evaluate their experience and future expectations of an e-course. A statistical analysis was additionally performed to assess the impact of the e-program on student’s results in the final examination. 2.1. Web-based courseware The e-program of the Department of Oral and Maxillofacial Surgery was based on the Content Management System (CMS) “Medical Schoolbook” that was developed at the Peter L. Reichertz Institute for Medical Informatics at the Hannover Medical School. The Medical Schoolbook is an open source software for creating dynamic websites. The Medical Schoolbook System was realised on a Linux system with the Apache web server, the programming language PHP and the database MySQL. Through a web browser the PHP application allowed content from the database to be read and enabled authors to insert their content into the database. Structure and content were stored in the database, but the layout was defined by the PHP application (Fig. 1) (Kupka et al., 2006). The Medical Schoolbook was configured in a tree structure. Primarily, the user began with a start page (“father-node”) and navigated through the hierarchical structure. Each node was linked to several “child-nodes”. Secondarily, particular nodes were linked with each other, leading to a network. For every node (P0-Px) a website can be generated (Fig. 2) (Matthies et al., 2003). Because of this configuration the learning content was presented in a nonlinear way what made exploratory learning possible. The student was able to investigate the field of knowledge on his own pathway and discovered connections between the domains. Our Medical Schoolbook consisted of eight domains: a. Dental X-ray equipment for radiography b. Radiation protection

Fig. 1. Schematic diagram of generating e-learning applications using the Content Management System “Schoolbook”. After generating websites from a database, a configurated HTML-code is transmitted to a web browser via a web server.

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Fig. 2. Representation of the hierarchical structure of the online course “Medical Schoolbook”. P0-P19 demonstrates schematically different main- and subsections (nodes). A website can be generated for each section. Subsections can be linked to each other so that the user discovers learning content and context in a non-linear way.

c. d. e. f. g. h.

Physical basics Interactive-learning module Technical instruction Various radiographic techniques X-ray examination of tooth fractures X-ray examination of mandibular fractures

The web-based e-modules combined text, graphics and other visual multimedia techniques to enhance the e-learning process. Important characteristics were interactivity as well as hyperlinks to up-to-date information in the World Wide Web. The unit “radiation protection” was hyperlinked to the corresponding law text. Interactivity was given in a learning unit where the student was asked to place the X-ray apparatus correctly for obtaining an accurate radiograph. Correct alignment resulted in commendation while a misalignment of the X-ray apparatus caused an explanation to appear as to why the radiograph becomes distorted (Fig. 3a and b). It was a distinctive feature that the construction of our online courseware allowed a number of lecturers to function as an editor. This reduced the need for the eight teachers of the dental radiology course to co-ordinate any changes to the programme required by any of them. Accredited editors could modify every single module separately from the others. An editor could add or delete text, illustrations or videos in previously-designed form fields. In this

way the e-modules could be up-dated individually and temporally independently of any local computer. The Content Management System “Medical Schoolbook” enabled the author to create a webbased multimedia application without the need to be familiar with web technologies (Matthies et al., 2003). At the beginning of the dental radiology lecture the Medical Schoolbook of the Oral and Maxillofacial Faculty was introduced. As there was compulsory attendance, every student on the course was reached. The use of the Medical Schoolbook was presented with AV projection and a handout was distributed to every student. An explanation of the use of the student’s unique password as well as navigation through the hierarchically structured system was given. The handout also included an e-mail address to leave helpful suggestions, criticism or questions behind. Access to the web-based Medical Schoolbook was possible at any time and any place. All users had free Internet access at the Hannover Medical School and they had a password to access the website from their computer at home. 2.2. Dental radiology lectures The dental students at the Hannover Medical School had to attend the dental radiology lectures for one semester in their third year of study. The lectures included physical and theoretical basics, legal requirements of radiation protection and practical instruction,

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Fig. 3. (a) and (b) Screenshot of the interactive-learning module. The user is able to define a position of the X-ray apparatus and take a radiograph virtually. The user can view the taken radiograph immediately. Success or failure is given in text and image. Note the difference of the proportions of the teeth on the X-rays of (a) and (b), caused by different positions of the X-ray apparatus.

as dental students were required to take X-rays autonomously in the second part of their studies. The lectures and a final examination took place unchanged in content and procedure each year. Lectures were held once a week for 2  45 min, altogether 10  2  45 min, i.e. 20 units per semester.

2.3. Examination At the end of the semester the participants had to pass an assessment to receive authorisation to take X-rays. The examination took as the form of a written test consisting of 20 multiple-

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choice questions, approximately one-third being related to clinical practice. Questions had to be answered within 30 min. To pass the test students had to answer 60% of the answers correctly.

Table 1 Tabulation of the frequency of responses (in percentage) to the questionnaire distributed to the users of the e-program in 2006 and 2007. Note that the majority of participants indicate a very positive attitude towards e-learning and have no problem using this new technology.

2.4. Evaluation At the end of the dental radiology course, i.e. after having had the opportunity to use the e-program for one semester, a questionnaire was distributed to the users of the online course and completed anonymously. The questionnaire asked about their experience and expectations of web-based courseware. In addition it included questions about the use of computers in education in general as well as questions about the Medical Schoolbook in particular. The questionnaire consisted of free text questions as well as Likert scale questions, introduced by Rensis Likert (empirical social research) to measure personal preferences. The statements for the Likert scale were “Strongly agree”, “Agree”, “No difference”, “Disagree” and “Strongly disagree”. 2.5. Study design Firstly, the results of the final examination of group 1 (n1 ¼ 42) and group 2 (n2 ¼ 48) which had been taught by lectures only, were analysed and, secondly were compared statistically to the results of the examination of group 3 (n3 ¼ 71) and group 4 (n4 ¼ 67), which were provided by the online courseware. Students of all groups had the same qualifications prior to enlisting to the dental radiology course. 138 students (n3þ4) had access to the online courseware and were assessed in the evaluation. In the first year (n3, 2006) the return rate of the questionnaire added up to 64%, of whom 77% of the students were female and 23% were male. In the second year (n4, 2007) 99% of the students completed the questionnaire, 55% were female and 45% were male. Altogether 115 students completed the questionnaire. The median age was 22 years in both groups. 2.6. Statistics Data were interpreted by using SPSS 15.0 and Microsoft Excel 11.5. Results were expressed as means  standard error of the mean. Between-group data were compared using the Pearson ChiSquare Test. Differences were considered significant at P < 0.005. Results of the evaluation were tabulated anonymously. Answers to the Likert scale questions were listed and outlined as percentage of respondents giving the same answer. Student replies to the open questions were reviewed and the frequency of replies for each question documented. 3. Results 3.1. Evaluation of the e-course The question of how intensively the students had used the “Medical Schoolbook” showed the most significant differences between the two classes. While in group 3 (2006) nearly 60% of the students used the e-program rarely, in group 4 (2007) this figure dropped to 31%. In both years more than one-third of the students claimed frequent use of the e-program. Free text answers gave the following reasons for infrequent usage: “no Internet access at home” (4), “log-in did not always work” (2), “I do not like to work with the Internet, I prefer photocopies” (2). The results of the remaining questions obtained from group 3 (2006) and group 4 (2007) were very similar (Table 1). More than 80% of the students in group 3 and group 4 used the web-based eprogram at home, of these more than 70% were able to access the

2006

2007

Question 1: How intensive have you used the “Medical Schoolbook”? Very intensively 33% Infrequent usage 7% Rarely 60%

34% 35% 31%

Question 2: Where have you used the “Medical Schoolbook”? At university 9% At home 91%

21% 79%

Question 3: If you have Internet access at home, what kind of access do you use? Modem 15% 9% ISDN 19% 12% DSL 67% 79% Question 4: Did you have any problems using the e-course at home? Too long loading-times 17% Other problems 10% No problems 73%

15% 4% 81%

Question 5: What is your attitude towards e-learning in principle? Positive n/a Undecided n/a Negative n/a

72% 16% 12%

Question 6: Do you have fun when working with computers? Yes n/a Don’t know n/a No n/a

73% 15% 12%

Question 7: Are you computer literate? Definitely Not sure No

64% 16% 19%

n/a n/a n/a

Question 8: Did you rework themes difficult to understand by using the ecourse? Yes n/a 28% Seldom n/a 31% No n/a 40% Question 9: Would you appreciate an expanded offer of e-courses? Yes 75% No 25%

81% 19%

Internet via DSL (Digital Subscriber Line). More than two-thirds of the students stated that they did not have any problems using the “Medical Schoolbook” at home, but 16% complained about loading times being too long. Students in group 4 (2007) were asked additionally about their attitude towards e-learning in principle. Approximately 70% indicated a positive response to web-based courses, 16% were undecided and only 12% had a negative standpoint. Agreeing with this, more than 70% of the respondents claimed to enjoy working with a computer, 15% were undecided and 12% tried to avoid it. More than 60% of the undergraduates claimed to be computer literate, while only 20% admitted poor computer skills. Students were asked if they used the e-program for reworking themes they found difficult to understand in dental radiology. About 25% of the respondents agreed or strongly agreed, while a larger number (40%) denied having done rework with the Medical Schoolbook. The majority of the users in group 3 (2006) and group 4 (2007) agreed or strongly agreed that the content of the e-learning modules was clearly structured and that the screen layout was appealing, but nearly half of the respondents declared having problems with the navigation of the website. More than 40% held that the content of the Medical Schoolbook was not adequate when compared with the dental radiology lectures. A similar number of

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Table 2 Answers to the Likert scale questions were listed and outlined as percentage of respondents giving the same answer. Comparison of the results of the survey in 2006 and 2007. Take notice of the common consent that the layout is appealing and the content clearly structured. 2006

a. Content clearly structured b. Appealing layout c. Navigation: easy to follow? d. Good addition to corresponding lecture e. Good help for exam preparation f. Timesaving learning method

2007

Strongly agree/agree

No difference

Disagree/strongly disagree

Strongly agree/agree

No difference

Disagree/strongly disagree

54% 46% 33% 31% 27% 29%

21% 27% 13% 25% 21% 29%

25% 27% 54% 44% 52% 42%

70% 51% 25% 21% 34% 13%

16% 28% 16% 31% 30% 33%

13% 21% 58% 48% 36% 54%

course, in group 4 (2007), only 1 out of 67 students was unsuccessful in the final exam. This was a marked improvement in the failure rate of the final assessment. The failure rate for the traditional courses, when compared to the failure rate for the courses supported by e-learning, dropped from 40% to less than 2%. The failure rate for each year is shown in Fig. 4. The final test scores were significantly better in group 3 (n3 ¼ 71, 2006) and in group 4 (n4 ¼ 67, 2007) than in group 1 (n1 ¼ 42, 2004) and group 2 (n2 ¼ 48, 2005) with a P-value <0.001 (Fig. 4). 4. Discussion

Fig. 4. Failure rate (expressed as percentage) of the final exams of the dental radiology course from 2004 to 2007. Web-based courseware was implemented in 2006. The difference of the failure rate from 2004 to 2007 is statistically significant (*p-value < 0.001).

students were concerned that the information in the e-course would not be sufficient for passing the final examinations. Half of the students considered that learning with the Medical Schoolbook compared to conventional textbook learning did not save time (Table 2). In free text questions students were asked to describe missing content as well as to list suggestions for improvement. The student’s comments to the open questions were very similar in both classes. The following statements stood out because of the frequency with that they were reported: “simple and selfexplaining navigation”, “less full text, more headwords”, “more self-monitored exercises”, “more information would be appreciated”, “more information relating to the corresponding lecture”, “printable downloads (no blue background colour)”. In summary, nearly 80% of the respondents would welcome an extended range of e-programs and would appreciate further web-based lessons in other fields of study. 3.2. Final examination e an annual comparison The statistical analysis of the results of the final examinations of the dental radiology course revealed outstanding results (Fig. 4). In the first group (2004), that attended only traditional lectures, 15 out of 42 students did not pass the final examination. In group 2 (2005), one year before the e-program was established, 48 students were enrolled for the dental radiology lecture, of them 19 students failed in the written test. In group 3 (2006), the Medical Schoolbook was implemented and only 7 of the enrolled 71 students did not pass the final examination. Two years after initiating the web-based

The e-program we implemented supports the dental radiology lectures and leads to a significantly better outcome in final examinations. The web-based lessons include theoretical information as well as an interactive-learning module and are developed for use by undergraduate dental students in their third year of study. The aim of this evaluation was to receive course feedback, to analyse the computer skills of today’s students as well as their attitude towards e-learning and to obtain information for improvement of future online courses. In the early development stages of e-programs, hopes were raised of reductions in costs and labour with the implementation of online courseware at universities, but, due to a lack of equipment and IT skills, these economies have yet to be realised. According to a study of the German Academy Information System in 2008 (Kleimann, 2008), investments in equipment and skill enhancement were made in the last few years that provided a new basis for possible rationalisations. In 2001 the German Federal Ministry of Research and Education enacted a support program for “New Media in Education” whereby e-learning achieved a higher priority. This was driven by estimates of the increasing number of students enrolling over the next few years as well as the potential economic benefits of the use of reasonable CAI at universities. An expansion of capacity in education due to the introduction of online courseware is expected in sectors where elearning supports or even replaces a large number of lectures. In this way, the additional capacity obtained exceeds the numbers of new staff required for creating web-based courses. Due to this development distance education has established itself as an officially recognised method for acquiring a graduate degree. Distance education provides courses that are taught to students who are completely separated by time and place from the teacher. Techniques of delivery for these classes include: online courses, videotaped courses, correspondence via phone or radio or live-interactive courses (Mattheos et al., 2008). Nevertheless, traditionally established universities are just starting to implement e-learning as a supplement to their conventional classroom teaching, which is, especially in the field of dental radiology, a slow progress. Computer-assisted methods have arrived in nearly every area of medicine, but are little-noticed in medical education. As demonstrated by Nickenig et al., dental implant placement can be learned without risk and planned in

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three-dimensions at the computer (Nickenig and Eitner, 2007). Furthermore, computer simulation enables the surgeon to train virtually before operating on patients, as previously published by Donatsky et al. in regard to orthognathic surgery (Donatsky et al., 2009). Katori et al. in their study demonstrated the computerassisted resection of tumours (Katori et al., 2008), and Schramm et al. presented the benefits of computer-aided navigation in craniomaxillofacial surgery (Schramm et al., 2008). As indicated by these authors the use of computer-assisted methods has become quite common in clinical medicine, but is seldom found in medical education. Hence, paper about the introduction of online courses for undergraduate education in radiology are rarely documented. The Internet offers information portals for professionals, such as the website www.RadiologyWiki.org, presented in the study by Streeter et al. This site is produced by the collective effort of many users and is hoped to develop into a collaborative authorship tool for communication (Streeter et al., 2007). The Medical Image Resource Centre (MIRC), developed by the Radiological Society of North America (RSNA), as mentioned in the report by Guo-Liang et al., aims to integrate Picture Archive and Communication System (PACS) images into a digital library of electronic teaching files as an online tool for teaching diagnostic radiology in continuing education (Guo-Liang and Tchoyoson, 2006). These online reference resources are, however, designed to be used by specialists with previous knowledge. Seitz et al. concluded that most homepages of the departments of diagnostic radiology of German universities offer collections of cases. A web-based training program that is comparable in quality to a didactic CD-ROM teaching program was not found (Seitz et al., 2003). In addition, Seitz et al. pointed out that no program used the ability to give credits to the users with regard to official training programs. This could also be an improvement we could develop in our Medical Schoolbook. The continuous growth of the World Wide Web and the increase in technical innovations enables the user to receive data faster, making it possible to present teaching material on websites interactively. The improvement of technology in the near future with increased personal accessibility makes the distribution of real e-learning possible (Reynolds et al., 2007). It is therefore desirable that online courses are not established just to bring technology as a tool into the curriculum but rather for enhancing and enriching education. Reports of studies vary concerning the effectiveness of online courseware. Tan et al. demonstrated in their study in the field of dental radiology that a 100% e-learning course produced equivalent learning outcomes to those achieved with didactic lectures (Tan et al., 2009). Rogers et al. ascertained that students who participated in a face-to-face seminar about surgical techniques obtained higher achievements when compared to students who took part in a computer-assisted course containing the same subject (Rogers et al., 1998). According to Rogers, Vichitvejpaisal et al. compared e-learning to conventional textbook learning and concluded that students in the e-learning group demonstrated inferior results (Vichitvejpaisal et al., 2001). Contrary to Vichitvejpaisal et al., Padalino and Peres evaluated the acquisition of knowledge between one group of nurses who participated in traditional classroom training and another group of nurses who took part in a web-based course. The e-learning group achieved higher scores in post-tests (Padalino and Peres, 2007). Interestingly, Qayumi et al. came to the conclusion that CAI can not only be superior to textbook learning but can also be more helpful for people having problems with learning with conventional methods. Their study demonstrates that e-learning has the greatest effect on students with lower overall achievement and the least influence on students with overall high achievement levels (Qayumi et al., 2004). Correspondingly, our study demonstrates that the number of students failing in the final examination decreased by more than 30% only

two years after the introduction of our online course. Heye et al. indicated that an interactive multimedia learning platform with authentic clinical cases is the ideal method for supporting and expanding medical education in radiology (Heye et al., 2008). Rochester and Pradel demonstrated in their study that pharmacy students preferred a hybrid web-based/classroom-based course instead to purely web-based lessons or purely classroom-based lessons (Rochester and Pradel, 2008). Our study transfers these principles to medical education and corresponds with Howlett et al., affirming that educational online courses can be effectively blended with other forms of teaching to allow successful undergraduate delivery of radiology (Howlett et al., 2009). Overall, most publications confirm the efficacy of web-based courseware. As Rose and Wheaton showed dissimilar conclusions made by diverse authors may result from poorly designed online courses, variations in evaluation procedures or differences in the educational system (Rose and Wheaton, 1987). In 2003 Eynon et al. indicated that students then were mostly concerned about not having computer access at home, the costs of access at home, inadequate IT skills and lack of time to access the site (Eynon et al., 2003). The results of our study demonstrate that student’s concerns have changed completely. In 2007, more than 80% of the participants have Internet access at home and are frequently using it. Because of low cost telephone providers and unlimited data and time contracts it became irrelevant how much time is spent online in respect of costs. Two-third of the undergraduates claimed to be computer literate, regardless of sex. Nevertheless, our study also identifies problems that have to be solved in computer-based teaching. This includes a simplification of the navigation in the program as well as the request for more selfassessment exercises comparable with exercises in the final examination of the course. Problems with the navigation can be solved by improving the introduction of the Medical Schoolbook at the beginning of the course or online. Self-assessment exercises will be implemented. The students would appreciate a better relationship between the online course and the corresponding lecture as well as the provision of printable downloads. We are not happy with these suggestions. The Medical Schoolbook is supposed to be a selfcontained learning unit and the provision of printable downloads results in the creation of conventional learning material which is contradictory to the intention of online courseware. We created an online course in step with actual practice. Following this the participants achieved higher test scores than the control group and as a result, it is assumed that they improved their competencies mainly in the practical domain of dental radiology. The majority of the respondents declared a positive attitude towards web-based courses and indicated they enjoyed working with computers. The vast majority of the students (78%) would welcome an expanded range of e-courses. The results of our study show that enrolled students want computer-assisted courses, but e-learning is still not integrated in medical education as a matter of course. The offer of web-based courseware at universities is therefore an appealing factor for new students. Used as an effective supplement to traditional education, online multimedia learning can simplify a teacher’s preparation for lectures. This can be particularly interesting for medical teachers, because they are not only involved in education but also in patient treatment. The Internet offers as many possibilities for the creation of teaching tools as it raises questions how its usage best suits the educational purposes. Guidelines for developing an online multimedia module as a teaching tool are uncommon. Some authors, like Johnson and Schleyer, eagerly demand a standardised multimedia design for e-courses (Johnson and Schleyer, 1999), while others state that computer materials must be provided in the style of

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teaching in the course and the style of learning of the students attending the course, to achieve success (Devitt and Palmer, 1999). Our own experience has shown us that it is necessary to adhere to certain standards and guidelines when creating online courseware, but in addition the e-learning modules must be individualised to address students requirements in a particular course. By default, a web-based courseware should include  Clearly expressed learning goals in each chapter.  Application-oriented examples.  Interactive modules and illustrations that cannot substituted by a lecture or textbook.  Embedded questions to give feedback to the students.

be

Consequently, the first step in creating multimedia modules is to understand what the student needs to know and what sort of assessment takes place. This leads to the decision about which way the e-learning material should be presented, considering psychological aspects as mentioned at the beginning. Thus, if the examination of a course derives from a recall of facts, an e-learning module that takes behavioural approaches into account can be developed, but on the other hand, cognitive-learning methods are recommended when the assessment of a course is based on the ability to use presented material in novel situations and to solve problems that were not explicitly given in the presented material. At the best, medical teachers build online courseware in collaboration with computer scientists, always having the users point of view in mind. After an introduction phase of the web-based course, an evaluation has to be undertaken to analyse the user’s response to the e-program. Thereafter, problems must be solved and suggestions of the participants need to become implemented for enhancing the online course. Evaluations need to be performed at frequent intervals to assure compliance with quality standards. 5. Conclusion The results of our survey shows that e-learning is appreciated in the student body and leads to significantly better test scores in final examinations. We have demonstrated that well designed programmes are set to establish online courseware as an essential part in education. Web-based courseware allows the user flexibility to choose both the time and place to learn. Learning material can be designed in step with actual practice and clinical problems can be simulated. Especially in the medical sector, the implementation of e-learning can be useful, because well-reasoned learning modules including real-world examples, provide the opportunity to learn from mistakes without consequences. This enhances the clinical training in undergraduate and postgraduate education. The introduction of online courseware as a supplement to our dental radiology lectures has been shown to be successful. The positive response to our web-based courseware, the request of further e-programs and the improved test scores in the final assessment confirm the effectiveness of our Medical Schoolbook and lead to the conclusion that e-modules providing these opportunities can also be beneficial in other areas of continuing education. The development of e-learning is an evolutionary process (Kupka, 2008). Ineffective computer-assisted programmes will fail while successful online programmes will establish themselves (Ammann et al., in press). To inform and advance this development, our study presents the current students views of e-learning that should have an impact on future online courseware. Exploration of further factors for improving contemporary education is a matter for subsequent investigations.

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