- Email: [email protected]
Virtual biomedical universities and e-learning
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 ( 2 0 0 7 ) 331–335
journal homepage: www.intl.elsevierhealth.com/journals/ijmi
Editorial
Virtual biomedical universities and e-learning a r t i c l e
i n f o
a b s t r a c t
Keywords:
In this special issue on virtual biomedical universities and e-learning we will make a survey
Virtual university
on the principal existing teaching applications of ICT used in medical Schools around the
E-learning
world. In the following we identify five types of research and experiments in this field of
Patient simulations
medical e-learning and virtual medical universities.
Computer based instruction
The topics of this special issue goes from educational computer program to create and
Indexing and searching resources
simulate virtual patients with a wide variety of medical conditions in different clinical set-
Digital video and audio resources
tings and over different time frames to using distance learning in developed and developing countries program training medical informatics of clinicians. We also present the necessity of good indexing and research tools for training resources together with workflows to manage the multiple source content of virtual campus or universities and the virtual digital video resources. A special attention is given to training new generations of clinicians in ICT tools and methods to be used in clinical settings as well as in medical schools.
1.
Introduction
Significant improvements in medical education and the development of computer assisted instruction can be expected from technological achievements both in hardware and software tools. At the beginning of the century (2001), Ward et al. [1] published in the Lancet a paper noticing that rapid advances in communication and information technology (C&IT), and the use of the worldwide web has important implications for education. The volume of information available on the web is so important, that both students and teachers need to be trained to manage it effectively. He advocates that the Medical schools must develop some new ways in which communication and information technology can be used to enhance the learning and teaching environment. By looking at the recent publications in Medline (Pubmed) we can see five types of applications in e-learning: Simulations of physiological or biological process for teaching, simulation of clinical cases, virtual reality and virtual patient, e-learning tools and platforms for storing and indexing ressources, video and sound recording of lectures for distance and differed learning. A recent paper by Bond et al. [2] dealing with “Learning to use the Internet as a study tool: a review of available resources and exploration of students’ priorities” reports that best resources are not necessarily the ones that are eas-
ily found by students. The aim of the study was to identify the online information resources available to assist students develop Internet searching skills, and to explore the students’ priorities in online guides. The study found that there were good online guides available, but that, perversely, the better guides tended to require the best searching skills to locate them. “A few students were used to search online support, however the majority felt that if they had the skills to locate such resources they wouldn’t use a study guide to improve these skills, and if they did not have the skills they would not think of using an online guide to develop them.” This shows the difficulty of assessing that a good resources is well known and used by students and that even with good guides most of them will ignore them. In this special issue, we will present some interesting work in the field: a first paper by Sijsterman deals with the training of medical students in inter-physician communication skills using the Dynamic Patient Simulator® (DPS), a two year project by the Academic Medical Center at the University of Amsterdam and the Leiden University Medical Center. Then for distance learning education we present the experience of F. Lau from University of Victoria regarding the Distributed Health Informatics Graduate Education for Working professionals in Canada. One of the hope of distance education and e-learning technologies is also to provide help and quality
332
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 ( 2 0 0 7 ) 331–335
education for the developing countries according the their needs and their level of accessible technology. The RAFT project is presented by Geissbuller and the cooperation of WHO and Mali in Central Africa. Ten years ago, when we started the Medical Virtual University in radiology [3], there were a few running projects in Europe and France and we decide to combine our efforts and share our existing and future resources and tools in a national project named the French Virtual Medical University (UMVF). From this project experience three papers have been selected: a first one by Cuggia and al. deals with the indexing and research tools for student and teachers, a second paper from Renard and al. on the workflow tools developed to coordinate the multiple source production of teaching resources in the UMVF and a third paper by Dufour and al. on the distance learning with digital video. In order to use ICT in the context of medical education we definitively need to train the new generation of clinicians. A paper by Hersh stress that there is an increasing need for a larger and better trained workforce in medical informatics. The goal of the American Medical Informatics Association 10 × 10 program is to educate 10,000 clinicians in medical informatics by the year 2010. Finally a paper by Staccini deals with hospital e-heath collaborative and workflow-oriented digital portfolio to support a nationwide program of practices evaluation in blood transfusion area.
2.
Simulations for training
As was stressed in the introduction, modern approaches to teaching and learning basic science include collaborative learning, problem-based learning and the use of computer simulations. Available computer technology allows the use of dynamic models, making learning more efficient. Simulation systems, which provide artificial cases to the student for discussion and management without risk for the patient, bring a new dimension in teaching, the dimension of experience acquisition. They allow the development of cognitive feedback to help the learner to understand why he does something and how he might differ from experts, about the tasks and himself as an actor in the decision process.
2.1.
Virtual bio-physiological process simulation
Many difficult concepts in physiology, for instance, are truly learned only when the student’s brain converts heard or read words, static pictures and diagrams into moving models. Computers are now sufficiently powerful and the Internet sufficiently fast to allow fast distribution of multimedia materials which are especially useful for teaching physiology [4]. An interactive Computer based instruction (CBI) must exhibit intelligent behavior (e.g., reasoning capability). Indeed, for a CBI to “interact” with a user beyond responding to “start,” “forward,” or “backward” clicks, it must have an understanding of the current user-context and carry out meaningful actions accordingly. Such an understanding could not hold without the proper representations and semantics describing a user-
context nor without the specific inference schemes to carry out meaningful actions. In the framework of the COAST, Courseware Authoring for Scientific Training system, Diomidous et al. [5] developed a “modeler environment,” which is used to describe the different tools and mathematical functions available for building models, and the “simulation author environment.” It is used to build sequences based on multimedia simulation, so as to gradually replace laboratory practicals that are becoming obsolete and costly, and to improve student’s understanding of complex systems.Similarly qualitative models can be developed and can be used for simulation of physiopathological models [6].
2.2.
Virtual patient simulation
The Minnesota Virtual Clinic, a web-based educational tool for simulating patients representing a variety of conditions and cultural backgrounds exposing students to critical basic science and clinical concepts in the context of patient care [7]. It is based on electronic Patient records (EPR) and such a process of independent decision making is something a student or resident may ever gets in medical practice. Zary et al. [8] developed the Web-based Simulation of Patients (Web-SP) project in order to facilitate the use of realistic and interactive virtual patients (VP) in medicine and healthcare education. Web-SP focuses on integrating simulation-based education into health sciences curricula, by making the creation and use of virtual patients easier. The Web-SP system was constructed to support easy authoring, management and presentation of virtual patient cases. More recently, a computer program has been developed at the Leiden University Medical Center for creating and running patient simulations. .This system is presented in the paper by Sijstermans in this special issue.It allows students to perform a vast range of medical procedures such as medical history taking, physical examination, ordering of and reviewing of laboratory tests and investigations and finally the planning of treatments. This enables students to make decisions during a simulation where the status of the patient may change over time
2.3.
Clinical case simulation
There is a long experience of various medical decision aid and clinical case training methods either with presential methods or with differed computer based method. In the context of internal medicine and radiology we develop simple clinical case containing a clinical context, a set of images asking for student interpretation and finally a final diagnosis [9]. More sophisticated clinical interactive clinical cases can also be implemented where the student can simulate time oriented reasoning by ordering lab tests with a delay (urgent or not) and wait until he gets news results and proceed toward clinical reasoning and final diagnosis. Experimental use of patient simulations in medical education has been going on for the past twenty-five years. The purpose of these simulations is to offer students a virtual patient on whom they can practice medical history taking, physical examination, laboratory and functional tests
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 ( 2 0 0 7 ) 331–335
ordering and assessment, inferring differential diagnoses and treatment planning. A student is provided with different kinds of feedback generated within the virtual learning simulation environment. In the last decade, Clinical Reasoning Learning has been used during clinical training courses in many universities. The goal of this educational activity is to develop problem solving and diagnosis skills in medicine, using previously acquired medical knowledge. Medelez et al. [10] propose the integration of educational resources and computer systems to help students during the reasoning process, and in order to prepare students to look for medical information. We also describe a Computer-Supported Collaborative Learning Environment that integrates Information and Communication Technologies in order to improve the Clinical Reasoning Learning Sessions. Following the introduction of computer-supported, problem-based learning (PBL) Stromso et al. [11] study changes in student learning approaches. They propose distributed problem-based learning (DPBL) in a computersupported learning environment. The introduction of DPBL did not seem to affect the participants’ use of regulating strategies or their mental models of learning. After the DPBL test period, group discussion and tutor input were reported to have less influence on students’ self-study, while the students perceived themselves as being less active in groups and as expecting less from their tutors. Siimilarly,Wilson et al. [12] developed an interactive learning tool for teaching rheumatology with a simulated clinical case studies program. It contains a series of interactive web-based clinical case studies. The case studies program developed were well received by both biomedical and medical students. This approach provides a way to increase the exposure of students to clinical cases involving interactive diagnostic and treatment procedures, that mimic real-world scenarios, but with fewer resource implications. In the context of the development of PACS environment, teaching cases can also be developed with real pathological images [13].
3. Virtual reality, video and virtual classroom New paradigms have been experimented for distance learning using Internet [14] and have been also used for Project based experiential distance education [15]. Virtual patient simulations make use of virtual reality (VR). VR is a computer technique that simulates reality as truly as possible through the use of a VR-helmet or a data glove. This technique would allow the simulation of an actual physical examination or even surgical procedures on virtual patients. Surgical simulation is increasingly being considered for training, testing, and possibly credentialing in medicine and surgery. At the University of Washington they have designed a virtual reality (VR) suturing simulator. Berg et al. [16] describes Virtual reality simulators for dermatologic surgery. This work aims at defining the concept of surgical skill and discussing how it can be measured in the context of validating VR surgical simulators.
333
Other video tools may be used for distance education namely the virtual class and visio conference Today, the visioconference on IP (norm H323) is a reality. The main advantages are: low cost, standard equipment access and services such as chat, program sharing or white boards The visioconference on IP, must have a quality compatible with a teaching usage especially with regards to quality of service: sound output rate, security and user friendly interface. This has tested between several universities across France: Lille, Marseille, Nice, Nancy, Rennes,Rouen and Paris either equiped with visioconference theater or simple workstations equipped with specific software. There is now a large choice of technologies and visioconference services that can be used for virtual classes. The following choices are presented in the paper by Dufour and a specific tool for comprehensive virtual class has been tested namely: Visioconference VRVS (virtual class videoconferencing system) enables distant collaborative work with an interface mixing sound and video, chat, document sharing and deskstop. This system is web oriented to reserve virtual conference room and the connection can be made either by a workstation with a webcam . . . or by a visio conference room. Although the previous tools are readily available in institution they may be still too sophisticated for large populations with a minimal of technology. The paper by Hersh in this special issue shows that for a large wide public (clinicians) a simple tool may be the more adapted namely voice and sound with presentation slides are the most easily accepted and simple to use for distant and asynchronous learning. He stresses the need to help the faculty to adapt to developments in modern medicine, as well as to the needs and demands of future medical students.
4.
Medical virtual universities
Lau and Bates [17] gave an excellent review of e-learning practices for undergraduate medical education. The University of British Columbia medical school enrolment will increase because of collaborations with campuses and medical centers across the province. MEDICOL (Medicine and Dentistry Integrated Curriculum Online) [18] provides a variety of Webbased resources that act as important adjuncts to all the teaching components of the medical and dental undergraduate curriculum. MEDICOL play an increased role in distance learning by continuing to deliver the teaching resources, as well as facilitating synchronous communications (e.g., Problem Based Learning, chat rooms) and teaching (e.g., videostreamed lectures) to students located across the province. It uses WebCT, a course-management platform to provide the following functions: tracking students’ progress, promoting student-to-student and student-to-instructor interactions and delivering self-directed learning components including multimedia learning modules (clinical skills, radiology, evidence-based medicine, etc.). Another popular approach of medical training is problem based learning (PBL). Ruderich et al. [19] design CAMPUS—a flexible, interactive system for web-based, problem-based learning in health
334
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care. They developed a flexible and realistic system, CAMPUS, which supports the case authors with appropriate vocabularies and an authoring tool. There are different kinds of case presentations to the users in accordance to the level of professionalism of the user and the scenarios. An evaluation within internship training has shown, that such programs are found useful by medical students. Harden and Hart [20] started in 2002 an international virtual medical school (IVIMEDS) with a high-quality education programme embodying a hybrid model of a blended curriculum of innovative e-learning approaches and the best of traditional face-to-face teaching. Key components are a bank of reusable learning objects, a virtual practice with virtual patients, a learning-outcomes framework, and self-assessment tools. In 2005, Francis Lau at Health Information Science department University of Victoria set up a distributed Master of Science Heath Information program across Western Canada (BC, Alberta) for working professionals. He uses Virtual Class software, the system and future project is described in the following paper in this special issue. With regards to the UMVF project there are several elearning platform used by the French Medical Schools [21] (Claroline, Moodle) but we emphasized the necessity of having a common descriptive form for each resource and we designed a workflow to transmit each form to the UMVF data bases for indexing and retrieving the teaching resources. The paper by Renard in this special issue presents the methods used and the implementation of the workflow tool that is used for free by medical SDC hold belonging to the UMVF consortium. Then the indexation process may be improved by using MESH to complete the notices by a manual indexation which is available in the Cismef French medical repository [22]. The paper by Cuggia in this special issue deals with the corresponding meta-engine associated wit the indexing process. Staccini et al. paper deals with a collaborative and workflow oriented digital portfolio to develop a nationwide program of practice evaluation in the blood transfusion area in the context of health professional assessment and evaluation. He developed a web based collaborative platform which involves the assessed physician and his tutor who follow him, the director of the program and the supervisor who manage the global system. Such an approach seems to be promising to manage distance assessment process all over a region or nation. To finish with this section the paper by A. Geisbuhler deals with a North South e-learning project named RAFT supported by the University of Geneva and the UN for introducing distant learning in a developing African country namely Mali. By using adapted simple technology they have shown that it is possible to promote distance education at a low cost even in the rural areas of central Africa.
5.
Discussion
In the following papers of this special issue, the authors present their approaches and experiments together with their evaluation of tools, content, usability. As we already know the assessment of virtual tools and distance education is difficult, because there is no reference to golden standard and
the use of controlled randomized trial is almost impossible in practice The paper by Sijtermans stressed the important issues concerning evaluation • Do students feel that they have improved their skills by using distant and/or ICT based educational environment? • How can we evaluate students usability of the e-learning tools and contents? • Are students satisfied by use of distant and non presential education and training? • Do students recommend such program to be incorporated in the medical or health professionals curriculum? Similar question may be raised for the teachers and tutors: • Do they feel that they have improved the quality of knowledge transmitted to the student by using distant and/or ICT based educational environment? • How can we evaluate teachers performance without or with the e-learning tools and contents? • Are the teachers satisfied by use of virtual distant and non presential education and training? • Do the teacher feels that they are doing a better job we the same amount of time investment? The paper by Sijstermans shows clearly that virtual learning simulation environments should be more widely implemented in medical settings so as to increase students’ competence, acceptance and awareness of education in interphysician training. In the framework of UMVF, El Balaa [23] proposed an instrument for measuring medical student satisfaction with virtual campus. Bernardo et al. [24] developed and assessed the first online course for undergraduate medical students on experimental surgery at the Federal University of Sao Paulo-UNIFESP, Brazil. The results show that students have significantly improved their knowledge on experimental surgery after the course.
6.
Conclusions
In a recent paper Valcke et al. [25] present Information and communication technologies in higher education: evidencebased practices in medical education. This paper stressed that ICT is expected to foster collaborative learning in the medical knowledge domain. They insist on the importance of prior knowledge and the need for real-life and practical experiences. The article concludes by underlining the need for evaluative studies in the promising field of ICT-based collaborative learning. Although the Dynamic Patient Simulator seems an appropriate method for training medical students in inter-physician communication training and the first assessment of UMVF seems to be promising there is a need for further research in evaluation, usability and assessment in the field of distance and virtual education. Such studies may be designed by using an approach such as The Virtual Usability Laboratory developed by Kushniruk et al. [26] to support the collection, integration and analysis of a variety of usage data of web based systems and applications.
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 ( 2 0 0 7 ) 331–335
references [16] [1] J.P. Ward, J. Gordon, M.J. Field, H.P. Lehmann, Communication and information technology in medical education. Lancet 357 (9258) (2001 Mar.) 792–796. [Erratum in: Lancet 357 (9266) (2001 May) 1452]. [2] C.S. Bond, D. Fevyer, C. Pitt, Learning to use the Internet as a study tool: a review of available resources and exploration of students’ priorities, Health Info. Libr. J. 23 (3) (2006 Sep.) 189–196. [3] L.P. Seka, A. Fresnel, D. Delamarre, C. Riou, A. Burgun, B. Pouliquen, R. Duvauferrier, P. Le Beux, Computer assisted medical diagnosis using the Web, Int. J. Med. Inform. 47 (1–2) (1997 Nov.) 51–56. [4] Y. Lessard, P. Siregar, N. Julen, J.P. Sinteff, P. Le Beux, Multimedia and physiology: a new way to ensure the quality of medical education and medical knowledge, Stud. Health Technol. Inform. 124 (2006) 899–904. [5] M. Diomidous, I. Verginis, J. Mantas, The construction of a simulation-based system for the development of powerful and realistic models and practicals for healthcare professionals, IEEE Trans. Inf. Technol. Biomed. 2 (3) (1998 Sep.) 174–182. [6] N. Julen, P. Siregar, J.P. Sinteff, P. Le Beux, A qualitative model for computer-assisted instruction in cardiology, Proc. AMIA Symp. (1998) 443–447. [7] S.M. Speedie, C. Niewoehner, The Minnesota Virtual Clinic: using a simulated EMR to teach medical students basic science and clinical concepts, AMIA (2003) 1013. [8] N. Zary, G. Johnson, J. Boberg, U.G. Fors, Development, implementation and pilot evaluation of a Web-based Virtual Patient Case Simulation environment—Web-SP. BMC Med. Educ. 6 (2006 Feb.) 10. [9] B. Pouliquen, F. Le Duff, D. Delamarre, M. Cuggia, F. Mougin, P. Le Beux, Managing educational resource in medicine: system design and integration, Int. J. Med. Inform. 74 (2–4) (2005 Mar.) 201–207. [10] E. Medelez, A. Burgun, F. Le Duff, P. Le Beux, Integration of electronic resources and communication technologies during Clinical Reasoning Learning sessions, Stud. Health Technol. Inform. 90 (2002) 107–111. [11] H.I. Stromso, P. Grottum, K. Hofgaard Lycke, Changes in student approaches to learning with the introduction of computer-supported problem-based learning, Med. Educ. 38 (4) (2004 Apr) 390–398. [12] A.S. Wilson, J.E. Goodall, G. Ambrosini, D.M Carruthers, H. Chan, S.G. Ong, C. Gordon, S.P. Young, Development of an interactive learning tool for teaching rheumatology—a simulated clinical case studies program. Rheumatology (Oxford) 45 (9) (2006 Sep) 1158–1161. Epub. 2006 Mar. 10. [13] M. Fieschi, G. Soula, R. Giorgi, J. Gouvernet, D. Fieschi, G. Botti, F. Volot, Y. Berland, Experimenting with new paradigms for medical education and the emergence of a distance learning degree using the internet: teaching evidence-based medicine, Med. Inform. Internet Med. 27 (1) (2002 Mar.) 1–11. [14] J.R. Moehr, D.J. Protti, F.Y. Lau, N.A. Grimm, Project based experiential distance education: an oxymoron? Int. J. Med. Inform. 73 (2) (2004 Mar. 18) 157–163. [15] A. Rosset, O. Ratib, A. Geissbuhler, J.P. Vallee, Integration of a multimedia teaching and reference database in a PACS
[17]
[18]
[19]
[20]
[21]
[22]
[23]
[24]
[25]
[26]
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environment, Radiographics 22 (6) (2002 Nov.–Dec.) 1567–1577. D. Berg, G. Raugi, H. Gladstone, J. Berkley, S. Weghorst, M. Ganter, G. Turkiyyah, Virtual reality simulators for dermatologic surgery: measuring their validity as a teaching tool, Dermatol. Surg. 27 (4) (2001 Apr) 370–374. F. Lau, J. Bates, A review of e-learning practices for undergraduate medical education, J. Med. Syst. 28 (1) (2004 Feb) 71–87, Review. M. Broudo, C. Walsh, MEDICOL: online learning in medicine and dentistry, Acad. Med. 77 (9) (2002 Sep.) 926–927, Review. F. Ruderich, M. Bauch, M. Haag, J. Heid, F.J. Leven, R. Singer, K.H. Geiss, J. Junger, B. Tonshoff, CAMPUS—a flexible, interactive system for web-based, problem-based learning in health care. Medinfo. 11 (Pt 2) (2004) 921. R.M. Harden, I.R. Hart, An international virtual medical school (IVIMEDS): the future for medical education? Med. Teach. 24 (3) (2002 May) 261–267. J.M. Brunetaud, S. Darmoni, N. Souf, E. Dufresne, R. Beuscart, A resource server for medical training, Methods Inf. Med. 41 (2) (2002) 177–182. S.J. Darmoni, J.P. Leroy, F. Baudic, M. Douyere, J. Piot, B. Thirion, CISMeF: a structured health resource guide, Methods Inf. Med. 39 (1) (2000 Mar.) 30–35. Z. El Balaa, H.J. Philippe, C. Volteau, P. le Beux, J.M. Nguyen, Construction of an instrument for measuring medical student satisfaction with virtual campus, Stud. Health Technol. Inform. 116 (2005) 897–902. V. Bernardo, M.P. Ramos, H. Plapler, L.F. Poli de Figueiredo, Web-based learning in undergraduate medical education: development and assessment of an online course on experimental surgery, Int. J. Med. Inf. 73 (2004) 731– 742. M. Valcke, B. De Wever, Information and communication technologies in higher education: evidence-based practices in medical education, Med. Teach. 28 (1) (2006 Feb) 40–48, Review. A.W. Kushniruk, R. Owston, K. Ho, F. Pitts, H. Wideman, C. Brown, S. Chu, The Virtual Usability Laboratory: Its Application in Evaluation and Analysis of Use of Web-based Health Information Resources and Simulations, AMIA Annu. Symp. Proc. (2006) 993.
P. Le Beux ∗ Laboratory Medical Informatics, Medical School University of Rennes 1, Rennes, France M. Fieschi Laboratory Medical Informatics, Medical School University of Aix Marseille, Marseille, France ∗ Corresponding
author at: Laboratory Medical Informatics, ´ Faculte´ Medecine, 2 Av Pr Leon Bernard, 35043 Rennes, Cedex, France. Tel.: +33 2 99 28 42 15; fax: + 33 2 99 28 41 60. E-mail address: [email protected] (P.L. Beux) 1386-5056/$ – see front matter © 2007 Published by Elsevier Ireland Ltd. doi:10.1016/S1386-5056(07)00060-3
journal homepage: www.intl.elsevierhealth.com/journals/ijmi
Editorial
Virtual biomedical universities and e-learning a r t i c l e
i n f o
a b s t r a c t
Keywords:
In this special issue on virtual biomedical universities and e-learning we will make a survey
Virtual university
on the principal existing teaching applications of ICT used in medical Schools around the
E-learning
world. In the following we identify five types of research and experiments in this field of
Patient simulations
medical e-learning and virtual medical universities.
Computer based instruction
The topics of this special issue goes from educational computer program to create and
Indexing and searching resources
simulate virtual patients with a wide variety of medical conditions in different clinical set-
Digital video and audio resources
tings and over different time frames to using distance learning in developed and developing countries program training medical informatics of clinicians. We also present the necessity of good indexing and research tools for training resources together with workflows to manage the multiple source content of virtual campus or universities and the virtual digital video resources. A special attention is given to training new generations of clinicians in ICT tools and methods to be used in clinical settings as well as in medical schools.
1.
Introduction
Significant improvements in medical education and the development of computer assisted instruction can be expected from technological achievements both in hardware and software tools. At the beginning of the century (2001), Ward et al. [1] published in the Lancet a paper noticing that rapid advances in communication and information technology (C&IT), and the use of the worldwide web has important implications for education. The volume of information available on the web is so important, that both students and teachers need to be trained to manage it effectively. He advocates that the Medical schools must develop some new ways in which communication and information technology can be used to enhance the learning and teaching environment. By looking at the recent publications in Medline (Pubmed) we can see five types of applications in e-learning: Simulations of physiological or biological process for teaching, simulation of clinical cases, virtual reality and virtual patient, e-learning tools and platforms for storing and indexing ressources, video and sound recording of lectures for distance and differed learning. A recent paper by Bond et al. [2] dealing with “Learning to use the Internet as a study tool: a review of available resources and exploration of students’ priorities” reports that best resources are not necessarily the ones that are eas-
ily found by students. The aim of the study was to identify the online information resources available to assist students develop Internet searching skills, and to explore the students’ priorities in online guides. The study found that there were good online guides available, but that, perversely, the better guides tended to require the best searching skills to locate them. “A few students were used to search online support, however the majority felt that if they had the skills to locate such resources they wouldn’t use a study guide to improve these skills, and if they did not have the skills they would not think of using an online guide to develop them.” This shows the difficulty of assessing that a good resources is well known and used by students and that even with good guides most of them will ignore them. In this special issue, we will present some interesting work in the field: a first paper by Sijsterman deals with the training of medical students in inter-physician communication skills using the Dynamic Patient Simulator® (DPS), a two year project by the Academic Medical Center at the University of Amsterdam and the Leiden University Medical Center. Then for distance learning education we present the experience of F. Lau from University of Victoria regarding the Distributed Health Informatics Graduate Education for Working professionals in Canada. One of the hope of distance education and e-learning technologies is also to provide help and quality
332
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 6 ( 2 0 0 7 ) 331–335
education for the developing countries according the their needs and their level of accessible technology. The RAFT project is presented by Geissbuller and the cooperation of WHO and Mali in Central Africa. Ten years ago, when we started the Medical Virtual University in radiology [3], there were a few running projects in Europe and France and we decide to combine our efforts and share our existing and future resources and tools in a national project named the French Virtual Medical University (UMVF). From this project experience three papers have been selected: a first one by Cuggia and al. deals with the indexing and research tools for student and teachers, a second paper from Renard and al. on the workflow tools developed to coordinate the multiple source production of teaching resources in the UMVF and a third paper by Dufour and al. on the distance learning with digital video. In order to use ICT in the context of medical education we definitively need to train the new generation of clinicians. A paper by Hersh stress that there is an increasing need for a larger and better trained workforce in medical informatics. The goal of the American Medical Informatics Association 10 × 10 program is to educate 10,000 clinicians in medical informatics by the year 2010. Finally a paper by Staccini deals with hospital e-heath collaborative and workflow-oriented digital portfolio to support a nationwide program of practices evaluation in blood transfusion area.
2.
Simulations for training
As was stressed in the introduction, modern approaches to teaching and learning basic science include collaborative learning, problem-based learning and the use of computer simulations. Available computer technology allows the use of dynamic models, making learning more efficient. Simulation systems, which provide artificial cases to the student for discussion and management without risk for the patient, bring a new dimension in teaching, the dimension of experience acquisition. They allow the development of cognitive feedback to help the learner to understand why he does something and how he might differ from experts, about the tasks and himself as an actor in the decision process.
2.1.
Virtual bio-physiological process simulation
Many difficult concepts in physiology, for instance, are truly learned only when the student’s brain converts heard or read words, static pictures and diagrams into moving models. Computers are now sufficiently powerful and the Internet sufficiently fast to allow fast distribution of multimedia materials which are especially useful for teaching physiology [4]. An interactive Computer based instruction (CBI) must exhibit intelligent behavior (e.g., reasoning capability). Indeed, for a CBI to “interact” with a user beyond responding to “start,” “forward,” or “backward” clicks, it must have an understanding of the current user-context and carry out meaningful actions accordingly. Such an understanding could not hold without the proper representations and semantics describing a user-
context nor without the specific inference schemes to carry out meaningful actions. In the framework of the COAST, Courseware Authoring for Scientific Training system, Diomidous et al. [5] developed a “modeler environment,” which is used to describe the different tools and mathematical functions available for building models, and the “simulation author environment.” It is used to build sequences based on multimedia simulation, so as to gradually replace laboratory practicals that are becoming obsolete and costly, and to improve student’s understanding of complex systems.Similarly qualitative models can be developed and can be used for simulation of physiopathological models [6].
2.2.
Virtual patient simulation
The Minnesota Virtual Clinic, a web-based educational tool for simulating patients representing a variety of conditions and cultural backgrounds exposing students to critical basic science and clinical concepts in the context of patient care [7]. It is based on electronic Patient records (EPR) and such a process of independent decision making is something a student or resident may ever gets in medical practice. Zary et al. [8] developed the Web-based Simulation of Patients (Web-SP) project in order to facilitate the use of realistic and interactive virtual patients (VP) in medicine and healthcare education. Web-SP focuses on integrating simulation-based education into health sciences curricula, by making the creation and use of virtual patients easier. The Web-SP system was constructed to support easy authoring, management and presentation of virtual patient cases. More recently, a computer program has been developed at the Leiden University Medical Center for creating and running patient simulations. .This system is presented in the paper by Sijstermans in this special issue.It allows students to perform a vast range of medical procedures such as medical history taking, physical examination, ordering of and reviewing of laboratory tests and investigations and finally the planning of treatments. This enables students to make decisions during a simulation where the status of the patient may change over time
2.3.
Clinical case simulation
There is a long experience of various medical decision aid and clinical case training methods either with presential methods or with differed computer based method. In the context of internal medicine and radiology we develop simple clinical case containing a clinical context, a set of images asking for student interpretation and finally a final diagnosis [9]. More sophisticated clinical interactive clinical cases can also be implemented where the student can simulate time oriented reasoning by ordering lab tests with a delay (urgent or not) and wait until he gets news results and proceed toward clinical reasoning and final diagnosis. Experimental use of patient simulations in medical education has been going on for the past twenty-five years. The purpose of these simulations is to offer students a virtual patient on whom they can practice medical history taking, physical examination, laboratory and functional tests
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ordering and assessment, inferring differential diagnoses and treatment planning. A student is provided with different kinds of feedback generated within the virtual learning simulation environment. In the last decade, Clinical Reasoning Learning has been used during clinical training courses in many universities. The goal of this educational activity is to develop problem solving and diagnosis skills in medicine, using previously acquired medical knowledge. Medelez et al. [10] propose the integration of educational resources and computer systems to help students during the reasoning process, and in order to prepare students to look for medical information. We also describe a Computer-Supported Collaborative Learning Environment that integrates Information and Communication Technologies in order to improve the Clinical Reasoning Learning Sessions. Following the introduction of computer-supported, problem-based learning (PBL) Stromso et al. [11] study changes in student learning approaches. They propose distributed problem-based learning (DPBL) in a computersupported learning environment. The introduction of DPBL did not seem to affect the participants’ use of regulating strategies or their mental models of learning. After the DPBL test period, group discussion and tutor input were reported to have less influence on students’ self-study, while the students perceived themselves as being less active in groups and as expecting less from their tutors. Siimilarly,Wilson et al. [12] developed an interactive learning tool for teaching rheumatology with a simulated clinical case studies program. It contains a series of interactive web-based clinical case studies. The case studies program developed were well received by both biomedical and medical students. This approach provides a way to increase the exposure of students to clinical cases involving interactive diagnostic and treatment procedures, that mimic real-world scenarios, but with fewer resource implications. In the context of the development of PACS environment, teaching cases can also be developed with real pathological images [13].
3. Virtual reality, video and virtual classroom New paradigms have been experimented for distance learning using Internet [14] and have been also used for Project based experiential distance education [15]. Virtual patient simulations make use of virtual reality (VR). VR is a computer technique that simulates reality as truly as possible through the use of a VR-helmet or a data glove. This technique would allow the simulation of an actual physical examination or even surgical procedures on virtual patients. Surgical simulation is increasingly being considered for training, testing, and possibly credentialing in medicine and surgery. At the University of Washington they have designed a virtual reality (VR) suturing simulator. Berg et al. [16] describes Virtual reality simulators for dermatologic surgery. This work aims at defining the concept of surgical skill and discussing how it can be measured in the context of validating VR surgical simulators.
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Other video tools may be used for distance education namely the virtual class and visio conference Today, the visioconference on IP (norm H323) is a reality. The main advantages are: low cost, standard equipment access and services such as chat, program sharing or white boards The visioconference on IP, must have a quality compatible with a teaching usage especially with regards to quality of service: sound output rate, security and user friendly interface. This has tested between several universities across France: Lille, Marseille, Nice, Nancy, Rennes,Rouen and Paris either equiped with visioconference theater or simple workstations equipped with specific software. There is now a large choice of technologies and visioconference services that can be used for virtual classes. The following choices are presented in the paper by Dufour and a specific tool for comprehensive virtual class has been tested namely: Visioconference VRVS (virtual class videoconferencing system) enables distant collaborative work with an interface mixing sound and video, chat, document sharing and deskstop. This system is web oriented to reserve virtual conference room and the connection can be made either by a workstation with a webcam . . . or by a visio conference room. Although the previous tools are readily available in institution they may be still too sophisticated for large populations with a minimal of technology. The paper by Hersh in this special issue shows that for a large wide public (clinicians) a simple tool may be the more adapted namely voice and sound with presentation slides are the most easily accepted and simple to use for distant and asynchronous learning. He stresses the need to help the faculty to adapt to developments in modern medicine, as well as to the needs and demands of future medical students.
4.
Medical virtual universities
Lau and Bates [17] gave an excellent review of e-learning practices for undergraduate medical education. The University of British Columbia medical school enrolment will increase because of collaborations with campuses and medical centers across the province. MEDICOL (Medicine and Dentistry Integrated Curriculum Online) [18] provides a variety of Webbased resources that act as important adjuncts to all the teaching components of the medical and dental undergraduate curriculum. MEDICOL play an increased role in distance learning by continuing to deliver the teaching resources, as well as facilitating synchronous communications (e.g., Problem Based Learning, chat rooms) and teaching (e.g., videostreamed lectures) to students located across the province. It uses WebCT, a course-management platform to provide the following functions: tracking students’ progress, promoting student-to-student and student-to-instructor interactions and delivering self-directed learning components including multimedia learning modules (clinical skills, radiology, evidence-based medicine, etc.). Another popular approach of medical training is problem based learning (PBL). Ruderich et al. [19] design CAMPUS—a flexible, interactive system for web-based, problem-based learning in health
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care. They developed a flexible and realistic system, CAMPUS, which supports the case authors with appropriate vocabularies and an authoring tool. There are different kinds of case presentations to the users in accordance to the level of professionalism of the user and the scenarios. An evaluation within internship training has shown, that such programs are found useful by medical students. Harden and Hart [20] started in 2002 an international virtual medical school (IVIMEDS) with a high-quality education programme embodying a hybrid model of a blended curriculum of innovative e-learning approaches and the best of traditional face-to-face teaching. Key components are a bank of reusable learning objects, a virtual practice with virtual patients, a learning-outcomes framework, and self-assessment tools. In 2005, Francis Lau at Health Information Science department University of Victoria set up a distributed Master of Science Heath Information program across Western Canada (BC, Alberta) for working professionals. He uses Virtual Class software, the system and future project is described in the following paper in this special issue. With regards to the UMVF project there are several elearning platform used by the French Medical Schools [21] (Claroline, Moodle) but we emphasized the necessity of having a common descriptive form for each resource and we designed a workflow to transmit each form to the UMVF data bases for indexing and retrieving the teaching resources. The paper by Renard in this special issue presents the methods used and the implementation of the workflow tool that is used for free by medical SDC hold belonging to the UMVF consortium. Then the indexation process may be improved by using MESH to complete the notices by a manual indexation which is available in the Cismef French medical repository [22]. The paper by Cuggia in this special issue deals with the corresponding meta-engine associated wit the indexing process. Staccini et al. paper deals with a collaborative and workflow oriented digital portfolio to develop a nationwide program of practice evaluation in the blood transfusion area in the context of health professional assessment and evaluation. He developed a web based collaborative platform which involves the assessed physician and his tutor who follow him, the director of the program and the supervisor who manage the global system. Such an approach seems to be promising to manage distance assessment process all over a region or nation. To finish with this section the paper by A. Geisbuhler deals with a North South e-learning project named RAFT supported by the University of Geneva and the UN for introducing distant learning in a developing African country namely Mali. By using adapted simple technology they have shown that it is possible to promote distance education at a low cost even in the rural areas of central Africa.
5.
Discussion
In the following papers of this special issue, the authors present their approaches and experiments together with their evaluation of tools, content, usability. As we already know the assessment of virtual tools and distance education is difficult, because there is no reference to golden standard and
the use of controlled randomized trial is almost impossible in practice The paper by Sijtermans stressed the important issues concerning evaluation • Do students feel that they have improved their skills by using distant and/or ICT based educational environment? • How can we evaluate students usability of the e-learning tools and contents? • Are students satisfied by use of distant and non presential education and training? • Do students recommend such program to be incorporated in the medical or health professionals curriculum? Similar question may be raised for the teachers and tutors: • Do they feel that they have improved the quality of knowledge transmitted to the student by using distant and/or ICT based educational environment? • How can we evaluate teachers performance without or with the e-learning tools and contents? • Are the teachers satisfied by use of virtual distant and non presential education and training? • Do the teacher feels that they are doing a better job we the same amount of time investment? The paper by Sijstermans shows clearly that virtual learning simulation environments should be more widely implemented in medical settings so as to increase students’ competence, acceptance and awareness of education in interphysician training. In the framework of UMVF, El Balaa [23] proposed an instrument for measuring medical student satisfaction with virtual campus. Bernardo et al. [24] developed and assessed the first online course for undergraduate medical students on experimental surgery at the Federal University of Sao Paulo-UNIFESP, Brazil. The results show that students have significantly improved their knowledge on experimental surgery after the course.
6.
Conclusions
In a recent paper Valcke et al. [25] present Information and communication technologies in higher education: evidencebased practices in medical education. This paper stressed that ICT is expected to foster collaborative learning in the medical knowledge domain. They insist on the importance of prior knowledge and the need for real-life and practical experiences. The article concludes by underlining the need for evaluative studies in the promising field of ICT-based collaborative learning. Although the Dynamic Patient Simulator seems an appropriate method for training medical students in inter-physician communication training and the first assessment of UMVF seems to be promising there is a need for further research in evaluation, usability and assessment in the field of distance and virtual education. Such studies may be designed by using an approach such as The Virtual Usability Laboratory developed by Kushniruk et al. [26] to support the collection, integration and analysis of a variety of usage data of web based systems and applications.
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P. Le Beux ∗ Laboratory Medical Informatics, Medical School University of Rennes 1, Rennes, France M. Fieschi Laboratory Medical Informatics, Medical School University of Aix Marseille, Marseille, France ∗ Corresponding
author at: Laboratory Medical Informatics, ´ Faculte´ Medecine, 2 Av Pr Leon Bernard, 35043 Rennes, Cedex, France. Tel.: +33 2 99 28 42 15; fax: + 33 2 99 28 41 60. E-mail address: [email protected] (P.L. Beux) 1386-5056/$ – see front matter © 2007 Published by Elsevier Ireland Ltd. doi:10.1016/S1386-5056(07)00060-3