The internet and the globalisation of medical education

Hyperglobalist, sceptical, and transformationalist perspectives on globalization in medical education

PURPOSE

Globalisation has been hotly debated in recent decades and has seemingly had a profound impact on medical education. This review synthesises the medical education literature using key perspectives from globalisation theory by Holton (Making globalisation).

METHODS

Holton (Making globalisation) recognised three key perspectives in globalisation theory-hyperglobalist, sceptical, and transformationalist. This article critically reviews the literature on globalisation in the field of medical education using this theoretical framework.

RESULTS

Hyperglobalist and sceptical perspectives dominated early periods of medical education literature on globalisation, projecting it either as a mainly positive or mainly negative force, respectively. Most forecasts grounded in these perspectives have not materialised in medical education policy and practice. Since 2010, the volume of scholarship about globalisation has increased and has been predominantly transformationalist in perspective, recognising a reality that has both positive and negative consequences.

CONCLUSIONS

The medical education literature has mirrored the broader social science literature, in moving over time from hyperglobalist and sceptical positions, towards a 'third wave' of globalisation thinking that is transformationalist. Medical education practitioners and policymakers should be mindful of these perspectives and trends as they navigate the opportunities and challenges presented by globalisation.

Skin Cancer Education Interventions for Primary Care Providers: A Scoping Review

Primary care physicians (PCPs) are often the first line of defense against skin cancers. Despite this, many PCPs do not receive a comprehensive training in skin conditions. Educational interventions aimed at skin cancer screening instruction for PCPs offer an opportunity to detect skin cancer at earlier stages and subsequent improved morbidity and mortality. A scoping review was conducted to collect data about previously reported skin cancer screening interventions for PCPs. A structured literature search found 51 studies describing 37 unique educational interventions. Curriculum elements utilized by the interventions were divided into categories that would facilitate comparison including curriculum components, delivery format, delivery timing, and outcome measures. The interventions varied widely in design, including literature-based interventions, live teaching sessions, and online courses with durations ranging from 5 min to 24 months. While several interventions demonstrated improvements in skin cancer knowledge and competency by written exams, only a few revealed positive clinical practice changes by biopsy review or referral analysis. Examining successful interventions could aid in developing a skin cancer detection curriculum for PCPs that can produce positive clinical practice and population-based changes in the management of skin cancer.

Evaluating the Efficacy of an Online Learning Tool for EEG Teaching: A Prospective Cohort Study

ObjectiveTo determine the effectiveness of a 6-month, interactive, multi-modal, web-based EEG teaching program (EEGonline) in improving EEG analysis and interpretation skills for neurologists, neurology residents and technologists, particularly in resource-limited settings.MethodsBetween June 2017 and November 2018, 179 learners originating from 20 African countries, Europe and USA were registered on the EEGonline course. Of these, 128 learners (91% African) participated in the study. Pre- and post-course multiple-choice-question (MCQ) test results and EEGonline user logs were analyzed. Differences in pre- and post-test performance were correlated with quantified exposure to various EEGonline learning modalities. Participants' impressions of EEGonline efficacy and usefulness were assessed through pre- and post-course satisfaction surveys.ResultsNinety-one participants attempted both pre- and post-course tests (71% response rate). Mean scores improved from 46.7% ±17.6% to 64.1% ±18% respectively (p<0.001, Cohen's d 0.974). The largest improvement was in correct identification of normal features (43.2% to 59.1%, p<0.001, Cohen's d 0.664) and artifacts (43.3% to 61.6%, p<0.001, Cohen's d 0.836). Improvement in knowledge was associated with improved subjective confidence in EEG analysis. Overall confidence among post-course survey respondents improved significantly from 35.9% to 81.9% (p<0.001). Lecture notes, self-assessment quizzes and discussion forums were the most utilised learning modalities. The majority of survey respondents (97.2%) concluded that EEGonline was a useful learning tool and 93% recommended that similar courses should be included in EEG training curricula.ConclusionsThis study demonstrated that a multi-modal, online EEG teaching tool was effective in improving EEG analysis and interpretation skills and may be useful in resource-poor settings.

New ideas for teaching electrocardiogram interpretation and improving classroom teaching content

Background

Interpreting an electrocardiogram (ECG) is not only one of the most important parts of diagnostics but also one of the most difficult areas to teach. Owing to the abstract nature of the basic theoretical knowledge of the ECG, its scattered characteristics, and tedious and difficult-to-remember subject matter, teaching how to interpret ECGs is as difficult for teachers to teach as it is for students to learn. In order to enable medical students to master basic knowledge of ECG interpretation skills in a limited teaching time, we modified the content used for traditional ECG teaching and now propose a new ECG teaching method called the “graphics-sequence memory method.”

Methods

A prospective randomized controlled study was designed to measure the actual effectiveness of ECG learning by students. Two hundred students were randomly placed under a traditional teaching group and an innovative teaching group, with 100 participants in each group. The teachers in the traditional teaching group utilized the traditional teaching outline, whereas the teachers in the innovative teaching group received training in line with the proposed teaching method and syllabus. All the students took an examination in the final semester by analyzing 20 ECGs from real clinical cases and submitted their ECG reports.

Results

The average ECG reading time was 32 minutes for the traditional teaching group and 18 minutes for the innovative teaching group. The average ECG accuracy results were 43% for the traditional teaching group and 77% for the innovative teaching group.

Conclusion

Learning to accurately interpret ECGs is an important skill in the cardiac discipline, but the ECG’s mechanisms are intricate and the content is scattered. Textbooks tend to make the students feel confused owing to the restrictions of the length and the format of the syllabi, apart from many other limitations. The graphics-sequence memory method was found to be a useful method for ECG teaching.

Skin cancer education for primary care physicians: a systematic review of published evaluated interventions

BACKGROUND

Early detection of melanoma may provide an opportunity to positively impact melanoma mortality. Numerous skin cancer educational interventions have been developed for primary care physicians (PCPs) to improve diagnostic accuracy. Standardized training is also a prerequisite for formal testing of melanoma screening in the primary care setting.

OBJECTIVE

We conducted a systematic review to determine the extent of evaluated interventions designed to educate PCPs about skin cancer, including melanoma.

DESIGN

Relevant studies in the English language were identified through systemic searches performed in MEDLINE, EMBASE, BIOSIS, and Cochrane through December 2010. Supplementary information was obtained from corresponding authors of the included studies when necessary.

APPROACH

Studies eligible for inclusion formally evaluated skin cancer education interventions and were designed primarily for PCPs. Excluded studies lacked a specified training intervention, used decision-making software, focused solely on risk factor identification, or did not directly educate or assess participants. Twenty studies met the selection criteria. Data were extracted according to intervention content and delivery format, and study outcomes.

KEY RESULTS

All interventions included instructions about skin cancer diagnosis, but otherwise varied in content. Curricula utilized six distinct educational techniques, usually incorporating more than one. Intervention duration varied from 12 min to over 6 h. Eight of the 20 studies were randomized trials. Most studies (18/20, 90%) found a significant improvement in at least one of the following five outcome categories: knowledge, competence, confidence, diagnostic performance, or systems outcomes. Competence was most commonly measured; no study evaluated all categories. Variability in study design, interventions, and outcome measures prevented correlation of outcomes with intervention characteristics.

CONCLUSIONS

Despite the development of many isolated educational interventions, few have been tested rigorously or evaluated under sufficient standardized conditions to allow for quantitative comparison. Improved and rigorously tested skin cancer educational interventions for PCPs with outcome measures focusing on changes in performance are needed.

The growth, characteristics, and future of online CME

INTRODUCTION

Physician use of online continuing medical education (CME) is growing, but there are conflicting data on the uptake of online CME and few details on this market.

METHODS

Analyses of 11 years of data from the Accreditation Council for Continuing Medical Education (ACCME) and a survey of 272 publicly available CME Web sites.

RESULTS

The data suggest that online CME was 6.9%-8.8% of CME consumed in 2008. If previous exponential growth continues, online CME is likely to be 50% of all CME consumed within 7-10 years. Most (60%) online CME is produced by medical publishing and education companies. The online CME marketplace is consolidating, with 16% of surveyed sites providing 76% of available credits. Currently, 70% of online CME is offered at $10 or less per credit. Most online CME uses low-technology educational approaches, such as pure text and repurposed live lectures.

DISCUSSION

Online CME use is growing rapidly and is likely to be half of all CME consumed by practicing physicians within a few years. The pattern is consistent with Christensen's model of "disruptive innovation," whereby an innovative technology eventually displaces an incumbent technology by first providing a relatively low-quality, low-cost product that meets the needs of unserved customers. The technologies being developed for online CME may facilitate broader changes in medical education as well.

Evaluation of a web-based ECG-interpretation programme for undergraduate medical students

BACKGROUND

Most clinicians and teachers agree that knowledge about ECG is of importance in the medical curriculum. Students at Karolinska Institute have asked for more training in ECG-interpretation during their undergraduate studies. Clinical tutors, however, have difficulties in meeting these demands due to shortage of time. Thus, alternative ways to learn and practice ECG-interpretation are needed. Education offered via the Internet is readily available, geographically independent and flexible. Furthermore, the quality of education may increase and become more effective through a superior educational approach, improved visualization and interactivity.

METHODS

A Web-based comprehensive ECG-interpretation programme has been evaluated. Medical students from the sixth semester were given an optional opportunity to access the programme from the start of their course. Usage logs and an initial evaluation survey were obtained from each student. A diagnostic test was performed in order to assess the effect on skills in ECG interpretation. Students from the corresponding course, at another teaching hospital and without access to the ECG-programme but with conventional teaching of ECG served as a control group.

RESULTS

20 of the 32 students in the intervention group had tested the programme after 2 months. On a five-graded scale (1- bad to 5 - very good) they ranked the utility of a web-based programme for this purpose as 4.1 and the quality of the programme software as 3.9. At the diagnostic test (maximal points 16) by the end of the 5-month course at the 6th semester the mean result for the students in the intervention group was 9.7 compared with 8.1 for the control group (p = 0.03).

CONCLUSION

Students ranked the Web-based ECG-interpretation programme as a useful instrument to learn ECG. Furthermore, Internet-delivered education may be more effective than traditional teaching methods due to greater immediacy, improved visualisation and interactivity.

Can an online osteoporosis lecture increase physician knowledge and improve patient care?

Internet-based lectures are a popular means of disseminating medical knowledge, but the impact of osteoporosis lectures on physician knowledge and patient care is unknown. We designed an Internet-based lecture discussing the prevalence of, screening guidelines for, risk factors for, and physical signs of osteoporosis. Immediately before and after viewing the lecture, 6 physician participants completed questionnaires to gauge change in knowledge. From each participant's clinic, we randomly selected and reviewed 10 charts of new female patients at least 60 yr old, half before and half after the lecture. Charts were blindly scored to determine physician attention to screening guidelines for, risk factors for, and signs of osteoporosis. Physician knowledge increased significantly after the lecture, with mean pretest and posttest scores of 63% and 99%, respectively (p=0.03). However, physician attention to patient risk factors for and signs of osteoporosis did not change after lecture "attendance." Surprisingly, no patients who met age-specific screening guidelines (age> or =65 yr and no prior dual energy X-ray absorptiometry [DXA]) were referred for DXA, either before or after study participation. We conclude that physician knowledge can increase after a single online osteoporosis lecture, but patient care is not altered. Further research is needed to discern optimal osteoporosis educational encounters that enhance patient care.

A review of evaluation outcomes of web-based continuing medical education

INTRODUCTION

The Internet and worldwide web have expanded opportunities for the provision of a flexible, convenient and interactive form of continuing medical education (CME). Larger numbers of doctors are accessing and using the Internet to locate and seek medical information. It has been suggested that a significant proportion of this usage is directly related to questions that arise from patient care. A variety of Internet technologies are being used to provide both asynchronous and synchronous forms of web-based CME. Various models for designing and facilitating web-based CME learning have also been reported. The purpose of this study was to examine the nature and characteristics of the web-based CME evaluative outcomes reported in the peer-reviewed literature.

METHODS

A search of Medline was undertaken and the level of evaluative outcomes reported was categorised using Kirkpatrick's model for levels of summative evaluation.

RESULTS

The results of this analysis revealed that the majority of evaluative research on web-based CME is based on participant satisfaction data. There was limited research demonstrating performance change in clinical practices and there were no studies reported in the literature that demonstrated that web-based CME was effective in influencing patient or health outcomes.

DISCUSSION

The findings suggest an important need to examine in greater detail the nature and characteristics of those web-based learning technologies, environments and systems which are most effective in enhancing practice change and ultimately impacting patient and health outcomes. This is particularly important as the Internet grows in popularity as a medium for knowledge transfer.

Assessing the reliability and validity of a residency selection process examination: a preliminary study between the national board of medical examiners and the University of Panama Faculty of Medicine

BACKGROUND

The Ministry of Health of the Republic of Panama is currently developing a national examination system that will be used to license graduates to practice medicine in that country, as well as to undertake postgraduate medical training. As part of these efforts, a preliminary project was undertaken between the National Board of Medical Examiners (NBME) and the Faculty of Medicine of the University of Panama to develop a Residency Selection Process Examination (RSPE).

PURPOSE

The purpose of this study was to assess the reliability and validity of RSPE scores for a sample of candidates who wished to obtain a residency slot in Panama.

METHODS

The RSPE, composed of 200 basic and clinical sciences multiple-choice items, was administered to 261 residency applicants at the University of Panama.

RESULTS

The reliability estimate computed was comparable with that reported with other high-stakes examinations (Cronbach's alpha = 0.89). Also, a Rasch examinee proficiency item difficulty plot showed that the RSPE was well targeted to the proficiency levels of candidates. Finally, a moderate correlation was noted between local grade point averages and RSPE scores for University of Panama students (r = 0.38).

CONCLUSIONS

Findings suggest that it is possible to translate and adapt test materials for use in other contexts.

ELERA: a WWW application for evaluating and developing radiologic skills and knowledge

RATIONALE AND OBJECTIVES

To provide an online facility for evaluating, comparing, and building expertise in radiologic anatomy and clinical radiology.

MATERIALS AND METHODS

Project participants were recruited from an experienced special interest group of students at the local medical school. A rigid protocol was agreed upon, defining and assigning the tasks of case selection, data entry, test task creation, and peer review. The presentation of test tasks and evaluation of user input was implemented as a custom web application.

RESULTS

ELERA, an online assessment and learning resource based on 1,650 pathologic cases and 550 anatomy cases, was created and made publicly accessible as a world wide web application.

CONCLUSION

The project design facilitated the creation of a free, highly accessible and user-friendly resource that offers capabilities for individual longitudinal and intersubject comparative assessment.

A randomised trial of an online lecture with and without audio

OBJECTIVE

To determine the impact of adding audio-feed to an online lecture on screening given to medical students who were participating in an outpatient clerkship.

DESIGN

Prospective, randomised, controlled study.

SETTING

Vanderbilt University School of Medicine, Nashville and Wake Forest Medical School, Winston-Salem.

PARTICIPANTS

A total of 59 Years 3 and 4 medical students.

MAIN OUTCOME MEASURES

Students' use of time, satisfaction with the lecture experience, and knowledge. Educational intervention The online lecture was developed at Vanderbilt University. At Vanderbilt, 16 Year 4 medical students were randomised to the lecture on screening with audio and 17 Year 4 medical students were randomised to the same lecture without audio. At Wake Forest, 13 Year 3 medical students were randomised to the lecture on screening with audio and 13 Year 3 students were randomised to the same lecture without audio.

RESULTS

The audio lecture required 20 more minutes to complete than the non-audio lecture. Students in the audio group were more satisfied with their experience than students in the non-audio group. Students in the audio-feed group achieved a trend for higher post-intervention knowledge scores, with the difference attributed to the students at Vanderbilt.

CONCLUSION

Audio narration is an important aspect of an online lecture. The distribution of online lectures to students at different sites and different training levels requires further study.

An Internet survey of asthma treatment

The aim of this investigation was to study pharmacological treatment in relation to asthma severity among patients visiting an asthma web site on the Internet. The study comprised 650 subjects from 30 countries with self-reported asthma that participated in an Internet based patient survey. The survey was posted on the web site Asthma Information Centre (www.mdnet.de). Moderate or severe night cough or wheezing was reported by 43% and activity limitation by 55% of the asthmatics. Short-acting beta-agonists were used by 67% and inhaled steroids by 59%. The use of short-acting beta-agonists decreased with age, whereas the use of inhaled steroids, long-acting beta-agonists and antileukotrienes was lowest in the youngest (0-20 years) and highest age groups (> 60 years). The use of short-acting beta-agonists increased, and the use of inhaled steroids decreased with the severity of nocturnal symptoms (p < 0.01). Side effects were most often reported for oral beta-agonists (42%) and least often for antileukotrienes (9%). We conclude that despite problems with selection and external validity, an online asthma survey produces results that agree highly with more resource-demanding surveys. We find that many asthmatics have a low level of asthma control, and the survey indicates that underuse of inhaled steroids is one of the reasons why the goals set up in asthma guidelines so far have not been reached.

Effect of an Internet-based curriculum on postgraduate education. A multicenter intervention

We hypothesized that the Internet could be used to disseminate and evaluate a curriculum in ambulatory care, and that internal medicine residency program directors would value features made possible by online dissemination. An Internet-based ambulatory care curriculum was developed and marketed to internal medicine residency program directors. Utilization and knowledge outcomes were tracked by the website; opinions of program directors were measured by paper surveys. Twenty-four programs enrolled with the online curriculum. The curriculum was rated favorably by all programs, test scores on curricular content improved significantly, and program directors rated highly features made possible by an Internet-based curriculum.

Assessing medical students' clinical sciences knowledge in France: a collaboration between the NBME and a consortium of French medical schools

PURPOSE

The French government, as part of medical education reforms, has affirmed that an examination program for national residency selection will be implemented by 2004. The purpose of this study was to develop a French multiple-choice (MC) examination using the National Board of Medical Examiners' (NBME) expertise and materials.

METHOD

The Evaluation Standardisée du Second Cycle (ESSC), a four-hour clinical sciences examination, was administered in January 2002 to 285 medical students at four university test sites in France. The ESSC had 200 translated and adapted MC items selected from the Comprehensive Clinical Sciences Examination (CCSE), an NBME subject test.

RESULTS

Less than 10% of the ESSC items were rejected as inappropriate to French practice. Also, the distributions of ESSC item characteristics were similar to those reported with the CCSE. The ESSC also appeared to be very well targeted to examinees' proficiencies and yielded a reliability coefficient of.91. However, because of a higher word count, the ESSC did show evidence of speededness. Regarding overall performance, the mean proficiency estimate for French examinees was about 0.4 SD below that of a CCSE population.

CONCLUSIONS

This study provides strong evidence for the usefulness of the model adopted in this first collaborative effort between the NBME and a consortium of French medical schools. Overall, the performance of French students was comparable to that of CCSE students, which was encouraging given the differences in motivation and the speeded nature of the French test. A second phase with the participation of larger numbers of French medical schools and students is being planned.

Women physicians are early adopters of on-line continuing medical education

INTRODUCTION

On-line continuing medical education (CME) provides advantages to physicians and to medical educators. Although practicing physicians increasingly use on-line CME to meet their educational needs, the overall use of on-line CME remains limited. There are few data to describe the physicians who use this new educational medium; yet, they clearly are the innovators and early adopters who will facilitate the growth of this educational technology. It would be useful to instructional designers and CME developers to better understand the characteristics of this influential group.

METHODS

We studied the actual use of several different on-line CME programs within three different groups of physicians. The on-line programs were developed as part of research studies funded by the National Institutes of Health, with no relationship to commercial interests. They were presented to physicians using mass mailouts (two physician groups) or personal contact and were accompanied by incentives to reduce resistance to the new technology. We compared the characteristics of physicians who chose to use these on-line programs with demographic data from larger populations representing the groups from which these users originated.

RESULTS

We found that physicians who used these on-line CME programs were younger than average and, importantly, more likely to be female than expected. This finding was consistent across different types of physician populations and different types of CME programs.

DISCUSSION

Based on data reflecting actual use of on-line CME, younger physicians appear to be adopting on-line CME more rapidly than others, and women physicians appear to be adopting on-line CME at a faster rate than their male counterparts. This latter finding conflicts with the impression provided by some survey-based studies that male physicians are more likely than female physicians to use on-line CME. The data suggest that the growth of on-line CME is most likely occurring in diffusion networks dominated by relatively new medical school graduates and, possibly, women physicians. These results provide valuable insight to those who seek to develop and market on-line CME and those who seek to reach women physicians with CME programs.