Anthony J. Levinson

Internet-based learning in the health professions:a meta-analysis

CONTEXT The increasing use of Internet-based learning in health professions education may be informed by a timely, comprehensive synthesis of evidence of effectiveness. OBJECTIVES To summarize the effect of Internet-based instruction for health professions learners compared with no intervention and with non-Internet interventions. DATA SOURCES Systematic search of MEDLINE, Scopus, CINAHL, EMBASE, ERIC, TimeLit, Web of Science, Dissertation Abstracts, and the University of Toronto Research and Development Resource Base from 1990 through 2007. STUDY SELECTION Studies in any language quantifying the association of Internet-based instruction and educational outcomes for practicing and student physicians, nurses, pharmacists, dentists, and other health care professionals compared with a no-intervention or non-Internet control group or a preintervention assessment. DATA EXTRACTION Two reviewers independently evaluated study quality and abstracted information including characteristics of learners, learning setting, and intervention (including level of interactivity, practice exercises, online discussion, and duration). DATA SYNTHESIS There were 201 eligible studies. Heterogeneity in results across studies was large (I(2) > or = 79%) in all analyses. Effect sizes were pooled using a random effects model. The pooled effect size in comparison to no intervention favored Internet-based interventions and was 1.00 (95% confidence interval [CI], 0.90-1.10; P < .001; n = 126 studies) for knowledge outcomes, 0.85 (95% CI, 0.49-1.20; P < .001; n = 16) for skills, and 0.82 (95% CI, 0.63-1.02; P < .001; n = 32) for learner behaviors and patient effects. Compared with non-Internet formats, the pooled effect sizes (positive numbers favoring Internet) were 0.10 (95% CI, -0.12 to 0.32; P = .37; n = 43) for satisfaction, 0.12 (95% CI, 0.003 to 0.24; P = .045; n = 63) for knowledge, 0.09 (95% CI, -0.26 to 0.44; P = .61; n = 12) for skills, and 0.51 (95% CI, -0.24 to 1.25; P = .18; n = 6) for behaviors or patient effects. No important treatment-subgroup interactions were identified. CONCLUSIONS Internet-based learning is associated with large positive effects compared with no intervention. In contrast, effects compared with non-Internet instructional methods are heterogeneous and generally small, suggesting effectiveness similar to traditional methods. Future research should directly compare different Internet-based interventions.

Instructional design variations in internet-based learning for health professions education: A systematic review and meta-analysis

Purpose A recent systematic review (2008) described the effectiveness of Internet-based learning (IBL) in health professions education. A comprehensive synthesis of research investigating how to improve IBL is needed. This systematic review sought to provide such a synthesis. Method The authors searched MEDLINE, CINAHL, EMBASE, Web of Science, Scopus, ERIC, TimeLit, and the University of Toronto Research and Development Resource Base for articles published from 1990 through November 2008. They included all studies quantifying the effect of IBL compared with another Internet-based or computer-assisted instructional intervention on practicing and student physicians, nurses, pharmacists, dentists, and other health professionals. Reviewers working independently and in duplicate abstracted information, coded study quality, and grouped studies according to inductively identified themes. Results From 2,705 articles, the authors identified 51 eligible studies, including 30 randomized trials. The pooled effect size (ES) for learning outcomes in 15 studies investigating high versus low interactivity was 0.27 (95% confidence interval, 0.08–0.46; P = .006). Also associated with higher learning were practice exercises (ES 0.40 [0.08–0.71; P = .01]; 10 studies), feedback (ES 0.68 [0.01–1.35; P = .047]; 2 studies), and repetition of study material (ES 0.19 [0.09–0.30; P < .001]; 2 studies). The ES was 0.26 (−0.62 to 1.13; P = .57) for three studies examining online discussion. Inconsistency was large (I2 ≥89%) in most analyses. Meta-analyses for other themes generally yielded imprecise results. Conclusions Interactivity, practice exercises, repetition, and feedback seem to be associated with improved learning outcomes, although inconsistency across studies tempers conclusions. Evidence for other instructional variations remains inconclusive.

What do we mean by web‐based learning? A systematic review of the variability of interventions

Medical Education 2010: 44: 765–774

Virtual reality and brain anatomy: a randomised trial of e-learning instructional designs

Context  Computer‐aided instruction is used increasingly in medical education and anatomy instruction with limited research evidence to guide its design and deployment.

The value of basic science in clinical diagnosis.

Background The role of basic science knowledge in clinical diagnosis is unclear. There has been no experimental demonstration of its value in helping students recall and organize clinical information. This study examines how causal knowledge may lead to better recall and diagnostic skill over time. Method Undergraduate medical students learned either four neurological or rheumatic disorders. One group learned a basic science explanation for the symptoms. The other learned epidemiological information. Both were then tested with the same set of clinical cases immediately after learning and one week later. Results On immediate test, there was no difference in accuracy (70% for both groups). However, one week later, performance in the epidemiology group dropped to 51%; the basic science group only dropped to 62%. Conclusions Basic science knowledge relating causal knowledge to disease symptoms can improve diagnostic accuracy after a delay.

Method and reporting quality in health professions education research: a systematic review

Medical Education 2011: 45: 227–238

Computer animations in medical education: a critical literature review

Context  Animations can depict dynamic changes over time and location, and illustrate phenomena and concepts that might otherwise be difficult to visualise. However, animations may not always be effective and educators who use animations must understand the principles that govern their use.

New directions in e-learning research in health professions education: Report of two symposia

Background: The use of Computer Assisted Instruction (CAI) is rising across health professions education. Research to date is of limited use in guiding the implementation and selection of CAI innovations. Aims: In the context of two symposia, systemic reviews were discussed that evaluate literature in Internet-based learning, Virtual Patients, and animations. Each session included a debate with the goal of reaching consensus on best current practices and future research. Methods: Thematic analysis of the discussions was performed to arrange the questions by theme, eliminate redundancy, and craft them into a cohesive narrative. Results: The question analysis revealed that there are clear advantages to the use of CAI, and that established educational theories should certainly inform the future development and selection of CAI tools. Schools adopting CAI need to carefully consider the benefits, cost, available resources, and capacity for teachers and learners to accept change in their practice of education. Potential areas for future research should focus on the effectiveness of CAI instructional features, integration of e-learning into existing curricula and with other modalities like simulation, and the use of CAI in assessment of higher-level outcomes. Conclusions: There are numerous opportunities for future research and it will be important to achieve consensus on important themes.

Haloperidol induces persistent down-regulation of tyrosine hydroxylase immunoreactivity in substantia nigra but not ventral tegmental area in the rat.

The dopamine antagonist haloperidol can cause tardive side-effects that may persist after the drug is withdrawn. We studied the time course of changes in dopaminergic neurons of the substantia nigra and ventral tegmental area following withdrawal of haloperidol. Rats received daily intraperitoneal injections of saline or haloperidol for eight weeks and were killed at two, four or 12 weeks after the final injection. Sections of substantia nigra and ventral tegmental area were processed for tyrosine hydroxylase immunohistochemistry. Quantitative morphometric analysis was carried out blinded in order to determine the number, cell body size and topography of tyrosine hydroxylase-positive cells, and the immunoreactive area of the substantia nigra and ventral tegmental area. In haloperidol-treated rats, tyrosine hydroxylase-positive cell counts were normal in ventral tegmental area but were decreased in substantia nigra by 34% at two weeks withdrawal and by 52% at four weeks withdrawal; cell counts were almost fully recovered by 12 weeks withdrawal. Cross-sectional area of tyrosine hydroxylase immunoreactivity within the substantia nigra demonstrated a similar pattern of reduction, with full recovery by 12 weeks withdrawal. Mean cell size, by contrast, was essentially unchanged at two and four weeks withdrawal, but was significantly decreased in sub-regions of substantia nigra at 12 weeks withdrawal. These results indicate that haloperidol can produce selective changes in midbrain dopamine neurons that persist long after discontinuation of the drug. This decrease in tyrosine hydroxylase-immunoreactive cell counts may play a role in the neurobiology of the persistent tardive syndromes associated with the use of neuroleptics.

Where is evidence‐based instructional design in medical education curriculum development?

If you are interested in developing evidence-based educational materials, you should be aware of Richard E Mayer’s work on the principles of instructional design, which are nicely summarised in this edition of the journal. Over his career, Mayer has developed and empirically tested theories of multimedia learning, while elaborating principles and guidelines on how to design and develop instructional materials. His work is also an excellent complement to the recent paper by van Merriënboer and Sweller on cognitive load theory, and together these articles highlight the increasing interest in applying the science of educational psychology to medical education curriculum materials.