Jorge G. Ruiz

The Impact of E-Learning in Medical Education

The authors provide an introduction to e-learning and its role in medical education by outlining key terms, the components of e-learning, the evidence for its effectiveness, faculty development needs for implementation, evaluation strategies for e-learning and its technology, and how e-learning might be considered evidence of academic scholarship. E-learning is the use of Internet technologies to enhance knowledge and performance. E-learning technologies offer learners control over content, learning sequence, pace of learning, time, and often media, allowing them to tailor their experiences to meet their personal learning objectives. In diverse medical education contexts, e-learning appears to be at least as effective as traditional instructor-led methods such as lectures. Students do not see e-learning as replacing traditional instructor-led training but as a complement to it, forming part of a blended-learning strategy. A developing infrastructure to support e-learning within medical education includes repositories, or digital libraries, to manage access to e-learning materials, consensus on technical standardization, and methods for peer review of these resources. E-learning presents numerous research opportunities for faculty, along with continuing challenges for documenting scholarship. Innovations in e-learning technologies point toward a revolution in education, allowing learning to be individualized (adaptive learning), enhancing learners interactions with others (collaborative learning), and transforming the role of the teacher. The integration of e-learning into medical education can catalyze the shift toward applying adult learning theory, where educators will no longer serve mainly as the distributors of content, but will become more involved as facilitators of learning and assessors of competency.

Learning objects in medical education

A learning object (LO) is a grouping of instructional materials structured to meet a specified educational objective. Digital LOs, which can be stored electronically, allow a new approach to instructional activity, making medical education more efficient, and potentially more cost-effective. They are reusable and can incorporate text, graphics, animations, audio, and video to support and enhance learning. A learning object can stand alone or be aggregated with additional objects to create larger forms of educational content meeting multiple educational objectives. Digital learning objects located in online repositories can be accessed by many computers and are easily handled by an array of learning management systems for delivery to learners at any time. Integrating digital learning objects with traditional educational methods in a blended learning approach assists medical educators in meeting the challenges of competing priorities. Multimedia LOs enable learners to tailor their experience to their preferred learning style. Through the use of learning objects, learners’ reactions, their acquisition of knowledge, skills and attitudes, and their behavioral changes become readily measurable. Learning objects provide multiple research opportunities, such as their use in adaptive learning, their added value in preclinical versus clinical education, and their impact as part of a blended learning strategy. Practice points•A learning object is a grouping of instructional materials structured to meet a specified educational objective.•Learning objects are interactive, interoperable, multimedia and easily accessible in online repositories.•Learning objects can stand alone or can be aggregated to create larger forms of educational content to meet multiple educational objectives.•Learning objects allow a blended learning approach to instructional activity, making medical education more efficient and potentially more cost-effective.•Learning objects create new teaching efficiencies for educators and create new learning opportunities.

Avatar-Mediated Training in the Delivery of Bad News in a Virtual World

BACKGROUNDnDelivering bad news to patients is an essential communication skill for physicians. Educators commonly use standardized patient (SP) encounters to train physicians in the delivery of bad news. It is expensive to use actors, for logistical reasons such as travel and scheduling, and there are limits to the characters and conditions an actor can portray in teaching encounters. Thus we studied the feasibility of creating SP avatars in a virtual world for the task of training medical trainees to deliver bad news. The SP avatars are easily customized for different scenarios and amenable to distance learning.nnnMETHODSnWe recruited 10 medical trainees to interact with a standardized female avatar in a three-dimensional simulated clinic, where the trainee was to inform the avatar of her newly diagnosed breast cancer. The trainee evaluated his or her self-efficacy in delivering bad news via an affective competency score (ACS) before and after the encounter. Two palliative care specialists evaluated each trainees performance using the Bad News Assessment Schedule and the performance ACS.nnnRESULTSnThe self-efficacy ACS scores of the trainees improved overall: before, 20u2009±u20094, versus after, 24u2009±u20093, pu2009=u20090.001 (maximum scoreu2009=u200930). All participants considered the experience positive and commended the novel approach, although noting that the avatars were not able to portray body language cues.nnnCONCLUSIONnParticipants viewed the avatar-mediated training as an excellent approach for learning how to deliver bad news but believed it could not substitute for real patient interactions. However, participant self-efficacy improved, which suggests that avatar-mediated training in a virtual world is a viable educational approach for skill training in delivering bad news.

The Consortium of E‐Learning in Geriatrics Instruction

This paper describes the activities of the Consortium of E‐Learning in Geriatrics Instruction (CELGI), a group dedicated to creating, using, and evaluating e‐learning to enhance geriatrics education. E‐learning provides a relatively new approach to addressing geriatrics educators concerns, such as the shortage of professionals trained to care for older people, overcrowded medical curricula, the move to transfer teaching venues to community settings, and the switch to competency‐based education models. However, this innovative education technology is facing a number of challenges as its use and influence grow, including proof of effectiveness and efficiency. CELGI was created in response to these challenges, with the goal of facilitating the development and portability of e‐learning materials for geriatrics educators. Members represent medical and nursing schools, the Department of Veterans Affairs healthcare system, long‐term care facilities, and other institutions that rely on continuing streams of quality health education. CELGI concentrates on providing a coordinated approach to formulating and adapting specifications, standards, and guidelines; developing education and training in e‐learning competencies; developing e‐learning products; evaluating the effect of e‐learning materials; and disseminating these materials. The vision of consortium members is that e‐learning for geriatric education will become the benchmark for valid and successful e‐learning throughout medical education.

Normal Respiratory Rate and Peripheral Blood Oxygen Saturation in the Elderly Population

To the Editor: Age-specific normal limits for a number of vital signs and physiological parameters have not been established in the elderly population. The limits for younger adults are not always applicable because of ageassociated physiological changes and the increase of interindividual differences with age. Regarding the respiratory system, there are few data on normal respiratory rate at rest (RR) and peripheral pulse oximetry values (SpO2), which are major parameters in clinical practice and easy to measure, and become altered quickly in respiratory and cardiac diseases. (Increased respiratory rate is often the only visible sign of a respiratory infection.) This was a cross-sectional study of 791 noninstitutionalized individuals aged 65 and older living in Spain to establish the limits of normal RR and SpO2 in the elderly population. The sample was collected using multistaged probabilistic sampling and stratified according to sex, size of place of residence (rural, urban, or big city), and geographic location with a nonproportional age stratum (523 subjects aged ≥80). A sample of 576 participants was considered necessary to estimate RR and SpO2 with 5% error and a design effect of 1.5. Survey data were collected between 2007 and 2009. The survey was carefully designed to reduce nonsampling errors, the survey takers received specific training, and the field work was thoroughly supervised. RR and the SpO2 were measured with the participant in a seated position after a rest of at least 10 minutes. SpO2 was measured using a pulse oximeter (9500; Nonin Medical, Plymouth, MN), and RR was measured by directly observing thoracic movements for a 30-second period. As a distraction maneuver, the survey takers pretended to measure the radial pulse, so that participants would not be aware that their respiratory rate was being measured. All information about participants’ medical background was collected as control variables. Two consecutive analyses were conducted. First, all participants with pathologies that proved to affect RR or SpO2 independently in multivariable models were excluded. A subsequent more-restricted analysis was performed by excluding all individuals who had any clinical factor showing significant influence in bivariate analyses. Participants with dyspnea during the examination were excluded from all calculations. Normal RR limits were represented according to percentiles that delimit 95% of the sample (2.5–97.5) and percentiles that delimit 99% of the sample (0.5–99.5). Limits of SpO2 were represented according to the first and fifth percentiles. Calculations were weighted according to age, sex, and size of place of residence. History of chronic obstructive pulmonary disease (COPD) was the only variable that independently influenced RR and SpO2 in the multivariate models. Once individuals with COPD were excluded, the RR distribution appeared bell-shaped, with 0.67 kurtosis and 0.43 asymmetry, and was significantly different from the theoretical normal distribution according to the Kolmogorov contrast test. Percentiles 2.5 and 97.5 were 12 respirations per minute (rpm) (95% CI = 10–12 rpm) and 28 rpm (95% CI = 28–32 rpm), respectively. Percentiles 0.5 and 99.5

E-learning as evidence of educational scholarship: a survey of chairs of promotion and tenure committees at U.S. medical schools.

Purpose To ascertain the attitudes of chairs of U.S. medical school promotion committees toward e-learning and how their institutions recognize and reward faculty for e-learning as a scholarly activity. Method In 2007, the authors mailed a questionnaire to chairs of promotion and tenure committees at 123 U.S. medical schools. Chairs rated the importance of major areas of clinician–educators’ e-learning performance using a five-point scale (1 = not important; 5 = extremely important). In another section, chairs rated the quality of information that is usually available to evaluate faculty performance in e-learning scholarship using a five-point scale (1 = low quality; 5 = excellent). Respondents were also able to enter qualitative comments about the role of e-learning and educational scholarship at their institution. Frequency distributions for each question were examined to identify any irregularities in the data, and descriptive statistics were used to summarize responses to questions. Themes were extracted from the qualitative data. Results The response rate to the survey was 51% (63/123). Fifty-six (88.8%) participants indicated that educational scholarship was at least moderately important to a candidate’s chances of promotion. Forty-eight (76%) respondents recognized e-learning as a meaningful contribution to scholarship. The chairs rated several levels of evaluation as well as types of e-learning activities and products: changing learner outcomes, developing and disseminating materials, authoring publications, receiving grant awards, serving on editorial boards, and directing a program. Conclusions Promotion chairs value selected e-learning activities and products as evidence of teaching scholarship.

An Interactive E-Learning Tutorial for Medical Students on How to Conduct the Performance-Oriented Mobility Assessment

Abstract We evaluated the effectiveness of an e-learning tutorial (iPOMA) as a supplement to traditional teaching of the Performance-Oriented Mobility Assessment. Second-year medical students (137) completed the iPOMA, in preparation for a session on fall risk assessment consisting of a lecture, practice with elder volunteers and small group debriefing. Before and after the tutorial, students completed online questionnaires, a quiz on POMA scoring immediately after the tutorial and competency assessments on POMA performance 1 month later. Self-efficacy in using the POMA increased and post-tutorial quiz scores were significantly correlated with self-efficacy. Students who completed the tutorial performed significantly better on the verbal instructions portion of the POMA. The iPOMA is an effective instructional modality.

Caídas en la población anciana española: incidencia, consecuencias y factores de riesgo

INTRODUCTIONnFalls in the elderly constitute a public health concern. The objective of the present study was to collect updated data on the frequency of falls in the Spanish elderly population, as well as to analyse their consequences and associated risk factors.nnnMATERIAL AND METHODSnThis prospective study was conducted on a probabilistic sample of 772 Spanish, community dwelling, older adults. During the baseline visit, data were collected on functional capacity, history of falls, disease background, number of medications used, balance impairment, use of walking aids, cognitive capacity and depression symptoms. Participants were followed up for one year by means of quarterly phone calls, where they were asked about the number of falls occurred in that period, as well as their consequences and associated use of healthcare resources.nnnRESULTSnDuring the one-year follow up period, 28.4% (95%CI 24.9-32.1) of participants suffered one or more falls, while 9.9% (95%CI 7.4-11.4) suffered multiple falls. One-third of the falls were due to accidental extrinsic causes. Among participants who had suffered falls, 9.3% suffered a fracture (3.1% hip fracture), and 55.4% required healthcare services (29% were managed in the hospital emergency room, and 7.3% were admitted to hospital). Risk factors identified through multivariate analysis were: advanced age (>79 years), not having a companion, using more than 2 drugs, dependency in BADLs, impaired strength or balance, and use of walking aids.nnnCONCLUSIONSnFalls continue to be a major public health concern in Spain. Given that some of the associated risk factors may be modified, introducing programs aimed at tackling this problem should be regarded as a priority.

Computer-Based Programmed Instruction Did Not Improve the Knowledge Retention of Medication Instructions of Individuals With Type 2 Diabetes Mellitus

Purpose The purpose of this study was to investigate whether computer-based programmed instruction (CPI) with a dynamic avatar (DA) improves retention of medication information better than text (controls) or better than CPI with text (T-CPI), CPI with voice (V-CPI), or CPI with static avatar with text (SA-CPI). Methods Participants with type 2 diabetes mellitus were enrolled in a randomized controlled trial comparing TDS with CPI in 4 conditions (T-CPI, V-CPI, SA-CPI, and DA-CPI). CPI sequentially delivers segmented information in text or voice followed by a multiple-choice question. Immediately after the user selects an option, CPI delivers elaborated feedback. Satisfaction was measured immediately after the interventions, and medication knowledge was measured at 2 weeks. Results One-hundred fifty individuals (30 per group) with a mean age 62 years (standard deviation [SD] 7.99 years) participated. There were no baseline differences in race, body mass index, education, and health literacy. Medication knowledge retention at 2 weeks was not significantly different between the groups, df(4), F = 0.17, P = .95 (TDS, mean = 25.43, SD = 5.11; T-CPI, mean = 25.07, SD = 4.98; V-CPI, mean = 25.77, SD = 4.89; SA-CPI, mean = 25.83, SD = 5.31; and DA-CPI, mean = 24.93, SD = 6.25). Satisfaction scores were significantly lower for TDS, df(4), F = 3.11, P = .01. Conclusions CPI did not improve medication knowledge retention at 2 weeks. CPI led to higher patient satisfaction compared with controls.

Avatar-mediated home safety assessments: piloting a virtual objective structured clinical examination station.

BACKGROUNDnAvatars and virtual worlds offer medical educators new approaches to assess learners competency in home-safety assessments that are less time-consuming and more flexible than traditional home visits. We sought to evaluate the feasibility and acceptability of implementing an avatar-mediated, 3-dimensional (3-D) home simulation as a virtual objective structured clinical examination station for geriatric medicine fellows.nnnMETHODSnWe developed a 3-D home simulation in the virtual world Second Life (Linden Lab, San Francisco, CA) containing 50 safety hazards that could affect the safety of an elderly person at home. Eight geriatric medicine fellows participated in a 16-station objective structured clinical examination, with one station assigned to the 15-minute 3-D virtual world simulation, where the fellows home visit was performed by navigating his or her avatar in the virtual world simulation. The fellows were instructed to find the home safety hazards in the simulated environment and then provide specific written recommendations. Two reviewers independently scored the fellows written findings against an inventory-based checklist.nnnRESULTSnThe geriatric medicine fellows scored a mean of 43%u2009± SDu20099 on the inventory-based checklist. The scoring of the 2 reviewers showed a high interrater reliability (88%). Six of the 8 participants (75%) rated the simulation as excellent. Four of the 5 women (80%) and none of the 3 men (20%) participating in the virtual objective structured clinical examination needed navigation assistance in the 3-D virtual house.nnnCONCLUSIONnThe 3-D, avatar-based, virtual geriatric home safety objective structured clinical examination is a practical and acceptable alternative to the traditional home safety visits in an objective structured clinical examination setting.