Ann Thorac Surg 2006;81:1760-1766
© 2006 The Society of Thoracic Surgeons
Original article: Cardiovascular
Multimedia-Driven Teaching Significantly Improves Students' Performance When Compared With a Print Medium
Reinhard Friedl, MD
a
,
*
,
Helmut Höppler, MD
a
,
Karl Ecard
a
,
Wilfried Scholz, MD
a
,
Andreas Hannekum, MD, PhD
a
,
Wolfgang Öchsner, MD
b
,
Sylvia Stracke, MD
c
a Department of Heart Surgery, University Hospital of Ulm, Ulm, Germany
c Department of Cardiac Anesthesiology, University Hospital of Ulm, Ulm, Germany
b Division of Nephrology, University Hospital of Ulm, Ulm, Germany
Accepted for publication September 21, 2005.
* Address correspondence to Dr. Friedl, University Hospital of Ulm, Department of Heart Surgery, Steinhövelstr. 9, 89073 Ulm, Germany (Email: reinhard.friedl{at}medizin.uni-ulm.de).
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Abstract
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BACKGROUND: In this study, we compared the educational value of a multimedia module about aortic valve replacement as a preparation for the operating room with a print medium of identical content.
METHODS: One hundred twenty-six students were randomly assigned in a prospective study to either use the multimedia course (n = 69) or a print version (n = 57). A 20-item multiple-choice test was performed before and after learning with the respective medium. Both groups participated in an operation during which they were evaluated with 28 standardized tasks and questions. Individual motivation, computer literacy, and didactic quality of both media were assessed with psychometric tests.
RESULTS: There were no significant differences in the multiple-choice pretest (multimedia, 30.6% ± 12.4% versus print, 27.9% ± 11.4%) and posttest responses (multimedia, 76.7% ± 13.3% versus print, 76.9% ± 11.1). Mean percentage of correct answers during the operation was 82.9% ± 10% in the online group and 64.7% ± 12% in the print group (p < 0.0001). The multimedia group needed significantly (p < 0.001) less study time (105 ± 24 minutes) when compared with the text group (122 ± 30 minutes). There were no statistically significant differences in motivation, computer literacy, and didactic quality of either medium.
CONCLUSIONS: Regarding factual knowledge, there is no difference between multimedia-driven learning and a print medium. During heart operations, when understanding of complex temporal and spatial events is essential, students' performance is significantly improved by multimedia-enhanced teaching. The latter further proved to be more efficient in terms of study time.
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Introduction
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The World Wide Web is playing an increasingly important role in medical education owing to its advanced multimedia capabilities and the power to distribute instructional content internationally. In the heart surgery community, computer-assisted instruction is believed to be a necessary and powerful tool to improve training of residents [1,2], and various approaches to establish multimedia-driven education have been described [3–7]. In spite of enthusiastic endorsements and continued improvements in software and technology, few well-designed studies clearly demonstrate improvement in knowledge and skills when compared with traditional teaching modalities [8, 9].
We recently reported the development and first evaluation (students and residents) of a multimedia course about standard aortic valve replacement, which is internationally accessible at the medical teaching platform LaMedica (www.lamedica.de) [10–12]. It has been designed to prepare students and novice residents as team members in heart surgery operations and integrates more than 100 surgical video sequences, interactive two-dimensional and three-dimensional models, texts, and images. Learning objectives have been defined as follows: at completion of the multimedia course the user should have acquired knowledge about the different surgical steps of a standard aortic valve replacement, the instruments used, the safeguards and pitfalls of critical steps, and basics of communication among surgeon, perfusionist, and anesthesiologist, as well as the principles and practical issues of extracorporeal circulation and myocardial protection (Fig 1) [12]. It is internationally accessible at www.lamedica.de in the subsection MediCarta.
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Fig 1. Screenshot of the online multimedia course about aortic valve replacement (German text). It has a media window (left side), a text section with hypermedia and media control functions (middle), and a navigation window (right side). The system and content is internationally available at http://www.lamedica.de. The media window shows a video about the placement of annular sutures at the aortic ring. Because not all important details can be recorded on video, additional three-dimensional animations show details of the procedure from different perspectives, eg, the position of the subannular pledgets from a left ventricular viewpoint. (Reproduced with permission from the Department of Heart Surgery, University of Ulm, Ulm, Germany.)
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This study has been performed to assess the impact of the multimedia system in improving students' procedural knowledge as required during operative procedures in heart surgery. In a prospective randomized, trial it has been compared with a print medium of identical content while carefully controlling for frequent confounders. Our work has been supported by the German Ministry of Research and Education [13].
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Material and Methods
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From November 1, 2002, to July 16, 2004, a total of 126 students were prospectively and randomly assigned to either use the multimedia course as described by Friedl and colleagues [12] (n = 69) or a print version (n = 57). The print medium is not just a collection of screenshots of the multimedia program but an adjusted and highly structured booklet of 62 pages providing identical content, identical type of teaching, and a similar attractive layout (Fig 2). Continuous media as videos, sound, and (interactive) three-dimensional animations have been replaced by multiple screenshots and text-based description.
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Fig 2. Example of the 62 pages of print medium of the control group (German text). It provides identical content, identical type of teaching, and a highly structured layout. Continuous media as videos, sound, and (interactive) three-dimensional animations have been replaced by multiple screenshots and text-based description. (Reproduced with permission from the Department of Heart Surgery, University of Ulm, Ulm, Germany.)
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Demographic data in both groups were comparable: 62 students were male (n = 35 multimedia group versus n = 27 print group) and 64 female (n = 34 multimedia group versus n = 30 print group). Mean age in both groups was 25 ± 3 years, and students were in their 4th ± 1 year of medical training. They have completed all basic medical science courses and at least 1 or 2 years of clinical training including general surgery. Participation was voluntary and part of an elective course in heart surgery.
The study was performed in our multimedia laboratory and operating theater in a standardized manner (Fig 3). After a short introduction, each participant studied the program in a self-directed, self-paced manner while study time was not limited. In the multimedia group, speed of data transmission (bandwidth) by means of the Internet was 100 MB/s.
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Fig 3. Flow diagram of the prospective, randomized study design. All users completed a 20-item multiple-choice (MC) pretest referring on factual knowledge. Actual motivation and computer literacy of each student was assessed by the Questionnaire on Current Motivation (QCM) and Confidence in the Use of Computers (CUC) questionnaires. Students were prospectively randomized to either the multimedia or print group. A 20-item multiple-choice posttest was performed thereafter, and the overall didactic quality of the respective medium was evaluated using the HILVE questionnaire (Heidelberg inventory to evaluate teaching courses). Next day, both groups participated in a heart operation during which they were assessed with 28 standardized tasks and open questions targeting toward a procedural understanding of the operation.
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Both groups completed a 20-item multiple choice pretest and posttest, referring to factual knowledge immediately before and immediately after exposure to the respective course. Actual motivation and computer literacy of each student was assessed by the following psychometric and validated tests: Questionnaire on Current Motivation (QCM) [14, 15] and Confidence in the Use of Computers (CUC) composed of 11 items [16, 17]. The QCM assesses initial motivation. From 18 items, four motivational factors are generated: probability of success (the learners' level of certainty about whether they will succeed in performing the task), fear (about failing in the task), challenge (the extent to which learners perceive this task as requiring competence), and interest (in the topic) [14]. The overall didactic quality of the respective medium was evaluated after the posttest using the HILVE questionnaire (Heidelberg inventory to evaluate teaching courses) [12, 18–20]. In this model, 15 didactic dimensions, generated from 42 items, are summarized to the factors "conditions of teaching," "competence of teaching," and "student behavior," which influence the factor "outcome of teaching." Next day, both groups participated in a heart operation during which they were assessed with 28 standardized tasks and open questions targeted toward a procedural understanding of the operation, eg, "What should you ask the anesthesiologist before sawing the sternum?" or "Palpate the aorta and demonstrate where you would perform cannulation." Intraoperative evaluation was performed by a specially trained observer at defined steps of the operation. The comparisons of the pretest and posttest were made using Student's t test and reported as significant when p was less than 0.05.
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Results
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All participants were able to complete their course. There were neither technical problems nor significant problems with the learning software, and none of the participants was excluded from the study. Completeness of data was 100%.
The multimedia group was slightly more motivated than the print group when tested with the QCM (score, 1 through 7; Fig 4), although the difference was not significant. In detail, self-estimated probability of success revealed 4.93 ± 0.32 in the multimedia group and 4.74 ± 0.21 in the print group. Anxiety about failing in the task (fear) was 2.95 ± 0.55 in the multimedia group versus 3.05 ± 0.57 in the text group. All users expected the task to be rather challenging (4.8 ± 0.71 in the multimedia group versus 4.54 ± 0.71 text group). The interest in the topic was 5.04 ± 0.42 in the multimedia group and 4.8 ± 0.27 in the print group.
The CUC questionnaire (score, 1 through 4; Fig 5) revealed that confidence in the use of computers was equal in both groups: print group, 2.91 ± 0.74 and multimedia group, 2.82 ± 0.79.
Mean percentage of correct answers to the 20 questions of the multiple-choice knowledge pretest was 30.6% ± 12.4% in the multimedia group and 27.9% ± 11.4% in the print group (Fig 6). Mean percentage of correct answers to the posttest was 76.7% ± 13.3% in the multimedia group and 76.9% ± 11.1% in the print group. Knowledge gain (increasing number of correct answers in the posttest when compared with pretest) was highly significant (p < 0.0001) in both groups (Fig 6). The multimedia group needed significantly (p < 0.001) less study time (105 ± 24 minutes) when compared with the print group (122 ± 30 minutes; Fig 7). Performance in the operating room was significantly improved in the multimedia group (Fig 8), in which 82.9% ± 10% of tasks and questions were resolved correctly when compared with the print group (64.7% ± 12%; p < 0.0001).
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Fig 6. Results of the multiple-choice pretest and posttest on factual knowledge of the multimedia and print groups. Knowledge gain (increasing number of correct answers in the posttest when compared with pretest) was highly significant (p < 0.0001) in both groups.
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Fig 7. The multimedia group needed significantly (p < 0.001) less study time (105 ± 24 minutes) when compared with the text group (122 ± 30 minutes).
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Fig 8. Performance in the operation room was significantly improved in the multimedia group, in which 82.9% ± 10% of tasks and questions were resolved correctly when compared with the text group (64.7% ± 12%; p < 0.0001).
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The results of evaluation of the didactic quality with HILVE are summarized in Figure 9. Teaching conditions were rated positively. Most users felt comfortable with the intellectual level of the course, and the dimension demand (optimum score = 4, exactly right) was rated with an overall mean of 4.13 ± 1.21 by the multimedia group and 4.11 ± 1.15 by the print group. The relevance of the subject was rated almost equally by both groups: multimedia, 5.09 ± 1.61 versus print, 4.94 ± 1.55. Overall operability and design of the program was judged to be positive (5.61 ± 1.14 multimedia group versus 5.8 ± 1.19 print group).
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Fig 9. Results of the psychometric evaluation with HILVE (Heidelberg inventory to evaluate teaching courses) to evaluate overall didactic quality of both courses. Items of the HILVE questionnaire are accumulated to didactic dimensions, eg, operability and design. Didactic dimensions are summarized as the factors conditions of teaching, competence of teaching, and students, which influence the factor outcome of teaching.
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The users thought that the respective medium is a useful and competent instrument for learning. The structure and sequence of presented topics were highly rated (structure, 6.21 ± 1.06 multimedia group versus 6.30 ± 0.77 print group). Most participants thought that relevance and practical issues of surgical steps are well illustrated and discussed and that they were stimulated to reflect on the content (review of content, 5.99 ± 1.18 multimedia group versus 5.73 ± 1.25 print group). Evaluation of the instructional competence of either medium revealed 5.94 ± 1.06 in the multimedia group versus 5.89 ± 1.12 in the print group, and commitment of the author to teaching was positively rated: 6.31 ± 0.86 in the multimedia group versus 6.05 ± 0.89 print group.
Most users stated that they have not specially prepared themselves for the course, and the required study time was regarded low in contrast to traditional courses (diligence, 3.51 ± 1.67 multimedia group versus 3.17 ± 1.63 print group). Users assessed their previous knowledge (4 = exactly right) at a range from 3.72 ± 0.6 (multimedia group) to 3.25 ± 0.8 (print group).
Teaching with both media seemed to result in successful and effective learning. In general, participation in the course and its concept was of interest retrospectively (interestingness, 5.51 ± 1.66 multimedia group versus 5.46 ± 1.56 print group) to all users. Users thought that they learn effectively with either medium (quantitative learning, 5.68 ± 1.13 multimedia group versus 5.45 ± 1.23 print group), and participation supported a profound understanding in the subject matter (qualitative learning, 5.78 ± 1.21 multimedia group versus 5.36 ± 1.3 print group). The course seemed to stimulate self-directed learning with both media and an intrinsic motivation in heart surgery (motivation, 5.83 ± 1.13 multimedia group versus 5.50 ± 1.16 print group). The general appraisal was 6.10 ± 0.51 in the multimedia group and 6.12 ± 0.65 in the print group.
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Comment
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This study describes instruction and competency assessment for multimedia-driven education in heart surgery. When compared with a print version of identical content, the demonstrated multimedia system is an equally effective instrument to impart factual knowledge (Fig 6). Self-directed, multimedia-driven learning significantly improved students' procedural knowledge and performance during operations of the open heart (Fig 8). The multimedia course further showed to be significantly more efficient in terms of required study time (Fig 7).
Evaluation of multimedia learning programs has a number of limitations if care is not taken in qualitative research methodology [21]. For example, when students' perceptions of their learning as an evaluative measure of a computer-assisted instruction program is used, positive findings may be related to the novelty of the medium, the so-called Hawthorne effect. We carefully controlled our comparative evaluation for frequent confounders as demanded by others [8, 22, 23]: (1) identical learning environment and exposure to learning in our media laboratory, (2) identical content and information, (3) identical type of teaching, and (4) assessment of preexisting knowledge. We further assessed initial motivation (QCM) and the individuals' confidence in the use of computers (CUC) in both groups. All students were accustomed to the use of computers (Fig 5) and rated their computer literacy around average (interestingly the print group scored slightly better). This excludes the possibility that a multimedia student may have worse results than a student who worked with the print version because of problems with the computer medium. The CUC focuses on subjective evaluation of confidence in the use of computers. However, a high correlation between the results of the CUC and declarative and procedural computer knowledge has been demonstrated [16], and it is reported as a valid and reliable tool. A significant lack of motivation or anxiety to fail did not confound students' performance in one of the groups as can be seen from the results of the QCM (Fig. 4). The HILVE model takes into account a variety of factors influencing the learning process and outcome. From the findings of the psychometric evaluation with HILVE, we further conclude that both courses were of equal didactic quality. Overall teaching conditions and the competence of the respective medium were rated positively, the previous knowledge in relation to the presented content seemed to be adequate, and the subsequent outcome of teaching was judged as very favorable (Fig 9). In summary the results of our comparative study are not confounded methodologically by differences in instructional methods, informational content, computer literacy, or individual motivation as criticized in previous studies [8, 24].
Both groups scored almost equally in the multiple-choice pretest and, analogous to the self-estimation with HILVE (dimensions, quantitative and qualitative learning), had a highly significant knowledge gain as can be seen from the pretest and posttest results (Fig 6). We conclude that both media are equally effective in imparting factual knowledge. These findings are supported by other randomized controlled studies in which computer-assisted instruction is at least as effective as other methods of education [21, 25].
Although both groups assessed their teaching outcome as positive and demonstrated to have learned effectively, the multimedia group scored significantly higher during the operation. This phenomenon remains to be elucidated. However, we would like to emphasize that the course has not been developed to train and prepare haptic technical skills but to integrate factual (cognitive) knowledge in real-life scenarios as a prerequisite to the development of skills and strategies [26]. In previous studies using the QCM, which is based on a cognitive–motivational process model [14], initial motivation was found to be a predictive factor for subsequent learning outcome. The factors challenge and interest strongly affected students' performance when knowledge had to be transferred to and applied in a specific task. However, this effect was only present when the learning process was flexible, self-directed, and adjusted toward the transfer of knowledge whereas it was absent when learning was more fact-oriented [15]. From the fact that in our study challenge and interest were rated almost equally in both groups, one may conclude that the multimedia program stimulates a more constructivistic learning process that better prepares a process of cognitive apprenticeship in the operating room. The multimedia course provides a more situated learning environment in which high-quality videos related to all single steps of the surgical procedures are used to achieve a high level of authenticity. Situated learning, in which content is referred to and presented in daily life situations, is associated with improved medical problem-solving in the real world [27]. In addition, comprehension of conceptually difficult topics (eg, complex anatomic structures, extracorporeal circulation, and surgical techniques and processes) are augmented by the use of interactive two-dimensional and three-dimensional simulations [4, 28]. In summary, the course makes intensive use of interactive media (Fig 1), thus stimulating the different visual and auditory receptors of the learning individual, which seems to improve understanding and transfer of complex temporal and spatial events.
There are yet relatively few media comparative assessments about the benefits of training with Web-based multimedia programs, and only a few studies report positive changes in knowledge that are believed to be translated into changes in practice [25, 29, 30]. In many cases it seems to be methodologically difficult to expose students to similar clinical scenarios. In contrast, aortic valve replacement is a highly standardized procedure with little variation in surgical techniques. In our opinion, advantages of multimedia-driven learning are strongly related to a certain type of content in which image-, video-, and three-dimensional–derived information carries a clear additional value. For example, educational advantages of multimedia-augmented learning over print media have been observed when students had to identify anatomic structures or learn basic surgical skills [31, 32].
Furthermore, multimedia-driven learning with LaMedica proved to be a significantly more efficient learning method in terms of study time (Fig 7). This phenomenon has been also reported by others in media comparative studies [23, 33]. Although the reasons have not been fully elucidated, we believe from personal observation that the understanding of surgical techniques is easier and consequently faster when mediated with continuous and interactive media, eg, videos or three-dimensional animations.
The presented concept to prepare students with multimedia-based learning in an authentic environment and subsequently expose them to a real operation has been implemented into the e-curriculum at our university as a facultative course. Our data demonstrate a clear-cut advantage for multimedia-driven learning. It sufficiently prepares students to participate as a team member in an operation of the open heart, for which understanding of complex temporal and spatial events is essential.
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Acknowledgments
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This work was supported by the German Ministry of Research and Education, grant number BMBF 08NM054A. We wish to thank the following persons, without whose skillful contributions this project could not have been realized: Freddi Gaisler for computer programming and technical engineering and Melissa B. Blau, MD, PhD, for coordination of the whole project.
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Abstract
Introduction
