Ann Thorac Surg 2006;82:1790-1795
© 2006 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Comparative Evaluation of Multimedia Driven, Interactive, and Case-Based Teaching in Heart Surgery
Reinhard Friedl, MDa,*,
Helmut Höppler, MDa,
Karl Ecarda,
Wilfried Scholz, MDa,
Andreas Hannekum, MD, PhDa,
Wolfgang Oechsner, MDb,
Sylvia Stracke, MDc
a Department of Heart Surgery, University Hospital of Ulm, Ulm, Germany
b Department of Cardiac Anesthesiology, University Hospital of Ulm, Ulm, Germany
c Division of Nephrology, University Hospital of Ulm, Ulm, Germany
Accepted for publication May 31, 2006.
* Address correspondence to Dr Friedl, University Hospital of Ulm, Dept. 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: Multimedia-augmented instruction with various approaches is used in heart surgery. There is little evidence which instructional techniques and media are of advantage to impart knowledge more effectively and lead to better application of knowledge in the operation room.
METHODS: Sixty-nine students learned with an interactive, case-based teaching (ICBT) course about aortic valve replacement. They were compared with historic controls exposed to identical information provided by a multimedia module presenting content systematically (SMM; n = 69) and a print medium (PM; n = 57). Motivation, computer knowledge, and didactic quality were evaluated with psychometric tests. All groups performed multiple choice pretests and posttests and participated in live surgery during which their performance was assessed.
RESULTS: All groups had equal computer knowledge, but the ICBT group felt significantly less-motivated and more challenged. Multiple choice posttest results were comparable (ICBT 80.2% ± 10.9%, SMM 76.7% ± 13.3%, PM 76.9% ± 11.1). During surgery, the ICBT (79.2% ± 16%) and SMM groups (82.9% ± 10%) performed significantly better than the PM group (64.7% ± 12%; both p < 0.0001). Overall didactic assessment was significantly worse in the ICBT group when compared with the SMM and PM groups.
CONCLUSIONS: For novices in heart surgery, ICBT was less motivating than traditionally structured content (SMM and PM). The ICBT did not improve performance in the operation room. However, both multimedia groups could better apply their knowledge during live surgery. The PM is as effective as multimedia when factual knowledge has to be retained.
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Introduction
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There is a growing interest in the heart surgery community to enhance the teaching and learning of students and residents with online, multimedia-augmented instruction [1–5]. We could recently demonstrate that students' performance during heart surgery in the operation room was significantly improved by the use of a systematic multimedia module (SMM), which was structured in a textbook-like manner when compared with a print medium (PM) [6].
Interactive, case-based teaching (ICBT) is hypothesized to be even more effective when clinical skills and decision making processes are to be imparted. Users may engage in a constructivist learning process which leads to better retaining and application of knowledge in concrete medical problems [7, 8]. Consistently, the Thoracic Surgery Directors Association (TSDA) has recently implemented clinical surgical cases in their web-based e-curriculum as an alternative approach to a textbook-like presentation of multimedia content [9]. While many investigators agree that generally, media-enriched content (eg, by the employment of videos and interactive animations) may facilitate understanding of complex surgical topics [10–12], there is little evidence in the literature which particular method of multimedia driven instruction is of advantage to impart knowledge more effectively and leads to better application of knowledge in clinical scenarios [13, 14].
We have restructured our SMM content about standard aortic valve replacement [15] to an ICBT system where the user is continuously prompted to interact with a patient-centered scenario while continuously solving various questions and tasks. This study has been performed to elucidate whether students trained with ICBT are more capable of retaining factual knowledge and would be better able to apply their knowledge during live heart surgery when compared with historic control groups that have been instructed with SMM and PM [6].
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Material and Methods
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Learning objectives have been defined as follows: knowledge about the symptoms and diagnosis of aortic stenosis, main diagnostic procedures, the different surgical steps, safeguards and pitfalls of critical steps, as well as practical issues of extracorporeal circulation and myocardial protection. Learning objects (eg, videos or text segments) have been reorganized to an ICBT module with the database driven on-line authoring system LaMedica [10, 15–17]. "Interactivity" is represented as free-text entry tasks, to bring text or objects in a correct order, to animate objects (eg, "mark the area where you would perform aortic cannulation"; Fig 1) and multiple choice (MC) questions.
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Fig 1. Screenshot of the interactive case-based teaching course about aortic valve replacement (text is originally in German). It has a task section (left side), an interactive media window (middle), and a navigation window (right side). On this screen, the user is prompted to mark the area where he wants to cannulate the aorta with mouse commands on the picture. (Reproduced with the permission from the Department of Heart Surgery, University of Ulm.)
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From October 11, 2004 until June 23, 2005 a total of 69 students were included in a prospective study. Thirty-five students were male and 34 female. Mean age in both groups was 25 ± 3 years and students were in their fourth ± 0.5 year of medical training. They had completed all basic medical science courses in a traditional curriculum and at least one or two 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 theatre in a standardized manner as previously reported [6]: all users completed a 20 item MC pretest referring on factual knowledge. Next, initial motivation and computer literacy of each student was assessed by the Questionnaires on Current Motivation (QCM) [18] and Confidence in the Use of Computers (CUC) [19]. After a short introduction, each participant studied the ICBT module in a self-directed, self-paced manner. Speed of data transmission (band width) by internet was 100 MB/second. A 20 item MC post-test was performed thereafter and the overall didactic quality of the respective medium was evaluated using the HILVE questionnaire (Heidelberg inventory to evaluate teaching courses) [6, 15, 20]. 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 as described [6]. We compared the ICBT group versus two historic control groups, published in Ref 6: first, an SMM group that learned the same amount of content in a methodologic approach to teaching and second, a group that learned the same amount of content with a PM. The control groups performed the same tests under the same conditions. The comparisons between the study group and the control groups were made using a t test and reported as significant when p was less than 0.05.
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Results
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Interactive, Case-Based Teaching Module
An ICBT course has been developed; it starts with the patient's history, continues with important diagnostic procedures, and proceeds to the various surgical and technical steps. The course ends with a patient interview at the day of discharge and integrates approximately 50 high quality surgical video and audio sequences, interactive two- and three-dimensional models, as well as illustrations and photographs. It is structured in 30 interactive steps, where the user is prompted to make a decision and receives immediate feedback (Fig 1). The course is accessible at www.lamedica.de in subsections Clinic and Operation Room.
Evaluation
All participants were able to complete the multimedia course. There were neither technical problems nor significant problems with the learning software. Assessment of initial motivation with the QCM (Fig 2) revealed that self-estimated probability of success in the ICBT group (4.53 ± 0.1) was significantly lower when compared with the SMM group (p < 0.001) and with the PM group (p = 0.03). Fear to fail in the following tasks was significantly higher in the ICBT group (3.5 ± 0.43) when compared with the SMM group (p < 0.0001) and the PM group (p < 0.001). Conclusively, the ICBT group (5.10 ± 0.47) expected the task to be more challenging when compared with the SMM group (p = 0.04) and the PM group (p < 0.001). Initial interest in the topic was almost equal in the ICBT group (5.06 ± 0.22) and the SMM group while being less in the PM group (p = 0.04 vs SMM).
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Fig 2. Results of the evaluation of initial motivation with the Questionnaire on Current Motivation (QCM). The results of the SMM and PM historic control groups have been published in Ref 6. (ICBT = interactive, case-based teaching; PM = print medium; SMM = systematic multimedia module; a: p < 0.001 ICBT vs SMM; b: p = 0.03 ICBT vs PM; c: p < 0.0001 ICBT vs SMM; d: p < 0.001 ICBT vs PM; e: p = 0.04 ICBT vs SMM; f: p = 0.04 SMM vs PM.)
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When preexisting computer knowledge was assessed with the CUC questionnaire, we found that it was 2.93 ± 0.74 in the ICBT group and almost equal to the control groups.
In the ICBT group, mean percentage of correct answers to the 20 questions of the MC pretest was 38.7% ± 15.9% and thus significantly better when compared with the SMM group (p < 0.01) and PM group (p < 0.0001) (Fig 3). Mean percentage of correct answers to the posttest was 80.2% ± 10.9% in the ICBT group and comparable with the control groups. Knowledge gain (increasing number of correct answers in the post-test when compared with the pretest) was highly significant (p < 0.0001) in all groups (Fig 3).
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Fig 3. Results of the multiple choice pretest and post-test on factual knowledge. The results of the SMM and PM historic control groups have been published in Ref. 6. (ICBT = interactive, case-based teaching; PM = print medium; SMM = systematic multimedia module; a: p < 0.01 ICBT vs SMM in the pretest; b: p < 0.0001 ICBT vs PM in the pretest.)
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Mean study time in the ICBT group was 109 ± 70 minutes and comparable with the SMM control group (SMM 105 ± 24 minutes). Due to the high standard deviation in the ICBT group, only the SMM group was significantly faster (p < 0.0001) than the PM group (122 ± 30 minutes).
In the operating room (Fig 4) the ICBT group performed 79.2% ± 16% of all tasks correctly. The SMM group had comparable results in the clinical tests and both multimedia groups performed significantly better than the PM group (both p < 0.0001).
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Fig 4. Performance in the operation room was significantly improved in the ICBT and SMM groups when compared with the PM group (both p < 0.0001). The results of the SMM and PM historic control groups have been published in Ref. 6. (ICBT = interactive, case-based teaching; PM = print medium; SMM = systematic multimedia module.)
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Assessment of the didactic quality of the ICBT course with HILVE (Fig 5) showed that users found it significantly more demanding with a mean rating of 4.86 ± 0.98 (optimum score = 4, exactly right) when compared with the control groups (both p < 0.0001). Interest in, and relevance of, the subject (ICBT 5.11 ± 1.56) as well as operability and design (ICBT 5.53 ± 1.23) was rated almost equally to the control groups. The program structure of the ICBT course revealed 5.69 ± 1.02 and seemed to be significantly less clear to follow than the control groups (both p < 0.0001). The dimension review of content focuses on the issue whether examples and relationships between theory and clinical practice are shown and whether controversial issues are discussed. It was assessed with 5.83 ± 1.05 by the ICBT group and comparable with the controls. The ICBT module was felt to facilitate understanding of complex content (instructional competence 5.40 ± 1.19) to a significantly lesser extent than the PM and SMM groups (both p < 0.0001). Users rated the authors' commitment to teaching in the ICBT group (6.02 ± 0.87) similar to the PM group and both significantly lower than in the SMM group (both p < 0.01). In analogy to the MC pretest results, the ICBT group was prepared better (diligence 3.85 ± 1.60) than the PM group (p = 0.001) and slightly better than the SMM group. The ICBT students assessed their previous knowledge with 3.15 ± 0.85 (4 = exactly right) and almost equal to the PM group, but both less optimal than the SMM group (both p < 0.01). Generally, participation in the course and its concept was of similar interest to the ICBT group (interestingness 5.23 ± 1.60) and the control groups. Users' self-assessment of teaching efficacy with emphasis on the amount of content (quantitative learning) was rated 5.09 ± 1.26 by the ICBT group and thus significantly lower than in the SMM group (p < 0.0001) and in the PM group (p < 0.05). Qualitative learning reflects to what extent participation supports a profound understanding of the subject matter and was scored with 5.67 ± 1.04 by the ICBT group, thus comparable with the SMM group but both significantly better than the PM group (p < 0.05 vs ICBT and p = 0.001 vs SMM). The course seemed to stimulate self-directed learning and intrinsic motivation on the topic in the ICBT group (5; 41 ± 1.28) and PM group to a significantly lesser rate when compared with the SMM group (both p < 0.001). The general appraisal was 6.02 ± 0.72 in the ICBT group and almost equal to the control groups.
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Fig 5. Results of the psychometric evaluation with HILVE (Heidelberg inventory to evaluate teaching courses) to evaluate overall didactic quality of both courses. The results of the SMM and PM historic control groups have been published in Ref. 6. (ICBT = interactive, case-based teaching; PM = print medium; SMM = systematic multimedia module; a: p < 0.0001 ICBT vs SMM and PM; b: p < 0.01 SMM vs ICBT and PM; c: p = 0.001 ICBT vs PM; d: p < 0.0001 ICBT vs SMM and p < 0.05 ICBT vs PM; e: p < 005 ICBT vs PM and p = 0.001 SMM vs PM; f: p < 0001 SMM vs ICBT and PM.)
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Comment
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Investigators in the field of medical education strongly recommended improving the quality of research in the field of computer-assisted instruction by comparing different approaches of multimedia driven instruction (eg, SMM approaches vs ICBT) while maintaining the identical amount of information provided [13, 14, 21, 22]. It has been criticized that there is no valid comparison group when multimedia-enriched content is compared with a print medium because the multimedia group still takes full advantage of the computing platform by incorporating video, audio, and hypermedia functions [14, 21]. This study has been performed to get deeper insights into the nature and significance of different instructional techniques and media in heart surgery education and the kinds of activity and learning they are supposed to sustain.
We compared two different multimedia driven instructional methods (ICBT, SMM) and a PM. Although the latter may be methodically controversial as outlined in the previous paragraph, PM are still most popular in teaching and learning, and their field of application in a growing world of web-published, educational multimedia content needs to be redefined.
Our results indicate that ICBT, where students have to respond to certain tasks after which they receive immediate feedback, did not result in improved performance in the operation room when compared with SMM, which is a more passive learning format (Fig 4). However, both multimedia groups scored significantly higher when they had to apply their knowledge during heart surgery when compared with a PM. It has been emphasized that computer-assisted instruction should map onto real life clinical experience and students assessment should be performed in clinical reality rather than in multimedia or skills laboratories to gain valuable data to estimate to what extent computer-assisted instruction affects the outcome of real interest; users performance in clinical routine [23]. So far, there are little more data available to what extent multimedia driven learning is translated into positive changes during live surgery [11, 24]. Hong and colleagues [25] report that multimedia-enhanced SMM preoperative teaching has led to positive results when anatomic knowledge had to be applied in the operation room, although this study lacked a control group.
Multimedia driven teaching (ICBT and SMM) did not result in a better ability to retain factual knowledge than a print medium, as can bee seen by the MC post-test results (Fig 3). These data are comparable with findings from the evaluation of the TSDA prerequisite internet hybrid surgery curriculum, where content in heart surgery had to be acquired by novice residents with methods of multimedia either using a text-book like presentation style or a cased-based approach. A PM group served as control [9]. No marked difference was seen in the "in training examination" between the multimedia groups and the PM group. The investigation, however, did not further differentiate the results of the two multimedia groups. The "postmatriculation faculty surveys," however, revealed that the multimedia groups could better apply the acquired knowledge in oral examinations [9]. In the few previous reports, where ICBT was compared with SMM teaching, ICBT again did not result in significant learning gains superior to those achieved from SMM learning when tested with MC pretests and post-tests [26, 27].
Our study is limited in that it is not prospectively randomized but includes historic control groups. However, we carefully controlled for frequent confounders in all three groups: initial motivation (QCM), computer knowledge (CUC), MC pre- and post-test knowledge, and an identical learning environment in our multimedia lab. All groups were exposed to the same content while the teaching style, the medium, and the interactivity were diversified. However, the content of the SMM and PM group was already online and available at the time the ICBT group went into the course. Some of the ICBT students had prior access to the learning material. This may explain why the ICBT group stated that they were better prepared for the course (HILVE, dimension diligence) and why the ICBT group scored better in the MC pretest. Interestingly, this did not result in better MC post-test outcomes or in improved performance in the operation room.
Our results may be further elucidated by the results of the psychometric evaluation, where significant differences in the evaluation of the ICBT course could be observed. Although confidence in the use of computers (CUC) was almost equal in all groups, the ICBT group anticipated a significantly lower probability of success, was more afraid of failing in the task, but also felt more challenged (which is the extent to which learners perceive the task as requiring competence), than the control groups. It has been shown that in multimedia driven learning a low degree of fear and a high anticipation of probability of success were most predictive for positive learning results when factual knowledge had to be acquired and this may explain why the ICBT group's knowledge gain in the MC post-test was less pronounced, despite having better pretest results. Interest and challenge were most predictive for positive learning results targeting toward a deeper comprehension and application of knowledge as required in the operation room, where both multimedia groups scored significantly higher [28].
After having completed learning with the respective medium, the HILVE questionnaire (Fig 5) revealed that the ICBT group still felt their task significantly more demanding and found the program structure significantly less clear and less easy to follow. Although all media and courses have been produced by the same authors, ICBT students assessed the instructional competence and commitment of the authors to teaching significantly lower. In accordance with the pretest and post-test results, self-estimated efficacy of teaching with emphasis on the amount of content (quantitative learning) was significantly less pronounced in the ICBT group. Our students are embedded in a traditional curriculum and, as reported by others [26, 29], obviously the majority is more comfortable with the traditional instructional methods (SMM, PM), which present content in a systematically structured way similar to their previous course learning experiences. Concordantly, the dimension program structure was rated lowest in the ICBT group. This finding has been further observed by the TDSA internet hybrid surgery curriculum, where less than 10% voluntarily used an ICBT course that was provided as an alternative approach to SMM while offering the same amount of content [9]. In our study, the ICBT group had a mean study time similar to the SMM group and both were faster than the PM group, which is in accordance with previous findings [7, 30, 31]. Differences in study time reached significance only in the SMM group; in the ICBT group, it had a large standard deviation and total learning time varied from 34 to 300 minutes. In addition, motivation to proceed with the respective learning format was lowest in the ICBT group (HILVE, dimension motivation). From our observations, we conclude that many students are less adapted to an ICBT learning format.
The ICBT and SMM groups assessed the quality of teaching ("My comprehension of the subject is much more profound than before working with the multimedia module") significantly higher than the PM group. This may further explain why both multimedia groups were better prepared to apply their knowledge during live heart surgery.
From our data, and those observed by Gold and colleagues [9], we conclude that PM are as powerful and equally effective as multimedia driven learning methods (ICBT and SMM) when factual knowledge has to be acquired by beginners in heart surgery. However, PM seem to be less efficient in terms of study time. Students were best prepared to apply their knowledge in the operation room when they were trained with methods of multimedia. The ICBT did not improve performance in the operation room and psychometric evaluation showed that ICBT was less accepted and students were less motivated. We speculate that ICBT may be a more appropriate and effective instructional method for novice users, who are already embedded in and used to a case-based curriculum, and for advanced learners to acquire clinical problem solving skills. In further studies, it would be of interest to identify, initially, different types of learners through appropriate psychometric tests in order to provide an adaptive instructional format that is tailored to their individual needs.
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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 for their skillful contributions to this project: Freddi Gaisler for technical engineering and Melissa B. Blau, MD, for coordination of the project.
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Abstract
Introduction
