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Multimedia based computer aided learning in postgraduate medical education: The LMF (Luddite Mentality Factor) as a barrier to entry

T. J. R. Lambert
Coordinator Research & Teaching
Postgraduate Centre for Psychiatric Research and Education
Graylands Hospital, Western Australia

1. Introduction

The training of specialist medical practitioners combines a practical, clinically driven 'hands on' apprenticeship together with independent, non-clinical acquisition of knowledge. The clinical apprenticeship model has evolved from traditionalist guild based pedagogical models and retains the notion that clinical skills are primarily acquired through emulation of a guild master or clinical Supervisor. The supervisor is an accredited member of one of the specialist Colleges, for example, Physicians, Surgeons, Dermatologists or Psychiatrists. The model dominates in postgraduate psychiatric training as in all other areas of postgraduate medical training. This paper discusses the application of this model to psychiatric training and the desirability of, and difficulties associated with, the introduction of interactive, multimedia based computer aided learning to postgraduate psychiatric training.

Section 2 discusses the current structure and problems of postgraduate training in psychiatry. In section 3, the reasons for the incorporation of interactive multimedia courseware into the postgraduate training scheme are outlined. Section 4 explores the courseware strategies and philosophy underpinning the development of a computer aided learning in postgraduate psychiatric training. The implementation of an hierarchical three level approach to courseware design is discussed and is followed, in section 5, with a brief mention of the putative role of video. Section 6 discusses some of the problems associated with the establishment of a new technology into an existing IT framework. The paper concludes with a reflection on further directions for the medical postgraduate training process.

2. Current postgraduate training models

Training of postgraduate specialists occurs mainly in large teaching hospitals. Patients are treated by a team composed of medical personnel, allied health personnel such as occupational therapists, psychologists, social workers and pharmacists, nursing staff and a number of students. The trainee specialist, the Registrar, is employed in an apprenticeship relationship with the supervisor. As in all apprenticeship systems, the dominant medical model relies upon strict maintenance of the supervisor-pupil relationship. The supervisor provides not only clinical supervision of the trainee's daily medical functioning, but also provides a role model for the running of the multi-disciplinary team, a role which the trainee must acquire in order to herself become a functioning specialist.

In the medical system the apprenticeship aspect of the system is wholly practical. The faults of the supervisor are easily inculcated in the pupil and hence perpetuated. Therefore, serious problems associated with the development of practical skills can arise when supervisory quality is poor.

In order to overcome the potential difficulties of single supervisor-pupil relationships, rotational placements are usually transacted every six months. Notwithstanding this, there is still the possibility of isolation, poor modelling/supervision, particular medical school bias, and so on, which might limit or adversely bias the overall acquisition of clinical skills. In general, however, most accredited medical schools have a reasonable clinical reputation.

The second component of postgraduate medical training involves the acquisition of a data base, a purview of the science of the discipline. Once again, a traditionalist model is typically applied. The trainee receives a series of lectures and is expected to read the relevant literature and memorise a series of appropriate text books. The principal problems associated with this mode of knowledge acquisition are as follows:

  1. There is a major disjunction between the acquisition of clinical and academic skills. What is read is conceptual and only becomes practically enforced when experienced in a clinical setting.

  2. The steady erosion of teaching resources are an increasing problem. University personnel have in the main withdrawn from postgraduate into undergraduate teaching to accommodate larger student numbers. Therefore, members of the respective colleges are called upon to provide postgraduate lecturing as well as clinical supervision. The availability of adequate teaching resources is currently a critical limiting factor in the planning of formal lecture courses. Often teachers are drawn from private practice where their livelihoods are compromised by the time commitments involved in the preparation and delivery of lectures. Consultant psychiatrists from the public sector are also facing increasing time constrains due to restriction on manpower resources and increasingly limited opportunities for non-clinical duties.

  3. The falling number of consultant psychiatrists willing and able to teach in postgraduate courses will inevitably lead to increasing difficulties in the maintenance of standards.
The lecturer's role is to perpetuate the transmission of up to date and relevant medical knowledge and be able to adequately function in a pedagogical role. Some difficulties in this area include, In order to address these issues, the curriculum committee of the WA Branch of the Royal Australian and New Zealand College of Psychiatrists undertook to explore the integration of interactive multimedia based computer aided learning into the training program for postgraduate psychiatric trainees.

3. Why Interactive Multimedia based computer aided learning (IMMCAL)?

Computer aided learning appears to offer some distinct solutions to the above problems. In terms of knowledge base, IMMCAL was seen to be able to provide, There are also other advantages to Computer aided learning. For example, In order to estimate the demand for the new technology teachers, supervisors and trainees in Perth were questioned on their knowledge and interest in using IMMCAL resources. Although only 50 percent of trainees had some knowledge of computers, 65 percent indicated a willingness to investigate the new technology. Of consultants, approximately 5 percent indicated a willingness to utilise any new technology. This response was despite open ended offers for training and assistance using electronic presentation aids, desktop publishing resources, and IMMCAL. Whereas about 25 percent of consultants had experience with computers, their exposure had been mainly to word processing and principally in the DOS environment. They indicated the following with regard to computer aided learning: Rather than the responses reflecting indifference, ignorance or dispassionate intellectual curiosity, the main affect was of fear and distrust. There was also a distinct Luddite aspect to the respondent's attitudes. Given that teaching resources are limited, as discussed above, it seemed at first paradoxical that a potential boon to consistent teaching would be so received. However, medicine is essentially a conservative profession and its practitioners are both self selecting and conditioned towards conservative attitudes. Against this somewhat reductionist explanation is that modem biomedicine has embraced technology to the point that it has become a technocracy in itself. This, of course, is a source of constant criticism, for it is argued that patients have become reified and no longer exist as individuals. There may be an implicit resistance within the psychiatric profession to the mechanistic treatment of psychiatric patients. Ibis distrust of purely technological approaches to the care of patients may underlie the corresponding distrust of machinery at the teaching level. For the remainder of this paper, this attitude will be termed the Luddite Mentality Factor, or LMF.

In order to overcome the LMF it was decided that the incorporation of IMMCAL resources would have to proceed 'bottom up'. That is, trainee psychiatrists would be inculcated with pro-technology propaganda, be given multiple opportunities to interact with computers both in active and passive roles, be given unlimited help with computer questions and be urged to purchase home based computers. It was hoped that as the user base expanded, the demand would flow upwards to their consultant supervisors/teachers.

4. Courseware strategy and philosophy

After some experimentation with acceptable levels of complexity for trainees, a general courseware design philosophy was mooted and implemented in further courseware design. The courseware currently implemented has an hierarchical, tripartite configuration which can be best summarised as follows:

Level 1:Overview of a subject,
Level II:Hypertext based (knowledge) tutorial,
Level III:Structured self examination/assessment of subject.

Figure 1 presents a flow chart of trainee progression through the courseware. At level I, trainees enter at the level of movie overviews then progress through to the main area of knowledge dissemination, the hypertext based tutorials, (level II). At any point, multiple leaps in topic focus are available and students may wish to run overviews of related topics without proceeding through to the next level. When the student feels she has mastered the subject, the assessment level is entered, (level III). Here the student works through structured examination material, still involving full multimedia techniques, which aims to formally test the student's knowledge. If necessary, the student may return to any of the lower levels to refresh or expand knowledge and re-enter the assessment stage at the same or higher assessment levels.

Figure 1

Figure 1

4.1. Overview mode: Level I

Being wary of many student's initial hesitancy with regard to the use of computers, the first level attempts to present the main themes of a topic and requires only minimal student driven interaction. Multimedia techniques are utilised in order to interest the student and accent particular concepts. The main device employed at level I is the overview movie.

Overview movies are opened from the desktop (or from within other topics). Concepts are presented in point form and combined with full screen colour, 31) graphics and animations to support main themes. The overview movie runs at a predetermined pace, which can be hastened by the viewer or stopped at any point using a pause button. Although branch points are available in the overview mode, the flow of the overview is predominantly linear and aims mainly to whet the appetite for the subject, refresh the memory if being used for a quick review, or serve as an entry point in an integrated three level program. When students confront branch points in overviews, they are usually in the form of pictorial buttons which indicate the option of moving to either nested levels of difficulty within the topic area, subsections or related overview topics.

This level of interaction allows students to slow or speed movies, determine some degree of direction but allows for no in depth querying of the tutorial database. In order to develop the themes presented in the overview, the student must progress to the next level, the hypertext based SuperCard tutorial.

4.2 Hypertext/knowledge base mode: Level II

The hypertext based knowledge base allows for an in depth exploration of topics. All tutorials share a common interface and navigation techniques. Students navigate using direct linear paging or via hypertext leaps which may be controlled by text objects, buttons, graphics and so on. Navigation aids, information panels, directories of topics are all contained in 'menu strips', which are common resources, standardised for all tutorial types, allowing students to concentrate on lesson content rather than on learning new navigation protocols. Typically, tutorials open with a one page summary of the area. Students are then presented with a tabular list of relevant areas or concepts pertaining to the topic theme. Using clickable lists, students may select a topic by clicking on its title. The same main index may be called up as a floating palette anywhere within the tutorial and allows students to move throughout the tutorial without having to necessarily return to the main index itself.

For example, a student working in a psychopharmacology tutorial reads about the anticholinergic side effects of a neuroleptic drug thioridazine and notes that the agent is 'atypical'. The word "atypical" might either be in bold, have an asterisk after it, or be a different colour, signalling an embedded hypertext link, the model being dependent on the protocol adopted by the teacher/courseware designer. By clicking on the word, a brief explanation of the term 'atypical neuroleptic' might appear in its own mini-window overlaying the main screen. In this new information panel, the student may also be asked whether she wishes to pursue this topic in more depth. If the student elects to do so, the requisite button is pressed and the student is taken to the new tutorial area on "atypical neuroleptics". The program notes the starting location and when the student has finished with the new area, will return to the origin of the inquiry with a simple click on a dedicated menu strip button. Alternatively, the student might elect to call up the index and go to a completely new topic area, again from a dedicated menu strip button. These hypertext based leaps need not necessarily be restricted to the hypertext domain; overview movies, self assessment tests or live video may be called up and run either as an overlay to the current screen or in its own right as the principle program.

Hypertextual links serve not only to link different areas but also to embed different levels of knowledge. For example, one student might wish to know more of the advanced pharmacology of thioridazine than is presented 'on the surface'. She would either select this from the main topics menu, which can be called up as a floating mini-screen at the touch of a button, or click on a special button embedded in the text or attached to a graphic. For students not interested in this area, the above steps need not be taken and the student passes by this level. However, teachers may design the structure of the tutorial to include must view areas so that students would necessarily consider them if progressing through a topics in the main sequence.

The sophistication of the hypertext links is only limited by the teacher's own internalised associations and available resource data, graphics, sounds, and video.

Once a student has explored a tutorial in sufficient depth she may progress to the assessment level. This mode may be entered by selecting a suitable quiz from a popup menu found in the menu strip or from the menu bar. Relevant examination areas are listed whilst unrelated ones are dimmed.

4.3 Examination/assessment mode: Level III

At this level, the student is taken through a self paced examination of what she has learned from the first two levels. Determination of the student's retention of knowledge may be attempted using a wide variety of techniques. Clinical vignettes may be shown either in text or video format and suitable questions posed. Answer paradigms can be selected from multiple choice, simple text, or matching items by dragging and clicking on screen objects. Alternatively, open ended questions might be formulated and students further tested on their conditional answers. This model incorporates a high degree of program 'intelligence' - key words, phrases, or concepts may be all be pre-programmed into the session so that students are not limited to simply typing A, B, or C. Conditional logic and branching allows the assessment to flow with student and/or make corrections with pre-programmed feedback. At all times the program keeps track of responses to questions, time taken with responses and a large number of other key variables. At the end of a session, the computer can easily report overall scores, previous scores, areas of poor performance, and any other user programmed or system variable.

Assessment and feedback can be designed to incorporate a number of expected performance levels. If, for example, a student did not master a test on "The phenomenology of perception" to a target score of 70% then she would not be allowed to proceed to the next level of assessment, which might be on clinical applications. The student is presented with a summary of the assessment performance at any one level and given the option of repeating the test, viewing suitable overview movies, being returned to the SuperCard tutorial or other options such as contacting the (live) tutor.

This module, although used to assess performance by students, can also perform as fully functioning multimedia software. This means that to amplify points, give individualised feedback or to recall specific points from previous tutorials, animation, sound and live video may all be incorporated. The task of examination is itself embedded in a framework for further learning and educative experience.

At this level, the courseware is able to not only deliver progress reports to the student but additionally store all the above data in a form for later perusal by tutors. In this manner, a complete three level course is able to assess the student's capability by ultimately examining the way the student performed in the assessment module. The reports can be as detailed as the tutor requires. For example, recording individual text answers, the time taken for each first attempt, second attempt, and so on. Individualised teaching or remedial help may then be applied to students with particular areas of difficulty, either directly by tutors/teachers or by the provision of further individualised courseware.

5. Role of video

Mention has been made of the incorporation of sound, graphics, animation and video. Clearly, simple, static monochromatic figures, as used in this paper, cannot begin to express the impact and dynamism of interactive multimedia courseware. In particular, the issue of video needs some clarification.

In the early developmental phase, our projects were in black and white and had limited sound and almost no animation. Time and time again the need to incorporate more sound, colour, and most importantly, video became manifest. Ibis is more so in psychiatry when compared, for example, to traditional pharmacology. Optimal courseware would not only have recourse to embedded information concerning a topic, but could be more easily put into context by a patient describing symptoms, side effects, or other clinical pathology in their own words. The associated epiphenomena would hopefully be clear, presenting a gestalt which would complement the formally presented knowledge. Many people learn more quickly within dynamic audio visual paradigms. Only brief video segments would be required to illustrate important clinical points.

The main impact of incorporating video segments is to augment the link between the clinical apprenticeship and the formal teaching and acquisition of relevant knowledge. The computer functions as a proxy for the consultant, pointing out the important aspects of a video situation, as though it were an interview or examination just performed.

6. Developmental problems

The courseware philosophy outlined above has had to deal with a number of external difficulties. As noted, it was hoped that the introduction of IMMCAL would occur bottom up. Unfortunately, the LMF is not simply an artefact of conservative medical practitioners alone. Postgraduate education facilities often exist within the domain of state Health departments which have a centralised attitude towards the incorporation of IT resources into clinical settings. Locally, there has been a long term embargo against non-IBM microcomputers and the need to develop an alternative hardware infrastructure to subserve audio visual educational software was met with some resistance. This has required a certain degree of creative budget allocation to non-IBM hardware from within postgraduate funds. Another technique employed locally was to develop strictly for a single platform (ie. Macintosh), and encourage end users to buy home machines and thus build a hardware enclave for IMMCAL without dependence on the DOS superstructure. By arranging academic purchasing deals and encouraging IMMCAL through the use of computerised information systems in the Postgraduate Education management system itself, trainees have been exposed to the benefits of the new technology.

Further progress in establishing IMMCAL has been the recent formation of an Australasian consortium for computer aided learning, therapy and teaching, (CALpsych), developed by the author in conjunction with the Psychiatry department at the University of Tasmania. The consortium will help promote the development, distribution and research into IMMCAL resources in tertiary and post-tertiary psychiatric medical education in Australasia.

7. Conclusion

It seems likely, in reviewing the progress made in this state, that it may well be the next generation of medical consultants and educators who embrace the technology and concepts of IMMCAL and make it a fundamental component of postgraduate education. The Luddite mentality factor may well represent a passing socially conditioned response to change and the pragmatic technocracy of modem biomedicine will hopefully incorporate IMMCAL in its basic infrastructure.

It is clear that for the current satisfactory standards of postgraduate medical education to be maintained, the reliance on traditional models of medical pedagogy will have to be supplemented by effective and efficient computer aided learning resources.

Author: T. J. R. Lambert, Coordinator Research & Teaching
Postgraduate Centre for Psychiatric Research and Education
Gascoyne House, Graylands Hospital
John XXIII Ave
Mount Claremont WA 6010

Please cite as: Lambert, T. J. R. (1992). Multimedia based computer aided learning in postgraduate medical education: The LMF (Luddite Mentality Factor) as a barrier to entry. In Promaco Conventions (Ed.), Proceedings of the International Interactive Multimedia Symposium, 451-461. Perth, Western Australia, 27-31 January. Promaco Conventions. http://www.aset.org.au/confs/iims/1992/lambert-t.html

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