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

1. Introduction

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

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 University personnel have in the main withdrawn from postgraduate into undergraduate teaching to accommodate larger student numbers.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.

• practitioners who might be excellent clinicians and clinical supervisors may be poor lecturers/tutors;

• the possibly of marked differences in standards between different courses and within the same courses when it is taught by differing personnel;

• a dearth of adequately experienced/qualified educators for particular subjects;

• complaints from trainees of the inadequacy of overly simplistic lectures, given in a style more suitable for undergraduates;

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

• delivery of known and College accredited standards of education;

• a means of overcoming the tyranny of distance for trainees based in outlying clinics;

• a means of surmounting the difficulties of scheduling attendances at lecture sessions and training meetings;

• up to date knowledge with the additional ability to assess the retention of both new and previously understood principles;

• the drive to acquire new knowledge by virtue of the exciting medium by which it is delivered.

• It caters for individualised instruction.
• It allows for interaction with the courseware material.
• It requires fewer tutor/educator resources.
• The content is easily adaptable, for example, to locality and experience.
• The material may be easily updated and expanded.
• It is reliable.
• It may have long term cost advantages.

• I can't possibly see how you can get a computer to do a persons work

• I don't believe computers can use sound, video, animation and hypertext (whatever that is)

• It's a gimmick, a technological toy

• There is no possibility of it being useful in teaching postgraduate clinical students even in an adjunctive role 'The only good computer is a dead computer

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

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

4.1. Overview mode: Level I

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

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

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

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

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 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