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The many faces of technology in medical education

Parvati Dev
Stanford University School of Medicine, California

The teacher-student interaction in education has developed through the centuries. We now have many rich methods through which information is transmitted from one to the other. However, more than fifty years ago (Rapplye, 1932), educators began to feel that the glut of information to be transferred was overloading the available channels and that new methods had to be developed to increase the efficiency of the process (Figure 1). Since that time, the problem has not diminished, even though new teaching methods, such as student initiated learning and problem based learning, have been introduced and have provided a context within which learning occurs.

Figure 1

Figure 1: Consider the situation When all these channels are
replaced by a single channel, the computer screen.

Computer technology has been proposed as a means of making available a vast body of information, both text and other media, to the student at the time and place of need. It could present a professor's lectures, but with all necessary background material available on demand. It could be the intelligent tutor, observing the student's effort and providing feedback or correction as necessary, at any hour of the day. As with the well known flight simulators, the computer could provide a virtual environment in which the student physician could practice safely the many new and routine procedures they must learn.

What is the actual situation today? Which of these possibilities have been achieved? What did it take to achieve them?

The computer as lecturer

Figure 2 presents a screen from a program that is a lecture on Arterial Blood Gas Analysis in a course on respiratory physiology. A lecture is a sequential event moving forward through time, and occasionally interrupted by questions.

Figure 2

Figure 2: A screen from Arterial Blood Gas Analysis, a computerised lecture.

On the screen, in figure 2, the central block of text is the lecture, and consists of a few bulleted points or a short description. The italicised text has a hyperlink to expanded information, such as a definition or a glossary. The diagram below may be animated, or it may be replaced by an equation that is explained in the text above. The equation itself may be accompanied by a quiz that sets mathematical problems using the equation. Navigation arrows at the base of the screen allow the user to move forward at their own pace, and also backward when desired.

In an evaluation experiment, learning was measured in two groups of students, one that attended the live lecture and another that used the computer program (Clark and Raffin, 1992). Both groups enjoyed the material. Both groups learnt equally well. The computer group spent longer on the program than the other group did in lecture. The computer group felt that it was valuable that they could link to background information that they might be unable to reach during a lecture.

However, there are some other benefits when listening to a live lecture. A good lecturer will adjust his style and content to the audience. No two lectures on the subject are the same. Conceivably, the computer program could be given the intelligence to know multiple ways of presenting the material and to be able to query its user to determine the best method of presentation. No medical education programs currently in use have this level of sophistication.

Both the lecturer and the computer program have their unique advantages.

The computer as experience simulator

This is an exciting area indeed, one that raises the possibility of technologies such as virtual reality. A few years ago, computer video disc programs, such as DeXTER, presented challenging clinical situations. After each video sequence, interaction options were presented that allowed the user to manage the situation. Each choice elicited a different clip of follow on video. The use of real actors and rapid action allowed the creation of a sense of urgency and, emotional involvement. Users could explore management options without endangering a real patient, though danger to even the simulated patient seemed to elicit considerable emotional response. However, the ability to interact only at fixed times and with few options reduced the sense of an immersive reality.

Recent three dimensional representations of anatomy viewed in endoscopic surgery permit a much greater range and variability of interaction. Besides viewing the anatomy through the simulated endoscope, the user can access miniature endoscopic tools for biopsy, excision and other operations. Any of these actions are available at all times, adding to the sense of immersion. Tactile feedback from the instruments adds to the realism and to the usefulness of the simulation. Systems such as these are either in the research stage or are beginning to be fielded commercially.

The considerable expense of a virtual reality simulation has lead many to create less realistic, less immersive, but still quite useful, simulations of clinical encounters. Figure 3 shows a history taking screen from a program, Real Problems, developed at Stanford University. Questions are displayed on the screen. The user chooses one and the simulated patient answers. The user progresses through the physical examination, the tests, the diagnosis and management.

Figure 3

Figure 3: A history taking screen from Real Problems,
a program that simulates a clinical encounter.

The user cannot ask questions that are not available in the list. To make available all possible questions, the list would be very long or hierarchical, both of which present user interface difficulties. On the other hand, a short list of questions reveals the clinical problem before all the questions are asked. A voice based query system may allow flexibility without displaying an unwieldy list of questions.

The computer as an information resource

Pedagogically, this is the method that provides most freedom to the student. Technically, we find a vast array of methods by which computers make information resources available. We will look at some examples and at the technology underlying them.

Internet sites: The single biggest information resource today is the web of sites linked by the Internet. Prior to the era of the World Wide Web, some sites provided resources of files that could be downloaded using ftp or gopher protocols. Now files at remote sites can be viewed directly using the http protocol. The embedded links in these files provide an enormous number of predetermined navigation paths between files. The richness of these navigation paths hides the fact that we may travel only where the author allows. Text search tools, on the other hand, create virtual links customised for the searcher.

The sheer volume of information makes it necessary to develop methods of prioritising or rating the information in terms of its value relative to the question asked. Many well known sites began by providing a catalogue of other sites where high quality information was available. A combination of content developed with local expertise together with a good catalogue of other sites characterises the best medical Web sites today, for example, University of Iowa's Virtual Hospital (http://indy.radiology.uiowa.edu/).

The next step for the Internet as an educational information resource will be the availability of predefined, well designed searches. Construction of a search expression that has both good precision and good recall (that is, both relevant and comprehensive.) requires the experience of a trained reference librarian. A well designed search, executed when needed, will provide relevant and up to date information. The SHINE project and other information retrieval projects at Stanford are investigating different aspects of the information structuring and retrieval process.

Another method of improving the results of the search process is to improve the quality of the stored information. Many sites that are building local content are investigating methods of structuring and standardising information such that retrieved information is in an expected format and contains information at the granularity and depth expected. At the clinical trials structured paper project at Stanford, papers on clinical trials are scanned and structured after they are published. A text search on this database will retrieve a desired section of a paper instead of retrieving the whole paper or only the sentences in which the word occurs.

A third improvement in Internet based information access is to make the query process far more intuitive and simple than it is today. Keyword based search requires some understanding of how content has been keyed. Text based search requires understanding of the domain and it retrieves every occurrence of the word, in some priority order. It would be desirable if the query system had some understanding of the user and the problem under study. The query is then constrained by the machine's understanding of the context and may result in a more precise search.

Information sites on local or networked machines: Numerous information resources have been developed that operate only on local networks. Much of this development predates the explosive development of the Web. The Slice of Life video disc (University of Utah) is an excellent example of an image resource. Figure 4 is a screen from BrainStorm, a neuroanatorny program developed jointly by researchers at Stanford University and the University of New South Wales.

Figure 4

Figure 4: A screen from BrainStorm, a neuroanatomy resource

The computer as teacher/tutor

The computer can be more than a deliverer of content or a resource for information. It may actually be an intelligent tutor, analysing the student's strengths and weaknesses, and suggesting learning paths. Figure 5 suggests a feedback model of the computer as teacher.

Figure 5

Figure 5: A model of the computer as teacher

The computer possesses domain knowledge that it will impart to the student. The domain knowledge may be a collection of facts, some procedural knowledge or a simulation. Components of the knowledge may even be characterised as definitions, explanations, examples, etc. The computer also has a repertoire of teaching methods. These may be simple drill and practice or some more complex method. The computer uses a teaching method to present knowledge to the student.

The student has his or her learning methods. Some are visual and prefer diagrams. Others need lists of facts. When the teaching method matches the learning method, learning is expected to be optimal. As the student learns, he builds a framework of facts, concepts and, alas, misconceptions.

It is possible for the teacher, though a process of evaluation, to build some model of the student's state of knowledge. This model can then inform the teacher's teaching methods so as to improve the match with the learning methods and to correct or build on the student's domain knowledge.


The computer can indeed present many faces in medical education. We expect to see it have an impact on all aspects of medical teaching, from lecturing to evaluation and accreditation. Beyond teaching, the computer will provide an environment within which the teacher and student will exchange administrative information, conduct office hours and discussion sessions, view bulletin boards and lists of frequently asked questions, and perhaps even exchange social banter. Today the computer is used in some isolated classes, and its use is still the exception, Tomorrow, routine teaching will be through the computer and live interaction will be used either for facilitation of routine learning or encounters with exceptional teachers not yet represented by the computer.


Rapplye, W. C. (1932). Medical Education: Final Report of the Commission on Medical Education. New York: Association of American Medical Colleges.

Clark, R. A. and Raffin, T. A. (1992). Efficacy of computers in teaching arterial blood gas analysis. Academic Medicine, 67(6), 365-6.

Author: Dr Parvati Dev
Stanford University School of Medicine
Stanford, California USA

Please cite as: Dev, P. (1996). The many faces of technology in medical education. In C. McBeath and R. Atkinson (Eds), Proceedings of the Third International Interactive Multimedia Symposium, 10-14. Perth, Western Australia, 21-25 January. Promaco Conventions. http://www.aset.org.au/confs/iims/1996/ad/dev.html

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