Postgraduate medical education by distance learning

Journal of Audiovisual Media in Medicine 1986, 9, 69-73 Printed in Great Britain

Postgraduate medical education by distance learning B. M. HIBBARD, R. J. MARSHALL and T. M. HAYES

In an attempt to solve some of the problems of providing continuing medical education for candidates preparing for postgraduate examinations in a geographically scattered region, a pilot study in distance learning was undertaken. The design of the postgraduate work was based on experience gained from a well established undergraduate distance learning programme using loudspeaking telephones over the public telephone exchange and lines. Six postgraduate centres participated in the program me.

Emphasis was placed on tutorial teaching. Student reaction was evaluated from questionnaires and the interaction between the participants was measured. The teaching method proved to be popular with the teachers and students and a generally high level of interaction was achieved.

This system is relatively inexpensive and considerable finan- cial savings to the Health Service could be achieved, whilst at the same time it provides opportunities for instruction by specialists whose teaching can be made widely available to num- bers of postgraduate students that would otherwise find difficulty in attending, say, day release courses at the teaching centre.

Most medical teaching centres arrange short courses or day release program- mes extending over several weeks or months for doctors preparing for higher or postgraduate examinations. In the case of day release, course participants often find i t difficult to be free for all the sessions and in-service candidates work- ing at small isolated hospitals are particularly disadvantaged by the need to travel long distances at times when they cannot be spared from professional commitments. We found a particular teaching problem in Wales, where there are nine Health Districts and seventeen Postgraduate centres.. Only three of these centres are within 20 miles of the University Hospital at Cardiff, whilst six are over 50 miles away, one being 173 miles distant. This hospital is also 72 miles from its nearest teaching centre, which is in an adjoining English region.

B. M. Hibbard, MD. PhD. FRCOG, is Professor of Obstetrics and Gynt~ecology, R . J . Mur- Shall, PhD. FBIPP. FRPS. AIMBI, is Director Of Medical Illusrrution & Audiovisual Services, and T. M . Hayes, M B . BCh. FRCP, is Director and Dean of Postgraduate Studies, University of Wales College of Medicine, Cardiff, U K .

Mid and North Wales are mountainous and whilst there is a fast south-west motorway link travel by the north- south road and rail links is slow.

Distance teaching

Schemes for teaching and learning at a distance have been used for many years in various parts of the world (Common- wealth Secretariat, 1985), for secondary and tertiary education as well as job or vocational training, professional in- service training and community education (Open University, 1982; Parker and Olgren, 1985).

Learning at a distance with modern technological methods can be done in several ways and may involve complex two-way video systems or simple telephone or radio links for sound only transmissions to distant groups of students. Visual aids are essential for most medical teaching and these can be made available to distant groups by real time television using landline, fibre optic cable or microwave transmission (Wil- liams, 1985), or by advance distribution of video cassettes, slide sets and/or printed material.

The 'linked tutorial'

The educational techniques used i n distance learning range from lecture-type sessions to unstructured discussions. usually based on recently undertaken homework. Small group tutorials are the most popular and possibly the most effective on-the-spot conventional

I

Figure 1. Sketch map of Wales showing the location of Postgraduate Centres linked by telephone for the distance learning project.

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teaching method and we sought to provide this type of teaching to iis many postgraduate students as possible in ii

number of centres by the 'linked tutorial'. An essential component in the concept o f linked tutorial teaching is free interaction and 'live' discussion between groups o f student.. ;? vveral centres and their tutor, alid this feature gives i t ; i n advantage over other methods such ;is self-teaching packages with video cassettes and tape-slide pro- grammes. distributed by mail and dis- cussed by correspondence.

Following the successful introduction o f the linked tutorial. now in its fifth year. t o the undergraduate Obstetric and Gynaecology course (Hibbard et a l . , 1985a.b; Marshall e t a l . , 1985). pilot courses for MRCOG and MRCP postgraduate candidates were given by telephone i n January-February 1985 with participating centres a t Cardiff, Swan- sea, Carmarthen. Haverfordwest, Ban- gor and Wrexham (Figure 1 ) . No attempt was made to evalute the effectiveness of the teaching itself, which was based o n the traditional syllabus for the MRCOG and MRCP courses that have been conducted at the medical teaching centre in Cardiff for several years. The efficacy of the technology and the use made of the facility for two-way communication were. however, evaluated by questionnaire and from tape recordings made of the teaching sessions. This paper describes our experience and ti ndi ngs.

The organization of linked tutorials

Format of sessions

Tutors were drawn from Medical College and National Health Service (NHS) staff and they were given a brief explanatory talk on methods and a demonstration of the equipment before preparing their teaching material. They were generally allowed to develop their own form of presentation and coni- munication. For the majority of sessions copies of slide sets were prepared and sent out in advance to the peripheral centres but for three of the sessions specially prepared video recorded material was used and this was also copied and circulated in advance. The duration of sessions ranged from 22 minutes to more than 1 hour, the number of slides used in each session ranged from 10 to 36 (mean 28) and in the sessions where videotape was used the duration of the taped material was approximately 30

minutes. Overall, 29 tutorials were conducted by 23 teachers over a period of H weeks. The number of postgraduates attending varied between three and eight per centre.

E quipmeni

Audio communication between teacher and student groups, as well as communication between the groups them- selves, was made over the existing public telephone network through the ordinary telephone exchanges. The equipment used for linked tutorials by telephone is relatively simple. The teacher is provided with a 'Kirk' loudspeaking telephone whilst student groups have a special teleconferencing unit-the 'Conference 2000'. Groups of students are connected with the teacher through the public telephone lines by means of a switching control and bridging device, the 'Telspec Bridge' (Figure 2). The Kirk loudspeaking telephone enables the teacher to speak to students and listen to their replies without having to hold the instrument. The 'Telspec Bridge' and its associated small switch panel allows the teacher, or better an operator assisting him, to call the student groups and connect them all to the teacher's telephone and hence to each other's instruments. Alternatively and better, at the time arranged for the teaching, the students can call a number allocated to a switch point on the bridge and be connected to the teacher in that way.

The 'Conference 2000' units provide the students with a telephone handset and push button 'dialling' facility together with ii simple switching control that transfers the call to a combined microphone and loudspeaker. Once contact has been made the group speaks to the teacher and to other groups and listens to teaching or discussion by means of this composite unit (Figure 3 ) . An extension microphone can be connected to the 'Conference 2000' for use if the group is larger than can comfort- ably be accommodated iis a cluster around the unit. but this facility was not available at the time of the study.

The teacher's telephone, together with the bridging unit and its switch panel was arranged on a desk in a small, quiet room from which a teacher could run the tutorial.

Audiovisual aids

So that a teacher could use slides or videotapes to illustrate his presentation and follow these as his talk progressed. the room was also equipped with an automatic slide projector, ii videotape replay machine and a video monitor. At the District Postgraduate Centres the student groups were similarly equipped with audiovisual apparatus. and the appropriate copy of a set of slides or videotape was sent in advance of a teaching session.

The videotapes were designed espe- cially for use in distance learning. and included a break or breaks a t which

Figure 2. Distance teaching with the 'Kirk' loudspeaking telephone. The 'Telspec' bridge is operated here by an assistant leaving the teacher free to concentrate on his presentation.

70 Hihhard et al.

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Figure 3. Students at the postgraduate centres listen to the teacher and speak to him over the 'Conference 2000'. Nore the provision of apparatus for slide projection and tape replay.

they were stopped for discussion during their presentation. Sets of slides used for linked tutorials also need some special preparation. I t is helpful for the set to start with a photograph of the teacher who is presenting the talk, so as to personalize the presentation. As well as using slides of photographs of patients. of X-rays. ECGs and other data. illustrative material with simple headings can also be used to assist students in keeping up with the stages of a talk. and to reinforce or clarify important teaching points. There needs to be steady, but not overwhelming presentation of illustrative material, used rather after the manner of a good tapelslide presentation. I t is important that no illustration is left on the screen after the topic i t illustrates has been dealt with and the speaker is on another tack but not ready for his next slide. Blank slides are a help here and should be used if there is no appropriate illustration available. One possible hazard is that a group of students may get a series of slides 'out of step' and thus find the talk almost incomprehensible. To avoid this, each slide in a set must be numbered in such a way that the number appears projected onto the screen, and the teacher must be careful to signal the slide changes verbally and announce the number of the slide to which he is speaking.

Evaluation Interaction The telephone allows immediate in-

teraction between student and teacher in distance learning. 'Interaction' in this sense describes the verbal exchanges that take place during teaching. Inter- action is. therefore, an important factor in 'live' distance learning, and one which distinguishes it from other methods such as correspondence courses, undiscussed tapelslide or video packages, or broadcast talks designed to aid private study. We felt it was important that some measure be made of the interaction that took place during the pilot project for MRCP and MRCOG postgraduate students, as this would provide an indication of the manner in which the two-way sound links were being used, if they were being used effectively, and if each of the centres was taking an active part in the possibi- lities for discussion.

Complex methods have been devised for the detailed analysis of interaction between teachers and groups of students (Brown, 1975). These methods provide patterns or diagrams tha t can be used to classify a teaching style. A 'contracted' method for scoring interaction has also been described (Brown, 1982). In a relatively simple analysis of the interaction that took place during our postgraduate teaching by telephone, it was decided to score only those verbal exchanges that were over and above the delivery of the planned or prepared teaching. Thus analysis was restricted to counting questions asked by a student and questions asked by a teacher that received an answer or in either case allowed the teacher to ex-

tend the discussion or correct a student response.

Each teaching session was recorded on audiotape at the teacher's telephone. The tapes provided objective records of the sessions that could be examined in detail and at leisure, and they obviated the need for siting an observer or scorer in the sound studio with the teacher and operator. By replaying the recordings i t was possible to time accurately each teaching session. to classify the 'style' of the teaching. to count the frequency and type of interactions made between the participants and note the way in which interaction was distributed amongst postgraduate groups.

Student reaction

The attitudes of the postgraduate students were assessed from the replies to questionnaires issued at each session. The questionnaires asked a number of technical and educational questions concerning the audibility of the tutor and of the other centres, the ease of use of the equipment and the perceived value of the session compared with more traditional forms of learning. All the questions were of the multiple choice type except for a linear analogue scale asking for an overall assessment of the session ranging from 'extremely un- favourable' to 'extremely favourable'. All replies were anonymoug.

Five centres participated in the MRCP course and six centres in the MRCOG course (Cardiff did not have a group of students for the MRCP course since a separate traditional course was already in progress). Seventy-seven questionnaires were returned for the MRCP course and fifty-one for the MRCOG course.

Interaction

There was a considerable spread of the scores of interaction for individual teaching sessions, but no significant differences overall between the MRCP course and the MRCOG course or, more interestingly, between the MRCOG sessions using videotape and those using only slides.

The number of interactions ranged from 129 in a 52-minute session to 2 in a 33 minute session, with a mean of 58 interactions per session. A standardized interaction rate for each session was obtained by expressing the number of

The Journal of Audiovisual Media in Medicine (1986) Vol.9/No.2 71

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Table 1. Interactions between teachers and students

Mean Interactions per hour (SD) Teacher-student Student-teacher Total

Slide sessions 89.7 (58.2) 5.7 (10.2) 95.4 (54.6)

MRCOG 57.6 (22.8) '1'0.4 (9.8) 67.8 (24.6)

Both courses 86.4 (57.6) 6.0 ( 9.6) 92.6 (52.8)

Videotape sessions 45.3 8.1 53.4

MRCP 97.8 (63.0) 4.2 (10.2) 101.4 (59.4)

There are n o statistically significant differences

interactions/hour of teaching time (Table 1) . Standardized interaction rates ranged from 186 to 3.6 interactionslhour for teacher to student interaction, and from 45.6 to 0 interactions/hour for student to teacher interaction.

Overall the teachers were well prepared and effective in raising discussion and asking questions of the students. Analysis of the distribution of discussion between groups at the various centres showed that most teachers managed to spread the discussion relatively evenly amongst the postgraduate groups, although there is some sug- gestion that a check list of centres, against which the teacher could keep a score of questions asked, might assist some teachers to avoid over- questioning one centre whilst neglecting another altogether.

The figures show that discussion tended to be one-way-from teacher to student-students raised very few questions or points of discussion (see Table 1). This is because most teachers used the time allocated for their presentation in delivering their talk and asking questions, leaving little opportunity for the student groups to question the teachers or start discussion. One teacher proved to be the exception to this general finding. He received 33 questions from postgraduates (at a rate of 45,6/hour), but he deliberately set out to elicit discussion and used a 'stooge' student with him in the sound studio to stimulate this kind of exchange. The value of co- moderators in maintaining participant interest and reducing the tutor's burden has been stressed elsewhere (Pereyra, 1985).

Analysis of questionnaires

Almost all of the participants found the equipment easy to use; only four re- ported any difficulty. The clarity of reception (Table 2a) of the tutors at the postgraduate centres was graded as

'acceptable' (very clear or quite clear) by 83.6 per cent of the respondents. The audibility between peripheral centres was not so satisfactory (Table 2b), being graded as acceptable in only 17.2 per cent of reports.

When asked to compare the sessions with similar seminars given in their own hospitals (Table 3a) 37.1 per cent believed that they were more valuable, 38.7 per cent felt that they would be of equal value and 24.2 per cent felt the audioconferencing seminars were of less value. When asked to compare the audioconferencing course with the same course held in their nearest teaching centre (Table 3b) 81.5 per cent felt that

Table 2. Audibility

the new course was of more value and only 6.5 per cent would have preferred it to have been held at the teaching centre. Of the students 87.5 per cent thought this form of learning was an acceptable alternative to having to travel to their nearest teaching centre. The overall assessment of the course by the postgraduates, rating it on a linear analogue scale between 'extremely un- favourable' and 'extremely favourable', produced a mean score of 68.6 per cent.

Cost effectiveness

I n assessing the expenses of the courses we compared the cost of the telephone charges with the notional mileage and subsistence costs of the postgraduates travelling to their nearest teaching centre. We have assumed that the course fees remain the same and that these will cover the costs of running the course. We have not included the cost of repro- ducing the slide sets. Some SO00 copies of 2 x 2 inch slides were made. These will be used. with a few revisions and additions, for future courses, and their costs spread over several years. The potential for savings depends upon how many students there are i n each centre

MRCP MRCOG Both (%)

a. Audibility of the tutor

44 } (83.6) 31 13 39 24 63

'Iear }'acceptable' Quite clear Jus t about Not at all

7 13 20 0 1 1

b. Audibility between peripheral centres . . 2

11 Very Quite 'Iear clear )'acceptable' } (17.2) 1 8 19

Just about Not at all No record

54 36 90 10 3 13

3 3

Table 3. Comparison with having the s a m e seminar held locally or in t he nearest teaching centre

MRCP MRCOG Both (%)

a. Compared with focal seminar More valuable 33 13 46 (37.1) Equal value 31 17 48 (38.7) Less valuable 12 18 30 (24.2)

b. Compared with nearest teaching centre More valuable 64 37 101 (81.5) Equal value 10 5 15 (12.1) Less valuable 2 6 8 ( 6.5)

72 Hibbard et at.

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but with one exception in Wales, for the centres used in this pilot project there is a saving even when only one student is present in a centre and if six students are present for a course of eight 3-hour sessions, the potential saving to the NHS for the group could be in excess of f3000.

Discussion

This form of distance teaching and learning appears to be very acceptable to postgraduate medical students in Dis- trict General Hospitals. It is obviously a major advantage that they d o not have to leave their own hospital and therefore are able to attend the course even though engaged in clinical work until shortly before the starting time, or if they are standing by on emergency call. I f necessary, all the junior staff in the specialty can attend the course without someone having t o stay i n the hospital on call whilst the others travel to a teaching centre. The saving in travelling time can also be considerable. The same medical teachers and

teaching content of sessions were used as for the traditional course but the teachers had to give more time to the preparation of their material because of t h e discipline imposed by the new medium. However. even those who had been wary of taking part said that they found the experience rewarding and a change from the usual teaching methods.

We d o not believe that the telephone should be used for delivering lectures from a distance without the possibility of interaction, that is more easily done by a recorded lecture, but it is appropriate for seminar or tutorial type teaching where interaction between students and teacher is important. Indeed the rela- tive anonymity of the audioconferencing system may encourage those who would otherwise be silent at a conventional seminar to join in. This may be the explanation for the unexpected result that the audioconferencing seminar was preferable to holding the same seminar in the students’ own hospitals.

I n this pilot study we found that the participants in the separate centres had difficulty in hearing and understanding each other, even though they could hear and be heard by the tutor quite satisfac- torily. This was a particular problem when trying to generate discussion between the groups when the tutor needed to repeat much that the students had said for the benefit of the other centres. One contributory factor was that En- glish was not the first language of many of the participants and accents can be distorted during transmission, but there were other technical problems amen- able to correction which we have now overcome (i) by insisting that the centres joining in these courses provide a room with satisfactory acoustics, (ii) by providing a direct telephone line which does not go through the hospital switchboard, and (iii) by providing each centre with a hand microphone with a ‘press to speak’ button.

All 17 postgraduate centres in Wales are now equipped with ‘Conference 2000’ units, and the bridge is wired up for 10 conference participants. Because it uses the established public telephone network and exchanges, the system is capable of accepting a participant from any part of the world provided he has a telephone. We recently took part in a telephone conference with five participants that included one from Alaska and another from Wisconsin, USA.

The equipment used for these.courses has other uses. It may be used by other professions within the NHS and possibly by groups outside the NHS such as the Open University. Administrative meetings, case conferences and similar discussions between professional groups are all feasible. A private network could also be used for data transmission between libraries, laboratories and com- puter users.

Acknowledgements

We are particularly indebted to Mrs Maureen Thomson and Mrs Pauline Trigg, Postgraduate Secretaries, and to the staff of Medical Illustration and Au- diovisual Services for the many and

varied enthusiastic contributions to this project. We are also grateful to the Postgraduate Organizers and Adminis- trators in the co-operating centres for their help in setting up the sessions. Our special thanks are due to Professor H . L. Duthie, Provost. University of Wales College of Medicine for his sup- port and encouragement.

References

Brown G. (1975) Microteaching: A Prog- ramme of Teaching Skills. London, Meth ue n.

Brown G. (1982) Analysing Small Group Teaching. The Medical Teacher, Eds. Cox K. R. and Ewan C. E. Edinburgh, Churchill Livingstone.

Commonwealth Secretariat (1985) Dis- tance Teaching in Higher Education. Final Report of Commonwealth Meeting of Specialists, Cambridge, England, 6-1 1 January 1985. London, Commonwealth Secretariat.

Hibbard B. M., Marshall R. J., Evans R. W. and Duthie H. L. (1985a) Medical teaching at a distance: Audiovisual materials and the linked tutorial. In: Parker L. A. and Olgren C. H. comps. Teleconferencing and Electronic Communications IV. Madi- son, CIP, pp. 15-23.

Hibbard B. M., Marshall R. J., Evans R. W. and Duthie H. L. (1985b) Linked tutorial teaching by teleconference and video cassette. Medical Education 19, 396-402.

Marshall R. J., Hibbard 6. M., Evans R. W. and Duthie H. L. (1985) Audiovisual materials and the telephone: Medical Teaching at a distance. Journai of Au- diovisual Media in Medicine 8, 66-71.

Open University (1985) Tutoring by Tele- phone: A handbook. Milton Keynes, Open University Press.

Parker L. A. and Olgren C. H. comps. (1 985) Teleconferencing and Electronic Communications IV. Madison, CIP.

Pereyra S. G. (1985) Highlights: Connex user Roundtable ‘84. In: Parker L. A. and Olgren C. H. comps. Teleconferencing and Electronic Communications IV. Madi- son, CIP, pp. 82-88.

Williams A. R. (1985) Interactive television for distance learning. Journal of Audiovisual Media in Medicine 8. 57-64.

The Journal of Audiovisual Media in Medicine (1986) Vol.9INo.2 73

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Documents

Postgraduate medical education by distance learning