Medical Education 1989, 23, 522-525

Computer education of undergraduate medical students: a 2-year experience

A. GOUVEIA OLIVEIRA & F. GALVAO MELO

Institute .f Biomathematics, Faculty of Medicine ofthe University of Lisbon

Summary. Computer literacy will become a necessity for doctors in the near future, as computer applications for clinical medicine are gradually developed and successfully imple- mented in the medical environment. Two years ago we began an optional course on computer systems for first-year medical students, as part of the biostatistics course at the University of Lisbon. The results of this experience show that computer education should be well adapted to the needs of students, and educators must con- tinuously evaluate the students’ reaction and anticipate the need for sudden changes in the course structure, which are often necessary to capture students’ attention.

Key words: *education, medical, undergraduate; medical informatics/*educ; mathematical computing; Portugal

Introduction

Although computers have been very successful in some areas of medical care, especially image analysis and signal processing, and very promising in others, like expert systems for clinical diagnosis and decision-making, applica- tions directed to the support of everyday medical activities are still all but non-existent. Most doctors would agree that what they need is a friendly and interactive computer system, which, among other things, would help them to collect and organize patient data, display the relevant information they need in an appropriate way, compute diagnostic probabilities and pro- duce acceptable clinical reports. In addition, data

Correspondence: Dr A. Gouveia Oliveira. Instituto de Biomatematica, Faculdade de Medicina, 1699 Lis- boa CODEX, Portugal.

should be entered easily and quickly, in a way perfectly integrated with doctors’ normal medical activities, and be available for future research work.

The development of such a system raises a great many problems. However, a large amount of research work has already been done and the specifications for these systems are now more clearly defined. It seems reasonable to expect that soon some applications will match doctors’ demands and computers will gradually find their place in routine work in wards, out-patient clinics, laboratories and operation rooms. By then, doctors should be familiar with computers, meaning that they should not only be able to work with them but also willing to accept the change in routine that a computer system often imposes.

We share with other authors the opinion that computer education should be seriously con- sidered as an important area in medical education (Knapp & Miller 1987). Although many medical students have had some experience with personal computers, this is often restricted to computer- games and the writing of small programs. Students usually lack the motivation for using a software package to accomplish some necessary work because they seldom have a strong need for database management or word-processing, for example. Computer-assisted instruction (CAI) has been used for some time as a teaching tool, but again these are highly specific applications, much different from the normal operation of multipurpose application packages, because they do not require the least computer literacy.

Because students usually have this kind of superficial attitude towards computers, structur- ing and running a course on computer systems is not straightforward. This paper reports a 2-year

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experience on computer education for first-year medical students at the University of Lisbon, summarizing the problems, the various solutions tried, and the benefits that can be expected form the inclusion of this course in medical school curricula.

The first year

In 1987 we decided to introduce an optional course on computer systems as a complement to the biomathematics and biostatistics course for three reasons. First, students could immediately perceive in a statistical package an application for their new computing skills and an opportunity to exercise them in a useful way. Second, this would probably give them some awareness of the increasing impdrtance of the quantitative sciences in medicine and, hopefully, help them make the link between statistics and clinical practice that could increase their interest in this course. Third, the availability of statistical pack- ages opened the way to widespread utilization of multivariate analysis by investigators unfamiliar with the underlying concepts and applicability of these models: the instant retrieval of ‘significant’ results often diverts people from the need for careful analysis of the study conditions and the discussion of intermediate results (Feinstein 1972). Teaching computer systems and the use of a statistical package within the biostatistics course may be the only way to control this practice.

The course programme consisted of 13 one- hour weekly lessons, and included a very short introduction to computer science theory,

elements of operating system commands (mostly house-keeping commands), and finally the basic notions on how to use a typical statistical pack- age. Each class was attended by 10 students, with one IBM-compatible computer per person. We selected Microstat (Ecosoft Inc., USA) as a suitable example statistical package mainly because ofits ease of use and menu-led operation. The main topics of this course are summarized in Table 1.

We soon realized that computer systems theory did not seem to be very appealing to medical students, and had to terminate this part after only two lessons. After some courses on operating system commands we also found out that, after an initial enthusiasm, students were beginning to grow bored, possibly because they could see nothing happening on the screen. However, they learned enough to carry out difficult exercises on file management com- mands. The application program was very well received and, indeed, students appreciated the opportunity to exercise their statistical know- ledge on real patient data. We were hoping that this would increase their interest in biostatistics, but in the end grades were not different from previous years.

The second year

In the second year we designed a completely different course, favouring a more practical approach to computers. We still had a 16-hour complete course on computer theory, but sepa- rated from the practical course. The topics (Table

Table 1. 1987 course programme

(1) (2) (3) Input/output devices (4) (5) Operating system commands (6) (7) MD-DOS commands (I) (8) MS-DOS commands (11) (9)

(10) (1 1) (12) (13)

Computer concepts and general function General architecture and components of modern computers

System software: concept, purpose and types

General operation of a computer

Applications software: concept. Software packages Statistical packages: data entry and editing Statistical package: descriptive statistics Statistical package: data reduction (graphics, tables) Statistical package: data analysis with examples

524 A . Gouveia Oliveira G. F. Galvao Melo

Table 2. 1988 course programme (theoretical)

(1) Computer concepts, function and components (2) Primary and secondary storage (3) Inputloutput devices and other peripherals (4) System software and commonly used MS-DOS commands (5) Applications software: concept. Software packages (6) Computer communications. Communications networks (7) Files and databases. Concepts, analysis and design (8) Choice of a computer system

2) included the operation system commands, and the course was profusely illustrated with over 500 colour slides. Simultaneously, students were given a practical course, introducing them from the very start to the operation of a statistical package. This time we had selected STATA (Computing Resource Center, USA), mainly because of its superior graphcs capabilities, but also because of its ease of use and possibility of choice between command mode or menu mode. In fact, the menu system is somewhat poor but students readily adapted to the command mode, which they seemed to prefer. The course covered data input and editing, variable transformation, data labelling, graphics, descriptive statistics, x2 tests, Student’s t-tests, one-way analysis of variance, correlation and regression, multiple linear regression, logistic regression, and survi- val analysis and Cox models (Table 3). Again, real patient data sets were used t o illustrate the exercises to emphasize the close relation between biostatistics and clinical medicine. This course was given in 1%-hour weekly lessons for 12 weeks.

We found this course more suited to the needs

of the students, who seemed to be more inter- ested than in the previous year. Students were also able to go much further in the utilization of this package than previously, and become acquainted with a number of methods that are frequently encountered in clinical publications but cannot be discussed in detail o r included in the biostatistics course. Attendance at the theo- retical course, however, remained disappoint- ing, but students’ lack of computer literacy did not seem to affect their practical learning. As a general opinion, the students found the course interesting but more hours were needed and at least on a twice-weekly basis. As first-year students, they still did not believe that statistics and computers had much to do with clinical medicine. This is a well-known and much- discussed problem for teachers of medical statis- tics (Feinstein 1977).

The next year

Based on this experience, we plan to modify again the structure of next year’s course. It will have only 12 hours of theoretical lessons but at

Table 3. 1988 course programme (practical)

General operation of a computer system Statistical package: data entry Data editing and data labelling Variable transformation Graphics: histograms Graphics: bivariate plots Tables and x2 tests Student’s t-tests and one-way analysis of variance Correlation and regression Logistic regression. Analysis of residuals Survival curves. Kaplan-Meier and actuarial methods Survival analysis and Cox models

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least 30 hours of practice, the former as one hour weekly and the latter as 1% hours twice weekly. We believe this to be the optimal duration and periodicity of lessons. We will still use the same statistical package, but the main modification will be better coordination between the biostatis- tics course and the computers course. Practical lessons devoted to the planning, conduction and analysis of simple observational research will also be included.

Acknowledgement

This work was supported in part by the Funda- cao Luso-Americana para o Desenvolvimento.

References

Knapp R.G. & Miller I11 M.C. (1987) Clinical rele- vance: an issue in biastatistical training of medical students. Medical Education 21, 32-7.

Feinstein A.R. (1972) Clinical biostatistics. XIV. The purposes of prognostic stratification. Clinical Phar- macology and Therapeutics 13,285-97.

Feinstein A.R. (1977) Clinical biostatistics. XXXIII. On teaching statistics to medical students. Clinical Pharmacology and Therapeutics 18. 1214.

Received 8 February 1989; editorial comments to authors 6 April 1989; accepted for publication 8 May 1989