Interactive Video Learning in Medical School P. A. Dervan

Department of Pathology, Mater Misericordiae Hospital and University College, Dublin.

Medical education is heavily image orientated. Anatomi- cal photographs, diagrams, graphs, line drawings and physio- logical tracings contribute to the education of medical sto- dents during their preclinical years. Later, words are supple- memed with clinical photographs, gross and microscopic pathology, electron micrographs, photographs of microbes, photographs of medical and surgical procedures, ECG trac- ings, radiographs, ultrasonographs and CT scans. These images are scattered throughout textbooks, atlases and teach- ers' transparency slide sets. Histology and pathology images come in the form of gists slide preparations that are viewed with a microscope. ' : .

A compendium of these images is now available on a few videodises and these images are accessible using interactive videodisc 0VD) hypermedia technology ~,z3. An IVD work- station consists of a computer with its own hard disc and monitor, a videodisc player with its laser videodisc, an addi- tional high resolution colour monitor and the appropriate software to link everything together. The "Slice of Life" videedisc (produced by the University of Utah) contains approximately 35,000 high quality images - clinical photo- graphs, pathology, radiology etc. similar to those found in hundreds of diverse textbooks and atlases. As the student reads text on the computer monitor the clickofa mouse-driven cursor on a key word instantaneously summons the accompanying image on the IVD screen. For example, while reading notes about lung cancer on the computer monitor the student calls up in rapid succession, clinical photographs, x- rays, photographs of gross specimens and histology sections. Points of interest on the video image are highlighted with arrows, and explanatory text accompanies each image.

Alternatively the student uses a computer screen as an electronic cross-reference index. Specific words, topics or illustrations can be located almost instandy. A click.on a different word or phrase produces a definition, explanation or minitutorial. In addition to this tutorial interactive exercise one can call up a series of multiple choice questions and these are linked to various images. The computer continuously tells the stodent what percentage of questions were answered correctly. At present, most of the availableprograms concen- trate on undergraduate medical courses.

In the future, IVD technology will also play a role in postgraduate specialty training. Some specialities'are more image-orientated than others, for example, pathology and radiology rely heavily on images of various types. Intellepath (Intelligence Pathology) is an artificial inteliigence/expert system program for residents in pathology 4.

Corres~nacn~: Prof. Peter A. Dervail, MSc, MD, FRCPath.. U.C.D.'Department of Pathology, Mater Misericordiae Hospital. Dublin 7.

This system operates in two major modes: (a) a tutorial mode and Co) a diagnostic mode. The tutorial mode is similar to that described above. The diagnostic mode works as follows. The resident is studying the histology sections, for example, of a lymph node biopsy specimen, and tells the computer what featuCes he sees down the microscope. The computer suggests a differential diagnosis and lists the likely probability for each diagnosis.

The resident compares and contrasts his case with video images of dozens of similar cases. The logic used in arriving at a particular diagnosis is explained. If some features k,e entered incorrectly these can be corrected interacfivcly at any time and the diagnostic probability is updated instantly. All instructions are selected from a screen menu with a mouse; no typing is necessary.

Worldwide it is estimated that about 100 pathology depart- ments are beginning to incorporate imeJase IVD teaching into their undergraduate programs. One d~epartment (Robert Wood Johnson Medical School, New Jersey) has replaced approxi- mately 80% of its traditional undergraduate pathology teach- ing with IVD independent learning ~. Since changing to the new system, the average percentage grade in examinations has increased significantly. Similar improvements have also been shown at the University of Arkansas ~. Univeristy Col- lege Dublin has recently set up an IVD pathology laboratory for its medical students.

What are the advantages of lVD learning? 1. Students like it. Most love it, and consider it a fun way to

learn. They do not need keyboard (typing) skills as the computer mouse navigates its way through the various options.

2. The IVD laboratory creates an environment favourable for study and leads students to accept a more active role in obtaining information. In small groups they discuss and argue about which answers are best. Information acquired through effort is retained better than facts learned pas- sively 7~. Learning in the conventional lecture tutocial system tends to be passive where the tutor talks and the students listen. Active learning, in general, is more effec- tive than passive learning.

3. Students learn at their own pace. The computer is infi- nitelypatieat. Askit the same question repeatadly; it never gets iiritated.

4. Students can monitor their progress and getinstant feedack on their learning curve. It allows the tutor to concentrate on explaining more difficult and subtle concepts and

.~_Jeaves the student to get on with acquiring more straight- " "forward information.

5. Programs such as Iutellepath systematically go through differential diagnoses and bidng to mind diseases that might otherwise be forgotten.

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W h a t about the disadvantgages? (1) The main one is cost. To set up a laboratory for 120

students (12 workstations) costs in the region of s although with some innovative accounting and purchasing it is possible to red uce this cost considerably. Twelve worksta- tions would allow half tile class, at any one time, to use the laboratory with five students to each workstation. It is preferable, however, to divide classes into smaller groups and have groups of two or three students work at each unit.

(2) At presgnL there are many, often incompatible, hyper- media sysiefns available. The computer industry has not yet arrivedat a universally acceptable standardL ! t may be several years before this problem is solved. Approximately 80% of educational vidcodiscs are produced in the USA, and NTSC (the type of video signal standard in the USA but not in Europe) compatible video players and monitors are required to run these. This NTSC compatibility contributes to cos t

(3) The difference between a mediocre and an excellent system is in the software. There are only a few outstanding programs available yet. To run a successful IVD teaching program it is probably u~ful (but not essenti'al) to have at least one computer endmsiast in the department.

How is IVD technologylikely to develop in medical schools? Most will start by introducing a few units. Some medical schools will set up 1vD laboratories and make these laborato- ries 0vailable to medical students to use like a library. Many medical libraries will include IVD facilities (just as at present they include computerised CD ROM literature search facili- ties) and before long. videodises may be available in libraries to borrow just like books. It is not inconceivable that ten to fifteen years from now medical students will have their own computers with built-in videodisc readers.

Despite dic tremendous advantages of IVD technology, it is highly unlikely that good core textbooks will be replaced. Practical skills like good case history taking and demonstra- tion 0f physical signs will not be replaced by computer.

Also, the good teacher/communicator will survive and remain essential to all teaching programs. Eventually IVD technology will be regarded as just a teaching aid, a very powerful aid.

References l. Mercer, L, Pringle, J. H., Rae, M. J. L, Harkin, P. J. R., Lauder, I. How

do we teach pathology? The laser vldeedisc and computer-assisted teaming. J. Pathol. 1988: 156, 83-89.

2. Kumar, K., Hodgkins, M. Use of interactive vidcodi~c for teaching of

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pathology laboratory cases. J. Pathol. 1990: 160, 145-149. 3~ Gorstein, F.,Trelsted, R. "l~epathologistasstudentandeducator. lltnn.

Pathol. 1990: 2l, 1-3. 4. Nathwani, B. N., Fleckennan, D. E., Horvitz, B. L, Lincoln, T. L.

Integrated expert systems *rod videodisc in surgical pathology. Hum. Pathol. 1990: 21, 11-27.

5. Raskova, J'., Martin, E. G., Ttdstad, R. L., Shea, S. M. independent learning in pathology. Arch..Pathol. Lab. Med. 1989:113,204-206.

6. ]'ones, R., Schoultz, T. Teaching pathol.ogy in the 21st century: Assess- ment of required studem use of interactive videodiscs designed to teach basic pathology. Hum. Pathol. 1990: 21, 6-10.

7. Tosteson, D. C. New pathways in general medical education. N. Engl. L Med. 1990: 322, 234-238.

8. Colvin, R. B., Wetzal, M. S. Pathology in the new pathway of medical education at Harvard MeScal School. Am. J. Clin. Pathol. 1989: 92, $23- 3O.

9. Fox, B, Multimedia in a muddle. New Scientist. 1991:1787, 35-39.

EXPERT COMMENTARY It is rather difficult to referee a review article of this sort.

This is p~ticularly so because Dr. Dervan has the only appropriate equipment in Ireland. No-de of the rest of us involved in teaching is so fortunate. The nearest most of us have come to such a system is the new computer room/ catalogue at the National Gallery in London.

The article is ase nsible and clear account of the situation for those who have not had direct experience. I think the paper should be published promptly so that people become aware of this development and so that those responsible for funding universities and educational systems cannot say "I did not know". In particular I would want Professor Dervan to emphasise and emphasise again the second advantage he lists. Thatis thatthe IVD hthoratory creates an environment favour- able for ACTIVE learning.

There is perhaps one particular point I would like him to emphasise. From my experience in other places, systems like these, when used in conjunction with good personal teaching improve the quality of instruction. To make such systems work properly they actually need an increase in staff time, an iacreasein stafftraining and an increase in staff equipment. In the present understaffed and underfunded situation in which Irish medical schools find themselves, I would not wish any enthusiasm for FVD learning to be used as an excuse for increasing student numbers without corresponding increases in staff numbers. Equally, they are not a way of reducing teachers while maintaining student numbers.