Electric Differential Multimedia Laboratory Bibliography
Michael P. D'Alessandro, MD,*
Jeffrey R. Galvin, MD,*
William E. Erkonen, MD,*
Mark A. Albanese, PhD,Ý
Vera E. Michaelsen, BA,
Joan S. Huntley, PhD,§
Robert M. McBurney,§
Greg Easley, MA§
Peer Review Status: Externally Peer Reviewed
From the *Department of Radiology, Electric Differential Multimedia Laboratory, ÝOffice of Consultation and Research in Medical Education, Medical Student, The University of Iowa College of Medicine, and §Second Look Computing, Weeg Computing Center, The University of Iowa, Iowa City, Iowa.
Supported by a grant from The University of Iowa Department of Radiology Resident Research Fund
Reprint requests: Jeffrey R. Galvin, MD, Department of Radiology, The University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242-1009. Phone: 319-356-7268 FAX: 319-356-2220
Abstract
Rationale and Objectives
Information overload is a significant problem for the modern
radiologist. This prospective study compares the instructional
effectiveness of a multimedia textbook (HyperLung) with a lecture.
HyperLung is a radiologic multimedia textbook about imaging diffuse
lung disease, and it was created by using a multimedia authoring
tool, The Annotator(TM), on the Apple Macintosh computer.
Methods
Forty-nine staff physicians and residents in the Department of
Radiology were randomized to receive instruction either by HyperLung
or a lecture. The instructional content was the same in both groups,
and both groups were pre- and post-tested. The actual time spent in
each instructional situation was recorded.
Results
The instructional effectiveness of the multimedia textbook and
lecture was equal. The instructional efficiency of HyperLung was only
60% of the lecture. Users of the multimedia textbook found it
enjoyable and straightforward to use.
Conclusion
Multimedia textbooks have a promising future in radiology education.
Keywords: Education, radiology, computers, multimedia, hypermedia.
Introduction
Although radiologic knowledge is rapidly increasing and changing,
traditional radiologic instructional techniques have changed little
since the time of Roentgen.1 Educators have hypothesized that
computer-driven multimedia instruction may be one answer to this
information overload.2 Multimedia instruction makes use of text,
video, audio, images, and animation to convey information. In
multimedia instruction students are in active control of their
learning, whereas in a lecture they are primarily passive recipients
of knowledge. Multiple media affect multiple senses and more closely
simulate the optimal learning environment that medical students and
physicians are exposed to in clinical work. Multimedia instruction
moves our powerful medical learning paradigm of "See One, Do One,
Teach One" from the clinics into classroom computers.
The goal of this prospective study was to create a radiologic multimedia textbook and compare its instructional effectiveness with a lecture. We define a multimedia textbook to be a multimedia computer program that patterns its user interface after a printed textbook but incorporates functions beyond those of a printed textbook such as the ability to play video clips and audio clips and to display an almost unlimited number of high-resolution images. Our hypothesis was that the instructional effectiveness of a multimedia textbook would be at least equivalent to that of a lecture.
Methods
We created a multimedia textbook (HyperLung) that provided a clinical
approach to the imaging of diffuse lung disease via high-resolution
computed tomography (HRCT). HyperLung was created using The
Annotator(TM) (The University of Iowa Second Look Computing, Iowa
City, Iowa, USA), which is a Hypercard application running on an
Apple Macintosh computer (Apple Computer, Cupertino, California,
USA). The Annotator(TM) is a multimedia authoring tool that creates
sophisticated multimedia "pop-up" textbooks. The Annotator(TM) is a
media processor, processing media in much the same way a word
processor processes words. The Annotator(TM) uses text created by an
author as its primary medium, and then it annotates this text with
related descriptive media including additional text, images, video
clips, audio clips, and animations. The Annotator(TM) design metaphor
emulates a printed book to facilitate navigation. Our multimedia
textbook has a Table of Contents (Fig. 1), discrete chapters (Fig.
2), indices (Fig. 3), a dictionary, provisions for student testing,
word search capability, and the ability to take notes in the margins
(Fig. 4).
The images used in HyperLung were digitized into the Macintosh using a Lumisys DIS100 film digitizer (Lumisys, Mountain View, California, USA). The raw digitized images were processed using NIH Image (National Institute of Mental Health, Bethesda, Maryland, USA) which was used to adjust image contrast, brightness and size. The final images had 8 bits of gray scale depth and were 400 x 400 pixels in size.
Staff physicians and residents in the Department of Radiology were randomized into two groups. Group 1 (n=25) received instruction via HyperLung, and Group 2 (n=24) received instruction via a 50-minute lecture. The information content in HyperLung and the lecture was the same. Both groups were pre- and post-tested around their randomized instruction. The pre- and post-tests consisted of the same 10 static HRCT images displayed as photographs. On both the pre- and post-tests 3 of the 10 questions consisted of image pattern recognition, and 7 questions consisted of penetrating knowledge questions concerning the images presented. The length of time operating the computer and the lecture time were recorded by observers. The HyperLung group voluntarily completed a questionnaire designed to measure their response to the multimedia textbook following completion of their instruction, the major question being did you find this an enjoyable and worthwhile learning experience.
Results
There was no significant statistical difference in pre-test scores
between the two groups (t(47)=.98, P=.33). The pre-test mean percent
correct for the HyperLung group was 58.8%, whereas that for the
lecture group was 53.3%. The post-test mean percent correct for the
HyperLung group was 83.2%, whereas that for the lecture group was
82.9%. There was a statistically significant gain in knowledge
between the pre- and post-test in both groups (F(1,44)=19.41, P less
than .0001), but there was no significant statistical difference in
the instructional effectiveness between the two groups (F(1,44)=1.20,
P=.28) (Table 1). There was, however, a significant statistical
difference in learning efficiency (F(1,44)=7.56, P less than 0.0086)
(Table 2). The HyperLung group experienced a post-test mean percent
gain of 20.3% per hour of instruction, whereas the lecture group
experienced a gain of 34%. Thus, HyperLung was only 60% as efficient
as the lecture for learning. The residents outperformed the faculty
regardless of the form of instruction used, and this finding was
statistically significant (F(1,44)=5.53, P less than 0.0232).
Seventy-five percent of the HyperLung group found the multimedia
textbook an enjoyable learning experience, and 100% of the HyperLung
group found it straightforward to use.
Discussion
Although much has been promised in multimedia instruction, little has
been delivered.3 A MEDLINE search found one study evaluating the use
of computer-assisted instruction in the radiology literature.4 The
"drill and practice" instructional technique of Jacoby et al4
predated the existence of multimedia learning. The MEDLINE search
yielded no studies in the radiologic literature comparing multimedia
textbooks with traditional forms of medical instruction, because the
powerful and affordable computer hardware and software necessary to
create and play back sophisticated multimedia textbooks have not been
available until recently. One year ago we created our own multimedia
authoring tool, The Annotator(TM), to solve the software side of the
problem. In the meantime, powerful and affordable computer hardware
for the creation and playback of multimedia textbooks became
available. The consumer multimedia mass market is poised to take off
and make multimedia learning available for general instructional
purposes.
Pre- and post-testing documented that the short-term instructional effectiveness of a multimedia textbook was equal to an excellent lecture, and this confirms the results of a previous study.4 The lecture, however, proved to be the most efficient form of instruction. This is not surprising since the HyperLung group had the opportunity to review material that was initially confusing to them, whereas the lecture group did not. Thus, a lecture will generally be more efficient for teaching new material than a multimedia textbook. Some increase in efficiency for the multimedia textbook is likely to exist for fast readers and more generally for reviewing material because the learner can skim or completely skip over material for which they feel sufficiently prepared. HyperLung was extremely easy to use, but most physicians required a few minutes for familiarization before delving into the computer instruction. This familiarization time counted toward their overall learning time, decreasing HyperLung's learning efficiency. It should be mentioned that the lecture conditions were optimal in this study. The lecturer was one of the consistently highest rated lecturers in the department. Furthermore, the lecture was the only one of the day as opposed to one of many in an average day of medical school or a continuing medical education program. Thus, in actual practice, we would expect the gap in learning efficiency to be somewhat less than encountered in this study. Interestingly, the additional learning time used by the HyperLung group did not result in a better test performance than the lecture group. This may be partly due to limitations in our testing. Test score internal consistency reliabilities at pre- and post-test were only .55 and .54, respectively. The items were fairly discriminating at pre-test with all item-total correlations exceeding .25 and half of the items having values exceeding .40. Thus, the somewhat low reliabilities are probably due to using only 10 items. Ceiling effects may have played a role in the failure to detect treatment effects. Scores of 90% and above were obtained by 53% of the participants on the post-test and 27% achieved perfect scores. A longer test would likely enable finer discriminations to be made among the examinees. It remains to be seen which instructional technique provides the best long-term retention of knowledge, which we plan to assess in a 12-month follow-up.
The issue of instructional efficiency deserves further comment. In today's academic fiscal environment, it is no longer efficient or economical for faculty to present the same basic information on a repetitive basis. Instead of forcing lecturer and students to congregate in a specific place at a specific time, we can transfer the lecture information to a multimedia textbook allowing medical students, residents, and physicians to learn and review at their own convenience and pace. The faculty can thereby shift their teaching role from that of repetitive lecturer to that of instructional manager and tutor.
The creation of HyperLung required several hundred hours. However, most of this time was used to learn about the computer and to design an approach to the creation of multimedia textbooks6. By using our approach faculty may create a multimedia textbook in the same amount of time it takes them to create a scientific paper or exhibit. Our approach allows for the separation of the creation of content, which is the faculty's responsibility, from the creation of the multimedia textbook, which is the responsibility of a graphic artist. Just as faculty in the past have submitted text and images to graphic arts departments and gotten scientific posters in return, today they may submit text, images, video clips and audio clips to properly equipped graphic arts departments and receive in return completed multimedia textbooks. Faculty are not responsible for the layout, design and production of any printed textbooks they author. In the same way, by using our approach, faculty are no longer responsible for the layout, design and production of any multimedia textbooks they author.
In 1975, Felson et al5, pioneered an instructional technique called the "viewbox seminar" to teach the radiology of coal workers' pneumoconiosis. This interactive instructional approach made the viewbox seminar an early form of multimedia instruction. The experiences of Felson et al with the viewbox seminars caused them to reflect that:
"Active student participation, as in these seminars, is better for learning than passive participation, as in lectures...the student learns better if he likes the method of learning; or at least, he is more apt to stay alert."
Although these seminars were well received and considered a highly effective way to teach radiology, the logistics and cost required to stage them was considerable. Today, computer hardware and software have finally caught up with the viewbox seminar idea, and we can now create multimedia textbooks that encapsulate the active learning nature of the viewbox seminars without their logistics and cost problems.
Conclusion
We have taken the first step in the evaluation of multimedia
textbooks as a method of teaching radiology. Our easy and
straightforward technique for the creation of multimedia textbooks
has been documented,6 and it works on all computer hardware
platforms. Multimedia textbooks appear to be at least as effective a
form of radiologic instruction as the traditional lecture. Although
multimedia textbooks may not always be as efficient a way of learning
as a lecture, they can be a more efficient way to teach and may
become popular in this time of fiscal austerity in medical education.
Furthermore, student response to multimedia textbooks is
overwhelmingly positive. Therefore, we feel multimedia textbooks have
a promising future in radiology education and deserve further
research and evaluation.
Acknowledgments
The authors thank Nola Riley for her secretarial assistance and
Phyllis Bergman for her editorial assistance. A special thanks to Dr.
E.A. Franken Jr., for providing the educational atmosphere and
support to complete this project.
References
List of Figures
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