impact of a cybertutor in dermatological teaching

Education

Impact of a cybertutor in dermatological teaching

Mariana Soirefmann1,2, MD, Cristiane Comparin1,2, MD, Juliana Boza1,2, MD,Chao Lung Wen1,2, PhD, and Tania Ferreira Cestari1,2, PhD

1Department of Dermatology, Hospital de

Clinicas de Porto Alegre, Federal University

of Rio Grande do Sul, Brazil, and2Department of Telemedicine, Hospital das

Clinicas de S~ao Paulo, University of S~ao

Paulo, Brazil

Correspondence

Mariana Soirefmann, MD

General Francisco de Paula Cidade

556/ 202 C

Porto Alegre

Brazil, 91330440

91330440

Brazil

E-mail: [email protected]

Conflict of interest disclosures: none.

Abstract

Background The potential value of multimedia programs as an accessory instrument for

medical education has already been demonstrated in several areas. However, most of

them lack adequate validation. The authors proposed this study in order to develop and

evaluate a computer multimedia program, aiming at providing a more attractive and state

of the art learning tool in dermatology.

Methods The cybertutor was developed containing clinical cases, self-education classes,

and short video presentations. In order to evaluate its impact, 50 undergraduate students

attending the third year of Medical School at UFRGS were randomized into two groups:

group 1 was submitted to a multimedia program on a specific dermatological subject –

parasite infestations, and group 2 to standard classes on the same subject. Both classes

were taught by an experienced teacher, on the same subject and at the same time. In the

end, the level of knowledge acquisition for the two groups was evaluated by a multiple

choice test.

Results The average of correct answers was 11.16 (SD = 1.625) in group 1 and 11.96

(SD = 1.645) in group 2. There were no statistically significant differences between the two

groups (P = 0.09). The majority (80%) of the students who attended the cybertutor group

showed interest in taking part in similar activities.

Conclusions According to this study, multimedia programs may be used for

undergraduate education in Dermatology as a complementary educational tool. Contact

with an instructor is still considered to be important and should be offered simultaneously.

Introduction

Undergraduate medical school curriculum is often basedon principles that were established in the early 18th cen-tury. Formal lectures and practical learning at outpatientunits or at patients’ bedsides were and still are part of thecurriculum of most medical schools.1 However, this edu-cational model is being questioned for several reasons,which include decrease in knowledge retention and stu-dent interest, financial constraints on educational pro-grams, emphasis on memorization of concepts rather thanon intuition and rationality, and decrease in time avail-able for faculty members, which are not only involved inteaching medical students and residents but also in per-forming clinical work and/or research.2–6

In late 1984, the General Professional Education of thePhysician report recommended a thorough revision of themedical curriculum. Its authors have suggested, amongother things, that medical curricula should be revised to relyless on classroom lectures and more on independent study

and problem solving in order to increase active learning andraise the level of knowledge retention amongst students.7

Moreover, over the past decade, medical care deliveryhas shifted from an inpatient to an outpatient model.Therefore, medical students are often required to com-plete community rotations in an ambulatory setting toachieve learning goals. Many of these students completetheir rotations at distant sites, making it difficult to returnto campus to attend required lectures.8

In order to allow all these changes in medical curricu-lum, advances in technology were crucial. Current devel-opments in information technology and in video andphotographic equipment have allowed the transmission ofimages with a resolution similar to that of color slides.9

Moreover, published studies have shown that the accu-racy of digital images is about 85%, confirming thatimages could be considered reasonably accuratewhen comparing with real patient observation.10 Finally,web-based learning is becoming increasingly popular ininstitutions of higher education.8

International Journal of Dermatology 2013, 52, 722–727 ª 2013 The International Society of Dermatology

722

Although the potential value of multimedia programs asan accessory instrument for medical education has alreadybeen demonstrated in several areas,2,11 most of these pro-grams have not yet been validated. Bearing that in mind, wehave proposed this study aiming at evaluating the impact ofa computer-aided learning program as an optional tool toteach dermatology to undergraduate medical students.Moreover, we have intended to verify if students exposed tothis particular multimedia program would have a similarlevel of knowledge compared with traditional expositiveteaching in order to properly validate this method.

Materials and methods

Prospective, double-blind, randomized clinical trials (RCTs) with

undergraduate students in the third year of Medical School at

the Federal University of Rio Grande do Sul – UFRGS.

Students who have not attended dermatology classes were also

invited to participate.

Sample size was based on a previous study of Seabra et al.2

A power analysis indicated that through the analysis of a

sample of 50 subjects, it would be possible to detect a two-

point difference in average with a power of 80%, P < 0.05 for a

one-tailed t-test.

The project was submitted and approved by the Institutional

Ethics Committee (IEC), and all volunteers have signed a Term

of Free and Informed Consent and have given their

authorization for image use.

Equipment

A Sony digital camera Cybershot® (5.1 megapixels) was used

to photograph dermatological lesions, under Informed Consent;

a desktop microcomputer with Windows XP was used to save

and process digital images; Adobe Acrobat Dreamweaver

Software was used as tools to create the website that had the

capacity to upload digital images to the clinical form; Web

Servers based on Windows, with MS-SQL database and ASP e

ASP Net applicatives; Tandberg videoconference equipment

with ISDN/IP transmissions to online interaction, if necessary.

Study development

The study was divided into two parts: the first one was the

development of a multimedia computer program, called

cybertutor; the second part consisted of an evaluation of this

new educational tool in Dermatology.

Part 1

The development of the cybertutor was performed at the

Telemedicine and Applied Photobiology Laboratory from the

Research Center of Hospital de Cl�ınicas of Porto Alegre, HCPA

(UFRGS), with technical support from the Telemedicine

Department of the University of S~ao Paulo (USP). It is an

interactive multimedia program.

The cybertutor is a software that was developed using

Microsoft’s .net platform (ASP) and utilizes a databank based on

MS-SQL. Access is restricted and can occur only by inserting a

pin number. Authorized users possess a pin number, and users

are categorized according to their profile, thus safeguarding the

privacy and the identity of the patients listed (only the doctor who

is treating a given patient has access to a given patient’s

complete name, while other doctors are only able to visualize the

initial letters of the first and last names of the patient).

The software was developed by a team of system analysts

from the course of telemedicine of the FM-USP (Faculdade de

Medicina da Universidade de S~ao Paulo/Medical School of the

University of S~ao Paulo) under the coordination of a professor

and researcher of the telemedicine course.

The standard patient’s clinical information file was created

having the most relevant data of a standard dermatology clinical

information file as a model. The cybertour clinical information

file can support up to five digital images or MP4 videos

alongside a description of the lesion portrayed. Besides that,

the clinical information files were where the electronic clinical

files were developed containing CID’s databank, a record of all

medicines available as well as a list of the interactions between

different types of drugs.

The contents of the cybertutor include the following.

1 Thirty clinical cases: after IEC approval and having obtained

informed consent, typical cases of the most common

dermatological disorders were selected among patients

attending the Dermatological Unit of HCPA. The dermatological

disorders included were: eczema, atopic dermatitis, irritant

contact dermatitis, allergic contact dermatitis, virus infections,

bacterial infections, superficial fungus infections, parasitic

infections, psoriasis, acne, rosacea, non-melanoma skin cancer,

melanoma, melasma, alopecia areata, androgenetic alopecia,

urticaria, lichen planus, pruritus, and prurigo.

Relevant clinical data as well as pictures of the

corresponding disease were included using the Adobe Acrobat

Dreamweaver software. Four single-choice questions were

posed for each clinical case. The choices for answers were

commented, whether they were correct or not, using both

explanations about differential diagnosis and therapeutic options

available. Additionally, updated references about each disorder

were obtained from Medline and Cochrane databases and also

from dermatology textbooks.

2 Self-education classes: five theoretical classes were prepared

as PowerPoint presentations. The choice was based on the

updated curriculum of UFRGS, which is made up of the

following courses: terminology in dermatology and primary

lesions; parasite infestations; superficial fungal infections;

cutaneous manifestations from systemic diseases; cutaneous

neoplasm and eczemas.

3 Short video presentations covering the most frequent

dermatological procedures, such as skin punch biopsies,

shavings, simple excisions, and local anesthesia.

ª 2013 The International Society of Dermatology International Journal of Dermatology 2013, 52, 722–727

Soirefmann, Comparin, Boza, et al. Impact of a cybertutor in dermatological teaching Education 723

Part 2

Evaluation of the impact of a computer-aided learning program,

using a multimedia presentation on parasite infestations in

dermatology as a model, in order to compare knowledge

retention and students’ interest when exposed to either

cybertutor or traditional classes.

The impact of the cybertutor in dermatological teaching was

measured by an RCT. Fifty students in the third year of

medical school at UFRGS that had not yet undergone

dermatology rotation were randomized into two groups: group 1

had free access to a multimedia program of Infestations in

Dermatology (Figs. 1 and 2); and group 2 attended a standard

lecture on the same subject, at the same time. The standard

lecture was prepared and presented by a dermatology teacher

who was not involved in the development of the cybertutor. To

guarantee the consistency of both presentations, the same

class plan, including the main topics to be covered, was

followed by both teachers, the one who prepared the cybertutor

presentation and the other who prepared the thought class.

Both dermatology teachers had the same level of expertise and

teaching experience. At the end, the level of knowledge

acquisition for the two groups was evaluated by a multiple-

choice test, containing 15 questions, prepared by another

blinded instructor. Immediately after exposure, students who

attended the cybertutor also answered a six-statement

questionnaire, based on the Likert scale, about their subjective

feelings on computer teaching method, including their opinion

about digital lecture format as an adequate replacement for live

lectures.

Results

Complete data were available for 25 students who com-pleted the digital lectures and 25 students who attendedthe live lectures. Samples were quite similar, and therewas no significant statistical difference regarding averageage, as presented in Table 1.The objective evaluation showed no statistically signifi-

cant difference between the grades of the two groups(P = 0.09). The average of correct answers was 11.16

Figure 1 Self-education classes: dermatological infestations


Education Impact of a cybertutor in dermatological teaching Soirefmann, Comparin, Boza, et al.724

(SD = 1.625) in group 1 and 11.96 (SD = 1.645) ingroup 2. These data are also presented in Table 1.Students’ personal opinions about which teaching

methods were found best are presented in Table 2. Morethan 80% of the students considered the cybertutor asfriendly and educational. In addition, more than 60% ofthe students considered this multimedia program a pleas-ant activity. Eighty percent of the students manifestedinterest in participating in similar activities in other medi-cal topics in the future. However, most of them believed

that it did not entirely replace the instructor, emphasizingthe relevance of the professor and student interaction.

Discussion

The process of education has evolved over time in acontinuing effort to meet the needs of our society.12

While traditional methods and practices of formal edu-cation (including lectures with writing boards, learner-transcribed notes, and heavy reliance on printed materi-als) are still effective for some courses, there are deficien-cies when they are applied to the learning and teaching ofscience and technology, both on a local institution andglobal basis.12

In this context, the use of multimedia programs inmedical education would have some advantages overtraditional teaching methods.2,13 Multimedia technologiesallow professors to save time as they enable the presenta-tion of new texts, graphs, and audio and video record-ings. These elements can be changed, added, or deletedinstantly, allowing both students and doctors to research

Figure 2 Dermatological infestations: sarcoptes scabiei

Table 1 Characteristics of the sample and test results

Group 1 Group 2

Teaching method Multimedia program Standard lecture

No. students 25 25

Average age (years) 22.6 22.64

Average of correct answers

(%)a11.16 (74.4) 11.96 (79.73)

aTotal of 15 questions.



on a constantly updatable learning tool.2,14 In addition,students may potentially increase the time they devote totheir studies once the educational content is available forconstant or repeated practice and can be examined oraccessed whenever students may deem necessary.13,15 Fur-ther advantages of multimedia programs are the ability tointeract with students and to receive immediate feedbackso that they can learn what their weak points are andthus learn from their mistakes much quicker than theywould usually be able to.13

Shaikh et al. studied the efficacy and feasibility of mul-timedia programs for pediatric medical education. Therewas significant improvement (mean improvement 22%,P < 0.002) in competency in five out of the six areasassessed. In addition, 88% of trainees were very satisfiedwith the teaching methodology (� 5 on a 7-point scale),and 86% were very likely to apply the information intheir future practice.16

In an effort to address the concern of internal validityof the present study, the material presented in the derma-tological tutorial was identical to the material covered inthe traditional lecture.13 Regarding results, we observedthat students who used the computer-aided multimediaprogram obtained 74.4% right answers, while those whotook the class answered 79.7% of the questions correctly.The difference between the groups was not statisticallysignificant or clinically relevant. Therefore, the use ofmultimedia programs as a complementary tool for derma-

tological teaching allows students to have at least thesame learning performance and level of cognition as thosewho attend traditional lectures. These findings were alsoobserved in studies that used multimedia programs forteaching other medical specialties, such as neuroanatomy,surgical technique, and general urology.2,17,18

The majority of students who took part on the electro-nic cybertutor group agreed that this multimedia programis educational but said that it does not replace professors.These findings were also observed in other papers thathave already been published. Hong et al. publishedthat the use of computers and the Internet is a usefuland effective way to teach dermatology.19 Moreover,Potomkova et al. found out that medical Web-based tuto-rials represent an effective educational tool supportingself-directed learning.20

Despite the increased use of multimedia programs inmedical education, barriers still remain to the widespreadimplementation of this methodology. One of the mainbarriers is the lack of evidence of computer-aided learningprogram effectiveness as an educational tool. In addition,a possibility for future research would be an improvedevaluation of the long-term retention of computer-aidedlearning program vs other teaching methodologies.Finally, long-term retention of knowledge is a very impor-tant consideration, as the majority of medical students’exposure to dermatology is in the first three years of med-ical school.13

Final considerations

Multimedia computer-assisted training programs providea more stimulating and realistic training environment thatapproaches the reality of the patient and doctor relation-ships, as it happens in real life.Within the limits of this study, the computer-aided

learning program is at least as effective as traditionallecture teaching of dermatological infestations to medicalstudents. Therefore, multimedia programs may be used forundergraduate education in dermatology as a complemen-tary educational tool. It is important to emphasize that thedirect contact with an instructor is still considered to beimportant and should be concomitantly offered to stu-dents. The instructor may act as a distant tutor, while thestudents have a more active attitude in the learning pro-cess, exploring the information available and selecting themost important for their knowledge acquisition.Regarding dermatological teaching at our institution,

we plan to utilize multimedia computer-assisted trainingprograms blended with traditional teaching methods toengage different learning styles and effectively increasestudent contact time with dermatological material duringspecific dermatology instruction and throughout medicaltraining and careers.

Table 2 Cybertutor group: students opinions on multimediaprogram based on Likert scale

Question

number

Disagree

fully (%)

Disagree

partially

(%)

Neutral

(%)

Agree

partially

(%)

Agree

fully

(%)

1. The program

is user friendly

4 0 0 32 64

2. The program is

pleasant to

use

4 4 24 32 36

3. The program

produced

immediate

memorization

0 20 32 44 4

4. The program is

educational

0 0 12 32 56

5. I would like to

have a similar

program for

other topics

0 12 8 44 36

6. Programs

similar to

this one can

replace the

teacher

40 40 8 8 4


Education Impact of a cybertutor in dermatological teaching Soirefmann, Comparin, Boza, et al.726

The importance of multimedia programs in medicaleducation will most likely move beyond the scope ofundergraduate medical education. In the future, multi-media programs in medical education may become oneof the major methods of teaching graduate medical stu-dents as well as continuing medical education for pri-mary care physicians, dermatologists, and otherphysicians as well.

Acknowledgments

This work was supported by the Telemedicine Depart-ment of the University of S~ao Paulo (USP) and the Tele-medicine and Applied Photobiology Laboratory from theResearch Center of HCPA, UFRGS.

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