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Transforming Traditional Curricula: Enhancing Medical Education through Problem-Based Learning,
Multimedia and Web-based Resources
Mike Keppell, The University of Melbourne
Gregor Kennedy, The University of Melbourne
Kristine Elliott, The University of Melbourne
Peter Harris, The University of Melbourne

Abstract
This paper describes the transformation of a traditional medical curriculum into a problem-based, technology-enhanced learning environment. The use of Information Technology (IT) is an important feature of the new curriculum. Clinical based medical problems are delivered to students in tutorial settings, via TopClass software, over the Web. Additional learning resources such as websites, image banks, practical experimental simulations, self-assessment tests, Shockwave learning modules and multimedia modules can also be accessed by students via the computer.

The paper begins by outlining the educational context in which the transformation of the traditional curriculum was made and the organizational structure that was put in place to facilitate these changes. It then discusses the web-based and computer-facilitated learning (CFL) aspects of the curriculum along with the processes of design, development and project management that were used in the creation of multimedia teaching materials.

1. Educational Context
The medical course at the University of Melbourne has traditionally been taught using a discipline-based approach. In the early years of the course, students undertook discrete subject blocks from the six pre-clinical departments of Anatomy & Cell Biology, Biochemistry & Molecular Biology, Microbiology & Immunology, Pathology, Pharmacology and Physiology. Exposure to clinical scenarios came later in the course (predominantly in years 4-6) after students had gained an understanding of the basic sciences relevant to medicine. Internal review mechanisms and student feedback in recent years had highlighted a number of deficiencies in the traditional course. In broad terms, these included insufficient integration between the basic and clinical sciences, insufficient attention to teaching communication skills, problem-solving skills and social aspects of health, and an overload of biomedical detail that was exacerbated by unnecessary duplication of content in subjects originating from different departments. In an effort to remedy these deficiencies and also to incorporate current theories of medical education, a new medical curriculum was introduced in 1999. The pedagogical model for the new medical curriculum incorporates elements of Problem-Based Learning (PBL) and Self-Directed Learning (SDL) (Koschman, Kelson, Feltovich & Barrows, 1996). The primary focus of learning in semesters 2-5 is medical problems (known as problems of the week) which are presented to students in small group tutorial settings. A key feature of the new curriculum is the horizontal integration across disciplines and the vertical integration of clinical situations with basic scientific material (Keppell, Elliott, & Harris, 1998).

About the authors...

2. Organisational Structure
The organisational structure and personnel put in place to facilitate the transformation of the medical curriculum is shown in Figure 1. The Faculty Education Unit (FEU) combines medical and curriculum expertise to oversee the development and implementation of the new curriculum. The Faculty Information Technology Unit (FITU) deals with administration and IT requirements of the curriculum, and provides a focal point for development of multimedia educational technologies throughout the Faculty. This unit also oversees staff involved in network administration and administration of the Student Computer Resource Centre. The Biomedical Multimedia Unit http://www.medfac.unimelb.edu.au/bmu/ is a sub-unit of the FITU and employs instructional designers, graphic designers, programmers, an evaluator and a TopClass specialist to complete work on the medical curriculum and multimedia modules. The role of this unit is to assist the FEU in delivering, through the Web, the problems of the week. It also oversees the design, development and evaluation of computer facilitated learning modules.

Demo 1 : An external link to a interactive movie (287 KB) showing each semester's topic. Shockwave plugin required.

Figure 1. Organisational Structure - IT and Multimedia - Faculty of Medicine,
Dentistry and Health Sciences

(Click on the image to see a larger version, 42KB)
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3. Problem-Based Learning (PBL) 
The elements of PBL used in the new curriculum involve clinical-based reasoning whereby students solve hypothetical clinical problems in small groups under the guidance of a tutor. Schmidt (1993) suggests that PBL is a method of learning (teaching) that is based on cognitive psychology principles such as "prior knowledge activation and elaboration through small-group problem analysis; the construction of problem-oriented semantic networks, including contextual cues derived from professionally relevant problems; and the fostering of epistemic curiosity" (Schmidt, 1993, p.427). Central to Schmidt's (1993) definition of PBL are the following issues: (1) prior knowledge, (2) activation of prior knowledge, (3) elaboration of content, (4) restructuring of semantic networks/schemata and (5) development of an intellectual scaffold. To explain the rationale of PBL, each of these terms will be discussed below in turn.

3.1 Prior Knowledge 
In the context of medical education, PBL attempts to immerse students in the process of solving a clinical problem. The first step in this process is to examine the learner's existing or prior knowledge. Schmidt (1993) suggests that the extent of prior knowledge is one of the major determinants of the "nature and amount of new information that can be processed" (p. 424). The importance of prior knowledge has also been stressed by Ausubel (1968) who states that knowledge is acquired when it is meaningfully related to, and, thereby, subsumed an already existing concept or body of knowledge. The essential factor in the acquisition of knowledge is that content must be linked to what is previously known.

3.2 Activation of Prior Knowledge 
Under the guidance of the PBL tutor, an exchange of ideas between students in the PBL session assists in activating their prior knowledge. This exchange needs to occur before students further investigate learning resources, for it creates a "learner readiness" by asking the students to generate hypotheses for the problem.

3.3 Elaboration 
The storage and retrieval of information is said to be enhanced when elaboration of the material takes place (Schmidt, 1993). In the medical context, information is elaborated when students listen to other students' hypotheses in relation to the problem of the week and determine the merit and worth of these different diagnoses. The cognition involved in recognising the merit and worth of these different perspectives begins the process of elaboration. The use of additional learning resources in the form of journal articles, books, multimedia teaching modules and relevant websites further elaborates student learning. A second round of PBL discussions at the week's end also allows students to obtain a more in-depth and differentiated understanding of the problem.

3.4 Restructuring 
The cognitive networks that are restructured during learning are referred to as schemata. Gagne (1986) defines schemata as "a set of interconnected propositions centering around a general concept, and linked peripherally with other concepts." Depending upon the existing knowledge of the student, a process of accretion, tuning or restructuring occurs to actively change existing schemata. Schemata are not static but continually evolve in content and structure. When new learning occurs, new schemata develop or old schemata undergo structural changes. When more information is incorporated into an existing data structure accretion is said to occur. The existing database does not change in form but is built upon. Tuning refers to the adjustment of existing data bases. The continual tuning or minor modification in categories of interpretation (schemata) occurs in order to bring the categories more in congruence with the functional demands placed on them (Gordon & Rennie, 1987). Restructuring is an important process for changing existing schemata or developing new schemata. It involves a difficult learning process and does not occur easily. New schemata must be devised to interpret new information, or old schemata may be re-formulated. This concept of restructuring may have important implications for medical students who are unable to apply their basic scientific knowledge to clinical situations.

The modification of existing schemata is also a powerful means of strengthening the retrieval of the information through contextual cues contained in the trigger sequence of the problem of the week. The concept of situated cognition explains why this may be the case; learning is a process of enculturation. In this instance, the medical student is being enculturated into the process of diagnosing a clinical case. The PBL session allows this enculturation to be further reinforced by providing authentic activity. This is one way that medical students can act as meaningfully and purposefully as do practitioners (Brown, Collins & Duguid, 1989).

3.5 Scaffolding 
In the process of PBL, the student develops a framework to use with subsequent problems of the week. Ausubel (1960) refers to this framework as an intellectual scaffold. Intellectual scaffolding is an infrastructure of information to which new material can be anchored (Ausubel, 1960). By beginning a task embedded in a familiar activity, students recognize the legitimacy of their implicit knowledge, and its availability as scaffolding in apparently unfamiliar tasks (Brown, Collins & Duguid, 1989, p. 38).

4. Information Technology
The use of Information Technology (IT) is an important feature of the new curriculum. The IT components of the curriculum are shown in Figure 2. IT is utilised to deliver medical content in two ways. These include the use of the web-based problem of the week embedded in the TopClass Learning Framework and stand-alone, computer facilitated learning modules. The TopClass Learning Framework provides a central access point for students to enter the on-line course work, complete self-assessment tests, view class announcements, participate in discussion groups and send and receive messages from teachers or peers. The problems of the week are delivered to student tutorials over the web via TopClass.

Presently, with the second year of the medical curriculum completed, 60 problems of the week have been designed, developed and implemented. Approximately 160 problems of the week will be required for the entire curriculum. Self-directed learning resources, in the form of computer facilitated learning modules, are also required to support the core content of the problems. Approximately 70 modules are currently under development within the Faculty, and it is envisaged that 100 modules will be required to support the curriculum in its entirety (see http://www.medfac.unimelb.edu.au/bmu/projects/projectTitle.asp).

The features of a problem of the week and the computer facilitated learning (CFL) modules will be described and demonstrated in the following sections. It is hoped that this will show how IT, interactive multimedia and web-based resources are being used to support the new integrated curriculum.

4.1 Computer-Based Problems of the Week
Each problem of the week begins with an audio and/or visual trigger. The aim of the trigger is to set the stage for the problem by providing students with an image of the hypothetical patient and some of the circumstances surrounding the medical scenario. An example of a problem of the week is shown at http://www.medfac.unimelb.edu.au/Med/examplePOW/trigger.html. Following the trigger, students are instructed to list information about the patient, identify the problems, list possible causes of each problem (hypotheses), provide a rationale for each hypothesis, prioritise the list of hypotheses, and then determine what other additional information (physical examinations, laboratory tests, etc.) is required to differentiate between hypotheses. During this process students are given supporting information about the current medical condition, past medical history, physical examination, progress, and investigation results.

4.1.1 The Development Process
As in any undertaking in which there are a large number of stakeholders (in this case medical, curriculum, educational, content, multimedia and IT delivery experts), it is often difficult to coordinate the conceptualisation, design, development and delivery of educational material to students. Clear communication between the various stakeholders is essential to avoid misconceptions and misunderstandings. In our design and development, regular discussions are undertaken to avoid communication difficulties and also to provide stakeholders with an awareness of their role in the development process. The production stages for the problem of the week are shown in Table 1.

Table 1. Production components for the problem of the week.

Figure 3. Questions for a first semester problem entitled "Just checking".

In development an attempt is made to match the nature of the medical condition or context to the appropriate media type (e.g., static image, sequence of static images, video, audio, or Shockwave movie). A trigger, for example, that portrays a medical condition such as myasthenia gravis needs to show the progressive nature of skeletal-muscle fatigue. Consequently, video is the most appropriate media to illustrate this progressive nature. Other triggers needed to demonstrate distinctive sequential changes in a process can be portrayed through a series of digitised photographs using a Shockwave movie. Often, a single digitised photograph conveys sufficient information to begin the problem-based learning approach.

The main aim of development is to create authentic triggers that can "suspend the disbelief" of students and allow them to approach each problem of the week as if it were a real life clinical case. The challenge of creating authentic practise stimulations that mirror the complexity of real life medical situations rather than creating neat and tidy medical packages has previously been discussed (Elliott & Keppell, 2000). Sufficient detail was included in the triggers to enable students to begin the process of formulating hypotheses about the underlying medical condition without compromising on the complexity of reality. A well-designed trigger should, for example, encourage the formulation of hypotheses by students. A poorly designed trigger, however, may make the medical condition too obvious and could inhibit this process.

An external link to the authors' demo of shockwave movie as a medical trigger (267KB)

An external link to the image of medical trigger (55KB)

5. Computer Facilitated Learning Resources
An important aspect of our approach is the emphasis on interactive CFL modules. These multimedia teaching modules are used extensively in the new course as learning resources in areas where students have traditionally had difficulty or in areas where the use of media, such as video, audio or animation, is particularly appropriate to demonstrate a concept or principle. The emphasis of these teaching modules is on complementing the learning objectives of the problem of the week. (See http://www.medfac.unimelb.edu.au/bmu/projects/projectTitle.asp.)

For example, we have designed and developed a multimedia module, "Communicating with the Tired Patient," which examines the communication process between doctors and patients and focusses on integrating biological, psychological and social factors in clinical diagnosis.

When investigating a patient's complaint (such as chronic tiredness), students find that the body language and emotional response of a patient is often as important as his or her verbal response. Video is an ideal medium to capture both verbal and nonverbal responses for students. The module we have developed allows medical students to listen to a doctor's questioning method and to see how question, tone and wording affect a patient's reactions and demeanour. Students are able to view a patient's response and then answer questions about their perceptions and understanding of the clinical interview.
(See http://www.medfac.unimelb.edu.au/bmu/projects/detail/theTiredPat.htm)

"Communicating with the Tired Patient" was designed so that the user is an active participant in the virtual interview. The user plays the role of a doctor in a clinical interview and makes decisions about how she or he wants the interview to be conducted. The user listens to different questions and then chooses a question to ask the patient. The user is then able to see the implications of asking this question by observing and listening to the patient's video response. Following this step, the user is then asked a question regarding the doctor-patient interaction and the verbal and non-verbal responses observed. By reflecting on the question and the response, the user is then able to choose the subsequent direction of the interview (Liaw, Kennedy, Keppell, Marty & McNair, 2000).

The introduction of this module into first-year medicine should begin to sensitise students to the complexities of the communication process between doctor and patient. It is hoped that this will enhance their clinical interactions in the long term.

Demo 2: An external link to a demo of the the Tired Patient.

5.1 The Development Process

The Biomedical Multimedia Unit (BMU) at the University of Melbourne utilises a design and development model as a framework for completing projects (Keppell, 1998). Its main focus has been to develop a common framework (within the Faculty and within the BMU) in order to optimise the design and development of quality educational CD-ROMs and web-based materials.

The model emphasises the design, development and evaluation of CFL resources. An obvious starting point for any project is a needs assessment. In this phase the purpose, organizational factors, trainee factors, available resources, teaching and learning design and the delivery environment provide the context for the work undertaken on the project. A needs assessment determines the educational design parameters of the project and provides the context for design and development. The design phase focuses on creating the conceptual architecture for the development of the CFL resource. Evaluation is interspersed throughout the model in order to assure successful alignment with teaching and learning goals.

Demo 3: An external link to an interactive demo (1322 KB) of the Design and Development. Shockwave plugin required.

Fundamental to the entire design, development, delivery and management approach are the curriculum/pedagogical underpinnings that influence the design and development process. Consequently, the design and development of the problems of the week and the computer facilitated learning modules embody the rationale of the integrated curriculum and PBL. This is important, as Kennedy and McNaught (1997) suggest that "a culturally inclusive approach should be used in IMM design," and that "it is essential to consider both the design and use of IMM within particular educational contexts" (p. 4). What is of importance is to "match the desired educational outcomes of an interactive multimedia module with the elements which have the greatest potential to achieve those outcomes" (Kennedy & McNaught, 1997, p. 7).

6. Conclusion
We have currently completed more than 60 problems of the week, and over seventy computer facilitated learning modules are in the process of design, development and evaluation. Research on the educational impact of the IT component of the new curriculum is focussing on the problems of the week and the SDL teaching modules and their impact on the teaching of medical concepts to students.

We will continue to research PBL, through multimedia training, evaluation, design, development and project management. As students graduate from the program, we expect greater call for continuing education. We plan to expand the learning environment into a CFL and internet based system for life-long learning.

7. References
Ausubel, D. P. (1960). The use of advance organizers in the learning and retention of meaningful verbal material. Journal of Educational Psychology 51: 5, 267-272.

Ausubel, D. P. (1968). Educational psychology: A cognitive view. New York: Holt, Rinehart & Winston.

Elliott, K. & Keppell, M. (2000). Visual triggers: Improving the effectiveness of virtual patient encounters. In R. Sims, M. O'Reilly, S. Sawkins (Eds.), Learning to Choose: Choosing to Learn. Proceedings of the 17th Annual ASCILITE Conference. Lismore, NSW: Southern Cross University Press. (pp.275-283).

Brown, J. S., Collins, A. & Duguid, P. (1989). Situated cognition and the culture of learning. Educational Researcher Jan-Feb, 32-42.

Gagne, R. M. (1986). Instructional technology: The research field. Journal of Instructional Development 8: 3, 7-14.

Gordon, C. J. & Rennie, B. J. (1987). Restructuring content schemata: An intervention study. Reading Research and Instruction 26: 3, 162-188.

Liaw, T., Kennedy, G., Keppell, M., Marty, J. & McNair, R. (2000). Using multimedia to assist students with communication skills and biopsychosocial integration: An evaluation. Australian Journal of Educational Technology, 2000 16(2), 104-125.

Kennedy, D. M. & McNaught, C. (1997). Design elements for interactive multimedia. Australian Journal of Educational Technology 13: 1, 1-22.

Keppell, M., Elliott, K. & Harris, P. (1998). Problem based learning and multimedia: Innovation for improved learning of medical concepts. In R. M. Corderoy, (Ed.) Australian Society for Computers in Learning in Tertiary Education. Ascilite '98 Conference Proceedings. (pp. 417-424). University of Wollongong, NSW.

Keppell, M. (1998). Design and Development Model. Biomedical Multimedia Unit, The University of Melbourne

Koschmann, T., Kelson, A. C., Feltovich, P. J., & H. S. Barrows (1996). Computer-supported problem based learning: A principled approach to the use of computers in collaborative learning. In Koschmann, T. (Ed.) Computer Supported Collaborative Learning: Theory and Practice in an Emerging Paradigm. Mawah, NJ, Lawrence Earlbaum.

Schmidt, H. G. (1993). Foundations of problem-based learning: some explanatory notes. Medical Education 27, 422-432.

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IMEJ multimedia team member assigned to this paper	Ching-Wan Yip