Dr. med. Alexander Nast Division of Evidence Based Medicine (dEBM), Klinik für Dermatologie Charité Universitätsmedizin Berlin, Campus Charité Mitte Charitéplatz 1 D-10117 Berlin Tel.: +49-30-45 0-51 8-28 3 Fax: +49-30-45 0-51 8-92 7 E-mail: email@example.com
Background: Numerous e-learning initiatives have been launched during the last decade. Many of them have not been continued, due to lack of acceptance on the part of the students, low quality or insufficient financial funding. Since 2002, the DEJAVU project has been integrated into the curriculum at the Department of Dermatology at Charité-Universitätsmedizin Berlin. DEJAVU offers an online archive of recorded lectures, lecture hand outs, structured learning modules, and case reports as well as online information about the courses/classes.
Methods: Since beginning of the summer semester 2005, the student's acceptance and utilization of the online offerings was regularly surveyed, using anonymous questionnaires handed out together with the final exams. The teaching staff's opinions about e-learning were surveyed by means of a single anonymous questionnaire.
Results: At the end of winter semester 2006/2007,93.5% of the students were aware of the existence of the e-learning program. The average amount of time spent with the program was 14.7 hours over the course of one semester. 66.8% of the students considered the program as very useful for their dermatology training. The lecture notes were the most frequently used online resource. Among the teaching staff, 86% considered e-learning a useful addition to traditional teaching.
Conclusions: Our results show that e-learning is very well accepted by our students. It offers an additional way of acquiring knowledge and should be used to complement traditional ways of teaching.
E-learning generally refers to computer-assisted learning using Internet-based or non-Internet-based learning materials and programs . In recent years it has primarily been used to refer to Internet access to learning materials and is also used as such in the present paper. In the past 10 years a number of e-learning projects have been initiated. Yet, after initially being greeted with enthusiasm, many of these have failed due to lacking acceptance among students and teachers or because of lacking resources. Thus, only a very small proportion of German medical schools offer e-learning programs.
One such initiative is the Dermatological Education as Joint Accomplishment of Virtual Universities (DEJAVU) project. This e-learning program was started in 2001 as a joint project of the universities of Mannheim (now Berlin), Würzburg, and Jena. Funding was initially provided by the German Federal Ministry of Education and Research (BMBF). Originally, at the heart of the project was a multimedia database with various learning materials. After the initial funding ran out, the project was continued in Berlin with the support of MeduMobile (Medical Education Mobile) and ELWIS Med (e-learning for the sciences), two department-wide projects for integrating e-learning into teaching (both were supported by the BMBF project “e-learning services for the sciences”) and the e-learning program was expanded in an interactive learning platform . Since 2006 the DEJAVU project in Berlin has been financed only by the teaching budget of the department of dermatology.
DEJAVU offers students the chance to familiarize themselves on their own with topics in dermatology or to review their knowledge independently. It is a purely optional supplement to classroom lectures. In its current version, DEJAVU includes texts, case studies, online lectures, lecture notes, thematic training modules (e.g., on efflorescences), and a practice test. Along with external links, DEJAVU also offers a platform for communication between students and teachers in chat rooms and forum discussions. At the heart of DEJAVU are online lectures which are updated every semester. Students have access to an online archive that contains PowerPoint presentations which are synchronized with sound recordings from lectures. Online classes have been recorded in MP3 format and synchronized with the slides using Microsoft Producer 2003 for Microsoft Office PowerPoint. Students are thus able to review part or all of all currently offered classes.
To ensure adequate acceptance and assess actual usage, students are asked to evaluate the program at the end of every semester. Data collection is important for user-oriented planning of the e-learning program. The present paper gives a summary based on the data collected thus far. There are a number of published studies evaluating the usefulness and acceptance of e-learning programs in medical training. Studies have investigated such topics as student acceptance and use of e-learning as well as potential improvements in learning achievement as a result of e-learning compared with the traditional classroom lecture format.
Smolle and colleagues conducted a controlled study with 26 medical students to compare the traditional classroom lecture format with a computer-based training program (CBT) in dermato-oncology. On the final exam, the authors found that questions based on information taught by CBT were answered correctly 9.8 % more often than those for which the correct responses were provided in traditional classroom lectures .
As Fischer and colleagues reported in 2005, implementation of a case-based computer learning program in the curriculum of internal medicine could achieve high acceptance and motivation among students; in their study 47 % reported subjective learning success and 95 % said they would like to continue to study with the program [4, 5].
In a study by Wahlgren and colleagues, students reported extremely high acceptance (100 %) of the e-learning program developed by the authors, which is based on clinical cases and called NUDOV (Nationellt Undervisningsprogram i Dermatologi Och Venereologi). Use of NUDOV did not, however, lead to significantly better test results on the final written exam .
Freeman and colleagues investigated the acceptance of an e-learning program among 124 students of pharmacology. Only 30 % of students preferred online lectures over traditional teaching. Half of students rejected the idea of replacing classroom teaching with e-learning. The round-the-clock availability of e-learning programs and thus added flexibility was considered a distinct advantage . In a study of 329 psychology students, Grabe and colleagues examined preferences for lecture summaries, detailed lecture notes, or audio recordings of classroom lectures. Lecture summaries were clearly preferred (61 %), followed by detailed lecture notes (19 %) and audio recordings (3 %). A correlation between the preferred format (classroom teaching versus various e-learning services) with test results did not reveal any clear advantage of one method over the other . The aim of this study is to examine the acceptance and knowledge of students and teaching staff on the use of e-learning in dermatology at Charité University Medicine in Berlin.
Integration in the curriculum
DEJAVU is intended for medical students in the second clinical semester and should be used alongside lectures to clinical examination courses. The program is also available upon request to students of other departments.
Technical implementation of the e-learning program
We use the open source learning system (LMS) Moodle which is installed at the Humboldt University in Berlin as the platform for providing contents. The Moodle system offers all necessary functions, from user administration to communication tools and other tools for creating content in a well-organized and user-friendly interface. No prior knowledge of programming is needed.
To use the system, instructors need a standard PC with a broadband Internet connection, Microsoft PowerPoint, and an Internet browser. Students must have a standard PC with a broadband Internet connection (important for accessing online lectures which require a high-speed, continous connection), an Internet browser, and a valid e-mail address. Registration with DEJAVU requires a password which student enters once after registering his or her Moodle account. Passwords are distributed during the lectures or at orientation, during which DEJAVU is also briefly introduced.
Students: The use and usefulness of the e-learning program has been evaluated with an ongoing survey since 2005. The survey is conducted at the end of every semester when final exams are held. Questions ask about the technical equipment used by the student, frequency of use of the e-learning program, and an evaluation of its individual components. Instructors: Instructors were surveyed once in 2005 at the beginning of the ELWIS-Med project. Questions were asked about experience with e-learning, the usefulness of the program, and willingness to participate in the e-learning project.
Surveys were anonymous and participation voluntary. All data were stored in a Microsoft Excel database and analyzed using SAS/SPSS.
Technical equipment of participating students
In 2006 the survey asked 404 students about the technical equipment they used. Of these 188 (465 %) had a DSL connection. Fifty-three students (13.1%) had ISDN (Figure 1). Students were also asked about the type of rate they pay (e.g., flat rate or by the minute). Of those students with Internet access (316), 178 (56.3 %) had a flat rate and thus unlimited use. The remainder paid per minute.
Student use and acceptance of the e-learning program
The first survey was conducted during the summer semester of 2005 and included 91 students, with subsequent surveys being conducted at the end of each semester thereafter. During the winter semester of 2005/2006, there were 268 students surveyed, in the summer semester of 2006 there were 256 survey participants, in the winter semester of 2006/2007 there were 260, and in the summer semester of 2007 there were 190.
Awareness of the DEJAVU e-learning program
Awareness of the existence of the online program has steadily risen. In the summer semester 2005 82.4 % or respondents were familiar with it. By the summer semester 2007 this number had increased to 93.5 %.
Use of the e-learning program
There are enormous differences among students by semester with regard to the hours spent using the e-learning program (Figure 2). The median in summer semester of 2007 was 10.0 and average 14.7 hours (standard deviation: 1.57). Figure 2 shows that in the summer semester 2007 26.3 % of students spent between 0.1 and 5 hours working with DEJAVU. These figures are based on self-reports. Along with non-responses, answers such as “days” or “forever” were not included in the analysis.
Value of individual components of the program
The practice exam was used by the greatest number of students, followed by lecture notes (i.e., PowerPoint lecture slides without sound) and online lectures (PowerPoint slides with sound).
Figure 3 shows the use of different components (online lectures, lecture notes, etc.) and the most important learning module. The results given here are reflected in the desire for expansion of the e-learning program. Topping the users' wish list was a continuation of online lectures (52.1 %), followed by the desire for additional thematic modules (34.2 %). Of those who said they did not visit the online lectures, 64.1 % cited technical difficulties such as lacking equipment.
When asked about the usefulness of the DEJAVU e-learning program for their training in dermatology, 66.8 % of students said it was extremely useful and another 16.3 % said it was highly useful.
Survey of instructors on e-learning
A total of 21 instructors participated in the survey. These included 18 assistant physicians and 3 senior physicians. 66.7% of respondents said e-learning was a useful or highly useful supplement to traditional classroom lectures. None of the instructors found e-learning to be of little or no use (Figure 4). 28.6 % found that transferring course contents from traditional classroom lectures to e-learning modules would be useful or very useful. 28.6 % said it was of little or no use. Around half of surveyed instructors said they had a clear understanding of e-learning and its potential for teaching (Figure 5). Only 19 % had previously used e-learning. 28.6 % were interested or very interested in participating in an e-learning project, while 33.3 % had little or no interest.
University medical education is changing. In times of few resources and growing demands placed on universities by new German regulation on the licensing of doctors, medical schools need innovative concepts. E-learning offers the potential for providing more course options to students. It allows students to view course material independently and at their convenience on their own PC. Given its visual nature, dermatology is particularly well-suited to the use of this medium.
For more than three years the department of dermatology at the Charité in Berlin has built on three BMBF projects to assess potential uses of e-learning and its acceptance among students. Our results show that e-learning is well accepted by dermatology students. Both awareness of the program as well as average use have grown considerably over the years. This may be viewed as an expression of the high level of acceptance by students of the e-learning program. In a study on the acceptance of an e-learning course in pharmacology, Hahne and colleagues reported a low level of acceptance which they attributed primarily to poor quality of the e-learning program . After Hahne et al. there is the risk that e-learning projects of poor quality will negatively influence the willingness of students to use e-learning in general. Yet Martin Fischer describes the potentially positive influence of e-learning on the use and practice of methods for gathering and managing information .
Our data indicate a high demand for e-learning and its popularity among students. This was especially evident for online lectures. Our findings thus diverge from the low level of acceptance of audio courses reported by Grabe et al. in 2007 . This is perhaps due to students having better technical equipment over time. Online classes, in particular, require high-speed Internet. Lower necessary broadband speeds may also explain why lecture notes were accessed more often. The comparably low use of case reports (compared with lecture notes and online lectures) may be due to their pure report-like nature; Fischer and colleagues [4, 5], for instance, cited very high acceptance of case-based learning methods.
The wide variation seen in hours spent using the e-learning service shows that its appeal varies. E-learning is an additional service designed to complement classroom lectures. It should not completely replace conventional teaching methods such as lectures and bedside teaching. A few students spent a very large number of hours using DEJAVU, suggesting that for some e-learning is the preferred way to learn, while not necessarily demonstrating that one method of teaching necessarily is superior to the other. This appears to be confirmed by the previously mentioned findings of Grabe and colleagues, who found no clear correlation between test results and preferred learning method.
Our survey did not reveal any strong resistance to e-learning. Respondents generally cited technical problems as the reason for not using the service. As students have better technical equipment this would be expected to be less of a problem.
Use of the Moodle learning management system was very positive. This system allows simple creation of contents without prior knowledge of programming as well as the ability to communicate with students. It also offers a way of providing course contents, e.g., for smaller groups, as is common in bedside teaching. The majority of instructors similarly recognized and accepted e-learning as an additional learning resource. Yet, its integration into actual teaching slow. One reason may be that most instructors surveyed are involved in bedside teaching and less so in seminars and lectures. Developing e-learning modules for bedside teaching could help increase acceptance.
We are grateful for the support provided by the teaching secretariat of the Department of Dermatology, Allergology and Venerology, headed by Frau Judith Rosteck, as well as the cooperating partners in DEJAVU who helped initiate the DEJAVU project.