Virtual Lectures: A New Teaching Format For The Medical School Curriculum

INTRODUCTION

For the past 20 years computer manufacturers and software developers have promised that information technology will transform how students of all ages learn in the future.1 That promise is rapidly becoming reality, as evidenced by the recent explosion of distance learning programs in traditional colleges and universities and the emergence of online universities.² In the world of medical education, software development lags behind hardware acquisition. Medical educators world-wide are only now beginning to use authoring programs such as PowerPoint, Flash, Director, and Authorware to merge text, animated drawings, digital video and sound tracks into dynamic, highly interactive educational products.^3-5 As the educational value and entertainment index of these programs increase, computer-based programs will begin to seriously compete in both efficiency and effectiveness with textbooks, live lectures, and even face-to-face small group exercises.

In this article I will describe how I am using the authoring programs Flash and Director to produce virtual lectures in histology and gross anatomy. I will also address the impact that information technology will soon have on medical education. Basically, I believe that information technology will change our world from one in which the best and most up-to-date medical information has been restricted to a privileged few at a comparatively high cost to one in which the information is available to almost everyone at very low cost. The best and most current medical information has been limited until recently to a privileged few because it has been available through the teachings of medical educators at only the best medical schools in the world. That restriction is no longer a necessary fact of life because the Internet can bring the words and visual aids of any medical educator into any computer in the world with broadband access to the Internet. Everyone will ultimately have access to the teachings of the best instructors in the world for each basic science and clinical field. Emphasis on teaching the basic sciences and clinical fields in medical school will shift toward tutoring students on how to transform medical information into medical knowledge, and subsequently from medical knowledge to clinical expertise.

Flash and Director are authoring programs produced by Macromedia. Flash is particularly suited for the production of animated figures. Using Flash, images can be moved along defined paths, rendered semitransparent or completely faded out of view, and changed in shape and color. Flash is currently used to prepare almost all of the animations in websites. Director enables an author to direct the production of his/her own movies; hence, its name. In particular, Director can be used to synchronize Flash-generated animated drawings with audio tracks. Furthermore, Director permits programming that allows student interactivity. Director movies can be saved in a format called projectors that are suited especially for the distribution of educational software because they can be played as self-running application files (that is, files that do not require inherent software at the user’s end).

Whereas Flash can be self-taught in a few weeks, the use of Director requires considerably more study if the user does not have prior experience writing code for authoring programs. However, when I was introduced to Flash and Director five years ago, I was surprised most by the fact that the basic features of these icon-based authoring programs can be mastered by a teacher within only a few weeks to a few months. These programs quickly empower a teacher to prepare his/her own educational software. In other words, we have entered the era in which teachers at all levels of education can not only serve as content experts but also as graphic artists and programmers in the production of educational software.

It is plausible that individual medical educators or small teams of medical educators will develop most of the best educational software produced in the next 20 years. Such individual and team enterprises will each have the means to produce, market, and distribute their software worldwide at relatively low cost. It is also likely that reliance by medical students on this software as their best source of medical information will increase with each passing year. At some point within the next 20 years, therefore, I believe that a crucial nexus will be attained, namely, recognition by both the medical educators and the medical students at every medical school that the educational software in certain fields produced by educators at other medical schools is decidedly superior to the programs or software offered by their own medical school. As that nexus approaches, it is likely that the teaching responsibilities of basic and clinical science instructors at every medical school will change. Instructors who have not produced high quality software products will be required to integrate other schools’ software into their courses.

The effect of information technology on the live lecture format will play a leading role in this dramatic change. I like live lectures: I liked them as a student, and I like them now as a teacher. Live lectures enable an expert in a given field to use plain language as he/she introduces students to the central facts or themes under study. Watching an animated, skilled lecturer who knows how to use imaginative audiovisual aids in his/her presentation can be a stimulating and long-remembered experience.

As an instructor with 27 years of experience lecturing on gross anatomy, I also recognize, however, that live lectures have their limitations. First and foremost, it is frankly impossible for most medical students to remember the bulk of the information presented during a 50-minute lecture. In other words, although live lectures are extremely effective and efficient in introducing students to an area of study, they are neither effective nor efficient in helping students study the details or concepts of the area. Second, students seated in the back half of a large lecture hall do not see audiovisual aids as clearly as those in the front seats. Even if images (such as PowerPoint slides) are kept simple and labeled with large text, students rarely have more than a few minutes to study an image before the lecturer proceeds to the next topic and image. Third, even when a lecturer takes care to speak slowly and clearly, some students may miss or misunderstand the lecturer’s remarks and thus take either incomplete or incorrect notes. Students are always presented with the conundrum of whether to just sit and listen in order to understand the central theme of the lecturer’s presentation or to intermittently suspend listening in order to take notes on details.

Therefore, when I was first introduced to Flash and Director 5 years ago, my first thought was that these two authoring programs could be combined to produce virtual lectures that not only correct for the limitations of live lectures but also introduce a new and stimulating feature to the lecture format: the synchronization of animated drawings with a lecturer’s remarks. Virtual lectures are not digital recordings of a live lecture, but rather lectures created in the virtual world of computers. If virtual lectures are distributed with a verbatim transcript of the lecturer’s remarks, students are given three different ways to learn the subject matter: listening to the lecturer, watching the animations, and reading a verbatim transcript of the lecturer’s remarks. In other words, virtual lectures accommodate three different types of learners: the auditory learner, the visual learner, and the textual learner.

GUIDELINES FOR VIRTUAL LECTURES

I have used Director’s capability to synchronize Flash-generated animations with audio tracks to produce virtual lectures on histology and gross anatomy. At the time of writing this article, I have completed eight virtual lectures on the histology of the digestive system and am working on the seventh of eight virtual lectures on the gross anatomy of the lower limb. I have adopted five principal guidelines in the preparation of these virtual lectures:

(1) Make the lecture format an active learning process by dividing virtual lectures into 1 to 3-minute long segments called scenes. A period of 1 to 3 minutes is generally sufficient to introduce and explain a topic or concept in a lecture. Stopping virtual lectures at the ends of scenes gives students not only the flexibility to match the pace of the lectures with their learning ability but also the capacity to change the lecture format to better fit their learning style. At the end of each scene, students have several options: go back over the scene again; proceed directly to the next scene; take notes; refer to other materials, such as a textbook or a website; or (if two or more students are watching the lecture together) discuss the scene with the other students. Virtual lectures are thus an improvement over live lectures because they afford students the opportunity to transform the lecture format into an active learning process.

(2) Title the scenes in each virtual lecture and list the titles in a menu at the beginning of the lecture. The titles essentially provide a bulleted list of the main topics that will be discussed in each virtual lecture. The menu at the beginning of the lecture also serves as an aid for review, as it permits students to quickly jump to any scene in the lecture.

(3) Include animated drawings in almost every scene. The importance of this guideline cannot be over-emphasized. It is critically important because it takes advantage of the fact that most people are better visual learners than auditory learners.⁶ The literal translation of the ancient Chinese proverb says it best: A picture’s meaning can express ten thousand words. It follows that an animated sequence of pictures can convey even more.

Animated drawings are particularly effective for teaching subject matter involving movements, such as the patterns of blood and bile flow in classic liver lobules, the vesicular transport of IgA into the lumen of the digestive tract, or the relative movements of the lower limbs during the walking gait. In discussions of structural anatomy (such as the histological architecture of a tissue or the gross structure of a synovial joint), where there is not any movement to be illustrated, animation can be applied by constructing a drawing of a microscopic region or gross structure in a stepwise fashion. Different parts of the drawing and their attendant labels are sequentially brought into view to create the sensation of animation and depth.

(4) Attempt to illustrate in the final image of a scene all the important facts, relationships, and concepts discussed in the scene. In other words, the final image should summarize the chief topics addressed in the scene. This guideline resolves the problem in live lectures of students having insufficient time to study a slide before the lecturer proceeds to the next topic and slide. It should be noted, however, that there are instances when the chief feature of a scene is an animation instead of just a static drawing or the final image cannot adequately display all the drawings presented during a scene. In such instances, students can still review the animation or other drawings at the end of a scene because Director’s programming tools make it possible to switch back-and-forth between the final image of a scene and one or more animations and drawings.

(5) Distribute a verbatim hard copy of the lecturer’s remarks with the software. This feature particularly helps textual learners. Because reference to the hard copy is the quickest way to access the subject matter discussed in a scene, it is the feature most likely to be used when students review a lecture in preparation for an examination.

DISCUSSION

As a tool used by students to learn information, it is likely that virtual lectures will prove to be more efficient and effective than all other instruments. First and foremost, they are lectures, which, until the advent of information technology in the late 20^th Century, were the most efficient tool for conveying information. Virtual lectures improve upon live lectures by teaching mainly through visual means (that is, through animation), which enhances comprehension and recall (6). Second, they transform the lecture format from a passive to an active learning process. Third, they address potential apprehension by students that material was missed or misunderstood during lecture.

The most important and distinctive feature of virtual lectures is their presentation of animated drawings in synchrony with a lecturer’s remarks. A personal story bears telling at this point, because it explains why I believe that this feature significantly improves comprehension and recall. The first virtual lecture I prepared with Flash and Director was a lecture on the histology of the liver. As I developed the storyboards for the scenes, I thought that an interesting way to emphasize the fact that the endothelial cells lining the hepatic sinusoids are densely fenestrated would be to discuss how the fenestrations permit the exchange of lipoprotein particles between the liver’s hepatocytes and the portal circulation. Although I had researched and written an article on lipoprotein metabolism about a year prior to beginning the virtual lecture on liver histology, I was chagrined to discover that within that year’s time I had forgotten much of what I had written, mainly because none of my annual teaching activities include discussion of lipoprotein metabolism. Therefore, I had to read my own article to refresh my memory before I could prepare an animation showing how lipids are exchanged among VLDL particles, HDL particles, and cells as the lipoprotein particles pass through the capillary beds of extrahepatic tissues and how this exchange of lipids transforms the VLDL particles into IDL particles. It is now 5 years since I prepared that animation, and I can still recall every salient fact because it is very easy for me to replay in my mind EVERY ANIMATED STEP of that scene. The experience of preparing this scene affirmed for me the fact that most of us understand better and remember longer what we see and do than what we hear or read.

The major drawback of virtual lectures is that they deny students the opportunity to ask questions of a lecturer in real time. Questions have to be deferred to either email or a scheduled question-and-answer session. This drawback does limit the value of virtual lectures in small classes (classes of 30 or fewer students). In a small class, the give-and-take between a lecturer and the students is valuable because it permits the lecturer to address individual needs and problems; interest in and appreciation of the subject matter increases because education becomes personalized. Such personalization, however, becomes increasingly difficult as class size increases. In classes of 100 or more students, everyone recognizes that, up to now, the live lecture format has been basically the only practical way for every student to take advantage of an instructor’s teachings. Virtual lectures, however, provide a better alternative to teaching large classes. It is thus likely that the extent to which virtual lectures replace live lectures in medical school and allied health courses will be a function of class size, with the guideline being that the larger the class size, the greater the value of virtual lectures.

As a tool used by medical educators to teach, virtual lectures elevate the curriculum to new levels. The curriculum of the pre-clinical years no longer has to be a dense schedule of live lectures through which students are introduced in lock step to narrowly defined disciplines, such as the various anatomical sciences, biochemistry, physiology, immunology, and pharmacology. Teachers are freed to use virtual lectures in combination with other educational tools (textbooks, websites, problem-based exercises) to focus student effort on using medical information to acquire medical knowledge and to develop clinical skills. As described by Newby et al.⁷ in their book Instructional Technology for Teaching and Learning, information technology provides the means by which teachers’ roles will “shift from the usage on the stage” to the “guide on the side”. Instead of conveying information, they will help learners make use of new information tools to find, analyze, and synthesize information; to solve problems; to think creatively; and to construct their own understandings.

Medical educators, in particular, are also freed to explore integration of their courses both horizontally (within an academic year) and vertically (across academic years). Because virtual lectures make it convenient and easy for teachers to learn what is being taught in other courses, virtual lectures may accelerate the trend of teaching the basic sciences from a more integrated perspective. For example, virtual lectures could greatly assist a team of basic science teachers (consisting of a gross anatomist, histologist, biochemist, physiologist, and immunologist) to work with a gastroenterologist to create a program where first-year medical students learn from a team of basic science teachers the gastroenterology view of the digestive system. Such an approach would present basic science material in its most relevant perspective.

Despite all the lofty pedagogical benefits of virtual lectures just cited for both students and teachers, it would not be surprising if convenience and time management prove to be the principal factors that bring virtual lectures into the medical school curriculum. With virtual lectures, students can enjoy all the benefits of live lectures from the convenience and comfort of their own home or a place of their choosing. It is difficult to believe that most students will choose to slog through inclement weather and congested traffic to attend an 8:00 AM lecture in a cramped and stuffy lecture hall if the alternative is to walk into the kitchen nook, study, or bedroom at home and turn on the computer to “attend” a virtual lecture. This choice should only grow in popularity as students come to recognize the time-saving nature of asynchronous and distance learning. Although almost all of my students evaluate me as a superior lecturer, I believe, nonetheless, that most students a decade from now will prefer virtual performances of my efforts to that of live ones, mainly because of the convenience and the time saved in “attending” a virtual lecture. The truth be told, if I were a student right now, I would prefer my virtual lectures; that is why I am working on them.

There are, however, several factors that will impede the development of virtual lectures and their introduction into the medical school curriculum. Quality virtual lectures require hundreds of hours to complete. Moreover, there is very little financial incentive to undertake such efforts. Apprehension by both faculty and deans, however, is the greatest impediment. Although I have been judged to be a superior lecturer throughout most of my teaching career, I am not the best or second best basic science teacher in my school; at best, I am tied for third or fourth position with a number of other instructors. If I were not an advocate of virtual lectures, I would probably perceive the replacement of my live lectures by someone else’s virtual lectures as a threat, if not to my livelihood, then certainly to my professional self-esteem. If I were a dean of academic affairs contemplating the introduction of virtual lectures, I would be confronted with a multitude of issues:
??bf?How will the school fill the hours in the first and second years previously occupied by live lectures?
??bf?How can senior teaching faculty be encouraged to adapt to the use of virtual lectures?
??bf?Do teaching faculty need to know more about information technology than the use of PowerPoint and the school’s learning management system?
??bf?What will students think of the school’s reputation if some courses are taught, in effect, by teachers in other medical schools?

Given the time and effort it will take to prepare quality virtual lectures, it is possible that many schools will begin exploring how to use information technology to change the lecture format by introducing digital recordings of the school’s current live lectures. Such digital recordings are relatively easy and cheap to produce and feature the school’s own teachers. Their production should prompt teachers to take the initiative in evaluating how this new medium can be best employed. Such evaluation would presumably lead to the gradual inclusion of Flash animations and thus the gradual conversion of the digital lectures into virtual lectures.

In conclusion, I believe that one of the most significant ways that information technology will change medical education will be the substitution of many, if not most, live lectures during the preclinical years by virtual lectures. Student recognition of convenience, better time management, greater comprehension and improved recall should all combine to popularize virtual lectures. Faculty recognition of a greater opportunity to tutor students as well as to teach their subject matter should enhance the extent to which students appreciate and actually use the basic sciences in clinical practice.

Finally, examples of scenes from some of my virtual lectures (including the scene from the histology lecture on the liver discussed in this article) can be reviewed by emailing the author at anafxs@gwumc.edu.

REFERENCES

1. Roblyer, M.D. and Edwards, J. (2000). Integrating Educational Technology into Teaching, Chapter 1: Educational Technology in Context: The Big Picture, New Jersey, Prentice-Hill, Inc.
2. World wide Learn, (the world’s largest directory of online education) www.worldwidelearn.com
3. Sanford, B., Schmidt, R., and Jensh, R. (2003). Intermediate and Advanced PowerPoint Presentations. Proceedings of the Seventh Annual Meeting of the International Association of Medical Science Educators, Georgetown U., Washington, D.C.
4. Anderson, P. and Walsh, J. (2003). Web Pedagogy: Developing and Delivering On-Line Instructional Content for the Health Sciences. Proceedings of the Seventh Annual Meeting of the International Association of Medical Science Educators, Georgetown U., Washington, D.C.
5. Gould, D. J and Dolan, T. (2001). The Cranial Cavity and Meninges; An Example of a Course Specific Digital Lecture. www.mednet2001.drmm.uniud.it/proceedings/paper.php?id=67
6. Robbins, J. (1997). High Impact Presentations: A Multimedia Approach, p. 118, New York, John Wiley & Sons.
7. Newby, T. J., Stepich, D. A., Lehman, J. D., and Russell, J. D. (2000). Instructional Technology for Teaching and Learning: Designing Instruction, Integrating Computers, and Using Media, Chapter 11: Issues and Directions in Instructional Technology, p. 264, New Jersey, Prentice Hall.