ERIC EJ1136302: E-Learning and Medical Residents, a Qualitative Perspective

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by  ERIC

Information Systems Education Journal (ISEDJ) 14 (1)
ISSN: 1545-679X January 2016
E-Learning and Medical Residents,
a Qualitative Perspective
Jill Segerman.
[email protected]
Elaine Crable
[email protected]
Information Systems
Xavier University
Cincinnati, Ohio 45207, USA
James Brodzinski
[email protected]
College of Business
Valparaiso University
Valparaiso, Indiana, 46383, USA
Abstract
Medical education helps ensure doctors acquire skills and knowledge needed to care for patients.
However, resident duty hour restrictions have impacted the time residents have available for medical
education, leaving resident educators searching for alternate options for effective medical education.
Classroom situated e-learning, a blended learning delivery method, was created to find an effective
option for medical education. Qualitative phenomenological research was used to understand
residents’ perceptions of the effectiveness of, and interactions in, classroom situated e-learning and
traditional lectures. In-depth interviews were used for data collection. Analysis of the data revealed
all participants found classroom situated e- learning effective, and had a preference for interaction
that included discussion with the educator and other learners. Recommendations for future research
include a replication of this exploratory study with residents in other residency programs, and
quantitative research comparing the learning outcomes of classroom situated e-learning with
traditional lecture based learning.
Keywords: E-learning, E-education, Medical education, Online learning, Distance Learning, Resident
Education.
1. INTRODUCTION Accreditation Council for Graduate Medical
Education (ACGME) instituted a mandatory
Medical education is an integral component of reduction in resident duty hours with the intent
the medical system for ensuring that doctors to improve overall patient safety (Lin, Beck, &
acquire and maintain skills and knowledge Garbutt, 2006). Resident education is
essential for patient care. Residency programs considered a part of duty hours. Therefore, the
generally provide residents with increased reduction has resulted in a reduction of resident
hands-on experience with patients. In 2003, the education (Tempelhof, Garman, Langman, &
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Information Systems Education Journal (ISEDJ) 14 (1)
ISSN: 1545-679X January 2016
Adams, 2009). Residents reported that Residency program directors must ensure that
restricted duty hours have led to less time for their programs offer “effective educational
education (Mathis, Diers, Hornung, Ho, & Rouan, experiences for residents that lead to
2006) and missed medical education measureable achievement of educational
opportunities due to a focus on service delivery outcomes in the ACGME competencies”
to patients (Vidyarthi, Katz, Wall, Wachter, & (Accreditation Council for Graduate Medical
Auerbach, 2006). Education, 2007). The core competencies
established by the ACGME are: “patient care,
To resolve this dilemma innovative options are medical knowledge, interpersonal and
needed to help residents find time for the communication skills, professionalism, practice-
education needed to become skilled doctors. based learning and improvement, and systems
While lecture is the most common mode of based practice” (Accreditation Council for
delivery (Robertson, Yun & Murray, 2009), time Graduate Medical Education, 2011, section 4).
constraints require the use of other modes of
learning. Blended learning, which combines A survey of residency program directors in 2011
face-to-face interaction with e-learning, is being revealed that more than half of the respondents
explored as an alternative modality for medical believed that duty hour restrictions would
education. Potential benefits of this approach negatively impact residents’ achievement on at
have been shown to include flexibility (Crouch, least five of the six ACGME core competencies
2009), improved test scores (Lewin, Singh, (Antiel et al., 2011). In 2011 ACGME reduced
Bateman, and Glover, 2009), and significant the number of resident work hours which in one
cost savings (Sung, Kwon, & Ryu, 2008). institution resulted in a decrease in the number
of patients treated by residents and the number
This study investigates an option for effective of conferences offered, however, no change in
delivery of medical education that combines e- test scores was evident (Vucicevis et. al., 2014).
learning with face-to-face interaction, reflecting Program directors must determine how to
the limited amount of time necessitates all effectively deliver resident education within the
education for residents is effective. The use of context of their own programs (Holmboe et al.,
e-learning takes advantage of technology and 2005). E-learning could be a solution to the
the ability to access learning anytime and learning dilemma.
anyplace. However, it lacks face-to-face
discussion, which has been considered critical for E-Learning
student thinking and reflection. There is a need E-learning is a form of distance education, and
to find, and use, innovative educational options distance education is over 100 years old when
that will meet the learning needs of residents one considers correspondence courses (Means,
and the educational goals of residency program Yoyama, Murphy, Bakia, & Jones, 2009). Today,
directors (Templhof et al., 2009). In addition, distance learning has broadened into a wider
there is a need to understand residents’ variety of options, including e-learning, which
perceptions of effective medical education and has become the quickest growing type of
innovative learning methods in order to build e- learning in education (Mahle, 2007). E-learning
learning opportunities to provide quality is one of many phrases used to describe a
educational opportunities. learning experience that employs some type of
computer based technology to deliver education
2. LITERATURE REVIEW or profession development (Remtulla, 2007).

Resident medical education is a mandatory E-learning can be used in a variety of ways, by a
component of an accredited residency program, variety of learners, and for a variety of reasons.
yet mandated hours, full and demanding It can be used for synchronous learning,
schedules, and responsibilities make it requiring the e-learners and educators to
challenging for residents to find time to participate in learning experiences at the same
participate fully in formal medical education time, even though they are in different locations
(Templhof et al., 2009). Moreover, continuous (Means et al., 2009). Khirwadkar (2009)
physician medical education is critical to indicated that technology could engage learners
maintain and improve healthcare for all patients in meaningful dialogue around a topic, can
(Mazmanian, 2010). However, limited time and provide problem-based learning, or can be used
a continual increase in, and changing of, content to solve, or work on real life problems. Learners
in the field of medicine make medical education can experience e-learning as it attempts to
more challenging than ever (Accreditation mimic the traditional classroom experience, like
Council for Graduate Medical Education, 2007). a lecture based class, or it can create an

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Information Systems Education Journal (ISEDJ) 14 (1)
ISSN: 1545-679X January 2016
experience that is completely different from Along with these benefits come some potential
traditional classroom encounters such as problems associated with e-learning Solitary e-
electronic games, simulations, problem-based learning can be an isolating experience for
learning, or multifaceted group projects (Means, learners, and discussion supports students’
2009) critical thinking and reflection (Cook &
McDonald, 2008). Cook (2006, p. 59) found
E-Learning and Medical Education potential disadvantages could include “social
Medical education has been delivered in multiple isolation, de-individualized instruction, high
ways, with a variety of results. While medicine development costs, technical problems, and poor
continues to evolve, medical education still instructional design.”
primarily relies on passive lecture-based
experiences (Graffam, 2007). The use of web Blended Learning in Medical Education
based learning for medical education can be The use of blended learning for medical
traced back to 1992 (Westmoreland, Counnsell, education has similar variations in the definition
Tu, Wu, & Litzelman, 2010). E-learning for and usage of the term. One example of blended
medical education can be used in many ways, learning included a combination of face-to-face
resulting in a variety of possible advantages lectures and e-learning modules to teach
including: easy access to case-based learning, doctoral students in pharmacology (Crouch,
self-paced learning, connecting learning in the 2009). Another blended learning project
clinic with learning outside of the clinic (Stern, combined online modules, face-to-face
2008), flexibility, adaptability of content for discussions, and video presentations, to teach
different learners or groups, and easily general practitioners (Bekkers et al., 2010). A
updatable content (Webber, 2007). third type of blended learning, for new nurses,
was made up of face-to-face classroom sessions
Technology allows for easier creation of, and followed by a series of e-mailed questions,
access to, patient-based learning, which is delivered over time, to the learners. The nurses
considered a hallmark of medical education e-mailed their responses to the questions they
(Smith, Cookson, McKendree, & Harden 2007). received. Then the nurses were sent
Patient-based learning refers to the use of instructional feedback on their responses (Sung
patient cases as an educational tool, much like et al., 2008).
scenario based learning. Additionally, e-learning
in medical education can remove barriers related Medical students in a blended learning program
to location and time. Residents assigned to had better exam scores than their peers, who
rotations in off-site locations may not be able to took the same course in a face-to-face lecture
attend lectures at their learning institutions, or format. The blended learning course combined
hospital (Gray & Tobin, 2010). E-learning the use of e-learning modules, online
provides a broad variety of ways to present communication, and weekly communication with
content and innovative options for delivering a preceptor (Lewin et al., 2009). General
education (Bove, 2008). Researchers have practitioners who participated in a blended
found that residents are comfortable using e- learning program on antibiotic resistance
learning methods of education (Westmoreland, reported increased awareness and confidence
Counsell, Tu, Wu & Litzelman, 2010). when making decisions about prescribing
antibiotics for patients. They also reported a
Technology has been used in a variety of ways decrease in the amount of antibiotics they
to deliver medical education. Text, images, and prescribed after the blended learning program
sound can be delivered electronically. This (Bekkers et al., 2010).
eliminates the need to access expensive
machines to view certain test results like x-rays, Organizational staffs have realized benefits from
echocardiograms, and other test results. Sounds offering blended learning as a medical education
from stethoscopes, and ventricular assist devices option. The initial cost for creating the e-
can be turned into audio files and made learning component of blended learning can be
available to residents to analyze. Simulation high, but can ultimately result in a cost savings
offers a way for learners to try new skills in a over face-to-face classes. This is because
safe environment (Takayesu, Nadel, Bhatia, & blended learning allows for continued use of
Walls 2010). Content available on smart phones, electronic learning components that once
or through computers located in common areas created, can be used repeatedly (Sung et al.,
near patient rooms, can provide valuable just-in- 2008). Blended learning has been reported to
time tools when caring for patients (Bove, be less demanding on faculty time, because
2008). educators are not required to be the sole

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Information Systems Education Journal (ISEDJ) 14 (1)
ISSN: 1545-679X January 2016
disseminator of the course content (Crouch, options that will meet the learning goals of
2009). residents and residency program educators
(Tempelhof et al., 2009).
Learners in medical education have also
reported benefits from blended learning, beyond The purpose of this qualitative study was to
their gain in knowledge. Learners enjoyed the examine residents’ perceptions of the
flexibility that blended learning could offer effectiveness of blended learning and the
(Crouch, 2009). Doctors, in a blended learning effectiveness of traditional face-to-face lectures.
program for continuing education in clinical care, In-depth interviews were used for collecting
appreciated the blended learning approach data. The sample size was nine residents at a
(Shaw, Long, Chopra, & Kerfoot, 2011). Medical pediatric hospital. Given the value of education
students, in a blended learning program, during residency (Charap, 2004), the high
enjoyed the learning experience, and reported demand on residents’ time, and their limited
that they were able to apply the information time for education (Baker et al., 2010),
they learned directly to the clinical setting alternatives to traditional face-to-face education
(Lewin et al., 2009). is needed. Blended learning has the ability to
combine face-to-face interaction with e-learning
Blended Learning For This Study and could be an effective alternative to
The form of blended learning for this study is traditional lecture education.
classroom situated e-learning, a form created
specifically for use with residents at a pediatric Research Methods and Design
hospital in Ohio. This mode of synchronous This study was guided by the following research
learning puts a small group of residents and a questions:
facilitator in the same room. The content is
contained in the e-learning module, which is Question 1: How do residents perceive the
displayed on a screen located at the front of the effectiveness of classroom situated e-learning
room. The facilitator leads the residents through and traditional lecture based learning?
the e-learning module, where residents are
encouraged to solve problems, share ideas, and Question 2: How do residents perceive the
ask questions, as they move through the case interaction between the student and the content,
and the tasks being presented. The module is the facilitator or instructor, and other students in
also designed to simulate the decisions, test classroom situated e-learning and traditional
results, and order of decisions that residents lectured based learning?
must make when seeing patients.
A qualitative research method was used for this
New innovations in medical education are study because it provided the ability to gain a
needed to produce excellent doctors, and deeper understanding of the phenomenon from
residency programs are in search of innovative the perspective of the participants (Moustakas,
options for delivering effective medical education 1994), which was the intended goal of the
(Robertson, Yun, & Murray, 2009). Classroom research. This is an interpretive research
situated e-learning has the potential to meet approach, used to understand how something
those needs. However, research must be works, as opposed to trying to fix something
conducted to determine if the learners believe it that does not work (Schram, 2006). The
is an effective form of medical education. interpretive approach fit with the intention of the
research, to understand the effectiveness of
3. RESEARCH METHOD classroom situated e-learning for medical
education with residents from the learners’
This study addressed the need to find an perspectives. A phenomenological perspective
effective mode of medical education that would was used to understand how people make
make the most efficient use of medical residents’ meaning of an experience or phenomenon
limited time. Restrictions in residency hours (Patton, 2002). The aim of phenomenology is to
have impacted the time residents have for understand what an experience means for those
medical education (Accreditation Council for who have lived it (Moustakas, 1994). A small
Graduate Medical Education, 2011). Residents sample size is typical of qualitative research
also experience a highly demanding workload. (Rudestam & Newton, 2007) and is based on the
Both factors limit the time residents have for specific goals of qualitative research, in
participating in medical education (Baker, Klein, comparison to the larger sample sizes needed
Samaan & Lewis, 2010). In addition, there is a for quantitative research. Qualitative research
need to find and use innovative educational

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Information Systems Education Journal (ISEDJ) 14 (1)
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usually relies on gathering in-depth data from Question Elements Theme
small samples (Patton, 2002). 1. Problem-based or case
Perceptions of based learning
Sixteen residents participated in at least one e- classroom-situated 2. Access to an expert
learning session and of the sixteen, nine e-learning 3. Interactive or active
pediatric residents agreed to participate in the effectiveness learning
study. A total of ten interviews were initially 4. Small-group learning
conducted with the first interview being a pilot.
Perceptions of the 5. Practical or applicable
An interview protocol was created and reviewed
effectiveness of content
by three individuals to establish face validity: a
Traditional Lectures 6. An engaging educator
classroom facilitator and medical fellow; a
Table 1: Thematic Results of Research
classroom facilitator who was a physician, and a
Question 1
university professor who was a medical

anthropologist specializing in qualitative
Comfort and familiarity was one of the reasons
research. As a result of these reviews the
given for residents’ preference for lecture based
interview protocol was revised and piloted with
learning. However, only three of the
one resident. A transcript of the interview was
participants in this research made mention of
reviewed and further revisions of the protocol
lectures as a form of education with which they
resulted in an instrument that would ensure that
have comfort and experience. According to
the research goals could be addressed.
Participant 7, “I think they’re fine …it’s what I’m

used to so … I learn well with them obviously or
Each of the nine residents was interviewed for a
else I probably would not have gotten this far.”
length of time that varied from 33 minutes to
None of those participants, however, said it was
one hour. The average length of the interviews
their preferred way of learning, and two of the
was 43 minutes. During the interviews residents
participants mentioned their belief that there
were provided with the definitions of effective
were better ways for them to learn. Participant
medical education and interaction in medical
5 described a level of comfort with traditional
education being used in this research. For the
lectures: “Definitely I think in medical school it
purpose of the research effective medical
was more lecture format, and I think that’s just
education was defined as education that
the way my brain worked at that time, so I was
increases residents’ knowledge in at least one of
used to it.” However, Participant 5 went on to
the ACGME’s six core competencies; patient
describe a change in how he currently prefers to
care, medical knowledge, interpersonal and
learn:
communication skills, professionalism, practice

based learning, and systems based practice
“Now it’s more on the fly, I think it’s more time,
Interaction in medical education was defined as
and plus I won’t be listening … if it’s not applying
interaction between the resident and the
directly to my care and my scope of practice.”
content, the resident and the facilitator or

educator, and the resident and other residents
Research Question 2
or learners.
How do residents perceive the interaction

(between the student and the content, the
4. RESULTS
facilitator or instructor, and other students) in

classroom situated e-learning and traditional
Research Question 1
lectured based learning?
How do residents perceive the effectiveness of

classroom situated e-learning and traditional
This question has two elements: participants’
lecture based learning? This question had two
perceptions of the interactions in classroom-
elements: participants’ perceptions of the
situated e-learning; and participants’
effectiveness of classroom situated e-learning;
perceptions of the interactions in traditional
and participants’ perceptions of the effectiveness
lectures. In addition, each element was divided
of traditional lectures.
into the three types of interaction, between the

learner and the content, the learner and the
Analysis of the questions resulted in a total of
educator, and the learner and other learners.
six themes, which were delineated based on the

two elements. A combination of direct quotes
Analysis of the residents’ responses to this
and paraphrased statements were used to
question resulted in a total of seven themes,
support each theme. These themes are
which are delineated based on the two elements
summarized in Table 1.
of the question, and the three types of

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Information Systems Education Journal (ISEDJ) 14 (1)
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interaction. A combination of direct quotes and least two core competencies as a result of
paraphrased statements were used to support participating in classroom situated e-learning.
each theme. The themes are summarized in Six participants reported an increase in
Table 2. knowledge in at least one core competency, as a
result of participating in an effective traditional
lecture.
Method of Learning

Type of
The first research question was divided into (a)
Interaction Classroom Traditional
effectiveness of classroom-situated e-learning
E-Learning Lectures
and (b) effectiveness of traditional lectures.
Content 1. Discussion
Analysis of the data revealed four themes
2. Through the
regarding effective aspects of classroom situated
computer

Educator 3. Providing 7. Asking
e-learning: (1) problem-based or case-based
practical or questions of
learning, (2) access to an expert, (3) interactive
real world the educator
or active learning, and (4) small-group learning.
content
Data analysis revealed two themes concerning
4. Asking
participants perceived effective aspects of
questions of
traditional lectures: (5) practical or applicable
the educator
content, (6) and an engaging lecturer.
5. Feedback
Participants self-reported positive outcomes, and
from the
preference for classroom situated e-learning,
educator
adds a new dimension to the possible effective
Learner 6. Discussion educational options available for use and for
Table 2: Thematic Results of Research research in resident education.
Question 2
These findings support the need for research
that explores new ways to provide resident
Discussion education (Tempelhof et al., 2009), and the use
This research explored participants’ perceptions of blended learning for resident education (Lewin
of their lived experiences in classroom situated et al., 2009).
e-learning and traditional lectures. The research
specifically looked at their perceptions of the The second question was used to learn
effectiveness of the two forms of education, and participants’ perceptions about their interactions
the interactions they experienced in both forms in classroom situated e-learning and traditional
of education. All of the participants had lectures. Interaction in education was based on
experienced both traditional lectures and Moore’s (1989) description of three types of
classroom situated e-learning prior to interaction; with the content, with the educator,
participating in the research. The research was and with other learners. The second research
conducted using a qualitative, phenomenological question was divided into (a) classroom situated
approach. e-learning, and (b) traditional lectures, which
were each further divided by the three types of
Effectiveness was defined as an increase in interaction. When describing classroom situated
knowledge in at least one of the ACGME six core e-learning, the two themes revealed by data
competencies. The competencies are: “patient analysis, for interaction type 1 (interaction with
care, medical knowledge, practice-based the content) were (1) discussion and (2) through
learning and improvement, interpersonal and the computer. The three themes named for
communication skills, professionalism, and interaction type 2 (interaction with the educator)
systems-based practice” (Antiel et al., 2011, p. were: (3) providing practical or real world
185). information, (4) asking questions of the
educator, and (5) feedback from the educator.
Resident achievement of all six competencies is The one theme named for interaction type 3
a requirement for resident education programs (interaction with other learners) was (6)
(Accreditation Council for Graduate Medical discussion. There was no theme for interaction
Education, 2007). The first research question type 1 (interaction with the content) during
was used to understand participants’ perceptions traditional lectures. The one theme for
of the effectiveness of classroom situated e- interaction type 2 (interaction with the educator)
learning and traditional lectures. All nine was (7) asking questions of the educator, and
participants reported increased knowledge in at

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Information Systems Education Journal (ISEDJ) 14 (1)
ISSN: 1545-679X January 2016
there was no theme named for interaction type reported that interaction with the content was
3 (interaction with other learners). the most important form of interaction for their
learning. However, they had the most
Evaluation of the findings revealed the agreement regarding interaction with other
participants preference for education that is learners, and said discussion with other learners
based on adult learning theory. All nine had a positive effect on their medical education.
participants found classroom situated e- They also valued conversation and question
learning, based on adult learning theory, to be asking in all three types of interaction.
effective. Six of the nine participants were able
to name an effective traditional lecture, which There were limitations to this research. The first
are based on pedagogy (Stratman et al., 2008). being the use of qualitative research design,
Four of the six themes addressing residents’ which resulted in a small sample size. In
perception of the effectiveness of classroom addition, participation in the research was
situated e-learning and traditional lectures can voluntary, and those who chose not to
be correlated with at least one assumption of the participate could have differing perceptions than
andragogical model, Knowles’ model of adult the residents who chose to participate. Also, the
learning theory (Knowles et al., 2005). timing of the interviews, at the end and
beginning of the academic year, could have
When asked the most important form of affected the participants’ perceptions of the
interaction, for their own learning, six educational experiences.
participants chose interaction with the content,
two chose interaction with the educator, and one Resident program directors and educators could
chose interaction with other learners. This use the data from this research to further inform
matches Moore’s (1989) description of the their decisions regarding the educational
importance of the three types of interaction. The opportunities they provide their residents, and
data analysis revealed seven themes for the creation of new educational experiences.
interaction in classroom situated e-learning and There are practical applications that could be
traditional lectures. However, when looking considered for residency programs based on the
across the three types of interaction and the two results of this research. The applications for
types of learning formats, discussion stood out consideration are the value of incorporating
as a preferred form of interaction. In addition, blended learning into resident education; the
no themes emerged for interaction with the value of incorporating opportunities for resident
content for traditional lectures, although discussion and conversation, and asking of
learners indicated they believed that type of questions; and the desire to lessen the use of
interaction to be most important for their traditional lectures as a form of medical
learning. In addition, not theme was indicated education in residency.
for discussion in traditional lectures, which was
the resident’s preferred method for interaction. This research added new information to the
existing body of knowledge regarding options for
5. IMPLICATIONS AND CONCLUSIONS effective resident education. However, it also
supports continued research in this area.
This research used qualitative, Quantitative and qualitative research in the use
phenomenological design, to answer two of blended learning, in the form of classroom
research questions. The questions addressed situated e-learning, and other blended learning
residents’ perceptions of the effectiveness and options, is needed to increase the understanding
interaction in classroom situated e-learning and of the potential benefit of blended learning for
traditional lectures. Analysis of the data medical education. Additional research could
collected from this research revealed 11 themes also address the potential benefits of interaction
regarding participants’ perceptions of the between learners, in the form of discussion, and
educational experiences. conversation and question asking in medical
education.
Participants found blended learning, in the form
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Editor’s Note:
This paper was selected for inclusion in the journal as a EDSIGCon 2015 Meritorious Paper. The
acceptance rate is typically 15% for this category of paper based on blind reviews from six or more
peers including three or more former best papers authors who did not submit a paper in 2015.

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