Result: Can medical students from two cultures learn effectively from a shared web-based learning environment?
Centre for Medical Education, University of Gifu, Gifu, Japan
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Further Information
OBJECTIVE This study aimed to establish whether medical students from 2 different cultures can learn effectively from a shared web-based learning environment. METHODS Students from the College of Medicine, Edinburgh, UK and the Medical School, Gifu, Japan shared 2 weeks of teaching and learning in clinical genetics, using problem-based learning in a web-based application (WBA). Questions about language, time zone, agreement about the curriculum (learning outcomes, tutor activity and assessment) and specific pedagogical issues about the educational effectiveness of students' learning were considered. RESULTS AND CONCLUSIONS The evidence indicates that a shared WBA is practical where the learning outcomes and problem scenarios are common and students are fluent in the same language. Problem-based learning transfers itself best to online discussion boards when the numbers in the group are 16 or more. Students do not use the WBA as a primary source of resource material, and they augment the discussion boards with face-to-face meetings with peers and tutors.
AN0027968252;esf01jan.08;2019Jun04.08:21;v2.2.500
Can medical students from two cultures learn effectively from a shared web-based learning environment?
Objective This study aimed to establish whether medical students from 2 different cultures can learn effectively from a shared web‐based learning environment. Methods Students from the College of Medicine, Edinburgh, UK and the Medical School, Gifu, Japan shared 2 weeks of teaching and learning in clinical genetics, using problem‐based learning in a web‐based application (WBA). Questions about language, time zone, agreement about the curriculum (learning outcomes, tutor activity and assessment) and specific pedagogical issues about the educational effectiveness of students' learning were considered. Results and Conclusions The evidence indicates that a shared WBA is practical where the learning outcomes and problem scenarios are common and students are fluent in the same language. Problem‐based learning transfers itself best to online discussion boards when the numbers in the group are 16 or more. Students do not use the WBA as a primary source of resource material, and they augment the discussion boards with face‐to‐face meetings with peers and tutors.
Keywords: education, medical, undergraduate/*methods; problem‐based learning/*methods; *culture; Japan; Scotland; multicentre study [publication type]; *Internet
Problem‐based learning (PBL) and e‐learning are now routinely used in many medical schools. The University of Edinburgh, in the UK, introduced PBL into its curriculum in 1998 and in the same year began to develop and implement the Edinburgh Electronic Medical Curriculum (EEMeC). The University of Gifu, Japan, introduced PBL in 1996 and has piloted online learning tutorials using both e‐mail lists and by following PBL principles.[1] International affiliations, such as Universitas 21 (http://www.Universitas21.com) and International Virtual Medical School (IVIMEDS) (http://www.ivimeds.org), are indicative of opportunities that have been taken to establish global partnerships that are aligned with e‐learning.
Tichon[2] acknowledges the recent trend for universities to offer online courses and reports on the quality of experience in motivating students through online PBL over a 12‐month period. Orrill[3] describes the tools that support online PBL, and Dennis[4] has demonstrated that there is no significant difference (and therefore no disadvantage to students) between the outcomes of graduate students using computer‐mediated PBL with an asynchronous threaded discussion tool and those using traditional PBL. Salmon[5] has written extensively about the dynamics of online learning and teaching.
However, there is very little evidence in the literature about online learning shared between students who are attending medical schools in different countries. This investigation sets out to evaluate the experience of an online, PBL activity in a cross‐cultural situation. The study explores how far it is possible to use a web‐based application (WBA) as the single source for teaching and learning by undergraduate students in an international dimension using student‐centred approaches characteristic of PBL. Questions about language, time zone, agreement about the curriculum (learning outcomes, tutor activity and assessment) as well as specific pedagogical issues about the educational effectiveness of students' learning were considered.
The schools
The College of Medicine in Edinburgh, UK and the Medical School in Gifu, Japan each run courses in clinical genetics for Year 2 students. These courses overlap in time for a period of 2 weeks and have broadly similar learning outcomes. Teachers at both schools were interested in shared teaching and learning. Both schools had established PBL programmes. Students in both schools were used to using computer‐based learning environments(EEMeC in Edinburgh and Blackboard in Gifu). The similarities were considered to be sufficient to carry out a trial of inter‐university teaching and learning without causing any disadvantage to the students.
Methods
The learning environment
The shared WBA known as the 'Gifu and Edinburgh Learning Activities Through Interactive Networking' (GELATIN) was programmed specifically for this investigation. GELATIN was an online PBL and communication platform used by all the students in this study. The philosophy of the platform was based on existing experience of the EEMeC and it has many of the features described by Britain and Lieber.[6] The main utilities include discussion boards, a reference board, learning materials and facilities for personal profiles. All teaching and learning was conducted through the WBA. The web‐page was introduced to the students and an orientation session prepared.
The students
The 220 Edinburgh students and 80 Gifu students were arranged in their normal PBL groups, each with 8 students per group. The normal PBL groups were kept to preserve the regular social structure of the students. Ten PBL groups of Edinburgh students (the Edinburgh‐paired group) were paired with the 10 PBL groups of Gifu students (the Gifu group), with 16 students per subgroup. The remaining Edinburgh students continued in their usual PBL subgroups (
Language
English was the language used. This has to be qualified in the context of Japanese medical education. The entrance requirement to Gifu medical school includes English. 'Medical English' is a component of the course. However, it was not known how the range of ability, in English, of the Japanese students would affect the distribution of the assessment results. Some Japanese students are very active in learning English, and might have a comparative advantage over their peers. If this was true, it would be revealed in the distribution curve. It was also surmised that Gifu students might achieve low scores in comparison with Edinburgh students, as a result of psychological resistance to English and the additional necessary workload above the PBL task.
The case and assessment task
The academic organisers (WL and YS) agreed that the learning outcomes of the 2 schools were very similar. A case about a family with a history of phenylketonuria was selected as the clinical context. The case was provided online to all students. It opened at the start of the first week and the scenario was extended at the start of the second week.
The groups were given a task based on the case, which was to be assessed. Issues about the assessment were problematic because the schools normally use different assessment instruments. Edinburgh uses a portfolio and an end‐of‐semester examination. Gifu uses case reports and end‐of‐course examinations. It was considered important to have an assessment that was common to all the students. It was therefore agreed that the task would require the writing of a letter supposedly from a consultant to the family practitioner who had referred the patient. This would be used formatively for the Gifu students (who received support for writing in English, as required). This is a normal assessment exercise for Edinburgh students. A carefully worded explanation and marking scheme was given to all students so that the expectations were made as clear as possible.
Evaluation
Evaluation was completed by analysing the content of the WBA and by administering a questionnaire that sought student opinion (available as supplementary material). Activities on the WBA included the nature of online actions, discussion threads (categories and frequency), materials downloaded to the resource area, and the general pattern of usage.
The student questionnaire had a maximum of 38 questions (some questions were not relevant to all 3 groups). Each question had 5 possible responses, scored on a 5‐point Likert scale, where 5 = strongly agree, 4 = agree, 3 = neither agree nor disagree, 2 = disagree and 1 = strongly disagree. Cronbach's alpha was calculated for each group separately and for all the groups combined in each case. Only those students who answered all the questions relevant to their particular group were included. Cronbach's alpha can be viewed as the correlation between the scale considered and all possible scales containing the same number of items that could be constructed from a hypothetical universe of items that measure the characteristic of interest. It expresses the co‐efficient of reliability and the usual acceptable score is 0.70. The Kruskal−Wallis test was used to compare the responses to each of the 32 questions answered by all 3 groups of students. Bonferroni correction was applied to take account of multiple comparisons.
Results
Analysis of the use of the application
GELATIN discussion boards generated 81 threads, of which 59 were from Edinburgh−Gifu subgroups and 22 were from Edinburgh‐only subgroups, and a total of 462 messages (Fig. 1). (A thread is defined as a specific topic that generates a series of messages.) The average number of threads per subgroup for the Edinburgh−Gifu subgroups was 6; that for the Edinburgh‐only subgroups was 3. Seven Edinburgh‐only subgroups did not utilise the discussion boards at all. However, a significant amount of cross‐group discussion emerged on the EEMeC discussion boards.
Graph: 1 Frequency of messages
A pattern of statements emerged in the student discussion boards (Fig. 2): students first introduced themselves and then listed some key questions of interest. This led to a detailed discussion about the questions and resource materials were added. Students raised a broad range of issues, including medical, psychological, geographical, cultural and historical issues related to consanguinity and inborn errors of metabolism. Students commonly exchanged information about their colleges, as well as personal information. Gifu students were able to communicate in English better than had been anticipated by their teachers.
Graph: 2 Message categories
A total of 86 uploads were made by students to the group libraries; 53 entries were from Edinburgh‐Gifu groups (Edinburgh‐paired with Gifu) and the remaining 33 were attributable to Edinburgh‐only groups. All except 1 of the Edinburgh‐Gifu groups entered data into their group library, while only 4 of 14 Edinburgh‐paired groups utilised this function.
Questionnaire
The following 3 groups of students completed a questionnaire: Gifu students; Edinburgh‐paired students, and Edinburgh‐only students (Table 1).
1 Summary of responses to the questionnaire
Table 2 summarises the significant results.
2 Responses with significant results
Assessment
Because of the different assessment programmes used in the schools, the assessment exercise was formative for the Gifu students, but was marked as 'course‐work' for Edinburgh students. Tutor WL marked all the letters and tutor YS second‐marked a sample of 30%, to a predetermined marking scheme. Gifu students were given support in writing in English, and the marking scheme allowed grammatical errors to be forgiven. All the students succeeded in completing the task and no significant differences were found in the distribution of results between the 2 schools using a paired
An analysis of the questionnaire results for the Japanese students did not indicate any significant bimodality in the distribution of scores. This suggests that the extra effort of working in English had not favoured students who were more actively interested in English.
Discussion
The study set out to establish if it was possible to prepare a virtual learning environment that could be shared by undergraduate students in an international dimension, using student‐centred approaches characteristic of PBL. Other questions raised at the start of the project were about language, time zone and agreement about the curriculum (learning outcomes, tutor activity and assessment). Specific pedagogical issues about the educational effectiveness of student learning were considered.
The evidence confirms that learning and teaching does take place in a shared WBA, although this assertion requires further qualification. Students engaged with all the functions of the WBA but the WBA did not emerge as the sole vehicle for their learning. Students spontaneously adopted a blended learning strategy and arranged their own face‐to‐face discussions with their peers and teachers, suggesting that the functions of this WBA were not sufficient to displace personal contact. Some Edinburgh‐only students set up some discussion threads using the more familiar EEMeC discussion boards, suggesting that they preferred their usual WBA. This did not occur with students at Gifu, probably because Gifu subgroups were all paired with Edinburgh subgroups. Responses to the student evaluation (Q35 and Q36) indicated that GELATIN did not make a significant contribution to Edinburgh students' understanding of research for the case, although it found more favour with Gifu students. The fact that GELATIN was not perceived by the students as the primary learning mechanism was perhaps because it was introduced for a short period within an established programme. This suggests that consistency and conformity of WBAs in time and across institutions should be established at the start of the programme because the relationship is difficult to change during the programme.
In the normal pattern of PBL, students introduce themselves initially, then read the case, 'brainstorm' to establish the key issues of interest, and prepare questions for private study. At a later meeting, information with references is brought back to the group for discussion, synthesis and conclusions. Evidence from the discussion threads indicates that students attempted to follow this process, but as text‐based messages limited the pace and speed of the discussion, the nature of the interaction was inevitably different. The paired groups generated more interaction than the control group and individuals in the paired groups displayed interest in getting to know each other. It was also noted that the students set up face‐to‐face study subgroups outside the WBA. It was necessary for Gifu students to discuss some things in Japanese to help them learn more English. It is normal for Edinburgh students to have short intermediate meetings between PBL sessions. This suggests that the merits of the WBA are not sufficient to overcome face‐to‐face discussion. However, unlike face‐to‐face PBL where specific times for meetings are arranged, contributions to the threads were more regularly distributed throughout the week, and were not restricted to specific times, although these had been timetabled.
Group size also appeared as an influential variable in the discussion threads. The paired subgroups (of 16 individuals each) were larger than the control subgroups (8 individuals each) and therefore more threads were generated in the paired subgroups. This led to speculation that discussion groups in WBAs require a much larger number of participants in order to develop a suitable critical mass of activity. Just as face‐to‐face groups seem to work best when numbers are between 6 and 9, discussion threads work better when the numbers of contributors are larger, possibly over 20. This is a variable worthy of further investigation.
The reasons for using English have already been outlined, but the consequences for the student experience were not easily established. All the Japanese students contributed in English and all the tutors agreed that the students' performance was better than they had anticipated: many individuals wrote in near‐perfect English. The issue of using English was not included in the student questionnaire, but some of the results of the questionnaire may be explained by taking the use of English into account. These are discussed in more detail later.
Apart from the obvious delay between posting and responding to messages, there was no evidence to suggest that different time zones (Japan was 9 hours ahead) had any significant influence on the function of the WBA. By comparison, the time‐log of the Edinburgh EEMeC discussion boards indicates that students log on throughout a 24‐hour period, suggesting that the GELATIN asynchronous time zone functioned equally as well as same‐time or real‐time discussion boards. However, the 2‐week time window was felt by the observers to be too short to allow the students to get used to the WBA or to get to know each other.
Student satisfaction with the delivery of the curriculum was variable. Edinburgh students found both the case (Q9) and the task (Q20) more interesting than did Gifu students. Edinburgh students were encouraged to work with other students much more than Gifu students (Q18), although the reasons for this are not easily identified from the available evidence. The information and comments given by tutors were also favoured more by Edinburgh students than by Gifu students (Q4 and Q7). One hypothesis that may account for this is that non‐native English language speakers find that learning academic concepts in English is more challenging and are therefore distanced from the concepts and find the topic less engaging than native speakers.
Although the task itself was planned and agreed with Gifu teachers, Gifu students, generally, did not perceive writing a letter in English as a useful task and may not have recognised its professional value.
Evidence from the questionnaire indicated that GELATIN was not perceived as a primary resource for reference materials. GELATIN was not set up with a repository of information, but it did have a library to which students could download resource information. This was thought not to be useful (Q29). A possible explanation for this may be that resource materials are not useful in themselves until they are edited to answer specific questions, in which case the judgement refers more to the nature of the materials than to the facility.
Limitations
The short time‐frame restricted the quality of sampling as, ideally, observations should not be made until the activity becomes routine and no further change is detected. Although the time window was short, the authors believe the evidence is sufficiently clear to make some broad conclusions.
Questions about differences in the use of English between first‐ and second‐language users could not be fully explored within this study.
Conclusions
Online learning, using a PBL approach, between students who are attending different medical schools is probably practical where participants share the same language and have a common curriculum. The structure of the WBA should be based on the WBAs normally used by participating schools and there should be sufficient time for students to orientate themselves to both the WBA and other students. The traditional format of PBL does not seem to transfer easily to threads on discussion boards where the number of students in the group is 8, but works well when the group has at least 16 members. However, students do not rely totally upon online discussions for the exchange of ideas and have a natural tendency to arrange face‐to‐face meetings with peers and tutors and to seek learning resources from sources outside the WBA. Both of these traits suggest that programme coordinators should recognise the significance of blended learning in institutions that have full‐time students.
<bold>Contributors: </bold> PE initiated and co‐ordinated the project and drafted the paper. YS co‐ordinated the project in Gifu, and, with WL, established the academic content and marked the assessments. MB wrote the web‐based application. All authors were tutors on the programme and read and edited the final draft.
<bold>Acknowledgements: </bold> the authors acknowledge Keith Wylde and Kathryn Shreck of the College of Medicine and Veterinary Medicine ACT Office, Edinburgh, for assistance with data entry on the student questionnaire, and Dr Susan Holloway, clinical scientist, South East of Scotland Genetics Service, for advice and support with the statistical calculations.
<bold>Funding: </bold> none.
<bold>Conflicts of interest: </bold> none.
<bold>Ethical approval: </bold> ethical approval was granted by the College of Medicine and Veterinary Medicine Ethics Committee by chairman's decision. The project was conducted with the approval of those with overall responsibility for the respective medical school programmes.
Overview
What is already known on this subject
Students are motivated by PBL online. There is no significant difference between the outcomes of graduate students using computer‐mediated PBL with an asynchronous threaded discussion tool and those using traditional PBL.
What this study adds
This study identifies evidence about an experience with an online, PBL activity in a cross‐cultural situation.
Suggestions for further research
A long‐term study of online PBL using a web‐based application would enable a SWOT analysis that might lead to successful curriculum partnerships between medical schools.
<bold>Figure S1</bold>. Questionnaire.
Please note: Blackwell Publishing are not responsible for the content or functionality of any supplementary materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.
Graph: Supporting info item
Graph: Supporting info item
References
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3 Orrill CH. Supporting online PBL: design considerations for supporting distributed problem solving. Distance Educ 2002 ; 23 (1): 41 – 57.
4 Dennis JK. Problem‐based learning in online versus face‐to‐face environments. Educ Health 2003 ; 16 (2): 198 – 209.
5 Salmon G. E‐Moderating: the Key to Teaching and Learning. UK: Kogan Page Ltd, 2002 ; 10 – 36.
6 Britain S, Liber O. A Framework for the Pedagogical Evaluation of Virtual Learning Environments. Report to JISC.
By Phillip Evans; Yasuyuki Suzuki; Michael Begg and Wayne Lam
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