Applying the cognitive theory of multimedia learning: an analysis of medical animations

Context Instructional animations play a prominent role in medical education, but the degree to which these teaching tools follow empirically established learning principles, such as those outlined in the cognitive theory of multimedia learning (CTML), is unknown. These principles provide guidelines for designing animations in a way that promotes optimal cognitive processing and facilitates learning, but the application of these learning principles in current animations has not yet been investigated. A large‐scale review of existing educational tools in the context of this theoretical framework is necessary to examine if and how instructional medical animations adhere to these principles and where improvements can be made. Methods We conducted a comprehensive review of instructional animations in the health sciences domain and examined whether these animations met the three main goals of CTML: managing essential processing; minimising extraneous processing, and facilitating generative processing. We also identified areas for pedagogical improvement. Through Google keyword searches, we identified 4455 medical animations for review. After the application of exclusion criteria, 860 animations from 20 developers were retained. We randomly sampled and reviewed 50% of the identified animations. Results Many animations did not follow the recommended multimedia learning principles, particularly those that support the management of essential processing. We also noted an excess of extraneous visual and auditory elements and few opportunities for learner interactivity. Conclusions Many unrealised opportunities exist for improving the efficacy of animations as learning tools in medical education; instructors can look to effective examples to select or design animations that incorporate the established principles of CTML.     

How effective is self‐guided learning of clinical technical skills? It’s all about process

Objectives  Mounting evidence suggests that trainees acquire psychomotor skills better when they are allowed self-guided access to instructional material and when they set goals that are related to performance processes rather than performance outcomes. The present study assessed whether self-guided access to instruction and the setting of process goals lead to better acquisition of clinical technical skills.
Methods  To learn wound closure skills, 48 medical students were randomly assigned to one of four groups in a 2 × 2 study design. Self-guided participants were able to access the instructional video freely, whereas control participants were restricted to watching only those video segments accessed by their matched self-guided participant. Each group was further divided into two subgroups, comprising a process goal subgroup, where participants set goals focused on performance mechanisms, and an outcome goal subgroup, where participants set goals focused on performance products. Performance on pre-, post-, retention and transfer tests was assessed with hand motion measures and expert evaluations. Group differences were evaluated using one-way anova s.
Results  The self-guided group with process goals showed greater skill retention than its matched control group, whereas the self-guided group with outcome goals did not. Furthermore, the groups with process goals performed better on the transfer test than the outcome goal groups. Outcome goal participants accessed the instructional video most frequently.
Conclusions  Our findings advance the study of independent learning in medical education. Trainees used interactive and structured instructional materials to effectively self-guide their learning of clinical technical skills. However, a self-guided benefit was demonstrated only when trainees set process goals.     

Health education and multimedia learning: educational psychology and health behavior theory (Part 1)

When health education researchers began to investigate how individuals make decisions related to health and the factors that influence health behaviors, they referred to frameworks shared by educational and learning research. Health education adopted the basic principles of the cognitive revolution, which were instrumental in advancing the field. There is currently a new challenge to confront: the widespread use of new technologies for health education. To better overcome this challenge, educational psychology and instructional technology theory should be considered. Unfortunately, the passion to incorporate new technologies too often overshadows how people learn or, in particular, how people learn through computer technologies. This two-part article explains how educational theory contributed to the early development of health behavior theory, describes the most relevant multimedia learning theories and constructs, and provides recommendations for developing multimedia health education programs and connecting theory and practice.     

Professional Power Through Education: Universal Course Design Initiatives in Occupational Therapy Curriculum

ABSTRACT

The American Occupational Therapy Association (AOTA) has put forth a Centennial Vision that requires academic settings to explore and evaluate modes of instruction for future occupational therapy practitioners. The authors of the Centennial Vision call for occupational therapy to be recognized as a powerful profession that contributes to the health and wellness of society. They further state that education is a key factor to achieving this power aspect of the vision, and this will require innovative instructional methods that produce positive educational outcomes. This study explored the effectiveness of Universal Course Design (UCD) in occupational therapy curriculum. UCD ensures the best learning environment and instructional methods for all learners prior to instruction, as opposed to altering the learning environment or instructional methods for a select few after instruction has begun. The findings indicate that those students participating in UCD methods demonstrated higher educational outcomes in occupational therapy curriculum (t == 3.885, p ==.000). Therefore, this instructional method appears to be a beneficial process to realizing some of the key goals set forth in the AOTA Centennial Vision.     

How to achieve synergy between medical education and cognitive neuroscience? An exercise on prior knowledge in understanding

A major challenge in contemporary research is how to connect medical education and cognitive neuroscience and achieve synergy between these domains. Based on this starting point we discuss how this may result in a common language about learning, more educationally focused scientific inquiry, and multidisciplinary research projects. As the topic of prior knowledge in understanding plays a strategic role in both medical education and cognitive neuroscience it is used as a central element in our discussion. A critical condition for the acquisition of new knowledge is the existence of prior knowledge, which can be built in a mental model or schema. Formation of schemas is a central event in student-centered active learning, by which mental models are constructed and reconstructed. These theoretical considerations from cognitive psychology foster scientific discussions that may lead to salient issues and questions for research with cognitive neuroscience. Cognitive neuroscience attempts to understand how knowledge, insight and experience are established in the brain and to clarify their neural correlates. Recently, evidence has been obtained that new information processed by the hippocampus can be consolidated into a stable, neocortical network more rapidly if this new information fits readily into a schema. Opportunities for medical education and medical education research can be created in a fruitful dialogue within an educational multidisciplinary platform. In this synergetic setting many questions can be raised by educational scholars interested in evidence-based education that may be highly relevant for integrative research and the further development of medical education.     

Better learning through instructional science: a health literacy case study in "how to teach so learners can learn"

Health education and behavior change interventions typically pay little attention to the intervention's instructional foundation. Combining the fields of health literacy, cognitive psychology, and adult learning theory, this article provides an integrative scientific approach, called the BEAN (Better Education and iNnovation) model, to creating an instructional foundation based on how individuals acquire knowledge and skills. The article uses a case study example from an adult literacy center's health literacy class to explore how environmental factors and instructional strategies can be applied to health education and behavior change interventions. Data for this case study were derived through 20 hours of classroom observation and qualitative interviews with 21 adult education students and 3 instructors. Results provide practical examples of environmental factors and instructional strategies designed to facilitate learning, such as fostering autonomy, activating prior knowledge, and fostering perspective change. Results also describe the resulting health behavior changes of students attending the health literacy class, such as increased medication adherence and physical activity, improved nutritional habits, and increased question asking of health practitioners. This article serves as a first step to encouraging researchers and educators to consider the importance of drawing on cognitive psychology and theories of adult learning to create a scientifically based instructional foundation for health behavior change programs. Additionally, by drawing on the expertise of adult educators well versed in the science of instructional design, this article also demonstrates that the adult education classroom is an excellent setting for conducting health education and behavior change interventions.     

Strategies to read and learn: overcoming learning by consumption

Medical Education 2010: 44 : 340–346 Objectives This article discusses the need for, and value of, providing students with instruction in how to use comprehension strategies as well as the effectiveness of inducing strategy use through cognitive disequilibrium. The leading assumption that guides this article is that learning facts and figures is not enough. Students need to build deep knowledge that is interconnected, coherent and includes understanding of potential causal mechanisms. Doing so requires going beyond the printed page by generating inferences and developing coherent explanations. Inferences and explanations allow the student to make links between concepts in the material and, importantly, to make connections to prior knowledge. These connections render students’ understanding of new material more coherent and, in consequence, deeper and more stable. Discussion This article describes two means of inducing students to construct a deeper understanding of new material. One means of challenging students is through cohesion gaps in a text (or a lecture) that require the student to generate inferences to understand the relationships between concepts. Although low‐knowledge readers are not able to generate these inferences, relatively high‐knowledge readers (e.g. medical students) are more likely to successfully generate inferences to bridge conceptual gaps, and doing so results in a deeper understanding of the material. A second means of inducing active processing is to provide students with instruction and practice in how to use comprehension strategies. This article describes methods of providing such instruction, including the intelligent tutoring system, iSTART. Conclusions The overarching goal of the research described in this article is to scaffold students towards ideal learning strategies. This cannot happen simply by telling students about good strategies. It is ineffective to inform a student that the content will be better understood if it is explained or evaluated. Such an approach is a victim of learning by consumption attitudes towards education.     

Multi-dimensional profiling of medical students' cognitive models about learning

INTRODUCTION: In current constructivist paradigms, learners' previous subject-matter knowledge, or cognitive models, provide the foundations for the construction of new knowledge. Learners' cognitive models about learning also mediate students' capacities to learn in their chosen topics of study. The diverse backgrounds of students entering medicine suggest that they might come to medical studies equipped with a wide variety of cognitive models about learning. Some current theories tend to reduce students' cognitions about learning to parsimonious representations, such as surface-deep approaches or mastery-performance goals. It is possible that such reduced representations underrepresent, or misrepresent, the complexity of students' cognitive models about learning. Good quality teaching needs to take account of learners' cognitive models, not just about subject matter, but also about learning. This study investigated the diversity and complexity of medical students' cognitive models about learning. METHODS: A total of 7 graduate entry, clinical-year medical students volunteered for in-depth interviews about learning. NUD*IST text analysis software and correspondence analysis were employed to identify dimensions and to profile students' responses. RESULTS: The correspondence analysis identified a significant 4-dimensional solution that illustrates the contributions of multiple variables to students' cognitive models about learning. Individual profiles highlight diversity between participants. DISCUSSION: This study provides evidence that students' cognitive models about learning are complex and highly differentiated. Representations of what students know about learning need to take account of such complexity in order to inform instructional practice more adequately.     

Cognitive apprenticeship in clinical practice: can it stimulate learning in the opinion of students?

Learning in clinical practice can be characterised as situated learning because students learn by performing tasks and solving problems in an environment that reflects the multiple ways in which their knowledge will be put to use in their future professional practice. Collins et al. introduced cognitive apprenticeship as an instructional model for situated learning comprising six teaching methods to support learning: modelling, coaching, scaffolding, articulation, reflection and exploration. Another factor that is looked upon as conducive to learning in clinical practice is a positive learning climate. We explored students’ experiences regarding the learning climate and whether the cognitive apprenticeship model fits students’ experiences during clinical training. In focus group interviews, three groups of 6th-year medical students (N = 21) discussed vignettes representing the six teaching methods and the learning climate to explore the perceived occurrence of the teaching methods, related problems and possibilities for improvement. The students had experienced all six teaching methods during their clerkships. Modelling, coaching, and articulation were predominant, while scaffolding, reflection, and exploration were mainly experienced during longer clerkships and with one clinical teacher. The main problem was variability in usage of the methods, which was attributed to teachers’ lack of time and formal training. The students proposed several ways to improve the application of the teaching methods. The results suggest that the cognitive apprenticeship model is a useful model for teaching strategies in undergraduate clinical training and a valuable basis for evaluation, feedback, self-assessment and faculty development of clinical teachers.     

A system for assessing use of patients' time

Education and patient education literature provide evidence that time spent in instruction, particularly when the student or patient is actively involved, is positively related to understanding. Time spent on other tasks is not positively related to outcomes. The way in which health professionals and patients spend their time together, however, has not been adequately researched. A system is described for assessing how patients spend their time in environments where health care is delivered. When the system was employed in a multidisciplinary diabetes clinic, it was found that almost two-thirds of patient nonwaiting time was spent in assessment. Only 20% or 12 to 15 minutes, was spent in instruction; in only four of these minutes wee patients actively involved. Although it may be common sense that people learn better when actively participating in an instructional session, these data suggest that common sense may not be common patient education practice.     

Measuring instructional quality in community-orientated medical education: looking into the black box

OBJECTIVES: Decentralizing medical education to community settings has raised issues of instructional quality. The need to evaluate community-based instruction accents the need to adopt a systems perspective, moving beyond factors known to comprise general clinical teaching effectiveness to include factors that focus on instruction as a process. Application of evaluation models using traditional input-output analysis can be flawed. This approach--dubbed the 'black box'--typically examines inputs and outputs, but often ignores throughputs. DESIGN: In this article we open the black box, using theory to examine the underlying processes that define community-based medical education. We first describe the components and processes of an instructional model that is framed by the philosophy of quality and grounded in experiential learning theory. Without examining the critical processes at work inside the black box - i.e. how students come to acquire clinical knowledge and how behaviours are influenced - it is difficult to assess which programme features contribute to success. Tensions created by the absence of consensus on the outcomes of instruction and the challenge of developing adequate measures are highlighted. SETTING: State University of New York at Buffalo. SUBJECTS: Clinician-teachers, learners and patients in the environment. RESULTS AND CONCLUSIONS: We conclude with describing a tool for evaluating community-based instruction that is guided by the context of our model.     

Nutrition Education Needs and Learning Preferences of Michigan Students in Grades 5, 8, and 11

An assessment of nutrition education needs and learning preferences of students in grades 5, 8, and 11 was conducted to target instruction toward areas of highest need and strongest interest of students using teaching methods they prefer. This research evaluated students knowledge, attitudes, and practices related to the Dietary Guidelines for Americans, including knowledge of the new Food Guide Pyramid; attitudes about school lunches and learning about nutrition; nutrition topics of interest; and preferred methods for learning about nutrition. Although results varied across grade level, generally students need to learn about the Food Guide Pyramid; the relationship between dietary fat, weight status, and health; and food sources of fat, salt, and fiber. They want to learn about personal health — how to control weight, improve diet, and prevent disease — using instructional methods that actively involve them. Results provide information relative to students' interest, understanding, and application of the Dietary Guidelines.     

Cognitive load theory in health professional education: design principles and strategies

Context Cognitive load theory aims to develop instructional design guidelines based on a model of human cognitive architecture. The architecture assumes a limited working memory and an unlimited long‐term memory holding cognitive schemas; expertise exclusively comes from knowledge stored as schemas in long‐term memory. Learning is described as the construction and automation of such schemas. Three types of cognitive load are distinguished: intrinsic load is a direct function of the complexity of the performed task and the expertise of the learner; extraneous load is a result of superfluous processes that do not directly contribute to learning, and germane load is caused by learning processes that deal with intrinsic cognitive load. Objectives This paper discusses design guidelines that will decrease extraneous load, manage intrinsic load and optimise germane load. Discussion Fifteen design guidelines are discussed. Extraneous load can be reduced by the use of goal‐free tasks, worked examples and completion tasks, by integrating different sources of information, using multiple modalities, and by reducing redundancy. Intrinsic load can be managed by simple‐to‐complex ordering of learning tasks and working from low‐ to high‐fidelity environments. Germane load can be optimised by increasing variability over tasks, applying contextual interference, and evoking self‐explanation. The guidelines are also related to the expertise reversal effect, indicating that design guidelines for novice learners are different from guidelines for more experienced learners. Thus, well‐designed instruction for novice learners is different from instruction for more experienced learners. Applications in health professional education and current research lines are discussed. Medical Education 2010: 44 : 85–93     

Towards effective evaluation and reform in medical education: a cognitive and learning sciences perspective

Health professions education is dealing with major transformations in light of the changing nature of the health care delivery system, including the use of technology for “just in time” delivery of care, evidence-based practice, personalized medical care and learning, as health professionals strive to integrate biomedical advances and clinical practice. This has forced the medical education community to reassess the current teaching and learning practices and more importantly, the evaluation of the medical education process. There have been recent advances in cognitive and learning sciences theories, some of which can inform medical educators about best teaching and learning practices and their impact on the evaluation process. An understanding of these theories provides a sound rationale for choosing specific instructional strategies and choosing evaluation measures that assess the curricular objectives. The review begins with an overview of evaluation and assessment in education, followed by an overview of major theories from the cognitive and learning sciences. Next, the role of cognitive and learning sciences theories in informing the process of medical education evaluation is discussed, including its impact on student learning, performance and professional competence, as well as recommendations for reform of medical curricula based on such theories. The paper continues with the elaboration of current trends in health sciences education, particularly medical education, and available evidence for the impact on student learning and performance as well as areas where more research is needed.     

What can clinical teachers learn from Harry Potter and the Philosopher's Stone?

Many clinical teachers acquire a working knowledge of the principles of teaching and learning through observation, by adopting positive and rejecting negative examples of clinical instruction. Well selected vignettes of teaching behaviours taken from contemporary film and literature may provide rich substrate by which to engage clinical teachers in discourse about instructional technique. This paper draws on J K Rowling's novel and its companion film, Harry Potter and the Philosopher's Stone, and critically analyses the teaching styles of the staff at Hogwarts School of Wizardry and Witchcraft in the context of contemporary generic and medical education literature. Specifically, it argues that effective teachers demonstrate not only an in-depth knowledge of their discipline but possess a keen appreciation of the cognitive changes that occur in their students during the learning process. They are, furthermore, proficient in core instructional skills such as small group facilitation, feedback and questioning. Most importantly, effective teachers model appropriate attitudes in their professional setting and possess highly developed personal qualities such as creativity, flexibility and enthusiasm.     

Informal self-regulated learning on a surgical rotation: uncovering student experiences in context

The ability to guide one’s own learning is an essential skill for the health professional. The apprenticeship model of undergraduate education offers an opportunity to engage in self-regulated learning as students work to set goals, evaluate the available opportunities and seek out those with the greatest potential for learning. A close examination of how students navigate their clinical rotations could therefore foster greater understanding of how students learn to guide their own learning. The study presented here aimed to examine undergraduate medical students’ day-to-day learning strategies in order to better understand the process of informal self-regulated learning in practice. As a secondary objective, we sought to provide a forum for students to share and critically reflect on their own self-regulated learning strategies. A series of focus groups were conducted with medical students on a surgical rotation. Participants were asked to discuss issues relating to the strategies and behaviours that they had implemented in order to maximize their educational experience. Three distinct approaches to informal self-regulated learning were identified: Participants articulated tendencies to acquiesce to a perceived lack of learning opportunities choose from available learning opportunities and create their own learning opportunities. The results are interpreted through the lens of self-regulated learning theory and implications for medical education are discussed.     

Web-based continuing medical education (I): field test of a hybrid computer-mediated instructional delivery system

BACKGROUND: The Internet and the World Wide Web (the Web) present exciting new possibilities for distributing educational materials at a distance and facilitating collaborative learning among geographically isolated physicians. This article provides a brief overview of the Web as an instructional delivery platform and discusses its strengths and weaknesses as a potential medium for enhancing distance learning opportunities for rural and remote physicians. It also describes an innovative hybrid instructional delivery model that was field tested by the Telemedicine Centre to determine its efficiency and effectiveness for providing Web-based instruction. A hybrid model merges the Web and CD-ROMs (compact disk read-only memory) to use several of the more valuable instructional components of Web-based education (i.e., multimedia, interactive forms, hypermedia, and computer-mediated communications). The results of the field test indicate that the hybrid delivery model was an efficient means for delivering computer-mediated continuing medical education instruction on dermatologic office procedures to a group of rural physicians in low telecommunication bandwidth regions.     

Mental model progression in learning the electron transport chain: effects of instructional strategies and cognitive flexibility

This study investigated the effect of two instructional strategies, segmented and holistic, on the progression over time of learners’ mental models toward that of an expert with the moderator of cognitive flexibility. Sixty-four juniors and seniors in a college metabolism course were randomly assigned to one of the two strategies for instruction on the electron transport chain. The data were analyzed with a repeated measures general linear model. Mental models progressed significantly for both strategies (p < .001), and a significant interaction was found between cognitive flexibility and instructional strategy on mental model progression (p = .02). The segmented strategy was superior for learners with higher cognitive flexibility but inferior to the holistic strategy for lower cognitive flexibility learners. Results have important implications for differentiating instruction on the basis of learner characteristics.     

Applying multimedia design principles enhances learning in medical education

Medical Education 2011: 45 : 818–826 Context The Association of American Medical Colleges’ Institute for Improving Medical Education’s report entitled ‘Effective Use of Educational Technology’ called on researchers to study the effectiveness of multimedia design principles. These principles were empirically shown to result in superior learning when used with college students in laboratory studies, but have not been studied with undergraduate medical students as participants. Methods A pre‐test/post‐test control group design was used, in which the traditional‐learning group received a lecture on shock using traditionally designed slides and the modified‐design group received the same lecture using slides modified in accord with Mayer’s principles of multimedia design. Participants included Year 3 medical students at a private, midwestern medical school progressing through their surgery clerkship during the academic year 2009–2010. The medical school divides students into four groups; each group attends the surgery clerkship during one of the four quarters of the academic year. Students in the second and third quarters served as the modified‐design group (n = 91) and students in the fourth‐quarter clerkship served as the traditional‐design group (n = 39). Results Both student cohorts had similar levels of pre‐lecture knowledge. Both groups showed significant improvements in retention (p < 0.0001), transfer (p < 0.05) and total scores (p < 0.0001) between the pre‐ and post‐tests. Repeated‐measures anova analysis showed statistically significant greater improvements in retention (F = 10.2, p = 0.0016) and total scores (F = 7.13, p = 0.0081) for those students instructed using principles of multimedia design compared with those instructed using the traditional design. Conclusions Multimedia design principles are easy to implement and result in improved short‐term retention among medical students, but empirical research is still needed to determine how these principles affect transfer of learning. Further research on applying the principles of multimedia design to medical education is needed to verify the impact it has on the long‐term learning of medical students, as well as its impact on other forms of multimedia instructional programmes used in the education of medical students.