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Editors’ Note: Physician Assistant programs extend the level of patient support in doctor’s offices and medical facilities. PA training also benefits from web-based training. Research here is directed to what courses are amenable to web-based courses, and which elements are predictive of student success. An introductory course on medical terminology was chosen for this research.

Effect of teaching/learning methodology
on effectiveness of a web based
medical terminology course?

Paul David Bell, Suzanne Hudson, and Michelle Heinan
 

Abstract

The purpose of this study was to investigate how a particular method of instruction can impact the effectiveness of an on-line or web based course in delivering subject content. Two different versions of an existing web-based medical terminology course were compared in order to determine which was more effective in teaching content to first semester students in a physician assistant studies program at a 4-year public university. Learner achievement and learner satisfaction levels for the two different course versions were compared. The mean exam scores total and the mean increase in knowledge assessment score did not differ significantly for the two teaching protocols once the achievement measures had been adjusted for initial medical terminology knowledge. Reasons are offered to explain why this occurred and, in addition, differences in learner satisfaction ratings for the two course versions are discussed.
 

Introduction

The World Wide Web (WWW) has become firmly entrenched in our working and social lives. Not only is it a space where people can communicate, work, trade, and spend leisure time, but it has also increasingly become a place to learn.^1,2 Both the academic and business sectors have made significant commitments to the adoption of web based technologies for learning and training. For example, in addition to the great number of courses and academic programs offered on-line, academically accredited virtual universities now exist in cyberspace. The health care industry has also adopted internet based technologies for patient health care management and the Pew Health Professions Commission has advocated the inclusion of internet and web based technologies in the professional education of future allied health professionals. In particular, they recommend the training and development of specific competencies in the use of information technologies such as the Internet for patient care management and continuing professional education.³

In light of the investment being made in the development of the Internet for training and education, evaluating the effectiveness of web based instruction is a critical pursuit. Most research into the effectiveness of web based learning is composed of media comparison studies that concentrate on the effect of the course delivery medium on learner outcomes. Although the comparison of delivery media is a recognized component of educational technology research, some have proposed that media comparison studies have been unproductive ^4-6 This area of research has found no significant differences in student learning regardless of whether the learning medium is video, www, computer assisted instruction or traditional face to face environments. It is doubtful, then, whether such research contributes to a better understanding of what factors make for effective web based learning.^7,8 Therefore, the focus of web based learning research should, instead, be on understanding what elements may be predictive of student success in web based courses.⁹

Reviews of educational technology research suggest that investigational research of instructional methods used in on-line learning environments can produce more useful information about what works versus what doesn’t in effective web based instruction.^8,9 Instructional design methods influence learning regardless of whether one is speaking of a face-to-face traditional classroom delivery or a web based on-line distance learning format. Instructors/teachers exert control over content and the methods used to teach it.  An effective course is, therefore, the product of good teaching. And good teaching includes knowing how to deliver appropriate subject matter content via optimal teaching and learning methodologies. A three year study of Innovations in Distance Education spearheaded by Pennsylvania State University (PSU) concluded that when it comes to teaching on-line technologic competence alone is not sufficient for guaranteeing effective technology integration. It went on to emphasize that good teaching is described by the educational event experienced by both the instructor and the learner and that the delivery mode is secondary to that event. ¹⁰ Furthermore, McFadden, et al. (1999) summarize that concerns regarding the quality of distance education courses should be no different than those for the traditional classroom.¹¹ They conclude that quality is the responsibility of the professor whether teaching on-line or in front of a classroom. If this is so, then it would appear that the instructional design phase and the decision to employ specific methods of content delivery are important determinants of what makes a quality or effective web based course.^12,13

The purpose of this study is to investigate how a particular teaching/learning methodology can impact the effectiveness of an on-line web-based course in delivering subject content. Two versions of an existing web-based medical terminology course that differed according to the teaching/learning methodology utilized were compared in order to determine which was more effective in teaching content to first semester students in a physician assistant studies program at a 4-year public university. Learner achievement as measured by knowledge assessment and learner satisfaction levels for the two different course versions will be compared.

Health care professionals must be able to communicate with each other about patients and their health care via the language of medicine. Physician Assistant (PA) students, therefore, must take medical terminology during their first semester in the PA program at ECU in order to gain a working knowledge of medical terms, including an overview of abbreviations most commonly used in health care. The medical terminology course required of PA students is a 2 credit 5 week summer course offered through the health information management department. The department of health information management in the school of allied health has been offering this course since 1980 and began teaching it on-line to first semester PA students in the summer of 2000 in lieu of the traditional face to face classroom format. The decision to place PA curriculum courses on-line was taken for two reasons, first, in response to the President of the University of North Carolina system’s directive to place more on-campus courses on-line and secondly, in order to provide a medium that could deliver learning to students who needed to work to support themselves and their families while they were also studying to be physician assistants.

In the summer of 2002 two different versions of the introduction to medical terminology course were created. This was done in order to investigate the extent to which instructional methodology plays a role in determining the effectiveness of web based learning.

Learning medical terminology involves learning word roots, prefixes and suffixes derived from Latin and Greek word forms. Mitchell and Myles define second language learning as “the learning of any language to any level provided only that the learning of the “second” language takes place sometime later than the acquisition of the first language”(1).¹⁴ According to their definition, then, learning medical terms is very much like learning a second language. Therefore, teaching medical terminology can benefit from second language learning research and what it has to offer as far as the theoretical bases for second language teaching models.

The many theories of language learning can be distilled down to two main schools of thought. One, the universal grammar theory, represents the viewpoint that language learning is mainly the result of working an individual’s innate “grammar” control box. Therefore, the process of learning a second language is a neuro-cognitive process and language skills are a matter of habit formation. Teaching methodologies that are founded on this theory emphasize audiolingual teaching methods that have students practice particular patterns of language through structured dialogues and drills until the language is sufficiently rehearsed for responses to be automatic. ^{14, 15, 16} On the other hand there is a very different school of second language learning that believes that the process of language learning is very much influenced by the social environment of the learner. That is, according to this sociolinguistic orientation, second language learning is a social constructivist activity. And it is chiefly by communication and social interaction that the learner inductively acquires the grammar and rules of discourse. Thus, teaching methodologies based on this theory stress communicative interaction among learners and instructor rather than the memorization of language patterns through drill and repetition.^{14, 17,18}

The 2 course versions were equivalent in the following aspects: They included the same programmed text book (Exploring Medical Language: a student centered approach by LaFleur Brooks, Mosby 5^th edition); contained the same sequence of study units, the same introductory PowerPoint lessons on prefixes and suffixes, cancer terms, specialist terms, and the same “checklists” or reviews of terms to know for each exam. They also contained matching collections of external links to web pages containing more information on the same variety of topics. Both versions also contained the identical “fill in the blanks” exercise on anatomical planes, body cavities and directional terms. Course content for both versions was uploaded into identical web based course shells or templates designed by Blackboard. Blackboard is a company that provides software for electronic or distance education and has been the standard infrastructure for the creation of on-line courses at ECU since 2000.

Furthermore, both course versions included the same exams. Exam content and format were equivalent and questions were asked in the same sequence. For each exam 2/3 -3/4 of exam items were multiple choice questions designed to evaluate student comprehension of medical terms and another ¼ to 1/3 of exam items were fill-in-the-blank questions constructed to assess student comprehension of medical abbreviations.

Despite these similarities, the 2 course versions differed in one important way. Each included independent learning activities that differed from the other according to the particular language learning methodology they represented. These methods were in turn based on the two very different language learning theories or models discussed above.

One version of the introduction to medical terminology course; henceforth, referred to as the Tutorial was designed with the universal grammar approach to second language learning in mind. A web based tutorial entitled Web Learning Services, developed by MC Strategies, was built into this version of the on-line course. MC strategies develops and delivers web based training for the health care industry. Their medical terminology curriculum has been offered since 1986. Learners can learn, review, and self test in medical terminology at their own pace via this program. It is flexible enough such that the instructor is able to configure lesson content and sequencing in order to correspond to the course textbook. Learners read text that explains terms and also listen to sound files of correct pronunciation of unit terms. At the end of each unit learners take an exam and receive immediate feedback from the program on their performance. Thus, learners exposed to this independent learning activity interact only with the computer program and drill terms until they are committed to memory. There are 45 separate lessons that correspond to the 12 units of study in the curriculum.

The other version of the introduction to medical terminology course; henceforward, referred to as the CS/DB (Case Study/Discussion Board) version was designed based on the communicative approach to second language learning. In this version 12 case studies were formatted into PowerPoint presentations and then uploaded into Blackboard. In addition, sound files of the instructor reading each case study were uploaded into the same folder containing the PowerPoint presentation. This was done to make it possible for on-line learners to read and hear medical terms used in a clinical scenario. Next, case study discussion questions were uploaded to the Blackboard discussion board center. Students were, then, required to respond to a minimum of two case study questions per unit as well as reply to a minimum of 2 of their colleague’s responses. Learners received feedback through fellow learner and instructor replies to initial and subsequent postings. This asynchronous discussion board activity was designed to facilitate interactive communication among learners and instructor. As such, it was a threaded discussion in which learners had to correctly employ medical terms in the context of their discourse. It was, therefore, a platform for the communicative interaction crucial for learning medical terms in context.

Although, current second language learning methodology borrows from both second language learning theories described previously, most second language learning methods draw from the sociolinguistic theory. These models are collectively referred to as “communicative language teaching” or CLT.¹⁹ In this approach the teacher is viewed as a needs analyst and counselor who designs tasks for the learner and the learner is seen as an improviser and collaborator in the learning venture. Learners exposed to this form of second language learning learn the rules of grammar via the process of communication and interaction. Feedback to their “improvisations” of language usage helps the learner create his grammar control box for the target language. Therefore, based on this rubric of second language learning methodology, it is hypothesized that those PA students who are enrolled in the CS/DB version of the course will learn more medical terminology as reflected in higher total exam and in the difference in post and pre-course knowledge assessment scores compared to the PA students enrolled in the Tutorial version of the course. It is further hypothesized that in addition to achievement, learner satisfaction ratings will also be higher in the CS/DB sections than in the Tutorial sections.
 

Methods

There were 49 PA students taking the course. Of these, 22 were true distance (or off-campus) learners, and the rest were on-campus students. The distance learners were divided into two sections such that the gender composition, age distribution, and prior health care related experience were similar for these two sections. One of the distance-learner sections was taught using the Tutorial method, and the other was taught using the CS/DB method. The on-campus group was also divided into a Tutorial section and a CS/DB section such that the gender composition, age distribution, and prior health care related experience were similar for the two sections. Both groups had to complete the same prerequisite courses before applying to the PA program and meet the very strict academic requirements for acceptance into the program. The chief difference between the two groups of learners, then, was in the version of the introduction to medical terminology course to which they were exposed.

The two medical terminology learning protocols were evaluated and then compared based on the level of learner achievement and the level of learner satisfaction with the particular protocol. Achievement in the course was measured by the exam score total, and by the difference in post- and pre-course knowledge assessment scores. The assumption is that an evaluation of student learning in medical terminology can be made based on performance on four exams and on a comparison of pre-course knowledge assessment and post-course assessment scores. These exams and assessments consist of multiple choice and fill-in-the-blank question items. These question types have long been considered appropriate for testing factual recall and applied knowledge and as such have been used historically in the assessment of clinical competence.²⁰ Thus, the higher the exam score totals and the greater the improvement between pre vs. post course assessment scores, the greater the amount of learning and mastery of medical terminology that occurred.

Both of these achievement outcomes were analyzed using a general linear model with protocol (CS/DB or Tutorial) as a factor, and pre-course knowledge assessment score as a covariate. The pre-course knowledge assessment score was included as an explanatory variable since it is reasonable to assume that students who start the course with a greater knowledge of medical terminology have an advantage over those with lesser knowledge. The analyses were carried out using SPSS 10.1.

In addition to comparing the learning achievement of the two protocol groups, the groups were also surveyed for their level of satisfaction with the particular learning method (CS/DB or Tutorial) used. Kirkpatrick’s work concerning the sequence of evaluation of programs suggests that measuring the reaction or satisfaction level of program participants can provide information about learner’s motivational level for learning. Although a positive reaction cannot in and of itself guarantee learning, negative reactions may very well reduce the possibility of it occurring. ²¹

The survey contained 10 Likert scale items. Learners indicated the degree to which they either agreed or disagreed with these statements. Eight of these items were the same or very similar for the two teaching protocols. These are given in Table A along with results of the survey. The two remaining items were different for the two protocols and are given in Table B. Learners completed this survey during the last week of the course and submitted it anonymously via the Zoomerang survey site. 42 of 49 students completed the survey. Four (4) of the students who did not complete the survey were in the CS/DB sections, and three (3) were in the Tutorial sections.

The opinion ratings for the two protocols on the first eight Likert scale items were compared using Wilcoxon-Mann-Whitney test. The StatXact program was used to do these analyses. The Wilcoxon-Mann-Whitney test is a nonparametric test that is considered more appropriate than a t-test for ordinal data (such as Likert scale data).

 

Results

For both achievement measures (exam scores total and increase in knowledge assessment score), the pre-course knowledge had significant predictive power at the 0.05 significance level (p= 0.001 and 0.000, respectively) but protocol did not. Hence the mean exam scores total and the mean increase in knowledge assessment score did not differ significantly for the two teaching protocols once the achievement measures had been adjusted for initial medical terminology knowledge. The mean increase in knowledge assessment score for the CS/DB sections was nearly significantly higher than for the Tutorial sections (p = 0.054), but the actual predicted difference in adjusted means was only 2.5 percentage points. For a student with a pre-course knowledge assessment score equal to the average value of 66.3%, the predicted increase in knowledge was 25.8 percentage points for the CS/DB protocol, and 23.3 percentage points for the Tutorial protocol. The predicted means for the exam scores total were nearly identical for the two protocols (305.9 and 305.5, respectively, for a student with a pre-course knowledge assessment score of 66.3%). Hence the teaching protocols were about equally effective as measured by either achievement outcome.

The 8 items that were the same or similar for the two protocols on the learner satisfaction survey were compared using the Wilcoxon-Mann-Whitney test. (Please see Table A.) The opinion ratings for the CS/DB sections were significantly higher than those for the Tutorial sections for items 3 and 8, (p = 0.016 and 0.002, respectively) and nearly significantly higher for item 2 (p =0.057). For items 1-5 and 8 the ratings in the CS/DB sections tended to be higher than in the Tutorial section, but not significantly higher. For item 7 the ratings in the Tutorial section tended to be higher than in the CS/DB sections, but again, not significantly higher.  

Table A

       * Opinion Rating: 1. Disagree, 2. Somewhat Disagree, 3. Somewhat Agree, 4. Agree

Table B

Opinion ratings for protocol-specific survey questions. Opinion ratings for survey questions that were the same or nearly the same for the two protocols
 

       * Opinion Rating: 1. Disagree, 2. Somewhat Disagree, 3. Somewhat Agree, 4. Agree

Discussion

The original hypothesis that those PA students who are enrolled in the CS/DB version of the course will learn more medical terminology as reflected in higher total exam and in the difference in post and pre-course knowledge assessment scores compared to the PA students enrolled in the Tutorial version of the course is not supported by the results.

In this case the above finding would appear to argue for the lack of any effect of instructional design/methodology on learner achievement. However, the influence of instructional method on learning medical terminology may be overshadowed by other factor(s). One such factor may be learner ability. For example, the learners in this study were all students in the physician assistant studies program. This professional program has very competitive and selective entrance requirements. Thus, such a selective admissions process will result in a cohort of individuals characterized by high academic achievement as measured by GPA. In addition, PA students like other health care professional students, such as medical students, are characterized by high goal setting behavior and high academic persistence. Research regarding the phenomenon of student persistence has demonstrated that student attributes such as academic ability, goal setting behavior, and internal locus of control correlate strongly with an individual’s drive to persist academically.^22,24. It is plausible, then, that highly motivated learners who take control of their own learning can demonstrate high achievement levels in a wide variety of learning environments. Therefore, learner attributes such as ability and intrinsic motivation may well trump learning methodology to the extent that there are no differences in learner achievement as measured on exam and knowledge assessment performance.

Moreover, the type of assessment measure used to evaluate learner achievement may not have been well suited for demonstrating the effects of instructional design on learner achievement. It may well be, for example, that different learning methods emphasize different levels of learning such that one method emphasized more superficial learning; whereas, the other method stressed deeper learning. For example, the tutorial method was basically drill and practice of word parts and the tutorial exams were all multiple choice items. The CS/DB method required students to read clinical case studies that utilized terminology in context and then to respond to discussion questions on that content. For the most part these questions fell into the analysis, application and synthesis domains of Bloom’s cognitive taxonomy. Thus, this activity required more than rote memorization as it obliged students to utilize more critical/analytical thinking skills during their learning.

However, the two groups of students were assessed via the same short answer multiple choice items. The majority of these question items required learners to indicate their comprehension of word terms. It is quite possible to perform well on such test items by only utilizing superficial learning strategies such as memorization. Furthermore, deep learning strategies such as reflection and analysis may not be necessary in order to perform well on such short answer exams. Thus, regardless of the instructional design/method utilized to learn medical terms, the learners may have adapted their learning style to accommodate the superficial nature of the testing instruments. The research indicates that successful learners are not only deep learners but “adaptable or strategic learners” who know how to adjust their learning style in order to suit the circumstances of their learning and testing environment.^25-28.  In this case both sets of learners but especially the CS/DB learners adjusted their learning strategies to match the cognitive level of the assessment instrument.

Although both groups of learners were equivalent in their opinion regarding how effective their course version was in helping them to learn medical terminology, the two learner groups had different perceptions concerning their learning experience. More CS/DB learners believed that the course provided sufficient opportunities for interaction and communication between learners than did Tutorial learners. This is really not surprising. CS/DB learners engaged in asynchronous communication as an on-line learning activity whereas learners in the tutorial section did not. The other notable differences in the opinion rating came in response to questions 2 and 8. In question 2 the CS/DB group rated the effectiveness of the on-line testing format more highly than the Tutorial group. This may have occurred because it was viewed as a welcome change from the on-line discussion board activity. As such, the novelty effect of the on-line testing experience translated into higher rankings for question 2 than for the tutorial group for whom this on-line testing was viewed as just more of the same. They had to complete a total of 85 tutorial exams during the course. In question 8 each group is asked about the effectiveness of the graphics included with their version. More CS/DB learners than tutorial learners believed that their version’s graphics helped them to understand and remember medical terms. This finding is expected because there was a real difference in the quality of the graphics used in each course version. The graphics included with the case study/discussion board version included pathology photos and animations while the tutorial (educode) graphics were mostly clip art quality images.

Another interesting finding is that both groups were equally “lukewarm” (2.74 on the Likert scale; somewhere between “somewhat disagree” and “somewhat agree”) in their agreement with the statement that success in learning medical terminology depends mostly on how much interactive communication the learner engages in. This finding is supported by some anecdotal comments that students included with their university course evaluation forms. Several CS/DB learners indicated that they were not sure that the CS/DB method was appropriate for an introductory level course in medical terminology, offering that such an activity would be more appropriate for an advanced course such as clinical diagnosis. This finding suggests that learners may have definite expectations about how course subject matter content and course curricula is to be taught and may be “somewhat” disappointed when the actual teaching/learning design method does not match that expectation.

Future research into the relationship between instructional design and learner outcomes in on-line learning environments should include qualitative analyses of both learner performance and learner satisfaction/opinion ratings, in order to discern those factors that facilitate learner achievement in on-line learning. In addition, it is important to perform this type of research with different learner populations in order to understand how on-line learning experiences can be designed to reach a wide variety of learners with different learning styles. For example, many universities are employing distance learning technologies to teach both their adult continuing education students as well as their traditional on and off-campus undergraduate students. Therefore, a future research design might assign learners to one learning method vs. another based on individual cognitive or personality attributes in order to learn which attributes correlate with which specific learning or instructional methods.

This line of research should also be conducted in a variety of subject matter courses in order to determine which instructional methods match up best with what types of learning to be achieved. It is also important to match assessment instruments with the type of learning (surface vs. deep) that is taking place.

 

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About the Authors

Paul David Bell, MS, RHIA, CTR, is associate professor in the Department of Health Information Management in the School of Allied Health Sciences at East Carolina University. The health information management and health services management programs are offered as on-line distance learning programs for the first time in fall 2003.  He is, therefore, very interested in learning more about how to teach and learn in a web-based distance learning environment.

Contact Mr. Bell at: Department of Health Information Management, School of Allied Health Sciences, East Carolina University, Belk Building Room 304, 100 Curry Court, Greenville, NC 27858. Tel. 252-328-4468, Fax 252-328-4470, email: bellp@mail.ecu.edu
 

Suzanne Hudson, Ph.D., is Assistant Professor in the Department of Biostatistics, School of Allied Health Sciences, at East Carolina University. Contact her at: Department of Biostatistics, School of Allied Health Sciences, Belk Bldg @ Curry Court, East Carolina University.
Tel. 252-328-4442, Fax 252-328-4470, email hudsons@mail.ecu.edu
 

Michelle Heinan, EdD. PAC, is Associate Professor of Clinical Medicine, Academic Coordinator and Director, PA Program , Methodist College Physician Assistant Graduate Program, Division of Medical Science. Her previous position was Interim Chair, Department of Physician Assistant Studies, School of Allied Health Sciences, East Carolina University.
Dr. Heinan received her Ed.D. from Nova Southeastern University in 2003.

Michelle Heinan EdD, PAC, Associate Professor and PA Program Director
Methodist College Physician Assistant Graduate Program
5400 Ramsey Street, Fayetteville, NC 28311
Tel. 910-630-7614  E-Mail: mheinan@methodist.edu