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Problem-Based Learning (PBL) has been the primary educational modality at the John A. Burns School of Medicine (JABSOM) since 1989. In PBL, students work in small groups to process through health care problems (HCPs), which are essentially patient cases. The students discuss their hypotheses and possible explanations for the clinical findings, and develop a list of learning issues (LI) which are topics and concepts needed to learn about to better understand the HCP. The students research their LI, create a handout or presentation, and then present their LI to the PBL group for discussion at the next session. Many articles have discussed the positive values of PBL including better problem-solving skills, higher USMLE Step 2 scores, and increased retention of material.1,2
Some medical schools have been utilizing computer and web-based multimedia scenarios to enhance the text-based PBL cases for their students since the early 2000's.3,4 The multimedia format made the patients in the cases realistic and more importantly, the students found the cases were more stimulating and improved self-directed learning.3,4 While computer technology has been utilized by students for many years, in the past it was cumbersome for students to take notes on digital documents. Most schools found that their students were still printing electronically disseminated materials. The introduction of the iPad in 2010 allowed individuals to take notes directly on digital documents and provided a portable alternative to access the internet and other digital media.
Since its introduction, numerous medical schools have integrated iPads into their curriculum. In 2011, nine medical schools reported using iPads in their curriculum.5,6 Current estimates indicate that 25% of all US medical schools require the use of iPads.5,6 The majority have used this tablet technology to deliver course and lecture material in digital format. Some have also taken advantage of the versatility and interactive capability of ePublications (ePubs), which are digital text books that allow for the integration of video, audio, and other interactive features. ePubs are useful for medical courses and have been shown to increase student interest and retention of material. 6,7 The medical schools that have incorporated iPads into their curricula have found many benefits of this technology, including increased student satisfaction, cost savings, and more innovative course materials.6,7 In 2012, JABSOM conducted a pilot study to see if integrating iPads into the PBL curriculum would be both feasible and satisfying for the students in terms of navigating through the HCPs and their LI handouts. In addition, the use of technology to digitally enhance the HCPs to make them more interactive and fun was explored.
During the third curricular unit (MD3) for first year medical students, 12 students, who already owned iPads, volunteered to participate in the study. These students were placed into two PBL groups that received all of their HCPs and LI handouts electronically and were asked to refrain from printing any course material. For these groups, digital annotations were added to the electronic versions of the PBL cases. These annotations included color pictures with “pop-up” descriptions, audio files, and video files. The annotations allowed the students to see physical findings, diagnostic studies, slides, and hear heart and lung sounds instead of reading a description on paper. The students were encouraged to hypothesize and discuss what they were seeing and hearing before they looked at the “pop-up” descriptions, with the aim to improve both their clinical skills and clinical reasoning skills. All lecture handouts were delivered electronically to the pilot students. The study was continued in the fourth curricular unit (MD4) and 12 new students were added to the study, bring the total to 24 students, comprising four PBL groups. Eight of these 24 students did not own iPads and were given loaners for the duration of the unit. This allowed the evaluation of whether students who were not familiar with the use of iPads would have more difficulty navigating through the cases and using the annotations.
At the end of the study, the overall performance of the iPad students compared to non-iPad students and student/tutor satisfaction with using iPads for PBL was examined. The results were overall positive, from both the students and the faculty tutors, for the use of iPads in PBL. T-tests were conducted and there were no significant differences between the iPad “naïve” students and those that already owned their own iPads. This was measured both in terms of overall performance and satisfaction ratings. In MD3, there was no significant difference between the test scores of iPad students compared to traditional “paper” students. However, in MD4, the iPad students' scores, analyzed via a t-test, were statistically higher than the “paper” students. (Figure 1)
In each of the categories for satisfaction, all of the iPad students rated the use of iPads compared to paper for PBL as “better” or “much better.” (Table 1)
All of the pilot students “strongly agreed” that the digital case enhancements added to their overall learning and that the iPads made the cases more fun. In addition, 92% of the students felt it was “easy” or “very easy” to use the iPads to take notes on the cases and the handouts, with the other 8% finding it “difficult.” The same 92% of students reported they did not print out any of the electronically distributed material during the units. The 8% who found annotating difficult, none of whom were iPad naïve students, reported that they printed out approximately 75% of the material. All of the PBL tutors that participated in the pilot found the iPads to be a beneficial adjunct to PBL, enjoyed having only electronic cases and handouts, and found that student learning issues and presentations were also better compared to traditional “paper” groups.
“It was so much better going through the cases with the iPads. The picture and sound enhancements definitely added to our learning and made the cases more fun. They also made me think harder about clinical findings and situations.”
“I felt that our group processed the cases more efficiently than when we were using paper. It is really nice not to have to carry around a heavy binder full of papers.”
“Presenting LI's was really smooth. Not having to worry about color printing made everyone more creative in making their LI's.”
“I never want to go back to using paper cases. The students really seem to enjoy the case enhancements and having to look at the pictures and listen to the sounds without being told what they are looking or listening to also helps to boost their clinical skills.”
“The quality of the student learning issues was noticeably superior in this group of students. They made good use of color pictures and diagrams and used the annotative features in iAnnotate to make their presentations and handouts more interactive.”
At JABSOM, there are roughly 90 HCPs over the first two years of medical school, supplemented by 8 hours of lecture per week. Until 2012, the HCPs, LI handouts, and lecture handouts were all duplicated on paper. Approximately 411,000 sheets of paper were distributed in each medical class cohort during their two preclerkship years. Considering the cost of paper, ink, copier/printer maintenance, binders, and other office supplies, it was estimated that approximately $3,500 would have been saved for each of the 6 preclerkship curricular units if paper handouts were replaced with electronic media.
Although the sample size of this pilot study was small, the results were positive. In addition to the cost savings from not printing out PBL and lecture materials, multimedia case enhancements were provided, which improved learning and satisfaction for the students. An unanticipated benefit found in the study was the improvement in the quality of student-generated learning issues. In the past, students did not often include color pictures, tables, and diagrams into their handouts because of the cost to print color handouts. If printed in black and white, the pictures in their handouts came out very dark. By having electronic versions of the handouts, students started to incorporate more color into their learning issues. They also included more sound and video files, links to useful web resources, and interactive pop-ups into learning issues, making the discussions in PBL groups more fun, fulfilling and memorable.
The success of the pilot study, including the costs savings, increased student and tutor satisfaction, preservation of overall performance, and ease of note taking, prompted the JABSOM curriculum committee to decide on incorporating iPad use for all students. Starting with the Class of 2016 in the Fall of 2012, all incoming students are required to have an iPad. This requirement replaced the previous requirement for all students to have a laptop. Although it was determined that students would still need access to computers, the resources located at JABSOM are more than adequate to support that need.
The incorporation of iPads into the curriculum has not been completely smooth and as with any new initiative, several challenges were encountered in implementing this technology. The following are some of the areas that have been and are currently being addressed.
The largest challenge was orienting all tutors to the new system. Although all tutors in the pilot study embraced the technology and found it to be easy and beneficial, they volunteered to participate in the study and were probably amongst the more “tech savvy” faculty tutors. When the iPads were introduced to all faculty tutors, a significant amount of training was required to utilize the iPads effectively and efficiently, especially for those tutors who were not as comfortable using the technology. Despite the training sessions, there was still faculty who were uncomfortable with using the iPads in tutorial. In addition, in PBL groups that had tutors who were “frustrated” with the use of the iPads, they were less likely to fully embrace the use of iPads for their curricular needs. These students were more likely to use laptops in tutorial and to print out case material and handouts. While this behavior still remains a challenge, the JABSOM Office of Medical Education (OME) faculty are working towards improving the training in iPad use for both tutors and students. OME is also working on expanding the utilization of the various iPad technologies to broaden the benefits of using iPads in the curriculum.
The addition of iPads to the curriculum also increased our information technology (IT) needs, primarily the need to expand capacity of the wireless system. It was previously thought that the wireless needs would not increase because the iPads would simply replace laptops in respect to the number of devices that would be connecting to the wireless system. However, many students were bringing both their laptops and iPads to tutorials, which almost doubled the number of devices trying to connect wirelessly. This problem was easily addressed by upgrading the wireless routers and emphasizing the important role IT plays in medical education.
When introducing the requirement for iPads into the curriculum, there needed to be more than just cost savings as a benefit to justify the new expense for students. To accomplish this, it is necessary to take full advantage of iPad features and to ensure the PBL cases are uniformly being enhanced for the students through the use of annotation. This has required the PBL course directors to learn new skills in utilizing digital media for case design and has also pushed for the faculty to brainstorm ways to make full use of the technology. This is an ongoing process and is an area that the course directors are currently working on.
During the current academic year (2013–2014), both the first and second year students will be utilizing iPads in the curriculum. This means that starting in academic year (2014–2015), all of the third year students in their clinical rotations will have iPads. This opens up many possibilities for the clinical clerkships, who are currently exploring ways to utilize this technology in the clinical years. Some of these possibilities include the production and utilization of ePublications to enhance clinical learning, improving access to point-of-care resources for the students, and improving organization and communication for the clerkships.
JABSOM's preclerkship faculty continues to explore ways to make PBL cases more interactive and to innovatively utilize iPads in their courses. The number of medical education applications for iPads has increased exponentially in the past two years. Measures to determine which applications can be of most utility to our students will be needed. A survey of the current students is needed to explore their iPad use, this will help explore how this technology can be better utilized to the fullest benefit for the students.
We would like to thank the students and tutors that volunteered to participate in the pilot study. The JABSOM curriculum committee is commended for taking the bold steps needed to move forward with this innovation in medical education.
None of the authors identify a conflict of interest.