Monday, 31 March 2014

NUS-Prime: Technology Enhanced Learning - Three Case Studies, Monday, 5 May, 2014

Technology Enhanced Learning in Health Professions Education: 3 Case Studies

Dear colleagues and fellow educators, 

Thank you for confirming your attendance at the upcoming NUS-PRIME session. I have made a summary of the material I will be presenting, and some additional online resources available for your review before the session. Please have a look at this and either or both email me any comments or questions you might have or post them directly onto the blog.

Yours sincerely, 

Poh Sun

Dr Goh Poh Sun
MB,BS(Melb), FRCR(UK), FAMS(Singapore), MHPE(Maastricht)
Associate Professor and Senior Consultant,
Department of Diagnostic Radiology,
National University Hospital
National University Health System,

email -

LinkedIn -

Slideshare educational presentations and papers -

Summary of presentation - 3 case studies in Technology Enhanced Learning

Opening remarks

Maastricht MHPE Master Thesis: Use of case pairs can potentially improve the efficiency and effectiveness of radiology residency (April, 2012)

Ericsson KA, Krampe RT, Tesch-Romner C. 1993. The role of deliberate practice in the acquisition of expert performance. Psychol Rev 100:363–406

Use of hyperlinked clinical case repositories in medical education

Use of hyperlinked radiology case repositories in medical education

Digital curation

4C - ID model applied to residency education (management of hyperdense lesions on emergency head CT in patients with suspected acute stroke)

PhD proposal in medical education (deliberate practice and mastery training, ongoing program, from mid 2012 to current)

"Teaching styles that incorporate various forms of technology can facilitate a more interactive learning process for students, providing deeper learning, more motivation and more interest in the subject (e.g. Clark 2002; Schultze-Mosgau et al. 2004; Allen et al. 2008; Gormley et al. 2009). Based on the literature, e-learning and experiential simulation learning are likely better mediums for training physicians if health educators are properly trained in how to incorporate technology into the curriculum. Most studies, however, tend to be based on case studies and are not generalizable."

"Several barriers prevent technology and telemedicine from being a more integrated component of health professional training: (1) cost, (2) efficiency, (3) engaging students and (4) bias against online inferiority. The initial investment for many medical technologies can be as high as $300,000 (De Lorenzo 2005). Consequently, educators are reluctant to integrate new means of training. Aside from cost, another barrier derives from an educators’ reluctance to learn how to operate technological resources. With new technology, class instruction preparation requires far more front end work, especially among those who are unfamiliar with the technology (Lockyer et al. 2006; Boerema et al. 2007). A related obstacle is that teachers of health professionals are trained as health professionals, not as educators (Alur et al. 2002). A third concern with e-learning concerns engaging student participation (Lockyer et al. 2006; Boerema et al. 2007), which is associated with poor implementation and design of the training program. If an e-learning program is properly created, it should be as demanding and as engaging as a traditional classroom setting (Clark 2002; Emami et al. 2009), but that takes considerable efforts from instructors. The idea that fully online education is an inferior learning technique if not used properly is also common in many e-learning studies (e.g. Svirko & Mellanby 2008) and appears to be an underlying attitude generally. Researchers have consequently tried to establish e-learning techniques as valid ways to learn, focusing less attention on what should be taught using e-learning approaches. In short, many educators may dismiss the possibility of using various technologies—including e-learning—in the classroom prior to giving these training methods a chance because of preconceived attitudes they have about technology and education."

above quoting from Mason et. al. 2014. Use of technology and perceptions of its effectiveness in training physicians. Med Teach 36: 333–339


Allen EB, Walls RT, Reilly FD. 2008. Effects of interactive instructional techniques in a web-based peripheral nervous system component for human anatomy. Med Teach 30:40–47

Alur P, Fatima K, Joseph R. 2002. Medical teaching websites: Do they reflect the learning paradigm? Med Teach 24:422–424

Boerema C, Stanley M, Westhorp P. 2007. Educators’ perspective of online course design and delivery. Med Teach 29:758–765

Clark D. 2002. Psychological myths in e-learning. Med Teach 24:598–604

De Lorenzo RA. 2005. How shall we train? Mil Med 170:824–830

Emami H, Aqdasi M, Asousheh A. 2009. Key success factors in e-learning in medical education. J Med Educ 12:81–89

Gormley G, Collins K, Boohan M, Bickle IC, Stevenson M. 2009. Is there a place for e-learning in clinical skills? A survey of undergraduate medical students’ experiences and attitudes. Med Teach 31:e6–e12

Lockyer J, Sargeant J, Curran V, Fleet L. 2006. The transition from face-to-face to online CME facilitation. Med Teach 28:625–630

Schultze-Mosgau S, Thomas Z, Lochner J. 2004. Web-based, virtual course units as a didactic concept for medical teaching. Med Teach 26:336–342

Svirko E, Mellanby J. 2008. Attitudes to e-learning, learning style and achievement in learning neuroanatomy by medical students. Med Teach 30:e219–e227


Three Case Studies:

A. At a regional/international conference setting (Symposium on Technology Enhanced Learning, TELroundtable@APMEC2014 at the 11th APMEC in Singapore)

Educational setting - International health professions education conference

Educational challenge - How to engage audience, promote interaction.

Theory - Provide all key information beforehand for advance review. And platform to view and discuss.

Table outlining educational learning theories and theorists

Most influential theories of learning (UNESCO)

Adult learning theories (abstract, AMEE guide No. 83)

Adult learning theories (pdf, AMEE guide No. 83)

Developing questionnaires for educational research (abstract, AMEE guide No. 87)

Method - Use of email to manage, organise and document discussions amongst 6 panelists (3 from Singapore, 1 Sri Lanka, 1 New Zealand, 1 Australia). And website/blog to present content, platform for discussion both before, during and after session, and document reflections from panelists after the conference. The website with available content was announced at opening ceremony of 11th APMEC. 

Results - Very good attendance at session. 1 comment/question posted 24 hours before session, 1 during session. Majority of time during 90 minute session was spent in Q and A and discussing content and educational issues, rather than presenting information. Spike in review of material during the session, and after session. Each panelist submitted short reflection posted on 11th APMEC symposium website (below).

Discussion and Reflection - Simple technology enhanced panel and audience engagement and interaction, documented our interaction, and provided information about viewership, and level of interest in topic - by number, and type of questions, majority at session, minority online. The majority of participants chose to engage at the session live. Having a symposium website however allowed other conference registrants not at session, and interested local and international educationalists to review the material. Our interaction was documented on the symposium website, and this platform allowed the panelists to review and reflect on the process of creating content, co-ordinating our presentations, our participation in the symposium, and facilitated writing a short reflection about our involvement in the symposium, which could be immediately shared online.

B. At an institutional level (Learning@NUHS project at the National University Hospital, Singapore)

Educational setting - Residency training at an academic medical centre

Educational challenge - To provide consistent, high quality content to facilitate resident training

Theory - Deliberate practice, mastery training, distributed practice, cognitive overload, constructivism, active learning

Method - Systematic collection content from day to day departmental and interdepartmental (multidisciplinary) teaching sessions (eg. case presentations, multidisciplinary rounds), which is edited and indexed, followed by selective hyperlinking, with combination of content which has been authored and created in-house with curated online content

Results - Year 2 of three year pilot project, with 1st year engaging both leadership and departmental educators, as well as working with initial group of volunteers; there is systematic online content being systematically created by one department, for one specific module on topic of emergency neuroimaging interpretation (EMD authoring, with radiology, neurology and neurosurgery collaboration and peer review, and pilot resident content testing), one specialty collecting and curating regular multidisciplinary round content (Ophthalmology; with one initiative in NUHS, and 2nd international collaboration with PGY2 resident in Department of Opthalmology and Visual Sciences, University of British Columbia, Canada), and initial content being uploaded by 8 departments (see below), and several "grassroots" consultative and collaborative educational projects.

Screenshot of Learning@NUHS intranet content repository landing page

Discussion and reflection - Use of an iterative engagement and development model, and project website/blog, facilitated thinking, development of consensus, monitoring progress and documenting development milestones in the project. The project site is also an educational tool, and faculty development resource, for both local and international educators.

and original pilot project website

     Normal chest radiograph (M1, undergraduate)

     Imaging of respiratory disorders (M2, undergraduate)

C. And departmental/individual teacher level (CasedBasedLearning@NUHS project in the Department of Diagnostic Radiology, National University Hospital, Singapore)

Educational setting - Radiology department with 33 residents and fellows

Educational challenge - Providing access to teaching content for residents on shift or leave; documenting teaching for asynchronous review, both before and after each interactive teaching session; providing an opportunity for all residents both onsite and offsite to attempt case based problem solving, and to document this process for feedback and educational purposes

Theory - Deliberate practice (with feedback), mastery training, constructivism

Method - Use of clinical case material with teaching value, collected and curated daily, made available on website/teaching blog (anonymised, un-annotated, with no clinical or other information provided, i.e pure perceptual / image recognition, categorisation and statement diagnosis and single sentence justification exercise). All residents on-site and off-site attempt 10 cases, and email single statement diagnosis followed by single statement justification to instructor first 10 to 15 minutes, followed by face to face interactive discussion, with one resident's notes of sessions, follow-up annotated images, and anonymised resident answers available for review.

Results - Residents have found teaching format engaging and useful; and actively and enthusiastically participate in this process; monthly sessions, over the last 7 months. Shift, post-call residents and those on leave find accessibility of teaching material and record of discussions useful.

Discussion and reflection - Use of SMS notification of session, unknown diagnosis clinical case material on teaching website for deliberate practice followed by feedback in interactive teaching session, and record of material discussed for offline review leverages on simple familiar "technology" that both residents and instructors are familiar with - (SMS), email and a website/teaching blog.

           Mastery training and deliberate practice example: Topic - acute neuroimaging


Additional "reading"

(e)Learning using content from an (e)Repository CAN be assessed and evaluated ... (e)Scholarship (some thoughts) .. and 2 related reflection pieces on MedEdWorld.

(e)Learning; digital repositories and digital scholarship (Slideshare)

     (e)Scholarship or digital scholarship

MOOCs and the Flipped Classroom (Slideshare)

Evaluating teaching - quantity and quality (some methods and examples)

as a case study, compare and contrast digital version of Paulo Coelho's book "Manuscript Found in Accra" with hardcopy print format

“What’s most interesting about his approach is not so much what he says, but what he suggests about how texts should be read. In this iPod shuffle worldview, anything and everything can be read selectively” Silvio Meira at the Digital Book Congress in São Paulo (Brasil)

"According to Meira, Paulo Coelho’s latest book exemplifies how we read and interact, and it is a great example of what texts will be like in the future."

eLearning in clinical teaching (London deanery)

Current and future trends in eLearning (Imperial College, London)

Short eLearning modules (Leeds Institute of Medical Education)

Social media bootcamp (Canadian Healthcare Education Commons)

(e)Learning (reflection and some curated online resources)

Some thoughts on Mastery Training

My Day: Japanese sushi chef Yosuke Imada (BBC) vs Meet Singapore's coffee king Adrin Loi (BBC)

Knowledge process analysis: Framework and Experience

Measurement of knowledge, process and practice in knowledge management

A Model of Organizational Knowledge Management Maturity based on People, Process, and Technology

Constructivism in practice: The case for meaning-making in the virtual world

Knowledge translation: Introduction to models, strategies and measures

Images of knowledge process practice model or

Adaptability is more important than talent


Anders Ericsson

Deliberate practice

The experience trap

The making of an expert

Deep expertise can hinder performance

The power of synthesis

Value of human input (vs Artificial Intelligence)

The new era of talent

A new age of distruption

How to become world-class at anything

The first 20 hours


  1. Hi Dr Goh,

    Thank you for sharing your knowledge on leveraging technology (e.g, social media, web 2.0) to facilitate medical teaching, sharing of teaching materials and engaging students as post-teaching activity. The sharing session was insightful as you shared with us on tips to plan the teaching curriculum and the medium to engage students.

    I would like to know on how you come to a decision to make use of platform such as blogspot, slideshare to share your teaching material? My concern here is how you managed the level of confidentialty and security when you upload your teaching material on the mass virtual platform as whoever able to access your teaching material may make reference to it.

    1. Whether to make teaching materials on the internet is no longer a "personal" choice. Technology makes information sharing in a seamless manner, whether it is intentional or not. However, feeling uncomfortable or having doubts is normal for both individual and institutes. For individual content owners, do they still own the copyright of these materials? How much do their institutes value these online materials? For institutes, what does the institute benefit from online information sharing? An institute cannot just simply jump on the wagon of putting info online.

      With all these doubts and questions, free online information sharing is happening. A couple of examples are MOOC - Massive open online course, Open Education Resources ( There are non-profit organizations working on guidelines to protect intellectual properties. Experts, even general audiences' feedback contribute to improve the quality of these information.

  2. Hi Tina,
    Thank you for attending the presentation and your question. May I recommend the following short presentation on Slideshare, weblink below, which I hope answers your question. This process we are engaged in demonstrates the utility of the use of "social media" in a professional context. One analogy might be writing a letter to a national newspaper, for example the Straits Times or New York Times, both of which have not only a local, but international audience; or letter to the editor of a local or international medial journal, for example the Singapore Medical Journal, or NEJM. In a blog, the author of the blog takes on the role of the editor, and discussion moderator.

  3. Your intention, as an educator, when you choose to use blogs or Slideshare in a professional context is to specifically share content, which you have authored, or discovered (as a recommendation). A useful guideline is to follow the standards you and your peers currently adhere to, with classroom and lecture material that you use and recommend. In this day and age, anything you share with students can potentially be disseminated and referenced to. Even if it is originally not in digital form.

  4. Strongly recommend you always, and continuously seek feedback and comments from your peers and teaching colleagues, initially within your department, then institutionally, before moving regionally and internationally. Do background reading and research. Get some training. Start very slowly, initially on the intranet, i.e. within an institutional password protected platform, where every item shared, and every comment is not anonymous, and where every participant is either an official staff member or registered student. As you gain confidence, and expertise, very slowly and carefully share educational material on progressively more public platforms. You could argue that slides and material shared in an international conference should have many, if not all, the characteristics of educational material that you, your peers, and your institution would be comfortable sharing online.

  5. Ultimately, as with any "educational technology", there are both benefits, and also potential pitfalls when using an educational tool or platform. When used with care, thoughtfully, and with increasing experience, the benefits often outweigh any potential risks, which can be mitigated. Similar debates occurred when paper, and then the printing press were invented, and used.


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