International Journal of Medical Informatics 50 (1998) 59 – 68

Integrated medical informatics with small group teaching in

medical education

Heng-Shuen Chen a,*, Fei-Ran Guo b, Chien-Tsai Liu a, Yue-Joe Lee c,

Jye-Horng Chen d, Chia-Chin Lin a, Sheng-Mou Hou e, Bor-Shen Hsieh a
a
Department of Medical Informatics, College of Medicine, National Taiwan Uni6ersity, No. 1 Jen-Ai Road, Section 1,
Taipei 100, Taiwan
b
Department of Family Medicine, National Taiwan Uni6ersity Hospital, No. 7 Chung-Shan South Road, Taipei, Taiwan
c
Department of Social Medicine, National Taiwan Uni6ersity, No. 1 Jen-Ai Road, Section 1, Taipei 100, Taiwan
d
Institute of Electric Engineering, National Taiwan Uni6ersity, No. 1 Roose6elt Road, Section 4, Taipei 100, Taiwan
e
Department of Orthopedics, National Taiwan Uni6ersity, No. 1 Jen-Ai Road, Section 1, Taipei 100, Taiwan

Abstract

National Taiwan University College of Medicine (NTUCM) introduced small groups of teaching and basic-clinical
integrated courses for medical students in 1992. By using computer network and multimedia techniques, this study
tried to overcome barriers to learning in small group teaching. The Department of Medical Informatics of NTUCM
established campus networking and computer classrooms and provided Internet and intranet network services
including mail, netnews, bulletin board systems (BBS), world wide web (WWW), gopher, ftp and local file servers. To
implement an interactive learning environment, the authors first tried mail lists, newsgroups and BBS. Next an
integrated learning system prototype on the WWW was developed to provide functions including online syllabus,
discussion boards simulated to BBS, online talk, interactive case studies, virtual classroom with video on demand
(VOD) and Internet medical resources. The results showed that after the medical students completed the required
course of medical informatics and had good network access using a network to communicate with each other became
a daily practice. In the future, the system will extend to the tutoring of clinical practice and continuing medical
education. The authors expect a national medical education network and more international cooperation and
exchange. © 1998 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Medical education; Small group teaching; Computer assisted Learning medical informatics

1. The new pathway: small group teaching

* Corresponding author. Fax: + 886 2 23659043; e-mail: In September 1992, National Taiwan Uni-
[email protected] versity College of Medicine (NTUCM) began

1386-5056/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved.

PII S1386-5056(98)00052-5
60 H.-S. Chen et al. / International Journal of Medical Informatics 50 (1998) 59–68

the new pathway to reform the medical edu- Table 1

cation curriculum. The major change was to Curriculum of medical informatics for 2nd year medical
students
integrate courses in basic and clinical sci-
ences. These integrated courses combined fac- Curriculum of medical informatics (4 h/week,
ulty from basic and clinical science using including practice)
both didactic lectures and small group inter-
active discussion [1]. The purpose of newly Basic computer concept
Basic network concept
introduced small group teaching was to in-
Computer language BASIC (2)
spire active learning. With a cooperative and Operating system
social learning environment, small group dis- Chinese system and word processor
cussion can greatly enhance student–teacher Database and data processing
and student–student interaction [2]. Computer medical resources
For the new pathway, the authors recruited Multimedia and CAI
Computer statistics(2)
clinical faculty as tutors to join and guide Intelligent health information system
small discussion groups. In a small group, Medical diagnostic decision support systems
medical students learn to use critical thinking Computer medical record and computer reminder
and problem solving skills for active learning.
The discussion is just the beginning. The
students need more medical information and manufacturing computer products and the
teaching materials to fulfill their curiosity. In National Information Infrastructure (NII)
these circumstances, a computer network and program started in 1995. But for the medical
multimedia technology can play an important field there was a time lag to catch up with the
role in supporting small group teaching. new technology mostly due to early dissocia-
Computer assisted learning is also a new tion with other sciences. Because of educa-
trend for medical education [3–5]. tional competition in the form of entrance
examinations and the 7-year undergraduate
to graduate system of medical education,
2. Medical informatics in NTUCM most medical students have little opportunity
to use computers. Therefore the authors had
In recent years, the Taiwan information to teach both the teacher and the students
industry ranked the third in the world in and help them to use the existing resources

Table 2
Usage of mail server for medical students

Grade Rank Number Log-ins/day People/day

Med1 student 7 133 0 0 (0%)

Med2 student 6 133 21 8 (6.0%)
Med3 student 2 133 287 61 (45.9%)
Med4 student 3 136 166 52 (38.2%)
Med5 student 4 133 162 42 (31.2%)
Med6 student 1 134 319 68 (50.7%)
Med7 student 5 137 115 32 (23.4%)
Total 939 1070 263 (28.0%)
 H.-S. Chen et al. / International Journal of Medical Informatics 50 (1998) 59–68 61

Table 3 virtual medical campus and overcome barri-

Mailing lists of small group teaching courses ers to learning in small group teaching. The
Number of Clinical diag- Medical problem
goal was to develop an intelligent interactive
e-mails nosis solving computer network system on the Internet to
provide a socialized, cooperative learning en-
Tutors (4) Nine e-mails 14 e-mails vironment for second to fourth year medical
0 Tutor B,C,D Tutor D students [8]. In this study, the authors collab-
2 Tutor C orated with clinician, computer scientist,
5 Tutor B
medical engineers, psychologists and educa-
7 Tutor Aa
9 Tutor A tors to develop a web-based learning environ-
ment [9].
Students (33) 13 e-mails 13 e-mails
1 Three stu- Five students
dents
2 Three stu- One student 3. Subjects and methods
dents
3 Two students 3.1. Subjects
4 One student
Total partici- One tutor, Three tutors, eight In the School of Medicine at NTUCM,
pants seven students students there were 939 students divided to seven
Total e-mails 22 e-mails 27 e-mails grades. The second to fourth year medical
students were chosen for small group teach-
a
Tutor A went abroad for 1 month and kept active in ing. In each grade there were about 135
the mailing list. students divided into 16 small groups. Each
group had a tutor who was usually a young
[6]. In 1994, medical informatics became a attending physician.
required course for second year medical stu-
dents in the School of Medicine, NTUCM 3.2. Method
[7]. After establishing campus networking
and computer classrooms and developing the Without the support of a computer center
education and research program for medical on the medical campus, the Department of
informatics, the authors started the first De- Medical Informatics set up all the hardware
partment of Medical Informatics in Taiwan and software for the computer network as-
in August 1996. sisted learning environment. A curriculum of
In 1995 NTUCM carried out NII distance medical informatics for medical students was
education and tale-consultation pilot projects also organized. The first stage focused on
awarded by the Ministry of Education and setting up the network environment on the
the Department of Health. Through these medical campus and gathering baseline data
programs NTUCM set up external communi- for medical informatics and small group
cation networks from dial-up terminal tele- teaching. The second stage was to remove
phone line services, integrated service digital barriers between faculty and students by set-
networks (ISDN), T1 and T3 lease lines, to ting up network services. In the third stage,
an asynchronous transfer mode (ATM) net- the authors tried to develop an integrated
work. By integrating multimedia computer learning environment system on the world
assisted learning applications to the network wide web (WWW) to enhance self-learning
infrastructure, the authors tried to establish a and small group discussion on the network.
62 H.-S. Chen et al. / International Journal of Medical Informatics 50 (1998) 59–68

Fig. 1. BBS statistics during a day, total log-ins: 4314, average usage: 14 min.

4. Result 4.2. Internet and intranet ser6ices

4.1. Curriculum for medical informatics and Servers were installed included (1) mail
campus network servers automatically providing all students
e-mail accounts, (2) a netnews server provid-
In 1994 medical informatics became a re- ing about 10000 newsgroups and moderating
quired course of two credits for second year 50 tw.med.* news groups in the medical field,
medical students. The course was 4 h a week (3) a bulletin board system providing 165
and consisted of 1 h of lecture and 3 h of discussion boards including all the medical
practice. The content included basic com- specialties through a news server feeding to
puter concepts, computer language, operating all the other medical colleges in Taiwan, (4)
systems, basic network concepts, Office pro- WWW servers allowing all faculty and stu-
grams and applications for medical informat- dents to establish homepages and (5) other
ics (Table 1). For the campus network the public services including gopher, ftp and a
backbone was fiber distributed data interface 250 user Novell server on the local area net-
(FDDI) which underwent an upgrade to work [3]. The authors recruited several medi-
ATM. Twenty Ethernet subtends consisting cal students each year to become system
of over 2000 nodes were connected to three operators after they had completed the medi-
major router nodes in a star shape. All build- cal informatics course. Fifteen students were
ings were wired including the student dormi- trained and assigned to handle these servers.
tories and dial-up terminal service was
provided to students living at home. Two
computer classrooms were established. One 4.3. Computer network learning en6ironment
was a mobile classroom consisting of 140
486PC notebooks brought in by the students About 1000 log-ins per day was noted for
to use in class, the other was 40 multimedia the mail server of the school of medicine,
Pentium PCs. All workstations of both class- which has about 1000 accounts and nearly
rooms were able to access the Internet 30% students logged in each day (Table 2).
directly. Two mailing lists of small group teaching
 H.-S. Chen et al. / International Journal of Medical Informatics 50 (1998) 59–68 63

Table 4
BBS statistics of people, departments and case discussion group

Discussion board Rank Visits/day Posts/mo Time (s/visit)

People
Med1 student 6 356 1435 130
Med2 student 2 480 1202 130
Med3 student 5 369 510 85
Med4 student 7 336 714 62
Med5 student 3 419 511 113
Med6 student 1 510 364 105
Med7 student 8 275 140 91
Internship 11 224 111 84
Residentship 12 204 164 107
School of medicine 19 164 32 37
Med alumni 23 135 41 94
Case discussion 114 16 15 90
Departments
Psychiatry 36 80 109 156
Internal med 84 29 20 52
Pediatrics 90 26 11 93
ObsGyn 91 26 15 92
Ophthalmology 100 22 14 74
Surgery 106 20 6 62
Dental med 108 19 22 99
Rehabilitation 112 17 9 67
Dermatology 116 16 11 59
Family medicine 122 15 13 35
Neurology 133 12 12 38
Urology 138 11 8 71
ENT 139 11 8 41
Forensic med 146 10 3 52
Anesthesiology 154 6 1 70
Average (165 boards) 64 62 107

courses ‘Clinical Diagnosis’ and ‘Medical the second course. Tutor B and C became
Problem Solving’ were set up to encourage active in the second course, however tutor D
tutors and students to use e-mail for discus- was always inactive (Table 3).
sion among four small groups including four There were much more utilization for the
tutors and 33 fourth year medical students. bulletin board systems (BBS), about 4000
For 4-month periods for each course, there log-ins per day with three peak at noon, 5
were both 13 e-mail response from about one and 10 p.m. (Fig. 1). Furthermore, the dis-
fourth of the students, which is seven and cussion board for each class in the medical
eight students, respectively. Among four tu- school was read around 200–500 times per
tors only tutor A was active and sent nine day comparing with 20 times per day for
e-mails in the first course and always kept boards of clinical departments (Table 4) or
active even during when he went abroad in case discussion boards associated with small
64 H.-S. Chen et al. / International Journal of Medical Informatics 50 (1998) 59–68

group teaching. A survey of participants re- online talk, interactive clinical case study
vealed nearly 60% were medical stu- (Fig. 4), virtual classroom with multimedia
dents(Table 5). Although the discussion lecture note combining video on demand
board was not very active, the board man- (VOD) (Fig. 5) and network medical re-
ager, who was a medical student, treasured a sources for small group teaching course of
lot of excellent materials including clinical 2nd to 4th year medical students.
cases, frequent asked questions, articles of
clinical experience and several clinical pathol-
ogy conference files (Table 6). 5. Discussion
An integrated learning system prototype
on the WWW platform with Common-Gate- Traditional medical education focused on
way Interface (CGI), Javascript and Java lectures and gave too much information to
techniques was developed (Fig. 2). It pro- students. Memorizing the facts without
vided functions including online syllabus, dis- thinking caused a reduction of creativity and
cussion boards simulated to BBS (Fig. 3), problem solving capability. Small group
teaching and discussion enhance self-directed
Table 5
Participant of case discussion board of BBS learning and knowledge acquisition [10]. Dur-
ing the learning process, a student must
Participant Number % spend a lot of time searching for medical
information outside the textbook and must
Medical students grade 1–3 20 33 carry out data management [11]. Problems
Medical students grade 4–7 15 25
Non medical students 7 12
might occur at each step and the student has
Graduate students 8 13 no one to discuss these problems with. The
Resident 0 0 tutor, who is responsible for heavy clinical
Faculty 1 2 duty, cannot find time to discuss problems
Nurse 2 3 with the students after class. Since face to
Paramedical 1 2
face interaction was not possible, syn-
Other 6 10
Total 60 100 chronous or asynchronous interaction
through Internet or intranet communication
was the best solution.
Table 6 Medical students in Taiwan generally lack
Analysis of case discussion board of BBS computer knowledge and capabilities and
Item Number
about one third are computer illiterate [12].
However they participated in the Internet
Rank 114 world through the most popular network sys-
Daily visit 16 log-ins tem such as BBS without difficulty. After
Monthly posts 15 articles taking the compulsory course of medical in-
Average reading time 90 s
formatics, the activities on Internet and medi-
Digest: board manager(medical student) cal literature searching increased greatly and
Clinical cases 20 cases the preference for graphic user interface
FAQ: 10 specialty 200 articles
(GUI) was also enhanced [12]. For different
Clinical experience: 13 articles
Intern survival guide 13 pages type of network system, using e-mail mailing
CPC 9 cases list for group discussion is the simplest way,
but the participation usually very low due to
 H.-S. Chen et al. / International Journal of Medical Informatics 50 (1998) 59–68 65

Fig. 2. Integrated web-based distance learning system.

poor interaction and lacking integration student to a BBS class board was 20 times
function with other system. Users need to higher than in a mailing list (Table 7) and it
learn several difficult UNIX commands to was the major group learning factor consid-
use the mail server, or they need to have a ered within small group teaching [13].
dedicated PC with Windows based POP3 In recent years, WWW became more and
program installed for e-mail receiving. Most more popular. The web server of School of
tutors of small group teaching failed to do so, Medicine, National Taiwan University, which
so they were not active in the mailing list. provide disk storage for homepage of medical
Internet BBS is a very friendly network sys- students and faculty, had 25000 hits per day.
tem integrated with online chat, netnews, go- The advantage of a WWW system is it com-
pher, even text mode WWW works within a bines hyper-linked multimedia and graphic
BBS. That’s the reason why it attracted a lot user interface designed with CGI, Java tech-
of users especially beginners, however it was nique. It seems WWW has become the total
considered to be recreational rather than edu- solution.
cational. Students loved it and indulged in it, In this study, the authors tried to integrate
but faculty and senior doctors considered it a web-based medical information system us-
time-wasting. The engagement of a medical ing a multimedia database to support the
66 H.-S. Chen et al. / International Journal of Medical Informatics 50 (1998) 59–68

Fig. 3. Web BBS for small group teaching course of 2nd to 4th year medical students.

Fig. 4. Interactive clinical case study for medical students.

 H.-S. Chen et al. / International Journal of Medical Informatics 50 (1998) 59–68 67

Fig. 5. Virtual classroom with multimedia lecture notes and VOD.

Table 7
Participation of different type of network for a medical student class

Type of network system Read frequency Post frequency Engagement

Mailing list 40/day 0.1/day 1/400

Case discussion board 1.6/day 0.05/day 1/32
Class board 400/days 20/day 1/20
WWW high ? ?

application of computer assisted learning nication among students and tutors, but also
through a kernel of the CGI program. In expand the learning environment. In the fu-
the same manner, it can also be used in ture, the authors will extend the system to
tele-consultation, distance education and the tutoring of clinical practice and continu-
tele-homecare. ing medical education. The authors expect a
By integrating medical informatics in the national medical education network and
small group teaching curriculum, the authors more international cooperation and ex-
provide not only a new pathway of commu- change.
68 H.-S. Chen et al. / International Journal of Medical Informatics 50 (1998) 59–68

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