ContentsMethods Type of study
Pattern of utilization
Results Articles description
Figure 1 – Flowchart representing the articles selection and the exclusion criteria
Type of Study
Table 1 – This table represents the extraction of some analysed variables of our study
How to successfully implement e-learning for both students and teachers
pplication of e-Learning in Under-Graduated Medical teaching - A Systematic Review
Application of e-Learning in Under-Graduated Medical teaching - A Systematic Review
ALVES, C., firstname.lastname@example.org ALVES, S., email@example.com BARBOSA, R., firstname.lastname@example.org BARREIRA, J., email@example.com CERDEIRA, M.E., firstname.lastname@example.org COSTA J., email@example.com FIGUEIREDO A. R., firstname.lastname@example.org MARQUES, M., email@example.com MARTINS, A.C., firstname.lastname@example.org REIS, B., email@example.com SEIXAS, R. firstname.lastname@example.org
Advisers: Mário Dinis Ribeiro, MD, PhD email@example.com
Altamiro Costa Pereira, MD, PhD firstname.lastname@example.org
University of Oporto
Faculty of Medicine
Introduction: E-learning is an operating system, under which smaller application programs can be designed to run. It supports the act of learn at distance, by web. This new learning method is referred as very helpful supporting future doctors, stimulating knowledge acquisition. E-learning in the medical teaching is a growing area so our study analyses the articles related to the use of E-learning by undergraduate medical students. Aim: Understand the importance of e-learning starting by mentioning its advantages and disadvantages and measuring its impact in the academical success of undergraduate med students and its pattern of utilization, through a systematic review. Methods: We made a systematic review, using PubMed. The included articles provided us the source of data to extract and treat: the pattern of utilization of e-Learning by medical students, its advantages/disadvantages and its influence in academical success. We used SPSS software for database construction and data analysis. Considering that we were analysing categorical variables, we measured the frequency. Results: We analysed 16 articles. Most mentioned type of resources were the web-based platforms (n=10). The utilization pattern was referred in four articles and the influence in academical success in two. In them, the majority visited the Internet-based course at night (39%) and at home (72%). The students gave more positive ratings to e-learning than traditional methods (90% -67% respectively).Twelve articles mentioned increase of accessibility of information as e-learning’s greatest advantage. As for disadvantages six articles referred psychological issues and 4 referred the lack of interaction student/teacher and high economical costs associated to e-learning. Discussion: E-learning will have an increasingly important role to play in medical education. Web-based technologies may be successfully implemented in medical education settings. Students don’t see e-learning as replacing traditional instructor-led training but as a complement to it.
Key-words: Web-based learning; E-learning; electronic learning; Medical Education; Under-graduation.
Starting from the expression “e-learning” (“electronic-learning”), we conclude that its underlying concept derives from the association between the teaching and the always-growing potentialities of technology. 
About the application of E-learning in under-graduated medical teaching there is by now a small number of articles published, although during our bibliographic research we verified a growth of this number, for the same query, in a short period of time.
In this context, e-learning is more than a software platform – in definition is a major piece of software, as an operating system, an operating environment, or a database, under which various smaller application programs can be designed to run – which supports the act of learn at distance, in an easy and fast way, by web. It is also a way to spread knowledge, allowing its availability at any time, in every place. 
In addiction to the offer of programmatic contents and related supporting documents, this new learning method also provides the possibility to interact with other users. By using forums and frequently asked questions (FAQs), it’s possible to share points of view and clear up any possible remaining doubts at the moment. 
E-learning can be used in several areas and fields. However, our work will only fall upon the study of its importance on the undergraduate medical teaching.
E-learning comes with solutions and methods, which can be very helpful in supporting doctors with access to the up-to-date medical knowledge and achievements.  It allows creation of interactive model of learning, which stimulates knowledge acquisition. Another advantage is that e-learning provides flexibility in both time and location, while accessing medical curriculum presented online.  There is a possibility of collaboration between teachers and students from different universities, which allows exchange of knowledge and experiences. 
Our aim is to understand the importance of e-learning starting by mentioning its advantages and disadvantages and by measuring his impact in the academical success of undergraduate medical students and its pattern of utilization, through a systematic review. So, this study will be very useful, because it gathers very relevant information about a current theme whose importance is expanding.
Type of study and articles search
A systematic review of the articles found in Pubmed using the query: ("Education, Medical/education"[MeSH] OR "Education, Medical/methods"[MeSH] OR "Education, Medical/statistics and numerical data"[MeSH]) * ("Education, Distance/classification"[MeSH] OR "Education, Distance/methods"[MeSH] OR "Education, Distance/statistics and numerical data"[MeSH]) OR ("e-learning" AND "medical education") OR ("web-based learning" AND "medical education") OR (“electronic learning” AND “medical education”)
We proceeded to a first selection that consisted in reading the titles and the abstracts of the articles (each article was read by, at least, two reviewers). The articles were selected by applying the exclusion and inclusion criteria. Considering the non excluded articles, some of them were not immediately included because there were various disagreements between the first two reviewers, which required a third one. Of the included articles, only those which could be physically obtained suffered a second selection that consisted on reading the full article. The articles were selected once more by applying the same exclusion and inclusion criteria. In the same way, some articles were excluded and others were not. Those not excluded required the agreement of both reviewers (however in some cases it was needed a third reviewer).
Inclusion criteria of the articles
Exclusion criteria of the articles
This work is a systematic review, which is based on the articles selected according to the exclusion/inclusion criteria previously defined.
Variables and data collection methods
The included articles provided us the source of data to extract and treat, more specifically:
Beyond these variables we will equally analyse the place and time of the elaboration of the article, the type of students that were the subject of the study (pre-clinical and clinical) and the type of article: systematic reviews, where we will find articles that congregate in a organised form a big amount of results related to researches on one determined theme; evaluation studies where are included studies in which evaluations where made, either submitting the analysed students to special questionnaires, either comparing a control group to a exposed group; descriptive report where the author reflects and argues about a determined subject (e-learning). The most used resources in e-learning platforms are also mentioned.
Considering the above variables we used SPSS (Statistical Package for Social Sciences) software 14.0 for Windows for database construction and analysis of data, considering the type of variables in study – categorical – we measured relative frequencies as well as absolute frequencies.
We found 188 abstracts in the bibliographic research in PubMed, on 31/11/2006 and after two selections we obtained 16 articles to analyse (Figure 1)
After making the second selection we analysed the initially defined variables and we verified that about 70% (n= 11) of the selected articles had been made on the last three years and that 50% (n=8) were from European countries (one quarter of those were created in UK) (Table 1).
We classified the included articles in three types: systematic reviews, evaluation studies and descriptive reports. The majority of the selected articles were evaluation studies (10 out of 16). Of the remaining types there are 3 of each (Table 1).
Relatively to the type of students, in six of the sixteen articles there was no mention to the type of participants. Of the ten remaining, half were Pre-clinical e and the other half were Clinical (Table 1).
By analysing the evaluation studies we verified that all of the articles mentioned the use of web based platforms. Seven of them referred the use of Internet connective tools and half mentioned specialized software. Less articles made reference to self-Assessment and, simulations and scan pictures and only 3 refers de utilization of videos/videoconference (Graph 1).
Pattern of utilization of e-learning
Only four of the analysed articles had information on the pattern of utilization. The results and its analysis is represented in Table 2
Table 2 – This table represents the articles that include data about the pattern of utilization, as well as the extracted results and its analysis.
Advantages and Disadvantages
Considering all of the articles analysed, in 75% (n=12) was written that e-learning increased the accessibility to information. The ease of dissemination of information (n=9) and updating contents (n=8) were also referred in more than half of the considered articles. Less than 50% of the articles mention advantages such as a greater flexibility and control that students have over their own learning style (n=5), the standardization of contents (n=3) and the increase of technological skills (n=2) when dealing with this type of learning (Graph 2).
Of all the disadvantages mentioned 38% (n=6) of the articles referred to psychological issues of the teachers who still have some reluctance in associating e-learning to the traditional teaching method of Medicine. Twenty-five per cent (n=4) of the articles refer to problems of the teachers’ adaptation to the new technologies required by this teaching method, the lack of interaction student/teacher, the fact that the software needs to be improved and also economical issues since e-learning demands expensive technical and technological support. Difficulties in accessing computers and Internet as well as organizational issues are mentioned in fewer articles (n=2) (Graph 3).
Influence in academical success of e-learning
From the sixteen selected articles only two included data that was referred to the influence of e-learning in the students’ academical necessities, and to its comparison with the traditional teaching method (Table 3).
Table 3 – This table represents the articles that include data about the influence of e-learning among the students, as well as the extracted results and its analysis
To comprehend the importance of e-learning in under-graduated medical teaching sixteen articles were analysed. Based in four of them, which referred the pattern of utilization, students accessed to e-learning platforms in variable periods of the day and 39% during night periods. A great percentage of students access e-learning in faculty (64%), but 74% are able to access outside, the majority at home (72%). 
Although medical students lack familiarity with the whole extend of web technologies, as we also detected, they are getting used to visiting the internet for educational purposes.  The main advantage, mentioned in twelve articles, was the increase of accessibility of information that e-learning provides. The ease of dissemination of information and in updating contents was cited in nine and eight articles, respectively.
Studies referred that students are very satisfied with e-learning. Learners’ satisfaction rates increased with e-learning, compared to traditional learning.  Most studies agree that e-Learning could serve as a supplement for lectures and seminars. However, about as many students disagree with the statement that e-Learning could replace traditional methods.  In fact E-Learning is a component of, but not a substitute for other forms of teaching, and interestingly, students do not see e-learning as replacing traditional instructor-led training but as a complement to it, forming part of a blended-learning strategy. 
Web-based technologies may be successfully implemented in medical education settings and an online course designed to undergraduate medical students has a promising educational value. 
The main disadvantage, mentioned in six articles, was teachers’ difficulty in adapting their method of teaching with this new way. Other important disadvantage is the high economical costs necessary for the acquisition of the needed technology and software. Creating e-learning material involves several components: once content is developed, it must be managed, delivered, and standardized. Content comprises all instructional material, which can range in complexity from discrete items to larger instructional modules.  There is also the need to invest in the teacher’s formation and specialization as well as hiring professionals to deal with computer associated areas, since there is still some apprehension on behalf of the teachers. 
What seems certain, however, is that the new learning technologies and e-Learning will have an increasingly important role to play in medical education. 
Most of the reviewed articles reported favourable results with the e-Learning content and technologies deployed, the lack of methodological details, small sample size and specific technologies involved in these studies have made it difficult to generalize their findings to other settings. About the analysed articles, most of them did not contain information that could allow us to achieve the defined objectives, thus making our work harder. They aimed essentially to a specific type of e-learning or its implementation in a particular establishment making scarce the data related to the pattern of utilisation and impact of e-learning. We also expected to have a higher number of articles to support our conclusions.
Numerous research opportunities exist in the relatively new field of e-Learning.  But future articles should refer the pattern of utilisation as well as the impact E-learning has in the academical success. In the future studies, potential areas for research are the differential use of e-learning in preclinical versus clinical years, the incorporation of e-learning as part of a blended-learning strategy and an exploration of methods for simplifying the e-learning creation process to gain wider acceptance and use.
Trying to predict the future of e-learning is like trying to guess which colours and shapes will appear at the other end of the kaleidoscope. The colour combinations and shapes are wonderful to see, yet they blend and change at the twist of the dial. 
The authors sincerely thank to Mário Dinis Ribeiro, MD, PhD and Altamiro Costa Pereira, MD, PhD for the critical comments and assistance with the manuscript preparation.
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