Application of e-Learning in Under-Graduated Medical teaching a systematic Review icon

Application of e-Learning in Under-Graduated Medical teaching a systematic Review


pplication of e-Learning in Under-Graduated Medical teaching - A Systematic Review

Application of e-Learning in Under-Graduated Medical teaching - A Systematic Review


Advisers: Mário Dinis Ribeiro, MD, PhD 

Altamiro Costa Pereira, MD, PhD 

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. [1]

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. [1]

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. [2]

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. [3] 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. [4] There is a possibility of collaboration between teachers and students from different universities, which allows exchange of knowledge and experiences. [5]

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.

^ Methods

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”)

Articles selection

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

  • All the articles accessing the impact and the use of e-learning and medical under-graduated teaching.

Exclusion criteria of the articles

  • Articles in languages different from Portuguese, French, Spanish and English;

  • Articles related to dentistry and veterinary medicine;

  • Articles that are not available in FMUP’s and IPO’s libraries as well as in databases;

  • Articles that only describes programs, treatments, systems and universities.

Study Design

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:

  • The^ Pattern of utilization of e-Learning by medical students, where we intended to analyse some aspects like the place where students aced e-learning, the time when this platform is more often used and frequency that students use e-learning, as well as the time that they stay online;

  • The Advantages/Disadvantages of e-Learning that are usually mentioned in the articles;

  • The Influence in academical success, through the comparison of results that students achieve using e-learning or only the traditional education method.

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.

Statistic analysis

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.

^ Results

Articles description

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)

^ Figure 1 – Flowchart representing the articles selection and the exclusion criteria

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).


Local of Study (Country)

Year of Publication

^ Type of Study

Type of Participants

V. Bernardo et al [19]



Evaluation Study


J. M. Brunetaud et al [9]



Evaluation Study


S. Childs et al [8]



Systematic Review

Not stated

M. de Maio et al [17]



Evaluation Study


T. Dornan et al [20]



Evaluation Study


P. Goettner et al [12]

Not mentioned


Descriptive Report

Not stated

M. Gotthardt et al [10]



Evaluation Study


R.M. Harden et al [14]

Not mentioned


Descriptive Report

Not stated

R.M. Harden et al [6]



Descriptive Report

Not stated

D.G. Healy et al [11]



Evaluation study


F. Lau et al [15]

Not mentioned


Systematic review

Not stated

T.M. Link et al [18]



Evaluation Study


K.S. Negaswari et al [13]



Evaluation Study


R.K. Nevgi et al [21]



Evaluation Study


J.G. Ruiz et al [16]



Systematic review

Not stated

A.S. Wilson et al [7]



Evaluation Study


^ Table 1 – This table represents the extraction of some analysed variables of our study

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



T.M. Link et al, Medical University of Vienna, Austria[18]

  • 49% report using a kind of E-Learning at least once per month.

  • 12% of the students are inexperienced having used at most one kind of e-learning program at least once per term.

About an half of the students use e-Learning at least once per month.

We can verify that the percent of inexperienced students with e-Learning is low.

M. de Maio et al, Faculty of Medicine, University of Sao Paulo, Brazil [17]

  • 28% of the students visited 1 to 3 times a week

  • 8% visited more than 3 times a week.

The time the students remained connected was:

  • more than 2 hours (49%)

  • less than 1 hour (31%)

  • variable (20%)

The period of the day they visited was:

  • 8% in the morning

  • 14% in the afternoon

  • 39% at night

  • 39% at variable times

About an half of the students remained connected more than 2 hours and some of them said that the time they remained connected was variable.

The majority of students visited the Internet-based course at night or at a variable period of the day.

M. Gotthardt et al, University of Marburg and University of Giessen, Germany [10]

  • Most students accessed the material from home (72%)

  • From computer halls at the university (62%),

  • From friends' homes (14%)

  • From other places (such as Internet cafes) (4%)

These two studies show that the majority of students are able to access e-Learning resources from off-campus, but the percent that accesses from the university is also high.

The second also refers that e-Learning was more visited during working hours.

D.G. Healy et al, University College Dublin, Ireland [11]

  • 74, 4% of students were able to access e-Learning from off-campus internet access.

  • The majority of e-Learning usage (64.6%) took place during working hours with little usage on the weekend (21.1%).

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).



M. de Maio et al, Faculty of Medicine, University of Sao Paulo, Brazil [17]

Students’ evaluation of the basic and clinical material provided on E-learning:

  • Excellent - 15%

  • Good – 36%

  • Satisfactory - 38%

  • Poor – 6%

  • Not enough – 5%

The majority of students classified E-learning as Good or Satisfactory.

M. Gotthardt et al, University of Marburg and University of Giessen, Germany [10]

  • Positive ratings for e-Learning: 90%

  • Positive ratings for traditional methods (HTML and PDF): 67%

E-Learning had more positive ratings than traditional methods. However, in the second there is a large interval, so results are not statistically significant.

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%). [10][11]

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. [19] 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. [10] 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. [18] 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. [7][16]

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. [19]

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. [16] 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. [16]

What seems certain, however, is that the new learning technologies and e-Learning will have an increasingly important role to play in medical education. [6]


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.

Future approach

Numerous research opportunities exist in the relatively new field of e-Learning. [6] 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. [6]


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.


  1. Vollmar HC, Schurer-Maly CC, Frahne J, Lelgemann M, Butzlaff M., An e-learning platform for guideline implementation--evidence- and case-based knowledge translation via the Internet. Methods of Information in Medicine. 2006; 45(4): 389-96.

2. Harden RM., A new vision for distance learning and continuing medical education, The journal of continuing education in health professions, 2005, 25(1):43-51

3. Vozenilek J., Huff J. S., Reznek M., Gordom J. A., See One, Do One, Teach One:

Advanced Technology in Medical Education. Acad Emerg Med, 2004, Vol. 11, pp. 1149- 1154

4. Ruiz JG, Mintzer MJ, Leipzig RM., The impact of E-learning in medical education. Academic Medicine: journal of the association of American Medical Colleges. 2006; 81(3):207-12.

5. Curran VR, Fleet L., A review of evaluation outcomes of web-based continuing medical education, Medical education, 2005, 39(6):561-7

6. Harden RM, Hart IR, An international virtual medical school (IVIMEDS) the future for medical education, Medical Teacher, 2002 May;24(3):261-7

7. Wilson AS, Goodall JE, Ambrosini G, Carruthers DM, Chan H, Ong SG, Gordon C, Young SP, Development of an interactive learning tool for teaching rheumatology - a simulated clinical case studies program; Rheumatology (Oxford), 2006 Sep;45(9):1158-61, Epub 2006 Mar 10

8. Childs S, Blenkinsopp E, Hall A, Walton G, Effective e-learning for health professionals and students - barriers and their solutions. A systematic review of the literature--findings from the HeXL project, Health Information and Libraries Journal, 2005 Dec;22 Suppl 2:20-32

9. Brunetaud JM, Leroy N, Pelayo S, Wascat C, Renard JM, Prin L, Beuscart-Zephir MC, Comparative evaluation of two applications for delivering a multimedia medical course in the French-speaking Virtual Medical University (UMVF), International Journal of Medical Informatics, 2005 Mar;74(2-4):209-12

10. Gotthardt M, Siegert MJ, Schlieck A, Schneider S, Kohnert A, Gross MW, Schafer C, Wagner R, Hormann S, Behr TM, Engenhart-Cabillic R, Klose KJ, Jungclas H, Glowalla U, ^ How to successfully implement e-learning for both students and teachers, Academic Radiology. 2006 Mar;13(3):379-90

11. Healy DG, Fleming FJ, Gilhooley D, Felle P, Wood AE, Gorey T, McDermott EW, Fitzpatrick JM, O’Higgins NJ, Hill AD, Electronic learning can facilitate student performance in undergraduate surgical Education: o prospective observational study, BMC Medical Education. 2005 Jun 29;5:23

12. Goettner P, Effective e-learning for healthcare, Health Management Technology. 2000 Dec; 21 (12):64, 63

13. Nageswari KS, Malhotra AS, Kapoor N, Kaur G, Pedagogical effectiveness of innovative teaching methods initiated at the Department of Physiology, Government Medical College, Chandigarh, Advances in Physiology Education, 2004 Dec;28(1-4):51-8

14. Harden RM, Myths and e-learning, Medical Teacher, 2002 Sep;24(5):469-72

15. Lau F, Bates J, A review of e-learning practices for undergraduate medical education, Journal of Medical Systems, 2004 Feb;28(1):71-87

16. Ruiz JG, Mintzer MJ, Leipzig RM, The impact of E-learning in medical education, Academic Medicine. 2006 Mar;81(3):207-12

17. de Maio M, Ferreira MC, Experience with tha first Internet-Based course at the Faculty of Medicine, University of São Paulo, Rev Hosp Clin Fac Med Sao Paulo. 2001 May-Jun;56 (3):69-74

18. Link TM, Marz R, Computer literacy and attitudes towards e-learning among first year medical students, BMC Med Educ. 2006 Jun 19;6:34

19. Bernardo V, Ramos MP, Plapler H, De Figueiredo LF, Nader HB, Ancao MS, Von Dietrich CP, Sigulem D, Web-based learning in undergraduate medical education: development and assessment of an online course on experimental surgery, International Journal of Medical Informatics. 2004 Sep;73(9-10):731-42

20. Dornan T, Hadfield J, Brown M, Boshuizen H, Scherpbier A, How can medical students learn in a self-directed way in the clinical environment? Design-based research, Med Educ. 2005 Apr;39 (4):356-64

21. Romanov K, Nevgi A, Learning outcomes in medical informatics: comparison of a WebCT course with ordinary web site learning material, International Journal of Medical Informatics, 2006 Feb;75(2):156-62. Epub 2005 Aug 5

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