Academic Psychiatry 28:60-65, March 2004
© 2004 Academic Psychiatry
Distance Learning Technologies in the Training of Psychiatry Residents: A Critical Assessment
Douglas A. Walter, Ed.D.,
Peter B. Rosenquist, M.D. and
Gary Bawtinhimer, M.D.
Dr. Walter is Program Director at the Natchez Regional Medical Center, Natchez, Mississippi. Dr. Rosenquist is Associate Professor of Psychiatry at Wake Forest University School of Medicine, Winston-Salem, North Carolina. Dr. Bawtinhimer is Associate Clinical Professor of Psychiatry at East Carolina University School of Medicine, Greenville, North Carolina. Address correspondence to Dr. Walter, Natchez Regional Medical Center, Seniors Behavioral Health Program, P.O. Box, 1488, Natchez, MS 39120, bigskyman{at}hotmail.com (E-mail).
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ABSTRACT
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Objective: The advent of videoconferencing technology has created opportunities to pool educational resources across different training programs. Methods: The authors surveyed participants and presenters in a seminar series utilizing interactive video-conferencing and a web-based course management system. Results: Trainees with access to high-speed real-time connections rated their experience more highly compared with those who used slower web streaming technology, particularly with regard to the sound quality. Conclusions: Specific recommendations on optimizing the use of video-conferencing and web-based course management tools in the training of residents are offered.
Key Words: Distance Learning • Resident Education
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INTRODUCTION
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As with many graduate medical education programs, residency training in psychiatry is facing ever increasing financial constraints. In part, this has been a result of reductions in graduate medical education (GME) funds following the passing of the Balanced Budget Act of 1997. These financial pressures have been exacerbated by decreases in patient revenues and the impact of managed care on reimbursement for clinical services. Historically, practice plans have been utilized to subsidize and support residency training. The changing GME financial landscape has challenged existing programs to find more cost effective approaches for training residents (1).
One innovative and potentially cost effective approach for training residents in psychiatry is through the use of real-time video-conferencing and web-based course management tools. Video-conferencing capability has improved nationwide, capitalizing on the significant improvements in current technology. Distant departments can now design an optimal lecture series, pool their faculty teaching resources, and eliminate some of the costs associated with the duplication of educational services. Using web-based course management tools, such as BlackboardTM, a web site that supplements and enhances the benefits of these seminars and addresses certain weaknesses inherent in the use of video-conferencing can be created.
Video-conferencing and telemedicine technologies have facilitated residency training as well as postgraduate continuing medical education (CME) (3, 4, 5). Early efforts focused upon overcoming both geographical barriers and considerable costs associated with sending physicians to distant sites for educational purposes (e.g., transportation, lodging, and time away from work). This technology was shown to be feasible in a study of interactive video-precepting of family practice residents. Its use by residents, however, eventually diminished and equipment problems occurred approximately 20% of the time (5). In conjunction with an Area Health Education Center (AHEC), the University of Arkansas for Medical Sciences conducted a comparison study of face-to-face and video conferencing presentations for family practice residents and achieved similar posttest scores on a measure of presentation content. The residents, however, reported a decline in their satisfaction with the video-conferencing technology for didactic education (4). Residents also raised concerns regarding the practical limitations of video-conferencing when compared to "face-to-face" contact between participants and presenters.
In both of these studies, difficulties were noted in the quality of both the visual and verbal interactions between sites. These problems were attributable, in part, to the varying technical capabilities, unreliable equipment, as well as difficulties in establishing and maintaining video-conferencing links.
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METHOD
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The Department of Psychiatry in The Brody School of Medicine at East Carolina University (ECU) offered three separate seminar series on the topic of managed care to senior residents utilizing video-conferencing technology. The first series of seminars was offered during the winter semester of 1998–1999. Medical educators, at distant locations made live presentations to psychiatry residents at the medical schools of ECU and at Wake Forest University (WFU) (2). East Carolina University functioned as the bridge for these video presentations, channeling the incoming video-conferencing material to the information highway between these two North Carolina universities that were separated geographically by more then 150 miles. A second series of seminars, using a similar format, was offered to the psychiatry residents at ECU during the winter semester of 1999–2000. Surveys of the seminar presenters and participants followed each seminar.
Findings from the first two seminar series were then considered in planning for the third series of seminars, forming the basis for the present study. These seminars were provided to residents at ECU, the University of Michigan, and the University of Miami, with ECU functioning as the host for the web site and the hub for the interactive video-conferencing seminars (Figure 1). Available technology dictated a major difference in the bandwidth between sites. While ECU and University of Michigan trainees viewed the seminar in real time via integrated systems digital network (ISDN) (384 Kbps) videoconferencing linkage, the University of Miami participants used the course web site as presentations were video streamed (80 Kbps) in real time or watched them at a later time by accessing an archive file through the web site. All participants had access to BlackboardTM, a web-based course management tool. The web site was constructed with separate files established for each of the presenters. Each file contained the presenter’s course outline, PowerPoint® presentation slides, a list of suggested readings (with on-line access to those articles whenever possible), and a digitized video file of the presentation. Each presentation was stored within this file as two separate videos: one for participants with access to high-speed Internet connections (video speed playback of 80 kbps or more) and another for those with slower speed Internet connections (20 kbps or more). The videos became available within 24 hours following the presentation.
The course web site contained a number of other support tools for presenters and residents. Each of the residents, presenters, and site faculty were able to send e-mail to one another through the web site and, if needed, they could open and use a chat room for course related discussions. There were also separate files established within the web site for additional information related to the major managed behavioral health care web sites, managed care related publications, associations, and other resource materials. The web site was constructed to allow for the evaluation of residents’ attitudes pertaining to managed care as well as assessment of their current knowledge regarding the course material.
Residents at ECU and the University of Miami as well as the seminar presenters evaluated their experience via questionnaire, inviting both quantitative and qualitative feedback. The quality of the technology was specifically rated on a 5-point Likert scale (5=excellent, 4=very good, 3=ok, 2= poor, 1=unacceptable). Differences between the groups (all participants versus presenters; ECU versus Miami participants) were assessed using the Mann-Whitney U test for ordinal data. The Mann-Whitney U examines at the locations of one set of scores relative to the locations of the other set of scores. If U is not significant, then the rankings of one set of scores are similar to the rankings of the other set.(6)
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RESULTS
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Eight seminar participants from ECU and 11 from Miami responded to the survey. Mean ratings for each group are presented in Table 1. Miami participants reported less satisfaction with the experience, with significant differences identified for overall sound quality (U=67, p<0.0155) and ability to hear the presenter’s questions and comments (U=55, p<0.0148). The groups did not diverge significantly in ratings of picture quality, the quality of audio visual materials, or the ability to interact with the presenter.
Qualitative feedback from the ECU residents noted some concerns regarding the scheduling of the seminars, (e.g., time of day) and the inconvenient location of the seminar room (the video-conferencing center was located in a building a short distance from the resident outpatient clinic). There were some problems noted in displaying PowerPoint® demonstrations and presenter outlines during some of the presentations. Residents at the University of Miami noted some concerns with accessing the web site and viewing the seminars when they used their computers outside of the university setting. These problems were enough of a barrier that two residents reported that this would limit their willingness to participate in similar courses in the future.
Surveys were also completed by eight of the 11 presenters who participated in the series of seminars (Table 2). No significant differences were found for comparable variables between presenters and participants. The feedback from the different presenters varied significantly from site to site and tended to reflect the quality of the video-conferencing connections between their location and ECU. Those presenters and participants located at sites that had high speed interactive connections were more satisfied. Wake Forest University, a site connected with ECU over a state-wide network that utilized a high speed combination of microwave and T1 connections, reported excellent picture quality and very good sound quality. They did not report concerns about a noticeable time delay in the interactive presentation.
Presenters at sites that depended upon ISDN connections showed a more diverse rating of the interactive video-conferencing seminars. These connections were usually at 384 kbps. Responses from those sites emphasized more technically related including problems with video and audio quality and operation of the related equipment. One site experienced significant difficulty due to the lack of adequate equipment. This presentation site was noted to have very limited space and lacked the ability to integrate audio/visual materials into the presentation. None of these problems was reported to be significant enough to limit participation.
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DISCUSSION
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The video-conference seminars presented at ECU, the University of Michigan, and the University of Miami demonstrate alternate means of simultaneously teaching psychiatry residents located at distant sites. The number of participants and presenters involved in the series of seminars was small. These findings, however, do provide some insight into some of the potential systematic strengths and weaknesses of teleconferencing and internet-based technology in the training of residents. Higher ratings were seen with high speed real-time connections, compared with the slower web streaming technology. Specifically, significant differences between the groups highlight the essential importance of the auditory capabilities of distance learning technologies. These findings are consistent with the expectation that far more information is being transmitted in the words of the speaker than by what may be communicated nonverbally by the speaker in a standard lecture format. Students naturally turn visual attention elsewhere (i.e., to static slide or to their notepaper) while maintaining auditory attention on the speaker. Therefore, under low bandwidth conditions, our findings suggest that the auditory "feed" should receive priority, though this would require further study. This study was performed naturalistically, and thus suffers from incomplete control over experimental variables. Ideally, a dependent design with repeated measures by the same individuals for the different technological qualities would yield more definitive comparisons. We could learn much from the art of web page design, as an Internet savvy generation has come to expect a polished audiovisual presentation.
Our samples were not randomized, though there is no reason to suspect that the trainees at Miami differed systematically from those at ECU. It is also possible, given the small sample size, that results would be altered by the responses of trainees who did not complete the survey. However, participants who did not complete the survey were not available on the day that the survey was administered, and failure to complete the survey was believed to be unrelated to their feelings regarding the course. Presenter survey results were limited to eight, as presenters who provided two seminars only completed one survey, and the author did not complete a survey on his presentation. Finally, we must also consider the influence of the seminar topic and the quality of the teaching upon satisfaction with the technology. Would a distance technology seminar on another topic that may be more interesting to trainees than "managed care" have a halo effect on perception of the technology? Our faculty was selected as national "experts" in their topic areas, but we did not query participants about the quality of the teaching. Some teachers are inherently better at interacting with students, and these should be the ones teaching, whether face to face or through electronic interface. Separating the medium from the message has always been difficult, but these variables should be addressed systematically in future research or quality improvement programs. Appendix 1 provides a list of recommendations to improve the use of video-conferencing technology in the medical education of resident physicians.
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SUMMARY
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The potential benefits from the use of video-conferencing technology in the didactic training of residents in psychiatry are significant. This technology is being underutilized at the present time. Despite the significant potential cost savings of limited training funds, reduced duplication of training seminars, and the preservation of physician man-hours, (otherwise lost in travel time and attendance at off-site continuing medical education locations) effective utilization of video-conferencing will require a philosophical commitment from interested schools of medicine to venture into alternative teaching methodology. Only then will the expanded utilization and full potential of this innovative teaching tool come to fruition. For video-conferencing to become a "mainstream" teaching format, it will require involved universities to look beyond some of the fears and concerns inherent in collaborative work, especially that which involves new and innovative technology. The goal, of course, is to enhance the overall learning experience of residents through the sharing of faculty expertise. Video-conferencing and web-based technologies are improving, resulting in the expansion of instructional capabilities. Utilizing video-conferencing and integrating this technology into curricula offers an opportunity for participating universities to look beyond the traditional ways of teaching. Medical education is, perhaps, one of the areas best positioned to take advantage of the emerging age of video-conferencing.
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REFERENCES
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- Magen J, Banazak D: The cost of residency training in psychiatry. Academic Psychiatry 2000; 24:195–201[Abstract/Free Full Text]
- Walter DA, deGroot CM, Ulzen TP, Rosenquist P, Daniels A, Dewan NA, Weathers V: A new teaching program: tele-medicine, psychiatric residents, and issues germane to managed care. Academic Psychiatry 2000; 24:209–213.[Abstract/Free Full Text]
- Burgess LPA, Holtel MR, Syme MJ, Birkmire-Peters DP, Peters LJ, Mashima PA: Overview of telemedicine applications for otolaryngology. Laryngoscope 1999; 109:1433–1437[Medline]
- Lewis YL, Bredfeldt RP, Strode SW, D’Arezzo KW: Changes in residents’ attitudes and achievement after distance learning via 2-way interactive video. Family Medicine 1998; 30:497–500[Medline]
- Mills OF, Tatarko M, Bates JF, Hunsberger TA, Everhart-Yost E, Pendleton V: Tele-medicine precepting in a family practice center. Family Medicine 1999; 31:239–243[Medline]
- Norusis MJ: SPSS Introductory Statistics Student Guide. Chicago, SPSS Inc, 1990
This article has been cited by other articles:
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L. P. Krain, J. M. Bostwick, and S. Sampson
"It's High-Tech, But Is It Better?": Applications of Technology in Psychiatry Education
Acad Psychiatry,
February 1, 2007;
31(1):
40 - 49.
[Abstract]
[Full Text]
[PDF]
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ABSTRACT
INTRODUCTION
