Journal of Audiovisual Media in Medicine

ISSN: 0140-511X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/ijau19

Is your audiovisual teaching effective? R. J. Marshall & R. W. Evans To cite this article: R. J. Marshall & R. W. Evans (1992) Is your audiovisual teaching effective?, Journal of Audiovisual Media in Medicine, 15:1, 17-21, DOI: 10.3109/17453059209051379 To link to this article: http://dx.doi.org/10.3109/17453059209051379

Published online: 10 Jul 2009.

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Journal of Audiovisual Media in Medicine 1992; 15: 17-21

Is your audiovisual teaching effective?

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R. J. MARSHALL and R. W. EVANS

Medical illustrators produce vast numbers of images used in audiovisual programmes for medical teaching. We know that students can learn by using audiovisual teaching materials but do not always know how well they learn, particularly in comparison with other teaching methods. To find out how effective audiovisual teaching is, it must be evaluated or measured. This paper looks at the evaluation of a range of medical audiovisual teaching programmes and their effectiveness by observation, questionnaire, tests and examinations.

llustradores medicos producen enormes cantidades de imagenes utilizadas en programas audiovisuales para enseiianza medica. Sabemos que 10s estudiantes aprenden utilizando material audiovisual, per0 no sabemos si aprenden bien en comparacion con otros metodos de ensenanza. Para averiguar la eficaz de ensenanza audiovisual, hay que evaluar y medirlo. Esta ponencia estudia una gama de programas de ensetianza audiovisual medicos y su eficaz valorado por observacion, cuestionario, pruebas y por examen.

Les illustrateurs medicaux produisent de grands nombres d'images utilisees dans les programmes audiovisuels d'enseignement de la medecine. Nous savons que les etudiants peuvent apprendre en se servant d'outils d'enseignement audiovisuels mais ne savent pas toujours dans quelle mesure ils assimilent et en particulier, par rapport a d'autres methodes d'enseignement. Pour determiner a quel point I'enseignement audiovisuel est efficace, on doit I'evaluer et le quantifier. Cet article passe en revue une gamme de programmes d'enseignement medical audiovisuel et leur efficacite estimee par I'observation, le questionnaire, des tests et des examens.

Medizinischen lllustratoren produzieren viele Dias fur audiovisuellen lehrprogrammen und das medizinisch Unterrichten. Wir wissen dap viele studenten mittels audiovisuelle Hilfsmitteln lernen Konnen aber wir wissen nicht immer wie gut sie lernen. U m zu wissen wie wirksam audiovisuelle Unterricht ist mug es abgeschatz oder gemessen werden. Dieser Bericht untersucht eine Reihe von medicinischen audiovisuelle lehrprogrammen und ihre wirksamkeit durch Beobachtung, Fragebogen, Prufungen und Examina.

Part of the training for illustrators encourages the development of skills with which to evaluate the quality of images not only from a technical point of view as drawings or photographs, but also as useful, accurate records for medical teaching. These skills of evaluation can be developed by viewing the work of others and discussing it - in the department or at exhibitions and workshops at meetings - and may be

R . J . Marshall, PhD, Hon FBIPP, Hon FRPS, AIMI is Professor and Director of Medical Illustration and Principal of the School of Medical Photography, and R . W . Evans, CertEd, FBIPP is Assistant Director of Medical Illustration at the University of Wales College of Medicine and the South Glamorgan Health Authority, Cardiff, UK

01992 Butterworth-Heinemann Ltd 0140-511X/92/010017-05

sharpened by the careful selection and preparation of an individual's work for higher qualifications and distinctions, or for publication. In the medical illustration department at Cardiff there have been regularly held audits of patient photography that are attended by all of the photographic staff. These began partly as a form of quality control and partly, but more importantly, as a way of enabling all the photographic staff to see the range of clinical work passing through the department. When the formal teaching of medical photography began, in 1969', the audits became critique seminars at which the students and staff were required to present work that they had helped to produce. Such presentations required them to give a brief

medical background to the photography and discuss the quality, appropriateness, and effectiveness of the pictures as illustrations, as adequate records and, particularly, as suitable and effective teaching material - probably the most important aspect of the seminar. Other objectives were to teach medical photography using the photographs as examples, and to provide practice in presentation skills. The audit side of the critique seminar has recently introduced a system of scoring, or marking, on a scale of 1-10, to ascertain the perceived overall quality and value of the work as teaching examples. The marks given by all staff and students taking part in a session are averaged for each patient's series of photographs. The target has been set at

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7.5, and a mean score for any’work below that figure is considered to require remedial attention. Audit/ critique sessions are held twice weekly and allow the staff and students to view and discuss 160 slides of some 40 patients each week. A critique of this kind assesses only still images of patients and there are established rules to foIlow for standard representational photography. Teaching slides of graphics, diagrams, charts and other material should also be evaluated. Over the last 50 years or so conventions and rules have been developed for the design and production of text slides and diagrams. They give guidance as to how much or how little detail to put on, and the use of type styles, backgrounds and colours, so as to maximize their teaching potential’. Computer-generated graphics on slides are now produced in large numbers, and there is great scope for producing bad slides that look good, and in which the medium may obscure or even obliterate the message that they have been designed to carry. Some medical teachers dislike the ‘polish’ of certain types of computer-generated slides, feeling that they can give scientific data a distracting commercial appearance3. A set of rules based firmly on well-researched evaluation is needed here. Collections of images are often selected and used as parts of a more complex teaching package such as book illustrations or a tapelslide programme. Once illustrations have been employed in that way, or a videotape comprising many images has been produced, the whole package should be assessed or validated along established principles. Medical illustrators produce teaching materials of various kinds and complexity, but few are fully evaluated to find whether they are truly fit for their purpose - teaching students effectively. It is often assumed that these materials will teach and this may well be the right assumption - after all, teaching materials have been produced for years, and the users of them are still coming back for more! Audiovisual materials can save teacher-time. The materials can teach, but it is not always known how well they can teach, particularly how well they teach in comparison with other methods. Effectiveness of videotapes in teaching clinical medicine

In Cardiff live television and videotaped television had been produced for teaching for many years before a planned 18

programme for teaching clinical medicine to undergraduates by videotape was embarked upon. Evidence in the literature suggested that medical students could learn from videotape^^,^, but there was little evidence that clinical medicine could be taught effectively using videotape. The effectiveness of video recording in transmitting clinical knowledge and skills to medical students was tested by recording on videotape a series of five demonstrations, as they were given by five clinicians to a group of students randomly selected from the first clinical year (personal group), and then showing these recordings to a similar group of students from the same year (video group). The effectiveness of the teaching given to both the personal group and the video group - teaching which was, of course, identical as regards content and method of delivery by the teacher - in terms of whether content was retained, was tested by a multiple choice examination completed by both groups of students at the end of the sessions. The students were then thanked for helping with an experiment comparing videotape teaching with personal teaching, that as far as they were concerned had been completed. However, 3 weeks later a structured clinical skills test was set up without notice, and each student was asked to perform the five clinical tasks in succession in five separate rooms. The same patients and volunteers who had been used in the original demonstrations were used at this time. The students were tested by five examiners who were unaware of the identity of the tutors who had given the original demonstrations and also of which students belonged to each group. Clinical tasks were broken down into sequential steps as they had been by the demonstrator. Each examiner was provided with a check-list for each student who was asked to reproduce the major part of the demonstration and was scored for correctness of procedure, presentation, spontaneity and fluency, and correct conclusion. The results showed no statistically significant differences between the scores of the two groups taught by the two methods6. Student response to videotaped teaching

From the study, it was found that videotapes of clinical methods could be used to provide students with ‘personal’ instruction by specialist, expert teachers, and that they learned as effectively

by studying tapes as by watching the teacher himself. Having produced a series of videotapes, the students’ response and attitude to being taught clinical methods by these means was studied. The effectiveness of videotapes in communicating clinical methods and skills depends largely upon the interest they can generate in students. Dwyer7 has claimed that student perceptions of the value of different types of visual illustration are not valid assessments of their instructional effectiveness, but the student view is nevertheless useful. To assess student response to videotaped teaching of clinical skills, ten tapes on history-taking and physical examination were placed in the library of the University of Wales College of Medicine on shelves alongside books on relevant subjects. There was no particular publicity and no efforts were made to persuade students to use them, but full facilities for viewing the tapes were available. The students’ response was assessed by means of questionnaires completed voluntarily and anonymously after they had viewed tapes. The most popular tapes were on complete systematic examination, on cardiovascular examination and on history-taking, which together were viewed by 46% of the respondents. On acquisition of clinical methods, 84% thought they gained new knowledge on practical steps, 42% said that they gained new thoughts and 24% thought that they had learned new techniques on clinical methods. A further 28% stated that they would like the tapes to be more comprehensive and to include more abnormal signs. The results show that students view videotapes with interest and well-made tapes can be used to supplement bedside learning’. Effects of videotaped teaching on the final MB examination

Several more videotapes on clinical methods were produced and copies were added to the series held in the library, where they were freely available. No special monitoring of the rate of viewing by students was undertaken, but there was an observed heavy demand during the immediate preexamination period. The approach of the final MB examinations provides students with a strong motivation to improve their clinical skills and methods. It is not always possible to exploit this motivation in clinical teaching because there are rarely enough clinical teachers available. Videotapes Marshall and Evans

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can obviously help, and to assess the perceived value of these we sent a questionnaire to all 145 students at Cardiff who took the final MB in the summer of 1985 and we received 108 (74%) completed questionnaires. Of the respondents, 74 (69%) had viewed from 1 to 20 videotapes on clinical examination. In answer to the question of whether the viewing of the tapes before the examination had improved their clinical performance in approaching the ‘short’ clinical problems and demonstrating clinical signs, 35 students (47%) said that they were better prepared to respond to examiners’ requests, 24 (32%) thought they were better prepared to greet and approach patients, 56 (76%) admitted to having learned new clinical skills, 61 (82%) stated that they were better prepared to demonstrate clinical signs to the examiners and 46 students (62%) felt that the tapes had helped them to progress smoothly and rapidly through a sequence of examination steps. Only 15 students (20%) thought that the tapes helped them to summarize their findings and 15% thought that the tapes helped them to answer examiners’ questions. The majority of viewers considered videotapes to be an excellent adjunct to self-learning in preparation for the final examination, and wanted more videotaped examples of abnormal signs. Four examiners were also interviewed. They had collectively examined 32 students in ‘short’ cases, and said that they saw a more professional, coordinated approach and progression through some of the clinical tasks in several of the students in comparison with previous years. The findings suggest that videotapes are a useful supplement to learning during the period before the final examination when students are keen to learn. They also give pointers towards the kind of teaching that should be included in future videotape productions’. They are, of course, subjective findings only, and objective findings such as the effects of audiovisual materials on examination or test results can tell us more about their teaching potential. Can video teach more efficiently than traditional methods? A dental teaching study is a useful pointer here.

orthopaedic surgeon must know bones, so a dental surgeon must understand and recognize the nuances of tooth form, and be able to identify correctly each of the teeth of the human dentition. The subject has been taught in various ways, from the making of wax carvings of individual teeth to using computer-generated graphics, and there are textbooks having separate chapters each devoted to the morphology of a single tooth. In Cardiff the course was traditionally taught by the use of real teeth and enlarged models of teeth using live, closed-circuit television in the ‘magnifying glass’ mode to provide the students with enlarged images of the teeth during demonstrations. This approach to teaching demanded 76 h of teacher time to cover lectures, demonstrations and small group teaching. A set of five videotapes, each lasting approximately 30 min, was produced to a plan designed by the Oral Biology Department. These tapes encapsulated the course content with the first being an introductory tape designed to motivate the students by explaining the importance of the subject and illustrating its applications in clinical dentistry, forensic odontology and palaeopathology. Comparative animal dentitions and the nomenclature and notation of the human dentition are included. Tapes two to four detail the morphology of the permanent incisors and canines, and premolars and molars, respectively. Close-up photography of natural teeth and of models is used extensively, together with freehand diagrams and

prepared graphics. The fifth tape illustrates the main difference between the deciduous and permanent teeth, and their arrangement in the arches. Most of the video recording was carried out under studio conditions using two cameras for general and close-up views. Additional macro views were incorporated at the post-production stage. It was also possible to record some scenes on location to add interest, e.g. a videotape of the unearthing of a buried skull alongside a motorway for subsequent forensic studies of the dentition. During the period 1984-1986 the tapes were used gradually to replace the traditional teaching of tooth morphology (Figure 1). In 1984, the same lectures and seminars were given as in previous years, but the tapes replaced entirely the demonstration sessions. In 1985 no formal lectures were given and instead the tapes were shown to the students, with the showings followed by small group seminars. In 1986 there was no formal teaching and the videotapes were shown to the students working in small groups with examples of natural teeth, and they then had free access to their own copies of the tapes in the Dental School Library, for the whole time of the course and for an additional 4 weeks. They were therefore entirely ‘self-taught’ with no staff intervention and with variable learning hours for each student. For the years 1983-1986, 1 month after the course ended, students were examined by a ‘spotter’-type of class test in which 50 teeth were to be Mean class score

Year

1983

1984

I

Demonstrations

1

Videotapes

1985

Lectures

Lectures

Videotapes

I

Seminars

I

41.3

Seminars

48.1

Seminars

49.9

1986

Videotapes in dental teaching

Television and videotape recording is widely used in teaching dentistry. We looked at the use of videotapes in teaching tooth morphology”. Just as an

Figure 1. Conventional teaching of tooth morphology by demonstrations, lectures and seminars, was gradually replaced by a set of videotapes that encapsulated the course content. Mean class scores increased over the period of the experiment.

The Journal of Audiovisual Media in Medicine ( I 992) Vol. 15INo. 1

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identified. The system of marking,used was arbitrary, but repeatable. Scoring was strict, making no allowance for minor errors. For example, a lower left central incisor identified as a lower right central incisor received no marks. The changing teaching strategy and the mean scores for each student year are shown in Figure 1and a steady improvement year by year can be seen. To test for possible variation of ability among the four classes, the A-level performance achieved before entry to the Dental School was compared. This was done by computing mean A-level scores for each student using the grades in each of the three subjects required for entry. Grade A was awarded five points and grade E one point. Points were totalled for the three subjects for each student, and means and standard deviations for each of the four student years were calculated. The A-level and scores for each year are shown in Figure 2 . There is no statistically significant difference between scores for each class. The performance of the four classes (years) taught tooth morphology by conventional means (1983), by a mixture of conventional means and videotapes (1984-1985) and by videotapes alone (1986), can be seen to improve significantly from 1983 to 1984 when the tapes were first used (Figure 3). The improvement continued, although not significantly, as increasing use of the videotapes was made. In 1986 when there was no direct teacher input to the course the highest mean result was achieved, but the standard deviation was higher in that year. The efficacy of videotaped instruction together with considerable saving of teacher time is nicely demonstrated by the study. As the teaching material used in this study, and in the clinical studies, is unlikely to become out of date rapidly, it is cost-effective and should be of use for many years.

’’1

No s t a t i s t i c a l l y sinnificant differences

1983

1984

1985

1986

Class/ year

Figure 2. Mean A-level scores for students at admission to the Dental School for the classlyears taking a spotter test‘for tooth morphology in the years 1983, 1984, 1985 and 1986.

20

1983

1984

1985

1986

Classlyear

Figure 3. Mean classlyear scores ‘spotter test‘ for recognition of tooth morphology. Score for 1984, when videotapes were first introduced, was significantly higher than the score for 1983. Scores continued to increase slightly as use of videotapes completely replaced traditional teaching methods. Discussion

Many studies carried out over the last two decades have established that audiovisual materials and video recordings can be as effective in teaching a variety of skills and modifying attitudes as other, perhaps more traditional, methods of teaching4%’. Audiovisual teaching is often better and more meticulously prepared for recording and preservation than is traditional teaching, which is usually ephemeral. Audiovisual materials can be used at relatively simple levels of production. There is, for example, a place for short sequences of tape untitled and unedited, for use as a kind of ‘moving slide’ (i.e. a demonstration of a Parkinsonian gait to illustrate a talk on that topic). Audiovisual materials that are to be used by the student for private study, however, must be well designed and well produced if they are to be effective. Quality of design and production can be tested by objective measurement of the teaching potential of the materials by testing understanding and retention of knowledge and by subjective assessment of the perceived value of the materials by students and by other professionals. However, there is much to learn about the design and construction of teaching materials so as to maximize their teaching effect. There are basic rules of production to be but much of the work at Cardiff is created intuitively as far as the photography is concerned, and is often put together at the post-production stage according to vaguely formulated routines that are believed to provide a logical presentation of information in an ‘interesting’ or attractive way. Many audiovisual materials are designed and put together in ways that follow or

imitate techniques used in long established teaching and presentation strategies. This is not surprising because such techniques have become accepted and have proved to be relatively effective over many decades. There is much still to be researched and much work to be done on the design and construction of medical audiovisual teaching materials - research like that of RoshalI3 who compared the effects on instructional efficacy of different angles of camera position in making films teaching knot-tying, a simple perceptual motor task. For one motion picture film the camera was placed over the shoulder of the demonstrator at what was deemed the ‘subjective’ angle. For another film the camera was placed opposite the demonstrator at what Roshal termed the ‘observer’ angle. The subjective angle was found to be more effective on a test of performance, possibly because it more closely approximated the actual task, there was more ‘realism’. In a third film that involved an animation technique, the two ends of the rope were presented against a neutral background and appeared to tie themselves into a knot. This was the most effective of the films. In a review of Roshal’s findings Miller14 noted that it is important in effective teaching to build up discrimination so that the student will respond only to relevant cues and not be misled or distracted by irrelevant cues. Roshal’s animated film of knot-tying was a pictorial abstraction based on relevant cues that distinguished a particular knot from any other. Merrill et al. followed up Roshal’s work, using four different camera angles for filming history-taking sessions which produced ‘subjective’, ‘observer’, ‘lateral’ and ‘combined’ angles and various permutations of these. They found no significant differences between the teaching effectiveness of the various versions, perhaps because their subject matter (the history-taking interview) and the complicated pattern of presentation used may have obscured cues. There was a suggestion that the version of the film showing the physician only (observer) and the patient only (subjective) led to slightly greater learning achievement. Our own experience in making teaching videotapes of history-taking has suggested that the sound recording is much more important than the picture recording, and that a recording of a wellconducted history-taking can be as effective a teaching aid used as sound on1yl6.

Marshall and Evans

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There remains then, a major task to be done in researching production methods (including such matters as viewpoint, angle of view, perspective, the mix of long, medium and close shots and others), research that we suspect is only being carried out at present on an empirical basis by the makers of television commercials. The effects of right brain-left brain appreciation on comprehension of medical audiovisual teaching materials, and the selection and balance of appropriate ‘mixes’ of words and images have only recently started to be considered”. What is required perhaps is the compilation of a kind of vocabulary of medical audiovisual teaching materials that can be fitted into a grammar of audiovisual presentation. It is important to assess the efficacy of audiovisual teaching materials by a variety of methods to test their potential for teaching, by examining medical students for knowledge retention and understanding, observing patterns of usage and by offering them attitudeseeking questionnaires after they have used the materials. The results of assessment and evaluation can reassure everyone that the production plans and methods are appropriate and can confirm or otherwise that the technical methods are correct. They can help to identify strengths and weaknesses in a piece of teaching material, and indicate any modifications. Assessments of efficacy can help in the production of better teaching materials, and, most importantly, they can highlight the value of the medical illustrator’s contribution to teaching and learning.

a large team of our medical, dental and medical illustration colleagues. We are particularly grateful to Dr M. Afzal Mir, Professor Reginald Hall, Dr David Whittaker, Professor Sir Herbert Duthie and the many students who took part. Without their enthusiasm for experimentation in the advancement of medical education the teaching material and the evaluations and assessments would never have been made.

8. Mir MA, Marshall RJ, Evans RW et al. Videotapes for teaching clinical methods: medical students’ response to a pilot project. J Audiovis Media M e d 1985; 8 : 90-3. 9. Mir MA, Marshall RJ, Evans RW, Mir L. The use of videotapes in improving clinical performance in the final MB examination. J Audiovis Media Med 1987; 10: 131-4.

References

10. Whittaker DK, Marshall RJ, Evans RW. The use of videotapes in teaching tooth morphology. J Dent Educ 1989; 10: 581-3.

1. Marshall RJ, Evans RW. An approach to teaching medical photography - the Cardiff school. Br J Photogr 1979; 126: 881-5.

11. Gilder RS. Fundamentals of video production and script writing. J Audiovis Media M e d 1989; 12: 93-5.

2. Ollerenshaw R. Design for projection: a study of legibility. In: Duncan CJ ed. Modern Lecture Theatres. Newcastle Upon Tyne, UK: Oriel Press, 1966.

12. Millerson G. The Technique of Television Production. London: Focal Press, 1990.

3. Marshall RJ, Young S, Rees S. A medical college service for computergenerated graphics with DIY aspects. J Audiovis Media M e d 1991; 14: 141-5.

13. Roshal SM. Effects of learner representation in film-mediated perceptual motor learning. Technical Report SDC 269-7-5. Port Washington, New York: Special Devices Center, 1949.

4. Paegle RD, Wilkinson EJ, Donnelly MB. Videotape versus traditional lectures for medical students. M e d Educ 1981; 14: 387-93.

14. Miller NE. Graphic communication and the crisis in education. AVCommunication Rev (Special Issue) 1957; 5: 3-5.

5. Beswick W, Cooper D, Whelan G. Videotape demonstration of physical examination; evaluation of its use in medical undergraduate teaching. M e d €doc 1962; 16: 197-201.

15. Merrill IR, Yaryan RB, Carbone JV, Musser TS, Vandervoort HE. The effectiveness of motion pictures at different stages of learning history-taking. J Med €doc 1969; 44: 595-603. 16. Mir MA, Marshall RJ, Evans RW, Hall R, Duthie HL. Teaching clinical historytaking: a comparison between the use of audio and videotapes. M e d Educ 1986; 20: 102-8.

Acknowledgements

6. Mir MA, Marshall RJ, Evans RW, Hall R, Duthie HL. Comparison between videotape and personal teaching as methods of communicating clinical skills to medical students. 5 r Med J 1984; 288: 31-4.

In planning, producing and evaluating the audiovisual materials described in this paper we have worked closely with

7. Dwyer FM. Adapting varied visual illustrations for optimum teaching and learning. MedBiollllustr 1971; 21: 10-13.

The Journal of Audiovisual Media in Medicine (1992) Vol. 15lNo. 1

17. Gilder RS. Left brain-right brain theory and the design of medical teaching materials. J Audiovis Media M e d 1982; 5: 45-50.

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Is your audiovisual teaching effective?

Medical illustrators produce vast numbers of images used in audiovisual programmes for medical teaching. We know that students can learn by using audi...
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