A pilot study on implementation of an e-learning course for clinical education in oral medicine

This study presents the process of implementing an e-learning course for clinical education in oral medicine and examines its impact on students’ knowledge and satisfaction. Thirty six (39.6%) fifth-year undergraduate students participated in the study. Every week before their clinical practice, students studied relevant e-learning materials and completed an assessment test. At the end of the semester, students’ knowledge and attitudes towards elearning were assessed by the knowledge test and anonymous questionnaire. Students who had access to the e-learning course had significantly better knowledge than students who did not have access to the e-learning course. Exposure to the e-learning course contributed to a better understanding of oral medicine curriculum, increased confidence with oral medicine patients and easier participation in oral medicine clinical practice. This study provided evidence that the e-learning can be implemented as a valuable adjunct to 508 V. Brailo et al. (2015) clinical education in oral medicine.


Introduction
At the School of Dental Medicine, University of Zagreb, oral medicine is taught for four semesters (7 th , 8 th , 9 th and 10 th semesters). The first two semesters (7 and 8) consist of lectures, seminars and preclinical exercises. Semesters 9 and 10 consist of clinical practice under the supervision of a tutor. After completing the 10 th semester students take the final exam which consists of 45 multiple choice questions. Transition to the clinical portion of the education rarely goes smoothly. Students tend to forget materials taught through lectures and seminars. They usually begin studying only a few weeks before their exams and they often lack theoretical knowledge necessary for active participation in the clinical working with oral medicine patients.
Our primary task was to find a way to motivate students to become more prepared for their clinical work because we do not want to spend precious clinical time on repeating materials that students should already have learned from lectures and seminars. Clinical sessions last 90 minutes and review sessions would take a minimum of 20-30 minutes from this time.
e-Learning came up as a logical solution as it offers flexibility for learning independent of place and time constraints. Students may access teaching materials from anywhere, individualize their learning process and learn at their own pace (Puljak & Sapunar, 2011). Unlike "classical" teaching methods such as lectures and seminars, where the teacher transfers knowledge and students are passive recipients, e-learning promotes active learning where students become creators of their own base knowledge (DeBate et al., 2011;Gadbury-Amyot & Brockman, 2011). Another advantage of elearning is that students can access learning materials several times as opposed to only having one exposure shared through a lecture or a seminar. Furthermore, e-learning offers environments free from distractions which often cannot be avoided in lecture halls (Rosenberg, Grad, & Matear, 2003). Studies have shown that e-learning is at least as effective as other learning methods in dental education and that students generally have positive attitudes towards it (Mattheos et al., 2008;Rosenberg, Grad, & Matear, 2003).
The research questions of the study include the following:


Can e-learning course be implemented in the clinical education in oral medicine?  What is the impact of the e-learning course on students' knowledge?  How are students satisfied with the new teaching method in their oral medicine education?

Description and administration of the e-learning course
A free version of the eFront e-learning platform (Epignosis LLC, USA) was used to create the course. The course was introduced in the 9 th semester as a supplement to the clinic and consisted of 15 modules in the 9 th and 15 modules in the 10 th semester. In the 9 th semester, each module consisted of theoretical materials covering examination of the oral medicine patient, laboratory testing in oral medicine, medication prescription, writing referral letters, most common oral lesions etc. Each module also had a quiz to assess students' knowledge. Multiple choice questions, open-ended questions, true/false questions, and matched pairs were used in the quizzes.
Every week before the clinic students were obliged to study the module materials and complete the quiz (10-20 questions). The system automatically calculated the percentage of correct answers giving students immediate feedback on their performance. The threshold was set to 80% correct answers. Students had the opportunity to access materials and take the test as many times as they preferred. Without completing the quiz, a student's attendance in the clinical portion of the class was not registered. In this way, a high level of knowledge about each module and students' preparedness for clinical work was achieved.
In the 10 th semester, the e-learning focus was on the application of acquired knowledge in realistic clinical situations. Students were assigned a virtual patient case scenario (Department's clinical photo archive was used) every week, where they had to establish a correct diagnosis, perform corresponding laboratory tests, and prescribe a treatment. Procedural sequencing was similar to the procedures done in real-life. A forum for comments and exchange of ideas related to each case was also made available to students.
Along with the clinical case, every week students had to solve a quiz that included material taught in the 9 th semester. These quizzes were more complex and required higher levels of knowledge according to Bloom's taxonomy (such as analysis and synthesis) than the quizzes from the 9 th semester (which were based on remembering and understanding) (Bloom, Engelhart, Furst, Hill, & Krathwohl, 1956).
As this was a pilot project, the e-learning course was available to 36 out of 91(39.6%) of the fifth year undergraduate students. e-Learning course participation was decided by the clinical tutor.

Outcome measures
The aim of this study was to assess students' knowledge and attitudes towards e-learning. Informal survey was used for that purpose. Knowledge was assessed by 14 open-ended questions at the beginning of the 10 th semester. The questions were also distributed to the control group of students who did not have access to the e-learning course. Answers were checked by a single investigator (AAR). Possible score was 0, 0.5 and 1 point for each question.
Attitudes towards the e-learning course were measured at the end of the 10 th semester, after the final exam. Five-point Likert scale that determined level of agreement (1-strongly disagree to 5strongly agree) with each of the 11 statements was used.
Furthermore, we compared the final exam grades between the students who had access to the e-learning course and the students who did not have access to the e-learning course. The exam grades were numerical (1 to 5).

Data analysis
Numerical data (i.e. 0, 0.5 or 1 for knowledge assessment and 1-5 for attitudes and exam grades) were organized in MS Excel (Microsoft Excel, Microsoft Inc. USA) spreadsheets and processed using SPSS 20.0 software (IBM Inc., USA). Differences between the two groups were assessed by the chi-square test and student's t-test when applicable. p values lower than 0.05 (p<0.05) were considered statistically significant.

General data
Thirty six fifth year undergraduate students participated in the e learning course. Control group consisted of 55 fifth year undergraduate students who did not have the access to the e learning course. Student characteristics and their use of e-learning software are shown in Table 1.

Students' knowledge
As shown in Fig. 1, students who had access to the e-learning course had significantly higher number of correct answers than the students who did not have access to the elearning course (6.6 ± 2 vs. 1.9 ± 1.5; p=0.0003) as assessed by the 14 open ended questions at the beginning of the 10 th semester. The bars in Fig. 1 represent average number of correct answers ± one standard deviation. Significant difference between students who had access to the e-learning and students who did not have access to the elearning course was observed. As shown in Fig. 2, no difference in the final exam grades at the end the 10 th semester, was observed between the students who had access to the e-learning course and the students who did not have access to the e-learning course (p=0.414). The bars in Fig.  2 represent percentage of students with corresponding final grades. No difference between students who had access to the e-learning and students who did not have access to the e-learning course was observed.

Student satisfaction
Students' attitudes and satisfaction with the e-learning course are displayed in Table 2. A great majority of the students expressed positive attitudes towards the e-learning course.

Discussion
e-Learning has proven its efficacy as a teaching method in various dental disciplines (Al-Jewair, Azarpazhooh, Suri, & Shah, 2009;Al-Jewair, Qutub, Malkhassian, & Dempster, 2010;Meckfessel et al., 2011;Mitov, Dillschneider, Abed, Hohenberg, & Pospiech, 2010;Rosenberg, Grad, & Matear, 2003;Tan, Hay, & Whaites, 2009). Its use has been described in the field of oral medicine as well (Jontell, Mattsson, & Torgersson, 2005;Porter et al., 1996). Our results are in concordance with the aforementioned studies and indicate that e-learning can be successfully integrated in oral medicine clinical education. Exposure to the e-learning course contributed to a better understanding of the oral medicine curriculum, increased students' confidence with oral medicine patients and made the participation in oral medicine clinic easier.
Exposure to real-life patients and hands-on clinical cases cannot often be achieved in the oral medicine clinic due to time and place constraints as well as the prevalence of certain oral disease in the general population. In a discipline where mucosal lesions can have a great degree of variability, visual information from the textbooks and lectures is often insufficient and may not reflect real life situations (Jontell, Mattsson, & Torgersson, 2005). As a result of the aforementioned circumstances, students are exposed to a limited number of hands-on cases/oral lesions which will negatively affect their clinical experience. With the use of the e-learning software and the Department's photo/video archive realistic clinical case scenarios can be created (as was done in this study). In this way students can be exposed to a great number of virtual clinical cases and the aforementioned problem can at least partially be alleviated. Furthermore, students can practice clinical skills important for the management of oral medicine patients such as describing oral lesions, ordering lab tests, writing referral letters and prescribing medication. E-learning enables students to undertake these activities numerous times at their own pace opposed to only 90 minutes per week in a real life clinical sessions. We would however, like to emphasize that e-learning can by no means substitute student's encounter with the real patient, but can rather be used as a valuable adjunct to the clinical education.
As the results of this study show, exposure to the e-learning course can positively affect student's knowledge. Students who were exposed to the e-learning course had better knowledge than their colleagues who did not have access to the course. The difference in knowledge was evident during the semester (as assessed by the knowledge test) but not in the final exam grades. Students usually start studying few weeks before the final exam and catch up with the curriculum which can explain the lack of difference in the final exam grades.
Nevertheless, we believe that the e-learning course has fulfilled its purpose, as our primary intention was to motivate the students to learn during the entire academic year and have theoretical knowledge necessary for active participation in the clinic. The element of obligation had to be present in order to assure regular attendance in the course, as nearly one third of the students (27.8%) disagreed or strongly disagreed with the statement "I would have regularly accessed e-learning materials even if hadn't had the obligation to pass the assessment test before every clinic". In spite of the fact that students had to be actively involved in the course for the entire academic year, they felt that the e-learning course did not significantly interfere with their other curricular activities and did not take much of their time.
Students expressed positive attitudes toward the e-learning course and found the e-learning software easy or very easy to use. This is not surprising as the majority of the students are born between 1988 and 1992 and belong to a so called Net generation. This generation grew up surrounded with information technology and is very open to the use of new technologies. Internet is very important part of their daily lives and a computer is a medium that is more familiar for them than a textbook (Oblinger & Oblinger, 2008). In spite of the students' openness to the new technologies, quality of the e-learning materials is more important for students' satisfaction than the variety of media used for the creation of the course (Tan, Hay, & Whaites, 2009). As stated by McNeely, technology should be used "as a learning tool, not just the cool new thing" (McNeely, 2008). We believe that we managed to meet students' expectations as the great majority of the students (83.3%) gave highest grade to the quality of the e-learning materials.
This study has several limitations. First of all, this was not a randomized control trial. Students were not randomly assigned to the e-learning/non-e learning group. The involvement in the e-learning course was based on the decision of the clinical tutor. The study did not prove superiority of e-learning over classic teaching methods, but it confirmed its value as an additional educational tool in oral medicine. Secondly, one might argue that the sample was relatively small (36 students). However, we feel that the responses from 39.6% of the fifth year students can predict trends in students' learning preferences and adoption of new technologies with a high degree of certainty.

Conclusion
e-Learning can provide innovative and interactive ways of presenting learning materials and offers numerous possibilities that can facilitate learning process (Mattheos et al., 2008;Rosenberg, Grad, & Matear, 2003). In a discipline like oral medicine where visual information is essential for knowledge adoption, students can be exposed to a greater number of oral lesions than is possible through classical learning tools such as textbooks and lectures. Integration of various visual information such as clinical photographs and videos enables teacher to create realistic case scenarios that can alleviate the problem of physical constraints and low prevalence of some oral lesions in oral medicine practice. This can increase student's confidence in dealing with real-life clinical situations. In spite of its limitations, this study provided evidence that e-learning can be implemented as a valuable adjunct to clinical education in oral medicine.