Saturday, 12 March 2016

Evidence of e-learning in surgical education -  literature review 

GoPro head worn camera recording for surgical education CSC, Cambodia

9 December 2012

The database used to search for articles was Academic Search Complete from the digital library of the OUM LMS.  The search terms e-learning, medical education and surgery were used. This Boolean search returned 596 articles, of which those relevant articles with research on various e-learning techniques as the dependent variable, and outcomes in learning as the independent variables on the population of surgical trainees were chosen. The search was limited to full articles in peer-reviewed journals between   2002 and 2012.

One of  the  references   (Larvin, 2009), was used as a framework to understand the current thinking and practice of e-learning in the surgical environment. Larvin is an authority on e-learning in surgical education both as a leader and practitioner in the Royal Colleges of Surgeons in the United Kingdom, which is the body that is responsible for surgical education and training in the United Kingdom.  He acknowledges that e-learning remains a novelty in surgical education as compared to undergraduate medical education where it has become common practice. Larvin adds that e-learning has tremendous potential in surgical education as compared to other specialties. The introduction of the European Working Time Directive has added further challenges to surgical education in Europe. All the Royal Colleges of Surgeons in the United Kingdom have agreed on the importance of e-learning to augment asynchronous learning for surgical trainees. The results of the survey conducted by the Royal Colleges on the effectiveness of e-learning has shown great acceptance by surgical trainees and emphasises the importance of adding value, linking to existing and other e-learning resources. Formative assessment within e learning has been found to be valuable as it provides safe and valuable feedback for surgical trainees.(Larvin, 2009 p 136)

Methodology and measure

Various methodologies were employed in these researches to study the effect and acceptance of eLearning in surgical training. Citak et al., Corrigan et al., and Coughlan et al.,  (Citak et al., 2009; Corrigan et al., Coughlan et al., Coughlan et al 2012) used a similar  methodology of survey to assess the effectiveness of e-learning in surgical education.  Cital et al  (Citak et al., 2009) had used an online trauma surgery repository for the teaching of trauma surgery for medical students in Hanover. Here they surveyed the students after the use of the independent variable which was the online trauma surgery Schoolbook for the academic year and the dependent variable was the satisfaction obtained from the use of the e-learning trauma surgery repository by completing the questionnaire. The questionnaire designed for this had included the evaluation of the students of the e-learning based on the mode of accessing, utilization and opinion toward the e-learning material. .  Corrigan et al (Corrigan et al., 2012) similarly used an online repository of surgical educational material as the independent variable in their study and surveyed the participants on the effectiveness of the online repository through questionnaire.  Here the authors had use a commercial tool to measure usage of the online repository and a survey based feedback. Response rate for those participants was 67% making it valid. Effectiveness of the programme was measured with a focus group again having the same response rate. Coughlan et al   (Coughlan et al 2012) used a CD-ROM format of e-learning as the independent variable and  survey questionnaire to evaluate the surgical content and learning benefit among surgical trainees. By using this they excluded problems of web-based learning in terms of connectivity and bandwidth. They had modified a validated questionnaire which was used to evaluate instructional multimedia application interface features proposed by Reeves and Harmon (1994).

Bhatti et al.,  Hull et al and Ridgway et al., however performed primary research by using various e-learning programs as the independent variable and measured performance, using standardise assessment tools, as the dependent variable. Bhatti et al (Bhatti et al., 2011) had used standard lecture and an e-learning program as their independent variables and measure its effectiveness using an assessment tool consisting of Multiple-choice questions and Extended matching questions  which are validated knowledge acquisition assessment tools in medical education, where performance in this assessment was the dependent variable. Hull et al (Hull et al., 2009) had used bedside teaching and computer-based learning as the  independent variable in their study however they included sequencing of these as another independent variable in their study.  The effectiveness in producing learning in their study was performed by measuring performance at a standardise validated assessment tool in the clinical setting, the objective structured clinical examination (OSCE).

Ridgway (Ridgway et al., 2007) studied the effect of two  e-learning programs, independent variables, one being a text only learning material and the other text and  audio . The effectiveness of these independent variables was assessed by the use of standard assessment tool which was a multiple-choice questionnaire  designed   specifically to assess learning of  the text and graphical material presented in the lecture
series.  Acceptability was assessed by standardized anonymous questionnaire based on Likert scales for the different independent variables and focusing on ease of use, accessibility, relevance, content and satisfaction measure using survey questionnaire.

Except for the Coughlan study where the population were surgical trainees all the other studies  included medical students in the population.  In Bhatti et al., study(Bhatti et al., 2011) , the population of medical student were subjected to various learning materials  as the independent variable, they being normal lecture and e-learning and were randomised using a web-based randomisation program called QuickCalcs which has been validated as an appropriate tool in the clinical setting by Suresh et al (Suresh, 2011).
In the Hull et al study the medical student population was randomised using a randomisation software into two groups where one had the sequencing of bedside teaching followed by computer-based learning as compared to the other which had computer-based learning prior to bedside teaching as the independent variable.
In the Ridgway et al study there was no randomisation of the population of medical students. All of them were entered into the independent variables which consist of a lecture series consisting of text with no audio and another  independent variable consisting of lectures with audio. Therefore the whole populations were subjected to different intervention in the form of the learning material being a multimedia e-learning and without multimedia.

In the other three studies (Citak et al., 2009; Corrigan et al., Coughlan et al., 2012) there was  no randomisation of the population as it was a survey of all those involved and  the return rate of questionnaires were satisfactorily and acceptable levels for qualitative research.


The results from the survey type studies in this literature review (Citak et al., 2009; Corrigan et al., Coughlan et al 2012), showed general acceptance and utilisation of e-learning by students in surgical education at undergraduate and postgraduate level. Citak et al had shown that even the instructors had found the e-learning useful in their teaching. Coughlan et al had shown the participants had benefited and found the e-learning relevant to the learning needs and indicated that the e-learning be expanded to other nonsurgical topics.

The experimental papers, Bhatti et al.,  Hull et al and Ridgway et al , the authors had shown that e-learning with multimedia content is effective in bringing about knowledge acquisition in undergraduate teaching. Bhatti et al had shown that “e Learning supplemented with a podcast results in greater knowledge acquisition when compared with a traditional lecture, without a loss of satisfaction with teaching.”(Bhatti et al., 2011 p 459). Hull et al in their study showed that e-learning with bedsides teaching in that sequence was most effective for students to learn  orthopaedic knee examination however if only one modality was available bedside teaching was preferred than solitary e-learning. Ridgway et al clearly showed that the addition of audio to web-based learning improved examination results.(Ridgway et al., 2007 p 168).

This literature reviews has shown that there is evidence to show the effectiveness and usefulness of e-learning programs in surgical education. It has good acceptance and utilisation of e-learning repositories by learners in surgery and produces some guidelines for design of instructional materials for e-learning in the surgical educational environment. 


Bhatti, I., Jones, K., Richardson, L., Foreman, D., Lund, J., & Tierney, G. (2011). E-learning vs lecture: which is the best approach to surgical teaching? Colorectal Disease, 13(4), 459–462.

Citak, M., Calafi, A., Kendoff, D., Kupka, T., Haasper, C., Behrends, M., Krettek, C., et al. (2009). An internet based learning tool in orthopaedic surgery: Preliminary experiences and results. Technology & Health Care, 17(2), 141–148.

Corrigan, M., McHugh, S., Sheikh, A., Lehane, E., Shields, C., Redmond, P., Kerin, M., et al. (2012). Surgent University: the establishment and evaluation of a national online clinical teaching repository for surgical trainees and students. Surgical innovation, 19(2), 200–204. 

Coughlan, J., and Brinkman, W.-P. (2011). Design considerations for delivering e-learning to surgical trainees.  International journal of e-health and medical communications . 2(2). 14-23

 Hull, P., Chaudry, A., Prasthofer, A., & Pattison, G. (2009). Optimal sequencing of bedside teaching and computer-based learning: a randomised trial. Medical education, 43(2), 108–112. 

Larvin, M. (2009). E-Learning in surgical education and training. ANZ Journal of Surgery, 79(3), 133–137.

Reeves, T. C., &  Harmon, S. W. (1994). Systematic evaluation procedures for interactive multimedia for education and training. In S. Reisman (Ed.), Multimedia Computing - preparing for the 21st Century (pp. 472-505). London: Idea Group Publishing

Ridgway, P. F., Sheikh, A., Sweeney, K. J., Evoy, D., McDermott, E., Felle, P., Hill, A. D., et al. (2007). Surgical e-learning: validation of multimedia web-based lectures. Medical Education, 41(2), 168–172.

Suresh, K. (2011). An overview of randomization techniques: An unbiased assessment of outcome in clinical research. Journal of Human Reproductive Sciences, 4(1), 8–11. doi:10.4103/0974-1208.82352

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