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Linear Versus Web-Style Layout of Computer Tutorials for Medical Student Learning of Radiograph Interpretation

Posted Jun 30, 2007 Updated Apr 7, 2023
By Martin V. Pusic MD MA , Vicki R. LeBlanc PhD , Steven Z. Miller MD
12 min read

Rationale and Objective

We sought to determine which is more effective in increasing skill in radiograph interpretation: a linear (PowerPoint-style) computer tutorial that locks the student into a fixed path through the material or a branched (Web-style) version that allows random access.

Materials and Methods

We prepared a computer tutorial for learning how to interpret cervical spine radiographs. The tutorial has 66 screens including radiographs or graphics on almost every page and five unknown radiographs for the student to interpret. One version (linear) presents the material in a linear sequence with the unknown radiographs heading up “chapters” detailing an important aspect of the task. In the second (branched) version, the same 66 screens were accessed through hyperlinks in a frame beside the unknown radiographs. One hundred thirty-nine medical students at two sites participated in a randomized single-blinded controlled experiment. They interpreted cervical spine images as a pretest and then completed one of the two tutorial versions. Afterward, they did the same examination as a post-test.

Results

The tutorial was successful, in both layouts, in improving the subjects’ ability to interpret cervical spine radiograph images (effect size 2.1; 95% confidence interval 1.7−2.5). However, the layout did not make a difference to their gain in ability. Students in the linear group completed the tutorial in 17% less time ( P < .001) but were slightly less likely to rate the tutorial as “valuable.”

Conclusion

For these novice learners, computer tutorial layout does not affect knowledge gain. Students may be more satisfied with the linear layout, but in time-pressured situations, the Web-style layout may be preferable because it is more efficient.

The skill of radiograph interpretation includes recognition of visual features and the use of a procedure to ensure that all relevant information is considered. Students learn this skill through a combination of instruction and practice. Computer tutorials are an excellent medium for this learning since they facilitate aggregation of representative radiograph examples, and they allow novel instructional designs that are more interactive than textbooks or radiology teaching files ( ). There are a large number of online resources and CD-ROM computer tutorials available for this particular skill ( ). Unfortunately, rigorous evaluations of their educational impact are lacking.

These computer tutorials are generally laid out in one of two formats. The first type is a linear PowerPoint style of presentation that is behaviorist in that the goals are prespecified and the path of the student is largely determined ahead of time by the instructor. The behaviorist philosophy specifies that learning best takes place when a desired change in behavior is prespecified ( ). The educator provides a program of instruction specific to named objectives. Typical examples of instructional designs based on this “top-down” philosophy are lectures and programmed instruction. This method has the advantage of being very efficient.

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Methods

Participants

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Computer Tutorials

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Figure 1, Schematic representation of the layouts of the two tutorials. In the linear group, the content of the tutorial was presented using serial screens of information. Unknown images are presented in sequence as one of the first screens for a given section of the tutorial. For example, the “Alignment” section begins with an image for which the key feature was malalignment of the cervical spine. For the Web-layout group, the content of the tutorial was presented using serial unknown images. The tutorial included the same number of unknown images but they were grouped together to form the backbone of the tutorial. Knowledge content could be accessed in any order from any of the unknown images. For each of the unknowns, a hyperlink was included that lead the student to the appropriate section for learning about the given anomaly.

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Linear tutorial

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Figure 2, Three screen captures from the linear cervical spine x-ray computer tutorial. (a) First, an unknown case is presented from the linear tutorial. The student is asked to click with the left mouse button over a feature that suggests that this radiograph may be abnormal. (b) Second, after the student clicks on the unknown screen, the tutorial first presents a textual explanation of the features. (c) Third, clicking on the “Outline” button of the textual explanation reveals this visual explanation where the features on the radiograph are segmented and interpreted.

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Web-style tutorial

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Figure 3, Screen captures from the Web-style layout computer tutorial. All screens can be accessed through hyperlinks arranged in a frame along the left-hand side of the screen. The right-arrow button takes the student to the next unknown case. The radiograph shows the same case of C1C2 malalignment as seen in Figure 2 .

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Experimental Design

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Outcome Measure

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Procedure

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Data Collection

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Data Analysis

Item scoring

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Item analysis

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Reliability analysis

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Outcome analysis

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Student path through tutorial

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Results

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Figure 4, Study flow diagram.

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Instrument

Item analysis

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Reliability of instrument

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Outcomes

Classifying the images by specific lesion

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Table 1

Measured Outcomes for the Students Comparing the Two Intervention Groups

Branched Group (n = 69) Linear Group (n = 70) Overall (n = 139) Statistical Significance Scores: precisely identifies lesion (marks of seven abnormal findings) Pretest (SD) 0.9 (1.0) 0.8 (0.9) 0.9 (1.0) Post-test (SD) 3.9 (1.2) 3.9 (1.2) 3.9 (1.2) Difference (SD) 3.0 (1.4) 3.1 (1.5) 3.1 (1.4) Effect size ⁎ : pretest versus post-test (95% CI) 2.1 (1.7 to 2.6) 2.1 (1.7 to 2.5) 2.1 (1.7 to 2.5) F (1,137) = 615; P < 0.001 Effect size ⁎ † : branched versus linear (95% CI) −0.06 (−0.39 to +0.27) F (1,137) = 0.3; P = 0.61 Time on tutorial (min), mean (SD) 24.3 (9.7) 29.2 (8.2) 26.8 (8.8) 95% CI diff (2.3 to 8.0) Screens viewed, mean (SD) 112 (61) 135 (33) 124 (50) 95% CI diff (7 to 40) Time per screen viewed (s), mean (SD) 14 (5) 13 (4) 14 (4)P = NS Learning efficiency: Marks of 10 improved from pretest to post-test per minute spent on tutorial (SD) 0.12 (0.13) 0.06 (0.07) 0.09 (0.11)P = 0.004 ‡

Scores indicates whether the student was able to indicate the exact lesion reported by the radiologist.

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Table 2

Examination Scores Before and After the Computer Tutorial, Based on the Radiograph Finding

Finding (# of questions) View PreTest Score Mean (SEM) PostTest Score Mean (SEM) Difference (95% CI) Effect Size for Computer Tutorial Normal ( ) Lateral 0.63 (0.02) 0.31 (0.02) −0.32 (−0.26, −38) −0.64 C1/C2 Malalignment ( ) Odontoid 0.13 (0.03) 0.77 (0.04) +0.64 (0.55, 0.75) 1.3 Increased predental space ( ) Lateral 0.29 (0.03) 0.83 (0.02) +0.54 (0.47, 0.60) 1.1 Vertebral Subluxation ( ) Lateral 0.02 (0.01) 0.27 (0.03) +0.25 (0.19, 0.30) 0.70 Vertebral body crush ( ) Lateral 0.03 (0.01) 0.14 (0.03) +0.11 (0.05, 0.17) 0.39 Inadequate film–C7 not visible ( ) Lateral 0.08 (0.02) 0.81 (0.03) +0.72 (0.64, 0.80) 1.44

Scores represent the proportion of subjects who were able to correctly identify the level and nature of the abnormality.

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Classifying the images as normal versus abnormal

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Time and learning efficiency

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Subjective rating

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Qualitative analysis of paths

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Figure 5, Visual representations of the path taken by the students through the tutorial. In the graphics above, each row represents the log file of one student, while each cell in the grid represents a single screen viewed in the computer tutorial. The cells are color-coded according to the legend given here, where a given color represents a specific chapter in the tutorial. Only the first 60 screens viewed are shown. (See Results for interpretation.)

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Discussion

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Conclusions

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Acknowledgments

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Academic Radiology, Volume 14, Issue 7
Journals General Radiology
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