nteraction and repetitions are the cornerstones
for learning any skill. Traditional learning has more human involvement;
thus opportunity for repetition is curtailed so as to respect patient
autonomy and prevent psychological stress to the patient as well as the
student. E-learning involves technology and simulation, which can be
repeated any number of times, exactly the same way or in changed
scenario to improve the levels of learning. Innovations in technology
and devices have brought a revolution in learning. The field of medical
education cannot remain immune to the effects of this aptly called
E-revolution. In the era of computers and hand-held devices, teaching
and learning have gone far beyond the textbooks, venturing into various
components of the digital world. The United Nations and WHO have
acknowledged e-learning as a useful tool in addressing educational needs
in healthcare workers, especially in developing countries [1,2]. We
herein review the various features of e-learning in the context of its
adoption in the medical education scenario in India and other similar
countries.
Definition
According to Ellaway & Masters [3], "e-learning
encompasses a pedagogical approach that typically aspires to be
flexible, engaging and learner–centered; one that encourages interaction
(staff–staff, staff–student, student–student), and collaboration and
communication, often asynchronously (though not exclusively so)." The
common denominator is the use of technology and electronic devices to
enhance learning [1-4]. It may also be defined as an approach to
teaching and learning, representing all or part of the educational model
applied, that is based on the use of electronic media and devices as
tools for improving access to training, communication and interaction,
and that facilitates the adoption of new ways of understanding and
developing learning [1]. Web-based learning, Online learning,
Distributed learning, Computer-assisted instruction, or Internet-based
learning are also used synonymously and interchangeably for this type of
learning [4].
Characteristics of E-learning
The three primary characteristics of e-learning are
the nature of the learning experience, synchronicity of participation,
and presence or absence of face-to-face instruction [3]. Depending upon
the nature, the learning experience is termed ‘didactic’ when the
learning material is literally handed over to the student and they
cannot change it, and ‘active’ when the student has control over the
learning process. In the Interactive type, the learning content evolves
as the course progresses and co-learners interact; the instructors act
as facilitators and help in the evolution of learning.
The learning is termed Synchronous when the
instructions are provided on the spot, as in face-to-face teaching, and
Asynchronous when there may be a time gap between the instructions
provided and response of the learners. In synchronous learning,
participants interact with instructor in real time. There is interaction
between the participants using the available audio-visual aids like
chat, virtual classrooms, and audio- and video-conferencing.
E-learning is divided into Complete or full learning,
and Blended or mixed-learning, depending upon the use of the method as
either replacement or augmentation of the face-to-face learning. There
is no physical contact of any sort in complete e-learning, whereas some
contact remains in the blended type of learning. In the blended type,
both the methods are used at some point of time during the whole course.
Learning management administration has a major role
in success of e-learning. They have to provide technological support and
keep the system functional for maximum benefits. Teachers must undergo
faculty development to learn the technology. Students also learn about
the tools and technology. Institute must develop a separate IT
department to look after this technology.
Learning management system (LMS) is a single window
software application for the teachers, students and the parents that
delivers and manages instructional content, identifies and assesses
individual and organizational learning or training goals, tracks the
progress towards meeting those goals, and collects and presents data for
supervising the learning process of the organization as a whole [5]. The
teachers create and deliver content, monitor student activity, and
assess students’ performance; the student can access content directly on
devices, can take the tests and quiz, and submit online using the
internet. The student can also assess their performance. Parents can
access course curriculum, attendance and performance analyses. Learning
management system has in-built responsibilities, which are as follows:
Registration (Enrol and administer learners online for web-based,
instructor-led, and all other learning activities); Scheduling (schedule
courses and define curricula to address individual and organizational
learning needs); Delivery (deliver online courses and assessments or
schedule instructor-led courses); Tracking (track the progress of the
learners and create reports); Communication (communicate by chat,
discussion forum, mail, screen sharing and e-seminars); and Testing
(test and assess competency, learning styles and student commitment).
The LMSs are presently used in AIIMS, New Delhi for teaching in the
Anatomy Department. These are also being used by The International
Pediatric Association, World Association of Medical Editors, Committee
on Immunization - The Indian Academy of Pediatrics, and Asian Pacific
Pediatric Association to name a few [6]. There are many on-line LMS
software available like Modular Object-Oriented Dynamic Learning
Environment (MOODLE).
E-learning methods can vary from as simple as
audio cassettes to as complex as multi-point video-conferencing
facilities supported by online applications. Table I
provides a list of e-learning interventions used in the medical field
[1].
TABLE I E-learning Interventions
Intervention |
Comments |
Non-networked computer-based e-learning |
The learners
need not to go online. They are not connected to each other and
the learning occur independent of each other. Learning occurs
through static methods like pen-drives or CDs. |
Internet and
local area network- based e-learning
|
The learning
takes place through the Internet or a local area network. Many
participants can share the content and the e-learning . Examples
are LMS, Moodle, Blackboard |
Psychomotor
skills trainer |
The
development of fine motor coordination skills and techniques are
attained through Technology.Example |
Virtual
reality environments |
Real or
artificial environment is generated with the help of technology
and the participants get a real time feeling of doing the same
thing.
|
Digital
game-based learning |
Application
of game principles and mechanics in non-game contexts in solving
problems. The technology helps in solving the problems as they
come.
|
Role in Medical Education
The integration of e-learning in medical education is
the need of the hour. Medical Council of India (MCI), the regulatory
body of medical education in India, has recognized the importance of the
technology and has included the use of electronic means in the broad
competency "Lifelong learner committed to continuous improvement of
skills and knowledge [7]." An Indian medical graduate must have obtained
this competency at the time of graduation. The student has to
continuously acquire new skills and keep himself abreast of latest
development, a goal presently considered difficult to attain in the
absence of technology. The use of e-learning can help them achieve the
goal of continuous professional development, considering the vastness of
syllabus, paucity of time, and already overburdened schedules [8].
Recognizing the importance of information technology for the doctor of
today, the General Medical Council in UK also advocates that medical
graduates should be able to "make effective use of computers and other
information systems, including storing and retrieving information [9]."
From a simple ‘disseminator of content’, teachers are
increasingly metamorphosing into ‘facilitators for learning’ [4,10],
which is facilitated by e-learning tools that provide a variety of
online resources [11]. E-learning technology can be used in the
augmentation of all the learning domains viz., cognitive,
psychomotor and affective. In the cognitive domain, group teaching in
classrooms could be enhanced by providing online material like
pre-lecture assignments and audio-video clips during the sessions. Even
students could be provided with virtual resources like audio-video
clips, podcasts, animations, and web-links for self-directed learning
intended to be used at home, or as part of Flipped lectures. Psychomotor
skills, although best learnt with real practice, can also be augmented
by technology, at least up to the ‘knows how’ level. Audio-visual
demonstration of procedures, diagnostics and interventions can be
provided. Students may read through the explanations and view checklists
of procedural skills before actually practicing the same under
supervision in clinical postings or in skill laboratories. In the
affective domain, videos of scenarios depicting good and bad
communication-skills, role-plays and counselling sessions, and
self-recordings can be used to stimulate learning. Other modalities
include online case-studies and patient logs, clinical decision support
systems, virtual patients, medical video games, E-books, e-atlases,
teaching databases, and digital versions of online journals.
Common Modalities for E-learning
Flipped classroom: Flipped classroom approach
means that the tasks performed by the students are flipped or reversed
between the class time and self-study time. Majority of the learning is
done by the students themselves – before the class and outside the
classroom – by utilizing online resources like videos, recorded
lectures, PowerPoint presentations, and handouts provided by the
teacher. The advantage of this type of blended teaching is that instead
of merely information transfer, discussion and student-centered learning
and problem solving takes place. It means the shifting of the teacher
from typical ‘sage-on-the-stage’ to the ‘guide-by-the-side’ [12]. Indian
experience with the technique has shown good acceptance by medical
students [13].
Smartphones: Smartphones have great potential for
e-learning in medical education as they are handy, provide the required
information at the point-of-care, and help in better decision-making.
With the increasing usage of the smartphones and user-friendly apps by
the medical students, this will further gain popularity. There are
various mechanisms by which e-learning can be imparted by smartphones –
e.g., apps like dosage calculators, growth charts, Curofy, Docplexus,
SCAT; web-based features like PubMed for handheld devices; and social
media apps like Facebook, WhatsApp, and YouTube [14]. These mechanisms
have the potential to increase collaboration, problem-solving and
networking in the medical students, allowing them to share images and
data, and participate in blogs or video-conferencing.
Clinical decision support systems: These are
another breakthrough in e-learning where the clinician makes a decision
keeping in mind the inputs provided by the support system and
interpreting them with their own understanding. Typically, data is
provided to the technology-enabled systems where it is analyzed and then
decision-making options are given to the treating doctors, at the
point-of-care (bedside, outpatient setting, etc.); e.g.,
UP TO DATE (http://www.uptodate.com/home/product).
Online education sites: Online sites such as
Stanford Medicine 25 (https://stanfordmedicine25. stanford.edu)
teach the art of bedside clinical examination – an art that is swiftly
disappearing from the curricula of the medical students, owing to the
over-importance of the theoretical concepts. Here e-learning can come in
handy as the skills can be imbibed after watching the online content,
revised when needed, and are a major assistance for self-directed
learning – even during professional life.
Skill laboratories: These are the places where
the upcoming physician can practice and hone the relevant skill in a
controlled environment before practicing them on real patients. The
simulation-based method has become a part of curriculum of all medical
specialties. Not only the beginners but the experts have also shown to
be benefitted by these laboratories [15]. Basic clinical skills to
complex surgical skills can be practiced using these labs [16,17]. The
experience can be gained by working on manikins or with standardized
patients in controlled ‘mistake-forgiving’ training environment. The
skill laboratories have also been shown to be following the modified
version of Peyton’s Approach [18]. They use structured format, and
depending upon the performance of the students, graded challenges and
exposures to a variety of clinical skills that can be provided.
Assessment and feedback can also be provided by this modality. Airway
management, resuscitation, arrhythmia management, cardiac monitoring,
scrubbing, and placing an intravenous catheter are few examples of the
procedures which could be learnt and practiced in skill laboratories.
Teachers’ and Students’ Perception
Students have reported that they attain more
knowledge by understanding the subject better, acquire better skills,
feel more satisfied due to easy accessibility, flexibility, and
increased interactivity with co-participants [19]. Lack of interaction
with the teacher [20] and in-depth group discussion for clarification of
concepts for complex topics has also been reported [21]. Various studies
report that students prefer e-learning as a supplemental tool rather
than replacement one [23,24].
Teachers perceive that e-learning saves time in
editing and updating of content [24], setting-up laboratory equipment,
and repeating the experiments [25], which could be utilized for
face-to-face classes [26]. They also do not have to worry about
variation in content delivery [27]. The less tech-savvy generation of
teachers consider imposition of e-learning as an additional burden
because they think it is less worthy, have time-constraints in
developing the content, and have lack of confidence in meeting the
technical demands [28].
Advantage of e- learning are described in Box
I.
Box 1
Advantages of E-learning |
• Flexibility and ease of access:
E-learning is not fixed or time bound to a particular schedule
and is very easily accessible, so learners can choose a place
and time of their own liking [29]. Teachers can also update and
edit the learning material at their own convenience [24]. The
accessibility of the content via small size of the
gadgets, mostly hand-held, also complements this feature [30].
• Cosmopolitan nature: E-learning is
sans frontiers, and this has been found to be useful in remote
and rural areas as well [31]. The participants may actually
belong to any part of the globe [32]. Rare cases and diseases
peculiar to a particular geographical area can also be studied
globally.
• Time-saving: More number of students
can be taken up at same time, thereby reducing the time needed
for total lectures. The content once made is eternal, and can be
revisited any number of times. The saved time in preparing
lectures can be used by the teachers to hone their higher level
of cognitive e-learning [25,26].
• Stop-gap arrangement: E-learning can
be used to hone the skills before actually encountering the real
patient. This decreases the probability of error and also saves
time. This allows repetition, and thereby improvement in the
desired skills [33,34].
• Adult learning principles:
E-learning helps in deeper learning, increases self-motivation,
and fulfils the adult learning principles [4,34]. It also allows
the participants to set their own pace as per their learning
styles and can be used as best suited tool for personalized and
interactive e-learning experience. It is tailored to student’s
needs and is learner-centered, thus helping in self-directed
learning [1,11].
• Uniformity: Since identical
information is posted to all the participants, the curricula
uniformity is maintained across the learners. The students
posted in off-site campuses also receive identical inputs. This
helps in the uniform attainment of learning objectives because
of equal availability of quality and quantity of information
dispersed [1,35].
|
Indian Experience
Presently e-learning in medical education in India is
growing at a good pace. Computers, smartphones and internet have carved
a niche for themselves in the life of medical students. Currently, most
of the e-learning activity done by the residents in the medical colleges
is limited to data search for their thesis and research work. The use of
technology in medical education in other areas is in a nascent stage.
Supporting this fact, 89% of the participants in a recent study used
computer-based literature searches at least once per month to either
prepare presentations (90.2%), carry out research [65%], or to research
patient- related problems (60.3%) [36].
Frehywot, et al. [37], in a systematic review
on e-learning in medical education in resource-constrained settings,
reported the major reasons of using e-learning to be a faculty shortage,
to cast the net wider, and to maximize the use of resources by the
students.
St. John’s Hospital, Bangalore and Christian Medical
College, Vellore have utilized TUSK platform developed by Tuft’s
University for all their e-learning activities, especially to build
support for their undergraduates to work in rural and underserved areas
of India through strengthening distant learning efforts. The TUSK
software contains full-text syllabi, slides, lecture recordings (audio
and video), class schedules, course evaluations, dissection guides, a
quiz and case maker, grade book, and other resources made available by
the faculty [38].
Online Google groups are being used extensively by
the Medical Council of India to train the medical faculty under one-year
fellowship in medical education at ten nodal centers across India.
Listserv is being used as an e-learning platform in the FAIMER
fellowship conducted at various centers in India.
India’s first telemedicine center at Apollo Aragonda
Hospital in the state of Andhra Pradesh was inaugurated in 2000 [39],
and since then there are more than 500 telemedicine centers linked with
about 50 specialist hospitals across the country. The telemedicine
software system has been developed by the Centre for Development of
Advanced Computing and is used to connect many medical institutes of
India [40]. The postgraduates are also benefitted by the webcasts made
available by professional bodies e.g., Indian Academy of
Pediatrics. Edusat lectures are being delivered daily for the medical
undergraduates in Punjab.
Despite these efforts, e-learning has reached very
few medical colleges. The usage of technology in medical education is
not free of challenges and following are few of hurdles which prevent
the widespread usage of e-learning:
Hardware and software issues: The technological
infrastructure in form of hardware and software is compulsory to run
e-learning program. The issues related to the hardware are cost,
shortage of units, and lack of technical knowledge to operate them
[6,41]. The software issues include the need to obtain licenses [42],
and frequent up-gradation of hardware required to support them.
Round-the-clock access at both home and off-campus is necessary for
e-learning to have maximum impact.
Connectivity: The success of e-learning also
depends upon the internet connectivity [10,43]. Adequate bandwidth would
be needed at various levels to ensure proper downloading – lower speed
or interruptions lead to sub-optimal use of this modality.
Financial issues: The impetus of starting these
programs means financial burden for installation, running, and
maintenance of the e-learning program [44-46]. It would also need
developing the infrastructure and recruiting the staff. This will put
additional burden on the institution’s resources, and the administrators
may be reluctant to invest on e-learning.
Security and safety of personal information: The
privacy and security of data has to be maintained. With the expanding
cyber world, cybercrimes are exponentially increasing, and more
efficient ways of providing security for identity management are needed
[47]. Latest anti-virus software and operating systems are also needed.
The issue of plagiarism, with respect to the online content, also needs
to be taken care of.
Faculty and support staff shortage: One of the
most important challenges would be to ensure the availability of faculty
and support staff. The medical fraternity is already overburdened and
doctors are doubling up as academic persons. There is dire need of more
staff for designing, teaching, and tutoring the new students about
e-curriculum and modification of the existing system to complete or
blended e-learning [1,5]. The support staff is also required to maintain
the ever-changing requirements of e-learning.
Technical support: Even if the infrastructure
is present, the technical support to run the system, awareness about the
support materials, quick solutions to the technical glitches is lacking
[35,48]. The trainers are frequently not aware of the type of support
required in particular programs. Many studies have concluded that
awareness about computer technology and competency as well as
proficiency in usage of computers at learners’ level is ‘a must’ to
adopt this technology [49].
Lack of face-to-face interaction: The bulk of the
early teaching is with traditional face-to-face interaction; its
non-availability in e-learning is a well-recognized challenge [34,50].
The lack of tutor support, especially in understanding the complex and
‘difficult-to-understand’ topics, have also been cited as a disadvantage
of e-learning [51].
Psychological issues: There is resistance to need
of change in both the teachers and students alike, especially when there
are no guidelines [5]. The need of information or guidance for grasping
the concepts of this seemingly difficult topic makes learners even more
skeptical [44]. Prevailing myths about the e-learning may also
discourage the learners [44,52]. The attitudinal aspect is one of the
hindrances in implementation of e-learning strategies in India.
Language barriers [10]: Many studies have found
that language is a barrier in implementation of e-learning [25]. Similar
to the bulk of conventional learning, the instructions in e-learning are
provided in English, which may make its adoption somewhat difficult for
those not well-versed with the language.
The Way Forward
E-learning is a significant advance with the
potential to change the face of medical education in India in the coming
years. For this to happen, Institutions and teachers need to be prepared
to accept the change, and put-in the required resources — whether
manpower or time or money. For successful incorporation of e-learning in
the existing set-up, the following attributes are essential: motivation
and self-discipline; ability to study independently or schedule study
time; understanding the e–learning process; and adequate equipment and
dedicated work space/support. It is up to the medical educators and
administrators to incorporate these modalities, and researchers to test
these in the Indian settings to inform decision-making. The students are
ready and waiting.
Acknowledgement: Dr Amit Jain for help in writing
the manuscript.
Contributors: DM conceived the write-up, prepared
the initial format, and finalized the manuscript. SKD and MB prepared
the initial draft, and the pre-final version. DV provided important
intellectual inputs in the conception and preparation of the manuscript,
and made significant contributions in the preparation of the final
version. All authors approved the final version of manuscript.
Funding: None; Competing interest: None
stated.
References
1. Al-Shorbaji N, Atun R, Car J, Majeed A, Wheeler E
(eds). E-learning for undergraduate health professional education - a
systematic review informing a radical transformation of health workforce
development. World Health Organization, Geneva, 2015. Available from:
http://whoeducationguidelines.org/ content/e-learning-report.
Accessed June 18, 2016.
2. George PP, Papachristou N, Belisario JM, Wang W,
Wark PA, Cotic Z, et al. Online e-learning for undergraduates in
health professions: A systematic review of the impact on knowledge,
skills, attitudes and satisfaction. J Glob Health. 2014;4:10406.
3. Ellaway R, Masters K. AMEE Guide 32: E-Learning in
medical education Part 1: Learning, teaching and assessment. Med Teach.
2008;30:455-73.
4. Ruiz JG, Mintzer MJ, Leipzig RM. The impact of
e-learning in medical education. Acad Med. 2006;81:207-12.
5. Childs S, Blenkinsopp E, Hall A, Walton G.
Effective e-learning for health professionals and students – barriers
and their solutions. A systematic review of the literature—findings from
the HeXL project. Health Inf Libr J. 2005;22 Suppl 2:20-32.
6. Randell D. E-learning for continuing education:
exploring a new frontier. Med Lab Obs. 2001;33:24-8.
7. MCI Vision 2015 Booklet. Medical Council of India.
Available from: www.mciindia.org/tools/announcement/MCI_booklet.pdf.
Accessed June 18, 2016.
8. Choules AP. The use of e-learning in medical
education: A review of the current situation. Postgrad Med J.
2007;83:212-6.
9. Outcomes for Graduates. Available from:
http://www.gmc-k.org/Outcomes_for_graduates_Jul_15.pdf _61408029.pdf.
Accessed September 27, 2016.
10. National Journal for Basic Medical Science.
Effective use of e-learning in basic medical sciences. Available from:
http://njbms.com/physiology/effective-use-of-e-learning-in-basic-medical-sciences/
#.V2UcMhIcky4. Accessed June 18, 2016.
11. Chodorow S. Educators must take the electronic
revolution seriously. Acad Med. 1996;71:221-6.
12. King A. From sage on the stage to guide on the
side. Coll Teach. 1993;41:30-5.
13. Veeramani R, Madhugiri VS, Chand P. Perception of
MBBS students to "flipped class room" approach in neuroanatomy module.
Anat Cell Biol. 2015;48:138-43.
14. Mazloomy Mahmoodabad SS, Barkhordari A, Nadrian
H, Moshiri O, Yavari MT. Survey of ownership and use of mobile phones
among medical science students in Yazd. Pak J Biol Sci. 2009;12:1430-3.
15. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon
D, Scalese RJ. Features and uses of high-fidelity medical simulations
that lead to effective learning: A BEME systematic review. Med Teach.
2005;27:10-28.
16. Lynagh M, Burton R, Sanson-Fisher R. A systematic
review of medical skills laboratory training: where to from here? Med
Educ. 2007;41:879-87.
17. Lund F, Schultz J-H, Maatouk I, Krautter M,
Möltner A, Werner A, et al. Effectiveness of IV cannulation
skills laboratory training and its transfer into clinical practice: A
randomized, controlled trial. PloS One. 2012;7:e32831.
18. Nikendei C, Huber J, Stiepak J, Huhn D, Lauter J,
Herzog W, et al. Modification of Peyton’s four-step approach for
small group teaching - a descriptive study. BMC Med Educ. 2014;14:68.
19. Juliani CM, Corrente JE, Dell’ Acqua MCQ.
Comparing the teaching-learning process with and without the use of
computerized technological resources. Comput Inform Nurs.
2011;29:212-20.
20. Bains M, Reynolds PA, McDonald F, Sherriff M.
Effectiveness and acceptability of face-to-face, blended and e-learning:
a randomised trial of orthodontic undergraduates. Eur J Dent Educ.
2011;15:110-7.
21. Armstrong P, Elliott T, Ronald J, Paterson B.
Comparison of traditional and interactive teaching methods in a UK
emergency department. Eur J Emerg Med. 2009;16:327-9.
22. Seabra D, Srougi M, Baptista R, Nesrallah LJ,
Ortiz V, Sigulem D. Computer aided learning versus standard lecture for
undergraduate education in urology. J Urol. 2004;171:1220-2.
23. Kong J, Li X, Wang Y, Sun W, Zhang J. Effect of
digital problem-based learning cases on student learning outcomes in
ophthalmology courses. Arch Ophthalmol. 2009;127:1211-4.
24. Chu LF, Chan BK. Evolution of web site design:
implications for medical education on the Internet. Comput Biol Med.
1998;28:459-72.
25. Jeffries PR, Woolf S, Linde B. Technology-based
vs. traditional instruction. A comparison of two methods for teaching
the skill of performing a 12-lead ECG. Nurs Educ Perspect. 2003;24:70-4.
26. Toumas M, Basheti IA, Bosnic-Anticevich SZ.
Comparison of small-group training with self-directed internet-based
training in inhaler techniques. Am J Pharm Educ. 2009;73:85.
27. Flowers SK, Vanderbush RE, Hastings JK, West D.
Web-based multimedia vignettes in advanced community pharmacy practice
experiences. Am J Pharm Educ. 2010;74:39.
28. Pozzessere G, Rizzo PA, Valle E, Mollica MA,
Sanarelli L, Morano S, et al. A longitudinal study of multimodal
evoked potentials in diabetes mellitus. Diabetes Res Edinb Scotl.
1989;10:17-20.
29. Ward JP, Gordon J, Field MJ, Lehmann HP.
Communication and information technology in medical education. Lancet.
2001;357:792–6.
30. Goldsworthy S, Lawrence N, Goodman W. The use of
personal digital assistants at the point of care in an undergraduate
nursing program. Comput Inform Nurs. 2006;24:138–43.
31. Bhatia RP. Features and effectiveness of
e-learning tools. Global J Business Manag Inform Tech. 2011; 1:1-7.
32. Naing C, Wai VN, Durham J, Whittaker MA, Win NN,
Aung K, et al. A systematic review and meta-analysis of medical
students’ perspectives on the engagement in research. Medicine
(Baltimore). 2015;94:e1089.
33. Vivekananda-Schmidt P, Lewis M, Hassell AB, ARC
Virtual Rheumatology CAL Research Group. Cluster randomized controlled
trial of the impact of a computer-assisted learning package on the
learning of musculoskeletal examination skills by undergraduate medical
students. Arthritis Rheum. 2005;53:764-71.
34. Qureshi IA, Ilyas K, Yasmin R, Whitty M.
Challenges of implementing e-learning in a Pakistani university. Knowl
Manag E-Learn Int. 2012;4:310-24.
35. Hadley J, Kulier R, Zamora J, Coppus SFPJ,
Weinbrenner S, Meyerrose B, et al. Effectiveness of an e-learning
course in evidence-based medicine for foundation [internship] training.
J R Soc Med. 2010;103:288-94.
36. Kalita J, Misra UK, Kumar G. Computer-based
literature search in medical institutions in India. Ann Indian Acad
Neurol. 2007;10:44.
37. Frehywot S, Vovides Y, Talib Z, Mikhail N, Ross
H, Wohltjen H, et al. E-learning in medical education in resource
constrained low- and middle-income countries. Hum Resour Health.
2013;11:4.
38. Zachariah A, Albright S, Grandin W, Anand A,
Berman H, Lee MY, et al. Adapting a US university e-learning
system for an Indian medical school: team building through student
ambassadors. Available from:
https://www.researchgate.net/publication/232252098_Adapting _a_US_university_e-learning_system_for_an_
Indian_medical_school_team_building_through_student_ ambassadors.
Accessed June 18, 2016.
39. Ganapathy K. Neurosurgeon, Apollo Hospitals,
Chennai, Telemedicine in India-the Apollo experience, Neurosurgery on
the Web. 2001.
40. Bedi BS. Telemedicine in India: Initiatives and
Perspective, eHealth 2003: Addressing the Digital Divide-17th Oct. 2003.
41. McAuley RJ. Requiring students to have computers:
questions for consideration. Acad Med. 1998;73:669-73.
42. Meyer SM. The adoption of technology in higher
nursing education. Curationis. 2001;24:32-6.
43. Yeung JC, Fung K, Wilson TD. Prospective
evaluation of a web-based three-dimensional cranial nerve simulation. J
Otolaryngol Head Neck Surg. 2012;41:426-36.
44. Harden RM. Myths and e-learning. Med Teach.
2002;24:469-72.
45. Kenny A. Untangling the Web – Barriers and
benefits for nurse education – An Australian perspective. Nurse Educ
Today. 2000;20:381-8.
46. Grigg P, Stephens CD. Computer-assisted learning
in dentistry. A view from the UK. J Dent. 1998;26:387-95.
47. Alves P, Uhomoibhi J. Issues of e-learning
standards and identity management for mobility and collaboration in
higher education. Campus-Wide Inf Syst. 2013, Apr 11. Available from: http://www.emeraldinsight.com/doi/
abs/10.1108/10650741011033053?journalCode=cwis. Accessed June 18,
2016.
48. Pande J, Hart LA. An online course in health
policy: Pearls and perils of cyberspace teaching. Distance Education
Report. 1998;2:4-5.
49. Klamma R, Chatti MA, Duval E, Hummel H, Hvannberg
EH, Kravcik M, et al. Social software for life-long learning.
Educational Technology Society. 2007;10:72-83.
50. Sweeney J, O’donoghue T, Whitehead C. Traditional
face to face and web based tutorials: A study of university students’
perspectives on the roles of tutorial participants. Teach High Educ.
2004;9:311-23.
51. Gerdprasert S, Pruksacheva T, Panijpan B,
Ruenwongsa P. An interactive web-based learning unit to facilitate and
improve intrapartum nursing care of nursing students. Nurse Educ Today.
2011;31:531-5.
52. Clark D. Psychological myths in e-learning. Med Teach.
2002;24:598-604.