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Resident rankings of various teaching methods. The residents were asked to rank each of the 10 teaching formats from 1 (best) to 10 (least effective). Each box represents the interquartile range of rankings for that teaching method. The line bisecting each box is the median rank for all residents (median rank for the small-group seminar is 1, so the line is not visible). P<.05 was considered statistically significant. MCQ indicates multiple-choice question; and CMP, case-management problem.

Resident rankings of various teaching methods. The residents were asked to rank each of the 10 teaching formats from 1 (best) to 10 (least effective). Each box represents the interquartile range of rankings for that teaching method. The line bisecting each box is the median rank for all residents (median rank for the small-group seminar is 1, so the line is not visible). P<.05 was considered statistically significant. MCQ indicates multiple-choice question; and CMP, case-management problem.

Table 1. 
Responses to Survey Questions Stratified by Sex*
Responses to Survey Questions Stratified by Sex*
Table 2. 
Ranking by Use of Various Computer Applications
Ranking by Use of Various Computer Applications
1.
Santer  DMD'Alessandro  MPHuntley  JSErkonen  WEGalvin  JR The multimedia textbook. Arch Pediatr Adolesc Med. 1994;148711- 715Article
2.
Spooner  SA On-line resources for pediatricians. Arch Pediatr Adolesc Med. 1995;1491160- 1168Article
3.
Jelovsek  FRAdebonojo  L Learning principles as applied to computer-assisted instruction. MD Comput. 1993;10165- 172
4.
Desch  LW Pediatric computer-assisted instruction. Arch Pediatr Adolesc Med. 1995;149303- 304Article
5.
Barnett  GO Information technology and medical education. J Am Med Inform Assoc. 1995;2285- 291Article
6.
Chodorow  S Educators must take the electronic revolution seriously. Acad Med. 1996;71221- 226Article
7.
Koschmann  T Medical education and computer literacy: learning about, through, and with computers. Acad Med. 1995;70818- 821Article
8.
Woodin  KSahler  OJedHaggerty  RJedNazarian  LFed AAP Pediatrics Review and Education Program on Compact Disk.  Elk Grove Village, Ill American Academy of Pediatrics1997;
9.
Lang  WP Trends in students' knowledge, opinions, and experience regarding dental informatics and computer applications. J Am Med Inform Assoc. 1995;2374- 382Article
10.
Haynes  RBMcKibbon  KABayley  EWalker  CJJohnston  ME Increases in knowledge and use of information technology by entering medical students at McMaster University in successive annual surveys. Proc Annu Symp Comput Appl Med Care. 1992;560- 563
11.
Kidd  MRConnoley  GLCesnik  BMcPhee  W What do medical students know about computers? Med J Aust. 1993;158283- 284
12.
Schwirian  PMMalone  JAStone  VJNunley  BFrancisco  T Computers in nursing practice: a comparison of the attitudes of nurses and nursing students. Comput Nurs. 1989;7168- 177
13.
Whiteside  MFTysinger  JWPeirce  JC Residents' knowledge about and attitudes toward use of computers. Teaching Learning Med. 1993;5138- 142Article
14.
Rowe  BHRyan  DTTherrien  SMulloy  JV First-year family residents' use of computers: knowledge, skills and attitudes. Can Med Assoc J. 1995;153267- 272
15.
Debehnke  DJValley  VT Assessment of the current computer literacy and future computer needs of emergency medicine residents and faculty. Am J Emerg Med. 1993;11371- 373Article
16.
Fikar  CR The internet and the pediatrician: should there be a connection? Clin Pediatr (Phila). 1996;5229- 235Article
17.
Gouveia-Oliveira  ARodrigues  Tde  Melo FG Computer education: attitudes and opinions of first-year medical students. Med Educ. 1994;28501- 507Article
Educational Intervention
May 1998

Pediatric ResidentsAre They Ready to Use Computer-Aided Instruction?

Author Affiliations

From the Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Md. Dr Pusic is now with the Pediatric Emergency Department, Montreal Children's Hospital, Montreal, Quebec.

Arch Pediatr Adolesc Med. 1998;152(5):494-498. doi:
Abstract

Objective  To assess pediatric residents' readiness to use computer-aided instruction (CAI).

Design  Survey.

Setting  Pediatric residency program based in a tertiary care children's hospital.

Participants  Four pediatric residency classes.

Assessment Instrument  Self-administered questionnaire.

Main Outcome Measures  Residents' access to computers and the Internet, experience with CD-ROM and World Wide Web computer tutorials, and attitudes toward CAI. Responses were stratified by age, training level, sex, and previous computer education.

Results  Fifty-one (69%) of the residents owned a computer. Men were more likely than women to own a computer (20 [87%] of 23 men vs 31 [61%] of 51 women; P=.02). Medical education software was used by 18 (28%) of 65, but only 2 (4%) of 74 had ever purchased CAI. Twenty-seven (36%) of 74 regularly accessed medical education World Wide Web sites. Nineteen (26%) of 74 had never accessed the Internet. Of those who had, 50 (91%) of 55 continued to do so at least weekly. Eighteen (95%) of the 19 residents who had never accessed the Internet were female (P=.005). Men were twice as likely to have Internet access at home (P=.01) and were more likely to regularly visit medical education World Wide Web sites (P=.02). Attitudes toward CAI were positive. Most respondents would be willing to use CAI developed at their institution. Most residents ranked CAI ahead of printed teaching materials but behind personal teaching by a pediatrician. Attitudes did not differ by sex.

Conclusion  Despite positive attitudes toward CAI, pediatric residents are not yet universally ready to use CAI.

PEDIATRIC RESIDENTS must assimilate a large amount of information during a relatively brief training period. In recent years, the development of new forms of computer-aided instruction (CAI)1 and the availability of large amounts of medical data on the Internet2 have provided additional tools to accomplish this task. These tools have been shown to be effective in a wide variety of medical education settings3 and to have specific advantages compared with traditional methods of teaching.4 In recent editorials, several prominent medical educators have encouraged the use of CAI.57 Tutorials on CD-ROM are now an integral part of the Pediatric Review and Education Program of the American Academy of Pediatrics.8 However, the degree to which pediatric residents are capable and willing to use these new tools is not known.

Use of and attitudes toward computers (hereafter PCs) by nursing, medical, and dental students are well documented.9 For each of these groups, the rate of PC ownership has been shown to be rising, and attitudes toward PCs are generally positive.912 Less is known about the students' facility with the Internet and medical education software (MES), since most surveys have not addressed these issues. Some studies9,11 have found a gender difference in rates of PCs knowledge and ownership.

Recent surveys of postgraduates have also reported increasing rates of PC ownership.1315 The residents generally had positive attitudes toward PCs, but most wanted more computer training while still residents.14,15 The most popular use of PCs was word processing,15 whereas medical education programs were not highly rated.14,15

The Internet has great potential as a mechanism for delivering educational material to residents.2,16 Many Internet sites offer excellent medical education in many forms. Internet e-mail discussion groups (listservs) have increased communication among physicians with similar interests.2 Little is known about the ability or willingness of pediatric residents to use the Internet for medical education, or about their capability to use the increasing amounts of MES, available principally on CD-ROM.

Before the planned introduction of a curriculum of computer tutorials in a mixed World Wide Web (WWW) and CD-ROM tutorial format, 4 classes of pediatric residents were surveyed to assess their readiness to use CAI. Attitudes toward computers, access to PC equipment, and PC experience and skills were surveyed (each expected to contribute to the success in using the curriculum).

SUBJECT AND METHODS
SUBJECTS

A 4-page questionnaire was sent to 4 classes of pediatric residents at the Johns Hopkins Children's Center, Baltimore, Md, between June 1 and August 31, 1996. Each class consisted of approximately 22 residents. The class graduating in 1996 was surveyed at the end of their training in June 1996, whereas the class graduating in 2000 was surveyed within the first 2 months of their training. Consent was inferred from the return of the survey by hospital mail. Questionnaires were tracked by physician identification number and not by name. The study design was approved by the Institutional Review Board of the Johns Hopkins School of Medicine.

SETTING

The Johns Hopkins Children's Center is a tertiary care academic institution affiliated with the Johns Hopkins School of Medicine. Internet access is provided at almost all PC terminals in the hospital. The affiliated Welch Medical Library provides free Internet access to pediatric residents' homes. The hospital uses an electronic patient record with pediatric clinic notes entered by the resident directly into a PC terminal. The hospital has an extensive WWW site (http://www.med.jhu.edu/peds/pedspage.html) with many educational resources. No formal medical informatics curriculum exists, but the Office of Medical Education is active in presenting PC concepts to the residents. In addition, the Welch Medical Library provides continuing education courses at nominal cost to residents.

QUESTIONNAIRE

The self-administered questionnaire consisted of 53 items, mainly yes-no questions regarding the nature of the residents' PC equipment and PC-related experience. The residents were asked to rank 10 different teaching formats and their use of 10 different PC applications. The survey was inspected for face validity by 2 pediatricians and an epidemiologist, none of whom were directly involved in the survey. The survey was piloted on 6 medical students. The questionnaire may be inspected at the following Web site: http://www.dal.ca/˜iwkpem/pusic/cai.html.

OUTCOME MEASURES

Primary outcome measures were the (1) attitudes toward and capability to use CD-ROM or WWW tutorials, (2) PC ownership and rate of use, (3) PC applications used, (4) experience with the Internet, and (5) experience with MES and they were stratified by age, sex, training level, and previous PC education.

DEFINITIONS

The PCs were defined as obsolete if they had <4 megabytes of RAM or had a central processing unit below 486 for the DOS platform and a monochrome Macintosh Classic or earlier generation for the Apple platform. These configurations would be unable to play a medical education CD-ROM even if the computer were equipped with one. A PC was designated multimedia if it was equipped with a CD-ROM drive.

STATISTICS

Descriptive statistics were used to summarize the survey responses. For proportional data, comparisons were made using the χ2 test. Age and MES expenditure were the only continuous variables. Because they were not normally distributed, comparisons of these variables were made using the Mann-Whitney U test. Comparisons of rank scores such as the ranking of teaching methods were performed using the Wilcoxon signed rank test. All tests were 2 tailed, with significance at α<.05.

RESULTS

Seventy-four of the 90 residents completed the survey, for a response rate of 82% (Table 1). Mean (SD) age of respondents was 28.8 (2.6) years (range, 25-39). Fifty-one respondents (69%) were female. Nonrespondents did not differ from respondents in terms of age, sex, or training level.

PC OWNERSHIP

Fifty-one (69%) of the pediatric residents owned PCs. Of the nonowners, 4 (5%) of 23 had access to a PC other than at work. The most popular models were IBM-compatible in 29 (59%) of 49 cases, with Apple computers owned by 19 (39%) of 49. Laptop PCs were owned by 7 (15%) of 48 residents. Among the 26 residents who reported the type of PC and the amount of RAM, 5 PCs (19%) were considered obsolete. Twenty-nine (57%) of 51 PCs were equipped with a CD-ROM, whereas 23 (45%) of 51 had a sound card and speakers. Thirty-eight (75%) of 51 of the PCs had modems.

USE

Most residents who owned a PC (29 [57%]/51) used it less than 2 hours per week; however, 15 (29%) of 51 used the computer more than 8 hours per week (range, 0-14 hours per week). Use of specific applications is shown in Table 2. Word processing was the most used PC application (used by 64 [98%] of the 65 residents who answered the question), followed by MEDLINE searching (42 [65%]/65) and Internet access (39 [60%]/65). Medical education applications were used by 18 (28%) of the 65.

INTERNET

Nineteen (26%) of 74 of the residents had never accessed the Internet. Of the residents who had accessed the Internet, 50 (91%) of 55 continued to do so 1 or more times per week (median, 2 times per week; range, 0-10 times per week). Of all residents, 22 (36%) of 74 regularly visited medical education WWW sites. Whereas 24 (47%) of 51 PC owners regularly accessed WWW sites, only 3 (13%) of 23 nonowners did so (P=.005). Twelve (16%) of 74 had accessed their own institution's home page. Two (3%) of 74 belonged to an e-mail discussion group, whereas 12 (16%) of 74 had seen an x-ray film on the WWW.

MEDICAL EDUCATION SOFTWARE

Whereas 42 (57%) of 74 residents had used MES in medical school, only 2 had ever purchased MES. This contrasted with a mean expenditure on textbooks of $296 in the previous 2 years. When asked if they had ever found a WWW site that was better than a typical journal article, 57 (77%) of 74 responded that they had not. The residents were asked to rank 10 different teaching methods. The results are shown in the Figure 1. The residents generally ranked PC tutorials behind personal teaching by an attending pediatrician but ahead of other learning methods that did not involve personal instruction. The following tabulation shows the residents' ranking of PC tutorials compared directly with each teaching method listed: More than 70% preferred a PC tutorial to grand rounds (48 [73%] of 66) or reading a journal article (48 [71%] of 68).

Even when compared with personal teaching by a pediatrician, a sizable percentage preferred the PC tutorial. Most residents would be willing to use WWW (49 [86%] of 57) or CD-ROM (60 [81%] of 74) tutorials developed at their institution. Asked if the hospital library would be suitable for completion of a 1-hour PC tutorial, 18 (78%) of 23 non–PC owners responded "yes," compared with 25 (49%) of 51 owners (P=.02).

SEX

The influence of sex on rates of PC ownership and PC experience are summarized in Table 1. Whereas 20 (87%) of 23 men owned one, only 31 (61%) of 51 women did (P=.02). Women were more likely to have completed a college PC course for credit (17 [33%] of 51 women vs 6 [26%] of 23 men), but this difference was not statistically significant.

On almost all questions concerning the Internet, women reported significantly less frequent use and less experience. Of the 19 residents who had never accessed the Internet, 18 (95%) were women. Whereas 22 (96%) of 23 male residents accessed the Internet on at least a weekly basis, only 30 (59%) of 51 female residents did so. Male residents were twice as likely to have Internet access in their homes (15 [65%] of 23 men vs 17 [33%] of 51 women; P=.01). Male residents were also significantly more likely to visit medical education WWW sites regularly, significantly more likely to have seen an x-ray film on the WWW, and significantly more likely to have found a WWW site that they considered on a par with a typical journal article. Attitudes toward WWW and CD-ROM tutorials and ranking of CAI compared with other teaching methods did not differ by sex.

AGE AND TRAINING LEVEL

Neither age nor training level was found to be statistically significantly associated with any of the responses listed in Table 1. Computer owners were slightly older than nonowners (29 vs 28 years; P=.06).

PREVIOUS PC EDUCATION

Twenty-three (31%) of 74 respondents had taken a college PC course for credit. Only 4 (5%) of 74 had taken any form of noncredit PC course. These results were not correlated with any of the responses listed in Table 1, and did not influence the residents' attitudes toward CAI.

COMMENT

This survey was performed to assess the readiness of pediatric residents to use CAI. Specifically, we hoped to assess readiness of residents before introducing a curriculum of PC tutorials in a mixed WWW and CD-ROM tutorial format. Although readiness is a subjective measure, the following factors would at least contribute to the residents' likelihood of success in using the curriculum:

1. Attitudes toward PCs. A negative attitude would clearly make implementation more difficult.

2. Access to PC equipment. Although all of the residents have access to PCs at the hospital, this is not necessarily the best environment for completing these tutorials. In addition, PC owners would be expected to be more PC literate than nonowners.

3. Computer experience and skills. Experienced PC users, especially those already using forms of CAI, would be expected to have less difficulty adapting, since their existing skills could be transferred to the new situation.

This study has several limitations. It is a cross-sectional survey of the residents at 1 institution, and therefore its results are not directly generalizable. The survey instrument is new. Although the response rate was excellent, the power to detect trends between classes was low due to small numbers in each cell.

Most of the residents expressed a willingness to use both CD-ROM and WWW PC tutorials. They ranked CAI ahead of journal articles, textbooks, case-management problems, and multiple-choice question review. Although overall they consistently ranked PC tutorials behind personal contact with an attending physician, significant percentages preferred the PC tutorial even over small-group teaching sessions with a pediatrician. This positive attitude toward PCs has been seen on most previous surveys 912 and, in this population, may reflect positive experiences in medical school or a societal disposition toward the new technology.

Whereas all pediatric residents can be assumed to have more or less equal access to traditional medical education resources (eg, textbooks), this survey showed that not all residents would have equal access to a CAI curriculum. Whereas the PC ownership rate of 69% compared favorably with that of previous surveys,13,15 the actual number of residents equipped with multimedia PCs capable of taking full advantage of the CD-ROM format was well below half. Similarly, less than half of the residents had Internet access at home. Barnett5 has suggested that the full potential of CAI will not be realized until individual ownership of PCs is possible. That PC-owning residents were 3 times more likely than nonowners to regularly access medical education WWW sites would seem to confirm this.

There appeared to be a sex bias to this uneven access to CAI. Women had a significantly lower rate of PC ownership and much less experience with the Internet. It is striking that 18 of the 19 residents who had never accessed the Internet were women. Previous surveys have found a sex difference in rates of PC ownership, attitudes toward PCs, and PC knowledge.9,11,17 In a survey of 140 Portuguese 1st-year medical and dental students, Gouveia-Oliveira et al17 found that only 23% of the women rated themselves PC literate compared with 61% of the men; however, the women were as likely as the men to consider PCs important in medicine. In 1990, Lang9 surveyed 1st-year dental students. Although he did not find any sex difference in rates of computer ownership or attitudes toward PCs, there were significant differences in PC experience and knowledge. When the students were resurveyed in their third year of training, the differences had disappeared. This training effect suggests that the sex discrepancy observed in our study is likely amenable to active educational intervention, especially given that the attitudes of the women toward CAI were as positive as those of the men. Indeed, sex differences may be narrowing, as general PC literacy rises each year.9,11 Kidd et al11 surveyed 1st-, 4th-, and 6th-year medical students and found a marked sex difference in self-reported PC ability in the 6th-year class, but none in the 1st-year class. When Lang9 repeated his survey of 1st-year dental students in 1993, he found very little sex difference.

Previous experience with PC applications and the Internet would be expected to facilitate the incorporation of CAI into the residents' curriculum. Most directly applicable would be experience with existing CAI applications. More than half of the residents had used CAI in medical school; however, despite the plethora of CD-ROM medical titles available in medical bookstores and the self-reported positive attitude of residents toward them, only 2 had ever bought MES. The reasons for this merit investigation. Almost all of the residents had had experience with word processing applications, suggesting that CAI that uses interface components from word processing packages might be more readily accepted.

Although delivery of CAI by the Internet is possible today,2 the residents had little experience with this method. Nineteen (26%) of the residents had never accessed the Internet. The WWW site of the residents' home institution offers a great deal of information relevant to pediatricians, yet only 12 (16%) of the residents had ever accessed it. Despite there being several e-mail discussion groups of interest to pediatricians,2 only 2 of the residents belonged to any.

Uneven PC access and varying levels of PC experience suggest that, despite their positive attitudes, the residents were not yet universally ready to use CAI. However, a significant vanguard of the residents had started to regularly visit medical education WWW sites. Once the residents had been exposed to the Internet, 50 (91%) of 55 continued to use it at least once per week. This suggests that an active educational intervention such as an introductory course could be of lasting benefit and would allow the residents (especially women) more equal access to the burgeoning store of medical education materials available on CD-ROM and the Internet.

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Article Information
Article

Editor's Note: To my knowledge, every American medical school already has or is in the process of putting all sorts of educational material (not to mention clinical service information) over the (or their) Net. This and other surveys show that residents have ready access to computers, but they are not yet ready to use them. That won't take very long; the faculty, however, are another story.—Catherine D. DeAngelis, MD

Accepted for publication November 25, 1997.

Thanks to the residents who took the time to complete the questionnaire and Anne Duggan, ScD; Kevin Johnson, MD; and Andrea Pusic, MD, MHS; for their editorial help with this manuscript.

Funded in part by a grant from the Ambulatory Pediatric Association, McLean, Va.

Corresponding author: Martin V. Pusic, MD, Pediatric Emergency Department, Montreal Children's Hospital, 2300 Tupper St, Montreal, Quebec, Canada H3H 1P3.

References
1.
Santer  DMD'Alessandro  MPHuntley  JSErkonen  WEGalvin  JR The multimedia textbook. Arch Pediatr Adolesc Med. 1994;148711- 715Article
2.
Spooner  SA On-line resources for pediatricians. Arch Pediatr Adolesc Med. 1995;1491160- 1168Article
3.
Jelovsek  FRAdebonojo  L Learning principles as applied to computer-assisted instruction. MD Comput. 1993;10165- 172
4.
Desch  LW Pediatric computer-assisted instruction. Arch Pediatr Adolesc Med. 1995;149303- 304Article
5.
Barnett  GO Information technology and medical education. J Am Med Inform Assoc. 1995;2285- 291Article
6.
Chodorow  S Educators must take the electronic revolution seriously. Acad Med. 1996;71221- 226Article
7.
Koschmann  T Medical education and computer literacy: learning about, through, and with computers. Acad Med. 1995;70818- 821Article
8.
Woodin  KSahler  OJedHaggerty  RJedNazarian  LFed AAP Pediatrics Review and Education Program on Compact Disk.  Elk Grove Village, Ill American Academy of Pediatrics1997;
9.
Lang  WP Trends in students' knowledge, opinions, and experience regarding dental informatics and computer applications. J Am Med Inform Assoc. 1995;2374- 382Article
10.
Haynes  RBMcKibbon  KABayley  EWalker  CJJohnston  ME Increases in knowledge and use of information technology by entering medical students at McMaster University in successive annual surveys. Proc Annu Symp Comput Appl Med Care. 1992;560- 563
11.
Kidd  MRConnoley  GLCesnik  BMcPhee  W What do medical students know about computers? Med J Aust. 1993;158283- 284
12.
Schwirian  PMMalone  JAStone  VJNunley  BFrancisco  T Computers in nursing practice: a comparison of the attitudes of nurses and nursing students. Comput Nurs. 1989;7168- 177
13.
Whiteside  MFTysinger  JWPeirce  JC Residents' knowledge about and attitudes toward use of computers. Teaching Learning Med. 1993;5138- 142Article
14.
Rowe  BHRyan  DTTherrien  SMulloy  JV First-year family residents' use of computers: knowledge, skills and attitudes. Can Med Assoc J. 1995;153267- 272
15.
Debehnke  DJValley  VT Assessment of the current computer literacy and future computer needs of emergency medicine residents and faculty. Am J Emerg Med. 1993;11371- 373Article
16.
Fikar  CR The internet and the pediatrician: should there be a connection? Clin Pediatr (Phila). 1996;5229- 235Article
17.
Gouveia-Oliveira  ARodrigues  Tde  Melo FG Computer education: attitudes and opinions of first-year medical students. Med Educ. 1994;28501- 507Article
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