Medical Teacher, Vol.

17, No, 2, 1995

149

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AMEE Medical Education Guide No. 6.

Evaluating multimedia applications for medical
education

M. J. ATKINS & C. OHALLORAN, University of Newcastle, UK

Introduction
There is no shortage of conflicting views on the potential of multimedia applications. For some people they seem revolutionary-a new and unique way to design
powerful learning experiences which will change forever the inadequacies of
conventional teaching. For others they seem so much hype-just another twist in
the long road of educational technology that has always promised much and
delivered little. Both supporters and sceptics can point to research findings to
support their case.
So what is meant by multimedia applications? Here the term will be taken to
mean courseware which integrates video, audio and graphical material with text
and number operations. CD-ROMs, interactive videodiscs and learning packages
produced from authoring software are examples of multimedia applications. T h e
courseware runs on a computer workstation under the control of a program itself
designed to make the learner interact with what is shown on the screen. T h e
interaction can be achieved through a mouse, keyboard, joystick, by touching the
screen and increasingly by voice command (see Figure 1).
The complexity and sophistication of multimedia applications vary greatly. In
their more limited form multimedia applications may simply be text-based tutorials
linked to a large database of images. By contrast, in their more elaborate form,
multimedia applications can be designed to let users explore an environment as
though they were in it, control a simulation of a dynamic system, and participate
in apparently real-life situations making decisions and seeing the consequences
immediately. Multimedia applications are also beginning to exploit the new
telecommunication technologies of networks, fibre-optic cables and satellites.
Students can therefore now be linked to teachers or experts who are geographically
remote, or to distant databases, and not least to each other for asynchronous peer
support in learning.
With this understanding of multimedia applications in place we can now return
to the issue of how to evaluate their usefulness in medical education. The issue
breaks down into three related questions:
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FIG.1. Interactive technologies.

Can multimedia courseware be designed for the type of knowledge we want

medical students and practitioners to acquire or does the fact that it is based on
the discipline of computer programming inevitably limit its usefulness?
What is the nature of the differences between learning from a multimedia
simulation and learning from real cases and events? Are the differences a help or
a hindrance in the development of professional expertise?
Can multimedia applications make us more aware and critical of our own
practice? Or are they such an artificial experience that they have no power to
change the way an established professional works?
These questions can be tackled by looking first at the nature of the knowledge that
we expect medical professionals to acquire and relating that knowledge to what
multimedia applications have to offer.
Second, one can take the current explanations of medical reasoning and of how
medical expertise develops and link this analysis to the characteristics and capabilities of multimedia applications.
The nature of the knowledge to be acquired

Several writers have attempted to analyse the different types of knowledge that
professionals use in their work. Eraut (1 994), for example, argues that professionals use three types of knowledge: propositional, personal and process knowledge.
For the purposes of this article, we will concentrate on just two of his categories:
propositional knowledge and process knowledge.
Acquisition of propositional knowledge

This comprises the facts, theories and concepts derived from subjects and disci-

Evaluating multimedia applications

15I

Learning objectives explicit

Assessment criteria explicit
Map of material
Conceptual scaffolding
Recalls relevant prior learning
Steps from simple to complex
Formative and diagnostic feedback
Help, hints and advice facility
Clear deductive explanations
Use of dynamic visuals and graphics
Branching and routeing on basis of user test scores

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FIG.2. Characteristics of courseware which facilitate acquisition of propositional howledge

plines. It is codified and made accessible to learners through textbooks and

lectures. It grows and changes through research that has been accepted by the
academic community. It is the stuff, of course, of the preclinical syllabuses in many
medical schools. For example, the General Medical Council (GMC) for the UK
in its recent publication Tomorrows Doctors (GMC, 1993) puts propositional
knowledge at the heart of its new core curriculum:
The student should acquire a knowledge and understanding of health and
its promotion, and of disease and its prevention and management in the
context of the whole individual and his or her place in the family and in
society.
This goal is broken down into knowledge objectives such as a knowledge and
understanding of the sciences basic to medicine and recurs in the curriculum
themes of human biology, human disease, the public health, and man in
society.
Medical students are traditionally required to memorize propositional knowledge, replicate it and interpret it. Sometimes, though not very often, they are
encouraged to use it to provide a critical perspective on current practices in the
profession. Of course we would like students not just to acquire propositional
knowledge but also to understand it at a personally meaningful level so that when
they treat real patients they actually apply their propositional knowledge-but we
know that such transfer is highly problematic and that experts appear not to use
their subject knowledge base very much (Pate1 & Groen, 1986).
So can multimedia applications help us to acquire and understand propositional
knowledge? Yes, they certainly can. There are plenty of studies which show that
courseware is an efficient as well as an effective way to learn this sort of knowledge.
There are some useful congruences between the way computer programs work and
good instructional design. So one could reasonably expect high quality, well-designed courseware to have the characteristics listed in Figure 2 . It should define the
learning objectives explicitly for the learners, and give them a good idea of the
criteria that will be applied to assess their knowledge.
It should help learners to make sense of the material they are working through
by giving them, at the start, some idea or map of the ground they are going to
cover, and by clarifying any key concepts they will need to use to anchor the sense
they make of the material. This is often referred to as providing the necessary
mental scaffolding for the new knowledge. Similarly, through an early revision

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M. J. Atkins G.C. Olialloran

section, it should require the user to recall and rehearse any prior learning to which
the new material needs to be related.
A computer program works by linking together small parcels of code into longer
and more complex strings or units. So courseware can quite easily be designed to
break down difficult topics into small, manageable steps, carefully sequenced so
that they lead the learner from the simple to the complex, or from an understanding of how separate systems work to an understanding of how they interact with
one another.
Multimedia applications should be programmed to provide formative feedback
to the student both to motivate and to build up the learners understanding of the
strengths and weaknesses in his or her knowledge acquisition so far. It can also
incorporate summative assessments and gradings which can contribute towards
course marks.
It is normal for applications to incorporate features to help the students when
they get stuck, and suggestions on study skills that will enable the learner to get
the most out of the application.
One of the more powerful features of instructional design, the teaching of
concepts deductively, is also worth looking for. Multimedia applications should
present learners with a clear definition of the new rule, category, principle or
concept and then show many examples of that rule to reinforce its acquisition in
the mind of the learner. It is even better if the program also shows the learner
negative examples of what the category does not cover so that its boundaries are
firmly established. If deductive instruction is followed with an exercise using an
observe and identify format, or a compare and contrast format, the acquisition
of the concept is more likely to be consolidated. (The visual databases behind
multimedia applications are large enough to hold the many examples needed for
this approach.)
If the courseware includes knowledge of complex objects then one would expect
the application to allow the learner to see a three-dimensional representation of
that object and to rotate or manipulate the image. Similarly, with knowledge of
systems, one would look for a combination of computer graphics and video to
explain how the system functions dynamically. It is very difficult to do this with
conventional media and it certainly helps learners if they can visualise the phenomenon as well as read or hear about its properties.
Finally, one would look for the inclusion of diagnostic tests at certain points in
the learning sequence. Performance at these points should then determine how the
user is routed through the next stage of the application or indeed back through a
remedial loop if that is appropriate. The same approach can be taken with a
problem-solving application using the profile of a users decisions at certain points
as the basis for branching and routeing. (The if-then logic of programming
languages is exactly what is needed to achieve this design feature.)
While there are clearly some useful design features which can be incorporated in
multimedia courseware to improve the acquisition of propositional knowledge,
there are also some limitations which evaluators need to be aware of (see Figure
3).

First, the testing-routeing feature is not truly intelligent. Although different

users will be routed in different ways through the material, the underlying program
will not react dynamically, on the fly, to the needs of a particular learner. All
routeing decisions and feedback messages will have been pre-programmed, and if

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Branching and routeing not genuinely intelligent

Explanations/expositions not unique to user
Predominance of one learning style
Lack of differentiation in pace and degree of user control

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FIG.3. Common limitations of courseware for acquisition of propositional knowledge

a particular users response has not been anticipated, or if the user has an
unforeseen profile of decisions on a simulation, the program will not be able to
create a new category of feedback or find a unique route through the material for
the learner.
This leads to a deeper point. It is much easier to plan a structure for the material
to be covered than to design good interactivity for the learner. By interactivity one
does not mean the number of mouse clicks per minute required by the simulation.
One means the quality of the dialogue that is possible between the individual
learner and the application. Good interactivity requires the designers to model the
learner in some way. And modelling a learner is enormously difficult. It means
taking into account partially correct knowledge, misconceptions, inadequately
differentiated concepts, half-understood theories and deeply held intuitive understandings of phenomena which happen to be wrong. This is where, of course, good
human teachers come into their own precisely because they are able to elicit what
a learner knows uniquely, and can differentiate their explanations in individually
tailored ways.
The lack of flexibility in the design of a multimedia application can be a
hindrance in other ways. For example, sometimes the designers have, without
knowing it, favoured one type of learning style or problem-solving strategy in the
way that the material has been structured. Learners with a different predominant
style may be disadvantaged and will learn sub-optimally. By no means everyone,
for example, likes to learn in the step-by-step, serial manner. Some prefer to get
a holistic feel for the topic. Then again, if you are an able learner you may get
frustrated if you cannot control your own pacing and sequencing through the
material. On the other hand, if you are a weak learner you need much more
structuring from the program so that you cannot skip over the conceptually
difficult sections. It is rare, however, to find an application which starts by
diagnosing a users preferred learning style, or optimum level of control, and then
presents the material on an appropriately differentiated basis.
Now that we have looked at what multimedia applications can and cannot do for
acquiring propositional knowledge, we need to examine their role in helping
students achieve that deeper level of understanding in which the knowledge
becomes personally meaningful and can be applied in practice. Here too courseware has something to offer and there are features which evaluators should look for
(see Figure 4). For example, evaluators should expect to find analogue or digitized
video segments which allow students to see in practice what they have just learned
as propositional knowledge.
Nascent understanding can also be reinforced if the user is placed in a realistic
simulation of practice, based on video segments, and required to make decisions
or solve problems, drawing on subject knowledge and integrating it to do so.
Deep learning can be facilitated if the courseware has been designed so that
learners are required to generate their own explanations, definitions or categories
inductively, through observation and analysis of several cases presented on the

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M. J. Atkins & C. OHalloran

Visual demonstration
Realistic simulation of practice
User-generated explanations
Microworlds, interactive models, simulations of systems
Learner control of variables
Projects, investigations

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FIG.4. Characteristics of courseware facilitating deep understanding.

screen. The learner should then be asked to check hisher understanding against
the views of others, including experts, which have been recorded on the database.
Even more powerfully, multimedia applications can be designed as what are
called microworlds which model the interaction of variables in a system or
situation. In high-quality courseware, learners are given control over the variables,
their strength, duration, valency etc., so that they can predict, test and refine their
understanding of causal relationships. This is a good way of challenging learners
misconceptions, forcing them to construct new mental models which better
account for the results they see in the microworld simulation.
Finally, it is possible to use multimedia applications as databases and ask
students to design appropriate research projects or investigations using particular
methodologies to do so. This can teach the student quite a lot about the
characteristic ways that a discipline creates new knowledge, its tests for truth, and
the way it handles evidence. As an added bonus, exposure to such applications
may also allow a student to get some idea of the essential complementarity of the
characteristics of human thought-its hunches, intuition, common-sense checks
on possible explanations of results and so on-and the characteristics of the
powerful computational tools now available on computer platforms-for example
the performance of complex and sophisticated statistical calculations, low error
rate on repeated operations, or three-dimensional modelling (Macfarlane, 1990).
Once again, though, there are limitations to what multimedia applications can
accomplish in facilitating personally meaningful learning (see Figure 5). Two in
particular stand out.
First, because of the underlying structure of computer programming, one often
finds that multimedia simulations of real practice seem too neat and tidy. There
is a profound sense in which they are contrived. Users cannot opt for solutions that
have not occurred to the designers; the range of decisions is strictly predetermined.
This may limit the extent to which users can transfer their learning from the
multimedia application to the ward, clinic or surgery.
The same criticism can sometimes be applied to multimedia applications
designed for student research projects. For example, knowledge creation in the
sciences is often messy, ambiguous, full of dead-ends and U-turns. Yet programmers seem unable to resist the temptation of designing the application to
follow the order of research publications, an order which tends artificially to tidy
up the research process.
The second reservation is this. As one would expect from a computer platform,
Contrived, artificial nature of practice simulation
Tidying up of research process
Difficulty in coping with non-algorithmic material

FIG.5 . Common limitations of courseware for deep understanding.

Evaluating multimedia applications

155

microworlds and simulations work best when the subject-matter has an underlying
mathematical or algorithmic base to it. In other words, when the relationship
between variables can be precisely described and predicted. This is non-problematic for some parts of the medical curriculum. But it is not so good for others. For
example, when it comes to modelling the interaction of ethical and moral issues,
or historical causation, there are rather few underlying, consistent and therefore
programmable rules.

Acquisition of process knowledge

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Based on Erauts (1994) work, the following can be seen as part of process
knowledge:
knowing how to collect information, data and evidence;
knowing how to do things (skilled behaviour);
being able to plan, evaluate, make decisions and solve problems;
being able to communicate appropriately in different professional contexts.
Multimedia applications can offer some assistance here.
There are clearly some particular ways of collecting information in medicine,
such as taking and recording comprehensive case histories which can be assisted by
practice on (interactive) video sequences of real and simulated patients. Meanwhile the existence of large audio and visual databases can increase the competence of users in very specific ways such as listening to heartbeats or observing
micro-organisms under magnification. Exposure to multiple examples can help
students to develop pattern recognition which in turn should help them in
diagnosis of real patients.
Meanwhile real-time footage of events in casualty or in the operating theatre can
be replayed many times and under slow motion or frame-by-frame commands to
build students competence in spotting and noting significant features, changes or
events. Training in how to observe should thereby be facilitated.
This brings us to the subcategory of skilled behaviour which would encompass
the GMCs list of basic clinical procedures such as basic and advanced life support
and venepuncture. Skilled behaviour is quite difficult to define-not least because
experienced practitioners act intuitively, processing much information from the
situation they are dealing with at a smart, pre-conscious level. So skilled behaviour
is usually associated with complex sequences of action that have become spontaneous and automatic, beyond the influence of conscious, explicit thought and
control (Broadbent, 1993; Boreham, 1994). It is clearly necessary for the practitioner to develop this routinized way of working in order to cope with the
pressures of professional life, but modelling such behaviour to the novice through
a multimedia application may not help the novice that much. There may be
intermediate developmental stages through which the novice has to pass which do
not allow short cuts. It is, however, worth flagging here that the next generation
of multimedia applications-applications which make use of of intelligent mannequins or of virtual reality-may be able to speed up the process of acquiring
basic clinical procedures by giving students concentrated preliminary practice, with
high-quality feedback, before they have a go on real patients.
That brings us to deliberative thinking: the conscious planning, forward reasoning, evaluating and decision making which lie at the heart of some at least of a

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M. J. Atkins & C. OHalloran

doctors work. We know that deliberative thinking does not occur from propositional knowledge alone. It depends on a knowledge of contexts and past cases that
is built up from experience (Patel & Groen, 1986; Allen & Bordage, 1987).
Indeed, two studies (Patel et al., 1988; Patel et al., 1990) concluded that (propositional) knowledge of the basic sciences and the more practical clinical knowledge
form two separate domains in memory with their own individual structures and
that the clinical knowledge cannot be embedded into the basic science knowledge
structure (although the reverse may be possible). Further, Eraut (1994) among
others makes the point that what characterizes deliberative thinking in a profession
such as medicine is that there is frequently no one correct answer or a guaranteed
road to success: propositional knowledge usually provides only partial help.
Problem solving in medicine may not follow a neat, rational and logical pattern
and indeed the hypothetico-deductive approach to clinical reasoning has been
shown to be a weak model to adopt (Feltovich & Barrows, 1984; Groen & Patel,
1985). More frequently the professional is dealing with uncertainty about outcomes, insufficient information from the context, time constraints, and the
requirement to involve others in the decision-making process.
Can multimedia applications help here? As described above, multimedia simulations can put the learners into an apparently real situation using video footage,
requiring them to make decisions against time constraints and see immediately the
consequences of those decisions. The narrative can unfold in different ways
according to the decisions made at the branching points. T o this extent multimedia courseware can be a good practising ground for real-life deliberative thinking.
It should also be possible to design a simulation that forces users to draw on their
basic science knowledge in order to tackle the problem presented. Multimedia
courseware may in fact be better able to forge such links systematically and
thoroughly than the rather serendipitous experience of on-the-ward teaching.
But the danger, as also identified before, is that because of the demands of
programming, the simulation is built on an implicit hypothesis-test-hypothesistest chain which imposes an artificial dynamic on the learning experience and
unfortunately represents the weakest of the models of clinical reasoning. There is
often a further irritation in simulations, also caused by the requirements of
program branching. It is this. The scenario stops periodically and gives the user a
predetermined list of alternative actions to take. However, in real life, part of the
skill of the practitioner is precisely in knowing when to intervene and what the
realistic choices are. In real life, there is no deus ex machina to say decide now; this
is your list of options.
There is one further major problem with this type of application which impacts
on its effectiveness in developing appropriate communication skills: the user is not
truly a variable in the scenario that is unfolding. The user interacts through a
mouse click, text entry, touch screen or occasionally by voice command. But the
program cannot take into account the non-verbal aspects of communication, the
way that a patient will react quite differently to medical staff with different
personalities, tones of voice, appearance, age, gender, race and so on, let alone to
doctors or nurses of different perceived status. Similarly, the courseware can only
show fellow professionals reacting to the results of a users multiple-choice
decision. One can argue that this is a very crude approximation of how communication in a team or group actually occurs and that it does not give a feel for how
communication shapes behaviour continuously. So there is not a true modelling in

Evaluating multimedia applications

Dreyfus & Dreyfus

Schmidt et al.

Novice

Elaborated causal
networks

157

Advanced beginner
Competent performer

Abridged networks and

causal models

Proficient
Expert

Illness scripts and

case memories

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FIG.6. Two stage models of novice-expert progression.

these simulations of the two-way or multiple dynamics of real interactions on the

ward, in the clinic or in the surgery,
Developing the expert

The question here is whether multimedia applications can assist, speed up or

improve the process by which the novice moves through stages of increasing
competence to something that we would recognize as expertise.
There are various models in the literature which try to pin down what distinguishes the novice from the expert and explain how the development from one to
the other occurs (Feltovitch & Barrows, 1984; Coughlin & Patel, 1986; Dreyfus &
Dreyfus, 1986; Schmidt et al., 1990). Some of the models have better empirical
support than others. Several suggest that there are distinct stages to the process.
All are hampered to some extent by the fact that it is difficult to get inside the mind
of the expert performer to see what is actually determining that individuals
behaviour. And since many of hisker apparent decisions will have been taken at
the routinized level (i.e. beyond conscious control) it may be difficult for himher
to explain having acted in a particular way.
One of the best known stage models (see Figure 6) is that of the brothers
Dreyfus. They suggest that there are five developmental stages: novice, advanced
beginner, competent, proficient, expert. During the first three stages behaviour
follows rules, then guidelines but is under conscious planning. After the competent
stage, they argue, a holistic approach emerges in which flexible interpretation of
the context takes over from the application of rules or guidelines, and a deliberate,
analytical approach is used only when a novel problem presents itself. When
things are going normally, they say, experts dont solve problems and dont
make decisions; they do what normally works.
A rather different stage model can be found in the work of Schmidt and his
co-authors. In their model subject knowledge and analytical thinking also dominate the early stages but are gradually supplemented (but not submerged) by
causal models based on experience. These causal models are gradually reformed in
the light of the contextual factors under which diseases emerge. This increasingly
experientially based knowledge finally takes the form of illness scripts and case
memories, the latter stored vividly in episodic memory and linked to the appropriate illness scripts for quick access.
What emerges strongly from their study is the very idiosyncratic nature of expert

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M. J. Atkins & C . OHalloran

knowledge and performance, determined as it is by the particular cases that a

doctor has encountered in his or her career.
One could argue from these descriptions of stage models that multimedia
applications may have considerable use in the early stages-typically for students
in medical school-and in the early years on the wards, but that beyond a certain
stage, for example the stage of competent performer in the Dreyfus model, their
usefulness would decline. Courseware is good for direct instruction of propositional knowledge but that is not appropriate for the proficient or expert performer.
In the latter two stages deliberative decision making and problem solving are of
decreasing importance and analytical thinking is apparently needed for only a small
minority of cases where a significant novel feature is encountered.
So does that limit the role of multimedia applications? T h e answer will depend
on three factors:
First, the extent to which learning from simulated cases is as good at building
up experience as learning from real life. If it is comparable, then working on
databases of cases may speed up the process of acquiring expertise and could
form an important part of Continuing Medical Education.
Second, the extent to which the Dreyfuses are right about the absence of
propositional knowledge and analytical thinking in expert performance. Eraut
(1994) has argued that just because such knowledge is not explicit does not
mean that it is not implicated in the apparently spontaneous decisions. And
Schmidt et al. (1990) argue that propositional knowledge remains available to
the expert and is used when he or she encounters a case for which hisiher
previous experience of patients provides no guide.
Third, if indeed experts do not rely on formal knowledge, whether this is a state
of affairs we are happy about or whether we feel that experts should be more
analytical and deliberative in their performance? Intuition, as we know, can be
horribly fallible. It is at least possible that multimedia applications could round
out a doctors partial experience of real cases. And just as airline pilots are
required regularly to go through refresher training on a flight simulator in which
they experience non-routine events and the unforeseen combinations of factors
which have led pilots into making mistakes so too, perhaps, professionals in the
medical field should be encouraged to spend time on multimedia case simulations. These simulations could require them to think analytically as well as
intuitively, to review the adequacy of their underlying propositional knowledge,
to reflect critically on taken-for-granted practices, to be assessed and given
feedback on how they handled non-routine problems. In this way the full
continuum of professional expertise might be addressed and not just the
intuitive dimension.

Conclusions
Returning to the three questions posed in the introduction we are now in a
position to put forward some answers.
(1) The fact that multimedia applications are based on the discipline of computer
programming can be a strength in the teaching of propositional knowledge,
but imposes some limits on their value in developing process knowledge.
(2) There is a plausible case for using multimedia applications to speed up the

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Evaluating multimedia applications

159

development of expertise and to balance the over-reliance on case memories

as the basis for decision making. But the nature of the relationship between
formal knowledge and experientially based knowledge in expert performance
is still poorly understood and therefore the guidelines which can be given to
courseware developers remain rather tentative.
( 3 ) We still do not know the extent to which there is transfer from the experience
of a multimedia simulation to the way that professionals go about their work
in real wards, surgeries or operating theatres. Some aspects of current simulations are probably sufficiently lifelike to result in transfer; others are not.
Training on simulations seems to work for pilots but the dynamics of decision
making in medial contexts are very different. We need many more stringent
studies of transfer, including research on the new generation of virtual reality
applications, before investing too heavily in this approach to continuing
medical education.

Notes on contributors
MADELEINE J. ATKINS is Head of the Department of Education, University of
Newcastle, Newcastle-upon-Tyne.
C. OHALLORAN is in the Regional Postgraduate Institute for Medicine and
Dentistry at the University of Newcastle, Newcastle-upon-Tyne.

Correspondence: D r M. J. Atkins, Department of Education, St Thomas Street,

Newcastle upon Tyne NE1 7RU, UK. E-mail: m.j.atkins@newcastle.ac.uk

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