A Multimedia CD-ROM Tool to Improve Student Understanding of Bile Salts and Bilirubin Metabolism

8/2/2019 A Multimedia CD-ROM Tool to Improve Student Understanding of Bile Salts and Bilirubin Metabolism

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29:40-50, 2005. doi:10.1152/advan.00015.2004Advan Physiol EducSamy A. Azer

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Education .. TextbooksCommunication .. MultimediaMedicine .. CholestasisMedicine .. Medical StudentsPhysiology .. DigestionPhysiology .. Enterocytes

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http://www.the-aps.org/.American Physiological Society. ISSN: 1043-4046, ESSN: 1522-1229. Visit our website atDecember by the American Physiological Society, 9650 Rockville Pike, Bethesda MD 20814-3991. Copyright 2005 by the

courses and in the broader context of general biology education. It is published four times a year in March, June, September andis dedicated to the improvement of teaching and learning physiology, both in specializedAdvances in Physiology Education
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ing, thereby stimulating student understanding of importantbiomedical principles. It has also been proposed that integra-tion has the potential to enhance retention of knowledge andthe ability of students to apply knowledge in real-life situations(13). The educational outcomes of integration of basic sciencesand clinical sciences in a multimedia CD-ROM has beendiscussed in the literature (7, 46). It is believed that integrationwill allow students to

realize the significance of information learned from basicsciences such as physiology, anatomy, biochemistry, phar-macology, and pathology in clinical situations (46),

understand the scientific basis behind patients presentingsymptoms and elicited physical signs,

use knowledge learned from biological sciences to buildmechanisms and understand the pathogenesis of differentdisorders,

discover the relationship between biological sciences andtheir clinical applications (46),

enhance student skills in reasoning, justification, and inter-pretation of laboratory findings, and

retrieve what they learned when they encounter similarcircumstances in clinical practice.

What Are the Educational Values of Using PBL Cases in a

Multimedia CD-ROM?

Although many students cope admirably with the didacticteaching (e.g., lectures and seminars) and follow up theirlearning using textbooks or other resources, there are studentsfor whom the addition of alternative methods of learning/teaching enhances their knowledge base and understanding ofthe relevant material. Learners differ in choosing the bestmethod of instruction for their learning. However, there iscurrent evidence that students comprehend an issue by doingtasks and actively engaging in solving a problem (1, 3, 12, 18).The use of PBL cases in a multimedia CD-ROM will allow

Fig. 1. Study profile. Participants volunteered in the MCQs test in weeks 9, 10, and 11.

Table 1. Summarises the problem-based learning (PBL) cases and main concepts raised in the curriculum including lecturesand practical classes at the University of Melbourne during weeks 911 (hepatobiliary system weeks).

Week PBL Case Covered in Curriculum Main Issues/Concepts Raised in Lectures

Week 9 Breast milk jaundice in a full-term newborn Liver structure and functionUse of liver enzymes in liver disorders and other diseasesBilirubin metabolism and liver dysfunction

Week 10 Liver cirrhosis Alcohol and liverCells of the liver and their functionPatterns of liver injury

Week 11 A patient with epilepsy and drug interaction (role of the liver in drug metabolism) Drug metabolism and excretionPharmacodynamics and pharmacokinetics principlesDrug interactions

Teaching with Technology

41COMPUTER-AIDED LEARNING AND HEPATOBILIARY SYSTEM

Advances in Physiology Education VOL 29 MARCH 2005
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students to develop a number of learning skills (14, 15, 26, 32,38) including

hypotheses generation for each problem identified in thetrigger,

building mechanisms to explain their hypotheses, collection of new information via medical history and clin-

ical examination, ranking their hypotheses on the basis of the new informationand clinical findings,

understanding the scientific basis behind patient symptomsand clinical findings,

interpretation of laboratory findings, weighing evidence for and against each hypothesis, making decisions, reflection on psychosocial, ethical, and moral issues in the

case, and outlining the management plan, management options, and

factors that may affect the management plan.

The aims of this study were 1) to assess student views on amultimedia CD-ROM integrating basic and clinical sciencesrelated to the liver, bile salts, bilirubin metabolism, and hepa-tobiliary transport; 2) to assess the usefulness of PBL casesincluded in the CD-ROM; and 3) to assess student learningbefore and after using the multimedia CD-ROM.

METHODS

Subjects and setting. One hundred and six first-year medical stu-dents volunteered to participate in this study during weeks 911 ofsemester two during September 2002. Table 1 shows the curriculumcontent covered in weeks 9 to 11. The title of the subject taught insemester two was Nutrition, Digestion & Metabolism, 510112.Before week 9, the curriculum covered PBL cases and five lectures per

week related to nutrition, obesity, diabetes, and the gastrointestinalsystem. The educational objectives of these lectures were to helpstudents to think broadly about issues, search for more information,and foster their skills to reuse learned information. The lectures weredesigned to enhance student skills to think in an integrative way.

During weeks 911, a multimedia CD-ROM, titled The Liver:Understanding Bile Salts and Bilirubin Metabolism: An InteractiveComputer Program Integrating Basic and Clinical Sciences (6) waslisted as a resource to complement the objectives of these weeks.Students were randomly allocated into three sessions during weeks 9,10, and 11 to use the multimedia CD-ROM. Students spent 4 hcompleting the CD-ROM. Participants in this study (106 students)completed a descriptive self-administrated survey. Of those surveyed,only 87 students volunteered to complete a test comprising 23 mul-

tiple choice questions (MCQs) as well (the original test was composedof 25 questions, but two questions were excluded before the use of thetest because they were not clear). A cover letter was distributed withan anonymous questionnaire addressing the goals of the survey andthe study. It was also stated on the cover letter that by returning the

Table 2. Summary of educational objectives and interactive tasks in each module in the multimedia CD-ROM, titled The Liver:Understanding Bile Salts and Bilirubin Metabolism: An Interactive Computer Program Integrating Basic and Clinical Sciences

Module Educational Objectives Interactive Tasks Included in the Multimedia CD-ROM

Module 1: Interactive PBL cases Case 1: Abdominal pain/gallstones. Generate hypotheses Case 2: Drug-induced liver dysfunction Build mechanisms for their hypotheses Case 3: Jaundice in a pregnant refugee patient Refine hypotheses on basis of available evidence

Seek new information from history or clinicalexamination

Interpret laboratory findings Plan management strategies

Module 2: The functions andstructure of liver cells

Understand the structure and function of the liver at bodysystem, organ, cellular, and molecular levels

Build a liver model Drag and drop exercise Build flow charts Observe the direction of bile and blood flow in a

liver model Move transporters to the sinusoidal and canalicular

domains of a hepatocyte and test their functions Work out quizzes and answer MCQs and scenario

based questions

Module 3: Bilirubin metabolismand liver function tests

Understand the metabolism of bilirubin, the pathogenesis ofjaundice, and the scientific basis and uses of bilirubin andliver enzyme blood levels in hepatobiliary disorders

Build liver models Label chemical structures Build flow charts Move transporters to their appropriate site and test

their functions Work out quizzes and answer MCQs and scenario

based questions

Module 4: Bile salts andenterohepatic circulation

Understand recent developments in the transport of bile saltsand the enterohepatic circulation in health and disease

Build liver models Build flow charts Realize how differences in chemical structure of

bile salts affect their solubility and function Move transporters to their appropriate site and test

their functions Construct an enterohepatic circulation model Observe consequences of pathological processes

on the enterohepatic circulation Work out quizzes and answer MCQs and scenario

based questions

MCQs, multiple choice questions.


42 COMPUTER-AIDED LEARNING AND HEPATOBILIARY SYSTEM

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completed survey you are giving permission to the investigator to use thedata in a research project.

Study design. Early in week 9 and before working on the multime-dia CD-ROM, students completed a test comprising 23 MCQs (con-trol group, n 27). During week 10, another group of students, afterattending six lectures addressing issues related to the liver, completingthe breast milk jaundice PBL case in their groups, attending Tutorial1 of a PBL case on liver cirrhosis, and after working on the multi-

media CD-ROM, answered the same test questions used in the controlgroup (group 1, n 18) (Fig. 1). During week 11, after completingtwo PBL cases and Tutorial 1 of a PBL case covering the role of theliver in drug metabolism and before working on the multimediaCD-ROM, a third group of students completed the same test used inthe control group (group 2, n 21). At the end of the last session inweek 11, the same group of students answered the same test questions(group 3, n 21). The questions used in all tests were identical, andtheir contents reflected the educational objectives of the multimediaCD-ROM and the medical course. The introduction of the multimediaCD-ROM in these weeks aimed at enhancing self-directed learningand a deep understanding of difficult concepts. It also providedstudents with the opportunity to apply knowledge learned in clinicalsituations and restructure knowledge learned from other resourcesaccording to their needs. These approaches aimed at enhancing

student understanding and mastering of main concepts related to theliver and hepatobiliary system. It also helped in their formativeassessment via the feedback provided in PBL cases and the tasksincluded in the multimedia CD-ROM.

Software package. Development of the multimedia CD-ROM wasundertaken in 3 yr from February 2000 to December 2002 and wasevaluated during September 2002. The preparation of these moduleswas a demanding task aimed at creating an innovative and creativepackage that encourages self-directed learning. The Liver CD-ROM(6) comprises four main modules (see Table 2). The interactive

activities in the multimedia CD-ROM have been designed by using aparticular media component and an interface that best enhances theengagement of users, facilitation of integration of knowledge, andenforcement of the educational principles discussed. Table 2 summa-rizes the educational objectives and interactive tasks in each modulein the multimedia CD-ROM. The pedagogical model underlying TheLiver CD-ROM highlights the educational philosophy of PBL. TheCD-ROM comprises a number of interactive tasks, which enhances

deep understanding of concepts, application of knowledge, engage-ment in the learning process, weighing evidence for each hypothesis,and ability to critically analyze information and make reasonabledecisions. Table 3 summarizes examples of the interactive activitiesused in The Liver CD-ROM. The CD-ROM also encourages stu-dents to identify problems, generate hypotheses, collect new informa-tion, build mechanisms, construct a three-dimensional liver model,assess consequences of pathophysiological changes, identify factorscontributing to a problem, interpret laboratory findings, and design amanagement plan. Figure 2 summarizes the multistage educationalprocess and feedback designed in the template of the PBL cases.Figures 3 and 4 show examples of two screens from The LiverCD-ROM.

Questionnaire. Students who used the multimedia CD-ROM wereinvited to complete a five-point Likert scale questionnaire (45), where

1 indicated strongly agree and 5 indicated strongly disagree. Inthe questionnaire, students were asked to make a valued judgment inrelation to these main areas: 1) background and demographical data;2) objectives, directions, and contents of The Liver modules; 3)interactivity, navigation, and use of color; 4) PBL cases; and 5)comments on best aspects of the package and any other comments.The background and the demographical information (questions 18)were designed to obtain information about gender, age group, whetherthey were school leavers or graduate entrants, had completed degreesbefore their enrollment in the course, whether they were local citizens

Table 3. Examples of interactive activities used in The Liver CD-ROM

Interactive Activity What Do Students Need to Do? Educational Objectives

Build a liver model Students read brief information about eachstructure in the animation

Learn the anatomy and function of different cells in theliver

Students construct a liver sinusoid usingendothelial cells, Kupffer cells, neurokinin cells,red blood cells, and stellate cells

Understand which of these structures is inside oroutside the endothelial sinusoid

Understand the relationship between different structuresforming a liver

Three-dimensional model helps students to seerelationships and better understand pathophysiologicalmechanisms

Once students have completed this portion, moveon to a three-dimensional animation of liver cells(hepatocytes)

If student fails to place it in the correct position,it bounces back to its original place

Show the correct transporters at sinusoidaland canalicular membranes of a liver cell

Students read a brief summary about eachtransporter

Difference between transporters at sinusoidal andcanalicular domains

Students drag and drop appropriate transporters tothe sinusoidal or canalicular domains of a livercell (hepatocyte) animation

Understand the function of each transporter Understand the processes by which bilirubin and bile

salts are taken up by liver cells (hepatocytes) If a transporter is moved to the wrong place, the

transporter bounces back to its original place

Understand the enterohepatic circulation of bile salts

and bilirubin Understand the different mechanisms by which jaundice

occurs

Provide reasoning Type evidence for and against each hypothesisstudent has

Understand the importance of collecting informationusing history, clinical examination, and laboratory tests

Weigh the evidence for each hypothesis andrefine students final hypothesis

Practice interpretation of findings and their significance Practice the scientific approach in decision making

Build mechanisms for students hypothesis Design a flow diagram that summarizes thepathogenesis of students hypothesis

Realize the significance of information provided inhistory in constructing a mechanism

Learn how to integrate information from physiology,pathology, biochemistry, and microbiology as studentbuilds mechanism

Discover gaps in knowledge and need to search forinformation to complete mechanism



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Objectives, directions and contents of modules. Table 5shows that participants agreed that the aims of the packagewere clear from the start, the contents were logically organized,and the key concepts were easy to identify. They also agreedthat the flow and sequence of information from screen to screenwas logical, and the content was pitched at an appropriatelevel. No differences were found when responses were com-pared on the basis of academic background, gender, citizen-

ship, or first language of participants. School leavers, particu-

larly those from a non-English speaking background, felt therewas too much information per screen. Differences were signif-icant from the prospective groups (Table 5). No differenceswere found on this issue when data were evaluated on the basisof gender and citizenship. Students commented that 24screens in module 4 contained too much information.

Interactivity, navigation, use of color, and graphics. Table 6shows that participants agreed that the package was interactive,

encouraged them to reflect on educational issues related to

Fig. 3. A screen from module 2 of TheLiver CD-ROM showing an interactive taskaimed at building a liver cell model andappropriate bile salt transporters at the sinu-soidal and canalicular domains and under-standing their function. Feedback is providedto help the learner as needed.

Fig. 4. A screen from module 2 of TheLiver CD-ROM showing an interactive task

aimed at identifying the sinusoidal trans-porter responsible for the sodium-indepen-dent bile acid uptake. Feedback is providedto help the learner as needed.



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areas discussed, and the PBL cases and feedback were mean-ingful. Participants also agreed that it was easy to navigatearound the package with the buttons and links being easy tounderstand. They also agreed that the colors were well usedand that graphics helped them to better understand concepts

related to the liver and were of high quality and clearly relatedto the topic. No differences were found when responses werecompared on the basis of academic background, gender, citi-zenship, or first language of participants.

PBL cases in the multimedia CD-ROM. Table 7 shows thatparticipants agreed that the PBL cases kept them engaged,were useful to their learning, and matched with the overall

philosophy of the program. No differences were found on thebasis of citizenship or first language. Compared with graduateentrants, school leavers showed a more positive attitude towardthe PBL cases and agreed that the cases kept them engaged(P 0.033). Female students compared with males, agreedthat the PBL cases matched with the philosophy of the course(P 0.012) and were useful to their learning (P 0.048). The2 test was used.

Table 4. Summary of the MCQs test scores for the controlgroup and the three groups using the multimediaThe Liver CD-ROM.

Group Control Group 1 Group 2 Group 3

Results 7.83.5 (27) 14.34.8 (18) 10.12.8 (21) 16.75.3 (21)

Values are means SD; number in parentheses is number of students whovolunteered to undertake the test.

Table 5. Rating participant views regarding the objectives, directions, and contents of the modules and effects of academicbackground, gender, citizenship, and first language

Statement Ranking

Academic Background Gender Citizenship First Language

Graduate(27; 25%)

School Leavers,(79; 75%)

Females(68; 64%)

Males(38; 36%)

Australia(67; 63%)

Overseas(39; 37%)

English(59; 56%)

Non-English(47; 44%)

Instructions were clearfrom the start S. agree 3 (3) 7 (9) 7 (7) 3 (3) 6 (6) 4 (4) 7 (7) 3 (3)

Agree 17 (16) 49 (46) 42 (40) 24 (23) 43 (41) 23 (922) 38 (36) 28 (26)Neutral 3 (3) 18 (17) 14 (13) 7 (7) 11 (10) 10 (9) 7 (7) 14 (13)Disagree 4 (4) 5 (5) 5 (5) 4 (4) 7 (7) 2 (2) 7 (7) 2 (2)S. Disagree 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

Aims of the package wereclear from the start S. agree 7 (7) 16 (15) 17 (16) 6 (6) 15 (14) 8 (7.5) 15 (14) 8 (7.5)

Agree 17 (16) 48 (45) 41 (39) 24 (23) 42 (40) 23 (22) 37 (35) 28 (26)Neutral 2 (2) 14 (13) 9 (8.5) 7 (7) 8 (7.5) 8 (7.5) 5 (5) 11 (10)Disagree 1 (1) 1 (1) 1 (1) 1 (1) 2 (2) 0 (0) 2 (2) 0 (0)S. Disagree 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

Contents were clear andlogically organized S. agree 4 (4) 18 (17) 15 (14) 7 (7) 15 (14) 7 (7) 14 (13) 8 (8)

Agree 21 (20) 50 (47) 45 (43) 25 (24) 47 (44) 24 (23) 41 (39) 30 (28)Neutral 2 (2) 10 (9) 7 (7) 5 (5) 4 (4) 8 (8) 4 (4) 8 (8)Disagree 0 (0) 1 (1) 0 (0) 1 (1) 1 (1) 0 (0) 0 (0) 1 (1)S. Disagree 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

It was easy to identify keycontents and importantinformation on screens S. agree 6 (6) 13 (12) 12 (11) 7 (7) 10 (9) 9 (9) 11 (10) 8 (7.5)

Agree 18 (17) 45 (43) 40 (38) 23 (22) 44 (42) 19 (18) 38 (36) 25 (24)Neutral 1 (1) 15 (14) 10 (9) 6 (6) 8 (7.5) 8 (7.5) 6 (6) 10 (9)Disagree 2 (2) 6 (6) 6 (6) 2 (2) 5 (5) 3 (3) 4 (4) 4 (4)S. Disagree 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

The flow was logical S. agree 4 (4) 17 (16) 13 (12) 8 (7.5) 13 (12) 8 (7.5) 11 (10) 10 (9.5)Agree 16 (15) 47 (44) 41 (39) 22 (21) 41 (39) 22 (21) 37 (35) 26 (24.5)Neutral 7 (7) 13 (12) 12 (11) 8 (7.5) 12 (11) 8 (7.5) 10 (9) 10 (9)Disagree 0 (0) 2 (2) 2 (2) 0 (0) 1 (1) 1 (1) 1 (1) 1 (1)S. Disagree 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

There was too muchinformation per screen S. agree 1 (1)* 7 (7) 5 (5) 3 (3) 5 (5) 3 (3) 1 (1) 7 (7)

Agree 2 (2)* 19 (18) 15 (14) 6 (6) 11 (10) 10 (9) 9 (8.5) 12 (11)Neutral 4 (4)* 30 (28) 21 (20) 13 (12) 18 (17) 16 (15) 17 (16) 17 (16)Disagree 19 (18)* 22 (21) 27 (25.5) 14 (13) 32 (30) 9 (8.5) 31 (29) 10 (9)S. Disagree 1 (1)* 1 (1) 0 (0) 0 (0) 1 (1) 1 (1) 1 (1) 1 (1)

Contents were pitched toappropriate level S. agree 4 (4) 8 (7.5) 6 (6) 6 (6) 9 (8.5) 3 (3) 9 (8.5) 3 (3)

Agree 16 (15) 46 (43) 44 (41.5) 18 (17) 41 (39) 21 (20) 35 (33) 27 (25.5)Neutral 3 (3) 19 (18) 10 (9) 12 (13) 9 (8.5) 13 (12) 9 (8.5) 13 (12)Disagree 4 (4) 6 (6) 8 (7.5) 2 (2) 8 (7.5) 2 (2) 6 (6) 4 (4)S. Disagree 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

Values are number of students ranking the question; numbers in parentheses are percent of students answering. S. agree, strongly agree; S. disagree, stronglydisagree; graduate, those with prior university degree; school leavers, those with no prior university degree. Groups were studied by using the 2 test. All P valueswere not significant unless marked. A P value of0.05 was considered significant. *P 0.002; P 0.006. ***A P 0.05 was considered significant.



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dia CD-ROM resources must provide a medium different fromtextbooks, should stimulate student learning, and retain theirattention, as well as meet the educational objectives of thecourse. The multimedia CD-ROM used in this study fulfilledthese goals. Use of a wide range of interactive tasks in themultimedia CD-ROM, such as building liver models, a dragand drop exercise, observing the direction of bile and bloodflow in a liver model, move transporters to the sinusoidal andcanalicular domains, and answering MCQs and scenario-basedquestions, has enhanced student comprehension of issues dis-

cussed and allowed them to apply knowledge gained frombasic sciences into clinical situations. The hyperlink providedin the program facilitated integration of the contents andallowed students to search, for example, for difficult terms byusing the glossary, visiting pages in other modules whenneeded, proceeding to the next page, or exiting the system.

It is of interest to note that students enrolled in a PBL courseare usually challenged with the structure and design of text-books and the fact that most undergraduate textbooks arediscipline-based and focus on information rather than theenhancement of cognitive skills and application of knowledge.For example, textbooks in basic sciences might ignore theclinical significance of information discussed and their use inunderstanding of disease pathogenesis and underlying mecha-

nisms. Several recent studies (19, 28, 41, 48) have also iden-tified areas of deficiencies in textbooks and a number oflimitations. In a recent article published in Advances in Phys-iology Education (5), it has been shown that most recom-mended undergraduate medical textbooks are limited in dis-cussing bile salt transporters, bile formation, and mechanismsunderlying cholestasis and drug-induced hepatobiliary dys-function.

Considering these limitations, the multimedia CD-ROMused in the study has been designed in an innovative way thataddressed these needs. The finding that school leavers, partic-ularly those from a non-English speaking background, felt thatthere was too much information per screen is of interest. The

data show that there were no differences in regard to this issueon the basis of citizenship indicating that these differences aremost likely related to language competency rather than thelearning style of participants. After the completion of thesurvey in September 2002, the multimedia CD-ROM wasreviewed by the author and three medical students, andchanges were made to four screens to facilitate the delivery ofinformation in an innovative and gradual way. The use of PBLcases in this multimedia CD-ROM has been found useful bythe students and kept them engaged. It also matched with the

overall philosophy of the program. No significant differenceswere found on the basis of citizenship or first language.Compared with graduate-entry students, school leavers showeda more positive attitude toward the PBL cases and agreed thatthe cases kept them engaged (P 0.033). In the mean time, thestudy shows that there were no other significant differencesbetween the two groups in regard to a total of 17 questions(Tables 57) and the general comments addressed in thequestionnaire used. Furthermore, there were no general com-ments in the questionnaires collected that give any indicationthat the use of a CD-ROM or multimedia is of less value tostudents with a university degree. It may be that the statisticallysignificant difference reflects a subjective self-assessmentprocess, whereas the written responses reflect a more objec-

tive and elaborative pattern of participants to these ques-tions. The reason for the differences in perception of the twogroups is not clear. It might be that students with a prioruniversity degree prefer small group discussion of PBL casesand collaborative learning, whereas school leavers preferworking on PBL cases on their own. This might partly explainthe difference observed in this study; however, the explanationprovided is hypothetical and needs further study.

The findings also indicate gender differences in regard toperception. Female students compared with males agreed thatthe PBL cases matched with the philosophy of the course (60females vs. 26 males, P 0.012) and were useful to theirlearning (53 females vs. 19 males, P 0.048). The effect of

Table 7. Rating participant views regarding the PBL cases in module 1 and effects of academic background,gender, citizenship, and first language

Statement Ranking

Academic Background Gender Citizenship First Language

Graduate(25; 25%)

School Leavers,(74; 74%)

Females(65; 66%)

Males(34; 34%)

Australia(61; 62%)

Overseas(38; 38%)

English(55; 56%)

Non-English(44; 44%)

Cases were designed in a way thatmatches with the curriculum S. Agree 11 (11) 23 (23) 28 (28)* 6 (6) 26 (26) 8 (8) 24 (24) 10 (10)Agree 12 (12) 40 (40) 32 (32)* 20 (20) 29 (29) 23 (23) 25 (25) 27 (27)Neutral 2 (2) 11 (11) 5 (5)* 8 (8) 6 (6) 7 (7) 6 (6) 7 (7)Disagree 0 (0) 0 (0) 0 (0)* 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)S. Disagree 0 (0) 0 (0) 0 (0)* 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

PBL cases kept me engaged S. Agree 2 (2) 11 (11) 9 (9) 4 (4) 6 (6) 7 (7) 7 (7) 6 (6)Agree 17 (17) 36 (36) 38 (38) 15 (15) 33 (33) 20 (20) 30 (30) 23 (23)Neutral 4 (4) 26 (26) 16 (16) 14 (14) 20 (20) 10 (10) 16 (16) 14 (14)Disagree 0 (0) 1 (1) 1 (1) 0 (0) 0 (0) 1 (1) 0 (0) 1 (1)S. Disagree 2 (2) 0 (0) 1 (1) 1 (1) 2 (2) 0 (0) 2 (2) 0 (0)

PBL cases are useful to my learning S. Agree 2 (2) 13 (13) 12 (12) 3 (3) 11 (11) 4 (4) 10 (5) 5 (5)Agree 17 (17) 40 (40) 41 (41) 16 (16) 35 (35) 22 (22) 31 (31) 26 (26)Neutral 4 (4) 12 (12) 6 (6) 10 (10) 9 (9) 7 (7) 10 (6) 6 (6)Disagree 2 (2) 8 (8) 5 (5) 5 (5) 5 (5) 5 (5) 3 (3) 7 (7)S. Disagree 0 (0) 1 (1) 1 (1) 0 (0) 1 (1) 0 (0) 1 (1) 0 (0)

Values are the number of students ranking the question; numbers in parentheses are percent of students answering. Groups were studied using the 2 test, AP value of0.05 was considered significant. *P 0.012; P 0.033; P 0.048.



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gender on student perception about interprofessional PBLcourses has recently been raised (39). Reynolds (39) also foundthat women expressed greater enjoyment at taking responsibil-ity for their own learning and had more positive views aboutworking with students from another course.

The use of the MCQs test in the study aimed at the assess-ment of understanding of main learning concepts related to the

liver, bile salts, and bilirubin metabolism. The questions in-cluded in this test were free from grammatical clues (4). Theresults show that compared with the control group, the meantest results of group 1 (students attended 6 lectures and com-pleted a PBL case on breast milk jaundice in their groups plusattended Tutorial 1 of the PBL cases on liver cirrhosis and usedthe multimedia CD-ROM before undertaking the test) andgroup 3 (students completed 11 lectures, two PBL cases,Tutorial 1 of a PBL case covering the role of the liver in drugmetabolism, and the MCQs after using the multimedia CD-ROM) were significantly different (P 0.001 for each). Thisindicates that curriculum material and the multimedia CD-ROM have improved their performance in the test. However, itappears that the lectures and curriculum material alone did notsignificantly improve student performance in the test (group 2vs. control, P 0.084). At the same time, the mean test resultsof group 3 were significantly higher compared with those ofgroup 2 (P 0.001), indicating significant improvement in themean test results after using the multimedia CD-ROM.

Furthermore, the test results of group 2 were significantlylower compared with those of group 1 (P 0.014), and themean test results of group 1 were not significantly differentfrom those ofgroup 3 (P 0.613), which may indicate that themultimedia CD-ROM alone was able to enhance their testresults.

One might hypothesize that the MCQs used in the testaddressed topics included in the multimedia CD-ROM rather

than those of the curriculum. This is less likely to be the case,because the test questions were focused on main conceptsdiscussed in the problem of the week and were not focused onminute details. However, the higher mean test scores of group3 students compared with those ofgroup 2 students (16.6 5.2vs. 10.1 2.8) are not necessarily related to specific advan-tages of the multimedia CD-ROM contents over the curriculummaterial addressed in these weeks. The explanation is mostlikely related to the wide range of interactive tasks provided inthe multimedia CD-ROM. These interactive tasks enhancedstudent understanding of main concepts discussed in PBLtutorials, exposed them to a wide range of exercises, testedtheir higher-order cognitive skills, and allowed them to thinkconceptually. These effects might explain why mean scores of

group 3 students were higher.In conclusion, using bile salts, bilirubin metabolism, and

their hepatobiliary transport as an example, the incorporationof a multimedia CD-ROM into the first-year medical coursehas the potential to improve student understanding of the mainconcepts in a variety of body systems. Additional studies areneeded to compare the effects of using such tools in medicaland health education on long-term competency and higher-order cognitive skills.

ACKNOWLEDGEMENTS

The author thanks the first-year medical students at the University ofMelbourne who participated in this study; colleagues at the Faculty Informa-

tion Technology Unit and Biomedical Unit for their help and support duringthe preparation of the multimedia CD-ROM used in this study, particularly thegraphic designers of the project Andrew Bonollo and Avril Martinelli and theproject managers Dr. Mike Keppell and Kevin Sweeney; reviewers of thecontents of the CD-ROM Professors Prithi Bhathal and Roy Robins-Browneand Drs. Norman Eizenberg and Howard Grossman; and Prof. Peter Harris andAssoc. Prof. Susan Elliott for encouragement and support during the prepara-tion of the grant application for the multimedia CD-ROM project. Drs. GregorKennedy and Mike Keppell kindly provided advice during the preparation ofthe questionnaire for this study. The author also thanks fifth-year medicalstudents Adam Pendlebury, Lindy Washington, and Rowena Christiansen forvaluable comments on The Liver CD-ROM; and Dr. Barbara Goodman, theAssociate Editor ofAdvances in Physiology Education, and the three reviewersof the manuscript for their constructive comments on the paper and usefulfeedback.

GRANTS

The Liver CD-ROM was funded by a grant from Teaching and LearningMedical and Educational Technology Committee Grants, the University ofMelbourne, Victoria, Australia.

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A Multimedia CD-ROM Tool to Improve Student Understanding of Bile Salts and Bilirubin Metabolism

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