In the UK trainees in general medicine who are less than 2 years post-graduation (UK Foundation Yr 2 [F2s]) are required to attend compulsory face to face training sessions¹⁷

For eight teaching sessions, all postgraduate trainees based at Hammersmith and Charing Cross Hospitals were contacted by email one week prior to a scheduled postgraduate respiratory training session and asked to access respiratory e-modules prior to the training session. Because some postgraduate trainees reported difficulty accessing NHS emails both an email and letter was sent for the last cohort of trainees in this study (n=21). A questionnaire was constructed by the authors and piloted for face validity on junior doctors attached to clinical staff in the home department. We checked for content validity by piloting on consultant members of the teaching faculty. We elected to not provide a tight definition of terms such as “minimal” and “moderate” as we were not interested in respondents’ absolute exposure to e-learning. In contrast, we were trying to gauge the trainees’ individual perceptions of their exposure which we considered to be a better indication of their degree of comfort with computer-based learning. Trainees were asked to complete this questionnaire (Appendix) when they attended the session regarding their prior e-learning use. In addition, their actual usage of the recommended e-learning material was monitored.

Specialist registrars at all of the Imperial College Trust hospitals (Charing Cross, St Mary’s and Hammersmith) were emailed and invited to participate in one of three nominal group technique sessions at Hammersmith Hospital and Charing Cross Hospital. The nominal group technique was designed to elicit opinions of e-learning amongst 21 postgraduate trainees who attended one of the three sessions. Nominal group technique is carried out in a group environment and utilises an “expert” group or panel. In this study experts were defined as postgraduate trainees who had a medical degree and some postgraduate training. The nominal group technique tool¹⁸ is a highly structured process in which individuals work alone to generate answers to a single specific question. These individual ideas are shared, then ranked and discussed by the group as a whole, ending with a top-ten rank for each group. Each session used the same question for all participants: “What influences your use of e-learning?” which was chosen specifically to elicit both positive and negative responses.

Semi-structured telephone interviews were undertaken with 13 specialist respiratory registrars to discuss their views about medical postgraduate training and e-learning. The questions were piloted as before and the interviews were undertaken by one of the authors (SFS) who had no professional or personal relationship with any of the interviewees. Calls were recorded with the knowledge and permission of the interviewees and interviews transcribed and themed by all three authors independently.

Ethical review was undertaken and permission to carry out these studies was granted by the Head of the North West Thames Foundation School. All subjects gave their informed consent prior to participating in the study.

The postgraduate trainees (n=98, 66 females) who took part in the initial questionnaire were one (56/98, 57%), two (29/98, 30%) or more (13/98, 13%) yrs post graduation. Whilst 13% (13/98) had no previous experience, 22% had (22/98) minimal experience of e-learning and 63% (62/98) had moderate/high experience. One person failed to indicate their level of experience. Only 12% (12/98) had no internet access at home. Approximately one third of the group (37%; 36/98) used the internet daily for educational purposes (that is, for extending their clinical knowledge irrespective of whether or not this was in preparation for formal assessment), whilst 55% (54/98) used it one to four times per week. The remaining eight failed to respond to this question. A majority of trainees (64; 65%) spent between one to four hours per week updating their clinical knowledge using all modalities.
Only 40 participants out of the total of 98 (41%) accessed the e-learning modules prior to respiratory teaching sessions. Previous exposure to e-learning did not affect the proportion accessing the materials. Of those with low/minimal exposure, 36% (13/35) accessed the modules, whilst 44% (27/62) of those with previous moderate/high exposure did so (p=0.451 Mann Whitney). This is illustrated in Figure 1.

Figure 1

Of the 77 trainees contacted by email alone, only 33% (25/77) accessed the modules, but of the 21 trainees who received both a letter and email reminder, the access rate was higher (71%, 15/21, p=0.002, Mann Whitney. When asked why they had not accessed the e-learning material, most stated that they did not know about it, or did not receive the email that had been sent, had no time, or had no access to their hospital email away from the hospital site (Table 1).

Figure 2

On average, participants (n=21) in the nominal group technique study had 6yr postgraduate training (mean age 31 years; 11M, 10F). Approximately one third (38% 8/21) had had moderate/high previous exposure to e-learning. Half (52%; 11/21) were graduates from a UK medical school. Table 2 shows the top 10 ranked responses from each of the three nominal groups. Ease of access and availability of the internet was identified by all three groups, as well as the ability to learn in your own time to fit your schedule. Objective self-assessment was cited highly by two groups. Negative points about e-learning were cost, the loss of personal interaction and a preference for working in groups, technical problems and difficulty reading on-screen.

Figure 3

Of the 13 trainees [age 34±3; 11F, 2M] who volunteered to take part in a telephone interview, 10 (77%) were UK medical school graduates, and six (46%) graduated before 2000. All of the trainees stated that they had either minimal or no exposure to e-learning as undergraduates. All had internet access at home and 10 (77%) used the internet for educational purposes for two to four hours per week. Six (46%) spent between two and four hours updating their clinical knowledge per week. Three out of the 13 trainees (23%) downloaded educational material to an iPod. A majority (9; 69%) thought that e-learning should be embedded into the training programme although some suggested that initial piloting and training were required.

“I think that would be quite helpful actually. The way that we have our teaching sessions ... it is not always possible to get to them because if you’re on call or your team is short you can’t always go so I think it would be quite useful to have some aspects of it done in e-learning” SPR-9

When trainees were asked how many training days could be potentially replaced by e-learning, responses varied from none to a maximum of 50%. Maintaining the social interaction of training days was emphasised, and need to use the full teaching day without gaps was highlighted.

“I quite like e-learning because I can take a lot on board. But I also like the social interaction in meeting the other respiratory registrars so I think may be a maximum 50%”. SPR-2

The ideal length of an e-module was thought to be under two hours by the majority of respondents (54%). A significant minority, (5;39%) suggested between two and four hours, but this was dependant on the topic and whether users could interrupt the module and restart where they had left off without loss rather than return to the beginning. Most respondents (9; 69%) thought that e-modules should be a compulsory component of post graduate certification. If this were put in place, nearly all (12; 92%) would complete the modules at home because a lack of free, uninterrupted study time made e-learning difficult to complete at work.

“There is no reason why it shouldn’t [be a compulsory component of post graduate certification]. At the moment we are having to compulsorily attend lectures to finish, to be signed off at the end so there is no reason why in the future. I mean obviously all these things would have to be piloted and at the beginning you wouldn't want to make them compulsory and you know you want to test them and make them user friendly first” – SPR-8

Specific diseases, bronchoscopic anatomy, physiology, lung function, radiology and interpretation of x-ray or spirometry results were suggested as areas that would lend themselves to delivery via e-learning.

Our study suggests that there may be a mismatch between self-reported use and actual use of e-learning materials. Whilst 92 % of junior trainees reported using the internet for educational purposes at least once a week, less than half actually accessed the e-modules prior to their teaching session, despite requests from the teaching administrators. The initial questionnaire showed that only a minority of junior trainees made use of e-learning materials prior to planned teaching sessions. This may in part reflect contact problems with employer-based email accounts since, when a letter was used to contact trainees, use of the materials increased. (In our hospital group, when using hospital networked computers, there is access to hospital or affiliated university email accounts only.) Our results also show that encouragement to access e-learning materials may need spoken and written reinforcement. Even with such methods, however, usage was only 70% - other reported reasons for non-usage included lack of access, technical difficulties and a lack of time.

If e-learning is to become a significant element of the junior trainee curriculum, it may need to become compulsory. Novel ways of embedding e-learning into the curriculum may need to be utilised.

The nominal group and telephone studies confirm the perceived advantages and disadvantages of e-learning and the need for optimal methodologies. The importance of access was reinforced by the nominal group work which indicated that ease of access to computers and the internet was ranked highly by all groups. A lack of access may be a significant barrier to trainees' use of e-learning. Cost (paying for e-module access) was cited as a barrier by 2 of the 3 groups. We were particularly interested to discover that many postgraduate trainees choose to pay for online materials even when free-to-access material of equal quality is available.

Overall, it appears from the nominal group work and telephone interviews that senior postgraduate respiratory trainees seem more receptive to the positive benefits of using e-learning as part of their postgraduate training than juniors. However it is important to note that the former were volunteer participants in our study, whereas the juniors were attending a normal timetabled training session.

Specialist trainees reported that in some disciplines, viewing an e-module is regarded as compulsory (e.g. viewing a module of cardiotocography prior to obstetric trainees starting in the labour ward; SpR-2, personal communication). Where emphasis is being placed on full documentation of training (e.g. Royal College of Obstetricians and Gynaecologists²⁸), online modules may be regarded by NHS Trusts as a verifiable and cheap method of demonstrating that trainees have received adequate training in particular subjects. However, without careful assessment, there is no evidence that the training session has been completed and the necessary understanding adequately internalised by the trainee.

It is important to consider the intended purpose of the e-modules. The decision whether each e-module needs to be compulsory or whether it should be viewed as a resource to enhance trainees’ self-directed learning is a crucial one. Provision of e-modules to all trainees and specialist registrars to ensure equal access to respiratory knowledge is admirable, but enforcing compulsory completion of e-modules will not necessarily ensure that they achieve practical competence. The approach needed may vary according to subject matter and speciality. For example, trainees may be encouraged to voluntarily view some material on “Emergencies in Cystic Fibrosis” or “Criteria for lung transplantation” (rare topics to which they may not have had much clinical exposure), but be required to view an e-module on safe insertion of an intercostal drain prior to a clinical training session (whether on a simulator, mannikin or patient).

During the telephone interviews, trainees suggested a multitude of different topics that would lend themselves to delivery by e-learning, in particular, bronchoscopic anatomy, physiology and interpretation of x-ray or spirometry results. What is now needed is for careful thought regarding which parts of a speciality training curriculum are best delivered by clinical apprenticeship and observation, which are best delivered by seminars and face-to-face teaching and which are best delivered by self-directed learning, including use of e-learning modules.

The extent to which computer assisted learning may be substituted for true clinical experience is limited by the fact that the majority of learning materials provide no opportunity for practical skills acquisition. Whilst use of simulators in craft training is increasing²⁹, the availability of simulators able to replicate complex scenarios is currently limited and costly. In contrast, introduction to new knowledge or subject areas may be more usefully undertaken using e-learning. One example could include acquisition of background theoretical knowledge regarding complex areas (such as orphan lung diseases or selection for lung transplantation). Another could include preliminary exposure to interactive video recordings and modules concerning practical techniques (such as thoracoscopy, use of non-invasive ventilation and intercostal tube placement). Other subject areas drawn from respiratory medicine that may lend themselves to e-learning modules are the understanding of bronchoscopic anatomy and the interpretation of lung function tests, where different trainees work at different rates and the ability to go back over uncertain areas may be advantageous.

Embedding of such materials within the training curriculum may be done by simply, for example, by suggesting to trainees that one e-module be completed per term. Use of the materials should in some way be related to an opportunity for discussion of the content with teachers and other trainees. This could be an online exchange, a face-to-face discussion of a particular module, a presentation by trainees on what they gained from the module, or by the use of interactive quizzes.

In some specific circumstances it might be necessary for safety reasons to mandate that a particular module be undertaken (for example, before assessment of competency to insert chest drains). However, there is no certain connection between compulsion and outcome and such practices may be defensive rather than being well supported by the educational literature. As the technical problems associated with e-learning become fewer, it appears that trainees’ willingness and acceptance of their use becomes greater. Time to utilise such materials is limited during the working day however, so the timescale for their use needs to be generous. Furthermore, the materials must be produced in such a way that they are attractive and welcomed by trainees.

A recurrent theme in studies with specialist registrars was the social element of training days. All participants rated the social interaction and face-to-face teaching on study days as highly important. Interestingly, most recognised the need to undertake e-learning in their own time, but wanted private study to be an adjunct, rather than a replacement, for training days.

Junior trainees were attending timetabled training days, whilst the senior trainees who contributed to the nominal group and telephone studies were volunteers, who may have had a particular interest in e-learning. Thus, unlike the juniors, the senior trainees may be less representative of their peer group as a whole.

As with all studies in medical education, we are limited by the specific context in which the postgraduate education is being delivered, in this case, two London-based hospitals within a single National Health Service Trust. Previous studies show that there is variation between European countries and that British trainees are more reluctant to engage with e-learning than many of their European peers²³. Thus, our results may not be generalisable to other parts of Europe or even to other hospital contexts with the United Kingdom.