Medical education for rural areas: Opportunities and challenges for information and communications technologies
Joan M Sargeant
Continuing Medical Education, Faculty of Medicine, Dalhousie University, Canada
Joan M Sargeant
Continuing Medical Education, Faculty of Medicine, Dalhousie University
Resources in medical education are not evenly distributed and access to education can be more problematic in rural areas. Similar to telemedicine«SQ»s positive influence on health care access, advances in information and communications technologies (ICTs) increase opportunities for medical education. This paper provides a descriptive overview of the use of ICTs in medical education and suggests a conceptual model for reviewing ICT use in medical education, describes specific ICTs and educational interventions, and discusses opportunities and challenges of ICT use, especially in rural areas. The literature review included technology and medical education, 1996-2005. Using an educational model as a framework, the uses of ICTs in medical education are, very generally, to link learners, instructors, specific course materials and/or information resources in various ways. ICTs range from the simple (telephone, audio-conferencing) to the sophisticated (virtual environments, learning repositories) and can increase access to medical education and enhance learning and collaboration for learners at all levels and for institutions. While ICTs are being used and offer further potential for medical education enhancement, challenges exist, especially for rural areas. These are technological (e.g., overcoming barriers like cost, maintenance, access to telecommunications infrastructure), educational (using ICTs to best meet learners«SQ» educational priorities, integrating ICTs into educational programs) and social (sensitivity to remote needs, resources, cultures). Finally, there is need for more rigorous research to more clearly identify advantages and disadvantages of specific uses of ICTs in medical education.
|How to cite this article:|
Sargeant JM. Medical education for rural areas: Opportunities and challenges for information and communications technologies.J Postgrad Med 2005;51:301-307
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Sargeant JM. Medical education for rural areas: Opportunities and challenges for information and communications technologies. J Postgrad Med [serial online] 2005 [cited 2019 Jul 19 ];51:301-307
Available from: http://www.jpgmonline.com/text.asp?2005/51/4/301/19244
Resources in health care are not evenly distributed and access to high quality medical care can be more problematic in rural areas. The same is true for medical education, and learners at all levels of the curriculum-medical students, residents, and physicians-in rural locations often experience decreased access to education. Factors interfere with access to both formal programs, such as distance from a clinical teaching centre, and informal learning; e.g., limited availability of current medical information., In fact, working in isolated environments where access to peers, education and information is limited, is one of the highest risk factors for physicians' loss of medical competence.
Similar to telemedicine's influence on health care access, advances in information and communications technologies (ICTs) have increased opportunities for medical education. ,,,
This paper provides a descriptive overview of the use of ICTs in medical education from an educational perspective. Its purposes are to:
1. Suggest a conceptual model as a framework for reviewing ICT use in medical education .
2. Describe the use of specific technologies and integrated technology systems in medical education.
3. Consider opportunities and challenges the technology offers for medical education, especially in rural areas.
Materials and Methods
The literature review was conducted using PubMed-Medline, PubMed-Central and ERIC databases, 1996- 2005, for research studies and pertinent theoretical publications including journals and texts. Key search words included general terms such as: "telehealth," "telecommunication," "distance learning," "distance education"; and specific terms such as: "videoconference," "audioconference," "computer-aided instruction," "Web-based learning," "handheld technology," "learning repositories; levels of medical education: "undergraduate," "graduate," "post-graduate," "continuing"; and "rural health," and "international approaches." Theoretical approaches were included to place the review within an educational and social context, and selected studies to demonstrate use of ICTs within diverse elements of medical education.
A conceptual model for reviewing ICT use in medical education
Guidance for the appropriate use of ICTs for distance and distributed learning comes from research and theory in general education. ,,,,, As in traditional face to face education, a number of learning theories (e.g., behavioral, cognitive, social) provide information about educational strategies and effective education takes place within an educational system. This system is composed, very simply, of the following interactive components: ,
2. educational materials and information resources
4. connections among the above and is influenced by the:
5. educational environment, and
6. social environment (In medical education, this specifically includes the healthcare environment.)
These components and environments are presented schematically in [Figure 1], suggesting a conceptual, yet practical model for considering the roles which ICTs play a role in medical education. In traditional education, learners, learning materials (both specific course materials and general information resources) and instructors are temporally and physically connected. In distributed learning, ICTs connect learners, instructors and materials. When using ICTs for education, the temptation is often to focus more on the technology and less on the learners and instructors, often to the detriment of the educational quality., And, education does not take place in a vacuum and environments moderate learning and educational outcomes. These include the educational environment, influenced by factors such as available support systems and learners' prior experiences, and social and health care environments; e.g., local support and access to relevant health care resources. Each component deserves attention.,,
Using this model, individual ICTs and functions each serves in distributed learning will be briefly discussed, followed by a more detailed description of the uses of specific ICT within medial education.
ICTs in medical education, similar to the ones used in telemedicine and general education, range from simple to complex and fall into four general groupings:
1. The telephone is the earliest, simplest and sometimes the most overlooked technology.
2. Video-conferencing incorporates computer technology to provide interactive, "real-time" transmission of audio and video, and transmission of files, graphics, etc.
3. Computer technology and software enable computer-aided instruction and with the Internet, support Web-based learning, computer conferencing, and access and transmission of large databases, files and images.
4. Handheld technologies can be used alone or linked to the Internet to provide "just in time" information.
The conceptual model in [Figure 1] depicts the general functions which these ICTs serve in medical education. They connect learners, instructors and educational materials in different ways:
1. Connecting learners and instructors in "real-time" or synchronously : Simple ICTs, like the telephone and audio-conferencing, and more advanced ones like video-conferencing connect learners and instructor for "live" educational sessions. Internet "chat" or conferencing programs also provide synchronous communication.
2. Connecting learners and instructor "asynchronously:" This refers to interpersonal interaction occurring over time, not at the same time, enabled through the Internet via email, list serve and numerous conferencing programs.
3. Connecting learners, instructors to learning resources (specific course materials) : Before ICTs and even today, correspondence courses provided paper course materials to learners by mail., With computers and the Internet, these are now available electronically; e.g., course outlines, cases, images, simulations, and examinations.
4. Connecting learners to learning resource (information resources) : Access to current information is paramount for medical practice and the Internet and computers now offer this; e.g., access to libraries, databases, journals, texts, decision-making tools, and clinical guidelines. These resources are important in formal instruction and also for informal continued learning.
Descriptions of the use of specific ICTs and integrated technology systems in medical education
This section describes uses with examples of the identified ICTs and their educational functions:
1. Traditional telephone and audio-conferencing
Often neglected as learning tools, the telephone and audio conferencing connect learners and instructor for formal and informal medical education. One long-standing program is offered by the Memorial University of Newfoundland, Canada in continuing medical education (CME). Since the 1960s, rural physicians are linked for a 1-hour audio-conferenced program with clinical experts. The program continues to be well-received and valuable. A similar program has been used in the UK for undergraduate and postgraduate programs. Audio conferencing enables interaction among learners and the instructor and is an affordable and effective means of education.
2. Interactive videoconferencing
Videoconferencing is used extensively for formal medical education. It synchronously connects learners, instructors and course materials. It effectively provides traditional programs for physicians and other health professionals at distributed sites and supports their interaction. ,,,,, Videoconferencing connects sites for grand rounds and other sessions traditionally hosted by a medical centre, and allows peripheral sites to present clinical material during these rounds. ,,,, Electronic diagnostic images (e.g. computerized tomography, angiograms) and video-clips or live videoconferencing of the patient can also be transmitted, adding value to the programs., Other CME initiatives using videoconferencing include journal clubs and small-group learning. ,
In undergraduate and residency education, videoconferencing use is increasing and includes students and residents in rural and distributed sites, including family medicine and cardiology residents. ,,,, More recently, videoconferencing is being used in combination with other ICTs to develop distributed campuses for faculties of medicine. (see section 5 below).
Videoconferencing also facilitates skills instruction and assessment at a distance. Examples include teaching surgical procedures through off-site observation, teaching hand assessment techniques for physical therapists, improving pediatric resuscitation skills through observation and participation, assessing neonatal resuscitation skills and assessing surgeons' informed decision-making skills using a video conferenced standardized patient. ,,,,,
3. Computer-assisted instruction and Web-based learning
Computer-assisted instruction (CAI) refers to using computer technology to enhance instructional design and provide instruction, while Web-based learning incorporates these features with the connectivity of the Internet. CD-ROMs are an example of an accessible yet sophisticated multi-media computer-aided instructional medium. They can be an effective learning tool for knowledge and skills and are easily and cheaply distributed. ,, The relative accessibility and affordability of digital camera and video technology enable the creation of sophisticated materials; e.g. multi-media texts. ,, CD-ROMs link the learner and learning resources.
Multi-media CAI combined with the Internet for formal courses connects learners to sophisticated learning resources. Examples include an undergraduate program teaching examination of the eye and ear using computer-assisted interactive learning and virtual reality. Other multi-media programs include assessment of the learner; e.g., the "interactive patient" program evaluates performance in history taking, physical examination, diagnosis and treatment. In radiology, a sophisticated Internet-based program assesses knowledge and skill matched to the learner's level. In pathology, a web-based tutorial hosted on a US web site improved grading of images by 643 practicing pathologists from across the United States (72%) and outside the US (28%), emphasizing the broad population the Web serves.
Web-based programs enable interpersonal interaction and collaborative learning among learners or learners and instructors, either synchronously or asynchronously, especially important for rural and isolated medical and health professionals. An example is an interactive electronic notice board developed as a forum for discussion of clinical problems for medical students in rural settings and their clinical preceptors. Other multi-media programs on the Internet link learners, resources and instructors for formal instruction. One such CME program included a didactic multi-media component, interactive cases with feedback and enabling tools and resources, supplemented with Web-conferencing. WebCTδ is an educational course management software supporting both synchronous and asynchronous communication, used for undergraduate, post-graduate and continuing education. Evaluation of formal CME programs using this courseware showed that physicians valued access to relevant programs and interactions with instructors and learners, but interpersonal interaction required appropriate facilitation., Another intervention for Web-based learning is a journal club, including links to pertinent articles and a discussion board for interaction.
In addition to facilitating formal learning, the Internet provides access to medical information, journals, libraries and databases for all levels of medical education and lifelong learning. These resources are traditionally easily accessed by learners at modern medical schools, but are often less accessible to learners and practitioners outside these facilities.,, The negative impact of not having access to current medical information is serious for learners at all levels and especially for practitioners.
Access to the Internet by North American physicians is increasing in the US from 10% of physicians surveyed in 1997 to 78% in 2001, and in Canada from 63% in 1999 to 88% in 2003. ,, Most use it as a source of information for clinical practice and particular patient problems. In the US, about 90% responders used email and about 65% used the internet to search the medical literature. With increasing use of electronic resources via the Internet, US physicians reported decreased use of journals and local CME programs. Online evidence-based databases show promise in answering clinical questions. Students graduating from US medical schools in 2001 reported feeling comfortable in conducting sophisticated searches of medical information databases. These findings have implication for designing medical education curricula.
To summarize, computer-mediated multi-media instruction and the Internet can effectively link learners to learning materials and information resources, to each other, and to instructors.
4. Hand-held computers in medical education
Since their introduction in the early 1990s, the use of hand-held computers or personal digital assistants (PDAs) has increased. Generally, they link the learner/practitioner directly to the information resource. They are most frequently used to access clinical and evidence-based information at the point of care, providing immediate access to journals, databases and calculators for clinical procedures. ,, They are used in undergraduate and postgraduate education for recording and monitoring learners' clinical experiences, data collection, log books and evaluation . More recently, cellular telephone technology provides hand-held capacity to perform many electronic and communications activities: capture and transmit digital images, access email, search the Internet, and store information,  but few if any formal studies of its use in medical education have been reported.
5. Distributed and integrated learning systems
Beyond using technologies individually, educational programs and systems are being developed which integrate various ICTs and/or integrate ICTs with traditional education approaches, connecting learners, instructors and resources in various ways. A European integrated web-based system for distance learning in mammographic digital imaging processing includes network-delivered interactive multimedia courses and tutoring via collaborative browsing and "white boarding" or editing of the content, supported by video, audio and text communication and transfer of data files. In Taiwan, programs using video-conferencing and web-based CME network with a virtual classroom are available to satisfy the needs of physician-education in rural areas.
Highly sophisticated and integrated learning systems are in use for teaching surgical and other skills. Virtual environments combining robotics, video-conferencing and internet transmission provide real-time consultation, education and mentoring during surgery for remote surgical residents and students and learners in other countries.,, Asynchronous learning in surgery can be aided by high-quality optical capture using a laparoscope and robotic arm to create video clips which are then validated by an expert review panel, for collaborative learning of surgical procedures.
An innovative system for continuing surgical education incorporates both ICTs and traditional approaches. This is a model for training rural surgeons in India, where long distances and few specialists cause particular challenges. Using principles for surgical training, the authors propose integration of self-instructional materials, observations of operative procedures through live video transmissions or recorded videos and CDs, and hands-on experience in local hospitals under supervision.
The Internet also supports international collaboration in medical education through creation of and access to large databases and resources, or learning repositories. These store electronic educational materials referred to as "reusable learning objects"; e.g., single diagrams, images, course overviews. Educators and learners can use these to create a course or learning module. This is an exciting opportunity as collaborating educational institutions can customize and re-use learning materials, and share and refine high quality educational strategies. One such collaboration is the International Virtual Medical School (IVIMEDS), a collaboration of 37 institutions.  Another is the Hong Kong International Consortium for Sharing Medical Student Assessment Questions, a partnership of 12 medical schools sharing their pools of assessment questions, and collaborating to increase access to rigorous and affordable assessments.
Medical schools, currently challenged to serve rural populations and educate medical students distributed over large geographic areas, are responding in creative ways using ICTs and traditional educational methods. Australia, for example, is implementing rural clinical and medical schools to reduce health differentials between rural and non-rural communities and indigenous and non-Indigenous people. One system has a satellite link, four videoconferencing units, computer lab, communications links for videoconferencing, and high-speed Internet links. Other studies report the need for ICTs for education at undergraduate and practitioner levels and to support physicians. ,,,, In Canada, one medical school is collaborating with other non-medical campuses to prepare students for rural practice using synchronous education and web-based support in undergraduate education.
Opportunities and challenges related to the effective use of ICTs, especially in rural areas
To return to the educational model, [Figure 1], ICTs and integrated systems using them connect learners, instructors and experts, formal learning materials and information resources in various ways, with the potential to realize a more equitable distribution of high quality medical education. While benefiting all learners and teachers, the opportunities are greatest for rural areas with limited access to the resources of academic medical centres. Summarized briefly, opportunities are in three general categories: interpersonal connection, connections with resources, and collaborative systems for international partnerships:
1. Interpersonal connections: Through ICTs, individual learners can interact with and learn from fellow students, colleagues, experts and instructors, previously inaccessible.
2. Connections with resources: As well as increasing access to formal course materials, ICTs also provide novel and important learning experiences; e.g,. virtual patients and environments provide risk-free settings for practicing skills ranging from history-taking to complex surgical procedures. New cellular phone technology can provide access to these resources anywhere, anytime, emphasizing that one of the most significant contributions of ICTs is the potential for universal access to timely and accurate clinical information.
3. Collaborative systems for international partnerships: In addition to benefiting individual learners and institutions, international collaborations using learning repositories and Internet communications, are working to improve medical education globally through shared resources and expertise.
While these benefits may now be realities for some learners, practitioners and medical schools, they are not universal and rural areas in particular may have more difficulty realizing them. Benefits result from a sophisticated combination of technology, applied educational theory, and environmental factors, held together by a high degree of organization. Challenges identified in studies cited above and by reviews of medical education interventions using ICTs,, arise in three main categories: 1) technology, 2) educational environment and 3) health care and social environments. [Figure 1]
1. Technological challenges
These relate to using the appropriate ICT and having appropriate support for its use. The appropriate technology means the one that will meet the educational objectives in a feasible and sustainable manner. As noted above, using relatively simple ICTs combined with traditional approaches can be effective, and for rural areas, may overcome technological barriers. Challenges include limited access to communications capability (e.g. access to broadband Internet, cellular phone networks), cost, maintenance, learners' and instructors' training in the ICT and support for remote sites. Each requires planning and monitoring for the ICT to effectively contribute to education or collaboration.
2. Educational challenges
Incorporating ICTs into educational interventions is often a challenge. Their use in education is often limited by inadequate attention to educational principles and evidence for effective learning.,,,, For example, educational outcomes are strengthened by instructor and learner preparation for ICT teaching environments, consideration of learners' prior experience and knowledge base, matching learning goals with the specific technology and administrative support. Additionally, learners and instructors need new skills; e.g., information search, management and critical appraisal skills for using information resources such as websites, electronic journals, and databases, and instructors able to teach these skills.
3. Challenges created by local health care and social environments
Synergy between the goals of the education program and those of the local health care community facilitates learning. On a practical level, this also means having the appropriate health care resources at remote sites so that learners can put into practice the skills and knowledge newly acquired via ICT-enabled education, usually from urban sites with greater resources., ,  More broadly, educational programs offered by ICTs have the capacity to cross demographic, social, economic and national boundaries. Hence, they need to be culturally sensitive, relevant to local health care priorities and supportive of local resources. Medical education has the potential to "bridge the digital divide", to enhance health care of underserved populations and education of remote physicians and other healthcare providers.,
On a related note, many rural areas suffer from a shortage of physicians. While recent studies have identified many factors influencing physician recruitment and retention, several medical schools have designed specific rural undergraduate programs which appear to be positively influencing recruitment and retention. ,,,,,,,, One small CME study found limited evidence that providing distance education positively influenced recruitment and retention and further research is needed.
This paper proposed a conceptual model as a framework for reviewing ICT uses in medical education (i.e., linking learners with instructors, specific course materials and/or information resources). Using the model, it described specific technologies and their uses as educational tools, and identified opportunities and challenges presented by ICT use in medical education. While there is a great opportunity to improve access to medical education, to improve the quality of education and to facilitate collaboration amongst individual learners and institutions; challenges do exist, especially for rural areas. These includes technological (e.g., overcoming barriers like cost, maintenance, access to telecommunications infrastructure), educational (using ICTs to best meet learners' educational priorities) and social (sensitivity to remote needs, resources, cultures). Finally, there is a need for more rigorous research to more clearly identify advantages and disadvantages of specific use of ICTs in medical education, to determine the specific conditions under which they are effective, and to understand the use of complex educational systems using multiple ICTs. 
The author wishes to acknowledge the contributions made by Nicolette O'Connor, the Dalhousie University Office of CME research associate to this paper. She was a tremendous help in conducting literature searchers, compiling references and creating [Figure 1].
|1||Hirsch W. A world of knowledge at your fingertips: the promise, reality, and future directions of on-line information retrieval. Acad Med 1999;74:240-3.|
|2||Barnes BE. Creating the practice-learning environment: using information technology to support a new model of continuing medical education. Acad Med 1998;73:278-81.|
|3||Lewkonia R. Educational implications of practice isolation. Med Educ 2001;35:525-9. |
|4||Field MJ. Telemedicine: a guide to assessing telecommunications in health care. Washington DC: National Academy Press; 1996. |
|5||Tangalos EG, McGee R, Bigbee AW. Use of the new media for medical education. J Telemed Telecare 1997;3:40-7. |
|6||Wootton R. Telemedicine. BMJ 2001;323:557-60. |
|7||Hjelm NM. Benefits and drawbacks of telemedicine. J Telemed Telecare 2005;11:65-9. |
|8||Cyrs TE, Smith FA. Teleclass teaching: a resource guide. 2nd ed. New Mexico: New Mexico State University; 1990.|
|9||Perraton H. Open and distance learning in the developing world. London: Routledge; 2000. |
|10||McCormack C, Jones D. Web-based education systems. Toronto: John Wiley and Sons, Inc; 1997. |
|11||Yoon SW. In Search of Meaningful Online Learning Experiences. New Directions for Adult and Cont. Educ., Winter 2003:100:9-30. |
|12||Johnson SD, Aragon SR. An instructional strategy framework for online learning environments . New Directions for Adult and Cont. Educ., Winter 2003:100:31-40. |
|13||Howard C, Schenk K, Discenza R. Distance learning and university effectiveness: changing educational paradigms for online learning. London: Information Science Publishing; 2004.|
|14||Merriam SB, Caffarella RS. Learning in adulthood. 2nd Edn. San Francisco: Jossey-Bass Publishers; 1999.|
|15||Mayer RE. The Promise of multimedia learning: using the same instructional design methods across different media. Learning and Instruction 2003;13,125.|
|16||Tanriverdi H, Iacono CS. Diffusion of telemedicine: a knowledge barrier perspective. Telemedicine J 1999;5:223-44.|
|17||Eva KW, MacDonald RD, Rodenburg D, Regehr G. Maintaining the characteristics of effective clinical teachers in computer assisted learning environments. Adv Health Sci Educ 2000; 5:223-46.|
|18||Aoun S, Johnson L. Capacity building in rural mental health in western Australia. Aust J Rural Health 2002;10:39-44.|
|19||Treloar C. Evaluation of a national and international distance education programme in clinical epidemiology. Med Educ 1998;32:70-5.|
|20||Curran V, Kirby F, Allen M, Sargeant J. A mixed learning technology strategy for providing continuing medical education to rural physicians. J Telemed Telecare 2003;9:305-7.|
|21||Hibbard, BM, Marshall RJ, Hayes TM. Postgraduate medical education by distance learning. J Audiov Media Med 1986;9:69-73. |
|22||Klein D, Davis P, Hickey L. Videoconferences for rural physicians' continuing health education. J Telemed Telecare 2005;11:97-9.|
|23||Misra UK. Telemedicine for distance education in neurology: preliminary experience in India. J Telemed Telecare 2004;10:363-5.|
|24||Allen M, Sargeant J, MacDougall E, Proctor-Simms M. Videoconferencing for continuing medical education: from pilot project to sustained programme. J Telemed Telecare 2002;8:131.|
|25||Langille DB, Allen MJ, Sargeant JM. Assessment of the acceptability and costs of interactive videoconferencing for continuing medical education in Nova Scotia. J Contin Educ Health Prof 1998;18:11. |
|26||Gruppen LD, Hutchinson SP, Gordon PJ, Roser S. An evaluation of the efficacy of interactive videoconferencing in residency and continuing education. Acad Med 1996;71 Suppl 1:S7-9.|
|27||Havens C. Videoconferencing and CME: pearls of wisdom, learned from ten years of experience. The Permanente Journal 2001;5:58. |
|28||Sclater K, Alagiakrishnan k, Sclater A. An investigation of videoconferenced geriatric medicine grand rounds in Alberta. J Telemed Telecare 2004;10:104-7. |
|29||Sargeant J, Allen M, O'Brien B, MacDougall E. Videoconferenced grand rounds: needs assessment for community specialists. J Contin Educ Health Prof 2003;23:116-23.|
|30||Gagliardi A, Smith A, Goel V, DePetrillo D. Feasibility study of multidisciplinary oncology rounds by videoconference for surgeons in remote locales. BMC Med Inform Decis Mak 2003;3:7. |
|31||Allen M, Sargeant J, Macdougall E, O'Brien B. Evaluation of videoconferenced grand rounds. J Telemed Telecare 2002;8:210-6. |
|32||McCrossin R. Successes and failures with grand rounds via videoconferencing at the Royal Children's Hospital in Brisbane. J Telemed Telecare 2001;7:25-8.|
|33||Wilson SF, Collins F. Video outreach journal clubs. Rural Remote Health 2005;5:355. |
|34||Allen M, Sargeant J, Mann K, Fleming M, Premi J. Videoconferencing for practice-based small-group continuing medical education: feasibility, acceptability, effectiveness and cost. J Contin Educ Health Prof 2003;23:38-47.|
|35||Callas, P, Bertsch TF, Caputo MP, Flynn BS, Doheny-Farina S, Ricci MA. Medical student evaluations of lectures attended in person or from rural sites via interactive videoconferencing. Teach Learn Med 2004;16:46-50. |
|36||Sen Gupta TK, Wallace DA, Clark SL, Bannan G. Videoconferencing: practical advice on implementation. Aust J Rural Health 1998;6:2-4. |
|37||Reznich, CB. Videoconferencing for instructional and administrative purposes: the audience reacts. Med Educ Online [serial on the Internet]. 1997 [cited 2005 Sep 22];2:1-4. Available from: http://www.msu.edu/~dsolomon/t0000004.pdf|
|38||LaRocca Lewis Y, Bredfeldt RP, Strode SW, D'Arezzo K. Changes in residents' attitudes and achievement after distance learning via two-way interactive video. Fam Med 1998;30:497-500. |
|39||Finley JP, Beland MJ, Boutin C, Duncan WJ, Dyck JD, Hosking MCK, et al . A national network for the tele-education of Canadian residents in pediatric cardiology. Cardiol Young 2001;11:526-31. |
|40||Gul YA, Wan AC, Darzi A. Undergraduate surgical teaching utilizing telemedicine. Med Educ 1999;33:596-9.|
|41||Barden W, Clarke HM, Young NL, McKee N, Regehr G. Effectiveness of telehealth for teaching specialized hand-assessment techniques to physical therapists. Acad Med 2000;75:43-6. |
|42||Kon AA, Marcin JP. Using telemedicine to improve communication during paediatric resuscitations. J Telemed Telecare 2005;11:261-4. |
|43||Cronin C, Cheang S, Hlymka D, Adair E, Roberts S. Videoconferencing can be used to assess neonatal resuscitation skills. Med Educ 2001;35:1013-23. |
|44||Curran VR, Aziz K, O'Young S, Bessell C, Schulz H. A comparison of face-to-face versus remote assessment of neonatal resuscitation skills. J Telemed Telecare 2005;11:97-102.|
|45||Clever SL, Novack DH, Cohen DG, Levinson W. Evaluating surgeons' informed decision making skills: pilot test using a videoconferenced standardized patient. Med Educ 2003;37:1094-9. |
|46||McKimm J, Jollie C, Cantillon P. ABC of learning and teaching: Web based learning. BMJ 2003;326:870-3. |
|47||Roy D, Sargeant J, Gray J, Hoyt B, Allen M, Fleming M. Helping family physicians improve their cardiac auscultation skills with an interactive CD-ROM. J Contin Educ Health Prof 2002;22:152-9.|
|48||Finley JP, Sharratt GP, Nanton NA, Chen RP, Roy DL, Paterson GL. Auscultation of the heart: a trial of classroom teaching versus computer-based independent learning. Med Educ 1998;32:357-61.|
|49||Zeisel SH, Plaisted CS. CD-ROMS for nutrition education. J Am Coll Nutr 1999;18:287. |
|50||Tegtmeyer K, Ibsen L, Goldstein B. Computer-assisted learning in critical care: from ENIAC to HAL. Crit Care Med 2001;29 Suppl 8:N177-82. |
|51||Braner AV, Zenel J, Goldstein B. Pediatrics: an interactive program. Philadelphia: WB Saunders; 1999.|
|52||Neonatal resuscitation program: textbook of neonatal resuscitation, with CD-ROM. Fourth Edition. Chicago, American Heart Association and American Academy of Pedicatrics; 2000. |
|53||Grundman JA, Wigton RS, Nickol D. A controlled trial of an interactive, web-based virtual reality program for teaching physical diagnosis skills to medical students. Acad Med 2000;75:47-9.|
|54||Hayes KA, Lehmann CU. The interactive patient: a multimedia interactive educational tool on the world wide web. MD Comput 1996;13:330-4. |
|55||Grunewald M, Heckemann RA, Wagner M, Bautz WA, Greess H. ELERA: A WWW Application for evaluating and developing radiologic skills and knowledge. Acad Radiol 2004;11:1381-8.|
|56||Kronz JD, Silberman MA, Allsbrook WC, Epstein JI. A web-based tutorial improves practicing pathologists' Gleason grading of images of prostrate carcinoma specimens obtained by needle biopsy: a validation of a new medical education paradigm. Cancer 2000;89:1818-23. |
|57||Walker J, Thomson A, Smith P. Maximising the world wide web for high quality educational and clinical support to health and medical professionals in rural areas. Int J Med Inform 1998;50:287-91.|
|58||Fordis M, King JE, Ballantyne CM, Jones PH, Schneider KH, Spann SJ, et al . Comparison of the instructional efficacy of internet-based CME with live interactive CME workshops: a randomized controlled trial. JAMA 2005;294:1043-51. |
|59||webCT.com [homepage on the Internet]. Vancouver, British Columbia: WebCT Canada [cited 2005 September 22]. Available from: http://www.webCT.com. |
|60||Curran VR, Lockyer J, Kirby F, Sargeant J, Fleet L, Wright D. The nature of the interaction between participants and facilitators in online asynchronous continuing medical education learning environments. Teach Learn Med 2005;17:240-5.|
|61||Sargeant J, Curran V, Jarvis-Selinger S, Ferrier S, Allen M, Kirby F, et al . Interactive online continuing medical education physicians' perceptions and experiences. J Contin Educ Health Prof 2004;24:227-36. |
|62||Jacobs JL, Thomas S. The future of the journal club. Amsterdam: IOS Press; 2004.|
|63||Zollo SA, Kienzle MG, Henshaw Z, Crist LG, Wakefield DS. Tele-education in a telemedicine environment: implications for rural health care and academic medical centers. J Med Syst 1999;23:107-22.|
|64||Dorsch J. Information needs of rural health professionals: a review of the literature. Bull Med Lbr Assoc 2000;88:346-54.|
|65||O'Brien B, Sargeant J, Ryan K. How internists in Nova Scotia meet their continuing education needs. Annales CRMCC 2000;33:164-8.|
|66||Casebeer L, Bennett N, Kristofco R, Carillo A, Centor R. Physician Internet medical information seeking and on-line continuing education use patterns. J Contin Educ Health Prof 2002;22:33-42.|
|67||Martin S. Two-thirds of physicians use the web in clinical practice. Can Med Assoc J 2004;170:28. |
|68||Martin S. Almost 1 in 5 MDs now have web sites. Can Med Assoc J 2002;167:1047. |
|69||Bennett, NL, Casebeer LL, Kristofco RE, Strasser SM. Physicians' internet information-seeking behaviors. J Contin Educ Health Prof 2004;24:31-8. |
|70||Schwartz K, Northrup J, Israel N, Crowell K, Lauder N, Neale AV. Use of online evidence-based resources at the point of care. Fam Med 2003;35:251-6.|
|71||Casebeer L, Kristofco RE, Strasser S, Reilly M, Krishnamoorthy P, Rabin A, et al . Standardizing evaluation of on-line continuing medical education: physician knowledge, attitudes, and reflection on practice. J Contin Educ Health Prof 2004;24:68-75.|
|72||Ebell M, Rovner D. Information in the palm of your hand. J Fam Pract 2000;49:243-51. |
|73||Fischer S, Stewart TE, Mehta S, Wax R, Lapinsky SE. Handheld computing in medicine. J Am Med Inform Assoc 2003;10:139-46.|
|74||Recommendations for Handheld Hardware and Software, Dalhousie University Faculty of Medicine - Spring 2005, 6th edition [on the Internet]. Halifax, Nova Scotia: Dalhousie University; [updated 2005 April 18; cited 2005 Sep 15]. Dalhousie University, Faculty of Medicine; [about 2 screens]. Available from: http://handheld.medicine.dal.ca/index.htm. |
|75||Costaridou L, Panayiotakis G, Sakellaropoulous P, Cavouras D, Dimopoulos J. Distance Learning in Mammographic Digitial Image Processing. Br J Radiol 1998;71:167-74.|
|76||Cellphones.etc[homepage on the Internet]. Edmonton: WCS Cellphones Online Inc. c2005 [cited 2005 Nov 28]. Available from: http://www.cellphones.ca/.|
|77||Chen HS, Guo FR, CHing-Yu C, Chen JH, Kuo TS. Review of telemedicine projects in Taiwan. Int J Med Inform 2001;61:117-29. |
|78||Rafiq A, Moore JA, Zhao X, Doarn CR,Merrell RC. Digital video capture and synchronous consultation in open surgery. Ann Surg; 239: 567-73|
|79||Lavrentyev V, Rafiq A, Merrell RC. Telesurgery as an integral part of medical education curriculum. Telemed J E Health 2004;10:585.|
|80||Pearson AM, Gallagher AG, Rosser JC, Satava RM. Evaluation of structured and quantitative training methods for teaching intracorporeal knot tying. Surg Endosc 2002;16:130-7. |
|81||Rafiq A, Moore JA, Doarn CR, Merrell RC. Asynchronous confirmation of anatomical landmarks by optical capture in open surgery. Arch Surg 2003;138:792-5. |
|82||Jena TK, Agarwal AK. Distance education - a training tool for rural surgeons. Indian J Surg 2003;65:50-4.|
|83||Geueke M, Stausberg J. A meta-data-based learning resource server for medicine. Comput Methods Programs Biomed 2003; 72:197.|
|84||Harden RM, Hart IR. An International virtual medical school (IVMEDS): the future for medical education. Med Teach 2002;24:261-7. |
|85||Hkwebmed. Org [homepage on the internet]. Hong Kong: International Consortium for Sharing Medical Student Assessment Banks. [Updated 2005 Jul 8; cited 2005 Nov 25]: Available from: http://www2.hkwebmed.org/webmed|
|86||Lawson KA, Chew M, Van Der Weyden MB. A revolution in rural and remote Australia: bringing health education to the bush. MJA 2000;173:618-24. |
|87||Sturmberg JP, Reid AL, Thacker JL, Chamberlain C. Project report: a community based, patient-centred, longitudinal medical curriculum. Rural Remote Health [serial on the Internet] 2003 [cited 2005 Sep 22];210: [about 7 p.]. Available from: http://rrh.deakin.edu.au/articles/subviewnew.asp? ArticleID=289|
|88||Delaney G, Eing Lim S, Sar L, Yang SC, Sturmberg J, Khadra M. Challenges to rural medical education: a student perspective. Aust J Rural Health 2002;10:168-72. |
|89||Sturmberg JP, Reid A, Khadra MH. Community Based medical education in a rural area: a new direction in undergraduate training. Aust J Rural Health 2001;9;14-8.|
|90||Hays R. Rural initiatives at the James Cook University School of Medicine: a vertically integrated regional/rural/remote medical education provider. Aust J Rural Health 2001;9:2-5. |
|91||Booth B, Lawrance R. Quality assurance and continuing education needs of rural and remote general practitioners: how are they changing? Aust J Rural Health 2001;9:265-74.|
|92||Lau F, Bates J. A review of e-learning practices for undergraduate medical education. J Med Syst. February 2004;28:71-87.|
|93||Curran VR, Fleet L. A review of evaluation outcomes of web-based continuing medical education. Med Educ 2005;39:561-7. |
|94||Chumley-Jones HS, Dobbie A, Alford CL. Web-based learning: sound educational method or hype? A review of the evaluation literature. Acad Med 2002;77:S86-93. |
|95||O'Rourke A, Dolman E, Fox N, Lane P, Roberts C. The Wisdom Project: virtual education in primary care. Health Libr Rev 1999;16:73-81. |
|96||Davies D. E- Learning. In : Dent JM, Harden RM, editors. A practical guide for medical teachers. 2nd edn. Edinburgh: Churchill Livingston; 2005. p.221.|
|97||Hovenga EJS, Hovel J, Klotz J, Robins P. Infrastructure for reaching disadvantaged consumers: telecommunications in rural and remote nursing in Australia. J Am Med Inform Assoc 1998;5:269-75. |
|98||Chang BL, Bakken S, Brown S, Houston TK, Kreps GL, Kukafka R, et al . Bridging the digital divide: reaching vulnerable populations. J Am Inform Assoc. 2004;11:448-57.|
|99||Jones JA, Humphreys JS, Adena MA. Rural gps' ratings of initiatives designed to improve rural medical workforce recruitment and retention. Rural Remote Health 2004;4. Online|
|100||Jones JA, Humphreys JS, Adena MA. Doctors' perspectives on the viability of rural practice. Rural Remote Health [serial on the internet] 2004 [cited 2005 Sep 22];4:[11 p.]. Available from: http://rrh.deakin.edu.au/publishedarticles/article_print_305.pdf|
|101||Veitch C, Grant M. Community involvement in medical practitioner and retention: reflections on experience. Rural Remote Health [serial on the Internet] 2004 [cited 2005 Sep 22];4: [9 p.]. Available from: http://rrh.deakin.edu.au/publishedarticles/article_print_261.pdf|
|102||Shannon CK. A community development approach to rural recruitment. J Rural Health 2003;19:347-53. |
|103||Brooks RG, Walsh M, Mardon RE, Lewis M, Clawson A. The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of the literature. Acad Med 2002;77:790-8.|
|104||Rabinowitz HK, Diamond JJ, Markham F, Rabinowitz C. Long-term retention of graduates from a program to incrase the supply of rural family physicians. Acad Med 2005;80:728-32. |
|105||Pathman DE, Konrad TR, Dann R, Koch G. Retention of primary care physicians in rural health professional shortage areas. Am J Public Health 2004;94:1723-33.|
|106||Wilkinson D, Birks J, Davies L, Margolis S, Baker P. Preliminary evidence from Queensland that rural clinical schools have a positive impact on rural intern choices. Rural Remote Health [serial on the Internet] 2004 [cited 2005 Sep 22];4(340): [9 p.]. Available from: http://e-jrh.deakin.edu.au/publishedarticles/article_print_340.pdf|
|107||Curran V, Rourke J. The role of medical education in the recruitment and retention of rural physicians. Med Teach 2004;26:265-72.|
|108||Sargeant J, Allen M, Langille D. Physician perceptions of the effect of telemedicine on rural retention and recruitment. J Telemed Telecare 2004;10:89-93. |
|109||Letterie GS. Medical education as a science: The quality of evidence for computer assisted instruction. Am J Obstret Gynecol 2003;188:849-53.|