is the textbook dead? examining the technologies used by ... · blogs were read by about 20% of...

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Gooi A. MedEdPublish 2014, 3: 5

http://dx.doi.org/10.15694/mep.2014.003.0005

Is the Textbook dead? Examining the Technologies Used by Medical Students to Learn

Adrian C.C. Gooi

Received: 17/02/2014

Accepted: 17/02/2014

Published: 17/02/2014

Abstract

Background: As newer technologies including Web 2.0, mobile computing, and social media extend into

medical education, the divide between student methods of learning and instructor strategies for teaching

continues to widen.

Methods: This study used questionnaires to examine e-learning in medical school.

Results: Thirty-five faculty and 117 students responded to the questionnaire. The percentage of students

using tools at least weekly for education was statistically more than faculty for online search engines,

textbooks, wikis, smartphones, Facebook, pocketbook references, and YouTube. Most faculty were

comfortable contributing to a textbook or pocketbook, about half reported the ability to post on Facebook, but

very few reported comfort with other e-learning tools. Faculty indicated a willingness to further their e-

learning skills with improved faculty support. Students indicated a desire for improved use of educational

technology in the future.

Conclusions: At our institution, the textbook remains alive and well, but the traditional didactic lecture may

be disrupted or changed by newer teaching strategies. Although the use of educational technologies will vary

greatly between medical schools, this study highlights the gap that can exist between the technological

expertise of faculty and educational needs of medical students.

Practice Points

1. Medical students use many e-learning tools with much greater frequency than faculty.

2. Faculty have low levels of comfort with many e-learning tools, but indicate a strong desire to improve

their skills.

3. Improved faculty development in e-learning, greater integration of educational technologists, and

continued reassessment of current practices can help faculty keep up with the evolving learning

practices of medical students.

Keywords: [Suggest a maximum of 6 keywords appropriate for your article here]

Article Open Access

Corresponding author: Adrian C.C. Gooi [email protected]

Department: University of Manitoba

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Article

Introduction

What resources do medical students currently use to learn? Medical education has evolved, and will

continue to evolve, as new technologies emerge. Kamel Boulos and Wheeler (2007) describe the

development of Web 2.0 as a more interactive and collaborative form of medical education and resources

compared to Web 1.0. These Web 2.0 modalities include wikis, blogs, podcasts, and social networks. Along

with the development of how information is organized online, there has also been an evolution of how people

are accessing this information. The use of desktop computers has given way to more portable laptop

computers, including use in the classroom (Rush, 2008). The access to electronic medical resources has

become even more mobile with the development of personal digital assistants (PDAs), followed by

smartphones and tablet computing (Garritty and El Emam, 2006).

The World Wide Web has become a resource for health information since the 1990s (Hardey 2008).

Gilmore describes how the Web itself has undergone a transition from a mostly ‘read-only’ Web 1.0 to a

‘read-write-participate’ Web 2.0 (also known as the ‘social Web’), reflecting a trend towards participation,

openness, and democratization (as cited in Hardey 2008, p. 182). Web 2.0 includes Wikipedia, Facebook,

Google, YouTube, Twitter, blogs, social bookmarking, and social gaming. The literature has already shown

the use of social software to be quite prevalent amongst medical students. Sandars et al. (2008) found that

over 90% of medical students used instant messaging and 70% used social networking sites. They found that

blogs were read by about 20% of students, whereas only 8% actually wrote their own blogs. However, this

study is based on data more than 5 years old, and the use of Web 2.0 has most certainly increased since that

time. The significance of Web 2.0 has led to the development of courses to help educators use these tools

(Rethlefsen et al. 2009). However, the question remains – what proportion of students and teachers currently

use Web 2.0 technologies in medical education?

Just as PDAs, tablets, and smartphones have become more prevalent in society, their use has also

grown in patient care and in medical education. Hunter et al. ( 2010) advocate the use of smartphones for the

practice of plastic surgery, and provide a list of recommended websites and applications. These tools may

also be used to teach procedural skills. Hawkes et al. (2012) describe using smartphone technology to teach

neonatal intubation. Mobile technology has also been found to be useful on the ward. A study by León et al.

(2007) found positive attitudes towards supplied smartphones for internal medicine ward residents. The

literature has also examined the use of portable computing by instructors. Ferenchick et al. (2010) conducted

a national survey of Internal Medicine clerkship directors and found that the majority (59-95%) used portable

computing for educational activities. Some specialties have created an iPad app specifically for residency

education (Rohrich et al., 2011). Despite increasing academic interest in the use of mobile medical education,

most of the literature focuses on examples of implementation of the technology. Research on prevalence of

use describes mostly general use, not specific applications or programs, and data on use within recent years is

scarce. Literature review found no studies that cross-sectionally compared use of mobile technology for

junior versus senior medical students.

This project aims to add to the literature by specifically exploring what resources and technologies

medical students are currently using to learn compared to what technologies instructors are using to teach.

The aim of this study was to address the following questions:

What resources do students use for their personal learning in and outside the classroom (textbooks vs

computers vs mobile devices)?

What proportion of students uses each of these technologies?

Is electronic medical education a disruptive innovation, replacing textbooks or traditional classroom

teaching?

Is there disconnect between how students currently learn and how instructors teach them?

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Methods

Study design

This study used a questionnaire to collect data on e-learning. Approval was obtained from the

institutional Research Ethics Board. The study was conducted at the University of Manitoba in Canada. Data

were collected between April to June 2013.

Subjects

The subjects assessed included junior medical school students (Med1&2, pre-clerkship), senior

medical students (Med3&4, clerkship). Instructors were surveyed through the Curriculum Committee, as this

group included instructors significantly involved with medical education and with representation across all

specialties and departments.

Data Sources and Measures

The study and questionnaire were vetted by researchers, subject matter experts, and students. The

data sources were the attitudes and reported behaviours of medical students and instructors regarding the use

of technology and medical reference resources. The broad constructs examined were the use of technology

for education, and the comfort with developing and using these technologies.

Questionnaires were collected from students and faculty regarding the use of technology and medical

reference resources. Please see Table 1. Faculty were given an additional questionnaire regarding their

comfort with using e-learning technologies. Please see Table 2. Data included frequency of use of

technology (ordinal data from hourly to yearly to never), and faculty comfort with using technologies (ordinal

data using a 5-point Likert scale from Strongly Disagree to Strongly Agree). A section in the questionnaire

allowed for additional comments. The questionnaire was sent by email with a reminder email at 2 weeks.

Table 1. Questionnaire on use of e-learning technologies

Level of training Med 1&2 Med 3&4 Faculty Smartphones are a valuable

educational resource Strongly Disagree Disagree Neutral Agree

Strongly Agree

Tablet computers are a valuable educational resource

Strongly Disagree Disagree Neutral Agree

Strongly Agree

How often did you use the following technologies specifically for EDUCATIONAL uses (ie. students using for LEARNING/ STUDYING/ IN-CLASSROOM/ ON-THE-WARDS, or instructors using for TEACHING)?

Hourly Daily Weekly Monthly Yearly Never

Textbook

Facebook

Wikis (ie. wikipedia)

YouTube (or other online videos)

Tablet Computer

Online Learning Modules

Pocketbook Reference

Online Discussion Board

Desire to Learn

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Smartphone

Twitter

Search Engine (ie. Google)

Blog

Please comment on the use of e-learning in medical school

Table 2. Questionnaire to faculty on comfort with using e-learning technologies

I have the comfort to/ am able to:

Strongly Disagree Disagree Neutral Agree

Strongly Agree

Contribute to a Textbook

Contribute to a Pocketbook Reference

Participate in an Online discussion board

Use iClickers in a lecture

Post on Facebook

Post a Blog entry

Record a video for YouTube (or online videos)

Tweet on Twitter

Contribute to a Wiki (ie. Wikipedia)

Develop a simulation session for education

Create online assessments (quizzes, surveys)

Develop an Online learning module

Develop a Tablet application

Develop a Smartphone application

Data Analysis

The data were analyzed to examine for differences between the following groups:

1. Medical student vs faculty use of technology.

2. Med 1&2 vs Med 3&4 use of educational technology.

Results

A. Response rate

The Response rate was 34% for Med 1&2 (74/220), 20% for Med 3&4 (43/220), and 70% for faculty

(35/50). The response rate was 27% for all medical students (117/440), and 31% for all responses (152/490).

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B. Students vs Faculty

The data were compared between students and faculty for percentage using e-learning technologies at

least weekly for educational use.

Smartphones and tablets - students vs faculty

The data showed that more students used a smartphone at least weekly for educational purposes than

faculty (82% vs 35%, statistically significant, p <0.001) but used a tablet computer equally often for education

(37% vs 29%, p = 0.56). Most students and faculty felt that both smartphones and tablets are valuable

educational resources. Compared to faculty, more students agreed that the smartphone is a valuable

educational resource (89% vs 71%, statistically significant, p = 0.027), but not so for the tablet (67% vs 83%,

p = 0.11). Please see Table 3.

Table 3. Use of Smartphones and Tablets (Student vs Faculty)

Use of Smartphones and Tablets (Students vs Faculty)

Student Faculty p-value

Use smartphone at least weekly for education* 82% 35% <0.001

Use tablet at least weekly for education 37% 29% 0.56

Agree that smartphone is a valuable educational resource*

89% 71% 0.027

Agree that tablet is a valuable educational resource 67% 83% 0.11

*p-value < 0.05

Frequency of use of technology for educational use - students vs faculty The percentage of students using technologies at least weekly for educational purposes was

statistically more than faculty for online search engines (e.g. Google), textbooks (electronic or paper), wikis,

smartphones, Facebook, pocketbook references (e.g. antimicrobial guides), and YouTube. Please see Table 4.

There was no statistical difference for the use of online learning modules, tablet computers, online discussion

boards, blogs, or Twitter. Please see Figure 1.

Table 4. Percentage with at least weekly use of technology for EDUCATIONAL use (Student vs

Faculty).

Percentage with at least weekly use of technology for EDUCATIONAL use (Student vs Faculty)

Student Faculty p-value

Search Engine* 96% 68% <0.001

Textbook* 85% 26% <0.001

Wikis* 84% 12% <0.001

Smartphone* 82% 35% <0.001

Facebook* 56% 3% <0.001

Pocketbook Reference* 50% 24% 0.014

YouTube (or online videos)* 47% 9% <0.001

Online Learning Modules 40% 24% 0.13

Tablet Computer 37% 29% 0.56

Online Discussion Board 15% 6% 0.26

Blog 6% 3% 0.86

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Twitter 6% 3% 0.86

*p-value < 0.05

Figure 1. Percentage with at least weekly use of technology for EDUCATIONAL use (Student vs

Faculty)

*indicates statistically significant difference

C. Med 1&2 vs Med 3&4

Frequency of use of technology for educational use - Med 1&2 vs Med 3&4 The percentage of Med 1&2 students using technologies at least weekly was statistically more than Med 3&4

for Facebook, YouTube, Online learning modules, and online discussion boards. Please see Table 5. Med

3&4 students had statistically more use of pocketbook references. There was no statistical difference for the

use of Twitter, tablet computers, textbooks, search engines, smartphones, wikis, or blogs. Textbooks were still

used at least weekly by 85% of students (87% of Med 1&2, 83% of Med3&4). Please see Figure 2.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percentage with at least weekly use of technology for EDUCATIONAL use (Student vs Faculty)

Student

Faculty

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Table 5. Percentage with at least weekly use technology for EDUCATIONAL use (Med 1&2 vs

Med 3&4)

Percentage with at least weekly use of technology for EDUCATIONAL use (Med1&2 vs Med3&4)

Med1&2 Med3&4 p-value

Facebook* 81% 6% <0.001

YouTube (or online videos)* 62% 17% <0.001

Pocketbook Reference* 36% 71% 0.0017

Online Learning Modules* 51% 17% 0.0021

Online Discussion Board* 23% 0% 0.0049

Twitter 8% 0% 0.23

Tablet Computer 34% 40% 0.69

Textbook 87% 83% 0.84

Search Engine 97% 94% 0.9

Smartphone 82% 80% 1

Wikis 84% 83% 1

Blog 5% 3% 1

*p-value < 0.05

Figure 2. Percentage with at least weekly use of technology for EDUCATIONAL use (Med 1&2 vs

Med 3&4)

*indicates statistically significant difference.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percentage with at least weekly use of technology

for EDUCATIONAL use (Med1&2 vs Med3&4)

Med1&2

Med3&4

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D. Faculty comfort with using educational technologies

Figure 3 indicates the percentage of Faculty that feel that have the comfort to/ are able to use various

educational technologies. Most Faculty were comfortable contributing to a textbook or pocketbook, 46%

reported the capability to post on Facebook, and very few faculty reported the ability to create online

assessments (23%), develop online learning modules (17%), develop tablet applications (6%), or develop

smartphone applications (3%).

Figure 3. Percentage of Faculty with comfort/ability to use educational tools

E. Faculty comments

One theme that arose from faculty comments was the general limited use of e-learning tools for

teaching in medical education.

The faculty stated the following regarding their use of e-learning and future directions of medical

education:

“[Future directions include] teaching and replacing lectures, engaging learners, faculty development

and support.”

“I would love to incorporate more technology but am very uncertain and lack confidence in how to go

about it.”

“[We should develop] new ways to engage students - i.e. smartphone in class surveys… or real-time

surveys in class rather than clickers”

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“E-learning is a way to track competency attainment in a competency based curriculum – e-learning

to flip the classroom”

“I see it as a priority to develop greater knowledge of e-learning resources among instructors,

including myself. I don't know enough about them to use them properly, but I would like to learn.”

The most commonly used tools were PowerPoint or videos, but very few faculty members used online

discussion boards, created online quizzes, or referenced smartphone apps. Some faculty reported using

additional technologies such as cloud computing and simulation sessions. Faculty also expressed a lack of

comfort with developing e-learning tools such as contributing to a wiki or developing apps for smartphones or

tablets. Faculty, however, expressed a great desire to use educational technologies in the future, and requested

greater support in learning how to use tools such as improved classroom interaction, online teaching content,

and competencies tracking. They also requested standardization across the curriculum on the use of e-

learning.

F. Student comments Themes from the student comments included frequent use of e-learning tools, students regarding e-

learning as very valuable to their education, faculty lacking comfort for the use of educational technologies,

and a desire for increased use and improved use of e-learning technologies in the future.

The following are some quotes from the students:

“Build on existing e-learning tools that are widely available… Thereby there can be no live lectures,

and instead group sessions where students and faculty interact.”

“I think smartphones and tablets are really the future, mostly due to their practicality and

convenience.”

“A large priority should be to centralize all electronic learning into one system.”

“More frequent unmarked quizzing [formative assessment] of our growing knowledge would help us

assess our progress.”

“Priorities for e-learning would be to develop a system where students are given the appropriate time

and resources to learn on their own in an efficient and effective manner.”

“I am excited about the school using more e-learning; it has a lot of strengths and is often more easily

accessible than some traditional resources. My main concern with e-learning is when the

technology/delivery takes priority over content - sometimes a resource is flashy or convenient, but the

actual content delivered is inaccurate or is presented in a way that impedes rather than facilitates

learning and absorbing the information.”

“Electronic learning resources are important to integrate into the curriculum, but only where it is

logical and this augments or exceeds the quality of existing resources. A good example is maintaining

existing gross lab facilities instead of transitioning to an all-digital anatomy curriculum like some

schools have done. It would be hugely detrimental to the education process. Alternate non-digital

resources should be maintained. For example, having textbooks easily accessible through the library

proxy would be great, but there should still be physical textbooks available on reserve for individuals

who prefer to study that way or want to switch it up to fight off fatigue from staring at a screen. It is

the classic multi-modal approach just applied to education and it is what works.”

“E-learning is the true norm of learning. Rather than having specified lectures with attendance,

lectures should be taped and resources made available for students to pursue on their own schedules.

Scheduled sessions should be used to teach clinical skills, and have problem based learning. With this

curriculum, students will be better prepared for the independent learning expected from us in

clerkship and the rest of our lives.”

Students reported that while hardcopy textbooks were still used, most students preferred electronic

versions of the textbooks. The anatomy lab was one specific area where hardcopy textbooks were found to be

still quite useful. There also seemed to be a movement from predominant laptop use to increasing tablet use

in the classroom.

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Online quizzes and online case modules were felt to be of great value to medical education. Students

indicated a desire for more questions and quizzes to be available online. They also strongly indicated that

more content should be placed on mobile technology such as smartphones and tablet computers for medical

education in the future. Students, similar to faculty, also reported increasing use of cloud computing for

education.

Students felt that faculty members were about 10 years behind students when using educational

technologies. Instructors in medical school were felt to be particularly poor in use of e-learning. The general

consensus was that “compared to undergrad, [instructors] cannot use PowerPoint effectively in medical

school”. The students reported that only about 50-60% of the class attended classroom lectures.

Student comments indicated a desire to increase use of e-learning for the future, including streaming

all lectures online in real-time, updated clinical skills videos, case modules, less focus on the classroom, and

standardization of e-learning delivery. One student’s statement was echoed by the group: “What I think they

need to do most with the new curriculum is to stop punishing people that are not going to lectures. Some

people can’t sit there and listen to someone talk for an hour and get anything out of it. And it’s not like it’s a

small number of people, it’s a lot of people. Why is it a problem that I’m learning on my own? … As a

medical school, shouldn’t the top priority be [training] people that know what they are doing and not people

who went to class?”

Discussion

Response Rate

The overall response rate for this study was 31%. This is similar to response rates found in the

literature for web-based surveys. A meta-analysis of web-based surveys found an average response rate of

34%, with a range from 7% to 88% (Shih and Fan, 2008). The response rate in this study was higher for Med

1&2 students versus Med 3&4 students. Senior medical student response rates may have been affected by

increased clinical obligations on the ward, on call, and on electives.

Medical Students compared to Faculty

Medical students used smartphones much more often for educational purposes compared to faculty

(82% vs 35%). This reflects a movement towards increasing use of smartphones and mobile technology in

medical education (Ozdalga et al. 2012). These technologies extend beyond physician training to increasing

use in the delivery of patient care (McMahon 2013). This study found that 96% of students used search

engines at least weekly for educational purposes. Such widespread use is supported in the literature, with

speed and ease of information retrieval often cited as reasons for usage (Schattner et al. 2013). As both strong

and weak resources may be found through such search engines, increased medical student training in

Information sciences would help students retrieve accurate information for education and patient care.

Fifty-six percent of medical students used Facebook at least weekly for educational purposes. These numbers

are in stark contrast to the only 3% of faculty who used Facebook at least weekly for medical education. Only

46% of faculty felt that they knew how to create a post on Facebook. Evidently, online social networking is a

technology with a great divide between student use for learning and faculty use for teaching. Junior students

used Facebook much more than their senior counterparts (81% of Med 1&2 students vs only 6% of Med 3&4

students). This difference may represent the different nature of pre-clerkship (mostly in class) vs clerkship

(mostly in the hospital) training, or it may reflect a true growth in the use of social networking by younger

students. As the realms of social media and medical education merge, further guidelines must be developed

into curricula to optimize educational uses and maintain professionalism (Ross et al. 2013). Although social

networking may represent an excellent opportunity for engaging students, it remains difficult to determine the

role of faculty as participant, moderator, or administrator.

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Despite the literature reporting increasing use of Twitter and blogs in education, the study found their use at

this institution to be rare amongst both medical students and faculty alike. Within all groups, only 8% or less

used these technologies for educational purposes. The author recognizes that these tools may be used much

more frequently at other center and thus may have greater potential for medical education at those institutions.

Med 1&2 compared to Med 3&4

Eighty-one percent of Med 1&2 students used Facebook at least weekly for educational purposes

compared to only 6% of Med 3&4 students. Compared to Med 3&4 students, Med 1& 2 students used

YouTube, online learning modules, and online discussion boards more frequently for educational purposes.

Again, these differences may reflect the difference in training format between these student groups, or may

represent a true growth of e-learning amongst medical students.

Med 3&4 students used pocketbooks more often than Med 1&2 students, likely due to the senior students

being on the wards and more often needing a quick point-of-care source for reference.

Faculty comfort and abilities in e-learning

Despite their widespread use and perceived value amongst medical students, few faculty have comfort and

expertise using e-learning technologies. Faculty did strongly express, however, a desire to improve their

skills. A few strategies may help improve faculty adoption of e-learning: (1) Increased faculty awareness on

the value of using e-learning technologies, (2) Improved faculty development in the implementation of these

technologies and (3) Educational technologists to bridge the gap between the faculty as subject matter experts

and educational technologies as part of an instructional plan. Strategies for e-learning success are of

educational and emotional importance in medical school (Ellaway 2007). Lessons may be learned from other

educational realms, such as K-12 education and other professional schools (Howland and Wedman 2004).

Many medical institutions may need to increase their educational technology personnel significantly in order

to meet the growing demands for e-learning.

Are e-learning tools disruptive technologies?

Textbooks were still used frequently by medical students, and pocketbook references still in common use by

senior students. Though many of the newer e-learning tools were used as frequently or more frequently

compared to these traditional educational resources, they do not seem to be disruptive technologies. At this

point, educational technologies have not replaced their more established counterparts, and the textbook seems

to remain alive and well. The traditional didactic lecture, however, appears to be undergoing at least an

evolution. As the desire to use e-learning increases by both faculty and medical students, medical curricula

will see increasing use of mobile technology, online content, electronic classroom interaction, “flipped

classrooms”, and electronic formative and summative assessments (Prober and Heath 2012). These

educational models allow the student to progress through much of their education through self-study, and in

any location. With medical education undergoing transformation, the question remains on what the role of

face-to-face sessions will be in the future, and how to make these sessions as effective as possible as newer e-

learning strategies become more prominent. Although we must always ensure that the use of e-learning tools

is founded in sound teaching strategies, educational technologies make possible an expanded vision for

medical education in the 21st century (Harden 2008).

Future Directions

Given the findings of this study, the following suggestions may help guide the future of e-learning in medical

education:

Increased faculty development in the use of e-learning technologies

Increased involvement of educational technologists in medical education

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Strategies to maximize the interaction and effectiveness of face-to-face classroom sessions in

combination with e-learning

Integration of mobile technology in medical education

Consideration of the use of social networking in medical education and the policies required for

implementation

D. Recommendations for Future Research

The literature on e-learning and medical education continues to expand rapidly. Future research

related to this study may include examination of different strategies for faculty development in e-learning and

further assessment on the implementation of policies for social networking in medical education. A study

similar to this one may be conducted at other institutions to assess the generalizability of this paper’s findings.

Other e-learning tools may be studied such as cloud computing, massive open online courses (MOOCs), and

online audience response systems. Lastly, because technology is developing so rapidly, the data of this study

may be outdated by the time the reader has reviewed the findings. This study (or one similar) may be repeated

in a few years to examine how the learning practices of medical students have further evolved, and to

determine if faculty have been able to close the gap between their e-learning capabilities and the educational

needs of the students.

Assumptions and Limitations

The study assumes a normal distribution of the study groups. Responder bias may exist with a greater

response rate from people whom are more technologically inclined. The external validity of this project is

uncertain, as there are likely medical schools which use more e-learning and other schools that use less e-

learning than the one in this study. However, some principles from this study are likely generalizable to other

institutions.

C. Conclusions and Implications

The use of educational technologies continues to expand as newer technologies are developed. This study

found that medical students used many of these technologies more often than faculty. Faculty comfort and

ability was lacking for many of the e-learning tools that were frequently used and felt to be valuable by

medical students. Faculty, however, indicated a strong desire to improve their skills with educational

technologies. Improved faculty development in e-learning can help faculty keep up with the evolving

technological learning practices of students in medical education.

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Notes on Contributors

A.C.C. GOOI, MD, FRCSC, MEd is the Director – Online Learning for undergraduate medical

education at the University of Manitoba.

Acknowledgements

I am grateful to Lynne Smith for her guidance on this study as part of a Masters in medical education

program, and to all the students and faculty involved in this study.

Declaration of Interests

The author reports no declarations of interest.

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