Radiologia Brasileira - Publicação Científica Oficial do Colégio Brasileiro de Radiologia

^IMaster, Program of Post-Graduation in Radiology, Faculdade de Medicina da Universidade Federal do Rio de Janeiro (UFRJ), MD, Radiologist, Head for the Unit of Mammography – Pro-Echo, Rio de Janeiro, RJ, Brazil
^IIPhD, Universidade Federal do Rio de Janeiro (UFRJ), Physician for the Service of Gynecology, Hospital Universitário Clementino Fraga Filho da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
^IIITitular Professor, Department of Radiology, Physician for the Service of Radiodiagnosis and Nuclear Medicine, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil

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INTRODUCTION

Distance education is a method that offers a more continuousupdating for health professionals, and may be defined as ateaching/learning method where the student is given access to apreviously prepared instructional material, and where thelearning process is conducted by a professor at distance. It isimportant to note that distance education is not anymorecharacterized by the distance, considering that the virtualityallows more and more effective meetings to occur, in fact,allowing the education to happen⁽¹⁾.

In practical terms, the integration of the new informationtechnology into the imaging diagnosis has allowed theradiologists to "export" their abilities, sharing information,reducing costs, and improving the efficiency, quality andcoverage of their services. Different formats of continuedmedical education may be associated withtelemedicine⁽²⁾. Programs for teachingradiology and nuclear medicine may be quite adaptable to distanceeducation.

In Brazil, programs of continued medical distance educationare a relatively recent issue, but in Europe, United States ofAmerica and Canada, they have already existed for a long time.Considering the huge territorial extent of our country, theinternet-conducted distance education arises as a viablealternative for knowledge dissemination⁽³⁾.

After the internet consolidation in the eighties,academic-specific systems and softwares (the so called virtuallearning environments) were developed⁽⁴⁾.Usually, virtual learning environments are constituted byintegrated tools contemplating the three great groups of generaldistance education tools: administration, coordination andcommunication. In this course we have chosen to utilize thevirtual learning platform called "modular object-oriented dynamiclearning environment" (Moodle), because, besides being a freesoftware, it is extremely easy to use and meets our needs asnaive users. This virtual learning environment includes acommunity with more than 130,000 registered users, running in 75languages, across 169 countries, and being utilized by 197Brazilian institutions⁽⁵⁾. Moodle offers toolsfor monitoring the browsing activities of each participatingstudent, identifying the web pages visited as well as the accessduration. The software allows the reconstruction of the student'sbrowsing activities and respective session-browsing times.

The present study idealized a course whose theme was "Sentinellymph node, prevention, early diagnosis and biopsy – a newtechnique for approaching breast cancer" in theinternet-conducted distance education modality. The model wasaimed at involving the participating students in an interactivedistance learning experience with other participants, stimulatinginformation exchange.

The development of the course required a research ontheoretical, pedagogical and technological foundations of thedistance education methodology. It was necessary to overcome thefour classical steps in distance-education: planning, design,production and services⁽⁶⁾. Also, it wasnecessary to investigate, identify and analyse a range ofnon-presential pedagogical strategies related to the learning inthe distance education process, to allow the adaptation of thedidactic material available⁽⁷⁾. The inclusionof hypertexts allowed a direct access to other texts andcontents, enhancing the interaction dynamics and velocity ofaccess to multiple contents⁽⁸⁾. The model wasbased on the collaborative learning methodology, withsimultaneous involvement of the participating students,including, for example, the study of clinical cases withquestions to generate considerations on the matter in a forum asan open space aimed at broadening thediscussions^(9,10).

MATERIALS AND METHODS

The general coordination for the course was undertaken by asingle professor who was responsible for gathering didacticmaterial and adapting it to the distance education methodology,besides monitoring the compliance with the established timetable,conducting the interface with the informatic team, and offeringthe course in the period between October and December/2005.

The course was structured into five sections: the first one,called "Acquaintance space", included a panel where news and tipswere continuously posted, and a discussion forum was utilized asa "coffee shop" for ideas exchanging. The second one was called"Learning module" and was utilized for presentation of didacticclasses. The third one, called "Activities", included exercisesfor knowledge retaining configured as "clinical case". The fourthsection was called "Interaction space", with forums for debateson clinical cases. The fifth section, "Library", was utilized forpublishing references, texts and articles aimed at deepening thestudent's knowledge about the themes approached by course.

The instructional material was hierarchically and sequentially made available for the students in the form of hypertext. Fourteen 30-minute theoretical classes and 12 activities divided into five clinical cases and seven questions were offered to be commented in the corresponding discussion forums (Figure 1).

During the classes, links were made available to provideimmediate access to the proposed exercises. The student couldaccess the links to solve the exercises or to proceed in thereading of the text. For resolution of the proposed questions andclinical cases, discussion forums were opened up aiming atbroadening a debate based on the collaborative learning concept.The participating students were supervised by the coursecoordinator who was also responsible for enhancing theinteraction among them. Periods were suggested for students topost comments on the discussion forums. For each comment posted,the student received an electronic message automatically sent bythe virtual learning environment. Every time a new material waspublished, the coordinator sent e-mails inviting the students toparticipate in the activities.

RESULTS

After publicizing during the Brazilian Congress of Mastology, in September/2005, 15 students applied for the course. Two of these students had no e-mail address and for this reason they gave the course up; other four students were not able to submit the electronic application in the virtual learning environment and, unfortunately, could not qualify for the program. The course was started with nine students; all of them were physicians with Title of Specialist in Gynecology and Obstetrics, and four of them in Mastology, working in mastology clinics, two in top positions. The ages ranged between 32 and 54 years, and the professional experience, between eight and 27 years. Five were men and four were women. In the distance-education modality, the course reached eight cities in four Brazilian states (Figure 2).

The participating students highlighted the opportunity tofamiliarize with the sentinel lymph node biopsy as the mainmotivational factor for them to participate in the course.

During the course, the number of visits to the virtuallearning environment varied according to each module contents.The first module was accessed by all of the students enrolled inthe course. The mean browsing time was 15 minutes per access tothe virtual learning environment, most frequently occurring after10:00 PM.

The next two modules discussed aspects related to the earlybreast cancer detection, the Breast Imaging Reporting and DataSystem (BI-RADS^®)⁽¹¹⁾, themanagement of non-palpable lesions and the role of the TNMstaging (classification of malignanttumors)⁽¹²⁾. A decrease in the browsing time ofthese modules contents was observed. Generally the browsing timewas very short, indicating a possible lack of interest from thestudents probably because they already knew the subject matter.Two students completed the exercises, three accessed the wholecontent but did not participated in the activities, and fourfailed to access the course.

In the fourth and last module, when the sentinel lymph nodebiopsy technique was approached, there was a considerableincrease in the browsing time per student, indicating that thistopic met the students' personal interest.

A section of presential class and a theoretical evaluationwere scheduled for February/2006. The students would be given theopportunity to experience practical activities related tosentinel lymph node biopsy, and would be submitted to a writtentest. None of the students attended this activity.

The time spent by the coordinator for monitoring the coursewas approximately 10–15 minutes/day, from Monday to Friday. Mostof times, this was enough to check the students' accesses andfeedbacks.

The present study was experimental. Data and results areavailable at the site of the course⁽¹³⁾.Certainly, additional studies are necessary to evaluate theeffectiveness of the distance education method for professionalupdating in medicine.

DISCUSSION

In distance education, a detailed planning covering all thephases of the process is critical. There is no possibility tochange the teaching strategy, and this implies a reduction in theflexibility of the original course objectives. Considering theexperimental character of the present study, the course wasoffered at no cost, and no certificate was given to participatingstudents. From the very beginning, we knew that it would be verydifficult to keep the studentsmotivated^(14–17). Despite the fact that thesentinel lymph node biopsy is a new technique, sufficient toattract the students, it could not guarantee their effectiveparticipation in the course.

Despite a well detailed program including a timetable and timeload, an evaluation of the students' profile demonstrated thattheir higher expectation was related to the sentinel lymph nodebiopsy technique that was presented only in the fourth module ofthe course. Most probably, this fact has discouraged the majorityof students, causing a decrease in the number of accesses and inthe browsing time in the virtual learning environment.

The utilization of pedagogical collaborative learningstrategies has proved to be effective for increasing the level ofmotivation of the participating students, and enhancing theaccomplishment of the proposedactivities^(9,18,19). However, this method isbased on the assumption that the students must be interested intheir activities, and such activities must be meaningful atpersonal level⁽¹⁹⁾. Main factor that movesprofessionals up is the necessity of being updated in the labormarket^(14–17,20).

As regards the communication among participating students, thecourse was approached as an asynchronous experience. There was noappointment. In spite of the availability of a chat board in thevirtual learning environment, this resource was not utilizedbecause this was the first experiment of the team with distanceeducation, and real time activities would have required a highertechnical level. On the other hand, asynchronous tools do notrequire the simultaneous presence of the participating studentsand information may be accessed at their leisure. The publishedinformation is available to be accessed by the group. Thesematerials are more carefully prepared and, generally, the finalproduct presents a higher quality. However, for beingasynchronous, it is easier for the students prioritizing otheractivities and temporarily to abandon thecourse⁽²¹⁾.

For evaluating and validating resources and strategies, it wasnecessary to make adjustments according to student's availabilityto attend the course, mean connection time, questions/answersagility, and participation in forums. A higher dispersion of thestudent's attention was clearly observed during the temporaryabsences of the course coordinator, demonstrating the fragilityof a process supported only by a single person, and not by ateam.

Based on the difficulties found during the course and, withthe purpose of refining the program, it may be concluded that: 1)the knowledge of the students´ profile facilitates thedialogue and the learning process that must be adapted to theirrhythms and differences; 2) the course organization must provideclear information and evaluation criteria, besides a clearlydefined timetable; 3) the method made the students toautonomously manage their learning; 4) in terms of value-added,it is necessary to create an engaged virtual community tocontinue the sharing of experiences, even after the coursecompletion.

Acknowledgments

The authors thank Dênia Falcão de Bittencourt,Psichologist and Professor for the Post-Graduation Course ofDistance Education Methodology at UnisulVirtual/Unisul; SociedadeBrasileira de Mastologia (SBM) (Brazilian Society of Mastology) –RJ Section; ProEcho – Diagnóstico por Imagem; andContempory – Soluções em Informática.

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Mailing address:
Dra. Santuzza Kelmer
Estrada da Gávea, 681, bloco 02, ap. 2302, São Conrado
Rio de Janeiro, RJ, Brazil, 22610-001
E-mail: santuzzaks@gmail.com

Received September 26, 2006. Accepted after revision December 4, 2006.

* Study developed in the Program of Post-Graduation in Radiology at Faculdade de Medicina da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil.