Instructional Design Variations in Internet-Based Learning for Health Professions Education: A Systematic Review and Meta-Analysis

Cook, David A. MD, MHPE; Levinson, Anthony J. MD, MSc; Garside, Sarah MD, PhD; Dupras, Denise M. MD, PhD; Erwin, Patricia J. MLS; Montori, Victor M. MD, MSc

doi: 10.1097/ACM.0b013e3181d6c319
Internet-Based Learning: Systematic Review

Purpose: A recent systematic review (2008) described the effectiveness of Internet-based learning (IBL) in health professions education. A comprehensive synthesis of research investigating how to improve IBL is needed. This systematic review sought to provide such a synthesis.

Method: The authors searched MEDLINE, CINAHL, EMBASE, Web of Science, Scopus, ERIC, TimeLit, and the University of Toronto Research and Development Resource Base for articles published from 1990 through November 2008. They included all studies quantifying the effect of IBL compared with another Internet-based or computer-assisted instructional intervention on practicing and student physicians, nurses, pharmacists, dentists, and other health professionals. Reviewers working independently and in duplicate abstracted information, coded study quality, and grouped studies according to inductively identified themes.

Results: From 2,705 articles, the authors identified 51 eligible studies, including 30 randomized trials. The pooled effect size (ES) for learning outcomes in 15 studies investigating high versus low interactivity was 0.27 (95% confidence interval, 0.08–0.46; P = .006). Also associated with higher learning were practice exercises (ES 0.40 [0.08–0.71; P = .01]; 10 studies), feedback (ES 0.68 [0.01–1.35; P = .047]; 2 studies), and repetition of study material (ES 0.19 [0.09–0.30; P < .001]; 2 studies). The ES was 0.26 (−0.62 to 1.13; P = .57) for three studies examining online discussion. Inconsistency was large (I2 ≥89%) in most analyses. Meta-analyses for other themes generally yielded imprecise results.

Conclusions: Interactivity, practice exercises, repetition, and feedback seem to be associated with improved learning outcomes, although inconsistency across studies tempers conclusions. Evidence for other instructional variations remains inconclusive.

Dr. Cook is associate professor of medicine and director, Office of Education Research, College of Medicine, Mayo Clinic, Rochester, Minnesota.

Dr. Levinson is associate professor of psychiatry and director, Division of e-Learning Innovation, McMaster University, Hamilton, Ontario, Canada.

Dr. Garside is associate professor of psychiatry and associate director, Division of e-Learning Innovation, McMaster University, Hamilton, Ontario, Canada.

Dr. Dupras is assistant professor of medicine, College of Medicine, Mayo Clinic, Rochester, Minnesota.

Ms. Erwin is assistant professor of medical education, College of Medicine, Mayo Clinic, Rochester, Minnesota.

Dr. Montori is professor of medicine and director, Knowledge and Encounter Research Unit, College of Medicine, Mayo Clinic, Rochester, Minnesota.

Correspondence should be addressed to Dr. Cook, Division of General Internal Medicine, Mayo Clinic College of Medicine, Baldwin 4-A, 200 First Street SW, Rochester, MN 55905; telephone: (507) 266-4156; fax: (507) 284-5370; e-mail: (cook.david33@mayo.edu).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text and PDF of this article on the journal's Web site (www.academicmedicine.org).

© 2010 Association of American Medical Colleges