Otoscopic examination is crucial to diagnose otologic conditions, which are common in general practice.(4) However, studies have shown that teaching and learning of otoscopic examination are often inadequate at both the undergraduate and postgraduate levels.(2) Nowadays, with the rapid progression in multimedia technology, it has become easier to use web-based platforms for teaching and learning. Web-based teaching can offer many potential advantages over the traditional method of teaching (5). Web-based teaching can allow students to learn using graphic images, sound and video, accessing content anywhere else other than class, interactive learning by quiz or feedback, and to revisit the content for revision. Web-based teaching is also a low-cost teaching method with wide accessibility (6). Grundman et al. concluded that visual and audio was able to augment the learning of a particular examination skill. In their study, the students’ examination skills and diagnostic ability showed improvement using web-based learning compared to revising printed lecture notes (5). In another study in 2016 by Stepniak et al, web-based learning was found to be effective in teaching otoscopy for undergraduate medical students (7). However, this study utilised a high end, and expensive simulator with a very limited follow-up period of only one week. In this study, the long term effectiveness of learning otoscopy through a newly developed online platform was assessed using online questionnaires on the level of confidence in the otoscopic examination and one best answer questions on diseases of the ear canal and tympanic membrane to test the diagnostic ability.
Level of Confidence
Student acquisition of knowledge and skills in otoscopy can be measured via students’ self-evaluation opportunities. An example of such evaluation is self-reporting of perceived confidence level in performing the various tasks in the otoscopic examination. This study utilized such methods using a 5- point Likert scale to determine the level of confidence in the otoscopic examination. A similar evaluation was used by Kaf et al in their interventional study of thirty-two first-year undergraduate audiology students (3). On the other hand, Swamy et. al. in 2014, assessed their subjects using a 4-point Likert scale in an interventional study on a simulated model (SimMan) to improve the confidence level in performing otoscopy (8). We feel that utilising a 5-point Likert scale is better compared to a 4-point scale to observe differences in subjects’ level of confidence across the different sampling points in the study.
This study demonstrated a significant increment in the subjects’ perceived level of confidence in performing otoscopy following the intervention. This increment is sustained at even four months following the study intervention, showing that a web-based learning platform may be an effective addition in teaching and learning of otoscopic examination. To the best of the authors’ knowledge, no similar interventions have published similar outcomes in the English literature at the time of writing. Other interventions described in the literature included a small group structured teaching by You et al, high fidelity simulator by Swamy et al and supplementary training by Kaf et al (3, 8, 9)
Comparing the subjects’ self perceived level of confidence in external auditory canal and the tympanic membrane, we found that the final year medical undergraduate students were less confident in the identification and abnormalities of the tympanic membrane compared to the external auditory canal. This finding concurred with a similar study by You et al, who mentioned that it was challenging to assess tympanic membrane due to its location and inaccessibility compared to external auditory canal (9). This was reflected in our results where the mean level of confidence score to identify the conditions in tympanic membrane is slightly lower at T3 (8.84) than the external auditory canal (9.09).
Diagnostic Ability
Students’ diagnostic ability can be measured by using questions with marks. The questions may include normal ear and common diseases of the external auditory canal and tympanic membrane, but must be validated by experts. The diagnostic ability of study subjects was similarly explored by previous authors like Kaf et al, Wu et al and Moberly et al using short answer questions. In a study conducted by Kaf et al, in 2013, the authors used the 54-questions and short-answer examination to assess the students’ knowledge on otologic anatomy and pathology (3). In parallel, Wu et al used a series of 25 images while Moberly et al used questions with 7 different types of pathologies along with 1 image showing the normal anatomical structure (10, 11). Each correct answer was given one mark and the total marks attributed to the students’ diagnostic ability (3). Thus, in this study, we determined the diagnostic ability by providing 25 validated one best answer questions given by a panel of experts. The questions composed of 8 common diseases (3 questions per pathology) of the external ear, middle ear, and 1 question about the normal ear. Each correct answer was given one mark.
A significant improvement in diagnostic ability scores on both the external auditory canal and the tympanic membrane was demonstrated in the present study. In line with previous study by Moberly et. al, the diagnostic ability of otoscopic examination increased after the intervention (11). The long term retention for diagnostic ability was also measured 4 months following the intervention. Similar to the level of confidence, the diagnostic ability in otoscopic examination among students was sustained at high scores over a period of four months. The results showed a significant difference in diagnostic ability scores when compared 4 months following intervention (5.20) to the baseline (4.38). The results obtained were similar to a previous study conducted by Dastjerdi et al who concluded that a multimedia program on teaching empirical science among second-grade students showed better retention in learning 3 months following the intervention compared to traditional methods (12). We postulate that this sustained improvement in the diagnostic ability scores is explained by the Kolbe model of experiential learning where lectures and small group training in the fourth undergraduate year provides concrete experience on otoscopy examination.(13) Patient experiences and case scenarios encountered during and outside of the formal posting may allow reflective observation, abstract conceptualisation and active experimentation, but lack of discussion and feedback mechanism may deter learners from reflecting and progressing on the experience ladder. Using the online discussion forum, timely feedback was given, juxtaposed with instructional content related to the educational materials provided in the platform itself. This way, students are actively learning, which can be more effective for the student. This timely, immediate feedback mechanism provides reassurance and confirms progress among students, more so if it is made public and readily available.(14)
This study has limitations to be acknowledged including the high rate of dropouts due to incomplete data. The researchers, however, managed to achieve the targeted sample size to obtain a considerably good study power of 80%. We recommend further studies to rigorously send reminders using more platforms including phone calls and provide more incentives so that subjects are able to complete the study outcome measures. All the excluded subjects were individually interviewed via a phone call to identify the potential factors contributing to their poor compliance to the study. Audio recording of these interviews were anonymised and analysed using thematic analysis. The main reason mentioned was not enough time to adhere to the given study time lines (70.84%) and did not notice reminders given to complete the questionnaires given (29.16%). Direct questions were asked regarding accessibility, ease of navigation and whether excluded subjects will continue to access the online platform despite being excluded. All excluded subjects agreed that the materials provided were accessible, it was easy to navigate the web- based platform and they continued to use the learning platform despite being excluded. Additionally, this study did not have a control group without intervention to compare the study outcome measures. A future randomized, prospective interventional study is needed to confirm and consolidate our study findings.
Novelty of the study
This study developed a supplementary web-based learning platform for the medical undergraduates of Universiti Kebangsaan Malaysia which is tailored towards the needs of the current curriculum of the university as well as the local setting. Adapting a web-based learning platform developed by the Western countries may not only be costly, but may lack linguistic and cultural adaptations unique to the learner and their future patients. This study demonstrated long term positive effects on students’ level of confidence and diagnostic ability which was not demonstrated in previously published interventions in teaching and learning of the otoscopic examination.(9, 10) A web-based learning platform may offer many potential advantages in the current teaching method and should be incorporated to improve the level of confidence and diagnostic ability in otoscopic examination among the undergraduate students.
Learning on otologic condition was provided by content experts in otorhinolaryngology in a formal three-week posting. Study subjects assimilate the previously learnt knowledge with the patients’ clinical condition after reviewing the educational video to improve their understanding of the otoscopic examination. The online discussion provided a platform for further discussion, inquiries and feedback. Furthermore, the flexibility of viewing the video repeatedly allowed discussion among peers. Thus, students were able to identify, plan, and react to the information during the discussion. Timely feedback by an experienced otorhinolaryngologist will construct new knowledge and understanding to achieve the intended learning outcomes.
The above process is related to social constructivist theory which emphasizes the role of social contexts of learning, and the knowledge which is mutually built and constructed. According to Vygotsky (15), social interaction between learners and other knowledgeable persons contributes to learning through the development of the cognitive domain (i.e., language, thought, and reasoning). Another important concept highlighted by Vygotsky is the role of Zone Proximal Development (ZPD) in which the students were able to solve their patients’ problems due to the opportunity they had to communicate and collaborate with one another through online discussion with peers and feedback information from the content expert. Hence, two-way online interaction enabled students to identify and justify their weaknesses and strengths based on their existing knowledge.
How will this paper make a difference in medical education practices?
This study sheds light on more effective ways to train future doctors in the otoscopic examination. This skill is important to master before they graduate especially as they are preparing themselves to diagnose otologic conditions and manage these diseases independently in general practice. Failure in teaching and learning of otoscopic examination will contribute towards future problems such as misdiagnosis, antimicrobial resistance and, even morbid complications. It is appealing to the general practice as a significant proportion of patient presents with ear complain, the most prevalent being, otitis media with effusion which is reported to be as high as 18.3% among preschoolers.(16) In the light of the coronavirus pandemic where distant learning is becoming the norm, this paper provides more evidence on the effectiveness of using a web-based learning platform to supplement clinical teaching in medical education practices.