Technology enhanced learning in undergraduate health professions education: An Indian perspective

Introduction: Health professions education in India is moving to an outcome based curriculum. Technology is known to facilitate acquisition of higher levels of knowledge and skills and also aid in assessing competencies. Objective: 1. To find the role technology plays in undergraduate health professions education in India 2. To compare its effectiveness to traditional educational methods 3. To study the undergraduate students’ perceptions regarding use of technology for teaching-learning Material and Methods: A review of articles pertaining to use of technology in India in the last 10 years was carried out in Pub Med and Ovid MD. 16 articles were included in the review after screening. Results: Technology has been incorporated in supplementing face to face instruction to enhance knowledge, clinical decision making, developing communication skills, and assessment of outcomes. There was mixed evidence as to its effectiveness. Students perceive the usefulness of technology in education and have a positive attitude towards it. Conclusion: There is a wide scope to introduce use of technology for online instruction, skills training and assessment. More evidence needs to be generated regarding its effectiveness in improving knowledge in the Indian context, so that our decisions can be based on evidence. Faculty training programs for use of technology will help in creation of resources and its implementation in curriculum.


Introduction
The current healthcare environment is dramatically different from the one that shaped our existing educational programs, with greater accountability to provide quality and cost effective health care. Health professions education (HPE) is one of the critical elements in the evolving health care scenario in India. MCI, the regulatory body of medical education in India, has proposed to revise the existing undergraduate medical education programme to a competency driven curriculum. 1 This will shift the emphasis from knowledge achievement to achievement of milestones and demonstration of competencies.
Technology plays an effective role in facilitating basic knowledge acquisition, improving problem solving and decision making skills, aiding the teaching of psychomotor and attitudinal skills. The educational experience is more learner controlled, resources more accessible, permitting students to set their own pace and aid the instructor to customize instruction according to the different learning needs of each student. 2 The new generation of learners are more accustomed to technology enhanced learning environment from an early age and very receptive to the possibility of use of technology and the social media platform for edutainment. 3 Role of technology in delivery of HPE: Role of technology is expanding over years in field of HPE and some of the areas are mentioned below: 4 1. Technology for face-to face instruction a. Electronic smartboards which can digitally capture the instructor's chalkboard drawings and make them available for review or dissemination via other online platforms b. Audience  We also searched Google scholar with the related search words in various combinations which returned two articles fulfilling the study criteria. Full text articles were collected from the databases, few from the journal websites and research gate.

Data Extraction and Management
Information related to study design, sample of the study, outcome measures and conclusions were tabulated. The articles were then grouped depending upon the purpose of the study.

Results
This comprehensive search returned 211 articles. After removing duplicates, we were left with 144 articles. These were further screened and 125 articles were removed on the basis of title and abstract and 3 studies were removed in the second phase of screening the full texts. This process identified 16 original research articles studying different aspects of use of technology in undergraduate HPE in India in the last decade. The process of selection and evaluation is depicted in Fig. 1. Amongst these only 2 used a mixed method approach to research. All these papers were analyzed and the key information was entered in Microsoft Excel. Table 1 Journal of Education Technology in Health Sciences, May-August 2018;5(2):69-79 71

Discussion
Out of the 16 articles reviewed 6 studies (Sr. No. 1-6 in Table 1) surveyed the digital literacy, attitudes and access to internet. 10 studies (Sr. No. 7-16 in Table 1) were descriptive in nature and detailed the educational innovation implemented. Amongst these 10 descriptive articles 4 of them (Sr. No. 7-10 in Table 1) evaluated the reactions and perceptions of the learners -Kirkpatrick's level 1. The remaining 6 studies (Sr. No. 11-16 in Table  1) evaluated the program for its effectiveness as well as the participants' reactions and perceptions.
According to survey conducted by Panchabhai TS et al. there was a subset of students who had lesser access and hence lesser capabilities to use computers. 5 Internet was accessed mainly through mobiles. 6 Medical information was retrieved from various sites commonly being Wikipedia, Google scholar, Medscape, Web MD, You Tube medical videos to name a few. [6][7][8] Internet was also used to participate in online CME programmes. 6

What role does technology play in undergraduate health professions education in India
We looked at the different strategies for utilization of technology in undergraduate HPE in India. They mainly involved technology to support traditional teaching asynchronously in a blended format. Varghese J et al. linked all lecture presentations to the institutional e-learning website helping learners to revise the concepts. 9 Viswasom and Jobby used projected enlarged images to teach osteology. 10 Image based questions in a quiz format was used to revise Ophthalmology concepts by Bandhu SD and Raje S. 11 Gaikwad and Tankhiwale made interactive PowerPoints available at kiosks for easy access and included questions as challenges. 12 Abraham et al. made learning more active by the creative use of multimedia, by the students, to learn a topic. 13 Videos were included for not only achievement of higher levels of cognition by Chavda et al. but also communication skills by Jagzape et al. 14,15 A mobile learning application to teach clinical decision making skills was created for interns in prosthodontics by Deshpande et al. 16 This platform analyzed the student's treatment plan in patient cases based on the chief complaints and pretreatment oral images and also gave feedback regarding the ideal treatment plan. Creation of such apps do require financial support. Kaliyadan et al. used computer terminals to administer self-learning digital modules in dermatology. Apart from interactive PowerPoints they included quizzes, crosswords and puzzles using Hot Potatoes TM , a free software. 17 Grover C et al. conducted the end post exam in dermatology in the OSCE format using computers to test higher cognitive and problem solving skills. This eased the organization of the exam and made it possible to include a variety of dermatoses selected from a photobank of images from patients in daily OPDs. 18 We found no reports of use of simulators or virtual patients for training or assessments of competencies. There are many studies reporting use of simulators and virtual reality for training in surgical skills in different specialties, critical care and advanced cardiac life support but data regarding its use in undergraduate education is lacking. [19][20][21] Other countries have integrated learning management systems in undergraduate medical education. Use of open course learning management systems like MOODLE was reported in a variety of subjects but its use seems to be in the nascent stage in India. 22 The barrier in adopting simulators and virtual reality could be entrenched in its high cost of procurement and maintenance. Another factor could be the easy availability to patient cases for clinical skills teaching and assessment. Use of learning management systems requires trained personnel to create and manage the platform for its continuous and effective use.

Is the use of technology more effective than traditional educational methods
Effectiveness of a tool is one of the important factors deciding its incorporation in curriculum. Two studies used non -equivalent comparisons group in a pre-test/ post-test design and one with only post-test for comparison. Two other studies were planned as a single group pre-test /post-test design and one with a single group post-test only design. Student' test scores were compared and analyzed as proxy to improved students' knowledge. Use of technology appeared to be more effective in increasing students' knowledge in few studies. 12,14,16,18 A study by Kaliyadan et al. showed no difference in scores whereas that by Viswasom and Jobby showed higher scores in traditional method of teaching -learning osteology which they attributed to improper planning and training of faculty implementing the change. 10,17 We need more rigorous study design to draw valid conclusions in this regard. However, we do believe that effectiveness of technology is not only gain in knowledge but also about how the students learn and interact with the tools and hence why did technology help students learn should be the question answered. Rasmussen et al. and George et al., also concluded in their systematic review that e-learning both in the online and off line format was equivalent and probably superior to the traditional learning in improving knowledge and skills. 23,24 Technology only serves as a means to an end and a clearly defined goal, well mapped outcomes and a clear implementation plan will contribute to its success.

What are the undergraduate students' perceptions regarding use of technology for teaching-learning
All the studies reviewed reported learners to have a favorable attitude towards use of technology. They perceive use of technology to be useful in improving their understanding, increasing the interactivity, promoting active and self-learning. The learners reported that their interest, motivation, and understanding increased which led to enhanced knowledge and performance. It helped in linking knowledge to practice and increased their confidence in managing cases and making clinical decisions. [9][10][11][12][13][14]16,17,25,26 The study by Joseph et al. reported that use of simulations may adversely affect communication skills, team behavior and feelings of empathy for a real patient. 26 Their concerns over their adverse effects need to be attended to by using a variety of pedagogical techniques to maximize the benefits of each.

Conclusion
Technology is creating a greater foothold in education in India but its use in HPE seems to be in it's infancy. Learners are ready to welcome greater use of technology for education. Adoption of different ways for online learning for undergraduates like use of learning management systems and skills training is the need of the hour. There are numerous opportunities for research in India to guide evidence based selection and implementation of ways to enhance HPE using technology. We recommend faculty development programmes to train the educators in creating digital resources and using technology for instruction and assessment. This will accelerate the transformation of the current HPE and make it, affordable and accessible to all learners.

Limitations of the study
This study did not involve systematic search of other databases like Cochrane, EMBASE, SCOPUS which may have yielded more studies for review.