E-LEARNING IN THE FIRST SEMESTER OF AN UNDERGRADUATE
MEDICAL CURRICULUM
Josef Smolle, Institute of Medical Informatics, Reinhard Staber, Virtual Medical Campus
Department, Florian Hye, Virtual Medical Campus Department, Elke Jamer, Student RecordsRegistrar’s Office, Silvia Macher, Quality Assurance and Organization of Teaching, Heide Neges,
Quality Assurance and Organization of Teaching, Gilbert Reibnegger, Vice-Rector’s Office for
Teaching and Studies, Medical University of Graz, Austria
Context of the virtual learning environment at the Medical University of Graz
In 2002, an integrated curriculum of human medicine was started at the Medical University of Graz,
Austria. The curriculum was aimed at an early integration of basic sciences with clinical application, a
problem-centred design and collaborative teaching of various disciplines [1-3]. The curriculum is
organized in modules of five weeks each, with various specialties contributing to each module. In
addition, tracks referring to biomedical background, medical skills, and communication/ supervision/
reflexion extend through the whole curriculum. In the 6th year, a practical undergraduate internship
and 4 weeks of general practice are implemented.
The integrated approach of the curriculum requires learning material beyond that of conventional
textbooks, since standard textbooks do not fulfil the requirements of interdisciplinary teaching and
learning. Therefore, a virtual learning environment was implemented with the start of the curriculum,
which is designated as Virtual Medical Campus (VMC) Graz [4]. The VMC Graz was initially
supported as a project by the Federal Ministry for Education, Science and Culture in 2002, and as a
strategic development in 2005. From the beginning, the VMC was designed to provide an overview of
the structure of the entire curriculum, which was gradually filled with learning objects referring to the
needs of the various lectures, seminars and practical courses. At first, the VMC was only used to
provide material in addition to face-to-face education. Meanwhile, an increasing number of lectures is
available in electronic form instead of face-to-face teaching, providing blended learning in selected
topics. In addition, besides human medicine, the curricula of dental medicine and of nursing science
have been implemented in the VMC, and cooperative programs have been started with the Medical
University of Vienna, Austria, and the Medical Faculty of Maribor, Slovenia.
At the Medical University of Graz, usually an average of 800 students starts their curriculum in
human medicine every year. According to Austrian federal law, up to 2004 each Austrian student
applying for human medicine was admitted. In June 2005, the legal situation changed since the
European Union considered it incompatible with European Union regulations that Austrian
universities accepted all Austrian students, while requiring proof of a university place in their home
country for students of other European countries. Therefore, from beginning of the academic year
2005/06 onwards, all European students applying for a university place in Austria had to be treated
equally as the Austrian applicants. This is particularly important for human medicine, since about
25.000 applicants are rejected in Germany every year, and each of them has now gained the right to
apply at an Austrian Medical University.
In the first run in 2005, more than 3000 students applied for human medicine at the Medical
University of Graz, about 2000 of them coming from Germany. Therefore it became evident that the
Medical University would not be able to accomplish traditional face-to-face teaching for such a large
number of students. On the other hand, a selection process had already been designed for the end of
the first semester. Therefore the Medical University rector and the vice-rector for teaching and studies
decided to accept all applicants at the beginning of the semester, and to perform a selection
examination at the end of the semester. In order to manage the large number of students, teaching in
the first semester was entirely based on the virtual e-learning environment already available.
At the Medical University of Graz, a total of 300 university places are available from the second stage
onwards every year. Since 200 places were already occupied by students who had finished the first
stage during the last year, only 100 new places were available.
Content creation process
Structure of the first semester of the medical curriculum
The first semester of the medical curriculum of human medicine includes three modules and one track
course. The majority of the courses was designed as lectures, only a minority was intended in an
interactive workshop format. The contents of the first semester comprise mainly basic sciences
(physiological chemistry, biophysics), anatomical nomenclature and general biology. In addition,
however, first insights into clinical disciplines are provided. In a regular first semester, a practical
course in nursing is included. In the academic year 2005/06, however, this course had to be postponed
until the second semester, since more than 1.000 students were beyond the capacity of our teaching
hospital.
The following list shows the formal structure of the first term:

Module 01: From law of nature to life; 5.1 ECTS credit points
- Basics of physiological chemistry I
- Basics of biophysics I
- Anatomical terms and definitions

Module 02: Components of life; 4.7 ECTS credit points
- Osteology
- Basics of physiological chemistry II
- Basics of biophysics II

Module 03: Cell, tissue, health issues; 7.1 ECTS credit points
- Chemical components of living organisms
- The cell
- Genetics
- Tissues
- Embryonic development
- Preventive medicine

Track: Introduction to medicine; 7.7 ECTS credit points
- Practical course in nursing
- Introductory clinical lectures
- First aid
- Physical examination
Strategy for content creation
Though several learning objects were already available from former years, the e-learning contents for
pure online learning had to be reshaped, and a large number of learning objects had to be newly
created.
The vice-rector’s office for teaching and studies invited all academic staff involved in the first
semester to five consecutive workshops, each of these workshops dealing with a certain aspect of the
ongoing virtual semester. The workshops were dedicated to content requirements for virtual lectures,
content requirements for virtual seminars, organization of the track “Introduction to medicine”,
organization of the final examinations, and eventual impact of high school credits.
The team of staff participating in the workshops agreed that each learning unit should refer to a
particular textbook chapter when appropriate, and had to contain an electronic learning object of the
computer-based training type, with a minimum of five frames for a lecture learning unit and a
minimum of 20 frames for a seminar learning unit. Computer-based training learning objects of
seminar learning units were considered to be obligatory for students. Additional presentation and
visualization objects were encouraged. In learning units without a textbook reference, presentation
and visualization objects covering the whole topic were mandatory. For practical aspects, interactive
simulations and video clips were recommended. Furthermore, deadlines for the finalization of the
electronic contents have been agreed upon. With October 1st, the beginning of the semester, all
textbook references of the virtual semester had to be online, together with the first part of module 1.
The other contents had to be finished gradually according to a fixed time table, with the last objects of
the virtual semester to be finished by December 20th.
Types of learning objects
A total of 200 learning objects of the interactive computer-based training (CBT) type were created
[5], each comprising between 5 and 48 frames. This type of learning object is based on the branching
tutorial programs of Crowder, with elaborated feedback to each choice according to the concept of
Musch [6]. Many frames were accompanied by images. The CBT learning objects have been
generated by a simple-to-use authoring tool developed for the Virtual Medical Campus Graz. At the
end of each learning path, students have the opportunity to transmit an automatically created message
to the system indicating individual data of the student and the scoring achieved in the particular CBT
learning object. Submission of this message was obligatory for CBT learning objects linked to
seminar-type learning units.
Presentation and visualization learning objects (150 learning objects) were mainly created using
Powerpoint® or Acrobat PDF® format. In addition, several HTML-based presentation and
visualization learning objects were created.
Three interactive simulations were used in biophysics, and four video clips were created for the topics
“first aid” and “physical examination”.
Organization of the final examinations
After one semester of distance learning through the Virtual Medical Campus, all students were invited
to take part in the final examinations which were scheduled on two consecutive days in Graz in
January. On the first day, three consecutive examinations referring to modules 1, 2, and 3,
respectively, had to be performed. Each of these module examinations consisted of 60 multiple choice
questions. Students obtained regular marks ranging from 1 (very good) to 5 (not passed) for each of
the three module examinations. The limit for gaining a positive mark was a proportion of at least 66 %
correct answers. On the second day, a summative test comprising all topics of the semester was
performed with 420 multiple choice questions. For this test, no regular marks, but only scoring points
according to the number of correctly answered questions were given. Finally, a ranking of all students
was created, where the marks of the module examinations were weighted with 40 % and the points
achieved in the summative test with 60 %.
Student’s access, system performance and user interaction
3336 Students pre-registered for the virtual semester. From the beginning, it was communicated that
the semester will take place by e-learning only, and that only 100 students will earn a university place
for the second semester. 1269 students finally registered, with about 40 % of students from Austria,
45 % students from Germany and 15 % of students from other countries.
Temporary log-in accounts were activated for all pre-registered students on October 1st, and were
gradually replaced by full accounts as soon as an individual had fulfilled all formal steps of
registration. During the semester, 858.000 visits to learning objects were recorded. Students used the
electronic learning system 24 hours a day for all days of the week, with up to 17.000 visits per day.
The highest data traffic was recorded between 12.00 and 18.00 o’clock, but usage continued with
tapering intensity until the early morning, with the number of visits rising again by 6.00 o’clock.
There were only 4 scheduled interruptions of online access for a couple of hours due to system
upgrading. There were no unscheduled or unexpected interruptions and no significant delays in online
acess.
Students sent in a total of 257.000 feedbacks from CBT learning objects, most of the feedbacks
indicating a score of 85 % correct answers and higher. Figure 1 shows the distribution of scores in the
CBT feedbacks of a particular not obligatory CBT learning object referring to anatomical
terminology.
600
500
400
300
200
100
0
85
90
95
100
Figure 1: Student’s feedback of learning object “Anatomia systemica I”, Anatomical terms and
definitions, Module 1. In 822 feedbacks, students achieved 98.3 +- 3.1 % correct answers.
Communication between students and teachers was managed through e-mail forms submitted by
students. The forms were forwarded to the particular teacher concerned, and the answer of the teacher
was published together with the original question as an appendix to each of the modules. By this
approach, repeated identical questions had only to be answered once. During the semester, 724
answers were created by teachers filling a total of 113 printed pages in A4 PDF format.
Examination results
In each of the module examinations, all marks ranging from 1 to 5 were represented. 104 students had
positive marks in all three examinations, 96 of them were within the 100 best ranked students after the
summative test has additionally been taken into account. Remarkably, there was a close correlation
between the marks obtained in the module examinations and the scores obtained in the summative test
(r = 0.72; p < 0.00001) already within the subgroup of the 100 best students. This finding illustrates
that both parts of the ranking system (module examinations and summative test) have a high
reproducibility within the subgroup of high performing students.
Positive marks were achieved in 17.1 %, 23.6 % and 14.5 % in the three module examinations, with
66 % correct answers being the pre-set threshold for a positive mark.
A more detailed analysis of module 1 examination revealed striking differences in outcomes
depending on the electronic learning objects provided. When the contents were completely
represented by computer-based training learning objects, 65.9 +- 0.7 % correct answers were
achieved, compared to only 51.4 +- 0.5 % when the contents were not fully represented by computerbased training learning objects (t-test for paired values: t = 28.3, p < 0.0001).
100
80
60
40
20
0
CBT(+)
CBT(+/-)
Figure 2: Multiple choice questions referring to topics which had been entirely represented by
computer-based training learning objects (CBT(+)) were answered correctly in a significant higher
proportion than questions referring to topics which had only partially been represented by computerbased training learning objects (CBT(+/-)).
Lessons learned from the virtual semester
Our experience shows that it is possible to teach a large cohort of students in the first semester of
human medicine through e-learning only. It became evident that high-performing students were
particularly able to face the challenge successfully. On the other hand, it seems to be not so easy for
medium- or low-performing students to acquire the necessary knowledge and intellectual skills
through pure e-learning. This might particularly be true when – as in our case – the very first semester
is entirely virtualized, and might be less important when only a proportion of lectures in higher
semesters will be based on e-learning in a blended learning approach.
One has to take into account, however, that there were other changes beside the switch from face-toface teaching to e-learning. At first, the amount of knowledge presented and examined was higher
than in previous years, since there were more lecture units and fewer reflective seminars and practical
courses. Furthermore, it was for the first time that all module examinations had to be passed on the
same day, since in previous years the module examinations could be passed gradually at 5 – 8 week
intervals. Finally, the whole amount of MC questions had been newly prepared, so that regular
training of questions used in prior examinations was only of minor help.
Remarkably, examination results seem to depend on the method of electronic delivery of the contents.
When computer-based training learning objects covered the contents of an entire topic, than the
performance of all students at the examinations was considerably better than when there were only
few computer-based training frames giving selected hints only and leaving the main part of knowledge
transfer to textbook references or presentation and visualization learning objects.
Complete e-learning in the first semester of human medicine was performed in a singular situation
confounded by political and organisational constraints. It became evident that it can be successfully
performed from a formal point of view, relying on a technically stable virtual learning environment
and dedicated staff ready to undertake the challenges of virtualization. When the first semester is
studied entirely in a remote learning format, a high degree of self competencies is needed by students
to perform successfully. Results obtained in the subsequent examinations seem to be highly selective
and reproducible particularly in the subgroup of high-performing students.
In the future, special emphasis will have to be put on the mode of electronic delivery, the types of
learning objects, degree of elaboration, guidance of the learning process according to individual
needs, individual feedbacks and time consumption on the one hand, compared with examination
results on the other. Thereby, the discussion on e-learning methods, drawbacks and merits will shift
from formal and theoretical discussions towards collecting evidence from experimental and field data.
This approach may finally result in a reliable concept of evidence-based e-learning.
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Corresponding author
Univ.-Prof. Dr. med. univ. Josef Smolle
Institute of Medical Informatics, Statistics and Documentation
Auenbruggerplatz 2/V
A-8036 Graz, Austria
josef.smolle@meduni-graz.at