Images in Rheumatology: A Multimedia Program for Medical Education*
David J. Nashel and John J. Martin Medical Service Veterans Affairs Medical Center Washington, D.C.
*Supported in part by Medical Information Management Office Department of Veterans Affairs, Washington, D.C. physicians with basic information and representative clinical and x-ray images for the medical
ABSTRACT In recent years, undergraduate medical education has benefited from the use of computer-based instructional progrwns. However, in the case of clinical and postgraduate medical education there is a scarcity of such programs, particularly those with access to high-resolution images. Having a fundamental knowledge base of disease-associated images is crucial for the physicians during the diagnostic process. To fill this gap in clinical instruction in the rheumatic diseases, Images in Rheumatology was developed. By using a hypertext fornat, one may select representative color images of a clinical disease or view x-ray changes typical for one of the rheumatic disorders. In addition, for each displayed image there is an associated sound-bite which explains in detail what abnormalities are present and how the user may differentiate the disease being viewed from other illnesses. An extensive review element is also included so that one can assess their fundamental knowledge of rheumatologic images. The Images in Rheumatology program has been implemented in the DOS (IBM Microchannelf). and Windows( environments.
specialty.of Rheumatology. IMAGES AND MEDICINE
Medicine is necessarily an image intensive discipline. Health professionals are continuously confronted -with patients who have specific and visible clinical lesions. A physician is regularly called upon to interpret x-rays or pathologic specimens and to decide whether they are suggestive of, or pathognomonic for a particular disease. Thus, having a fundamental knowledge-base of diseaseassociated images is crucial to the diagnostic process, one that is carried out by all physicians. Of the recent advances in medical technology that have had the greatest impact in diagnostic medicine, imaging technology is clearly preeminent. Consider the crucial role that has been established for such high-technology tools as computed tomography (CT), magnetic resonance imaging (MRI), and ultrasonography, each provides a unique image of the inner body, areas heretofore only accessible to the surgeon or pathologist. Thus, the technological advances in medical science compel the health professional to acquire an ever expanding knowledge base of images.
INTRODUCTION
For decades, textbooks, laboratory exercises and formal lectures augmented by 35mm slides have typified traditional instruction in undergraduate medical education. More recently, image databases on videodisk have become important adjuncts to standard curricula in the preclinical sciences. However, in the case of clinical and postgraduate medical education, there is a paucity of computer-based instructional programs, especially those using high-resolution images. A program called Images in Rheumatology (IR) was developed at the Washington, D.C. Veterans Affairs Medical Center to fill the gap in clinical instruction for the rheumatic diseases. The purpose of IR is to provide students, trainees and attending 0195-4210/92/$5.00 0 1993 AMIA, Inc.
PROGRAM DEVELOPMENT The development objectives for IR were to produce a program which would utilize highresolution images, digitized sound, and have the potential for showing video. Initially, IBM's Audio/Visual ConnectiorB software running under DOS on a microchannel computer was chosen for this endeavor. This implementation of IR has been successfully integrated into the teaching program of our medical center for more than a year. However, with the promulgation of Multimedia PC standards, IR has now also been ported to the Windows) environment. using Asymetrix Toolbook® .
798
trum of classic images that are associated with that illness. Unlike IR, it is unusual for textbooks to have large numbers of high-quality color images because of the prohibitive publication costs their inclusion represents. Often a single black and white image must suffice as the teaching component. On the other hand, IR offers the user an avenue for viewing hundreds of high-resolution color and greyscale images that are called up from the hypertext screen. Lastly, and perhaps most important, textbooks do not provide the user with ready methods for information review nor do they test knowledge of representative images for specific disease entities. With its separate Board Review module, IR is tailored to the review process which reinforces image retention and bolsters the information that has been gleaned from the "frontend" of the program.
A high-resolution Hitachi!) RGB framegrabber camera and Nikon%) slide scanner were used to digitize (capture) all of the images used in IR. Since each medical image is approximately 500KB in size, a large collection of such images, as is the case with IR, requires a high-volume storage device. A Panasonic®( optical WORM drive with a capacity of 400 megabytes per disk. was chosen for this purpose PROGRAM FEATURES OF IR At the outset, a sample hypertext paragraph is displayed and the user is shown how to display images. A help section then demonstrates the function of various icons. Following this, the program begins and a series of menu items are displayed. Some items are dedicated to the more important rheumatic diseases (e.g. Rheumatoid Arthritis, Osteoarthritis), while others are more generic. For example, if the user clicks on the button designated "Collagen Vascular Disorders", a submenu appears with a new series of buttons, one for each of the diseases in this category. Once a disease has been selected for review, three further options are presented, Clinical, Laboratory, and X-ray. By choosing the "Clinical" button, a series of text screens with core information on the clinical aspects of that particular illness are displayed. For each image an explanatory sound-bite is provided. Images may be reviewed, and audio can be replayed. Another important segment of IR is the "Board Review" element. Every doctor in training aspires to becoming board certified in his or her specialty of medicine since this attests to their competence to practice. Thus, the Board Review section of IR is particularly popular among students and housestaff (interns, residents and fellows) especially those who are studying for a board examination.. It tests their knowledge of important illness-related images.
FUTURE IMPLEMENTATIONS OF IR As the largest health-care system in the United States, the 172 hospitals of the Department of Veterans Affairs is a unique setting for dissemination of multimedia programs such as IR. Fully half of all the physicians-in-training will work, at least part of the time, in a VA medical center. IR was designed to be a prototype for fashioning similar instructional programs in other Internal Medicine subspecialties. Using IR as a model, one could take a teaching slide and x-ray collection of another subspecialty and develop a similar instructional program. Because the hundreds of images included with IR require massive storage capacity, distribution of the program on floppy disks is virtually impossible. CD-ROM is the most practical medium for disseminating programs such as IR and we are working in that direction.
CONCLUSION Because knowledge in the medical sciences continues to expand at such a rapid pace, new and imaginative techniques of instruction are needed to enhance traditional teaching methods. Interactive mutimedia programs such as IR should provide an attractive means of reinforcing essential information, and programs incorporating high-resolution images are bound to play an important role in medical education.
MULTIMEDIA VERSUS TEXTBOOKS IR is not intended to be a substitute for a standard medical textbook. It serves, instead, as a supplement to this traditional information source. Yet, IR does have several unique advantages over the conventional medical text. First, as a multimedia program it allows for interactivity and also provides audio enhancement of information, features which are not part of the textbook environment. Second, it is often difficult for the reader to abstract from a textbook the crucial elements of a disease and to have ready access to the whole spec-
Acknowledgmento. The authors wish to thank James D. Finkelstein, M.D., Chief, Medical Service, Washington Veterans Affairs Medical Center for his support of this project.
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David J. Nashel and John J. Martin Medical Service Veterans Affairs Medical Center Washington, D.C.
*Supported in part by Medical Information Management Office Department of Veterans Affairs, Washington, D.C. physicians with basic information and representative clinical and x-ray images for the medical
ABSTRACT In recent years, undergraduate medical education has benefited from the use of computer-based instructional progrwns. However, in the case of clinical and postgraduate medical education there is a scarcity of such programs, particularly those with access to high-resolution images. Having a fundamental knowledge base of disease-associated images is crucial for the physicians during the diagnostic process. To fill this gap in clinical instruction in the rheumatic diseases, Images in Rheumatology was developed. By using a hypertext fornat, one may select representative color images of a clinical disease or view x-ray changes typical for one of the rheumatic disorders. In addition, for each displayed image there is an associated sound-bite which explains in detail what abnormalities are present and how the user may differentiate the disease being viewed from other illnesses. An extensive review element is also included so that one can assess their fundamental knowledge of rheumatologic images. The Images in Rheumatology program has been implemented in the DOS (IBM Microchannelf). and Windows( environments.
specialty.of Rheumatology. IMAGES AND MEDICINE
Medicine is necessarily an image intensive discipline. Health professionals are continuously confronted -with patients who have specific and visible clinical lesions. A physician is regularly called upon to interpret x-rays or pathologic specimens and to decide whether they are suggestive of, or pathognomonic for a particular disease. Thus, having a fundamental knowledge-base of diseaseassociated images is crucial to the diagnostic process, one that is carried out by all physicians. Of the recent advances in medical technology that have had the greatest impact in diagnostic medicine, imaging technology is clearly preeminent. Consider the crucial role that has been established for such high-technology tools as computed tomography (CT), magnetic resonance imaging (MRI), and ultrasonography, each provides a unique image of the inner body, areas heretofore only accessible to the surgeon or pathologist. Thus, the technological advances in medical science compel the health professional to acquire an ever expanding knowledge base of images.
INTRODUCTION
For decades, textbooks, laboratory exercises and formal lectures augmented by 35mm slides have typified traditional instruction in undergraduate medical education. More recently, image databases on videodisk have become important adjuncts to standard curricula in the preclinical sciences. However, in the case of clinical and postgraduate medical education, there is a paucity of computer-based instructional programs, especially those using high-resolution images. A program called Images in Rheumatology (IR) was developed at the Washington, D.C. Veterans Affairs Medical Center to fill the gap in clinical instruction for the rheumatic diseases. The purpose of IR is to provide students, trainees and attending 0195-4210/92/$5.00 0 1993 AMIA, Inc.
PROGRAM DEVELOPMENT The development objectives for IR were to produce a program which would utilize highresolution images, digitized sound, and have the potential for showing video. Initially, IBM's Audio/Visual ConnectiorB software running under DOS on a microchannel computer was chosen for this endeavor. This implementation of IR has been successfully integrated into the teaching program of our medical center for more than a year. However, with the promulgation of Multimedia PC standards, IR has now also been ported to the Windows) environment. using Asymetrix Toolbook® .
798
trum of classic images that are associated with that illness. Unlike IR, it is unusual for textbooks to have large numbers of high-quality color images because of the prohibitive publication costs their inclusion represents. Often a single black and white image must suffice as the teaching component. On the other hand, IR offers the user an avenue for viewing hundreds of high-resolution color and greyscale images that are called up from the hypertext screen. Lastly, and perhaps most important, textbooks do not provide the user with ready methods for information review nor do they test knowledge of representative images for specific disease entities. With its separate Board Review module, IR is tailored to the review process which reinforces image retention and bolsters the information that has been gleaned from the "frontend" of the program.
A high-resolution Hitachi!) RGB framegrabber camera and Nikon%) slide scanner were used to digitize (capture) all of the images used in IR. Since each medical image is approximately 500KB in size, a large collection of such images, as is the case with IR, requires a high-volume storage device. A Panasonic®( optical WORM drive with a capacity of 400 megabytes per disk. was chosen for this purpose PROGRAM FEATURES OF IR At the outset, a sample hypertext paragraph is displayed and the user is shown how to display images. A help section then demonstrates the function of various icons. Following this, the program begins and a series of menu items are displayed. Some items are dedicated to the more important rheumatic diseases (e.g. Rheumatoid Arthritis, Osteoarthritis), while others are more generic. For example, if the user clicks on the button designated "Collagen Vascular Disorders", a submenu appears with a new series of buttons, one for each of the diseases in this category. Once a disease has been selected for review, three further options are presented, Clinical, Laboratory, and X-ray. By choosing the "Clinical" button, a series of text screens with core information on the clinical aspects of that particular illness are displayed. For each image an explanatory sound-bite is provided. Images may be reviewed, and audio can be replayed. Another important segment of IR is the "Board Review" element. Every doctor in training aspires to becoming board certified in his or her specialty of medicine since this attests to their competence to practice. Thus, the Board Review section of IR is particularly popular among students and housestaff (interns, residents and fellows) especially those who are studying for a board examination.. It tests their knowledge of important illness-related images.
FUTURE IMPLEMENTATIONS OF IR As the largest health-care system in the United States, the 172 hospitals of the Department of Veterans Affairs is a unique setting for dissemination of multimedia programs such as IR. Fully half of all the physicians-in-training will work, at least part of the time, in a VA medical center. IR was designed to be a prototype for fashioning similar instructional programs in other Internal Medicine subspecialties. Using IR as a model, one could take a teaching slide and x-ray collection of another subspecialty and develop a similar instructional program. Because the hundreds of images included with IR require massive storage capacity, distribution of the program on floppy disks is virtually impossible. CD-ROM is the most practical medium for disseminating programs such as IR and we are working in that direction.
CONCLUSION Because knowledge in the medical sciences continues to expand at such a rapid pace, new and imaginative techniques of instruction are needed to enhance traditional teaching methods. Interactive mutimedia programs such as IR should provide an attractive means of reinforcing essential information, and programs incorporating high-resolution images are bound to play an important role in medical education.
MULTIMEDIA VERSUS TEXTBOOKS IR is not intended to be a substitute for a standard medical textbook. It serves, instead, as a supplement to this traditional information source. Yet, IR does have several unique advantages over the conventional medical text. First, as a multimedia program it allows for interactivity and also provides audio enhancement of information, features which are not part of the textbook environment. Second, it is often difficult for the reader to abstract from a textbook the crucial elements of a disease and to have ready access to the whole spec-
Acknowledgmento. The authors wish to thank James D. Finkelstein, M.D., Chief, Medical Service, Washington Veterans Affairs Medical Center for his support of this project.
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