Eur J Dent Educ 2001; 5: 67–76 Copyright C Munksgaard 2001

Printed in Denmark. All rights reserved

ISSN 1396-5883

Distance learning in academic health education

A literature review
Nikos Mattheos1, Martin Schittek1, Rolf Attström1,2 and H. C. Lyon3*
1
Department of Periodontology, Centre for Oral Health Sciences, Malmoe University, Malmoe, Sweden; 2Department of Periodontology and Fixed
Prosthodontics, School of Dental Medicine, University of Berne, Berne, Switzerland; 3Notre Dame College, Manchester, NH USA

Distance learning is an apparent alternative to traditional professionals not accessible by traditional methods. Distance
methods in education of health care professionals. Non-interac- learning applications still lack the support of a solid theoretical
tive distance learning, interactive courses and virtual learning en- framework and are only evaluated to a limited extent. Cases re-
vironments exist as three different generations in distance learn- ported so far tend to present enthusiastic results, while more
ing, each with unique methodologies, strengths and potential. carefully-controlled studies suggest a cautious attitude towards
Different methodologies have been recommended for distance distance learning. There is a vital need for research evidence to
learning, varying from a didactic approach to a problem-based identify the factors of importance and variables involved in dis-
learning procedure. Accreditation, teamwork and personal con- tance learning. The effectiveness of distance learning courses,
tact between the tutors and the students during a course pro- especially in relation to traditional teaching methods, must there-
vided by distance learning are recommended as motivating fac- fore be further investigated.
tors in order to enhance the effectiveness of the learning. Numer-
ous assessment methods for distance learning courses have
been proposed. However, few studies report adequate tests for Key words: distance learning; health education; methodology;
the effectiveness of the distance-learning environment. Available effectiveness; interactive learning.
information indicates that distance learning may significantly de-
crease the cost of academic health education at all levels. Fur- c Munksgaard, 2001
thermore, such courses can provide education to students and Accepted for publication 31 May 2000

D ISTANCE LEARNING (DL) is not a new phenom-

enon. Correspondence courses are reported to
have existed in England as early as the 1840s. The
tively limited. There is continuing debate regarding
which academic disciplines are suitable for distance
learning (4). It seems that the special character and
University of Chicago established a correspondence objectives of medical and dental education have
division in the 1890s (1). Applications of distance caused the introduction of distance learning to be de-
learning have closely reflected the evolution of com- layed for a number of years. However, due to the re-
munications technology (2). The explosive progress of markable achievements in technology and the increas-
communications experienced during the last 20 years, ing need for continuing updated knowledge, DL to-
has greatly enhanced the possibilities of DL, boosting day has become an important alternative to tra-
the number and the potential of applications. Already ditional methods of education in the health care pro-
in 1995, a third of higher institutions in USA were fessions.
offering DL courses, while another 25% had plans to A survey among 35 FDI association members (5),
introduce DL within the coming three years (3). concluded that there will be a strong interest for dis-
Distance learning was introduced long ago, evalu- tance learning in the near future amongst dentists,
ated and accepted in many disciplines such as liberal while Hinman (2) sees DL as the only feasible way to
arts, humanities, social and political sciences, mathe- help the USA’s 500,000 public health workers to meet
matics etc. (4). The introduction of DL to health-care new challenges. DL is also reported to be the most
students occurred much later and experience in the appropriate way to serve the growing demand for
field of medical and dental education is still compara- postgraduate and specialist education, a demand that
cannot be accommodated by existing university struc-
* Fulbright Professor of Medical Education and Informatics, tures (6). In that sense, DL will be especially attractive
Ludwig Maximilians University, Munich, Germany. to certain categories of professionals who are practi-

67
Mattheos et al.

cally excluded from access to traditional continuing aim to present the practitioner with advanced com-
and postgraduate education due to a variety of social, petence, as reflected in a higher diploma or MSc de-
professional, geographical and economic factors (7). gree. A third category could be DL courses that aim
With the first formal DL medical curriculum already at the development of specialist skills and competence
under development (2, 8), geographical barriers are (Table 1). It becomes increasingly important to ident-
fading and professionals or students seeking com- ify the unique social and professional characteristics
petence and skills development will have access to a and learning needs of each group, as these will direct
global market. In this way, DL could be a field of the appropriate methodology and technology for a
major competition between universities in the years successful distant course.
to come and the first indications of this are already The evolution of technology has dominated the
visible (9). learning methodologies of distance learning to the ex-
The purpose of this review is to summarise the tent that a similar evolution can be observed in dis-
present experience in the field of distance learning in tance learning courses. Correspondence or home-
health education and to report the current state of the study courses in the form of printed material and mail
art, as well as the future trends and tendencies that were the first distance learning applications to be re-
can be identified. The review will focus on undergrad- ported (2). From a methodological point of view, we
uate and postgraduate education of medical and den- can refer to these kinds of applications as ‘‘non-inter-
tal professionals, as we believe both are directed by active distance learning‘‘. This term describes courses
the same needs and principles. Current literature and run at a distance in which the learning objectives are
resources will be examined, mostly focusing on publi- achieved through one-way communication, with no
cations made during the last decade, as technology student-tutor or student-student interaction em-
has dramatically changed the potential of DL during ployed at any stage. At this point, it is important to
the last 10 years. In this review, factors that relate to distinguish student-tutor interaction from that of
learning methodology, acceptance and overall effec- user-content or human-computer interaction, which
tiveness of DL are investigated, leaving aside the de- can be observed in many recent applications. Recent
tailed technological aspects, which are reviewed in a non-interactive DL courses are facilitated by a large
separate article (10). variety of media such as videotapes, television pro-
grammes, Web pages, CD-ROM and more. Non-inter-
active distance learning appears to be the simplest
Evolution of distance learning
and oldest type of health distance education, yet it is
applications in health education
still preferred by many institutions, as it is possibly
Two main categories of distance learning applications the least demanding in student and tutor resources.
can be currently identified in dental and medical edu- The method is widely applied in the continuing edu-
cation: the undergraduate applications and those that cation of health professionals, but very few appli-
aim at health-care professionals. In the group of cations can be found for undergraduate students.
undergraduate applications, we can distinguish DL The student-tutor live interaction possibility at a
that was introduced in the traditional curriculum or distance, starting in the late 1950s, added a whole new
replaced part of it, and extra-curriculum applications, dimension to distance learning. Interactive distance
where DL was carried out parallel to traditional learning allows us to speak of ‘‘second generation’’
teaching. applications. Teleconference, two-way audio and
At a postgraduate level, there are continuing edu- video applications, interactive television and radio
cation applications, credited or not, that aim to main- shaped a whole new kind of distance learning, intro-
tain and update the professional competence of the ducing new methodological and structural aspects.
practitioners. We can then identify DL courses that However, due to the complexity and cost of the em-

TABLE 1. Categories of distance learning applications in academic health education

undergraduate distance learning 1. in- curriculum distance learning
2. extracurricular distance learning

postgraduate distance learning 1. structured advanced education (MSc, Diploma, etc.)

2. specialist education
3. continuing education credited
non-credited

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 Distance learning in academic health education

ployed technologies, this kind of distance learning cated to preserve or even enhance interactivity and
was unattractive for the individual professional. On teamwork (13). Another strength reported is that all
the contrary, these methods benefited collective for- interactions can be recorded and serve as a basis for
mations such as associations, hospitals, universities, assessment purposes or the planning of learning strat-
ministries, etc., which could bring together large num- egies (3). We are in the very beginning of this phase in
bers of professionals, thus greatly reducing the cost academic learning, and research in the field is needed
per person. before we are able to draw conclusions. However it
A third generation of distance learning is now vis- appears that virtual classrooms, standardising the
ible, characterised by ‘‘virtual learning environments’’ technology, will allow researchers to focus on the
or ‘‘integrated distributed learning environments’’ (3). learning method rather than the media used for dis-
Although still in its infancy, the ‘‘virtual classroom’’ tance learning (Table 2).
represents a promising new potential in distance
learning (3). The former term is rather new and not
yet absolutely defined. However, for the purposes of
Analysis of the factors of importance in
this study we could refer to a virtual classroom as the
distance learning
learning environment created on the internet, which
resembles, in terms of interaction, method and func- Theoretical framework and learning methodology
tion, an on-campus academic classroom (10). At this After close examination of the DL experiences pre-
point, it is important to note that according to this sented so far, one can see that they lack the support
definition, not every educational application on the of a solid theoretical framework. Such a theoretical
internet is a virtual learning environment. Indeed, background would allow the research outcome of in-
what we commonly see on the internet are variations dividual studies to be replicated and generalised in
of non-interactive distance education, sophisticated other contexts. In a recent review on DL research by
textbooks or course-related archives of information the Institute for Higher Education Policy (April 1999)
(11). Rather than being a new medium, a virtual class- (4), this fact was reported as a missing link in re-
room is the powerful combination of a variety of me- search, which requires further investigation. This re-
dia and resources, with the internet as a backbone. view emphasised the need to develop a more inte-
Audio-visual interaction, synchronous and asynchro- grated programme of research in distance learning
nous text discussions, on-line libraries and search en- based on theory. Theory allows researchers to build
gines, on-line sharing of working files and documents on the work of others and thereby increase the prob-
are some of the basic communication elements of vir- ability of addressing the more significant questions re-
tual classrooms (12). These environments are indi- garding distance learning. A similar remark was

TABLE 2. Main characteristics of distance learning applications according to the level of interaction provided
1st generation 2nd generation 3rd generation

correspondence interactive courses virtual classrooms

courses

interaction no interaction audio (early) audiovisual

evaluation audiovisual (late) synchronous-asynchronous text discussions
questionnaires sharing of working files and resources
on-line libraries

technical demands less demanding both server and client demanding mostly server demanding

technology mail, workbooks, tapes, slides, teleconference internet

videos radio, TV broadcast, CD- two-way video multimedia
ROM, web applications microwave TV HTML
fibre optics, satellite

methods self-teaching didactic courses problem-based learning

study groups dynamic knowledge networks

mostly applicable to individual professionals professionals or undergraduates professionals or undergraduates

larger groups individuals or groups

Data from Mattheos et al. (10).

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Mattheos et al.

made by Gianni et al. (13) with regard to web-based the formation of small study groups was in many
applications. cases favoured. Smith et al. (18) noted that partici-
In early DL projects and correspondence classes, the pation in distance learning groups has a better com-
method followed was basically an imitation of the pletion rate than home-study instructional methods.
didactic teaching model. Correspondence courses are Indeed, it appears that most of the authors strongly
usually of a modular structure, with some self-assess- recommended the option of teamwork, although it
ment questions or tests upon completion of each mod- could possibly limit self-paced learning (19). This is
ule. In some cases, recommendations and links for especially true for the undergraduate applications,
studying could be included, to allow a more self-di- where small groups of students were essential compo-
rected form of learning. This structure allowed pro- nents in most published cases. The question raised,
fessionals to follow their own pathway, especially however, is how much active guidance should the dis-
with regard to time, to fit better the continuing edu- tant groups receive from mentors/tutors, especially
cation needs of busy practitioners. This kind of dis- regarding undergraduate applications. In the case de-
tance learning is indicated to provide continuing edu- scribed by Kamien et al. (17), a third of the students
cation to dentists otherwise not reached by more tra- disliked the student-run case discussions, describing
ditional methods (14). the process as ‘‘the blind leading the blind‘‘. The same
As DL courses were becoming more and more criticism is not found in undergraduate DL courses
structured, more complicated methods were with more actively guided groups (13).
attempted. Although the initial approach of the corre- In postgraduate applications, authors seem to fa-
spondence courses was didactic, the later introduction vour teamwork as well. Smith et al. (18) rated student-
of interactivity enabled teamwork and even problem- student interaction as a very important element of the
based learning (PBL), which many educators con- success of their DL course, referring to it as ‘‘com-
sidered appropriate for the DL environment (13, 15). munity development‘‘. In another case, Houston (20)
The Welcome Tropical Institute, in a study con- reported that a group of doctoral students taught with
ducted in Africa and Pakistan (16), concluded that a two-way compressed video, emphasised that the sup-
PBL approach is no less acceptable or effective than a port they received from their group at remote sites
more conventional method of distance learning. How- was important in causing them to persist in finishing
ever the need for a very thorough briefing on the use the program (20). This is consistent with 15 DL in-
of PBL modules was emphasised. That is in agree- structors surveyed in Ohio, who stressed strongly that
ment with Kamien et al. (17) who rejected the use of instructors should develop classroom interaction in an
PBL in their distance course, due to the students’ need interactive television course (21).
of previous experience with this educational method In general, formation of small, self-organised study
in order to comprehend the content of the course. groups seems to be popular amongst designers and
Other aspects that were highlighted were the value of participants of distant courses. However, it must be
consistent, active support by a doctor appointed as a noted that a minority of DL postgraduate students
mentor to the isolated learner and the need to ensure propose private study as the preferable method (22).
that the learning material was adapted to local con- In an attempt to match the two methods, Ndeki et al.
ditions faced by the student (16). The level of human (23) concluded that a regional core team should sup-
interaction during a PBL course is reported to be suc- port the efforts of individuals throughout the pro-
cessfully preserved or even enhanced (3) within a vir- gram, establishing a balance between individual work
tual classroom by the fact that the electronic media and group work. However, it appears that teamwork
allow real-time communication between group mem- and individual work can contribute in different ways
bers, as well as with the tutor. In fact, the addition to the effectiveness of a DL course. A detailed con-
of asynchronous instruments for knowledge sharing, sideration of the social, economical and cultural back-
adds a new dimension to the interaction between the ground of the users, as well as their individual learn-
resources and the learner (13). ing needs, might indicate the best method or combi-
nation (14).
The role of individual participation versus
teamwork in distance learning Personal interaction in distance learning
The introduction of interaction in DL gradually The discussion about remote interaction soon brought
brought up many aspects in methodology that de- up questions about face-to-face contact. It is accepted
manded special study. With courses based on tutor- by definition that DL refers to situations in which the
student interaction, teamwork was now available and tutor and the student are physically remote. However

70
 Distance learning in academic health education

personal contact between tutors and participants has are an important method for assessing competency in
been employed at various stages of many DL courses clinical dental procedures in DL methods. Case pres-
with positive results. What is the role of in-person entations were reported by the authors to evaluate
contact in distance learning and how important can it performance in contexts that resembled those to be
be? encountered following the educational program. Lang
Personal contact appears in the form of introduc- (31) added that students’ peer evaluation of one an-
tory meetings (15), workshops (24), group-study ses- other’s activity should be part of the evaluation
sions (17), local visits of tutors (23, 25) or even chair- scheme of a distance-learning course.
side supervision (15). The duration of these meetings Another trend introduced by the on-line courses
can vary from 1-day workshops to 2 weeks in campus and virtual learning environments suggests the as-
training (15), depending on the overall duration of the sessment of the total student participation during the
DL course. Most of these meetings aimed to introduce course (11). As these environments have the ability to
participants to the methodology or the technology of record all the interactions and contributions during a
the course (3, 26), or were focused on the develop- course, the total participation of a student is available
ment of communication skills, activities that accord- for either self, tutor or group assessment in terms of
ing to Holborow et al. (15) are not easily performed both quality and quantity. However, it remains yet to
through distance teaching. Personal contact during be investigated in what ways the recorded interac-
DL courses is reported to have a strongly motivating tions relate to the competence developed.
effect upon students and was strongly recommended In conclusion, although many methods of assess-
by all authors. In addition, preparatory meetings re- ment have been proposed so far, none of them is yet
portedly save much course time and trouble, espe- adequately tested in the environment of DL appli-
cially during technology dependent courses. cations. There is an indication that future DL assess-
It appears therefore that DL does not exclude per- ment methods will be based more on students’ total
son-to-person contact. On the contrary, personal con- activity than on the occasional filling in of ques-
tact at some stage is believed to accelerate the pro- tionnaires or exams. Assessment in DL must become
gress of the course and enhance the potential of DL. a major research field as applications become more
demanding. One of the key points for designing high
Assessment methods in distance learning quality distance education should be to ensure that
As DL courses moved to ever higher and more com- the students receive the education they are exposed
plicated learning objectives, assessment of the stu- to (2).
dents’ participation became a necessity. Self-paced
correspondence courses relied almost completely on Student motivation
self-assessment tests or questions (27). As courses Motivation amongst students participating in DL
were structured leading to credits, skills or even courses is another topic of interest. It is commonly
higher degrees, a kind of peer assessment had to be reported that distance learning in general is plagued
introduced. However, little can be found in relevant by high drop-out rates (4, 18). That is especially true
publications regarding assessment. In-campus exami- if DL courses are not a compulsory part of an accred-
nations after the completion of the DL course, ap- itation system, curriculum or degree (32). On the con-
peared to be a quite safe way for student assessment trary, dentists appeared more motivated when the dis-
in some cases (28). tant course was leading to accreditation points (14)
Van Putten et al. (29) reported the use of internet and undergraduate students when they were told that
for the assessment of undergraduate students to be part of their final exams would be based on the com-
beneficial. The most recent trends, however, tend to puter-instructed material (32). Bonazzi et al. (33), in a
assess students’ competence by means of more hol- research analysis, concluded that evaluation results
istic approaches such as case presentations and as- are related to the student’s degree of self motivation
signments. Radford (30) noted that tutor-marked as- in DL. This suggests the importance of self-motivation
signments enable acquired knowledge to be applied for successful participation in a DL course.
in real situations. Successful completion of the dis- Tutor-student personal contact (3, 23), work in
tance course included completion of 3 tutor-marked study groups and student-student interaction (18) are
assignments by the students, and a final written suggested as strong motivating factors. Smith et al.
paper. (18) during a DL program, reported no drop-outs at
In the same way, Smith et al. (18) assessing a web- all, and Holborow et al. (15) also reported a very high
based DL course, concluded that case presentations completion rate. In both cases, however, participants

71
Mattheos et al.

were charged a tuition fee in advance, which possibly The results from the few original research papers
filtered out less motivated students. available in academic health education, recommend a
more critical approach. Authors of comparative re-
Overall effectiveness of distance learning search studies tend to find similar levels of achieve-
Many methods and technologies have been de- ment between distance and classroom students, as in-
veloped and proposed for DL of health-care students. dicated by exam and test scores (32, 38–40). In ad-
The major question that is raised, however, has to do dition, Lyon et al. in a very carefully controlled study,
with the effectiveness of the method. Can we defend found that students using computer instruction
the effectiveness of this form of health education, reached the learning objectives in 43% less time than
especially in comparison with traditional teaching the control group without any loss in the competence
methods? Can medical and dental students be edu- developed (32). In another study, Rogers et al. (39)
cated at a distance and what is the level of com- compared computer instruction to lecture feedback
petence developed in comparison to traditional seminars for the purpose of teaching a basic surgical
teaching? skill. Although both groups were found equally effec-
In order to answer these questions, we undertook a tive in conveying the cognitive information associated
literature review, with the intention of identifying the with the skill, the computer-instructed group pre-
current state of research in medical and dental DL. sented significantly lower performance scores. A
After reviewing more than 50 published cases, our weakness in the above study, however, could be that
conclusion was that there is a lack of original research computer-instructed students had not had the benefit
investigating the effectiveness of such courses, and of the feedback available to the in-classroom teaching
therefore a lack of valid recommendations. An over- group.
view of some of the most characteristic published Regarding interactive distance learning, a very in-
cases can be found in Table 3. teresting study was designed by Lewis et al. (38),
The majority of studies so far consist of descriptions aimed at comparing two-way video with in-classroom
and case reports, in which the authors usually present teaching. Again, the authors found no significant dif-
their experiences of a certain DL model, including de- ference in the exam scores of the distance and the in-
scriptions of the technology and the learning material. classroom group. However, the attitude that interac-
Although evaluation of the results is presented in tive video instruction was an effective medium of
many cases, it usually focuses on student and faculty teaching declined significantly among the students of
attitudes about the DL education, overall satisfaction the distance group, as they found the video confer-
with the course and problems experienced through- ences to be more boring than expected. In addition,
out the program. Most studies conclude with an in- interaction amongst participants in the experimental
creased appreciation of distance learning by the par- group was rated as poorer than anticipated and class-
ticipants and faculty (Table 3), the achievement of room residents asked more questions than their col-
learning objectives (22, 34) and that DL has a positive leagues attending at a distance. This finding is in
impact upon the participants’ skills and competence agreement with another controlled comparative study
(18, 35). The most commonly employed means of by Gould et al. (41). The experimental group in this
evaluation is completion of questionnaires after the study attended an internet based course on periodon-
course (Table 3). However, strong indication exists tology. Although the study is still undergoing evalu-
that participants’ opinions are often subject to differ- ation, the authors found that the contribution of most
ent kinds of bias factors and therefore cannot be a sat- participants to the asynchronous discussions was
isfactory way of evaluating distance learning (4, 36). poor (41).
In some cases, authors have tried to point out the ef- With regard to cost-effectiveness, many authors
fectiveness of their courses by means of more measur- agree that costs are minimised with distance learning.
able entities, such as measuring the amount of interac- In support of this, Hibbard et al. (37) describing a DL
tion during the course (31, 37), presenting the com- program, claimed that the National Health Service
parative pass rates in state exams (24), or the increas- saved more than £3000 per participating group, in
ing number of applicants for their course (15). The comparison to the cost of the traditional methods of
change in the participants’ skills and knowledge was education. Kudryk et al. (42) mentioned that thanks
also studied, but in most cases where it occurred, it to the use of the examined teleconference system, the
was carried out by means of self-assessment ques- US Army saved much money in terms of travel ex-
tionnaires rather than any external judgement (18, 27, penses, experts’ compensation and lost duty hours.
35). Ndeki et al. (23), dividing the cost of a single doctor’s

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 Distance learning in academic health education

TABLE 3. Overview of the most characteristic studies published since 1985 regarding DL applications in health education
Author Year Method Type Subject Evaluation Results, conclusions

1 Williams (45) 1985 interactive UG medicine not present increased acceptance

television
2 Marshall et al. 1985 telephone UG medicine not present increased acceptance
(19) conference
3 Hibbard et al. 1986 telephone Ex medicine questionnaire increased acceptance
(37) conference
4 Kamien et al. 1991 audiovisual UG general questionnaire increased acceptance
(17) material, study medicine
groups
5 Patterson et al. 1991 printed material CEP fissure carries questionnaire changes in diagnostic procedures of users
(27)
6 Holborow et al. 1991 telephone HD dentistry not present increasing number of students, high completion rate
(15) conference, site
visits, audiovisual
material
7 Lyon et al. (32) 1992 interactive UG medical controlled group similar test scores in both groups
software study computer group needed 43% less time
8 Lang WP (31) 1992 computer UG dentistry questionnaire, positive acceptance,
conference recording of problematic evaluation,
interaction students developed information access and
retrieval skills.
9 Marshall et al. 1993 printed material, ST medical not present not present
(48) telephone photography
conference
10 Dockning S (28) 1993 printed material CEP nurse education not present not present
11 Dirksen et al. 1993 microwave UG nurse education questionnaire similar achievements and attitude between distance
(43) television and in classroom students, complex and expensive
technology
12 Ndeki et al. (23) 1995 printed material, CEP medicine questionnaire, enthusiastic acceptance, increased motivation
site visits pre-post test
13 Hayes et al. (49) 1996 web-based CEP medical user comments enthusiastic acceptance
patient
14 Macfarlane et al. 1996 hypertext CEP epidemiology not present not present
(46)
15 Hinmman AR (2) 1996 satellite CEP epidemiology not present increased cost – effectiveness
transmission
16 Van Puten (29) 1996 web based UG prosthodontics not present internet environment suitable for examinations
17 Tanenbaum 1996 not present UG dental hygiene not present not present
et al. (1)
18 Gould et al. (41) 1997 asynchronous CEP dentistry controlled group low participation from most users study undergoing
conference study evaluation
19 Cochrane et al. 1997 workbooks, Ex medicine not present better pass rate of course users increased
(24) teamwork acceptance
20 Kudryk et al. 1997 two-way video CEP dentistry cost- in 38 of 40 cases, diagnosis was possible at
(42) effectiveness distance
study
21 Bailey J (44) 1997 two-way int. UG paediatric not present increased faculty/student acceptance
video dentistry
22 Kuramoto et al. 1997 audiographics CEP nurse education questionnaire positive acceptance, technical difficulties
(25) teleconference
23 Lewis et al. (38) 1998 two-way video CEP family medicine controlled group similar achievements in both groups, decreasing
study acceptance and low level of interaction in distance
group
24 Smith et al. (18) 1998 two-way video HD general questionnaire increased acceptance, high completion rate,
dentistry improvement in skills of users
25 Gianni (13) 1998 virtual classroom UG medicine recording of high level of interaction, theoretical background
interaction development
26 Agius et al. (34) 1998 web based UG occupational questionnaire gains in technological expertise,
medicine, env. group reports achievement of learning objectives
health
27 Rogers et al. 1998 computer based UG surgical skills controlled group similar achievement of learning content, lower
(39) study proficiency level in the computer instructed group
28 Hobbs et al. 1998 in classroom, UG emergency controlled group similar achievements in distance and control
(40) computer medicine study groups.
network, satellite
network
29 Dugas et al. 1999 web based CEP medicine not present not present
(47)
30 Fox et al. (35) 1999 virtual class CEP medical questionnaire improvement in 8 skills of users
informatics (pre-post)

Figures in parenthesis refer to the numbered reference list. UG: undergraduate education, Ex: preparation for state examinations, CEP: continu-
ous education of professionals, HD: leading to higher degree, ST: specialist training.

73
Mattheos et al.

participation fee in a distance course by the number that DL is able to cut down the cost of dental and
of people living in the area in which the doctor prac- medical education at all levels.
ticed, estimated the cost per affected person to be Correspondence courses, interactive courses and
$0.38. However, a number of studies of DL courses virtual learning environments seem to represent three
report increased costs and complexity (43), while a main generations of distance learning in health edu-
widely-adopted finding is that distant and especially cation. The evolution of the technology between these
on-line courses are more time consuming and labour three generations has allowed major changes in the
intensive for educators than in-classroom teaching (3). DL methodology as well. The existing technology has
This indicates an increased cost of educational and the potential to facilitate complicated distance learn-
teaching resources. ing environments and highly structured learning
Amongst presently available studies, there are methods.
many indications that DL can be an effective way to Designers of more recent applications tend to ap-
educate health professionals. However, no solid evi- preciate team-work and the formation of small groups
dence seems to have been produced. In addition, only more than individual study, although the latter ap-
weak indication exists towards identifying the meth- pears still to be more applicable to many categories
odological factors that would make the difference be- of professionals. Also, accreditation, team-work and
tween a successful and a not successful distance personal contact in DL, are stressed by most authors
course. Case studies are not based on comparative re- as important factors for increasing motivation and
search protocols that could test the effectiveness in a minimising drop-out rates.
controlled environment, with a random sample, ex- The learning methodology employed in DL has
cluding all the extraneous variables. These con- changed during recent years. Early applications as
clusions are in agreement with the findings of the well as self-study courses have mostly relied upon
American Institute for Higher Education review, didactic teaching models. The interactive applications,
which concluded that there is a relative paucity of especially the virtual learning environments, tend to
true, original research dedicated to explaining or pre- employ more complicated methods such as PBL and
dicting phenomena related to DL (4). Among the key dynamic knowledge networks (13) with encouraging
shortcomings of the research is lack of control over results. Just as in traditional teaching, the learning
extraneous variables and therefore inability to prove method rather than the medium seems to be a sig-
cause-effect relations. The selection of the student nificant factor for the effectiveness of a DL course and
sample, as well as the lack of control over reactive the attitude and achievements of its participants.
effects such as the novelty effect, are also reported as At the same time, assessment methods have passed
shortcomings (4). However, it can be argued that several stages, from no assessment, self-assessment
educational research cannot be as flexible as research questions or on-campus examinations, to evaluation
in the laboratory and therefore the same strict rules of actual cases, presentations and tutor-marked as-
cannot be applied. signments. The trend of virtual learning environments
Distance learning appears to be a promising answer is that student activity throughout the course can be
to many of the current problems and challenges faced recorded and assessed. It is also proposed that stu-
by medical and dental education. However, before dents could assess the activity of their colleagues
moving on to new revolutionary ways of training doc- within the course.
tors, much work is still to be undertaken. The real There is a lack of a theoretical framework to support
potential of distance learning in health education, distance learning applications. Cases reported so far
especially in comparison with traditional teaching seem to focus rather on the effectiveness of a certain
methods, remains to be proven. technology than on the design and evidence of effec-
tiveness of a learning method. Encouraging and
sometimes enthusiastic results are widely presented
Conclusions
in case studies. However, more carefully controlled
Distance learning is becoming increasingly apparent studies seem to suggest a cautious approach, although
as a promising method in dental and medical edu- they tend to agree that students educated through DL
cation. It appears that DL is able to cover the educa- courses present similar achievements with their in-
tional needs of certain categories of professionals and classroom controls.
students not otherwise attainable by traditional Trying to characterise DL as ‘‘effective’’ or ‘‘not ef-
methods for social, professional, economic and geo- fective’’ as a medium for health education, appears to
graphical reasons. There is also sufficient indication be the wrong approach. The term ‘‘distance learning’’

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