Research into teaching methodologies indicates that assigning a good tutor to individual students can produce the most effective learning results. Over 20 years ago, Bloom demonstrated that students who receive one-on-one instruction performed two standard deviations better than students in traditional classrooms [1]. The positive learning outcomes of one-on-one tutoring have been credited to students' participation in discussions and tutorial dialogues [2]. In addition, a skilled tutor can directly assess the student's strengths and weaknesses and tailor the presentation of instructional material to the learner's needs [3, 4]. However, finding a skilled tutor for each student is, in most countries, unrealistic and economically not feasible.

It is usually assumed that a low student-faculty ratio is a necessity for quality education. However, in many colleges worldwide and especially in introductory courses, enrollments are usually high. The predominant form of instruction in such high enrollment courses is large lectures as it is assumed that these are the only low-cost alternatives available. Such lectures have been criticized for treating all students as identical individuals, ignoring the fact that students have different levels of interest, learning styles, motivation, attention span and ability to learn [5]. For example, while students with weaker skills need more attention and opportunities for interaction, students with stronger skills need opportunities to excel and accelerate their learning independently [6]. Additionally, current students, who are dubbed as the "net-generation", seem to have less attention span than previous generations [7]. This makes it more difficult for even a very professional lecturer to maintain students' attention in a large lecture presentation setting. In summary, traditional large lecture presentations have problems in engaging the students and in meeting their individual learning styles.

To give students a better opportunity for interaction in large enrollment classes, some universities combine large lecture presentations with discussion sections in smaller groups. However this multiple sections model also has its challenges. Sometimes these sections are often still quite large and are dominated by the same presentation techniques. Additionally, the instructor may develop his or her own set of course materials and deliver what is basically the same material in his or her own style. Therefore, although in theory this model may lead to better interaction with students, in practice this model often produces a remarkable lack of uniformity in learning outcomes due to lack of coordination and inconsistency [6].

The advances in information and communication technology have directed attention to online learning methods, also known as e-learning. With the introduction of the Internet and the World Wide Web, e-learning has shown a major potential for providing more flexible access to courses content and instructions. Therefore, e-learning might address large enrollment problems by delivering course contents and instructions to learners anytime and anywhere. Furthermore, well designed e-learning courses can enhance the quality of learning experiences and outcomes by promoting the concept of learner-centered courses and encouraging students self-learning. A prevailing presumption is that learning a complex body of knowledge effectively, requires a community of learners that can be expanded and supported through e-learning [8, 9]. Another conjecture is that asynchronous discourse is inherently self-reflective and therefore more conducive to deep learning, than is synchronous discourse [10, 11].

Both groups of students were invited to three group discussions. Analysis of focus group discussions data yielded three major themes. First, students enrolled in the e-learning course highlighted how the course helped improve their outcome of learning. Students reported that "they achieved better through the e-learning course", and that e-learning "helped plan their studies and helped (them) to understand the subject". Students raised the issue of their wish for the e-learning course to include other parts of the PH curriculum other than RH to help them with their studies for the whole course, and if possible to have sections in Arabic (as the e-learning modules were written in English). The second theme focused on interaction. Students were very positive regarding interaction, and feedback from the tutors responsible for the e-learning course and from each other in the forums. They expressed that they "could now communicate between each other and with the teachers using the e-learning course platform". They also described how the e-learning course "helped them with learning through interactions with each other and how they were motivated to create links to new learning material". They expressed a wish for more images and interactive animations and videos as well as links to external resources, although they had created some of their own that were approved by the course facilitators. The third theme was related to the e-course system. Students expressed they had a "Very Good experience"with the e-learning system, and raised the issue of their wish for "the system to re-open after deadlines"to give them a chance to revise for exams.

Analysis of focus group discussions data for students not enrolled in the e-course generated two themes. The first addressed issues related to the course. They highlighted the fact that the e-course was time consuming and required commitment to course deadlines. Students expressed that "it consumed too much time", that they "ran out of time"and "could not keep up with the course deadlines". The second theme focused on the access to computers and internet. Most of them had no personal access to internet and/or computers. Additionally, the university does not provide any computer and internet connection facilities for students. However, they expressed wishes to access the e-Learning course before the end of the academic year through cyber cafés for exam revisions.

Results of the final online questionnaire showed that students' satisfaction with the e-learning course exceeded 95% (163/171) and that the majority (92% - n = 157/171) agreed that the course was well organized and ran smoothly. They expressed their appreciation to have the "chance to do all they wanted and needed to do freely, whenever they wanted". Their opinions on traditional lectures were that these were "not interactive"and that they were "passive listeners only with little chance to participate".

Thanks to the Internet and steady growth of educational technologies, the number of e-learning resources available to educators has dramatically increased. Repositories or digital libraries have been established within medical education, to manage access to e-learning materials [15]. In undergraduate medical education, e-learning offers learners materials for self-instruction and collaborative learning. The idea of a collaborative learning community is a critical concept in medicine where high order learning is desired [5]. Although some institutions have tried to use e-learning as a stand-alone solution to updating or expanding their curricula, it is best believed to begin with an integrated strategy that considers the benefits and burdens of e-learning before revising the curriculum [16]. Additionally, there is evidence for the effectiveness and acceptance of e-learning within the medical education community [17], especially when combined with traditional teacher led activities [18], which coincides with our methodology.

As with other educational materials, there are two major approaches to the evaluation of e-learning: process and outcomes. In our study we concentrated on evaluation of the outcome through measuring changes in learners' knowledge, or attitudes. The evaluation framework outlined by Kirkpatrick, can be used to evaluate e-learning interventions. The Kirkpatrick model defines four levels of evaluation based on outcome: satisfaction, learning, change in learner behavior, and organizational change/patient outcome [15], all of which coincide with our study except the fourth item. Our findings show that despite that e-learning was a new thing for the students they were highly satisfied with the e-learning course. The majority enjoyed learning using this method. Their overall scores improved as they proceeded in the e-learning module. All differences between pre and post-quiz scores of the e-learning module were highly significant. These findings are similar to those of other studies evaluating online courses [19]. When comparing reproductive knowledge scores between students participating in the e-learning course and those attending the regular lectures only; we found a highly statistical significant improvement for students in the first group. This coincides with other findings that show effect sizes favored e-learning compared to classroom instruction [20]. No difference was found among males and females attending the e-learning course, regarding their scores which shows no sex preference concerning e-learning.

We explored students' perceptions towards the ease of questions on the knowledge questionnaire. We found that nearly a quarter of students (24.3%) enrolled in the e-course (group 1) reported they found the questions easy. Inversely, 44% of students attending the Face-to Face traditional lectures (group 2) found questions difficult which may be attributed to better learning behavior for group 1.

A comparison of mean scores on the CEQ scales was conducted between both groups of the study. Students enrolled in the blended-learning course had higher significant mean scores for the Good Teaching Scale. This is consistent with another study that reported instructor ratings to be strongly correlated with student satisfaction [21]. Similarly, students on the e-learning course had significantly higher scores for the Clear Goals Scale and the Appropriate Workload Scale which agree with reflections of Norman 2008showing e-learning to be more efficient than its alternatives where students participating in e-learning are reported to achieve the same amount of work in about 30% less time [22]. On the other hand, no difference between both groups was detected for the Appropriate Assessment Scale and the Generic Skills Scale which partly concur with a study that found no significant differences between student groups on achieving team process skill [18]. An observation of a more positive achievement regarding course learning objectives, perceived by students in the first group, is consistent with our findings. Researchers concluded that the results provide evidence to support e-learning format without compromising pedagogy. They also suggest that this format enhances students' perceptions of their learning [18].

The results of our focus group discussions showed that students were satisfied with the e-system and expressed they had a "very good experience with the e-learning system". Additionally, improved learning outcome was stressed as the e-course " helped plan their studies"and " helped them understand the subject". They especially enjoyed the "chance to do all they wanted and needed to do freely, whenever they wanted"and how "the e-learning course helped them with their learning". These findings iterate those reported in 2007 about the flexibility of e-learning [23], allowing learners' greater control over the learning environment and freedom to move at their own pace, thus adapting to characteristics of individual learners such as cognitive and learning styles.

Our results denote that an online course with activities for interaction between students and instructors and amongst students can overcome many educational drawbacks encountered in large enrolment classes, enhance student's learning thus overcoming pit-falls of traditional learning. In addition, student's perceptions of diversified visual and interactive e-learning content elements were very positive. The integration of e-learning into undergraduate, graduate, and continuing medical education will promote a shift toward adult learning in medical education, wherein teachers no longer serve solely as distributors of content, but become facilitators of learning and assessors of competency. It is recommended that universities with large enrollment classes adopt e-learning and provide facilities for its implementation. This can be achieved by providing computer halls with internet connections on campus and at university dorms.