Medical undergraduates at University College Dublin (UCD) have a forty two week training period in surgery. This is divided in two parts, a 28-week period and a 14-week period. Students are allocated clinical attachments to hospital surgical services and rotated though the spectrum of surgical specialities. During these rotations they participate in ward, theatre and outpatient activities but have no clinical responsibilities. Clinical "by the bedside" teaching with clinical lectures in small groups is provided. In addition a formal lecture programme is delivered and library facilities are provided for independent learning. This structure is the same in the initial 28 week and the later 14 week periods. The clinical sites are identical, and clinical rotations are organised so that all students get an exposure to all surgical specialties over the course of their training over the entire 42 week period. Whether an individual student goes through a particular rotation in the initial 28 weeks or the later 14 weeks, is a random allocation.
At the end of the first period of the programme, undergraduates have a surgical examination consisting of a multiple choice paper and a clinical examination. For the purposes of this paper this is referred to as the entry examination. At the end of the second period of the course students take the final exit examination in surgery. The exit exam also consists of a multiple choice exam and clinical exam with an additional written short answer examination.
iCAL-SURG was used during the second period of the surgery course, after students had taken their entry examination. The only fundamental methodology difference between these two training periods was the introduction of the iCAL programme. The questions presented through the iCAL system are identical in style to those presented in the short written examination and clinical examination problem solving scenarios.
The class was divided into quartiles on the basis of this entry examination. Utilisation of the iCAL programme by students was optional and was compared with absolute performance and change in class ranking in the final examination. One hundred and forty eight students completed the two year programme. Data on these students' utilisation of the iCAL platform was analysed.
Technical infrastructure
All students in UCD Medical Faculty are conversant with use of ICT, with CAL used to deliver up to 35% of preclinical courses. Clinical students have access to a suite of networked high specification multimedia PC's with T1 internet access. This facility is available to students from 8.00 to 18.00, weekdays. iCAL-SURG is also available anywhere with an internet connection. Online course material is delivered within the Blackboard http://www.blackboard.com Virtual Learning Environment. Courses are password protected and use of iCAL-SURG by individual students is monitored. Instructors can find the number of times each student has logged on to iCAL-SURG, the areas of the course accessed, the time and day of log-on. The number of times the site was accessed by the student is referred to as the "hit rate". It is not possible to record the content viewed or duration of student activity, once logged on.
iCAL-SURG
During this pilot phase, iCAL-SURG use was optional and did not form part of the assessment process for students. This phase concentrated on the COURSE DOCUMENTS and the ASSIGNMENTS areas in Blackboard. The COMMUNICATION area was used for both social and academic purposes but only accounted for 5.3% of use of iCAL-SURG and no assessment was made of this in relation to student performance.
In the COURSE DOCUMENTS area [Fig, 1,2] lecture notes are available prior to lectures, either as Powerpoint, Adobe Portable Document Format (PDF) or Microsoft Word files. The material available on the iCAL system not only included material presented at lectures but also additional supplementary material. Old examination question papers and sample answers are also available here. In the ASSIGNMENTS area each week the academic staff uploaded a short series of clinical questions with suggested answers made available made available [Fig. 3]. Students read these and studied the relevant areas in text books or in discussion with tutors and peers. Students could also take online OSCE examinations [Fig. 4,5]. This was presented as a series of photographs with related clinical details. Students were asked to answer the questions in a prepared downloaded Microsoft Word document, which they then uploaded to the "Digital Dropbox" in Blackboard. These submissions were reviewed by academic staff. On the following day sample answers were published [Fig. 4,5] which students could compare with their submissions.
Statistical analysis
A Student t test was used for comparison between groups of two. Where more than two groups were involved an ANOVA was performed followed by Post-hoc analysis as appropriate, with a Fischer's least significant difference test. Data involving class rank was analysed non-parametrically with a Mann Whitney U Test for comparison between groups of two, a Kruskal Wallis where more groups were involved and a Spearman Rank Correlation for investigating correlations. Alpha was set at 0.05.