A systematic review on inpact of
e-learning for post-graduated medical education
Ana Cristina Silveira email@example.com
Ana Sofia T. Baptista firstname.lastname@example.org
Catarina Quina email@example.com
Fábia S. G. Carvalho firstname.lastname@example.org
Joana V. Vargas email@example.com
João A. G. Faria firstname.lastname@example.org
Leonor M. G. S. Marques email@example.com
Luís C. P. Braz firstname.lastname@example.org
Orlando M. Cardoso email@example.com
Rui João G. Cerqueira firstname.lastname@example.org
Sofia M. Pina e Silva email@example.com
Susana M. G. da Silva Santos firstname.lastname@example.org
Advisers: Mário Dinis Ribeiro, MD, PhD email@example.com
Altamiro da Costa Pereira, MD, PhD. firstname.lastname@example.org
Introduction: E-learning has established itself as an innovating learning method due to the
changes in society and technology. It has been adopting new computerised and multimedia based
technologies providing not only a mean of communication between teachers and students but also a
way of self-learning and sharing knowledge and ideas. Understanding if it is used, how often and
what are its real effects and efficiency in comparison with classroom-based learning will allow an
valuable data to enhance the didactic and organisational aspects of e-learning. Although these are
very important questions we still do not have enough studies providing information to give them an
Aim: to synthesize current scientific results in a systematic review assessing the importance
of e-learning in medical post-graduating population.
Methods: A systematic review of published articles in Pubmed and Scopus Databases. All
measuring in some way the impact of e-learning in medical post-graduating population.
Results: The three reviser’s trial provided 225 (two hundred and twenty five) articles. Data
extracted from the 20 articles selected was treated in “SPSS 14.0 for windows”. The majority of
studies was published in USA (45%); were identified articles since 1999 although the major part was
published in 2006 (25%). Only 2 from the 20 articles referred a tendency of growth in the usage of e-
learning; 3 studies reefer a knowledge gain in WB learners and 1 study found virtual models
comparable to conventional training. 20% of the studies mentioned effects in clinical performance, 1
revealed an overcome of embarrassment, 2 cited a faster and more appropriately response in real
situations and 1 stated an increase in awareness in prescribing habits. Participants’ attitudes were
referred in 11 articles, in 9 of those the attitudes were positive; the negative attitudes were mainly
difficulties in implementation (2 out of 3) and low level of motivation (1 out of 3).
Discussion: E-learning has advantages for both students and teachers. Despite the lack of
contact between them, which is pointed as a factor of low motivation, the number of users and courses
is increasing. As many technologies are required, these courses need great investments; although it is
proved that in long term they diminished costs with education. As there is not enough information
about this recent theme more, intervention studies are required. For now e-learning should be
considered as a complementary method for the traditional method of teaching.
Key-words: Medical education (MeSH); Web-based education; e-learning; post-graduation; medicine;
distance education (MeSH).
The concept of Distance Education is known since the 19th century. It was born from the need
of a growing population to face a competitive world and improve their skills. It has evolved in the last
few years as new technologies have been created and applied. With the recent development of the
World Wide Web, distance education has taken a large step towards the creation of the idea of e-
learning – “online computer (web)-based educational training”  through electronic means, such as
web, intranet, or other multimedia materials .
In fact, this method has been increasingly implanted worldwide, trying to make students’ life
easier. The main idea is to turn learning into a kind of exchange between master and student rather
than a legacy which is transmitted as unidirectional as it has been for many years. In distance
education the student is challenged to have an active participation in his own education (according to
the principles of “Active involvement of the learner enhances learning”, “Interaction between teachers
and students is the most important factor in student motivation and involvement”, ” Students benefit
from taking Responsibility for their learning”, ”There are many roads to learning”, “Experience
usually improves teaching” ). Medical schools have been implementing Virtual Learning
Environments (like “moodle”, for example) – a set of electronic teaching and learning tools, a
platform providing online student support and electronic communication .
Medical education is education related to the practice of being a medical practitioner, either
the initial training to become a doctor or further training thereafter. Medical education and training
varies considerably across the world. Various teaching methodologies have been used in medical
education, which is an active area of educational research.
Medicine, as a complex multidisciplinary field, has been implementing computerised
technologies, with e-learning being a central point of the process, in order to make a bridge between
distance education and medical education. These technologies include web-based education, virtual
reality (high fidelity human patient simulation). Web-based learning (WBL), for instance, can serve to
efficiently deliver educational programs to physicians who may be far from each other and from full-
time medical school faculty . The importance of these programs is revealed in the standardizing of
students’ learning and curricular elements.
However, little is known about the effectiveness of e-learning in post-graduate medical
education and how it compares to conventional methods.
The aim of the present study is to make a systematic review to understand the impact of e-
learning in medical post-graduating population. Consequently, we will try to answer several
important questions that arise:
- How often is e-learning used by medical students?
- Which are its effects in learning?
o Is e-learning effective?
o What are the participants’ attitudes?
This study is a systematic review for which we defined a strategy in order to accomplish the
nuclear aim referred above; the strategy finds its principal foundations in the exclusion and inclusion
Scientific papers/manuscripts assessing e-learning in post-graduate medical education.
After the application of the query, each abstract was analysed by two revisers; in case of
disagreement, a third reviser stated his/her opinion. The decision to include an article was based on
inclusion criteria. Thus, all articles which weren’t related with e-learning on medical post-graduation
were not included. Note that even when the abstract was not found we decided to include it. The full
texts, of the included abstracts, were then searched manually, using FMUP (Faculdade de Medicina da
Universidade de Porto) library, IPO (Instituto Português de Oncologia) and the web, through medline
and regular Google search.
Written in other languages than Portuguese, English and Spanish.
No information about at least one of these topics:
- Frequency of usage of E-learning;
- Effects in clinical performance;
- Participants’ attitudes.
This systematic review is based on a search made in two steps: the first using Medline (through
PubMed) as a data base; the second one using Scopus to find more articles.
The search in Pubmed was made using a query (using MeSH and non-MeSH terms) which
provided us articles under the topic of e-learning and its impact on medical post-graduation. We found
the using of synonyms an important point of this query too.
In addition, we stipulated the 1st February 2007 as the end date for our search; this means that
articles indexed after this data were not included.
The query we have created to Pubmed’s research is: ("Education, Medical/education"[MeSH]
OR "Education, Medical/methods"[MeSH] OR "Education, Medical/statistics and numerical
data"[MeSH]) * ("Education, Distance/classification"[MeSH] OR "Education,
Distance/methods"[MeSH] OR "Education, Distance/statistics and numerical data"[MeSH]) OR ("e-
learning" AND "medical education") OR ("web-based learning" AND "medical education") OR
("electronic learning" AND "medical education"). We believe this is the one which suits our aim the
Within the query there are some words that are important to our search in order to help us find articles
which are, at the same time, specific but not too much limitative. In fact:
- OR between “Education, Medical/education”[MeSH], “Education, Medical/methods” and
“Education, Medical/statistics and numerical data”[MeSH] makes possible the inclusion of articles
which refer to methods, education, statistics and numerical data in medical education (we didn’t use
AND because it would restrict the search only to articles which had, at the same time, the three
- AND (*) was used to include articles which had, at the same time, the concept of medical
education (first part of the query) and e-learning (second part of the query), or other equivalents;
In the last part of the query, which was linked to the other part by the connector “OR”, we did
not include MeSH terms in order to enlarge the search results. This was particularly important because
the terms “e-learning”, “web-based learning” and “electronic learning” have no translation into MeSH
terms and not including them could result in loss of information. Each one of these words was
combined with “medical education” by an “and”.
Since we cannot use MeSH terms in Scopus, we have to define a different query in order to
make our search. That query is: (TITLE-ABS-KEY ("E-Learning" OR "Web-based learning" OR
"Electronic Learning" OR distance) AND TITLE-ABS-KEY ("Medical Education" AND Graduate)).
- This query has two parts separated by an AND. This operator assures that the selected articles
include together terms of the first and second parts. Thus will increase the possibility of finding articles
that better fit our goal by combining all the expressions;
- “TITLE-ABS-KEY” before each part of the query refers to a predefinition we made to
certificate that at least one of the terms appears in the title, abstract or even in the key words of the
article helping to direct our search;
- As in pubmed, “OR” is the operator that enlarges the search. In fact, OR functions to add the
articles were the subsequent term appears to the articles including the previous term. “OR” was used
between all the terms of the first and second parts of the query.
The quantitative analysis was based in several topics we thought to be adequated to our study,
such as number of participants, type of study, medical speciality, teaching methods, country in which
the study was made, year of publication, others. Using “SPSS 14.0 for windows” outputs were
For the results analysis we identified evaluation domains:
a. Frequency of usage;
b. Efficiency of e-learning;
c. Effects in clinical performance;
d. Participants attitudes:
◦ Positive aspects;
◦ Negative aspects.
The creation of these domains preceded the articles search..
Under the domain “frequency of usage” it will be analysed if the medical population is using
this kind of teaching/learning methods and, if they are, which is the frequency they access to the WBL
platforms: is it an habit or a sporadic utilisation?
The use of e-learning has, for certain, consequences on learning process. The variable
“efficiency of e-learning” will analyse these consequences, trying to understand which are the effects
and how they are shown in real/simulated trials.
The interference of e-learning will be also analysed on clinical performance: what kind of
improvements will be verified in those who use WBL platforms or virtual patient simulators; is it only
a theoretical influence or the practice and attitudes in real clinical situations are affected.
The “participants’ attitudes”, how do they feel using these learning methods, if it is useful or
not, if they like the materials and other aspects that can support (or not) the use of these technologies in
post graduated medical education instead of traditional methods will be exposed in this variable.
The literature search in PubMed and in Scopus Database (using both queries referred above in
Data Source) identified 188 (one hundred and eighty eight) and 45 (forty five) studies respectively
(until 1st of February of 2007). In a total of 225 (two hundred and twenty five) articles, 8 (eight) were
found in both databases (see appendix 1).
Using “SPSS 14.0 for windows” to plot data related to the articles, we measured the agreement
of the two revisers concerning the application of inclusion criteria, using kappa intervals with
correspondence to five different degrees of agreement. The proportion of agreement between the two
revisers was 90% (proportion of agreement= (81+88)/188=90%; kappa = 0, 798 which corresponds to
a “substantial agreement”).
All the data extracted from the articles was treated in order to make possible the interpretation of results and accomplishment of some conclusions.
Some data was quantitatively analysed using “SPSS 14.0 for Windows”(Table 1).
Table 1- Results quantitatively analysed using “SPSS 14.0 for Windows”.
Publication artigo Title First Author Country Duration Medical Speciality
1999 1 Teaching clinical trials electronically Østbye, T. CANADA 2 Family Medicine
2001 2 Medical education with the Internet: a pilot training programme in reproductive medicine. Jenkins J.M. UK 5 Reproductive Medicine
3 Collaborative online learning: a new approach to distance CME Wiecha J.M. USA 2 Family Medicine
4 An electronic learning portfolio for reflective continuing professional development Dornan T. UK 12 Omitted
5 Women physicians are early adopters of on-line continuing medical education. Harris JM Jr. USA 24 Family Medicine
6 Designing tailored Web-based instruction to improve practicing physicians' chlamydial screening rates. Casebeer USA 11 Family Medicine
7 Portable interactive faculty development for multiple site clinics using computer-based CD-ROM modules. Ogden P.E. USA Omitted Omitted
8 A model for online interactive remote education for medical physics using the internet Woo, M.K. CANADA Omitted Medical Physics
9 Sjunet--the national IT infrastructure for healthcare in Sweden Malmqvist G. SWEDEN Omitted Omitted
2004 10 Distance learning: linking CME and quality improvement O'Riordan M. IRELAND 36 Family Medicine
11 Satcom based distance education in medicine - Evaluation of Orissa telemedicine network Singh, K. INDIA 12 Radiology
12 Distance learning courses in occupational medicine - Methods and good practice Wagner, N.L. INDIA 12 Occupational Medicine
13 The future of medical education is no longer blood and guts, it is bits and bytes. Gorman P.J. USA Omitted Omitted
14 A new vision for distance learning and continuing medical education. Harden R.M. USA Omitted Omitted
15 Preference of distance learning methods among post-graduate occupational physicians and hygienists. Burgess G. UK 3 Occupational Medicine
16 Evaluation of an online bioterrorism continuing medical education course. Casebeer L. USA 21 Family Medicine
17 The impact of E-learning in medical education Ruiz J.G. USA Omitted Omitted
18 Facilitating interpersonal interaction and learning online: linking theory and practice Sargeant J. CANADA Omitted Family Medicine
19 Radiology education: a glimpse into the future Scarsbrook A.F. UK Omitted Radiology
Web-based versus face-to-face learning of diabetes management: the results of a comparative trial of
20 Wiecha J.M. USA 18 Family Medicine
Frequency of usage
No article was found presenting information about the number of medical doctors using WBL
platforms or participating in online courses. Yet two articles refer a tendency of growth in the number
of users and the amount of time spent by practioneers . Also the majority of users belong to the
female sex and to younger etary groups. 
Another article refers that in the US and UK some universities do not have a campus anymore,
they deliver their training exclusively by distance learning courses. Masters courses in distance mode
for occupational health & safety and occupational medicine (OSH) are available in other countries.
Almost 100% of all postgraduate teaching in occupational medicine is done by distance education in
the UK. In Australia a multitude of high quality masters programs in OSH can be done in distance
education mode. 
Efficiency of E-learning
Three studies evaluated knowledge gains with WBL interventions  . Two of them
measured participants’ scores in multiple-choice tests and one of them use case vignettes to evaluate
the participants’ knowledge in that case:
- One of these used a research method that included pretest/posttest self-controlled studies
involving two groups: students in WBL group showed a statistically higher post test score and a
greater gain in overall scores from pre-test to post-test than did students in «face to face» group
(Table 2). A written case analysis was also used, and it revealed that students in the WBL
group were more likely than students in «face to face» group to correctly order the
interventions on the post test (Table 3) .
Table 2- Performance outcomes of students enrolled in the online Diabetes curriculum
Conventional Diabetes Online Diabetes
Curriculum n=85 Curriculum n=74
Mean Percent Correct Mean Percent Correct
Evaluation Case Before After Gain Before After Gain Difference P Value
Component (After- (After- in Gain for
Before) Before) difference
History (12 items) 34.6 30.6 -4.02 34.9 37.4 2.5 6.6 0.069
Essential exam (four 66.6 72.9 7.32 60.8 72.9 12.1 4.8 0.29
Assessment (two items) 61.7 71.4 9.76 62.5 68.2 5.7 -4.0 0.60
Plan (seven items) 30.4 37.1 6.71 26.0 44.1 18.1 11.4 0.025
Referrals/education 44.7 43.5 -1.19 43.3 46.7 3.5 4.7 0.32
All items 40.8 42.1 1.30 39.2 46.9 7.2 6.4 0.008
Wiecha JM., 2006
Table 3- Change in test-case management behavior of students enrolled in web-based versus conventional
Conventional Diabetes Curriculum Online Diabetes Curriculum
Total # of Interventions Total # of Interventions P Value
Interventions Not Correctly Ordered Interventions Not Correctly Ordered
Ordered on Pretest at Posttest n (%) Ordered on Pretest on Posttest n (%)
1,549 512 (33.1) 1.336 507 (38.0) 0.018
Wiecha JM., 2006
- Other study, using only one test after the intervention, stated a statistically significative higher
mean score of correct answers in the WBL group than in the face-to-face group .
- Another one uses case vignettes to evaluate physicians knowledge of biologic and chemical
threats. Responses to clinical vignettes were compared between both groups: participants and
nonparticipants. (tables 4 and 5)
Table 4- Comparison of correct case responses
Participant (N=61) Nonparticipant (N=64)
Cases Frequency Percentage Frequency Percentage p
47 75.8 35 54.7 0.01*
disseminated 56 90.3 60 92.3 0.69
22 36.1 19 29.7 0.45
58 93.6 49 77.8 0.01*
ciprofloxacin 57 91.9 59 90.8 0.82
Casebeer L., 2006
Table 5- Confindence in finding information to guide diagnosis
Information Mean SE Mean SE
biologic 8.21 0.24 7.17 0.26 0.01*
chemical or 8.03 0.29 7.05 0.29 0.02*
radiation 7.64 0.32 6.71 0.31 0.04*
6.44 0.35 5.89 0.34 0.26
Casebeer L., 2006
The responses from the nonparticipant group and the participant group were then sorted by the
physicians’ years in practice and self-designated geographic practice settings (urban, suburban, or
rural). There were no significant differences in the percentage of correct responses depending on the
location of the practice setting. However, statistically significant differences did exist in responses
associated to the number of years physicians indicated they had practiced. The participant group was
more confident than the nonparticipant group about finding information to guide the diagnosis of a
patient with biologic, chemical, toxic, or radiation exposures but not in addressing mental health issues
related to terrorism.
Comparison of preferred learning formats revealed no significant differences between
participants and nonparticipants. Nearly 80% of participating physicians and 84% of nonparticipants
preferred Internet modules as a learning format. CD-ROM and printed literature followed as preferred
learning formats (table 6). 
Table 6- Education format preferences
Participant (N=61) Nonparticipant (N=64)
Formats Frequency Percentage Frequency Percentage p
Internet module 48 80.3 54 84.8 0.49
Videotape 16 24.2 18 27.3 0.69
CD-ROM 32 48.5 34 51.5 0.73
Audiotape 8 12.1 6 9.1 0.57
Printed literature 30 45.4 31 47.0 0.86
Casebeer L., 2006
- One article stated that Software based simulators, which create virtual models, were found to
be comparable to conventional training. 
Effects in clinical performance
We found one article referring that WBL enables patient and doctor to overcome the
embarrassment factor .
Two articles evaluated clinical performance (clinical exercises) of students/practioneers that
used WBL, and proved that they were capable of responding faster and more appropriately than those
who had learnt from a conventional (“face-to-face”) course, when dealing with real clinical situations
In addition, one article stated that the on line courses provide relevant and applicable updates
on therapeutics and everyday practice :
- They increases the confidence in treatment;
- They increases the awareness in prescribing habits.
1) Positive aspects
Six studies refer that there is a general tendency of participants to demonstrate a positive
opinion about WBL ,,  ,,.
Two of these defined the following common characteristics that make e-learning or WBL
platforms attractive for both students and teachers  :
- Learning delivery
- Easy access
- Available at any time
- Personalized instruction
- Easy updating of contents
- Good learning interface
One article summarized these features in an original model called CRISIS (Table 7). 
Table 7- CRISIS model
CRISIS Criteria Features of E-learning and IVIMEDS
Convenience Learning at a distance and “just-in-time”
Relevance Defined learning outcomes and up-to-date
Individualization “Just-for-you” learning
Self-assessment Assessment and feedback integrated with
Independent learning Curriculum map and guided learning
Systematic Learning outcomes
Harden RM., 2005
Another advantage of e-learning concerns the reduction of costs in education, as it allows to:
   
o decrease teachers/tutors salaries;
o Avoid the necessity of teachers/students to travel;
o Reduce the need for big buildings;
o Avoid paper based material and books.
Another article focused that WBL platforms can constitute a significant help because they
avoid many difficulties of “learn-by-doing” such as :
- Operative costs (the operating room is the “surgeon’s classroom” an expensive place for
- Decrease in the amount of time available for formal teaching;
- Teaching opportunities are dependent upon the random flow of patients through the
2) Negative aspects
Two articles pointed out some difficulties concerning the implementation of e-learning: those
who contact for the first time with e-learning tend to show a negative attitude and discomfort with its
utilization, which is increased by the lack of face-to-face contact or the absence of formation courses.
One article also emphasized that there is a low motivation level for those practioneers/students
who spend too much time in front of the computer, instead of contacting with patients .
The results by medical speciality are summarized in Table 8.
Table 8- Summary of results by medical speciality
Family medicine (reproductive (occupational medicine;
n=8 medicine; radiology) medical physics)
Frequency of Increase in number of There is an increasing number of
usage users(1) - post-graduate web based courses
Efficiency of Knowledge gains measured Software based simulators
e-learning in on-line theoretical tests(3) are comparable to -
conventional training (1)
Effects on Enhances practioneers
clinical performance measured in - -
performance practical tests(2)
Participants Positive (4) Positive(2) Positive (1)
Attitudes Negative (1) Negative (1)
The number of WBL courses, as well as medical post-graduate users, is rapidly increasing,
which shows that e-learning is becoming an important source of information for both practioneers and
medical doctors in their Continuing Medical Education. This has been a powerful driving force to the
leaders in Medical Education who have challenged Medical Schools to exploit the potential of distance
learning technologies and use Interactive Web-based courses to supplement and complement
There is a great investment in the application of computer-based technologies to CME, and
medical education specifically represents a major category of life-long education because of its
potential for high costs and adverse consequences of performance. Despite this great investment, a
reliable overall evaluation, based on randomized controlled trials to provide data on the effectiveness
of online course intervention, is still missing. This illustrates the complexity of carrying out research in
real educational settings.
However, there are good evidences that e-learning has advantages, not only for the students (as
they can learn quicker and have a better clinical performance), but also for the teachers (as it helps to
create more correct and fair evaluation parameters).
In this study, a pretest/posttest study was found and it revealed knowledge gains in those who
were submitted to WBL interventions. In fact, these results expressing a gain in practicing physicians’
knowledge can only be conclusive in these studies, as the studies without a control group cannot
separate web-specific from content-specific learning gains.
Another difficulty about the analysis of the results was to explain why online users learn
quicker and have a better clinical performance when compared to conventional curricula users, as
different disadvantages are pointed to e-learning and face-to-face courses. The slight superiority of
WB learners may be due to the fact that they have to write and post for feedback, while in face-to-face
courses, learners participate in oral discussions to reach consensus. This means that face-to-face
learners could reveal a lack of attention during the sessions, while (due to its design) this is less
possible among web-based learners. At the same time, it is refeered that there is a low level of
motivation among WB learners that cannot have enough contact with patients. So, face-to-face
methods are also important to practical clinical formation.
E-learning has proved to be a consistent method among the clinical and practical subjects
rather than in theoretical ones. In post-graduation, the clinical practice is highlighted and this can be a
possible reason to explain why WBL appears more often in post-graduate CME than in basic academic
Different kinds of limitations can influence and thus interfere with the final result of the work. - it
is possible to point out some of them, although many are unpredictable, almost impossible to find and
The first thing which early appeared very clear was that not only the number of studies in this field
of e-learning in postgraduate medical education was reduced, but also the number of articles we could
include among these was small. Importantly, access was not possible to 44% of the included articles.
The language was undoubtedly one of the most limiting factors, since only articles written in
Portuguese, English or Spanish were read.
In addition, the fact that the articles found revealed to be heterogenic and include much more
qualitative considerations than quantitative and statistical data was another of our central limitations. It
is also important to refer that there was a considerable number of articles found that only describe
characteristics and functioning of programs of e-learning rather than their implementation and impact.
Additionally to these things referred above, the fact is that, even though we tried to prevent grave
errors by putting at least three elements of the group responsible for each step, the inclusion/exclusion
of articles, extraction of data and comparison of results are activities that involve lecture which is by
itself non objective and interpretative.
It would be important to make more studies evaluating the implementation of WBL courses.
Instead of putting WB against face-to-face curricula, to decide which is better, it has been
demonstrated that WB curricula is a secure option in Medical Education. The usage of WB courses
(conciliated with paper based material) in decentralization of medical school instruction has, therefore,
proved to be a new and effective procedure.
We can anticipate that medical education will increasingly take advantage of the benefits of
distance learning to improve the quality of post-graduation courses.
The authors would like to acknowledge Doctor Mário Dinis Ribeiro for his mentorship and Professor
Doctor Altamiro da Costa Pereira for his advice, and our colleague Tiago Adrego for his technical
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Flowchart 1- Participants’ selection
Read titles and
abstracts (2 revisers)
PARTICIPANTS from 225 articles found
Acesses e-learning? Is it included by two
In medical education?
Is it included just
Included Yes by one reviser?
Read abstract and
No access to full article;
Obtain full article title by the third
54 full articles Yes
Exclusion Criteria No
Read full article
Written in other languages than Portuguese
or English Is it included by
the third reviser?
With information about at least one of these
topics: Apply exclusion
- Frequency of usage; criteria
- Efficiency of E-learning;
- Effects in clinical performance;
- Participants attitudes.
Is it excluded?
20 full articles