The Michael G Detroiter School of Medicine at McMaster University in Hamilton, Ontario, offers major programs in undergraduate, postgraduate, and graduate medical education. The Undergraduate Medical Program for the MD degree has 148 students admitted each year. The three-year program uses a problem-based approach to learning that can be applied throughout the physician's career. The components have been organized in sequential blocks with early exposure to patients and case management. The academic program operates on an 11-month annual basis, and students qualify for the MD degree at the end of the third academic year.

The curriculum is delivered through a blend of small group tutorials, lectures, and clinical experiential or apprenticeship learning, with the balance weighted toward tutorials in the first 18 months and the apprenticeship model for the second half of the program. Traditionally, the tutorials used print resources as the springboard for problem-based learning. Students would receive a six-page handout that contained progressive disclosure of a clinical patient problem that would be used for discussion, issue generation, and learning objective setting. The tutorial problem handout would also contain a resource page with suggested readings and human resource contacts.

Since 2003, McMaster has been working on a project to make the curriculum electronically accessible, as well as develop new e-learning content. The program distinguishes between e-learning and e-curriculum, which is the management and conversion of print resources for electronic management, access, and delivery.

 

The move to electronic

In creating the electronic resources it was important to balance the key internal needs with insights into instructional design obtained from education research. After extensive review of both of these aspects, three main requirements were identified. First, it was important to deliver the curriculum in different media formats; in particular, print versions for the face-to-face small group tutorials and web-based for online access. Moreover, because not all tutorial locations have Internet connections, it was necessary to have an option to output to CD-ROM. The existing method involved using separate word processing documents to convert materials to HTML for web delivery, which amounted to unnecessary overhead and an inefficient process for updates and edits.

Second, McMaster needed to be able to personalize versions for various audiences. For example, tutors needed a guide version that included annotations and train the trainer type guidance notes. Finally, the program deliverables needed to be SCORM-compliant and use eXtensible Markup Language (XML), which is increasingly being adopted and promulgated by the medical education community. There are several repositories of health science learning objects, such as the American Association of Medical Colleges MedEdPortal, which emphasize technology and indexing standards, as well as MedBiquitous, which promulgates XML standards in medical education and administration. This had critical implications for collaborative curriculum development with other medical programs, as well as other health science programs within the institution. Developing a strategy that did not lock the program into a particular proprietary format or specific vendor also was critical to success.

Pedagogically, one of the biggest challenges was consistency among the curriculum materials. Without a clear structure in place, subject matter experts would author tutorial materials as they saw fit rather than adhering to the perspective of curriculum planners or principles of instructional design.

Enter the Structured Content Development Model (SCDM)

The SCDM is a design and development process aimed at producing reusable content across a variety of delivery platforms and environments. The core principles of SCDM encompass both a shift in technology and in instructional design. With respect to learning content, it's critical to first understand how instructional design must adapt, and then understand how technology can be used to implement a new practice.

Building solid learning materials requires the careful analysis of a variety of factors, such as learner profiles, training environment, business environment, and so forth. The result of such analysis feeds design decisions. SCDM wholly embraces what the instructional designer brings to the process for designing and developing learning. The shift for the instructional designer is in the transfer of results into a hard-coded set of rules about how to author content. Although the creation of this set of rules is part of the typical instructional design process, it becomes a tangible asset that is structurally implemented within an authoring environment with the added advantage of reusability in SCDM.

Rules

 

In SCDM, "set of rules" means more than having a specific suite of authoring tools available within an authoring environment. Instead, tools refer to individual units that can be used ad hoc, with no particular order. The "set of rules" determines the process and context, and it strings together tools based on the process and context that the author is creating within. This is aptly called content structure.

To exemplify this notion of rules, let's examine a simple matching activity that's commonly used in print and online learning materials. The content structure of a matching activity, whether it's delivered in print or online, typically uses the following design:

Note key relationships described by this simple diagram. Designers must create both a matching activity and activity instructions. Also, if designers create an Item A, they must create a match for Item A, as well as provide both positive and negative feedback. However, designers do not have to create an Item B after creating an Item A. This leaves flexibility for a content author to create as many items as they need.

Technology

With respect to a shift in technology, SCDM is dependent on the use of eXtensible Markup Languages (XML), as well as the concept of separating the way content is presented from the way it is delivered. XML says nothing about how content looks or behaves; it simply describes content. XML is a language without borders as it requires developers to create their own coding tags, which are descriptions used to define the content, and apply those tags in a non-predetermined way. The list of descriptions can be as simple as paragraph and image or complex and introduce context and audience elements such as classroom notes or advanced students. The taxonomy available to content developers must come from a content structure defined by the instructional designer.

As with general content authoring, there is a set of rules for authoring content that is coded in XML. First, designers need somewhere to house the content structure. Fortunately, there are a variety of XML authoring systems available to consumers that provide the proper environment. Next, designers need a way to deliver the content. Enter the delivery template, which dictates how content looks and functions for the end user. For McMaster, there are several layers to a delivery template, including styles, communication logistics, Macromedia Flash configuration files, and anything else that renders content in a specific format and communicates with a host environment around exact protocols. Delivery templates speak to the unique taxonomy created in the content structure and must be designed around the nomenclature of the content structure.

This is the basis on which SCDM enables reuse of content. It is a step beyond the basic concept of learning objects, which typically refers to finished technological artifacts that are granular enough to be used in a variety of places. SCDM goes further because it unbinds content to a medium or to a finished product. Content does not persist as a packaged technological artifact other than its XML encoding. Therefore, content can migrate across media, context, and technologies without ever needing to be re-authored.

Developing initial content structures

The McMaster MD program required a structure that offered a high degree of authoring flexibility, yet still employed a taxonomy that was a meaningful reflection of the content itself. At first, designers were keenly interested to see whether natural patterns emerged as authors started to create content. The plan was to create a more focused and complex content structure once standard patterns became clear. These patterns provided the template that enabled the content structure to evolve into a more complex infrastructure and standardized authoring environment.

It was equally important for the content structure to work within semantics that properly reflected the pedagogical approach. Having analyzed the content and McMaster requirements, it was clear that the content structure would require elements designed for both the core curriculum of tutorial problems, as well as elements that would permit the development of case-based virtual patient e-learning modules.

With the foundation for the content structure established, designers needed to refine the rules and available tools required by authors. For example, was it important to demand that authors always follow a procedural order in providing content, such as always presenting a problem before presenting a diagnosis or always offering a solution to every problem? Such questions began the thought process for determining what tools to make available to authors. It was important to ensure that content authors could create dynamic and engaging content that would teach problem-solving and solution-generation skills.

After probing into the rules and tools, the next step was to determine a structure that allowed for the presentation of problems or solutions independent from one another. Content authors needed the capability to create segmented objects that could be collated and mixed in a variety of ways. To do so, the authoring environment included tools that were specific to the various stages of a patient problem-based e-learning approach, such as Hypothesis Widget, (a widget that allowed students to formulate a list of possible diagnoses). In addition, content creators needed access to tools that tested against evidence or the advice of virtual mentors. Therefore, designers had to combine simplicity in the rules with focused semantic objects that spoke directly to the type of learning that authors were going to create.

Developing the delivery templates

Because McMaster had already taken initial steps in creating online or electronic problem-based learning, there were branding guidelines for inspiration. The requirements, however, for a global delivery template were different than those used to generate the original courses. The delivery templates had to work independent from any one delivery system. McMaster University is involved with other organizations with whom they wanted to share content. In addition, McMaster wanted to single source the content and continues a paper-based version of the medical curriculum.

As a result, all elements within the delivery template were developed to be compliant with e-learning SCORM standards in order to ensure mobility among various LMSs. In addition, the various elements within the content structure (such as the hypothesis widget) were created as independent graphical elements that could be mixed and matched in an electronic environment or a paper-based format. This last consideration also meant that the real estate on a screen or on paper adjusted itself accordingly.

The flexibility inherent in the content structure and delivery template proved to be the ultimate challenge. This was purely a logistics issue because a more regimented content structure and delivery template makes it easier to test for quality assurance. The process for quality assurance in this case, meant that designers of the McMaster program had to try every combination of elements and content types to guarantee that the technology behind the delivery template would accommodate everything.

Results

Using SCDM has helped the McMaster medical school implement a successful e-learning program, which has lead to several administrative and pedagogical advantages.

  1. The McMaster program used existing content from print tutorial materials to develop a standardized content structure for core curriculum materials that were successfully delivered from a single source of content to multiple audiences (tutors and students) across multiple media (print, web, and CD-ROM). This has made it easier to enforce program-wide conventions with the standardized structure. It also has helped McMaster maintain consistency across the traditional face-to-face, small group tutorials and e-learning curricula. Curriculum management is also more straightforward for authors because edits and updates are made to the single content source.
  2. SCDM has enabled staff to better focus on their tasks. For instance, curriculum administrators and assistants have a standardized template to input and update content, and because multimedia assets are maintained within a centralized repository for ease of reuse and access, they can easily output materials to print or web as needed. Also, instructional designers have hard coded good design principles into the content structure that helps maintain consistency and effectiveness of the materials, which also enables subject matter experts to focus on content rather than instructional design and formatting. Finally, graphic/user interface designers can maintain control over the look and feel of the print output and web interface.
  3. McMaster capitalized on its initial efforts in problem-based e-learning and the traditional Socratic method of medical teaching to standardize a content structure for medical education. This structure is now used to supplement tutorials, lectures, and experiential apprenticeship learning as part of a blended delivery strategy throughout the curriculum.
  4. By employing XML and SCDM, McMaster has the additional advantage of developing standards-compliant content, as well as a searchable content management system and asset repository. Export to non-SCORM-compliant formats is also an option, and has been useful for CD-ROM output in locations without Internet access. It has also uncoupled the content from dependence on any a single vendor's specification/proprietary format, and enabled output into various LMSs. This has been useful for collaborative projects with other programs and institutions that rely on a different LMS.
  5. SCDM has allowed for an extremely granular and efficient approach to content development, creating a catalog of reusable learning objects and assets for ongoing curriculum development and sharing across other medical schools, other medical learners (postgraduate and continuing medical education), and other health science programs.
  6. XML's separation of content from presentation has created advantages for collaborative projects because it permits flexibility of reusing existing content while creating new delivery templates that can incorporate new graphic design or branding elements.