Visualization Technology in Medical Education

Sherman Gorbis, D.O., F.A.A.O. ¹

Richard C. Hallgren, Ph.D.²

¹ Department of Osteopathic Manipulative Medicine

² Department of Physical Medicine & Rehabilitation

College of Osteopathic Medicine

Michigan State University

East Lansing, MI 48824

Abstract

Visualization technology offers the possibility of profoundly changing the way in which osteopathic medical students assimilate basic osteopathic principles by giving them the ability to interactively explore biomechanical components of the musculoskeletal system, and to investigate the effects that changes in physical properties can have upon functionality. We are developing a multiple volume series of computer-assisted learning (CAL) modules which use three-dimensional, visualization technology to enhance the acquisition of knowledge and skills necessary for clinical evaluation and treatment of the cervical spine. These materials, designed to serve as an adjunct to teaching strategies that faculty are currently using, are available to students on campus through the Kobiljak Resource Center at Michigan State University College of Osteopathic Medicine (MSUCOM) and via the Internet (http://hal.bim.msu.edu/EdTech) to individuals and groups who are physically removed from the MSU campus. In addition to addressing needs in undergraduate and graduate medical education, these osteopathic materials, delivered to users via CDROM, have been approved for obtaining Category 1-B CME credits (http://hal.bim.msu.edu/cme).

We anticipate that the use of these materials will facilitate understanding of static and dynamic relationships among physical components of the musculoskeletal system, thus contributing to ongoing efforts to develop and maintain physician, faculty, and student expertise in areas that are uniquely osteopathic. While we have restricted our initial efforts to the cervical and lumbar spines, future modules will include other regions of the body. Ultimately, we will enable students to visualize the effects of pathology as they interactively control an articulation in three-dimensional space.

Key Words: Internet, computer-assisted instruction, distance learning, osteopathic, CME

Acknowledgements: This study has been supported in part by Research Grant #95-05-405 from the American Osteopathic Association, Chicago, IL.

Address reprint requests to:
Richard Hallgren, Ph.D.
Department of Physical Medicine & Rehabilitation
Michigan State University
East Lansing, MI
Telephone: 517-355-4674
FAX: 517-432-1339
E-Mail: hallgren@msu.edu
Web: http://hal.bim.msu.edu

Background

The Internet has facilitated the dissemination of scientific information throughout the world. Two of the more notable projects on the Internet are: the National Library of Medicine’s (NLM) Visible Human Project (http://www.nlm.nih.gov/research/visible), a collection of on-line digital images of complete male and female cadavers for use in medical research; and the Human Genome Project’s (http://www.er.doe.gov/production/ober/hug_top.html) map of the human genome, that biological sum of characteristics that makes each of us individually unique.

The Internet has the potential to profoundly change how we teach because it provides medical educators with increasing opportunities to deliver interactive technology to a target audience both locally and over large distances. There are several reasons why we think that the Internet will have a long-term impact upon medical education: 1) The Internet is based upon a client/server model that facilitates the creation and updating of educational materials; 2) The Internet is able to provide transparent delivery of information to different types of computers; 3) The amount of money that is being invested in Internet infrastructure helps ensure that it will not be a passing pedagogical fad; 4) The Internet is capable of providing valuable health-sciences information to remote sites.

Unfortunately, the simple presentation of information is not a sufficient condition for learning to occur. Effective learning tools must engage the student, causing them to assimilate new information and to construct meaning from it in terms of what they already know. While computer-based learning modules (CBLMs) offer distinct advantages over material in printed form, commercial software has not specifically addressed the unique needs of an osteopathic medical student to visualize and understand concepts that are space/time dependent. Historically, visualization technology has been used in two separate and distinct environments. The scientific and engineering community has used it to convey information to a viewer. The entertainment industry has used it to engage a viewer. The perceived utility of visualization techniques took a quantum leap forward when the entertainment industry realized that computers could be used to create special effects in movies. Shortly after that, the scientific community realized that there was potential for not only presenting information but also for holding a viewer's attention while it was being presented. Unfortunately, until recently, the cost of hardware and software required to develop and deliver a sophisticated visualization application placed these tools beyond the reach of the average educator. But now, with increasing computational speed and decreasing cost, what we could only dream of doing on a personal computer in the mid-1980s has now become reality. An image that once took 20 minutes to render (10) can now be visualized in a fraction of a second. This means that educators can focus on content rather than being consumed with the mechanics of the delivery system.

Methods

Computer-based instruction is a proven method for delivering high-impact, interactive multimedia presentations that makes the educational process more enjoyable for students. Research has produced convincing evidence that students who receive a simultaneous presentation of verbal and visual information perform better on problem-solving tests than do students who only receive a verbal explanation(3), and demonstrates increased comprehension and long-term retention of materials(4,5). Students typically use materials such as these: a) as an advanced organizer to acquire basic concepts; b) as a supplement to lecture materials; c) as a tool for review. It has been found that when materials are viewed before class, time spent in class is better used to synthesize information rather than merely to obtain facts.

In order to provide students with a media-rich, interactive environment we use a combination of two or more of the following: text, graphics, images, video, audio, animation, and simulation. Animated "gif" files are used for free-running animations; Java-based programs are used for those instances where an interactive animation and/or simulation is desired; Quicktime video and audio are used as a tool for reviewing selected parts of demonstrations performed during lectures; Virtual Reality Modeling Language (VRML) is used to interactively view anatomy and morphology of selected structures.

The instructional modules work with computers that are readily available to most medical students. The software is designed to execute on a 133 MHz Pentium PC computer with 32 Mbytes of RAM memory, 16 bit color at 800X600 resolution, 100 Mbytes of free disk space, a sound card, and a CD-ROM player. For purely pragmatic reasons, we have elected to use Internet Explorer 4.0 for the user interface and either Windows 95 or NT 4.0 as the preferred operating system. The user needs only to be able to successfully navigate a windows-based interface using a mouse. For those users off campus who may not have access to a high-speed Internet connection, the preferred modality of distribution is a CDROM.

Content

Palpatory criteria for identifying and evaluating somatic dysfunction within the musculoskeletal system have been described and taught in many different ways. While osteopathic physicians may sometimes differ in their use of these criteria in diagnosis and as guides to treatment, there is general agreement on the importance of identifying pathology and restoring normal function (6). Accurate knowledge and detailed understanding of normal human morphology and kinesiology is essential for identifying pathology and restoring normal function. Computers, by themselves, have not been proven to be superior to lectures and/or textbooks in transmitting purely factual information (7). Consequently, basic morphology can probably still be best learned from a textbook. However, the impact that structure has upon dynamic function is difficult to appreciate using static media. By merging morphologic and kinematic data into a computer-generated, three-dimensional animation model, we are able to enhance a student’s ability to visualize the impact that pathology can have upon function within the musculoskeletal system (8). One area that is often difficult for students to grasp has to do with the impact of vertebral morphology upon coupled motion mechanics. Coupled motion is a term used to describe a predictable secondary movement that occurs as a result of some primary movement (9,10). Turning a bolt (a primary movement) causes it to move in or out (a secondary movement) of a threaded hole. There are several physiological examples of coupled motion mechanics that are important for an osteopathic physician to know and understand. One of the most important of these occurs in the lumbar spine where axial rotation is coupled with sidebending as a consequence of the physical orientation of the articular facets (11,12). In the absence of dysfunction, neutral mechanics (Type I) are characterized by coupled movement of side-bending and rotation to opposite sides. Nonneutral mechanics (Type II) are characterized by coupled movement of sidebending to the same side as

rotation. Coupled patterns of motion are complex and not easily visualized with static pictures, but an animation sequence greatly enhances student comprehension. Figure 1 shows three frames representing Type I coupled motion of the lumbar spine. The left panel represents full right passive rotation; the center panel represents the neutral position; and the right panel represents full left passive rotation. Notice that rotation to the left results in coupled sidebending to the right, and that rotation to the right results in coupled sidebending to the left.

While some topics lend themselves to simple animation, other topics lend themselves to simulation.¹³

For example, an asymmetric change in tension between contralateral muscles produces detectable differences in palpable resistance to rotation when opposing directions are compared. Physically, this results in decreased range of motion (ROM) that an osteopathic physician can detect during a physical examination. Figure 2 shows an example of restricted motion that is a consequence of simulated asymmetry in muscle tension. It is extremely difficult to detect this restriction when looking at the static set of three images. However, if one were to go to our Web site (http://hal.bim.msu.edu/edtech/cervical/biomechanics/lower/page_3.html) and view the animated sequence, it would be clear that left sidebending is restricted. One would then gain a better appreciation for the effectiveness of our modules to illustrate musculoskeletal dysfunction.

Quite simply, our strategy in the development of this technological tool has been to exploit the number-crunching power of computers to generate representations of 3-dimensional structures in areas that are difficult to understand without the aid of animation and/or simulation, and to use the Internet to provide access to these materials both on campus and at distance locations.¹⁴

Conclusions

Visualization technology, one component within the discipline of medical informatics, has the potential to facilitate student understanding of static and dynamic relationships among physical components of the musculoskeletal system. By properly integrating these materials with traditional undergraduate educational modalities such as lectures and laboratories, we hope to facilitate student understanding of basic osteopathic principles. With a better understanding of basic osteopathic principles, we anticipate that our students will score higher on Osteopathic National Board Examinations as well as feel more comfortable applying these principles in patient care. Like most osteopathic medical schools who rely upon community-based resources for clerkship and graduate osteopathic medical education, MSUCOM also has a responsibility to support its trainees (through distance learning opportunities), and trainers (through faculty development). While the decentralized model of osteopathic medical education provides real-world training for students and residents, it presents challenges for administration of the curriculum, and assuring quality and equal access to faculty and students across the different hospitals that participate in the MSUCOM Statewide Campus System (SCS).

We believe that by using computers as tools to implement medical informatic applications, we will be able to provide students with the ability to access information from a wide range of sources 24 hours per day. This will be especially beneficial for hospital staff who have varying work schedules, time restrictions, and geographic constraints. Increased implementation of computers into medical education is not the goal, but rather a means to facilitate the educational experience of our students, thus enhancing the quality of osteopathic medical education across the entire educational spectrum.

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