Australasian Medical Journal AMJ 2011, 4, 6, 300-307 [630336]

Australasian Medical Journal [AMJ 2011, 4, 6, 300-307 ]

300 Medical students’ perceptions of using e-learning t o enhance the acquisition of
consulting skills
Warnecke E1 Pearson S2
1. Senior Lecturer
2. Lecturer
School of Medicine, University of Tasmania, Hobart, Tasmania, Australia

RESEARCH

Please cite this paper as: Warnecke E, Pearson S. M edical
students’ perceptions of using e-learning to enhanc e the
acquisition of consulting skills (SE Med Ed). AMJ 2011, 4, 6,
300-307
http//dx.doi.org/10.4066/AMJ.2011.736

Abstract

Background
This study aims to evaluate medical students’ perce ption of
the usefulness and effectiveness of an e-learning p ackage
developed to enhance the acquisition of consulting skills.
Method
A survey with mixed method data analysis was conduc ted.
Participants were 67 medical students completing th eir
third year primary care rotation as part of a five- year degree
at the University of Tasmania. Participants comple ted a 10
question anonymous online survey after using the e-
learning package
Results
Of the participants, 92% found it enjoyable and 95% found
the e-learning package useful; 75% perceived it to be
effective in increasing their performance and 91% b elieved
it increased their knowledge in consulting skills. Benefits for participants’ confidence, style and structure of co nsulting
skills were found.
Conclusion
Participants found the e-learning package to be enj oyable
and effective. E-learning should be further utilise d in a
blended learning environment to support face-to-fac e
teaching in consulting skills.
Key Words
Blended learning, e-learning, medical, consulting s kills

What this study adds:
1. Utilises a blended learning approach.
2. Gives weight to the student: [anonimizat]
3. Knowledge of how students learn consulting skil ls

Background
E-learning has a well-established role in medical e ducation
and it has been found to be effective in enhancing learning
and is well accepted by students.1-3 E-learning can be used
both as a stand-alone teaching tool and in a blende d
learning environment where it is linked to face-to- face
teaching.

Developing good communication and consulting skills is
fundamental for improving health outcomes and devel oping
an effective therapeutic relationship.4 Consulting skills have
traditionally been taught face-to-face. This study, however,
looks at using a blended learning strategy to enhan ce the
acquisition of these important skills and better ut ilise Corresponding Author:
Name: Dr Emma Warnecke
Address: School of Medicine, University of
Tasmania. Private Bag 34. Hobart. 7000
Ph:0061 3 6226 4898 Fax:0061 3 6226 4894
Email : [anonimizat]

Australasian Medical Journal [AMJ 2011, 4, 6, 300-307 ]

301 valuable face-to-face teaching time. There is evide nce for
the effectiveness of blended learning on results; 1,5 however,
there is little literature exploring medical studen ts’
perceptions on the usefulness and effectiveness of e-
learning to complement face-to-face teaching.

A consulting skills programme, utilising standardis ed
patients and video feedback for medical students ha s been
developed at the University of Tasmania (UTAS). Thi s style
of teaching has been effectively used in medical ed ucation
for some time.6,7 The process and content of consultations
focuses on a patient-centred model considering the
patient’s perspective.4 Experience in this teaching and
learning environment found students characteristica lly take
the first one or two sessions to understand the con cept and
standards expected of them, leaving little time for them to
develop and improve their skills. In response we ha ve
developed and produced a consulting skills e-learni ng
package to complement and support the face-to-face
teaching. An e-learning package was chosen for its
flexibility and evidence of its quality and effecti veness.8,9 It
is important to create effective e-learning experie nces the
students perceive as meaningful. Therefore, in eval uating
the use of the e-learning package the focus was aim ed at
the perceptions of the medical students using it.

The aim of this study was to evaluate medical stude nts’
perception of the usefulness and effectiveness of a n e-
learning package to enhance the acquisition of cons ulting
skills. This study, therefore, seeks to add to the literature on
blended learning by focusing on student perceptions . It also
adds to the current understandings of how students learn.

Method
We conducted an anonymous online survey. Eligible
participants were medical students completing the t hird
year primary care rotation as part of a five-year d egree at
UTAS. The study was run in the first semester of b oth 2009
and 2010. Students were given access to the consult ing
skills e-learning package to use during their eight week primary care rotation to support face-to-face teach ing. After
the rotation, all eligible participants were sent a n email
inviting them to participate in the trial. The ema il outlined
the purpose, the voluntary nature of participation and
emphasised the anonymity of the trial. This email also
contained a web link to the online survey. This an onymous
method of survey collection was chosen to encourage
student participation. The survey responses were co llected
online and only available to the authors in a non-i dentifiable
form. This trial received ethics approval from the UTAS
Human Research Ethics Committee. Completion of the
survey was taken as implied consent.

Description of e-learning package
The e-learning package includes: an audio-visual le cture
recording, outlining the theory and expectations of the
consulting skills program; videos of a third year s tudent
consulting with a standardised patient; videos of a n
experienced doctor performing consultations, utilis ing the
methods outlined in the lecture and video examples of the
feedback process used in the small group tutorials after
each consultation. Students were able to view the e-
learning package as many times as they wish, at the ir own
pace, whenever they perceive it to be useful. The o nline
lecture runs for approximately one hour and the vid eos on
average for approximately 10 minutes.

Evaluation of the e-learning package
The survey consisted of 10 questions. Three survey
questions allowed for free text comments and the
remainder had multiple set responses from which
participants could choose. Demographic information was
limited to age and sex to preserve anonymity. The 1 0 survey
questions were designed by examining the work of
Kirkpatrick 10 and the four levels of evaluating training
programmes: reaction; learning; behaviour; and resu lts.
The reaction of students was measured by asking the m to
rate their enjoyment in using the e-learning packag e by
endorsing one of four options ranging from ‘extreme ly
enjoyable’ to ‘not enjoyable’ or ‘unsure’. To measu re

Australasian Medical Journal [AMJ 2011, 4, 6, 300-307 ]

302 learning, participants were asked to indicate wheth er they
perceived the e-learning package greatly increased, slightly
increased or did not affect their knowledge. Behavi our
change was measured by asking how they believed the ir
consulting skills would change as a result of using the e-
learning package in a free text format. Results of using the
e-learning package were measured in several ways. F irstly,
by asking students to rate their perception of the effect on
their preparation for face-to-face consulting skill s sessions
as greatly increased, slightly increased, no increa se or
unsure. Secondly, they were asked to indicate wheth er they
thought the e-learning package had improved their
performance in consulting skills (yes, no or unsure ).
Participants were also asked how many times they vi ewed
the e-learning package (one, two, three or more tha n three
times), their purpose in using it and how useful th ey found
it (extremely, very, somewhat, not useful or unsure ). An
additional question was included in the 2010 survey to
obtain information regarding students’ evaluation o f the
effect of using the e-learning package on improving their
performance in the end of semester objective struct ured
clinical examination (OSCE) results. We were not a ble to
compare to actual results, as the data was anonymou s.

Data analysis
Mixed method data analysis was undertaken. Data wer e
analysed using simple descriptive statistics. Chi s quare
analysis was also used to explore the relationship between
demographic variables and measures used in the eval uation
of the training package. Fisher’s exact test is rep orted
where expected cell counts were below five. Due to small
numbers in some of the response categories for some
variables categories were collapsed. A p-value of l ess than
0.05 (two tailed) was considered statistically sign ificant.
Statistical analyses were performed using SPSS vers ion 17.
Qualitative analysis involved thematic analysis of free text
comments, which deepened the understanding of the
student experience.11

Results
Of the 108 eligible participants, 67 (62%) responde d to the
survey and completed the survey in full. Two partic ipants
were excluded from data analysis as in free text co mments
they stated they did not view the e-learning packag e. Thirty-
six responses (55%) were collected in 2009 and 31 i n 2010.
The majority of participants were female (n=39 (60% )). Of
participants, 61.5% (n=40) were aged 21–23 years. O ther
age ranges of participants were; 15% (n=10) 18–20 y ears,
14% (n=9) 24–30 years and 8% (n=5) over 30-years-ol d. One
participant selected the option to not state their age.
Analysis of the wider UTAS population found 52% of third
year medical students in 2009/10 were female and th e
average age was 23 years.

Most participants (92.3%, n=60) rated the e-learnin g
package as enjoyable. Of these participants, two (3 %) found
it extremely enjoyable, 29 (48%) found it very enjo yable and
29 (48%) found it somewhat enjoyable. Three (5%)
participants did not enjoy using the e-learning pac kage and
two (3%) were unsure. Females were much more likely to
report overall higher levels of enjoyment than male s X2 (2, N
= 65) = 10.53, p = .004 (Figure 1).

Australasian Medical Journal [AMJ 2011, 4, 6, 300-307 ]

303 Similarly, a majority of participants (90.8%, n=59) reported a
perceived increase in knowledge as a result of usin g the e-
learning package. Of these, 21 (36%) reported use g reatly
increased their knowledge and 38 (64%) reported a s light
increase in knowledge. Six (9%) participants repor ted use of
the e-learning package had no effect on their knowl edge.
Females were more likely to report increases in kno wledge
that males X2 (2, N = 65) = 8.63, p = .013 (Figure 2).

When asked about the effect of using the e-learning
package on preparation for performing consulting sk ills, 25
(38%) participants believed the use of the e-learni ng
package had increased their preparation. Of these, 21 (84%)
reported use had greatly increased their preparatio n and
four (16%) reported a slight increase in preparatio n. Thirty-
nine (60%) participants reported use of the e-learn ing
package led to no increase in preparation and one
participant was unsure. There were no differences b etween
males and females. Overall 75.4% (n=49) of particip ants
reported improvements in their perception of their
performance.

Most participants viewed the e-learning package at least
three times (n=24, 37%). Twenty-three (35%) partici pants
viewed the learning package once and 18 (28%) twice .
There was no statistically significant difference b etween males and females with regard to the number of time s the
e-learning package was viewed. The e-learning pack age
was, however, viewed significantly more often in th e 2010
cohort when compared with the 2009 cohort X2 (3, N = 65) =
9.65, p = .019. There were no significant differences
between characteristics of the two cohorts that mig ht
explain this difference. There was a significant po sitive
association between the number of times the e-learn ing
package was viewed with increased enjoyment X2 (4, N =
65) = 12.12, p = .008, increased knowledge X2 (4, N = 65) =
12.11, p = .009, and usefulness X2 (4, N = 65) = 10.34, p =
.016.

Students were asked about their purpose in using th e e-
learning package. They were given eight set options from
which they could choose as many as were true for th em.
Positive selection of four options was the most fre quent
with a range of 1–7 options. Table 1 lists the resp onses for
each option. Females were significantly more likely to state
their purpose for using the e-learning package was to
enhance learning in consulting skills X2 (1, N = 65) = 5.02, p =
.025 and also to help prepare for the practical ses sions in
consulting skills X2 (1, N = 65) = 4.82, p = .028 (Figure 3).
There were no significant differences between males and
females with regard to all remaining options.

Free text comments could be provided as an alternat ive to
the set options or in addition. Qualitative analysi s of free
text comments enquiring about students’ purpose in using
the e-learning package was limited as only four par ticipants
provided comments. However, the theme of checking t he
expected standard and structure required was reveal ed in
three of the four comments.

Qualitative analysis was undertaken of the free tex t
responses to the question asking participants how t hey
perceived their consulting skills changing as a res ult of using
the e-learning package. Sixty-three (97%) participa nts
provided a free text comment. Dominant themes of ch anges

Australasian Medical Journal [AMJ 2011, 4, 6, 300-307 ]

304 in confidence (8 comments), style (18 comments) and
structure (17 comments) were revealed.

Table 1. Students’ responses to purpose in using
the e-learning package
Purpose (options given) Yes
N (%) No
N (%)
To understand the concept
of consulting skills (CS)
35 (54) 30 (46)
To enhance learning in CS 36 (55) 29 (45)

To help prepare for the
practical sessions in CS

45 (70)
20 (30)
To learn from watching how
a practicing GP performs a
consultation
39 (60) 26 (40)
To learn from watching a
fellow student perform a
consultation
33 (51) 32 (49)
To consider your own style
of CS 29 (45) 36 (55)
To learn how to get the
most out of a debrief
session
12 (18) 53 (82)
To help achieve the learning
outcomes in the primary
care rotation
16 (35) 49 (75)

In rating the usefulness of the e-learning package the
majority of participants (95%, n=62) found it to be useful. Of
these, six (10%) participants rated it as extremely useful, 37
(60%) as very useful and 19 (30%) as somewhat usefu l. Two
(3%) participants rated the e-learning package as n ot useful
and one participant was unsure. Free text comments were
also an option with this question and 20 participan ts made a
comment. The dominant theme was the ongoing resourc e
the package would provide.

Participants (n=29) in the 2010 survey were asked i f they
felt the use of the e-learning package would improv e their
performance in the end of semester OSCE. Twelve (41 %)
participants chose yes, six (21%) chose no and 11 ( 38%)
were unsure. There was no statistically significant difference
between males and females with regard to the useful ness of
using the e-learning package on OSCE performance. W e
analysed age as a variable in determining outcomes from
using the e-learning package and no statistically s ignificant
differences were noted.

Discussion
This study found medical students perceive the cons ulting
skills e-learning package to be an enjoyable and us eful
resource. It was also perceived to be effective in increasing
knowledge and performance in consulting skills. Fem ales
differed from males in reporting greater levels of enjoyment
and gains in knowledge. The consulting skills e-lea rning

Australasian Medical Journal [AMJ 2011, 4, 6, 300-307 ]

305 package has been demonstrated, in the opinion of st udents
to be a worthwhile complement to face-to-face teach ing.

This study is consistent with the finding of other studies on
the positive effect enjoyment has on learning.12 It is also
consistent with a previous finding of increased enj oyment in
female nurses using a similar skill-based e-learnin g
package.13 Student engagement with the e-learning package
suggests it has allowed for active and deep learnin g to occur
and therefore act as a useful complement to face-to -face
teaching.14 A recent meta-analysis looking at Internet-
based learning in health professionals found Intern et-based
learning to be favourable across a range of learnin g styles,
contexts, topics and learning outcomes and showing a large
effect on learning compared with no intervention an d a
similar effectiveness to traditional methods.15 An e-learning
package was chosen so participants could view it as many
times as they wished, whenever it suited them. It w as
therefore encouraging from a teaching and learning
perspective to see most participants viewed the lea rning
package more than once and that increased benefit w as
obtained by increasing the number of times it was v iewed.
The fact that it was viewed more frequently in 2010
compared with 2009 was also encouraging to see. A
potential explanation for this may be that a favour able
perception of the e-learning package in 2009 led st udents to
recommend it to the following year and therefore in crease
its use.

Given the purpose for developing the e-learning pac kage
was to improve students’ understanding of the conce pt and
standards required in the face-to-face consulting s kills
teaching, it was surprising to see only 38% of part icipants
believed it increased their preparation for consult ing skills.
This perhaps relates to students’ overall perceptio n of their
sense of feeling prepared. It was also interesting to note
38% of participants were unsure if use of the e-lea rning
package would increase their OSCE performance. This also
perhaps tells us more about student confidence and self-
perception of how they perform in examinations. The se are both areas that could be further explored in a foll ow-up
study with an enhanced qualitative component of ana lysis.
The existing qualitative analysis did certainly add to the
quantitative results. For example, exploring change s in
consulting skills revealed several dominant themes for
confidence, style and structure. The following quo tes
illustrate this well:

“I have become more confident and now believe I
could manage management cases and cases
requiring specific skills (e.g. counselling). It wa s
good to see several different styles in practice an d
draw from them, to refine my own consulting skills
method. I especially enjoyed some of the more
challenging cases (e.g. grief, overseas patient,
sexual history cases etc).”

“It was reassuring to know that I was conducting
my consults in a similar way to a practicing GP. It
has given me a lot of confidence in taking historie s
from patients. I have also picked up some tips on
the value of asking a couple of additional question s
and getting as much information as possible.”

“I think it was useful to see other people doing th e
consulting and I liked hearing about some different
structures for consulting in the (online) lecture. I
used this learning to partly inform the constructio n
of my consulting pro-formas I use with patients.”

In contrast some participants did not comment, or w ere
unaware of, any changes:

“Unsure, I doubt there will be any change.”

One quote illustrating the purpose of using the e-l earning
package highlighted exactly the reason for developi ng the e-
learning package:

Australasian Medical Journal [AMJ 2011, 4, 6, 300-307 ]

306 “To gain some idea of the standard and level
expected of us and the construct of sessions.”

Free text comments regarding the usefulness of the e-
learning package highlighted the benefits of using a blended
learning approach and allowing students to make the ir own
evaluations:

“I liked that the student examples were not
scripted as perfect. It was helpful to identify wha t
areas I thought the students missed and then see if
the debrief agreed.”

Relevance in medical education is important and fin ding
student resources relevant to the actual skills med ical
students need to be a competent doctor can be chall enging.
Increasing the relevance and efficacy of medical ed ucation
warrants our focus and attention and therefore this
evaluation of e-learning package adds to the litera ture in
this regard.16 As a self-directed learning activity it also has
promise in delivering high quality learning experie nces in
the current climate of increasing student numbers. Gormley
et al 3 have shown students feel quality online learning h as a
positive impact on their skills. Their study, howev er,
compared e-learning to more traditional forms of cl inical
skills teaching. It must be remembered the focus of our
study was evaluating e-learning in a blended enviro nment,
rather than encouraging e-learning as an alternativ e to face-
to-face teaching.

Potential limitations of this study include the sma ll
participant numbers and the slightly higher partici pation in
females (60%). This may reflect a preference for e- learning
or a possible desire to please the rotation coordin ator. This
could be explored in greater depth in a follow-up f ocus
group study to further investigate the benefits of e-learning.
The ability of this study to detect any significant associations
between age and outcomes was limited by the small
numbers in several of the age range categories. UTA S
accepts both local and international students. It a lso accepts mature age and postgraduate students as well as sch ool
leavers. In 2009 51% of third year medical students were
male and the average age was 24 years. The age corr elates
well with this study’s results. These factors incre ase the
generalisability of these finding to a wider medica l
population. Due to the online, anonymous nature of the
study we could not compare effectiveness to an obje ctive
measure of results such as their actual performance on the
OSCE. This could be incorporated into a future stud y to
further strengthen the results. As the study was un dertaken
by the coordinator of the primary care rotation, st udent
responses may have been biased towards more favoura ble
evaluations. This potential effect was, however, mi nimised
through the use of an anonymous survey.

Conclusion
Participants found the e-learning package to be enj oyable,
useful and effective in increasing knowledge in, an d
preparation for, consulting skills. E-learning shou ld be
further utilised in a blended learning environment to
support face-to-face teaching in consulting skills and allow
for flexibility in delivery of medical education. T hese results
can also be used to show future students the potent ial
benefits of the e-learning package available to the m to
stimulate and motivate increased use. Further studi es
should also explore more fully student experiences via focus
groups and link use to OSCE results.

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PEER REVIEW
Not commissioned. Externally peer reviewed
CONFLICTS OF INTEREST
The authors declare that they have no competing int erests.
ETHICS COMMITTEE APPROVAL
This trial received ethics approval from the Univer sity of
Tasmania Human Research Et hics Committee .