Enter: The Living Medical Textbook

Huge lecture courses could soon become obsolete here. Taking their place are animated online videos that students watch in their dorm rooms.

By Patrick Gilbert

Two years ago, Murray Sachs, head of biomedical engineering, went before his department's advisory council with a proposal. Sachs wanted to use discretionary funds to produce an electronic version of BME's flagship course, Physiological Foundations for Biomedical Engineering. Faculty had grown tired, he said, of giving their introductory lectures to huge groups of students with little opportunity for exchange. By putting the lectures online, they would be able to use classroom time discussing key topics like experimental design and applied physiology.

In the Gestalt-rich tradition of a Hopkins education, such a proposal seemed revolutionary-and expensive-to the advisory committee. "They were concerned that electronic lectures might eliminate the human element in teaching," Sachs recalls. "They questioned how parents who are paying $25,000 a year for tuition would feel about their kids being taught in dorm rooms rather than at the feet of the great master." Still, in the end, the committee gave its approval. And with one stroke, it opened the door to a whole new kind of pedagogy at the School of Medicine.

Today, a revolution is under way in classrooms and dorm rooms here. Students are sitting at their computers and learning medicine by watching videotaped lectures that contain graphics, full-length animation and virtual laboratories. Hand in hand with these presentations, they are manipulating electronic notebooks to clip and paste portions of the visual or audio text they consider most relevant. Nothing quite like this is being practiced anywhere else in academia, technology-education experts say. And spearheading the whole transition is one young faculty member who's convinced there's got to be a better way to train future physicians than through the one-way distribution of information in large lectures.

At 46, Harry Goldberg may not look much older than his students, but he's had his Ph.D. in molecular biophysics for nearly 15 years. He's also armed with two master's degrees-one in computer science, the other in education. His home department at the School of Medicine, though, is the one that Sachs directs-biomedical engineering. Goldberg long ago got hooked on both the decades-old protein-folding problem-how a simple protein chain winds itself into a particular three-dimensional shape-and on using artificial intelligence to help decode that mystery. Computers, he says, are inseparable from biophysics: You'd better know your way around the first if you want to make any headway in the second.

Still, it's Goldberg's degree in education-the one he went for "to learn how we learn"-that tied together his ideas on pulling the basic medical school curriculum into the world of 21st century technology. "So often, we're delivering only facts in the classroom," he says. "Instead of seeing students as a vacuum, and the instructor's job as pouring in as many facts as possible, I wanted to redefine the role of the classroom lecturer, to provide core content some other way so that when students come to class, we could focus on applying the content."

Goldberg saw almost instinctively how computers could transform a rote introductory course into an interactive medium. "We've come to the point," he says, "where computers are simply a tool. If you were writing a poem and I asked what you were doing. You wouldn't say, I'm using a pencil. Today's students aren't impressed with what computers can do. They want to know what else they can do."

Early in 2000, Goldberg began mapping out his concept, which he named The Living Textbook. That same year, he took his idea to the National Science Foundation and came up with $500,000 to build the technology to put his Living Textbook into operation. With added support from his department, he began his experiment with Physiological Foundations for Biomedical Engineering.

Goldberg went first to his colleague Rai Winslow. "I wanted a faculty member who had a reputation for being a leader in his field to pilot the Living Textbook," he says. "But it had to be someone who had the enthusiasm for engaging students. Rai fit that bill."

Winslow was skeptical, kept putting Goldberg off, hoped, in fact, he would turn elsewhere for his first videotaped lectures. "I thought it was going to be a horrific task to prepare the material," Winslow admits now. "But I never looked forward to giving these lectures. There's nothing worse than standing in front of a large lecture hall full of students, most of whom aren't paying attention."

Goldberg, however, persisted, and a month later, Winslow reluctantly found himself stepping into a campus studio to tape three lectures on the heart's muscle cells-cardiomyocytes. He uses this content in the undergraduate course he gives regularly to about 140 entering biomedical engineering majors and also in the basic physiology course on organ systems at the School of Medicine.

As it turns out, Winslow breezed through the videotaping in just three hours and helped Goldberg prepare a series of virtual experiments using his model of the cardiomyocyte. With only one retake necessary, the taping took just about the same time as delivering the lectures in class would have. To confirm that the tapes contained all the information students needed, Goldberg gave copies to a group of upperclass biomedical engineering students to review. They listed the questions they were left with, and Winslow incorporated that material into the tapes. Goldberg then polished off the production by adding electronic "choreography." To illustrate the section on conductivity in the heart, for instance, he added a lecture length animation showing electrical impulses traversing the heart muscle that had been created by his team of illustrators. As the final step in his package, he integrated a virtual laboratory session into the lecture.

Goldberg gave a CD-ROM of his cardiomyocyte electronic textbook to every first-year medical student in the physiology organ systems course in the spring of 2002, with instructions that it should be viewed outside class. Immediately, Winslow noticed a change inside the classroom: The ambience was livelier. Students began asking questions and staying afterward to discuss content. "The course suddenly had become a lot more enjoyable," Winslow says.

By last year, David Nichols, vice dean for education, knew that despite the best efforts of Goldberg and a few other faculty, the School of Medicine had some catching up to do with electronic teaching. Reed Hall, the medical student dormitory, wasn't even wired for Internet access. For the new technology to become part of teaching, it was clear that a formalized plan from the dean's office would be required. And so, in the spring of 2002, Nichols gathered a group of students, library experts and administrators and asked for a vision for computerized learning at the medical school. To a person, the group agreed the new teaching methods made sense, if for no other reason than the budget factor. Medicine today is changing so rapidly that curriculum and textbook revisions have become expensive. Online education materials are easier to generate and cost less to update.

With a nod of approval from Dean/CEO Ed Miller, Nichols now was ready to move. And he had no doubt whom he wanted to lead the advance. In a swift decree, he created the School of Medicine's Office of Academic Computing and named Harry Goldberg its head.

Second-year medical student Danesh Mazloomdoost had always pegged himself as someone who learns best by reading-until last spring. The minute he popped Goldberg's Living Textbook into his laptop, he discovered a whole new way to grasp the tough course on heart cells. Instead of plowing his way through the standard text and then showing up later for Winslow's lecture and taking notes, Mazloomdoost suddenly found himself getting everything simultaneously-and absorbing it. One window on his laptop showed Winslow in action, while another window was scrolling a transcript of Winslow's talk and a third was delivering animated illustrations of the content.

"I like techno-savvy stuff," Mazloomdoost says. "Getting the lecture this way gives you all the options for learning: Watching, hearing, reading. You can skip over parts that you already know, and you can play it so the professor talks twice as fast. I like that a lot-time is the one thing medical students lack most."

Mazloomdoost especially took to the electronic notebook feature. When he spots an important statement or image or definition it can nail the concept for him. With a couple of clicks he copies the item to his custom-created study guide. He can edit his notes, add comments, save the whole thing, send it to the printer, even bookmark where he left off. And instead of waiting days to try a related experiment, he hops instantly to the built-in lab and cements what he's just learned.

Finally, Mazloomdoost admits what may be his favorite reason of all for preferring e-class. "There are times during a lecture when you just zone out. You have no idea what you missed, and you don't want to be the one asking a stupid question to find out. Not all students are morning people. This way, you watch the lecture at the time that's best for you."

"We've now demonstrated," Goldberg says, "that The Living Textbook is as effective as a large lecture hall." Reed Hall has been rewired, and students now tune into the Internet lectures in their dorm rooms. For his next step, then, he and the dean's office stand poised to put Hopkins in the vanguard of computer-based medical education across the board. Goldberg will use electronic teaching to create everything from course-management programs to virtual patients.

Currently, he is making every first- and second-year medical school core lecture available to students on the Hopkins intranet through an approach called streaming video. Starting with the 90 lectures and nearly 36 professors in the organ systems course, these film versions of professors presenting their material can be viewed through a secure, password-protected server a half-hour after class is finished. The streaming videos don't contain the bells and whistles of The Living Textbook, but they do allow students to review complicated subject matter they've heard in class in the privacy of their own room. Medical schools at Tufts, Stanford, Penn and Harvard have been providing this service for some time.

On an early spring day almost a year ago, Physiology Director Bill Agnew could hardly control his excitement as he witnessed students viewing videos of the lecture on cardiovascular physiology that he had given earlier that morning. These online sessions, Agnew believes, will have uses far beyond the medical school curriculum. They can help residents and fellows study for their boards or clinicians catch up on rapidly emerging fields-like genetic medicine. They can be invaluable for augmenting continuing medical education courses. And some first-year students, he says, already have asked for archived second-year lectures to be available over the summer so they can prepare ahead.

"This is heady stuff," Agnew declares. "To see students reacting to this simple use of computer-based learning is unbelievable. These kids can do amazing things with computers. It only makes sense to augment their learning with this technology."

Still, amid this dramatic pedagogical turnaround, questions abound: Just how far should medical education shift away from textbooks and classrooms toward the computer? To what extent will faculty and students embrace the concept of online teaching? With all of the financial pressures on the medical school, will the resources be there to see this revolution through? And finally, what do you do with faculty who aren't interested in electronic teaching? Some question whether medical students will come to class once the new methods take hold. Others worry about their lecture materials being reused without permission. A few simply prefer traditional teaching.

But Goldberg remains sanguine. "So far," he says, "students are using the streaming video lectures to review course material, not in lieu of going to class. And most faculty are learning to appreciate the advantages of this technology. It isn't meant to reduce the time they spend in the classroom. It's meant to improve the quality of their contact with students."

Goldberg's goal now is to place every core lecture onto electronic format." He's begun by working with six Hopkins faculty members and two from other medical schools to transfer the entire standard textbook on the cardiovascular system. The material will become part of the next organ systems course. Goldberg is enthusiastic. "It's pretty clear," he says, "that the dean's office has made a big investment in technology and infrastructure. I'm convinced now that we can go as far in electronic education as the faculty and the medical school want."