P.H.V. Cumpston, Anaesthesiology and Intensive Care, The University of Queensland, Brisbane, Australia. Phone: +61 7 253 1847 Fax: +61 7 253 7202. Email: P.Cumpston@mailbox.uq.oz.au
R.D.M. Jones, Anaesthesiology and Intensive Care, The University of Queensland, Brisbane, Australia. Phone: +61 7 253 1847 Fax: +61 7 253 7202. Email: D.Jones@mailbox.uq.oz.au
This paper summarises our experiences to date with the WorldWideWeb as we seek to develop a tool by which educational material at undergraduate and postgraduate levels may be delivered to students who are geographically dispersed. Some strengths and weaknesses of this technology are identified and we discuss some of the problems arising during the adaptation of educational material for the global environment.
Departments of Anaesthesia and Intensive Care are the largest single hospital specialty. In Queensland there are approximately 200 specialist anaesthetists, of which just under 50% are located outside the Brisbane metropolitan area and remote from access to central teaching resources [1] . At any one time there are also approximately 50 registrar anaesthetists ( specialists in training ) and up to 70 medical students undergoing their anaesthetic attachment. As a department we are looking at ways in which current and emerging communication technology may be used to aid in the delivery of educational material to all student levels.
Most Anaesthetists practice their work in relative solitude and must be somewhat flexible in their hours of work. Therefore we wished to explore communication media which provided educational resources which could be 'browsed' by individuals in their own time. Although technologically literate, the demands of work often do not permit study of lengthy instruction manuals prior to 'having a go'. Consequently any teaching package must be easy to use and intuitive.
The WorldWideWeb provides an excellent communications vehicle which may fulfill our requirements. Since it's inception only a few years ago, the web has demonstrated a tremendous growth in traffic ( fig 1 from [HREF 2] ).
The work described in this paper 'went live' in August 1994. Since then there has been a similar explosion in the number of medical establishments making use of the WWW. These may be divided into two broad categories, some examples of which are listed below.
The number of sites offering medical material has now expanded to the point where 'virtual libraries' or indexes of resources have been developed, the most comprehensive of which is probably The Medical Matrix [HREF 8].
At the time of the inception of our WWW project Prof Keith Ruskin [HREF 9] had established a world wide email mailing list, and subsequently a gopher server, based on a computer system ' gasnet.med.nyu.edu ' [HREF 10]. Our two systems have evolved in parallel as both groups share a common interest in the use of WWW technology to solve educational problems.
Our involvement with the WWW project was planned in three phases:
This paper reports our experiences during phase 1 and indicates potential pitfalls for others who might follow our path.
It was decided to establish a WWW area hosted on one of The University of Queensland central computers, which was already running a web server [HREF 11].
This has several advantages:
Our department, whilst well supplied with computers ( IBM-PC ), did not have direct internet access when this project commenced. Consequently all WWW maintenance and development was performed over a modem link. Whilst at times frustrating, this access restriction served to remind the development team that this was the means of access for the majority of users. This has helped to establish our preference for small files and graphics which load rapidly.
The initial pages were crafted using an ASCII editor and coded directly. Traditionally our department has supplied to students a series of 'lecture notes' which provide useful background material to supplement the lecture, tutorial and clinical components of our course. An aim of the WWW project is the conversion of this material to HTML. Coding by hand was very labour intensive so various computerised aids were investigated. The most suitable for our needs was a template for Microsoft Word for Windows (TM), CU_HTML [HREF 12]. In February 1995 Microsoft released their beta version of 'Internet assistant' for word. Early experience of the development of web pages in this environment are very favourable and the current web pages, including this paper, have been recompiled using this software.
Our WWW teaching material is in the form of tutorials which readers can examine at their leisure. Topics covered to date include:
As the WWW has expanded and more Anaesthesiology sites have been developed, indexing of such documents has become a significant problem. Whilst each web site may maintain a list of related material within its own pages, the maintenance workload is significant. The Anaesthetic internet community has evolved towards a rationalisation of indices. A central list of Anaesthesiology WWW servers is maintained on the GASNET server as 'the virtual library ' [HREF 13] whilst at The University of Queensland, both locally generated material and links to distant sites are collated into a 'Global Anaesthesiology Textbook [HREF 14].
Whilst of major benefit to users, such indexes and their contents bring secondary problems. Concern has been raised regarding the quality and accuracy of material being published on the web as no single person has explicit editorial control. A scientific paper, submitted to a learned journal, undergoes a process of stringent peer review before publication. Two mechanisms of quality assurance are available for WWW application:
Since the release of 'NETSCAPE' and the implementation of the 'mailto:' URL there has been a ready feedback mechanism to the author of any document. We have combined this with a more public discussion on the email mailing list now hosted by our department ( AIC-L@mailbox.uq.oz.au ). In this way, we hope we can retain some element of 'peer review', but maintain the speed and timeliness of publication which is one of the main attractions of the WWW.
Each access by a WWW client ( eg. MOSAIC, NETSCAPE ) is logged by server software to a log file. These ASCII files may be analysed and activity levels established both for the server as a whole and for individual files. However the analysis software however must run on the server and therefore we have been unable to make use of this facility because of our dependence on University central facilities. A system has been established whereby an extract of the server logs is emailed weekly to the webmaster where it is analysed in the windows environment using Microsoft Access after prefiltering through a custom written parsing routine.
Our WWW area became available for public access on 24th of August 1994. Since that time, all accesses have been logged and analysed on the basis that one host, successfully requesting any number of files within a 24hr period, counts as one access.
At the time of this review ( March 1995 ) our system has been accessed by a total of 1400 host computers. 225 of these ( 16% ) were from Australia and New Zealand, the remainder originating from all continents ( fig 2 ). During February 1995, our area received over 100 accesses per week, one fifth of which were from the Australasian continent. There has been a marked growth in the overseas access rate, compared to local use. This probably reflects the distribution of internet access amongst anaesthetic specialists world wide. However following several highly successful demonstrations, and a discount agreement with one service provider, email feedback indicates many more Australian users are in the process of coming on line. Indeed an early indication of this may be seen from the figure ( OzNz accesses, red line on fig 2 ). Feedback received has been very positive and we feel ready to progress to the next phase of our project.
We have explored WWW presentation of previously published scientific papers from specialist journals. While it is technically not difficult to convert these documents, the issue of copyright has significantly retarded work in this field. When a scientific article is published, copyright is usually assigned from the author(s) to the commercial owners of the journal. A system exists whereby one may ask for permission to reproduce all or part of an original article, giving full credit and identification of it's source.
There is no consistent response from medical scientific journals for these requests, even if requested by the original author. Some journals have refused all permission for internet reproduction, possibly regarding it as a form of competition. Some forward looking journals allow abstracts of their papers which have been accepted but not yet published to be made available for retrieval. Examples of this latter group include:
This is an avenue which must be actively explored in the future by the medical establishment. Whilst the system of peer review operated by the journals seems to serve the medical community well, it is common for a delay of about 1 year to exists between submission of an article and its appearance in print. In a rapidly changing medical world, this delay may make the observations redundant by the time of conventional publication. The WWW may help alleviate this problem.
To date our WWW development has centred around learning how to use the technology. During our development we have identified issues which others, following a similar path may do well to consider.
Due to our dependence on a central University facility, we have been frustrated by the lack of availability of forms for feedback. We hope to correct this in the near future with the installation of our own server. We envisage the use of forms primarily for two functions:
These two functions may of course be combined into a single form.
Some medical material is either of a confidential nature or unsuitable for general public presentation for reasons of taste. It is however essential that students be exposed to this material during their training to enhance their medical knowledge. A choice must be made, based on the circumstances of each institution, as to whether the WWW is an appropriate vehicle for dissemination of this material, or whether it might be more appropriate to store sensitive material on CD ROM and distribute to students directly. Alternatively the 'shared secret' principle of security may be applied and sensitive material placed in directories on the server which are 'password protected'.
Medical practitioners are licensed to practice by individual States or Countries. The WWW does not recognise these boundaries. Therefore readers of any material which recommend specific treatment in a given situation should be advised that this instruction is advisory. It is not possible for the author of WWW material in one country to take responsibility for how that material is used in a distant location. This is an important issue which has yet to be addressed and will become more important as the WWW and telemedicine in general becomes more prevalent.
Many institutions, including ourselves, use material from a variety of sources for which we do not hold full copyright eg diagrams from textbooks. In this situation either the original copyright terms allow reproduction for education purposes or this permission has been expressly obtained. Presentation of material on the WWW requires specific permission from the copyright holder, who may well object. All material should be checked to ensure that permission has been given for WWW display, especially images, before world wide dissemination.
Conversion of lecture material to HTML will not improve the quality of teaching per se. We are fortunate in having lecture notes written 'in house' specifically for our course which are of textbook quality. We also have a rolling program aimed at the production of WWW documents based on tutorials given as part of our weekly teaching schedule. We would recommend institutions considering use of the WWW to examine their existing educational material and bring it up to date, before contemplating conversion to an on line format.
Computer malfunction. It is vital that whoever is charged with the responsibility of server maintenance regularly performs a backup. Consideration must also be given to the availability of a backup server should a catastrophic disk failure occur. This is especially important if the educational course relies on material delivered by the WWW. In this regard some form of paper printed material may be advisable. Libraries burn down infrequently; the same can not be said for the malfunction rate of computers.
We have gained considerable experience in the generation and maintenance of WWW documents within the medical, specifically Anaesthetic, field. Problems encountered en route have been addressed and resolved where possible. The next stage in the evolution of this project is the provision of a server of our own, to permit the use of forms and server scripts. This should allow the integration of WWW technology into our weekly teaching schedule as a tool to enhance the quality of service we deliver. This will necessitate a shift from material aimed at a 'general interest' market to one more specifically related to our current educational commitments.
Ausweb95 The first Australian WorldWideWeb conference ausweb95