e-Learning : The Next Big Thing in Medical Education .

he rapid advances in Information and Communication Technology (ICT) and the wide use of the World Wide Web has important implications for education. This continuous advancement in technology (e.g. Broadband internet connections, Ubiquitous Computing , Open Source Softwares) in conjunction with the recent recommendations in medical education suggesting a move toward problem-based learning (PBL) and use of information and communication technologies. All these factors led to the evolution of the e-learning environment in medical education.

The electronic learning or e-Learning is an umbrella term, and if you ask five peoples what e-learning is or isn't?You will end up with five different answers.Usually it's used to describe two different modes: 1. Distance learning: is a teaching and learning system designed to be carried out remotely by using electronic communication.This mode is out the scope of this paper.2. Web-based learning: (also called computer-assisted instruction, Internetbased learning, and online learning): is the use of the internet, or a computer network for the purpose of providing education.
When we mention e-learning in this article we refer to this type.
*5 th year medical student.
Faculty of Medicine and Health Sciences, Omdurman Islamic University, Sudan.Cell phone: +249122884620 email: amr_sudan@hotmail.comRuiz J.G et al. defines e-learning as "the use of Internet technologies to enhance knowledge and performance" 3 .We can adjust this definition to become more consistent with the medical field to: "The use of internet technologies or computer networks for the purpose of providing domains of learning (knowledge, skills and attitudes) to the medical students".
The basic thing that distinguishes between the two modes is the physical separation of the student from the instructor and the classroom in the distance learning while the web-based learning is a method that definitely enhances the classroom experience.Simply, we can say that e-learning is the marriage between education and technology and this marriage leads to emerge of new concepts in medical education such as Blended Learning and e-Problem-based Learning.

T Blended Learning:
Is an approach that combines traditional face to face methods with electronic media; this may include combinations of face to face lectures supplemented by an online interactive self assessments with immediate feedbacks and online discussions through chat rooms or forums.Nowadays, there is a wide agreement among the medical educationalist that blended learning will be the ''next big thing'' in medical education.

Why We Need e-Learning in Medical Education?
One estimate suggested that by 2010 more than 30% of a physician's time will be spent using information technology tools 4 , and there is no doubt this will transform and change the learning and practice environment as a whole.The following factors justify our need for e-learning:

Models in Undergraduates Medical
Education: 1. Rich Media "Interactive" Simulations: The term 'rich media' or "interactive multimedia" is defining the combination of texts, static pictures, videos and sounds through the use of modern technology, e.g. the simulation of physiological processes or parasites life cycles.This will help the student's brain to convert heard or read words, and diagrams into moving models thus many difficult concepts in physiology or microbiology are learned and thus helps the acquisition of knowledge.

Virtual Learning Environments (VLE):
Also called Learning Management Systems (LMS), Managed Learning Environment (MLA) or Virtual Classrooms."They are sophisticated tools that facilitate distribution of information, administration and tracking of students' achievement, creating online assessments and communication between students/students and students/tutors through discussion boards and chat rooms" e.g.Angel™, Blackboard™.

Virtual Patients Simulations:
The American Association of Medical Colleges describes Virtual Patients (VPs) as: "Interactive computer programs that simulate real-life clinical scenarios in which the learner acts as a health care professional obtaining a history and physical exam and making diagnostic and therapeutic decisions" Since every student cannot observe every patient, with the use of VPs we can broaden the students' exposure to a greater variety of patients, they enable students to discuss, manage, and make decisions in a safe environment without risk to the patient and the status of patient may change over time thus VPs bring the dimension of experience acquisition to medical education 7 .
There is strong evidence, however, that media-rich VPs are at least as effective as standard teaching methods 8 .

Videoconference:
They are real-time interactions that take place over the Internet using features such as audio and video, chat tools, and documents sharing between two or more sites at the same time.
They can be used for a variety of purposes including personal use, administrative meetings, or in the clinical rotations where the students are distributed in different hospitals .
In our faculty we strongly need this model, because the males and females are taught separately and sometimes the teacher gives the same lecture twice a day!! Fig. 3 Videoconferencing system connects between five sites.(Source: Wikipedia).

Virtual Reality (VR):
A computer simulation of a real or imaginary system that allow people to interact or perform operations on the simulated system and shows the effects in real time using their natural senses and skills 9 .These systems range from simple stimulator for training medical students and nurses the suturing and cannula insertion skills to more complex simulators for colonoscopic procedures (e.g.MIST System -figure 5-and da Vinci Surgical System), they give the students and Surgeons an opportunity to gain the skills and view the outcomes before the patient undergoes surgery.Computer software can also produce VR effects (e.g.CAVE system, figure 4), Twoand three dimensional objects can be incorporated into the web that can be controlled by the viewer 10 .

Advantages of e-Learning:
With its many benefits, e-learning is the perfect complement to a traditional teaching methods, particular advantages of e-learning include: 1. Resources can be made available from any location in contrast to traditional libraries.2. "Just-in-time": as the learning materials are available 24/7 the students can learn when they need it.3. "Just-for-you": the students can learn at their own paces and they can also pause learning sessions at their convenience.4. It can encourage more independent and active learning.5. Increase of accessibility to information and ability to link resources in many different formats (e.g.hand-out contains links to electronic journal) this function are particularly useful for research, clinical activities and further readings.However, typical web-based courses must contain link to external resources in addition to assessment activities with feedback to learners and channels for communication and interaction between them rather than just displaying and storage of knowledge 11 .Fig. 4 Inside a CAVE (computer assisted virtual environment) to understand the anatomy of Cardiopulmonary system.(Source: British Dental Journal).
6.There is a possibility of collaboration between teachers and students from different universities, which allows exchange of knowledge and experiences (Distributed Synchronous Learning) 12 .7. Ease in Update: Updating electronic content is easier than updating printed material 13 .8. Promote the interactions, by means of emails and forums, and remove the psychological barriers between students and teachers.9.With time, the students and instructors will learn new technologies and technical skills.10.Numerous research opportunities and ideas exist in the relatively new field of e-Learning 14 .11.The e-Learning enhances the Problembased learning with its visual and interactive features; it allows the instructor to introduce photos and videos to the problem and give the students immediate feedbacks 15 .12. It prevents the lecturers reverting to traditional teaching methods (in institutes adopted PBL) allows them to retain their facilitator role, and encouraged students to explore, analyse and make decisions within the safety environment of a virtual patient simulation.13.Cost effectiveness: web-based learning can result in significant cost reduction, compared with traditional instructor-led learning 16 .Marked reduction related to travel costs, and labor costs, and the possibility of expanding programs with new educational technologies 16 .14. Finally, it's a Green Technology!! I think this is the best benefit over all, because elearning reduces the environmental impact (Eco-friendly) and allows people to avoid traveling and thus reducing the overall carbon output.Moreover, in the virtual environments there is some reduction of paper usage.

Future Prospects
Harden RM et al in his article An international virtual medical school (IVIMEDS) the future for medical education states "Trying to predict the future of elearning is like trying to guess which colours and shapes will appear at the other end of the kaleidoscope" 14 The future of e-learning will determine by two essential issues: The social networks such as Facebook™, MySpace™ and Twitter™ are also models of Web 2.0.Web 2.0 technologies characterized by their ease of use and rapidity of deployment, they offer the opportunity for information sharing (Blogs) and ease of collaboration (Wikis).In addition, they narrow the divide between the instructors and students, Students themselves become producers 19 .

Economical changes:
Whatever happens in the global economy will be a major influence over what happens in e-learning.This year as a result of the global economic crisis, the e-learning experts don't expect anything huge to happen in hardware, software or e-learning standards.But at the same time they expect increase in adoption of certain available technologies due to the pressure of recession, for example "quick & dirty" videos, web conferences and social networks.

Fig. 1
Fig. 1 Interactive simulation of Plasmodium life cycle contains texts, animations and audio.(Source: McGraw Hill).

Fig. 2
Fig. 2 Screenshot of Virtual Learning Environment of Royal College of Surgeons (Ireland).

Fig. 5
Fig. 5 Using MIST system for minimally invasive surgery training.Source: Laparoscopy Today Blog.