medical education in review

Computer-based teaching module design: principles

derived from learning theories
K H Vincent Lau

CONTEXT The computer-based teaching learning’) for articles published between 1990
module (CBTM), which has recently gained and 2012. The first search identified 29 stud-
prominence in medical education, is a teach- ies, dominated in topic by the cognitive load,
ing format in which a multimedia program elaboration and scaffolding theories. The sec-
serves as a single source for knowledge acqui- ond search identified 139 studies, with diverse
sition rather than playing an adjunctive role topics in connectivism, discovery and technical
as it does in computer-assisted learning scaffolding. Based on their relative representa-
(CAL). Despite empirical validation in the tion in the literature, the applications of these
past decade, there is limited research into theories were collapsed into a list of CBTM
the optimisation of CBTM design. This design principles.
review aims to summarise research in classic
and modern multimedia-specific learning RESULTS Ten principles were identified and
theories applied to computer learning, and categorised into three levels of design: the glo-
to collapse the findings into a set of design bal level (managing objectives, framing, mini-
principles to guide the development of mising technical load); the rhetoric level
CBTMs. (optimising modality, making modality expli-
cit, scaffolding, elaboration, spaced repeat-
METHODS Scopus was searched for: (i) stud- ing), and the detail level (managing text,
ies of classic cognitivism, constructivism and managing devices).
behaviourism theories (search terms: ‘cogni-
tive theory’ OR ‘constructivism theory’ OR CONCLUSIONS This review examined the
‘behaviourism theory’ AND ‘e-learning’ OR literature in the application of learning theo-
‘web-based learning’) and their sub-theories ries to CAL to develop a set of principles that
applied to computer learning, and (ii) recent guide CBTM design. Further research will
studies of modern learning theories applied to enable educators to take advantage of this
computer learning (search terms: ‘learning unique teaching format as it gains increasing
theory’ AND ‘e-learning’ OR ‘web-based importance in medical education.

Medical Education 2014: 48: 247–254

doi:10.1111/medu.12357

Discuss ideas arising from the article at

‘www.mededuc.com discuss’

Department of Internal Medicine, Yale–New Haven Hospital, New Correspondence: K H Vincent Lau, Department of Internal
Haven, Connecticut, USA Medicine, Yale–New Haven Hospital, 20 York Street,
New Haven, Connecticut 06510, USA. Tel: 00 1 347 749 4708;
E-mail: [email protected]

ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 247–254 247
K H V Lau

Learning theories
INTRODUCTION
The three leading classes of traditional learning the-
The computer-based teaching module (CBTM) is a
ories are cognitivism, constructivism and behaviour-
teaching format that has gained prominence in the
ism.13 Cognitivism emphasises: (i) the existence of a
last decades, in which a self-contained lesson is
memory system which assesses and organises new
delivered in a computer multimedia package, with-
information, and (ii) the importance of prior knowl-
out the complementary classroom component that
edge in the role of learning. Cognitivism is often
is traditional in computer-assisted learning (CAL).
applied to modern education in the form of cogni-
tive load theory (CLT).
The efficacy of the CBTM in medical education has
been validated by several randomised controlled trials
Constructivism emphasises active learning and lear-
in the past decade. Compared with the faculty-led lec-
ner-specific knowledge construction.14 It describes
ture, small-group format or self-study, the CBTM has
the important role of the teacher in understanding
been found to have improved1–4 or at least compara-
the learner’s rhetoric and intentions, and in present-
ble5–7 teaching efficacy. The CBTM has been vali-
ing information in such a way to fit into the learner’s
dated in the fields of psychiatry,1,6 dermatology,2
pre-set schema. Constructivism serves as a basis for
genetics7 and the teaching of procedures.5 Although
the discovery, elaboration and scaffolding theories.
individually robust, these studies involved heteroge-
neous topics, design methodologies and outcome
Briefly, behaviourism describes learning via condition-
measures. It remains unclear under which circum-
ing which ultimately changes behaviour such as by
stances the CBTM is best implemented in undergrad-
maintaining learners’ attention,15 but the theory has
uate and graduate medical education.
few applications in adult knowledge-based education.
In theory, the CBTM offers significant advantages
Classic learning theories
over traditional teaching modalities, which include
increased learner convenience, a learner-set pace,
Cognitive load theory
individualised interactability, a one-time resource
cost and potential dissemination across institutions.
Cognitive load theory describes learning efficacy as
However, the CBTM also poses unique challenges.
a function of working memory, which is divided into
It has been demonstrated to be considered less
intrinsic, germane and extraneous loads16,17 and has
engaging by learners as a result of its lack of human
a sum total that cannot be exceeded.
interaction.6 Learners have also reported lower lev-
els of confidence with new knowledge, possibly
Intrinsic load refers to the inherent difficulty of the
attributed to uncertainty if learning is misdirected
material and typically cannot be modified. Germane
in the absence of human validation.1 Perhaps the
load refers to the understanding of information and
greatest challenge to CBTM design lies in harness-
contextualisation through which to integrate the new
ing the unique opportunities afforded by this new
knowledge into one’s permanent memory. Extrane-
teaching format.
ous load refers to the attention paid towards the pre-
sentation of the material as opposed to the material
Despite its immense potential, to the author’s
itself. In CLT, the goal is to minimise extraneous load
knowledge there has been no significant effort to
in order to increase reserve for germane load.
assess and ensure the quality of the CBTM format
in medical education. The use of design principles
A simple example in education concerns the guide-
to guide educational material has been validated in
lines for the delivery of PowerPoint presentations,
other teaching formats within medical education,8
which suggest, for instance, that the number of lines
such as in CAL design,9 webpage design10 and mul-
of text per slide or the number of unique font col-
timedia material design.11,12
ours should be limited to prevent distraction from
the presentation contents.18
The purpose of this review was to examine the liter-
ature in CAL and learning theories to develop a set
Elaboration theory
of design principles that guide CBTM development
in medical teaching. Given the immense potential
Elaboration theory emphasises a meaningful
of the teaching format, a close examination of
sequence of instruction.19 Over the years, the theory
CBTM design optimisation is warranted.

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 Computer-based teaching module design

has moved from a simple-to-complex model to a visual and auditory channels. For example, a skill-
familiar-to-unfamiliar model. The simple-to-complex based video that teaches the placement of a central
model assumes that all learners perceive informa- line may be accompanied by audio narration rather
tion in the same way. The familiar-to-unfamiliar than subtitles or block texts.
model accounts for learner differences. There is
emphasis on learner motivation, which affects the Technical scaffolding theory
learner’s progression from the topics that are most
relevant and translatable to the learner, to topics First described in the 1950s, scaffolding refers to
perceived as less important. The revised elaboration planned or unplanned expert assistance targeted
theory also argues that new information be towards learners as they learn a concept or task.
grounded in authentic performance setting, The assistance may refer to spontaneous assistance,
illustrated, for example, by the presentation of a such as that delivered by answering a student’s
concrete problem and the subsequent backwards question, or planned assistance, such as that deliv-
working to attain the information necessary to solve ered by providing a new tool with which to solve
it.20 Two related theories are discovery theory,21 a problem students are not expected to solve on
which emphasises learning based on the learner’s their own. Recently, Yelland and Masters intro-
inquiry, and connectivism theory,22 which duced the term ‘technical scaffolding’, which
emphasises learner interaction. refers to a situation in which students are posed a
question and then provided with a finite number
A basic example in medical education is in one-to- of computer-based resources (e.g. websites or
one teaching, in which the teacher assesses a lear- online tutorials) through which they are encour-
ner’s prior understanding of material and elicits aged to seek the assistance they need to solve the
questions in order to establish the context on which problem.26
further knowledge can be built.
An example of scaffolding is the concept of prob-
Cognitive and learning styles theory lem-based learning in medical school, which has
gained widespread adoption. A problem is intro-
Recently investigated for its application to web-based duced and resources are provided for learners to
learning,23 the most direct application of cognitive find their own solutions, guided by teachers on an
and learning styles (CLS) theory is in the adaptation as-needed basis only.
of instruction to learner style. The concept of an
aptitude–treatment interaction is applicable when
one group of learners learns better with one METHODS
method and another group learns better with
another method.23 Although Cook et al.24 champi- Searches were carried out in Scopus for studies of
oned the idea, more recently Cook25 has argued classic learning theories under the three major
that strong instructional methods take precedence classes of cognitivism, constructivism and
over possibly negligible differential learning styles, behaviourism and their application to computer-
and that tools for characterising heterogeneous based learning. In addition, to capture more
groups of learners remain inadequate. Currently, recent studies based on learning theories that may
the validity of CLS theory as applied to multimedia not stem from these classic theories, a second
in medical education is unclear. search for studies into any learning theories
applied to computer-based learning, published
Multimedia-specific learning theories since 1990, was performed. Search parameters and
results are summarised in Fig. 1.
Cognitive theory of multimedia learning
The literature search provided an impression of the
In 1999, Moreno and Mayer11 investigated learning learning theories that garnered the most interest
via computer animation. These authors demon- within computer learning, notably CLT, elaboration
strated improved learning through concurrent audi- theory and scaffolding theory. Also relevant were
tory narration with animation over concurrent text the connectivism and discovery theories. Based on
with animation, supporting the principles that learn- their relative importance, these learning theories
ing efficacy is improved with the presentation of were collapsed to develop a set of 10 succinct
multiple modalities of instruction simultaneously in principles to guide CBTM design, and divided into
time, and that the working memory is split into three design levels to facilitate application.

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K H V Lau

Figure 1 Literature search methodology. CLT = cognitive load theory

may be displayed simultaneously to reconcile lear-

RESULTS ner and instructor goals.

The principles derived were divided into three cate- Framing

gories of application: global principles to be applied
at initial conceptualisation stages; rhetoric principles Supported by the CLT principle of maximising ger-
to be applied during the development of individual mane load, framing is the establishment of context,
segments and revisited during initial revision stages; which is more important in CBTM than in other
and detail principles to be applied to text and mul- teaching formats because it is not supplemented by
timedia decisions throughout development, and verbal instruction from a human instructor. Given
revisited in final revision stages. heterogeneous knowledge bases and learning styles,
context is learner-specific (e.g. the sequential–global
Global principles learner theory distinguishes between those who
learn through a linear analytic process and those
Managing objectives who learn in seemingly random segments until they
make sense of the whole30), as supported by the
Central to adult learning theory27 is learner partici- CLS. Therefore, framing becomes an important
pation in educational goal setting. In the CBTM, device for the reconciliation of the learner’s needs
the entire lesson is taught through the computer with the teacher’s objectives.
program with no complementary instructional for-
mat. As such, the objectives must be communicated A simple example is the display of a concept map
within the CBTM itself. It has been demonstrated at the margin of the screen, in which the segment
that both intellectual and social curiosity (towards with which the learner is currently engaged is
applicability to the clinical disease process) improve highlighted in order to establish how the present
learning and retention.28,29 segment fits into a part of the whole. For exam-
ple, a module that teaches about cirrhosis may fea-
Students should be encouraged to set goals in both ture a concept map in which, on a segment
pre-clinical and clinical lessons. Students may be describing liver function tests (LFTs), the path to
prompted to enter their own learning objectives in the topic is highlighted (e.g. ‘Overview?Diagno-
the form of questions. For example, a pre-clinical sis?Non-clinical?Lab?LFTs’). The purpose is to
lesson on lung cancer may invite questions such as help learners understand the context of each seg-
‘What predisposes a person to lung cancer?’ ‘How ment.
does smoking cause lung cancer?’ and ‘What is the
natural progression of lung cancer?’ The purpose is Minimising technical load
not that learners should identify all the objectives of
the module, but to encourage them to begin to On the basis of the CLT principle of minimising
develop a conceptual framework on which further extraneous load, the technical aspects of the CBTM
knowledge may be built. After the learners have should remain in the background and unnoticeable
entered their questions, the instructor’s objectives to the learner.

250 ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 247–254
 Computer-based teaching module design

Ideally, the goal of minimising extraneous load is ECG reading is best learned via repeated self-testing
not to develop a long tutorial explaining the techni- with incremental variations, which is the modality
cal aspects of the module, but, rather, to develop a used for this teaching module.’
module that uses navigation and signalling devices
common to typical computer applications, such that Technical scaffolding
no technical tutorial would be required at all. For
example, a neuroanatomy module may allow the Technical scaffolding introduces aid to learners at
use of a computer mouse drag to rotate a 3-dimen- predefined junctions, as advocated by Yelland and
sional representation of the brain, much as other Masters.26 The most efficacious use of this principle
web-based applications allow for mouse dragging to is in the context of ‘just-in-time’ learning,32 in
move an object along a web page. which users are asked a question which requires
additional information to answer. Learners are then
Rhetoric principles provided with a finite list of resources with which to
solve the problem.
Optimising modality
The CBTM offers the unique advantage of applying
In line with the CLT principle of maximising ger- technical scaffolding by providing learners with hy-
mane load, developers would benefit from familiar- perlinks to faculty-approved Internet resources. They
ity with the principles proposed and validated by may be offered in the context of a posed question
Mayer in his cognitive theory of multimedia learn- to ensure users have a specific intent when access-
ing.12 Every decision in choosing a modality (any ing these resources. For example, a module may
combination of text, diagram, audio, video, with or present a patient with new-onset atrial fibrillation
without interactivity) should be supported by evi- and ask whether the patient should receive anticoag-
dence whenever possible. ulation. Web links (e.g. Uptodate.com) that lead to
information about the CHADS2 (congestive heart
Important guidelines include using word and pic- failure, high blood pressure, age ≥ 75 years, diabe-
ture format simultaneously, displaying related text tes, previous stroke [2 points]) score may be pro-
in close proximity to the figure, and avoiding redun- vided. After understanding the concept, the learner
dant modality.31 An example of the lattermost is to must apply the new tool to the patient in the case.
use voice narration to accompany an endoscopy Note that the purpose was not to find the informa-
video rather than using subtitles and to allow for tion, but to apply it.
the simultaneous use of visual and auditory modali-
ties rather than saturating the visual modality. Elaboration

Making the modality explicit Elaboration theory emphasises learner decisions in

scope and sequence. The CBTM is uniquely advan-
On the basis of the CLT principle of minimising tageous for the application of elaboration theory as
extraneous load, the selected teaching modality it can allow the learner to make decisions on the
should be made explicit. Learners should not exert sequence of viewing content and on skipping seg-
effort on understanding the method of content ments altogether if he or she is confident in the
delivery. They should also not exert effort in ques- subject area. Although users may control the scope
tioning the validity of the modality. In medical and sequence of their learning, they should not be
school, learners often seek out ‘high-yield’ resources permitted to skip entire segments without validation
and are more receptive to learning when they feel of their knowledge. Passive validation may take the
their time is well spent. The predetermined selec- form of a summary of skipped content. Active vali-
tion of the modality assumes that the effect of CLS dation may take the form of a mandatory quiz cali-
is dominated by the efficacy of the teaching modal- brated to demonstrate competence prior to
ity.25 In other words, the modality is justifiably con- skipping a segment.
tent-centred, not learner-centred.
For example, a module segment on electroenceph-
Learners may benefit from the provision of an expli- alography (EEG) reading may offer the learner
cit statement of the teaching modality, as well as a the opportunity to attempt a quiz involving the
brief justifying explanation. For example, an electro- identifying of common EEG patterns; if the learner
cardiogram (ECG) reading module may be prefaced scores above a threshold, he or she may skip the
with the statement: ‘Education research shows that module.

ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 247–254 251
K H V Lau

Spaced repeating prompts free-text answers to quiz questions, and

subsequently displays the correct answer for
Well established in classic education theories,33 comparison and reconciliation.
spaced repeating is the concept of improving lear-
ner understanding and retention via non-sequential Detail principles
repetition. Built-in repetition may take the form of
a summary, as often employed in a traditional lec- Managing text
ture. In the CBTM, developers may use a quiz to
revisit previous content while assessing retention. To There is robust literature on text-based instruction
encourage active learning, developers may choose in medical education. Instructors would benefit
to use the teach-back method, in which the module from familiarity with the basic principles.

Table 1 Principles of computer-based teaching module design and examples of applications

Principle Example of application Learning theory basis Reference(s)

Global level
Managing Prompt learner to enter self-set Adult learning Sun & Li (2010)21
objectives objectives in the form of questions, Connectivism Xu & Zhang (2011)22
then display instructor objectives Discovery Roman & Kay (2007)28
for reconciliation Scaffolding Roman (2011)29
Framing Display a concept map of contents that CLT – extraneous Felder & Silverman (1988)30
is accessible throughout the module
Minimising Use intuitive and user-friendly technical CLT – extraneous Moreno & Mayer (1999)11
technical load devices employed by common computer Cooper (1990)16
applications

Rhetoric level
Optimising modality Use both audio and visual modalities CLT – germane Moreno & Mayer (1999)11
simultaneously when appropriate Mayer’s cognitive theory Cooper (1990)16
of multimedia learning
Making modality Explain modality and briefly justify its CLT – extraneous Moreno & Mayer (1999)11
explicit validity Cooper (1990)16
Technical scaffolding Prompt learner with questions; provide Scaffolding Sun & Li (2010)21
outside resources to fill in gaps in Technical scaffolding Yelland & Masters (2007)26
knowledge Discovery Cheuh & Barnett (1997)32
Elaboration Enable learner to control the sequence and Elaboration Moreno & Mayer (1999)11
offer an alternative to completing basic Discovery Cooper (1990)16
segments (e.g. by using a calibrated quiz) CLT – germane Sun & Li (2010)21
Spaced repeating Provide quiz at end of segments, use Spaced learning effect Dempster (1989)33
teach-back

Detail level
Managing text Use audience-appropriate language CLT – intrinsic Gunderman & McCammack (2010)34
germane James & Linte (2010)35
Lim (2012)36
Managing devices Use signalling and visual grouping CLT – extraneous Moreno & Mayer (1999)11 Mayer
(2010)12 Khalil et al. (2005)31

CLT = cognitive load theory.

252 ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 247–254
 Computer-based teaching module design

standardisation and optimisation of development as

the CBTM becomes more prominent, and the inter-
institution sharing of web-based resources.

Another barrier is faculty staff resistance. A study of

faculty members in a nursing school identified faculty
staff discomfort with web-based learning on the basis
of increased workload and role reconceptualisation.37
Faculty staff may anticipate increased work in course
development and commitment to online communica-
tion with learners. They may also anticipate a chal-
lenging transition from the role of an authority
Figure 2 Learning theory-based principles guiding figure in the classroom to that of a facilitator of
computer-based teaching module design knowledge acquisition in computer-based learning.
Potential solutions include employing software pro-
Examples include using audience-appropriate lan- grammers with expertise in CAL to collaborate closely
guage and managing curiosity with questions.34–36 with medical teachers in developing the CBTM. This
may require support from institutional administra-
Managing devices tion, which must be educated on the importance and
long-term cost-effectiveness of CBTM design.
Similarly to the managing of text, there is strong lit-
erature on the use of technical devices in computer- A final barrier to implementing the CBTM is that
based learning. research remains in its infancy. Empirical research
comparing the CBTM with more traditional modali-
Examples include the use of signalling and cuing to ties often assesses only learning outcomes and makes
highlight important material12 and making use of no mention of development costs. It also fails to
visual grouping.31 assess time-related costs to students, making the con-
clusion that a CBTM is more effective than a tradi-
Examples of the application and learning bases of tional lecture without measuring the time students
each principle are detailed in Table 1. A visual rep- spend on a module. Despite several robust studies val-
resentation of the principles divided by categories is idating the use of the CBTM, many remain wary of
shown in Fig. 2. this nascent teaching format.

For these reasons, it is important to standardise and

DISCUSSION optimise CBTM design, with the goal of better
informing research and driving widespread
The present review has examined classic and modern acceptance in the medical education community.
multimedia learning theories to identify a set of prin- The versatility of the CBTM is virtually limitless as its
ciples to guide CBTM design. This study complements functions expand concurrently with advances in com-
recent empirical works which demonstrate validity puter technology. To give the CBTM a fair evaluation
and efficacy. Future work would include prospective for its potential applications in the future of medical
studies comparing the efficacy of principle-guided ver- education, the design of computer-based resources
sus non-principle-guided CBTM design to validate must be made more robust and evidence-based.
and refine the principles. In addition to providing a
framework with which to develop and validate CBTMs,
Acknowledgements: the author would like to thank Dr. Marc
design principles are important in optimising the Triola for his advisement throughout this project.
CBTM format to enable a fair comparison with other Funding: none.
teaching formats in education research. Conflicts of interest: none.
Ethical approval: not applicable.
There remain many questions regarding the validity
and translatability of the CBTM modality as a nascent
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