The LINDSAY Virtual Human Project: An immersive approach to anatomy and physiology

RESEARCH REPORT

The LINDSAY Virtual Human Project: An Immersive Approachto Anatomy and Physiology

Janet K. Tworek,1,2 Heather A. Jamniczky,3* Christian Jacob,4,5 Benedikt Hallgrımsson,3 Bruce Wright1,61Office of Undergraduate Medical Education, University of Calgary, Calgary, Alberta, Canada2Faculty of Education, University of Calgary, Calgary, Alberta, Canada3Department of Cell Biology and Anatomy, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada4Department of Computer Science, Faculty of Science, University of Calgary, Calgary, Alberta, Canada5Department of Biochemistry and Molecular Biology, Faculty of Medicine, University of Calgary,Calgary, Alberta, Canada6Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada

The increasing number of digital anatomy teaching software packages challenges anat-omy educators on how to best integrate these tools for teaching and learning. Realisti-cally, there exists a complex interplay of design, implementation, politics, and learningneeds in the development and integration of software for education, each of which maybe further amplified by the somewhat siloed roles of programmers, faculty, and students.LINDSAY Presenter is newly designed software that permits faculty and students tomodel and manipulate three-dimensional anatomy presentations and images, whileincluding embedded quizzes, links, and text-based content. A validated tool measuringimpact across pedagogy, resources, interactivity, freedom, granularity, and factors outsidethe immediate learning event was used in conjunction with observation, field notes, andfocus groups to critically examine the impact of attitudes and perceptions of all stake-holders in the early implementation of LINDSAY Presenter before and after a three-weektrial period with the software. Results demonstrate that external, personal media usage,along with students’ awareness of the need to apply anatomy to clinical professional sit-uations drove expectations of LINDSAY Presenter. A focus on the software over learning,which can be expected during initial orientation, surprisingly remained after three weeksof use. The time-intensive investment required to create learning content is a detractorfrom user-generated content and may reflect the consumption nature of other forms ofdigital learning. Early excitement over new technologies needs to be tempered with clearunderstanding of what learning is afforded, and how these constructively supportfuture application and integration into professional practice. Anat Sci Educ 6: 19–28. © 2012

American Association of Anatomists.

Key words: gross anatomy education; medical education; virtual models; three dimen-sions; computer-assisted learning; innovations; student perceptions

INTRODUCTION

Anatomy teaching is undergoing a paradigm shift in medicaleducation (Terrell, 2006; Sugand et al., 2010). Typical formsof face-to-face small group hands-on sessions or large grouplectures face both internal and external pressures to change.Rising student numbers, concomitant with an increasingnumber of portable digital devices and pervasiveness of wire-less Internet access in teaching spaces add pressure when in-structor numbers are reduced, budgets may be constrained,and admissions criteria for healthcare education are distal to

*Correspondence to: Dr. Heather Jamniczky, Department of CellBiology and Anatomy, Faculty of Medicine, University of Calgary,3280 Hospital Drive NW, Calgary AB T2N3Z6, Canada.E-mail: [email protected]

Received 20 March 2012; Revised 30 May 2012; Accepted 16 June2012.

Published online 12 July 2012 in Wiley Online Library(wileyonlinelibrary.com). DOI 10.1002/ase.1301

© 2012 American Association of Anatomists

Anatomical Sciences Education JANUARY/FEBRUARY 2013 Anat Sci Educ 6:19–28 (2013)

the anatomists who teach the next generation of professionals(Drake et al., 2009). Professors’ personal experiences withweb-based media, or increasing standards of research andacademic publishing, may causally or tangentially push fac-ulty to question if time-consuming teaching can be betterencapsulated with media. A third movement pressing on largegroup science teaching is the pursuit of higher quality educa-tional experiences, which align subject matter with contextualapplication (Crouch and Mazur, 2001); these forms of teach-ing may be facilitated with technology. Finally, as studentsarrive to learning events with multiple personal digital tools,faculty are challenged to consider the ways in which learningis both positively and negatively impacted, and equally cau-tioned to take a critical view of what digital skills studentsactually possess, considering that many tools and deviceshave been purposely built for easy interface adoption overdeeper cognitive activity (DiLullo et al., 2011; Ellaway andTworek, 2011). The era of digitally based anatomy education,and its affiliated challenges, is upon us.

Multiple digital anatomy resources have been reported,including web-based offerings (Granger et al., 2006; Glin-kowski and Ciszek, 2007; Raynor and Iggulden, 2008; Reilly,2011); digitalized visual representations, notably based on theVisible Human dataset (e.g., Jastrow and Vollrath, 2003;Yeung et al., 2011) or radiological images (Jelacic et al.,2006; Marker et al., 2010; Tam, 2010); and three-dimen-sional virtual reality (Carmichael and Pawlina, 2000; Parikhet al., 2004; Temkin et al., 2006; Turinsky et al., 2008).These have been variably implemented for large group orself-directed study (Peck and Benton, 1970; Rolston andKochhar, 1971; Moffatt, 1974; Prentice et al., 1977; Mizeret al., 2002) and are inclusive of student-created objects(Philip et al., 2008).

Computer-assisted learning modules are likely more sup-portive of learning later in anatomy training when studentsare familiar with the materials, rather than as initial methodsfor learning content (Marsh et al., 2008; Wright and New-man, 2011). Careful design of anatomy materials for distanceeducation, even if used as self-directed adjuncts to face-to-face lectures, is necessary to enable successful learning out-comes (Smythe and Hughes, 2008). The affordances of thetool are both intentionally included in its design to enablelearning, but, in turn, impact what types of learning mayoccur. Specific design features have been noted as key for ena-bling learning: (1) including accurate visual representations,(2) student manipulation of pacing, and (3) control of naviga-tion (Kim et al., 1999; McKeough and Bagatell, 2009). Argu-ably one-way transmission forms of digital education (e.g.,podcasts, self-directed web modules) offer knowledge trans-mission that, without instructional implementation choices tofoster opportunities for deeper learning experiences, mayexplain the ‘‘no significant difference’’ phenomenon related tolearning with media (Russell, 2001).

Anatomists must be conscientious in their adoption andintegration of tools for learning, lest we fall prey to the sametrajectory documented in the digital education literature,where initial excitement over software soon succumbs to crit-icism over lack of learning outcomes (Cook, 2009; Cooket al., 2010a,b). Although sometimes viewed as a threat toface-to-face contact, digital anatomy resources have been sug-gested as valuable, scalable, and contextualized learningopportunities. The motivation for adoption may initiallyrelate to efficient distribution and time savings for both fac-ulty and students. The key area moving forward is how to

provide interactive knowledge building in digital educationthat compares with guided faculty teaching in face-to-faceenvironments. What deep learning experiences faculty mightbe able to create is in part dependent on how the tool isdesigned for learning. It is this endeavor we focus on with anew software for three-dimensional anatomy teaching.

A New Digital Anatomy Tool: The LINDSAYVirtual Human Project

The LINDSAY Virtual Human Project (LINDSAY Project,2011) consists of two complementary pieces of software(LINDSAY Presenter and LINDSAY Composer), under con-struction at the University of Calgary, which will eventuallybe merged into a single, powerful presentation, and simula-tion tool (Jacob et al., 2012). The LINDSAY Virtual HumanProject is named in honor of a former student at the Facultyof Medicine at the University of Calgary, Ms. Lindsay Kim-mett, who passed away while working on this program andwhose legacy includes support of educational initiatives formedical education, including the LINDSAY Virtual HumanProject. The LINDSAY Virtual Human Project is a synergisticundertaking designed to create software that permits any userto model and visualize anatomy in a three-dimensionalsimulation using two-dimensional computer interfaces (e.g.,laptop, tablet, etc).

LINDSAY Presenter is the anatomical presentation compo-nent of the Virtual Human software suite. The software pro-vides an interface through which three-dimensional humananatomy mesh data can be manipulated, assembled, and pre-sented in a fully customizable fashion. Currently, mesh dataare commercially prepared externally (Zygote Media Group,American Fork, UT) for incorporation into the software, andthe software does not permit individual users to enter anyother type of data. Anatomical content is presented in theform of a searchable atlas, from which individual partsthrough to whole systems can be dragged and dropped intoscenes, which are captured as slide sets similar to other com-mon commercially available presentation software. LINDSAYPresenter also includes common presentation features such astext boxes, hyperlinks, and line drawing. However, the inter-face incorporates many of the usability conventions of com-mon presentation software, users may leverage the hyperlinktool to create interactive cases with links to further contentand/or challenges. Although, the interface is much like stand-ard presentation-building software, LINDSAY Presenter maybe used by faculty and students to create presentations, tuto-rials, quizzes, or even interactive cases. Integration with web-based simulation media, e.g., game-based engines such asUnity, version 3.0 (Unity Technologies, San Francisco, CA) iscurrently being tested.

The goal of the LINDSAY project was not to re-createwhat is available elsewhere or in similar forms. However,examples of anatomy software exist that may be described asproviding three-dimensional depth and layering of anatomyon two-dimensional screens, e.g., Visible Body 3D HumanAnatomy Atlas (Visible Body, 2012) or 3D Human AnatomySoftware (Primal Pictures, 2007), LINDSAY Presenter movesbeyond these offerings in two key ways (Fig. 1). First, thethree-dimensional anatomy is of higher pixel resolution anddetail is available in most commercial offerings. Second, theuser is able to rotate and manipulate the anatomical presenta-tion within the slide; when features such as labels, hyperlinks,and text-based content are added, students or faculty may

20 Tworek et al.

use the software for large group, small group, or even inde-pendent tutorials. This achieves the intended goal of theLINDSAY Project to provide visual and manipulable modelsof anatomy into the hands of students and teachers for activelearning experiences. Although LINDSAY originally includedstereoscopic projections to provide truer three-dimensionalexperiences, as other projects are now announcing (e.g.,Brown et al., 2012), this was abandoned based on early stu-dent feedback that the experience was disorienting and distalfrom in-lecture learning experiences. LINDSAY Project is partof a suite of digital anatomy experiences allowing students tolearn independently on mobile devices, as is becoming popu-lar in another medical school program (e.g., NYULMC,2012). At present, the LINDSAY Presenter software remainsan in-house software project, with anticipated release beyondthe University of Calgary within the next year. This studywas the first study looking at how real users adopted thetechnology.

The Challenge of Evaluation, TechnologyDesign, and the Social Context of Technology

The evaluation of digital instruments for education has fre-quently been conducted with quantitative methods, followinga positivist view of learning (Russell, 2001; Cook et al.,2010b). Positivist designs presume that learning tools aretreatments, and the technology used to build them is withoutpsychological impact (Norman, 2002). This approach ignoresthe complex socio-cultural dynamics influencing teachers,

learners, and learning (Vygotsky, 1978; Lave and Wenger,1991) and may obfuscate the intervening layers of pedagogy,course, and program decisions coloring the implementationof technology for learning (Ellaway and Davies, 2011). Socio-cultural views recognize that conceptualizations of tools arevariously informed and re-shaped by participants (Brownet al., 1989). It is therefore important to evaluate the contri-bution of the tool itself, and from multiple perspectives, inde-pendent of learning outcomes such as knowledge retention ortransfer of knowledge to new settings.

Certain theoretical approaches of software engineeringand educational design, such as user-centered and agile meth-ods, emphasize that the design and development of innovativetools, such as LINDSAY Presenter, should use an iterativeprocess to incorporate user perspectives as a way of strength-ening the alignment between tool and intended use (Ricoet al., 2009; Garrett, 2010). The software team creatingLINDSAY Presenter followed user-centered and agile methodsby completing multiple iterative development cycles with stu-dents, faculty, medical school administration (e.g., financeteam, e-Learning team), and the LINDSAY Project manage-ment team (comprised of administrators, software developers,anatomists, and the manager of e-Learning). Consequently,multiple perspectives informed the creation of LINDSAY Pre-senter, which gave confidence that the tool was ready for gen-eral release to students and faculty.

New software is often met with hype cycles, with thebelief that educational software will benefit learning (Rogers,1995). In situations of collective excitement, the individual

Figure 1.

Screenshot of the LINDSAY Presenter user interface. A slide deck is shown on the left of the main scene window, and the embedded anatomy atlas is shown on theright. Multiple anatomy objects can be selected from the atlas and dragged-and-dropped into the main scene window.

Anatomical Sciences Education JANUARY/FEBRUARY 2013 21

opinions of the stakeholders co-influence to create a groupview of the design software that may have constructive ele-ments, but also unseen gaps. Individual stakeholders may beblind to their unique perspective relative to the actual imple-mentation for learning; each members’ perceptions fall on acontinuum between close alignment and distal understandingof the true consequences for learning. Admittedly within theLINDSAY Project, there existed a collective enthusiasm by allstakeholders at how the software would benefit learning, andthis was widely shared, despite an unclear picture of howusers, particularly students, might actually learn in independ-ent settings with LINDSAY Presenter. Knowing this, theauthors sought to conduct a study that include first training,then allowing the students for a period of independent soft-ware use, and gathering their feedback. This feedback wasthen shared with the other stakeholders (e.g., faculty, admin-istrators, LINDSAY Presenter team) before asking theserespondents to complete a survey on the positive and negativeimpacts of LINDSAY.

MATERIALS AND METHODS

Overview

The primary goal of the present research was to investigateif, after having incorporated stakeholder feedback throughoutthe main development cycles of a digital anatomy tool, inde-pendent usage of the tool matches the intended purpose. Thesecondary goal was to see if, once actual usage data were pre-sented to stakeholders, their opinions about the tool change.A mixed methods investigation was deemed more amenableto capturing the socio-cultural complexities of software foreducation, including perceptions, advantages, and issues withLINDSAY Presenter. The mixed methods consisted of abounded case study of students’ uses of LINDSAY Presenterover a three-week pilot. A survey was given to students bothbefore and after a three-week pilot. Data from observation,field notes, and focus groups in the pre- and post-surveyphases were analyzed and organized into themes; data satura-tion was reached; authors agreed on final themes and richdescriptions. Themes and survey results from the student dataare triangulated and discussed. Approval for this study wasgranted by the Conjoint Health Research Ethics Board of theFaculties of Medicine, Nursing and Kinesiology, University ofCalgary, protocol E-24306.

Participants and Recruitment

The undergraduate medical education program at the Univer-sity of Calgary is a three-year program leading to the MDdegree. The program has both urban and rural tracks in thefinal year, though all instruction in the first two years is con-ducted within the metro Calgary area. Students participatingin the study were drawn from the class of second-year stu-dents (n 5 180). First-year students were excluded becausethey were in the early months of adjusting to medical school;third-year students were excluded because they were away inclinical clerkship rotations. The IT representative for thesecond-year class agreed to assist with recruiting, and heapproached key contacts in the class who had time and inter-est. Word spread through these early contacts to the rest ofthe class, and the IT representative then gave a presentationto the full class inviting all who were interested to partici-pate. A group of 33 participants emerged; as reported by the

IT representative, this group reflected a diverse cross-sectionof the second-year class.

The author (H.A.J.) informed the participants the natureof their participation during an orientation to the pilot pro-ject and emphasized their choice to discontinue participationat any time. Lunch and necessary software upgrades to com-puters running Mac OS X version 10.5 or higher (Apple Inc.,Cupertino, CA) at the time the only operating system sup-porting LINDSAY Presenter) were offered at the first andfinal pilot meetings, though participants did not know aboutthese potential benefits during the recruitment phase. The 33participants formed the focus group piloting LINDSAY Pre-senter software. The resulting group of participants wasmixed in both their use of computers with Mac OS X(63.7%) and Windows XP, Windows Vista, or Windows 7(Microsoft Corp., Redmond, WA) (36.3%) operating systems.At time of recruitment, participants were asked to describetheir expertise with technology, which was recorded on anExcel spreadsheet (Microsoft Corp., Redmond, WA) listingthe participants. Students varied in depth of self-proclaimedtechnological experience; observations made during thecourse of the study confirmed a range of novice, intermediate,and sophisticated computer users in the cohort.

Qualitative Case Study

Case studies are chosen when insight, discovery, and interpre-tation are of paramount concern: ‘‘the researcher aims touncover the interaction of significant factors characteristic ofthe phenomenon’’ (Leong et al., 2003). Students’ uses ofLINDSAY Presenter form a case study bounded by the three-week pilot experience with the software (Creswell, 2003; Yin,2003). A variety of data collection methods may be used incase studies (Merriam, 1998). Observation was used duringstudents’ orientation to software and as they demonstratedthe software in focus groups. Focus groups engaged semi-structured interviews to inquire about students’ experienceswith the software, and how LINDSAY Presenter supportedlearning. Field notes were made at orientation, in the finalfocus group, and throughout the three-week pilot as studentswould contact the researchers (H.A.J. and J.K.T.) for help.These three sources of qualitative data were triangulated andbuilt into themes. Triangulation of these data with surveydata is addressed in the section following the description ofthe survey instrument. Methods for software usability assess-ment, such as task analysis and observational analysis, werenot used because the goal was not to assess the usability ofthe software from an engineering perspective, but rather aqualitative look at how students were able to leverage thesoftware for learning anatomy.

Survey Instrument

A validated survey instrument, AIDA, (Ellaway et al., 2002,2003) was used to gather and analyze the impact of LIND-SAY Presenter in the undergraduate program of medical edu-cation at the University of Calgary. The survey asks partici-pants to rate the extent to which key factors are positive ornegative influencers on the experience of using the softwarein question. The key factors are pedagogy (extent of educa-tional impact), resources (amount of time, money, effortexpended or saved), interaction (changes in quantity andquality of communication and collaboration), freedom(changes in quantity and quality of autonomy and freedom of

22 Tworek et al.

expression), granularity (changes in the quantity and qualityof flexibility, detail, and variety), politics (change in the quan-tity and quality of your or someone else’s power and influ-ence), and distal (changes in the quantity and quality of exter-nal reputations, auditability, and accountability). Studentsrate these key factors on a scale ranging from no impact, fol-lowed by minor, limited, significant, and major impact. Thescale is applied twice, that participants are able to rate boththe positive and negative impacts; the relative value of theseimpacts is set by the participants as they respond to the sur-vey. The AIDA survey does not aim to quantify the impact;instead it aims to ascertain which key factors are seen by par-ticipants as most impactful in their use of educational soft-ware. The key factors used in the AIDA survey were devel-oped by the research by Ellaway (2005), who asked multiplestakeholders to evaluate educational software. The triangula-tion of her results across nine studies resulted in the key fac-tors used in the AIDA survey.

The survey was administered online, using the in-houseonline survey tool. Responses were anonymous. Student partici-pants were asked to complete the pre-survey on the same day itwas issued, whereas the post-survey had a two-week windowto account for the final examinations students were writing.

Data Collection and Analysis

Focus groups occurred on the first and final days of the pilot,where students completed the online, anonymous surveybefore the focus group session. The survey was distributed asa link sent by email. The first focus group was to introducethe software to students and work out technical softwareloading and navigation issues. Students then had three weeksto independently assess LINDSAY Presenter. This openrequest was deemed daunting or too vague to many partici-pants, and so they were asked to try to create a learningmodule they felt would make a useful tutorial for peers usingLINDSAY Presenter. This objective was assigned only to con-structively guide their exploration of the software features.On the final day of the pilot, students were debriefed as agroup using semi-structured interview questions. Survey andfocus group results were compiled and shared with adminis-trative stakeholders, before these were asked to respond tothe same survey. The stakeholders included LINDSAY man-agement team, eLearning team, finance team, programadministrative coordinators, and faculty involved in fre-quently teaching medical students.

Survey data were compiled and analyzed in Excel (Micro-soft Corp., Redmond, WA) by multiplying the quantitativescores by the relative weighting of the factors, then reportingthese as a function of the weighting. This follows the vali-dated methodology for this survey (Ellaway et al., 2002,2003). Open-ended survey questions and semi-structuredfocus group feedback were analyzed for themes, which weregrouped into categories defined by participants’ words.Finally, quantitative survey data were triangulated with quali-tative results to provide a synthesis of perspectives on LIND-SAY Presenter as a tool for learning. Final reported formswere reference checked with participants.

RESULTS

Quantitative Survey Results

Student survey return rate was 100 % (33/33) for the pre-pilot survey and 97% (32/33) for the post-pilot survey.

Weighted scores for each of six factors (pedagogy, resources,interaction, freedom, granularity, and distal) before and afterthe pilot are reported in Table 1. Positive and negativeimpacts of these six factors before the pilot are plotted in Fig-ure 2A. At the start of the pilot, interaction, granularity, andfreedom of the software were the three features that studentsfelt would have the strongest positive impact on their experi-ence. These were followed by pedagogy (e.g., educationaldesign, educational methods), distal factors (e.g., impact onlearning outcomes; impact on teaching methods; impact onreputation of the medical school), and resources (e.g., time,people, cost, etc., involved in building a module). Positiveand negative impacts of each of the same six factors at theend of the pilot are plotted in Figure 2B. At the end ofthe pilot, interaction, granularity, and freedom remained themost important positive factors for students. Pedagogy alsowas rated as having a relatively less negative role after thepilot, though arguably remained stable as a positive factorfor using LINDSAY software.

Survey return rate for other stakeholders was much lower,both before and after the pilot. Some abstained fromresponding, whereas others specifically notified us of theirinability to complete it, clearly stating that they did not havethe experience to assess the educational value of the software.Further, the data for those surveys that were returned are notconsidered reliable, because subsequent investigation revealedthat many of these respondents felt unable to accuratelyassess the software, but still provided responses rather thandeclining to participate. These views represent an importantdynamic in the curve of adoption. Although all adopters maybe supportive and tout the potential of the software for learn-ing, discernment is necessary in identifying the voices whocan effectively attest to actual impacts on learning. Possiblecontributing factors to this situation will be reviewed in theDiscussion.

Qualitative Results

Three major themes emerged from the analysis, which collec-tively paint a picture of the software as an exciting tool thatrequires further work before students will be able to appreci-ate its power for learning. These three themes are the quality

Table 1.

Weighted Pre- and Post-Pilot Scores for Each Factor Surveyed inthis Study

Factor Pre-pilot Post-pilot

Positive

impact

Negative

impact

Positive

impact

Negative

impact

Pedagogy 0.49 20.32 0.49 20.28

Resources 0.13 20.12 0.13 20.11

Interaction 1.05 20.64 1.00 20.54

Freedom 0.72 20.41 0.69 20.37

Granularity 1.05 20.65 0.98 20.57

Distal 0.17 20.09 0.15 20.10

Anatomical Sciences Education JANUARY/FEBRUARY 2013 23

of the anatomy presented; software as a detractor from learn-ing; and students’ expectations for learning.

Working with highly motivated healthcare professions stu-dents revealed the importance of the software functioningwith the same level of granularity students are expected toknow for assessments and practice. The level of detail pro-vided by LINDSAY was a key concern: ‘‘The program does agreat job at showing gross anatomy but cannot highlight spe-cific muscles once a model is constructed. This limits thelearning impact’’ (Student 2; Nov 21, 2011). Many otherresources are available for the macro aspects of anatomy, andso it was the students’ hope that LINDSAY Presenter wouldoffer detailed access to microanatomy and incorporate physi-ology: ‘‘It would be more helpful to learn some of the smallerparts and how they fit together (i.e., understanding the biliarytree more—and then showing the physiology of how itworks)’’ (Student 7; Nov 21, 2011).

According to the students, the key feature of LINDSAYsoftware was the ability to display manipulable, three-dimen-sional images of human anatomy: ‘‘The ability to move andchange the body as needed is one of its strongest assets; espe-cially as it is sometimes hard to change the orientation of thecadaver specimen in the lab’’ (Student 3; Nov 21, 2011). Thepower of these features though shares similar limitations toother media for anatomy learning: ‘‘I think having the LIND-SAY Presenter may run the same risk as replacing cadaver

specimen with textbooks, atlases or illustrations—you losethe variability that is natural within the human body’’ (Stu-dent 3; Nov 21, 2011). Students also felt that the softwarewas limited from providing detailed cross-sectional and surgi-cal views: ‘‘It might be helpful to see sections/cuts of organs.For instance; just seeing the outside of a pancreas isn’t thatimportant; seeing where the bile ducts pass through the inte-rior or seeing the islet cells might be more important from aclinical/pathophysiology perspective’’ (Student 12; Nov 21,2011).

Inherent in these comments is students’ parallel demon-stration of a growing depth of understanding of their profes-sion. Students expect the software to be as mature andaligned with the required and demonstrated integrated formsof their domain of practice (e.g., health care of patients). Thisfinding may challenge some faculty members’ assumptionsabout how anatomy teaching should be focused on anatomi-cal basics and naming. The experiences with LINDSAY Pre-senter demonstrates that learners are acquiring and demon-strating a much more comprehensive picture of how anatomyintegrates into their future context of professional practice,which is in alignment with the growing trend of integratinganatomy teaching into the curriculum (McKeown et al.,2003; Zumwalt et al., 2007).

Software as a Detractor from Learning

The steep learning curve of the software demonstrated thatnot all students possess comfort and facility with the digital:‘‘I found the LINDSAY presenter difficult to use. I appreciatewhat it could be; but this was not my experience with it. I’mnot sure if I’m just inept; but the help window couldn’t helpme either. I could not get the Presenter to group differentorgans together; nor rotate together. This made it difficult tocreate the presentations that I wanted; which made me frus-trated; and detracted from the usefulness of the Presenter asa learning tool’’ (Student 5; Nov 22, 2011).

This was supplemented by the author’s (H.A.J.) observa-tions at the orientation session, where it took much longerfor students to learn to use the tool than anticipated. Thelabor-intensive nature of creating presentations or modules inLINDSAY was a critical juncture for adoption: ‘‘It is difficultfor us as students to create our own learning material becauseof the time needed to put into it. I believe it would be ofmost value if created by lecturers to use in lectures or to useit to create supplementary material for anatomy teaching inthe courses’’ (Student 3; Nov 22, 2011).

The resource demands of LINDSAY module creation didnot dissipate across the five-week pilot experience: ‘‘it takestime to build and create good programs’’ (Student 8; Nov 22,2011). The role of the student primarily focuses on learningand not the creation of materials; however, by participating inthe LINDSAY pilot, the students seemed to have gained anappreciation for quality learning as opposed to superficial usesof the software. Although the time to create modules is a nega-tive factor, a consequence of participation in the LINDSAYpilot is students are learning the preparation skills needed to bequality instructors. Teaching skills are often not taught in pro-fessional preparatory programs, even though these skills areexpected in subsequent phases of training (AFMC, 2010).

Students’ Expectations for Learning

Students expected that they could customize their learningexperience. Being able to customize learning meant to focus

Figure 2.

Plots of weighted positive and negative scores for six factors, surveyed bothbefore (graph A) and after (graph B) completion of the three-week pilot. Posi-tive impact indicated by blue bars, negative impact indicated by red bars.

24 Tworek et al.

LINDSAY use on the specific areas where students felt theyneeded to self-remediate. ‘‘I liked how I could customize myown learning; e.g. [sic] focus on areas that were unclear;delving into more detail...’’(Student 19; Nov 22, 2011). Theattractiveness of customization may reflect students’ personalmedia experiences. Prosumerism (Toffler, 1989), or, the abilityto produce one’s own media experiences for one’s own andothers’ consumption, is a predominant feature of contempo-rary digital media. From an educational perspective, students’requests for the software to support flexibility and customiza-tion is encouraging when viewed as an enabler of self-reme-diation. There is a movement within medical education forstudents to engage in self-directed learning. For LINDSAYsoftware, self-remediation may mean either the student bothcreates and uses the LINDSAY modules or more simply takesthe initiative to use pre-created modules: ‘‘I think that theLINDSAY Presenter would be best made as a program thatcan allow students to self-test themselves (where these self-tests can be made by staff or the students themselves andshared among the class)’’ (Student 1; Nov 21, 2011).

Despite this exciting ability to customize learning, studentsexpect the software to be in a ‘‘player’’ mode rather than a‘‘creator’’ mode. This goes against the intention of a manipu-lable software package where students could co-constructlearning: ‘‘As it stands now, LINDSAY is not an effective useof my time when it comes to studying. If pre-made moduleswere available to work through, then it would be very help-ful.’’ (Student 8; Nov 21, 2011). In addition, ‘‘Having a set ofLINDSAY tutorials might help provide a more "direct" andefficient way to learn the basics’’ (Student 10, Nov 21, 2011).Faculty and students should challenge what expertise devel-opment happens in learning experiences that are focused onknowledge-level outcomes. Dense and time-pressed curriculain the health professions education might constrain our viewsto ‘‘just getting the basics’’. Students held concerns aboutadding material to an already intense curriculum; the possi-bility that the software would discourage students fromattending laboratory sessions; and, that the existence of otherstudy options might reduce student buy-in. Despite these con-cerns, the overall sentiment towards LINDSAY is positive:‘‘Because LINDSAY Presenter is an additional tool to learnanatomy, I feel like it will have absolutely no negative impacton my learning; in fact; it might help foster learning fromhome rather than in the anatomy lab. However; this wouldbe one of my worries of the LINDSAY Presenter; as I do notthink that it should be used as a replacement or excuse notto go to the anatomy lab. If it is clear that the LINDSAYPresenter is a compliment to all other resources; then I feellike it will be a phenomenal addition to the University ofCalgary program’’ (Student 1; Nov 21, 2011).

Triangulation

Three key themes emerge across the qualitative and quantita-tive analysis: interaction, granularity, and freedom. Studentsexpect that these factors will have the most substantialimpact on their educational experience.

Interaction. Interaction was rated as having the strongestimpact both before and after the pilot, and this outcome isqualified by students’ reporting of both the value of engagingand interactive materials, while noting significant time invest-ment and difficulty in creating such learning objects.Although students are excited by the interactive potential,they are hesitant to invest their time to achieve this type of

interaction. In addition, several PC users reported additionalbarriers related to familiarity with the Apple/Mac OS plat-form, indicating that although interaction is important, fac-tors external to the software studied here do impact experien-ces and perception of the software.

Granularity. Granularity was rated as having the secondstrongest impact before and after the pilot. This outcome isqualified by numerous comments about the detail included inthe model set. Some students reported that the level of detailpresent in the anatomical system in which they were inter-ested met or exceeded their expectations, whereas othersreported a lack of detail in their system of interest. It wasclear that meeting certain minimum content standards isrequired, and that students expect that tools meant to beadditional resources will provide at least as much, if notmore, detail than is contained in core resources. Further, stu-dents were excited by the prospect of flexibility in the soft-ware, but as discussed above were in many cases unwilling toinvest the amount of time and effort required to create suchflexible learning objects.

Freedom. Freedom was also rated as having a strongimpact both before and after the pilot. Students expressedkeen interest in self-directed learning, provided that self-test-ing materials were provided to them beforehand. Customiza-tion of the software was also important, and followingreporting of bugs and broken features, students suggest anumber of feature upgrades, many of which are related toincreasing customizability of the software.

DISCUSSION

The pressures on post-secondary anatomy teaching are similarto broad issues in education (Rowan et al., 2009; Christensenand Eyring, 2011). Our institutions and programs are in anera of change, and there are exciting opportunities for thedirections of our courses and curricula. As faculty, we mayrecognize that the ways in which we were taught do not rep-resent the full spectrum of pedagogical options; we shouldnot respond to the digital for the sake of the digital; however,we should challenge our ways of teaching to use the digitalas a reason to thoughtfully consider how to achieve the bestlearning in our students (Jonassen, 2006; Mayer, 2005).

Software Remains the Focus

Both pre- and post-findings show the students remain focusedon what the software should and can do in terms of detail,customization, and personal manipulation of content. Despitethe changes made to improve the software, and that studentsbecame more accustomed to its use, students rarely relayedthe ways in which LINDSAY Presenter had a productiveimpact on their conceptualization and integration of anatomy.This finding reflects themes elsewhere in the digital educationliterature showing that initial acquisition of the technology isa barrier to learning with the tool (Jan and Jan, 2000;Ardichvili, 2008; Guldberg and Mackness, 2009). This resultis anticipated with a new software product, yet simultane-ously illustrates the importance of giving sufficient time towork out issues with, and orientation to, the software. Jump-ing directly to studying the educational impact in the firstimplementation might be too premature to contribute mean-ingful results to the digital anatomy teaching literature. Thecorollary argument is that the methods by which we examine

Anatomical Sciences Education JANUARY/FEBRUARY 2013 25

learning with digital media need to be carefully designed suchthat we are truly measuring learning and not satisfactionwith software.

Participants noted the value of the software for learningby comparing this to the existing tools they engage for anat-omy learning, such as textbooks and videos. Comparisons tofamiliar but established media like textbooks and videos,over newer digital tools more comparable to LINDSAY Pre-senter, may be like comparing apples and oranges, but isexpected given what media are readily available in students’sphere of influence and affordability. Requests for completedLINDSAY modules reflect the familiarity with producedforms of anatomy teaching for immediate consumption.Although twenty-first century pedagogy may espouse thevalue of creating one’s own learning (P21, 2011), instruc-tional design is either too time consuming an activity toundertake, or conceptually distant from the typical activitiesstudents think about as part of learning. As education shiftsto more participatory frames of engagement (Jenkins, 2009),students and faculty may need to reorganize around what itmeans to actively co-create knowledge.

Quality Education with DigitalTools Takes Time

Faculty contributions to digital anatomy teaching remaintime intensive but necessary. Students clearly expect the indi-vidualized feedback that comes from being able to approachfaculty with questions, requests for tutorials, and check-inabout their conceptualization of the material. In the digitalrealm, it is possible to package some (but not all) of these ele-ments as self-quizzes and embedded feedback. Programmingsuch elements with reasonable fidelity also takes time, insight,and skills in pedagogical design. If the future of anatomyteaching is in the digital realm, the systems of tenure andcompensation must account for the different forms and dura-tions of preparation that faculty must invest to make them-selves, the students, and the curricular program successful(Moore, 2007).

Evaluation Results and Influencing Voices

All stakeholders have been LINDSAY software enthusiasts,though many of these same people struggle with identifyingthe true educational impact of technology-enabled learning.The voices who design and fund such projects may be able toestimate the qualitative value of the software, without neces-sarily understanding how digital tools specifically improvelearning. Even among anatomists, the effectiveness of differ-ent methods of anatomy teaching are still being determined(McLachlan and Patten, 2006; Hilbelink, 2009). Excitementover new technologies for anatomy needs to be temperedwith clear understanding of what types of learning may besupported (e.g., knowledge, comprehension, application ortransfer), and how these constructively support future appli-cation and integration into professional practice (Fruhstorferet al., 2011; Kerby et al., 2011; Richardson et al., 2011).This is not a call to limit the exploration of digital anatomyteaching, but rather a caution for thoughtful approachesfocused on learning outcomes rather than measures of satis-faction.

We were initially concerned that the students who partici-pated in the pilot may feel unspoken political pressure to con-form to the excitement of their administrative leadership.

Review of their comments and the general sense of their sin-cerity at the focus group sessions gave us confidence that stu-dents were not performing to an expected conformity, butrather providing an honest assessment. The open posture theLINDSAY developers have toward feedback helps receive andincorporate the constructive criticisms. Clear and forthrightcommunication is key to the successful evolution of the soft-ware. If the ultimate goal is learning, research and develop-ment must work in concert.

Limitations

The evaluators are proximal to the project, which threatensreliability and validity of the findings. External validity wasimproved by using a validated survey instrument. Severalsteps were taken to increase internal validity: following themethods for the validated survey instrument, pattern match-ing, and explanation building in the qualitative analysis, andconfirming the findings with participants. A clear methodol-ogy was followed to increase the reliability of the qualitativeanalysis (e.g., case study protocol) and triangulation of thefindings.

Arguably, the results may be questioned as relating toimmature software. The software has been co-developed withusers and subject matter experts over two years. Early pilotswith individual stakeholder groups (e.g., faculty, student ITleads, administrators) declared LINDSAY software as readyfor learning and education in the health sciences professions.The present five-week pilot revealed deeper expectationsabout digital tools for learning than previous assessmentsfocused on feature sets provided. The authors would empha-size to digital projects at other schools the importance of fo-cusing on the actual types of learning (e.g., knowledge acqui-sition, comprehension, application or transfer to new con-texts) expected when considering the development of thesoftware.

The work is limited by not exploring an implementedcycle of education with LINDSAY Presenter. Further work isneeded to evaluate what learning is enabled when using thesoftware, particularly as different assets (e.g., tutorials, mod-ules, quizzes, etc) are produced for specific teaching purposes.The full trajectory of how digital anatomy tools might bene-fit, as well as detract from, learning is useful feedback for thelarger community of anatomy educators.

CONCLUSION

In recognizing the myriad factors influencing the success oftechnology-enabled learning, we come collectively closer toappreciating what learning with technology is, as opposed towhat we really hope it might be. Given the preponderance ofdigital media initiatives for anatomy, the lessons learned withLINDSAY Presenter provide timely insights into the chal-lenges and opportunities to make other technology-enabledlearning projects successful. If digital anatomy teaching is totruly transform practice, we need to consider the variousforms in which technology enables learning, in addition tothe pedagogical approaches in which we must become versedto make us and our students successful. The pressures onpost-secondary anatomy teaching are similar to broad issuesin education. We are in an era of change, and there areexciting opportunities for the directions of our courses andcurricula. We may recognize that the ways in which we were

26 Tworek et al.

taught do not represent the full spectrum of pedagogicaloptions. We should not respond to the digital for the sake ofthe digital, however. Rather, we should challenge our ways ofteaching to use the digital as a reason to thoughtfully con-sider how to achieve the best learning in our students.

NOTES ON CONTRIBUTORS

JANET TWOREK, Ph.D., is former manager of e-learning inthe Office of Undergraduate Medical Education and hasrecently successfully defended her PhD thesis on educationaltechnology for health sciences education in the Faculty ofEducation at the University of Calgary, Calgary, Alberta,Canada.

HEATHER JAMNICZKY, Ph.D., is an assistant professorin the Department of Cell Biology and Anatomy in the Fac-ulty of Medicine, University of Calgary, Calgary, Alberta,Canada. She teaches gross anatomy to undergraduate medicaland bachelor of health sciences students, and her researchinterests lie in interactive, inquiry-based basic science educa-tion.

CHRISTIAN JACOB, Ph.D., is a professor in the Depart-ments of Computer Science and Biochemistry and MolecularBiology in the Faculty of Medicine, University of Calgary,Calgary, Alberta, Canada. He is Director of Bioinformaticsand LINDSAY Virtual Human Project. He teaches evolution-ary computing to undergraduate and graduate students, andhis research interests lie in agent-based modeling of biologicalsystems.

BENEDIKT HALLGRIMSSON, Ph.D., is a professor inthe Department of Cell Biology and Anatomy and Senior As-sociate Dean of Education in the Faculty of Medicine, Univer-sity of Calgary, Calgary, Alberta, Canada. He teaches grossanatomy to undergraduate students and his research interestslie in the development and evolution of craniofacial malfor-mations.

BRUCE WRIGHT, M.D., is an associate professor in theDepartment of Family Medicine in the Faculty of Medicineand Associate Dean for Undergraduate Medical Education atthe University of Calgary, Calgary, Alberta, Canada. Heteaches physical examination and physicianship to undergrad-uate medical students.

ACKNOWLEDGMENTS

The authors thank the LINDSAY development team fortheir dedication, receptiveness, and demonstrated ingenuity inproblem solving throughout the iterative cycles of development.

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