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Background: At Manchester Medical School, students enter the clinical environment having received only limited teaching of cardiovascular examination. This is delivered during a 1-h lecture and 1 h of clinical teaching. I thought this was an insufficient amount of teaching and decided to try and rectify this issue. Six months into year 1 of clinical teaching, the students complete a 4-week Personal Excellence Pathway project, which is designed to help students explore areas of interest to them. To rectify the perceived lack of teaching, I created an interactive iBook that demonstrates in a detailed way how to examine a patient's cardiovascular system. Methods: The iBook was created using iBooks Author, a free Apple product. It is interactive and easy to use. I built it using free editing software such as iMovie and iPhoto. Full explanations and demonstrations of the examination itself and of the signs elicited were created using video, audio, clinical images, and links to a glossary. This core content was acquired by spending time in clinics, filming a consultant performing the examination, and acquiring images of clinical features on the wards. Results: Overall, given the breadth and depth of the subject covered, the iBook took less time to create than I had expected. Recording the video contents took far less time than expected. Obtaining the clinical images for the relevant signs took longer than expected. Conclusions: Many students now use iPads and Apple laptops as an integral part of their work. The creation of such an interactive iBook that is interesting and widely accessible by the students can be very beneficial to the medical student population. In this 4-week project, I showed that it is possible for a student to create an innovative learning tool in a short amount of time that can enrich the education of fellow students at medical school. Introduction In their third year of study, students at Manchester Medical School (MMS) begin their clinical education at one of the school's four base hospitals. They join their hospital with almost no clinical teaching or experience in examining patients. Students at the University Hospital of South Manchester (UHSM) begin their clinical years with "An Introduction to Clinical Learning" (ICL), a 3-week module of lectures and practicals. The module is designed to orientate students to the clinical environment and the basic clinical skills that can be used on the ward . As part of the ICL module, students attend a series of lectures and clinical skills sessions aimed at teaching and then rehearsing the examination skills required in their first clinical year. The lecture for each clinical examination was 1 h long; each was then followed by an hour-long practical session. This practical session was delivered by two foundation-year doctors to a group of five students. From my perspective, there was insufficient opportunity for preparation prior to the practical session. After the session, there was no proper time for consolidation; the student's next exposure was on placement, up to 6 months later and possibly with their consultant. Once on placement, they receive very little standardised teaching; each consultant has his or her own examination method and they will allocate varying amounts of time to teaching. Obviously, the potential exists for disparity and unevenness in teaching between groups. For this reason, I decided to create an educational resource that could be used by all at MMS, that could be distributed easily and that could also be clinically useful. The aim was to help standardise the teaching of clinical skills at UHSM. I chose to create an iBook detailing how to perform a cardiovascular examination. The iBook format was chosen because all MMS students are provided with iPads. The iBook could be easily distributed amongst the student body. The iBook format also provides advantages due to its portability, with students able to view iBooks "on the go" , a useful asset *Corresponding author: William Melton, Manchester Medical School, 263 Burton Road, West Didsbury, Manchester M20 2WA, UK, E-mail: email@example.com 122Melton: Student creation of an iBook aimed at fellow medical students in the medical student's busy schedule. Nguyen et al.  discuss how mobile learning, such as that provided by iBooks, can lead to access to education in a "flexible and seamless manner, available in any time and any place, which substantially enhances their learning experience". Students using the iBooks are also able to search within the book, seen by students as a major advantage over normal textbooks . My iBook is called "Cardiovascular Examination". The aim of this paper is to explain how I managed to create this iBook, in the 4 weeks available during a Personal Experience Pathway at MMS. This paper is neither an advertisement for me nor for Apple products; it is a description of how I went about creating the iBook. This paper does not include the specifics to help the reader create an iBook from scratch; these can be found in iBook Author manuals. The paper will include my personal experience of creating an iBook aimed at medical students and junior doctors. It will cover the key parts of the creation of the iBook, its publication, and finally some problems encountered in its creation. Hopefully, the paper will show that it is possible for students to create useful and relevant educational resources with limited staff involvement and very little prior experience. their ideal way for someone to present a case back to them. Objective Structured Clinical Examination (OSCE) checklist: revision checklist in the final chapter of the iBook. Glossary: the individual signs mentioned in the text are linked to the glossary where a small description, images of the signs, and an explanation of their causes can be found. Text The text for the iBook was written straight into the iBooks creation software using the following sources: Knowledge gained during placement: during placement, I was taught how to perform a cardiovascular examination by a number of consultants; this varied teaching was used to create the majority of the text. MMS examination instructions: instructions provided by MMS were used to ensure that the iBook stayed within the medical school's approved examination structure. Clinical skills textbooks and online resources: these resources were used when the content required more detail. Consultant knowledge: the final source of information was cardiology consultants at the hospital. These were very useful for when certain elements of the examination were difficult for a student to understand or explain. iBook creation method The iBook format was chosen because all students at MMS are provided with iPads at the start of their clinical years; this makes the iBook easy to distribute via the iBooks Store and can be used by all of the Medical School. This choice was made easier by the software, iBooks Author, that Apple has created and gives away for free to potential authors. This software was chosen as it enables a novice user to easily create and publish iBooks for the Apple iBooks Store to be used on iPads and Apple computers . In order to make the iBook stimulating and relevant to the clinical environment, a number of features are included to supplement the plain text: Video: there are numerous video recordings of consultants performing and explaining the detailed parts of the examination on a simulated patient and some videos of cardiological signs in real patients. Images: a large number of pictures illustrate some of the signs that may be identified on cardiovascular examination. Audio: originally intended to be used for examples of murmurs, but also used for consultants to describe Video Listed below are the necessary steps to create the video content: Identify the elements of the examination that require filming: the whole examination was filmed in one take; areas of the examination where medical students usually struggle were then identified by the consultant, and these were filmed separately in more detail. Arrange for a volunteer patient, a consultant, a free room, and the video equipment required (video camera, microphone, and camera stand). Film each individual element separately; where a real patient with classic signs is needed, then patients in clinics can be used. Each individual being filmed requires a separate consent form, depending on individual hospital policies. Melton: Student creation of an iBook aimed at fellow medical students123 Each recording needs to be individually edited using iMovie. Transitions were added at the beginning and end, and any white noise that could be heard in the background was erased. The videos can then be imported into the iBooks creation software. numerous websites that can aid an author with the creation of such widgets. I created the checklist with the help of the website bookry.com ; this website is free to use provided you import the widget with their logo. Glossary When writing the text for the iBook, it is important to link important findings through to the glossary. This will help the reader understand what may be found and provide examples of these findings. With text linked to the glossary, the student can see small elements from the glossary within the text, allowing easy referencing to help explain the text. Where necessary, the student can access the full glossary including pictures and references to further information. Images The necessary images can be acquired by spending time in the clinics and on the wards. Clinicians on the wards and in clinics can help to identify patients who had useful signs. It is then necessary to speak to these patients and assess them to ensure that their signs are easy to photograph and identify later. Their permission and a signed consent form are required before taking the relevant photographs. Again, it is important that each patient's images are accompanied by a consent form, again depending on the specific hospital policies. The most important images to find are of the common findings on examination such as scars from previous surgeries. When taking the images, it is important to ensure that the eventual reader will not be distracted by the background of the image and that the relevant signs are prominent within the image. The images in fact required very little editing. Any minor editing required was done using iPhoto, another free piece of software provided by Apple. This was used to increase the contrast slightly on some images so as to accentuate the findings, and also to crop the images to the right size for the iBook. Importing the images into the iBook using the iBooks creation software is straightforward; the images can then be placed in the text if required or in the glossary. Results Text The text is the key part of the iBook as it forms the basis for explaining how to perform the examination (Figure 1). Without clear and concise text, the iBook would not be useful as an instructive piece and would quickly lose the reader's attention. The text must also be easily understood by students from an early stage in their clinical education; for this reason, technical jargon was kept to a minimum. Writing the text for the iBook required around 24 h of research and writing; this required only limited previous knowledge, use of medical textbooks, and Internet resources. Video Audio The audio was recorded using a camera microphone and edited to remove background noise. Removal of the background noise was done using video editing software; the audio file was then imported into the iBooks creation software. A transcript of the audio was also provided for the reader. The use of video in the iBook is very important as demonstrating how to perform a cardiovascular examination is just as important as its description. For this reason, it is essential that the video is accurate (Figure 2). Filming the video sequences required 2 h during a normal working day; organising that time to fit with the consultant, the volunteer, and the author required substantial planning. Further editing of the video then required more time approximately 5 h for the video used in the iBook. It is important to remember that the resolution of the video used will have a substantial effect on the size of the iBook overall. For this reason, I would recommend using the medium resolution when exporting the video on the video editing software. Some hospitals may have an OSCE checklist The checklist is created outside of the iBooks creation software as a widget that can then be imported. There are 124Melton: Student creation of an iBook aimed at fellow medical students Figure 1:Example of the text describing how to perform the cardiovascular examination in the iBook. Figure 2:Example of videos integrated into the text showing how to perform a cardiovascular examination. Melton: Student creation of an iBook aimed at fellow medical students125 Figure 3:Examples of pictures integrated into the text to exemplify the clinical findings on examination. illustrations department that has the technical skills necessary to film and edit the videos and may be prepared to provide assistance. Images Images are another key element of the iBook. They can be used to demonstrate the key clinical signs and findings important in examination (Figure 3). The most easily acquired images are of permanent findings such as scars from previous surgery, and the common signs such as clubbing and tar staining. Finding the appropriate images required a large commitment to spending time in clinics and visiting the wards; for this, I attended clinics throughout the 4 weeks to find the clinical images. Therefore, it is important to start doing this early as an important clinical feature could disappear or the opportunity to photograph the patient before departure may be lost. However, this later proved to be impossible to carry out, as I was unable to find the equipment necessary to record the murmurs. In order to provide a way for students to experience the murmurs, a link was included in the text to an app that can provide the audio for common murmurs. Audio was also used later in the iBook. At the end of examinations, students are expected to present their findings back to their supervisor. This is challenging for all students. To facilitate this, a section was included where consultants detailed their view of the ideal way for students to present their findings. In this section, three consultants discussed how to present findings in three different situations: acute presentation, in-patient case, and out-patient case. The consultants then gave an example of the ideal patient presentation for each. OSCE checklist The OSCE checklist was included as a revision aid for the medical students who would be using the iBook as a revision aid (Figure 4). The checklist is an interactive tickbox exercise in which the students can mark each other against the Manchester standard. This widget required 2 h to create, but more complicated widgets could require Audio Originally, I intended for audio to be used in the iBook as an example of the common murmurs found on examination. 126Melton: Student creation of an iBook aimed at fellow medical students Figure 4:Example of the OSCE checklist widget.On the left side is the appearance as a closed widget in the book; on the right side is the appearance as an open widget. more investment of both time and money. The checklist is based on a similar one provided by MMS; this ensures that the students are able to test themselves to the standard required by the OSCEs. Discussion Certification for student education In order for the iBook to be considered for inclusion in the Manchester Medical Curriculum as an endorsed educational text, the iBook required validation by two cardiology consultants. This policy may change between universities and is obviously not a factor to consider if the book is not being created for university use. This aspect of the project was very demanding in terms of time, as both consultants were very busy and the demand on their time was significant. Nevertheless, it is essential to fact-check Glossary The glossary is a very useful part of any iBook and is separate but linked into the text. In this iBook, the glossary is used to explain and clarify the clinical findings from examination (Figure 5). In the glossary, the clinical findings are described, their main causes detailed, and in some cases pictures are used to illustrate these findings. Figure 5:Examples of the glossary.On the left is the glossary integrated into the text. On the right is an example of the stand-alone glossary. Melton: Student creation of an iBook aimed at fellow medical students127 the work and where necessary provide references for the information. Publication Once the iBook is complete, a few more steps are required before it can be downloaded from the iBooks Store. This may take a week or more, but much of this time is taken up waiting for Apple to approve the iBook for sale. These steps are unnecessary if the iBook is not going on the iBooks store. Preview your book on iPad: ensure there are no errors and that the format is correct. Submit the iBook to iBook Store: this requires setting up an account with iTunes Connect, downloading and installing iTunes Producer, providing a sample book, and completing a contract with Apple. Choose between a Paid and Free account: this part is done when setting up an account with iTunes Connect; paid accounts require more time to set up but allow the iBook to be sold. Create a sample book and cover art: this will then be packaged up using iTunes Producer, which will then upload the iBook to the iBook Store. Add the metadata: the requirements are different for paid and free iBooks but the general details required, such as title, author, and book description, apply to both. Creating the cover design: this is necessary for the iBooks store and for it to be appealing to people wanting to download the iBook. This required expertise in design and software that I did not possess; a fellow student was asked to help design the cover art. Should the iBook be available on other platforms? by creating the iBook on iBooks Author, it becomes harder to convert the iBook so it can be read on a separate platform. Therefore, if the author wants the iBook to be able to be read on a non-Apple device, then it cannot be created on this specific iBook creation software. Whether or not the iBook should be free: by marketing the iBook as free, it appeals to students more than if the book cost money. By publishing the iBook as a paid-for item, this brings up more issues with the iBook's publication. Consider purchasing an instructional handbook: this could save significant time for the author as it avoids making mistakes and can show the quickest and easiest ways to create an iBook. Controlling the distribution of the iBook: by uploading the iBook to the iBook Store, the distribution becomes easy to control; otherwise, the file can be passed around easily. Uploading the iBook also enables the author to keep track of the number of downloads and receive reviews from readers. Issues to consider While creating the iBook, I came across some issues regarding the creation of content and the later publication of the finished work. These are only the major problems that I faced in the production of the iBook and may not occur in the production of others. However, each author may face his or her own issues. Finding and creating the interactive content: one of the biggest issues faced in creating the iBook was finding some of the content required as examples in the iBook. Photos of clinical signs were particularly difficult to find, leading to some being left out of the iBook. Size of video content: the videos created for the iBook to help describe the methods of examination can be very long and therefore use a lot of space on both the computer used for editing and the iBook itself. This can be minimised by converting the videos to a lower quality on the editing software; this has to be a compromise between video quality and file size. Limitations There are limitations inherent in using iBooks Author and the Apple products, some of which have been discussed above in the "Issues to consider" section. A major limitation is the requirement to own an Apple computer to run the iBooks Author software, and this may deter many potential iBook authors who do not have access to Apple computers. A second major limitation is the requirement of the student users to own an iPad or Apple computer to read the iBook; at MMS, this is circumvented by providing all students with iPads. At other institutions, the necessity of owning an iPad or Apple computer raises ethical issues of discrimination and equality regarding uneven distribution of educational content . Limitations are also present in the creation of content such as the requirement for specialists to demonstrate the examinations and read over the iBook for validity. Creation of content is also limited by the availability of the hardware, such as cameras and video cameras, and the editing software required. 128Melton: Student creation of an iBook aimed at fellow medical students Future plans So far the iBook has been downloaded a hundred times from the iTunes store from five different continents. This is fewer than expected, but this may reflect the size of the iBook and a lack of marketing. In order to increase the knowledge of the iBook, free adverts in student publications are being looked at. From conversations with younger medical students at UHSM, I have found that they use the iBook as a reference guide during problem-based learning (PBL) sessions, on the wards to guide their examinations, and as a revision aid prior to OSCEs. I hope that the iBook will continue to form part of the curriculum at MMS and that students will continue to download the iBook. In the future, I plan to update the iBook as I obtain more clinical images and as errors are reported. I also plan to write two further iBooks detailing how to perform a respiratory examination and an abdominal examination. It would be interesting to see if the introduction of the iBook into the curriculum has led to any significant changes in both student satisfaction with clinical skills teaching at MMS and a change in OSCE marks for cardiovascular examination. These were the two areas in which I originally set out to make a difference. A study by Sloan in 2008  has shown that the use of eTextbooks (a format this iBook is part of) and iPads do not have a negative impact on students' grades and may, in fact, have a positive impact. It would also be interesting to research how the iBook is being used by medical students; currently, the only information I have is gleaned from informal conversations with fellow students. its specific parts and the photographing of clinical signs. Certification and subsequent publication can also require a large amount of time and were not included in the 4-week time frame of my project. These parts, however, can be ignored if they are not required. iBooks Author is a useful and intuitive piece of software that makes creating an iBook a simple process; however, thought should be given to publishing and the platform you want the iBook to be used on. There are a number of issues that warrant consideration before publication that have also been discussed. The issues detailed are in no way an exhaustive list, and different issues may be found when creating another iBook. In conclusion, educational iBooks can be created by both students and staff in a 4-week project block with very little prior knowledge and experience. There are numerous applications, both free and paid-for, which can help make the iBook look professional and be educational. Author contributions: The author has accepted responsibility for the entire content of the submitted manuscript and approved submission. There is no conflict of interest involved in the creation of this article. This article is not an advertisement for the iBook nor for other for Apple products; it is a description of how I went about creating the iBook. Research funding: None declared. Employment or leadership: None declared. Honorarium: None declared. Competing interests: The funding organisation(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication. Conclusions I intended to create the iBook as a way to rectify a perceived lack of standardised teaching at the hospital and medical school where I was based. I think that the iBook has gone some way towards standardising the provision of teaching at MMS, but uptake has been limited and whether it remains as part of the curriculum remains to be seen. During the 4-week project, I wrote the main content, filmed a consultant performing the examination, photographed the relevant clinical findings, and recorded consultants describing their ideal way of presenting a case back. After the 4-week project, the iBook was validated by two consultants and then published on the iBooks Store. Content creation for the iBook includes both normal and interactive content. The main substance of the iBook should be the text, but the most time-consuming part of creating the iBook is the filming of the examination and
Bio-Algorithms and Med-Systems – de Gruyter
Published: Jun 15, 2015
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