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Top1. Introduction
Multimedia applications have proven popular options in delivering education where the integration of different forms of media offer a structured approach to understanding the procedural tasks and decision points in practicing surgery (Luker, Sullivan, Peyre, Sherman, & Grunwald, 2008). Whilst evidence suggests that e-learning, for example in the form of interactive CD-ROMs can benefit surgical education (Baskin et al., 2008), the challenges in delivering this specialised learning material in an electronic format at both the undergraduate level and for continuous medical education/professional development remain (Cosman, Hemli, Ellis, & Hugh, 2007; Gold, Verrier, Olinger, & Orringer, 2002). E-learning comprises of two dimensions - interface design and learning that present specific challenges for delivering training. In terms of interface design, a key challenge in creating educational software is in presenting the appropriate scope and level of material that will engage learners without distracting their attention from the relevant items of training information (Ardito et al., 2006; Spires & Preece, 1999). With respect to learning, a key challenge is in the provision of high fidelity demonstrations of surgical procedures and equipment use to allow purposeful practice of surgical skills and attain some degree of feedback on performance for the different types of surgical learning tasks (Khan, Widdowson, & Tiernan, 2004).
Effective educational software seeks to integrate different multimedia formats such as video clips, graphics, animations and audio to provide an interactive and engaging learning experience. However, it has been long been established that poor usability of educational software can be detrimental to learning performance (Megali, Tonet, Dario, Vascellari, & Marcacci, 2005; Parlangeli, Marchigiani, & Bagnara, 1999). Difficulties in learning surgical techniques through multimedia training can arise not because of the learning material itself, but because of inappropriate media formats. For example, a simple animation of the way a surgical tool is used might be more effective than an actual video clip. But a video clip could provide more contextual and realistic detail about a surgical tool compared to graphics, animation or photographs. Design issues have therefore been related to the appropriate selection and organisation of multimedia so that they do not cognitively overload learners (Grunwald & Corsbie-Massay, 2006). However, evaluations of these multimedia training applications are limited, particularly within the surgical training domain, where existing design guidelines do not necessarily accommodate even basic surgical learning demands (Haluck, 2005).
Evaluations of multimedia training are important in understanding the design considerations particularly within the context of surgical education where the growth of the Internet promises increasingly multimedia rich programs (Larvin, 2009; Rissucci et al., 2008). CD-ROMs are being converted to a web-based format or delivered using CD/Web hybrid products (Gold, Begg, Fullerton, & Mathiesen, 2004) and Web 2.0 technologies have facilitated the sharing of educational content (Boulos & Wheeler, 2007), particularly in the use of wikis such as WikiSurgery (www.wikisurgery.com) (Agha, 2006). Given that research has shown that multimedia based surgical training can be flexible enough to adapt to the individual needs of the user with different levels of experience and associated demands for learning (Friedl et al., 2006), it is important to understand the features that support this mode of learning in order to optimise the use of surgical teaching software and inform the development of new computer-assisted curricula. This study uses a multimedia interactive training CD-ROM as a case to examine the interface design and learning process features and their interrelationships and in so doing overcomes many of the problems associated with web-based delivery of education such as bandwidth limitations, loading delays and video streaming in restricted sites.