Article Text

Download PDFPDF

Reconceptualising notes and handouts for the 21st century class
  1. Morkos Iskander1,2
  1. 1 School of Surgery, Health Education North West, England, UK
  2. 2 Department of Educational Research, Faculty of Social Sciences, Lancaster University, Lancaster, UK
  1. Correspondence to Dr Morkos Iskander, Department of Urology, Whiston Hospital, England L35 5DR, UK; morkos.iskander{at}

Statistics from

It has become a common part of undergraduate medical training to include case-based and problem-based learning as a way to advance students’ understanding and encourage the application of knowledge, with the overall goal of achieving a higher level of clinical ability.1 These usually involve the examination of a stylised and simplified clinical scenarios, allowing the students to explore a disease process, while being guided through the key points on the curriculum. At my institution, in common with others, these sessions are conducted in groups, with the discussion facilitated by a senior clinician. This approach has been demonstrated to be advantageous in promoting effective clinical reasoning.2

When facilitating such sessions, it is my usual practice to provide diagrammatic representations as an additional explanation of decision trees, diagnostic pathways or points of surgical anatomy. The use of additional materials has been suggested as a beneficial adjunct to text-based description and discussion.3 4 For practical purposes, these diagrams are either on a flip chart or on a whiteboard, making them visible to the whole group. Commonly, several students are seen copying these diagrams into their own notes and adding their own annotations as they see fit.

Increasingly, I have observed that students during these sessions are using technological means for note taking, largely laptops. The clear advantages of organising learning and revision notes using electronic means are self-evident, and the students themselves state that this method makes it easier to collate notes and cross-reference them across specialties while also being easier to store and search. However, the move to electronic notes poses a particular challenge when attempting to draw diagrams and equally makes combining diagrams on paper with electronic notes more cumbersome. It is also readily apparent that dividing the notes into electronic and paper formats may result in two incomplete sets that gain the advantages of neither format but retain the disadvantages.

Therefore, in an effort to reach a resolution for this situation, I have moved my diagrammatic representations and drawings from the low-technology end and onto an iPad Pro, largely using an Apple Pencil in combination with a free drawing application. This has had the overall effect of transferring the diagrams into electronic format, which is easily shared rapidly between the entire group through AirDrop or Bluetooth, while retaining the intuitive ease of hand-drawing and annotations. Undoubtedly, other formats of electronic pads can be used to a similar effect with the aid of an appropriate stylus.

The move towards this method of providing visual cues to support the students’ learning has been very well received by the students and has been a valuable additional tool to use within this educational setting. Discussions and formal feedback from the students suggests that it has been a positive addition to electronic note taking. Using the unified theory of acceptance and use of technology5 enables greater understanding of how this subtle adjustment of the provision of learning materials. As the performance expectancy, effort expectancy and facilitating conditions become increasingly favourable for electronic note keeping, it becomes increasingly important to align our teaching methods to their increasing use. The provision of materials in a way that makes integrating them into the individual’s notes will in itself lead to a higher level of use overall. It is my opinion that this will eventually lead on to a greater level of understanding and clinical proficiency.

This experience, and my subsequent change of teaching practices, has led me to believe that the delivery of medical education has the potential to evolve with advancing technology. Furthermore, this evolution of the delivery in medical education is becoming an increasingly necessary requirement of teaching as the way students’ learn changes. It is therefore imperative that those who deliver these small group sessions are aware of the various techniques and comfortable in their use. The challenge envisaged is that the delivery of the problem-based learning sessions, particularly during the latter years of undergraduate training, occurs in the hospital settings and away from the university. Therefore, active outreach and engagement to the peripheral sites of learning is needed to make full use of the pedagogical advantages offered by technology. Incorporating technology to this integral level in medical education is likely to place additional demands, in terms of increased training requirements for staff, and supplementary requirements for financial support, as well as the technical support required. However, it is my belief that the benefits gained through integrating technology outweigh the outlay of resources.



  • Contributors The author is a specialty trainee in urological surgery in Health Education North West and a doctoral candidate in educational research at Lancaster university.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.