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Online Anatomy Lab (OAL): A Self-Regulated Approach to the Instruction of Human Anatomy
Sally G. Boudinot & Bradley C. Martin
University of Georgia College of Pharmacy

Abstract
The Online Anatomy Lab was developed for first year pharmacy students to address a set of foundational learning objectives of the University of Georgia (UGA) College of Pharmacy Doctor of Pharmacy curriculum. This report describes how a self-regulated format was developed and instituted to accomplish two sets of goals identified as critical in the education of professional pharmacy students: content-oriented goals related directly to the learning of human anatomy and goals related to professional and personal development. The development, implementation, and evaluation of Online Anatomy Lab will be described.

1. Introduction
We developed and implemented a self-regulated, instructor-guided module to facilitate learning in the human anatomy laboratory. Students who complete the course should be able to do the following:

• identify, by name, significant human anatomical structures;
• describe the functions of these structures;
• define their relationship to larger physiological systems; and
• locate them in a model of the human body and on a patient where appropriate.

OAL supports student achievement of these content-area objectives through the following:

• clear visual images of anatomical structures that can be viewed from different angles by the student;
• lessons that give each student an individual opportunity to step through the identification process and explore the structures in context (rather than with a team of students as common in cadaver lab);
• numerous, self-paced practice opportunities; and
• self-scheduled testing.

In addition to providing a method for mastering human anatomy, OAL offers our students opportunities for professional and personal development. Our goals in these areas relate more to how students learn than what they learn. With the practicing pharmacist in mind, we developed our goals through informal discussions with pharmacist preceptors (pharmacists who work with pharmacy students during practice experiences). With OAL, we sought to

• give students a sense of control over their learning;
• facilitate independent learning;
• foster the development of self-motivation; and
• improve time management skills.

The self-regulated format was selected to accomplish these goals. The high degree of self-control that self-regulated learning affords facilitates the learner's feeling of motivation (Corno & Mandinach, 1983). Self-motivation is highly desirable in the field of pharmacy, where continuing professional education is mandated by regulating boards. Much of the pharmacist's continuing education (CE) is available online or in print as independent study materials.

It can be argued that the mastery of the learning objectives is a "recipience" process, that is, the student's simple acquisition of facts for the short term to successfully complete a quiz (Corno & Mandinach, 1983). This process requires little active engagement by the student, but is appropriate for the lower level skills required in this course. However, when students learn through OAL, they are also required to plan and monitor their activities. Students must plan when to take advantage of the availability of the study resources, schedule the quiz times, and determine how much time is needed for a particular topic. Furthermore, students must evaluate and assess other scheduling needs and prioritize them. They may monitor their progress through the "my record" feature available through the course software, WebCT (WebCT, Peabody, MA, USA). The ability to monitor grades may reinforce positive performance or encourage improvement if students have not performed satisfactorily. In order to successfully complete the module, an average grade of sixty percent must be obtained, and the ability to monitor the quiz grades gives students the capacity to know where they stand at all times. This may facilitate the feeling of being in control.

About the authors...

2. Development
2.1 Background
During their first year in a human anatomy laboratory students need to be able to remember and repeat facts; little high-level learning is required. Memorization of fundamental anatomical structures is crucial to the evaluative skills that follow in the Anatomy and Physiology Course, taught concurrently with OAL. The Online Anatomy Lab provides an efficient way for students to learn this important foundational material.

Different approaches have been used for the instruction of human anatomy. Historically, human cadavers have been, and in some schools still are, the preferred instructional resource. However, cadaver-based anatomy labs are fraught with many of the disadvantages found in other science laboratories, as cited by Bell (2000). Time, space, and financial constraints are administrative concerns. There are issues of safety in using the formaldehyde-prepared cadavers. Students often comment that it is difficult to differentiate structures and organs from cadavers that have been used for an extended period of time, and this concern is especially valid when students are asked to identify structures for an exam. To address these limitations, computer enhanced anatomy laboratories were adopted at UGA College of Pharmacy in 1995.

Even prior to the implementation of OAL, we decided to eliminate cadavers from the laboratory experience. Administrators within the College of Pharmacy purchased ADAM Interactive Software (adam.com, Atlanta, GA, USA). Students were taught in a traditional format with graduate teaching assistants preparing and presenting a brief handout with learning objectives identified for each topic. Students were shown the illustrations from their text that they were responsible for learning. These images had been downloaded into the ADAM program. The week following the instruction, students were given a written quiz created by their teaching assistant. The illustrations on the quizzes were difficult to read; the structures were hard to identify on duplicated quizzes. In addition, each teaching assistant had a different level of expectation and the level of difficulty varied among different quizzes.

Such difficulties are not found in the OAL. While requiring considerable time commitment from the instructor at its initiation, OAL requires very little maintenance time. Study resources are uniform and their availability is open to all students at specified and consistent times. Since all the resources and quizzes are written by one instructor, the level of expectation remains consistent. Quiz questions retain the same formats from topic to topic, and are randomly selected from a bank of available questions. These initiatives produce a consistent and predictable environment for the student.

2.2 Study Resource
When used as the primary multimedia resource for learning materials in OAL, ADAM Interactive Anatomy software supports effective learning, as described by Moreno and Mayer (2000). ADAM software allowed us to offer a series of "slide shows" based upon topics and objectives established by the faculty responsible for teaching the concurrent Anatomy and Physiology lecture course (Figure 1). These provide a series of interactive illustrations, selected by the instructor, alongside text that describes the illustrations and gives instructions to the student on how to manipulate the illustrations to identify the structures of note. These slide shows are available during reserved times in a student computer facility, and students view them when they choose. Students become actively engaged in the learning process as they read text and follow along with the visual images. They organize the images by following the commands described in the text.

An interactive demo (570 KB) of the Digestive System slide show demonstrates interactive illustrations alongside text that describes them and gives instructions to the student on how to manipulate the illustrations to identify the structures of note.
Requires Shockwave plugin.

2.3 Assessment
In 1997 the University of Georgia made available to its faculty WebCT instructional software. WebCT software facilitates online learning with "course tool software, resources, and academic expertise," and is the "most popular" online course development software "in the world," according to its web site. Faculty members were encouraged to incorporate features of online learning, using WebCT, into their courses where appropriate. A new method of assessing student learning of anatomy was needed, so it was decided that the quiz feature of WebCT would be an appropriate method of administering quizzes, furthering our goal of an online anatomy course.

3. Evaluation
3.1 Statistical Analysis
To assess the impact of the OAL on mastery of the learning objectives in human anatomy, we developed the following broad research question: Is there a relationship between OAL participation and performance and the educational outcomes in the Anatomy and Physiology course? The educational outcomes were operationally defined as midterm exam and final course performance in the parallel concurrent three semester hour Anatomy and Physiology (A&P) courses. The OAL midpoint is defined as the time of the first midterm exam in the parallel A&P course.

The OAL is offered both fall and spring semesters with topics that are concurrent and integrated with the traditional A&P course. The OAL was first offered to students during Spring 1999 and has been offered each ensuing fall and spring semester. Data on student performance in the OAL and the traditional A&P course were obtained for the first two semesters, Spring 1999 and Fall 1999; each semester was analyzed separately. Student grades in each Anatomy and Physiology course were linked by student identification to participation and performance information in the anatomy lab.

The resource study materials were arranged to correspond to the sequence of material taught in the A&P course. It was suggested that students complete one quiz per week as scheduled, although the students were not required to complete the quizzes in their scheduled order. The measure of student participation in the OAL lab consisted of the number of quizzes attempted prior to the first midterm exam in the corresponding Anatomy and Physiology course. Students had the opportunity to complete up to three or four quizzes (depending on semester) prior to the A&P midterm, though there was no requirement that they complete any of the quizzes prior to the midterm. Students, however, were required to complete all quizzes prior to the end of the twelve week period. OAL quiz average was used to measure student performance in the OAL course.

For each semester, analyses were conducted to assess the impact of student participation and performance in the OAL lab on both the A&P midterm and final course average. Ordinary least squares (OLS) regression models were specified and estimated to determine the influence of participation and performance for the OAL and traditional A&P course at the midterm and on the final course average. Initially, the OLS model was specified in the following general form:

Y_i = B₀ + B₁X_1i + B₂X_2i + B₃X_3i + E_i
where
Y_i = A&P Midterm score or A&P final course average for student i
X_1i = number of OAL quizzes attempted prior to A&P midterm
X_2i = mean of OAL quizzes at Midterm or Course conclusion
X_3i = Interaction term X1i * X2i
B₀ .. B₃ = Vector of OLS regression coefficients
E_i = residual error term

If the interaction term was not significant (p>0.05), the model was re-estimated without the interaction term so the main effects could be independently interpreted. Since students who completed zero quizzes prior to the midterm could not have an OAL quiz average, another alternative OLS model was estimated without the quiz average terms. Also, the number of quiz attempts prior to midterm was analyzed as a count measure and dichotomized (0-no quiz attempts, 1-one or more quiz attempts) in estimating the effect of the OAL on the final A&P course average. All computations were performed using SAS, and the a priori significance level was set at 0.05. (SAS Institute, Cary, NC, USA).

3.2 Student Surveys
Both student groups that participated in the Online Anatomy Lab were given surveys to assess the effectiveness of the instructional method in reaching the goals that relate to how the students learn. Students surveyed from Spring 1999 were asked to assess the difference between the online method of instruction and the traditional method of instruction that had been used the previous semester. Students in the second group (Fall Semester, 1999) were administered the survey via WebCT at the conclusion of that semester, but because they had only received anatomy instruction via OAL, they were asked questions that related only to that method of instruction.

4. Results
4.1 Statistical Analysis
There were 102 enrolled in both the OAL and the A&P courses during Spring 1999 and 98 students in both courses during the Fall of 1999. The student course averages were 78.51 and 77.07 in Spring 1999 for the OAL and A&P courses, respectively, and were 85.36 and 76.78 in Fall 1999. On average, students attempted 1.95 (max=3) and 1.66 (max=4) quizzes prior to the A&P midterm in Spring and Fall semesters, respectively.

The relationships between the number of OAL quizzes completed prior to the A&P midterms and OAL and A&P course performance at midterms and course end are reported in Tables 1 & 2. For all OLS models estimated, the interaction term between the number of OAL quiz completions and quiz average was not significant and, consequently, the interaction term was dropped from all analyses. In both semesters, there was a significant positive relationship between the number of OAL quizzes completed prior to the midterm and midterm performance (significant OLS coefficient for number of quiz completed), Tables 1 & 2. There was also a significant relationship between midpoint OAL quiz performance and A&P midterm and for final AOL quiz average and A&P final course average, Tables 1 & 2. Only in the fall semester was the number of quiz completions associated with final A&P performance, and that relationship was only significant when contrasting those who completed zero quizzes with those who completed one or more quizzes, Tables 1 & 2.

	Number of Quizzes Completed	Quiz Average	R2
A&P Midterm, all-inclusive (n=102)	2.77 (0.0041)		0.0796
A&P Midterm with at least 1 attempt (n=84)	0.024 (0.988)	0.341 (0.0019)	0.1153
A&P Final (n=102)	0.331 (0.578)	0.528 (0.0001)	0.4210
A&P Final* (n=102)	2.172 (0.185)	0.513 (0.0001)	0.4294

* Number of quizzes completed was dichotomized: 0=no quiz completed at beginning of semester, 1= one or more quizzes completed at beginning of semester.

Table 1. Spring, 1999
OLS Coefficients and p-values for Regression Models at Midterm and Final Course Average on A&P Exams

	Number of Quizzes Completed	Quiz Average	R2
A&P Midterm, all-inclusive (n=98)	5.33(0.0001)		0.1711
A&P Midterm with at least 1 attempt (n=84)	5.03 (0.0022)	0.161 (0.0832)	0.1548
A&P Final (n=98)	1.43 (0.0626)	0.841 (0.001)	0.4743
A&P Final* (n=98)	4.63 (0.0242)	0.863 (0.0001)	0.4832

* Number of quizzes completed was dichotomized: 0=no quiz completed at beginning of semester, 1= one or more quizzes completed at beginning of semester.

Table 2. Fall, 1999
OLS Coefficients and p-values for Regression Models at Midterm and Final Course Average on A&P Exams

4.2 Student Surveys
The initial group of students who used OAL was given the survey after completion of the Spring 1999 course, and they were asked to compare the two methods of instruction. Assessment of the traditional instructional method indicated that there was overwhelming disagreement with the following statement that appeared on the survey: "During the fall semester, the images on the quizzes were clear and it was easy to know what was being asked." This response reinforced the need for a new tool from the traditional photocopied, written exam. Students felt that the level of difficulty of the quizzes corresponded more appropriately in the spring (using OAL) than in the fall (with the traditional lecture-type delivery). This may be attributed to one instructor controlling both the content and the assessment. While students agreed that the grade received for the fall and spring lab segments reflected accurately the level of effort that was applied, they overwhelmingly felt that the material learned during spring semester "stuck with" them more than the material learned during the fall semester. Half the students admitted to being "apprehensive about taking quizzes on the computer," but there was a 58% disagreement with the survey statement: " I never got over my apprehension about taking quizzes on the computer." Concerning other questions, comments were mixed. Some students focused on the amount of work that the course required. Other students were more positive: "I love the use of WebCT to answer Anatomy Quizzes. It was much clearer where the pins were pointing (accurate and via different shades and colors)."

Students who received anatomy instruction via OAL during the fall semester were more positive in their comments and responses. This may be due to the revisions that were made both to the study resources and to the WebCT quiz modules. Their responses indicate that the educational objectives were being addressed. These students overwhelmingly felt that they were in control of the learning that took place, as indicated by a 93% agreement with the statement, "I felt that I had control over the learning that took place in anatomy lab." The images on the exams were clear and the material in the slide shows uniform, as indicated by an 81% agreement with the statement, "The material presented in the ADAM slide shows was presented in a uniformly thorough manner." This student response addresses the instructors' initial concern that the presentation of material by the graduate teaching assistants using the original teaching method was inconsistent. More than half felt that the grade they received was appropriate for the amount they learned. Almost three-fourths of the students felt that the grade they received was appropriate for the amount of effort put forth. Most of the students had not been tested online before and almost 60% admitted to being initially apprehensive. But 76% of this group of students disagreed with the statement, "I never got over my apprehension about taking quizzes on the computer." About half the respondents admitted to being procrastinators, but the same percentage stated a tendency to keep up with their work. More than half responded that they felt able to sift through material to decide what was important, a skill critical for independent learning.

Some typical comments made by students from both semesters when asked to assess OAL include the following:

• Self directed. You can go at your own pace. Also teaches time-management and self-discipline.
• Forces you to learn the material.
• I like moving at my own pace.
• Self-direction, good software, quizzes closely match study materials.
• A bit of visual aid helps along with lectures. For the most part it coincides with lectures (A&P).
• Convenience: I love choosing when I want to study and take the quiz.
• It helps you to be more responsible.

5. Discussion
The analyses indicate that student performance in the lab at the completion of the semester consistently explains the 40% variation in student performance in the parallel A&P course. On average, a one percentage point increase/decrease in skills lab quiz average translates to a 0.5 and 0.9 percentage point increase/decrease in the A&P course average in the spring and fall semesters, respectively. These findings suggest that this teaching innovation offered within the skills lab greatly influences student learning. One may counter these conclusions by suggesting that directionality of these relationships is reversed, that is to say that performance in the A&P course influences the lab performance and not vice versa. As a check to the directionality of the relationship, the number of quizzes attempted prior to the midterm was used to explain performance on the midterm. Across both semesters, a significant positive relationship was observed between the number of quizzes attempted and performance on the A&P midterm, with a stronger association observed in the fall semester. In the fall semester each additional quiz attempted translated to more than a five percentage point increase for the A&P midterm score.

Data for the fall semester suggest that the number of quizzes completed at the midpoint influences the final course average. Since students were required to complete all OAL quizzes prior to the A&P final exam and, consequently, have been exposed to all OAL material, the significant positive relationship observed between the dichotomous measure for quizzes completed prior to the midterm and final A&P course average (Table 2) may indicate that not only is exposure to the quiz material effective, but there may be some intrinsic motivational factor that is being measured by proxy in the form of quizzes completed. This relationship may suggest that the self-paced nature of this educational experience is having a positive impact on personal and professional development. This finding should be interpreted cautiously since this relationship was only observed for fall semester and not the spring semester.

Several limitations of this study should be acknowledged. First, the OAL quizzes and the A&P exams have not been empirically tested for reliability and validity. There is some evidence of validity demonstrated in the fact that the OAL quiz scores influence the variation of A&P course scores; however, this was not a specific objective of this study. Also, this study was performed using a convenience sample of students at one college of pharmacy. It is unknown to what extent the findings observed in this study could be generalized to other populations. There were several model specifications estimated leading to multiple statistical tests. Increasing the number of statistical tests performed in a study increases the possibility of detecting a significant finding which is purely based on chance (increased experiment wise alpha error rate). For associations where the p-value is much less than 0.05, this phenomena is of trivial consequence; however, for associations where the p-value is close to but less than 0.05, these associations should be interpreted with greater caution. Lastly, due to the non-experimental design of the study, all associations reported in this study are simply that, associations, and not necessarily causal relationships.

6. Conclusion
Overall, both the student surveys and the analysis of grades indicate that this instructional method is meeting some of the initial objectives. Performance and participation on the OAL quizzes is significantly and positively related to performance in the Anatomy and Physiology course. Given the directionality, strength, and consistency of these relationships observed across semesters, this study provides fairly strong empirical evidence of the effectiveness of the OAL educational experience.

In Fall, 2000, on the first day of classes, new first-year professional students were presented with student performance data from the Spring and Fall, 1999. It is hoped that by demonstrating a positive relationship in the performance on the anatomy quizzes and A&P exams, students will be motivated not to procrastinate.

We continue to evaluate student attitudes and performance in the Anatomy and Physiology course. The slide shows will be monitored for content and clarity, and enhancements will be made where appropriate. The slide shows will also be modified to reflect changes in the Anatomy and Physiology course as they occur, and the corresponding quizzes will be modified accordingly.

7. References
Bell, Jeffrey. (2000) The Biology Labs On-Line Project: Producing Educational Simulations That Promote Active Learning, Interactive Multimedia Electronic Journal of Computer-Enhanced Learning, 2 No. 2, October, 2000.

Corno, L and Mandinach, E.B. (1983). The Role of Cognitive Engagement in Learning and Motivation, Educational Psychologist, 18, 88-108.

Moreno, Roxana, and Mayer, Richard E. (2000). A Learner-Centered Approach to Multimedia Explanations: Deriving Instructional Design Principles from Cognitive Theory, Interactive Multimedia Electronic Journal of Computer-Enhanced Learning, 2 No. 2, October, 2000.

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IMEJ multimedia team member assigned to this paper	Yue-Ling Wong