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J Gen Intern Med. Jan 2005; 20(1): 68–74.
PMCID: PMC1490044

Web-based Curriculum

A Practical and Effective Strategy for Teaching Women's Health
Jennifer R Zebrack, MD,1,2 Julie L Mitchell, MD, MS,2 Susan L Davids, MD, MPH,1,2 and Deborah E Simpson, PhD3



To address the need for women's health education by designing, implementing, and evaluating a self-study, web-based women's health curriculum.


Cohort of students enrolled in the ambulatory portion of the medicine clerkship with comparison group of students who had not yet completed this rotation.


Third- and fourth-year medical students on the required medicine clerkship (115 students completed the curriculum; 158 completed patient-related logs).


Following an extensive needs assessment and formulation of competencies and objectives, we developed a web-based women's health curriculum completed during the ambulatory portion of the medicine clerkship. The modules were case based and included web links, references, and immediate feedback on posttesting. We discuss technical issues with implementation and maintenance.


We evaluated this curriculum using anonymous questionnaires, open-ended narrative comments, online multiple-choice tests, and personal digital assistant (PDA) logs of patient-related discussions of women's health. Students completing the curriculum valued learning women's health, preferred this self-directed learning over lecture, scored highly on knowledge tests, and were involved in more and higher-level discussions of women's health with faculty (P <.001).


We present a model for the systematic design of a web-based women's health curriculum as part of a medicine clerkship. The web-based instruction resolved barriers associated with limited curriculum time and faculty availability, provided an accessible and standard curriculum, and met the needs of adult learners (with their motivation to learn topics they value and apply this knowledge in their daily work). We hypothesize that our web-based curriculum spurred students to later discuss these topics with faculty. Web-based learning may be particularly suited for women's health because of its multidisciplinary nature and need for vertical integration throughout medical school curricula.

Keywords: women's health, computer-assisted instruction, medical education, adult learning, personal digital assistant

To correct the underrepresentation of women's health and gender-specific medicine in medical school curricula, national organizations have developed women's health core competencies for medical students and encouraged the evaluation of existing educational programs.1,2 As in other population-based areas such as geriatrics,3 palliative medicine,4 and medically underserved populations,5 educators have strived to improve women's health education through multidisciplinary and integrative approaches.69 However, there are many barriers to implementing curricular change, including limited lecture time, few faculty with expertise or interest in women's health, and faculty resistance to the change of existing curricula.1,10,11 Additionally, students' knowledge and clinical experiences with women's health vary and are often dependent upon preceptor expertise, student interest, and patient mix. Therefore, educational initiatives, such as new instructional delivery methods, may be needed to integrate women's health into existing curricula.10

Computer-assisted instruction (CAI) has been utilized in medical education to fill curricular gaps,12,13 supplement preclinical and clinical curricula,1420 and stimulate learners through problem-solving and interactive exercises.1520 However, we were unable to find a published evaluation of a women's health CAI. Computer-assisted instruction allows a few instructors to reach many learners, provides more uniform learning experiences, and can be more time efficient than lecture, with similar performance outcomes.21,22 This article will both present a model for the systematic design of a web-based women's health curriculum as part of an internal medicine clerkship and report findings regarding its feasibility, utility, and effectiveness.23


Target learners were third- and fourth-year students on the 1-month ambulatory medicine rotation, which is part of the 3-month internal medicine curriculum requirement. This rotation includes outpatient clinic sessions at multiple sites, a lecture series, and 1 to 2 self-study afternoons per week. As many women's health issues are core to the ambulatory medicine experience, this rotation provided an excellent opportunity for teaching and learning about women's health.

Needs Assessment and Barriers to Implementation

In 1999, Medical College of Wisconsin (MCW) educators24 conducted a multimethod needs assessment of women's health spanning the 4-year curriculum. A comprehensive set of competencies was developed based on critical review of the literature and recommended standards.25,26 Competencies were approved by the MCW Curriculum and Evaluation Committee. The degree to which objectives were taught was assessed with faculty and student surveys and student focus groups. Based on these results, the committee concluded that women's health education was inadequate and that curricular changes were needed. Major barriers associated with integrating and implementing a women's health curriculum included the limited number of faculty who were qualified and available to design, teach, and evaluate a curriculum, limited time on the students' schedule, and the size of each medical school class (200–210 students). In addition, a limitation specific to the ambulatory medicine rotation involved the time required to travel between off-campus clinical sites to attend the on-campus instructional activities.

Competencies and Objectives

Building from the MCW-approved women's health curriculum objectives and the American Board of Internal Medicine women's health medical knowledge competencies,27 we identified 40 women's health medical knowledge learning objectives for third- and fourth-year students on an internal medicine rotation (see Appendix available online at http://www.jgim.org). Learning objectives were written using recommended methods for formulating educational objectives28 and were reviewed by local women's health faculty physicians for content validity.

After reviewing these objectives and the existing medicine clerkship curriculum, which already included a lecture on breast cancer screening, 5 initial topics were selected as curriculum foci for the ambulatory medicine rotation: 1) osteoporosis (OS), 2) menopausal hormone therapy (HT), 3) cervical cancer screening and management of abnormal Pap test (CC), 4) smoking and smoking cessation: gender differences (SC), and 5) alcohol problems: gender differences (AP). Curriculum foci were selected based on the frequency of ambulatory-setting encounters with the problem and number of learning objectives covered. Future goals were established to expand the curriculum to address more objectives and topics.

Curriculum Development and Description

Curriculum development began in October 2001. In order to assess students' knowledge after curriculum completion and evaluate the effectiveness of our curriculum, we needed a password-protected, web-based platform with built-in testing and survey capabilities. Our institution's Department of Instructional Technology had already acquired a licence for Blackboard (Blackboard Incorporated, Washington, DC; http://www.blackboard.com), a widely recognized and well-established learning management system. Prior to our involvement, our institution's graduate school was the primary user of Blackboard.

We created and refined this curriculum in word processing software from November 2001 to February 2002. One module was developed for each topic, and each had a similar format: 1) 5 to 6 learning objectives, 2) a 2-question multiple-choice “warm-up” pretest, 3) case-based instruction, 4) references for further reading, 5) a list of pertinent websites, and 6) a 10-question multiple-choice posttest. Module learning objectives were written using recommended methods28 (e.g., “List the risk factors for the development of cervical cancer; identify the appropriate time for initiation of cervical cancer screening”). The case-based instruction included an unfolding patient case ending with 2 to 3 “trigger questions” to guide learning (e.g., “Are there social, racial, and/or ethnic differences among women who smoke? Besides pregnancy risks, what other tobacco-related conditions are unique to or more common in women? Write down your answers before continuing”). Informative readings, tables (e.g., hormone therapy formulations), and integrated web links (i.e., national organizations and guidelines) were provided to address these “trigger questions” after each case section. Pre- and posttest questions provided immediate feedback to the learner for correct and incorrect answers. Although not strictly monitored, the amount of time spent to develop and refine one module was approximately 20–25 person-hours of faculty time.

Our institution's Department of Instructional Technology played several critical roles in the initial implementation of our curriculum. An instructional designer created a website as a portal to the Blackboard system (this website also served other women's health education functions at our institution) and entered the module content, quizzes, and surveys into the learning management system. The department also created passwords for each learner every month, and paid the associated fees. Later, a Department of Medicine administrative assistant received basic training in Blackboard and generated logins and passwords each month.

To explicitly describe how to access the curriculum, we detailed the process in an instruction sheet distributed to students on the first day of the rotation. This sheet also contained their login and password and a women's health faculty e-mail address. Students were encouraged to e-mail faculty regarding questions on content or technical difficulties with the site. Once in the curricular website, students selected a module and moved freely through the material using “back” and “forward” navigational buttons near the top of the screen (these buttons were in addition to the navigation buttons on the web browser). Students could also skip around to various sections of the module and access references and pertinent websites with separate buttons. Students could submit answers to the posttests at any time.

From April to June 2002, we piloted four modules with students and general internal medicine faculty, and pilot data led to minor changes. The curriculum was formally implemented on July 1, 2002, and a fifth module (SC) was added in January 2003. Completion of the alcohol problems module was optional, while all others were required.

At the end of the rotation, students met for a 1-hour small group session (8–10 students) with one of the three women's health faculty members (JRZ, JLM, or SLD). This interactive “debriefing session” was a discussion of 6 cases, each accompanied by 3 to 5 questions, emphasizing key learning points and clarifying online material.

Once the development process was complete, updating of curricular content varied between modules and was necessary approximately 1–2 times per year.

Curriculum Evaluation

Four methods were used to evaluate the utility of this online instructional delivery approach. First, ambulatory medicine students participating from November 2002 to June 2003 were asked to complete a pre- and postrotation paper questionnaire. This questionnaire obtained information about students' prior experiences and attitudes toward online instruction and women's health, learning method preferences, and overall satisfaction including open-ended narrative comments. Pre-post responses were paired using a student number, with authors and statistician blinded to student identification and, because of a skewed distribution, analyzed using the Wilcoxon signed rank test.

Second, we utilized personal digital assistants (PDAs) to track students' patient encounters. All medicine clerkship students from July 2002 to June 2003 received a PDA preloaded with a patient log system created using Pendragon forms (Pendragon Software Corporation, Liberty, IL). Students were trained in the use of these forms at the clerkship orientation and were asked to complete forms for patients for whom they were primarily responsible during the clerkship. Specific to their patients, students recorded whether or not gender and its impact on health and disease was discussed with their faculty member and the level of intensity (low, medium, or high) of this discussion when present. The PDA responses of students who participated in the curriculum were compared to those who had not yet participated using χ2 analysis. Students who had not yet participated were those who elected to complete the ambulatory medicine rotation in their fourth year.

Third, all ambulatory medicine students from July 2002 to June 2003 completed an online 2-question multiple-choice pretest and 10-question multiple-choice posttest for each required module, and some completed pre-post tests for the optional module. Each examination was developed using a test blueprint defined by module objectives.29 Course faculty collaboratively established a pass/fail standard for posttests using recommended standard-setting procedures.30

Finally, students were asked to complete anonymous online evaluations after each module using Likert scale and open-ended narrative responses. Foci were time on task, ease and satisfaction with online learning relative to lecture, and value as a learning experience. A blinded statistician analyzed narrative responses from online postmodule evaluations and postrotation paper questionnaires using standard qualitative strategies to generate themes with frequencies.31


A total of 115 medical students rotated through ambulatory medicine and completed the required modules (OS, HT, and CC from July to December 2002; OS, HT, CC, and SC from January to June 2003). Forty-three of these students (37%) completed the optional module (AP).

Pre- and Postrotation Paper Questionnaires

From November 2002 to June 2003, 73 students completed both pre- and postrotation questionnaires, a 95% response rate for these months. Sixty-six percent of the students were male. Most students (74%) had completed the obstetric-gynecology third-year clerkship and had previous experience with CAI (12%, no experience; 55%, 1–2 experiences; 33%,≥3 experiences). Few students (7%) had prior additional training in women's health (e.g., job, research, externship). Prerotation student preferences and attitudes are shown in Table 1. Most students were confident in their web navigation abilities and enjoyed online learning. Ninety-one percent of students felt that competence in women's health and gender-based medicine was important to their future career. Seventy-one percent of students thought women's health and gender-based medicine was a topic that deserved special emphasis in required medical school curriculum, and one fourth of students planned to take a women's health elective. Self-study was favored over lecture as the preferred method for learning new material.

Table 1
Pre- and Postrotation Questionnaires: Student Preferences, Attitudes, Location of Curriculum Completion, and Overall Satisfaction

Postrotation questionnaires showed that most students completed the curriculum at home (Table 1). Ninety-six percent agreed that the women's health curriculum, including the online modules and small group case-based session, provided a valuable learning experience. Qualitative analysis of 61 narrative responses for the overall curricular experience revealed mostly favorable comments (Table 2). Completion of the curriculum resulted in increased confidence with online navigation (P <.01), but no significant change in opinions about the importance of being competent in women's health for their own future career or the need for a women's health emphasis in required curricula, plans to take a women's health elective, enjoyment of online learning, or learning method preference.

Table 2
Qualitative Analysis of Students' Narrative Comments (N =Number of Comments; Total Comments=420)

Personal Digital Assistant Log of Patient-related Discussions of Gender and Its Impact on Health and Disease

Personal digital assistant data were collected and downloaded for 158 of the 200 medicine clerkship students rotating from July 2002 through June 2003, a 79% response rate (Table 3). Technical issues (such as downloading in the presence of a firewall or inexperience with PDAs) impacted student compliance with form completion. Of the 158 students, 91 (58%) completed the web-based women's health curriculum and 67 (42%) students did not (as they were scheduled to complete their ambulatory requirement in their fourth year of medical school). The 158 students logged 3,906 patient encounters, of which 778 (20%) included a discussion of gender and its impact on health and disease. On average, students who received the women's health curriculum recorded significantly (P <.001) more encounters with a discussion of gender and its impact compared to students who had not yet received the curriculum (5.6 vs 4.0 mean encounters/student). Additionally, there was a significant association between participation in the women's health curriculum and the level of gender discussion, with higher levels of discussion associated with participation in the curriculum (P <.001).

Table 3
Personal Digital Assistant Logs and Online Postmodule Evaluations

Online Postmodule Multiple-choice Examinations

The 115 ambulatory medicine students completed a 2-question pretest and a 10-question posttest for each required module. The posttest pass standard was set at a cumulative score of 80% or greater. Mean scores were 74.4% for required pretests and 89.5% for required posttests. Seven of the 115 students (6%) were required to retake a module after failing to meet the pass standard.

Online Postmodule Evaluations

The 115 women's health curriculum students completed 372 postmodule evaluations (OS, 97; HT, 100; CC, 92; SC, 52; AP, 31), an aggregate response rate of 84% for all completed modules (Table 3). Most evaluations stated that the modules were easy to navigate, useful in content, clinically applicable, and augmented learning with pre-post testing. Almost half of all modules were completed in less than 30 minutes, with the majority being completed in less than 1-hour. The majority of students (85%) found the module provided a valuable learning experience and a large proportion (60%) preferred this online method over lecture. Overall, evaluation trends did not differ significantly among modules.

The number of narrative responses varied per module (OS, 66; HT, 73; CC, 67; SC, 30; AP, 23), with a total of 359 comments. Qualitative analysis of aggregate comments revealed 8 major themes (Table 2). Students cited module content as the most positive feature of the curriculum, followed by the structure or format of the module. The most frequently cited area for improvement was in the content category, with students' asking for clarification or more information.

E-mails to Faculty

Only one student e-mailed faculty with a question about module content. Eight students e-mailed faculty about technical difficulties, most often trouble with the login and password procedure.

Small Group Discussion

The end-of-rotation “debriefing session” reiterated the content of the online modules in a case-based small group discussion. Generally, the course of discussion addressed students' questions regarding the online material, but students were also quick to ask complex questions, presumably spurred from the independent study of this material. Discussion facilitators were uniformly rated good to excellent.


Despite the surge in online instruction, reports evaluating the feasibility and utility of web-based curricula are limited,3234 and descriptions of web-based women's health curricula are scant. In our evaluation of a systematically designed web-based women's health curriculum, we found web-based instructional delivery a viable alternative to face-to-face, faculty-intensive women's health instruction for third- and fourth-year medical students. Web-based learning may be particularly suited for women's health topics because of its multidisciplinary nature and need for vertical integration.

The positive findings associated with the online delivery of this women's health curriculum are not surprising if the findings are considered from the perspective of medical students as adult learners.35 Adult learners are motivated to learn topics they value and then apply this knowledge in their daily work. Indeed, we found highly positive attitudes toward women's health, and the lack of significant pre-post attitude changes is not unexpected due to ceiling effects. Students also demonstrated high knowledge scores after our self-directed curriculum and a significantly higher number of patient-related discussions about women's health with faculty. The principles of adult learning—recognition of a learning need, self-directed learning, desire to apply what they have learned—provide strong support for the utility of a web-based instruction for teaching women's health.

Other authors have also found knowledge gains using web-based curricula and student preference for e-learning.34 We also measured a behavior, namely discussions of women's health and gender differences with faculty, using PDA technology. In medical education, educators have used PDAs as teaching tools, procedure and patient log systems, and needs assessments.3638 Our use of this tool to measure behavioral change is a novel way to evaluate curricular outcomes.

We hypothesize that students enrolled in our women's health curriculum had more and higher-level discussions about women's health with faculty because, in adult learners, e-learning increases curiosity and subsequently prompts further learning directly from faculty. Other evaluations of behavioral changes are limited, and prior literature is mixed as to whether web-based learning enhances stimulation to learn.32,34,3941 Our finding provokes the need for more studies on web-based learning's effect on students' behaviors, specifically stimulation for more learning and application of what they have learned.

Our evaluation has some limitations. Our survey questions did not tease out the specific effects of the debriefing session separate from the web-based curriculum. Second, while we found that students exposed to the women's health curriculum reported a greater number and higher level of patient-related discussions of gender and its impact on health and disease with their faculty preceptors, this finding may be limited because these students also experienced an ambulatory rotation. Furthermore, our instructional model and evaluation findings may not be generalizable to other institutions and other disciplines. However, deficiencies in women's health and gender-based medicine in medical school curricula and institutional barriers to implementing these curricular changes are nearly universal.10 Web-based instruction, as we have demonstrated, offers another method of delivering women's health and gender-based information to medical students.

The web-based delivery of the women's health curriculum was selected to overcome limitations in resources, such as the number and availability of faculty with expertise in women's health and the accessibility of learners at off-campus sites, while meeting the need to teach a large number of learners specific content areas identified during the needs assessment process. Online curricula require faculty time, plus the added expense of learning management system licensing and support staff. Correspondence by e-mail to address student inquires, although infrequent in our experience, also requires dedicated faculty time. We did not strictly monitor the time required to create and sustain the online instruction, precluding a comparative cost analysis of online instruction versus repeated monthly 4 to 5 hours of face-to-face teaching.

Commercially available e-learning platforms can offer convenience and uniformity when implementing a large web-based curriculum that requires built-in testing. However, these systems differ in their features. We experienced some difficulties with the system available to us, such as the inability to customize the web page without additional fees (e.g., change location of navigation buttons or establish continuous visual flow with our women's health portal website), inability to perform statistical analysis within the system (e.g., calculate psychometrics for multiple-choice questions), and inability to track time and movements of the user. Educators developing web-based curricula should become aware of the strengths and limitations of the systems available to them.

Web-based instructional delivery depends on continued technical support. We were able to use commercial software and resources in our Department of Instructional Technology. Our program has been sustained because we trained our own assistants in site maintenance, updates, and password generation. Educators implementing a new web-based curriculum may not need assistance from a technical department if they choose a more robust learning management system that caters to educators without specific computer programming training.

This online instruction was designed to teach medical knowledge and did not provide “hands-on” clinical experiences. In order to be competent in caring for women, one must be proficient in certain clinical skills, such as communication regarding sensitive topics and gender-specific physical examination skills. As web-based instruction is limited in its ability to provide practice with these skills, its selection as an instructional delivery method must be matched to the type of instruction needed, selecting other delivery methods when hands-on skills are needed (e.g., standardized patients, clinical skills workshops).

Creating an online self-study curriculum does not replace the need for a large number of faculty competent to teach women's health. However, this curriculum may also be shared with faculty who wish to improve their own knowledge of women's health and thus serve as continuing medical education.


Population-specific, knowledge-based women's health education can be effectively delivered using a systematically designed web-based curriculum. Consistent with the principles of adult learning, this method of instruction for teaching women's health is rated highly by students on a required medicine clerkship and may stimulate further self-directed learning.


We would like to thank Collette Keating-Christensen and Steve Krogull, MS, for e-learning support and expertise, Dawn St. A. Bragg, PhD, and Arlene Helfrich for statistical analysis, Chris McLaughlin for editorial assistance, and Sue Goodman for administrative support.

This project was partially supported by a Learning Resources Grant from the Medical College of Wisconsin.

JGIM Abstracts:

Zebrack JR, Mitchell JL, Davids SL, Keating-Christensen C. A women's health web-site for learners at multiple levels. J Gen Intern Med. 2002;17:104.

Mitchell JL, Zebrack JR, Davids SL, Keating-Christensen C, Simpson DE. Students' use of and satisfaction with e-based instruction: experience with an online women's health curriculum. J Gen Intern Med. 2003;18:249–50.

Zebrack JR, Mitchell JL, Davids SL, Bragg D. The impact of an on-line women's health curriculum on OSCE skills and clinical teaching encounters. J Gen Intern Med. 2003;18:260.


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