The goal of medical educational curricula is to provide students with knowledge and the clinical competence to treat patients at the best state-of-the-art; wherever possible, in an evidence-based manner.¹ Up to the end of the last century, medical undergraduate education consisted mainly of face-to-face teachings, such as lectures, or self-directed use of paper-based books or lecture notes.² With the rise of the internet, the former options have been expanded by a new mediation of knowledge via digital online-supported teaching and learning scenarios (e-learning) and thereby become part of most modern medical undergraduate curricula.^3-5 The use of online-provided learning features and tools with its 24/7 availability and the possibility to offer more features than textbooks is very popular among students.^3-5 E-learning has become a self-evident offering in modern medical faculties,⁶ and it is also compulsory implemented into medical curricula.⁷ Some e-learning scenarios provide uni-directional information for online use or downloads (e.g. lecture notes, presentations etc.),⁵ whereas others integrate highly interactive tools like radiological diagnosis quizzes or virtual patients.^8-10 Also the use of so-called Web 2.0 media with podcasts, wikis or blogs has been discovered for medical teaching.^11,12 However, most presented offers are limited to single projects or have focused only on individual medical disciplines,^5,9,13 with only sparsely organized approaches on any medical school level.¹⁴

Nowadays, the provision of e-learning tools or complex blended learning scenarios depends on an online platform where students and teachers can get access to them.⁴ To address this issue, different forms of learning management systems (LMS) were established in medical faculties worldwide. A LMS can be defined as software that automates the administration, tracking, and reporting of training events and delivers learning contents rapidly.¹⁵ It also enables the provision of a structured curriculum, and eases both the accessibility of many contents and an all-in-one organization.¹⁶ Many studies have already reported on the use of LMS in undergraduate and even postgraduate medical teaching for the provision of e-learning contents or the access to libraries or discussion forums.^10,13,16-18 Also complex teaching concepts as spiral curricula are supportable by LMS.¹⁹

A sufficient familiarity of teachers with electronic media and LMS has to be regarded as the basis of modern teaching.^20,21 In order to ease the compliance of students to use digital teaching amendments, it is highly important that medical teachers know about potential pitfalls and students’ experiences, wishes or needs regarding the conception, design or provision of e-learning scenarios, tools and LMS. ²² However, until today, only few studies have concentrated on individual disciplines or topics instead of LMS as the main focus^13,23 – and those few who did were again linked to certain disciplines rather than to a medical school level. Also students´ problems with the use of e-learning tools are relevant, but only rarely reported in medical fields.²⁴ Overall, there is a lack in comprehensive empirical data on medical students´ use of digital learning tools and learning management systems as well as their expectations on the provision of those offerings.

The undergraduate curriculum at German medical schools consists of 12 semesters, characterized by a differing mix of lectures, seminars, bedside teachings, practical trainings, internships and problem-based learning. While LMS are implemented at almost all medical schools, e-Learning offerings are mostly voluntary and embedded into blended learning concepts.²⁵ The purpose of this study was to examine medical students’ needs and expectations concerning e-learning tools and their learning management system, based on their current utilization.

Within the three-month duration of the study, 505 students participated in the survey (of 4629 addressed). The mean age was 24.2 years (SD 4.4) and the mean study semester was 6.5 (SD 3.8). Of all participants, 340 (67.3%) were female and 161 (31.9%) were male. 4 students did not indicate their gender.

Provision of e-learning elements via learning management systems (LMS) is one of the key factors for a successful introduction and both effective and persistent usage of digitally supported learning concepts in medical education. ^4,7 This single-center survey enlightened some aspects of interest in a comprehensive approach concentrating on students´ use of a LMS and its e-learning tools as well as assessing their needs concerning those offerings on a medical school level. To our knowledge it is the first approach to address those topics in medicine without being connected to any single specific course or discipline.¹³ Concerning online knowledge sources in general, the medical school´s own teaching offers such as lecture notes were well liked, but were placed as being used at almost the same level as Wikipedia – far ahead of e.g. professional online journals. Also in other studies, Wikipedia was considered to be a relevant source of knowledge by students.^31,32 Despite such encouraging data,³³ there are also reasonable doubts among professionals concerning the actual reliability of Wikipedia’s contents.^34,35 The results presented here underline the necessity to foster studies about students’ media competencies and their learning behaviors. However, the findings also seem to recommend e.g. for national associations of individual medical disciplines that one should check articles in Wikipedia which deal with their area of expertise, and to correct or even edit them in a proven and certified manner. Future studies will have to address the question how students´ use of such internet sources can be positively influenced by offering instructive and well-approved digital learning tools.

As a central headline of students´ preferences for the LMS and its e-learning contents, the term “efficacy” could be stated. Offers should be clearly structured, easy to operate, time saving, praxis-oriented and focused on curricular lessons. Additionally, a good communication about where to find certain offers seems to be needed. Interestingly, fun with any offers or an especially attractive layout was seen by the majority of participants to be less important. This might be quite important for clinical teachers who will mostly be rather short of time 36 and could thus invest more effort on the provision of fact-oriented contents than on a sophisticated design.³⁷ At the same time it can be stated that most students regarded only few e-learning tools to be relevant for study preparation. Knowledge was apparently expected to be taught in as compact a manner as possible, resulting in a preference of those tools which seemed to lead quickly to a learning success, e.g. texts or videos rather than discussion forums or wiki-blogs. However, such a view on the results has to be seen critically, as still at least one-third of the participants supported forums and online tutoring. Along with this, there are examples of successful embedding among students using tools as discussion forums.^13,38,39 Others showed that their local populations appreciated discussion forums most, whereby downloadable data were only seen to be present in the midfield and a use of emails even at the end.¹³ It can be postulated that the ranking of different tools within a LMS will always depend on an individual course’s structure – e.g. when a close tutor contact is ensured and there is a steady encouragement of using the tools.³⁸

Regarding the above-mentioned students´ needs and concluded demands for teachers, faculty development approaches to support teachers´ familiarity with the LMS used and its established e-learning tools and services do seem to be recommendable.³⁷ When asking for students´ priorities of electronic tools provided by the medical school, a uniform study portal was regarded as most important. This can be based on the practical log-in use and easy handling of e-learning materials; students would then not have to switch between individual platforms. This issue was also supported by the free-text answers, where students requested an easy access to the LMS and its contents. Thus, it seems to be recommendable that medical schools offer one single LMS to offer all digital learning components.¹³ The “number one” purpose for the LMS usage was the acquisition of information about curricular contents, followed by learning for exams and the preparation and post-processing of seminars. Communication tools of the LMS were used less, whereas students’ answers had indicated that communication itself was a relevant aspect.  In this context, it was interesting that emails were still the main line of communication in the evaluated population. That could be explained together with a well-established email service of the university. Just as other authors have already suggested an embedding of libraries into LMS,⁴⁰ there could be a potential in connecting universities´ email accounts of students with a firmly established LMS into one password-protected platform.¹³

Students´ statements showed a strong desire for an active involvement in learning. Thus, e-learning offerings should include the possibility of interaction to promote the acquisition of knowledge.⁹ However, this aspect should be discussed critically. On the one hand, new features of the Web 2.0 and other means of teaching might be suitable to attract students´ attention,^12,39 and these are also demanded by some authors.⁴¹ This might also be a new and promising approach for the population evaluated here, whereby Facebook was not apparently considered to be especially important as source of learning, but rather secondary concerning online communication about study-related aspects. On the other hand, it should also be taken into careful consideration that concentrating on proven tools might be more effective for a medical school and its teachers in aiming to provide a good and satisfying education than to follow too much of any current hype.³⁷ Another interesting aspect taken from the free-text answers was the wish for retention of access to earlier learning materials. This could be important in the context of evidence-based medicine approaches with spiral learning concepts,^19,42 where a LMS could connect different learning levels by linking related contents.

Some limitations have to be recognized for this study. As the answers had to be given online, this could have led to a non-response bias, attracting only participants interested in the internet.⁴³ In addition, this was a single-center survey, and that limits its generalizability. There might be a bias that it was mostly those things addressed or answered which were also represented at our medical school. To learn more about this issue, this survey should be repeated in a multi-center approach on a national or international level. Either way, students´ answers will be influenced by the experiences they made at their medical school only. As that could give additional objective information about the using behavior of tools provided in a LMS, analyses of students´ behavior and preferences when using the LMS should be included and addressed in future studies.

By providing organizational information and learning materials, a LMS can serve as a decisive component of a medical school to support the use of e-learning materials. In our study, the leading purpose to use the LMS was the acquisition of information about curricular contents, followed by learning for exams and the preparation and post-processing of seminars. Students wanted the LMS to support an efficient learning, with clear, practice-oriented contents, which are easy to use. Thus, we conclude that teachers should put more effort on the provision of fact-oriented contents than on a sophisticated design. However, interactivity and integration into face-to-face teaching are important aspects in the perception of e-learning tools and should be supported. Teachers should be aware that free online sources as Wikipedia enjoy a high approval as source of knowledge acquisition. As this is a serious issue for medical education, national associations of individual medical disciplines should consider editing online texts in an approved manner. Finally, students´ demand for remaining access to earlier learning materials could support the use of LMS and e-learning tools in the context of spiral learning concepts. The data presented here could serve as an empirical basis for medical schools to improve their offers in the field of digital learning for students.