Designing multimedia instruction in anatomy: An evidence‐based approach

MEDICAL AND DENTAL EDUCATION

Designing Multimedia Instruction in Anatomy:

An Evidence-Based Approach

RICHARD E. MAYER*

Department of Psychological and Brain Sciences, University of California, Santa Barbara, California

This paper summarizes 10 research-based principles for how to design effective

multimedia instruction in medical education involving anatomy. Clin. Anat.

33:2–11, 2020.

Key words: Anatomy; Medical Education; Multimedia

INTRODUCTION

Medical education sometimes involves multimedia

instructional lessons such as classroom slideshow lec-

tures, online presentations, and even computer-based

simulations. This article explores how the design of

multimedia lessons in medical education can beneﬁt

from applying the science of learning–that is, research

and theory on how people learn (Mayer, 2009a, 2010,

2018). The goal of this article is to describe 10 evi-

dence-based principles for the design of multimedia

instruction that are relevant to medical education in

anatomy, based on decades of research in our labora-

tory at the University of California, Santa Barbara

(UCSB) and from researchers around the world (Clark

and Mayer, 2017; Mayer, 2009b, 2014a).

Multimedia messages consist of words (in spoken or

printed form) and graphics (in static form such as

photos or diagrams or dynamic form such as video or

animation); multimedia instructional messages are

multimedia messages that are intended to cause

learning (Clark and Mayer, 2017; Mayer, 2009b, in

press). Figure 1 is an example of a multimedia instruc-

tional message because it contains printed words and

graphics and is intended to foster learning. Multimedia

instructional messages that are relevant to medical

education include textbooks (with printed words and

static graphics), face-to-face slideshow lectures (with

spoken words, printed words, and static or dynamic

graphics), and online presentations (with spoken or

printed words and static or dynamic graphics).

Our laboratory at UCSB has a long-standing com-

mitment to basic research on how to design effective

instructional messages about the human body, includ-

ing instruction about teeth (Stull et al., 2009, 2010),

the blood stream (Mayer et al., 2008; Mayer and

Estrella, 2014; Parong & Mayer, 2018), neural trans-

mission (Wang et al., 2018; Xie et al., in press), the

human heart and circulatory system (Leopold &

Mayer, 2015; Leopold et al., in press), the human ear

(Fiorella & Mayer, 2013), the human digestive system

(Mayer et al., 2008), and the human lungs and respi-

ratory system (Mayer et al., 2004; Mayer and Sims,

1994). This work contributes to the larger research

base on how to design multimedia instruction (Clark

and Mayer, 2017; Mayer, 2009b, in press).

Instructional technology has a long and somewhat

disappointing history, ranging from instructional

movies in the 1920s to instructional radio in the

1930s to educational television in the 1950s to pro-

grammed instruction in the 1960s, in which strong

claims are made for the power of the latest cutting-

edge instructional technology, major investments are

made, and subsequent research fails to demonstrate

much beneﬁt (Cuban, 1986, 2001; Saettler, 2004).

Today, we have new computer-based technologies

that allow for the creation of dazzling multimedia les-

sons – including slideshows, animation, and video –

but these technologies alone do not produce learning.

The history of instructional technology teaches us that

instructional technology does not cause learning, but

instead instructional methods cause learning (Clark,

2001). Instead of taking a technology-centered

approach that focuses on the capabilities of the latest

technology, it makes sense to take a learner-centered

approach that focuses on how to adapt technology to

*Correspondence to: Richard E. Mayer, Department of Psycho-

logical and Brain Sciences, University of California, Santa Bar-

bara, California 93106.

E-mail: mayer@psych.ucsb.edu

Received 17 August 2018; Accepted 17 August 2018

Published online 21 November 2018 in Wiley Online Library

(wileyonlinelibrary.com). DOI: 10.1002/ca.23265

Clinical Anatomy 33:2–11 (2020)

the requirements of how the human information pro-

cessing system works (Mayer, 2009b).

Thus, the present article takes an evidence-based

approach in which we seek to determine which instruc-

tional techniques have been shown to improve learning

from multimedia messages in line with cognitive theo-

ries of learning. Four major steps in creating effective

multimedia instruction suitable for medical education

are: (1) Start with a clear instructional goal for the

instructional message. (2) Help learners focus on the

instructional message by reducing extraneous proces-

sing. (3) Help learners encode the instructional mes-

sage by managing essential processing. (4) Help

learners engage with the instructional message by fos-

tering generative processing. These steps are explored

in the remainder of this article.

START WITH A CLEAR INSTRUCTIONAL

GOAL FOR THE INSTRUCTIONAL

MESSAGE

The ﬁrst step in effective instructional design is to

clearly state your instructional objective (Anderson et al. ,

2001; Mayer, 2011; Pellegrino et al. , 2001). As noted in

Mayer (2011), an instructional objective is a description

of the intended change in the learner’sknowledge.An

instructional objective includes a description of what is to

be learned and how it will be tested. In short, you should

be able to describe the knowledge that you want the

learner to glean from the instructional message.

For example, consider the slide shown in Figure 1,

showing some basic anatomic information about the

human brain. Your instructional objective might be

that the learner knows the names and locations of

each of several key brain areas, and this can be tested

by pointing to each area and asking the learner to say

the name of the brain area. When you have a clear

statement of your instructional objective, this can

guide the creation of an effective instructional

message - which is a slide in this case.

In this example, the instructional goal is for the

learner to know the spatial layout of the brain - which is

a focus on structur al knowledge (e.g. , Where is the X?).

In contrast, the instructionalgoalcouldbetounderstand

how the brain works – which is a focus on process

knowledge (e.g. , What happens in the brain when some-

one tries to remember their phone number?). Alterna-

tively, the instructional goal could be to know about the

characteristics of each part of the brain – which is a focus

on factual knowledge (e.g., What does X do?). Thus, the

way you create the instruction message depends on the

type of knowledge you want the learner to acquire.

Once you have a draft of the instructional message

that conveys the target information, you have not com-

pleted your job as an instructor. In addition to presenting

the target information, your job as an instructor is to

guide the learner’s cognitive processing of the material.

This can be done by following evidence-based principles

for the design of multimedia instructional messages

(Clark and Mayer, 2017; Mayer, 2009b, 2014a, in press).

I break this task of guiding the learner’scognitiveproces-

sing into three sub-tasks: helping the learner focus on

the target information, helping the learner mentally rep-

resent the target information, and encouraging the

learner to make sense of the target information.

In the next three sections, I provide some evidence-

based techniques for accomplishing these sub-tasks.

The supporting evidence consists of studies that com-

pare the learning outcome scores on posttest of groups

of students who learn from a standard lesson versus the

same lesson with one feature added, such as a lesson

on the human respiratory system with words spoken in

formal language or conversational language. In inter-

vention stu dies such as these, differences between the

groups is often expressed as effect size (d), which is the

number of standard deviations better (or worse) that

the enhanced group did on the post-test as compared to

the control group (Cohen, 1988). Effect size provides a

common metric to aggregate across studies, with effect

sizes greater than d = 0.4 considered to be education-

ally signiﬁcant (Hattie, 2009).

HELP LEARNERS FOCUS ON THE

INSTRUCTIONAL MESSAGE BY

REDUCING EXTRANEOUS PROCESSING

In terms of guiding cognitive processing, we want

instructional techniques that guide the learner toward

processing of the target information in the instructional

message. Learners have a limited working memory

capacity, which means they can only process a few

pieces of information at any one time (Mayer, 2009b,

2011). If they use their limited capacity on extraneous

processing – cognitive processing that does not sup-

port the instructional goal – they are less likely to focus

on the target information. Thus, a primary goal in

designing effective multimedia messages is to reduce

extraneous processing. In this section, we explore ﬁve

techniques for reducing extraneous processing: the

coherence, signaling, spatial contiguity, temporal con-

tiguity, and redundancy principles.

Fig. 1. A slide show-

ing six brain regions.

Multimedia Instruction in Anatomy 3

Coherence Principle

For example, consider a situation in which the

screen is of full of interesting but irrelevant graphics

and factoids, such as shown in Figure 2a. If the

learner spends time focusing on these aspects of the

slide, there is less cognitive capacity available to

focus on the names and locations of the major brain

areas. In contrast, Figure 2b shows a revised version

of the slide in which the irrelevant material has been

weeded out. In a recent review, in 23 out of 23 experi-

mental comparisons, students performed better on

learning outcome tests with multimedia lessons that

eliminated extraneous material, yielding a median

effect size of 0.86, which is considered a large effect

(Mayer and Fiorella, 2014). This effect is strongest for

learners with smaller working memory capacity, when

the extraneous material is highly distracting, and

when the pace of the lesson is controlled by the

instructor rather than the learner (Mayer and Fiorella,

2014; Rey, 2012). In summary, the coherence princi-

ple is that people learn better from a multimedia

instructional message when extraneous material is

eliminated.

Signaling Principle

If you cannot completely eliminate the extraneous

material, the next best strategy is to highlight the

essential material. For example, if there is a lot of

nonessential printed text on the screen, you can high-

light the essential material, such as putting it in bold

font, underlining it, giving it a different color, or

Fig. 2. (a) Slide with extraneous material. (b) Slide without extraneous material.

[Color ﬁgure can be viewed at wileyonlinelibrary.com]

4 MAYER

repeating it in the margin. If there is a lot of nones-

sential spoken text in the narration, you can highlight

the essential material by speaking it with higher vol-

ume or more stress. If there are many nonessential

graphical elements on the screen in an animation or

video or even in a static graphic, you can highlight the

essential material through spotlighting in which you

gray out all the other areas except for the area being

described in the narration or by cueing the relevant

area on screen with an arrow or with distinctive color-

ing. Figure 3a shows an example of a slide on regions

of the human brain, in which a narration describes

each region in turn. In Figure 3b, the region being

described by the narration is circled, as a form of cue-

ing. In a recent review, in 24 out of 28 experimental

comparisons, students performed better on learning

outcome tests with multimedia lessons that signaled

essential material, yielding a median effect size of

0.41, which is in the small-to-medium range (Mayer

and Fiorella, 2014). The signaling effect was also

found in a more recent meta-analysis involving

103 studies (Schneider et al., 2018). This effect may

be strongest for students who lack prior knowledge,

when the display is complicated, and when signaling

is used sparingly. In summary, the signaling principle

is that people learn better from a multimedia instruc-

tional message when essential material is highlighted.

Spatial Contiguity Principle

Consider the slide shown in Figure 4a, which

involves the common practice of using a legend that

is keyed to parts of a graphic. Similarly, it is common

to have a caption at the bottom of a graphic. What is

wrong with these situations in which the words are

separated from the graphics they describe? The prob-

lem is that legends and captions can create extrane-

ous processing, in which the learner must scan back

and forth between the printed words and the corre-

sponding part of the graphic. This wastes precious

processing capacity that could have been used for try-

ing to encode and make sense of the material. To alle-

viate this design ﬂaw, we can move the printed words

next to the corresponding part of the graphic, as

shown in Figure 4b. This makes it easier for the

learner to build connections between corresponding

words and graphics, as has been shown in eye-

tracking studies (Johnson and Mayer, 2012). In a

recent review, in 22 out of 22 experimental compari-

sons, students learned better when corresponding

printed words and graphics were near each other on

the screen, yielding a median effect size of 1.10,

which is a large effect (Mayer and Fiorella, 2014). A

more recent meta-analysis of 58 studies also found

strong evidence for the spatial contiguity effect

(Schroeder and Cenkci, in press). The effect may be

strongest for students who lack prior knowledge and

when the material is complicated. In summary, the

spatial contiguity principle is that people learn better

from a multimedia instructional message when corre-

sponding printed words and graphics are placed near

each other on the screen.

Temporal Contiguity Principle

Consider an instructional episode in which an

instructor ﬁrstexplainswhatthestudentsareabout

to see in a brief animation on how one neuron com-

municates with another, and then th e inst ructor

shows the animation. In terms of multimedia learn-

ing theory, this is a problematic approach because

the learner’s working memory is too limited to be

able to hold the entire verbal explanation so it is

available when the animation i s presented. By sepa-

rating corresponding words and graphics in tim e, th e

instructor is reducing the chances that the learner

will be able to make connections between them in

working memory. The solution is to present corre-

sponding graphics and spoken words simultaneou sly.

In nine ou t of nine experimental comparisons, stu-

dents who received multi media lessons with simulta-

neous words and graphics scored higher on learning

outcome posttests than students who received

Fig. 3. (a) Slide with-

out cueing. (b) Slide with

cueing. [Color ﬁgure can

be viewed at wileyonline

library.com]

Multimedia Instruction in Anatomy 5

lessons with corresponding words and graphics sepa-

rate d in time, yieldi ng a median effect size of 1.22,

which is a large effect (Mayer and Fiorella, 2014).

The effect is strongest when the segments are large

and the pacing is not controlled by the learner. Anal-

ogous to the spatial contiguity princi ple, the tempo-

ral conti guity principle is that p eople learn better

from multimedia instructional messages when corre-

sponding graphics and narration are presented

simultaneo usly.

Redundancy Principle

Suppose you have a narrated animation on how

the human respiratory and circulatory systems work.

You might suppose that it would be useful to add

concurrent printed text at the bottom of the screen

tha t is identical t o the spoken text, so that learners

could have the option of reading or listening. How-

ever, in terms of multimedia learni ng theory, having

redundant spoken and printed text can create extra-

neous processing because learner s may try to recon-

cile the spoken and printed streams of words or they

may have to scan back a nd forth between the cap-

tions and the a nimation (Mayer, 2009b; Mayer and

Fiorella, 2014). In 16 out of 16 experimental com-

parisons, students l earned better from graphics and

narration than from graphics, narration, and on-

screen text, with a media n effect size of 0.86, which

isalargeeffect.Someimportantexceptionsarethat

it can be helpful to add just one or two basic printed

words to a narrated animation (Mayer and Johnson,

Fig. 4. (a) Slide with legend. (b) Slide with text integrated into graphic.

6 MAYER

2008) or to restate the printed sentence in a differ-

ent way than the spoken one (Yue et al., 2013); al so,

printed text is useful when the words are technical or

unfamiliar or not in the learner’s ﬁrst langu age

(Mayer and Fiorella, 2014). In summary, the redun-

dancy principle is that people learn better from mul-

timedia instructional messages containing graphics

and narration rather than graphics, narration, and

on-screen text.

HELP LEARNERS ENCODE THE

INSTRUCTIONAL MESSAGE BY

MANAGING ESSENTIAL PROCESSING

Suppose you have designed your instructional

materials so they achieve the goal of reducing extra-

neous processing by using some of the techniques

described in the previous section. The next important

step in guiding cognitive processing is to encourage

learners to mentally represent the essential material

from the lesson in their working memory, a process

that is called essential processing (Mayer, 2009b,

2011). In some cases, when the essential material is

complex for the learner, the amount of essential

material required for learning may threaten to over-

whelm the learner’s limited working memory capacity.

Thus, a primary goal in designing effective multimedia

messages is to manage essential processing. In this

section, we explore three techniques for managing

essential processing: the segmenting, pretraining,

and modality principles.

Segmenting Principle

Suppose you have a long multimedia lesson,

explaining the regions of the brain. We could present

a single, complete graphic showing the entire system

and describe it with a complete continuous verbal nar-

ration, as shown in Figure 5a. The problem with this

approach to instructional design is that presenting all

the information at once in a fast-paced narrated ani-

mation may overwhelm the learner’s processing

capacity. A solution is to break the lesson into basic

segments, each covering one main idea; the lesson

could stop after each segment and continue when the

student presses a CONTINUE key, as shown in

Figure 5b. In this way, the student can completely

digest one portion of the lesson before moving on to

the next one. In a recent review, in 10 out of 10 exper-

imental comparisons, students learned better when a

multimedia message was presented in learner-paced

segments rather than as a continuous presentation,

yielding a median effect size of 0.79, which

approaches a large effect (Mayer and Pilegard, 2014).

The effect is stronger for students with low prior

knowledge or low working memory capacity, and

when the segments are small. In summary, the seg-

menting principle is that people learn better when a

multimedia instructional message is broken into

learner-paced segments.

Pretraining Principle

Instead of breaking a complicated lesson into parts

that are presented under learner control, another way

to manage essential processing is to provide pretrain-

ing in the names and characteristics of the key com-

ponents. For example, before viewing a narrated

animation on the process of neural transmission, stu-

dents could be shown a diagram of the entire system

with each component labeled. When the student

clicks on a component, that component is spotlighted

and a brief animation shows what that component

does, while words describe the component’s behavior.

In a review of studies involving pretraining, adding

pretraining before a multimedia presentation

improved learning outcome test scores in 13 out of

16 experimental comparisons, yielding a median

effect size of 0.75, which approaches a large effect

(Mayer and Pilegard, 2014). The effect may apply

mainly to students who lack prior knowledge. In sum-

mary, the pretraining principle is that people learn

better from multimedia instructional messages when

they know the names and characteristics of the key

components.

Modality Principle

Consider what can happen when students view a

fast-paced multimedia lesson containing graphics and

printed words, such as exempliﬁed in Figure 6a. This

situation can create split attention in which students

cannot be viewing the graphic when they are reading

the caption and cannot be reading the caption when

they are viewing the graphic. In short, the visual

channel may become overloaded. As exempliﬁed in

Figure 6b, a solution to this problem is to off-load the

verbal material from the learner’s visual channel to

the learner’s auditory channel, by presenting the

words as spoken text (i.e., narration) rather than

printed text (i.e., captions). Humans have separate

information processing channels for processing

images (through the eyes) and sounds (through the

ears), so presenting words as spoken text frees up

capacity in the visual channel and makes more effec-

tive use of the auditory channel (Mayer, 2009b; Mayer

and Pilegard, 2014). In a review, students scored

higher on learning outcome tests when the words in a

multimedia lesson where changed from printed to

spoken text in 53 out of 61 experimental compari-

sons, yielding a median effect size of 0.76, which

approaches a large effect (Mayer and Pilegard, 2014).

There are cases in which the modality effect does not

occur, but these are consistent with multimedia learn-

ing theory: when the material is simple for the

learner, when the pacing of the material is under

learner control, when the words are highly familiar for

the learner, and when the learner has high prior

knowledge (Mayer and Pilegard, 2014). In summary,

the modality principle is that people learn better from

a multimedia instructional message when the words

are spoken rather printed.

Multimedia Instruction in Anatomy 7

HELP LEARNERS ENGAGE WITH THE

INSTRUCTIONAL MESSAGE BY

FOSTERING GENERATIVE PROCESSING

Even if students are able to encode the essential

material from a multimedia lesson and even if they

have cognitive capacity available because they have

not engaged in extraneous processing, they may not

exert the effort to understand the lesson. Thus, the

third instructional design goal is to motivate learners

to try to make sense of the essential material – a pro-

cess that can be called generative processing (Mayer,

2009b, 2011; Fiorella and Mayer, 2015). Generative

processing involves mentally organizing the material

into a coherent structure and integrating it with rele-

vant prior knowledge. Two instructional design tech-

niques intended to foster generative processing are

personalization and embodiment.

Personalization Principle

Consider the portion of a script for a narrated ani-

mation on the brain listed in the top of Table 1. As you

can see, the wording is in formal style, as indicated,

for example, by the use of third person constructions

(e.g. “the frontal lobe is located in the front of the

brain”). Learners can interpret formal wording as

meaning that the instructor does not care about

them, and therefore, the learner may not feel much of

a social partnership with the instructor. In contrast, as

exempliﬁed in the bottom of Table 1, suppose we

change the wording into conversational style, as indi-

cated by using ﬁrst and second person constructions

(e.g., “your frontal lobe is located in the front of your

brain”). The use of conversational language (which

can be called personalization) is a social cue that can

prime a feeling of social partnership between the

learner and instructor, which motivates the learner to

Fig. 5. (a) Slide from continuous presentation. (b) Slide from segmented

presentation.

8 MAYER

try harder to make sense of what the instructor is

communicating, and thereby improves the learning

outcome (Mayer, 2014b). In a recent review, using

conversational wording in multimedia lessons

improved learning outcome test scores in 14 out of

17 experimental comparisons, yielding a median

effect size of 0.79, which approaches a large effect.

Ginns et al. (2013) reported a similar effect in their

meta-analysis of personalization. The effect is stron-

gest for students who have low prior knowledge or

low achievement, and for short lessons. In summary,

the personalization principle is that people learn bet-

ter from a multimedia instructional message when

the words are in conversational style.

Embodiment Principle

Suppose a student is watching a video of a class-

room lecture in which an instructor narrates a slide-

show, or an animation in which an onscreen animated

character (i.e., animated pedagogical agent) narrates

a slideshow. This can be a somewhat alienating

Fig. 6. (a) Slide with printed text. (b) Slide with spoken text.

TABLE 1. Partial Script for Multimedia Lesson on the Brain

Formal Version

“The frontal lobe is located in the front of the brain. It is involved in reasoning, problem solving, movement, and

planning.”

Personalized Version

“Your frontal lobe is located in the front of your brain. You are using your frontal lobe when you reason, solve a

problem, engage in movement, or make a plan.”

Multimedia Instruction in Anatomy 9

experience that causes the learner to disengage from

the lesson. What can we do to prime the learner to

process the material more deeply, that is, to engage

in generative processing? One technique involves put-

ting the instructor (or agent) on the screen next to

the slide and making sure he or she engages in

human-like gesture, body movement, facial expres-

sion, and eye-contact. According to theories of multi-

media learning, when the instructor displays high

levels of embodiment (such as human-like gesture),

the learner is more likely to form a social partnership

with the instructor, and try harder to make sense of

what the instructor is saying (Mayer, 2014b). In a

review, Mayer (2014b) reported that in 11 out of

11 experimental comparisons, students learned bet-

ter from a multimedia lesson when the onscreen

instructor or agent displayed human-like gesture and

movement, yielding a median effect size of 0.36,

which is in the small-to-medium range. More recently,

Wang et al. (2018) found that pointing gestures can

be particularly helpful, suggesting that the signaling

principle may also come into play. In summary, the

embodiment principle is that people learn better from

a multimedia instructional message when the onsc-

reen instructor engages in human-like gesturing,

movement, eye-contact, and facial expression. This

applies both to human instructors as well as animated

agents that appear on the screen.

APPLYING MULTIMEDIA DESIGN

PRINCIPLES TO MEDICAL EDUCATION

Table 2 summarizes ten evidence-based principles

for designing multimedia instruction. As you can see,

research on multimedia message design has implica-

tions for medical education, including in anatomy, but

is there any evidence from actual medical class-

rooms? For example, suppose we took a slideshow

lecture from an actual class in medical school and

redesigned the slideshow lecture based on the

instructional design principles described in this article.

In a series of experiments intended to address this

question, medical students who learned from a rede-

signed slideshow lecture scored substantially higher

on immediate and delayed post-tests than medical

students who learned the same material in its original

format, with effect sizes in the large range (Issa et al.,

2013; Issa et al., 2011). This work encourages us to

continue to explore the potential beneﬁts of applying

evidence-based design principles to the design of

multimedia instructional lessons in medical education,

including anatomy.

ACKNOWLEDGMENT

Preparation of this article was supported by grant

N00141612046 from the Ofﬁce of Naval Research.

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TABLE 2. Ten Evidence-Based Principles for Designing Multimedia Instruction

1. Coherence principle: Remove extraneous material.

2. Signaling principle: Highlight essential material.

3. Spatial contiguity principle: Place printed text next to the corresponding part of the graphic.

4. Temporal contiguity principle: Present corresponding narration and graphics at the same time.

5. Redundancy principle: Present graphics and narration rather than graphics, narration, and on-screen text.

6. Segmenting principle: Break a continuous presentation into learner-paced segments.

7. Pretraining principle: Describe the names and characteristics of key components before presenting a multimedia

lesson.

8. Modality principle: Present words in spoken form rather than printed form.

9. Personalization principle: Use conversational language style.

10. Embodiment principle: Show an instructor who uses human-like gesture, eye-gaze, and movement.

10 MAYER

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