2014; 36: 183–185
eMEDICAL TEACHER
Best possible or best available? RACHEL H. ELLAWAY
It has become commonplace, perhaps even predictable that we now habitually use a variety of digital technologies in contemporary medical education. How often though do we reflect on why it is that we are using them? For some there may be no choice in the matter; the use of this system or that tool is simply decreed from on high. For others, their main motivation may be curiosity as to whether something works or at least works better than the alternatives, and for others it may simply be the novelty of a particular technology or the ‘‘cool’’ factor that sets the wheels in motion. Setting aside these other motives for the sake of argument, we can consider two main reasons for choosing to use an educational intervention; that it is the best thing to do or that it is the best we can do in the circumstances. In most educational studies, it tends to be the former question that gets asked more often, despite the compromise question being rather closer and more applicable to the messy realities we all inhabit. This reflects a fundamental difference between efficacy and effectiveness research (Streiner & Norman, 2009), something that has long been under-reported in medical education research, particularly involving educational technologies (Ellaway et al., 2014). In this sixtieth edition of eMT, I will explore why it is we use different educational technologies and the value propositions that underpin these decisions.
Is it the best thing to do? Optimal educational interventions are typically defined in terms of particular cognitive affordances; there is something in what a learner does, who or what she does it with, or the frequency, duration or sequencing of what she does, that leads to better or more desirable learning outcomes. So when is technology-enhanced learning (with its many synonyms including TEL, e-learning, TBL and CAI) the best way to learn? Clearly digital technologies do not learn for a learner (although they can be used to extend a learner’s memory and recall), but they can support and enable different kinds of learning activities by acting as a tool or medium, and they can be used as a proxy for a teacher by presenting material and responding to learner input. The activities within which educational technologies are used are therefore a better focus for this kind of question. However, when the use of a digital technology is one part of an educational activity then the educational value attached to the technology can no longer
be considered to be an intrinsic property of the technology alone. The confusion between technologies and activities is, I would argue, exacerbated by the ‘‘widely varied, and often competing, value propositions as to [educational technologies’] ultimate purpose and worth’’ (Ham, 2010, p. 34). If it is difficult to evaluate the educational worth of educational technologies without considering the way they bind to the contexts in which they are used, then are there alternative ways of looking at why we use them? Taking an activity perspective allows us to consider the value of different educational activities that involve digital technologies as well as the broader but more complex concept of their effectiveness. One way to look at this is to consider the mapping between an educational task and the forms of professional practice that it is designed to help students to learn. Whether it is being used as a medium or tool, the value of using a technology for educational purposes is, at least in part, related to whether the practice task is also digitally based. In other words, there is presumably better validity for using computers or mobile devices to learn tasks that are also computer- or mobile-based such as those related to e-health or point-of-care information access. This does not mean that simply using a computer to learn a computer-based professional skill or task is the best way to learn it, but there is at least some expectation that the medium for learning is appropriate to the task in hand. It can also be difficult to make the case that using digital media is an optimal approach given learners’ general preference for authentic human experiences over artificial technology-mediated ones. The assumption that using digital technologies is in and of itself a motivating influence on contemporary medical students is misguided. In general, medical students expect to be able to use digital technologies when the moment is right but not have this detract from learning directly from their preceptors and patients. Technology provides an essential enabling perimeter to what remains (or perhaps is even reaffirmed) as an intrinsically human experience.
20 14
Introduction
Making the most of what you have If it is difficult to show that the use of educational technology is an optimal way to support teaching and learning (although not impossible), then what about the alternative, that digital technologies are the best available means to support teaching and learning? Although this rarely gets reflected in the literature, this has become, at least based on discussions with
Correspondence: Dr Rachel Ellaway, Assistant Dean Curriculum and Planning, Associate Professor, Acting Director of Simulation, Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON P3E 2C6, Canada. Tel: +1 705 662 7196; email: [email protected] ISSN 0142–159X print/ISSN 1466–187X online/14/020183– ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.874209
183
R. H. Ellaway
colleagues at many different institutions and on personal experience, a far more common reason for using educational technologies. We can consider at least two different arguments within this category. The first is one of compensation or compromise. This relates to situations where traditional models of teaching and learning are no longer viable. For instance, a lecturer may leave without a viable successor; in this case the lecture may be replaced with a computer tutorial. Another example is where a program’s class size expands beyond the physical space available to give face-to-face lectures so that plenary events need to be recorded or webcast. Moving to a distributed model with learners in multiple locations can lead to similar responses. Even the pursuit of the flipped classroom, in which didactic material is prerecorded and studied before face-toface teaching, is based on a limited supply of face-to-face teaching capacity. In this case technology does not have to be a superior solution, it just needs to be no worse than what went before and to solve these logistical challenges. The second argument is based on opportunity. This relates to the convenience of having a technological solution to hand. For instance, having a learning management system (such as Moodle or Blackboard) available, particularly if it represents a significant investment, can lead us to see solutions to problems in terms of what the available technologies and systems can do, even if this use is not a great fit. A common result of this approach is that only a few features of such systems end up being used. Similarly, there has been a growing interest in using mobile technologies for, in or around medical education, often, it would seem, as a response to the opportunity afforded by so many contemporary learners having their own smartphones. In this case, technology is not so much actively selected as used as a default option. The focus in each of these situations is rather more on the logistics and operations of medical education rather than on purely pedagogical or instructional strategies. As I noted earlier, technology typically serves as an enabler for educational activity rather than as the activity itself.
The value of online technology The use of the Internet tends to change the way we interact with each other and with the world around us. Internet technologies can hide, blur or flatten social conventions. They can provide exponential connectivity between people and the resources they use. They can accelerate the speed of users’ actions and responses. They can expand the reach of those using them, defeating geography and temporal barriers. In all of these circumstances Internet technologies can be used to track and record what those who use it do, increasing their accountability and challenging privacy and confidentiality. Activities that require or can benefit from these affordances may find that the use of digital technology is more of an optimal choice than a compromise, even if it is at an activity level rather than a cognitive one. For instance, the primary activity may be for learners to work in community settings using technology to let them continue to work with the people and resources of their medical school. Similarly it may be that teachers need to track the clinical encounters of their learners 184
in order to give them feedback and to guide their clinical learning, and technology can be used to enable this. There is still an element of compromise in both examples, but the reasons for use are more affirmative at the activity level, affording the opportunity for learners to work and communicate at a distance or for teachers to oversee and manage the learning. These ‘‘Internet powers’’ would seem to add value to learning and teaching at the activity and activity system level but rarely directly at the cognitive level.
Discussion I have argued that the value of educational technology can be hard to identify, let alone measure, at a purely cognitive level, but it has increasing levels of relevance and traction at the activity and activity system levels. The implication of this axiological argument is that we need to look afresh at medical education scholarship as a whole and consider the broad questions this poses. For instance, to what extent should we focus on pursuing and measuring the cognitive superiority of one method over another to the exclusion of considering different levels of organization around these methods in the learning environment and the emergent properties of these different levels? Educational activities and educational activity systems seem worthy of more attention than they currently receive. I would further argue that this is not just a matter of intellectual interest, but a root and branch response to the needs of medical teachers who are seeking guidance on how to organize their teaching and learning systems to best effect, reflecting the assertion that: ‘‘professional action in education is about making moral or value judgments – it is not so much about what appears to work in a general sense, but what is appropriate for these learners in these circumstances. The notion that a generic, what works intervention can replace normative professional judgment is flawed’’ (Romeo & Russell, 2010, p. 55). If medical education scholarship is to inform and guide the professional judgment of medical teachers, then it needs to acknowledge and be meaningful at these different levels of organization and emergence. For instance, guidance for teachers looking to use educational technologies needs to include the motivational as well as the cognitive dimensions of its use, not just for teachers but also for their learners. For example, learners typically value rich and authentic faceto-face experiences over digitally mediated ones but they want the digital on-hand, and their decisions to use educational technologies tend to be for prosthetic rather than educational reasons by extending their memory, reach and so on (Ellaway et al., 2013). It may be that educational technology is a proxy for all educational interventions and that the argument set out in this essay is applicable to much of medical education. I have neither the space nor the remit (at least in this column) to explore this at any length. Suffice it to say that any educational intervention, concept or practice is to some extent a technology, a deliberate artifice intended to act on the
Best possible or best available?
world. Developing a more reflexive and habitual consideration of educational activities and activity systems would be a starting point, as would a more systematic consideration of why it is we pursue some educational methods and not others. Let us hope that the moral and value judgments of all medical teachers will be better served by a more inclusive consideration of why it is that we do what we do.
Notes on contributor RACHEL ELLAWAY, PhD, is Assistant Dean Curriculum and Planning, Associate Professor, Acting Director of Simulation, Northern Ontario School of Medicine, Canada.
Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the article.
References Ellaway R, Pusic M, Yavner S, Kalet A. 2014. Context matters: Emergent variability in an effectiveness trial of online teaching modules. Med Educ (in press). Ellaway R, Fink P, Graves L, Campbell A. 2013. Left to their own devices: Medical learners’ use of mobile technologies. Med Teach 36:130–138. Ham V. 2010. Technology as Trojan horse; a ‘generation’ of information practice, policy and research in schools. In: McDougall A, Murnane J, Jones A, Reynolds N, editors. Researching IT in education; theory, practice and future directions. Abingdon: Routledge. Romeo G, Russell G. 2010. Why ‘what works’ is not enough for information technology in education research. In: McDougall A, Murnane J, Jones A, Reynolds N, editors. Researching IT in education; theory, practice and future directions. Abingdon: Routledge. Streiner DL, Norman GR. 2009. Efficacy and effectiveness trials. Commun Oncol 6(10):472–474.
185
Copyright of Medical Teacher is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
eMEDICAL TEACHER
Best possible or best available? RACHEL H. ELLAWAY
It has become commonplace, perhaps even predictable that we now habitually use a variety of digital technologies in contemporary medical education. How often though do we reflect on why it is that we are using them? For some there may be no choice in the matter; the use of this system or that tool is simply decreed from on high. For others, their main motivation may be curiosity as to whether something works or at least works better than the alternatives, and for others it may simply be the novelty of a particular technology or the ‘‘cool’’ factor that sets the wheels in motion. Setting aside these other motives for the sake of argument, we can consider two main reasons for choosing to use an educational intervention; that it is the best thing to do or that it is the best we can do in the circumstances. In most educational studies, it tends to be the former question that gets asked more often, despite the compromise question being rather closer and more applicable to the messy realities we all inhabit. This reflects a fundamental difference between efficacy and effectiveness research (Streiner & Norman, 2009), something that has long been under-reported in medical education research, particularly involving educational technologies (Ellaway et al., 2014). In this sixtieth edition of eMT, I will explore why it is we use different educational technologies and the value propositions that underpin these decisions.
Is it the best thing to do? Optimal educational interventions are typically defined in terms of particular cognitive affordances; there is something in what a learner does, who or what she does it with, or the frequency, duration or sequencing of what she does, that leads to better or more desirable learning outcomes. So when is technology-enhanced learning (with its many synonyms including TEL, e-learning, TBL and CAI) the best way to learn? Clearly digital technologies do not learn for a learner (although they can be used to extend a learner’s memory and recall), but they can support and enable different kinds of learning activities by acting as a tool or medium, and they can be used as a proxy for a teacher by presenting material and responding to learner input. The activities within which educational technologies are used are therefore a better focus for this kind of question. However, when the use of a digital technology is one part of an educational activity then the educational value attached to the technology can no longer
be considered to be an intrinsic property of the technology alone. The confusion between technologies and activities is, I would argue, exacerbated by the ‘‘widely varied, and often competing, value propositions as to [educational technologies’] ultimate purpose and worth’’ (Ham, 2010, p. 34). If it is difficult to evaluate the educational worth of educational technologies without considering the way they bind to the contexts in which they are used, then are there alternative ways of looking at why we use them? Taking an activity perspective allows us to consider the value of different educational activities that involve digital technologies as well as the broader but more complex concept of their effectiveness. One way to look at this is to consider the mapping between an educational task and the forms of professional practice that it is designed to help students to learn. Whether it is being used as a medium or tool, the value of using a technology for educational purposes is, at least in part, related to whether the practice task is also digitally based. In other words, there is presumably better validity for using computers or mobile devices to learn tasks that are also computer- or mobile-based such as those related to e-health or point-of-care information access. This does not mean that simply using a computer to learn a computer-based professional skill or task is the best way to learn it, but there is at least some expectation that the medium for learning is appropriate to the task in hand. It can also be difficult to make the case that using digital media is an optimal approach given learners’ general preference for authentic human experiences over artificial technology-mediated ones. The assumption that using digital technologies is in and of itself a motivating influence on contemporary medical students is misguided. In general, medical students expect to be able to use digital technologies when the moment is right but not have this detract from learning directly from their preceptors and patients. Technology provides an essential enabling perimeter to what remains (or perhaps is even reaffirmed) as an intrinsically human experience.
20 14
Introduction
Making the most of what you have If it is difficult to show that the use of educational technology is an optimal way to support teaching and learning (although not impossible), then what about the alternative, that digital technologies are the best available means to support teaching and learning? Although this rarely gets reflected in the literature, this has become, at least based on discussions with
Correspondence: Dr Rachel Ellaway, Assistant Dean Curriculum and Planning, Associate Professor, Acting Director of Simulation, Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON P3E 2C6, Canada. Tel: +1 705 662 7196; email: [email protected] ISSN 0142–159X print/ISSN 1466–187X online/14/020183– ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.874209
183
R. H. Ellaway
colleagues at many different institutions and on personal experience, a far more common reason for using educational technologies. We can consider at least two different arguments within this category. The first is one of compensation or compromise. This relates to situations where traditional models of teaching and learning are no longer viable. For instance, a lecturer may leave without a viable successor; in this case the lecture may be replaced with a computer tutorial. Another example is where a program’s class size expands beyond the physical space available to give face-to-face lectures so that plenary events need to be recorded or webcast. Moving to a distributed model with learners in multiple locations can lead to similar responses. Even the pursuit of the flipped classroom, in which didactic material is prerecorded and studied before face-toface teaching, is based on a limited supply of face-to-face teaching capacity. In this case technology does not have to be a superior solution, it just needs to be no worse than what went before and to solve these logistical challenges. The second argument is based on opportunity. This relates to the convenience of having a technological solution to hand. For instance, having a learning management system (such as Moodle or Blackboard) available, particularly if it represents a significant investment, can lead us to see solutions to problems in terms of what the available technologies and systems can do, even if this use is not a great fit. A common result of this approach is that only a few features of such systems end up being used. Similarly, there has been a growing interest in using mobile technologies for, in or around medical education, often, it would seem, as a response to the opportunity afforded by so many contemporary learners having their own smartphones. In this case, technology is not so much actively selected as used as a default option. The focus in each of these situations is rather more on the logistics and operations of medical education rather than on purely pedagogical or instructional strategies. As I noted earlier, technology typically serves as an enabler for educational activity rather than as the activity itself.
The value of online technology The use of the Internet tends to change the way we interact with each other and with the world around us. Internet technologies can hide, blur or flatten social conventions. They can provide exponential connectivity between people and the resources they use. They can accelerate the speed of users’ actions and responses. They can expand the reach of those using them, defeating geography and temporal barriers. In all of these circumstances Internet technologies can be used to track and record what those who use it do, increasing their accountability and challenging privacy and confidentiality. Activities that require or can benefit from these affordances may find that the use of digital technology is more of an optimal choice than a compromise, even if it is at an activity level rather than a cognitive one. For instance, the primary activity may be for learners to work in community settings using technology to let them continue to work with the people and resources of their medical school. Similarly it may be that teachers need to track the clinical encounters of their learners 184
in order to give them feedback and to guide their clinical learning, and technology can be used to enable this. There is still an element of compromise in both examples, but the reasons for use are more affirmative at the activity level, affording the opportunity for learners to work and communicate at a distance or for teachers to oversee and manage the learning. These ‘‘Internet powers’’ would seem to add value to learning and teaching at the activity and activity system level but rarely directly at the cognitive level.
Discussion I have argued that the value of educational technology can be hard to identify, let alone measure, at a purely cognitive level, but it has increasing levels of relevance and traction at the activity and activity system levels. The implication of this axiological argument is that we need to look afresh at medical education scholarship as a whole and consider the broad questions this poses. For instance, to what extent should we focus on pursuing and measuring the cognitive superiority of one method over another to the exclusion of considering different levels of organization around these methods in the learning environment and the emergent properties of these different levels? Educational activities and educational activity systems seem worthy of more attention than they currently receive. I would further argue that this is not just a matter of intellectual interest, but a root and branch response to the needs of medical teachers who are seeking guidance on how to organize their teaching and learning systems to best effect, reflecting the assertion that: ‘‘professional action in education is about making moral or value judgments – it is not so much about what appears to work in a general sense, but what is appropriate for these learners in these circumstances. The notion that a generic, what works intervention can replace normative professional judgment is flawed’’ (Romeo & Russell, 2010, p. 55). If medical education scholarship is to inform and guide the professional judgment of medical teachers, then it needs to acknowledge and be meaningful at these different levels of organization and emergence. For instance, guidance for teachers looking to use educational technologies needs to include the motivational as well as the cognitive dimensions of its use, not just for teachers but also for their learners. For example, learners typically value rich and authentic faceto-face experiences over digitally mediated ones but they want the digital on-hand, and their decisions to use educational technologies tend to be for prosthetic rather than educational reasons by extending their memory, reach and so on (Ellaway et al., 2013). It may be that educational technology is a proxy for all educational interventions and that the argument set out in this essay is applicable to much of medical education. I have neither the space nor the remit (at least in this column) to explore this at any length. Suffice it to say that any educational intervention, concept or practice is to some extent a technology, a deliberate artifice intended to act on the
Best possible or best available?
world. Developing a more reflexive and habitual consideration of educational activities and activity systems would be a starting point, as would a more systematic consideration of why it is we pursue some educational methods and not others. Let us hope that the moral and value judgments of all medical teachers will be better served by a more inclusive consideration of why it is that we do what we do.
Notes on contributor RACHEL ELLAWAY, PhD, is Assistant Dean Curriculum and Planning, Associate Professor, Acting Director of Simulation, Northern Ontario School of Medicine, Canada.
Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the article.
References Ellaway R, Pusic M, Yavner S, Kalet A. 2014. Context matters: Emergent variability in an effectiveness trial of online teaching modules. Med Educ (in press). Ellaway R, Fink P, Graves L, Campbell A. 2013. Left to their own devices: Medical learners’ use of mobile technologies. Med Teach 36:130–138. Ham V. 2010. Technology as Trojan horse; a ‘generation’ of information practice, policy and research in schools. In: McDougall A, Murnane J, Jones A, Reynolds N, editors. Researching IT in education; theory, practice and future directions. Abingdon: Routledge. Romeo G, Russell G. 2010. Why ‘what works’ is not enough for information technology in education research. In: McDougall A, Murnane J, Jones A, Reynolds N, editors. Researching IT in education; theory, practice and future directions. Abingdon: Routledge. Streiner DL, Norman GR. 2009. Efficacy and effectiveness trials. Commun Oncol 6(10):472–474.
185
Copyright of Medical Teacher is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
