This article was downloaded by: [Memorial University of Newfoundland] On: 04 August 2014, At: 01:01 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
Educational Technology in Medical Education a
b
Heeyoung Han , David S. Resch & Regina A. Kovach
b
a
Department of Medical Education , Southern Illinois University School of Medicine , Springfield , Illinois , USA b
Department of Internal Medicine , Southern Illinois University School of Medicine , Springfield , Illinois , USA Published online: 18 Nov 2013.
To cite this article: Heeyoung Han , David S. Resch & Regina A. Kovach (2013) Educational Technology in Medical Education, Teaching and Learning in Medicine: An International Journal, 25:sup1, S39-S43, DOI: 10.1080/10401334.2013.842914 To link to this article: http://dx.doi.org/10.1080/10401334.2013.842914
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Teaching and Learning in Medicine, 25(S1), S39–S43 C 2013, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2013.842914
Educational Technology in Medical Education Heeyoung Han Department of Medical Education, Southern Illinois University School of Medicine, Springfield, Illinois, USA
David S. Resch and Regina A. Kovach
Downloaded by [Memorial University of Newfoundland] at 01:02 04 August 2014
Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, Illinois, USA
This article aims to review the past practices of educational technology and envision future directions for medical education. The discussion starts with a historical review of definitions and perspectives of educational technology, in which the authors propose that educators adopt a broader process-oriented understanding of educational technology. Future directions of e-learning, simulation, and health information technology are discussed based on a systems view of the technological process. As new technologies continue to arise, this process-oriented understanding and outcome-based expectations of educational technology should be embraced. With this view, educational technology should be valued in terms of how well the technological process informs and facilitates learning, and the acquisition and maintenance of clinical expertise. Keywords
As McLuhan viewed,4 given technology’s role as a message and translator, it is necessary to reflect on what experiences and meaning ET in medical education has contributed in the past in order to further advance medical education practices for the future. This article starts with a historical and interdisciplinary understanding of the concepts of ET. Then, we review ET practice and its empirical evidence in medical education, which will entail a critical analysis of current and previous views and dialogue about the role of ET in medical education. With this review of past ET practices, we attempt to project future directions for how ET may facilitate constructive changes in medical education.
educational technology, medical education
INTRODUCTION A valuable approach for medical education is to continuously and constructively reevaluate current practices in order to discover innovations and reforms that result in a more effective educational process as measured by learners, schools, and society.1,2 Advances in information and networking technology have led educators to rethink educational practices and integrate technological processes for educational innovations.1 However, scholarly dialogue on educational technology (ET) innovations in medical education has decreased in the last 25 years.3 This declining trend in education research has occurred despite ET increasingly permeating medical education practice. Examples include virtual patient cases, technologyenhanced simulation, computer-based assessments, two- and three-dimensional anatomy instruction, audience response systems, asynchronous learning activities, and digitized patient and educational materials.
Correspondence may be sent to Heeyoung Han, Department of Medical Education, SIU School of Medicine, 913 North Rutledge Street, Springfield, IL 62794-9681, USA. E-mail: [email protected]
HISTORICAL UNDERSTANDINGS OF EDUCATIONAL TECHNOLOGY Since Sydney Pressey’s introduction of testing machines in 1920 and Skinners’ teaching machine in 1958,5 the notion of ET, often interchangeably called instructional technology, has gone through several conceptual shifts.6 In earlier times, the field simply focused on the use of devices and audiovisual media for augmenting educational activities. As the discipline evolved, the initial attention on machines and products was challenged and conceptually extended to include a process view.7 This broadened view involves acknowledging ET as technological processes and open systems8 that represent wholeness of meaningful activities and applications of principles and theories for desired learning outcomes in continuous feedback loops.7,9 By adopting this systems view of instruction, the concept of ET evolves toward creation and management of technological processes. A systems view also includes a conceptual shift of learning in which ontological and epistemological understanding of knowledge and learning is extended from a sensory and authoritative view to one valuing an individual’s content specific experiences and tacit knowledge in defining educational technology. Thus the Association of Educational Communications and Technology articulated an inclusive definition of ET:6 “The study and ethical practice of facilitating learning and
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H. HAN, D. S. RESCH, R. A. KOVACH
improving performance by creating, using, and managing appropriate technological process and resources” (p. 1). In medical education, the prevailing understanding of ET has been the notion of technology as a product or a device and ET practices focused on ‘using’ technology.10–12 Engel defined ET as “technology in education and technology of education” (p. 771).10 In his view, ET was a technical device as a carrier of information and an aid to experience. This view of ET in medical education has continued in recent practice. Gunderman et al.11 viewed ET in radiologic education “as the use of information processing and communications technology to support education”(p. 1). In identifying educational technology infrastructure in medical schools, Kamin et al.12 also defined ET “as electronic and other forms of technology used to support teaching and learning. These include but are not restricted to computer-based learning programs, computerized mannequins, instructional Web sites, video/audio production, application development, and online course management” (p. 632). While the concept of ET has evolved toward a systems view of the technological process, the scope of educational technology in medical education has remained narrow and focused on the use of devices and computing programs to aid in the delivery of instructional information and resources.13 This conceptual gap in approaching ET may limit the practice and research of ET in medical education to adopting a certain technology for curriculum purposes rather than creating holistic learning process of meaningful activities and managing systemic technological processes. This process permits not only the facilitator of an instructional session to affect outcomes but also promotes a setting for learners to adapt and define their learning communities.14
THE ROLE OF EDUCATIONAL TECHNOLOGY IN MEDICAL EDUCATION The role of ET in medical education has been discussed for the last couple of decades.11,15–20 Reflections on the use of ET in medical education have evolved as medical educators tried to address pedagogical challenges, curriculum efficiency, and effectiveness. Identifying challenges in medical education caused by an information explosion, the need for lifelong learning, and decreased teaching opportunities in ambulatory practice, Barnett15 proposed the use of computers in medical education as a pedagogical approach to address the challenges. He saw the value of information technology in medical education especially as a tool for medical knowledge search, creating electronic documents, recording and indexing multimedia medical content, and interactive simulations including assessments. Mooney and Bligh17 also viewed the opportunities of technology use, particularly as a tool for multimedia presentation of medical content and information access through internet. Criticizing traditional training models in radiology relying on textbooks and apprenticeship models, Gunderman et al.11 argued that educational technology can create an anytime, anywhere, and interactive learning experience.
One of the major educational technology practices in medical education is e-learning.12 E-learning is also called web-based learning, online learning, or computer-based learning13 that includes online synchronous and asynchronous communication, learning management systems, and web-based multimedia to represent online lectures, virtual patients, self-assessments, and feedback.21 Evaluation studies discovered that students have positive attitudes toward e-learning and that e-learning methods had similar effects as traditional teaching on knowledge and skills.21–23 In a meta-analysis, Cook, Levinson, and Garside24 found no difference in time and learning efficiency between e-learning and noncomputer instruction. Acknowledging the advantages regarding e-learning, increasing attention has been paid to instructional design features that explain the effectiveness of e-learning rather than the instruction delivery medium itself.24–26 Simulation technology is another form of technology that has been used to address limited patient availability, infrequent occurrence of critical disease processes, faculty time flexibility, and outcome-based medical education needs within a pertinent contextual framework.27 Technology-enhanced simulation in medical education includes diverse modalities such as computer-based virtual reality simulators, computerized mannequins, microworlds, interactive simulations and games, and task trainers.28,29 Simple use of standardized patients or static mannequins without computerized capabilities is not considered technology-enhanced simulation. Reports studying the effectiveness of simulation technology have been published since the late 1960s, but the bulk of published work regarding simulation technology has been since 2008.30 Overall, the focus of simulation technology has been in undergraduate and graduate medical education where its applications have rapidly grown in the past 10 years, rather than in the realm of continuing education for practicing health professionals where its use is just starting to increase.31 The most common current applications of technologyenhanced simulation involve instruction in technical skills such as laparoscopic procedures, anesthesia and surgical skills, and physical examination skills, team and leadership skills, clinical reasoning, emergency resuscitation, and management. In addition to instruction, and despite scant validity evidence for simulation-based assessments,28 technology-enhanced simulation is commonly used to assess those skills trained, usually by observers who determine global ratings of performance for formative assessments, and rarely for making judgments for validation or certification purposes.32 In its current state, simulation in medical education is largely used for the purposes of training and assessment27 and much less so for quality improvement and research; it has yet to evolve into an organizational improvement tool.32 Recent meta-analyses have reported that simulation technology improves learning outcomes compared to no training, but evidence that it improves patient outcomes is modest at best.30,33,34 Following passage of the Affordable Care Act, health information technology (HIT) such as electronic health records
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(EHR) has played a pivotal role in patient care. HIT has been recently discussed as an important emerging ET in medical education for knowledge acquisition, decision support, and quality improvement.15,35–38 The HIT/EHR process reflects the education system in that large volumes of data are provided that need to be sorted and prioritized into a coherent cognitive structure for application to a given clinical problem.39 Helping students and faculty understand the strengths and weaknesses of these products is an ongoing issue. ET in medical education is not limited to those topics just discussed, yet these technologies represent an overall picture of the experience and messages that have been created in medical education. As a recent report identified, new ET will continuously emerge and change the pedagogical landscape of medical education.20 Consequently, it is important to reflect on the potential ways that ET will broaden and enhance the experience in medical education. WHERE ARE WE GOING? In this section, we attempt to envision the future directions of ET in medical education. First, we propose that medical educators embrace a broader concept of ET that is based on a systems perspective.6,8 Then we discuss the future of e-learning with a notion of lean medical education. Last, simulation and HIT are briefly discussed. Embracing a Broader Concept of ET With the publication of the Institute of Medicine’s Crossing the Quality Chasm,40 medicine has moved firmly onto a path of creating a system of transparently reported, process, and outcome-measurements dependent upon access to and application of large volumes of data with the goals of improving patient care and safety. This systematic shift in medicine requires medical education to adapt, including the technology it employs. Considering this shift and the process-oriented ET definition from the Association of Educational Communications and Technology discussed earlier,6,9,40 we propose ET in medical education is conceptualized as a process-oriented and systems-based pedagogical approach for facilitating learning and improving performance in patient care by the integrated mode of creating, using, and managing technological process and resources. ET should not be limited to the use of technical devices or tools but extended toward wholeness of technological systems where learning and performance are facilitated and improved for better patient care through continuous feedback loops. The importance of the need for continuous feedback is best exemplified by the American Board of Medical Specialties’ Maintenance of R 41 ). ABMS MOC aims Certification Program (ABMS MOC for physicians’ commitment to lifelong learning in a specialty through ongoing assessment of six core competencies defined by ABMS and ACGME in 1999. By including feedback systems, ET will have to incorporate developing both tacit knowledge (personal experience) and explicit knowledge (evidence), hopefully best knowledge that
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has a meaningful impact on patient care. Facilitating the continued interaction of a physician’s tacit and explicit knowledge while developing insight concerning this interaction will be a significant focus of future educational technology.42 All the formative and summative technological processes just delineated will need to be integrated into a coherent stream of performance data that serves as the basis of lifelong learning to help guide each learner across their entire professional career. Educational instruction including technology will need to be standardized but individually applied. Standardization of Resources and Individualization of Instructions Experiences with the flipped classroom, Khan Academy, and massive open online courses (MOOCs), have led educators to have high expectations that educational practices will improve with the use of technology. Although some of these approaches may appear to be simple, such as video podcasts of lectures followed by in-person interactive discussions, from a broader systems perspective, such models are fundamentally systemic processes that facilitate the notion of ‘lean’ in higher education.43 The concept of lean higher education represents continuous improvement by identifying and eliminating root causes of waste and inefficiency through value streaming maps.43 MOOCs and the Khan Academy demonstrate that lectures and courses are becoming shared instructional products.44,45 Students can freely access quality online lectures provided by highly regarded and accredited institutions anytime and anywhere.45 Thus, using instructors’ and learners’ time for creating and passively listening to lectures translates into nonvalue added steps in the value streaming maps. It would be a waste for all medical schools to create and deliver similar courses on Anatomy 101 in a traditional classroom given that the same credited course is available online at no cost. This emerging trend of sharing online massive courses among institutions has the potential to change the fundamental equation of teaching and learning in medical education by reducing the cost of redundant instructional products and knowledge transmission, and at the same time enhancing the quality of teaching and learning.45 A recent report also made a recommendation for national-level collaboration and leadership to create and share resources in medical education.20 Then, the real question for medical educators will become how to evaluate students’ progress, identify students at risk and address their study needs through individualized and customized instruction, which becomes a value-added process to achieve learning goals. Evolution of instructional courses, from closed locally created traditional lectures through e-learning and OpenCourseWare, eventually to MOOCS, does not only mean the use of multimedia technology to deliver lecture content but also creating the technological processes that facilitate value-added individualized instruction and learning experience. Technological processes incorporating customized instructional interactions through learning analytics, assessments, and meaningful
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feedback will be the future trend of educational technology practice and research to achieve lean medical education. This trend is not limited to undergraduate and graduate medical education but can extend to continuing medical education in terms of monitoring and addressing an individual physician’s lifelong learning. Simulation Integration with Competence Dashboard for Deliberate Practice The future of simulation technology can be envisioned by revisiting the original rationale of simulation, competence-based medical education. Simulation technology is not a simple use of simulators but involves creating opportunity and technological processes for deliberate practice and transfer of knowledge that leads to improved outcomes for patients. Recognizing that technology-enhanced simulation instruction improves knowledge acquisition, skills, and behavioral learning, the future discussion of simulation should emphasize the creation of technological processes where an individual’s simulation experiences are horizontally and longitudinally monitored, assessed, and remediated, and then used for certification or licensing.45 This effort should be focused toward tailoring simulation technology on individual learners. This would involve improving the opportunity and frequency of deliberate practice and feedback. Moreover, it would provide opportunities for improving the time flexibility of large-scale simulation centers which often offer limited time for training, practice, and assessment activities. For this process to be possible, individual competence portfolios and dashboard systems should be seamlessly integrated with simulation activities, which would then create efficient technological environments where learners monitor their competence and seek individualized deliberate practice and coaching. The benefits of integrated simulation systems are not limited to undergraduate and graduate medical education but have great potential to teach new procedures and protocols to physicians in practice and refresh their often declining knowledge and skills. One area where simulation technology is particularly relevant to continuing medical education and continuing professional development is interprofessional training that addresses the complexities of health care systems and the competencies and performance of multiple health care providers. In situ simulations would be particularly applicable in this domain,46 because simulation in real clinical environments targets the quality of systems of care and the complicated problems associated with health care delivery. One of the biggest obstacles of technology-enhanced simulation is cost. Tremendous financial support is necessary to create a large simulation training center. For this reason, it is imperative to question how to best use simulation facilities more efficiently and cost effectively.30 The cost-effectiveness applies not to one institution but to whole systems. Multi-institutional collaborative structure is also necessary. It would not make sense to build multiple simulation centers with the same simulation fidelity in the same region. Each simulation center should provide a
unique training capability that is shared with other healthcare institutions that provide complementary cooperation within the region. Taking the Lead in the HIT System Given the significant technological changes, physicians need to develop technological leadership to help strengthen and inform the HIT systems. The most immediate need is to teach medical students and physicians about EHRs, especially how the systems operate, so they will be capable of leading the creation, use, and management of HIT systems. The issue is not simply on how to access and input patient health information but how to prioritize and validate health information for correct decision making. Despite the rosy expectations of EHRs, the current EHR systems are neither user friendly or efficient.47,48 EHR features are driven by multiple vendors resulting in interoperability issues, which create tremendous inefficiency in patient care. Moreover, given the complicating structure of the systems, health information quality entered and retrieved by users can vary.38,49 Physicians need to understand these current state system imperfections within the context of optimally functioning systems that effectively and efficiently serve patient care needs. Therefore, educational opportunities can develop physician understanding of the HIT process. Knowledge about the system would entail a long-range call for technological leadership. Physicians should not just follow available technological process but proactively involve in creating desirable technological processes of the HIT system based on improved patient care decisions. Creating technological process for learning and performance improvement is an educational technology practice, which has been overlooked in medical education, yet will be imperative going forward. CONCLUSIONS The future of ET in medical education should not be limited to solely using technology for instruction but to developing systemic approaches that facilitate learning and improve patient care through creating, using, and managing technological process. As new technologies arise, this process-oriented understanding and outcome-based expectations of educational technology should continue. With this view, ET should be valued in terms of how well the technological process informs and facilitates learning and the development and maintenance of clinical expertise. REFERENCES 1. Irby DM, Wilkerson L. Educational innovations in academic medicine and environmental trends. Journal of General Internal Medicine 2003;18:370–6. 2. Irby DM, Cooke M, O’Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Academic Medicine 2010;85:220–7. 3. Rotgans JI. The themes, institutions, and people of medical education research 1988–2010: Content analysis of abstracts from six journals. Advances in Health Science Education 2012;17:515–27.
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EDUCATIONAL TECHNOLOGY IN MEDICAL EDUCATION 4. McLuhan M. Understanding media: The extensions of man. New York: McGraw-Hill, 1964. 5. Holmes B, Gardner J. E-Learning: Concepts and practice. London: Sage, 2006. 6. Januszewski A, Persichitte KA. A history of the AECT’s definitions of educational technology. In A Zanuszewski, M Molenda (Eds.), Educational technology: A definition with commentary. New York: Taylor & Francis, 2008. p. 259–82. 7. Finn J. Instructional technology. Audiovisual Instruction 1965;10:192–4. 8. Von Bertalanffy L. An outline of general system theory. The British Journal of the Philosophy of Science 1950;1:134–65. 9. Branch RM, Deissler CH. Processes. In A Zanuszewski, M Molenda (Eds.), Educational technology: A definition with commentary. New York: Taylor & Francis, 2008. p. 195–212. 10. Engel CE. Educational technology in medical education. Proceedings of the Royal Society of Medicine 1972;65:771–3. 11. Gunderman RB, Kang YP, Fraley RE, Williamson KB. Instructional technology and radiologic education. Radiology 2001;221:1–4. 12. Kamin C, Souza KH, Heestand D, Moses A, O’Sullivan P. Educational technology infrastructure and services in North American medical schools. Academic Medicine 2006;81:632–7. 13. Ruiz JG, Mintzer MJ, Leipzig RM. The impact of E-learning in medical education. Academic Medicine 2006;81:207–12. 14. Owen H. Learners re-shaping learning landscapes: New directions for old challenges? Proceedings ASCILITE Melbourne 2008. 15. Barnett GO. Information technology and medical-education. Journal of the American Medical Informatics Association 1995;2:285–91. 16. Koschmann T. Medical-education and computer literacy—Learning about, through, and with Computers. Academic Medicine 1995;70:818–21. 17. Mooney GA, Bligh JG. Information technology in medical education: Current and future applications. Postgraduate Medical Journal 1997;73:701–4. 18. Irby DM, Wilkerson L. Educational innovations in academic medicine and environmental trends. Journal of General Internal Medicine 2003;18:370–6. 19. Ward JPT, Gordon J, Field MJ, Lehmann HP. Communication and information technology in medical education. Lancet 2001;357:792–6. 20. Robin BR, McNeil SG, Cook DA, Agarwal KL, Singhal GR. Preparing for the changing role of instructional technologies in medical education. Academic Medicine 2011;86:435–9. 21. Cook DA, Garside S, Levinson AJ, Dupras DM, Montori VM. What do we mean by web-based learning? A systematic review of the variability of interventions. Medical Education 2010;44:765–74. 22. Cook DA. Where are we with web-based learning in medical education? Medical Teacher 2006;28:594–8. 23. Wutoh R, Boren SA, Balas EA. eLearning: A review of Internet-based continuing medical education. The Journal of Continuing Education in the Health Professions 2004;24:20–30. 24. Cook DA, Levinson AJ, Garside S. Time and learning efficiency in Internetbased learning: A systematic review and meta-analysis. Advances in Health Sciences Education 2010;15:755–70. 25. Cook DA, Levinson AJ, Garside S, Dupras DM, Erwin PJ, Montori VM. Instructional design variations in Internet-based learning for health professions education: A systematic review and meta-analysis. Academic Medicine 2010;85:909–22. 26. Gunderman RB, Kang YP, Fraley RE, Williamson KB. Instructional technology and radiologic education. Radiology. 2001;221:1–4; discussion 5. 27. Scalese RJ, Obeso VT, Issenberg SB. Simulation technology for skills training and competency assessment in medical education. Journal of General Internal Medicine 2008;23:46–9.
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28. Cook DA, Brydges R, Zendejas B, Hamstra SJ, Hatala R. Technologyenhanced simulation to assess health professionals: A systematic review of validity evidence, research methods, and reporting quality. Academic Medicine 2013;8:872–83. 29. Issenberg SB, Scalese RJ. Simulation in health care education. Perspect Biol Med. 2008;51(1):31–46. 30. Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, et al. Technology-enhanced simulation for health professions education: A systematic review and meta-analysis. Journal of the American Medical Association 2011;306:978–88. 31. Olson CA. CME congress, simulation technology, and the relationship between means and ends. Journal of Continuing Education and Health 2012;32:277–29. 32. Passiment M, Sacks H, Huang G. Medical simulation in medical education: Results of an AAMC Survey. 2011. Available from: https://www.aamc.org/download/259760/data/ 33. Zendejas B, Brydges R. Patient outcomes in simulation-based medical education: A systematic review. Journal of General Internal Medicine 2013;28:1078–89. 34. McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Academic Medicine 2011;86:706–11. 35. Spencer DC, Choi D, English C, Girard D. The effects of electronic health record implementation on medical student educators. Teaching and Learning in Medicine 2012;24:106–10. 36. Hammoud MM, Dalymple JL, Christner JG, Stewart RA, Fisher J, Margo K, et al. Medical student documentation in electronic health records: A collaborative statement from the alliance for clinical education. Teaching and Learning in Medicine 2012;24:257–66. 37. Hammoud MM, Margo K, Christner JG, Fisher J, Fischer SH, Pangaro LN. Opportunities and challenges in integrating electronic health records into undergraduate medical education: A National Survey of Clerkship Directors. Teaching and Learning in Medicine 2012;24:219–24. 38. Han H, Lopp L. Writing and reading in the electronic health record: An entirely new world. Medical Education Online 2013;18:1–7. 39. Davenport TH, Glaser J. Just-in-time delivery comes to knowledge management. Harvard Business Review 2002;80:107–11. 40. IOM. Crossing the quality chasm: A new health system for the 21st century. 2001. 41. ABMS. ABMS Maintenance of Certification. Available from: http://www.abms.org/Maintenance of Certification/ABMS MOC.aspx 42. Baumard P. Tacit knowledge in organisations. London: Sage, 1999. 43. Flumerfelt S, Green G. Using lean in the flipped classroom for at risk students. Educational Technology & Society 2013;16:356–66. 44. Morris AK, Hiebert J. Creating shared instructional products: An alternative approach to improving teaching. Educational Researcher 2011;40:5–14. 45. The Blue Ridge Academic Health Group. Report 17. Health Professions Education: Accelerating Innovation Through Technology. 2013. 46. Rosen MA, Hunt EA, Pronovost PJ, Federowicz MA, Weaver SJ. In situ simulation in continuing education for the health care professions: A systematic review. Journal of Continuing Education in the Health Professions 2012;32:243–54. 47. Kellermann AL, Jones SS. What it will take to achieve the as-yet-unfulfilled promises of health information technology. Health Affair 2013;32:63–8. 48. Mandl KD, Kohane IS. Escaping the EHR Trap—The future of health IT. New England Journal of Medicine 2012;366:2240–2. 49. Yudkowsky R, Galanter W, Jackson R. Students overlook information in the electronic health record. Medical Education 2010;44:1132–3.
Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
Educational Technology in Medical Education a
b
Heeyoung Han , David S. Resch & Regina A. Kovach
b
a
Department of Medical Education , Southern Illinois University School of Medicine , Springfield , Illinois , USA b
Department of Internal Medicine , Southern Illinois University School of Medicine , Springfield , Illinois , USA Published online: 18 Nov 2013.
To cite this article: Heeyoung Han , David S. Resch & Regina A. Kovach (2013) Educational Technology in Medical Education, Teaching and Learning in Medicine: An International Journal, 25:sup1, S39-S43, DOI: 10.1080/10401334.2013.842914 To link to this article: http://dx.doi.org/10.1080/10401334.2013.842914
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Teaching and Learning in Medicine, 25(S1), S39–S43 C 2013, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2013.842914
Educational Technology in Medical Education Heeyoung Han Department of Medical Education, Southern Illinois University School of Medicine, Springfield, Illinois, USA
David S. Resch and Regina A. Kovach
Downloaded by [Memorial University of Newfoundland] at 01:02 04 August 2014
Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, Illinois, USA
This article aims to review the past practices of educational technology and envision future directions for medical education. The discussion starts with a historical review of definitions and perspectives of educational technology, in which the authors propose that educators adopt a broader process-oriented understanding of educational technology. Future directions of e-learning, simulation, and health information technology are discussed based on a systems view of the technological process. As new technologies continue to arise, this process-oriented understanding and outcome-based expectations of educational technology should be embraced. With this view, educational technology should be valued in terms of how well the technological process informs and facilitates learning, and the acquisition and maintenance of clinical expertise. Keywords
As McLuhan viewed,4 given technology’s role as a message and translator, it is necessary to reflect on what experiences and meaning ET in medical education has contributed in the past in order to further advance medical education practices for the future. This article starts with a historical and interdisciplinary understanding of the concepts of ET. Then, we review ET practice and its empirical evidence in medical education, which will entail a critical analysis of current and previous views and dialogue about the role of ET in medical education. With this review of past ET practices, we attempt to project future directions for how ET may facilitate constructive changes in medical education.
educational technology, medical education
INTRODUCTION A valuable approach for medical education is to continuously and constructively reevaluate current practices in order to discover innovations and reforms that result in a more effective educational process as measured by learners, schools, and society.1,2 Advances in information and networking technology have led educators to rethink educational practices and integrate technological processes for educational innovations.1 However, scholarly dialogue on educational technology (ET) innovations in medical education has decreased in the last 25 years.3 This declining trend in education research has occurred despite ET increasingly permeating medical education practice. Examples include virtual patient cases, technologyenhanced simulation, computer-based assessments, two- and three-dimensional anatomy instruction, audience response systems, asynchronous learning activities, and digitized patient and educational materials.
Correspondence may be sent to Heeyoung Han, Department of Medical Education, SIU School of Medicine, 913 North Rutledge Street, Springfield, IL 62794-9681, USA. E-mail: [email protected]
HISTORICAL UNDERSTANDINGS OF EDUCATIONAL TECHNOLOGY Since Sydney Pressey’s introduction of testing machines in 1920 and Skinners’ teaching machine in 1958,5 the notion of ET, often interchangeably called instructional technology, has gone through several conceptual shifts.6 In earlier times, the field simply focused on the use of devices and audiovisual media for augmenting educational activities. As the discipline evolved, the initial attention on machines and products was challenged and conceptually extended to include a process view.7 This broadened view involves acknowledging ET as technological processes and open systems8 that represent wholeness of meaningful activities and applications of principles and theories for desired learning outcomes in continuous feedback loops.7,9 By adopting this systems view of instruction, the concept of ET evolves toward creation and management of technological processes. A systems view also includes a conceptual shift of learning in which ontological and epistemological understanding of knowledge and learning is extended from a sensory and authoritative view to one valuing an individual’s content specific experiences and tacit knowledge in defining educational technology. Thus the Association of Educational Communications and Technology articulated an inclusive definition of ET:6 “The study and ethical practice of facilitating learning and
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improving performance by creating, using, and managing appropriate technological process and resources” (p. 1). In medical education, the prevailing understanding of ET has been the notion of technology as a product or a device and ET practices focused on ‘using’ technology.10–12 Engel defined ET as “technology in education and technology of education” (p. 771).10 In his view, ET was a technical device as a carrier of information and an aid to experience. This view of ET in medical education has continued in recent practice. Gunderman et al.11 viewed ET in radiologic education “as the use of information processing and communications technology to support education”(p. 1). In identifying educational technology infrastructure in medical schools, Kamin et al.12 also defined ET “as electronic and other forms of technology used to support teaching and learning. These include but are not restricted to computer-based learning programs, computerized mannequins, instructional Web sites, video/audio production, application development, and online course management” (p. 632). While the concept of ET has evolved toward a systems view of the technological process, the scope of educational technology in medical education has remained narrow and focused on the use of devices and computing programs to aid in the delivery of instructional information and resources.13 This conceptual gap in approaching ET may limit the practice and research of ET in medical education to adopting a certain technology for curriculum purposes rather than creating holistic learning process of meaningful activities and managing systemic technological processes. This process permits not only the facilitator of an instructional session to affect outcomes but also promotes a setting for learners to adapt and define their learning communities.14
THE ROLE OF EDUCATIONAL TECHNOLOGY IN MEDICAL EDUCATION The role of ET in medical education has been discussed for the last couple of decades.11,15–20 Reflections on the use of ET in medical education have evolved as medical educators tried to address pedagogical challenges, curriculum efficiency, and effectiveness. Identifying challenges in medical education caused by an information explosion, the need for lifelong learning, and decreased teaching opportunities in ambulatory practice, Barnett15 proposed the use of computers in medical education as a pedagogical approach to address the challenges. He saw the value of information technology in medical education especially as a tool for medical knowledge search, creating electronic documents, recording and indexing multimedia medical content, and interactive simulations including assessments. Mooney and Bligh17 also viewed the opportunities of technology use, particularly as a tool for multimedia presentation of medical content and information access through internet. Criticizing traditional training models in radiology relying on textbooks and apprenticeship models, Gunderman et al.11 argued that educational technology can create an anytime, anywhere, and interactive learning experience.
One of the major educational technology practices in medical education is e-learning.12 E-learning is also called web-based learning, online learning, or computer-based learning13 that includes online synchronous and asynchronous communication, learning management systems, and web-based multimedia to represent online lectures, virtual patients, self-assessments, and feedback.21 Evaluation studies discovered that students have positive attitudes toward e-learning and that e-learning methods had similar effects as traditional teaching on knowledge and skills.21–23 In a meta-analysis, Cook, Levinson, and Garside24 found no difference in time and learning efficiency between e-learning and noncomputer instruction. Acknowledging the advantages regarding e-learning, increasing attention has been paid to instructional design features that explain the effectiveness of e-learning rather than the instruction delivery medium itself.24–26 Simulation technology is another form of technology that has been used to address limited patient availability, infrequent occurrence of critical disease processes, faculty time flexibility, and outcome-based medical education needs within a pertinent contextual framework.27 Technology-enhanced simulation in medical education includes diverse modalities such as computer-based virtual reality simulators, computerized mannequins, microworlds, interactive simulations and games, and task trainers.28,29 Simple use of standardized patients or static mannequins without computerized capabilities is not considered technology-enhanced simulation. Reports studying the effectiveness of simulation technology have been published since the late 1960s, but the bulk of published work regarding simulation technology has been since 2008.30 Overall, the focus of simulation technology has been in undergraduate and graduate medical education where its applications have rapidly grown in the past 10 years, rather than in the realm of continuing education for practicing health professionals where its use is just starting to increase.31 The most common current applications of technologyenhanced simulation involve instruction in technical skills such as laparoscopic procedures, anesthesia and surgical skills, and physical examination skills, team and leadership skills, clinical reasoning, emergency resuscitation, and management. In addition to instruction, and despite scant validity evidence for simulation-based assessments,28 technology-enhanced simulation is commonly used to assess those skills trained, usually by observers who determine global ratings of performance for formative assessments, and rarely for making judgments for validation or certification purposes.32 In its current state, simulation in medical education is largely used for the purposes of training and assessment27 and much less so for quality improvement and research; it has yet to evolve into an organizational improvement tool.32 Recent meta-analyses have reported that simulation technology improves learning outcomes compared to no training, but evidence that it improves patient outcomes is modest at best.30,33,34 Following passage of the Affordable Care Act, health information technology (HIT) such as electronic health records
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(EHR) has played a pivotal role in patient care. HIT has been recently discussed as an important emerging ET in medical education for knowledge acquisition, decision support, and quality improvement.15,35–38 The HIT/EHR process reflects the education system in that large volumes of data are provided that need to be sorted and prioritized into a coherent cognitive structure for application to a given clinical problem.39 Helping students and faculty understand the strengths and weaknesses of these products is an ongoing issue. ET in medical education is not limited to those topics just discussed, yet these technologies represent an overall picture of the experience and messages that have been created in medical education. As a recent report identified, new ET will continuously emerge and change the pedagogical landscape of medical education.20 Consequently, it is important to reflect on the potential ways that ET will broaden and enhance the experience in medical education. WHERE ARE WE GOING? In this section, we attempt to envision the future directions of ET in medical education. First, we propose that medical educators embrace a broader concept of ET that is based on a systems perspective.6,8 Then we discuss the future of e-learning with a notion of lean medical education. Last, simulation and HIT are briefly discussed. Embracing a Broader Concept of ET With the publication of the Institute of Medicine’s Crossing the Quality Chasm,40 medicine has moved firmly onto a path of creating a system of transparently reported, process, and outcome-measurements dependent upon access to and application of large volumes of data with the goals of improving patient care and safety. This systematic shift in medicine requires medical education to adapt, including the technology it employs. Considering this shift and the process-oriented ET definition from the Association of Educational Communications and Technology discussed earlier,6,9,40 we propose ET in medical education is conceptualized as a process-oriented and systems-based pedagogical approach for facilitating learning and improving performance in patient care by the integrated mode of creating, using, and managing technological process and resources. ET should not be limited to the use of technical devices or tools but extended toward wholeness of technological systems where learning and performance are facilitated and improved for better patient care through continuous feedback loops. The importance of the need for continuous feedback is best exemplified by the American Board of Medical Specialties’ Maintenance of R 41 ). ABMS MOC aims Certification Program (ABMS MOC for physicians’ commitment to lifelong learning in a specialty through ongoing assessment of six core competencies defined by ABMS and ACGME in 1999. By including feedback systems, ET will have to incorporate developing both tacit knowledge (personal experience) and explicit knowledge (evidence), hopefully best knowledge that
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has a meaningful impact on patient care. Facilitating the continued interaction of a physician’s tacit and explicit knowledge while developing insight concerning this interaction will be a significant focus of future educational technology.42 All the formative and summative technological processes just delineated will need to be integrated into a coherent stream of performance data that serves as the basis of lifelong learning to help guide each learner across their entire professional career. Educational instruction including technology will need to be standardized but individually applied. Standardization of Resources and Individualization of Instructions Experiences with the flipped classroom, Khan Academy, and massive open online courses (MOOCs), have led educators to have high expectations that educational practices will improve with the use of technology. Although some of these approaches may appear to be simple, such as video podcasts of lectures followed by in-person interactive discussions, from a broader systems perspective, such models are fundamentally systemic processes that facilitate the notion of ‘lean’ in higher education.43 The concept of lean higher education represents continuous improvement by identifying and eliminating root causes of waste and inefficiency through value streaming maps.43 MOOCs and the Khan Academy demonstrate that lectures and courses are becoming shared instructional products.44,45 Students can freely access quality online lectures provided by highly regarded and accredited institutions anytime and anywhere.45 Thus, using instructors’ and learners’ time for creating and passively listening to lectures translates into nonvalue added steps in the value streaming maps. It would be a waste for all medical schools to create and deliver similar courses on Anatomy 101 in a traditional classroom given that the same credited course is available online at no cost. This emerging trend of sharing online massive courses among institutions has the potential to change the fundamental equation of teaching and learning in medical education by reducing the cost of redundant instructional products and knowledge transmission, and at the same time enhancing the quality of teaching and learning.45 A recent report also made a recommendation for national-level collaboration and leadership to create and share resources in medical education.20 Then, the real question for medical educators will become how to evaluate students’ progress, identify students at risk and address their study needs through individualized and customized instruction, which becomes a value-added process to achieve learning goals. Evolution of instructional courses, from closed locally created traditional lectures through e-learning and OpenCourseWare, eventually to MOOCS, does not only mean the use of multimedia technology to deliver lecture content but also creating the technological processes that facilitate value-added individualized instruction and learning experience. Technological processes incorporating customized instructional interactions through learning analytics, assessments, and meaningful
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feedback will be the future trend of educational technology practice and research to achieve lean medical education. This trend is not limited to undergraduate and graduate medical education but can extend to continuing medical education in terms of monitoring and addressing an individual physician’s lifelong learning. Simulation Integration with Competence Dashboard for Deliberate Practice The future of simulation technology can be envisioned by revisiting the original rationale of simulation, competence-based medical education. Simulation technology is not a simple use of simulators but involves creating opportunity and technological processes for deliberate practice and transfer of knowledge that leads to improved outcomes for patients. Recognizing that technology-enhanced simulation instruction improves knowledge acquisition, skills, and behavioral learning, the future discussion of simulation should emphasize the creation of technological processes where an individual’s simulation experiences are horizontally and longitudinally monitored, assessed, and remediated, and then used for certification or licensing.45 This effort should be focused toward tailoring simulation technology on individual learners. This would involve improving the opportunity and frequency of deliberate practice and feedback. Moreover, it would provide opportunities for improving the time flexibility of large-scale simulation centers which often offer limited time for training, practice, and assessment activities. For this process to be possible, individual competence portfolios and dashboard systems should be seamlessly integrated with simulation activities, which would then create efficient technological environments where learners monitor their competence and seek individualized deliberate practice and coaching. The benefits of integrated simulation systems are not limited to undergraduate and graduate medical education but have great potential to teach new procedures and protocols to physicians in practice and refresh their often declining knowledge and skills. One area where simulation technology is particularly relevant to continuing medical education and continuing professional development is interprofessional training that addresses the complexities of health care systems and the competencies and performance of multiple health care providers. In situ simulations would be particularly applicable in this domain,46 because simulation in real clinical environments targets the quality of systems of care and the complicated problems associated with health care delivery. One of the biggest obstacles of technology-enhanced simulation is cost. Tremendous financial support is necessary to create a large simulation training center. For this reason, it is imperative to question how to best use simulation facilities more efficiently and cost effectively.30 The cost-effectiveness applies not to one institution but to whole systems. Multi-institutional collaborative structure is also necessary. It would not make sense to build multiple simulation centers with the same simulation fidelity in the same region. Each simulation center should provide a
unique training capability that is shared with other healthcare institutions that provide complementary cooperation within the region. Taking the Lead in the HIT System Given the significant technological changes, physicians need to develop technological leadership to help strengthen and inform the HIT systems. The most immediate need is to teach medical students and physicians about EHRs, especially how the systems operate, so they will be capable of leading the creation, use, and management of HIT systems. The issue is not simply on how to access and input patient health information but how to prioritize and validate health information for correct decision making. Despite the rosy expectations of EHRs, the current EHR systems are neither user friendly or efficient.47,48 EHR features are driven by multiple vendors resulting in interoperability issues, which create tremendous inefficiency in patient care. Moreover, given the complicating structure of the systems, health information quality entered and retrieved by users can vary.38,49 Physicians need to understand these current state system imperfections within the context of optimally functioning systems that effectively and efficiently serve patient care needs. Therefore, educational opportunities can develop physician understanding of the HIT process. Knowledge about the system would entail a long-range call for technological leadership. Physicians should not just follow available technological process but proactively involve in creating desirable technological processes of the HIT system based on improved patient care decisions. Creating technological process for learning and performance improvement is an educational technology practice, which has been overlooked in medical education, yet will be imperative going forward. CONCLUSIONS The future of ET in medical education should not be limited to solely using technology for instruction but to developing systemic approaches that facilitate learning and improve patient care through creating, using, and managing technological process. As new technologies arise, this process-oriented understanding and outcome-based expectations of educational technology should continue. With this view, ET should be valued in terms of how well the technological process informs and facilitates learning and the development and maintenance of clinical expertise. REFERENCES 1. Irby DM, Wilkerson L. Educational innovations in academic medicine and environmental trends. Journal of General Internal Medicine 2003;18:370–6. 2. Irby DM, Cooke M, O’Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Academic Medicine 2010;85:220–7. 3. Rotgans JI. The themes, institutions, and people of medical education research 1988–2010: Content analysis of abstracts from six journals. Advances in Health Science Education 2012;17:515–27.
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