The fact that medicine is a high technology field and is rapidly becoming even more immersed in the technology does not mean that medical instruction takes advantage of technological opportunity. The possibilities are far ahead of the implementation in some departments of some institutions, but unlike the advances of the past, the Information Superhighway is available to the students. No longer are they dependent upon the single faculty member to adopt a new practice before the instruction is available.
This article arises from my vantage point in educational technology. You must hear me brag, just a bit, to know the experience of which these comments are the culmination. As an innovator and researcher, I produced the first microcomputer program to gain official approval for use as an alternative to the paper-and-pencil accounting system for maintaining attendance records in the State of Oklahoma (or anywhere else, for that matter). I then produced a circulation and on-line catalog system for school library use, a gradebook system, a master schedule builder for high schools, and various drill-and-practice programs for K-12. After joining the staff of the local medical school as the Research Associate to the Department of Psychiatry and Behavioral Sciences, I produced several inventions, did research, and mentored adopting members of the faculty in the use of high technology. My observation of faculty reaction to newly available high technology and my discussions with other professionals about the technology and about the faculty form the basis of the opinions expressed here.
In the mid-1960s, Florida State University (FSU) was involved in a project to develop a computer-assisted instructional system for teaching migrant workers and other non-functional illiterate adolescents and adults. The system used an IBM 1440, a tape recorder, and a 35mm carousel projector for graphics. Markle (1964) and Mager (1962) developed instructional sequencing, which followed Bloom's Taxonomy (1956). Skinner's (1968) operant conditioning paradigm had led to workbook type programmed-instruction in reading. Discovery learning in science and individualized instruction in math and language arts were the watchwords. But this reflects the method and content that were being taught in the graduate school of education, not the methods of instruction in use by the professors. The courses were lectures, readings, and an occasional practicum. As Ed Smith relates in our Two Approaches to Literacy Education, the pre-vocational literacy project was an excellent teaching tool.
Although not in our report, the daily, hands-on, collaborative atmosphere was conducive to learning. If it is true that you only learn enough to survive, the fact that the computer is a stern taskmaster, allowing no mistakes, raised the bar for the group's performance. Every step of every lesson was to meet the criteria of group review for known entry behavior (knowledge and skills), performance objectives, and efficiency and accuracy in instructional strategy and execution. Everyone who could inject interest or humor got accolades. Everyone took part in the formative and summative evaluations of the team's work as a part of a team activity. Everyone on the team learned how literacy instruction was supposed to be handled, step by step, in a manner essentially similar to the Dick and Carey model (1996).
Please notice the multimedia computer in the above. Notice that the graduate students were not learning from the computer in the same sense that we now say, "My students learn 10 medical terms a day using Dr. Geeslin's Study Buddy program." Instead, they were learning to teach by teaching the computer, or at least by designing the lessons as if they were going to teach. This result of the project was accidental. The lessons learned from it, to my knowledge, were not implemented, and higher educational methods continued to be traditional, even after the insights gleaned from the project, until Gagne and crew arrived. That was over 30 years ago. The technology available has changed. The common desktop computer of the late 1990s is a dozen times more powerful than that old 1440 and now the computers are being linked together as networks, intraNET within an organization and InterNET across the country and around the world. What does the new generation of professors do with this power and what should they be doing?
The Evolving Phenomenon of Web Based Learning
TelNet is a method of communicating with a remote computer. Then came Gopher, the File Transfer Protocol (FTP), and the World Wide Web (WWW). Then FTP became a point-and-click operation. Want a file? Find it, highlight it, click it and tell the dialog box where to put it. This was a slick new way to use FTP on the Web; but to the rising tide of newbies, it was the Web. The newbies were not even surprised when websites began to show their Gopher directories. The newbies didn't even know there was a Gopher. To them, pouring onto the information superhighway by the million, there were just brightly colored, attractive Web pages and a few dull, boring places where all the information was stored.
Then came a new Browser, which would enable sound and full motion graphics, would handle user responses to forms, and would run small applications right on the user's computer, providing calculation and verification, image placement, timed functions, and the like, adding an almost unlimited number of functions to the Web. Internet Explorer's integration of functions blurred the once distinct features into a conglomerate that only very sophisticated purists could distinguish from computer use, and they only with effort. Soon, the concept of transparent connectivity through the Web reached Starfleet Command.
An imaginary episode of Medical-Education-OnDemand follows:
Stardate 32431point67, Dr. McCoy stands in the empty holodeck. "Computer, fetch Continuing Medical Education: Voluvion Heart Surgery from the Starfleet Website," he commands. In a moment the soft voice of the computer says, "Fetch complete, Doctor. Shall I run the program now?"
"Yes, " Dr. McCoy answers and the scene shifts. The room becomes a simulation of sickbay with a simulated Voluvion under the lights appearing real in every way, right down to the stench. A second simulated figure, a Starfleet Master Surgeon, now stands across the table.
"As I go through this, Doctor McCoy, pay strict attention to the rhythm, the cadence of this heart. Unlike a human heart, it must never stop. You'll have to get the implant through the valve with utmost precision. There is no second chance. Your patient will live or die by your timing," the Master Surgeon says. McCoy nods.
The real Voluvian Ambassador in sickbay hangs on by a thread. Only the new procedure, made available just hours ago, can save him. McCoy has muffed it twice. He is beginning to sweat, to doubt his ability to learn this one, but this time a snatch of a tune tugs at his inner ear and soon he is humming a rhythm, doing a dance, that perfectly matches the movements he will need.
Back in sickbay, the Ambassador on the table, McCoy dons a faceplate that will keep any stray drops of Voluvian blood from his eyes and that also displays a cut-away view of the patient generated by continuous CAT/PET scan updates transferred to the visor. McCoy is confident.
The imaginary episodes of Starship Enterprise have given Hollywood a chance to show the possibilities for Computer Mediated Medical Education (CMME). The imaginary episode of "Medical Education On Demand," above, portrays embedded technologies not too distant from those now available. The holographic technology, which would allow a lifelike and 3-dimensional visual simulation of patient and mentor, is ready. Although the Virtual Reality (VR) technology has not quite caught up with the cinematographers' art, the trail into the future is being blazed nonetheless. Today's advanced telecommunications, specifically the Web, have the potential to significantly impact medical education, reducing costs while improving the level of skills and abilities of the graduate. For example, to insure proper diagnosis and treatment, medical students are required to do supervised practice of various types. Some is classroom work, some is during a rotation to various medical settings, and the last is known as a residency. Simulations can offer the medical educator far better control over the conditions and diseases seen by the student than do the real-life but humdrum experiences of the teaching clinic. In addition, the computer can evaluate the adequacy of every step of the process, giving immediate feedback to the medical student. The text and pictorial simulation available from the Marshall University School of Medicine may not be an interactive holographic, but it is available on the Web. Called the Interactive Patient, it gives medical students, continuing medical education students, and med-school hopefuls a good simulation of an encounter with a patient, complete with a chief presenting complaint, interactive gathering of patient history, performing a physical exam, and reviewing the laboratory data and x-rays. After the workup, the user is encouraged to submit a diagnosis and a treatment plan to the computer system based on the information obtained. (Lehmann & Hayes, 1996). Physicians who complete the simulation successfully may obtain Continuing Medical Education (CME) credit. "Marshall University School of Medicine designates that this continuing medical education offering meets the criteria for 1.0 credit hours in Category 1 of Physicians Recognition Award of the American Medical Association provided it is used and completed as designed" (ibid.)
Searches for information on unrecognized symptoms, new medications
and procedures, and the like have, with the gradual improvement
of embedded technologies, become almost as easy as saying, "Computer,
access the National Library of Medicine."
MEDLINE makes a vast store of biomedical information immediately available to health care professionals nationwide, helping them in minutes to locate medical information that used to take days to find. Through MEDLINE, health care professionals can tap into NLM's computerized reservoir of 6 million-plus references to journal articles accumulated since 1965 and growing at a rate of 300,000 per year. Not only does MEDLINE allow individuals to call up a list of pertinent articles in minutes, but it also allows users to print abstracts for many of those articles at their own terminals. MEDLINE is accessible at 3,500 institutions, including universities, medical schools, hospitals, government agencies, and commercial organizations. Recently, growing numbers of individual health professionals have been joining the network (NLM, 1996).
A similar database is available in toxicology and many medical schools, such as the Oklahoma State University College of Osteopathic Medicine, are making available archives of text.
Overcoming Traditional Bottlenecks to Information Flow
Material stored in a library, especially in the traditional form of slides, can be made available on the intranet. The necessity of going to the library during library hours and securing a viewing room and the appropriate slides is replaced by Net access. Breaking the bottleneck of sync and moving to the freedom of a-sync access to traditional resources is a big step, fairly common to enterprises entering the Net. Access, however, is only a first step down the road to full use of information technology.
When I left the College, early in 1997, State health and demographic statistics were due to be made available on the OSU-COM server. These data include vital statistics, statistics on such things as teen childbearing and other health-related incidents, and physician surveys including geographic distribution. A recent epidemiological project carried out in collaboration with a Native American group (Geeslin, 1995) indicated that the tools of GIS allow a map to be overlaid with various of the archived statistical data to produce easily compared pairs of maps, such as household income on the left and numbers of low birth weight infants on the right. Examination of such spatial relationship is a key methodology in epidemiology. Because the system is scalable, data from any area of the country may be entered or pointed to, a request made, and the result viewed as a Webpage. Although the purpose of posting of archives is typically for reference purposes, this project suggests methodology that can make archived data dynamic and interactively instructional. The user can choose from the archives and databases those items of interest (e.g., low birth weight or rate of reported family abuse) and compare them to the vital statistics, the demographics of the area, to produce graphical and geographical displays. Because charts and graphs can be built just as easily as maps, they can also be used. Even changes over time for a geographical region may be plotted and viewed when enough archival statistical data is ready. The use of charts, graphs, and maps to make the dry statistics of health-related phenomena open up for visual inspection in response to queries makes archives more valuable than ever by making them active archives.
Meeting Felt Needs
WWW pages are most commonly used as electronic ads or as e-Catalogs to display merchandise. Posting to Web pages requires access privileges not often given to students; therefore, student use of the WWW for group communication is not likely. However, a new technology called conferencing overcomes the shortcoming by allowing discussion groups to post messages that are related by topic. WebBoard is a good example. Another technology, called a listserv, allows every member of a group to receive copies of messages mailed by any member to the listserv address. Either of these methods of sharing information is sufficient for medical students to post their lecture notes, a practice seen as vital to the students. This compendium of group experience is treasured for present study and for future review. The Internet provides the most powerful tools to date for collaborative study.
Finding Settlers for the New Frontier
Instructors in the Department of Psychiatry and Behavioral Sciences were reluctant to embark on new teaching paths. Although there were noted exceptions in other departments. The computer was seen as an expensive tool, difficult to learn and to use to do the traditional job of showing slides to the classes in support of the lecture. They limited other common uses of the computer to word-processing, statistical calculations, and departmental e-mail. Exceptional uses were in bio-feedback, where the computer was imbedded in the bio-feedback equipment and was not even recognized as a computer, and in the Automated Cognitive Rehabilitation Laboratory (ACReLAB), which uses a standard PC as the patient response platform.
Reflections, Conclusions, and Recommendations
High technology medicine demands high technology medical education and physicians in practice need continuing medical education on the use of the new medical technology. Pilots practice in a simulator, but physicians practice on patients. Medical education has unique difficulties and unique students, but it must also produce unique solutions. Computer technology offers medical education the means to accomplish this goal.
What of the traditional liberal arts education? What is the place of technology for the typical undergraduate? We remember that: (a) the overhead projector was to render chalkboards obsolete; (b) the videotape recorder and camera, now reduced to a camcorder, were expected to revolutionize teacher training, and on the job training; and (c) the TV and the recorded media accompanying its introduction was to bring the best of the world's instruction to every college classroom and laboratory. In 30 years, the effect in most colleges is negligible. The instructors still lecture, albeit with overheads and slides, supplemented with the occasional video. The examinations have not changed much from the multiple choice type, although they are now answered on bubble sheets so they can be graded by an optical mark reader. computer-based instruction, especially realistic simulation, is almost nonexistent. The impact of high technology has been a disappointment until very recently.
Now we are seeing a difference. This time the change is universal. The advances in telecommunications have come so fast that only the most flexible have stayed current. Everyone is behind the curve. The greatest single example of this successful expansion is the WWW, which has grown to the point of defining connectivity and, thereby, the next generation of computer operating systems, CPU micro-code, and changes at the telephone companies. The WWW has even caused changes in the marketplace, with the communications companies merging and the lines between TV, video-on-demand, and computer mediated communications blurring. Continued advancement in hardware will make the WWW more interactive, more lifelike, more like the holodeck, with new software pushing the hardware to its limits, leading to new developments in an upward spiral.
Will these advances change the face of higher education or will freshmen classes still consist of auditorium-sized classrooms where the videotape of a five-year-old lecture is shown by a teaching assistant? Will the students at least be able to address their questions to a knowledgeable scholar by e-mail?
The answers are yes, yes, and yes! Students have access. The scholars among them will find dozens if not hundreds or thousands of new opportunities to see, read about, and discuss the issues of common topics and those of esoteric nature, as well.
Hypertext has many possibilities in addition to those used in this article. Microsoft Word97 was used to write this piece. Pausing the mouse pointer over a link caused a pop-up to display the link, and distinguished bookmarks from links to other sites, an interesting and sometimes helpful bit of information. Also, the help system pop-ups gave definitions and explanations. Such features were limitations at the time of this writing, they could not easily be included. In the future, on-line documents will also yield such additional information about a term or concept with this simplicity. Perhaps even containing some kind of indicator built into the links to show what type of material or value you will find if you branch off the main track.
My greatest single recommendation is this: look around at the
changing landscape; resolve to make the investment of time and
energy required to merge onto the information superhighway; the
old ruts we all found so comfortable in the past are about to
be covered with cyber-cement, as the WWW paves the way into the
Dick, W & Carey, L (1996). The systematic design of instruction (4th ed.). New York: Harper Collins.
Geeslin, Robert Hawk (1995), Establishing epidemiological workgroups in Native American communities. Unpublished project carried out collaboratively with Behavioral Science Consulting, Inc. of Shidler, OK, to produce the Epi-Pro software system. A Phase II continuation grant request was submitted in April, 1996.
Lehmann, C. U., and Hayes, K. A. (1995)The interactive patient. [on-line] Available: http://medicus.marshall.edu/cme.htm
Mager, R. (1962). Preparing objectives for programmed instruction. Belmont, CA: Fearon.
Markle, S (1964). Good frames and bad. New York: John Wiley.
Skinner, B.F. (1968). The technology of teaching. New York: Appleton Century Crofts
Interesting Places to Visit:
The Virtual Hospital: Patient Information by Organ System:Neurological/Psychiatric. [On-line]. Available: http://indy.radiology.uiowa.edu/Patients/PatientOrgSys/OSNeuroPatient.htm
Juhnke, J and Powell, C. (1995). Emotional Support Guide: Internet Resources for Physical Loss, Chronic Illness, and Bereavement, University of Michigan, School of Information and Library Studies. Available from http://asa.ugl.lib.umich.edu/chdocs/support/emotion.asp.
Tinker, JH, MD and Wegrzynowicz, ES, MD (1995), Pain Clinic, Departmentof Anesthesia, Available from http://indy.radiology.uiowa.edu/Patients/IowaHealthBook/PainClinic.asp
Pediatric Nursing Division (1995), Pediatric Use of Patient Controlled Analgesia. The University of Iowa Hospitals and Clinics. Available from http://indy.radiology.uiowa.edu/Patients/IowaHealthBook/PedPCA.asp
Ackerman, L, RN, Haddad, S, MD, and Hitchon, PW, MD (1995), StereotacticProcedure: A Guide for Patients, Neuroscience Nursing Division,Department of Nursing, The University of Iowa Hospitals and Clinics.Available from http://indy.radiology.uiowa.edu/Patients/IowaHealthBook/Stereotactic.asp
Lapolla, Michael (1996), Oklahoma State University Telemedicine Center Homepage, Oklahoma State University College of Osteopathic Medicine, Tulsa, OK. http://telemed1.ocom.okstate.edu/webpages/telemed/default.htm
Lapolla, M (1996), Internet Directory of Health Care Sites, Telemedicine Center at the Oklahoma State University College of Osteopathic Medicine, 2345 Southwest Boulevard, Tulsa, OK 74107. Available from http://telemed1.ocom.okstate.edu/webpages/telemed/internet.htm.
Lehmann, Christoph U., MD and Hayes, Kent A. (1996), InteractivePatient, Marshall University School of Medicine, Huntington, WV. Available from http://medicus.marshall.edu/medicus.htm.
The Medical Matrix: http://www.slackinc.com/matrix/MEDED.asp contains links to over 25 sources of interactive, image-based, case study instruction challenging diagnostic skills. Most include visual images and diagnosis discussions. Nine offer CME credit.
Fill in the blank with your favorite technological breakthrough: videodisc, educational television, or Computer Based Instruction, then press your browser's back button to return to your place in the text.