Viewpoint

Big Changes are Coming: Is Medical Education Ready?

M. Aggie Manwell-Jackson, PhD, University of Texas Health Science Center at San Antonio

In the wake of the most significant presidential inauguration in the history of our relatively young country, there is palpable excitement regarding the incoming administration's embrace of transformational leadership and educational technologies. The excitement has firm foundation. The new administration has already demonstrated a strong commitment to learning and technology, both in their choice of tech savvy Education Secretary Arne Duncan and glimpses of an ambitious agenda outlining unprecedented governmental support for advanced learning technologies in higher education. Such commitment breeds a strong hope for transformational education in medical education as well. Perhaps now is the time to consider how the GIR can continue to stimulate an era of transformational education in our medical colleges, especially in light of uncertain budget outlooks.

The GIR is uniquely positioned to inspire, encourage, lead and nurture its member institutions towards an environment of transformational education. Much has already been done. The GIR Work Group's November 2008 report on Learning Management Systems, outlined in the latest Viewpoint, presented a framework for related best practices and standardization in a medical school environment. The report and subsequent discussions at the 2008 annual meeting encouraged the development of lifetime e-portfolios for medical students, institutional collaboration in technical standards, and cross-institutional research to evaluate learning technologies.

Discussions of these initiatives reference the well-documented Diffusion of Innovations cycle of technology adoption (Rogers 1962). The diffusion model is indeed a proven strategy to bring the early majority and late adopting faculty 'onboard'. However, reports of unused, discarded or stalled innovations may increase in the current economic climate. As the GIR plans next steps, perhaps we need to revisit Moore's Crossing the Chasm (1991) theory for some guidance in recognizing, avoiding and overcoming challenges. Moore emphasized that the greater the innovation's potential for disruption of the accepted norm, the wider the gap, or 'chasm', between early adopter and early majority adoption, and hence an increased risk for failure or stagnation. During stressful economic times the risk of "norm disruption" is intensified.

Moore recommends a six-step process to cross the chasm: 1) choosing a target market, 2) understanding the whole product concept, 3) positioning the product, 4) building a marketing strategy, 5) choosing the most appropriate distribution channel and 6) pricing. While all steps are important, IT development groups operating within an institution that has adopted Step 2 -- understanding the whole product concept -- may have the best opportunities for success. Within the concept of transformational education, such an institution is characterized by a complete service infrastructure powered by a culture of innovation.

This infrastructure is not necessarily apparent in bricks and mortar with the most state-of-the-art equipment. Rather, it is an organic process of development, integration, installation, training, well-advertised procedures, critical evaluation, and prompt and excellent support. It supports innovation through its visionary leaders, highly qualified, cross-functional teams that communicate quickly, honestly and often, and "empowered, caring, employees". The culture encourages excellence and innovation, invites questions and criticism at each step and is not afraid to abandon a project, even if it was the pet initiative of the CIO. CIO's in such a culture welcome feedback and opposing views, reward "good try's" and do not punish failure.

Here are some (still) common scenarios in classic innovation projects that could signify barriers to transformation education, and ideas how a whole product concept and a culture of innovation can overcome them:

All GIR members have been associated with educational technology projects utilizing the classic three-team-member approach to development: subject matter expert, instructional designer and instructional technologist. All team members are considered experts and take responsibility for achieving improved learning outcomes. Historically, teams are often grant-funded, with designated time and funds allotted for full team/faculty development and the implementation and use of state-of-the-art technology. Based on the premise that they will continue to contribute to a climate of excellence and provide a model for future development, best practices are rigidly adhered to and documented, based on the premise that they will continue to contribute to a climate of excellence and provide a model for future development. In this case the expectation is that they will be widely adopted and will have a significant positive impact on their program. However, often it is difficult to recruit experts, create a team and be productive in the first months of the funding cycle.

In an institution with a whole product concept to support innovation, the project would be assigned to a creative services team, composed of existing staff chosen based on the needs of the project. The majority of staff is funded by the institution and regularly attends professional development to maintain their skill sets. Project managers are designated for each project. They are known and trusted by their peers and know how to expedite time-intensive processes. Hence, they tend to be much more productive early in the development cycle. They know the faculty and are respected as colleagues.

Returning to the classic three-team-member model, after a product is successfully completed, it might then be used in isolation by faculty who do not wish to release ownership. Or the product may not be used at all, because while impressive upon review, expected resources are no longer available for marketing or distribution, if indeed they were ever included in the project plan. Early majority users report that the difficulty of integrating products into already packed curricula can be a result of several possibilities: the product is not a "good fit' in the sequence of learning, there is a lack of time for the required training, distribution is expensive or risks loss of ownership, or there is a high risk for poor learning outcomes and the dreaded low scores on course evaluations.

Within the whole product concept, the creative services team would discuss and resolve copyright and distribution early in the development process, incorporating controls into the product. The team and faculty would meet early in the timeline with the administrators, curriculum committees and course directors to plan curricula integration and confirm feasibility. They would develop prototypes midway through the process to pilot in low-risk, formative learning environments. Moreover, they would meet with the institution's faculty and staff development teams to develop learning materials and plan training that could be delivered efficiently and timely. The marketing and distribution plan would be incorporated into the project plan. A completed but underutilized product could also be assessed by the creative services team for new applications, redesign, or for integration, training and marketing.

Additionally, some intended long-range positive outcomes are at risk. Rather than increasing momentum and seeding the faculty with innovative ideas, members of the development team disband post production when not refunded. Meanwhile, those who took on the teaching load of the innovative faculty during product development are left without the benefit of either the product or the team member's expertise. Hence, they may express reluctance to support or join future technology endeavors. If they had been supportive of past innovations, but are now tenured in an institution with stagnant financial compensation, they may express frustration in a committee meeting that scarce funds are used to fill an instructional technologist position rather than a teaching assistant position.

With the holistic model, these risks are much less likely. Momentum, team processes, and innovation are present and, with the proper planning, supporting faculty can play a role throughout the process as key informants in focus groups or in small pilot projects that could duplicate as training.

Likewise, a more subtle but insidious sign of a chasm can emerge when early adopters or early majority faculty emulate the three-member team approach in form but not in substance. With the best of intentions, and perhaps strongly influenced by resources, faculty rely on their own teaching expertise instead of consultation with an instructional designer, or perhaps hire a web specialist with little educational experience. The third member of their team is often an administrative assistant or an inexperienced teaching assistant with little or no training in pedagogy or instructional technology.

While successful in some cases, results of these efforts can raise barriers to transformational education. In the worst cases, the result can be disjointed learning experiences, plagued with errors, technology glitches and misinformation to the students, with poor learning outcomes and dismal scores on course evaluations. Additionally, even if learning outcomes meet baseline program standards, emit acceptable student evaluations but show no significant improvement in previous methods, these acceptable learning outcomes may be considered 'good enough' and hence be a barrier to transformational learning.

None of the above scenarios are unique to a single institution and obviously they vary in degree. However, while barriers to technological innovation arise from a faculty perspective, faculty also relay concerns that the students' attention is diverted by technology. Faculty see that students don't bother coming to class because they would rather view lectures on their portable electronic devices or they come to lecture but use the time to surf the Internet and text each other. In answer to these concerns, during a recent health care education conference, a medical student panel was asked how they felt about faculty's concerns. Their responses were surprising and notable.

First, students expressed appreciation that in the age of digitization, massive amounts of materials are made available for review in several formats. Not surprisingly, they were uncertain how to sift for salient points critical for successful exam scores and for appropriate patient care. Hence, they requested more specific study guidance. However, a few noted that they sometimes appreciated a 'thick text', one that when dropped made a "thud" sound. They also didn't want to 'lose the face of medicine' in that they did not necessarily wish to attend fewer classes or be taught by a computer or a technologist, rather they wanted very pertinent, challenging class sessions, based on excellent teaching principles and practices, and enhanced by technologies that in turn enhanced their learning.

All of the outlined scenarios should be recognizable in some form to the reader. They are opportunities for transformation. By their nature, transformations tend to occur when stimulated by a crisis: in adult education, transformational learning occurs at that point where the student has a poor or failing grade, recognizes that he or she is in trouble, and is willing to take advantage of a learning solution to transform the learning process. GIR members can prepare solutions for transformational learning opportunities in several ways: investigating and developing best practices for creative services teams, working with other units to encourage intensive formal and informal faculty and staff development, and helping our colleagues and our faculty take full advantage of existing technologies. For example, how many of our users take full advantage of POT (plain old telephone) technology? We could work with our institutions to arrange for educational technology courses for teaching assistants for credit, and create certification programs as incentives for faculty development. Finally, we could host regular point-counterpoint forums for faculty and students to debate and discuss their opposing concerns.

In summary, even in the best of economic times, we may not recognize when our innovative processes have stalled or become a barrier to transformational education. We now face a situation where few institutions remain untouched by recent financial downturns. Hence, concurrent with the excitement of our new administration we need to be economically realistic, vigilant for signs of widening chasms in our adoption cycles, and intervene early with creative solutions. We can create opportunities to listen and develop our faculty and staff as well as our students. Finally, we can explore a whole product concept and assess how we encourage a culture of innovation.