When I was growing up, I had the great privilege of attending a private high school where I sat around a large oval wooden table with 10 to 15 other students. Those were the days before iPads and laptop computers, so students could not instantly access information the way they can now. Teachers were the expert authorities, and the information they taught us could not easily be verified. They could see our faces and whether our eyes were open or partly closed; they knew at a glance whether we were engaged in the topic. There was nowhere to hide. We could refer to our textbooks and notebooks, and there was a blackboard with chalk to illustrate ideas or pose questions.
Our goal was to avoid embarrassment, make a good impression, and learn what we needed to know to succeed in the class. The teachers’ goal seemed to be to create a lively, productive learning environment and to ferret out those laggards who had skimped on the assignment. These sometimes-conflicting goals led to intense class discussions, where we tried to impress our teachers but also tried to demonstrate our prowess at verbal combat with each other. Those who could think and speak cleverly with wit and a touch of sarcasm were envied and feared by the rest of us, who struggled to find the right words as the conversation flew by. After the preparation and studying we had done before class, we learned our subjects mostly from the debates we had, guided by our teachers.
As a teacher myself, I try, whenever possible, to emulate the face-to-face approach of my youth with my students even without the large wooden table we had then. I have taught college students, medical students, residents, and practicing physicians over the years, and this personal approach has generally worked for all of them. I often ask students to form a circle and pose a question or problem to the group just as my teachers once did. The resulting discussions vary depending upon the topic and the motivation of the students. Unfortunately, with groups of residents who are often sleep deprived and may not have done their assigned readings, the class discussions sometimes lack the fire that I remember from my days around the oval table, and the verbal jousting that then was frequent rarely appears in my classes. Instead, classes have a more cooperative, survivalist character as students try to avoid a major faux pas as they wait for me to teach them something—preferably from a slide. But I can still look into their eyes and see whether they are with me. I enjoy the opportunity to get to know my students, challenge them if I can, identify those who need extra help, and participate in their growth. Over time, some of them have become colleagues and friends, and our learning has grown into collaborations.
It was with some trepidation that I agreed to teach an online course to undergraduate students this year. My students would follow a carefully developed lesson plan with required readings, online tests, and required assignments submitted by a deadline displayed by a digital clock that reminded me of the timer on some kind of explosive device. I would provide feedback on their assignments that would result in a grade. If they had questions, they could submit them to a common “blackboard,” and either other students or I would attempt to answer them. My students could be across the country or on another continent. I would have no idea where they were, nor of any student’s gender, age, hair color, race, or ethnicity. I could be reading their assignments at home with music in the background, on an airplane, or in a hotel. I wondered whether I would I get to know any of my students; they would know little about me beyond what I wrote as a brief introduction, although they could go on the Internet and google me. What would I do if one of my students had difficulty with a concept? How would I be able to help?
Once I started the class, I didn’t have to wait long to encounter a student in trouble. The first assignment was challenging, and several students were having difficulties. I received e-mails asking my assistance, such as the one below. (All student information has been deidentified.)
Dear Dr. Sklar, I don’t understand how a placebo could have any effect. It is only saltwater. Why must you study a drug against a placebo? Is that ethical? I am anticipating applying to medical school in six months. I really need an A in this course. I’m willing to work hard but I need some help to understand this concept.
I wrote back,
Dear M, I agree that the placebo effect is confusing. I will send you some articles that may help explain how it works. For your assignment we are studying various types of evidence and the importance of control groups. That is where placebos come in. I looked at your quiz and your assignment. It seems that you are having trouble with the concept of a control group as well as the placebo effect. Is there any chance you could come in to my office where we could go over this?
Dear Dr. Sklar, I am working on a farm in Ohio more than 2,000 miles away from your office.
Eventually we were able to talk on the phone, and I found a graduate student who worked with the student over the Internet and identified resources that helped, but I felt unsatisfied. I wanted to be able to talk about my own experience with the placebo effect in research and clinical care and my own curiosity about why the saltwater placebo worked sometimes to relieve pain. But that was not something we could do easily over the phone or through e-mails.
As the class went on, I did begin to get to know some of my students by reading their assignments and responding to what I read or to subsequent e-mails. I wrote them encouraging notes as I corrected their assignments, and by the end there were some who felt that the class had been a valuable experience. But I wondered what that meant. Valuable in what way? Was it valuable because they were able to fit the class into their busy work schedules? Was it valuable because they could be in Ohio or Africa and complete a college course and get credit? Was it valuable because they could meet a requirement for graduation? How much would they remember, and would that help for any later course that built upon what I had taught in this one? I wondered how well distance learning worked, whether the benefits outweighed the costs, and how I could use the technology of the Internet to foster the best educational experience possible. I also wondered what kinds of relationships I would be able to develop with online students and how to make them useful.
Features of Distance Learning
Vrasidas and Glass1 describe distance learning as occurring through technology that mediates interactions between the learner and content, the learner and other learners, and the learner and the teacher. Thus it appeared that provision of content alone does not do the trick. The authors state that
learners’ skills to engage technology-mediated communication are important factors that will influence success in distance learning…. However, problems of teacher interface may have more to do with the success or failure of distance education than any other kind of interaction. Furthermore, the interface may not be simply a “medium” but may be content in its own right.
In other words, I had to be adept at the use of the Internet and other technology for my students to succeed.
MacLeod et al2 attempt to provide the theoretical perspective of sociomateriality for distance learning in medical education. They define distance learning as being institutionally based; having a separation of student and teacher either geographically or in time; having an inclusion of interactive telecommunications; and sharing resources, such as data, voice, or video. They also describe distributed medical education (DME), which is a type of distance learning in which there are decentralized community-based learning networks. They note that in DME not only is education the result of human interaction but it is also a function of the structure and constraints of the Internet and the other “material things” that provide an interface for the education.
Based on these theories, it became clear that I could not expect the approaches and materials that work effectively in a room with students to work with similar efficacy in a distance-learning environment. While similar content might be sent out to learners in both settings, the factors that determine whether the content is received and understood are different. In the classroom, success probably has more to do with factors such as the makeup of the class, the enthusiasm of the instructor, and any distractions in the room such as noise, while in the distance-learning environment the clarity of images, the students’ mastery of Internet technology, the ability for students to interact during and after the presentation, and the ability to ask questions of the instructor are among the factors that are probably more critical.
Does Internet-Based Learning Work?
Cook et al3 published a meta-analysis of Internet-based learning in the health professions, asking how such education compared to no intervention and how it compared to non-Internet educational interventions. They found that Internet-based learning increased knowledge and improved skills and behaviors. In particular, tutorials, longer-duration courses, and courses with online peer discussions seemed to have positive outcomes. The authors’ findings suggest that Internet-based and non-Internet-based instruction are generally similar in effectiveness.
Wong et al4 performed a realist review of Internet-based education to study the circumstances under which such education was effective and for whom. They adopted a theoretical approach that emphasized the diffusion of innovation theory of Rogers,5 which describes why innovations are adopted. Wong et al suggest that the relative advantages of using Internet-based education—such as access to learning and consistent content, links with assessment, convenience, lower costs, interactivity, and time saving—influenced adoption; they suggested that course developers consider these factors when designing Internet-based educational programs.
In this issue of Academic Medicine, Tackett et al6 describe the development of specific online medical educational videos intended for a global audience and posted on YouTube, and note that those videos had been viewed over 5 million times. It is likely that many of the factors noted by Wong et al are responsible for the rapid global adoption of this learning platform.
Similarly, in this issue, Le and Prober7 describe the creation of a digital “common curricular component ecosystem” that could be shared nationally or even internationally to reduce duplication and reduce costs of medical education. They describe how using the Internet to maintain and share the best teaching materials would allow institutions to mix and blend curricular elements, thus saving money that would have been needed for local development of the materials. Also in this issue, Jeong et al8 describe their scoping review of the literature on facilitators and barriers to self-directed learning programs in continuing professional development. They found that most barriers to self-directed learning were environmental factors, including access to tools and programs. Internet-based distance learning could help overcome such barriers.
Making the Most of Internet-Based Learning
I have three recommendations about distance learning using the Internet, based on my experience and review of the relevant literature.
First, we need to make Internet-based education as effective as possible, understand its limitations, and disseminate it as widely as possible. I say this because such education has provided educational opportunities to people who had previously been denied such access. In that regard, all educators need to understand the technology; appreciate how it can be used to improve knowledge, skills, and behavior; and participate in personalizing their educational offerings through the Internet with the support of design experts in distance learning.
Second, the interactions between teacher and students in the physical classroom, the hospital, the operating room, and the clinic provide different kinds of educational experiences from those obtained via Internet-based education. We need to understand these differences and attempt to replicate in-person interactions in the Internet-based learning platforms while also encouraging the mixing of in-person and Internet experiences so that students and teachers can understand the effects of technology on their learning and get the most out of both approaches. By investing in education research, we can find the most effective ways to mix online and in-person learning.
Third, we need to remain vigilant about the importance of the uniqueness of individual learning needs and styles. The experiences of teaching and learning are not the same for each person, and we need to match the learner with the best learning environment and resources for that learner, and do the same for teachers. The struggling learner still needs the support of an experienced teacher who can identify the causes of learning difficulty and find solutions. The Internet may not be the best learning tool for such a student. We need to continuously be mindful of the goals of our educational programs and consider what set of tools and processes will best help us meet them for all of our students. The Internet is a remarkable tool that can open up unimagined vistas, but it is not the same as a trusting relationship with a teacher; it is not a passionate learning companion like a resident who works with another resident to puzzle out a difficult diagnosis; and it is not a wise mentor like the professor who listens to a case presentation, engages in a dialogue to question assumptions, and guides the group of students to identify the gaps in their knowledge. In our zeal to share knowledge over the Internet through education, we must not lose sight of the person on the other side of the screen.
I have come to believe that Internet-based distance education can be a powerful adjunct to other educational platforms in health professions education, recognizing that it requires infrastructure support and expertise as well as professional development of faculty. It can level what has been one of the most uneven playing fields in the world—the access to information and knowledge. As new technology is developed, the opportunities for sharing resources will continue to increase and will require us to redefine the value of various educational experiences and how to assess competence. The resulting changes will sometimes be disruptive to current educational models and may threaten current hierarchies and financial relationships in health professions education. While the learning that occurs in the clinical setting will continue to depend on close personal and trusting relationships between faculty and students, there will likely be new Internet-supported ways for such relationships to occur, such as through telemedicine with a variety of mobile devices.
I hope we can embrace these new opportunities and learn how to use them effectively while remembering their limitations and also remembering the need to protect our patients’ confidentiality and values and the safety of our clinical environment. If we can learn how to more effectively harness this powerful learning platform, I believe we can accelerate the spread of knowledge in the world and thereby improve health equity for all.