Digital Medical Education

Today, in the 21st century, the volume of medical knowledge has grown exponentially. Historically, medical education was focused on developing clinical skills and medical knowledge. Today such a narrow focus is deemed completely inadequate. Now a physician is expected to be a medical expert who is also a scholar dedicated to lifelong learning, and who integrates new and rapidly progressing knowledge. He or she is expected to be an excellent communicator, a patient advocate, a leader within the health care system, and a collaborator working with a multitude of other professions. In 1996, the Royal College of Physicians and Surgeons of Canada recognized the need for this broad skill set with the publication of the CanMEDS physician competency framework (Frank, 2015). The CanMEDS framework provided a new set of goals within medical education. With these new goals come new challenges. The now antiquated assessment models struggle to evaluate many skills demanded in a competent physician. Studies have shown that traditional means of evaluation cannot easily assess the performance of many of the physician roles defined in the CanMEDS framework (Chou, 2008; Sherbino, 2013).

A new means of evaluating and determining the progress of a learner within medical education is required. This has led to the educational model of competency-based medical education (CBE) becoming adopted as the optimal means to evaluate and determine the progress of the medical learner. A CBE curriculum operates on the premise of defined educational objectives. The trainee must demonstrate proficiency in these define objectives to progress to more advanced tasks. The notion of CBE is not new, and the theoretical behaviorist underpinnings of this construct were first defined by experimental psychologists such as Thorndike and Skinner (Morcke, 2013).

The Royal College has responded to the adoption of a CBE framework by defining the physician roles with various competencies now called milestones. Collectively, these are to be evaluated (Frank, 2014). Now a new challenge is on the horizon for the medical educator. How can the educator evaluate proficiency within these now defined milestones? How can we determine if the medical trainee is indeed competent for his or her expected level of training in a given role? Without developing valid methods of evaluation, an effective CBE curriculum is impossible. I believe digitally assisted instruction will play an essential role in empowering both the medical trainee and the educator in learning, teaching and evaluating CBE milestones. Likewise, a growing body of work has demonstrated that technology-enhanced simulation is a superior for teaching and demonstrating mastery of many procedural skills required by healthcare professionals (Cook, 2013; Willis, 2015). Cognitive and problem solving tasks can also be effectively and efficiently taught and evaluated through the application of digital technologies. The digital medium is superbly poised to address such needs by applying connectivist theory. Furthermore, such technology facilitates discovery learning and learner centered design principles. Additionally, online assessment of graduate medical trainees has also been found to be effective in improving learner performance (Karakus, 2014; Nacca, 2014; Pusponegoro, 2015; Wickens, 2015). Collectively, these developments and insights into the digital facets of medical education suggest that these tools are useful adjuvants in instruction and assessment. This technology is particularly advantageous when applied to curricula based on CBE milestones, and due to the Royal College mandate towards this instructional design model, this technology is needed more than ever within medical education. Digital tools allow instructional objectives which are not commonly encountered at the bedside nor easily assessed within the everyday clinical environment to be teachable and assessable within a CBE curriculum. Therefore, the medical educator must be versed in educational theory and practice, along with digital technology application. Though successful implementation of clinical bedside teaching together with mindful instructional design which is inclusive towards digital technology the best possible learning opportunities to the physician in training can be provided.

References

Chou, S., Cole, G., McLaughlin, K., & Lockyer, J. (2008). CanMEDS evaluation in Canadian postgraduate training programmes: Tools used and programme director satisfaction. Medical Education, 42(9), 879-886.

Frank, J., Snell, L., & Sherbino, J. (2015). The Draft CanMEDS 2015 Physician Competency Framework. CanMEDS 2015.

Sherbino, J., Kulasegaram, K., Worster, A., & Norman, G. (2013). The reliability of encounter cards to assess the CanMEDS roles. Advances in Health Science Education, 18(5), 987-996.

Karakus, A., & Şenyer, N. (2014). The preparedness level of final year medical students for an adequate medical approach to emergency cases: Computer-based medical education in emergency medicine. International Journal of Emergency Medicine, 7(3), 1-6.

Morcke, A., Dornan, T., & Eika, B. (2013). Outcome (competency) based education: An exploration of its origins, theoretical basis, and empirical evidence. Advances in Health Science Education, 18(4), 851-863.

Nacca, N., Holliday, J., & Ko, P. (2014). Randomized Trial of a Novel ACLS Teaching Tool: Does it Improve Student Performance? Western Journal of Emergency Medicine, 15(7), 913-918.

Pusponegoro, H., Soebadi, A., & Surya, R. (2015). Web-Based Versus Conventional Training for Medical Students on Infant Gross Motor Screening. Telemedicine and E-Health, 21(12), 1-6.

Wickens, B., Lewis, J., Morris, D., Husein, M., Ladak, H., & Agrawal, S. (2015). Face and content validity of a novel, web-based otoscopy simulator for medical education. Journal of Otolaryngology 54(11) 1-8.

Within recent years the concept of gamification has acquired increasing popularity (Mckeown, 2016) More recently such educational technology utilizing gamification principles has been explored within medical education (Graafland et al., 2012). The interactive and collaborative nature of many online applications possibly lends well to both clinical and educational gamification principles. Central to the concept of gamification is motivations towards learning and changing behaviour. Evidence is shown that intrinsic motivation is more successful towards long-term behaviour change. Mandated change or extrinsic motivation has been shown to be less successful over long periods of time. The goal of gamification is to provide intrinsic motivation in the learner by connecting with their core values in providing rewards and positive reinforcement towards self-determined change (Ryan, & Deci, 2000). Successful games to continually challenge the player in order to keep the user interested with new tasks and experiences. This fits well with Ericsson’s theory of deliberate practice. A player should not be automatically good at the game however with repetitive training the player should be guided towards becoming an expert (Blohm, & Leimeister, 2013). Such a principle facilitated through carefully designed software holds much potential within medical education. After all, these basic principles are proven extremely motivational within the commercial context. Many of these concepts are used successfully within the video game industry in order to “hook” players into the game environment for long periods of time (Wit-Zuurendonk, & Oei, 2011).

Gamification within education falls under the category of “serious games”. The so-called serious games have non-entertainment purposes behind their design. They may be entertaining, and they should be intrinsically motivating, but their main purpose is towards changing behaviour and learned tasks. Upon review of the medical literature a few recent studies show promise (Graafland et al., 2012).

Digital laparoscopic simulation is shown a statistically significant correlation with handling surgical tasks within a live animal model (Rosenberg et al., 2005). An emergency department simulator game has also been developed and has shown promise in significantly increasing triage accuracy amongst nurses (Knight et al., 2010). Virtual patient simulators have also been developed which apply gamification principles. For instance, a virtual emergency department has been created were medical students manage six cases simultaneously. It has been shown that this technology improved team and leadership performance scores and enhanced medical content knowledge (Youngblood et al., 2008). These principles of gamification have also been applied at the organizational level. An online award based system was implemented for a surviving sepsis campaign which demonstrated a significant reduction in mortality (Mckeown et al., 2016).

With this success, these games could potentially replace certain aspects of clinical teaching. The self-directed nature of many such of many such games lends itself well to discovery learning and learner centred instructional design. One obstacle towards more readily adopting this technology has been proving content and face validity of the particular computer programs, which are often simulators (Graafland et al., 2012). Such evidence-based practice within medical education is required in order to adopt educational technologies which of the potential to directly or indirectly affect patient care. Recent systematic review demonstrated that out of 30 serious games identified within the medical peer-reviewed literature, only six had completed full validation (Graafland et al., 2012).

Within the future, and with the increasing evidence behind such games, this validation will likely accelerate, however this will slow adoption of this innovation. It may be more expedient to apply principles of gamification to junior medical trainees who are not yet immersed in the clinical environment. Massive online open courses (MOOCs), have applied many of these principles of gamification successfully (Harder, 2013). This is achieved through providing online badges, and applying the benefits of social media as a reward. In this way a learner who is successful in tasks is positively reinforced by receiving social capital (Harder, 2013). The development of such MOOCs is still a relatively early stage within medical education. This would be an area ripe for further research.

The need to train medical experts efficiently and to provide intrinsic motivation towards tasks which may not be generally immediately recompensing, demonstrates a potential demand for further gamification within medical education. The underlying educational theory behind gamification makes sense especially with the medical education context. The initial researchers produced over the last 10 years shows promise for profound benefits. Nevertheless, further research of gamification is required, especially in simulation-based learning.

References: Blohm, I., & Leimeister, J. (2013). Design of IT-based enhancing services for motivational support and behavioral change. Business and Information Systems Engineering, 55(4), 275-278.

Graafland, M., Schraagen, J. M., & Schijven, M. P. (2012). Systematic review of serious games for medical education and surgical skills training. British Journal of Surgery, 99(10), 1322-1330. doi:10.1002/bjs.8819

Harder, B. (2013). Are MOOCs the future of medical education? BMJ,346(2). doi:10.1136/bmj.f2666

Mckeown, S., Krause, C., Shergill, M., Siu, A., & Sweet, D. (2016). Gamification as a strategy to engage and motivate clinicians to improve care. Healthcare Management Forum, 29(2), 67-73. doi:10.1177/0840470415626528

Ryan, R. M., & Deci, E. L. (2000). Intrinsic and extrinsic motivations: classic definitions and new directions. Contemporary Educational Psychology,25(1), 54-67. doi:10.1006/ceps.1999.1020

Wit-Zuurendonk, L. D., & Oei, S. (2011). Serious gaming in women’s health care. International Journal of Obstetrics & Gynaecology, 118, 17-21. doi:10.1111/j.1471-0528.2011.03176.x

Web 2.0 technology has had an impact on education by facilitating a transition from static online resources to dynamic user-created resources. Such modern systems allow for continuous modification of content through the participation of users. These features present numerous educational opportunities for instructors and students alike.

Unsurprisingly, this technology has been embraced in medical education. Namely, social media have been increasingly used to educate healthcare trainees. A recent review of social media with medical education has revealed that collaborative online educational projects use platforms such as Wikimedia, and social bookmarking applications. This technology also uses blogs and forums such as Twitter and WordPress or phpBB which allows for interaction between instructor and learners through the posting of comments. Features of both of these technologies have led to content communities existing on platforms such as YouTube, Flickr, and Slideshare, and the use of social networking sites such as Facebook, ResearchGate and LinkedIn (Hamm et al., 2013). North American medical educators have led this adoption of Web 2.0 technology. A recent review revealed that approximately 63% of such resources are created by those based in this geographic location. Of the available technologies discussion forums, blogs and social networking are the most popular platforms used within medical education (Hamm et al., 2013).

This has led to discussions and the exchange of information formally confined to the clinical environment being brought online and made widely and publically available. This raises some important questions about professionalism. For example, nursing students who posted photos of a placenta, which they examined on an obstetrical rotation, on Facebook were expelled for unprofessional activity (Parkinson & Turner, 2014). Similarly, a recent study surveying Facebook profiles of medical students within one medical school class revealed 1% of trainee profiles demonstrating unprofessional content, such as demonstrations of excessive alcohol consumption or explicit language (Gupta et al., 2015). Likewise, 60% of American medical schools’ report cases of medical students inappropriately using social media in a clinical context (Moses et al., 2014). Such cases require the careful attention of those creating and using medical education content online within the educational context. Another concern is the dissemination of medical knowledge and possible and inappropriate use of this information. Liability concerns for content creators also warrants consideration.

Issues about patient confidentiality and professional boundaries are inherently raised through the adoption of these technologies. The greatest strength of free open access medical education (FOAM) is the ability to democratize medical knowledge. This requires the use of Web 2.0 technologies and for public dialogue. This same strength when misused can lead to professionalism and boundary concerns. Medical educators and trainees must find a balance between empowering medical professionals and students, facilitating reflection and self-expression, while defining necessary boundaries.

To assist those using these resources most regulatory bodies within medicine have created guidelines for the appropriate use of social media (College of Physicians and Surgeons of Ontario, 2016). Generally, this involves maintaining the professional and ethical principles expected within the clinical environment, especially those regarding patient confidentiality. Often it is also recommended that disclaimers be added to any general medical advice provided, and to be careful to represent professional designations carefully. Also, it is recommended that healthcare and academic institutions develop auditing policies for trainees and faculty (Moses et al., 2014). Through the mindful use of online digital tools, traditional medical education instructional methods can be enhanced. However, like any new technology, we must be aware of its limitations and potential dangers. The clinical setting holds some unique challenges that require particular attention in this respect and the specific rules governing appropriate use require frequent updating and re-evaluation as these digital tools rapidly evolve.

College of Physicians and Surgeons of Ontario. (n.d.). Social Media - Appropriate Use by Physicians. Retrieved February 07, 2016, from http://www.cpso.on.ca/policies-publications/positions-initiatives/social-media-appropriate-use-by-physicians

Gupta, S., Singh, S., & Dhaliwal, U. (2015). Visible Facebook profiles and e-professionalism in undergraduate medical students in India. Journal of Educational Evaluation for Health Professions, 12(50), 1-5. doi:10.3352/jeehp.2015.12.50

Hamm, M. P., Chisholm, A., Shulhan, J., Milne, A., Scott, S. D., Klassen, T. P., & Hartling, L. (2013). Social Media Use by Health Care Professionals and Trainees. Academic Medicine, 88(9), 1376-1383. doi:10.1097/acm.0b013e31829eb91c

Moses, R. E., Mcneese, L. G., Feld, L. D., & Feld, A. D. (2014). Social Media in the Health-Care Setting: Benefits but Also a Minefield of Compliance and Other Legal Issues. The American Journal of Gastroenterology, 109(8), 1128-1132. doi:10.1038/ajg.2014.67

Parkinson, J., & Turner, S. (2014). Use of social media in dental schools: Pluses, perils, and pitfalls from a legal perspective. Journal of Dental Education, (78), 1558-1567.

The rise of free open access medical education, arguably the most popular use of digital tools within medical education, has greatly altered the manner in which a clinical educator and trainee approach online learning. FOAM consists of various online tools such as blogs, podcasts, wikis and online videos. An adjuvant to this digital learning environment are certain elements of mainstream social media such as Twitter (Nickson & Cadogan, 2014). Although the term "FOAM" was coined only in the last few years the creation of these digital resources are not new, the origins of these tools within medical education date to at least 2002. Nevertheless, the popularity and mainstream acceptance of these resources have ballooned over the last decade with the most popular FOAM websites receiving over 10 million visits a year (Cadogan et al., 2014).

As a medical learner, I have certainly been aware of FOAM for several years. I have also used all of the mentioned incarnations of this resource, from blogs to podcasts. Nonetheless, my use of these resources has been fleeting at best. This runs somewhat counter to my trend to eagerly adopt technology in other realms of my life. At best these resources have remained on the very periphery of my medical education. Integrating these resources into my instruction of learners, has been largely relegated to passing on quotes found within an interesting blog here and there.

The next logical question to ask is why this is the case? On responding to this question I have a passionate response both as a medical learner, budding educator and as someone who envisions online learning as a fundamental aspect of the future of medical education. FOAM represents potential. It provides a glimpse at the power held by the digital platform when used as a medium to educate. This digital technology is not used to its full potential today, other areas of education outside of medicine stand as testament to this fact. One needs only to look at the many massive open online courses (MOOC) available to see this technology used more optimally.

When considering FOAM the following analogy comes to mind: The internet provides one of the most powerful tools ever developed to facilitate collaborative, interactive and learner-centered instruction. The internet which powers FOAM is the automotive equivalent to a Ferrari. If we push this technology, we could go 300km/hr. Today we do not use this potential power in how we apply FOAM. Instead, we drive our Ferrari 10km/hr...

Here are the underlying issues I have with FOAM as it stands today. Firstly, every day we have more and more blogs, podcasts and so on. How do we organize these resources? Sure, FOAM Search, a search engine utilizing google's underlying search engine and dedicated towards FOAM resources is a start. It does not resolve the underlying issue of disjointedness between different independently crafted resources. One would imagine a database resembling something more like PubMed would better serve this purpose. Alternatively, and even better yet, the format of a MOOC could gather up independent "lessons" crafted by various individuals and across different sites to over a mini-curriculum. Such integration would allow for comprehensive implementation of various learning theories and offer more evidenced based educational experiences. The application of MOOCs within a postgraduate medical education setting has shown much promise. The pre-existing FOAM resources would lend themselves naturally to this format (Subhi, 2014).

A MOOC format would also be a useful medium for increasing interactivity between learners and with instructors. FOAM applied in this manner would no longer be limited to instructional blogs and a comments. Instead, assignments and active participation of learners and instructors within the digital environment would be possible. This opens up many exciting instructional design principles (Subhi et al., 2014). Furthermore, elements of gamification are easily integrated within MOOCs. Of interest, the benefits of gamification have been recently presented within the medical education setting (Muntasir et al., 2015).

Another issue with FOAM today is quality insurance. Anyone can create a blog, podcast or post a wiki article. When conveying clinical information, the validity of the source is of importance. A peer-review process used by open access journals is a possible solution of this problem. A validated scoring system adopted within the FOAM community would help overcome this issue. Such a system is currently in development, yet such peer-review certification processes are not widespread at the moment (Thoma, et al., 2014).

FOAM must also look beyond current formats such as WordPress blogs and WikiMedia sites. Purpose built digital education sites would offer even further customizability and user interaction. Virtual patients have proven useful for various medical education experiences. Purpose built sites such as the VirtualER.org could allow for FOAM based simulation, combining the collaborative benefits of FOAM with the advantages of virtual online patients (Dafli, 2015).

At the end of the day, this all boils down to next generation FOAM focusing on integrating concepts of learning theory. FOAM should be assessed based on how well such theory is applied. A recent systematic review concluded that core learning principles derived from well-known learning theories should be applied to the creation of digital tools. This proposed system highlights optimizing modality, minimizing extraneous cognitive load, applying elaboration and discovery theory, spiral curriculum elements, optimizing modality through various online media formats, providing clear objectives to facilitate connectivist learning, and framing objectives (Lau, 2014).

FOAM holds an enormous amount of potential. I would even argue it is the future. However, the days are early yet. With the rise of more digital medical educators, the transition to next generation FOAM is likely inevitable. This transition is poised to be an exciting process and one which I thoroughly look forward to both as a learner and as an educator.

References

Cadogan, M., Thoma, B., Chan, T. M., & Lin, M. (2014). Free Open Access Meducation (FOAM): The rise of emergency medicine and critical care blogs and podcasts (2002-2013). Emergency Medicine Journal, 31(E1). doi:10.1136/emermed-2013-203502

Dafli, E., Antoniou, P., Ioannidis, L., Dombros, N., Topps, D., & Bamidis, P. D. (2015). Virtual Patients on the Semantic Web: A Proof-of-Application Study. Journal of Medical Internet Research, 17(1). doi:10.2196/jmir.3933

Muntasir, M., Franka, M., Atalla, B., Siddiqui, S., Mughal, U., & Hossain, I. T. (2015). The gamification of medical education: A broader perspective. Medical Education Online, 20(3). doi:10.3402/meo.v20.30566

Lau, K. H. (2014). Computer-based teaching module design: Principles derived from learning theories. Medical Education, 48(3), 247-254. doi:10.1111/medu.12357

Nickson, C. P., & Cadogan, M. D. (2014). Free Open Access Medical education (FOAM) for the emergency physician.Emergency Medicine Australasia, 26(1), 76-83. doi:10.1111/1742-6723.12191

Subhi, Y., Bojsen, S., Nilsson, S., & Konge, L. (2014). Massive open online courses are relevant for postgraduate medical training. Danish Medical Journal, 21(10), A4923.

Thoma, B., Chan, T., Desouza, N., & Lin, M. (2014). Implementing peer review at an emergency medicine blog: Bridging the gap between educators and clinical experts. Canadian Journal of Emergency Medicine, 12(2), 188-191. doi:10.2310/8000.2014.141393

FOAM Search, Retrieved January 31, 2016, from http://googlefoam.com/

Kenneth Van Dewark BMSc MD
McMaster FRCPC Emergency Medicine - PGY4

I'm currently an emergency medicine resident at McMaster University. Long before I had a passion for medicine I enjoyed exploring and developing online technologies. Over the years of my medical training, I have grown increasingly interested and involved in education. I believe all of these interests, medicine, digital technology, and education can work synergistically together to improve the care delivered to patients seen in our emergency departments.

To facilitate this aim, I am currently compleating a Masters of Education at the University of Ontario Insitute of Technology. This graduate program has a particular focus on digital technologies within education. I have also been developing a novel educational tool, an online simulated emergency department called the VirtualER. Research into this tool is ongoing and validation of this online simulator is underway. It is my strong belief that the online medium can assist in the education of tomorrow's physicians and that this technology must be continuously pushed forward. Blogs and podcasts are very useful tools and are the current foundation of Free Open Access Medical Education (FOAM). Yet, the online medium holds potential to greatly expand the current offerings and to facilitate the development of more interactive and learner-centered educational experiences. Similarly, it is my firm belief that as digital technology becomes an ever more important factor within medical education a further subset of clinicians who have a background in digital technology, education theory and bedside medicine will be required.

Regarding these various ideas, recently the Royal College of Physicians has generously assisted me in providing the opportunity for further development of such expertise through the Robert Maudsley Fellowship. This support has greatly assisted in both the development of the VirtualER and with my current graduate studies in education.

This blog will outline some of these ideas and explore the related literature. Oh, and of course, I will be testing out some new online technologies and sharing my thoughts! Please feel free to comment and provide your insight! I look forward to the exchange of ideas and related discussion!

- Ken