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Perspectives |
1 From the Division of Education, Department of Radiology, Indiana University, 702 N Barnhill Dr, Rm 1053, Indianapolis, IN 46202-5200. Received January 25, 2001; revision requested February 6; revision received February 16; accepted February 27. Address correspondence to R.B.G. (e-mail: rbgunder@iupui.edu).
Index terms: Education • Perspectives • Radiology and radiologists
Men have become the tools of their tools.
Henry David Thoreau (1)
As one of the most technology-intensive fields in medicine, radiologic educators have moved quickly to embrace the recent burst of innovation in instructional technology (IT). Whole new imaging modalities have been made possible with the development of ever more powerful and cheaper information processing, including spectacular advances in ultrasonography (US), computed tomography, magnetic resonance imaging, and positron emission tomography. In the same way that information technology has revolutionized the clinical practice of radiology, the proponents of IT-assisted education predict that it will revolutionize radiologic education (2). They have argued that the old ways of training radiologists, including reliance on textbooks and an "apprenticeship" model of one-on-one interaction, need to be updated. By using such IT tools as computers and the Internet, they argue, it is possible to develop more effective and efficient means of teaching radiology.
IT may prove to be an important adjunct to current educational practice, but IT is not the final solution for education. If we rely too much on IT, we are in danger of diminishing the vital human element in education, such as teacher-student interaction, face-to-face seminars, and teaching at the reading board. IT may replace the textbook but not the teaching radiologist.
The Value Of IT
While the precise meaning of IT is difficult to specify, IT may be broadly defined as the use of information processing and communications technology to support education. The value of IT lies in its ability to store, analyze, and communicate large amounts of information at very high rates of speed. These capabilities translate into a number of potential advantages for imaging education. Perhaps the most obvious is that learners can access instruction from virtually any site that has a computer and an Internet connection and can do so at any time, day or night (3). They can spend as much time as they wish and return as often as they like. Moreover, relative to the cost of traveling to and from another site, which could be across town or even in another country, the costs of accessing information are substantially reduced (4).
In short, IT can improve access to education and simultaneously lower its cost. Of course, the same could be said for more traditional educational media, such as printed journals and textbooks, which can also be studied anywhere at any time and do not require travel for instruction. To warrant the substantial investment that it requires, IT must prove itself superior to other educational media.
Other strengths of IT are not shared by printed materials. For example, IT enables instructors to integrate image, text, and sound in ways that standard textbooks cannot and provides learners the ability to access and organize information in an individualized fashion (5). Textbooks and journals are unable to link information or provide the same degree of learner customization of instruction. For example, some learners may prefer to see primarily graphics-based instructional material, while others may find verbal instruction more user friendly and effective. IT provides learners the opportunity to tailor the educational experience to their own learning styles and preferences (6). While an educator could, in theory, design several versions of a textbook in pursuit of the same objective, IT prevents the necessity of purchasing several versions to find the one that works best and can be programmed to provide customization that is both adaptive and instantaneous.
IT also enables educators to build more interaction into the learning program. Even traditional lectures with question-and-answer segments can be distributed to a wider audience through IT, for example, when learners at several sites are able to "attend" the same lecture simultaneously through video conferencing. Such virtual lectures can also be recorded and subsequently made available for further study and review (7). Through the design of interactive learning software, educators can encourage learners to adopt a more active role in their own education, rather than merely passively absorbing information from the printed word (8). By asking the learner to answer questions and solve problems, such software can enhance learners’ levels of engagement with the material and make it literally more engaging and enjoyable to learn.
Proponents of IT have also argued that it will prove more environmentally friendly, especially, over the long term. As opposed to printed books and journals, no trees need be felled to produce electronic teaching materials, and waste handling and recycling are not substantial problems. Distribution is less expensive and generates less pollution, because nothing needs to be transported in trucks. Instead of photocopying a chapter, learners can simply download it directly onto a handheld computer, which renders the same information less expensive and easier to carry. If they find a particular web-based learning resource unsatisfactory, they can simply stop accessing it, and delete any software they may have downloaded back into the bottomless pit of cyberspace. Yet, IT is not totally environmentally friendly. Disposal of rapidly obsolescent computers is a growing environmental problem, and the tendency of learners to print text-based materials, often multiple times, suggests that paper savings may be overrated (9).
Another advantage of IT is the fact that it enables instructors to continually update and revise learning materials. Once an author produces a new printed edition of a textbook, that book is fixed in form and content for several years. An electronically based textbook can be as dynamic as its creators choose to make it, incorporating new scientific and technologic developments, keeping users abreast of the latest clinical information, deleting material as it becomes obsolete, and continually incorporating user comments and suggestions (10).
IT can also provide instructors with more rapid and complete information on how learners learn, which can be used to enhance educational results. It can be time-consuming and expensive for a textbook author to determine how learners actually use the book. Which sections do they spend the most time on, which do they tend to skip, and how much time do they spend looking at pictures, as opposed to text? With IT, it is possible to track how much time each learner spends on various parts of the program and to obtain instant feedback on which aspects they find interesting and helpful.
IT can provide instructors with instantaneous test results as learners progress through the curriculum. Are they really getting a firm grasp of the difference between the appearances of airspace and interstitial abnormalities in the lung before they go on to study the pathologic processes that produce each? Where deficiencies or misconceptions are exposed, software can provide recursive remedial procedures to enable learners to be certain that they grasp key concepts before they move on.
The practice of radiology depends not only on a body of knowledge but also on a set of skills. What the radiologist is able to do is often no less important than what the radiologist knows. By using "hypermedia," IT makes possible the development of simulation models for teaching radiologic skills (11). For example, US simulation devices allow learners to study scanning techniques in a programmed setting that provides immediate feedback, rather than relying on less efficient trial and error with real patients. These devices provide learners a clear demonstration of the effects of transducer frequency or angle on image quality and diagnostic value.
The Limits of IT
To prove its worth, the proponents of IT need to provide convincing evidence that IT surpasses traditional educational methods in one of two arenas. The first such sphere is the efficiency of education. Simply put, can IT achieve the same results as traditional educational strategies, while consuming fewer resources in time, money, and effort? For example, can a computer-based tutorial on a particular radiologic topic provide residents the same level of understanding achieved by faculty lectures while permitting the reallocation of a substantial amount of faculty time from teaching to clinical work? As rates of clinical reimbursement have fallen, the educational activities of radiologic faculty have become proportionately more expensive, because every hour allocated to teaching is an hour of lost clinical productivity (12). Educational strategies that make education less radiologist intensive may prove attractive, by reducing the overall cost of education (13).
The other front on which the superiority of IT needs to be proved is educational effectiveness. Evaluations of efficiency focus on the amounts of resources expended by two different programs to achieve an equivalent result. Effectiveness addresses the value and quality of the result itself. To demonstrate that IT-based educational initiatives are more effective than traditional programs, it would be necessary to assess the educational outcomes achieved by both. Proponents could demonstrate that IT-based instruction is capable of producing higher scores on traditional measures of educational achievement, or they could argue that new measures of educational performance need to be developed to fully account for the educational advantages of IT. Some IT-based educational initiatives may turn out to be more effective than the traditional ways of teaching radiology because they achieve better results according to nontraditional measures, such as learner motivation or satisfaction (14).
Amid the groundswell of enthusiasm for the growing role of IT in radiologic education, it is important to recognize that IT is not a panacea. Radiologic educators should not expect to solve all of their educational problems merely by investing more heavily in computers, software, and Internet access. Simply substituting computers for lecturers is not necessarily the answer. Many of the empirical studies comparing IT-based radiologic education to more traditional educational techniques have failed to demonstrate any substantial advantage of IT, and others are so confounded that inferences about effectiveness cannot be drawn (15–17). Of course, the way to remedy this situation is not to give up on IT but to design fully cross-instructional studies with true randomization of subjects.
Some proponents regard the fact that results of IT studies are even comparable to traditional methods as proof that the superiority of IT will soon emerge, but this conclusion has yet to be established with rigorous empirical studies. Results of some meta-analyses have indicated the positive effects of IT on student performance (18). However, it is not IT per se, but rather the quality of instructional design, that improves learning. Computer delivery remains, at best, a secondary factor, and poorly designed or mediocre IT makes no substantially superior contribution to student performance (19).
Is IT-based instruction more efficient than traditional methods of teaching radiology? Certainly, once IT-based programs have been developed they require less face-to-face contact between radiologists and learners. However, the development costs of IT can be high (20). For one thing, most radiologists lack expertise in the design of new educational media. The costs of developing such expertise are substantial and include the cost of the educator’s time (21). Even once radiologic educators possess the necessary expertise, the development of high-quality IT-based instructional programs is demanding, requiring an amount of time, energy, and commitment at least equivalent to that of writing a book (22). Moreover, truly innovative educational leaders are unlikely to be satisfied with mere improvements in educational efficiency and will set their sights on the more difficult yet rewarding task of improving the effectiveness of radiologic education.
The issue of measuring educational effectiveness, however, is a thorny one. Innovators naturally have an interest in demonstrating the value of their products. Outcomes measures used by IT proponents for comparing traditional instruction and IT-based strategies may favor IT by focusing on outcomes on which IT is likely to perform best. For example, IT may tend to perform well in the area of transmitting basic radiologic knowledge but not so well in the area of fostering good time-management or interpersonal communication skills. A trial of IT-based tutorials versus traditional lectures or apprenticeship might be biased in favor of IT if the only outcomes measured were the learners’ knowledge base.
Another potential bias concerns the level of investment made in optimizing the two techniques. A researcher might invest a great deal of time and effort in making an IT-based educational intervention as effective as possible, while making no comparable investment in the quality of traditional lectures or apprenticeship experiences offered the control group. Before the conclusion that IT is superior can be drawn, another question needs to be answered: What would be the effect of a similar investment of time and effort in improving the existing curriculum? Were such an investment to be made, would IT-based instruction still prove superior? To guard against such biases, educational researchers must be careful to design outcomes measures that are as fair as possible.
Computer-based instruction cannot and should not completely replace fact-to-face instruction. Certain aspects of good radiologic practice must be acquired through apprenticeship in the real-world practice of radiology, not so much through didactic instruction as through emulation. For example, students and residents learn a great deal about how to interact with patients by practicing side by side with more senior physicians. Likewise, appropriate ways of interacting with colleagues, a general work ethic, and problem-solving approaches cannot be memorized from a computer screen (23,24). IT-based instruction can probably match or outperform textbooks in those areas of radiologic education that have relied on textbooks, but these represent areas in which the value of textbooks has always been highly limited.
Another limitation of IT-based instruction is the inability of extant computer programs to respond to questions with the same degree of precision, responsiveness, and understanding as a good teacher of radiology. To be sure, a good piece of educational software will include a battery of FAQs (frequently asked questions), but there is no guarantee that every good question could be anticipated by the software developers, and, unless the developers are online 24 hours per day, they will not be able to respond in a timely fashion to every question. Current work in the area of intelligent tutoring systems is attempting to address this problem (25).
The goal of radiologic educators is not merely to transmit information, but to foster the curiosity and incisiveness of learners. Every physician must be a lifelong learner, and preparation for this calling should permeate every phase of radiologic training, from medical school to continuing medical education. To foster the essential attributes of good learners requires a high degree of responsiveness to what learners are asking, and educational software cannot yet replace a good teacher in this arena.
Another crucial limitation of IT-based instruction is that, by replacing face-to-face interaction between radiologists and learners, it may deprive our best and most dedicated teachers of one of teaching’s greatest rewards; namely, the live interaction with students (26). For every instructor, there comes a point at which an additional hour of time in the classroom or at the view box becomes burdensome, and IT-based instruction can help to prevent burnout in such situations. However, the frigid isolation of a career devoid of direct contact with learners is no less counterproductive than a career burned out by excessive face-to-face teaching responsibilities. Some of our favorite radiologists report that one-on-one teaching has been the most rewarding aspect of their careers, and the sheer joy of teaching is something we must take care not to eliminate.
A similar caveat applies to that component of face-to-face interaction that takes place among learners. IT-based instruction is often built around the model of a single user sitting in front of a computer screen, interacting with the computer. Like the independent learner reading a textbook, there is much of value to be gleaned from such a situation. However, collegiality is an important part of professional life, and learners need opportunities to interact with one another, to exchange information and perspectives, and to develop friendships. Students taking classes purely through computer-based distance education frequently report that they know their colleagues, if at all, only by their user names, and not by their first names. This virtual anonymity reveals something important about the potential human limitations of a strictly virtual learning environment.
Conclusion
There is a risk that we become so enamored of our new educational tools that we allow the technology to drive our educational vision, rather than the reverse. IT is not an end in itself, but a means to an end (27). Just as it would be a mistake for chefs to allow their kitchen appliances to dictate what they cook, it would equally be a mistake for educators to allow their educational appliances to dictate what they teach. To some degree, technology probably can be substituted for teachers, but the ultimate goal of applying new technology should not be to replace teachers but to improve the effectiveness and efficiency of education. Especially in a high-tech field such as radiology, enthusiasm for new technologies is natural. However, the prospect of new technologic capabilities should not lead to the neglect of other important quality improvement efforts in education.
The choice to implement IT-based educational programs need not be made at the expense of everything else good in education. Just because we are adopting something new, we need not jettison everything old. The mistaken tendency to view the implementation of IT as the replacement of faculty with computers can undercut vital initiatives in ongoing faculty development (28). Likewise, educators can become so involved in the development of new IT skills that they lose sight of other equally vital educational missions such as curriculum design and evaluation (29). IT is not the message but rather a medium. To be sure, the medium can influence the message and even make the message louder and more clear, but the medium can never replace the message.
In the final analysis, it will never cease to be necessary to build our educational programs around nontechnologic questions such as what do our learners really need to know and why. Insofar as IT provides a more efficient and effective way of helping learners achieve these goals, it has an important role to play in radiologic education. Yet if IT is to realize its promise, it must be fully integrated into the larger evolving structure of medical education at all levels. Radiology programs will need to develop an adequate infrastructure to support the technology, faculty will need to invest time and energy in developing IT-related competencies, and learners themselves will need to see a real advantage to using it. IT will not supplant the larger culture of radiologic education; however, it has the potential to become a valuable contributor to it. On this score, much work remains to be done.
FOOTNOTES
See also the article by Friedenberg (p 5 ) in this issue.
REFERENCES
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