From Avatars to Yugma: Exploring Technologies

American College of Clinical Pharmacy (ACCP)

Spring Forum Meeting 2008

From Avatars to Yugma: Exploring Electronic Technologies to Teach
Facilitators: Donna Huynh and Stuart T. Haines

The following is a summary of the discussions of the participants at the ACCP Spring Forum Meeting held in Phoenix, Arizona on Sunday, April 3, 2008. This information was generated from a series of BRAINSTORMING activities regarding the potential uses, advantages, and disadvantages of various electronic technologies that could be employed during the teaching and learning process. As a brainstorming activity, the potential uses, advantages, and disadvantages outlined below may not be complete, accurate, or appropriate. Moreover, concepts are not fully described and require the reader to draw his/her own conclusion or interpretations.

The facilitators are NOT advocating for the use of these technologies and it should be recognized that any new technology requires a substantial commitment on the part of the users (instructors and students) to learn how to use the technology in an appropriate manner. While these technologies clearly have some potential benefits and may enable some forms of instruction that might not otherwise be possible, the facilitators STRONGLY recommend that technology should only be used when other methods are less likely to help the students to achieve the intended outcomes. In other words, technology should only be used when it is believed to be the best way to accomplish the instructional objectives.

Individuals who participated in the ACCP Program are free to download and use this information for whatever purpose they desire ... but if used for a scholarly or commercial endeavor, appropriate recognition of the facilitators should be given.

Avatars and Virtual Stimulations

Potential Uses

• Orient students to a patient's room in a hospital or long-term facility
• Observe mediation errors/communications
• Simulate emergeny or "code" situations
• Physical assessment of abnormalities
• Ensuring students see all types of patients, disease states
• Interprofessional scenarios (e.g. pharmacist-physician, pharmacist-nurse)
• Anatomy/visual physiology
• Structure Activity Relationships (visualize drug/receptor bindings)
• Sim-pharmacy
• Patient counseling
• Ethics (making a decision and seeing the outcomes)
• Experiencing adverse drug interactions
• Demonstrating sterile technique
• Dealing with patients with communication barriers (e.g. non-English speaking, hearing impairments)
• Virtual hospital rounds

Advantages

Disadvantages

Able to stimulate rare situations Fun Great prequel to "real" experiences Practice whenever they want (and as many times they want) Resource sparing (no need to pay for actors) Real time quizzing with formative feedback Active learning Good for visual learners Can develop scenarios based on student responses (layering) Standardized assessment Modeling of communication skills Simulated labs for basic science courses Self-learning Less inhibition to interact

Not "real" enough (not hands on, may not take it seriously) Difficult to cover all possible scenarios Access to internet Different learning styles Social isolation May not work well for students with limited technology or physical disabilities Decrease critical thinking Assessment of student use Have to follow a predefined path Older students may not relate to technology Too much like a game Doesn't work well for information that is constantly changing Requires students to be self-learners

Blogs

Potential Uses

• Developing a virtual journal club (students responsible for reviewing / critiquing assigned journals and posting summaries)
• Developing disease specific webpage
• Writing reflective journal entries for introductory or advanced practice experiences
• Reporting about student organization activities (upcoming or past events)
• Highlighting Lecture reflections (e.g. Most important points by the instructor)
• Debate controversial issues

Wikis and/or Google Docs

Potential Uses

• Writing SOAP notes or care plans as a group assignment
• Responding to drug information requestions / writing drug information papers
• Group work examing case studies - one group develops the cases ...and another group "solves" the case
• Developing a peripheral "brain" or study guide - an approved "cheat sheet" that all students are allowed to use for an exam OR on clinical rotations
• Facilitating small group or committee work
• Scheduling / coordinating group work (Google Docs ... Spreadsheets)
• Facilitate faculty collaboration on developing cases or other course materials
• Student presentations (Google Docs ... Powerpoint)
• Patient information leaflets
• Drug information monographs
• Setting up a budget for a community pharmacy (Google Docs .... Spreadsheet function)
• Developing policies and procedures for organization or business
• Developing a curriculum vitae or resume
• Writing a scientific abstract or poster
• Creating and facilitating the activities of interprofessional working teams

Blogs, Wikis, and Google Docs

Advantages

Disadvantages

Holds every one accountable for doing their share of the work ... you can track participation You don't have to sign into a secondary academic site Tools are available for free ... and readily available on the web No additional software is required Using these tools is pretty intuitive ... shallow learning curve Enables group work over distance (anywhere in world with Internet access) and time (24/7) Faculty can make comments/give feedback to students during the development process Can see peer review comments made by students to one another Information (student work) is unlikely to be lost ... stored on servers with MULTIPLE redundances Shy students who might not contribute to face-to-face collaborations might contribute more in this environment Reduces the need for paper (good for the environment!) Reduces the need to e-mail assignments back and forth between collaborators All collaborators can access the SAME document at any time

Social interactions / team work processes are different online; skill set that is needed for face-to-face collaborations won't be developed Feedback is not as immediate as face-to-face communications Open access/security/privacy issues (information is stored on distant server) Blogger, Wiki, or Google Doc Sites may be blocked at some universities Plagiarism issues (temptations may be greater; may be more difficult to police) Written assignments (regardless of whether this technology is used) require more instructor's time to review and provide feedback Do not facilitate the development of oral communication skills Student may feel uncomfortable / inhibited knowing they are being monitored during the process Students may make inappropriate comments (harder to manage inappropriate communications in on-line environment) If work is used by other students (e.g. peripheral brain), information may not be accurate

Discussion Boards

Potential Uses

• Creating a drug information discussion board and letting students from different practice sites answer them
• Discuss patient cases among several groups
• Post FAQs and other course mechanics (e.g. virtual office hours, daily updates)
• Ethics debates
• Journal club
• Reflection activities (student answer a question from reading and have other students respond)
• Stimulated patient interview (give minimal information related to a patient case and students need to post questions to ask patient)
• Preparation for job/residency interviews
• Cross campus student interactions on assignments
• Discussion of group projects
• Facilitate communication with students after they leave practice site
• Problem based learning
• Student moderating "online" discussion (e.g., post student's questions and let students answer them)

Advantages

Disadvantages

Accessibility of information Allow students to respond that otherwise wouldn't in the classroom Time management Serves different learning styles Decrease number of emails Allow time for student to think about answers Secure because of limited access Familiar technology Can post links Develop writing skills Promote teamwork

Access to resources may be an issue Copying/plagiarizing is easier to do Reduce face to face conversations (lack of personal interactions) May not serve those who learn in person Lots of time to monitor for students and instructors Uncomfortable with creating new threads instead of responding Difficult to read long posts online More difficult to search Misinterpretation of written communication Lurkers can hind Cultural issues in the way we express things Need many small groups Not real time (no sense of urgency), loss of acuity Loss of professionalism Requires (sometimes elaborate) ground rules to guide participation

Digital Portfolios

Potential Uses

• Collection of useful documents (and multimedia?) to support employment or residency applications
• Student Portfolios - track assignments completed during a specific experiential rotation or during entire series of advanced practice rotations
• Facilitate communication between students and their mentors and/or advisors throughout the learning process
• Repository of faculty-student evaluations for the entire course of student's learning experiences in school
• Residency portfolios
• Tenure and promotion portfolios for faculty
• Accreditation documents for schools and universities

Advantages	Disadvantages
Central repository easily accessible to the student, faculty, preceptors, and mentors Environmentally friendly? (cut down on paper) Less bulky (stored electronically) Easily to search and reorganize	Potential legal issues / privacy concerns Overwhelming amount of information Engender apathy / limited creativity (only cut and paste existing documents)

Online Conferencing

Potential Uses

• Student presentations / faculty lectures
• Communicate with students at distant sites / at home / from a remote location (e.g. while attending a conference)
• Development activities for preceptors
• Enables committee / faculty interactions at distant sites / from a remote location
• Lead small group discussions
• Lead discussions with students at remote practice locations (e.g. during APPEs)
• Office hours for faculty
• Online exam review sessions (pre-exam or post-exam debriefing)
• Mentoring meeting with students, faculty, mentoring when you can't meet face-to-face

Advantages

Disadvantages

Enable invited (national / international) experts to teach a class from a remote location Participants can be located anywhere (in the state, country, or world) .... as long as they have Internet access Allows participants to review material repeated Cheaper than traveling to remote locations Reduces travel time Job satisfaction ... you can work from home! Can reuse lecture that don't need updating Eliminate excuses why students weren't able to attend class No (smaller) physical space requirements .... don't need to build new classrooms or conference rooms

Must all be online at the same time (synchronous) [Facilitator note: sessions can be recorded and accessed later] Participants can easily get distracted by other things in their environment (unlike classroom environment) Interaction is not a rich as face-to-face interactions Managing "classroom" environment is difficult - need to use new tools / methods to acknowledge and respond to students Can't determine if the participants are paying attention Disengages some participants (similar to teleconferences) Connection speed ... requires high speed connect for video/audio to work well May be more difficult to follow speaker, slides, and student chat ... all at the same time Miss the subtle voice inflections or body language of the speaker

Teaching Excellence

An essay by Frances Wong
(Doctor of Pharmacy Student and former teacher)

After being a student for more than 18 years and a high school teacher for 3 years, I learned to view the profession TEACHING as a student and as a teacher. It does not mean I am an expert in analyzing this profession perfectly. It simply means that I think about teaching from two angles due to the different roles I have.

It is easy to ask a student to give some descriptions of an excellent teacher. Depending on the age/maturity/education levels of the students, the answers can range from sense of humor and caring to mastery of knowledge in subject and organization. Students see how a teacher delivers the “knowledge” but seldom sees how a teacher prepares a lesson.

It is also easy to ask a teacher to give some descriptions of an excellent teacher. Depending on the age group/audiences’ education level/teaching subjects, the answers can range from well-prepared and detailed lesson plans to good communication skills and classroom management. Teachers also focus on the delivery method when presenting a lesson in a classroom but sometimes neglect what students really need in order to learn and how to truly evaluate and assess students’ learning.

An interesting collection of views on good teaching was presented by Ken Bain in the book: What the Best College Teachers Do. There were many great pedagogy methodologies that I strongly believe college educators can use to their benefits. However, Bain stresses the most important thing is not to focus on the methodologies; it is to look at the before, during and after of teaching so one can evaluate and enhance his/her teaching. A good educator starts by examining his/her teaching philosophy before the class even begins. A philosophy which bases teaching on helping students to make connections between new materials with one’s previous knowledge and not just focusing on the delivery. All teachers want to be good teachers, but it is how one perceives “teaching” and “learning” that structures the way they help their students to achieve the ultimate goal of the class – learning. With that in mind, a teacher then can go on to planning out how he/she wants to reach that goal. During the course teachers will encounter different “curve balls” in classes that require open-mindedness and adjustments which will allow students to maximize learning. Evaluation after the class then becomes the key to climbing up the ladder toward excellent teaching. To create a good learning environment, one needs to make the much needed preparation, lesson planning, and assessments while keeping both teachers and students in mind.

After examining “teaching” from different angles, I see that even though there are many differences between primary, secondary, and post-secondary/higher education teachers, one thing we all have in common is the power to shape and influence the minds of our future. This commonality is the most important reason that we need to have good teachers for all types of students in all parts of the world. As pharmacy educators, are you ready to take upon this challenge in being as good of a teacher as you can possibly be? Whenever you are ready, the students are waiting.

Learning to be an Expert

The development of expertise is a fascinating area of cognitive science. I recently read a well-written story in Scientific American (August 2006, Volume 295, Number 2) on this topic entitled "The Expert Mind" by Philip E. Ross. Unlike the commonly held belief that experts have some innate talent that enables them to advanced knowledge and skills in a particular field (e.g. physics, history, health care, sports, music, chess), expertise is acquired through hard work and practice (practice, practice, and more practice). For most individuals of average intelligence, expertise in any field can be rapidly acquired in childhood and early adulthood. Undoubtedly individuals acquire knowledge and skills in some fields more easily than others - perhaps due to their personal learning style, positive feedback from mentors/teachers/parents, as well as social conditioning. But expertise in any field is primarily acquired through years of study and taking on challenges that are just beyond one's current level of knowledge/skill (known as the zone of proximal development).

The implications are important because it means that expertise is acquired through purposeful activity - and it is not something that is innately inherent. Or is it? What do you think?

Paradox and Profound Truth

This photograph is of a truly majestic tree at the Morikami Museum and Japanese Garden in Delray Beach, Florida. As you can see, the tree is strong and healthy. It is a lovely and very full tree with numerous branches. It shaded me from the bright sun. Further, it has an impressive root system. Thankfully, the tree was perched on a pedestal – otherwise, I would have not been able to capture its beauty through its canopy of leaves. “Perched on a pedestal?” you may well be asking yourself. Yes, this magnificent tree is a mere 18 inches tall and is among the many trees in the Morikami bonsai collection. The bonsai tree is counter-intuitive to my (admittedly Western) understanding of what a tree is. How it is possible to grow and shape such small trees is beyond me. And yet, despite their short stature, they are just as beautiful, grand, and majestic as their full sized brethren.

In his book "The Courage to Teach" by Parker Palmer devotes an entire chapter to exploring truth and the profound truths revealed by paradox. The world is full of paradoxes and it is often through the exploration of paradox that great scientific, philosophical, and mathematical achievements are made. And Dr. Palmer contends that each of us must explore our own personal paradoxes in order to reach a fuller, deeper understanding of ourselves.

Social Learning and the Diffusion of Knowledge

The Sydney Opera House, depicted in this photo, is among the most recognizable and beautiful structures in the world. The Syndey Harbour Bridge, which is the world's largest - but not the longest - single arch bridge in the world, overlooks the Opera House ... and from the top of the Bridge one can get a awe inspiring vista of the Harbour. The technical expertise required to build these structures was not developed in isolation but rather from the cumulative knowledge, skill, and cultural beliefs of the society that created them. It is through social learning that communities and cultures develop. It is through social learning that technological advances are diffused and adopted by a population, a profession, or a discipline.

Albert Bandura is perhaps the best known for articulating social learning (or social cognition) theory. While behaviorism postulates that learners are shaped by consequences (e.g. rewards and punishments) and constructivism theorizes that learners "construct" meaning from their personal experiences as they relate to previous experiences, social learning theory states that learners are largely shaped by observing other people in a social context. No single theory can explain (exclusively) how we learn. Clearly behaviorist and constructivist strategies both work. But I am intrigued by the power that social learning can have in shaping professional norms of behavior.

I think it is vitally important to read widely outside one's own discipline (including fiction!) to develop a greater understanding of the world. It is usually through my readings of these "tangential" materials that I have made surprising discoveries that have furthered my understanding as a teacher and health care practitioner. This alone is a strong argument why all professionals should have a liberal education - not merely a technical education in their discipline ... but I digress. I recently subscribed to Scientific American and I stumbled across an intriguing article in the April 2006 issue about social learning among orangutans in Sumatra (Why Are Some Animals So Smart? by Sarel Van Schaik pp64-71). Apparently the orangutan is not a particularly social animal and rather docile. Most orangutans do not use tools to forage for food - even though there would be a significiant advantage to adopting such a strategy. However, unlike their brethren throughout South East Asia, orangutans in the Kluet swamp of Sumatra are sophisticated tool users. Why? Researchers postulate that the use of tools is a cultural phenomena where the knowledge and skills necessary to use tools is perpetuated through social learning. Orangutans in the Kluet swamp are found in unusually high numbers (due to plentiful food and natural boundaries that prohibit their movement to other locations) - and this forces far more social interaction than most of their peers in other parts of Asia. It is through these social interactions that the brightest orangutans share their knowledge and skills with other members of the community (but not necessarily in an overt, intentional manner - they are orangutans after all!) . Most orangutans are bright enough to adopt tool use while they are in capacity when trained by humans. So intelligence can not explain the unique behavior observed in the Kluet swamp orangutans. Perhaps orangutans in the Kluet swamp have a great need to use tools? After all, necessity is the mother of invention - right? Doubtful - because food is generally plentiful in the Kluet swamp ... and orangutans in other areas have not adopted tool use in times of famine. Why hasn't the knowledge and skills needed to use tools diffused to other orangutan populations? Geography! There is little or no contact between the Kluet swamp population and other orangutan populations. Indeed, orangutans that have been displaced from the Kluet swamp loose the ability to use tools over time - presumably because the behavior is not reinforce by the community.

So - what are the implications of these findings for humans? Learning is a social (cultural) phenomena - and our collective intelligence sustains our development. The greatest achievements of mankind (as well as our tragic failures and exploitations) are not the result of a single great person or intellect – but rather the consequence of the cumulative knowledge perpetuated and expanded over time as well as the collective wisdom (or ignorance) of a particular society and culture. Great teachers know how to harness the power of social learning!

Books that Every Educator Should Read

I took this photograph recently in Rochefeller Center in New York City. Great architecture has always inspired me. On one level, the technical genious required to make these monumental structures is amazing. It requires a great deal of expertise to determine what is the best design and materials to withstand the slowly (and sometimes acutely) destructive elements of nature over years, decades, and even centuries. On another level, the artistic and creative genious that is required to make a functional structure into something that is aesthetically pleasing and evokes an emotional response is a gift. I think great teachers are like great architects. Creating great structures requires not only technical expertise but also a cultural sensitivity, an awareness of the surroundings, and an ability to visualize a potential that does not yet exist.

Every educator (who takes their vocation seriously) probably has two or three books that have shaped and inspired them as teachers. Here is a list of books that have influenced me the most over the past year:

What the Best College Teachers Do by Ken Bain (Harvard University Press 2004). This short, inexpensive (less than $15 thru Amazon.com) and inspiring little book was a delight to read. While the book cover is a bit goofy, Bain takes a scholarly (but accessible) approach to the subject matter. The bottom line - the best colleges teachers know and love the subject matter they teach ... engage their students to think about the most relevant questions that matter ... and have confidence that their students can (and will) meet high standards.

The Courage to Teach. Exploring the Inner Landscape of A Teacher's Life by Parker J. Palmer (Jossey-Bass 1998) is a book about the vulnerability of being a teacher and the importance of integrity and being whole. Great teaching is not achieved by employing superior pedagogical techniques but rather in developing self-awareness and connectedness to one's subject and students. My favorite chapter is entitled "Knowing in Community." Truth - according to Palmer - is a reality created by a dynamic web of communal relationships between "knowers." In the community of truth, there is no ultimate authority - but rather knowing, learning, and teaching is a dialogue among a community of people (knowers) who approach a common subject in a shared way (e.g. they communicate in a shared language, share rules of observation, and interpret information in a similar manner). It is only after we (teachers) abandon our need to be the ultimate authority that we can truly engage students to become members of the community of truth.

The Wisdom of Practice: Essays on Teaching, Learning, and Learning to Teach by Lee S. Shulman (Jossey-Bass 2004) is collection of essays (as the title would imply) on a wide range of topics related to pedagogy. Dr. Shulman is currently the President of the Carnegie Foundation - a non-profit organization dedicated to the advancement of teaching - and previously a professor in psychology at Stanford University (1982-1996) and a professor in educational psychology and medical education at Michigan State University. These essays span his career. Again, the focus is not on technique but the art and craft of teaching.

Educational Resources On-Line

This photo is from the Pompidou Centre in Paris - one of the world's greatest museums. The Pompidou is dedicated to modern art in its many forms - including photographs, films, scuptures, furniture, and architecture. Sure - no visit to Paris would be complete without seeing the Louvre or d'Orsey - but be sure to visit the Pompidou.

The Web is rich with resources and forums dedicated to education, teaching, and learning. Finding credible sources of informaton, however, can be a challenge. Here is a short list of on-line resources I have found very helpful:

Search Engines

ERIC (Educational Resources Information Center) is the world's largest educational database - similar to MEDLINE - with more than 1.1 million citations dating back to 1966. If you want to do a general literature search on an education topic or find the primary educational research literature, this is the first place to go!

Journals / Newsletters / Weblogs

BMC Medical Education provides access to full-text and abstracts to original research articles regarding professional, post-graduate, and continuing medical education.

The American Journal of Pharmaceutical Education (AJPE) is the official journal of the American Association of Colleges of Pharmacy. All manuscripts published since 2003 are available on-line in full-text.

The Carnegie Foundation was founded in 1905 and is dedicated to the advancement of teaching. They publish a monthy on-line newsletter called Carnegie Perspectives.

The Chronicle of Higher Education is a weekly newspaper covering a wide range of issues of interest to educators and adminstrators at institutions of higher learning.

The Learning and Forgetting Curves

This is a photo I recently took in Paris - a truly unforgetable city! I've traveled to Paris several times and I have fond memories from each trip.

Nearly everything we know today about learning and forgetting was "discovered" by Herman Ebbinghaus in the late 1800's.

Ebbinghaus, a psychologist, had a keen interest in memory and higher cognitive processes. He was the first to describe the "learning curve" and characterize retention. His experiments were quite clever. He was able to systematically measure how long it takes for people to "memorize" new information and how much was retain over time by developing a series of nonsense syllables and words. During his experiments, subjects repeated a series of nonsense syllables and/or words as many times as was necessary to reach an a priori level of accuracy (for example, three perfect reproductions without being prompted verbally or looking at it in writing). What he discover was that the time required to memorize nonsense syllables increased sharply as the number of syllables increased. I think we can all appreciate that it requires much more time and effort to memorize a 13-digit overseas telephone number than it does a 5-digit zip code. Ebbinghaus also discovered that people are able to memorize more in distributed learning sessions rather than by trying to assimilate everything in a single session.

Ebbinghaus then set out to determine the duration and strength of retention. Using a concept he invented, called the "savings method," he determined the number of repetitions required to relearn material (to the same criterion) and compared it to the number of trials initially required to learn the material. The more repititions you required to relearn the material, the more you had forgotten - he surmised.

What he discovered through these experiments are things we inutitively know. First, items that are associated with one another are more easily remembered together. These associations could be due to congruity (e.g. they appeared next to each other on the list) or due to remote association (e.g. the learner made some connections between the two items in their own mind). Second, we remember best what we FIRST and LAST encounter (the so-called primacy and recency effects) and tend to forget middle items. Third, even small amounts of practice, far less than what is required for mastery to the criterion level of performance, lead to "savings" (e.g. improved retention over time). Finally, most humans tend to forget 50% of newly learned knowledge in a matter of days or weeks. But the speed of forgetting is related to a number of factors. Most importantly, our ability to learn nonsense material (e.g. things we don't understand) is quite poor - requiring a great deal of effort - and the forgetting curve is quite steep. On the other hand, meaningful material (e.g. things that make sense because they relate to things we already know) takes only about one tenth the effort to learn and the forgetting is relatively gradual. Not surprisingly, the forgetting curve is nearly flat for vivid or traumatic experiences - perhaps because the learner "reviews" the memory repetitively in his/her mind.

What are the implications of Ebbinghaus' work? Many of our "best practices" in education are based on these findings and most of us probably take them for granted. For example, stating the important learning points at the being and end of a lecture relates to the primacy and lacency effect of memory. Breaking up material into small chucks of information - rather than massive amounts of information at a single sitting - relates to the inherently limited capacity that most of us have to absorb new information. Opportunities for practice during a lecture or workshop - even when its not mastered - improves retention. And encountering the material repetitively over time - rather than concentrating on it intensely for a short period of time - is a more effective learning strategy.

Cognitive learning theory (aka contructivism) postulates that we construct our own learning by making connections between what we sense (see, hear, feel, taste, touch) and what we already know. Ebbinghaus' experiments certainly provides evidence to support that contention - learning new materials is far more efficient when it is "meaningful" to the learner (not the teacher!!). But how can we, as teachers, make the material "meaningful?" .... That's a topic for another time.