Minds and Machines

In the 1970s, it would have been difficult to conceive the effects new developments in information technology would have on education. Who could have imagined that many learners would be able to carry around personal computers no bulkier than a book, that whole medical charts could be reduced to the size of a personal digital assistant and connected directly with hospital information systems, and that new software would make it possible for learners to interact directly with images and text, without the mediating presence of a live instructor, or that an electronic network called the World Wide Web would permit the nearly instantaneous dissemination of educational materials at incredibly low cost? Just beyond the horizon lie technologies that superimpose networks of information onto our daily lives and provide just-in-time access to databases and decision support resources.

Some uses of educational technology may be regarded as traditional, such as placing the content of a book or journal article online. Others, such as interactive software, are more innovative, and still others, such as simulation devices, may prove to be truly revolutionary. At one time, such technologies as the carousel slide projector, the calculator, photocopier, the slide rule, and the printing press were regarded as radical innovations. As new technologies continue to open up new possibilities for sharing knowledge, they will continue to shape medical education. We should welcome those that help us meet our core educational missions by increasing the effectiveness and efficiency of learning. To understand when we are really realizing such benefits, however, we need to be mindful of certain fundamental concepts of human learning that provide the foundation for incorporating new educational technologies into medical education. Three such concepts are the three distinct cognitive levels of medicine: information,knowledge, and understanding. Depending on which of these three cognitive levels we seek to address, the potential roles of new educational technologies will differ.

Information is the level of facts or data. When we convey information, we simply transfer it from one location to another, just as we might download a file from the Internet to the hard drive of a computer. Medicine is chock full of such information, including laboratory results, lists of differential diagnoses, and the risk factors for particular disease processes. When we think of sharing information, we think in terms of a transmission model of education. The goal of the educator is to move information into students from some outside source, such as the words the educator is speaking or the information contained in a particular reading assignment. Transferring information requires relatively little effort on the part of the educator, at least to the extent that the information contained in a lecture might be transmitted equally effectively by a recording, which would not require the educator to be present.

One of the drawbacks of a strictly informational account of medical education is the fact that information transferred often lacks context and purpose.

And when ideas lack context and purpose, they often remain relatively inert in the mind of the learner. For example, the information might be recalled and recited when the learner is appropriately prompted, but otherwise it might not be available for day-to-day problem solving. I may be able to recite the information on cardiopulmonary resuscitation contained on the instruction card in my wallet, yet be utterly incapable of applying that information effectively in a real-life emergency.

Another drawback of information is the ease with which it can inundate us like a flood, so that learners soon feel that we are drowning in it. The ability of new information technologies to transmit information more easily, more quickly, and less expensively means that the risk of information overload is becoming progressively more acute. We soon lose our bearings, and do not know how new information fits together with other concepts within and between domains. When that happens, new information may be essentially meaningless. Thus we cannot assume that more time in the classroom,longer and more extensive reading assignments, and greater educator effort necessarily translate into improved learning outcomes. In some cases, adopting such seemingly desirable policies may in fact prove counterproductive, resulting in reduced learner performance. For these reasons, it is impossible to achieve mastery or even competency in any field operating strictly at the level of information.

Knowledge may be conceptualized as information with a purpose. In the educational context, knowledge sharing involves both a sender and receiver, but it implies that at least the sender, and ideally the receiver as well, aim to foster the development of some new understanding or capability in the learner. As a result of the sharing of the knowledge, the learner should be changed in some way that shows up in behavior, ideas, or perspectives. Perhaps the learner understands the medical meaning of the term inflammation, begins to develop skill at placing an intravenous catheter, or grasps for the first time what it is like to look up at a group of physicians from a hospital bed. Knowledge is more likely than information to be retained and understood by the learner simply because it implies an intention on the part of the educator to impart something or on the part of the learner to understand something.

An example of knowledge is the material discussed in a traditional didactic lecture, where the lecturer has attempted to get across to the learners some theme or series of concepts. If the model of learning is strictly one way, then we are still talking about a kind of transmission, in which learners operate in a primarily passive, receptive mode. Yet it is not the same as mere information transfer, in the sense that the educator is trying to make the material meaningful to the learners.

Regarding technology, there is a risk that we become so enamored of our new devices that we forget our educational mission. Collecting information and putting it together in new ways is not, by itself, a recipe for enhanced understanding. We need to link knowledge to learners' prior experience. If we are teaching medical students how to recognize a particular physical examination finding, such as clubbing of the digits, we need to offer them insight into why clubbing is important and what could be causing it. We could never fail to recognize a case of clubbing, but if we do not know how to put that insight to use in the care of the patient, then its clinical utility is limited at best. On the other hand, if learners understand why clubbing is important, then we will be in a better position to study it in the first place.

The transferability of inert knowledge is poor, but dynamic knowledge can be transferred from one situation to another, because it has been thoroughly integrated into the learner's experience. We need to be able to see how what we are learning fits into a larger context, so that we can draw relevant distinctions, recognize relevant connections, and situate what we know in its most useful context. We might think of prior knowledge as a kind of scaffolding or framework into which new knowledge needs to be fitted. The more niches that scaffolding offers, the more likely we are to be able to find a place or places in which to situate it. For example, to be useful, we must connect knowledge to our understanding of the circumstances in which it applies. This is why hands-on simulation exercises are such a crucial part of training in cardiopulmonary resuscitation.

Like information, knowledge has limitations. For example, it does not tell us what it should be used for, nor does it show us how different knowledge domains fit together. It also leaves us unsure about what is most worth knowing. Again, we can pour more and more knowledge onto the heads of learners, but that alone will not improve their preparation to learn on their own. Learners need more than merely to know a lot, we also need to be able to discern what is more or less important to learn, and to be able to direct our own learning of it.

This is where understanding comes in. When we really understand a topic or a domain,we grasp what is most worth knowing about it, and how it fits together with other domains of our knowledge. When we study medicine,we face a seemingly insurmountable challenge, namely, the fact that we cannot know as much as there is to know. We must make choices, or someone else must make them for us, about what is most worth knowing. We need to prioritize our learning. To do this, we need to know how that knowledge will be useful during our practice. We also need to know what aspects of a subject we need to know "cold," and which we merely need to know well enough to be able to look them up in a reference work.

Someone who not only knows but understands medicine understands its fundamental characteristics, the domains of knowledge that are most essential to it, how such knowledge can be put to use for the benefit of patients, what questions are most worth investigating about it, and perhaps even something about how to learn it and therefore teach it. Generally speaking, it takes years, perhaps even decades, to develop deep understanding of a complex domain such as medicine, but there are strategies we can pursue as educators to try to make the learning process as effective and efficient as possible. For example, if learners are studying a particular medical discipline, we can encourage them to try to understand the role that that discipline plays in the larger scheme of healthcare, where its practitioners can make the greatest contributions to patients, and what conditions need to be in place for that potential to be realized.

Information can be conveyed through transmission and knowledge can be conveyed through statements, but understanding is fostered largely through questioning. This is one of the great insights embodied in the so-called Socratic Method, which seeks to draw out understanding through questioning. If we are going to understand something, we need to become actively engaged in reflecting on it, attempting to discover for ourselves what it means and why it is important. Socrates' method of interacting with his interlocutors was not so much to tell them things as to stimulate them by questioning to think for themselves. It is simply impossible to acquire genuine understanding in a passive fashion. The learner must be an active inquirer, or at least co-investigator, with the educator.

The challenge of using educational technology to facilitate learning increases as we move up the scale from information to knowledge to understanding. It is very easy to use an electronic network to transfer a large load of information to a learner. It is considerably more difficult to foster real understanding without face-to-face interactions between educators and learners. We make a grave mistake if we suppose that educational technology alone can somehow receive information and organize and convey it to learners in a way that makes it memorable, usable, and valuable in creating a deep sense of the cognitive domain of medicine. To move from novice to expert requires an enormous amount of instruction, practice, and reflection by both learners and educators. New educational technologies can make many learning tasks more efficient and even more effective. It can present content in ways that learners find congenial. However, it cannot substitute for an enlightened educator.

We cannot simply strap our old educational content onto new electronic media and expect them to boost our educational effectiveness into the stratosphere, because electronic media such as the Internet are equally good at delivering very good and very poor materials. New educational technologies can no more transform learning than buying a new truck could change the nutritional value of the groceries we deliver. Studies demonstrating that new educational technologies can enhance learning outcomes are so commonplace that they now often generate little interest. The educational effectiveness, however, often has less to do with the technology itself than with the instructional design. Poorly designed programs will not enhance learning no matter how sophisticated the technology that delivers them. Technology inappropriately applied will actually degrade, not enhance, our educational outcomes.

We must not forget that knowledge and especially understanding are shared in communities, where learning is like acquiring a new language. To excel as physicians, we need not only to retain a large collection of facts, but to act as excellent physicians act. This has to do with habits of practice, and with matters of character, as much as with cognition. A great deal of what we know, which Michael Polanyi called tacit knowledge, cannot be written down. We must work side by side, and converse with one another about what we are doing. These are learning objectives that an isolated learner perched in front of a computer screen may never be able to realize.

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