Outline

This chapter is concerned with the variety of resources that can be used in medical education, the ways in which they can be used, and any implications for practice. This chapter will start with some definitions and a typology of learning resources, it will then review many of the key underlying concepts in resource provision and use and consider learning resource lifecycles and the economics of their use. The chapter concludes with a review of some of the emerging factors that impact on the kinds of resources we may use in the future and their implications for practitioners in the years to come.

Scope

There are examples of learning resources in medical education going as far back as Persian, Egyptian, Greek, and Roman times (Loechel, 1960). Indeed, the use of artifacts and tools to support and enhance learning is one of the defining aspects of ‘education’. Because so many kinds of learning resources are used in contemporary medical education, let us define the term ‘learning resource’:

To further clarify the concept, it is helpful to consider borderline examples. For instance, an integrated curriculum that employs many learning resources may itself be considered a learning resource, because learners and teachers use the curriculum as an artifact through which they can contextualise their past, current, and future activities. Similarly, assessment items may or may not be considered learning resources, depending on the context in which they are used. An exam question may be considered a learning resource when it is used as a group problem in a classroom setting. The same question would not be regarded as a learning resource if it were used for purely summative assessment purposes. Clearly, the context of use defines (or redefines) a learning resource as much as any of its intrinsic properties.

Causality and context

The use of a learning resource is never causal. Simply making learning resources available to learners will not guarantee any kind of result. At best we can consider a probabilistic model of learning affected or catalysed by the use of a learning resource. Not only does this reflect the reality of learning but it also helps us understand the importance of design (that is, design of the resource itself and/or design of the activity context in which it is used). Essentially, a learning activity should be designed to effect its intended learning objectives for as high a percentage of its target learners as also demonstrates importance of context, typically in the form of an educational activity with associated learning objectives and target learners.

Clearly, almost anything can, in the right context, be used as a learning resource. A resource becomes a learning resource when it is incorporated into some kind of educational activity. Educational intent is therefore the defining factor that in turn is typically expressed in terms of learning objectives. While the design and application of learning objectives is a much wider topic than can be adequately covered in this chapter, the use of objectives is an important step in using any resource for learning.

The next consideration is who the intended learners are supposed to be. One way of answering this question is to view any group of learners as being made up of, say, quartiles, ordered on the basis of their learning abilities (with regard to specific topics). The top quartile (that typically uses every opportunity afforded to them and always excel), the bottom quartile (that often fails to use the opportunities afforded to them and always struggles), and lower and higher middle quartiles – see Figure 16.1. It is rare that resources would be targeted only at the higher quartiles (C and D in Figure 16.1) as they need little additional help to do well; most learning resources are typically targeted at the lower two quartiles (A and B). This model may of course not reflect a global assessment of learners’ abilities; it is simply a means of identifying (for instance from exam performance) what topics and concepts are particularly problematic for learners. Resources and the activities that employ them can therefore be more readily targeted at addressing the less tractable or accessible parts of the curriculum. For example, preclinical topics such as partial pressures or statistics often prove particularly challenging to learners. Additional information or activities can always be provided for the brighter or more industrious learners so as to create a more inclusive range of experiences. A key consideration with this model is whether the goal is to reduce the difference between the top and bottom quartiles (such as additional support, remediation) or to highlight these differences more clearly (such as in formative or summative assessment).

Figure 16.1 • Quartile model of learners in any given class or cohort.

Context clearly has a determining impact on the efficacy of any learning resource including the abilities of the instructor using a resource or how well aligned it is to the curriculum. In part, this reflects the probabilistic relationship between exposure to educational interventions and learning taking place, but it also highlights the importance of teachers (and their support staff) having sufficient facility and understanding of how to use resources as well as there being good alignment between any such use and the wider curriculum context.

A typology of learning resources

Having established a conceptual space for thinking about learning resources, the next step is to consider a more focused typology of learning resources in medical education.

Type A: Information and knowledge resources

These are typically text-based materials such as books, articles, and websites supported with diagrams, illustrations, photographs, audio, video, or animations. Notable forms in medical education include:

• Textbooks: systematically organised, canonical, and relatively context-free texts on single domains or topics intended for learners (rather than for an expert or lay audience). The material is typically structured so as to support a learning process. The format is largely text-based with diagrams, illustrations, and other more visual material supporting the text. Traditionally, programmes or courses identify a few key textbooks that are referenced. Other non-key texts are referenced but less often. Health care subjects (and in particular medicine) also make significant use of key reference materials including clinical handbooks (such as the Oxford Handbook series), pharmacopoeia (such as the British National Formulary), and expert opinion-based resources (such as UpToDate).

• Study guides and materials: specific to a course or subject context. Study guides are descriptive resources that are about both the organisation of a learning context as well as supporting learning itself (although this varies between institutions and cultures). Study materials on the other hand are issued in support of a particular activity and typically mix instructions to learners and tutors with course content. Study materials can take a number of different forms including lecture notes, problem-based learning (PBL) cases, and activity briefings such as for a simulated patient (SP) session. Typically, tutors or course organisers create their own study guides and materials, although some limited use is made of third-party resources.

• Presentations: typically take the form of lecture slides and notes, which are either computer based, such as PowerPoint, or older forms, such as overhead projector materials or 35 mm slides. Although PowerPoint has been around for several decades, it is only recently that it has become the de facto format for giving presentations. At present, preparing to give a lecture or talk is primarily about writing a PowerPoint presentation, while the talk itself is framed by the data projector’s glare and the susurration of its fan.

Once created, the next issue is how to make presentations available to learners. In addition to projection in a live lecture, presentations may also be webcast or recorded for subsequent viewing and review. Many teachers just give their learners the slide deck but should it be before the event, during the event, or after the event? Opinions vary, especially given the ways this is seen as affecting attendance and attention at lectures. Learning resource issues do not end with giving the presentation; they can also involve the provision of slides in other formats such as handouts. One other consideration regards how much sense a slide deck makes outside the context in which it was given. There are many who consider themselves adept at e-teaching, because they place their slides online even though they have little or no idea whether doing so is useful or effective, particularly in the absence of a presenter to create meaning around their presentation.

• Syndicated content: serially published resources that are streamed or downloaded from a common point to subscribing client systems. There are several common forms:

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– Feeds are primarily text and image based and they underpin the world’s news websites, blogs, and other online information providers. The main uses of feeds in medical education are to keep abreast of new developments, to follow educational blogs, and to receive news and updates on a course (if they are provided in a feed format).

– Audio-only podcasts are perhaps the most widely used syndicated materials in medical education with a great many institutions now publishing their lectures in a podcast format. Subscribing to a podcast means that each time a new edition is put online, it is flagged as such to subscribers and they can then download the file for listening as and when they want. The proliferation of music players (such as the iPod) has made this particularly well aligned to contemporary learner lifestyles. For instance, Apple’s iTunes platform has a whole section dedicated to iTunesU (see Figure 16.2) including a great many health care education offerings, all of which are free and open to use. Vodcasts are essentially the same as podcasts except they use video rather than audio. While podcasts are like serial on-demand radio broadcasts, vodcasts are more like on-demand television.

• Primary sources: typically research papers are a key part of educational activity designs such as PBL and the development of skills in evidence-based medicine (EBM). Sources may also include ‘grey’ literature such as government reports, strategy papers, and other non-peer reviewed materials. The role of the institutional library is key in using primary sources both in terms of developing literature searching and appraisal skills and in terms of ensuring technical access to sources both online and physical.

• Knowledgebases: aggregate websites, wikis, and databases of resources and information such as clinical guidelines. Wikipedia is perhaps the best known and most used online knowledgebase and in many ways the most contentious. Wikipedia can be more comprehensive and up to date than more traditional sources by making all of its information open to public editing and alteration. Some celebrate the ‘wisdom of crowds’, while others bemoan the ‘cult of the amateur’ in this approach (Keen, 2007). Increasingly limited specialist community knowledgebases such as Medpedia (http://www.medpedia.com) are emerging, which limit edit access to acknowledged subject specialists as a way of harnessing the power of collaborative and dynamic publishing while retaining significant editorial control.

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• Instructional software: this was, at least for a while, the main focus of the educational technology movement. Computer-assisted learning packages (CALs) proliferated with CD-ROM (and more recently DVD-ROM) or web-based instructional multimedia titles proliferated in the 1990s and early 2000s covering a great many subjects. While many of these titles still exist (such as the A.D.A.M., PathCAL and CLIVE series), the economics of creating these packages means that they largely serve the niche markets that are able to sustain them. One of the predominant areas that make use of instructional software is continuing medical education (CME) with substantial instructional multimedia offerings from providers such as BMJ Learning. Software resources do not have to be whole compiled packages; it is increasingly common for smaller components and individual files to be made available as reusable learning objects, including games, puzzles, and videoclips.

Figure 16.2 • iTunesU for Health and Medicine contains a large (and ever-growing) collection of podcasts and vodcasts on a range of medical and health care topics.

As a whole, type A resources tend to be passive (no change in state in response to a user’s input) or at best active (responding to input but not changing), but low in interactivity (changing in dynamic ways). The dominant instructional model is therefore primarily one of knowledge transfer or just-in-time reference.

Key concepts

The list of different types and forms of learning resources given in the last section is far from exhaustive. Exploring each of these areas could consume many volumes, so, for the purposes of this chapter, we will consider a number of key and common concepts and themes that unite them and point to ongoing innovation and development in this area:

Simply put, cognitive load theory suggests that any resource or activity design can be enhanced by removing all extraneous load (unnecessary graphics, details, and inappropriate media choices – such as trying to describe a square using only words rather than just showing an image) and adjusting germane load to best suit the learners’ abilities. Intrinsic load cannot be changed, but it can be ameliorated by creating subsets of a complex topic and then carefully re-integrating them to achieve understanding of the larger topic. Other cognitive phenomena include scaffolding (providing lots of support at first but then removing assistance as the learner develops mastery) and expertise reversal (learning is stalled or even driven down by using resources that are too easy) (Kalyuga et al, 2003).

Lifecycle

Learning resources clearly come from somewhere; they exist somewhere while they are being used and they eventually go somewhere else once their time is done. We can consider a lifecycle model as following a number of stages:

Figure 16.3 • A visual representation of the AIDA framework. There are seven factors (pedagogy, resource, interaction, freedom, granularity, politics, distal) – about here.

The whole learning resource lifecycle can be considered as a single cyclic model (see Figure 16.4).

Figure 16.4 • Lifecycle model for learning resources.

Unfortunately, but perhaps predictably, real life rarely conforms to such a rational and planned model as we have set out here. Resources can be created out of curiosity, and requirements and purposeful design may be omitted in favour of trial and error and there may be no evaluation, sustainability, or disposability model in place. This somewhat ad hoc approach is now increasingly challenged by evidence-based practice. The principles set out in Table 16.1, although basic in nature, establish an empirical basis for learning resource design and set a standard for future practice and development.

Table 16.1 Colvin Clark and Mayer’s evidence-based principles for designing and using learning resources ordered by effect size (multimedia has the highest effect, redundancy the lowest) (Clark and Mayer, 2008)

Lifecycle also involves contextual, cognitive, cultural, and educational dimensions. Some additional factors for consideration include:

Economics

A learning resource clearly represents an investment of time and money, not just to create it but also to sustain it over time. Although economic factors are often played down in favour of cognitive and professional factors in the literature, real-world practice is determined as much by what is fiscally possible as by what is desirable.

As an illustration of why this is a critical topic, let us consider the many initiatives during the 1990s to create courseware as a response to the new opportunities in teaching and learning afforded by increasingly cheap and ubiquitous personal computers in the learning environment. A huge commitment was made to creating materials individually, institutionally, and even at national and international levels. A reflection of Mao’s doctrine of ‘let a hundred flowers blossom’ dominated; certainly capacity was built, knowledge gained, and the field advanced. However, almost all of these resources are now lost to technological and cultural change. The investment might have been worth it in terms of developing practice in using educational multimedia, but that is almost all that remains. An equivalent investment in paper-based resources would have left a far more permanent legacy in terms of extant learning resources.

A TCO model allows us to consider both direct and indirect costs at every stage of the resource lifecycle (as outlined in the previous section), the key dimension being those costs not immediately associated with the resource but still essential to its creation, deployment, and operation. An outline of such costs is given in Table 16.2.

Table 16.2 A total cost of ownership (TCO) model for learning resources

A greater part of the costs associated with any intervention or technology are indirect and often go unnoticed; for instance, one model estimated that only 23% of the cost of technology is the technology itself; 21% is direct labour and 56% indirect labour (Kaestner, 2008). Although this model was developed in the context of primary and secondary schools, the importance of TCO is clearly shown; unless all costs are evaluated, the true value and impact of any resource or intervention can not be fully understood or appreciated.

There are a number of developments and initiatives that are looking to address issues of cost and flexibility in educational resources:

The other side of economics is to do with liabilities, rights, and licences. A learning resource is not a neutral artifact; it informs and guides learners in ways that may or may not be correct or even safe. It is usual practice therefore to include some kind of declaration regarding liability (who is responsible) and warranty (what happens when there is a problem). These are important concerns even if the resource is never going to be used outside the context in which it was created.

As soon as something is created, intellectual property (IP) comes into play. Unless otherwise contracted, the rights of a substantial innovation belong to the individual(s) who created it. However, the things employees create during or as part of their contracted work typically belong to the organisation they work for. Intellectual property is a concept larger than copyright but in the area of learning resources copyright is by far the main concern and this is complicated by there being no common model for defining rights for educational resource creation and use.

There is a continuum between full copyright and public domain: the former meaning that all rights are reserved and permission must be given to make legal use of a resource, the latter waiving rights altogether and allowing for any kind of use without requiring any kind of permissions from their authors. Creative Commons is one of a number of licensing models that sits between copyright and public domain, reserving some rights and giving others away. Creative Commons is particularly noteworthy both because it is particularly focused on content (as opposed to software for instance) and because it has proved very popular with individuals and institutions alike and has been translated into many different legal jurisdictions worldwide. A Creative Commons licence can be applied to a resource by its author(s) to specify to subsequent users whether:

By clearly stating the terms of its use, a resource can be safely published and reused. Without any such declaration the assumption must be one of full copyright and no use can be made without permission from its owners. There are some circumstances where limited reuse and copying are allowed, such as in libraries or under the terms of fair use agreements. But even this should be undertaken with care and consideration, not just for the copyright owners but also as an exemplar to the learners. Far too many teachers use copyrighted materials without permissions and this sends inappropriate messages to learners about what they can and should do with other people’s intellectual property.

The other main legal concern regarding learning resources, particularly in health care, is around confidentiality and privacy, primarily (but not exclusively) on behalf of patients. Health care institutions typically have consent policies and processes for recordings (images, videos, etc.) of patients while they are in a condition of care. However, if the terms of consent are not passed on with the resource, then subsequent uses may break the terms of consent, creating legal as well as professional liabilities for all concerned. It is good practice to make sure that any material that identifies patients is anonymised as far as possible (without losing utility) and properly consented with the terms of that consent appended or otherwise attached to the resource to ensure that subsequent use follows the wishes of the patient involved (Ellaway et al, 2006a).

Future developments

All future-gazing is doomed to ridicule and often what seemed like the future turned out to be the present in disguise. However, we can fairly safely predict that the Internet will continue to grow and change and research will improve our understanding and use of learning materials. At the same time, innovation and social, political, and cultural change will continue to confuse and distract faster than we can build sound evidence-based practice to manage this change. Cost will continue to be a major driver but new advances will change the economic distribution and the focus of where these costs fall. Institutional boundaries will be challenged as learners and faculty become increasingly nomadic within the broader infosphere and in such a world the idea of a learning resource may be altogether transformed and diversified. Of course it will be interesting to see whether any of this comes to pass.

Implications for practice

There is clearly more to designing and using learning resources than preparing handouts and slides. New technologies provide an ever-growing repertoire of tools and designs for learning and we are still coming up with new and innovative forms. This diversity presents significant challenges to teachers in keeping up with new developments and in deciding how and whether they should incorporate them into their practice. This chapter has set out the need for critical reflection on and discourse about the nature, application, and effects of learning resources on learners, teachers, institutions, and professions. If this chapter has introduced more complexity to your work, I apologise, but I hope you have also developed a greater appreciation of how to handle that complexity and make it work for rather than against you.