Suzannah Alexander

Academic writing

Instructional systems design—the program track I have chosen so that I can apply its theories to producing medical education—strives to deliver effective learning experiences that optimize knowledge acquisition by assessing the learners’ needs, determining the learning objectives, producing engaging solutions, and gauging the learners’ success. This process was first adopted by the US military and industry; specifically, the US Department of Defense introduced the ADDIE steps of analysis, design, development, implementation, and evaluation in 1975 (Battles, 2006). Since then, these principles have been applied to all levels of education in numerous settings, including corporate settings and in higher education. In medical education, most learning solutions now include asynchronous multimedia assets, microlearning activities, online courses, simulations, and virtual reality environments that supplement traditional classroom and clinical instruction. As such, the history of instructional systems design that follows focuses specifically on the evolution of online learning in medical education.

The History of Online Learning in Medical Education

Medical educators began using the problem-based learning model in the late 1960s and 1970s after they realized that teaching concepts, such as organ systems, without context was less than ideal. They theorized that using real-world examples to teach small groups would better develop complex problem-solving skills. Problem-based learning is still used today, and research is ongoing to evaluate how learning technologies can enhance problem-based learning strategies in medicine, including the use of learning management systems, interactive whiteboards, 3D anatomy and physiology programs, immersive virtual reality environments, and other specialized software (Jin & Bridges, 2014).

The goals of problem-based learning include teaching problem-solving skills, encouraging self-directed learning, and supporting collaboration and teamwork. The downside to using an online format is that medical education requires experts to provide immediate feedback to correct misconceptions before they become ingrained. As such, medical educators are grappling with how best to integrate new technologies as asynchronous learning opportunities that can be effectively combined with traditional face-to-face instruction. Even though modern learners generally prefer technological solutions over traditional paper cases, lecture instruction, and textbooks, only minor gains in knowledge acquisition and improvements in skills have been found thus far (Jin & Bridges, 2014).

Despite this finding, the ability of online medical education to expose learners to additional real-world, complex scenarios in a safe virtual environment is overwhelmingly appealing. When expert feedback is embedded within these learning modalities, they can successfully extend the traditional learning framework. The advantage of online instruction is that it can make clinical reasoning processes more explicit and can give learners the opportunity to reflect on and explain their own cognitive processes. In general, asynchronous learning is seen as a positive way to provide learners with additional opportunities to explore complex topics, but mostly in a synergistic or supportive role (Jin & Bridges, 2014).

Cognitive load theory was proposed in the late 1980s to help explain why it is difficult for some learners to integrate new concepts; essentially, learning is impeded when working memory is overwhelmed. Instructional design theory has been increasingly influenced by this concept, in that it is clear that previous knowledge and the way that information is presented can directly affect learning outcomes. Thus, instructional design must accommodate the differences in learners’ prior knowledge to prevent cognitive overload, which is especially important in medicine because there is so much information to recall at the same time that reasoning and procedural skills must be performed. It is important to understand how learning is affected by being a novice versus an expert and how mastery can be achieved through gradual progression. As more is learned about cognitive load theory and how new information is integrated into existing schema, online learning and instructional design must evolve to meet the demands of learning an ever-increasing amount of medical knowledge (Noushad & Khurshid, 2019).

Flipped classrooms—in which learners may read, watch video lectures, or engage in other homework assignments before in-person classroom meetings to allow for more interactive, instructor-led activities or discussions—gained momentum in the early 2000s. Medical educators across the United States have embraced this format, encouraging medical students and residents to participate in self-directed learning activities before coming to the clinical setting to apply what they learned in small-group settings with their peers. Flipped classrooms are thought to be beneficial because they provide learners with the ability to watch video lectures more than once when learners need to review the concepts; allow more time for active learning, discussions, and peer interactions, stimulating knowledge integration and retention; and give instructors more opportunities to provide real-time feedback and to correct misconceptions (Hew & Lo, 2018).

Around the same time that flipped classrooms became popular, the cognitive theory of multimedia learning was introduced based on how learners process both textual and visual media. This theory builds on cognitive load theory, stating that there are limits to how much learners can process in each format at one time, and it promotes active processing as well as the organization and integration of new concepts with previous knowledge. The cognitive theory of multimedia has direct implications for medical education, as medicine is heavily dependent on visual media to learn anatomy, understand physiological processes, conduct simulations, and create virtual reality environments. Best practices in multimedia creation have direct impacts on preventing cognitive overload and developing effective instructional design (Mayer, 2010).

Emerging Learning Technologies and the Future of Medical Education

With the changes in how medicine is being delivered now and will be delivered in the future through virtual visits, online patient portals, and digital instructions, apps, and other solutions for managing chronic conditions, it is more important than ever for medical educators to embrace new learning technologies because physicians will have to manage digital content in many aspects of their careers, through electronic health records, artificial intelligence in diagnostics, technical applications, and other online environments. Moreover, as digital natives become physicians, game-based activities and online collaboration and teamwork will become increasingly important. Medical education, and therefore instructional design, must adapt to effectively teach interdisciplinary teamwork skills, individualized patient care, diagnosis and management of more complex disease processes and comorbidities, and data-driven diagnostics and prognoses (Han et al., 2019). In addition, it is no longer acceptable for novice clinicians to practice procedural skills on real patients, such that simulations and virtual reality must be used to protect the public from being subjected to competency and mastery training (Battles, 2006).

Moreover, medicine is advancing at a pace that requires physicians to constantly seek out and integrate updates to the standards of care (Han et al., 2019). Continued competency is a critical goal of instructional design in medical education. There is a great need for skills training on new technologies (e.g., bedside ultrasound), communication for increasingly diverse patient populations and challenging situations (e.g., violent patients and end-of-life care), and team and disaster training (e.g., pandemic and mass casualty events), not to mention the continual updates to management processes and procedures, therapeutic interventions, and pharmacotherapy options (Battles, 2006).

Instructional systems design can be applied at all levels of medical education—in medical schools, residencies, fellowships, and practices—by different educational providers, including clinical instructors, support nonprofit organizations, hospital training teams, and commercial, technological, and pharmaceutical industry leaders. Instructional design solutions in medical education can be geared not only toward traditional coursework, but also toward just-in-time, point-of-care, or decision-support tools for physicians to use on the job at the bedside. Thus, the focus of instructional systems design for the future of medicine must aim to support the ever-changing clinical landscape.

References

Battles, J. B. (2006). Improving patient safety by instructional systems design. Quality and Safety in Health Care, 15(Suppl I), i25–i29. doi: 10.1136/qshc.2005.015917

Han, E. R., Yeo, S., Kim, M. J., Lee, Y. H., Park, K. H., & Roh, H. (2019). Medical education trends for future physicians in the era of advanced technology and artificial intelligence: an integrative review. BMC Medical Education, 19(1), 460. https://doi.org/10.1186/s12909-019-1891-5

Hew, K. F., & Lo, C. K. (2018). Flipped classroom improves student learning in health professions education: a meta-analysis. BMC Medical Education, 18(1), 38. https://doi.org/10.1186/s12909-018-1144-z

Jin, J., & Bridges, S. M. (2014). Educational technologies in problem-based learning in health sciences education: A systematic review. Journal of Medical Internet Research, 16(12), e251. https://doi.org/10.2196/jmir.3240

Mayer, R. E. (2010). Applying the science of learning to medical education. Medical Education, 44, 543–549. doi:10.1111/j.1365-2923.2010.03624.x

Noushad, B., & Khurshid, F. (2019). Facilitating student learning: An instructional design perspective for health professions educators. Research and Development in Medical Education, 8(2), 69–74. doi: 10.15171/rdme.2019.014

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