Technology-based Training

For the "Swamp" of Professional Practice

Joseph V. Henderson, MD
Interactive Media Laboratory
Dartmouth Medical School

© 1997, Joseph V. Henderson

This paper addresses the education and training of practitioners in professions such as medicine, law, military leadership and management, whose decisions can have great impact on the lives of individuals and/or organizations. While I acknowledge a continuing need for a practitioner to learn facts and principles, I am at least as concerned with habits of thinking, and the mental models that shape and filter the perceived practice world.

Learning occurs as part of formal (usually institutional) learning and in the real world. Both venues have their problems. The former tends to be heavy on facts and theory ("learning what"), neglecting the practical ("learning how"), and providing little grounding for the complex, non-deterministic "swamp" of professional practice. In the real world, "learning by doing" suffers from lack of feedback, since the consequences of decisions taken are often far removed in time and/or space; learning only works when the feedback is relatively rapid and unambiguous, conditions that are rare in the complex situations and systems of the real world.

Formal (institutional) education and training

Most of education places great emphasis on memorization of facts and theories, justified to large extent on preparation for standardized "tests of knowledge." The "recitation" (orally or through multiple choices) of abstract, theory-based "knowledge" is part and parcel of formal education in most of the world today, whether in grades 6, 12, or 18. This situation goes directly to habits of thinking, learning, and acting and to how these habits limit opportunities for growth and real-world problem solving. By and large, in education we approach the world as modern, "scientific" thinkers, believing it to be amenable to abstraction—and containing deterministic problems with clear, textbook solutions.

This schism between theory and practice is problematic. John Seely Brown at Xerox PARC and his colleagues note that, "… by ignoring the situated nature of cognition, education defeats its own goal of providing usable, robust knowledge." (I note that this stance is justifiable from many lines of evidence and thought, from cognitive sciences, to philosophy and learning theory.) Brown, et al, argue that educational approaches "that embed learning in activity and make deliberate use of the social and physical context are more in line with the understanding of learning and cognition that is emerging from research." These approaches, generally termed "situated learning," can have many or all of the following characteristics (modified from Herrington and Oliver):

Donald Schön, focusing on advanced education and training for the professions, is similarly critical. He contrasts the high ground of "manageable problems [that] lend themselves to solution through the application of research-based theory and technique" with the swamp of "messy, confusing problems [that] defy technical solution." Formal, institutional education for the professions, he notes, almost invariably emphasizes the former and deals inadequately, or not at all, with the latter.

"The irony of this situation is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, while in the swamp lie the problems of greatest human concern. The practitioner must choose. Shall he remain on the high ground where he can solve relatively unimportant problems according to prevailing standards of rigor, or shall he descend into the swamp of important problems and non-rigorous inquiry?
"The dilemma has two sources: first, the prevailing idea of rigorous professional knowledge, based on technical rationality, and second, awareness of indeterminate, swampy zones of practice that lie beyond its canons."

To address this problem, Schön recommends use of "reflective practicums," settings for formal learning

"… designed for the task of learning a practice. In a context that approximates a practice world, students learn by doing, although their doing usually falls short of real-world work. They learn by undertaking projects that simulate and simplify practice. . . The practicum is a virtual world, relatively free of the pressures, distractions, and risks of the real one, to which, nevertheless, it refers. . . It is also a collective world in its own right, with its own mix of materials, tools, languages, and appreciations. It embodies particular ways of seeing, thinking, and doing that tend, over time. . . to assert themselves with increasing authority."

Learning by doing in the real world

Peter Senge, of MIT’s Sloan School of Management, laments the "dilemma of learning through experience" in the complex, real world of practice. Learning by doing, he says, only works when feedback on our decisions is rapid and unambiguous. In the complex real world, experiencing the consequences of our actions is neither immediate nor unambiguous, and is often removed in time and space. "How, then," he asks, "can we learn?" Computer-generated microworlds re-create essential characteristics of a practice environment and " ‘compress time and space’ so that it becomes possible to experiment and to learn when the consequences of our decisions are in the future and in distant parts of the organization." Though Senge conceives of microworlds in terms of organizational, as well as individual, learning, they closely parallel situated learning and reflective practicums.

"These new microworlds allow groups to reflect on, expose, test, and improve the mental models upon which they rely in facing difficult problems. They are settings for both crafting visions and experimenting with a broad range of strategies and policies for achieving those visions. Gradually, they are becoming a new type of "practice field" for management teams, places where teams will learn how to learn together while engaging in their most important business issues."

Senge lists several attributes, but one of great interest, particularly given its lack in most other models, is the idea of "play." Deeper exploration of issues and strategies, along with reflection on individual and team learning skills, he states, "can be enlightening and ‘lightening’ because this reflection can be separated from the risks and pressures of real decision making." (I feel that this idea of play and "lightening," while not discussed in depth by Senge, is extremely important. We must pay more attention to the affective impact of learning experiences, including how enjoyable, esthetically pleasing, appropriately challenging, intellectually absorbing, and emotionally moving they are… or are not.)

Technology-based Situated Learning

(Or Reflective Practicums or Microworlds)

Interactive multimedia combines video, graphics (still and moving), audio, and text, potentially to provide very rich and powerful stimuli for learning. If carefully designed from an educational viewpoint, if appropriate to the learning audience, and if well-crafted, the potential for learning can exceed most other types of educational experiences, in terms of effectiveness, efficiency, and, given the pre-existing installation of necessary systems (multimedia computers, networks), ready availability.

Situated learning, reflective practicums, and microworlds are all amenable to delivery via interactive multimedia, whether via local- or wide-area networks, via CD-ROM, or via some hybrid of networks cum CD-ROM. Some educators argue that this is antithetical to the spirit and practice of situated learning, that interposing technology creates a deeper divide between the world of ideas and the world of practice. Others, including this author, believe that, if carefully designed, interactive multimedia can actually improve on real life experiences, for the same reasons given by Schön in support of reflective practicums and by Senge in support of microworlds. Simplification, while retaining complexity, contraction of time and space to witness the outcomes resulting from decisions, can provide powerful opportunities for learning. Making such learning experiences technology-based can make them more effective, efficient, and impactful. Further, it is made more available in that, having produced the educational experience, it can be replicated and/or distributed, and accessed at nearly any time or location.

An Example: Primary Care of HIV/AIDS Patients

Professionals are arguably the most demanding audience for education and training. They are generally well-educated, busy, skeptical, and demanding of excellence. Their practice world is complex and it often leaves the professional with too little time to pursue education and training. If a training experience is seen to be inadequate in any way, it is likely that the professional will not complete it (unless required to do so, with uncertain benefit to the learner or the requirer). An educational experience must address the characteristics and needs of this audience well.

In this section we present (to the extent possible without actually showing it) a new program for primary care providers, including physicians, nurse practitioners, and physician assistants, on the topic of HIV and AIDS. It is, we believe, an excellent example of technology-based professional education, incorporating some of the best, most appropriate, current educational design principles with excellent multimedia production, rivaling the quality of commercial-grade, strategy computer games. Primary Care of the HIV/AIDS Patient: a Virtual Clinic follows a situated learning design, using the intellectual context of a "Virtual Mini-fellowship" and the navigational—and concept map—device of a virtual HIV clinic, represented graphically and immersively.

Overarching Context: a "Virtual Mini-fellowship™"

Most clinicians would value a continuing education experience that provides for effective, efficient, and enjoyable learning. The ideal experience would probably involve a visit to a major medical center, with opportunities to see patients, to interact with experts (in the best case, a mentor), to attend excellent lectures, etc., all available as desired, on demand. But this kind of ideal learning experience isn't available to most practitioners. They're difficult, if not impossible, to conduct on a regular basis, much less "on demand." Further, good learning depends on having good teaching cases and good teachers, but their availability and quality are, to say the least, unpredictable. For most chronic diseases, it's impossible, in the short duration of a typical continuing education experience, to get first-hand sense of longitudinal care, the long-term physical and emotional impact of a disease on individual patients. Finally, even when good educational experiences are available, attending them usually involves significant expense and inconvenience to the practitioner.

Virtual Mini-fellowships seek to overcome these obstacles and to provide as close to an ideal continuing education experience as technology will allow. This program, dealing with HIV and AIDS,

These qualities are provided within a Virtual Clinic, a highly detailed, computer-generated environment that is intuitive and easy to use.

Governing Principles

The program was designed and produced so that it would be perceived by the intended audience as

These qualities were viewed as essential to assure the program's acceptance by the intended audiences. We elaborate:

Authoritative. The program’s host and mentor is John Bartlett, MD, Chief, Division of Infectious Disease at Johns Hopkins University School of Medicine and Johns Hopkins University Hospital. Widely recognized for his knowledge of HIV and AIDS, Dr. Bartlett is highly regarded as a "clinician's clinician," blending extensive scientific knowledge and clinical experience with a deep commitment to his patients and students. He is noted for his teaching abilities and clinical insights, and is in great demand as a lecturer and consultant. Dr. Bartlett is principal investigator for over $30 million in research funds at Hopkins and has written over 500 papers and nine books (24 editions). The program’s guest lecturers are Jay Dobkin, MD, and Joyce Anastasi, RN, PhD, authoritative representatives of their respective practitioner communities (medicine and nursing).

Effective. This is demonstrated via task-related, multiple choice questions, posed during management of a set of complex, simulated patient issues, both clinical and psychosocial. There are also elective activities that provide for heuristic learning and self-testing via content and context-related puzzles and immediate feedback. The user is likely to be satisfied with the program if it increases his or her sense of competence when managing patients with HIV disease. Effectiveness can best be assured when the program’s content is appropriate in scope and comprehensiveness, and is current and practical.

Comprehensive. Content is directed at improving the knowledge, attitudes, and skills of the professional who provides on-going, primary care to adults, adolescents, and children with, or at risk of, HIV Disease. Practice scope is assumed to be broad, potentially including prevention counseling, testing and test disclosure, initial and continuing evaluation and education, pregnancy counseling and management, prevention of HIV-associated conditions (including antiretroviral therapy and prophylaxis for opportunistic infections).

On the other hand, we assume that primary care providers will refer particular patient problems—such as serious opportunistic infection, psychiatric problems —for management by other care providers; the program will deal with these issues only with regard to the generalist’s role in coordinating care. Consequently, the program does not deal comprehensively with conditions normally involving care by sub-specialists or allied health workers.

Accurate and current. Development of content involved examination of the current literature (including information posted on "branded" Web-sites such as Centers for Disease Control and the National Institute of Allergy and Infectious Diseases), consultation and review by experts participating in the program (Drs. Bartlett, Dobkin, Anastasi) and outside experts, and consultation with representatives from the community of people with HIV. Dr. Bartlett’s case discussions, central to the program, are necessarily state-of-the-art, given his high degree of experience and knowledge, and his position at the center of HIV research. The program, with Dr. Bartlett’s discussions, will be updated yearly, or if developments in HIV treatment warrant, an earlier update will be done. In the next edition of the program, access to the WWW will be added, allowing automatic updating of certain data (e.g., annual statistics from the Centers for Disease Control and Prevention); audio covering the introduction of statistics for the coming years (through 2006) is already recorded and ready to be used. The next edition of the program will also link directly to a WWW site dedicated to the program, providing additional information and links to other, "branded" Web-sites that are relevant.

Practical. The program emphasizes the application of knowledge. It is centered—via simulation and interviews with real patients—on patient care. The program will apply Kolb’s learning cycle (see next section), taking a series of very complex topics and—without sacrificing substance—help make them understandable and applicable.

Efficient. The program must be perceived by a professional as providing great value in return for modest time-investment; for that reason, the program proper is delivered on no more than two CD-ROM discs. Time to complete the program ranges from two to eight hours, depending on how much the learner wishes to do.

Flexible. There is a great deal of flexibility in the program. These include the order and level of difficulty of simulated patient encounters (early and late disease; late disease only, etc.); case discussions by Dr. Bartlett that can be accessed (or not) after each patient encounter or by visiting the conference room; a completely optional selection of learning resources dealing with different topics, using different learning modes (active or passive: lectures, interviews, "Pearls of Wisdom;" activities), and an optional collection of patient interviews.

Educational Design

The program is mainly intended for individual use at home or in an office setting. Optimally, the program should be used in 2-3 sessions of 1-2 hours each.

Theoretical Basis. The program applies Kolb’s experiential learning theory and his notion of a Learning Cycle,as modified by Boisot.

fig. 1. kolb's learning cycle

Fig. 1. Kolb's Learning Cycle (modified by Boisot)

Kolb's experiential learning allows for differences in individual learning styles: experiences are translated into concepts, in turn channeling new experiences. There are four stages to Kolb's learning cycle (Fig. 1). Immediate, concrete experience is seen as forming a basis for observation and reflection. This, in turn, is abstracted and assimilated into models and theories about the real practice world. In a fourth stage, these models are applied as actions in new situations in the real world. The cycle then repeats itself indefinitely. In its original form, the arrows of Fig. 1 had a single head and the cycle moved only counter-clockwise. Boisot argues that Kolb's distinctions between "real," external activities and internal, concept-building activities are limiting, particularly with regard to the active experimentation stage. Rather, active experimentation can be thought of "as the deliberate and conscious manipulation of well-coded data complexions—whether this is carried out in one's head, on things, or in documents…" (Or, I would add, in simulations and computer-based activities.) If the active experimentation stage becomes a "locus of analytic activities then the cycle, still starting from concrete experience, could plausibly be run in both directions."

These ideas are very similar to Schön's "reflection-in-action." Reflection-in-action comes into play when a situation that develops falls outside the boundaries of what we've learned to consider normal; we embark on a process of critical examination of the situation, framing of the problem, on-the-spot information-gathering (experimentation) to explore the new phenomena. The experimentation may work, yielding expected results, or it may lead to surprises that call forth additional cycles of reflection-in-action. Reflective practicums, Schön argues, are an excellent venue for learning reflection-in-action.

Educational Strategy. Primary Care of the HIV/AIDS Patient cycles around "concrete" experiences, a series of encounters with a simulated patient, Laurie Matthews. The encounters will activate the modified Kolb cycle: reflective observation (during the "patient education" segments of each patient encounter), abstract conceptualization and model building (during diagnosis and problem list formulation) and active experimentation (decisions regarding work up and management). In addition, the stages of the cycle will be reinforced with other aspects of the program: concrete experience via interviews with real patients, first-hand feedback, and "Pearls of Wisdom" (during case discussions) from an expert, John Bartlett; abstract conceptualization via short lectures on aspects of HIV disease appropriate to the patient encounters; and active experimentation via a series of computer-based activities dealing with different HIV concepts.

Fig. 2. Modified Kolb Learning Cycle with associated program elements

The entire program constitutes a reflective practicum as described by Schön, akin to Senge’s microworlds, and achieving many of the characteristics of situated learning outlined previously. We use the term, "Mini-Fellowship" to describe the experience to users.

Some Final Thoughts

Professionals can, of course, learn from data and information bases; these will proliferate, become richer in content and media used, and become—electronically and conceptually—more accessible. And they will play an increasingly important role in professional education. However, it is important to distinguish between these systems and interactive multimedia programs that are specifically designed to be educational, that do more than simply provide the information. In these programs, experiences are crafted specifically to help people learn; in other words, they teach.

This view of an interactive media program that "teaches" has been somewhat out of favor; many educators prefer the data base, explore and discover model, with the learner constructing knowledge right and left, and into the dawn hours. But this philosophy avoids or ignores the challenge and flat-out excitement that great teaching and a wonderful sequence of ideas and experiences can bring to someone who must learn about something. And it ignores the enormous cost in time and energy to "construct" knowledge, likely to be particularly objectionable to busy professionals.

The best teaching programs can accomplish much of what a great teacher can do, while providing opportunities for learners to take in tacit knowledge, to explore a well-structured information/idea/experience space to "construct" knowledge, to have the best of both worlds. This kind of learning experience, to be complete, should have two more things. First, they must have what John Dewey calls "a career;" that is, they should give a strong sense of participating in a reality that has a past and present, and is going somewhere. In other words, it exists in time and space, if only in our imaginations. Second, the program should in some way enter and occupy a place in our hearts; there should be an emotional richness that speaks to our human caring. These can provide a unifying framework for a program's concepts and, at the same time, provide "information" that can't be codified, quantified, or computerized. That is, the human, rich, "swampy," non-deterministic stories of people and their situations can reveal the consequences of decisions made and actions taken, not simply their process.