Harness education technology for effective teaching in the modern era.

Over the last several decades, education technology has evolved from the screech of chalk on a chalkboard to the chick-a-chunk of a slide projector to the click of a mouse during a computer presentation. Medical education across all learning levels now incorporates newer education technology such as audience response systems, advanced simulation mannequins, and surgical simulators. Both newer generations of learners who are intimately familiar with technology and the coronavirus disease 2019 (COVID-19) pandemic have catalyzed the widespread adoption of education technology in hospitals and training institutions. The concept of education technology in medical training has conventionally focused on the use of technology—teaching with technology—in medical settings.1 However, education technology may be described more broadly, such as how it was defined by Han and colleagues: “Technological processes and open systems that represent wholeness of meaningful [educational] activities and applications of principles and theories for desired learning outcomes in continuous feedback loops.”1 To illustrate this definition with an example, education technology encompasses not only the simulation suite and equipment used for advanced cardiovascular life support training, but also the relevant curricular development, implementation, pedagogical strategies, and continuous quality improvement of educational activities using the simulation suite. Education technology offers a great opportunity for hospitalist educators to position themselves as experts, teach more effectively, and elevate the care of patients. However, educators may feel daunted when considering how best to practically incorporate the myriad available education technology modalities into instruction for their learners. As with any other educational tool, education technology must be appraised thoughtfully, applied appropriately, and learned diligently. Which education technology modality should be used? This question, while not wholly encapsulating education technology, may be particularly salient for hospitalist educators as they consider incorporating education technology into their instruction. In some respects, teaching with education technology is fundamentally no different than teaching with other techniques. For example, educators may develop teaching activities involving physical examination findings in patients with acute decompensated heart failure, the inpatient management of diabetes mellitus, or a patient case highlighting elements of clinical reasoning. They may consider different media to aid their teaching such as bedside examination, markers and a whiteboard, or slide presentation software. Regardless of the chosen medium, hospitalist educators should use well-established educational principles. They should develop intended learning objectives using models such as Bloom's Taxonomy, consider the context of the teaching activity (e.g., activity duration, learner stage of training, and need for learner accommodations), and ensure their own understanding of and competence with both the topic matter and the medium. The modality chosen should align with the objectives, content, context, and educator familiarity. These same principles and strategies apply when choosing modalities and developing activities using education technology. It is critical to assess the technological tool and how it will contribute to the pedagogical approach. With this in mind, Kimmons and colleagues developed the PICRAT model for technology integration in education.2 This model classifies the application of education technology along two dimensions: whether the learner's relationship with education technology is Passive, Interactive, or Creative (PIC); and whether the educator's use of education technology Replaces, Amplifies, or Transforms (RAT) previous versions of the activity. This model is well-suited to education research, as evidenced by its use in recent systematic reviews of online learning developments in medical education during the COVID-19 pandemic.3, 4 We suggest that the PICRAT model can also be helpful to hospitalist educators in appraising different education technology modalities, considering their appropriateness for a given educational activity, and deciding on which education technology tools to invest time becoming adept. Literature on the implementation and effectiveness of education technology is expanding. Recent examples include three systematic reviews by the Best Evidence in Medical Education Collaborative focused on educational activities across undergraduate and postgraduate medical education,3-5 a systematic review of social media in undergraduate medical education,6 and a scoping review of social media in medical education.7 These studies highlight the promise of education technology, which engages learners, offers flexible and self-directed learning, flattens hierarchies, and improves communication with instructors. The studies also highlight limitations of the literature such as generally modest study design quality and inconsistent theoretical underpinnings. Another limitation is that the vast majority assess lower-level Kirkpatrick Evaluation Model outcomes including those in level 1 (learner satisfaction or reaction), level 2a (change in learner attitudes), and level 2b (change in learner knowledge or skill). How might education technology change the practice of hospitalist educators? Here, we include practical examples of ways to incorporate education technology into hospitalist teaching techniques. Twitter is just one of several microblogging and social networking websites with numerous applications in healthcare including education, professional networking, and advocacy.7-9 The utility of Twitter as a teaching tool stems in part from its versatility. Tweets may be substantive (independently understandable), conversational, or a hybrid of the two.8 Engagement with the site may occur synchronously or asynchronously.9 Tweetorials (a portmanteau of “tweet” and “tutorial”) are particularly suited to education. A Tweetorial is a “short series of grouped multimedia tweets containing educational content centered around a particular topic … structured in an interactive fashion with polls to prompt active learning, stepwise revelation of diagnostic clues, and opportunities for questions and feedback.”10 Tweeting teaching points from daily rounds, pertinent images or figures, article summaries, and links to original literature or other resources. Composing a Tweetorial. Posing deidentified “consult” questions to reputable Twitter communities using hashtags (e.g., #NephJC for Nephrology Journal Club). Participating in and informing learners about Twitter chats and journal clubs11 on relevant topics (e.g., #JHMChat for hospital medicine, #GenMedJC for general internal medicine, and #IDJClub for infectious disease). IMAs allow for direct communication between two or more users. Examples of IMAs include Google Chat, WeChat, Slack, and Viber. Some social media platforms such as Facebook and Twitter also include IMAs. Electronic Medical Record-integrated secure messaging is increasingly available but has yet to be studied widely as a form of education technology. WhatsApp is the world's most popular IMA and the best studied in medical education.12, 13 It is a semiprivate IMA using end-to-end encryption. In healthcare, the use of WhatsApp may be classified into three main categories: educational with a curriculum (e.g., a predefined electrocardiogram interpretation curriculum with a set duration and an identified faculty moderator), educational without a curriculum (e.g., impromptu resource sharing, questions, and discussions of patient cases between members of a ward team), and noneducational (e.g., sharing organizational and scheduling information and socializing among resident colleagues).13 Hospitalist educators might find the greatest utility for an IMA like WhatsApp in the educational without a curriculum category. For example, one could create a WhatsApp group for the ward team to address unanswered questions from daily rounds and to share pertinent supplementary resources like scholarly articles, YouTube videos, links to Tweetorials, or relevant clinical reasoning cases such as those from the Human Diagnosis Project (HumanDx.org). Even for encrypted and semiprivate education technology like WhatsApp, no protected health information should ever be shared. Other education technology modalities that harness audio, video, or both serve as alternatives to traditional didactics (i.e., textbooks, lectures). The content and format range from simple recordings of traditional medical school lectures to summaries and discussions of recently published scholarly articles to the expansive free open access medical education (FOAM or FOAMed) movement of independent instructors operating outside of traditional medical education institutions.7, 14 Both YouTube and podcasts are used extensively and well-regarded by medical learners and educators alike.7, 14 Hospitalist educators may distribute relevant YouTube videos and podcasts to the ward team via another education technology tool such as Twitter or WhatsApp. These resources may be used in a “flipped classroom” model, in which educational material is reviewed by learners asynchronously to in-person activities (e.g., classroom didactics or rounding on the wards), and time with the educator focuses instead on knowledge application. Examples of select podcasts and YouTube channels relevant to medical education are included in Table 1. Engineers are taught computer-aided design programs. Machinists are taught to use computer numerical control machines. So, too, should educators be taught to use the tools of our trade. Medical education already often includes “teaching to teach” training on educational frameworks (e.g., Bloom's Taxonomy and the Kirkpatrick Model) and techniques (e.g., teaching scripts, chalk talks, and bedside teaching). Education technology (and education harnessing education technology) may be conceptualized like tools of other trades—as skills that require dedicated learning and practice. This responsibility falls in part on individual educators to invest time and effort to better understand education technology. However, and perhaps more importantly, there is also an opportunity at the system level for medical schools, hospital medicine divisions, national organizations, and medical journals to promote and disseminate best practices from education technology experts and early adopters. Some current examples include guidance on creating infographics and visual abstracts,15 steps to establish an online journal club,16 instructions on creating Tweetorials,10, 17 practical tips for designing a virtual asynchronous curriculum,18 and the Journal of Hospital Medicine's Digital Media Fellowship.19 Education technology holds promise for creative, novel educational activities for instructors and learners. There is a plethora of new education technology modalities that may be incorporated into hospital-based teaching. However, education technology should be applied prudently and according to sound educational principles. Indeed, education technology simply provides tools and, alone, is not a panacea that will automatically enhance the learning process. The PICRAT model is particularly well suited for appraising education technology and considering any incremental value of education technology over other approaches. As with all modalities, education technology should be aligned with clinical and educational contexts, competencies, learner level and style, and educator skill level. Finally, successfully teaching with education technology is a skill that requires dedicated development and practice. Hospitalist educators, along with their learners and their patients, are likely to benefit from becoming adept at using education technology to teach in the hospital. Dr. Houchens is employed by the United States Department of Veterans Affairs. The remaining author declares no conflict of interest.