The value of online learning and MRI: Finding a niche for expensive technologies

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1 2014, 1 8, Early Online The value of online learning and MRI: Finding a niche for expensive technologies DAVID A. COOK Mayo Clinic College of Medicine, USA Abstract Background: The benefits of online learning come at a price. How can we optimize the overall value? Aims: Critically appraise the value of online learning. Methods: Narrative review. Results: Several prevalent myths overinflate the value of online learning. These include that online learning is cheap and easy (it is usually more expensive), that it is more efficient (efficiency depends on the instructional design, not the modality), that it will transform education (fundamental learning principles have not changed), and that the Net Generation expects it (there is no evidence of pent-up demand). However, online learning does add real value by enhancing flexibility, control and analytics. Costs may also go down if disruptive innovations (e.g. low-cost, low-tech, but instructionally sound good enough online learning) supplant technically superior but more expensive online learning products. Cost-lowering strategies include focusing on core principles of learning rather than technologies, using easy-to-learn authoring tools, repurposing content (organizing and sequencing existing resources rather than creating new content) and using course templates. Conclusions: Online learning represents just one tool in an educator s toolbox, as does the MRI for clinicians. We need to use the right tool(s) for the right learner at the right dose, time and route. Introduction Online learning a term referring to a diverse array of instructional technologies and approaches that have in common their use of the Internet (Cook et al. 2010b) has received increasing attention in recent years. The promise of revolutionary approaches to learning that improve learning outcomes, reach huge numbers of students, individualize instruction, shorten the duration of training, and reduce costs has captured the attention of education leaders, administrators, politicians and journalists. A New York Times article even called 2012 The Year of the MOOC (Pappano 2012). Amidst this flurry of activity and interest, it seems prudent to pause, reflect and reconsider the value of online learning. What is the niche for this new technology, and how might value be optimized? The purpose of this article is to critically appraise the value of online learning by rebutting common myths, describing some true benefits that online learning can contribute and considering how the cost of online learning might be reduced. Myths associated with online learning Myth 1. Online learning is a single entity with homogenous effects Fact: Online learning encompasses a vast range of delivery approaches and designs Few people actually believe that online learning is truly a single entity, but educators often speak as if it were. It is essential to Practice points Online learning is not cheap, is not inherently more effective or more efficient than face-to-face learning, and will not (by itself) transform education. Online learning adds value by offering flexibility, control and big data analytics. Low-cost, low-tech, but instructionally-sound online learning ( good enough instruction) represents a disruptive innovation that will soon displace high-tech, high-cost online learning products. remember, in the discussion that follows and in our day-to-day activities, that online learning represents a great variety of configurations, instructional methods, presentation formats and patterns of integration with other instructional activities. Indeed, the lines between online and traditional learning are increasingly blurred (blended). Not only does the appearance and functionality vary, but also the effectiveness (Cook et al. 2010d) and the appropriateness in any given situation. For further elaboration on these points, see Cook et al. (2010b). Myth 2. Online learning is cheap and easy to implement Fact: Online learning is more expensive than it looks Recent articles in the lay press claim that online learning will save money (Pappano 2012; Reif 2013). Yet extremely little Correspondence: David A. Cook, MD, MHPE, Division of General Internal Medicine, Mayo Clinic College of Medicine, Mayo 17-27W, 200 First Street SW, Rochester, MN 55905, USA. Tel: ; Fax: ; ISSN X print/issn X online/14/ ß 2014 Informa UK Ltd. 1 DOI: / X

2 D. A. Cook empiric evidence has compared the full cost of online versus face-to-face instruction (Sandars 2010), and the limited data available suggest that online learning actually requires substantially more instructor time and greater overall cost (Rumble 2001; Spector 2005; Stotzer et al. 2013). Limited data in medical education confirm that online learning is costly, most notably in its demands on instructor/developer time (Huang et al. 2007; Delgaty 2013). To illustrate, the first two columns of Figure 1 show the resources (time and money) spent to develop the same hypothetical course as a traditional face-to-face lecture and as a typical online learning activity. The initial investment of faculty time in developing the course content will be about the same. But with a traditional approach the only additional time is the course delivery, whereas in an online course there are a number of additional resource-intensive steps including consultation with a technology expert or instructional designer; development, review, revision and pilot testing of the course; and course delivery. Some reduction in costs may be achieved with careful planning, as discussed later in this article (and illustrated in the figure, third column), but even then the development cost will still typically exceed that of a face-toface course. Of course, if instructor time is ignored, then online learning appears very economical; but such accounting of workload is unsustainable (Delgaty 2013). For courses that have an untapped pool of potential students, enrolling these students would distribute costs across a larger denominator and provided that costs remain fixed result in lower per-student cost. Such per-student savings are central to the MOOC s business model. However, most medical education courses lack such growth potential, and costs (especially instructor time) nearly always rise as enrollment expands. I emphasize the uncertainty in these estimates, and acknowledge that the cost of online learning is a rapidly moving target. Many tasks that would have been prohibitively expensive only five years ago (such as creating and posting a video online) can now be done quickly and at minimal cost. The point remains: online learning is usually not cheap. Myth 3. Online learning is more efficient (more learning per unit time) Fact: Online learning can be more efficient or less efficient than traditional approaches, depending on the situation Those who claim that online learning is more efficient sometimes point to studies showing greater learning gains for students in an online course. However, such arguments reflect a skewed selection of studies. In actual fact, students using online learning or traditional approaches perform, on an average, essentially the same on post-course assessments (Cook et al. 2008b). Of course, some online courses are superior to traditional approaches; but a similar number of traditional courses are superior to online, and in most studies it does not matter. Just as the quality of face-to-face instruction varies, and some instructional approaches are better suited than others for a given objective, the instructional effectiveness of online learning varies from course to course (Cook et al. 2010d). Thus, it is not the modality (online versus traditional) that matters, but the instructional design (Cook 2006). Courses that employ proven (and context-appropriate) principles of effective learning will be more effective than courses that do not, regardless of modality. Figure 1. Cost of developing and implementing a hypothetical online course, in comparison with a similar course using another instructional approach (i.e. lecture). Data were not measured in the context of an actual course, but rather were estimated for illustrative purposes based on the author s experience and in consultation with an experienced instructional designer. The cost metric is intended for relative purposes only; it could be loosely interpreted as hours, but also includes other factors (money and other resources). 2

3 Improving the value of online learning Online courses do not necessarily save time, either. A metaanalysis of studies comparing online learning with non-online instruction found great variability in which approach was faster, but on an average there was no difference in the time spent by learners (Cook et al. 2010c). Many authors (Cook 2005; Landsberg et al. 2012) have suggested that increased personalization (i.e. adaptive learning) gives online learning an efficiency advantage. Online courses often allow learners to slow down or speed up at their discretion, and this optimizes efficiency provided learners accurately self-assess their learning needs. Alternatively, the computer can use information about the learner (question responses, usage patterns or motivation to learn) to alter and thus optimize the learning experience (computer-adaptive instruction) (Lee & Park 2008; Cook 2012). A few studies have confirmed that this works in practice (Kohlmeier et al. 2003; Cook et al. 2008a; Kerfoot 2010), but it is prohibitively expensive and fraught with technical difficulties (Cook 2012). This is an area of active research, and the day may come when computer-adaptive learning is mainstream; but at present it seems a relatively distant promise. Myth 4. Online learning enables new instructional approaches that transform the learning process Fact: Online learning facilitates creative instructional design, but the fundamental principles of learning remain the same Many have proposed that computer-based resources such as multimedia, animations, games and virtual patients will radically change learning (Davis & Harden 2001). It is true that online learning does facilitate approaches that would be difficult using traditional media. However, these are unlikely to revolutionize education for at least two reasons. First, most computer-based innovations simply reflect new delivery modalities. The technology serves as a prosthesis to extend our capabilities, allowing us to do things faster, more accurately, and in more places simultaneously than would be possible without the technology (Amin et al. 2011). Yet, at a fundamental level, these innovations are nearly always only a new package for an old instructional approach. Computerbased audio and video clips replace cassette tapes, phonograph records, filmstrips, VHS tapes and live performance as a medium to communicate; animations automate activities that an instructor might have done using a chalkboard or physical models; the essence of most online games can be represented in other competitive activities; and virtual patients are simply the online equivalent of scenarios that could be embodied in written patient cases, standardized patient actors or real patients. Computers might simplify the delivery of these traditional approaches, or enable them to reach new audiences, but the essence of the activity remains relatively unchanged. Second and more importantly, computers do not fundamentally alter how people learn (Bransford et al. 2000). Core principles of learning (Merrill 2002; Mayer 2005) such as activation of prior knowledge, development of mental models, practice with real-life problems, repetition, and perhaps most importantly time on task (Cook et al. 2010c) remain the same. To the degree that computers make the implementation of such principles easier, they will improve education (some examples are listed below). However, learning occurs within the brain of the student, and computers can only facilitate (not supplant) this constructive process. One specific example of how the online revolution hype outpaces reality is the recent buzz about flipped classrooms (Prober & Khan 2013) i.e. requiring learners to complete specified online learning activities prior to arriving for a face-to-face session. The rationale is that this permits higherlevel activities (e.g. learner discussion) during the face-to-face discussion, and also introduces a temporal gap between the online and face-to-face sessions, both of which should in theory enhance learning. While I do not dispute the conceptual underpinnings, it seems unlikely that the flipped classroom (as presently defined) will have the radical benefits that many envision, if for no other reason than that the flipped classroom has been around for thousands of years. I imagine that teachers have always been asking students to come prepared for tomorrow s discussion. The chief differences now are the new delivery methods (e.g. videorecorded lectures) and the capacity to know exactly who completed their pre-class homework. It remains unknown how much these implementation-level changes will impact participation and outcomes. Moreover, pre-class activities require learner time, and since time is a finite resource then something else must be given up to make room (Cook & Dupras 2004). Another example of hype misrepresenting reality is computer animations. The benefits of computer animations are widely extolled, and many instructors and institutions invest substantial resources into developing high-quality animations that illustrate changes over time and location or highlight relationships among the component parts of a complex concept or structure. Yet, as shown in recent reviews, both theory and evidence suggest that animations often add little value, and in some cases paradoxically impede learning by increasing cognitive load (Tversky & Morrison 2002; Höffler & Leutner 2007; Ruiz et al. 2009). Carefully selected static images may be as or more effective for most instructional objectives (Betrancourt & Tversky 2000; Tversky & Morrison 2002; Höffler & Leutner 2007), and typically come at a substantial savings in development costs. The main exception is in training for motor/procedural tasks, for which animations (or video clips) do seem to offer value (Höffler & Leutner 2007; Ruiz et al. 2009). Myth 5. The Net Generation wants online learning Fact: There is no evidence of a pent-up demand for online learning While some have proposed that those in the rising Net Generation have greater expectations for online instruction (Sandars & Morrison 2007), recent evidence suggests that age cohort has less influence than predicted (Bennett & Maton 2010; Jones et al. 2010; Margaryan et al. 2011) and that students might prefer to use computers less than they currently do (Williams et al. 2011). A recent comprehensive review 3

4 D. A. Cook (Jones & Shao 2011) concluded that although younger students often have more experience using the newest technologies, there is not a natural demand for new technologies in their learning activities, and that the relationship amongst teachers, students and technology is determined by the requirements teachers place upon their students to make use of new technologies and the way teachers integrate new technologies in their courses. Interested readers should study the full report (available at What is the value of a new technology? Defining a niche So if online learning costs more and is not more effective, why should we use it? Stated differently, how can online learning add value to education? To answer this question, I will draw an analogy with an expensive but important clinical technology, magnetic resonance imaging (MRI). MRI offers excellent detection of pathology, especially in the brain and spinal cord. MRI technology improves substantially upon other imaging modalities such as computed tomography and pneumoencephalography. However, these advantages come at a high monetary price. Thus, from the outset it was recognized that only a minority of patients with neurologic complaints need an expensive MRI, and this technology was initially concentrated in few (often academic or tertiary care) centers. Even today, many medical centers continue to operate without an on-site MRI scanner, employing other diagnostic approaches for most cases and referring patients to another site for MRI when such is required. Clinicians usually opt for less expensive technologies, or for free diagnostic activities such as history and exam. Most physicians would agree that despite its expense MRI adds value to clinical medicine, but I doubt any would suggest that MRI should be used for every patient with back pain. Physicians do not ask How can I use an MRI today? Rather, they ask What diagnostic test will be most useful to diagnose this patient s problem? to which the answer might or might not be, An MRI. This decision is influenced by a myriad of factors including the physician s experience and comfort with other diagnostic modalities, tolerance of uncertainty and resource cost and availability. In short: (1) MRIs are expensive. (2) Not everyone needs an MRI. (3) Even though MRI technology is expensive, it adds value to clinical medicine in specific circumstances. Similar conclusions can be drawn for online learning. This technology offers new and exciting opportunities to educators, and is used with increasing frequency and increasing acceptance by both faculty and students. Yet, as outlined above, the cost of online learning often exceeds that of other approaches. As with the MRI, every course does not need to use online learning, nor does every institution need the same online learning infrastructure. Local expertise in, availability of, and comfort with various modalities might appropriately influence 4 the relative use of online versus other instructional approaches. Most importantly, online learning should be viewed as complementary to other approaches rather than superior (or inferior). The question is not, How can I use online learning today? but rather This group of learners has a learning need. What instructional approach will be most useful? Sometimes the answer will be, Online learning ; sometimes the answer will be Some other approach ; and often the answer will involve a combination of online and noncomputer approaches. In short: (1) Online learning is (usually) expensive. (2) Not every student, course or institution needs to use online learning. (3) Even though online learning is expensive, it adds value to education in specific circumstances. Increasing value If we define the value equation as Value ¼ Benefits Costs it becomes clear that value can increase despite higher costs if we realize an equal or larger increase in benefits. Despite its greater expense, MRI adds value in clinical medicine by offering diagnostic capabilities difficult to achieve using other approaches. Likewise, online learning offers many unique benefits other than enhanced effectiveness or reduced time that in some cases can justify increased costs (Ellaway 2014). These benefits or advantages cluster into three broad themes: flexibility, control and analysis. Added value: flexibility Online learning s arguably greatest contribution is the flexibility it offers to both students and instructors by overcoming barriers of time, distance, pace and scale (Cook 2007). In most online courses, participants can engage at any time, from anywhere. This substantially enlarges the potential reach (influence) of the course, decreases oft-unaccounted costs of training (such as time, money and opportunities lost in travel and facility fees), and (if enrollment rises) distributes costs over a large number of learners. Learners can also adjust the pace of instruction, moving quickly through familiar material and slowing down when needed. Depending on the objectives and with appropriate instructional design, some online courses accommodate growth in enrollment with only modestly increased demands on instructors, permit students to enroll in, start and complete the course without a fixed schedule, and can be repeated at relatively low incremental cost. Finally, online learning allows rapid dissemination of new or updated instructional materials (such as education on urgent changes in clinical practice) (Cook et al. 2014). Added value: control Online learning also gives instructors greater control over course processes. Centralized content and delivery standardizes and documents the quality of instructional design and

5 Improving the value of online learning implementation, facilitates content updates, and ensures that specific objectives (e.g. completion of patient cases with a defined spectrum of disease, or repetition to mastery) have been met. The focus and complexity of practice cases (e.g. virtual patients) (Cook & Triola 2009) can be optimized to ensure adequate representation of a topic without redundancy; this can supplement (and in some instances replace) real patients (or nonclinical experiences) in environments limited by time pressures or a narrow spectrum of problems. Student (and faculty) course involvement and assessment scores can also be automatically recorded for future reference (e.g. certification of competence or verification of participation). Centralization of content and recording of data can also facilitate scholarly activity, especially multi-institutional, longitudinal and multi-arm studies (Cook et al. 2010a). Added value: analysis Online learning usage data and learning outcomes provide a wealth of readily-accumulated information that can potentially be used to optimize instruction across an entire course and for individual students (Cook et al. 2010a). At a program level, detailed course data could identify weaknesses and strengths; this information would then guide decisions both to refine that course for future iterations and to develop or improve other courses. For individual students, the collection, analysis and interpretation of individual learner data could make computer-adaptive instruction a reality. While benefits are as-yet unconfirmed, large-scale collection and analysis of data ( big data analytics) (Manyika et al. 2011; Ellaway et al. 2014) can conceivably link data over time, learners, courses and even teaching programs to understand how to optimize individual and course-level instructional activities. Putting one more tool into the toolbox As does the MRI for clinicians, online learning adds one more tool to the educator s ever-expanding pedagogical toolbox. This toolbox already contains other effective approaches such as lecture, simulation, small group session, problem-based learning, Socratic method, self-reflection and adaptive instruction. Selecting the appropriate tool or combination thereof is analogous to the carpenter who must know when to use a drill, hammer, screwdriver or saw; or the clinician who must know when to rely on the history and exam versus when to get a head CT or brain MRI. Rather than having an inherent preference for one tool over another, best practice would suggest the need to select a tool based on immediate needs and available resources. To paraphrase an aphorism from clinical medicine, we need the right tool(s) for the right learner at the right dose, time and route. Such decisions will increasingly require sophisticated instructors with training in instructional design (or at least experience in the trade), familiarity with the relevant theories and empiric evidence, and skill in assembling both newly-developed and existing resources into a coherent whole. We may find that teams, rather than individuals, are best suited to this task (Robin et al. 2011). I also anticipate that we will soon develop educational best practice standards (analogous to building codes in house construction or clinical pathways in medicine) to guide such decisions. Online learning as a disruptive technology: why good enough may be good enough How good does a tool need to be? Does every online course require the latest technology, professional design or robust pilot testing? Of course not. The investment in a given course should match the needs of the course, and realistically take into account local resources. To this end, we must consider how online learning (or, more specifically, certain implementations of online learning) reflects a new, disruptive technology. One key feature of disruptive technologies is that they are often inferior to existing technologies (Bower & Christensen 1995). However, by targeting a new group of customers becoming readily accessible to the masses and by being good enough to meet the basic needs of that group, a new technology can gradually supplant the currently prevailing technology. In the near future, good enough online learning will almost certainly supplant the professionally-developed, hightech products that many online learning providers now showcase (and that educators and school leaders covet). Such products are indeed glamorous and push the limits of the technology, but they come at exceedingly high cost and many of the refinements have a low effectiveness-to-cost ratio. I am not suggesting we embrace poor-quality instruction. However, as illustrated in Figure 2, if 80% of the instructional effectiveness can be achieved at 30% of the cost (and it can, with proper course design using low-cost activities), it could lead to substantial cost savings, increase the market for application Effec veness (% of maximum) Ideal course Resources (% of maximum) Figure 2. Relationship between resource investment and effectiveness. This figure illustrates that most of the educational effectiveness (learning outcomes, learner satisfaction) in online learning can be achieved at substantially lower cost than the ideal course. Data were not measured in the context of a specific course, but rather were estimated for illustrative purposes based on the author s experience and in consultation with an experienced instructional designer. 5

6 D. A. Cook (e.g. smaller potential audiences), and empower educators with expertise in teaching but not technology to use these tools effectively. Lowering the cost of online learning The relative (per-student) cost of online learning often goes down as enrollment goes up (although this varies depending on the course design). Also, it may be worth a higher price (net increased value) if online learning solves practical and logistic problems, such as accommodating learners schedules, minimizing travel, enabling rapid dissemination of core content and facilitating courses that repeat frequently or to which learners subscribe on an ad hoc basis. However, it would naturally be ideal to lower the cost in absolute terms. As shown in Figure 1, savings will come primarily by reducing the resources (time and money) spent in developing content and course planning, development and pilot testing. There are at least four ways to achieve such cost savings. First, instructors can use high-value, evidence-based instructional designs and standardize best practices. Many of the features commonly associated with online learning have little added instructional value, and some expensive features actually impede learning. Eliminating such wasteful and counterproductive features could save substantial costs. Some opportunities include: Using static images instead of animations (see above) (Ruiz et al. 2009); Not investing in high-quality video productions (research shows that video resolution and frame rate may not matter to learners) (Ghinea & Chen 2003); Avoiding the use of unnecessary multimedia (a website should look refined and coherent, and graphics do add value, but extraneous graphics, videos and sound impede learning) (Mayer 2005). Second, instructors can employ authoring tools (Chapman 2008; O Neil 2008) that make the creation of good-quality instruction accessible even with limited training. Numerous software packages now support low-cost, low-expertise development of professional-appearing Web applications. Most computers and smartphones now come with photo and video editing software that enable creation of short educational clips with virtually no training and no overhead. Social media services such as Facebook and Googleþ offer intuitive tools for online collaborative learning. Other tools facilitate the development of virtual patient simulations and online games (O Neil 2008). Third, we can reuse and repurpose existing content rather than reinvent this anew for each course. If the American College of Physicians or another university has already published a useful online learning resource, if a video is already available on YouTube, or if a clinical practice guideline is freely available in PubMed, a teacher may not need to create a local online resource. Instead, the teacher s time might be better spent planning and sequencing instructional activities that promote active learning (such as questions, group projects and practice exercises) and identifying and appraising potentially useful resources. Some content resources are designed to 6 be incorporated directly into a new course (so-called reusable learning objects) while others require adaptation. Yet, even if the resource does not meet all desired objectives precisely, it may be good enough, especially when combined with other resources and the teacher s personal touch. Alternatively, students could identify and appraise their own information sources. This promotes self-regulated learning, (Brydges & Butler 2012) and also allows students to practice lifelong learning skills in a supervised context. Shifting the instructor s role from content creator to content organizer and designer of instruction may represent a fundamental transition (and corresponding faculty development need) over the next decade (Robin et al. 2011). Finally, we can use well-designed online courses as templates for subsequent courses. For example, a case-based course in management of abdominal pain might be used as a template for another course on chest pain (i.e. differing content but roughly parallel instructional objectives and approaches). Such a template might prescribe the general layout and sequencing of content pages, specific activities to stimulate effective learning and learner self-assessment/feedback; contain placeholders for summative assessment; and offer a uniform course evaluation. Instructional design experts could create, test and refine a library of such templates targeting recurring types of instructional objectives and learner needs. A content expert with limited technical expertise could then use a template to efficiently develop and implement a new course. Studying the cost of online learning This article speaks much of cost, yet in the absence of good cost data these discussions involve much guesswork, assumption and speculation. Readers interested in collecting information on cost, cost-effectiveness and overall value might consider the works of Hummel-Rossi & Ashdown (2002), Levin (2001) and Clune (2002). Conclusion: right tool, right learner, right dose, right time and right route The MRI nearly always comprises only a portion of a diagnostic evaluation that also includes history, exam and other laboratory and radiological tests. Likewise, the choice between online learning and non-computer approaches is rarely an either-or decision. Educators increasingly reflect this in their use of blended learning drawing upon both online and face-to-face approaches to efficiently achieve instructional objectives. Indeed, depending on where we draw the line, nearly all online learning is to some degree blended. The day will soon come in which online learning is no longer viewed as novel, but instead is lumped with paper handouts, the whiteboard and marker, PowerPoint slides and group discussion as just another tool to be used when needed. Teachers will capitalize on the strengths of each available approach as they select the right tool or combination of tools, guided by principles grounded in theory and empiric research. The quality of instruction will be determined not only by the

7 Improving the value of online learning quality of the component parts, but also by their relevance to instructional needs, objectives and contexts, and by how well they are stitched together (by human teachers) to create a seamless, coherent, efficient and effective learning experience. Glossary Authoring tool: A computer program designed to facilitate software development. As used in computer-based education, refers to programs that facilitate the development of polished computer-based educational resources with minimal technical expertise. O Neil AF The current status of instructional design theories in relation to today s authoring systems. Br J Educ Technol 39: Blended learning: The simultaneous or sequential use of online, face-to-face and other (e.g. hands-on simulation) instructional approaches to efficiently, effectively achieve objectives. Littlejohn A, Pegler C Preparing for blended e-learning: Understanding blended and online learning. London: Routledge. Disruptive innovation: A new technology whose performance is initially worse than existing technologies, but that meets the basic demands of a previously underserved market group. By gaining a foothold in a new market and then improving, the disruptive innovation eventually displaces the previously dominant technology. Bower JL, Christensen CM Disruptive technologies: Catching the wave. Harv Bus Rev January/February: Notes on contributor DAVID COOK, MD, MHPE, is a Professor of Medicine and Medical Education and Associate Director, Mayo Clinic Online Learning, Mayo Clinic College of Medicine and a Consultant in the Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota. Declaration of interest: The author reports no declarations of interest. 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