By David W. Chambers

There is a paradox involved with educational technology: its cost can be gauged by looking at the equipment, but its value depends on the context in which it is used.

When the dental school decided to issue laptop computers to all students, there was a debate over whether or not wthey should be allowed in the classrooms. I thought of this a few years ago while teaching a large seminar on research for first-year students. I required everyone to bring their laptop and we looked things up in class, did customized group exercises and actually wrote a paper in class. In a digression, I remarked that the Hippocratic Oath does not say “First, do no harm.” A few minutes later I noticed a lot of students huddled around a computer and suddenly I just caught an expletive and the words, “He’s right.” That is “just-in-time, just-for-me learning.” Had I passed out a copy of the oath and gone down on my knees begging students to read it, the probability of compliance would have been statistically insufficient.

[pullquote]We are coming to realize that learning technology is a paradox. The key is not the equipment; it is everything around it.[/pullquote]

We are coming to realize that learning technology is a paradox. The key is not the equipment; it is everything around it. This insight is at least 2,500 years old, and is found in the Taoist writings of Lao Tzu. “The value of a cup is not in its walls, but in the empty space they create.” The value of a 4G device is not its touchscreen text pad, but its giving us something intelligent – seeming to do while waiting for an elevator or cab.

Technology in the Curriculum

The dental school is now on its third generation of course management software systems. Faculty put lecture notes, PowerPoint presentations, readings, video clips and links to other resources online, along with assignments, chat rooms, quizzes and secure grade posting. We even administer final examinations in computer format. We have come a long way from the days when we videotaped lectures so students who were on extramural rotations could keep up with the lock-step curriculum. (I actually reviewed the sign-out slips in the library back then to learn the impact of our early move in technology; we could have saved the effort.)

The purpose of the lecture now is to serve the most important function of motivation. People such as faculty members are uniquely positioned to answer the question “Why should one be interested in a topic?” even when, by comparison with electronic media, they are poorly equipped to present the material in its full richness.

Leading universities such as Harvard, MIT, Cambridge and Oxford now have, by faculty vote, “open access policies” putting all course material on the Internet. The best educations are now virtually free. There are two reasons for this: digital technology has reduced the cost of transmission—an extraw digital copy is quite literally not worth charging for. The other reason is that the value of knowledge is not the packages of content; it is in the creative act of making new content and in the context that makes that content useful. The one who manages the context controls learning, not the one with the new gadget.

Here is an example. The course management software the Dugoni School of Dentistry uses allows faculty members to track who is using it. In the research course mentioned previously, I checked use patterns and found there was a minor blip in “eyes on page” when new content was announced (but not when it was discussed) and a major blip hours before an assignment was due. I also found that students who regularly used material on our course management software scored about a grade and a half above those who neglected it.

Being the first to implement electronic education technology does not guarantee impact. When the dental school occupied its current building in the late 1960s, we had an electronic real-time individualized polling system to promote active learning. You may have wondered what those little dials in the arm rests in Room 411 were for. At one time they were connected to a sophisticated system for measuring and displaying student input. It proved to be useless technology because the faculty of those days did not consider engaging students in discussion to be an authorized part of their jobs, especially in situations where differences of opinion could be made public. Curiously, one of the hot new educational technologies today is “clickers,” essentially the same concept, except now we use cell phone technology to register input.
Where are the disconnects in technology? Electronics has brought down the cost. But that doesn’t explain why we are now scrambling to reintroduce what we tore out decades ago. The driving change has been in the curriculum. We have shifted from a teacher-centered to a student-centered view of learning. In the old model, students were given credit for the amount of content they were able to extract from faculty members, and under such a system the status of both students and faculty members was determined by regulation of such transactions. Effective technology served to control this process and students crowded the front of the lecture hall to get a copy of the handout (quite literally a handout) and squirreled away semi-secret copies of old exams.

The curriculum at the Dugoni School of Dentistry today is designed around the concept of integrating knowledge and practice. And the integration that matters is the students’. Strands of knowledge, skills and values are woven together in a helix pattern that is held together by the Personal Instructional Programs theme. This is a natural extension of the competency-based curriculum that the school pioneered in the 1990s, where the purpose of dental education is focused on developing the capacity to practice rather than accumulating check-offs. In the model that existed before that, the method of instruction was fixed and the outcomes were allowed to vary (how else could we get a bell curve of student performance). Now the outcome is fixed (competency) and the available means of achieving it have blossomed. Technology means alternatives.

We have changed the context and that pulls new technologies into the mix. Perhaps the technology in greatest demand today is not electronic at all: it is seminar rooms needed for active learning where small groups of students and faculty members can explore different approaches, trace out the consequences of information and actions, verify the values that guide patient care and integrate what is known about the profession. That cannot be easily accomplished in lectures, and podcasts and PowerPoint downloads designed to substitute for talking heads don’t get the job done either. We have ample means for electronic communication and assembling support material; the technology bottleneck right now is physical space for interactive learning.

Technology in the Clinic and on the Web

One of the dental school’s competencies is that our graduates will be up-to-date in clinical technology. In the clinic this means digital radiography, implants, use of clinical microscopes, clinical photography, the constantly changing array of restorative materials and even a commitment to “goopless” (electronic) impressions. We have also installed a new clinic computer system: AxiUm. This does everything one could want in a clinic (at least it did when we installed it about a year ago) from electronic charting and records management to integration of digital radiology and remote access. It also structures faculty control of the treatment sequence, provides financial management and even offers a platform for clinical research.

[pullquote]It required about two years of planning to get ready for the conversion, according to Dr. Richard Fredekind, associate dean for clinical services.[/pullquote]

It required about two years of planning to get ready for the conversion, according to Dr. Richard Fredekind, associate dean for clinical services. All of the electronic capability existed in AxiUm off the shelf and could have been plugged in on very short notice. The hard part of the technology upgrade was understanding and agreeing on our clinical, educational and business models and processes. Technology is just as powerful for deepening the ruts of traditional ways of doing things as it is for opening up new methods.

Research conducted in the 1970s, as computers were entering the workplace, confirmed an aspect of the technology paradox we have been exploring: technology almost always makes things go faster, but not necessarily better. The faster or easier part is clear enough. What has been discovered is that technology most predictably leads to improvements when it forces a rethinking of the underlying work processes. The shift in word processing has been that those folks we used to call secretaries have become very scarce: professionals now do their own keyboarding (even though we are not as good at it as were our support staff). The problem has been that we have multiplied the number of documents we generate and the number of copies made, the proportion of Americans in the “information” economy (now over 70%) and the length of the average work week.

To date, our new clinic computer system has provided clear advantages in up-to-date imaging and records management, as well as convenience for access and patient management. It offers the potential for research and provides a rich database for clinic management. It also takes students and faculty members more time to enter, check and override the logic of the system. Dentists who have explored and experimented with electronic digital records in their practices confirm that technology that is not in harmony with practice patterns can be a heck of a pain.

Technology has also played a role in the administration of the dental school. Our website not only broadcasts our PR messages, it also interacts with our communities. Students sign up online for selective courses, RSVP and get tickets for graduation and manage enrollment for graduation and licensure testing. Faculty conduct such business as reviewing credentials for promotion and tenure, attending meetings at the Stockton campus via Skype and participating in surveys from their desks or remotely while at home or while traveling.

Resolving the Paradox

For many alumni, their first exposure to computer technology was Atari. This was the first video game company, founded in 1972 and disappearing in 1998. For millions of Americans, the company defined what computers do: they atari. The word describes a move in the game of Go, where one strikes or scores or captures. To atari is to succeed. Unfortunately, many still embrace this metaphor for our relationship with technology. Research with school children learning to access information on the Web has documented the strong tendency for students to Google until they find a match with the teacher’s request (an atari), and then they terminate the search. If we let it happen, learning can become defined as the “first hit.” The only thing sadder than technology becoming an end in itself would be for it to define the standard for the end of learning. This is the deep paradox of technology in an organization devoted to learning.

My guess is that readers will soon forget most of what is in this article. What are most likely to be remembered in the future are the stories about the Google search for the Hippocratic Oath, the arm rest dials in Room 411 and the story about Atari. There is a reason for this. These are examples of narrative rather than opinion or factoids. We remember things that have a structure with a beginning, a middle and an end—especially when we can insert ourselves at the beginning or the end. Electronic technology opens for us the amazing power of taking things apart into elements, stripping off the beginning and the end, of finding them quickly and for reassembling them in marvelous recombinations. But it only counts for learning when it is reassembled. Meaningful material always has a lead-in and a follow-up; it is part of the flow of professional life. Schools that issue computers or Web pages without creating the culture for turning these into the story about becoming a dentist have missed the point of technology.