medical education

Going Mobile: A review of mobile learning in medical education

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Next month will mark the 50th anniversary of mankind’s greatest accomplishment; landing human beings on the Moon. Yet today the vast majority of our learners each carry in their bag or packet a device with millions of times the computing power than the machines we used to meet this achievement. This is why one of my passions as an educator is mobile learning and the opportunities our unprecedented age now offers. I’ve enjoyed learning how to create resources such as a podcast and a smartphone application and how these have innovated the way I teach.

The Higher Education Academy defines mobile learning as “the use of mobile devices to enhance personal learning across multiple contexts.” Mobile learning itself is a subset of TEL or ‘Technology Enhanced Learning.’ There’s repetition of a key word: enhance/enhanced. We’ll come back to that word later.

This musing looks at some of the current evidence of mobile learning use in medical education and tries to pinpoint some themes and things we still need to iron out if we’re going to make the most out of mobile learning.

From Del Boy to Web 2.0

It’s safe to safe that mobile phones have come a long way since being used as a cumbersome prop in Only Fools and Horses. They are now a key part of everyday life.

More than 4 billion people, over half the world’s population, now have access to the internet, with two thirds using a mobile phone; more than half of which are smartphones.  By 2020 66% of new global connections between people will occur via a smartphone. We are now in the era of the internet of things such as touchscreen phones and tablets as well as smart wearables such as glasses or watches. Humans have been described as “technology equipped mobile creatures that are using applications, devices and networks as a platform for enhancing their learning in both formal and informal settings.”  It’s been argued that as society is now heavily characterised by the widespread use of mobile devices and the connectivity they afford there is a need to re-conceptualise the idea of learning in the digital age.

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A key development in the potential of mobile learning was the development of Web 2.0. The first iterations of the internet were themselves as clunky as Del Boy’s mobile, fixed, un-editable and open to a select few. Web 2.0 is known as the ‘participatory web’; blogs, podcasts and wikis. It is now possible for people with no computing background whatsoever to produce and share learning resources with massive success such as Geeky Medics.

Another aspect interlinked with these social and technological changes has been the shortening of the half-life of knowledge. By 2017 the half-life of medical knowledge was estimated at 18-24 months.  It is estimated that by 2021 it will be only 73 days. It’s therefore fairly easy to envisage a world where libraries of books will be out of date. Students will instead be their own librarian accessing knowledge on the go via their mobile device.

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In education when we look at professionals collaborating we think of a community of practice. Thanks to Web 2.0 the collaboration of professionals, patients and students in medicine has been given the epithet of ‘Medicine 2.0’. This represents a new community of practice and how technology links all of us in healthcare. Health Education England argue that digital skills and knowledge should be “a core component” of healthcare staff education. In order to reflect the new world of Medicine 2.0 medical schools in the US and Hungary have set up courses aimed at familiarising students with social media. A Best Evidence Medical Education review showed that mobile resources help with the transition from student to professional.

Towards collaboration

The general movement in mobile learning is towards collaboration. The unique features of mobile devices, in particular their portability, social connectivity and a sense of individuality mean they make online collaboration more likely as opposed to desktop computers that don’t have those features. A meta-analysis of 48 peer-reviewed journal articles and doctoral dissertations from 2000 to 2015 revealed that mobile technology has produced meaningful improvements to collaborative learning. The focus is on bringing people together via their mobile devices to share learning and practice.

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Perhaps the extreme of mobile learning and collaboration has been the advent of massive open online courses (MOOCs) since 2008.  These are courses without any fees or prerequisites beyond technological access. Some MOOCs are delivered to tens of thousands of learners. As a result along with mobile learning in general MOOCs have been credited with democratising education.  MOOCs have been suggested as best augmenting traditional teaching methods in the ‘flipped classroom’ approach. In the flipped classroom students are introduced to learning material before the classroom session with that time being used to deepen understanding.  In general the HEA credits mobile and online resources as providing an accessible toolkit for delivering flipped learning.

Medical students and mobile learning

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The tradition has been to divide students into digital natives (those who grew up with technology) and digital immigrants (those for whom technology arrived later on in life). This distinction assumes that younger people have innate skills with and a preference of technology. However, more recent evidence suggests that this distinction doesn’t exist and is unhelpful. Learners whose age falls within the category of being a digital native still need and benefit from teaching aimed at digital literacy. The notion of digital natives belongs in the same file as learning styles; they just don’t exist.

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Research into medical students use of mobile learning focuses on evaluating a specific intervention. These include Facebook, a novel Wiki platform, a MOOC and a tailor made smartphone application. While that has a use I’d argue that most students will appreciate any new learning intervention. As a result we’re still in the early days of understanding how students use mobile resources. That said, the evidence suggests that students quickly find a preferred way of using Web 2.0 resources. Whilst it’s been suggested that male students are less likely to ask questions via a Web 2.0 resource students overall seem to find them a safe environment and more comfortable than clinical teaching. It’s been suggested that mobile learning resource usage is linked to a student’s intrinsic motivation. The more motivated a student is the more likely they are to use a mobile resource. Medical students themselves report concerns regarding privacy and professional behaviour when using social media in education.

A 2013 systematic review of social media use in medical education found an association with improving knowledge, attitudes and skills.  The most often reported benefits were in learner engagement, feedback, collaboration and professional development. The most commonly cited challenges were technical difficulties, unpredictable learner participation and privacy/security concerns.  A systemic review the following year however reviewed only publications that included randomisation, reviews and meta-analyses and concluded despite the wide use of social media there were no significant improvements in the learning process and that some novel mobile learning resources don’t result in better student outcomes.   

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A recent review of literature on mobile learning use in medical education suggests that it remains a supplement only.  There still is not a consensus on the most efficient use of mobile learning resources in medical education but the ever changing nature of resources means this is probably inevitable. There’s that word enhance again. Is this is limit of mobile learning in medical education? To enhance more traditional teaching and not replace?

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There’s also the issue of whether students want more mobile resources. The most recent student survey by the Higher Education Policy Institute found that students prefer direct contact time with educators over other learning events.  44% of students rating their course as poor or very poor value for money included a lack of contact hours as part of their complaint.  Only tuition fees and teaching quality were reported more often as a reason for rating their course as poor or very poor value for money. More students (19%) were dissatisfied with their contact time than neutral (17%); an increase on the previous year. However, the survey did not explore mobile resources either as a contact time alternative or how students viewed their educators creating resources for them. 62% of Medicine and Dentistry students reported that they felt they had value for money for their tuition fees; this was the highest reported value for money of any subject.

According to the HEPI students in the UK are conservative in their preferred learning methods and this means any innovation takes time to become embedded in a curriculum. The HEPI recommend engaging with students and involving them in the development of any resource as well as building technology into curriculum design and for a nationwide evidence and knowledge base to be developed on what works.

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This is being done. Case studies in the UK show that the success of mobile learning in higher education has involved some degree of student inclusion alongside educators during design.  But there’s no evidence of this being done in UK medical schools. One example was published from Vanderbilt University, Nashville; a committee formed of administrators, educators and selectively recruited students.  This committee serves four functions: to liaise between students and administration; advising development of institutional educational technologies; developing, piloting, and assessing new student-led educational technologies; and promoting biomedical and educational informatics within the school community. The authors report benefits from rapid improvements to educational technologies that meet students’ needs and enhance learning opportunities as well as fostering a campus culture of awareness and innovation in informatics and medical education.

An example from a European medical school was found from the Faculty of Medicine of Universität Leipzig, Germany.  Rather than a physical committee their E-learning and New Media Working Group established an online portal for discussion with students over mobile resources as well as expanding the university’s presence across social media to help disseminate information.

The HEPI have also recommended that the UK higher education sector develop an:

“evidence and knowledge base on what works in technology-enhanced learning to help universities, faculties and course teams make informed decisions. Mechanisms to share, discuss and disseminate these insights to the rest of the sector will also be required.”

Medical educators and mobile learning

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Teachers’ attitudes toward and ability with mobile resources are a major influence on students deciding to use them. It’s been suggested that Web 2.0 offers opportunities for educator innovation. However, it has been shown that teachers may be less engaged than their students in utilising Web 2.0 resources especially in accessing materials outside of the classroom.

I’ve not been able to find any research in the literature looking at the perceptions of UK medical educators toward mobile learning. However, a recent online survey of 284 medical educators in Germany did show some interesting findings.  Respondents valued interactive patient cases, podcasts and subject-specific apps as the more constructive teaching tools while Facebook and Twitter were considered unsuitable as platforms for medical education.  There was no relationship found between an educator’s demographics and their use of mobile learning resources.

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It’s obvious that mobile learning offers great opportunities for medical students and educators. I hope this review has shown some of the trends in our current understanding of mobile learning in medical education: that the future seems to be collaboration, digital natives don’t exist and students need tuition in how to use mobile resources, research is currently limited to studying interventions, students value contact time and need to be included to make the most of resources and need to know more about what teachers think.

This is a time for leadership, for educators to start to fill these gaps in knowledge and expand on these trends. In September 1962 President Kennedy challenged his country to got to the Moon by the end of the decade. To say this was ambitious is an understatement; American’s had only got into space barely a year earlier. Yet the country rose to the challenge and on 20th July 1969 man walked on the Moon. I like how he said it. “We CHOOSE to go to the Moon.” Challenges are there to be met. We can meet the challenges of mobile learning in medical education if we choose to. We can choose to use mobile learning and help shape it. Or not. That choice is ours.