Matthew Roycroft: To TEL or not to TEL

TEL has many uses, but high quality mentoring and supportive relationships must remain the backbone of medical education

Matthew RoycroftTechnology enhanced learning (TEL) has expanded rapidly over the past decade. Learning with a technological element to it, such as e-learning or simulation, is now a regular part of continuous professional development; undergraduate and postgraduate medical education; and, for many clinicians, it’s also part of day to day practice.

It’s generally acknowledged that “technology offers real benefits and opportunities to support and enhance the delivery of excellent healthcare education,” but I think we are reaching the point where there’s a danger of taking this too far. A trainee isn’t able to get to a teaching day—oh well, there’s an e-module for that; you need to learn how to perform a simple procedure—don’t worry, there’s a video for that; can’t get to a clinic—no problem, there’s a PDF about what you may have seen anyway. Is work too busy to let juniors see the sickest patients under supervision? Never fear, there’s a simulation day to cover that instead.

The first example, of teaching days being replaced with e-modules, seems to divide opinion. This idea may be liked by trusts, as it’s more flexible and doesn’t require room booking, but I was surprised to find after recently discussing this with trainees that they like it too. They gave various reasons for this: not having to fight for leave, it being a more efficient use of time, some vague idea of it being “better,” not having to go to a venue they don’t know, etc. And this is despite the trainees I asked being in a training programme that offers a surfeit of training days, and those days being almost universally rated as “good” or “excellent.”

Yet, despite their endorsement, I can’t help but think that they’re losing out on other advantages that education in a face to face group add: it provides a forum for socialisation and for debrief, allows the session to be targeted to the audience and shaped by their questions and interactions, and opens up the opportunity for relevant off-topic discussion and pastoral support. Most importantly, I think, is that it allows for the normalisation of attitudes and behaviours with peers to take place, and for trainees to develop an awareness of how their experience, understanding, and knowledge compares to others. E-learning is very good at delivering facts and, indeed, for preparing trainees or students for facilitated teaching sessions (something known as the “flipped classroom” or “blended learning”), but they cannot replace real life experience, which is still a vital part in any education process.

The final example, simulations of seeing sick patients, is an area that’s evolved rapidly over the past decade and is generally viewed in a positive light by both those involved in teaching as well as by trainees themselves. Yet I think it’s important to look at why it evolved in the first place.

It wasn’t all that long ago that a junior doctor was able to see actual sick patients and had an SpR (as it was then) or a consultant close at hand to discuss their case with and to run all decisions past. Now the seniors see the patient directly and so the opportunity for experiential learning is lost. Replacing it with simulation simply isn’t the same (however much techno-positivist advocates say otherwise).

Don’t get me wrong, I’m not remotely against simulations and think it can be an excellent resource, but I simply don’t see it as a replacement for good old fashioned medical training and supervision. It seems to me that a lot of the present use of simulation is simply trying to fill in for the system’s current deficiencies in training, which have been created by trainees being denied more and more the opportunities to do tasks that their predecessors did at the same stage of training.

TEL undoubtedly has immense potential and a multitude of uses in medical education, but we need to be aware that it isn’t a panacea. It’s neither a replacement for high quality day to day supervision, nor should it be used instead of face-to-face teaching. TEL, as its name suggests, works best when it enhances or augments existing learning and teaching methods. Educationalists have to understand its uses but just as, if not more, importantly they have to understand its limitations in much the same way they did when computerised slideshows gained widespread adoption. Human contact, high quality mentoring, and supportive relationships have to remain the backbone of medical education.

Matthew Roycroft is a leadership fellow working for the School of Medicine in Yorkshire and the Humber and an ST6 in geriatric medicine/GIM on the RCP’s Trainees’ Committee. All opinions are the author’s alone and don’t necessarily reflect the viewpoint of any other organisation.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.