What social connections mean about the way we teach our students

F.R. "Fritz" Nordengren, M.P.H.

The Internet and mobile connectivity have increased the number of tools to communicate and build social connections. From the 1981 AT&T slogan “Reach out and touch someone” to Twitter’s “What’s happening?”, these tools have promised to improve our quality of life. The growth of these services creates opportunities in education to find new channels for students and faculty to share the learning experience. Coupled with the opportunities is the responsibility to understand their limits and the role of faculty mentors to prepare learners for professional practice.

As the number of social tools on the Internet increases and mobile devices offer new ways to stay in touch, it’s not uncommon to consider if the explosion of technology is bringing us closer together or creating distance between us.

At first glance, having many friends or contacts on social networks implies a great sense of connectedness. However, you likely have experienced the downside of electronic social circles, such as the recent party or lunch where other guests were staring into their digital devices and tapping messages to others. The connectedness of one-on-one conversations may be lost to the digital connectedness.

Understanding the importance of social connections and social capital gives us a key foundation for understanding how we can better prepare our students.

What is social capital?

Social capital is the study of connections between social networks. One of the books that brought social capital awareness to the mainstream interest was Robert Putnam’s Bowling Alone (2001).

The premise is that while more of us are doing more things, we are doing them alone. His research synopsis shows that while more people are bowling, fewer people bowl in leagues. More people are employed in the professions, but fewer per capita are members of professional associations. The idea, he suggests, is that our social connectedness is decreasing, even as more of us participate in activities.

Parallel to his discussion of social connectedness and the rise in social networking technologies is the study of loneliness led by John Cacioppo. In the book Loneliness, the University of Chicago professor states that loneliness is unrecognized as a mental illness, similar to the lack of recognition given to depression decades ago. Among other traits, he adds, lonely people sleep less well and can’t think as clearly, which can have a direct impact on a student’s ability to learn and perform at his or her best.

Understanding loneliness and the impact of technology on social connectedness can help faculty adjust teaching and advising strategies, especially in the typical medical education. Students are often placed in large cohorts, organized into study groups and work together for a common goal. Students are also sent on rotations, often alone, and many times in a new city or environment. While a rotation appears to be a more “lonely” experience than the cohort learning, students may feel loneliness in both educational settings. One of the goals of faculty and academic advisors is to help create an environment where students can perform their best. Can technology play a role?

Digital connectedness: a case of “haves” and “have nots”?

A study by the Pew Internet and American Life Project, issued in November 2009, notes that “the extent of social isolation in America is not as high as has been reported through prior research.” It states the number of Americans who are truly isolated is unchanged or minimally changed since 1985. Rather, the more pronounced social change is that Internet and mobile phone users have larger and more diverse core networks.

The Pew study appears to set up a “haves and have nots” division of social connectedness, with technology users potentially being better connected. A future study that identifies core network composition may help us truly see whether and how these tools are changing the makeup of our social network.

What does this mean for teaching and learning?

As use of online social networks appears to grow, what strategies can be employed to help learners? The answer can be inferred from the U.S. Department of Education study titled “Evidence-Based Practices in Online Learning: A Meta-Analysis and Review of Online Learning Studies.” The meta-analysis includes 51 study effects, 44 of which were with older learners. Among the findings are these three outcomes:

• Students who took all or part of their class online performed better, on average, than those taking the same course through traditional face-to-face instruction.
• Instruction combining online and face-to-face elements had a larger advantage relative to purely face-to-face instruction and purely online instruction.
• The effectiveness of online learning approaches appears quite broad across different content and learner types.

This suggests that by arranging curriculum to offer blended learning – a combination of online and face-to-face instruction – students are likely to have better performance. As educators, we recognize that some forms of instruction benefit from lecture in a large lecture hall. Other kinds of learning are best done alone and can more effectively be delivered via a web-based module. It is the role of the educator to recognize the limits and varying needs of individual learners.

It is also important to recognize that blended learning is not “add on” learning; it doesn’t mean simply adding five hours of web-based learning to an already full syllabus. Instead, identifying portions of the learning that can be moved out of the lecture hall and into the student’s computer allows lecture time to be concentrated on application, practice and a higher level of learning.

Timing is a factor, too. If web-based instruction or the use of social media communication tools is incorporated late in the curriculum, it may be too late for the student, especially for one whose potential for loneliness is high, to use and relate to the faculty member and advisor in a digital world. However, using these tools early in the program, perhaps even as part of orientation and ongoing through the curriculum, the student may be likely to both use the tool for social connectivity with faculty and continue to use the tool for learning reinforcement. The faculty member’s role in the social network is to help students understand the role of social connectedness and to navigate the changing world of technology.

Finally, the affective domain in health care education includes our role as models of appropriate behavior and use of digital, ever-present tools to our students. Early use of online tools in the curriculum can demonstrate best-practice modeling and begins formation of social ties for later learning. As we model what we consider the appropriate use of these tools, we likely will influence their use by our students in professional practice.

F.R. “Fritz” Nordengren is assistant professor and educational technology strategist in DMU’s College of Health Sciences.

Kenneth Hisley, Ph.D., used OsiriX software to transform sequential CT images of the thorax to in-depth three-dimensional views. Above, he dissected the view to expose an aortic aneurysm.

Kenneth Hisley, Ph.D., a
faculty member in DMU
anatomy department, is
manipulating a human torso to
reveal the thoracic cavity of a
human subject – slicing it
horizontally, observing the lungs
and thorax obliquely to show the
spatial relationshipsof the heart
chambers, right and left ventricles,
in relation to a lesion.

Hisley, whose academic interests include clinical imaging
and anatomical visualization, is exploring the thorax not
with physical scalpel and cadaver, but with their digital
equivalents: a sophisticated medical image processing
computer program called OsiriX and an x-ray-computed
tomography (CT) image series of a patient’s thorax and abdomen.

The OsiriX program allows anatomical observation from many viewpoints, zooming in and out of regions, redefining three-dimensional (3D) structural perceptions using tissue colors and transparencies, and the display or removal of arbitrary regions. Hisley sees this new software tool as simply an extension of the physical methods medical students come to know so well, with added advantages for visualizing spatial relationships.

In DMU’s anatomy laboratory, students dissect and explore cadavers at 43 dissection stations, each equipped with a 32-inch flat screen monitor offering dissection directions and descriptive atlas images. Hisley believes this system will be updated to exploit the power of current 3D visualization technology, allowing direct, guided student interaction.

“There are additional manipulations that are difficult or impossible to accomplish with the physical cadaver that might add entirely novel insights into the study of clinical anatomy,” he says.

For example, if a student wishes to understand visceral relationships using an unusual surgical approach, he or she can do so through layers of superficial-to-deep transparencies and without having to turn the physical body. Thus, manipulating CT and magnetic resonance imaging (MRI) image set reconstructions can enhance students’ anatomical knowledge in preparation for their clinical rotations and residencies.

“Physical and digital techniques, by their nature, augment each other,” Hisley says. “Physical dissection provides systematic detailed, spatial and haptic knowledge of anatomy, while digital exploration provides the opportunity for exploration using novel viewpoints increasing recall and a sense of clinical application.”

Previously, Hisley hypothesized that student generation and manipulation of 3D models in parallel with routine physical dissection would significantly improve students’ ability to recognize known anatomy observed from novel viewpoints. He assigned groups of students to explore a randomly assigned region of the body, one group using physical dissection; the other, digital dissection. Results showed that the digital dissectors did better in spatial logic assessment tasks while the physical dissectors were superior in the naming of specific structures. These preliminary outcomes indicate that both techniques should be used in combination.

“Physical dissection is still the gold standard, and I believe it always will be. True anatomical skill is the understanding of complex structures combined with the tactile understanding of the human condition so intrinsic to osteopathic education,” he says. “On the other hand, there is strong evidence that digital anatomical methods are part of the future of clinical practice. Students will need to understand it for this reason as well as for the additional insights it affords into the human body.”

Physicians, scientists, students and others will increasingly access 2D and 3D images on a variety of mobile devices.

His laboratory student research assistants are working with DMU’s osteopathic manual medicine (OMM) department, chaired by Brad Klock, D.O.’81, to create a 3D visualization model of the thigh’s fascial architecture and dynamics. A better understanding of fascial structural relationships using this digital demonstration model could enrich student understanding of fascial mechanics and OMM procedures.

Hisley’s ultimate goal is to create a DMU-wide online clinical anatomy resource by digitizing and reference-linking a wide range of information resource components (print, image, digital model, sound, etc.) into an indexed library database of training exercises. These accessible learning resources will be intended to execute on all Windows and Macintosh computing tools supporting the curriculum, including desktops, laptops, iPhone/ iTouches and iPads.

On the topic of technology, Vincent Grasso says embrace the machine – it benefits patients, takes health care to underserved areas and complements osteopathic medicine’s holistic approach.

S. Vincent Grasso, D.O.’91, has taken telemedicine to the most remote place on earth. As a postdoctoral associate in the Yale University School of Medicine’s surgery department and project manager in the NASA Yale Commercial Space Center for Medical Informatics and Technology Applications, he led a team of Yale researchers, MIT engineers and U.S. Defense Department personnel in using new technologies to monitor the endurance, physiologic status and the effects of extreme exertion, low oxygen and the cold on four Mount Everest climbers.

Vincent Grasso, at right, shows a cardiac device used to monitor a Mount Everest climber in 1998.

As a Yale publication described, “vest-like biopacks transmitted viral data from the slopes of the 29,028-foot mountain to the base camp at 17,000 feet, relaying the information to Yale by satellite phone and the Internet.” Grasso and his base camp colleagues also set up a video connection so they could talk face to face with a physician team back at Yale-New Haven Hospital and Walter Reed Medical Center.

“The Everest expedition team proved that one could remotely monitor the clinical and environmental state of each climber and remain in contact to diagnose, advise and assist within a 24/7 window,” he says.

The only problem with the cutting-edge technology: It was too cutting-edge at the time, May 1998. While the expedition helped NASA and its sponsors advance medical-monitoring systems for astronauts, it failed to spur rapid adoption of commercial applications of telemedicine among earth-bound humans.

“If the technology is too early, it’s more frustrating than if you have nothing,” Grasso says.

The world has changed. The federal government is pushing doctors, clinics and hospitals to have electronic health records for all patients before 2015. Some are embracing technology similar to the monitoring and transmitting devices Grasso used more than a decade ago on Mount Everest.

Among these adopters and innovators, Grasso is hyper-high tech, a Renaissance combination of surgeon, medical informatics expert, software architect, business analyst, entrepreneur, certified project management professional and adjunct professor at Stevens Institute of Technology in Hoboken, NJ. In July, he was appointed founding trustee for New Jersey’s regional health information exchange, NJ-HIGHT ECH, part of a national framework funded by the stimulus legislation to educate and assist care providers in sharing information securely.

Grasso’s ability to straddle clinical care, management and technology equips him to show how new technologies can result in financial and clinical benefits.

“I’m working on ways to bring value to the health care delivery community and prove that a new technology-rich model for enhancing return on investment exists – to meet the existing cost structure or beat it, and in tandem deliver better clinical outcomes,” he says. “That’s the holy grail.”

Grasso offers a laparoscopic training symposium in Bolivia.

Grasso has implemented technology in a number of health care efforts. Through the company he founded in 1999, Technology Integrations for Medical Applications (TIMA), he and his colleagues have trained physicians in war-ravaged Serbia and are enabling doctors and visiting nurses to make “virtual” house calls in New York and New Jersey. Last year, his team landed a five-year, $2.8 million grant from the U.S. Department of Health and Human Services to monitor and connect women of color with HIV/AIDS with clinics and hospitals around the country.

“The grant’s technology platform consists of a grid-based centralized and exceedingly secure solution operating within top-tier data centers, facilitating ease of use and access,” Grasso explains. “By giving participating clinics and doctors secure access to the solution, we empower a community of distributed care-givers with one record source.

“Doctors don’t have to make a capital investment in redundant systems to access the information. They can make decisions quickly with their work environments for timely intervention,” he adds. “That decreases decision-time related costs and improves clinical outcomes.”

Grasso is driven to utilize technology to serve the underserved. In 1991, as a medical student and Jesuit missionary volunteer in Peru’s cholera epidemic that year, he founded the nonprofit organization AYUDAMOS – Spanish for “we help” – to alleviate suffering in poor countries by coordinating donations of medical supplies, application of telecommunication technology and the expertise of physicians, engineers, scientists and other professionals. AYUDAMOS has trained surgeons in Bolivia and treated landmine victims in Cambodia, among other activities.

Closer to home, the organization’s Adopt-a-Clinic program is working with technology vendors and local non-governmental organizations to raise funds to add more clinics to the HIV/AIDS grant project.

“Our consortium approach allows for an efficient, effective means of offering services to the disadvantaged at a fraction of the traditional cost,” he says.

Vincent Grasso educates students at a Ugandan medical school.

Grasso is now working with Panasonic and Cywee via one of his start-up companies, Medical Motion Monitoring and Metrics (M4), to create technology-enhanced braces and bands that, when worn by patients, will enable their health care providers to monitor their home-based physical therapy. He’s planning more medical missions. And he’s working with a team to return to Mount Everest next year to test a new generation of monitoring and medical information systems on climbers.

These technologies, he says, create opportunities for D.O.s to show the value of osteopathic medicine and improve their patients’ lives.

“With all that’s going on in health care, some think it’s not a good time to get into medicine,” Grasso says. “But my pitch to students is they are very lucky to be healers. And if you work really hard and hustle, look at all the cool things you can do.”

Andrew Burchett, D.O.’03, admits with a laugh that when he agreed to become his health system’s medical information officer, he didn’t know what he was getting himself into. He took on the role in 2007, when the Avera health system – which provides services in South Dakota and surrounding states – launched an update of its Meditech software system; the previous system had been implemented 14 years earlier, eons in technology years.

“There are 50,000 patient charts in my clinic alone,” says Burchett, who has a full-time family medical practice at Avera McGreevy Clinic and also serves as chair of family medicine at Avera McKennan Hospital, both in Sioux Falls, SD. “Our goal is for all our systems to talk to each other, but we’re not there yet.”

Avera

Avera is not alone in that regard. According to a recent report in Business Week, just 10 percent of U.S. health care facilities used electronic health records in 2009. The federal government wants more than half of all facilities to use them by 2014, and it provided $36 billion in last year’s stimulus legislation to help them do so. Like many physicians, Burchett is convinced EHR s won’t fulfill one of their purported promises: cutting health care costs.

“The cost of implementation means savings can’t be part of the equation for a long time,” he says, noting that Avera McKennan and its clinics had to spend significantly more than the $40 million initially budgeted for the project – and that was just for an upgraded system. “Improved patient safety, quality and efficiency are what drive us.”

That’s where technology makes a difference. In recent years, Avera has developed several innovative technology applications, Avera eCare ™, that connect specialty care physicians and pharmacists to health care workers and patients in rural areas. Through two-way video and other equipment, 24 hours a day, seven days a week, Avera staff can view a patient in a rural facility miles away, guide its care providers, view the patient’s records and radiographic images, arrange for transportation to a bigger facility if needed, and review and approve prescriptions. eCare also provides patients with monitors set with individualized health instruction and follow-up care in their homes.

In addition to supporting rural practitioners, these services allow many patients to get care in their own communities. More important, they save lives. Since 2005, Avera’s electronic intensive care unit services alone have enabled nearly 400 individuals, who initially were not predicted to survive, to leave hospital care alive.

“That’s how technology can save lives and reduce costs,” Burchett says.

Look beyond the potentially torturous transition to electronic health records, requisite brain-cramping lessons on updated computer systems and their
hair-raising costs: New technologies are equipping physicians and others to give better patient care by enhancing diagnosis and treatment, increasing access
and more effectively educating future health care professionals.