• “Attentive”, “Auditors”, “Diggers”, “Browsers” and other online learning tribes..!

    Lessons learned from the “clickstream” of thousands of online learners in Implant Dentistry!

    I belong to the generation that was terrified at the sound of the word “dropout”.
    From very early in life we were taught to always finish what we started, regardless if this was an overloaded  lunch at the family table, the book  we got as present from auntie Mary or a boring class. Leaving a task unfinished was a major failure, not to mention dropouts from school, who  were in general perceived as losers, sad examples of what happens when you miss focus and persistence, exactly what you should avoid if you are to succeed in life.

    Then later on came the new economy or so , headlines filled with glorified dropouts, people like Steve Jobs, Bill Gates or Mark Zuckerberg who dropped out of College to create  Empires and Unicorns and then suddenly the possibility occurred that dropping out of University did not necessarily implied a life of shame and misery. On the contrary, people like myself who graduated only to find that completion of studies usually meant a decade of modest finances and a career start with a significant debt, seriously doubted the advice they received as teenagers.

    But my intension today is not to discuss the merits of completing a University programme or the chances of becoming a glorified hero of the new economy. The reason I write these lines is to help myself clarify what is the purpose and value of “course completion” in the new learning economy of on-line learning, on-demand education and Massive Open Online Courses.

    The reason I write these lines is to help myself clarify what is the purpose and value of “course completion” in the new learning economy of on-line learning, on-demand education and Massive Open Online Courses.Back in the year 1999, in one of my very first papers as a young and curious PhD candidate, I concluded  that distance learning was “plagued by a high drop out rate” (1). What I meant back then was that very few students actually finish what they started when it comes to not face-to-face courses. Back then “not face-to-face” courses implied a wide diversity of methodologies and technologies, from cassette recorded seminars, correspondence courses, television, diskettes and a pioneer internet virtual classrooms with 28 students which relied on 120 KB websites and CD-ROMs sent over the post (2). In particular of the later, we were proud to report back then that most of the students who started the course, were actually “there” (online, at the Internet Relay Chat network) when we finished it (3). Almost twenty years fast forward in 2019 and our 5-week virtual classroom enrolled more than 30,000 students in two years, only this time it was a “MOOC” or Massive Open Online Classroom. Much has changed in the meanwhile, technology,  US presidents, student generations, teaching paradigms, you name it…but one things still there, our own, private beans-counting at the end of class…

    Regardless if you teach a 25 students in a class or a 30,000 in a MOOC, there is a universal teacher question that always comes up: “How did we go with this course?”.

    This time, there is a large pool of data to try to fish the answer from, student ratings, learners’ feedback and stories and a long series of metrics. Regardless of the variety of metrics however, there is still one that dominates our understanding: the all-time-classic Completion rate. Fine, you enrolled thousands in the course, but how many did you “graduate”? And what does it say about a course if only 5 or 10 % of the students actually completed it?

    In such a question that is as old as education itself, lies the preconception of a merciless and inflexible duality: your students can either be “completers” or “drop-outs”. Consequently, a course that produces so many “drop-outs” must be in essence fundamentally flawed, even if it is a glorified e-learning innovation. 

    This brings me back a memory from my undergraduate years, the time we would also write our name in a small piece of paper and give it to the lecturer in the amphitheatre just before the start of the lecture. Beans counting again, only this time with a major, clear impact: You don’t have enough  beans at the end of the semester, sorry, you just have to come back!

    It doesn’t matter what you do in the amphitheatre, you can sleep, you can doodle, you can think of life, the Universe and everything, or you can just daydream, as long as you are there. Maybe even the physical presence is not necessary, as long as you can sneak out from the back doors sometime after the lights dim. This fundamental requirement for physical presence (regardless of any evidence of  intellectual presence) is something that has haunted me as of today. No matter the framework, I will never-ever force anyone to be physically present at my seminars.

    But that was a definition of a “teacher-centred” learning environment and I say that without any hint of judgement or criticism. It was a learning experience completely constructed and validated by the teacher. The teacher knows what you need to know, what you should be able to do in the end and how to get you there. Just follow the path, lecture after lecture, tutorial after tutorial, study the book, take the exam. Do this and there you are, delivered at the end of the semester, one step closer to being a doctor. Do this not and you will be a drop out. This has worked for centuries and it still works on, more or less, and I am not saying that there is something necessarily wrong with this. But this is not a MOOC.

    A MOOC, on the other hand is the definition of a “student-centred” learning  environment. A Teacher or a team of teachers has constructed a learning environment, but how this environment will be navigated is now completely up to the individual students, who might end up with very different learning experiences.

    To illustrate this a bit better, I would call on our experience with our MOOC in Implant Dentistry. We recently completed analysing the clickstreams from the first run of the MOOC in 2016, a run that attracted more than 7,000 learners in a course that was meant to last for 5 weeks (4). As with every course we have run in the past, there was a “prescribed” pathway, that is a linear progression from A to Z, which was constructed by the teacher, aiming to escort the learners in a progressive discovery of the topic, unlocking some critical competences on the way. The prescribed journey was meant to last five weeks and I envisioned a gradual journey hand in hand with my seven thousand students, finishing off with an on-line completion, digital graduation, a  cool pdf certificate and virtual champagne popping.

    Is this what happened in the end? Well not really, or not exactly to be precise. The course received very high ratings and a lot of praise from many learners all over the world. But it was about 25 % only of the learners that got to complete the course and even so, they did it in a very individual timeframe! 

    Looking at figure 1, you can see the number of completers for every day of the five weeks of the courseAlthough there is a significant number of students following my “prescribed” journey and completing the course at around the fifth week, the truth is that more people completed the course earlier than I had intended them to. And the rest? What about the 75 % of “drop outs” ? Well here it is that it gets even more interesting. Among the non-completers were large numbers of active students, who spent significant amount of time attending certain modules, participating into discussions or revisiting specific content regularly, so that we had to come up with the name “diggers” to describe them. They were however demonstrating a typical “non-linear” learning behaviour, completely disregarding my prescribed A-Z pathway in favour of their own unknown to me interests and priorities. In the end, many of them commented very favourably for what they got out of the course, but most of them never bothered to take assessments or collect points for completion and a certificate. .

    Studying the clickstream, we could see that only  28 % or the active learners followed a more or less linear pathway, while 72 % didn’t.

    We called the first group “attentive” while the second “auditors”. “Attentive” learners were much more likely to follow the teacher-prescribed learning pathway, achieved higher grades and 83 % completed the course and purchased a certificate. On the other hand, the non-linear “auditors”, took less exams, while no more than 3 % completed the course. Nevertheless, they demonstrated engagement with the content and activities, albeit not in its entirety and many actually.

    And here comes the tricky part of trying to make sense of the whole picture and assess the learning experience. In a conventional teacher-centred environment, one could be tempted to speak of a 25% completers , 75 % dropouts and a course with 25% completion rate. The reality however reflected by the study of the clickstream is very different.

    A course of these proportions on a clinical discipline  will inevitably attract a large and diverse audience of learners. Some will be still in their undergraduate studies seeking an overall understanding of the topic, while others will be postgraduates, specialising in one narrow field of Implant Dentistry. Many will be already practicing clinicians, already at diverse levels and scope of practice of implant dentistry. Finally, some others might be not clinicians, but scientists within related fields, representatives of the industry, medical engineers, dental technicians. The course had something for all, but not all were interested in attending the complete course. Inevitably,  in a  crowd of 30,000 learners, people have different objectives and different reasons to enrol in the course. Some came to follow the teaching of a specific speaker they admired, others to update themselves in a technique and topic they practice, others to have a sneak peek into the latest scientific updates. And the MOOC, being first and foremost a student-centred environment allowed them to get what they were looking for at the minimum cost of time and effort. These students did not drop out in my mind. They came and took what they needed and then they simply chose to “graduate themselves”, probably the ultimate right in a student-centred learning environment.

    So, with the experience we have acquired by now, I would have to seriously revise the statement of my 1998 publication: low completion rates is not a plague, but might even be a blessing, to the extent that it points out to a true student-centred learning experience. Completion of a course remains a teacher-defined metric and might be a valid measure of success to the extent that the teacher can correctly define the learning needs of the student. In a Massive Open environment however, this is simply impossible. Completion will only apply to a small number of students, usually novice in the topic, while a large segment of still active learners will seek to cater to their own specific needs. And this should be seen as a deficiency or failure of the course, on the contrary this might be a new significant strength of the MOOCs, which can create a flexible learning environment and accommodate diversity.

    Conclusively, yet again educational technology has outgrown our teaching paradigms and we are in urgent need of new tools to assess the quality and impact of MOOCs and consequently to improve teaching and learning with such media. Completion rates will always be a benchmark for assessing a course, but relying only on  old tools when assessing new learning environments will miss significant potential and can lead to misunderstanding and confusion. We need some out of the box thinking to go beyond the old dichotomous separation of completers and drop-outs and allow  the true student-learning environments to demonstrate the whole range of colours and shades they can capture!

  • A MOOC for Implant Dentistry?
    It’s been almost a week since enrolment opened for our MOOC, the first Massive Open Online Course in Implant Dentistry! As excitement grows, so does the daily list of mails and messages from all parts of the world crowding my inbox. Supportive comments from friends and strangers, suggestions, ideas, curiosity and questions, a whole lot of questions..!  

    … one question that strikes me as particularly interesting: “Will I learn to place implants in your course…?”

     Indeed,  an interesting question! …now let’s see if I can come up with an equally interesting answer!– What is a MOOC? 

    A MOOC is one of the most exciting educational developments of this century, the child of the marriage of Open Access with e-learning, all broadcasted live by the social media. The idea is relatively simple: make quality education accessible to everyone, anytime for free. In essence this idea has always been there, it’s only that now we have the technology to materialise it, at least to a significant extent. I believe the seed was planted when several top Universities decided to open up and share their curricula with the rest of the world, in several bold “Open Courseware” initiatives.

        Sharing content does not mean the sharing of education, yet this first step was in essence a giant leap, as it broke barriers of all sorts, from pure suspicion and protectionism, copyright and intellectual property issues to the simple innocent questions of the type “but if I put everything online who will come to my lectures?” What Open Courseware clearly demonstrated was that opening up your education and sharing with the world can actually make your institution stronger and benefit your programmes and your academics in many ways. After that experience, a MOOC became a natural next step, as soon as the technology matured. This time it was not just the content that was shared, it was the whole learning environment and the educational experience.  Just like any other course, a MOOC is based on a well structured learning environment, which allows not only delivery of content, but also supports all sorts of learning interactions and many different types of assessment. However, all this exists in a virtual learning space, as a MOOC is a fully on-line course. Unlike previous on-line courses however, the MOOC is reaching a massive scale of learners, usually counting to the thousands. 

    As with every other type of courses, the MOOC has also a distinct form and educational “culture”, much of which is directed by the potential and limitations of the technology that is utilised. In that way, a MOOC will typically utilise short bits of content as “mini-webinars” or short demos, coupled with hyperlinks to recourses, and supported by synchronous or asynchronous interaction with peers and tutors. It can all be matched to self- peer- or classical assessments and assignments and it strongly emphasises on the development of on-line learner communities, which very often will outlive the course.

    – Is a MOOC proper for Clinical Disciplines? 

    Initially, MOOCs were introduced to cover topics of general interest, where a large participation could be expected. It is no surprise that the first successful MOOCs addressed topics of generic theoretical nature. History, Philosophy, Economics, Applied Sciences, were among the first big hits. Gradually, as success stories paved the way, MOOCs emerged for more selective audiences, professional development  and niche topics such as Architecture, Mathematics, Computer Science, Law, Epidemiology and more.

    Clinical topics however remained outside the reach of this medium for a long time, as MOOCS were perceived by many to be unsuitable to address themes with a clinical focus. As of today, the only MOOCs I could identify with a clinical focus were 2: an introduction to Cataract Surgery and a course in Urology.

    So now we’re coming close to the core of the question we started with: is a MOOC a good medium to teach Implant Dentistry?  …And will you learn to place implants in the HKU MOOC?

    On the first question, the answer is yes, I do believe that a MOOC is a great medium to teach Implant Dentistry. The second question however requires a bit of work to address…!

    – From Teaching to Learning 

    Learning today is no longer perceived as the acquisition of information and skills, memorising of lists and learning how to use instruments. Especially within clinical health sciences, learning marks in essence a significant and permanent change, a change of mind! A change in our understanding, a change in our attitude and change in our abilities, which enables us to better serve our patients needs, but also deal with ill-defined problems and even produce new knowledge. In that sense, learning is seen through the lens of developing competences. These competences will drive our learning and will become the bricks that will build the wonder-tower of our professional practice.

     one of the greatest challenges 

    we face today, is that implant dentistry

    is often perceived as

    “knowing how to place implants”. 

     Dental implants is a wonderful scientific and technological achievement, which allows us to serve patients in ways never possible in the past. However one of the greatest challenges we face today, is that implant dentistry is often perceived as “knowing how to place implants”. In reality, the surgical placement of dental implants is only one isolated set of skills, while the most significant competences are actually prior and after this point. Today, the majority of problems or failures we encounter with implants, is not because the operator was not able to surgically place the implants, but the origins are usually in deficient understanding of either biology or technology and consequent improper treatment planning. 

    Overemphasis on surgical placement is a widespread trend today and it has lead many clinicians to the wrong direction. When it all becomes just a matter of “learning to place screws”, weekend courses,  usually industry-driven start to become the norm. Such courses at the “I’ll show you how to…” level are what we would call “product training” but they are not education.  Unfortunately, many young graduates, having had little exposure to what implant dentistry is all about during their undergraduate studies, often fall pray to “quick and dirty” courses which focus into teaching how to place implants rather than how to practice dentistry, with implants. And this is where the role of a MOOC could be critical.

    – A MOOC for Implant Dentistry? 

    When we conceived this course, we did not aspire to teach dentists how to place implants. Instead, we envisioned an unbiased,  comprehensive course in dentistry, which will  address the full extent of knowledge and skills a clinician needs to practice modern rehabilitative dentistry with dental implants. A scientific University course  could unfold the whole complexity of implant dentistry and present it’s rightful place in modern practice, its potential together with the limitations. At the end of this course, the student will know that Implant Dentistry is no rocket-science, but not a matter of “learning to place implants” either. Above all, we aspire to help the student understand what it takes to properly implement dental implant in clinical practice and which are the steps he needs to plan in his personal pathway to become a competent practitioner of implant dentistry. What more, we aspire to offer a global community of learners to support each student in this learning pathway of transformation.

    “ So will I learn to place implants in your course?” To rephrase this question in educational terms, it could actually ask: “Will I be competent to place implants after attending your course?” 

    The answer is No. If you have never placed an implant, this course will not make you competent in that. It will give you a good understanding of how implants are placed, but it will not get you ready to take up the blades and the drills. It’s an online course after all and no on-line course will make you competent in a clinical skill. No matter what is promised, you can’t learn to swim from YouTube if you’ve never been to water.

    This course however will show you why placing implants is not all that matters and it will teach you the essential knowledge and skills that you will require before and mainly after you place implants in order to secure successful treatments and satisfied patients. Furthermore, this course will offer you support in your first steps and create a network of people around you who would be able to share experience, knowledge and education with you. And as your experience grows, so will the benefits increase from attending this MOOC.

    “it’s not what you don’t know that gets you into trouble. 

    It’s what you know for sure,

    but you are wrong”.  

     Mark Twain said, “it’s not what you don’t know that gets you into trouble. It’s what you know for sure, but you are wrong”. Similarly, teaching of Impant Dentistry has suffered from oversimplifications, overestimation and underestimation of all sorts. In essence however, Implant Dentistry is exactly what the word describes: it’s first and foremost, Dentistry! It’s solving the patients problems and satisfying their need for aesthetics and function  in healthy and sustainable conditions. And this is what we will be teaching in this course: how to practice high level Dentistry, while appropriately including dental implants. It’s will be fun  🙂 Looking forward to seeing you all @ the first Massive Open Online Course in Implant Dentistry!