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Extended Mind How Digital Technologies Act as Cognitive Prostheses for Health Professionals and Health Professional Learners Dr. Rachel H. Ellaway Northern Ontario School of Medicine Cumming School of Medicine, University of Calgary

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Conflict of Interest Not evil if only Photographic images used under Fair Use not my copyright

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for Marty

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What just happened? Internet/information revolution Everything changed and nothing changed We are still humans, living in human societies But our actions and ability to act has been transformed The Internet grants us (super)powers

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Internet powers: remediation multiple channels of expression and interaction blurring and flattening social conventions breaking down barriers, encouraging communication

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Internet powers: speed accelerating speed of action and response instant global knowledge - the Twitter wave always on, always now

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Internet powers: connectivity everything is connected the Internet of things from 6 to 3 deg-frdm? everything is connected, dependent

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Internet powers: reach defeating geography and temporality interacting with friends, family, colleagues around the world synchronous and asynchronous communication

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Internet powers: observation all actions can be observed, tracked greater accountability, deniability panopticism? a post-privacy age?

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Internet powers: memory knowledge on demand nothing is forgotten your actions are forever

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Digital Professionalism Despite digital misdemeanours and risks Digital media are not an intrinsic threat to medical professionalism Ellaway RH, Coral J, Topps D, Topps MH. 2015. Exploring digital professionalism. Medical Teacher (in press).

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Digital Professionalism Professionals should use digital media for positive purposes in ways that support principles of patient care, compassion, altruism, and trustworthiness Ellaway RH, Coral J, Topps D, Topps MH. 2015. Exploring digital professionalism. Medical Teacher (in press).

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Digital Professionalism Professionals should be aware of the shaping nature of their relationships with digital media and they should maintain the capacity for deliberate, ethical, and accountable practice Ellaway RH, Coral J, Topps D, Topps MH. 2015. Exploring digital professionalism. Medical Teacher (in press).

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? How did you feel when you lost a digital device? 1.Ecstatically happy 2.Quite pleased 3.Mildly annoyed 4.Major disaster 5.It was like losing a loved one

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More than tools Digital technology is not just instrumentation; external and separate We weave the digital into all aspects of our lives The digital weaves itself around us it becomes a part of us

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Cyborgs We are cyborg cybernetic organisms - Clynes and Kline, 1960

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Clark our tools are not just external props and aids, but they are deep and integral parts of the problem-solving systems we now identify as human intelligence Clark, A. (2003). Natural-Born Cyborgs. New York, NY, Oxford University Press

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Cyborgs and augmented cognition Extended mind theory epistemic actions alter the world so as to aid and augment cognitive processes such as recognition and search pragmatic actions, by contrast, alter the world because some physical change is desirable for its own sake Clark A, Chalmers DJ. The Extended Mind - http://consc.net/papers/extended.html

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Epistemic actions D D E E S S Q Q T T E E U U

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S S E E D D Q Q U U E E T T

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Q Q U U E E S S T T D D E E

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External cognition Epistemic actions are the starting point for external cognition If the process had been done in your head then clearly cognition But if done outside your head then is it also cognition? Clark A, Chalmers DJ. The Extended Mind - http://consc.net/papers/extended.html

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External cognition A human linked with an external entity in a two-way interaction, creating a coupled system that can be seen as a cognitive system in its own right Clark A, Chalmers DJ. The Extended Mind - http://consc.net/papers/extended.html

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The cyborg physician Is Dr. Smith here: Using a mobile device? or A coupled human-device system? A cognitive agent not limited to biological boundaries

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The cyborg physician Many implications What is it we train? What is it we assess? What is the moral and accountable health professional?

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The cyborg learner If medical practice is increasingly cyborg Then we need to be engaging cyborg learners to prepare to be cyborg professionals What does that look like?

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Cyborg medical education Is already assumed We no longer require students to remember everything We require our students to know how to know How to access and appraise information and apply it to their practice Knowledge in databases, devices, patients, peers Their cognition is distributed

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Cyborg medical education But also resisted Current practice: Use of digital media discouraged Close your laptops Put that phone away No cellphones or other devices in class and particularly in exams We actively deny the cyborg entities (coupled human-resource systems) that will go on to practice medicine

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Cyborg medical education To teach and assess the cyborg professional: We need to teach them with their cognitive prosthetics and without them We need to assess them with their cognitive prosthetics and without them

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Dependence Many contemporary students + recent grads would struggle to function without their devices This reflects a dependence on extended cognition Is this a concern? Is this any better than complete abstinence? How can we approach this challenge in a meaningful way?

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Vygotskys ZPD Source: Wikimedia

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ZPDs and competency continua unguided learner no mobile device guided learner with a mobile device competency continuum

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ZPDs and competency continua unguided learner no mobile device guided learner with a mobile device Teaching and assessment without cognitive augmentation Teaching and assessment with cognitive augmentation competency continuum

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ZPDs and competency continua learner without a mobile device learner with a mobile device teaching and assessment across the continuum competency continuum

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ZPDs and competency continua learner without a mobile device learner with a mobile device competency continuum traditional exam observed practice with no device open exam observed practice with device teaching and assessment across the continuum

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With and without Mobile devices Internet A consult Peers A crash team, any kind of team Drugs, equipment Space, time Power, light, heat, water (too much, too little, wrong kind) Everything (roadside/wilderness)

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Socially distributed cognition? Our cognition socially distributed? Other people a part of our cognitive aparatus? Depends on a high degree of trust, reliance, and accessibility Such as a multiprofessional team, a PBL group, a CTU As trust, reliance and accessibility fall, so does distributed cognition We need to teach and assess across this continuum

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ZPDs and competency continua learner without cognitive augmentation learner with cognitive augmentation competency continuum Learner in the wilderness Learner in rural and remote Learner in community hospital Learner in AHSC teaching and assessment across the continuum

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Implications? Technology enhanced learning is not about what the technology can do Or about what the learner can do with the technology It is about the agency of coupled human-technology systems Educational technology is relational rather than instrumental

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Implications? Rise and rise of competency-based medical education Competence needs to be assured across a continuum ranging from augmentation to isolation Based on the degree of trust, reliance and accessibility of the external resource Whither EPAs?

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Implications? Its not what you use but what you become

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Change is Gordon Graham technological innovation cannot and should not be regarded merely as an improved means to a pre-selected end, because, while some technology merely modifies, other technology transforms Graham, G. (1999). The Internet://a philosophical enquiry, Routledge. p168)

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Implications? Using technology in medical education is a moral and ethical concern For all of us

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Challenges certain forms of social activity might be reconceived as less akin to communication and action, and as more akin to thought in some cases interfering with someone's environment will have the same moral significance as interfering with their person Clark A, Chalmers DJ. The Extended Mind - http://consc.net/papers/extended.html

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Challenges This is a hotly contested concept What is mind? Ethical and metaphysical concerns Value as a model vs a reality (cf system 1-2)? What are individual responsibilities, accountabilities? What is a moral agent?

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Challenges What is a human is one of the key debates of our age

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Inconclusion We are responsible for creating and sustaining capable, safe and caring health professionals Use of digital technologies will inform and direct much of their/our careers and the healthcare system, society, and the nature of the health professional Are we preparing them properly? Do we even appreciate what it is we are preparing?

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Inconclusion Physicians, students, and patients employ extended cognition Dependent on trust in, reliance on, and access to resources that extend the individual The design, use, evaluation of ed-tech needs to be recast to reflect this reality More importantly we need to rethink our response to extended cognition in the design, use, evaluation of medical education

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Conclusion Teaching with and without cognitive prosthetics Assessing with and without cognitive prosthetics Enabling practice with and without cognitive prosthetics (practitioner and patient) Technology a matter of becoming rather than using Technology a moral and ethical concern, not just instrumentation

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once the hegemony of skin and skull is usurped, we may be able to see ourselves more truly as creatures of the world Clark A, Chalmers DJ. The Extended Mind - http://consc.net/papers/extended.html

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Thank you Dr. Rachel H. Ellaway Northern Ontario School of Medicine Cumming School of Medicine, University of Calgary