Rethinking Medical Education

The ThinkerQuestions, observations, and recommendations toward reform of the process and content

A "dangerous phrase" (and a tribute)
Grace Murray Hopper, PhD (1906-1992)
Some observations about change and innovation from an authentic pioneer. I first wrote this piece on the birthday of one of the people who helped invent the modern computer: Grace Hopper was born in New York City in 1906. She began tinkering with machines when she was seven years old, dismantling several alarm clocks around the house to see how they worked. She studied math and physics in college, and eventually got a Ph.D. in mathematics from Yale (hardly a common event for women of that era).
   When the US entered World War II, Dr. Hopper wanted to serve her country. Her father had been an admiral in the Navy, so she applied to a division of the Navy called WAVES, which stood for Women Accepted for Voluntary Emergency Service. They turned her down at first, saying she was too old, at 35, and that she didn't weigh enough, at 105 pounds. But she wouldn't give up, and they eventually accepted her. With her math skills, she was assigned to work on a machine that might help calculate the trajectory of bombs and rockets.
   Dr. Hopper learned how to program that early computing machine, and wrote the first instruction manual for its use. And she went on to help write an early computer language known as COBOL — "Common Business-Oriented Language." She remained in the Navy, and eventually became the first woman promoted to the rank of "rear admiral."
   In her work and her thinking she displayed an attitude that is relevant to those of us who teach and shape the learning process. Many medical faculty members who are engaged in curricular planning and educational decision-making seem to have adopted the belief that educational approaches that have been used for many years must have proven their worth and deserve to be perpetuated. The best shorthand response to that assumption was provided by Grace Hopper, who said (slightly edited by me): "The most dangerous phrase in any language is: But, we've always done it that way."
   Another quotation that has also been attributed to Grace Hopper, which is also relevant to innovators, especially in some organizations: "It's easier to ask forgiveness than it is to get permission."
   Also credited to her, in the domain of goals, purposes, and risk-taking, is the quote, "A ship in a harbor is safe, but that is not what a ship was built for."

A small side story of possible interest: Admiral Hopper contributed a frequently used word and concept to our language. In the 1950's, working on one of the first EINIAC computers, she and her colleagues were stumped when it suddenly stopped working. After all regular diagnostic tests provided no help, she crawled inside this room-size computer, and deep in its innards found a moth that had died, short circuiting two connections. From then on, whenever anything went wrong with a computer, she referred to the problem as being a "bug" in the system. We should thank her, and maybe smile a little, the next time we find a use for her word.

For more information on Grace Hopper, please see her Wikipedia page.

   Hill Jason
Hilliard Jason, MD, EdD
First posted: 12/3/08
Revised: 1/25/12

Medical school curriculum - Part 1:
We must do better than we’re now doing*
The educated usually find themselves equipped 
to live in a world that no longer exists.
Eric Hoffer 
(US writer on social issues; 1902–1983)
Sixty years ago, when I was becoming a physician, medical school curricula were highly rigid, especially in the “basic science” years. At least in the US, they were also strikingly similar from school to school. In one of my early comments on curriculum design during that era I asserted that a randomly selected medical student in a randomly selected US medical school could probably be transported to another randomly selected school and continue his studies (then, nearly all US medical students were male), hardly noticing any changes in the expectations and tasks, and probably not finding much variation from the dull lecturing that dominated his time at his first school.
Curricular variations are here and growing. The current situation is meaningfully different from even 20 years ago. Instead of severely constraining curricular innovations, as they once did, accreditation groups and other influential leaders in medical education are being flexible. They are permitting, even encouraging, (some) deviations from the standard programs of the past. But, many signs of the past, and constraining influences remain. In general, established faculty members are inclined to sustain what is familiar from their own past, so medical schools tend to offer relatively minor variations from long-established curricular patterns. Sadly, for example, there is still widespread perpetuation of the separation of basic sciences education from clinical care, which is traceable to a misunderstanding of the message of the highly influential 1910 “Flexner Report.” In 1924, in a follow-up commentary, Abraham Flexner himself bemoaned that disappointing situation.
 During recent decades, many of the newly emerging medical schools, and a few well-established ones, have introduced some worthy and interesting variations in their curricula. Still, within each individual curriculum, regardless of how different their structures may be from most other curricula, there is still, usually, less flexibility than is needed for optimal learning by all students, and other legacy flaws continue to be perpetuated.
Many serious flaws from the past remain
In addition to the artificial and hurtful separation of basic science learning from clinical experiences, we have many leftover approaches that are still being corrected too slowly, if at all, in many of our world’s medical schools. Some of the most serious flaws (practices that violate the evidence of how humans learn best, as identified by good educational and brain science) are:
  1. We assume we know what all learners will need before we know much, if anything, about them as individuals: their readiness for the various aspects of medical learning, their current capacities, their actual needs, and more.
  2. We standardize the experiences we offer, ignoring the enormous diversity among learners.
  3. We move students from discipline to discipline, often hour-by-hour, providing no time for reflection, discussion, practice, or other steps needed for consolidating their learning.
  4. In our teaching and testing we continue to expect large amounts of memorization, despite the many limitations of human memory, the wide availability of memory-support technology, and the likelihood that much of what we expect students to remember will be irrelevant to the careers of many, if not all of them.
  5. We give high emphasis to the acquisition of information, despite the likelihood that much of that information will be obsolete relatively soon.
  6. We give insufficient emphasis to cognitive skills, such as information searching and assessment, problem analysis, and complexity management.
  7. We largely neglect social and emotional competencies, despite their central importance for intimate, human-oriented work, such as healthcare and teaching.
  8. We postpone or deny students opportunities to be doing for themselves the cognitive, emotional, and performance tasks they need to learn. Instead, we keep them passive for long stretches of time, merely reading about, or hearing about, or observing others doing those tasks.
  9. We postpone our assessments and the limited feedback we provide until far too late for having a constructive influence on learning.
  10. We do little, if anything, to ensure that those selected to teach are actually competent as teachers and are prepared for this important, challenging, complex professional work.
Curricular structures are changing; rigidity remains
The design and operation of many curricula have been contrary to, rather than supportive of, meaningful learning. The evidence is strong that our approach of providing largely similar experiences in medical school for a group of people who are highly diverse, who come from a wide variety of educational backgrounds, life experiences, and cultural traditions, and who have unique brain characteristics, is manifestly inappropriate. 
Even with the growing variety of curricular plans among our world's medical schools, within large parts of many curricula, groups of students are still typically expected to focus on the same topics, at the same time, in the same sequence, for the same duration, and are examined in the same ways. Not surprisingly, medical students, too often, consider medical school an initiation process, a painful rite-of-passage, not a meaningful, engaging, valued set of first steps in their professional careers. They see their careers as beginning later, which, regrettably, leaves them with an insufficient sense of "ownership" of much of what they are expected to do and learn while in medical school. Without a feeling of ownership, learners typically perform below their capacities and derive less from their invested time and effort than they would if they felt authentically engaged in, and had deep positive regard for, their learning experiences.
An alternative way of thinking about curriculum
A reasonable analogy for thinking about curriculum, and how it should be formulated, is our approach to patient care. We take it for granted that patients are sufficiently distinctive, even unique, in their characteristics and in the expression of the condition that brings them to a healthcare facility, that the first step in caring for them is an appropriately targeted, often thorough, diagnostic workup. And diagnostic checks of their evolving conditions, including their responses to our interventions, are routine and individualized.
As clinicians, we devise unique outcome goals for each patient. The clinical care we provide for people if shaped by the individualized set of outcome goals we devise for each person. We adapt our expectations to an interplay among what is biologically possible, what our resources can provide, and what the individual patient's age and prior health circumstances indicate are reasonable expectations. In other words, although there are many commonalities among the recommendations and steps we offer different patients with similar conditions, each patient gets, and certainly should get, a uniquely crafted, often fine-tuned set of offerings. And those offerings are continuously adjusted, as needed, in response to the additional information we continue gathering about them and their condition.
As clinicians, we have a deep respect for human diversity. That respect is now well embedded in modern healthcare culture. I’m persuaded that this perspective provides an appropriate starting point for thinking about medical curriculum. Contemporary brain research is providing convincing evidence that we are even more diverse as learners than we are as patients. 
Educational programs should be highly individualized. They should be at least as individualized and as carefully customized as is our approach in healthcare. Like the healthcare process, the education process is a set of interventions. In healthcare, perhaps without noticing anymore, we carry with us a general understanding of the features of optimal health, which becomes our starting point for formulating the unique set of outcome goals we devise for the care we provide for each patient. We quickly, often automatically, adapt our expected outcomes to the realities of each individual patient's situation.
Toward outcome goals for medical education
Although we aren’t likely to soon reach the same level of agreement about an idealized set of outcome goals for medical education as we have for healthcare, I propose that we need to work toward a far clearer sense of those desired outcomes than we now have. And, as we do in patient care, we need to then move backward from the ideal toward a formulation of individualized goals for each student, appropriately adapted to that person’s unique set of characteristics and needs. As we also do in patient care, we must postpone our formulation of goals for each student until we've assembled an appropriately thorough array of diagnostic findings for that person. 
The goals we formulate for each student must be developed in collaboration with the student, and must be seen as dynamic. These outcome goals need to be subject to continuous revision, guided by new findings that emerge from our continuing diagnostic data-gathering over time. Our long-standing heritage ofassuming we know what all students will need, even before we've met them, is badly overdue for rejection and replacement with a more appropriate approach, as I discuss further in Part 2.

   Hill Jason
Hilliard Jason, MD, EdD
First posted: 1/24/12
Revised: 1/25/12
* NOTE-1: As with all entries in this blog, your constructive critiques, recommendations and reflections are warmly encouraged. Please add your Comments below, or, to convey your reactions privately,  please send an email to: Many thanks.
* NOTE-2: I’m currently part of a small group that is conceptualizing a possible new kind of medical school for Europe, so, many elements of educational design are very much on my mind at this time. Inescapably, curriculum is a central consideration. My reflections for our deliberations have helped spawn this and other blog postings.

Medical school curriculum - Part 2:
Designing an appropriate curriculum.* 
It is not the strongest of the species that survive, nor the most intelligent, 
but the one most responsive to change. 
Charles Darwin
(English naturalist; 1809–1882)
NOTE: In the following discussion, I’ve focussed mostly on abstract generalities, not on the specifics of how to implement the recommended educational approaches, nor on examples of these approaches in action. I introduce the implementation theme in Part 3 of this curriculum series, and I will be offering more of the specifics and examples in subsequent postings. 
At least for a while, a new medical school provides an opportunity to pursue the dream of overcoming problems inherited from the past. We must begin by acknowledging that our legacy educational designs weren’t based on evidence from educational or brain research. They weren’t even based on careful or systematic reasoning. They grew out of the intuition and impulses of those in positions of leadership. Most often, those in positions of educational leadership gained their influence from prominence in domains only marginally related to the processes of medical education. Typically, those leaders were people who were admired for their clinical and/or research achievements, aided by their inclinations to publish their writings and to seek positions of prominence. Not all of their educational design decisions have proven to be inappropriate, but many have, as I summarized in Part 1 of this curriculum series. Some of our inherited curricular problems are especially serious and are long overdue for correction.

We must begin by being “diagnostic”
The first component of an educationally defensible curriculum needs to be a set of systematic, sophisticated diagnostic steps and strategies (assuming we’ve already defined a reasonable set of general outcome goals for medical education, as I discussed in Part 1). We need to devise, test, and refine an array of tools and experiences that can provide our incoming learners and us with a reasonable array of insights into several of each learner’s relevant characteristics, strengths, and areas of current, high priority needs. The following are some examples of information we will need to learn how to gather as part of the “diagnostic workups” we should be routinely doing, partly during the candidate-selection process, to decide who has the potential for becoming the kinds of physicians we want to graduate, and partly after their admission to the program, to guide the design of the experiences we will recommend for their initial phases of learning. For all incoming students, we need to determine the extent of their:
  1. capabilities as independent learners;
  2. capacities for reflection and accurate self-assessments;
  3. openness to, and established ways of responding to, feedback;
  4. levels of curiosity about the human condition and other matters;
  5. levels of social and emotional intelligence;
  6. skills as verbal and non-verbal communicators;
  7. levels of insight into their own characteristics and behaviors, especially in identifying whatever difficulties they have as learners;
  8. levels of understanding of contemporary issues in health promotion and healthcare;
  9. commitments to, and approaches to, sustaining their own health.
As you may have already recognized, the process of undertaking this comprehensive diagnostic phase brings the secondary, important educational benefit of helping the students gain a more refined sense of their own strengths and an enhanced awareness of the learning tasks that lie ahead.

Aren't there some outcomes needed by all students? 
There certainly are some foundation outcomes we should expect of anyone who is to be considered worthy of graduating from medical school. But, those outcomes need to be conceptualized quite differently from the way they’re most commonly formulated now. Our characteristic approach to defining outcomes (if we think about them at all) has been in terms of "content,” in terms of the information that graduates are expected to possess and the procedures they are expected to be able to perform. Only recently have we begun to include some focus on outcomes in terms of the “processes” in which our students engage: the cognitive and emotional competencies new physicians are expected to develop. And, even as these  “process outcomes” have begun to be pursued, the focus has been far more on the students' cognitive competencies (the ways they think and solve problems) than on their emotional and social competencies (the ways they understand themselves and others; the ways they detect and respond to emotional signals, the ways they communicate, and more).
Even as we move toward a fuller and more appropriate sense of needed outcomes, we’ve tended to remain more rigid than is optimal. And, we’ve not typically adapted to the fact that our graduates will pursue a wide spectrum of different careers. With some exceptions, different careers need different cognitive and emotional competencies. We need to learn how to produce graduates who have those generic competencies that are needed for most or all healthcare careers. Those commonalities are found far less in the sphere of “content” than they are in the spheres of “processes.”

“Producing” highly competent learners
A central challenge we face in redesigning medical education is learning how to prepare graduates who can all be trusted to be constantly seeking to learn and improve throughout their careers. For that, they will need to be effective at continuously monitoring their current limits and learning needs. The issue isn’t what they know and can do medically at the time of graduation. The issue is ensuring that they will have what it takes to keep learning and changing. They will need to be continually evolving, acquiring what they need to know and need to be able to do as required by the particular circumstances that exist at any given time. We must stop thinking of “content competencies” as static. It isn’t safe to assume that a reasonable command of the content needed at one point in time predicts the level of content mastery a person will have at another point in time, when the circumstances will be quite different. 

Am I suggesting that what we know is unimportant? 
Definitely not. When learning to think and problem solve, we need something to be thinking about. Medical students' learning experiences, as they work to enhance their capabilities as thinkers and problem solvers, need to happen around medically relevant topics and issues. So, we must define those contexts that present the students with the sorts of challenges that require them to be continuously thinking and problem solving. But the information they acquire while engaging in these processes needs to be accepted as being a secondary consideration, not as primary, as it now often is. The information that will be relevant to the issues they will face in the future will likely be quite different from the information they use at this time. The information itself should not be seen as the central basis for our teaching or for our assessments of learning, as most typically happens now.

Toward defining a 21st century medical curriculum 
We can confidently anticipate that the demands of careers in medicine at the height of our current students' working lives will be significantly different from current demands. Of course, we can't now forecast what those demands will be, nor how they might continue to evolve during our students' lifetimes. So, our central challenge is figuring out how to prepare young people to be optimally equipped for continuously adapting to a changing future. To accomplish that goal, we need to create educational programs that prepare medical graduates who are:
  1. highly accomplished learners;
  2. highly competent searchers for and interpreters of information needed while engaged in problem-solving and decision-making;
  3. deeply devoted to, and skilled at, monitoring their own adequacy for the tasks they need to do and the problems they need to manage;
  4. fully open to being carefully assessed on their performance at intervals throughout their careers; 
  5. willing, even eager, to receive guidance from appropriate coaches; and
  6. highly refined and effective in their interpersonal relationships, whether with colleagues, subordinates, students, patients, or the general public.

Attending to these obligations mustn’t be mere embellishments on a conventional curriculum. These must be central imperatives in all parts of the educational program. The curriculum needs to be sufficiently focused and consistent to ensure that all graduates are dependably competent in all these areas. These competencies must be seen as far more than the surface behavior that shrewd test-takers know to exhibit when they are being observed, but can relinquish when on their own, as is now found to happen with too many students in relation to some medical school goals during and following formal assessments. The six competencies listed above need to become core values that are “owned” by each learner and sustained throughout their careers. Too many medical curricula now fall far short as producers of this sort of graduate. 
   Each medical school should be attending to the task of defining what they consider the minimally acceptable levels of accomplishment in each of these six areas, as a guide to their student-selection process. All schools, it seems to me, then have the task of helping all of their students grow as far as they can beyond the levels at which they began their medical education. Creating and sustaining such a program will require many changes from the currently dominant pattern in the world's medical schools. At the center of these changes will be our need for highly accomplished, deep-thinking educators as both the teachers and the administrators of our educational programs. I seek to clarify and expand on these and other requirements for creating and maintaining a thoroughly professional medical curriculum in subsequent parts of this series.

NEXT: Part 3. Implementing an appropriate curriculum. (coming soon)
   Hill Jason
Hilliard Jason, MD, EdD
First posted: 1/24/12
Revised: 1/28/12
* NOTE-1: As with all entries on this blog, your constructive critiques, recommendations and reflections are warmly encouraged. Please add your Comments below, or, to convey your reactions privately,  please send an email to: Many thanks.
* NOTE-2: I’m currently part of a small group that is conceptualizing a possible new kind of medical school for Europe, so, many elements of educational design are very much on my mind at this time. Inescapably, curriculum is a central consideration. My reflections for our deliberations have helped spawn this and other blog postings.

Apple’s Education Announcement: 
A potentially large step into the future for textbooks and learning
Today (19 Jan. 2012), Apple Inc introduced three initiatives intended to "reinvent the textbook” and enhance learning. Did they live up to my dream of yesterday? No. Instead, they surpassed it!
Instead of announcing the “rental” system for textbooks that I had imagined, they are doing something better. To make textbooks more widely affordable, they announced agreements with several dominant textbook publishers to make their new e-textbooks available online for $15.00 or less each! At least 15 of the new generation e-textbooks, within this price limit, are already available. (Conventional texts in the US are typically priced at $60-100 each.) And these are permanent purchases. No need for them to be returned! And they will be so much more than static, printed texts. Among their main characteristics, they will be:
  • Highly dynamic, including audio, graphics, animations,  and videos.
  • Interactive, with adaptive questions and answers, changeable graphs and diagrams, and more.
  • Easily up-dateable by authors.
  • Customizable by students, with easy highlighting and note-making.
  • Fully searchable, for words, phrases, highlights and notes.
  • Enriched, with glossaries, study guides, and more.
In addition to announcing agreements with major textbook publishers, Apple unveiled a new, free app that will make it relatively easy for teachers (and others, perhaps even students) to create dynamic, “modern” textbooks using iBooks Author, available now for free download at the Mac App Store.
For accessing and using these new kinds of books, Apple also announced an update of their iBooks iPad app to iBooks 2. This app is also free, and also available now. Once installed or updated on you iPad, launch that app, click on the Store link in the upper-left corner, and you will see the promotions for the newly available textbooks. I suggest you consider downloading the free sample of the first two chapters of the E.O. Wilson Foundation’s new e-book, Life on Earth. It will give you a glimpse of this new category of “textbook”.
To see Apple’s video on these and other initiatives, including public commitments to these new style textbooks by the CEOs of 2 textbook major publishers, click here .
iTunes U app: Apple also introduced their enhanced iTunes U, with a dedicated app for accessing and using the resources offered there. As you likely know, many universities have been making some or all of their courses available online via iTunes U. The new iTunes U app lets teachers create and manage their courses, including components such as lectures, assignments, books, quizzes and syllabi, and offer them to iOS users (iPad, iPhone, iPod Touch users) anywhere. Some highly regarded universities, including Cambridge, Duke, Harvard, MIT, Oxford and Stanford have offered courses via iTunes U. As of today, elementary and high schools can also offer full courses through the iTunes U app. 
Learners anywhere can now take an entire course, with complete access to all course materials. Students are able to access their e-textbooks from within the iTunes U app, and any notes and highlights they add in these iBooks can be consolidated for review in one place. In addition to reading books, viewing presentations, lectures and assignment lists, registered students can receive notifications of the latest class information, can make appointments with their teachers and advisors, check class and school events, and more. The iTunes U app is available today as a free download from the iTunes App Store.
Educators are said to be able to quickly and easily create, manage and share their courses, quizzes and handouts through a web-based tool and utilize content and links from the iTunes U app, the Internet, the iBookstore, or the App Store as part of their curriculum. They can also upload and distribute their own documents such as Keynote, Pages, Numbers or books made with iBooks Author.
How much of a breakthrough is all of this for future education? That remains to be seen. On first exposure, the tools made available today seem genuinely impressive, with considerable potential for helping move education into a more engaging, meaningful, participatory, and consequently more effective era for learners. But this potential won’t be realized without major transformations in the sensibilities, understandings, and skills of the teachers who need to adopt, learn, and implement these resources. The record of our species generally, and of teachers specifically, as constructive responders to new opportunities that require alterations of assumptions, mindsets, and attitudes is hardly encouraging. But, enough teachers may have already moved into the world of twenty-first century technology to have the comfort base that will help them welcome, rather than be intimidated by, these new tools and processes.
I’ll be watching closely and hopefully (while experimenting a bit with these new tools myself). 
Hilliard Jason, MD, EdD
Jan. 19, 2012

My hope (dream) for future textbooks
Tomorrow, 19 January 2012, Apple Inc will host a media event, at an exceptional venue for one of their closely-watched announcements. Almost all their announcements are held in generic auditoriums in the San Francisco region. Tomorrow's will be held at the Guggenheim Museum, in New York City. Mystery always surrounds these events. The invitation for this one says only: "Join us for an education announcement in the Big Apple." 
The company's cryptic advance communications about their events generate rumors, speculations and predictions. This time, several commentators have wondered if Apple will be bringing electronic textbooks (e-textbooks) to their mobile devices, especially the iPad. 
For the first time, I’ve joined the guessing game. Yesterday (18/01/12) I contributed to an online discussion of Apple's coming announcement. The following is what I said, (slightly edited for this different context):
Traditional vs. Digital textbooks
Some college students have been quoted as saying they prefer paper-based textbooks to the digital versions. They aren't clinging to their conventional textbooks out of love for their size, weight or tradition. They choose paper-based texts because they can be resold at the end of their course. Currently, e-textbooks can't be resold. I suspect that textbook publishers manipulate the economics of textbook sales as part of their devotion to preserving their established business model.
My guess (dream) is that Apple will disrupt a whole industry again. This time it will be the textbook publishing industry (much as they've done to the computer industry, the music distribution industry, and others). They will announce a revolutionary model: they will start "renting" textbooks, not selling them. The student's cost for rental for the duration of their course will be a fraction of their cost for purchase. The students will be relieved of the hassle of reselling, and of carrying several heavy books around all day. They will no longer have to try keeping their textbooks clean to sustain their resell value. And the publishers and authors will get enough of a cut of every rental to keep them happy, because there will be many more of these books rented than were typically sold. Students on tight budgets will no longer have to struggle with depending on their library's small number of loaners, or on the awkward arrangement of sharing one book among several friends.
Like most people, I have no inside knowledge. But, I'll be sorely disappointed if my predictions aren't at least partially correct, largely because electronically published textbooks can bring huge advantages over their dead-tree-based counterparts. They are FAR less expensive to produce, warehouse, and distribute; they can be revised on the fly, rather than every 10 years; and the current influence of extremist groups on textbook content, especially for the early years of education, will be nearly eliminated (except for their local school districts). And, of greatest importance, the students will have use of far more valuable texts. In addition to being more up-to-date, their e-texts will be highly searchable for words and phrases, and for each student’s own bookmarks and notes. These twenty-first century “textbooks” will become far more powerful educational resources than conventional textbooks ever were or ever could be.
E-textbooks will eventually offer multi-media, interactive presentations. They will signal the arrival of a whole new era for the educational process itself. Teachers will eventually stop seeing themselves as conveyors of information. They will accept the research that has been confirming that the large-group lecture is an inadequate approach to teaching and learning. Instead, they will assign sections of these new "textbooks” as preparation for the highly participatory events that will replace traditional lectures. A functioning version of that future model can already be seen at the Khan Academy*:
In the new model, I'm persuaded, these learning resources will be far more like an elaborate, highly focused web site than like our current image of a textbook. The notion of a publication date will become obsolete. There will only be version dates for sections within the "book". At some point, hopefully soon, these educational resources will be unrecognizable as "textbooks”.
In my view, this is the way textbooks must evolve. A key question remains: how long will this transformation take? I don’t know, but here’s hoping this transformation begins in earnest very soon! Say, tomorrow. I can dream, can't I?
    -  Hill
Hilliard Jason, MD, EdD
The Khan Academy is an important glimpse of aspects of the future. But, the fact that it is offering its resources free isn't a forecast that appropriately presented, interactive, e-textbooks can't be sources of revenue for authors, publishers, and others. This site and its resources are free because they've received substantial funding from the Bill & Melinda Gates Foundation. As you likely know, many breakthrough innovations first happen because of support from philanthropy or the government.
Jan. 18, 2012

Why are you starting this blog now? - Part 1
My short answer: Several professional and personal factors coalesce to make this an appealing time for me to be creating and maintaining this blog. The main recent developments are:
  • The improving quality and expanding range of educational research.
  • New neuroscience research techniques are providing fresh insights into how our brains learn.
  • The arrival of "Web 2.0" (see below).
  • Some medical education programs are taking steps toward recognizing and rewarding deserving educators.
  • Colleagues and friends have encouraged me to have a regular outlet for sharing my reflections and ideas.
  • My current career stage provides me with some of the considerable time needed for this project.
My fuller answer, in 2 parts:

There are encouraging developments 
A glimpse at the list of journals and other sources of information about medical education, many of which are available in the links in two sidebar widgets on the left of this screen (Related Journals/Info and Related Organizations), confirms that many encouraging developments are underway. There are growing numbers of people doing educational research in the health professions, and there is an impressive number of organizations focused partly or largely on efforts to enhance educational quality in our medical schools. Also, there are growing numbers of meetings and conferences focused on education in medicine and the other health professions.
But, we have a paradox of progress with limited meaningful change

Why are you starting this blog now? - Part 2

Have you seen Part 1 of my answer to this question? If not, you can go to it here.

Partly, I'm starting this blog out of my impatience with the slowness of the progress I've witnessed

Resistance to change 
Throughout the 55+ years in which I've been a close observer of medical education I've seen the availability of information on ways to improve medical education move forward at a far faster rate than changes in the educational process itself. Although educational research has become increasingly sophisticated and more widely undertaken, resistance to revising established practices in medical education remains strong in many quarters. Those who try to initiate constructive changes are too often ignored and marginalized. Resistance to constructive change has many sources and takes many forms. Much is passive, not active, deriving more from indifference and ignorance than from overt rejection. Many teachers choose, or are forced by lack of awareness of alternatives, to rely on patterns similar to those they experienced as learners. As I've tried to point out elsewhere, we are doing far better with our "macro" decision-making (our organizational planning) than with our "micro" decision-making (decisions that are needed during moment-to-moment, teacher-to-learner transactions). Our overall planning strategies have evolved fairly steadily, but our day-to-day encounters between teachers and students remain largely in the hands of people who are not sufficiently prepared for the demands of the tasks we depend on them to pursue. Too much front-line teaching has not changed significantly from a half-century ago. 

Why does change come so slowly? 

Some readings for your consideration
The references below are meant for anyone who has an interest in understanding aspects of the teaching-learning process from a broader perspective than is usually available from the occasional education-oriented article appearing in the clinical or biological research literature they may routinely peruse, or even from intermittent scanning of the medical education literature. Each reference below offers some consolidation of findings and perspectives from multiple sources. I offer them hoping that you will find they provide you with a broader and deeper appreciation for the complex, fascinating process of human learning than may be available from more conventional sources. Several of these references are books that were written for the general public, not for health professions educators. I'm persuaded that they can be helpful to people who are serious about being effective educators and who appreciate good writing that is meant for a broadly educated, non-specialized audience.
I hope you find some fresh ideas and new directions here. I will supplement and refine this list from time to time, and I will add brief, specific commentaries as my time permits. 
Donovan MS, Bransford JD, Pellegrino JWHow People Learn: Bridging Research and Practice. Washington, DC: National Academies, 2000.
Gardner H. Intelligence Reframed: Multiple Intelligences for the 21st Century. New York: Basic Books, 2000.
Gardner HChanging Minds: the Art and Science of Changing Our Own and Other People’s Minds. Boston, MA: Harvard Business School Press, 2004.
Gawande, ABetter: A Surgeon's Notes on Performance. Picador. 2008.
Gigerenzer G. Gut Feelings: The Intelligence of the Unconscious. Viking Adult, 2007.
Goleman DEmotional Intelligence: Why It Can Matter More Than IQ (10th anniversary ed.). New York: Bantam, 2005.
Goleman DSocial Intelligence: the New Science of Human Relationships. New York: Bantam, 2006.

Heath C, Heath DMade to Stick: Why Some Ideas Survive and Others Die. Random House, 2007
Jason H. The importance–and limits–of best evidence medical education. Education for Health 13: 9 –13, 2000. (available online)
Jason H. CLAUDE BERNARD DISTINGUISHED LECTURE: Becoming a truly helpful teacher: considerably more challenging, and potentially more fun, than merely doing business as usual. Advances in Physiology Education, 31: 312-317, Dec 2007 (available online)
Marchese TJ. New Horizons for Learning. The New Conversations About Learning: Insights From Neuroscience and Anthropology, Cognitive Science and Workplace Studies (available  online). [Oct 2007].
MacDonald M. Your Brain: The Missing Manual. Pogue Press, 2008.
Montgomery K. How doctors think. New York: Oxford University Press, 2006.
Schacter DLHow the Mind Forgets and Remembers: the Seven Sins of Memory. London: Souvenir, 2003.
Squire LR, Kandel ERMemory: From Mind to Molecules. New York: Owl Books, 2000.
Stern DT. Measuring Medical Professionalism. Oxford University Press, USA, 2005.
Vella JLearning to Listen, Learning to Teach: the Power of Dialogue in Educating Adults. San Fransisco, CA: Jossey-Bass, 2002.
Weimer MLearner-Centered Teaching: Five Key Changes to Practice. San Fransisco, CA: Jossey-Bass, 2002.

I invite your comments on any of the entries above, and please share your suggestions of other references that should be added to this list.

  Hill Jason 
Hilliard Jason, MD, EdD
First posted: 8/16/08
Revised 11/17/08

Some tips for getting around and finding items of interest.
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  Hill Jason 
Hilliard Jason, MD, EdD

First posted on 9/9/08
Updated on 11/07/08
Updated on 1/18/09

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WELCOME!   About this Blog
Thanks for stopping by. I'm glad you're here.
This blog is a non-commercial, voluntary effort. Although I serve as "provocateur-in-chief," I try offering observations that encourage others to join the exchange. I try to keep my entries fairly brief and easily digestible. When a topic needs fuller development I refer to other entries in this blog, or to writing that others or I have done. Throughout this site you will find links that can take you to other parts of this site or to other web sites. Some links take you to a document you can read on-line or download for reading later.
The "posts" (entries) in this blog are meant to stimulate reflection and the exchange of ideas. I consider all my posts to be "works in progress." Although most of them are based on a good deal of thought and, when available, research by myself or others, I regard all my ideas as being in evolution, never as "final." I consider our "conclusions" in medical education, as in all of science, to be tentative, forever subject to the influence of new findings, and new insights. ("A conclusion is simply the place where you got tired of thinking." Author unknown)
I encourage your comments and look forward to ongoing, productive exchanges with you and others. For guidance on adding comments to this blog, please see this posting. (You can also reach that post via the FAQs, available in the ever-present menu bar, above.)

  Hill Jason 
Hilliard Jason, MD, EdD
First posted: 9/17/08
Revised: 11/16/08
2nd revision: 12/11/08
3rd revision: 12/16/08
4th revision: 1/3/09
5th revision: 11/2/10

Do we learn worthy lessons from being teachers?
Below is a Letter to the Editor of the US newspaper, the St. Louis Post-Dispatch, published on their website on 11-12-08 (shortly after the election of Barack Obama), and accessed the following day, from:
The writer (who is not someone I know), proposes several lessons that can be learned from being a teacher, suggesting that they are relevant preparation for a potential senior politician, and presumably others who take on major responsibilities. What do you think?
Learned by teaching
Two comments about President-elect Barack Obama predominate at the moment: He organized a stunningly successful presidential campaign, one without precedent; and concern about whether he can handle the diverse problems pressing on him now. People who raise these issues neglect one aspect of Mr. Obama's resume: He was a teacher for 12 years, teaching constitutional law at the University of Chicago.
Mr. Obama honed his organizational, prioritizing and communication skills in the classroom. Like good teachers everywhere, he can organize a diverse amount of material into cohesive units; he can prioritize, deciding what is and is not necessary to learn at the moment; he can explain complex systems in an easily understood manner; he can anticipate and answer questions; he can remain calm in chaos; he can handle the competing needs of individuals and groups; he can think on his feet and react quickly to diverse situations; and he understands the need to keep learning. 
The most important successful teacher characteristic he embodies is that he knows how to be in the midst of the activity without having to be the center of attention. Mr. Obama knows that he is not as important as the message he delivers and the ways he implements that message.
Clearly the politicians, the pundits and the press who question Mr. Obama's abilities never have taught. That is a shame. Being an experienced teacher provides the best credentials possible to those seeking jobs in the public sector.
Patricia Noland | Ballwin, MO
Some questions for your reflection and possible comments:
  • Do you agree that teachers have or routinely learn the characteristics and skills suggested by the writer?
  • If you are a teacher, do you have these characteristics and skills?
  • Do you consider these characteristics and skills worth trying to develop if they haven't evolved on their own from the experience of being a teacher?
  • Would you modify or reject any of these characteristics and skills? Why?
  • Are there other characteristics and skills you propose are also part of being a successful teacher? If so, what are they?
  Hill Jason 
Hilliard Jason, MD, EdD
* I'm indebted to Roger Oliver for bringing this letter to my attention.
First posted: 12/13/08

©2008-2012 Hilliard Jason

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