Rethinking Medical Education

The ThinkerQuestions, observations, and recommendations toward reform of the process and content
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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
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* 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: hkj337@gmail.com. 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.

 

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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
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* 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: hkj337@gmail.com. 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.

Might Apple Inc Revolutionize Education?  

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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). 
    Hill
Hilliard Jason, MD, EdD
Jan. 19, 2012

My hope (dream) for future textbooks  

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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*: http://www.khanacademy.org. 
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 new blog now? - Part 1  

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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:


PART 1
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








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Why are you starting this new blog now? - Part 2  

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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.

PART 2
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? 



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Do we learn these lessons from being teachers?  

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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?
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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
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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?
Thanks,
  Hill Jason 
Hilliard Jason, MD, EdD
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* I'm indebted to Roger Oliver for bringing this letter to my attention.
First posted: 12/13/08

An inescapable hazard of meaningful learning  

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An inescapable hazard of meaningful learning

A man learns to skate by staggering about making a fool of himself.
Indeed, he progresses in all things by making a fool of himself.
George Bernard Shaw (1856-1950)
A lesson about learning (from an unlikely source) For several years, while we lived in Florida, we traveled to Colorado in the winter, where we spent time with close friends from California and went skiing together. Like me, our friend Bill had grown up in Montreal and we both had been skiing for many decades. But neither of us had taken any ski lessons. During one of our Colorado trips, Bill excused himself from our little group and headed off to take a ski lesson. When we met up again at the end of the day, Bill announced that he had been hugely impressed by his instructor, Gary. With his characteristically generous impulse, Bill had hired Gary to be available to all of us for ski lessons the following morning.
Well, I immediately had a visceral understanding of Winston Churchill's telling observation, "Personally, I am always ready to learn, although I do not always like being taught." My trepidation about the coming ski instruction was substantially reduced after watching Gary work with Marcy and Jane. With each of them he did something we have tried for years to get medical teachers to do, with only marginal success: he began by being diagnostic. He talked to each of them about their sense of their capacities as skiers and then watched them as they did some skiing. He nicely customized his subsequent coaching to what they seemed to need most.
Then came my turn. After learning that I hadn't missed a ski season in more than 40 years, and that I was reasonably content with my capacities for handling the sorts of mountains we choose, he watched me ski. Then the fun began. Gary's first comment was, "When were they teaching that stuff you do with your shoulders? Was that in the 1930s or the 40s? We'll have to get rid of that habit. And the way you move your knees toward the slope. Am I right that that was fashionable in the 50s? That's got to go also." After two more questions and comments of the same type I was beginning to doubt my capacity to stand up on skis, let alone negotiate challenging runs ever again. I turned to Gary and asked, with a smile, "Tell me, is all this meant to be helpful, as it surely isn't feeling that way?"
To his credit, Gary laughed and immediately apologized quite sincerely. He explained that he should have known better, that he and the other instructors at their ski school are warned about situations like this and that he had neglected to act on what he knew. He went on to explain that whenever they were teaching someone who wanted or needed to make reasonably substantial changes in their accustomed ways of doing things, the learners needed to be cautioned that they would be going through a phase of feeling "functionally grotesque"! Oh, my, how that resonated for me! That was exactly how I was feeling. That day, thanks to Bill's generosity, I learned a great deal about becoming a better skier, but I learned even more about learning.
A companion of meaningful learning As George Bernard Shaw recognized (above), meaningful learning demands that we start doing things, or start thinking, in ways we've not done before. And, inescapably, as we undergo the transition from where we now are to where we want or need to be next, we are often faced with some unwelcome feelings. The process of making worthy progress in learning often brings with it a sense of feeling awkward, unsure, perhaps like being a beginner again. Sadly, many of us, and many of our students, are no better prepared for the unpleasant sense of feeling functionally grotesque than I felt on that ski hill a few decades ago. Programs that seldom or never push learners beyond their current capabilities sufficiently to cause them to feel functionally grotesque aren't serving those learners well.  And most learners, not understanding the need for this process or its value, will typically do what they can to avoid straying too far from their current comfort zone.
The process of meaningful learning When education is effective, it takes learners through a continuously escalating spiral, involving the sequence: diagnosing their current competence ➔ identifying those activities and tasks these learners most need right now for moving to a meaningfully higher level of competence ➔ active engagement by the learners with those activities and tasks at the new, higher level ➔ sufficient practice, reflection and feedback at the new level for achieving stable effectiveness ➔ offering new challenges to help the learners move to the next higher level, and so on. If meaningful learning is to occur, there is no avoiding the hazard along the way of feeling the uneasiness we associate with being a stumbling beginner. We are continuously needing to climb beyond our stabilized comfort level to an unfamiliar higher level. If learners are being appropriately stretched by their program, the feeling of being newly functionally grotesque is unavoidable. In well-functioning educational programs, that feeling is transformed from being an unwelcome set of sensations that are to be avoided, into being a welcome sign that some appropriate stretching is happening, from which meaningful — and desired — learning can grow. 
Making the uncomfortable acceptable, even welcome Several conditions are needed in an educational environment if learners are to be helped to feel that being stretched is constructive and desirable, rather than abhorred or ineffective. Most prominent among these conditions are:
  • a sense of trust between learners and teacher
  • an atmosphere of good humor  throughout the process
  • a continuous process of ensuring that the levels of challenge each learner confronts is appropriate to his/her level of need and readiness.
Insufficient challenge, which enables learners to remain within their existing comfort zone, isn't helpful. Excessive challenges can cause learners to retreat, to become self-protective. Ultimately, excessive challenges are more hurtful than helpful to learning. 
In future postings I will discuss the process of determining and titrating the levels of challenge we offer, and the processes of earning and sustaining authentic trust.
Some questions for your reflection and possible comments:
  • Do you have a reasonably clear sense of your learners' entry levels and their readiness for challenges that will stretch them sufficiently, without being excessive?
  • What steps do you and your colleagues take to prepare learners for feeling functionally grotesque at times and for supporting them through this phase of meaningful learning? (As GBS might ask, do you help them deal with the experience of feeling they are making fools of themselves?)
  • Have you and your colleagues developed any approaches to diagnosing and challenging your learners that you are willing to share with us? Your contributions here will be most welcome.
Thanks,
  Hill Jason 
Hilliard Jason, MD, EdD
First posted 10/27/08
Updated 11/27/08

Does jargon slip into your communications?  

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How much jargon slips into your communications? Does it help or hinder?
Incomprehensible jargon is the hallmark of a profession.
Kingman Brewster, Jr., (1919-88) 
Former President, Yale University
The line between serious and spurious scholarship
 is an easy one to blur, with jargon on your side.
David Lehman (1948-), U.S. poet, editor, critic
Do we use too much jargon? Some have observed that medicine may be the most jargon-ridden profession of all time. Others of us think that medicine’s use of jargon is surpassed by government bureaucrats and the military, but we must acknowledge that medicine gives them a reasonable level of competition. Those of us in healthcare seem to have special names and phrases for almost every ailment, management plan, instrument and body part. One of my anatomy professors published a paper in the mid-1950s in which he reported his calculation that first-year medical students need to acquire more than 20,000 new words and phrases, in addition to everything else they are expected to learn. Listen carefully to casual conversations among health professionals and you may find that a noticeable proportion of the words they exchange would be found in a medical dictionary but may not show up in ordinary school dictionaries. Yet, in my experience, when medical faculty are on the receiving end of someone else's jargon, they are about as jargon-averse as any group. Think of the dismissive reaction of some medical faculty to the language used by professional educators.
A lesson from a "consumer" I had my first lesson in the risks of overusing jargon more than 40 years ago. I was conducting the wrap-up, feedback session at the end of a national conference that I had chaired on Self-instruction in Medical Education. The first audience member to volunteer a comment was a physician who rose to say, “I’m sure I speak for everyone here when I extend warm thanks for this ground-breaking meeting to Dr. Jason and all the jargonaughts.” Message received! Loud and clear!
Ever since that formative experience I’ve made a special effort to pay close attention to the words and phrases that my colleagues and I use in various settings. I quickly came to realize that words can have different levels of utility under different circumstances. In medicine, as in most other specialized fields of human endeavor, words are appropriated or invented as labels for objects, situations and conditions that are commonly encountered in daily work. We don’t just talk about pain in the back in the way that most people would. We typically seek to be more precise by identifying that the pain is in the cervical, thoracic, lumbar, sacral or sacro-ileac area. We might even choose abbreviations, referring, for example, to S-I joint pain. Dentists don’t say to each other that a patient has an infection on the cheek-side of their gum, in the right, lower area. They say, instead, that the patient has a gingival abscess on the buccal surface, below tooth number 26.
This “insider’s” vocabulary can provide a useful, time-saving shorthand among those who understanding what is being said. To them, such words are genuine aids to efficient, precise communication.
Although specialized words and phrases can enrich and lubricate the exchange of information among those who share a professional sub-specialty, those same words can be sources of bewilderment to those who are from outside the inner circle. For outsiders, the insiders' words and phrases are dismissed as jargon. They are said to sound like unintelligible gibberish. As it happens, the word "jargon" is derived, in part, from the Middle English (12th to 15th century England and Scotland) word for "gibberish." 
Do you adapt your words to your audience? Clinicians can find themselves with two different targets of their communication in the same room at the same time. A dental colleague who is sensitive to this potential problem acknowledges the problem up front. When he does his initial exam, he informs his new patients that he will be using dental jargon as a shorthand for communicating concisely and precisely with his assistant while they are pursuing their various tasks. He then adds, "I promise to translate the important information into plain English when we're done."
Put another way, the same words and phrases that can be elegant communication in one context can be unintelligible gibberish in another. Successful communication is comprised of many parts. What is conveyed (sent out) is one part. Whether it is understood and accurately assimilated by the intended recipient is another part, and equally important. A challenge we face as teachers, among the many that should be getting our attention, is developing the self-conscious, reflective routine of tuning in on our verbal habits. Might we have become automatic in our use of some words and phrases? Might we be automatically using jargon with our non-medically-qualified patients or students, and might they be too timid or intimidated to let us know we're failing to communicate? You don’t have to be stuck with the name Jason or be familiar with Greek mythology to understand that we are all at risk of seeming like jargonaughts to some of those with whom we need to achieve successful communication.
Some questions for your reflection and possible comments:
  • How closely do you pay attention to the words (and possible jargon) you use routinely?
  • Are you in the habit of trying to adjust your vocabulary (including jargon) according to the "readiness" of those with whom you are speaking? If not, should you be doing so?
  • Do you help those you teach or supervise become sensitive to the role of jargon in their communication with patients and others?
Thanks,
  Hill Jason 
Hilliard Jason, MD, EdD


First posted: 10/20/08
Revised: 11/16/08

Does humor have a place in teaching? If so, what is it?  

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Does humor have a place in teaching?


Q: And what is the single greatest thing that sustains you?
A: A sense of humor. And I laugh at myself.
Kofi Annan (1938-) (7th Secretary General of the UN)
If I can get you to laugh with me, you like me better, 
which makes you more open to my ideas.
John Cleese (1939-) (British comedian, writer)
Less than three weeks before Barack Obama was elected to become the 44th President of the US, he and John McCain shared the stage at a fundraising dinner at which humor was expected. They each told a series of jokes, several at their own expense. The candidates were funny, and the event was humanizing. Several political commentators asserted that humor is a vital element of political success, and acknowledged that it is fortunate the aspirants have talented joke writers available.
Is humor also important in teaching? Let's consider some sub-questions.
What can humor accomplish? In teaching as in politics, effectively used humor can reduce the distance between authority figures (politicians, teachers) and their audiences. The right kind of humor can help a distant figure appear friendly, even safe and approachable. People who share a laugh, by definition, have something in common. If the something they've shared has been pleasant, barriers can be reduced and a sense of camaraderie can emerge.
Why reduce the sense of separation between teachers and learners? In too many educational programs, teachers are perceived as judges, as potentially hurtful assessors. Learners who are on guard, who are concerned about being found inadequate, avoid doing what is needed for learning. People who feel that their deficiencies will be held against them are unlikely to seek help they need. They strive to avoid being witnessed saying or doing anything outside their comfort zone, or anything at all. Do you recall avoiding eye contact with any of your harsh teachers? Have you seen students edge their way to the back of the group during rounds? Might you have been one of the many students who become quite ingenious at dodging questions in class? Why do students and faculty tend to fill the back rows of auditoriums first? To be worthwhile, learning needs to take us places we've not been before. We're only likely to embark on a potentially scary journey willingly if we feel we are in the presence of a guide who we perceive as likely to be supportive and helpful. (For another aspect of this topic, please click here.) Finding ourselves in situations we think could prove intimidating or belittling, most of us choose avoidance; we do what we can to keep from trying new, untested and unrefined ways of thinking or behaving. Cautious learners are handicapped learners. When teachers succeed in reducing perceived barriers between themselves and their learners, the prospects for worthy learning grow.
What kind of humor is appropriate in teaching? Humor can take many forms. The thoughtful humorist/author, Steve Allen (1992, 1993), asserted that most humor, at its roots, involves aggression and hurtfulness. Some American professional comedians of the past, such as W.C. Fields and Don Rickles, built their personas on their nasty put-downs of others. A case can certainly be made that a good deal of humor depends on sarcasm, ridicule, humiliation, insult, or retribution, and quite a lot of humor seeks to diminish its target individual or group. There is a large body of humor that is downright cruel, founded on racism, sexism, ageism, homophobia and even national or cultural origin. But a lot of humor is gentle, kind, even uplifting. Some of our most highly regarded, legendary comedians in the US, such as Bob Hope, Jack Benny, Bill Cosby and, more recently, Jerry Seinfeld, relied on hurtful humor only rarely. What made them endearing and popular, in part, was their capacity for poking fun at themselves. And this is the lesson that successful politicians and teachers have learned. The form of humor most likely to reduce the distance between people, to remove obstacles, is self-deprecating humor. 
What if I can't tell jokes? Unquestionably, some people are more comfortable than others as joke tellers. But breaking down barriers doesn't depend on joke-telling. A constructive sense of humor doesn't need to involve jokes at all. A good sense of humor is a prevailing mind-set far more than it is a capacity to tell funny stories, and that mind-set can be learned if it doesn't come naturally. A sense of humor that can bring teachers and students closer together involves a capacity to recognize and appreciate humor, not necessarily create it. To students, a teacher who never laughs, who doesn't seem to ever be non-serious, who doesn't respond positively to humor they introduce, can feel distant, even unpleasant and potentially antagonistic. A teacher who conveys displeasure at any student's effort to be funny is constructing a wall between herself and her learners. A teacher who seems to derive pleasure from the jokes or funny experiences told by students is greasing the gears of communication.
What are some examples of self-deprecating humor? Teachers can constructively poke gentle fun at themselves, and even make some helpful observations in the process, with no joke or punch-line involved. A teacher who is perceived as honest and who acknowledges having difficulties similar to those his students are experiencing can reduce barriers and can make a constructive contribution toward deflating beginning students' common but counter-productive fantasy that perfection is achievable. Are you able to see yourself saying anything like, "Are you having trouble squeezing your question into this non-stop exchange? Just shout it out, and please don't worry about possibly asking a stupid question. There are no stupid questions. Really. Just don't make me promise to never come up with a stupid answer." Or, what about, "Are you having trouble remembering some of the details in all the reading you've been doing? Hey, why should I be the only one here whose memory is undependable?" The critical feature of those sentiments is conveyed only partly by the words you say. At least as telling to students is the ways those words are conveyed. Among those students who don't know you yet, there are likely some who bring with them a fine-tuned radar for detecting potential danger, devised during prior dealings with hurtful teachers. Most students will notice whether you offer your observations with a smile or a frown, whether your manner seems sympathetic or not. You can also help the cause of confirming that you are safe and approachable through the way you use a light touch when responding to a student's comment. If one of your students says something like, "I think I'd find that procedure quite difficult to do," could you feel comfortable replying, with a smile, "Welcome to a large club, in which I'm a charter member."
Humor in teaching is more about atmosphere than jokes. Although there can be times and situations when well-selected jokes can be constructive contributors to an instructional event, they can also be risky. Jokes that are funny to some can be offensive to others. Jokes that seem awkwardly shoe-horned into situations where they are not fully relevant can backfire. More dependably constructive than jokes is gentle, pervasive good humor that influences the overall atmosphere of an instructional event. Of course, there are circumstances in which humor doesn't belong. Teaching in the presence of patients must conform to the reality of the situation. When conveying bad news, or undertaking a painful procedure, especially with a patient we don't know well, establishing a supportive but neutral posture is usually more prudent than seeking to inject humor. In other situations, however, bringing a light touch to what we say and how we say it can exert a positive influence on the atmosphere and enhance the value of our educational exchanges. In general, if we can find ways to bring down barriers, especially by occasionally being constructively self-deprecating, we will likely help our students feel more comfortable in our presence, which can help them become open to engaging in the inevitable risks involved in genuine learning. And we can get all that done without the benefit of hiring any presidential joke writers.
Some questions for your reflection and possible comments:
  • To what extent have you brought humor into your teaching so far?
  • Are there any approaches to lightening the atmosphere during your teaching that you've not yet tried, which you'd like to try?
  • Have you used any humor in your teaching in ways not mentioned in this piece that you're willing to share with others by adding a comment here? We'd love to learn from you.
  • Also, we admit to loving a good joke as much as anyone. Do you have any good jokes about teaching that you are willing to share?
Thanks,
  Hill Jason 
Hilliard Jason, MD, EdD
------------
Allen, S., Wollman, J. (1992). How to Be Funny: Discovering the Comic in You. Prometheus Books.
Allen, Steve (1993) Make 'em Laugh. Prometheus Books
First posted 10/18/08
Updated on 11/06/08

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