Medical Grand Rounds are a longstanding (dare I say, traditional) feature of the academic medical centre. In fact, their durability and continuing appeal might be considered somewhat perplexing in an age of increasing, almost frantic, busy-ness, and easy access to medical information and prepared presentations ready for review at our convenience. Here at Queen’s, they have become rejuvenated and are now a highlight of the academic week with the support of Dr. Archer and guidance of Dr. Mala Joneja.
The format is very simple: a formal lecture, followed by commentary and discussion from the audience. That audience tends to be quite eclectic, including medical students, residents, nurses, hospital administrators, and attending physicians ranging from junior staff to senior clinicians, some very much expert in the topic under discussion. The discussion following provides opportunity for those attending to add depth and perspective to the topic. Because it’s a gathering of thoughtful clinicians who lack for neither opinions nor willingness to express them, the dialogue following can be rich, far-reaching and highly entertaining. The challenge of the presenter is therefore considerable. With minimal technical “tricks”, relying largely on the content and style of their presentation, they must not simply inform but provide texture, context and deeper meaning to the topics under discussion.
Three recent, excellent Grand Rounds on contrasting topics delivered by individuals of different backgrounds and practice profiles provide insights about the “art and science” of the well- crafted and well-delivered lecture.
Dr. Zachary Liederman, a senior Internal Medicine resident, presented the topic of Myelodysplastic Syndrome. He described very nicely the current state of knowledge and clinical approach, and did not shy away from describing the complexities facing the treating physician when counseling a patient who has a condition that is causing minimal if any symptoms, and carries uncertain risk for progression. In the discussion that followed, senior departmental members questioned the obligation of treating physicians to disclose to every patient all information about conditions that are identified, but not the cause of symptoms, and of uncertain clinical significance.
Dr. Al Jin is a Neurologist with a impressive research background and clinical training in stroke. He is actively involved in “leading edge” approaches to diagnosis and management of this condition, sharing with the audience his insights about these emerging innovations, balancing thoughtfully the established and speculative, referencing the underlying scientific principles with practical clinical experience. As an acknowledged and respected expert in this field, he combined high levels of personal credibility with an engaging, respectful and balanced presentation. There was truly something for everyone, from the novice learner to seasoned clinician who treats stroke patients regularly.
Dr. David Holland is a well-established and highly-respected Nephrologist and educator. He presented a superb lecture on the topic of Disruptive Innovation in Patient Centred Care. He drew upon his clinical experience with chronic kidney disease and dialysis, but extended far beyond, providing insights drawn from industry and various models of change and innovation. Presenting with considerable panache and directness, he provided concepts and insights novel to most in the audience, and did so in a highly engaging and thought provoking discussion.
Three very different topics.
Three individuals of very different backgrounds.
All were highly effective in engaging their audience and presenting them with novel, fresh insights about topics in which many in attendance may have felt reasonably informed beforehand. In short, they all made a room full of people sit back, listen, and think again about something important to them.
How did they manage it? What makes any lecture effective? I would suggest there are a few common denominators.
· The content has relevance to the audience. It is something that is, for whatever reason, important to them in their occupation, private lives or, better yet, both.
· The content goes beyond simple transfer of knowledge. It extends facts and figures to a thoughtful discussion of the application, implications or meaning of the basic information.
· The presentation differentiates that which is factual and proven from that which is speculative, hypothetical or aspirational. In doing so, the presenter draws the audience into the discussion, allowing them to develop their own conclusions and thus extend thought and provoke further discussion
· The presenter is credible. This arises not simply from their background and qualifications, but from the way in which they interpret and present the information. The effective presenter, in fact, earns the trust of the audience by manner in which they present.
· The presenter is passionate about the topic under discussion. The audience must perceive that, at some level, the presenter cares about the subject on a personal level, to an extent that assures integrity about conclusions that are drawn.
· The presenter respects the audience. They truly wish to inform and advance understanding of the topic under discussion.
· The material is presented in a “user-friendly” and entertaining manner. This is not showmanship or a simple sprinkling of humorous anecdotes. It involves a skillful use of familiar concepts, analogies and parallel discussion lines to weave a narrative that informs while telling a story. It also requires a sense of the needs and preferences of the audience.
Despite a longstanding and venerable place in the history of medical education, the lecture format has come under considerable criticism, and is somewhat at odds with modern educational theory. It has been rightfully pointed out we no longer need lectures for simple knowledge transfer, since students have available to them a myriad of other information sources. It is also true that the lecture format can be a very passive experience for the learner, and may not engage them in the “active learning” process which is essential to deep and retained understanding of any topic. Medical schools, including Queen’s, have all engaged a variety of active, small group learning techniques. Many have abandoned the lecture format entirely.
The three examples and characteristics described above illustrate that the lecture format, appropriately structured and delivered, can be an integral part of a medical education curriculum, going far beyond passive information transfer, challenging students to extend their basic knowledge to the implications and application of the factual, thus deepening their understanding and providing a model for thoughtful reflection that should model processes they take into their professional lives.
At Queen’s, we have given considerable thought to the place of lectures and various learning techniques in our curriculum. A number of key decisions were made about 7 years ago when we engaged curricular renewal:
1. We would engage a variety of learning methods, including team based learning, case based presentations, facilitated small group learning, and lectures. In short, we would strive for a balanced blend of teaching methods. In addition to taking advantage of the benefits of all approaches, this allows us to model all methodologies for our students, who need to learn to teach themselves, a component of the scholar competency (the “medium is the message” approach).
2. We would use lectures not to provide basic information, but to allow experienced faculty to extend that information into discussions of significance, professional implications and clinical applications of knowledge.
3. We would structure into our courses sufficient resources, time and guidance for students to acquire basic information in a variety of formats, including on-line material, learning modules, reference material and reliable information sources that we would recommend. We would, to use the educational terminology, engage Directed independent learning.
4. We would dedicate significant components of our curriculum to helping students identify and recognize reliable information. In fact, much of the Scholar competency and most of our Critical Appraisal, Research and Learning (CARL) course (developed and guided by Dr. Heather Murray) is devoted to this goal.
5. We would promote faculty development opportunities for teaching faculty and recognize outstanding lectureship.
In short, we wanted fewer but better and more meaningful lectures, delivered to students already prepared with basic information and able to both discern credible information and make valid clinical decisions. To accomplish this, we required a committed, engaged and well-supported faculty, clarification among our students about the learning goals, and teaching spaces that allowed all this to happen.
Our School of Medicine Building, opened in September of 2011, was purpose built with these objectives in mind. The large group rooms were designed to allow for both lecture and small group teaching, and easily allow a teacher to transition between the two methods, so students can move easily between attending to a single lecturer and small group discussions on the issue under discussion.
The building also includes 30 small group rooms for both formal and informal learning.
Has it worked? Lectures continue to be featured in every course we offer but are now part of a teaching mix that includes all the other small group based methods we promote. The graph provided depicts the current percentages, a significant change over the past few years and a tribute to our faculty.
Do our students value lectures? Each year, the Aesculapian Society presents a “Lectureship Award” for the teacher in each course who they felt provided the most effective sessions. These are awarded after each course and are very highly valued by faculty.
The Canadian Graduation Survey, completed by all medical students at the completion of their final year, including 102 (99%) of our 2014 class, asks them to rate the overall quality of their medical education. Seventy-two percent of our graduates rate their experience as “excellent”, comparing to a national average of 29.6%.
So it seems we’re doing something right, and that the lecture has a secure future in undergraduate education, thanks in no small part to the example and contributions of excellent lecturers like Drs. Holland, Jin and Liederman.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education