In Defense of the Lecture

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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.

blog53-1Dr. 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.

 

aljinDr. 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.

 

david-hollandDr. 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.

Three approaches.

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.

lectureOur 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.

smallgroupThe 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.

Screen Shot 2015-02-17 at 6.47.27 AM

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%.

Percentage Responding
Screen Shot 2015-02-17 at 10.44.27 AMSo 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)
Associate Dean,
Undergraduate Medical Education

5 Responses to In Defense of the Lecture

  1. Thanks, Tony. Thought provoking as always. I think a key distinction here is that these lectures were not primary “content delivery” – i.e. something you could achieve easily by reading a book or review article on your own – but rather provocative presentations with audience dialogue. In medical school (perhaps in the wider university) in the past we have used some large class sessions to outline information that students have memorized and reproduced on tests. We know now that students can do some of this on their own – with appropriate guidance – and that the large class sessions can emphasize application and clarification with an expert. Not only is this better use of the teacher expertise but also proven to deepen student understanding and knowledge retention. There is a nice review here:

    http://www4.ncsu.edu/unity/lockers/users/f/felder/public/Papers/Prince_AL.pdf which includes the quote:

    “Teaching cannot be reduced to formulaic methods and active learning is not the cure for all educational problems. However, there is broad support for the elements of active learning most commonly discussed in the educational literature and analyzed here.”

  2. Richard van Wylick says:

    Lovely post.

    Lectures are like a work of art — it is all about composition and presentation (and a little about the artist’s reputation). There is also variation in what style or artist that an individual might enjoy. Although passively viewed and absorbed, a good lecture, like art, is memorable for the impression that it leaves with the audience rather than the detail of each brush stroke.

  3. Dr. Sanfilippo,

    Thanks for this great post! In the twitter #meded world, debate about whether “the lecture is dead” circulates every couple of months. I am a firm believer, as it seems you are, that the lecture does have a place in education but I wholeheartedly agree with Dr. Davidson that it should not be used primarily for content delivery.

    Lectures that provide a framework for further reading, a scaffolding of sorts that I can hang future acquired knowledge on are my favourite variety. Having these at the beginning of a course (to shape how to go about acquiring knowledge) or at the end of a course (to remind me of a reasonable organizational structure for all of the information that I have acquired) makes so much sense. When an expert shares with me their “framework” or “approach” it sticks but when they just share information it usually doesn’t. With a framework, I can often fill in the blanks, and more importantly learn to identify the right questions to ask when I am unable to. There are a few VERY strong examples of such lectures in the UG curriculum including Dr. Connelly’s “Colours of the Newborn” which provided an approach to the neonate using colours (red, blue, white and yellow). Dr. Gibson’s “Approach to Delirium” is another great example. I have adopted and modified these approaches and actively, not passively, attach knowledge to these expertly laid scaffoldings, information seems to stick without much effort. Faculty development around framing topics, instead of covering topics would be of benefit throughout the curriculum.

    I do worry that students rely passively on information delivered in lectures. The number of times the question “will the slides be posted” is asked is mind boggling and I think the reason the question arises is that students are trained to memorize information from slides. Why? Because we know that test questions most often come directly from lectures instead of extending beyond them (maybe I stand to be corrected). The idea that there is an absolute right and wrong answer, based on information delivered directly in lecture form persists. The reality hits hard in clerkship that this is not the case. Asking good questions and being able to search for answers but ultimately becoming comfortable with making decisions despite uncertainty is what I am learning medicine is all about. If assessment drives learning (to be debated at another time), I am not convinced that our current pre-clerkship summative assessments are driving the right kind of learning. It is totally possible that I don’t see the whole picture and would love to learn more.

    Thanks for an interesting discussion!

    Eve

  4. Stephen Arccher says:

    Letter from a Dinosaur: Having learned Medicine in a Lecture based system I would advocate for maintaining lectures as a significant component of Medical Education. A lecture can be engaging or dry, accessible or apochryphal, but I would argue the medium is not itself flawed. Socrates’ peripatetic “walk and talk” method of teaching and the lecture have both been tested by more than a millennium of medical educators. Clearly the modern world values the lecture (from political stump speeches to TED talks). A good lecturer can inform, entertain and change your worldview.

    I issue an open invitation: Come to Medical Grand Rounds each Thurs am (0745) -hear a lecture that might just change your practice (like the one recently delivered by Dr. Holland on the disruptive effect of truly implementing a patient-centred care model)! http://deptmed.queensu.ca/blog/?p=952

    Lets give speech and chance!

    • As a fellow dinosaur, couldn’t agree more.
      As the guy responsible for our curriculum, agree the lecture format has great value when used in conjunction with other learning methods, directed to our established learning objectives and when delivered by informed and engaging speakers like Dr. Holland (and yourself).

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