Boy Scouts, Role Models and the Hidden Curriculum

Last Saturday morning, entering our local Loblaws supermarket, my wife and I were confronted by an adorable and entirely engaging boy of about 8 years of age dressed in a Boy Scout uniform.  He handed us a plastic bag and explained in a most earnest and obviously practiced speech that they were collecting for the Food Bank and we were invited to fill the bag during our shopping.  He was polite, articulate, sincere and clear, both about the process and ultimate destination of the donations.  In short, he was utterly irresistible, and we would have been convinced even if his cause had not been so worthy.

As he was speaking, I hadn’t really noticed the gentleman standing behind him, dressed in a version of the same uniform, who now spoke up and greeted me by name.  I recognized Bill Racz, my former Professor of Pharmacology, who had taught me many years ago about adrenergically active medications and the evils of pharmaceutical advertising.  I’ve continued to encounter Bill around campus over the years in contexts ranging from teaching and committee work to our mutual incompetence at noontime basketball at the gym.  In talking to Bill that morning, I learned for the first time that he’s been involved in the Boy Scouts movement for over 35 years.

On the way home, I couldn’t help reflecting on the tremendous generosity of spirit that motivates an accomplished and highly respected academic to donate time and energy to such a community cause and, more importantly, to modeling those values to young people in the most powerful way possible, by actually living the experience.  It’s easy to imagine that young boy one day taking on the same role and passing those lessons on to another generation.

The powerful influence of role modeling in medical education is well appreciated.  Medical graduates invariably recall particular teacher/mentors as much more influential to their eventual development than any curricular element or teaching methodology.  At a medical leadership symposium I attended recently, panelists were invited to individually list key components of effective leadership.  Common to every list was some variation on “lead by example”.  An extensive body of research is emerging on the “Hidden Curriculum”, a term used to refer to all the factors that influence learner development but are outside planned curriculum, arising as a result of observed behaviors and attitudes expressed unintentionally.  What’s becoming clear in the education world, and has always been clear to good parents, is that what we do is much more powerful that what we profess.  Good teachers and good leaders know this and therefore strive to “walk the walk”.

By “walking the walk” that Saturday morning, Bill Racz was providing an invaluable example and living lesson to a group of young boys.  He continues to teach and inspire me.

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Auda abu Tayi would have made a great Course Director

The Academy Award winning motion picture “Lawrence of Arabia”, provides surprising and instructive studies in leadership.   The main character, T. E. Lawrence, portrayed brilliantly by Peter O’Toole, is a junior officer in the British Army during the First World War.  He finds himself unable to conform to a model of leadership that demands unquestioning obedience to superiors of dubious competence, and threatens harsh punishment for questioning authority or any act of “insubordination”.  After being assigned to explore the Sahara desert and seek out alliances with the Bedouins, he encounters Auda abu Tayi, a tribal chief portrayed with equal brilliance by Anthony Quinn.  Lawrence is perplexed by the apparent paradox of Auda’s ability to unify usually rebellious and independent individuals, despite their “uncivilized” state and lack of any traditional military regulations or hierarchical command structure.   In a particularly memorable scene, the two are negotiating in Auda’s luxurious tent.  Lawrence presses Auda, challenging his authority and ability to maintain control of his people.   Auda rises in anger, lists the many wounds he has suffered for his people, points dramatically to the throngs of tribesmen waiting outside, and declares, “I AM A RIVER TO MY PEOPLE”.  The entire tribe, on cue, rises and cheers in agreement.  Lawrence gets the message.  He understands, for the first time, that Auda’s authority stems not from inherited right or fear of reprisal, but from the fact that his leadership is earned by understanding and providing for the needs of those he leads.  He will maintain his influence as long as he provides.

History teaches that every prominent and highly successful leader achieves and maintains authority by understanding and providing for the needs of whatever political or social structure they lead.  Leadership and service are intertwined.  Similarly, every great overthrow or rebellion can be traced to a failure to continue to provide for those needs.

Leadership in a medical or academic context would seem a long way from the Arabian Desert or rebellions, but some intriguing presentations I attended recently at the AAMC annual meeting on the topic would suggest there are similarities worth noting.  Dr. Eugene Washington, a highly respected leader in medical education and Dean of UCLA School of Medicine, lists the following elements as essential to leadership at any level, whether it’s direction of a course, department or entire university:

  1. Leaders create a shared vision of what the organization, or group, is striving to achieve.
  2. Leaders affirm the core values of the organization
  3. Leaders motivate individual members, by finding roles that are of value and interest to both the member and the organization
  4. Leaders achieve a “workable unity” within the organization, which is a commonly held understanding of every member’s role in achieving organizational goals
  5. Leaders manage, which means solving problems and ensuring both fairness and openness in the execution of those solutions.  This also means assuring accountability for all members.
  6. Leaders continually communicate and seek input from their members
  7. Leaders serve as a symbol and lead by example.

This might seem rather lofty and a long way from the role of a Course Director in the Undergraduate curriculum, but I believe these elements are operative in any leadership role, and that any effective change requires solid leadership.  We’ll explore this further in upcoming blogs.  In the meantime, I’d suggest dropping by Classic Video to pick up a copy of Lawrence of Arabia.

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Curricular Goals and Objectives

In an article entitled “The Case for Core Curriculum”, author James Bradshaw raises concerns regarding university teaching that should cause some unease as we consider our medical courses and curriculum.  “The tide seems to be turning”, he writes, “with business leaders lamenting that, although the new talent arriving at their doorsteps has deep technical knowledge, it lacks the skills needed to put this knowledge to full use”. (http://www.theglobeandmail.com/news/national/time-to-lead/why-university-students-need-a-well-rounded-education/article4610406/)

Rather disturbingly, this observation echoes the growing concern among postgraduate training directors and clinical faculty that our graduates seem adept and comfortable providing factual information, but considerably less so when challenged to assess undifferentiated patient presentations and integrate factual information into cogent and practical management plans.  Lest we dismiss such commentary as isolated rumblings, it’s useful to keep in mind that the results for Queen’s graduates on the MCC Part 2 examination would seem to support the contention that our graduates struggle in the domains of clinical reasoning and comprehensive patient management, in sharp distinction to their well above average performance in knowledge-based components of the Part 1 examination.  Although the effects of our revised curriculum and enhanced assessment practices are not yet influencing examination results, it would seem unwise to simply dismiss these observations.

Bradshaw goes on to point out that, at the university undergraduate level, there exist political, logistic and economic barriers to providing integrated educational experiences that address what we, in the medical education context, would term “competencies” rather than traditional discipline-based content.  Indeed, we are well aware of the challenges of blending traditional disciplines and developing both content and assessment that address what many refer to as the “softer skills” relevant to medical practice, such as critical thinking, communication with disparate populations, collaboration, and the ability to advocate effectively for patients, health system delivery, and oneself.

Our curricular goals and objectives, as well as our Competency Framework (see “Curricular Goals and Competency based Objectives”), was developed in 2007 and has served as the central focus for the restructuring of curriculum and assessment methods that has allowed us to both develop a much more effective learning experience for our students, and achieve compliance with all accreditation standards.  The principles it espouses should remain our central guiding force.  However, the observations noted above should cause us to consider whether a clearer definition of the expectations we have for our graduating students is in order, recognizing that many of the competencies we espouse (professionalism, advocacy, communication, collaboration) are not ends in themselves, but necessary components of a graduates “competence” to assess, diagnose and manage patients with a variety of clinical presentations.

I’ll be encouraging a dialogue on this issue at our major committees and among our Course Directors.  This blog seems an appropriate place to start.  Feel free to provide feedback.

 

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Think Different

In 2004, a young securities advisor named Salman Khan began tutoring his 10 year old cousin in basic math.  Despite her obvious intelligence, Nadia was having difficulty academically, was falling behind her classmates, and beginning to believe “I can’t do math”.  He began by talking to her by phone every evening for about an hour.  Between talks, he would send her emails with lessons or exercises to complete.  Before long, Nadia was doing much better in school and, in fact, surpassing her classmates and getting eager to learn more.  In addition, a number of other cousins began to join in on the lessons.  When the number reached about 15, Salman realized he needed a better method to post the lessons.  A friend suggested You Tube.  Although he admitted to a sense at the time that You Tube was “just for videos of cats playing the piano”, he began to use it.  In addition to reaching more of his cousins, this allowed him to develop lessons in other areas of need, such as history, English and general science.  In addition, the lessons started getting picked up by other people worldwide.  He began to develop a somewhat ambitious vision of providing “free education to anyone, anywhere”.  He quit his job to devote himself full time to his rather lofty goal.  The initiative began to grow and catch the attention of some prominent benefactors, notably Bill Gates.

The result of all this is the Khan Academy, a not-for-profit organization with no headquarters but about 40 employees who have developed and posted thousands of video lessons in a variety of subjects that reach about 43 million users world wide and now provide their on-line educational material at no charge in 16 languages.   The lessons are interconnected so that they build incrementally and allow learners to work at their own pace and develop expertise analogous to school courses.  The material has gone beyond individual usage and is now being picked up by school boards to supplement their curriculum.  In most cases, this is leading to a change in the teaching philosophy, since teachers can devote class time to group activities, consolidating experiences, or individual instruction.  Teachers have been particularly impressed with the ability to track individual student progress, and identify various patterns of learning and needs.  There are numerous personal testimonies from adults who had returned to learning after having given up themselves as a result of failure in the traditional school system.

Are there lessons here for medical schools?  I think a few:

  1. We now have technology that allows us to do things in drastically different ways.  Although we don’t have to change because of the technology, we no longer need to feel constrained by traditional models.
  2. The world belongs to those who are willing to set a goal and to engage solutions with an open mind, imagination, and a sense that anything is possible.  Steve Jobs changed the world with the philosophy that we need to  “Think Different”.
  3. We all learn differently, as children, as university students, as adults.  Our methods should identify and encourage those differences rather than limiting learning to those who happen to fit the traditional model.
  4. Learners need to consolidate the basics before moving on to advanced learning.  Khan identified early on that his students were having difficulty in traditional schools systems because the class had to move on to new topics before the basics were completely mastered by all students.
  5. The learning method Khan has developed is not only more effective, but, amazingly, requires less resources and expense to support than the traditional model.

The world is providing opportunities to do things better, and not necessarily by consuming more resources.  We need to Think Different.

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Think Different

In 2004, a young securities advisor named Salman Khan began tutoring his 10 year old cousin in basic math.  Despite her obvious intelligence, Nadia was having difficulty academically, was falling behind her classmates, and beginning to believe “I can’t do math”.  He began by talking to her by phone every evening for about an hour.  Between talks, he would send her emails with lessons or exercises to complete.  Before long, Nadia was doing much better in school and, in fact, surpassing her classmates and getting eager to learn more.  In addition, a number of other cousins began to join in on the lessons.  When the number reached about 15, Salman realized he needed a better method to post the lessons.  A friend suggested You Tube.  Although he admitted to a sense at the time that You Tube was “just for videos of cats playing the piano”, he began to use it.  In addition to reaching more of his cousins, this allowed him to develop lessons in other areas of need, such as history, English and general science.  In addition, the lessons started getting picked up by other people worldwide.  He began to develop a somewhat ambitious vision of providing “free education to anyone, anywhere”.  He quit his job to devote himself full time to his rather lofty goal.  The initiative began to grow and catch the attention of some prominent benefactors, notably Bill Gates.

The result of all this is the Khan Academy, a not-for-profit organization with no headquarters but about 40 employees who have developed and posted thousands of video lessons in a variety of subjects that reach about 43 million users world wide and now provide their on-line educational material at no charge in 16 languages.   The lessons are interconnected so that they build incrementally and allow learners to work at their own pace and develop expertise analogous to school courses.  The material has gone beyond individual usage and is now being picked up by school boards to supplement their curriculum.  In most cases, this is leading to a change in the teaching philosophy, since teachers can devote class time to group activities, consolidating experiences, or individual instruction.  Teachers have been particularly impressed with the ability to track individual student progress, and identify various patterns of learning and needs.  There are numerous personal testimonies from adults who had returned to learning after having given up themselves as a result of failure in the traditional school system.

Are there lessons here for medical schools?  I think a few:

  1. We now have technology that allows us to do things in drastically different ways.  Although we don’t have to change because of the technology, we no longer need to feel constrained by traditional models.
  2. The world belongs to those who are willing to set a goal and to engage solutions with an open mind, imagination, and a sense that anything is possible.  Steve Jobs changed the world with the philosophy that we need to  “Think Different”.
  3. We all learn differently, as children, as university students, as adults.  Our methods should identify and encourage those differences rather than limiting learning to those who happen to fit the traditional model.
  4. Learners need to consolidate the basics before moving on to advanced learning.  Khan identified early on that his students were having difficulty in traditional schools systems because the class had to move on to new topics before the basics were completely mastered by all students.
  5. The learning method Khan has developed is not only more effective, but, amazingly, requires less resources and expense to support than the traditional model.

The world is providing opportunities to do things better, and not necessarily by consuming more resources.  We need to Think Different.

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What We Expect of Our Students. What They Can Expect

This past month the class of Medicine 2016 was welcomed to our school.  As part of that welcome they were provided with a number of presentations from faculty leaders.  Included in those presentations was an articulation of four key expectations of them as medical students at Queen’s.

1.         Devotion – We expect our learners to no longer regard themselves as simply students but as individuals who are embarking in the first stages of their life’s work.  Consequently we expect them to show focus and dedication to their work, not simply to pass exams or please teachers but to learn the body of information that will be relevant to the care of their future patients.

2.         Their Best Effort – The students were told that their selection process assures us that they had the fundamental capacity to learn and practice medicine.  However that will only become a reality if they apply themselves to their studies appropriately. They will require knowledge, skills and personal attributes beyond anything that has been required of them in the past.

3.         Trust – We expect the students to trust that the curriculum is designed with considerable thought and with their learning goals in mind.  In fact every component of our curriculum links to an accepted competency and fits within a deliberately designed continuum of learning.

4.         Respect – We expect the students to be respectful of each other, their patients, volunteers, faculty and their professional status.  It was emphasized that they are under an increased level of scrutiny as representatives of the medical profession and that there will be accountability regarding their general deportment and behaviour.

In exchange, our students were told that they can expect the following:

1.         To be part of a supportive community within the School of Medicine.

2.         That they will receive the best efforts of our faculty to ensure their learning.

3.         That they will be heard. A variety of mechanisms intended to provide both open and confidential communication are provided.

4.         That they will have opportunities to engage a variety of activities that have been developed by faculty and students here at Queen’s to advance their personal and professional interest.

5.         That they will be encouraged to develop individual interests and be provided support whereever possible.

6.         That they will be accorded respect as individuals and as junior members of the profession.

 

 

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education

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Our First Edition

This is the first edition of an initiative intended to provide better communication links to Course Directors and faculty who are teaching in the Undergraduate Program.  InfoMeD will contain updates on curricular initiatives as well as information regarding informational programs and educational material that would hopefully be very helpful to all teachers.  We welcome your input and commentary and will share these with other faculty.

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education

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