Imagine it’s just before 8:30 on a Monday morning in the School of Medicine Building. The class is assembling for the first session of the day – a lecture to be delivered by a clinical faculty member who teaches perhaps 4-5 times each academic year. The session has been prepared based on objectives assigned by the Course Director. This material, they’re assured, is consistent with the course plan and important to the overall learning plan for the class. As the 8:30 mark approaches and then passes, a sense of unease comes upon the room as it becomes clear that only about half the seats will be occupied. The lecturer, conscious of time, needs to get underway and does so, but is unsettled both by the poor attendance and apparent distraction of those students present, all of whom appear more attentive to their individual screens than to the dialogue. The students in attendance pick up on this unease and reflect it in their feedback about the session. The faculty member is left somewhat discouraged and perhaps embittered that their efforts appear to have been spurned by students, who they might perceive as poorly motivated and unappreciative. In short, everybody loses.
This is, fortunately, not a common occurrence in our school, but is an issue that comes to attention periodically, often early in the winter term when learning fatigue and the weather seem to combine to reduce student enthusiasm. When it does occur, it can be quite damaging and threatens to compromise the excellent student-faculty interaction that is otherwise a strength and characteristic of our school.
What’s really going on? It’s a topic, I think, worth some thought and exploration.
Even a quick literature survey (see below) makes it clear we are not alone with respect to this issue, and there’s no shortage of perspectives on causes and solutions.
The lecture has a long and venerable place in the history of medical education. Great physicians of the past such as Harvey and Osler are remembered as much for their lectures and oratory as for their scientific discoveries. Indeed, medical schools and universities continue to recognize excellence through named lectureships.
The classical lecture is unadorned with slides, videos or instantaneous audience feedback. It is, simply, an encounter between a learned, skilled orator and eager, attentive learners. An accomplished lecturer is informative, inspirational, provocative and thought provoking, and is somehow able to weave all these elements into a compelling narrative, capturing the attention of listeners at a very personal level, leaving them satisfied and enriched for the experience. Listeners at such sessions are wholly engaged, with no personal or electronic distractions. The attempt to “multi-task” is irrelevant, and in fact, detrimental to the experience.
Modern approaches to medical education quite rightfully emphasize the importance of active, small group and case-based approaches. At our 2007 accreditation review, our school was strongly criticized for being too “lecture heavy”. At that time, 80-90% of our teaching content was delivered in lecture format. The curricular review group tasked with revising our curriculum in the wake of that review decided (I think wisely) not to abandon the lecture format entirely, but to establish a balance with small group and case-based teaching, which it felt bring great and complimentary value to our students. Our School of Medicine Building was, in fact, designed with the clear intention of providing venues where both lecture and small group format teaching could be provided, even within the same session. Transition was difficult but has resulted in our current curriculum providing about 40-50% of teaching content in lecture format.
To get a clearer idea of this issue at our school, I surveyed the second year class, posing three simple, open-ended questions:
- What do you find most valuable about lectures?
- Why do you attend lectures?
- Why do you not attend lectures?
I deliberately avoided providing pre-stated options and instead asked for narrative responses. Sixty students provided about 200 separate commentaries. Eleni Katsoulas, our Assessment Consultant, and I then carried out an analysis of the responses. The major themes that emerged are as follows:
What do you find most valuable about lectures?
It appears that what students find most valuable about lectures (37% of responses) is that attendance provides some educational value above and beyond what they can get from their own review of the available information. Almost as many (35%) expressed this somewhat differently, in terms of “clarification” of the information, which we interpreted as providing greater understanding about specific points or differentiation of more clinically relevant information rather than deeper understanding. About 20% identified the direct interaction with faculty and ability to ask questions as the most valuable feature. Smaller numbers identified the interaction with their own classmates (6%) as the most valuable feature, and a few (2%) noted the ability to bring real patients into the sessions.
Why do you attend lectures?
The most common responses, by far, were comments related to the concept that attendance at lectures enhanced and deepened learning of the material (64%). About 16% attend lectures as a means of keeping track of the curriculum and not falling behind. Thirteen percent attend for purely social reasons, to interact with classmates. A few (3%) attend only when particular assessments or specific learning events are planned. Another 3% indicate they attend only because they’ve paid tuition to do so and essentially wish to “get their money’s worth”.
Why do you not attend lectures?
The most common reason (44%) students cite for not attending lectures is a belief that the sessions bring not value beyond what they can derive through their own review of the material. Another 29% miss for a variety of reasons that could be termed “personal”, which includes anything from preferring to sleep in, to events or activities that they find difficult to schedule outside lectures times. An additional 20% miss lectures in order to attend other activities they feel are more important to their learning, such as observerships. Three percent note that they have found they simply don’t learn in a lecture format, and another 3% indicate they choose not to attend when they fail to see the “relevance” of the material presented.
Additional comments included several expressions of disappointment on the part of students regarding low attendance, and a desire for video recording of lectures.
So, what are we to make of all this? A couple of key points would seem to emerge from both our results and the literature, perhaps self-evident, but relevant to this issue and probably worth articulating.
The students of today have very different learning needs than those of a generation (or two) ago. Fundamentally, they don’t need to attend lectures to gain pure knowledge or factual information, as did the students of Harvey and Osler or, for that matter, as did many of our current senior faculty. That information is readily available to them. Effective teachers understand this and, in addition to factual information, provide personal insights and novel perspectives borne of their own experience and ideas that enhance and complement the student’s personal learning experience. This “higher level” learning that students speak of can take many forms. It may involve explanation of key and complex concepts, guidance to key sources of reliable information, learning how to “translate” factual information into clinical decision-making, or simply the “real life” picture of how experienced clinicians manage the conditions they’re attempting to learn and understand. Fundamentally, they don’t need us (faculty) to deliver information they can easily and more efficiently obtain in other ways. They’re looking for something more.
The lecture is a very human, and therefore “social” event. This is what gives the lecture its power and potential to be a highly effective learning opportunity, providing something above and beyond what can be attained from any recorded material or electronic format. But this is only true if the format is appropriately utilized. From the perspective of faculty, this brings considerable responsibility, and probably some significant stress. They are the centre of attention. The lecture basically excels or fails on their “performance”. Moreover, their “real time” presence at the event requires them to be personally invested in the event, and allows them to interact with the listeners, sense their receptivity to the material, vary their approach, and respond to individual questions. What they provide, in essence, is something very personal, and much more valuable than simple recitation of facts and information.
Students, for their part, also contribute to the success of the lecture by not simply showing up, but by truly attending and participating actively. They must recognize that they get maximal value (the “higher level learning”) by being actively engaged and listening carefully not simply for the factual information, but for added insights the faculty member is able to provide.
In a greater sense, we might regard all this in the context of the Information-Knowledge-Wisdom paradigm. Information consists of all the factual content and points of understanding that are essential to the practice of medicine. The essentials of anatomy, physiologic processes, pathologic conditions and clinical examination would be examples relevant to the study of medicine. Knowledge can be defined as the accumulation of key information, in a manner that allows it to be used for a specific purpose. Learning how to manage a patient presenting with a particular clinical condition requires such accumulated and integrated knowledge. Wisdom is the ability to make correct judgments and decisions. In medicine, it can be considered the ability to decide whether established approaches are appropriate in a particular patient, or how to approach a specific patient when diagnosis is elusive or established approaches are not available. Wisdom derives from a combination of personal attributes, much accumulated knowledge/expertise, and acquired experience. Albert Einstein once said, “wisdom is not a product of schooling but of the lifelong attempt to acquire it.”
The educational process can be thought of as progressions through those three stages of learning as illustrated below:
In medical education, they clearly overlap, but the first two years of medical school can be considered as largely devoted to developing the information component, with some development of knowledge-based approaches to clinical illness. Clerkship and residency further develop and refine the knowledge component and, hopefully, begin the process of developing wisdom. The development of wisdom, of course, never ends, and never reaches perfection. In fact the three components are perhaps better illustrated in this way:
Getting back to the lecture issue, its true place can be considered as providing a means to impart the knowledge and wisdom components of medical practice to the novice learner. That may be its greatest power, and greatest purpose.
The lecture, I would conclude, has evolved and must continue to evolve with the needs of our learners, but has a unique and valuable role in medical education. It is important that both students and faculty understand and actively engage its purpose if it’s full educational potential is to be realized.
A final, summarizing message to our students on this topic might be to remind them of a well-established adage:
“Knowledge speaks, but wisdom listens”
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Many thanks to Eleni Katsoulis, UGME Assessment Consultant, for her valuable assistance in the compilation of information for this article.
Further reading suggestions:
- Charlton BG. Lectures are an effective teaching method because they exploit human evolved “human nature’ to improve learning. Medical Hypotheses 2006; 67:1261.
- Dolnicar S. What makes students attend lectures? The shift towards pragmatism in undergraduate lecture attendance. Conference proceedings of the Australian and New Zealand Marketing Academy. 2004. (http://ro.uow.edu.au/commpapers/81)
- Massingham P, Herrington T. Does attendance matter? An examination of student attitudes, participation, performance and attendance. Journal of Univeristy Teaching and Learning Practice 2006; 3: 82.
- Harvard Initiative for Learning and Teaching. 2014. Lecture attendance research: Methods and preliminary findings. http://hilt.harvard.edu/files/hilt/files/attendancestudy.pdf