Of Robots, Worms and Youthful Inspiration

The Day the Earth Stood Still is a science fiction movie released in 1951. Filmed entirely in black and white, it is based on a 1940 short story by Harry Bates entitled Farewell to the Master. The story involves an alien visitor to earth named Klaatu, portrayed by Michael Rennie. The real star of the show is an eight-foot tall, death-ray-emitting robot named Gort who accompanies Klaatu. As one might imagine, mayhem ensues.

I was recently surprised to learn that it’s possible to connect that motion picture with the sophisticated systems that are rapidly developing and being used in robotically assisted surgery. As someone who grew up being told reading and viewing science fiction was a waste of time, this was of some interest to me.

That connection begins with one Victor Scheinman.

Mr. Scheinman, who grew up in New York City, recalls being terrified of Gort after seeing The Day the Earth Stood Still for the first time at the age of 9. He hid in his bed, unable to sleep due to nightmares in which he would imagine the robot standing in his room. His father, a psychiatrist who practiced in Manhattan and taught at Columbia, advised him to build a model of the robot as a means of dealing with his fears. In doing so, Mr. Scheinman began to develop mechanisms to animate the arms and legs of his models. This led to a variety of projects that were encouraged by his parents and teachers, and to a series of entries and prizes in various science fairs. He went on to earn admission to the Massachusetts Institute of Technology at the age of 16.

His work at MIT and then Stanford eventually led to development of “The Stanford Arm”.

Victor Scheinman with a hydraulic arm built in Stanford’s artificial intelligence lab Credit: Bruce Baumgart/Stanford University Archives

 

In her book, “The Robot: The Life Story of a Technology” (2007), Lisa Nocks, writes:

“In contrast to heavy, hydraulic, single-use machines, his Stanford Arm was lightweight, electric, mutliprogrammable, and could follow random trajectories instead of fixed ones. Scheinman showed that it was possible to build a machine that could be as versatile as it was autonomous.”

The technology was picked up and advanced by Joseph Engelberger and George Devol who formed Unimation in 1977, the world’s first robotics company which, with support from Scheinman and General Motors, developed the Programmable Universal Machine for Assembly (PUMA), the prototype of which now resides in the Smithsonian Institution. The PUMA was quickly introduced to the automotive industry revolutionizing the assembly line process. The 200 and 500 series PUMAs are of “desktop” size and therefore applicable to surgical applications. The first recorded applications were for assisting brain biopsies in 1985. In 2000, the daVinci surgery system became the first robotic system approved by the Food and Drug Administration. A key development that allowed for approval involved improved, high resolution and three-dimensional imaging that allows the operator to utilize the mechanical arms without laparoscopic guidance.

And so, much has developed from youthful imagination, creativity and energy, suitably nurtured and allowed to develop.

Recently, we’ve seen what might be the beginnings of another such example. Reports describe the very impressive accomplishments of four young people from Toronto. Beginning with an idea inspired by her grandfather’s illness, young Annabel Gravely decided to devote her eighth-grade science project to investigating causes of muscle deterioration in Amyotrophic Lateral Sclerosis (ALS). Hypothesizing a link with the muscle loss in ALS and that which is known to occur during prolonged periods in space, Gravely and her schoolmates (Alice Vlasov, Amy Freeman and Kay Wu) proposed to send a tube of microscopic worms (Caenorhabditis elegans, for those of you taking notes) into space aboard the International Space Station in order to examine the effect of zero gravity on the worms and particularly on the activity of a specific enzyme sphyingomyelinase (ASM) known to be linked to ALS.

 

 

(http://www.cbc.ca/news/canada/toronto/worms-space-science-students-1.4766124).

 

Dr. Jane Batt, a respirologist and scientist at St. Michael’s Hospital, learned of their interest and provided them space in her lab to carry out preparatory work, as well as connections with the space agency. All this resulted in a cannister of worms spending a ten-week sojourn aboard the space station, after which it was found they not only survived quite nicely in space, but were longer and larger than their earthbound control group, and expressed lower levels of ASM. Although the link between ASM and ALS associated muscle loss is not yet clear, the findings support further investigation, and were published last month:

Young Ms. Gravely (now 16 years old) and her colleagues have their first publication citation.

 

And so, we have two accounts of youthful inspiration, one arising in response to an imaginary threat, the other from the memory of a beloved grandparent. Both bring much credit to the young people involved and remind us that age need be no barrier to creative thinking and dedication to a goal. However, the significance of these success stories goes far beyond the young originators themselves.

Potentially groundbreaking ideas, like seeds cast into the air, must find fertile ground if they’re to flourish. Scheinman and Gravely were able to find such fertile ground in the support and encouragement of their families, schools and communities without which their brilliant insights might have never come to fruition.

Transformative innovation can be thought of as applied inspiration. The originating idea is necessary, but insufficient if not supported.

In the world of medical education, we encounter many potential Scheinmans and Gravelys, who experience their own moments of inspiration. Given the “busyness” and apparent urgency of our educational and clinical lives, it’s easy for them, and for us, to let those opportunities pass in favour of achieving more immediate short-term goals. From time to time, it serves to be reminded that great achievements can start from rather humble origins – such as scary science fiction movies and microscopic worms.

 

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Don’t skip over getting ready

When I was a teenager, my Dad had a poster in his high school vice-principal office that featured a picture of a bird’s nest with blue eggs in it. The caption read: “most of life is getting ready.”

I really didn’t like that poster because it was all about patience and I was all about getting on with the next thing. I was always about what comes next: finish high school, go to university, get the job.

It took a long time for those lessons in patience to sink in and for me to accept that much of life is getting ready. And a lot of the getting ready is hidden, behind the scenes, like what’s going on in those blue eggs in that poster’s nest.

It’s a lot like how we spend our summers when we’re involved in teaching that follows the traditional academic year cycle (which excludes our clerks and clerkship faculty who learn and teach year-round).

At UG, especially for the upcoming pre-clerkship academic year, we spend a lot of the summer getting ready. The Education Team, Course Directors and teaching faculty are looking at course evaluation reports and looking at where improvements and changes are needed. The Curricular Coordinators are getting everything set in MEdTech so things run smoothly. And a multitude of other behind-the-scenes support team members are quietly getting on with getting ready. While the end results of all this preparation are evident, the tremendous amount of work involved usually isn’t.

For planning purposes, we need to think ahead, look at the big picture and always be thinking of the next thing. But for teaching and learning, being in the moment matters, too. And, sometimes, you’re in the moments that are about getting ready.

Sometimes we dismiss the “getting ready” stage as a holding pattern, as mere waiting. It’s not the “good stuff” or the “important stuff”. But getting ready is every bit as important as what comes next. Without getting ready, the good stuff can’t happen.

Think about the last big celebration you took part in (maybe for a birthday or special holiday). Did it involve presents? Did you take some time to find the perfect gift, picking out wrapping paper and bows, maybe a special card? Did the recipient take a moment to appreciate that effort or tear right in? Maybe you were the recipient. Did you savor the moment, or dive right in? My Mom always insisted we read the card first, how about you? Regardless of slow savoring or exciting unwrapping, it was a special moment, that made the preparation – the getting ready – worth it.

Sometimes getting ready is taking a breather (as we hope our pre-clerkship students are doing with their summer!) or augmenting skills, and sometimes is doing all the necessary preparation to make things run smoothly for the “big” event. It’s important to recognize that, from a pedagogical perspective, this getting ready – either course prep, or “introduction to” instruction – isn’t wasted time, but necessary steps along the way.

So be in the moments of getting ready.

Meanwhile, we’ll get back to work reviewing course evaluation feedback, revising preparatory materials and SGL sessions. Looking at which learning event worked well and which need some tweaking and which need a major overhaul. Are assessments well-mapped to learning objectives? Is the rubric clear or can we improve that? What about annotating those objectives….

(And, as always, if you’re in need of help with any of the above, get in touch. We’re here to help).

 

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This post is about nothing

I discarded quite a few topics for this week’s post as I didn’t want to “waste” a key topic on the “downtime” for many of our faculty and students of the summer break between semesters (excluding all those students and faculty involved in Clerkship, of course).

Sure, I could write about learning objectives, and active learning strategies, or assessment tools and rubrics, but these informational items would likely be missed by quite a few people off on summer pursuits.

And, really, I want you to miss them as anyone’s holiday break (however long or short) should be used to pursue as little as possible. A few years ago, when I was teaching at Loyalist College, I had students ask me what I wanted them to work on over a holiday break. It turns out my colleagues had given several detailed assignments. Firmly believing in the need to relax and recharge, I told them I wanted them to sleep in and eat cookies for breakfast. (I got pretty good instructor evaluations that year; I hope it wasn’t just about the cookies).

So for this post, I thought to myself: “I should write about the benefits of doing nothing”. A short Google search later, I’ve discovered this is hardly a unique idea – and there’s evidence-based research to back up these benefits.

In fact, in a 2014 Forbes article, Manfred Kets De Vries pointed out that “slacking off and setting aside regular periods of ‘doing nothing’ may be the best thing we can do to induce states of mind that nurture our imagination and improve our mental health”.

An Australian blogger drew attention to a study by Bar-Ilan University that demonstrated that daydreaming correlates with performance. “They found a wandering mind does not hamper the ability to accomplish a task, but actually improves it by stimulated a region of the brain responsible for thought-controlling mechanisms.” (Read more about that study here.)

Other research points to relaxing (i.e. doing nothing) being good for your heart, fighting the common cold, maintaining a healthy weight, sleeping better, and contributing to improved mental health.

Pico Iyer, author of The Art of Stillness: Adventures in Going Nowhere wrote of the virtue of doing nothing in a 2014 CCN article. He noted: “It’s an old principle, as old as the Buddha or Marcus Aurelius: We need at times to step away from our lives in order to put them in perspective. Especially if we wish to be productive.”  (Watch his Ted Talk, where he emphasizes the benefits of stillness, here: https://www.ted.com/talks/pico_iyer_where_is_home)

So, the next time I post, I’ll have more tips and tools for your educational toolbox. In the meantime, focus on wellness and, well, doing nothing. You can start with this slide show of Ten Ways to Enjoy Doing Nothing.

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Dynamic Learning Environments – not just for academic centres

Several years ago, the Association of American Medical Colleges (AAMC) developed and publicized a statement on the learning environment.

 

The statement nicely articulates three key points about effective medical learning environments:

  • Medical education and exemplary patient care go hand-in-hand.
  • They feature a pervasive atmosphere (dare I say “culture”) of mutual respect and collaboration on the part of all involved in the delivery of patient care.
  • Everybody involved is both a learner and a teacher, and feel free and comfortable in both roles.

Lofty goals and expectations, to be sure. In fact, the skeptical among us may consider these to be merely aspirational statements, expressing unachievable ideals.

I’m pleased to report that this is not the case. In my experience, I often encounter learning environments that are nicely meeting those lofty goals. Most commonly, these are in large teaching hospitals where available resources, space and academic focus combine to produce close-to-ideal learning environments. Recently, I had the opportunity to see similar success in a much smaller site.

I attended the Third Annual Georgian Bay Healthcare Wellness Research and Innovation Day held at the Collingwood General and Marine Hospital.

 

Organized by Collingwood Chief of Staff Dr. Michael Lissi and supported by Dr. Peter Wells and Program Manager Michelle Hunter of the Rural Ontario Medical Program, this year’s theme was Geriatrics and involved a thoughtful panel discussion followed by a series of very well-qualified and engaging speakers.

 

The hospital cafeteria, re-purposed for the occasion, was standing-room-only as about 150 folks from all areas of the health care community, as well as interested local residents, packed the room and contributed to the discussion. The sessions were live-streamed to several sites.

In addition to the presentations, hospital corridors were used to feature about 60 posters featuring studies carried out by local practitioners and learners working in the community.

I was there largely because two of our students who are in Collingwood completing placements.

Meds 2019 students Daniel Weadick and Claire Tardif

Claire Tardif and Daniel Weadick of Meds 2019 are, by all accounts, both enjoying the experience and learning a great deal. They’re integrating well into that local learning environment, working with multiple physicians, other learners and health care providers. Dan summarized it all rather effectively. In his own words “there’s a lot to like”.

 

For me, the whole experience was a little surreal. Having grown up in Collingwood and worked in the various jobs in and out of the local hospital, I found myself reviewing posters and meeting local physicians in the same rooms and corridors in which I’d made deliveries and portered patients many years ago.

 

 

 

Medical education theorists have described the learning process in many ways, but all agree that the knowledge and skills

with conference organizer and Collingwood Hospital Chief of Staff and surgeon Dr. Michael Lissi

learned through largely classroom and simulated settings are insufficient unless integrated and applied to real patients. That process of application must be progressive, beginning with highly supervised settings where learners can begin to experience clinical care and decision making in safe and nurturing environments, while at the same time allowing them to progress to increasing levels of independence as their skills and growing confidence allows. For the medical student, highly-structured and learner-dense academic hospital settings are certainly valuable and essential, but may provide unintentional “ceilings” to professional development, and limit the appreciation of continuity of care that occurs outside the specialized ward and is so critical to patient outcomes. Community placements in smaller centres can complement their learning by providing that context.

 

In the end, medical education is fundamentally about providing and identifying environments where motivated, talented students can encounter generous and welcoming practitioners in settings that strive to provide excellent patient care and learning for all involved.

 

I’m pleased (and perhaps a little proud) to say that my home town is one of those places.

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The Twelve Roles of Teachers

(This post summarizes key points from AMEE Guide No 20: The good teacher is more than a lecturer–the twelve roles of the teacher by R.M. Harden & Joy Crosby)

In our talk of teaching, we often focus quite narrowly on classroom-based teaching – team-based learning (our SGL) and lecturing – and on clerkship seminars and bedside teaching. By doing so, we can overlook some of the other roles required in medical education.

In fact, there are 12 roles of teachers in medical education and each is worth exploring.

Harden and Crosby (2000) identified these 12 roles based on their analysis of “the tasks expected of the teacher in the design and implementation of a curriculum in one medical school”; a study of “diaries kept by 12 medical students over a three-month period”, which analyzed their comments on teacher roles; and from other literature on the roles of teachers in medical education (p. 336). They then validated the 12 roles they identified using a questionnaire completed by 251 teachers at the University of Dundee Medical School.

Harden and Crosby grouped their 12 roles into six areas of activity (two roles each) and further noted which roles required medical expertise and which teaching expertise and which involved direct student contact, with the remaining with students at a distance to the activity.

How many of these areas of activity and roles do you recognize in your own teaching practice?

Information provider – lecturer, clinical or practical teaching

“The teacher is seen as an expert who is knowledgeable in his or her field, and who conveys that knowledge to students usually by word of mouth,” they note, pointing out in all contexts the teacher selects, organizes and delivers information.” They stress that “The clinical setting, whether in the hospital or in the community, is a powerful context for the transmission, by the clinical teacher, of information directly relevant to the practice of medicine.” (p. 337)

Role model – on-the-job role model; teaching role model

“Students learn by observation and imitation of the clinical teachers they respect. Students learn not just from what their teachers say but from what they do in their clinical practice and the knowledge, skills and attitudes they exhibit,” Harden and Crosby wrote (p. 338). This role modelling extends to classroom-based activities, too:  “The good teacher who is also a doctor can describe… to a class of students, his/her approach to the clinical problem being discussed in a way that captures the importance of the subject and the choices available.” (p. 339)

Facilitator – learning facilitator; mentor

“The introduction of problem-based learning … has highlighted the change in the role of the teacher from one of information provider to one of facilitator. The teacher’s role is not to inform the students but to encourage and facilitate them to learn for themselves using the problem as a focus for the learning.” (p. 339)  Harden and Crosby note that the mentor role, while highly valued “is often misunderstood or ambiguous” (p 339) but suggest “the mentor is usually not the member of staff who is responsible for the teaching or assessment of the student” and that “Mentorship is less about reviewing the student’s performance in a subject or an examination and more about a wider view of issues relating to the student.” (p. 339)

Assessor – student assessor; curriculum evaluator

“The assessment of the student’s competence is one of the most important tasks facing the teacher,” they note. “Examining does represent a distinct and potentially separate role for the teacher,” they added, noting: “It is possible for someone to be an ‘expert teacher’ but not an expert examiner.” (p. 340)

“Monitoring and evaluating the effectiveness of the teaching of courses and curricula is now recognized as an integral part of the educational process. The quality of the teaching and learning process needs to be assessed through student feedback, peer evaluation and assessment of the product of the educational program.” (p. 340).

Planner – Course organizer; curriculum planner

For Harden and Crosby, curriculum planning and organizing courses goes hand-in-hand. The note that “Curriculum planning presents a significant challenge for the teacher and both time and expertise are required if the job is to be undertaken properly” (p. 341) while being an essential first step. This is closely followed by the importance of planning on the individual course level:  “The best curriculum in the world will be ineffective if the courses that comprise it have little or no relationship to the curriculum that is in place. Once the principles that underpin the curriculum of the institution have been agreed, detailed planning is then required at the level of the individual course.” (p. 341).

Resource developer – study guide producer; resource material creator

The increasing importance of the role of resource material creator helps students navigate in increased amount and quality of information available. “With problem-based learning and other student-centred approaches, students are dependent on having appropriate resource material available for use either as individuals or in groups.” (p. 341). The role of curator, through structured study guides, also helps navigate these resources: “Study guides…can be seen as the students’ personal tutor available 24 hours a day and designed to assist the students with their learning. (p. 341).

 

At different times, you may be called upon to fill any or all of these roles. If you’re interested in exploring any of them further, get in touch. I’m here to help you with all aspects of your teaching practice.

 

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Lectures aren’t inherently bad

In a pedagogical quest for active learning, we’ve somehow cast lectures in the role of arch-villain.

I’ve had conversations with faculty about their teaching which have started out with: “I know lectures are bad, but…”

This is definitely the case of a pendulum swinging too far. While research definitely supports active learning as the optimal way for students to retain learning – applying new knowledge either to simulated or real scenarios – the initial learning has to come from somewhere, and lectures are one of these sources.

Because of our focus on improving small group learning/TBL sessions in our curriculum, I can seem to be anti-lecture. The truth is, I’m actually a closet lecture aficionado. I own DVDs and CDs from The Teaching Company’s “Great Courses” series and love CBC’s Ideas. And the proliferation of podcasts has fed my love of lectures even more, as podcasts are nothing if not fabulous lectures. And TED Talks, who hasn’t lost a few minutes to those? Really, the world loves a good lecture.

Lectures absolutely have a place in universities in general and in medical education specifically. While we can’t – and don’t want to – return to a curriculum with 100% (or near to it) lectures, we can keep great lectures in our menu of methodologies to provide students with optimal learning experiences.

If you’re planning a lecture, or looking to improve an existing one, here are some things to consider:

Why do you want to do a lecture?

It’s ok if it’s just your first instinct, but think beyond that. Is this the best way to convey your content? How will providing this content in a lecture format enhance students’ learning?

Are you comfortable with the mechanics?

Lecturing is a skill which improves with practice. There are certainly standard “do’s” and don’ts”. For example, Don’t read your own slides; don’t keep your nose down in notes. And the classic: Don’t be boring. If you aren’t comfortable, do you have a plan to improve?

How can you keep things fresh and interesting for an hour or more?

Research on attention habits tell us that after 20 minutes of sustained listening, it’s hard to stay focused. With this in mind, how can you pace you lecture to break things up? Consider things like polls (with our PollEverywhere account), short think-pair-share activities, or other creative ideas. At least one instructor I know shows short topic-related videos and has the class stand up to watch them to get everyone out of their standard sitting positions.

What’s your follow-up plan?

If you think of lectures as content delivery, what’s your plan for students to be able to apply this new knowledge? Does your lecture lead into an application session in your own course or in another one? If you’re not the instructor for the follow-up session, be sure to coordinate with the person who is.

As with all your teaching endeavours, you’re not on your own. Get in touch – I’m here to help!

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Wolves among the sheep

How does a nurse, working in public hospitals and nursing homes, manage to murder frail, elderly patients without detection?

How does it go on for 20 years, resulting in the deaths of eight patients under her care?

Why did it only come to attention and stop when the perpetrator herself confessed openly to the crimes?

These questions are the focus of an inquest commissioned to investigate the actions of Elizabeth Wettlaufer, a former nurse now serving a life sentence for the crimes to which she has confessed.

The inquest is scheduled to release its final report this summer, but documents recently released reveal a number of very sobering facts that should concern any health care professional and, particularly, those with leadership or administrative positions:

  • She was fired from her first nursing job in 1995 for stealing medications. However, following intervention by her nursing
    Dave Childes – Canadian Press

    professional association, the firing was noted officially as a voluntary resignation.

  • Between 2007 and 2014, while working at the Caressant Care centre in Woodstock, Ms. Wettlaufer was reprimanded no fewer than nine times for medical errors and general incompetence, refused recommendations to take leaves of absence and ignored threats from her colleagues that her increasingly suspicious behaviour would be reported to her licensing body.
  • She was finally fired in 2014. That firing was again officially noted as a voluntary resignation after her union intervened. As a result of that settlement, Ms. Wettlaufer actually received $2,000 and a letter of recommendation.
  • Between 2007 and 2014, while all these concerns were under review, she continued to kill residents of the Caressant Care centre by administering lethal doses of Insulin.
  • On two occasions, the coroner’s office was notified about deaths at chronic care facilities where Ms. Wettlaufer worked. No autopsies or investigations were ordered.

If Ms. Wettlaufer had not voluntarily confessed her crimes, they might never have come to attention. She has recently spoken out about loose regulatory processes governing the use of Insulin which made it possible for her to administer overdoses without detection.

This is, regrettably, not the first instance of a health care provider using a position of trust to facilitate murder.

Harold Frederick Shipman was an English physician, considered one of the most prolific serial killers of all time. In January of 2000 he was found guilty of killing 15 patients under his care and sentenced to life imprisonment, but a subsequent inquiry linked him to over 250 murders over his thirty year career. It seems that, in retrospect, numerous warnings of misbehaviour were ignored, including the fact that one of his first victims, an elderly lady previously in good health who was found dead only a few hours after a visit from Dr. Shipman, had recently changed her will to bequeath her entire fortune to him. In fact, most of his patients were in good health prior to visits with him during which injections were administered. It appears that at least three of the murders were directly witnessed by other personnel but nonetheless went unreported.

 

 

Joseph Michael Swango is an American who is currently serving three consecutive life sentences imposed in the year 2000 for the murder of patients who were under his care while he was practicing as a physician. It now appears he was responsible for as many as 60 fatal poisonings of both patients and colleagues. In retrospect, it is clear that there were signs of very troubling behaviour during medical school. Although considered intellectually brilliant, he exhibited a fascination with dying patients, to the extent of preferring to work as an ambulance attendant rather than going to his classes. It was found at one point that he had submitted falsified documents regarding completion of required tasks. Numerous fellow students and faculty raised concerns about his behaviour and honesty. He was nearly expelled but was allowed to stay on because one member of a review panel felt he should be given a chance to remediate. He was allowed to graduate one year after his entering class and, despite a very poor evaluation in his dean’s letter, secured a surgical internship. While on clinical rotations, nurses had reported multiple instances of apparently healthy patients dying mysteriously while he was on duty. On one occasion, he was caught injecting a substance into a patient who subsequently became very ill. Despite these warnings, no major sanction was imposed, although the program revoked its residency offer. He went on to work as a paramedic and laboratory technician. By changing his name and falsifying documents he was able to get into a variety of different residency programs at medical schools across the United States, and therefore work as a physician, all the time murdering both patients and co-workers, usually with injections of arsenic. The American Medical Association eventually did a thorough background check on one of his applications and uncovered the pattern of previous incidents. As a result, all 125 American medical schools and over 1,000 teaching hospitals were alerted to his identity and record. Effectively blacklisted from further residencies, he fled to Africa where he secured positions and continued to commit murder. A very complex and thorough investigation eventually led to his extradition, indictment and conviction.

These are, mercifully, very rare and extreme examples. However, they remind us that the intelligent sociopathic personality may find the medical or nursing professions ideal environments to prey on the innocent and satisfy the craving to kill. They also remind us that the patterns of deviant behaviour start early and without major impact until fully empowered. Set amongst trusting patients and innocent, often naive colleagues who would have difficulty even conceiving such behaviour, these monstrous individuals are like wolves among sheep. They may also benefit from the well-meaning protection of colleagues and supervising faculty whose first instinct will always be to help and cure rather than condemn. As in the case of Ms. Wettlaufer, they may also benefit from professional organizations and legal processes that put the interest of the individual above potential impact on current and future victims. Unless counterbalanced by administrations and leadership willing to undertake legal challenges and defend the broader interests of the public, profession, and future patients, these behaviours can go unchecked.

The upcoming inquest report will surely identify several points at which our processes failed to act and put an end Ms. Wettlaufer’s serial murders. However, there are lessons here for us all who are involved in medical education. The degrees and qualifications we bestow convey an assurance to licensing bodies, institutions and the public that the individuals who hold them are not only knowledgeable and technically qualified, but also trustworthy. We must be vigilant with respect all those considerations, and be prepared to defend the integrity of our educational and evaluative processes. Our responsibilities extend beyond the individual learner, to the public and to potential future patients.

We must never set wolves among the sheep.

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Learning style quizzes are fun, but they shouldn’t inform teaching

When I completed my Bachelor of Education in the late 1990s, we spent a fair amount of time on learning styles. We explored Kolb’s styles (assimilator, diverger, accommodator, converger) and the VARK model (Visual, Auditory, Reading, Kinesthetic), and ones that incorporated relational aspects (social, independent, introvert, extrovert) in a quest to enhance our skills as educators to best meet our future learners’ needs.

It was presented as a “keys to success” insight – learn how to teach to each student’s preferred style, learn how to modify your instruction to meet every learner’s need, and all would be good.

From the learner’s perspective: figure out how you best learn, seek out learning experiences like that and voila – educational success.

We’ve heard this so often, from multiple avenues, that many of us accept it as an established principle rather than theories. (Just do a Google or an Amazon search and hundreds of sites and books will pop up).

A typical learning style inventory questionnaire and score sheet.

Human beings certainly have preferences – in learning and in all things. I really enjoy lectures. I like listening to someone else talk about an interesting topic and share knowledge and insights. I’ve had the pleasure of having some terrific history teachers, for example, who made things come alive in their storytelling. I learned a lot.

It was, in fact, an experience with a history course that helped me embrace the learning style message and hold it sacred for many years. I loved history and did really well in my high school courses without, I’ll admit, having to try very hard. Except for the unit on the Napoleonic Wars in Grade 11. I was away that week, at a conference, so instead of being in class for about an hour every day, I had the assigned chapters and the teacher gave me copies of his lecture notes. And I bombed the test. Being an auditory learner explained this. I hadn’t heard Mr. A’s lectures, so I didn’t learn as well. It made me feel better about my barely-passing grade, but was it true?

How did I usually learn history? I’d attend the classes (and take notes), read the assigned chapters, and reread my notes to study for the test. How did I do the unit on the Napoleonic wars? I read the assigned chapters and read my teacher’s notes. I actually spent about 50% less time on the unit than any other history unit that year. And I never took my own notes on that unit. Am I really an auditory learner and therefore didn’t test well on something I had to learn differently, or did I spend less time learning this material? Perhaps if I’d read the assigned chapters twice, or taken my own notes, or something else. Auditory learner doesn’t fully account for all variables.

Granted, I’m an n=1, but there’s an increasing body of research (with larger cohorts) that points to learning styles being a “myth”. Myth or not, there’s evidence that using a preferred learning style doesn’t lead to more or better learning. For example, Hussman and O’Loughlin (2018) found no correlation between learning styles and course outcomes for anatomy students, regardless of whether the students adapted their studying to align with their preferred learning style.

Knoll et al (2017) found that “learning style was associated with subjective aspects of learning but not objective aspects of learning.”

The other message in many of these studies: Context is key. Consider my history/auditory learning example, above. Lecture alone would not have gone over so well in an art history class. I may prefer to learn by listening, but isn’t it better to see the paintings rather than have someone describe them? Likewise, even if all the quizzes tell you that you’re an auditory learner, it’s a good bet that it still makes the most sense to learn about radiology using images. And procedural skills are best learned by actually physically engaging in them.

One on-going challenge of the cult of learning styles is it can become an excuse when students don’t master material (“The class didn’t suit my learning style” or “I need to better address students’ learning styles, how do I do that?”). However, a meta-analysis study by Hattie (2012) looked at 150 factors that affect students’ learning and matching teaching techniques to students’ learning styles had an insignificant effect (slightly above zero) (Hattie, 2012:79).

It’s good to remember that, as physicians, our students will have to learn and perform in a variety of ways (styles): reading, listening to people, looking at images of some sort or at patients when examining them, and use their tactile senses when examining patients, as some examples. Teaching them in a variety of ways, rather than using narrowly-focused learning style criteria, can only help them achieve this.

Key take-away points:

  • There are a variety of ways to learn and to teach and context matters
  • Some things are best taught in a particular way
  • We can have preferences for some learning experiences more than others, but we can learn in multiple ways
  • Your preferred learning style may not improve your learning
  • History lectures are always cool.  (They are, but that’s not relevant to this topic, really).

Note on classroom accommodations: Any discussion of learning styles and learning style research should not be confused or conflated with accommodations for learning disabilities or accommodations for physical disabilities which interfere with learning


My thanks to Dr. Lindsay Davidson, Director of Teaching and Learning, for talking through some of the ideas presented in this post.

References:

Hattie, J, 2012, Visible learning for teachers: maximising impact on learning, London, Routledge

Husmann, P. R. and O’Loughlin, V. D. (2018), Another nail in the coffin for learning styles? Disparities among undergraduate anatomy students’ study strategies, class performance, and reported VARK learning styles. American Association of Anatomists. . doi:10.1002/ase.1777

Knoll, A. R., Otani, H. , Skeel, R. L. and Van Horn, K. R. (2017), Learning style, judgements of learning, and learning of verbal and visual information. Br J Psychol, 108: 544-563. doi:10.1111/bjop.12214


Other cool reading on this topic:

From Frontiers in Psychology: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5366351/

From The Atlantic:

https://www.theatlantic.com/science/archive/2018/04/the-myth-of-learning-styles/557687/

From the BBC:

http://www.bbc.com/future/story/20161010-do-we-have-a-preferred-style-of-learning

 

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Improving your medical teaching practice one minute at a time

Making changes in how we do things can seem overwhelming – whether these are personal wellness habits, work habits, or teaching practice habits. In the face of a huge list or a major innovation it can seem easier to throw in the towel before you begin.

Sustaining change means adopting new practices and habits that you can stick with.

I recently took a six-week online fitness course that focused on these types of incremental changes. The course is designed for working and stay-at-home moms and recognizes that everybody is really, really busy. Our first challenge was to pick a new habit to adopt that could be easily incorporated into our regular day (I chose skip the elevator—take the stairs). Another challenge was to adopt a one-minute daily task and stick with it – because, as the course leader pointed out: everybody has one minute. I (finally) started doing daily balancing exercises for my multiple-injury-damaged ankles. I’m five weeks in on that new daily one-minute habit, so I think it’s going to stick.

Along the way, I started thinking about one-minute habits and how this could apply to medical education. So here’s my challenge to those looking to improve or change their teaching practice:

Think of one thing that you can do in one minute (a day, or one minute at a time) that could improve your work in medical education. Adopt that one-minute habit. Here are some suggestions:

  1. Immediately after teaching, take ONE MINUTE to jot down quick notes on what you want to change the next time you teach. Do it right after your session, or you may forget what it is.

  2. Create a Med Ed “feel good file” in Google docs or another electronic format (this might take more than a minute): put in things like great feedback fro course evaluations, notes to yourself when something went really, really well with a class or a clerk, notes on teaching things you’re really proud of. If you’re having a bad (teaching) day, pull up the file and take ONE MINUTE to remind yourself of the good things you do as a medical educator.

  3. Reserve the last minute of class, seminar, or rounds to get two-sentence student feedback on index cards – what’s their top take-away from your session/seminar/rounds and what’s their muddiest point right now? Have them take ONE MINUTE to give you this feedback. Over the next week, take ONE MINUTE a day to read through some of the cards. Use the feedback to inform changes to your teaching or to shape a follow-up session.

  4. If you’re logged into MEdTech, take ONE MINUTE to annotate your session objectives on MEdTech. You likely already have these objectives in your PowerPoint slides, so you can just match them up to the assigned ones. (If you have multiple objectives, use your ONE MINUTE to do what you can now!)

  5. Start a teaching ideas journal (could be a notebook, or a word file, or the Notes app on your smart phone). After you’ve read a journal article, or talked with a colleague, or attended a workshop, take ONE MINUTE to write down ideas for how to incorporate this new information into your teaching

  6. Email or phone me and ask for help. No, seriously, do this. True story: While I was writing this post, a faculty member called and said: “Do you have one minute right now for a question?” We might not solve your challenge in a ONE MINUTE phone call, but if not, we can set a time to get together.

Sure, you could take more time on some of these ideas — but not at the expense of feeling overwhelmed by “one more thing” on a big project to-do list. Also, remember, these are suggestions to select from. Don’t take on all of them, because that has potential to turn into an overwhelming, throw-away plan. Pick one or two, or create your own. Because everyone has one minute.

 

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Great Teaching. You know it when you see it.

What makes for a great teaching session? In medical school, we make prodigious efforts to answer that question. We collect reams of information, ranging from the extensive student feedback collected about all aspects of their learning experience, to analyses of objective measures of student success in both internal and external examinations. There is also much written about educational methodology, and which approaches are felt to optimize effectiveness. We establish policy and take effort to ensure those are applied throughout our curriculum.

But beyond all this, there is something about a successful teaching session that defies formal analysis and simply goes beyond the aggregate of measurable parameters. To use a phrase originally applied by a Supreme Court Justice to the understanding of pornography, “you know it when you see it”.

My walking route from the hospital to the undergraduate office takes me by the main lecture hall in the School of Medicine Building at least a couple of times each day. I often stop as I go by to see what’s happening. Sometimes, I’ll drop in and look in on the teaching session for a few minute

It is easy to spot a session that’s going well. There’s a certain energy in the room that is immediately apparent. The students are engaged, attentive, anticipating what’s to come. But even easier to read is the teacher. Whether it’s a basic scientist or clinician, something special happens when a natural teacher encounters a group of eager learners. Like the activation of a long dormant instinct, the encounter seems to set off a response in the teacher that energizes the session. It is no longer a recitation of facts and directives but rather a sincere effort to pass along acquired wisdom. Students, for their part, sense the effort and value of what the teacher is trying to do. They reciprocate with attention that energizes the teacher, setting up a feedback loop that makes the whole thing work.

I’m pleased to report that, by both the objective and “know it when you see it” assessment, the vast majority of the teaching sessions we provide are highly effective. It is also apparent to me that the vast majority of our faculty truly enjoys their teaching experience and finds it personally satisfying. That fact, more than anything, is the source of our success as a medical school.

And it happens a lot. Over the course of our four-year curriculum, over 700 full time and part time faculty members provide teaching sessions to our students, most of them practicing physicians with schedules full of more immediately urgent and financially rewarding pursuits. So how does it happen, and happen so frequently?

In an insightful commentary entitled What Makes a Good Teacher? Lessons from Teaching Medical Students” (Academic Medicine 2001:76(8);809) Ronald Markert identifies several factors that he believes characterize the best teachers. Although all are valid, two have always stood out to me as particularly relevant to the physician teacher. Quoting from Dr. Markert’s article:

 

A good teacher wants to be a good teacher. Teaching has to be its own reward. While recognition for outstanding teaching is commendable, faculty who are motivated only by formal honors will not achieve teaching excellence.

The focus of instruction should always be on student learning, not faculty teaching. Too often faculty members concentrate on what they want students to know. However, medical education is professional education, and we who teach medical students should go beyond our conceptions of what we think they should know and instead should search for what they actually need to know as practicing physicians.

 

Teaching, at its core, is a distinctly human interaction. It requires a connection, a mutual, unspoken relationship between two parties, one possessed of knowledge and the generosity to share, and one receptive to that knowledge. Essential to the learner is trust. They must assume their teacher is not only knowledgeable but is also motivated by their best interests.

Doctors are natural teachers. I believe this is, at least in part, because the selfless sharing of information and focus on the needs of the learner so well-described by Dr. Markert are also features of the physician-patient relationship. They also instinctively understand the concept of assumed trust, as critical to the teaching role as it is to provision of care to patients.

This week at medical school convocation, the graduating class will honour three such great teachers whom they have identified to receive the Connell Award. Named in honour of two previous heads of medicine, this award recognizes outstanding contributions to mentorship, lectureship and clinical teaching over their medical school experience. This year, Drs. Susan Moffatt, David Lee and Barry Chan have been selected and are, indeed, very worthy recipients.

 

 

Congratulations to them, and to all our faculty who contribute their time and natural talents to not only educating our students, but modelling for them the commitment and teaching skills that they will carry into their careers.

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