10 Things I Learnt (about education) In Four Years Away

After a four year stint working in Sydney in a high paced, challenging but rewarding Medical Education / Executive role I have returned to my old service in Newcastle and was recently invited to present at Grand Rounds* so I decided I would talk a little bit about what I have learned in the past years and chose a theme of a blog format in order to demonstrate some of the current trends for blended and online learning.

*Grand rounds are an important teaching tool and ritual of medical education and inpatient care, consisting of presenting the medical problems and treatment of a particular patient to an audience consisting of doctors, residents and medical students. The patient was traditionally present for the round and would answer questions; grand rounds have evolved with most sessions now rarely having a patient present and being more like lectures.

So in no particular order of any real significance here are the top ten things I have learned about medical education in the last four years.

1. Power Points are Visual Aids

OK, I’ve known this for a while but I had been frustrated by being subjected to so many boring, content heavy presentations over the years and a lot of the time from folks who should have really known better.  I’ve also played around with other formats of visual presentation (including no visual aids at all) such as Prezi and whilst these technologies possibly better focus the user on getting the most out of the visual medium I’ve seen bad Prezis as well.

Often the powerpoint (or Prezi or Keynote…) presenter seems to be attempting to put all of the content from their presentation on the slide in a defensive manner, by which I mean it cannot be said later that a certain point was not covered.  If you are worried about forgetting something or leaving something out there’s actually a better way of addressing this and Microsoft also make a product that handles this problem its called Word.

One day I came across this excellent TedX talk from David JP Phillips that explains some of the problems and some of the solutions.  You should really watch it.  It brought me back from Prezi to Powerpoint. In summary:

1. Powerpoints are Visual Aids
2. One Message per slide
3. Text and Image should enhance your verbal – avoid full sentences
4. Dark Backgrounds
5. Use contrast and size
6. Maximum 6 points per slide

After you have finished watching David Phillips, gone and tidied up your presentations and wowed them at your next pitch you might want to obtain some further comic relief from Don McMillan.  See left.

Oh and as a bonus related learning here’s a link to Philip Guo’s blog post about why 6 minutes is the optimal length for videos for retaining learner engagement.

Power points are visual aids.  Microsoft also sells a word processor.

2. Audience Engagement is Vital

Today learning is as much about imparting knowledge as it is about developing passion and confidence in the learners to demonstrate that they already know quite a bit and through active processes can build on this.

There are now great technologies available for engaging your audience in a discussion including one well-established one (taking questions). However, I have definitely found that some of the newer technologies improve the participation of a greater number of audience members, particularly the more digital native learner and also permits those who are more introverted to more actively participate.

My favourite tool for doing this so far is PollEverywhere.

3. Social media has its use in medical education but there are pitfalls and we are still trying to understand its impact

I left facebook many years ago, got my life back and never looked back.  At the moment I am fighting pressure to rejoin as so many of my learners now use this platform as a mechanism for social learning. Many probably don’t know how much learning they are actually doing in relation to their medical capabilities.

Of course the rise of #FOAMed would not have been possible without the internet and social media like twitter and facebook.  But for many the jury is out as to whether we are witnessing more medutainment than a true revolution and improvement in learning styles.

That being said I have certainly managed to expand my international group of peers through sharing findings on twitter and some of the conferences I have been involved in have had more people observing virtually than live which at least improves the accessibility angle for information.

My other impression is that perhaps we are just witnessing the rebirth of communities of practice (see below) in medical education by harnessing of technology.

4. Possibly the best part of a conference is the opportunity to network

Following on from the audience engagement angle and also the collaboration angle (see below) I have come to the strong opinion that the presentations are possibly one of the least important functions of medical conferences.  Its long been noted that sending doctors to medical conferences is probably a poor ROI in terms of knowledge transfer.

However maybe there are other functions to holding conferences?

Having run two major medical conferences in 3 years I have observed that such events do give delegates time out from their daily work to pause and reflect on new ideas and ways of working.  They also provide for the opportunity to bounce ideas of one another.

That’s why when we put on the recent NSWMET2016 Conference collaboration, networking and ideas exchange were key values of the event.  Panel sessions went for no more than an hour, speakers were given a speakers run-down clock of 15 minutes and time was specifically allocated for questions from the audience.  Moreover the time between breaks was more than the usual.

We have had plenty of anecdotes post conference about how the event has led to collaborations that would not have occurred if not for the networking opportunity.  For example, I am now involved in a research project on intern work readiness between my own university and another NSW medical school.

5. Knowledge is constructed.

I’m a confirmed constructivist which means I believe that knowledge is not so much transferred but developed as a consensus amongst others.  My evidence for this – every day experience and practice.  Most of us as doctors have a trusted “goto” or perhaps several trusted “gotoes”.  The students and trainees I talk to learn socially in groups and use each other as a resource.  They also pick up on habits of seniors or trusted experts and treat these learnings with as much reverence as for the information they might read in a book.

Constructivism is about active learning and contextualizing the process of constructing knowledge rather than acquiring it. Constructivists believe that knowledge is constructed based on the learners own experiences and ideas about their environment. Learners continuously test these ideas through social negotiation. The learner is therefore not a blank slate but brings their own past experiences and culture to a learning situation.

A common misunderstanding regarding constructivism is that instructors should never tell students anything directly but, instead, should always allow them to construct knowledge for themselves. This is actually confusing a theory of pedagogy (teaching) with a theory of knowing. Because constructivism theorises that all knowledge is constructed from the learner’s previous knowledge, regardless of how one is taught, even listening to a lecture involves active attempts to construct new knowledge.

6. Communities of Practice are being revitalised as Peer to Peer and Near to Peer Learning and through modern technology.

As I will note elsewhere in this blog the students and trainees that I talk to express a very keen desire to learn from both each other (peer to peer) as well as those directly above them (near to peer).  In the same vogue they also generally mention a strong desire to be more informed about learning and be better teachers themselves.  Which I definitely find refreshing.

Peer teaching is not a new concept. It can be traced back to Aristotle who used his own senior students to teach some of his more junior students.  As a theory it was first posed by Scotsman Andrew Bell in 1795, and later implemented into French and English schools in the 19^th century. It has become increasingly more popular in public school education over the last 3 or 4 decades.  No doubt partly because of its potential more economic approach.

In higher learning peer learning can take many different forms. Universities have for some time employed postgraduate students as tutors for undergraduate programs as a form of surrogacy teaching.  In medical education you often will see the medical students on the wards quizzing the interns and the interns seeking guidance from the specialty trainees. Cooperative learning is generally when small groups of learners are formed, with each person in the group responsible for teaching others on a unique piece.  I used this approach myself with my study group when preparing for Psychiatry Fellowship examinations.

There are many benefits of peer and near to peer teaching including:

• Students receive more time for one on one personalized learning
• Direct interaction between students promotes active learning
• Peer or near to peer teachers reinforce their own learning by instructing others
• Students feel more comfortable and open when interacting with a peer or near peer
• Peer teaching can be a financially efficient alternative to hiring more staff members
• The teachers then receive more time to focus on other aspects of the teacher role

Peers and students also share a similar experience and context, allowing for greater understanding.  This particular point should not be understated in my opinion.  I personally believe that some of the true benefit of near to peer and peer to peer learning derives from the fact that the teacher and learner are close or similar in their knowledge and current construction of knowledge.  Essential components of the learning experience are therefore less likely to be omitted as they are present in the consciousness of those teaching rather than buried deep as an automatic part of the heuristic with a master of the subject.

A question I have about all of this peer to peer and near to peer learning is how far removed are they from the concepts of communities of practice.  The answer probably lies in the word “practice” and perhaps peer to peer and near to peer and communities of practice can be seen as lying on a spectrum of social learning where the learner moves from a peer learning type network where the challenge is constructing foundation knowledge or knowing and as the learner progresses they then move towards a level of mastery where the social learning is more about doing, where in the words of Wenger one of the original proponents:

“Communities of practice are groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly.”

7. Marketing is and will become even more important in medical education.

I was recently asked to comment on the outline of a new curriculum for a medical school program.  Normally when I approach such tasks I like to give some practical feedback as well as think creatively and try to consider alternative perspectives that might be considered a bit more out of the box.

My little “epiphany” in regards to this task was about marketing.

A few years back a colleague and I were trying to figure out what to do with a problem we had in filling up the places in our local psychiatry training program.  We soon realized that the actual program (product) was quite good.  Trainees who entered it liked it.  The real problem was that not enough doctors were aware of how good it was, i.e. we hadn’t effectively marketed id.  So we set about correcting this problem using some fairly simple techniques such as increasing the number of the local junior medical staff who gained exposure to a psychiatry term.  Quite soon the benefits of this approach were coming through and they have continued to this day.

More recently I have been doing some research in this area, which is actually a global problem.  Even amongst the medical profession there can be significant stigma towards psychiatry.

To the left is a picture of Edward Bernays.  He was a very successful entrepreneur and thinker.  He managed to solve many problems of stigma, such as the fact in the early 1900s few women smoked cigarettes because of social taboo.  For this and many other reasons he is regarded as possibly having few scruples.

He was actually the nephew of Sigmund Freud and the story goes that he lent Freud some money to help him finish one of his earlier texts.  In return Freud sent Edward an early copy of the text.  Bernays drew inspiration from Freud’s works and developed the hypothesis that humans were far more likely to be driven by unconscious irrational emotional states than logical conscious positions.

Bernays was notorious for the publicity stunt and celebrity placements. He once recruited a group of attractive debutants to smoke openly in public view in the middle of the New York Easter Parade.  AT one point in time he was apparently profiting from selling celebrity product placements in magazines, whilst also receiving fees from the celebrities agents and a marketing fee from the company for which product he was placing.

What has this all got to do with a medical school curriculum then?  A couple of things at the very least I think.  Firstly, for good or not so good I think we need to be aware of the potential of marketing approaches to alter behaviour (think Big Pharma).  Secondly, on a practical level I think we will all need to have some skills in marketing in an online world.  Most of us as doctors will need to have an online presence and be managing our reputations online as our patients more frequently start “googling” us.

8. Mandatory training and learning are probably not great bedfellows.

Make a learning experience mandatory and chances are someone will complain about it.  Sometimes this may be with reason.

Fundamentally I think we all fancy ourselves as adult learners, as capable of determining our own learning needs.  Sadly, the evidence for us being good determinants of our capability gaps is very poor and most of us benefit greatly from receiving feedback from others.

Of course another fundamental flaw with adult learning theory is that it generally encourages the learner to pursue learning interests that are of interest to them which is unlikely to cover off on the more boring but essential bits such as for example hand washing.

So what can we do in health services to ensure that mandatory training occurs and perhaps ends up for at least some learners a learning experience?

Here are a few ideas:

1. Gamification. Most humans are inherently competitive even with themselves. Confront learners with the evidence of how much mandatory training they have completed versus their peers.
2. Make it accessible and bite-sized and easy for the learner to pick up from where they started.
3. Role model.  Share with your learners the fact that you have completed your mandatory training.
4. Don’t mix up compliance with mandatory training.  If there is a policy that must be complied with.  Print it off.  Get employees to sign it,  Store it electronically.  Please don’t dress it up as a wasteful learning exercise.

9. Passion

Passion in education goes a long way.  In compiling this blog post I researched the fascinating story of the Dr Fox Effect*.

*The Dr. Fox effect is a correlation observed between teacher expressiveness, content coverage, student evaluation and student achievement.

The Dr Fox Effect has been cited in a lot of medical literature as showing a link between student enjoyment of a teaching session and knowledge attainment.  And whilst some later research may appear to contradict this relationship somewhat, the idea that learners benefit greatly from someone who teaches their subject with passion is implicit to most of us as we can all generally recall at least one great teacher in our lives who had a lasting impression on us.

The original Dr Fox experiment was of course conducted in psychiatry or more specifically to a group of educators in psychiatry and psychology at the University of Southern California School of Medicine in 1970.  An irrelevant topic was chosen for a faculty development session.  The topic, “Mathematical Game Theory as Applied to Physician Education”, was chosen to eliminate the factor that the learners might know information about the actual subject. Learners were divided into two separate classrooms; one classroom would be lectured by an actual scientist and the other by an actor who was given the identity “Dr. Myron L. Fox”, a graduate of Albert Einstein College of Medicine.

When both “Dr. Myron L. Fox” and the scientist presented their material in an engaging, expressive, and enthusiastic matter, the learners rated Dr. Fox just as highly as the genuine professor. This lack of correlation between content-coverage and ratings under conditions of high expressiveness became known as the Dr. Fox Effect.

Interestingly none of the learners detected the fraud despite the fact that the actor Michael Fox had been given only a day to prepare and was relatively well known having paid roles on television as a doctor, as well as acting in Hogan’s Heroes and Batman.

10. There’s no place like home.

I’ve only really called two places home in my life.  My birth town of Hobart and my adopted town of Newcastle.  Having spent the last 4 years of my life commuting between the “big smoke” of Sydney and Newcastle its nice to drop roots down again in a place that I am more comfortable living and working in.

The Newcastle #meded scene has some particular qualities about it that reflect some of my above learnings, in particular its affinity for collaboration.  Uniquely for a medical school the Joint Medical Program is part owned between 2 universities and 2 health services.

I am now looking forward to getting stuck into the next phase of my #meded career in a familiar place.