Tuesday, December 31, 2013

Independent Learning in MedEd

Lessons In Independent Learning From The Classroom For MedEd

I write on this because I have unusual, if not unique experience, in medicine and as a general psychologist who somehow became a facilitator of curricular, methodological and cultural change for school education using a central, integrated system designed by an international multidisciplinary team.

Complaining About Reality
There are a series of questions and problems that are coming up in medical education on Twitter that boil down to the culture of Independent Learning for post-graduate doctors but also apply to any graduate program and they require far more than 140 word sound bites to address them.
One side of the problem is that newly qualified specialists feel unready to cope with the rigours of their new job after leaving the protected environment of MedEd and mentorship, always having somebody to fall back and rely upon, http://www.kevinmd.com/blog/2013/12/graduate-medical-education-failing.html. They claim to be unprepared for real medical world responsibility.
The trite answer is that this is inevitably going to happen sooner or later. Sooner or later, every doctor will be thrown into the complexities and uncertainties of medical practice and be expected to swim. There is nothing that can fully prepare them for what it feels like to practice without a safety net and be where the buck stops.
The only remaining question is whether this should happen sooner or be postponed to later.
The old way was to do it sooner, literally taking newly qualified medical students and throwing them in at the deep end to see if they would sink or swim. They were really unprepared. It was extremely traumatic psychologically, even psychiatrically. It was yet more dangerous for the patients. So now intensive effort is put into delaying this event and doing everything possible to prepare the doctor for this eventual challenge and soften the blow. The time that it happens has been postponed until they have as much knowledge and experience as possible.
In a comment to Dr T Chan’s much needed defence of MedEd against these accusations, http://boringem.org/2013/12/22/counterpoint-graduate-medical-education-will-fine/, I used the metaphor that being let loose in medicine is like a parachute jump. What used to happen is that the newly qualified doctor was thrown out of the plane with only theoretical knowledge of what to do next. Now, doctors have practiced freefall in a simulator and safe landings off a scaffold in preparation. It is still going to be a little bit scary when jumping for the first time from 5000 feet but nothing compared to having done it the old fashioned way. It is a hell of a lot safer for everybody involved than the old way.
Problem resolved. End of story. It is impossible to completely remove this slight feeling of inadequacy and uncertainty but modern medical education has reduced this dramatically and maybe even optimally. To expect any more is unrealistic, especially when a host of other external pressures on MedEd are taken into consideration. Simply, they are doing a damn fine job of addressing this problem.

A Greater Perspective
However, the other side of this came up on Twitter and it got more complicated. Medical educators were talking about problems of getting doctors to adopt the culture of Independent Learning. I was shocked, horrified and angry. You mean that for all the lip service that is paid to Independent Learning in the education system, years of school, university and medical school have not indoctrinated them to the culture of Independent Learning? The students still want Dependent Learning methodology of teach recites elements of curriculum for students to regurgitate in their examination to get an ‘A’ or at least pass if they have memorised half of it?
No wonder they are unprepared for the real world when that is their attitude towards medical education. There will be no syllabus or curriculum. There is no turning round to the patient and saying ‘Sorry, my teacher did not explain that’, ‘You have got the wrong disease’ or ‘You weren’t in my syllabus’. They will have to cope with everything that is thrown at them including difficult risk/benefit decisions with multiple pathologies and all sorts of psychological and sociological factors where the answers are far from certain. And forget grades in the real world of medicine. Even straight ‘A’s is not good enough, let alone scraping by. They are going to have to get 100% first time and consistently or patients will die.
These archaic, schoolish attitudes to MedEd are inappropriate in clinical practice. They are unacceptable. They come from the traditional culture of Dependent Learning that even school education claims to have relegated to a dark past.
The educational mentality that a doctor at the top of their profession needs is the culture of Independent Learning. It is a joy and love for powerful knowledge that is independently discovered because it is needed in real life. There is a thirst for all knowledge and constant, self-motivated process of self-improvement towards perfection when this Independent Learning culture has been fully adopted. It is exactly what a doctor needs.
Independent Learning also teaches the self-confidence necessary to deal with the complexities and uncertainties of life that are everyday life in medicine. That is what these newly qualified specialists are lacking.
Paradoxically, the darkest past of MedEd did have a solution that created the culture of Independent Learning in medicine. It was to set impossibly high standards to pass examinations allied with crap incompetent teachers and methodology. It worked. Students had no choice but to become self-taught.
It really was not helpful. Worse still, in the modern world where interns and residents pay for their MedEd, it was unsalable. So teaching standards had to improve for every imaginable reason but at the same time, that made the paradox painful. The better teachers are, the more students can rely and depend on them. Catch-22. Better teaching standards appear to cause more Dependent Learning.
That only happens when the students are accustomed to the Dependent Learning culture as their norm. It is in their subconscious minds and their emotions demand it, even making hypocrisy of their well-intended words about Independent Learning. Their actions just keep slipping into the same old Dependent Learning habits. And that is obviously what has happened in the past educational experience of these doctors throughout high school, university and med school. Proclamations that this is not true are disproven by the evidence. They still want teacher to spoon feed them information to regurgitate for the sake of grades. They have been indoctrinated by example and experience to Dependent Learning.
And that is when the apparently no-win situation happens. If the Dependent Learning culture persists, the better the teachers are, the more dependent the students will try to become. They will pressurise the teacher to participate in a co-dependent relationship because that is all that they know.
The only solution is to full adopt a culture of Independent Learning.

Independent Learning is A Complete System
The first thing to realise is that a good-enough teacher is about as useful as a good-enough doctor. Neither will deliver the very highest levels of quality in the service they provide. In education, only the best teachers can create the culture of Independent Learning. However, it can be learned systematically and through the self-disciplined practice guided by knowledge and understanding.
Having said that, I really wished I was facilitating educational reform workshops to doctors with a clean slate rather than teachers with years of bad habits to erase and rewrite. I would have valued the clinician’s self-discipline and objective focus. Perhaps more importantly, the clinician has learned to adopt a more holistic thinking style in order to make difficult diagnoses in the complex contexts based on consistency and fit, the performance in explaining all of the available evidence both objective and subjective. 
This type of curricula requires this type of complex thinking. The culture of Independent Learning is a system and worldview that is complete unto itself. It is like an organic ecosystem where the function and survival of each element depends on the existence and practice of every other element. So the culture of Independent Learning has to be practiced as a whole. If any part is missing, the whole system collapses and somehow learning becomes dependent again.
There is no picking and mixing. This is a matter of high level critical reading which is life and death to the medical profession. Just because blah blah blah said something works in a different system does not mean that it applies in Independent Learning. The only evidence that counts is the evidence that has been found within this interactive and interdependent system. The international evidence is that the whole system works better than any other form of education at every level.
In fact, these systems can produce the most miraculous results or sometimes no change at all. This is not well understood within the field of academic educationalists but the former seems to happen when the background culture provides a few appropriate, missing pieces to the jigsaw that the educationalists have provided to make that whole. If society provides the wrong pieces to the jigsaw, the whole system breaks down.
For a start, the workshops to introduce and implement the curriculum required the participants to generate basic principles in education during group work so that they would own and take responsibility for the changes that needed to be made. Their idea of team working was hierarchical, passive-aggressive anarchy. Two or three would take over using impenetrable jargon as a weapon to exclude the rest who would end up silently in a corner. They would come up with every bizarrely, idiosyncratic intricacy but complete miss the really simple and obvious conclusions that they had to reach. They did not just fail in the educational sense. They achieved the exact opposite including damaging the confidence of the excluded.
If the background cultural concept of teamwork is like this, the educational system that relies on teamwork being a positive educational experience is doomed to fail. If teachers use impenetrable jargon as a weapon to assure their superiority rather than plain English to share knowledge, all that the students can do is to repeat what teacher says word for word in their exams without understanding a word of it. The gravest problems come from getting a single one of the foundational basics wrong and the house of cards is brought down.
These educational systems for Independent Learning are all about getting a wide range of basic principles right. Get them all right and the outcomes will be marvellous. Since these systems always measure outcomes, they always have teeth attached. You do not want this thing to be your enemy. You do not want to be its reluctant slave either, especially when you can be its master. If you master all of the basics, this ominous system becomes your obedient pet and you find that it gives incredible flexibility.

Class Size
Independent Learning works well with class sizes between 21 and 40 with the optimum being 28-32. These numbers come from the importance of group work in Independent Learning. It is primarily in the group work that Independent Learning takes place. Up to 80% of classroom time can be spent in group work, including presentations and larger projects.
In my experience, the optimum group size is 7-8 for formal, flat-structure group working and the optimum number of groups is 3-5 with 4 being about the best balance in practice, remembering that each group will need time to present its conclusions and discuss them with the class.
Many educationalists will go much higher than this on the principle that the more participants, the more diversity and the more likely they will come up with all of the answers rather than that being left to the teacher. Many, such as Jeremy Harmer, mention 50 as an ideal number but some go as high as 200. Even at 50, group size is starting to become unwieldy and unmanageable or the number of presentations too time consuming and repetitive for viewers if they are considering similar issues.
However, they all agree for this reason that smaller class sizes do not foster Independent Learning or its culture. If there are only 2 groups, the dynamics are of one group competing, often unhealthily, with another rather than presenting to the majority of the class. Smaller group sizes reduce diversity and discussion. In smaller groups the concept of students clarifying what they have just learned often fails and peer teaching is preferable in both ethical and practical terms.
The demand for smaller class sizes is simply the reaction to the lecture mentality in the Dependent Learning culture. It is seen as providing more access, time and attention from the teacher, which is regarded as proving the quality of the experience but is also a classic sign of Dependent Learning.

The Pro-Actively Present Lesson Plan
Of course, the great, naturally born geniuses of education do not need to formally plan their lessons. They know exactly the right thing to do. And it comes with experience too so planning lessons is just for beginners. The mark of a good teacher is not planning lessons. It is proof of just how great a teacher they are.
Completely wrong. That is old fashioned thinking from the days of dependency. The Independent Learning culture requires structure and forethought that only comes from formal, written lesson plan. More than just being prepared, when it has become a pro-active and present part of the lesson, lesson planning is

  • ·         A means of maintaining focus and the structure of the lesson
  • ·         An innate system of constant self-improvement for the lessons and the teacher
  • ·         A system of observation with student rewards to motivate
  • ·         A cultural learning tool in itself
The key is to understand that lesson planning is a long term process. The first time that the particular lesson is going to be taught, the lesson plan is a guess that is going to be tested in reality. First lesson plans are not supposed to be perfect. They are certainly not rigid. The important factor is that they are supposed to be annotated during the lesson and afterwards to see how long individual elements of the lesson took and how they could be improved upon next time the lesson is given. What worked well can be identified and repeated. Sudden inspiration by the teacher or students can be recorded and remembered. Any problems can be noted to try to think of another solution next time. Feedback is considered and included. They are also evaluated in terms of student performance in evaluations to identify which themes were effectively learned and which need a rethink and improvement.
After the lesson has been given a few times, it really does approach perfection.
So in a way, the lesson plan can be seen as an aide memoire. It also immortalises the past brilliance of students by recording their words and repeating them. The teacher really does become a facilitator of knowledge in a culture where the students hardly seem to need a teacher because they can do it for themselves. They can be as good if not better than the teacher.
This is a powerful reward system. The teacher is attentively listening to every word and noting it down. And when the teacher speaks, their words are laced with the individual and group wisdom of their students of the past, even their names. If you do not write it down, you will forget. You must be seen to write it down in the moment by the students so that they know their greatness will not be forgotten.
It is all a part of the ‘can do’ culture, a constant culture of proving just how intelligent and capable the students are. Every chance is enthusiastically grasped by the teacher to illustrate the point. They do not need a teacher. Students are capable of Independent Learning. Their confidence grows as Independent Learners.
The facilitator of knowledge surrenders the belief that teachers are the best direct teachers of knowledge and understanding. Many heads are better than one. The teacher, to whom all this came far too easily, rarely is the best person to explain a new concept to the lower band of students. Their peers, the ones that got the concept first time, are better at re-explaining the concept in words that they can relate to in their everyday life and practice.
The teacher writes all this down to improve themselves as a teacher and the lesson plan becomes student based knowledge and understanding over time. The teacher is repeating what the students of the past taught them.
Now that is cultural change. The traditional roles of student and teacher have truly been flipped by lesson planning. The traditional hierarchy of the know-it-all teacher who is better than the students can ever hope to be has been disbanded.
So why do they need a teacher at all?
The role of the teacher is in fact to provide structure to the learning environment for optimum Independent Learning to take place. The lesson plan is also the source of that structure. If the lesson plan is present and seen by all, if it is waved in front of the students’ faces to make sure that they notice its presence, it becomes a deep cultural symbol of forethought and organised thought.
A major part of teaching is teaching by example. If the example is not seen, the students learn nothing so do not be shy, as a teacher, about showing how much time and consideration you have put into structuring the lesson. Let the students see it. Give them a chance to respect it.
The presence of the lesson plan teaches prioritisation. There is not time to do every single thing that we would like to do in life, in medicine or in the classroom. This is time management. There is no time to get lost in the details and forget the basics. If we get all of the basics right and think of everything that is really important, everything comes together for the best results.
And there is a time and a place for everything. Teaching time is precious and must be put to the best use. There are other times to learn the details.
The presence of the lesson plan shows the thought, consideration and time management of the teacher to prevent side tracking and getting lost in the details. The students see just how much the lesson must cover and that there is not time for the little things.
The lesson is focused on a deep understanding of the basic principles of the theme that leads to real world mastery. That is the teacher’s responsibility, not the learning of the details. Learning the details is done by the students in their own time, from textbooks or the web, once they have mastered the fundamental concepts. It is the responsibility of the student to memorise those details and the teacher cannot memorise them for the student.
However, they might teach them learning and memorisation strategies. They will also ask the class to share any tricks that they use.

Experiential Learning Cycles
Independent Learning demands structure or it fails. There is a time and a place for everything and everything must happen at its appropriate time. There is an order in which things must happen for independent learning to occur.
There is a time for the teacher to answer questions and help the students to understand but if that happens before the students have been given every opportunity to work it out for themselves, that possibility has just been sabotaged.
There is a time for practice and application but it is right at the end of the cycle once the students have a really deep understanding of the principles that they will practice and apply. The last thing that the student needs is to get it wrong when with a little patience they could get it right first time. It will damage their confidence. This is about establishing good new habits of thought and practice through consistency so that they become second nature. Every time they get it wrong they are preventing and delaying that process. They must be given every chance to get it right first time and every time.
So Independent Learning happens in very specific order of four stages known as the Kolb Cycle of Experiential Learning, first described in 1984.

Ideally, which is the case with learning something new with a blank slate, the process begins with Concrete Experience. Realistically in MedEd, this is a case of relearning something that has been learned in the past in theoretical and usually dependent terms. It may well have been practiced before but in suboptimal terms that need rewriting, starting again at Concrete Experience and asking the students to do their best to forget their old attitudes and habits.
The very concept of Concrete Experience can be difficult for doctors in theory. It is to deal with something innately or naturally in practical terms without understanding it or really knowing what you are doing. It appears to be the antithesis of everything that they know about medicine. However, they are perfectly happy to accept this situation in terms of psychology, communication skills and the very structure of the English language that they are using all the time. Often, with routine practical skills, they are just done the way that they are done and the precise anatomy that is being dealt with is a distant memory that is rarely thought about actively.
Concrete Experience is learned by copying without understanding or questioning why things are done the way that they are done. Just get on with it. Do not ask silly questions.
And that is the response of the teacher during this stage of the Independent Learning cycle. There will be time for understanding and questions later.
Reflective Observation follows. Now the student individual or in groups reflects on why they did as they did in Concrete Experience. This must be done in their own words, words that they can truly and deeply relate to in their own lives to foster deep understanding that they can apply in real life.
In Abstract Conceptualisation the teacher teaches the formal, academic version of the subject, relating the technical words and jargon to the students versions of understanding in their own words so that they can ‘translate’ the jargon of the research, papers and textbooks that they read on the subject to their real world understanding. Any errors in the students’ Reflective Observation are corrected and their understanding placed into context, showing how far it can be generalised and its limitations or exceptions.
And the students are allowed to ask questions now!
Now the students should have a really good understanding at every level of the basic principle that was being taught in the cycle. They apply this in Active Experimentation then the students themselves, in pairs or groups, evaluate themselves compared to the principle that they have learned to see whether they were following it or not. This process continues until they have established the habit of the correct practice of the principle which has now become second nature. They do not need to think about the whys and wherefores. They can just do it.
The cycle is complete. They have returned to Concrete Experience but this is a very different Concrete Experience. They are doing the right thing as second nature supported by knowledge and understanding. They do not have to think about what they are doing but that knowledge is there in the background if ever they need it in complicated cases in order to adapt.
This forms the foundation in which they can move on to the next Experiential Learning Cycle on a new principle, building on the previous cycles. One cycle builds upon another.
The four stages of the Kolb Experiential Learning Cycle incorporate four very differ learning styles, two diametrically opposed pairs, between feeling and theoretical thinking and watching and doing. At first glance, you may think ‘That is nice. The cycle allows each person to learn using the learning style that they are best at!’
Oh this is far cleverer than that! Learning styles are themselves learned. Everybody is capable of learning by all four methods. It is just that they have learned to rely on some more than others from experience. Some they have never thought or practiced in the past as a result of their educational and societal experience. They may even have mental blocks against them.
The best way to learn is to be willing and able practice all four learning styles synergistically and learn at every level. That is exactly what the Kolb Experiential Cycle encourages and promotes.
(I must say that the moment I saw the Kolb Experiential Learning Cycle, I fell in love with it. I marvelled at its simplicity, elegance and astonishing completeness. The more I thought about it, the more perfect and wonderful it became.)

A General Methodology Framework for MedEd
The Kolb Experiential Learning Cycle is in a way the theoretical expression of optimal Independent Learning. A General Methodology Framework is the practical, step by step expression.
Plenary/Interaction – The presentation of new knowledge or a revision of old knowledge that will be necessary to deal with this theme.
Real World Examples – The real world application of the knowledge and understanding that is to be learned in this lesson in its everyday context.
Testing Comprehension – Each individual student writes answers to questions on the examples that make them carefully analyse the text and think about it. They are not expected to get the answers right, just to think about it.
Reflection in Groups – Groups are given specific tasks and questions to answer to gain a fundamental understanding of the core objective in their own words that they understand and can apply in the real world.
Presentation of Group Work – With Questions and Answers from the rest of the class followed by a class discussion.
The Teacher Teaches! – The teacher takes the rules of the students, correcting them if necessary, extrapolates them and explains any limitations or exceptions. They teach them the jargon that they will encounter in their research as it relates to their owned concepts and gives references and advice on further reading in the subject.
Application and Self Evaluation – The class now knows the concepts and put those concepts into real world practice then they self-evaluate to see how they perform according to those principles that they have learned. Teacher goes from group to group ensuring that this is occurring.
Project Work – Groups are given different aspects of the topic to research in detail and present to the class. May be a recurrent process, with a dozen or more projects being done within the cycle over weeks.
Into The Real World – The group examines real patients, helping one another. Then they discuss the diagnosis and treatment plan as a group so that they learn and integrate a wider perspective on patient management before presenting it.
Evaluation – For individuals to test their really fundamental understanding and application of the subject from first principles.
Feedback Advice – What the student is doing well and what they need to work on in future.
Re-Evaluation – Depending on what has been learned well and learned inadequately, lesson plans and even the curriculum are reconsidered to perfect them.

Understanding of The Objective
The Experiential Learning Cycle is the core and the backbone of Independent Learning but it is far from everything. It is only used for the mastery of the most fundamental principles that must be deeply understood for mastery of the subject to be attained. So it is only used when there is a specific, understandable concept that must be mastered.
It is used for new principles and concepts. It is also used to correct concepts that have been mis-learned or misunderstood, often because society has got the wrong end of the stick.
This is where the structured classroom time is important. Anything that is not profound understanding of principles is external to the Experiential Learning Cycle. It is incidental detail to the core cycle that happens to crop up in class. Usually, these are the details that it is the students’ responsibility to learn and memorise and it happens at least as well outside of the classroom structure.
So the objectives of what is to be taught using the Kolb Cycle must be very, very carefully defined and thought through. In fact there are very few of these fundamental objectives that can be taught using the Kolb Cycle.
Lesson planning is where this forethought takes place. To an extent, this is usually done for the individual teacher. The identification of these fundamental objectives that must be taught is an essential and really difficult part of designing a curriculum. That is such a difficult job to do really well that it requires massive collaboration of the very best experts. This is true to the extent that governments import the very top international experts to design their school curricula.
It is necessary to ensure the highest levels of Independent Learning. Individual teachers are rarely able to do this alone. They need central guidance. They are generally given the ‘Contents’ of what they should teach by international experts and are then left to ‘Distribute’ those contents into individual lessons according to their local experience of teaching their students to decide which of the contents will require more or less time and emphasis. They decide the details of how they will be taught.
Examples of objectives for MedEd are perhaps few and far between. Some examples would include:-
·         Dispelling any societal belief that we mainly breathe to take in oxygen when the normal drives to respiration are carbon dioxide levels and maintaining blood acid/base balance.
·         Concreting the belief of the importance of exercise in health including early mobilisation, physical therapy and avoiding bed rest in recuperation.
·         Teaching the importance of Cognitive Empathy for healthcare professionals.
·         Changing the culture of reliance on investigations rather than clinical acumen.
There are so few of these fundamental principles in MEdEd that a single cycle can last for weeks, using numerous and varied examples of real world application in group work. The cycle is the core of this work that is ever present but hundreds or thousands of other facts and details are being learned around this one central core principle. They are not facts or details that require this deep understanding and they are not being taught using the Kolb Cycle. They are being learned incidentally, almost by passive osmosis. They are being discovered rather than taught.
The teacher is only really responsible for their students understanding the core principles and instilling the culture of Independent Learning. There is a transfer of responsibility for everything else to the students. They must learn all the details by themselves.
If students discover those details because they want and need to use them in real life, their retention rate soars. A non-medical example of this is that when teaching a foreign language, new vocabulary that the teacher teaches can have as low as a 10% retention rate. It literally goes in one ear and out the other. The more that it is processed between the ears, the more likely it is to stick. If the student has discovered and used the word independently, retention rates can increase to as high as 90%.

A Pre-Mature Conclusion
I shall stop here because this ‘blog’ is already over five thousand words and heading to the length of a short e-book even in this concise, abbreviated form. Further elements of Independent Learning such as Flat Structure Multi-Disciplinary Group Work for Education will become further blogs leading to a proper conclusion.
Already what has been written represents a cultural revolution in MedEd. It is such a cultural revolution in school education that there is still cultural resistance despite trying to introduce this type of education for over half a century now. There is talk of the teacher disappearing into the background and becoming only a facilitator of knowledge but a society of students and parents have not come to terms with this concept. They still expect the teacher to teach.
Hopefully, MedEd has a easier and more cooperative audience with its students being fully trained and highly intelligent doctors who deeply value their educational experience. However, they need to know what is going on too; the importance, objectives and methodology of the Independent Learning Process so that they can actively, even enthusiastically participate in that process. And that process does offer the most miraculous outcomes in terms of both competence and culture. It even offers a solution to the question of newly qualified specialists feeling like they are being thrown in at the deep end without a parachute. 

No comments: