Wednesday, January 8, 2014

Independent Learning for MedEd Part 2

Independent Learning For MedEd
Part II A Structured Learning Experience

I often wonder if it is amusement or sympathy that is being politely hidden behind the faces of those that grew up in a culture of using chopsticks when they see me try. My method is awkward to the extent of my hands almost trembling with tension and force. This is brute force of will. Elegant it is not but it is effective. It must almost be painful to watch. It is to me. Half way through the meal, fatigue sets into my ham-fisted fingers and by the end it actually starts to hurt.
Having passed the test of social acceptability, I have resorted to surreptitiously skewering the larger chunks and throwing them as quickly as possibly down my gullet in the hope nobody will notice what I have just done. I look on hungrily at the serving spoons with half a bowl of rice before me pretending that I am too full to eat any more.
Yes, I learned independently to use chopsticks. Any example or vague guidance, other than it is socially unacceptable to ask for a spoon or fork in a posh Chinese restaurant, came from others who had independently learned to use chopsticks under the same circumstances.
A few years ago I did ask for lessons from an expert user who kindly obliged. It was too late. I could do it the easy way if I concentrated and forgot everything else like taste, texture and company. The moment I lost focus, I was back into the old habit. Now I just accept the situation that I will never be able to use chopsticks with the delicacy of expert users. I will manage the way that I am and the more I eat with chopsticks the better I will get at doing it my way.

The last thing that you want in Independent Learning is to throw the learner in at the deep end hoping that they will find their own idiosyncratic way to keep their head above water and then turn it into a habit by practicing it. The worst case scenario is that they then start teaching their way to others rather than the best practice.
But that is how the traditional clinical education system worked. It is how many students and junior doctors have been ‘educated’ and made independent in the clinical and early medical years. It is how traditional clinical and medical education worked and it is still being used. By the time that they have come through to MedEd, it is an uphill battle. It is almost too late.

Getting It Right First Time
The purpose of the Kolb Experiential Learning Cycle is to establish solid good habits according to the very best practices that become second nature. The learners study what they are about to practice thoroughly to learn the rules of good practice before they Actively Experiment with those rules. They are conscious of those rules as they put them into practice and they are focused on them.
The result, when they are practicing something new, is that they hardly ever make a mistake. Self and peer evaluation within the group quickly corrects any deviation from the fundamental principle that they have been studying. The correct practice becomes second nature through getting it right consistently.
So every new principle that the learner meets, they are prepared for. This is how a well designed Independent Learning system grows self-confidence even for learners who have been told all their lives that they are not competent or capable in academic studies. They learn that they can get it right because they have the experience of always getting it right.
The key is that they are never presented with anything that they are not directly studying or have not already learned to deal with.
It is really obvious when teaching English as a Foreign Language. If the students are just learning the present tense, you do not give them texts that include the past and future. If they are learning how regular verbs work, you do not confuse them by throwing in irregular verbs. When they are learning ‘I was, You were, etc’, you do not throw a spanner into the works with the words ‘If I were Chinese’.
If you force the students to choose between ‘how much money’ and ‘how many moneys’ before they have learned about ‘much’ and ‘many’, what do you do when they get it wrong? Do you damage their confidence and this culture of them always getting it right by correcting them? Or do you let it pass to preserve their confidence? Now they think that they got it right so they continue to repeat their mistake. They establish a habit.
You are just postponing the problem and making it more difficult to deal with in the future. That habit is going to be very difficult to erase and you are going to have to damage their confidence in that process.
The only solution is to never expose students to anything that they do not know. If a student tries to get ahead of themselves and use something that they have not yet studied, they must be told to refocus on the objective of the lesson and be patient. Their desire to learn this is acknowledged. We will all learn this next week, next month or next year. First we must get those basics right and build systematically.
Letting students get ahead of themselves is Independent Learning in a sense but it is the old style, throwing them in at the deep end to see if they sink or swim and it has significant side-effects. It can establish average to poor habits that will need to be criticised and changed later to reach higher standards. Those habits may have already become fixed. They may well be defended. Change may be actively, consciously resisted.
Think of how difficult it is to change the grammar of a child who has been taught incorrect grammar by a parent. It is classist. It is racist. It is elitist. It is the teacher versus the parents. Every excuse comes up but the fact is that if the student writes like that the average reader will not understand them. If the student writes like that they will fail academic examinations and not just in a single subject. Their failure to express themselves in an intelligible manner will prevent the examiner from understanding what they are saying in every subject.
So this is why he most advanced educational processes start with curricular design that encompasses all specialties so that everything is taught in the correct order. One cycle builds upon another and the student is never expected to confront something unless they have already been taught it. Often different subjects dovetail. Students learn about heat, melting and evaporation in science a month before learning about water cycles and global warming in geography. They have the tools. They are prepared.
Students really need to know what a verb, noun, adjective, gerund and preposition are in their own language before encountering them in another language otherwise the teacher has to introduce these as a new concept and explain them in a foreign language. First language use is banned in modern methodology.
This is a coordinated team effort. Individual teachers used to traditional freedoms and the cultural belief that subjects are divided from one another and learned separately complain desperately. Their limited field of vision says that they can teach only for the benefit of their own subject and what is most important to the students in that subject.
Modern curricular design is done at the highest level and through all school levels from primary so that the students are always prepared for the culture in the next school. There are no inconsistencies or conflicts. It also includes those that have an interest in educational results such as future employers, universities, psychologists and sociologists. They also have input in telling the educationalists what the students need to learn to prepare them for real life, real life skills that are referred to as Competencies. The direction and scope of the curriculum is set and then put into an order so that one competency builds on another even across subjects.
This is handed down as the Contents of the curriculum. It is the core principles that must be taught during specific periods of the education cycle to ensure that the whole curriculum is finished on time and that the teaching of each subject interlaces. This is a basic framework to which the teachers may add but not subtract. They are the minimum standards of competency.
The curricular Contents are the big jigsaw. Each piece of that jigsaw, a Unit or Module, may be a month or two in duration. Each Unit or Module contains a variety of candidates for objectives or Competencies that can be used as the core Experiential Learning Cycles that the teacher distributes through their teaching calendar to create a smaller scale jigsaw puzzle. The pieces of the jigsaw within the jigsaw are the individual Lesson Plans. They provide the day to day structure for the students.
This is the level of structure and organisation necessary in the education system to ensure that students are never confronted with a problem that they do not already have competency in.
The teacher is no longer the teacher. They do not really teach anything. Modern educationalists prefer the term ‘facilitator of knowledge’. Students are best referred to as the ‘acquirers of knowledge’.
The prime role of the facilitator of knowledge is to give the optimum structure to the learning environment for Independent Learning to take place. It is a conceptual and cultural revolution in education.

The Tradition of Clinical Education
What medicine has inherited is a tradition born long before the Experiential Learning Cycle was a twinkle in Kolb’s eye. It is a system of lecturing, the most dependent learning, to provide a theoretical background and then learning independency and self-confidence the hard, unreliable and unsafe way, by throwing students and junior doctors in at the deep end.
These old ways are enshrined in the fundamental structure of the medical hierarchy and their roles. It may have seemed like a traditional apprenticeship but in fact it was exactly the opposite. The traditional apprenticeship was far closer to the modern model with the apprentice dealing with the really simple stuff until they had fully mastered it and could move on to more difficult and intricate work.
In traditional crafts, the dog’s body work of the apprentice is the easy work. It is to do little fragments that can be learned one by one to build a complete jigsaw of abilities. And this would be done under the mentor’s guidance, picking and choosing what the apprentice is capable of at the moment, what they have already been taught to do.
It is all topsy-turvy in medicine. The most difficult thing that there is in medicine is dealing with the entirety of the patient. That is the dog’s body work and it is what gets left to the most junior member of the team available. If there is a medical student, send them in first to sort through all the complexity and extraneous details so that the boss can save time and concentrate on the predominant medical problem itself.
The medical student and the junior doctor need to know far more than their mentors. They are expected to know the majority of what the specialist knows about their subject plus all of everything else. By now the specialist may well have forgotten half of what they once knew about the rest of the body.
Deciding which drug to use for heart failure is a protocol. Understanding the patient’s psycho-social environment requires vastly more skill so it is left to the medical student or most junior doctor. They do most of the communication. Everything is thrown at them unedited. They see the patient acutely ill and in pain. They get the most urgent decisions.
They hand their seniors simplicity on a plate.
In terms of learning, this is the outdated model of throwing the learners in at the deep end in the hope that they can make it up as they go along and keep their heads above water. They are constantly up against a level of complexity that is too advanced for them at this time and asked to find solutions. And their teachers have often learned the same way. They are examples and mentors who teach their habitual solutions to problems by example rather than those of best practice by the expert in the field.
We have also inherited a system that until relatively recently, focused only on the diagnosis and medical treatment. Communication and consideration of the whole person and their social setting was not prioritised in the learning process and where it happened, it was left largely to chance and the luck of having a good mentor. Or the communication style, which may not necessarily be skills or competency, is copied from a senior who is admired for other reasons.

Learning Communication
Learning clinical communication skills is complicated by the fact that the students already have two different sets of communication skills. They have a set of social communication skills which are largely verbal and they have a set of formal academic communication skills that are largely written. These are their fallback communication skills that they will fall back on to keep their heads above water unless clinical communication skills are taught to the point of becoming second nature using the Kolb Cycle.
The doctor patient relationship is very different from any social relationship or academic writing. Perhaps closest parallel in social relationships would be that of the ideal between a parent and their parent, a wise familial matriarch or patriarch who the parent looks to and goes to when they are stuck, in trouble and do not know what to do. They are fountain of wisdom, experience and knowledge in the family who is respect and self-assured enough to solve problems rather than seek popularity. Yet at the same time, they are devoted to their family’s interest in the long term.
Patients are seeing their doctor because they need help. They are in a situation that they cannot deal with themselves. They are looking for that idealistic matriarchal or patriarch, the fountain of knowledge, experience and wisdom who is devoted to their best long term interest and will help them solve a very concerning health problem.
Those that have experienced this type of relationship before medical school were not the matriarch or patriarch of their family. They are too young. With the nuclear family replacing the extended family and a society determined to worship youth, even the experience of this stereotype is fading.
Nobody goes to medical school with the social skills for the doctor patient relationship. In medical school they develop their academic communication skills but they are not a lot of good for the majority of patients. They need to learn a new skill set for every time they put on the white coat or scrubs. They need to be taught that new skill set intensively until it is second nature using the Experiential Learning Cycle under highly structured and focused conditions before they ever speak to a patient.
The Kolb Cycle relies on taking one thing at a time without distraction and working on it until it is second nature. Only then can that competency be built upon. That what is used in the most successful educational models and it is what the senior academic educationalists recommend for the education of competencies.
As soon as they are distracted by having to do too many things all at once, such as consider the diagnosis or treatment, they will slip into old habits. They will establish habits that are appropriate in their social lives and academia. Traditionally, doctors went for the academic side and talked to patients coldly, clinically and scientifically in a Medicalese that the patients did not understand.
That problem is well known and something has been done about it but not the consistent use of the best advice from academic and practicing educationalists. Now the pattern is emerging of doctors speaking to patients using common social skills as if they were talking to a friend or a grandparent.
The predictable consequences include trust and treatment compliance. There is also a loss of clinical objectivity that is an intrinsic part of the perfected matriarch/patriarch mindset. Doctors get as involved as they do with family or friends and burn out.
The same is true of pain management. Sending medical students and junior doctors off to deal with patients distressed by acute pain before they have deeply understood this complex subject means that they cope as best they can with their limited knowledge and experience. They develop habits that will be hard to break....
Morphine 10mg IM.
That is what happens if clinical students and junior doctors react with their societally indoctrinated panic over pain. It is connected with lumping together pain and injury rather than understanding the essence of pain as the mind’s perception of injury or harm. It is a societal fear that is not appropriate for a clinician who has a whole armoury of solutions to that pain, not least of which is curing the cause.
And these habits are going to be defended as if they are the very essence of a human doctor. Every justification, validation, rationalisation and excuse will come up to resist change. The only way to get it right is first time and to establish new habits that become second nature.
Perhaps the depth of this was the acceptance that ‘Pain is the fifth sign’. Not, tenderness is a sign. Muscle spasm is a sign. How pain makes the patient move is a sign. Clinical signs are found on the doctor’s observation and examination. Pain is a symptom that the patient reports. It is a damn important diagnostic symptom and does need treating but it is not and can never be a sign.
That is society talking, not clinicians who really and deeply understand pain.
Most doctors have learned about pain from those who never really learned about pain. They just learn about standard, knee-jerk practices based on a mix of either societal practice or overly academic and theoretical practice that would have pain ignored as unscientific and just in the mind.
I only learned about clinically based attitudes to pain as an anaesthesiologist. I only learned deeply about pain management outside of the operative period working in a specialist pain clinic and I had to relearn everything that I thought I knew.
Before that, I had already taught medical students what I thought I knew about pain when my management of pain was typically substandard for a non-specialist in the area.
Would anybody like a lesson in using chopsticks?
In structured Independent Learning, you learn the best practices from the experts in those practices, not those who have been mistaught and think that they know what they are doing.

A Structured Clinical Education
And clinical educators or classroom teachers are just as susceptible to this tendency of slipping into old habits, learned by experience from their teachers who were using traditional methods. If they practice these archaic, dependent methodologies before they have been re-educated in the new way, as soon as their consciousness slips, the old ways have slipped back in. They will become habitual and very difficult to change.
It is another reason for the lesson plan to habitually maintain the structure of Independent Learning. The teacher must think about their methodology before hand and ensure that it is not disrupted. They need a chance to think about it unpressurised by anything else so that they can focus on other matters in the moment of teaching.
The cases that the medical students see must be carefully selected so that the students do not encounter problems that they are unprepared for. As first point of contact, there is no case selection. The suspected appendicitis that has just come in might have Crohns but they might not have studied gastroenterology yet. If it is a female patient, they might have a gynaecological problem.
Give the student a chance to get it right!
What happens if the student presents the patient’s case because it sounds, in their limited experience, like appendicitis and it is not. Could they end up under the wrong specialty, getting the wrong treatment with the real cause of their problem deteriorating?
The young patient with shortness of breath and a history of allergy might be in anaphylaxis. What would it do to the student’s confidence if they die in front of them?
Is this practice for the convenience of the senior doctors and to get a bit of work out of the juniors or is it designed to be the highest standard of educational experience?
The next patient who comes through the door has complex multiple pathologies that a whole team of the best experts is going to struggle to come to terms with. What chance does the student or most junior have?
Competencies and confidence are built by always getting it right.
The next patient is a difficult communicator who wants to rabbit on about anything but their medical problem. After that comes the patient stuck in the sick role. Then there is the experienced addict who knows just which buttons to push for the innocent junior staff to get what they want. Now there is a psychiatric patient whose words barely relate to this reality.
In this uncontrolled and unstructured experience, students and junior doctors are thrust into the traditional learning experience of being thrown in at the deep end without preparation and just have to cope as best they can. They are forced into trial and error, developing substandard clinical habits and making errors. They get used to being wrong rather than growing their confidence by getting it right every time under controlled conditions with carefully selected cases.
They should be seeing those carefully selected cases for a specific educational objective that they have been prepared for beforehand. The education process should not be left to chance.
That means senior, experienced doctors manning the frontline rather than being rearguard generals protected from the conflict. Clinical students can safely build up their competences away from patients and then with the easiest, most straightforward cases. As junior doctors build up their positive educational experience, they can be exposed to medium level cases and finally move on to more challenging ones.

Is This A Question Nobody Dared To Ask?
It is common sense. It is the oldest educational principle, except in medicine. Exposure starts with the simple and builds on that foundation.
It did not work very well with dependent methodologies because few managed to grasp the concepts and gain the competencies. In the best systems of modern Independent Learning, the vast majority are attaining their competencies. It is producing outstanding results as one competency leads to the next and always built on solid foundations. The students achieve more academically and they are better prepared for life in the real world where half of the battle of life-long learning is confidence to learn independently.
It comes from a structured education system where practice and examples are carefully chosen for their educational value and the students’ needs so that competence and confidence are progressively fostered and harnessed under optimal educational conditions.
The traditional educational/training/apprenticeship structure that modern medicine has inherited is the reverse. Being kind, it appears to be based around practical workload not educational sense or practices. Being unkind, as an educational/training/apprenticeship system, it seems to have been based on the convenience of the teachers rather than the learning experience. It is not even based on the creation of the best product for the customer, in this case, life and death patient care.
For medicine to take Independent Learning very seriously would take a major revolution.

It would have to happen at all levels and starting at the latest for clinical students but also encompassing the education of the most junior doctors. Only then would MedEd receive doctors who already had the highest standard of education, competencies and confidence.

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