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MEdIC Series | The Case of the Absentee Audience

2017-01-04T18:32:43+00:00

LLSAslideHave you ever been at a lecture where the audience didn’t seem in ‘sync’ with the speaker?  Or perhaps as a junior presenter, some of you may have been at a lecture or two that just didn’t seem to work. This month, we ask you to advise Dr. Xiu, a presenter who is experiencing this exact problem. Come out and discuss the Case of the Absentee Audience.

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in pdf format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of the Absentee Audience

by Teresa Chan (@TChanMD)

The view from the lectern was less than inspiring. Dr. Nelly Xiu, a newly appointed Associate Professor, stood in front of a half filled lecture hall. Of the nearly forty residents and medical students who were supposed to be at the Emergency Medicine conference day*, only about half were physically at the talk. Nelly viewed the learners, watching them pull out their computers, smart phones, and the occasional journal, and wondered if any of them were mentally present.

At the end of her lecture, the tepid applause from the audience further reinforced her impression. Nelly was surprised when the chief resident, Andrew Smith, came up to chat with her after her lecture.

“Hey Dr. Xiu, good talk. Therapeutic Hypothermia is a really important topic,” he started. “I was wondering if you’ve ever thought about doing this topic as a workshop instead?”

Nelly looked at him, perplexed by his question. Clearly the students and residents had been wholly disengaged with her lecture, couldn’t he see that?

“Andrew, this was a mandatory class, and only 20 of the 40 learners on our teaching unit came. And then the half that did come were too busy texting and emailing to listen.”

“Well, I don’t think that’s fair.  A bunch of them are post-call, some of them were still rounding with their attendings, and some of them were sick. You’re right – this is mandatory – but sometimes that isn’t enough to get people in seats anymore. And it’s definitely not enough to make sure they’re paying attention.”

Nelly pondered this thought for a moment. If the word mandatory wasn’t enough to ensure learner attendance and attention, then what would she need to do to reach her audience?

Key Questions

  1. Andrew says: “…sometimes that isn’t enough to get people in seats anymore. And it’s definitely not enough to make sure they’re paying attention.  Is he correct in his statement? Why or why not?
  2. What are some issues that occur when you make a session ‘mandatory’?
  3. As a teacher, are there any preventative measures that you can use to prophylax against an absentee audience?
  4. What are some strategies that you might advise Dr. Xiu to use in her future sessions?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses one week after the case was published. This month the two experts are:

  • Dr. James Ahn (@AhnJam) is an emergency medicine physician in Chicago, IL. He is the associate program director and medical education fellowship director at the University of Chicago. His areas of interest include curriculum development and competency testing.
  • Dr. Stella Yiu (@Stella_Yiu) is an emergency physician in Ottawa, ON, Canada.  She is an assistant professor in the Department of Emergency Medicine at the University of Ottawa. She is the brains behind the Flipped EM Classroom.

On August 1, 2014 the Expert Responses and Curated Community Commentary for the Case of the Absentee Audience was posted.  You may continue to comment below, but your commentary will no longer be integrated into the curated commentary which was released on August 1, 2014.  That said, we’d love to hear form you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Teresa Chan, MD
ALiEM Associate Editor
Emergency Physician, Hamilton
Assistant Professor, McMaster University
Ontario, Canada + Teresa Chan
  • Alvin C

    There seems to have been a quite a shift in dynamics in regards to the roles of the educator and student. Traditionally, it was almost solely the students’ responsibility to stay focused and engaged, whereas now, educators have more of a responsibility to help students do that.

    Andrew raises numerous good points. It seems as if Dr. Xiu didn’t really understand the audience and factors that could contribute to their absence (physical or mental). Non-engaging lectures do not keep students’ attention (especially post-call) so a workshop would probably serve as a better learning tool. She should also consider using other forms of accessible media to cater to an audience with such diverse availability [eg. podcasts, video lectures, etc.] and a flipped classroom model to better engage the audience.

    • Thanks for being the first to break the ice Alvin! Also, to have a learner’s perspective start this case off is fantastic!

      It seems you really found Andrew’s statements resonated with you eh? Your comments seem to suggest that the traditional lecture may be something that you do not seem to enjoy? What do you think?

      • Alvin C

        Wow, after a busy weekend for me I’m coming back to a ton of amazing comments and suggestions for the case. Ever since first year of undergrad, I’ve never enjoyed lectures because I felt that they promoted a dull passive style of learning that never kept me engaged. I think a couple of key features of good lectures that resonate with me are: student accountability, using the term mandatory appropriately, and really attempting to engage the audience. Many traditional lectures taught by old-fashioned professors/lecturers lack in those three major areas.

        It is not uncommon for the majority of a class to attend a “mandatory” lecture, only to have the lecturer read the power point slides to the class with no suggestion of how the lecture would be applicable to future practice. Chances are, when our calendar shows that lecturer again in the future, people are unlikely to attend. When something is mandatory, instructors need to help students understand why.

        And again, it is just so important that lecturers try to engage the audience. Active learning helps students focus and pay attention. It also changes a lecture from something you can watch/listen to any time, to something you want to be present at to participate in. Most of the time here at McMaster, lectures are at the ungodly hour of 8am and if the lecturers are just promoting passive learning by reciting a rehearsed speech, students won’t find a need to attend.

        Finally, I think that student accountability (which generally means an engaged audience and a realization of the importance of the topic) really encourages students to want to participate in their learning. PBL and small group learning at McMaster emphasizes student accountability and it is equally applicable to lectures if done right. Not to mention, in the end when all is said and done, accountability is what drives us to keep learning and stay up to date in practice.

        Like @sluckettg:disqus said, most students WANT to want to engage in their learning. We just need instructors to give us a decent reason.

        • Deirdre Bonnycastle

          Can I quote you in a new faculty orientation I’m doing?

          • Alvin C

            Of course!

  • Anand Swaminathan

    This is very challenging and it’s happened to all of us. Once you establish yourself as a good speaker, the audience will follow but those first couple are really important. Here are some ideas:

    1. Flip the Classroom – send learners the ideas in advance with some FOAM readings. Now the learner has already bought in and they will recognize that they are coming in for a deeper dive into the topic.

    2. Make the talk dynamic – engage the learners with polls, group activities integrated into the talk. Even if your first talk isn’t widely attended, news will circulate that you give unique talks and attendance will jump.

    3. Ditch the talk – recruit another faculty member and make it a small group session

    4. If everyone has there laptops out, challenge them to find the info. Pik Mukherji out of LIJ/North Shore does this. The conference will be a clinical question and the residents have to search on-line for resources to guide the discussion.

    • S Luckett G

      Thanks for your reply, Dr. Swaminathan. Your comments really resonate with me as a learner, but also as someone who is looking forward to starting to give presentations (and hopefully eventually lectures) more frequently as a resident.

      I’m really curious…what would be your advice if your talk flops? How can Dr. Xiu get back on the horse?

      • Anand Swaminathan

        Unfortunately, nothing to say but focus on what things you may have done incorrectly, think of ways to get your audience involved and keep at it. It really does happen to everyone as some point.

        • Well, I think it might be useful to also consider setting up a peraonal learning plan.

          First, go watch a couple of the best speakers from your institution. Ask a friend/colleague that you admire if you can watch their lecture. See what works, what doesn’t. Take notes, give it a try.

          Also, consider getting some coaching. I’m personally going to go take Nancy Duarte’s workshop next month, but also worth considering just asking a peer or mentor to watch and give you honest feedback.

          • S Luckett G

            I would also suggest the difficult exercise of watching a video of yourself practising. You can get a good sense of whether you are doing something that seems closed off, off-putting, or just plain annoying…and even a good friend or colleague might be too shy to give you that difficult feedback!

  • Anand already beat me to the better answers, but I agree…Mostly.

    Flipping the classroom works if you have penalties associated with not doing the reading. Oftentimes, we have required readings that are being read during the discussion time (think of journal club). This defeats the purpose.
    It’s a tough line, because as (mostly) adult learners, they should be able to decide what is and isn’t important. But as the teacher, you’re responsible for making sure that they are adequately trained to be physicians. You don’t want the repercussion to be poor patient care, so sometimes you have to treat them more paternalistically than you would like for them to “get it.”
    As Brent and others have shown, teaching theory is poorly explained in most residencies, so many faculty are simply not clear on how to teach the difficult student. Even having done the ACEP Teaching Fellowship, I have struggled with this frequently.
    Making them participate works well, and doing discussions that keep them entertained is important.
    Another problem with many lectures that people tune out of is the, “I read my .ppt slides to you” lecture, which may or may not be the problem in this case. Fewer words, more pictures, and only 4 key points is a must.
    On the other hand, if it is an audience problem, then perhaps there needs to be a cultural change. Many of us have the last lecture of protected time become an episode of “the walking dead”. Doing workshops, simulations, or other activities becomes keep in keeping post overnight participants awake.

    • S Luckett G

      Thanks for the thoughtful comment, Dr. Hensley. In my past life, I did a lot of research with teachers, and I found that even amongst these trained specialists in learning there is often still a lack of knowledge about teaching theory. Why do you think we fail to teach or learn about how to teach and learn in medicine? What can we do about it?

      I’m also curious about making learners participate – in a reticent group, do you call learners out, or have you found another way? I’ve been in the position of listening to the crickets chirp after I ask a question of an audience, and it is very uncomfortable!

      • I wish I had an answer on how to rope people back in. A good joke might get them back. Calling on people often causes negative feedback in that they avert their eyes hoping not to be called on. Sometimes you have to do it. Nobody wants to be standing up there saying “Bueller, Bueller, Bueller.”

        Breaking the room up into teams can help. Sure, it reduces the number of questions you can ask, but encourages competition, which spurs activity.

        We fail at teaching mainly because we have been failed as learners. All of us emulate what we are exposed to. Everyone knows a handful of great lecturers, but most aren’t able to do what they do. So we do what we’ve been taught, which is 1 slide per minute, etc, etc.f

        The best strategy is to practice. Then you can add your nuances that make it interesting, and you’re able to give the eye contact you’re supposed to. Practice way more than you think you need to.

        • S Luckett G

          I like the idea of creating one’s own style, and I think you’re right in that it takes time and practise. I certainly have not found mine yet, and I think it’s much easier for me to simply copy the 1 slide per minute format if I’m feeling lazy…and afraid of failure. Having grown up in high-performance athletics, I am used to stumbling in sport. That’s what we do 90% of the time as athletes. Somehow, that is much more difficult to translate into teaching and presenting, maybe because we aren’t as accepting of failure in academics as we are in sport.

          Why do you think competition works so well for learners? Is it all just about showing off?

          • I think there is something to be said about both using intrinsic motivation and extrinsic motivation.

            House points (à la Harry Potter) clearly helps with external motivation… pride, competition, these are things most people in medicine have been exposed to since they were little Hermione Grangers putting up their hands in the first grade class. That sort of classical conditioning often is residual, even after all these years, and in the name of learning, I have used this technique myself.

            Chocolate bars are also a clear motivator. Both can be used as a prize if given after…. but also to energize a sleepy crowd, if given during/before. 😀

    • Anand Swaminathan

      Justin – great points. Nothing easy about learning to lecture. Practice helps and just getting out there and doing it.

      In the beginning, I modeled my talks after those that I saw as successful – Amal Mattu, Corey Slovis, Mel Herbert, Al Sacchetti etc. As I got more experience, I started to develop my own style. Now, I continue to listen to talks I’ve given and try to hone them. My style continues to change as I see others do great things – Cliff Reid, Scott Weingart, Simon Carley and others.

      The key is not getting complacent. Although it takes time, I update my talks every 6 months and I often make complete overhauls as my style changes.

      Listen to the podcast from iTeachEM where Natalie May, Simon Carley and I discuss some of these ideas (http://iteachem.net/2014/06/good-educator/),

      • S Luckett G

        Dr. Swaminathan, you describe learning to lecture like learning to do anything else; it requires practice, mentorship, and self-awareness (and maybe a bit of innate talent helps!). So why do we think that just anyone should be able to step to the screen and give a presentation at any moment? I remember giving several presentations in graduate school, but I don’t remember learning much about HOW to give presentations. What sorts of resources do you think institutions could supply to support the development of their lecturers, be they seasoned physician instructors, or green residents giving their first talks? Should direct instruction on teaching be integrated into our curricula?

        • Anand Swaminathan

          We have some talks on how to give a lecture which are helpful. Each resident is paired with a faculty member who has multiple roles. 1) review the content of the talk 2) give feedback on how to craft the talk 3) give feedback after the talk on what they can do to improve. This definitely helps. Faculty need to do the same thing. Have another faculty member give them feedback. I use a program to record my talks and then share with a friend at another institution to get feedback. Establishing these networks is a great way to get feedback and help you develop.

          • S Luckett G

            I like this mentorship model of resident presentation preparation! I find we are often in a position of being ‘precepted’ but not necessarily mentored. Sometimes we forget that the mode of presentation is just as important in delivering information as making sure we get the facts right.

        • Deirdre Bonnycastle

          We do a 2 day teaching course for residents. Our research shows their teaching improves by the end of the second day but that gain is lost if their department doesn’t reward good teaching.

          • S Luckett G

            That is all very encouraging and makes a lot of sense. Good to hear that this is being done and also followed.

  • Great case; as a student it is always painful to watch a lecture take a nose dive and then see poor attendance the rest of the module or for future talks. From a learner’s perspective, I think a few things separate the best educators from the rest. Here are some ideas Dr. Xiu could focus on for her next talk:

    1. Take a few minutes to know your audience before you make that title slide–not just their education level, but what content they are in the process of learning, what challenges they face, and the work culture they are a part of. This is a great way to identify how you can deliver content that truly meets the needs of the audience. It also empowers you to think about how you can frame your content within the unique needs of your learners. Even if this is a talk you have given dozens of times, you should stop and think of this specific lecture as a new instance and go through the same process as if you were giving the lecture for the first time. For instance, if you are the last lecturer of a 5 hour day of straight lectures, you should know this and anticipate the audience’s fatigue by the time you are ready to rock the mic.

    2. Flip the Classroom, but only if you are limber enough. The best thing about the flipped classroom model is that educators basically get to be their own hype-men and get learners psyched about what is to come. The downside is that often times the content sent out prior to the lecture/conference/discussion misses the mark. Make sure you provide content that adds value, does not replace the entire message of your talk, does not swamp learners with too much work relative to their workload, and–most importantly–builds interest. The classic case of a “flopped” classroom is the 7pm night before email, with 4 journal articles and a document of questions attached that gives away the diagnosis of the case with the file name–SLE-case-for-conference.docx.

    3. Put mandatory in context. Content is often designated as mandatory because it is vital to a learner’s education; however, the “mandatory” designation does little to convey that importance to students in a meaningful way. In reality, all of the core content students are presented with is mandatory–we need to learn it, and we know we need to learn it. In order to engage learners, emphasize the context of the material. How this skill/knowledge will impact their practice and the lives of their patients. Go beyond the basic epidemiology facts about heart disease that began every single lecture of our cardiology unit.

    4. Realize there are consequences when something is designated as mandatory. Not to add pressure to educators, but when mandatory events go poorly or seem to lack tangible importance, there is definitely a boy-who-cried-wolf effect. The worst thing that can happen is that learners begin to file your mandatory content into the same category as other content deemed mandatory by the administration (think, HIPAA training–yikes).

    • S Luckett G

      Scott, I agree – as a learner, I have had the very unfortunate experience of cringing in my seat as I watched a lecture fall flat.

      I especially like what you said about flipping the classroom. I can’t count the number of lecturers I had in med school who would send out 100 pages of reading and questions the night before the lecture. For you, what does flipping the classroom look like when done right? I completely agree with your list of “don’ts” but I’m really interested to see what’s on your list of “dos” for a limber flipper.

      • Great question. Sometimes I think it is almost harder the to define the “dos” because the best educators flip the classroom so effortlessly it seems organic.

        I think the best times I’ve been flipped, so to speak, the educator had a definitive grip on what they wanted me to walk out of their classroom knowing. I think they sat down and really thought through 3-4 objectives and then focused on how lead me to those points every step of the way.

        The first, most important “do” is how educators view the student’s understanding of preparation material. In the perfect classroom, every student will vocalize his or her misconceptions or gaps in knowledge. In reality, educators are faced with lecture halls of students who may never speak up. I think it is important to start the activity with a Q&A session about the preparation material to address any of those concerns. One time I was in a lecture where the presenter started with questions she had about the preparation work. It was an awesome way to set the tone of the talk and establish openness. While this is a total anecdotal conclusion, I think the best educators estimate the understanding of the preparation material to be somewhere at or slightly above where students might be if they were given a lecture on the topic. This prevents them from assuming their learners know everything and allows for the deeper dive into the material.

        To this end, I think educators should actively refer to the preparation work in the classroom activity. Whether it be a screenshot of a key slide or a direct quote from a podcast, I think it is important for educators to help learners see where all the pieces connect. It also ensures that the at-home learning was valuable for learners. If you can’t easily incorporate content from the assigned reading in a relevant way to your class activity, then is it really important for your talk?

        Another effective “do” is some means of accountability. This is a touchy subject, though, because I think teachers run the risk of belittling learners at times with meaningless assessments to ensure the required work is done.

        From my experience as a student, the most meaningful means of promoting accountability is putting learners in situations where they need the preparation material to succeed, and the material educators hold students accountable for is central to the objectives of the lesson. The best flipped classroom I ever participated in was based on anticoagulation. The night before, there was a great lecture online about various ways to anticoagulate someone. For one hour the next day, the lecturer posed cases of various difficulty to the class, asking us how we would treat the patient. Individual accountability was self-derived; the session would be useless without the background material. Additionally, this means of assessing accountability was inherently rewarding to us–we were putting basic science to tangible use, and of course there was a little bit of fun score keeping.

        Of course, some populations of learners need a more direct means of accountability. TBL models often impose a graded quiz at the start of sessions. I firmly believe that it is possible to hold learners accountable without the fear of a summative assessment, but it is often more challenging to achieve as an educator.

        • S Luckett G

          Wow, thank you so much for the comprehensive answer.

          I especially like what you said about accountability. If I’m reading you right, you are suggesting that the best solution to mandating preparation is having a situation that inherently rewards preparation. I have certainly participated in classrooms like this, and I agree that it is extremely rewarding to solve a problem that you couldn’t have solved unless you were well-prepared.

          The only caution I would offer to those who would use that strategy is that sometimes lecturers rely on only superficial knowledge of the preparation material for satisfactory completion of in-class activity. For instance, they may provide questions or cases that can be answered with something as simple as a direct quote from the required text. I find that both unsatisfying and, if I’m honest, a bit condescending. What do you think?

  • Matt Klein

    As a new PGY1, I’d echo Scott’s comment that we learners know we need to learn the content being provided, and (post-call fatigue aside) we’re eager to do so. Context is key – how the assigned topic going to manifest itself in the ED? What do I need to fear? Mel Herbert is fond of saying on EM:RAP that you need to know what you need to know… plus one step further. In my experience, lecturers often run into trouble when they feel responsible for covering two, three, four steps down the line. If there is an intricate specialty society classification scheme for [condition X], take Dr. Swaminathan’s advice and have learners use their devices to discover where to find it. Limiting the scope of a talk to a few key points & emphasizing their clinical importance, for me at least, seems to lead to the most engaging and memorable lectures.

    • S Luckett G

      Matt, thank you for your thoughtful reply.

      I find that as a PGY1 the immediacy of all the information (I know that I will need to apply it not just as a learner but as a junior practitioner with real responsibility!) inherently motivates me to soak up as much knowledge as I possibly can, and it sounds like you feel the same.

      You touch on an important aspect of our learning at this level, though: We need context because we don’t yet know what we need to know! Meta-cognition, as it’s called in the literature, isn’t really taught in med school. I’m trying to imagine a framework where we are taught to identify important context and gaps in our own knowledge directly, rather than acquiring it as a skill we incidentally pick up along the way. How – if at all – do you think that would change the way we engage with our lecturers? As a fellow PGY1, what do you imagine would be the best strategy for helping we learners develop that meta-awareness?

  • Michael Macias

    I think that the entire concept of the flipped classroom has developed as a result of our ability to gather a significant amount of high yield information on our own through online resources. There previously existed pearls of knowledge that were once sacred and elusive. They were hidden in the minds of the experts and could only be extracted by sitting and enduring an entire lecture. But hey at that time when it was the only way, it wasn’t so bad. But now I can get that tip in 5 seconds on a tweet, or read a blog on the topic when I am fresh and energized, on my own time. Mandatory lectures have now become a burden to the learner as the thrill is gone. And we are left with learners coming to lecture in the completely wrong mindset.

    Thankfully with the advent of social media, the conversation (albeit online) has become much more important and many learners have turned to this format which allows them to feel in control of their knowledge acquistion and therefore more receptive and engaged in their learning environment.

    The idea of participation in learning is not new but it is changing. Not forcing the learner to participate but rather convincing them that they want to. Establishing emotional connection. This is a core technique used to content strategy in the marketing world. Take TED talks, there are many lecture topics that would be bloody boring without the proper pitch, but they convince their audience that they must listen to this lecture, that the infomation they are hearing has ‘internal’ meaning to them beyond the facts.

    So as a learner, I would say :
    Make us WANT that information, get a hype man/woman and advertise
    Make it pretty (we like pretty things)
    Get us involved and show us other people are involved too
    Make us FEEL that the information you are going to give us hits areas of the brain deeper than the cortex (this is metaphor and not to be taken literally)
    Make us feel in control of our learning

    Tough laundry list to follow but in light of the modern learner with a finite attention span and a sea of information, the standard lecture simply won’t do.

    • S Luckett G

      Michael, I really identify with the thoughts you’ve shared.

      As a learner, I find that I WANT to want to engage with the material. I just need someone to give me a good reason, and it sounds like you feel the same way. One of my favourite lectures ever was an obstetrics lecture where the instructor used an episode of the TV show ER to walk us through an obstetrical emergency. He played short clips, pausing the video to ask us questions, have us critique management decisions, and solicit our predictions about what would happen next. I was on the edge of my seat the whole time, even though I had not been very excited about obstetrics walking in. I felt satisfied on my way out, as though I had learned a lot from that one lecture. Care to share about any similar experiences? How did the instructor get you to WANT the material?

      I’m also curious about the first part of your comment – are there any clinical pearls we can’t track down on our own? What’s the role of traditional mentorship if we can grab snack-sized bits of pre-wrapped information?

    • Thanks for your reply, it really resonates with me both as a teacher and a learner.

      I recently ventured to TEDactive to learn about their secrets – did you know that when you become even a TEDx speaker you get mandatory speaker development? It’s one of the key components of organizing a TEDx conference! When was the last time YOU got coached to be a speaker, eh?

      I’m continuing my quest now… and I have stumbled upon Nancy Duarte’s work. I will be taking her workshop at the end of August in California. Woohoo!

      But more importantly here is a free book that speaks to many of the issues that you considered in your response:

      http://resonate.duarte.com/#!page0

      She’s giving it away for free!

      She also talks about ALL of that in her TED talk which I love:
      http://www.ted.com/talks/nancy_duarte_the_secret_structure_of_great_talks

  • Esther Choo

    I came late to this so can I just say “ditto” to all the above? I will add that I think teaching is a partnership; the onus cannot be *entirely* on the instructor to capture attention. So one the one hand, “Make us WANT that information” is not up to me – learners need to want that information so that we are a team working together to effectively GET them that information. I cannot do interpretive dance so that my learners take some baseline interest; but when I have an engaged learner (hello, Matt Klein!) at the table, I feel inspired to do my part and be as energetic, clear, interesting and effective an instructor as possible. I do, however, absolutely agree with the statement that “the standard lecture simply won’t do,” and Alvin’s points about needing to be engaging. Gone are the days of Death by Powerpoint.

    Some instructor characteristics are timeless:
    – strong command of the topic
    – genuine passion for the topic matter
    – preparation specifically for the teaching activity and the audience
    – joy in the teaching process
    – interest in where the learners are, and where they need to go

    Some didactic session characteristics are consistently recommended among our pro educators:
    – interactivity
    – presentation Zen
    – humor (if that is your style)

    I love Anand’s point about developing your own style. I so admire our EM rockstars: Amal Mattu, Tyson Pillow, Diane Birnbaumer, etc., but I don’t even try to mimic any of their styles, because my personality is so different. I couldn’t carry it off! My own style, such as it is, allows me to be comfortable in my own skin up there.

    BTW, to Teresa’s point, I just found my first teaching / lecturing coach, and he is helping me iron out my weak points. The deliberate practice and frank feedback gives you stuff you can’t possibly give yourself, no matter how motivated you are to improve as a speaker.

    • S Luckett G

      Dr. Choo, you are not late to the party, just making a fashionable entrance.

      I’m glad you brought up Presentation Zen, because that was a resource I had mostly forgotten about. If I recall, the main message is simplicity in visual presentation leading to active engagement with the audience. I recall that the original book offered some very practical strategies for creating visual presentations that work with the audience.

      I like your point about learning being a partnership between instructor and learner. I think that sometimes we sceptical learners who have had many poor experiences of being taught become unwilling to be the first to engage in that learning partnership. What can savvy instructors do to get the ‘buy in’ that facilitates a good instructor-learner partnership?

      • I must say I am most certainly a fan of Presentation Zen, Esther!

        I was given that book as a suggestion, and I haven’t looked back.

        That said, deliberate practice with quality feedback is so very important. But the practice is key – also having lots of peers to vet and challenge you.

        I’ll be honest, I actually have asked several people to watch me present, and each time I get new insights into my performance. 😀 As a kid that grew up doing piano competitions, it feels *normal* to get adjudication after a talk…

        Always gotta learn more!

  • Victoria Brazil

    Impressed by the debate.
    Great topic and keenly felt conundrum in most medical schools.

    Mandatory and/or ‘electronic free’ is not a bad idea if it brings mutual responsibility on the part of the facilitator to make it worthwhile for the learner.

    Flipped classroom/ buzz group/ share and pair – whatever the terminology – large group sessions of more than 10 mins need interactive, shared problem solving discussions.
    ‘Content’ needs to be either provided beforehand, drawn out of the group, or opportunistically ‘inserted’ within the discussion

    This is relatively easy for us in clinical medicine because we can use case studies etc.

    Go and watch the excellent histologist/ anatomist/ biochemistry teacher to find real role models here !

    Thank for the excellent case

    • S Luckett G

      Thanks for your reply, Dr. Brazil.

      I’ve seen several instructors impose an ‘electronic free’ policy with varying levels of success. Above, Dr. Swaminathan suggested having audience members use their laptops as part of the lecture structure. I imagine both could work, but it would depend on how it was implemented. What would you suggest for implementing a successful ‘electronic free’ policy? What does it necessitate on the part of the instructor?

      My favourite part of any lecture is always the case study! Any tips for what makes an engaging case study?

      • Victoria Brazil

        Thanks for your interest.
        I think any of this is hard for the ‘once off’
        The concepts we’ve been discussing are best used in a trained audience !

        ie your learners have to adapt to flipped classrooms and be used to policies like electronic free or mandatory
        Trying to have a consistent approach from a educational program or institution is important, as well as learners seeing the rewards of engagement over time.
        I reckon it takes roughly the first half of a semester to get my year 3 medical student cohort there

        Case studies are all good – if I had a tip…. Keep it about the case
        Make sure you are getting learners to commit to ‘what would you do now’ or ‘what do you think is going on ?’ and then explore why.
        Don’t just present the case and then use it to tee off into didactics or discuss anecdotes of similar cases

        • S Luckett G

          I see what you’re you’re saying. It would be hard to maintain an ‘electronic free’ lecture theatre if the guy lecturing before you and the one after you both allow free use of laptops and smart phones throughout. Similarly, it would be difficult to tell learners that electronics were not allowed today if they were allowed yesterday. Ditto for any other sort of rule or guideline.

          Your point on using cases as a jumping off point for decision-making and directed discussion instead of just a starting point for didactics resonates with me as a learner. When I think about it, the most engaging cases I’ve seen were not just those where the lecturer had a set of learning points s/he wanted to present that there related to the case, but rather the cases where we were pressed to provide a rationale for our approach to the patient, or an analysis of the situation at hand.

          • Pik Mukherji

            Wow. Look at all the speakers responding to how to give a talk — everyone loves it when there seems to be engagement/interest! Agree not taught in residency, although the feedback by Andre on what to do differently in your case may be a great starting point. All our residents give talks, how can we make it a better experience for both them and the 30 residents in the audience? A designated resident and attdg. coach is a good place to start.

            On the rest-
            Chocolate: good. Shears/penlights: acceptable. Interpretive dance: makes your next talk very well attended.

            Everyone says interactive is best, but ignores the next obvious step. When you interact w audience, you have to respond to what they say! You may have objectives to get to- get comfortable with a roundabout approach. Get comfortable with learning things you hadn’t meant to go into. If you’re not having a discussion, how can you be having interactive engagement? So straying from your planned didactics, being comfortable discussing SAH during your syncope case, generally accepting that you won’t be able to do 1 min per slide or read off of your notes is where this ends up. Is that harder than the prev. accepted “canned talk?” Yes. Is the work apparent and appreciated by audience? Yes.

            Teresa, Duarte’s book is good, where are you doing a workshop?

          • There is a legendary lecture with interpretive dance from nearly a decade ago here at McMaster, and it is still reviled as the reason why no one will come to one of our academic days. I disagree with you re: the interpretive dance as a selling feature.

            For that Academic Day, For the past two years, we’ve gone from having a session as “mandatory” to active marketing of the talk to get attendance. We’ve used a combination of social marketing (Facebook group – McMaster MAD 2.0, if you wanna see), traditional marketing (great posters, word of mouth), and an improved “product” (we now focus very hard on recruiting the best kinds of speakers). We now do dedicated coaching and selection of speakers, explaining to them our goals and style that we want. Most speakers now do a great job, because it’s easier for them to understand what we want. Making it explicit is helpful.

            Totally more work, just like your discussion materials and prep… And anything that requires WAY more work can be a harder sell to the instructor. We are all busy, and our lives are full. That said, if this is an area of your craft that you’re interested in developing, then it is key.

            Pik, going to do the workshop in Sunnyvale. I think they only do it there.

          • S Luckett G

            Interpretive dance a reality? I (almost) wish I had been there!

          • S Luckett G

            Dr. Mukherji, I like your comment about flexibility in instructing. Some of the most difficult lectures I have had to sit through were taught by instructors who asked us to hold questions or gave excessively brief answers because ‘we have a lot of material to get through today’. More engaging were the lecturers who were able to go with the flow as it were, answering questions when they came up and diverging briefly from their planned talk during teachable moments.

            I wonder if one of the key components to a good lecture is preparing a talk adequately focussed that time is not a constraint. It seems to me that if you prepare an engaging talk and plan for interruptions and diversions you leave room to be relaxed and encourage interaction. What do you think?

          • Esther Choo

            If Pik Mukherji promises interpretive dance at a lecture, I will be there!

          • S Luckett G

            Me too!

          • Pik Mukherji

            Hmmm. Gonna be out in Sunnyvale in another week and a half. Should I attempt?

            And yes, I have lost bets, sung at conference, and in all likelihood will one day open with interpretive dance. Think that’ll get me to the ACEP stage?

            Javier below has done more for my pedagogy background than anyone and following every one of his links is good professional development. He’s also the reason that my long-standing “no such thing as an adult learner” comments didn’t leave me feeling like a complete idiot with no academic background.

            Now as far as my original comment, it would be preferable that the discussant (lecturer) have a degree of mastery on the field to really be comfortable w far ranging discussion and implications. But mainly its just comfort w uncertainty.

          • Javier Benítez

            Thanks Pik!

  • Javier Benítez

    The lecture has been around for centuries, and I don’t think it will go away. It won’t go away and that’s a good thing. What we should focus on is “What is the lecture for?”. This is a topic I have written about in this blog before (https://www.aliem.com/why-do-we-lecture/). In this blog post, with the help of two lectures given by Rhonda Sharpe and Eric Mazur, I addressed good and bad reasons for giving a lecture.

    Bank Model:
    Most educational systems that I know about use the lecture as their preferred method of “delivering” information. It is even used to support the curriculum to address some of its objectives. We sit all throughout our lives in a classroom passively lectured by someone as if our brains were empty containers to be “filled” with facts. This is part of a pedagogical practice which Paulo Freire called “banking education” (http://en.wikipedia.org/wiki/Banking_education). In this practice the learner is not encouraged to co-create knowledge with the teacher, but instead to “receive” and imitate what the teacher says and does. As you can see in this type of education there is little critical thinking and leaves the learner dependent of the teacher and the use of textbooks/review books. These resources are useful, but learners should be equipped with skills to go beyond these resources, including the lecturer, and be able to look at the evidence behind the practice of medicine.

    Co-construction of knowledge:
    One of the pedagogical practices that encourage knowledge co-construction include social constructivism (http://en.wikipedia.org/wiki/Social_constructivism). This practice can be seen in situated learning environments (http://en.wikipedia.org/wiki/Problem-based_learning), problem based learning (http://en.wikipedia.org/wiki/Problem-based_learning), and the likes. In this setting the learner is treated as a full participant of a community of practice (http://en.wikipedia.org/wiki/Community_of_practice) not only acquiring the necessary knowledge, but also developing skills and behaviors of the profession. Co-construction of knowledge requires an environment that supports active learning strategies (http://en.wikipedia.org/wiki/Active_learning), in and out of class, such as class discussions and peer-instruction.

    Why lecture, why not lecture:
    Learners need some background knowledge to participate in a community. This background knowledge can be acquired via various resources, including the lecture. The lecture has its use and limitations, just like any other tool. As Rhonda Sharpe mentioned the lecture can be a great tool to teach and gives these reasons why we should lecture (https://www.aliem.com/why-do-we-lecture):

    Reasons why we should lecture (Fry et al. 1999):
    1. Share new knowledge not available in other formats
    2. Demonstrate academic or professional skills – show framework of thinking
    3. Introduce a new topic via an overview
    4. Show how several aspects integrate or compare things
    5. Show how to solve problems

    Donald Bligh points out ineffective uses of the lecture: (http://isites.harvard.edu/fs/docs/icb.topic38998.files/Bligh_Ch1_and_Ch3.pdf):
    1. The lecture is as effective as other methods for transmitting information.
    2. Most lectures are not as effective as discussion for promoting thought.
    3. Changing attitudes should not normally be the major objective of a lecture.
    4. Lectures are relatively ineffective for teaching values associated with subject matter.
    5. Lectures are relatively ineffective for inspiring interest in a subject.
    6. Lectures are relatively ineffective for personal and social adjustment.
    7. Lectures are relatively ineffective for teaching behavioral skills.

    Flip Classroom vs Problem-Based Learning:
    The flip classroom has been cited as a useful method to acquire information before class. Class time is used for discussion, I have written about this as well (https://www.aliem.com/where-pedagogy-in-flipped-classrooms/). In my opinion Problem Based Learning has more effective pedagogical practices than the flip classroom. Howard Barrows, who developed PBL, wrote a taxonomy of problem based learning methods and their uses (http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2923.1986.tb01386.x/abstract). Advantages of using PBL as per Barrows include, but not limited to:

    1. Structuring of knowledge for use in clinical contexts
    2. Developing of an effective clinical reasoning process.
    3. The development of effective self-directed learning skills.
    4. Increased motivation for learning.

    Expertise Reversal Effect:
    Another disadvantage of lectures, especially in residencies, is the fact that learners are all at different levels of expertise. This effect, which is part of the cognitive load theory, has been studied by Sweller et al (http://en.wikipedia.org/wiki/Expertise_reversal_effect). They have found that instructional strategies that might benefit a group of learners in turn can be detrimental to others (http://link.springer.com/article/10.1007%2Fs10648-007-9054-3.)

    Lecture as a performance:
    We don’t know much on how this particular faculty lectured, but we should be remember the “Dr. Fox Effect” (http://iteachem.net/2013/06/the-dr-fox-effect/) Lecturing is a performance and even just engaging can fool people into thinking they are actually learning. Sometimes a fluent lecture does not lead to more effective learning than a disfluent lecture (http://www.timeshighereducation.co.uk/news/great-lecture-what-was-it-about-again/2004222.article)

    Technology can be a great aid to learning if used appropriately, but pedagogy should come first. We don’t know much about this faculty’s lecture performance to comment on that. A workshop doesn’t necessarily mean more effective for learning, especially if it’s a new topic. Sometimes rounding is more effective for learning than being in lecture. And no matter how interesting/engaging a lecturer might be, after a rough night call it’s difficult to learn anything.

    Teaching and learning are quite complex processes and require lots of responsibility from all parties involved. As you can see there are lots of factors to consider when looking at a learning environment. We focus so much on the lecture, but we talk so little about bedside teaching/learning. The classroom is a very decontextualized environment and it runs the risk of being too artificial for it to be applicable to practice. It can still be a place of dialogic practice, where teacher and student are both learners, but this also requires good training, motivation, and respect.

    Rhond Sharpe on lecturing https://www.youtube.com/watch?v=JnMfo4iUgks

    • S Luckett G

      Dr. Benitez, than you for your very comprehensive comment.

      I like how you have contrasted the idea of ‘banking’ with ‘co-construction of knowledge’. I’d argue that this has much to do with traditional ideas of surface versus deep processing. The literature has long supported deep processing (actively forming associations among concepts) as a more successful study strategy than surface processing (rote memorisation, highlighting). I think this concept is analogous to your description of having learners sit and passively receive information being less successful than engaging the learner as an active member of the community. Am I out in left field here?

      I’d also like to pick up on your comment about learning in the de-contextualised classroom environment versus the context-rich bedside environment. In my experience as a learner, I’ve found that the classroom environment works best when it is explicitly setting the stage for further learning and consolidation at the bedside. I’ve seen this work both in lectures and other traditional formats, and in standardised patient encounters. How can instructors make their lectures more relevant to clinical practice, beyond the oft-repeated mantra ‘you’ll need to know this in practice’? I’d love to hear your further thoughts.

      • Javier Benítez

        Hi S, thanks for your quick reply. Feel free, and this goes for anyone, to call me Javier 🙂

        You are spot on. Rote memorization and surface learning has its place in education. When we first encounter a topic we learn it at a surface level and need some rote memorization to have the concept and certain facts available in our minds for deeper learning. The problem is that in a “banking model”, which creates a culture of dependency, the focus is to “cover” all the material in a curriculum while sacrificing deep learning. The lecturer focuses on “covering” all material by writing more facts on a presentation slide, repeating more facts per minute, testing more facts, but fails to check for understanding from the students. The students become strategic about their studying and memorize only what is going to be on asked either by a teacher(lecture/bedside) or on tests. The implications of surface learning are many which include lack of understanding and long-term retention (http://exchange.ac.uk/learning-and-teaching-theory-guide/deep-and-surface-approaches-learning.html).

        In my opinion context rich lead to better learning than decontextualized environment. We should still keep in mind that authentic environments are not always appropriate for learning or assessments. This is where the judgement of a good educator comes into play. A good educator knows that the learner is not functioning in a vacuum and takes into account the learner’s zone of proximal development and the context of the learning experience. There are lots of factors that come into play when the learning experience/performance assessment is viewed in a contextualized manner. But a classroom/bedside environment can also help with the scaffold of important features of the learning experience, as you have pointed out. Clinician educators, hopefully this will be made into a specialty in medicine, and clinical teachers should move away from the “one-size-fits-all” education and get to know their learners in a way to enrich their clinical experience. In my opinion there is no one method to get people motivated to learn medicine, as pointed out in previous comments learning should be a partnership between all parties included. One of my preferred ways of learning medicine is making it into problem based learning. PBLs are full of context, stories, interactions, discussions, inquiry based learning that it is hard to imagine not learning the material in that setting. Stories have been around for ages as a way of learning, and medical practice has a rich oral tradition. Stories can serve as a tool to teach what’s implicit and explicit in the practice of medicine as well.

        Great questions S and discussion. Hopefully I have answered them in a clear manner. Thanks.

        • S Luckett G

          Excellent responses all around! You’ve really got me thinking. Thanks for participating so enthusiastically.

        • OMG. I just wrote about this exact phenomenon of individualized teaching/coaching on #ALiEMRP… Freaky.

          Also, writing a paper with a friend about stories in medical education. Double freaky!

          Thanks for reading my mind JB. 😀

  • Heather Murray

    I want to pick up on the electronic-free idea. I tried this for the first time last fall, and to my surprise it was quite successful. I teach some seriously boring things in medical school (diagnostic test statistics, anyone?!) and I’ve struggled to get engagement and interest. I asked the learners in my diagnostic tests lecture to put away their laptops. I promised them that the content was covered in an attached handout, and that online modules were provided for reinforcement, and asked them just to listen and participate. In the year end evaluations, many students commented that this was their favourite part of the course, and some even said that they appreciated being removed from electronic distraction. Some also said that the material was so clear that they had very little studying to do when the exam came around.
    I understand that this anecdotal evidence is not epidemiologically robust! But I was really pleased with how it all turned out, and will do this more in the coming year.

    • S Luckett G

      Dr. Murray, thanks for your reply. I have been thinking a lot about the electronic-free idea since it was mentioned in a prior comment, and I’m glad you’ve picked up on this thread.

      I am not a note-taker (indeed, nary a note taken in all of med school), but I know that many of my former classmates live and die by their notes, so I can see how promising handouts can be helpful in getting an electronic-free buy-in. I wonder if we could all use a crash-course in the value of engagement over obsessive note-taking as well, but perhaps this is just my particular orientation. What do you think?

      I recall your final lecture to my class. At the risk of brown-nosing, I remember saying to a classmate that you were en pointe that day. What did I love so much? You took us through the material with an understanding that it would be dull to a sizeable contingent of the class, you welcomed questions throughout the lecture and not just at the end, and you were FUNNY. Is how you use humour a necessary component of planning for classroom engagement?

      • Eve Purdy

        A very helpful part of the interactive sessions that you teach is giving a manageable amount of material to have prepared before hand so that we have the skills, vocab and confidence to engage meaningfully. I think these interactive sessions could be tech free too!

  • Michelle Gibson

    All right. I’ll play.

    You think you have trouble getting learners to pay attention? I teach …. GERIATRICS. To first year med students amongst others. I can guarantee you that very few learners get up in the morning jumping up and down with excitement over a geriatrics talk. Heck – I didn’t get excited about geriatrics until much later in my training – and I still can’t admit to thrills and excitement about teaching about frailty. I ‘compete’ with a course about breaking bones & the like (oooooo- trauma!), and one with cute babies (that’s just a way unfair advantage). I’m doomed before I open my mouth. When I first started teaching, I would teach to something like 30% of the class, and half of them were only pretending to be awake when I got there.

    How do I manage to teach and not give up? First – respect the learners. I try to know their schedule, so I know when there is a big midterm the next day, or that they are at the tail end of a rough week. I am clear (and I hope realistic) about pre-readings, and the respect extends to actually using the pre-readings (we’ve flipped the classroom where I teach). I give breaks when I’m supposed to. I don’t berate for not knowing things. I am explicit about why I think they need to know what I’m teaching (even if you’re going into peds, you have to get through clerkship, and your parents/grandparents are aging and my peds friends tell me that many grandparents are raising kids these days), and I keep it pitched at an appropriate level.

    Second- have high, but clear and achievable expectations of the learners. I try to create cases for our small-group learner that are at the right level, but that challenge the learners, but I’m there to support them. I’m also clear up front about assessment plans so learners know what is expected of them. While it would be nice to pretend that everyone wants to learn this because it’s important, let’s all just take a moment to appreciate the reality of med students, and then remember .. I teach GERIATRICS. 🙂

    Third – and this is very hard – I have to be prepared to fail. The only way that I can fix problem areas is to try new things. Trying new things does not always work. This means being ready to deal with negative teacher evals, which are incredibly difficult to read.

    Finally- I try very hard (but don’t always succeed) to be completely ‘in the moment’ for lack of a less cheesy phrase, when I’m teaching. I’m there to teach. I get coverage for my patients while I’m teaching (I have great colleagues) so I’m not worried about getting paged about a sick patient. If I’m having a bad day, I’m honest with the students about it (even faculty get rotten colds sometimes, it turns out), and try to make it up to them. They are usually very understanding.

    (Now- even more awkward for me- former and current students are actively commenting here – so perhaps they will jump in and call me out. Public ridicule – eek!)

    Overall- I agree with many of the comments made before me. As a Program director, I teach about teaching to my residents- and they get assessed and get feedback on their teaching. However, having completed my M.Ed while in practice, I found it fascinating to experience first-hand that just having profs who know about ed theory did not in any way guarantee effective teaching. (Is that diplomatic enough?)

    I’ve gone on long enough. I struggle with the “mandatory” thing. As someone who sees student results year after year, I know the direct correlation between many (even most) learners who struggle and their lack of attendance, so incitement to attend, or at least a way of monitoring (but not policing) attendance has helped us identify and help some struggling learners. However, it also feels a bit like micromanaging to me at times, especially for adults.

    But finally- I love to teach. (I even love to teach geriatrics despite my whining on here.) I hope that shows. I think that this helps get learners out of bed on a morning when it’s minus-something-horrible outside and they are expected to show up for a session about dementia, which is not what they pictured themselves doing when they applied to med school. Trust me. 🙂

    • S Luckett G

      Dr. Gibson, at the risk of sounding sycophantic, yours were some of the lectures I thought about when imagining what makes teaching effective.

      Admittedly, I do not have a burning desire to complete another medication review of an elderly patient, but I did learn a lot from your teaching sessions, largely because i was engaged in the process. In trying to think about what made your sessions successful, I think I’ve identified a few things: First, you identify that you come ON, you are teaching about GERIATRICS. You understand that we are not all excited about geriatric care, and making that clear is actually really helpful in getting ‘buy in’, as is making the learning relevant to us. Second, you never condescended to us. You got that we would be on our computers, you understood that we had limited prep time, and you respected that we were adult learners with a lot on our plates. Finally, in your team assignments, there was always a sense of healthy competition. I don’t think you did it intentionally, but we always wanted to get our parts of the assignments in FASTEST and make them the BEST.

      I’m curious as to whether this is an unexpected assessment of your classroom, or something you already knew! We seem to touch on some of the same points in our comments….

      Also, I recall when signing in for sessions became mandatory at QMed. Perhaps the later classes have rolled more readily with the punches because they have always had sign-in, but I know it chafed our class – indeed, it DID feel like ‘micromanaging’ and we felt that as adult learners we should be able to determine what is essential to our own learning. Of course, the problem with that is that it assumes adequate meta-cognitive monitoring of our learning, which not all of us are well-equipped to do. I’ve asked this above, but I’d like to pose the question to you: How can educators facilitate the development of meta-cognition in learners?

      PS, Minus-something-horrible outside seems to describe most of the weather I encountered October-May during med school…

      • Eve Purdy

        Dr. Gibson,
        One of the very important points that you hit on in your reply was that you love to teach. Students can feel when their professors are enthusiastic, not just about their subject matter but about helping us understand it. That alone is a very important recipe for success. The other statement that is important is that you know what is going on in your learner’s lives. Demonstrating respect for where we are (academically, personally, scheduling wise etc.) makes a two way street much more likely.

        @sluckettg:disqus – the question could be how do we develop meta-cognition in everybody in medicine. We all need work, I agree that it best start early. What would that curriculum look like? Agree many people who are skipping (especially wellness and professionalism sessions) seem to be the people who might benefit most.

        • S Luckett G

          Eve, I disagree – the question is how we develop meta-cognition in everybody! I think we all could use a healthy dose of it.

          I envision a curriculum that would include explicit instruction in meta-cognitive strategies. In my former life in literacy research, I worked on a similar curriculum for students with reading disabilities, and it is amazing how much can be achieved by simply explaining, modelling, and facilitating meta-cognition.

          • Soooo freaky. We’re about to help develop one here at Mac…
            I will need to see if I can bring you in on this….

          • Eve Purdy

            I took an interesting coursera course on clinical decision making. Some talk of metacognition. It runs again in January. I would highly recommend for medical students. https://www.coursera.org/course/clinprobsolv

        • Michelle Gibson

          I think that sometimes the right assessment can drive some of this. (Eek- assessment driving learning???) We recently ditched a whole series of reflections and traded them in for one graded team assignment about approaching diversity in health care – it was a very complex case that the 1st year students had to address. It was mandatory, and so everyone was there.

          The feeling (impossible to measure, but consistent from students and faculty involved) was that having students wrestle with a particularly challenging case in their small groups was effective. Student feedback was that they really appreciated the opportunity to discuss the case in a trusted setting. Faculty found the tone very positive as they went around listening to different group discussions, and said the answers provided were very thoughtful and mature, and demonstrated the students had really delved into the case in a non-superficial fashion.

          The hope was that for the rare student who was quietly sitting there with preconceived biases (or even frank prejudice) was exposed to his/her classmates openly and respectfully discussing how to help the family in the case (which involved cultural, spiritual, and LGBTQ/complex gender issues). While one can fake the “correct” reflective response as a student (“give them what they want to hear”), we wonder (hope?) if in fact some metacognition kicked in: “hey- I seem to be alone in these opinions – what does that mean? Am I wrong? Did my parents teach me wrong? Or maybe wrong isn’t the right word? Maybe I will listen here and think about other ways of thinking about this minority group.” I suspect this has the potential, at least of being more productive than just making the session about LGBTQ health mandatory.

          Now, as always, I’m not delusional – just fundamentally an optimist. 🙂 Yes, it is entirely possible some student just sat there like the proverbial log bump, and didn’t participate or engage. However, I am hopeful that he/she is more likely to engage in a (word I don’t love, but…) ‘authentic’ process, that is tied in some way to ‘meaningful’ (more quotes) assessment.

          My final assessment geek comment- more opportunities for self-assessment should, I think, help with the metacognition issue. However, we know we’re mostly not great (to put it mildly) at self-assessment. But to answer Sarah’s question- imagine this- as a student you suddenly get a useful summary after a series of exams (yes, I know exams might not be the right answer, but they’re there and they’re not going anywhere) letting you know that you are achieving the goals expected consistently with respect to history taking and what you need to look for on PE, but that you are not always meeting the objectives re: differential diagnosis and treatment. And, in terms of presentations- you really “got” cough & chest pain, but you struggled more with falls (never!) and abdominal pain.

          Would this help? It’s being done in some schools, and with electronic administration of exams it may even be possible soon at a med school in a medium-sized town in Ontario. 🙂

          As a teacher, you could get the same info – the class is solid on investigations, but not really getting treatment. Or, that they mastered falls, but somehow are confused about confusion.

          Imagine the potential of this- and that a session would be put in the curriculum as “TBA” – a held spot to address issues that came up on the midterm(s). It would require a bit of on-the-fly curriculum design, but there would be themes, and it would get easier.

          Then- take it another step. After each chunk of curriculum, there is a place for “catch-up”, which students take ownership for. You didn’t do well on anatomy? YOu use most of this 2 week period to take your anatomy feedback and use resources to brush up (not necessarily to get reassessed unless you fell below a clear threshhold). You struggled with DDx? Here is a module for you so you can practice before starting the next chunk.

          There are logistics that have my head spinning. And I’ve perhaps gone way off topic, but it starts to approach the issue of mandatory- carefully selected things that are mandatory, and sharing of key data, and responsibility for addressing areas of concern before the end of the ‘chunk’. Then, planned time for student-responsible learning, with resources provided by faculty, so students can really prepare for the next ‘chunk’.

          Again- note I’m generally an optimist. And as someone who literally was the launcher of a new curriculum back in 2009, I’m not ready to tackle that yet… but I’m thinking….

          I am such a #MedEd geek. Over and out!

          • S Luckett G

            Dr. Gibson, as a high schooler, I attended a mastery-based alternative school that operated very much as you described. We were responsible for figuring out what we didn’t know and seeking out additional resources (lessons from the teacher, which didn’t generally happen unless we were having trouble, texts, online resources, etc.). We attempted testing only when ready, which isn’t feasible in higher education, perhaps, but gave us ownership over the learning process. If enough students approached the calculus teacher with questions about integration, she would deliver a lesson. If an sizeable portion of the Latin class was struggling with diclensions, we had a lesson. Otherwise, we could have one-on-one tutoring sessions or cover the material in any other way that worked for us. Content was delivered to specifically address the deficits in our learning.

            I also wanted to offer a comment about team based exercises. Often there is a quiet student in any small group, who doesn’t offer much input during these exercises. What I hope will encourage you is that the other students in the group generally solicit the input of this quiet student, respectfully giving him or her a space to share. It’s all about building an environmental that facilitates trust, and a good exercise that encourages engagement can go far in doing just that.

      • Michelle Gibson

        I honestly wasn’t fishing for compliments, but I’m glad med review was memorable. I’m fascinated by the healthy competition part of things – I had no idea. I do enjoy finding funny (but professional) comments in the stuff I mark from students, especially when it reinforces that something I taught stuck (trust me – a huge thrill).

        I was really reflecting that some of my approaches come from the fact that I am not teaching anything “sexy”, so some would argue that I overcompensate. I would even argue that there is more excitement for Dr. Murray’s sessions since everyone usually accepts (albeit at times grudgingly) that they need to know her material.

        However, I guess the point I’m making is that every teaching session should be treated this way if possible. Mutual respect (which has to be earned) goes a long way. It also helps +++ if as a teacher you have a relationship with the learners. I know that if I am having a bad day when I teach the first year class, etc., I can just explain what is up (within reason!) and they will understand (there have been some less energetic sessions taught after a thrilling weekend with my kid’s gastro…)

        The “being present” or “being on” is more important, I think, than bells and whistles. I also teach sessions with no laptops where it’s more appropriate (the last hours of life, for example), and that has always been respected. (Key word for me it seems.)

        See below re: metacognition.

        • S Luckett G

          Speaking from the learner’s perspective, when the teacher respects the learners in her class, it is felt and appreciated. And nobody wants to let down a teacher who truly respects you as a student in her class.

  • Matthew Siedsma

    I meant to reply to this yesterday and now look at the wonderful work you’ve all done. Everyone above me has made some incredibly salient points. I just wanted to emphasize and add a few points.

    1. It’s so heartening to see the number of people interested in this topic. The fact that we have young physicians in training who realize we need to do a better job of educating and engaging this newest generation of physicians gives me a good deal of hope that we’ll accomplish that goal
    2. One of the things that has occurred to me time and time again is that for along while we’ve approached teaching medicine as it were no different than any other discipline. Except it’s not true. The concepts are more complicated and dynamic. Rules don’t apply and can rarely be followed in every circumstance. We focus on content because we have to, because you have to have some foundation to build on. But we continue to do poorly at teaching students and residents and young physicians HOW to think.
    3. We need to start focusing on teaching people how to think, how to learn. I’d love to see presentations in medical school, residency, and fellowship devoted just to those topics of metacognition, problem solving, and complex decision making. If you can find a way to just touch on that in any lecture you give people will stand up and listen.
    4. I agree that there is an implicit agreement between an educator and a learner. There needs to be some onus on the learner to WANT to learn. Some would argue that a great educator or presenter can make anyone want to learn anything. Others would argue that a learner who refuses to learn can’t be reached at any length. The truth is somewhere in the middle.
    5. The pull from devices and laptops is too great. Even when I’m in a lecture that I’m truly excited about, all it takes is a series of buzzes in a short period of time to make me concerned I’m trying to be reached for something urgent. Then I’m on my phone or tablet or laptop and even if it’s not urgent or the urgent issue is quickly resolved, it’s still there. It takes great strength to continue to ignore it after that. So I can certainly see why some would want to ban it during a particular talk. But maybe the interactive features being touted by some is a better answer. Hard to know until enough people try it out.
    6. If it’s possible for any presentation you give think about the Six Steps of Curriculum Building: General Needs Assessment / Problem Identification (why is this important globally in medicine or our specialty?), Targeted Needs Assessment (why is this important at our institution and to these specific learners/audience?), Goals and Objectives (who will learn how much of what by when), Education Strategies (how can I best get those objectives across to my learners), Implementation (anything special I need to consider so I can implement my strategy?), and Evaluation (how will I know if I did the best job I could have, what should I change for the next time I teach this topic?). If we did this more often I think most of our presentations would be good at the very least. Great comes later.
    7. Ask people you trust, people who know you, people who are good students and good teachers/presenters for feedback. Hopefully they’re people who will give you constructive criticism. As others have said above go and watch people who are great at teaching.
    8. If you can take a class, course, or something along those lines about being a better presenter do it. Most schools that offer a degree in education (medical education is even better) will likely have a class you can take or audit about becoming a better presenter.

    Just my three shiny pennies.

    • S Luckett G

      Thanks for adding your voice, Dr. Siedsma. I agree that it is encouraging to see so many so engaged in discussing an oft-neglected topic.

      I like the framework that you have shared for curriculum building. My sense is that the second step is often the essential missed step. A lecturer may have expertise and a good educational strategy, but if s/he has failed to identify why the audience should want to learn the material, it’s difficult to get the buy-in required for the teacher-learner partnership to develop. What do you think?

      I chuckled a bit when I read about the series of buzzes that takes your attention away from even the most engaging lecture. It sounded all too familiar!

      • I curriculum map is key. Thank you for bringing Kern’s 6 step model into it all. It truly is a must read for most junior educators (albeit a bit limited and cookie cutter for more experienced curriculum planners).

        The hidden power of a well planned lecture series can be helpful. When planning something that requires a team of speakers, like a conference or a curriculum block, I think it is paramount to ensure you have broad and complimentary coverage of key topics.

        e.g. in medical school, I was very frustrated as a learner when we learned about CHF 4 times in one wk, but never really was taught about ACS. Lots of heart failure researchers in the bunch of teachers – without guidance re: objectives and topics, they all spoke about their ‘pet topic’.

        • Matthew Siedsma

          Teresa thanks for ensuring someone gave credit where it was due. I know what you mean about being somewhat limited and cookie cutter but I think the key concepts Kern introduces and stresses always need to be considered. The beauty of the Six Step Approach is that it can be applied to one lecture or to a four year medical school curriculum. My understanding of it becomes better each time I interact with an experienced clinician-educator who has already internalized the steps but forces me to go through it every time we meet to discuss one of my curriculum projects.

          The importance of having a comprehensive set of goals is key as well. I think we continue to be limited by the fact that at many institutions, education takes a back seat in terms of resources to the research and clinical endeavors. You need to have a person or small group of people who can keep the big picture in mind. We have an education steering committee for the fellowship but at the end of the day there are a few key people who direct the overarching view for the core curriculum to ensure all the essential topics are covered.

          As opposed to what I’ve experienced elsewhere when people just delegate lectures to various faculty and expect things to get done however they get done. There’s no one really looking at the big picture and so you have, as Teresa pointed out, people lecturing on their “pet topics” because no one bothered to identify the overarching goals and specific objectives for each lecture / didactic / session / experience (whatever we’ve decided to call them these days).

      • Matthew Siedsma

        Luckett, thanks for taking such an active interest and engaging all of the experienced folks here.

        I find that when I think back on many of my own presentations or when I think about other lectures that didn’t work it’s clear someone (including me) missed at least one if not more of the steps. Missing any step can be devastating to producing a good presentation. In terms of motivating your audience, I think you’re absolutely correct. If you haven’t considered the needs of your intended audience then the likelihood of motivating them and engaging them in your presentation is pretty unlikely.

        As for the buzzes: just wait as you progress through training. The more responsibility you take on, the more hesitant you become as you try to ignore the phone. I think at some juncture you become able to transcend the phone if you’re important enough but I can’t see that far into the future.

        • S Luckett G

          I am terrified of ignoring my phone, even though I’m in the sweet spot right now where I am not important enough to get a message that’s truly urgent…

  • Petra Dolman

    Hey I thought this Ted Talk might be helpful for this discussion 🙂 Ramsey Musallam: 3 rules to spark learning

    http://on.ted.com/j0MZv

    • S Luckett G

      Great share! Thank you!