Lecture Halls without Lectures — A Proposal for Medical Education
N Engl J Med 2012; 366:1657-1659May 3, 2012
The last substantive reform in medical student education followed the Flexner Report, which was written in 1910. In the ensuing 100 years, the volume of medical knowledge has exploded, the complexity of the health care system has grown, pedagogical methods have evolved, and unprecedented opportunities for technological support of learners have become available. Yet students are being taught roughly the same way they were taught when the Wright brothers were tinkering at Kitty Hawk.
It's time to change the way we educate doctors. Since the hours available in a day have not increased to accommodate the expanded medical canon, we have only one realistic alternative: make better use of our students' time. We believe that medical education can be improved without increasing the time it takes to earn a medical degree, if we make lessons “stickier” (more comprehensible and memorable) and embrace a learning strategy that is self-paced and mastery-based and boosts engagement.
Research has elucidated the factors that make ideas sticky.1 For instance, messages are stickier when they are unexpected enough to capture our curiosity.
Consider this excerpt from a recent “Case Records of the Massachusetts General Hospital”: “A 37-year-old man was admitted to this hospital because of muscle pain and weakness. The patient had been well until the evening before admission, when mild diffuse myalgias developed. He awoke in the morning with diffuse muscle cramps and intense pain in his legs. . . . On arising to go to the bathroom, he felt unsteady and had difficulty walking. After he returned to bed, diffuse muscle pain persisted, with weakness in his arms and legs and numbness in his legs; he was unable to arise again.”2
Do you want to learn more? That's the power of the clinical scenario. The case's discussant reflects on the differential diagnosis that might explain this acute onset of weakness and pain, including inflammatory, infectious, toxic, metabolic, and autoimmune processes. A single such case could serve as the lead-in to multiple medical school topics that might otherwise seem dry and routine.
The goal is to time the story to captivate learners and underscore the relevance of knowledge they've recently acquired or that's about to be conveyed. Medical educators might take a cue from pop culture: even laypeople love medical mysteries, imbibing them in the form of television shows like House and Grey's Anatomy or from the New York Times “Diagnosis” column. When possible, we should seize that curiosity — the perfect fuel for learning.
Messages also become stickier when they come in the form of a story that elicits emotion in readers or listeners. Patients' stories are what make the acquisition of medical knowledge compelling. They serve as the scaffolding on which facts and concepts can be organized and reinforced. As Sir William Osler aptly said, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” Yet conversations with medical students about the first-year medical curriculum reveal that about half of lectures proceed without even the briefest example involving patients.
Attention to stickiness would make medical school lectures more engaging and memorable, but they would still be lectures. We think a more radical and important strategy is to move those lectures outside the lecture hall and to use class time for more active learning.
For most of the 20th century, lectures provided an efficient way to transfer knowledge. But in an era with a perfect video-delivery platform — one that serves up billions of YouTube views and millions of TED Talks on such things as technology, entertainment, and design — why would anyone waste precious class time on a lecture? We propose embracing a flipped-classroom model, in which students absorb an instructor's lecture in a digital format as homework, freeing up class time for a focus on applications, including emotion-provoking simulation exercises. Students would welcome more opportunities for case-based, problem-based, and team-based exercises — strategies that activate prior knowledge. Teachers would be able to actually teach, rather than merely make speeches.
Digital media make video lectures relatively easy to create, offer flexibility so that students can watch at their own pace and on their own schedule, and are popular with learners. For example, the Khan Academy, a nonprofit organization that offers online video lessons and exercises on elementary and high school topics, allows students to gain proficiency in core academic concepts at their own pace. If such a model were applied to medical school, class time would be freed up for higher-order and more interactive lessons. Teachers could track each student's progress and use that knowledge to inform focused, customized interactions with small groups of students. Recently, this approach was embraced by a public school district and several charter schools in Silicon Valley, and experience with this educational model has grown to encompass a broad range of content areas and learners. The Khan Academy has produced more than 2700 videos that are viewed monthly by more than 3.5 million students who perform more than 2 million online exercises each day.
This year, our core biochemistry course at Stanford Medical School was redesigned following this model; rather than a standard lecture-based format, the instructors provided short online presentations. Class time was used for interactive discussions of clinical vignettes highlighting the biochemical bases of various diseases. The proportion of student course reviews that were positive increased substantially from the previous year. And the percentage of students who attended class shot up from about 30% to 80% — even though class attendance was optional.
Evidence is accruing that online instruction is effective and scalable. For example, Stanford's computer science department has shifted several courses to instruction using 10-to-15-minute video segments with embedded quizzes to engage learners and test their comprehension. Professors use class time to challenge students with hands-on exercises, and class attendance has increased substantially. Off campus, three computer science courses, offered free, have been viewed by more than 350,000 enrollees from around the world.
Freeing up class time does seem to make a difference. In a recent study, researchers compared two sections of an undergraduate physics course that had a large enrollment.3 The first section used the traditional lecture model and was taught by a Nobel Prize–winning physicist. In the second section, which was led by teaching assistants, students grappled with real physics problems as they might be encountered by a practicing physicist. The students in the second, active-learning section were more engaged (as assessed by their course ratings) and more likely to attend class, and their scores on a course test averaged 74%, as compared with 41% among students in the traditional lecture section. A meta-analysis published by the Department of Education has concluded that “on average, students in online learning conditions performed modestly better than those receiving face-to-face instruction,” with larger effects if the online learning was combined with face-to-face instruction.4
That's the vision that we want to chase: education that wrings more value out of the unyielding asset of time. There are limits to the amount we can lengthen class periods and the additional homework we can assign, but we can use our limited time in ways that boost engagement and retention. Imagine first-year medical students learning critical biochemical pathways by watching short videos as many times as necessary in the comfort of their personal learning space. Knowledge acquisition is verified by repeated low-stakes quizzes. Then, in class, the students participate in a discussion that includes a child with a metabolic disease, his or her parents, the treating clinician, and the biochemistry professor. The relevant biochemistry — so dry on the page of a textbook — comes to life. The lesson sticks.
Sunday August 8, 2010
University senates have no bite
A UNIVERSITY Senate (consisting mostly of deans who are academics) helps with the governing of faculties and academic matters. Academics however, are convinced that the actual power is not with the senate but with the varsity’s management. Since it controls funds, those who are part of the management have the power and ultimate say in deciding where the funds should go to ensure their institution is among, if not, the best. The varsity’s management will put forth the argument that since the bulk of funds come from the government, it is accountable to the government and not the academics, who are represented by the senate.
Like many other organisations, a university functions with limited resources. To be effectively managed, these resources have to be centralised before being disbursed to respective faculties, centres and divisions. Much of the funds is allocated towards the salary of staff members including the academics.
Centres of excellence
Of late there has been an increase in centres of excellence created by universities to promote their relevant expertise and fields of study as warranted by the industries. The centres are to be staffed by academics that are there on secondment as administrators from other faculties. These academics have their teaching load reduced to enable them to carry out their duties in the centres effectively.
To solve the work load left by these academics, those who do not hold any administrative positions are asked to help out by taking in more students into their respective classes. There seems to be no choice. It takes time to recruit a new academician and to find the right one as good as the one who is seconded.
Administrative positions are held on rotational basis and seem to carry more weight, which is why it appeals to some academics. Moreover, it is a convenient excuse used by the academics when they fail to present writings and research. So, some may try their best to be appointed, and will try to hold on to their posts for as long as possible. Holding on to the position over a long period of time can be detrimental to an institution of higher learning.
Ascendancy to excellence is never by accident. It has to be a system that has to be both strict and fair to all concerned. If an institution wants to remain at the top, it has to have a gauging system of high quality, respected by others as fair and just. Years ago there was no quarrel because the voice of the academics was powerful and the management listened to them on how best to produce good graduates needed by the nation. The management was always there to lend support as an auxiliary force. Now, the roles are reversed. It is the management that is becoming more powerful and the academics are just the followers.
To the students, the best academics are the most enthusiastic, constantly updating them with relevant facts, figures and events. The academics, in turn, are constantly seeking to upgrade their knowledge without seeking favours or expecting a lesser workload from the the management. Their pride is in their work in the form of publications, presentations and research papers. Is it not ironic that despite doing so much, the academics are at the mercy of the varsity management?
Role of managers
What do university managers do? No one denies that managers are expected to manage and become effective managers with the regular courses they attend to upgrade their skills. The performance indicators are a good way to gauge their competence.
My point is that the university management should not be headed by academics. Academics are not trained to do managerial tasks. They will be able to discharge the delegated duties only satisfactorily. True, those seconded are taught the techniques of administration through courses given, but their minds have been trained as specialists in their chosen fields and subjects through years of study from graduate to postgraduate levels.
Consider the tasks academics who hold administrative posts have to carry out, like managing budget, planning tasks and projects, developing strategies and other cost-effective actions. It is impossible. They cannot see the relationship of the tasks delegated to them with the long-term needs of research and teaching of which they are trained to do. If there is anyone among them who performs well, it is only a relative comparison among the mediocre. He is thus made to look good. This will not be the case with the manager whose duty is to ensure that all rules drafted are followed accordingly and in accordance with government policy.
Who bears the blame for the poor preparation of a task in a faculty or a centre? It is none other than the academic. They face the risk in the preparation and the execution of tasks, but with no power to see that they are implemented effectively. The management has the power, but more often than not, none of the blame.
An article by Dr Arzmi Yaacob published in The Star on Sunday August 8, 2010
Plagiarism Lines Blur for Students in Digital Age
At Rhode Island College, a freshman copied and pasted from a Web site’s frequently asked questions page about homelessness — and did not think he needed to credit a source in his assignment because the page did not include author information. At DePaul University, the tip-off to one student’s copying was the purple shade of several paragraphs he had lifted from the Web; when confronted by a writing tutor his professor had sent him to, he was not defensive — he just wanted to know how to change purple text to black. And at the University of Maryland, a student reprimanded for copying from Wikipedia in a paper on the Great Depression said he thought its entries — unsigned and collectively written — did not need to be credited since they counted, essentially, as common knowledge.
Professors used to deal with plagiarism by admonishing students to give credit to others and to follow the style guide for citations, and pretty much left it at that. But these cases — typical ones, according to writing tutors and officials responsible for discipline at the three schools who described the plagiarism — suggest that many students simply do not grasp that using words they did not write is a serious misdeed.
It is a disconnect that is growing in the Internet age as concepts of intellectual property, copyright and originality are under assault in the unbridled exchange of online information, say educators who study plagiarism. Digital technology makes copying and pasting easy, of course. But that is the least of it. The Internet may also be redefining how students — who came of age with music file-sharing, Wikipedia and Web-linking — understand the concept of authorship and the singularity of any text or image. “Now we have a whole generation of students who’ve grown up with information that just seems to be hanging out there in cyberspace and doesn’t seem to have an author,” said Teresa Fishman, director of the Center for Academic Integrity at Clemson University. “It’s possible to believe this information is just out there for anyone to take.”
Professors who have studied plagiarism do not try to excuse it — many are champions of academic honesty on their campuses — but rather try to understand why it is so widespread.
In surveys from 2006 to 2010 by Donald L. McCabe, a co-founder of the Center for Academic Integrity and a business professor at Rutgers University, about 40 percent of 14,000 undergraduates admitted to copying a few sentences in written assignments. Perhaps more significant, the number who believed that copying from the Web constitutes “serious cheating” is declining — to 29 percent on average in recent surveys from 34 percent earlier in the decade.
Sarah Brookover, a senior at the Rutgers campus in Camden, N.J., said many of her classmates blithely cut and paste without attribution. “This generation has always existed in a world where media and intellectual property don’t have the same gravity,” said Ms. Brookover, who at 31 is older than most undergraduates. “When you’re sitting at your computer, it’s the same machine you’ve downloaded music with, possibly illegally, the same machine you streamed videos for free that showed on HBO last night.” Ms. Brookover, who works at the campus library, has pondered the differences between researching in the stacks and online. “Because you’re not walking into a library, you’re not physically holding the article, which takes you closer to ‘this doesn’t belong to me,’ ” she said. Online, “everything can belong to you really easily.”
A University of Notre Dame anthropologist, Susan D. Blum, disturbed by the high rates of reported plagiarism, set out to understand how students view authorship and the written word, or “texts” in Ms. Blum’s academic language. She conducted her ethnographic research among 234 Notre Dame undergraduates. “Today’s students stand at the crossroads of a new way of conceiving texts and the people who create them and who quote them,” she wrote last year in the book “My Word!: Plagiarism and College Culture,” published by Cornell University Press. Ms. Blum argued that student writing exhibits some of the same qualities of pastiche that drive other creative endeavors today — TV shows that constantly reference other shows or rap music that samples from earlier songs. In an interview, she said the idea of an author whose singular effort creates an original work is rooted in Enlightenment ideas of the individual. It is buttressed by the Western concept of intellectual property rights as secured by copyright law. But both traditions are being challenged. “Our notion of authorship and originality was born, it flourished, and it may be waning,” Ms. Blum said.
She contends that undergraduates are less interested in cultivating a unique and authentic identity — as their 1960s counterparts were — than in trying on many different personas, which the Web enables with social networking. “If you are not so worried about presenting yourself as absolutely unique, then it’s O.K. if you say other people’s words, it’s O.K. if you say things you don’t believe, it’s O.K. if you write papers you couldn’t care less about because they accomplish the task, which is turning something in and getting a grade,” Ms. Blum said, voicing student attitudes. “And it’s O.K. if you put words out there without getting any credit.”
The notion that there might be a new model young person, who freely borrows from the vortex of information to mash up a new creative work, fueled a brief brouhaha earlier this year with Helene Hegemann, a German teenager whose best-selling novel about Berlin club life turned out to include passages lifted from others. Instead of offering an abject apology, Ms. Hegemann insisted, “There’s no such thing as originality anyway, just authenticity.” A few critics rose to her defense, and the book remained a finalist for a fiction prize (but did not win). That theory does not wash with Sarah Wilensky, a senior at Indiana University, who said that relaxing plagiarism standards “does not foster creativity, it fosters laziness.”
“You’re not coming up with new ideas if you’re grabbing and mixing and matching,” said Ms. Wilensky, who took aim at Ms. Hegemann in a column in her student newspaper headlined “Generation Plagiarism.”
“It may be increasingly accepted, but there are still plenty of creative people — authors and artists and scholars — who are doing original work,” Ms. Wilensky said in an interview. “It’s kind of an insult that that ideal is gone, and now we’re left only to make collages of the work of previous generations.” In the view of Ms. Wilensky, whose writing skills earned her the role of informal editor of other students’ papers in her freshman dorm, plagiarism has nothing to do with trendy academic theories. The main reason it occurs, she said, is because students leave high school unprepared for the intellectual rigors of college writing. “If you’re taught how to closely read sources and synthesize them into your own original argument in middle and high school, you’re not going to be tempted to plagiarize in college, and you certainly won’t do so unknowingly,” she said.
At the University of California, Davis, of the 196 plagiarism cases referred to the disciplinary office last year, a majority did not involve students ignorant of the need to credit the writing of others. Many times, said Donald J. Dudley, who oversees the discipline office on the campus of 32,000, it was students who intentionally copied — knowing it was wrong — who were “unwilling to engage the writing process.” “Writing is difficult, and doing it well takes time and practice,” he said.
And then there was a case that had nothing to do with a younger generation’s evolving view of authorship. A student accused of plagiarism came to Mr. Dudley’s office with her parents, and the father admitted that he was the one responsible for the plagiarism. The wife assured Mr. Dudley that it would not happen again.
Edited from an article by Trip Gabriel on The New York Times, 1st August 2010
