Donald Clark – 21st century medical learning

“Death of the compliant learner” – almost all of my students are compliant, I hope Clark doesn’t buy into the idea that all of today’s students are somehow different? Even Prensky has moved on from the Digital Native debate

When the cost of education goes up, and the deliverable stays the same, you have the characteristics of a bubble → is higher education / medical education in a bubble (Malcolm Gladwell)?

Clark shows excerpt from Ferris Bueller’s day off to demonstrate poor lecturing style, gets a laugh but is caricaturing the format useful in terms of solving the actual problem?

Psychology of learning:

• Spaced practice
• Attention
• Assessment
• Learn by doing
• Collaboration

“The internet is shaping pedagogy”, this is the wrong way around. Effective teaching practice should make effective use of the internet.

“Lectures are ineffective for teaching”

• don’t inspire or motivate
• no critical thinking
• doesn’t emphasise values
• no social adjustment
• or behavioural skills
• only useful for transmitting information

Student and lecturer’s attention begins to fall off after 25 minutes, yet lectures often continue for much longer. Clark’s solution → record lectures! OR…change teaching practice to make use of that time more effectively

Cultural reasons for not changing teaching practice

Assessment is skewed towards favouring cramming

Is technology supporting assessment?

Surgeons who play video games perform better with laparoscopic procedures than those who don’t

I think Clark’s emphasis on technology misses the point. This isn’t the right audience to make assumptions about what technology should be used with what teaching approach. The message he’s sending is that we should use digital tools because they’re better. But he hasn’t spent enough time explaining what it’s better for and how.

The future of online continuing medical education: towards more effective approaches
Panel discussion (John Sandars, Pat Kokotailo, Gurmit Singh)

How do we get the new evidence base to change behaviour in health professionals? By delivering content and hoping → behavioural change

Online CME is about transmitting content from an “expert” to the person at home, and competing with their social lives. Does this have the intended impact of actually changing clinician’s behaviour? Sandars says “No”

How can the intended impact be achieved?

CME vs CPD
CME process whereby people keep updated regarding medical information
CPD includes CME but is more broad

e-learning implies that technology is used to enhance T&L but no definition of what technology is. I wish people would stop talking about e-learning until we demonstrate that it’s fundamentally different in terms of changing learning behaviour

List of digital tools and blending them with f2f spaces

Issues in obtaining evidence of effective CPD:

• Differing content in med ed → differing ways of delivering / teaching
• Traditional curriculum vs no curriculum
• Rare comparison between e-learning intervention and traditional intervention
• Difficulty with educational RCTs (very “medical” to think that RCTs are an important evaluative tool in education)

Kirkpatricks model to categorise the level of evaluative outcomes

Majority of research looks at participant satisfaction, but limited research demonstrating performance change in practice, no studies demonstrated that web-based CME had any effect on clinical practice

Internet learning associated with large positive effects compared with no intervention, but the effects were heterogeneous and small (internet learning interventions were broad in terms of content)

Comparison of different virtual patient desings suggest repetition, advance organisers, enhanced feedback and explicitly contrasting cases can improve learning outcomes (Cook at al, Academic Medicine, 2010)

Which “e-learning” techniques enhanced learning experiences?

• Peer communication
• Flexibility
• Support of a tutor who was also a moderator
• Knowledge validation
• Course presentation
• Course design

Effectiveness of the online course is mediated by the learning experience

Cost effectiveness of online CPD is mainly based on self-report, so data not robust (Walsh et al, Education for primary care, 2010)

Most to least effective approaches (Bloom, International Journal of Technology Assessment in Health Care, 2005):

• Interactive techniques (audit / feedback, academic detailing / outreach, reminders)
• Clinical practice guidelines and opinion leaders less effective
• Didactic presentations and distributed print material have little to no effect

Therefore, not much evidence for the use of online learning, and the effects that do exist, are small (smaller than traditional), course design is important, and interactivity appears to be key

Improving knowledge and skills without an associated change in behaviour, is useless

Discussion:

• Isolated, invidualised online CME is focused on delivering content more efficiently but that misses the point
• We need to integrate social components into the learning experience
• We evaluate episodic events and expect to find behavioural change
• It’s not about one approach or the other, we need to blend different teaching methods
• We need to stop talking about e-learning, we don’t talk about overhead projector learning

Problems with CME (currently)

• Exisiting models do not improve patient care
• Current models are incomplete, and are used for different reasons
• Use is unco-ordinated
• Participation is low
• Much research names existing models as “largely irrelevant”

Moving from knowledge and skills to changing behaviour. What is the / a new model?

The outcome must be: improving patient care. This comes about through supporting information exchange, opinion and advice to make sense of the complexity of practice

Technology used must be useful and relevant

Technology + pedagogy = outcome (is it this simple?)

Should move psychological learning theory to sociological theory

Professionals learns as they go about doing things, sharing tacit knowledge, discussing and interacting with others in social networks. As people interact they share ways of thinking, feeling and acting in daly life, which influences their behaviours and habits. We are living, learning and changing in practice. They are reflexive. Learning, behaviour and change are all dynamically connected in networks and make practice complex.

Learning practive should be embodied and emergent

Reflexive networks used in teaching and learning

We should be more strategic in collaboration, rather than having collaboration forced.

How do you evaluate outcomes?

• CME credits
• Self-report: was it relevant and useful?
• Patient care audit: do patients have improved outcomes?

Tacit knowledge = useful knowledge

Practice and learning are inseparable

If individual practice is only part of the team approach, is it reasonable to expect that changing an invidual’s approach will actually impact on patient outcomes?

Interprofessional workplace-based learning using social networks
JM Wagter

Difference between in/formal learning

80% of learning is outside the formal context. How do we make the informal learning explicit?

Between whom is learning taking place i.e. identifying actors within the network by mapping relationships between teams, professions, etc.

Look at density and information and communication flows

Everybody is involved in informal learning within networks, but the relationships are assymetrical and not collaborative or reciprocal

Network analysis is a useful method to identify relationships between professionals, but what do you do with the information i.e. how do you change the relationships?

Patient attitude to medical students experience in General Practice
H Cheshire

Patients lack confidence to ask students to leave when receiving a personal physical examination by a GP

Female patients are less likely to have positive attitudes with regards a medical student conducting an assessment, although the numbers are quite high nonetheless

The context of the examination changes whether or not patients are happy to have students present e.g. sexual health, etc.

Learning at a clinical education ward: first and final year nursing students’ perceptions
K Manninen

Final year students have an emphasis on supervisor relationships and are more dependant on feedback and affirmation but don’t experience internal authenticity, which is what drives the understanding of the nursing role.

First year students focus on patient relationships with concomittant feedback

Creating a student ER
A O’Neill

Highly integrated, student-centred, emphasis on PBL → creation of a student ER

Organisation based on teams, rather than a hierarchy. Team sees the patient concurrently, rather than consecutively

Approach allows the student to manage the patient with a focus on structured feedback. Tried to avoid students managing those with obvious serious pathology, cognitive dysfunction, etc.

Supervisor behind the student, not the other way around

Received positive feedback from students, in addition to significant improvement in student note-taking ability, among other clinical skills

Evaluating medical grand rounds – 10 years later
Mary J Bell

High numbers of repeated evaluations in order to determine reliability

We tend to give colleagues higher evaluator ratings

Highest scores had less to do with knowledge and presentation of objectives, and more to do with presenter style, level of presentation and enthusiasm → edutainment

When grand rounds were done using digital video, overal presenter ratings went down, seeming to concur with social learning theories i.e. we want to be in the same room as those we’re learning from (but is social just about physical presence?)

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Day 1 of #SAFRI programme finished, excited to be a part of it, but no-one to tweet with and no laptops allowed #

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If you haven’t seen it and are interested in the role the internet is playing in fundamentally changing society and education, it’s definitely worth a look.

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Today I came across an article that discusses the scenario (i.e. laptops in classrooms) from both perspectives, and offers some insight into the issue.  I’m intrigued at the possibility that laptops and internet connectivity may bring some advantage to the classroom.

The one point mentioned in the article that resonates strongly with me is the use of the word “engagement”.  I’ve often felt that students in my classes aren’t actively engaged with the content and recently I’ve started to think about options in terms of encouraging that process.  The idea that managing the expectations of both staff and students is also a powerful factor that’s often left to chance.

I guess it comes back to the point I made in the first article.  It’s not enough to throw technology at learning / teaching and expect it to solve the problem (if there’s even a problem to solve?).  The use of appropriate technology needs to be integrated into the curriculum if it’s to make any positive impact.

Here’s the link to the article:
http://bwatwood.edublogs.org/2008/11/16/students-and-laptops-in-the-classroom/

And to a site related to discussions about the use of laptops in classrooms:
http://cte-laptop.wetpaint.com/?t=anon

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Some studies in American classrooms have all but proven that the distraction of the Internet in class is too strong for students to ignore and that most of the lesson is spent checking email, catching up with friends and even shopping.  Now, after that initial foray into “embracing” technology”, it seems as if there’s a move towards banning laptops altogether.

This is the kind of about-turn I’d like to avoid.  E-learning, while I have no doubt will be a revolution in education, is not the idea that technology for it’s own sake is the way forward.  Just because it’s possible to have Internet access in class, does it mean that we should?  Rather, teachers must take an approach whereby technology is used in a way that enhances it’s advantages, while minimising the disadvantages.  Just because I put the course reader online doesn’t make it “e-learning”, and neither does having a student blog.  The technology in itself doesn’t enhance learning in any way, but how you use it can have powerful implications.

I’ve been toying with the idea of using a wiki to manage a course, whereby any change to either the course content, test schedule or mark availability can by syndicated through RSS to all the students in the class.  Students will have to, as a course requirement, both add to and edit course content (obviously moderated), which can also then be tracked.  I think that this may be one way to encourage them to actively engage with the content, as well as introduce concepts like peer review, referencing and drafting, which may also improve their reading and writing skills (another huge problem).  The point though, will be to make the learning outcomes apparent from the beginning, so that students know what’s expected of them.  Merely creating a wiki and telling students to “Go forth and create content” isn’t enough.

I think that technology will fundamentally change the way we teach and how students learn, but not just by throwing technology at the problem.  The trick is to figure out how to use technology to facilitate deep learning by getting students to actively engage with the content.  A bad teacher will continue to teach badly, no matter how much “technology” they use.

Link to the article that inspired this post:
http://www.britannica.com/blogs/2008/10/why-i-ban-laptops-in-my-classroom/

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