PHT402: Empathy and professional practice

This is my first post for the #pht402 professional ethics course that I’m participating in for the next few weeks. The topic for the first week is to explore personal objectives related to empathy and professional practice in the health care context.

384002I’ve been teaching the Professional Ethics course at UWC for five years and have always found it to be both deeply stimulating and deeply unsatisfactory. It’s stimulating because the classroom conversation around morally ambiguous situations is challenging and invigorating. I love seeing the different ways that students think about and respond to ethical dilemmas. However, I was always disturbed when the same students who could tell me about the SASP Code of Conduct and the HPCSA ethical rules of conduct were unknowingly unethical in their treatment of patients. I realised that knowing about ethics was different to being ethical.

As I delved into the problem I became increasingly interested in the concept of empathy and it’s role in both patient care and student learning and have recently begun to explore it in more detail. It turns out that “the roots of morality are to be found in empathy“, conveyed nicely in the quote that Lauren used at the start of her post this week:

When you think like this, when you choose to broaden your ambit of concern and empathise with the plight of others, whether they are close friends or distant strangers; it becomes harder not to act; harder not to help.

I think that this is the crux of what it means to care in the context of health care. To really come to an understanding of what the other person is experiencing. I think that some of these ideas come out really nicely in the conversation happening in the comments on Chantelle’s blog. I can’t imagine a more distressing situation than a mother who is worried about her child. How do you connect with someone who is going through something that you haven’t? How do you say to them, “I understand”, when you don’t? Chantelle talks about the value of human connection and I have to agree with her completely. You can have all the knowledge and skills in the world but if you can’t connect to other human beings, you’re going to be a pretty mediocre physiotherapist.

My own interest in the role of empathy is less about patient contact and more about my interactions with students. As much as I know (and research has shown) that having an emotional connection to your learning is essential, most students have the same challenges as Umr does when it comes to “sharing”. However, even though moving into these personal spaces is difficult, I believe that it is only through developing relationships between people that human beings can truly flourish. As Marna suggests in her post, if you’re oblivious to this patient’s life beyond your doors, it’s unlikely that you’ll make any progress with them. I also believe, as Charde has learned for herself, that connecting with patients goes beyond the simply technical “compliance” rationale and helps to develop a sense of professionalism and deeper, more meaningful engagement with others.

During this course I hope to learn more about how physiotherapy students at the University of the Western Cape think about, and respond to, morally ambiguous situations. I believe that universities are the places where we need to develop the human capabilities that will enable transformative social change and I like to think that this course is one small space where we can give it a go. I will be following as many blogs as I can, reading and commenting where possible, in an attempt to get a better understanding of how students think, so that I can learn how to be a better teacher.

Twitter Weekly Updates for 2011-08-08

  • Designing for Social Norms (or How Not to Create Angry Mobs) http://ow.ly/1vmJzH #
  • @alisa_williams Do u think it’s because no1 has shown them the value of collaboration? The system expects and rewards individual performance #
  • Anatomy of an incident: Helicopter crash at UCT http://ow.ly/1vmlK3. Interesting analysis of how the info spread #
  • Tell me again what you did? http://ow.ly/1viz3M. Useful framework for writing and brief insight into a no online learning community #
  • It’s easy criticise….and fun too (apparently) http://ow.ly/1viyT1. Writing papers is hard enough without nasty reviewer comments #
  • British man survives artificial heart transplant http://ow.ly/1viyNA #
  • elearnspace › 5 ways tech startups can disrupt education http://bit.ly/pxMWHf #
  • @RonaldArendse Been thinking about how much disruption can really happen in the institutional context. Can we disrupt at all? #
  • If you could throw everything out and start again, what would your classroom look like? Would you have a classroom? #
  • Visions of Students Today http://bit.ly/nIbERY. Another video by Michael Wesch #
  • Create a Research Space | Learning Journey http://bit.ly/nVyPhF. Great tips on using a framework for writing #

Sharing? Collaboration? No thanks

Last week I took our third year students to see a demonstration of the management of a patient with spinal cord injury as part of the Movement Science module that I teach. I noticed that during the demonstration many of them were taking pretty comprehensive notes, and thought that this would be a great opportunity to use a collaborative writing platform to create something useful for everyone in the class.

I proposed the following to them the next day:

  • I’d set up a shared online workspace, either using a wiki or Google Docs and create the document structure so that they’d just have to fill in the spaces from their notes
  • We’d use class time so that this wouldn’t be regarded as extra work
  • I highlighted the benefits i.e. additions to their individual notes from other students, adding multimedia e.g. video and images to enhance understanding, linking out to external sources to strengthen the evidence base, error correction by the group and myself, and creating a potentially useful resource for anyone else in the world

Their response…no thanks. It wasn’t even up for discussion. I found out that they didn’t even planning on typing up their notes, even after I’d pointed out the digital notes are searchable, expandable and shareable. They told me that if they wanted to share with their friends then they’d just photocopy the notes.

These aren’t selfish students, and they’re not limited by access to technology. They just don’t see that sharing in this context has any value for them as individuals, and that’s where I think the problem lies. They think that sharing doesn’t benefit them in the context of their learning (or studying as they call it, which I think is a fundamental problem in itself). They told me that they are connected but only in their social lives. They regarded studying as that thing they do in the classroom, and that learning comes from studying.

I also got the sense that they believe in some way that this is a zero sum game, in the sense that the notes they have will give them some kind of competitive advantage over other students in the class, thereby increasing the odds that they’ll get a higher mark. What it is they’re competing for is unclear. I wonder if grading is somehow related? Grading sets up a system of ranking and competition, not of sharing and collaboration. From that point of view, sharing knowledge is only good if it doesn’t impact on my own position in the ranking system. If you get a higher mark than me, it pushes me down the list. If sharing is seen as a zero-sum game in which your success impacts negatively on my success, then sharing isn’t a good strategy.

Anyway, I was pretty disappointed because I believe that sharing and collaboration has enormous potential for learning. What do I do…force them to share in the hope that they’ll see the light? Even if I design collaborative assignments that requires a sharing component, as long as they see it as work, I’m not sure that it’ll change their thinking.

Why open licensing benefits everyone

In 2009 I started an online physiotherapy encyclopaedia called OpenPhysio. It was a space for me to run a few assignments with my 4th year students at the time, as well as a bit of an experiment to see what would happen i.e. would physiotherapists and physiotherapy students automatically create and edit an online physiotherapy encyclopaedia. At the time I was unaware of the excellent Physiopedia that had been started a few months before by a physiotherapist in the UK (@rachaellowe).

Looking back, I think that the two projects had different goals (I stand under correction here. Rachael, feel free to set me straight in the comments). OpenPhysio was always meant to be a bit chaotic and informal, while Physiopedia was more structured and rigorous in who was allowed to edit the content. I was thinking “interesting playground”, while Rachael was probably thinking “evidence-based resource”. Here’s an excerpt from the OpenPhysio About page:

“OpenPhysio is an attempt to create a database of high-quality, physiotherapy specific content that is free for clinicians, students and educators to use, modify and improve……Hopefully, in time, OpenPhysio will become a useful resource, not only for accessing free, high quality content, but also as a teaching tool. For example, by giving students feedback on each contribution they make. The usual concerns about the quality of the content (issues around references and credibility) and plagiarism apply but these obstacles should not be prohibitive and in fact could also be seen as teaching opportunities to educate students with regards improving their academic writing skills.”

A few weeks ago Rachael contacted me to let me know that OpenPhysio was getting heavily spammed and it dawned on me that I haven’t really paid much attention to the wiki over the past few years, besides writing up the experience for publication and as a conference presentation. By coincidence, the domain name renewal came up a few days later and I decided to pull the plug on the project. We’re doing some things with social networks and clinical learning right now and I can always embed a wiki there if we need one. When I told Rachael that I was going to let the domain expire, she asked if she could port some of the content from OpenPhysio to Physiopedia, which I thought was a wonderful offer from her. And, because all content on OpenPhysio was licensed with a creative commons license, I didn’t have to get permission from contributors to “give away” their content.

OpenPhysio will go offline at the end of June, 2011 when the domain name expires but happily the content that has been contributed during the past few years has found a home at Physiopedia. Which is why I think that when we make use of IP licenses that allow and promote openness, we get to more easily share and build on what we know and understand about the world.

Twitter Weekly Updates for 2011-02-07

Posted to Diigo 05/21/2010

    • What do I mean by presence, and why do I think that it is relevant to PLEs?
    • 1. Presence as social richness
    • Communications are expected to somehow express the ‘social, symbolic, and nonverbal cues of human communication’, which is of course difficult in an online environment.
    • 2. Presence as realism
    • By creating a sense of reality  in the pictures they produce and create an experience that would be plausible in real life (Lombard & Ditton, 1997)
    • 3. Presence as transportation
    • The idea in this form of presence is ‘the degree to which participants of a telemeeting get the impression of sharing space with interlocutors who are at a remote physical site’ (Mulbach et al, 1995, p.293)
    • the participant perceives to be immersed in a virtual environment
    • 4. Presence and immersion
    • 5. Presence as social actor within a medium
    • A heightened form of presence is created, where it seems that an interaction with the viewer or another person is taking place on the screen, while in reality this is not the case
    • 6. Presence as medium as social actor
    • deep and meaningful learning results if three forms of presence play a role in education. They highlight cognitive presence, that ensures a certain level of depth in the educational process, which could be compared to “intensity” as highlighted by Shedroff (2009) in developing web-based experiences and “Vividness” by Lombard and Ditton (1997) in the creation of meaningful online experiences
    • Anderson (2008) also refers to social presence, which would be similar to the social presence described by Lombard and Ditton
    • in a formal educational environment that of a teacher presence
    • In PLE based learning the teacher presence is not there, but you could argue that there are knowledgeable others out there on the Web who might to a certain extent take on that role
    • The higher the number of human senses engaged in the activity, the higher the presence experienced will be
    • ‘visual media have more social presence than verbal (audio) media, which in turn have more social presence than written media
    • ‘The number of inputs from the user that the medium accepts and to which it responds’ could affect presence and the level of experience, while the type of input by the user, ie. through voice, video, or button clicks, and the type of response received was also seen as an influence on the level of presence (Lombard & Ditton, 1997, p.18)
    • So the higher the level of presence, the higher the level of involvement in the online activity and the deeper the experience. The question of how to create presence in the design of a PLE is an important one as at the heart of PLE-based learning would be a high level of engagement and depth of learning
    • The fruit of collective intelligence, which I (and others) have described as an emergent phenomenon, results from the linkages and connections between individuals, and not a counting of properties (such as survey results) of those individuals.
    • This emergent knowledge is not intended to compete with, or replace, qualitative or quantitative knowledge
    • Connective knowledge, in other words, does not refute or overturn existing knowledge; rather, it offers us a *new* type of knowledge, that *cannot* be confirmed or refuted by simple observation of data
    • why shouldn’t students’ work be available to other (future) students.

      Instead of binning their work after they get their marks, why shouldn’t we be making it available to others so that they can learn from their peers, from what others have done.

      He talks about this as if it were so obvious. Yet in academia we’ve always made sure to hide students’ work… ooohh the plagarism…. [it’s better to avoid plagiarism at all cost than actually educate not to plagiarise…]… in real life, we all look at what other have done to improve our work. Something isn’t right here!

    • Providing information is not really creating knowledge
    • there has always been and there will always be good pedagogy with or without technology

The role of feedback in medical education

This reflection on the role of feedback in education is based on a mailing list discussion as part of the SAFRI programme, as well as on a few of the assigned readings. I thank the organisers of the session, as well as all the participants in the conversation.

Guidelines for effective feedback

The assigned readings seem to focus on providing readers with a list of guidelines for providing effective feedback and while this list is not exhaustive, it serves as a starting point. Feedback is better when:
  • It is promptly given
  • It is specific to the task being assessed, and to the objectives that were set (of course, this assumes that the student has set objectives for the task)
  • It is performance-based i.e. the feedback is along the lines of what you did, as opposed to who you are. One participant made the point that while it is performance-based, it is done to improve performance, and not to evaluate it
  • It does not focus on too many things
  • It helps the student plan for future learning
  • Feedback should seek to encourage self-assessment, self-reflection and self-awareness
  • Should / Could be better received if the supervisor / clinician allows the student to comment first e.g. What did they think went well? What did they think could be improved? (one participant said that “…a lot of feedback that I have to give to students is actually on written assignments [which]…means that we cannot start with the student’s agenda. There is no interactive discussion, no possibility to listen, respond to non-verbal cues, observation, etc.”
  • Positive feedback should be given first (builds self-esteem and encourages better performance)
  • This positive feedback should not be followed with a qualifier e.g. “You did well, but…”
  • “Listen and ask, don’t tell and provide solutions”
I’m glad someone pointed out that this (long) list is wonderful in ideal situations but is impractical in many real-world situation, which is where we find ourselves most often e.g. large student:teacher ratios, overloaded faculty and limited time to spend with students. On further reflection, it seems clear that this issue is not specific to feedback, and affects almost everything we want to do as teachers. The problem with teaching is that the way we want to do it (i.e. small groups with focused attention) doesn’t scale very well and we need to come up with a fundamentally different approach to teaching. My own view is that the internet and various associated technologies can enhance communication in ways that do scale, and that therein lies part of the solution.

Complexity in feedback

My own initial thought on a list of guidelines was that it was a wonderful “how to” for providing effective feedback to students. However, as I progressed through the conversation, I began to have my doubts, starting with this one. I worry that having a list of guidelines may deceive us into thinking that if we follow the list then we’ve given good feedback. This is like a student thinking that following a list of questions is a good way to conduct an assessment. Giving feedback seems to be a dynamic process, affected by context (e.g. social / cultural background, type of placement / task) and an understanding of the person/ality receiving it. Someone suggested that the complex process of giving / receiving feedback was also about the identity and character of the receiver and that “…in order to protect the integrity of their beliefs and knowledge, [they] will reject corrective feedback and find ways to devalue it”. Some studies have identified the importance of eliciting thoughts and feelings before giving feedback, which might go some way to alleviating this.
One of the participants insightfully related this back to the MBTI session in March, where it was clear that “knowledge of personalities is useful when giving and receiving feedback. What we know about ourselves and others is important feedback management”. In relation to this, another participant raised the point that “…the issues of culture, gender, religion, belief, age are very important in feedback.  Also, feedback for average students is different than feedback for failing students [as well as for] students who think they’re doing well [but] are actually failing”. I think it’s important to note that feedback is dynamic, contextual and complex.

Inappropriate feedback

I found a common theme in the conversation that went along the lines of “feedback drives learning”. This may be a matter of semantics but I’d like to challenge the idea that it does drive learning and suggest that it can drive learning. This may seem pedantic but I think it’s important, because when we say (or imply) that it does, we’re operating under the assumption that all feedback is equal, which it clearly isn’t. This was pointed out by several participants, who suggested that feedback can be inappropriate “…because of how, when or where it is presented”. Some teachers seem to be guilty of using feedback to highlight their own skills and knowledge, while at the same time making it clear that the student lacks these things (or in one horrifying example, actively humiliating them).
When using my own experiences to make a point, I often include examples of my mistakes. I think that as role models, we need to model our failures (and to elaborate on how we moved past them) as well as our successes. Students seem to have an idea that we’re infallible, which unfortunately makes them believe they must be too. If we can highlight that we’re also subject to errors of judgement and prone to forgetfulness (a big one for me), we show them that we’re human and go a long way to establishing trust.

Feedback as a skill

There was a suggestion that giving “feedback is a skill that has to be learnt” and that we should emphasise its importance. This was taken further with the idea that receiving feedback is also a skill that needs to be learnt (e.g. listening, reflecting, analysing), and that we need to spend a lot more time preparing students to receive feedback effectively and with the right attitude / mindset. One participant spoke of students who receive feedback defensively, negating it whether it was appropriate or not. I liked the idea raised that feedback should not only emphasise knowledge, but also more generic skills like effective communication, conflict resolution, etc.

Feedback in teaching and learning

It was pointed out that feedback is not only about a student-teacher interaction, it can also be between peers or colleagues. In fact, feedback is “…for helping all who are interested in self development and actualization of goals, not only students”. This suggests to me that feedback between peers could be an important component of peer teaching, an area of that I’m increasingly interested in.
Feedback should also be given to students who are performing well. This will help to dispel the notion that feedback = criticism. It was pointed out that as teachers, we often have a tendency to focus on the student’s weakness (I know that I’m guilty of this), possibly as a remnant of our own experiences of being students, when this is how we received it. One of the dangers of focusing on the negative only, is inducing a lack of confidence on the students part, where they become incapable of identifying their strengths. Thus, feedback should be used to highlight strengths as well as weaknesses, in order to promote learning.

Feedback and evaluation

Before beginning, see the third point in the guidelines. All too often (as was pointed out by some participants), feedback = marks, and there is no action required after receiving the mark (or if there is, the response is along the lines of “What must I do to get a higher mark”). I wonder if we’re not the problem. We make the assumption (and model behavior showing) that feedback and marks are related, whereas they don’t need to be. Marks are quantitative, while feedback is qualitative. Marks are summative, feedback is formative. Apples are apples and oranges are oranges. When one person is evaluating another, there’s no real objectivity, and so quantitative measures of competence don’t seem to me to be a good fit.
We should distinguish between formative and summative assessment, and their relative relationships to feedback. In formative assessment, feedback is essential as its nature is to facilitate learning. In summative assessment, feedback is irrelevant because the nature of the examination is to evaluate, which we’ve seen is not the role of feedback.
I think we need to get away from this idea that feedback and marks are necessarily related. Of course they can be, but it doesn’t mean they must be. We have to disconnect feedback, which is about learning, and marking, which is about evaluation (and not a very good form of evaluation at that). If students are “marks driven” it’s because we’ve put marks at the centre of our curricula. How do we de-emphasise marks…well, by not marking (it’s radical, I know).

Feedback and reflection

In order for feedback to be effective and of any value, we must first identify the relationship between the task, the feedback, reflection on the task and feedback, and finally, acting on the feedback. Without first making sure that the receiver understands this, the feedback is of no value. We know that reflection drives deep learning, understanding and professional development, yet we leave little space in the curriculum for structured reflection (and forget about teaching students how to reflect). It was great to read the comment, “we do not learn from experience, but rather from reflecting on experience, and feedback must facilitate this reflection for the student”. I would argue that unless the feedback results in a behavioral change, it is ineffective. Of course, if the student cannot focus on anything but the mark, we clearly haven’t established for them the relationship between the task, the feedback, the reflection and the action.

“No feedback” as feedback?

There was a question of whether “no feedback could also be feedback”, and I agree with one response which stated that it was “…the most negative and most useless form of ‘feedback’ in that it borders on pure and simple indifference”, as well as being “regressive and inhibiting”. I’m reminded of a line from “A man for all seasons]]”, in which Thomas More states that …”the maxim of the law is ‘Silence gives consent'”. When I was a student and was not explicitly told to improve (and to do this), then it meant there was nothing to improve, which I found disturbing, knowing what kind of student I was. I worry that if we give no feedback, we risk the student believing that their performance is exemplary (which it may very well be, but then tell them that), or worse, that they don’t know what to believe, leading to anxiety and confusion.

Feedback as a form of academic literacy

I’ve also been thinking about feedback as a form of literacy, which was touched on by one participant, who suggested that “…conversation is a form of feedback, a sort of negotiation of understanding in which mutual feedback becomes recursive leading to shared understanding.  In this way, feedback is not one person who ‘knows’ helping another person who doesn’t ‘know’, rather it is mutual. By asking myself questions before and during the feedback, I am learning at the same time the other is learning”. I would take this in a more general direction and suggest that feedback is useless unless the student is at least familiar with the culture of the tribe, which includes the language and conventions we use.
We can give as much feedback as we like, but if we’re speaking a language the student doesn’t understand (I don’t mean English, etc.), we’re wasting everyone’s time. And in case you think that by final year, our students understand our “tribe”, think about this simple example: The first year student is starting out in the culture of higher education, the second year student is starting out in the culture of physiotherapy, the third year student is starting out in the culture clinical practice, and the final year student is starting out in the culture of being a physiotherapist. We need different languages and approaches for each of these different cultures / literacies / “tribes”.

Final thoughts

  • For most of the discussion, feedback was treated as a “thing”, rather than a process or interaction. My own view is that feedback is neither “given” nor “received”, but is a process that people participate in
  • How many of us ask our students for feedback on our feedback?
  • How many of use ask our students for feedback on our teaching? One participant had this to say “Should each of us offer the students who receive our teaching the opportunity to give feedback on our teaching as part of their learning? This may be a little threatening, but on the occasions that I have done so in the past it has mostly been encouraging and affirming. Occasionally uncomfortable.”
  • If we do ask for it, how many of us reflect on it and make an associated change in our teaching practice?