If there is anything that requires critical thinking skills, it’s taking care of people who are ill. When someone is ill they have more than a disease. In fact, the clinician is presented with an individual whose homeostasis has been disrupted. Before you get sick, you have a routine and things are in some sort of balance: you go to school or work, find time to connect with friends and family, do chores, pay bills, take a shower, have sex, get rest etc…But when illness sets in, the precarious balance that is life before is perturbed. An effective clinician sees all this, and approaches the ill patient with a wide angle lens. He or she is able to discern what matters in a particular context. Our research on contextualizing care indicates that that ability is in short supply. A major culprit for such a profound competency deficit may be attributed substantially to a medical education process that still relies heavily on lecture.
First, a reminder, for those who have been out of school for a while….A colleague of mine with a lifetime of experience facilitating adult learning writes:
Lectures had been seen as the ultimate in efficiency – simultaneously force-feeding information into the ears of hundreds of students at a time as they were jammed into lecture halls with rows of fixed seating. Yet, in truth, the uncomfortable seats most often had too-small arms to support notebooks for the most inefficient mode of information transfer – from the mouth of the often mumbling professor, to the impaired ears of the students; set in a sea of noise from a hundred others scribbling, coughing, sneezing and shuffling impatiently; to the imperfect handwriting of a hundred ink-starved pens and broken-point pencils. This, for the past century and more, was the model of high-quality teaching (and learning). Forgetting the hearing-impaired, forgetting the sight impaired who could not read the black or white board, the lectures droned on.
Lecturing is basically telling people stuff while they are captive. It’s mostly unidirectional, and learners are rewarded for their regurgitating capacity. Once they’ve been through the system it becomes their turn to lecture to people. If they get PhDs they can lecture from a podium. If they get MDs they can lecture in the exam room. We hear doctors lecturing to patients about how they have to quit smoking, eat better, exercise more, take their pills…often using medical terminology, unaware that what they are saying is incomprehensible. What they don’t often do is ask their patient why they aren’t taking their pills or eating better etc…What does it say about a person’s critical thinking skills when they think they know how to fix something before they’ve looked into why it’s not working?
Lecturing at the lectern is equally illogical: The teacher is transmitting information without knowing the learning needs of a diverse audience. Some students, like patients, may benefit from the information transfer. But for most, there are other learning needs. I remember sitting in lectures in college on the French revolution and feeling like I walked in late even when I got there on time. I was lost from the beginning because I lacked a foundation of knowledge that the teacher assumed I had. Similarly, a clinician lectures a patient unaware of the underlying struggles that individual is facing. Most people who don’t take their medication as directed probably won’t benefit from a lecture on how important their medication is. What they need is someone who will ask them about their challenges integrating something new, scary and that often changes how they feel into their daily routines…and then help them find their own solutions.
Lecturing is disrespectful. Don’t get me wrong: some like it, which is just evidence of learned helplessness. Lecturing is based on the premise that I know what you need and I’ll do the talking. It is ego gratifying for the lecturer, as they have the attention of many others (or the appearance, thereof. Most are on Facebook). Most importantly, it puts the teacher and learner on an unequal plane. And that comes to model the relationship between doctor and patient.
Not all learning requires conversation. Rote memorization works best with flashcards. Comprehension comes from reading (lecture is an inefficient alternative with lower long term retention). But learning to solve complex problems — to analyze and evaluate information, and to formulate and test hypotheses (see Bloom Taxonomy) — that requires direct engagement with the material…and when the “material” is other people, it requires engagement with them.
As long as we continue to lecture medical students we are treating them the way we don’t want them to treat patients and we are denying them the opportunity to build the skills they need to provide effective care.
I understand the concern here, but lumping all lectures and lecturers into a single bucket represents a logical fallacy. We all have heard lectures that inspired us. We all have hear stories that make us think.
We should not separate the lecture problem (and we all should admit that many lectures are poorly done) and the multiple-choice tests that follow.
We who teach clinical medicine on the wards and in the outpatient setting have a responsibility to be both role models and stimulants of thinking about how we can best work at the bedside.
Please do not fall into the trap of lumping all lecturers, all internists, all medical students.
Thank you for giving me an opportunity to elaborate. First let me be clear that when I say “lecture” I am referring to the traditional, passive lecture in which a bunch of students sit, typically for an hour, listening to a teacher talk about a subject as part of a structured curriculum designed to achieve a specific set of learning objectives. I am not including teaching at the bedside or providing brief overviews of topics in the clinical setting, both of which can be highly effective.
One of the most useful hours I ever spent as an educator was watching a You Tube video of an address given by Eric Mazur, a distinguished physicist at Harvard who had won every major teaching award for his engaging lectures (link pasted below). He described research he had come across showing that students don’t get much out of lectures even when they think the lecturer is terrific. He decided to test the finding with his own students. The test involved what’s called a “functional assessment” of their learning. Instead of the usual exams, in which they could get an “A” just by learning to “plug-and-chug” he decided to test their basic conceptual understanding of elementary principles of physics — knowledge that he assumed they all must have to do well on his test. In the video he describes the kinds of thought problems they had to solve that use such simple language a junior high student would understand them. Much to his chagrin, most of the class failed miserably. Most students were pre-Newtonian in their thinking. This revelation also accounted for a long standing puzzle: Although students thought he was terrific, at end of the year evaluations they also said they thought physics is boring.
He decided to make a radical change to his instructional method. Students still come to class and sit in the auditorium with one teacher (him) — but there is no lecture. He describes the flipped classroom methods he employs and the peer-to-peer learning exercises he facilitates. He saw dramatic improvement in students’ conceptual knowledge, no loss in their ability to “plug-and-chug” and a lot more students choosing to study more physics. Findings of his and others who are leaving lecturing behind have been published in Science and other leading journals.
The success of a teacher should be measured by only one criterion: the extent to which their students achieve meaningful, measurable learning outcomes. There appears to be a consensus among educators who study instructional methods that traditional passive lecture based instruction is not an efficient method for student achievement of meaningful, measurable learning outcomes.
Confessions of a Converted Lecturer: Eric Mazur
Personally, I have been encouraged to work toward a flipped classroom on my (once yearly) forays into the UAB introductory class, where I am charged with introducing aspects of health care coverage and its lack. So far, what I have managed to do is render my lecture more interactive (i.e. “how would you advise an uninsured friend with a diagnosed thyroid cancer but no options for a surgical appointment due to lack of payment on her diagnostic workup?”).
Having read your blog and heard your criticism of lectures, I re-fashioned this year’s talk with both optimism and self-doubt. Could I fashion a defense of the lecture by doing it well? Would “a good one” matter in any real measurable way, if all the scholarship you have read suggests few confer “measurable learning outcomes”?
I would offer up a kind of defense, in the form of 2 pushbacks-
First let me just lay out a vision of what a contemporary-style educational lecture might be and ask if we are sure the educational researchers and Dr. Mazur would find it generally inferior to “other methods”. Second, I’ll mention where or how a lecture sometimes feels necessary in light of the content.
Start with the proposition that one is giving a lecture (speaking >75-85% of the time while inviting audience involvement 15-25% of the time). Assume further that the lecturer uses every theatrical trick in the book, humor, wit, funny visuals and individualized anecdotes.
Those are the elements one finds in smartly conducted educational videos on Youtube (https://www.youtube.com/watch?v=EbBHk_zLTmY).
Then add in the potential drama and interaction that come from being in a live participatory audience. Without breaking the “lecture” template too much, there will be some open discussion in which 10-25 of the 140 assembled participants hear each other speak on the concepts in play, and the entire audience watches the speaker facilitate, rephrase, and connect their input to the topic at hand. But yes, it’s still a “lecture” in basic format, even if some interaction and theater are embedded. Plenty of didactics.
Despite what you have written, I’m not convinced that this more contemporary kind of lecture is generically and generally inferior across all topics and domains to other types of learning experience (obviously the TED organization has embraced it!). It may be done well or poorly. It may work for one topic area and be terrible for another. I would suggest it can be engaging in ways that allow new-comers to a topic to “take a stab” through brief response to the speaker, and test the waters in relation to a content domain where they might know very little.
The second style of pushback is to suggest a bit of why a 30-50 minute lecture sometimes seems necessary for a given topic area. Some topics we wish to share feel like parts of a bigger story that we (the teachers) don’t yet know how to write out in clean and highly digestible little book chapters.
My particular lecture is on health care “coverage”. There are some basic didactic matters of Medicaid, employer-insurance, high-deductible plans, etc. I put those in the assigned readings. But even Kaiser Family Foundation readings strike me as boring and unmemorable, so I tend to highlight a few fact-points and ask some questions about they mean.
But the didactic data (how many have insurance? how do they get it?) are deeply insufficient when speaking to a new audience of medical students. To responsibly discuss coverage on day 5 of medical school, I think one should broach larger questions that require a bit of introduction, discussion, then deliberation, and a taste of the ever-debated research data.
e.g. Does “coverage” assure access to care? Or if not, why not? Does “coverage” deliver health? There are legions of articles and book chapters that attempt to dissect these matters with care. And a few people should read them at length and debate them for a few months. But that’s not going to happen. Anatomy starts in a week!
Alternatively, the challenging questions can be strung together and made to tell a story, in 50 minutes. That story may not be entirely ready to be written down, to speak for itself, on its own. Isn’t that a great situation for a lecture, albeit with all the tricks of marketing and engagement one might devise?
Or, at the risk of being snarky here, do both the speaker and the listeners merely embody “learned helplessness” by virtue of speaking and listening in a large room for 50 minutes?
Thanks for sharing your perspective and raising questions. I think your approach of trying to engage some of the students in the lecture hall in discussion is in the right direction. I encourage you to get empirical about what instructional methods are most effective and do your own experiments. It is this approach that led Dr. Mazur to realize that his highly entertaining, award winning physics lectures that had become so popular weren’t achieving what he assumed they’d been achieving. And that revelation led to an experimental approach to instruction that resulted in the desired learning outcomes.
Start by writing out your desired learning outcomes for your session. Specifically, what do you want your students to be able to do after your session that you don’t think they can do before? What do you think is the most efficient and effective way to get them there? If there is content you want them to master, why not just write it out and have them read it? If there are ways in which you want them to learn to think about that content, why not have them read what you wrote and then come to class but, in class, spend the time challenging them with questions? Let them know in advance that you’ll start class with a for-credit quiz on the readings they were assigned. Maybe then break them into groups part of the time and have them challenge each other, with you facilitating. Finally, develop an assessment method for determining whether your students have in fact achieved the learning outcomes you had in mind.