Few medical faculty members are adequately prepared for their instructional responsibilities. Our educational traditions were established before we had research-based understandings of the teaching-learning process and before brain research began informing our understandings of how humans achieve lasting learning. Yet, there are several advantages you may have. If your expertise is at one of the frontiers of human biology, your teaching can be inherently fascinating to aspiring health professionals. If your work has implications for human health, you have another potential basis for engaging future clinicians. And, thanks to Claude Bernard's influence, you likely are “process oriented,” a necessary mindset for being an effective teacher. There are also challenges you may face. Your medical students will mostly become clinicians. Unless you can help them see connections between your offerings and their future work, you may not capture and sustain their interest. To be effective, teachers, like clinicians, need to be interactive, make on-the-spot decisions, and be “emotional literate.” If you aren't comfortable with these demands, you may have work to do toward becoming a truly helpful teacher. Program changes may be needed. Might your program need to change 1) from being adversarial and controlling to being supportive and trust based or 2) from mainly dispensing information to mainly asking and inviting questions? In conclusion, making changes toward becoming a truly helpful teacher can bring benefits to your students while increasing your sense of satisfaction and fulfillment as a teacher. If you choose to change, be gentle with yourself, as you should be when expecting your students to make important changes.
- Claude Bernard lectureship
- education reform
- faculty development
- health professions education
- medical education
many thanks for the privilege of helping you honor one the great scientists of all time.1 When Frank Belloni called me nearly a year ago, inviting me to contribute to your Claude Bernard series, I began wondering how best I could convey my admiration for Prof. Bernard. Eventually, I realized that a good way to honor him might be for me to emulate him, to do with you what I imagine he did to his peers and colleagues. So, for this time, I'll do my best to be like him: I'll be annoying.
Might you think that he wasn't annoying to his peers and colleagues? Well, let's reflect on what he did. He repeatedly drew attention to things his colleagues hadn't noticed, and he argued for new and different ways they should be conducting their research. How many of us enjoy being criticized and corrected? Most of us, I'm afraid, find that annoying. So, in his honor, I'll seek to be somewhat annoying, although gently, I hope.
I will try to proceed as I think Prof. Bernard would have, if, instead of human biology, he had taken the educational process as his area of focus. He would surely have started by gathering information. First, I imagine, he would have become highly familiar with the background, the context, of current medical education. I hope you agree that he would have been forced to conclude that a strikingly low percentage of medical faculty members have been adequately prepared for their instructional responsibilities. He would also have recognized that our educational traditions, which still dominate our practices, were established long before we had research-based understandings of the teaching-learning process and before brain research began informing our understandings of how humans achieve lasting learning.
Next, he would have gathered information on the outcomes of current educational practices. He would have looked for some observable consequences of our work. Before doing that, I'll offer a recommendation that's relevant to my theme, and then I'll clarify my main intentions for this session.
My First Recommendation
Now comes my first source of annoyance; assuming, like most people, you don't especially like being told what to do. In presentations and when reading papers, I strongly encourage you to not just sit there but continuously take notes and identify your “keepers”: those ideas, followup tasks, questions you want to pursue, anything else that pops into your mind. Thanks to good neuroscience research in the past two decades, we have confirmation of a conclusion some of us reached many years ago: human memory is flawed and unreliable! (Please see bibliography one for a sampling of the recent literature on our new and growing insights into the teaching-learning process.) If you think of anything that you want to remember later, do yourself a favor and write it down or, when reading a paper (if you don't already do so routinely), consider underlining, highlighting, and making marginal notes. And, if you make notes, I have one more important suggestion for you and your students: write your notes in your own words, not mine (or anyone else's). As you may well know, the bit of translation work you do in converting information into your own words is an important step in the “encoding” process, the process whereby your brain gradually converts new information into a lasting memory.
The Title of My Presentation (and My Implied Goals)
Let's take a moment to return to the mouthful of a title that I assigned to this presentation. I'll elaborate on a few key words to clarify my intentions. Being “truly helpful” means providing what others genuinely need, which implies getting to know a good deal about them: their interests, their confusions, their responsibilities, and their hopes (which you can do somewhat when in a live encounter and better when you have many encounters with the same people over time, but which you can't do as a writer). The best we can do as writers who are seeking to be helpful is to generalize from our knowledge of people who are similar to our anticipated readers.
Taking seriously the goal of being a genuinely helpful teacher places demands on conventional teachers that can be quite large and challenging. I'll review some of those challenges and encourage you to consider doing what's needed to overcome any that you feel apply to you. Overcoming these challenges is a form of investment toward the valuable returns of being meaningfully more effective for students and toward having more fun in the process. Please understand that I've used “fun” in my title as a synonym for “satisfying,” “fulfilling,” or “rewarding.” And, finally, “business as usual” is not a general pattern among teachers; it is unique to each teacher, much as learning patterns are unique to each student. I invite you to reflect on what your “usual” approaches to teaching are and whether they are consistent with what we now understand learners need.
Let's now continue our Bernard-like initial research and look for some external evidence about the consequences of our teaching. I offer you excerpts from a featured article in the Sunday edition of the New York Times, from April 8, 2007 (Ref. 10, bibliography two). It was written by Gina Kolata, one of this country's preeminent science writers. Figure 1 presents three quotations from this article, in sequence. As you look at these snippets of evidence, try to think: How would Prof. Bernard have reacted? And how do you react?
I trust you agree that Prof. Bernard would have concluded that something is seriously wrong. Although there may be multiple contributors to this state of affairs, it seems likely that one of his hypotheses would have been: something has gone wrong in the education of physicians. Well, that hypothesis has been studied fairly closely, and some conclusions now seem warranted. Among those conclusions, we can assert that far too many practicing physicians 1) resist being evaluated; 2) resist undertaking needed changes in their ways of working; 3) communicate poorly with patients, staff, and colleagues; 4) commit more errors than is acceptable; and 5) tolerate suboptimal continuing education offerings without complaint. In summary, too many physicians can be fairly described as damaged learners. (Please see bibliography two for a sampling of the growing literature on these educational outcome problems.)
Simply put, it is high time that we rethink the ways in which we typically offer medical education. In addition to evidence about the disappointing outcomes of our instructional efforts, we now have the benefit of several decades of increasingly well-done research about how best to conduct the educational process, and we have about two decades of stunning neurobiological and psychological research that provide us with clearer guidance than we have ever had as to what constitutes an effective educational program. I will touch on a few highlights of what we now understand and on some of the implications for what we should be doing as teachers.
Scientists as Teachers: Three Advantages
I will begin by noting three important potential advantages you have as teachers of the life sciences. First, your work very likely involves a focus on exciting frontiers. You probably have the large instructional advantage of dealing with subject matter that most people who are heading for a career of doing or using science would find engaging. Your task is not so much finding ways to make your areas of interest interesting to your students but avoiding doing anything that makes your material seem dull, uninteresting, or irrelevant. Sadly, too many science teachers regularly accomplish the latter, albeit inadvertently. As I hope you realize, there is a difference between passing exams and really learning. Authentic, lasting learning grows out of caring for material, of having a genuine sense of “ownership,” and connecting the teacher's offerings to one's interests, goals, and plans.
Your second inherent advantage is captured wonderfully by the motto adopted as the theme for this year's Experimental Biology meeting: “Today's Research: Tomorrow's Health.” In a few words those who crafted that motto clarified the potential appeal of your disciplines to future health professionals. Most of these students come to school with idealistic hopes for their own future contributions to people's health. If you can help them recognize the linkages between what you do and their dreams, you have the foundation for an exciting, effective learning experience.
Finally, your research work likely gives you the advantage of a deep understanding of “processes.” Thanks largely to Claude Bernard, as I expect you know, the focus of human biology research shifted in the 19th century from being mostly descriptive to being mostly process oriented. Assuming you are a process-oriented thinker, I expect that you are accomplished at devising and recognizing good questions. As you likely agree, good research begins with-indeed, is dependent on-good questions. You may also recognize that good patient care begins with good questions. In other words, orienting our teaching around questions can make our educational offerings more likely to be engaging to our students than is conventional teaching, which has been largely oriented around pronouncements and conclusions. Put another way, too much of science teaching has focused on the “products” of science when it needs to focus on the “processes” of science. Our conventional teaching programs are still getting students to accumulate information rather than helping them become good at the processes of searching for and assessing information, which are the real skills that they will need in their careers. Being compelled to acquire information, especially information that they won't be using on a regular basis soon, if ever, is not just futile-it is potentially quite hurtful. It conveys the damaging message that education is about following orders, not about using one's mind.
To emphasize the distinction between teaching based on the “products” (the “content”) of science and teaching based on the “processes” of science, I ask you to think briefly about a familiar quotation. It is widely attributed to Lao Tse, meaning that this insight has been around for more than two millennia! (Fig. 2).
Dwelling, as so many teachers still do, on the “facts,” the “conclusions” of science, they are feeding their students fish; leaving those students no better able to fend for themselves the next day than they were the day before. By focusing, instead, on processes, teachers can help equip students to spend their lifetime being effective learners, which is probably the most fundamental capability they will need.
Scientists as Teachers: Three Challenges
We now come to my most annoying observations. I offer you three challenges and encourage you to consider expending whatever effort may be needed to enhance your capabilities in any one or more of these areas that you regard as relevant to your situation. From all available evidence, we have to acknowledge that most teachers in the health professions are not as fully developed in one or more of these three areas as they should be, if they are to bring as high a standard to their instructional responsibilities as they do to the other parts of their professional lives (Fig. 3).
1. Understanding clinical tasks.
First, if you have never been a clinician, you face a considerable challenge as a teacher of health professionals. Your best chance of benefiting from the potential advantages I summarized above is being able to help your students see authentic linkages between your offerings and their future responsibilities. In other words, you need a fairly deep understanding of their future careers: the intellectual processes in which they will need to engage and the tasks they will face while seeking to be helpful to others. Such linkages don't work if they are treated as icing on the cake, as embellishments or afterthoughts, instead of what they need to be, the launch pads for inquiry, the foundation on which exploration and authentic learning are built.
2. Adapting to an instant-decision environment.
Second, effective teaching comes most naturally to those teachers who can do while teaching what they do in their other professional activities. If your other activities mainly involve doing research, you may face a special challenge. An essential feature of good research, as you don't need to be told, is deferred decision making. We postpone conclusions while we do all we can to tease away as many sources of ambiguity and confusion as we can on our way toward arriving at maximally supportable conclusions. The quality of our conclusions is primary, and the time required for getting there is secondary. Many of the intellectual tasks demanded by clinical care are essentially the reverse. Decision making in clinical care often needs to happen in real time, even under pressure. Clinicians have been described as needing to make adequate decisions in the face of inadequate information. On the spot, clinicians need to make the best decisions they can: Have I asked all of the relevant questions for now? Are any further tests needed immediately? Can this patient safely be advised to return home? Teaching involves-or should involve-essentially the same process. Like clinical care, effective teaching requires a high degree of interaction, with on-the-spot decisions being needed: Should I answer the student's question, or should I encourage her to try to respond to her own question? Or, should I ask the rest of the group to offer answers to the question? Or, should I defer the question to another time? and much more. Of course, as teachers, we have it in our power to protect ourselves from the challenge of needing to make on-the-spot, tough decisions by avoiding or minimizing interactions. This is what we accomplish when we offer uninterrupted, traditional lectures. Regrettably, that strategy is not only wasteful of time and energy but can be seriously hurtful to learners. It can contribute to creating damaged learners who may function below their potential for life. It conveys the message that acceptable learning can happen when sitting passively and listening to someone else talk. A mountain of accumulated evidence confirms that this is a patently incorrect message.
3. Being (or becoming) emotionally literate.
The third challenge relates to the environment in which teaching occurs. Being a human interaction, with consequences for feelings of personal competence, even with consequences for career survival, the teaching-learning process is, inescapably, an emotion-laden event. Again, much like clinical care, the teaching process requires people who have high levels of emotional literacy. That is, teaching requires people who are highly adept at reading and responding effectively to other people's emotional states. Teachers also need to be in sufficient touch with their own emotions to exert constructive control over the expression of their emotions in the service of maximizing their helpfulness to the learners they are serving. Being a researcher, especially a laboratory-based researcher, demands less emotional literacy. Although such literacy can be helpful in collaborative research work and in interactions with colleagues and staff, such competence is not usually considered necessary for the job. Truth be told, research careers can be attractive to, and available to, people who are socially and emotionally uncomfortable, even inept, as some highly esteemed researchers have famously been. Since our typical process of selecting people for faculty appointments and for teaching assignments has rarely given attention to the domain of emotional competence, the task falls to individual teachers to assess their own readiness for work in the emotionally demanding domain of teaching. Teachers, themselves, need to determine if they should be making the special effort required for being effective in the interpersonal world of education.
Some Practical Implications
I will try to pull this all together with a summary of some practical implications of my prior observations for the process of being a teacher. For this summary, I will refer to the notion of “mature” learners. I use this term to imply a range of characteristics needed for a lifetime of effective learning. Although I label the opposite as “immature” learning, I'm not implying youthful learning. Typically, young people are far better learners than are many adult students. Children who haven't yet been damaged by hurtful schooling or parenting practices are marvelous learners. Among other characteristics, they exhibit high curiosity, persistent effort, an inclination to practice repetitively, and a willingness to take risks, to fail, and to keep trying. They are wired for learning, and, when unimpeded by hurtful traditions, they engage in active learning eagerly and almost continuously. In contrast, many older learners are cautious, fearful of failing, intimidated by new learning tasks, and dependent on external approval, and they may be preoccupied with protecting themselves from the possibility of being exposed to demeaning or abusive judgments by their teachers or their peers. They are “immature” (damaged) learners.
Too often, the young adults we work with in colleges and universities have been damaged to the point of being mere shadows of, or distortions of, their earlier learning selves. If we are to take seriously our responsibilities of helping them become capable professionals, we must be willing to expend a good deal of effort, as needed, on corrective actions. And, we must be scrupulous in avoiding any actions or patterns that might reinforce their nonconstructive approaches to the tasks of learning. Figure 4 presents a summary of some of the main tasks I offer for your consideration.
Our “teaching styles” (our consistent instructional approaches and strategies) can have powerful effects on our learners, either negatively or positively, beyond the instructional goals we may be trying to achieve. For now, in the limited space available here, I will offer only limited comments, and I will mainly let Fig. 4 speak for itself.
The two largest shifts that the evidence indicates are most needed in current conventional teaching are 1) creating learning environments that have supportive, trusting relationships as their foundation and 2) shifting our instructional strategies from being dominated by “telling” (dispensing information) to approaches that are dominated by our asking and inviting questions. In many settings, the size of the shifts that are needed is huge. Many programs are well toward the wrong end of these two continuums, while some programs (perhaps yours) are fully on the appropriate side of each continuum. In far too many medical education programs there is abundant use of humiliation, coercion, and a fundamental misunderstanding of what is most needed for fostering meaningful, lasting learning. As I try to explain in another article that I'm now developing, control isn't teaching and compliance isn't learning. In the absence of sufficient preparation for their work as teachers, large numbers of medical faculty members assume that their job is done if they get their students to follow orders: to read what they were told to read, to show up in class, and to do what it takes to come up with the right answers to questions on whatever tests are administered. The residual benefits of such programs are shamefully limited, and the residual damage caused by such programs can be substantial.
The process of encouraging reflection and inviting questions, in an environment that is supportive and free of hurtful judgments, provides the foundation for helping learners become committed to and effective at being continuously self-assessing during and after whatever they do. Accurate, continuous self-assessment is a hallmark of mature professionals and is the basis of both safe performance and future learning. Professionals who lack the skill or the willingness or self-confidence to be looking critically at their own performance as a matter of routine, and who aren't open (even eager) to being observed and (constructively) critiqued by others, are at high risk of stagnating and even of becoming dangerous. A tell-tale sign that an educational program is overdue for reform is the presence of students who conceal their perceived deficiencies from their teachers rather than turn to their teachers for help with these difficulties.
I hope I haven't challenged you to the point of discouragement. If you aren't already the type of teacher I've proposed is needed for optimal education, I urge you to start taking small steps on the way to becoming one. And I emphasize “small” steps! People seldom do well when trying to make large changes quickly. If you decide that you are a candidate for one or more of the challenges I've offered, please be gentle and patient with yourself. In the long run, people usually make more effective, longer-lasting changes in important areas of their lives by setting achievable goals and allowing for the likelihood of some backsliding. With some confidence, I can promise you that any changes you decide are needed and you succeed in making will be a gift to your future students and will help you find deeper satisfaction (more fun) in being a teacher.
And, finally, next year when you are looking for someone to help you honor Claude Bernard, perhaps you should consider seeking someone who will be less annoying.
↵1 Since this article is based on a presentation that was part of an important event, I've sought to preserve some of the interactive, personal communication style that I try to use with an audience. Also, the occasion seemed to merit the offering of some sweeping generalizations, derived from a lifetime of research and experience, rather than a detailed exposition. So, within the article, I've not cited the sources from the literature in support of individual assertions. Instead, at the end, I offer two bibliographies that are the basis for what I said at the meeting and wrote here.
- © 2007 American Physiological Society