Why do student development and course climate matter for student learning?

how_learning_worksWe need to teach the student, not the content. Students are still developing their physician personas and figuring out how to act. They may be emotionally more mature than college students, but this is quite a different environment than college. In the hospital, we are interacting with different people in different degrees of duress. It is stressful.

Each student may approach it differently. One student may be aloof and cannot make a connection with a patient. Another may be very sensitive and takes everything too much to heart. They are still developing their purpose. What kind of doctor they want to be. Why did they want to be a doctor.

They need a safe environment where they can learn and grow. And yet, medicine has a tradition for pimping, gunners and malignant instruction. Instead we need to create an environment where we make uncertainty safe. Let students know that they can think and embrace complexity. Set this tone early.

What kinds of practice and feedback enhance learning?

masteryThe next step in attaining mastery, after breaking a task down into component pieces is to have students practice each component piece with feedback. They need to repeat it until they get it right. Each time they get it wrong, it’s our job to tell them how they got it wrong and how they can correct course.

how_learning_worksThis seems it may require too many iterations than can be realistically done in the classroom, given that we meet four times only. There really isn’t the time to internalize big things. But perhaps some of this can be offloaded online. (Can deliberate practice be done online with automated feedback? I’d think not.)

The feedback may come in the form of a rubric. Looking at the example from the previous post, we had broken the task of “assess an undifferentiated patient” into the following component pieces:

  1. Identify the chief complaint
  2. Create a differential diagnosis based on that complaint
  3. Create an illness script for each disease on that differential
  4. Use the illness scripts to perform a history and physical
  5. Determine how closely your patient fits your illness scripts, this is your pretest probability

Can students grade themselves on this rubric? I don’t think so, they don’t have the insight to answer, but this could form a good shift evaluation.

[✓] Identified chief complaint correctly
[✓] Differential diagnosis included all life threats
[✖] Able to create an effective illness script for each Dx on DDx
[✖] Focused history and physical
[✖] Assigns appropriate pretest probability

Practice can come with the patients they see and feedback from the physicians to whom they present. The evaluators would need to be trained on this sort of evaluation system, but I think it is more concrete. It is easier to grasp and easier to provide feedback (instead of the vague “how did I do?”).

It would be great if they were graded this way on each patient. Whenever the student got an “✖” they could ask why and get feedback. If they successfully completed a component piece, the positive feedback (✓) would encourage more of the same behavior. Goal-directed feedback should incorporate WHAT they are doing incorrectly, WHERE their performance is going well or poorly and HOW they can improve it.

How do students develop mastery?

how_learning_worksRevisiting the model of skill acquisition by the Dreyfus brothers:

  • novice
  • advanced beginner
  • competent
  • proficient
  • expert

Students gain skills stepwise. Initially, as the novice, they require all the mental efforts to be focused on the task at hand. They cannot handle distractions.

masteryAs an expert, our blind spot is recognizing the amount of effort it takes for students to engage in these tasks. We chunk tasks together and perform them effortlessly, without thought.

For our students we need to unpack tasks into manageable component parts, let them practice each part separately until mastered, then move on to the next task. Finally they can reassemble them back into the whole.

So it is unrealistic to ask novice students to assess an undifferentiated patient. They have no idea how to do so. And the amount of data coming at them is overwhelming. Instead, we can decompose this into component pieces. In the diagram to the left, a task is broken down into three component pieces: P1, P2 and P3.

In order to assess an undifferentiated patient, you should:

  1. Identify the chief complaint
  2. Create a differential diagnosis based on that complaint
  3. Create an illness script for each disease on that differential
  4. Use the illness scripts to perform a history and physical
  5. Determine how closely your patient fits your illness scripts, this is your pretest probability

To go further into testing would be overload at this point. Instead, allow the students to first master skill #1. Allow them to keep repeating until they can do it consistently. Then help them master skill #2. Then skill #3. Ultimately, put all the skill together.

Another process could be to order and interpret testing. In order to do so, you should

  1. Given a diagnosis, assign a test threshold
  2. Given that same diagnosis, assign a treatment threshold
  3. Place the pretest probability within that spectrum
  4. Decide whether testing is worth it or not

Each skill should be practiced in isolation until mastered before moving to the next one. When they’re all mastered, then practice putting it together.

How does the way students organize their knowledge affect their learning?

how_learning_worksStudents’ knowledge needs to be structured in a way that students can see its importance and application. This big picture is often lost to students who are just struggling to see the trees. As a content expert these connections are obvious to us, but they need to be explicitly spelled out to our students. Continue reading “How does the way students organize their knowledge affect their learning?”

How does students’ prior knowledge affect their learning?

how_learning_worksA student’s previous knowledge helps them establish new knowledge. By creating connections to this old material, they are able to build off it and solidify the new content in their minds. However it is important that this foundational knowledge be activated, sufficient, appropriate and accurate. If not, it can actually hinder learning.

So before teaching new material, we should activate the appropriate prior knowledge. This may be prior knowledge may be basic science background or material covered in an earlier class. Continue reading “How does students’ prior knowledge affect their learning?”

Visual – Verbal Interdependent Thinking

blahDan Roam, the author of a business book called “Back Of The Napkin,” wrote a second book called “Blah-Blah-Blah.” Though the title doesn’t suggest it, the book is about effective communication using a combination of verbal and visual methods and how to link the two. This is an integral part of the digital whiteboard lecture experience, so it’s worth looking at what Mr. Roam has to say.

What we’re ultimately trying to do is help our students create connections and find relationships. Sometimes these relationships are hard for the student to create on their own, so they need assistance from the teacher. Dan Roam shows us how to depict various relationships pictorially. Pictures alone often aren’t enough. They do warrant explanation.

We’re told that we are either visual or verbal learners, but the truth is most of us are probably a hybrid of the two. The verbal aspect (anthropomorphized as a fox in the book) relies on linear and logical structure. The visual aspect (depicted as a hummingbird) is more free-form, making non-linear leaps and connections. Pairing the two successfully increases the likelihood that everyone will understand the material presented. This pairing is what Mr. Roam calls VI-sual V-erbal InterDependent (VIVID) thinking.

Most of us are fairly comfortable with words (as we’ve been using them within bullet points on slides for years and years) but we’ve neglected the visual skills since 3rd grade. We are familiar with verbal grammar: nouns, verbs, adjectives, etc. The book supplies the tools to translate between verbal grammar to pictorial representations: vivid grammar.

I think the best way to do this is to step through an example. Since I’m creating my spider bites video, I’ll use this as an example.

Nouns and Adjectives (“What?”)

Blah PortraitNouns should be easy to depict with a picture. You don’t have to be able to draw well, just do your best attempt at a stick figure. If you have no idea where to start, you can search for images of your item and “cartoon” in a search engine for ideas.

bw spider 1bw spider 2Here’s an example of my black widow spider. It’s nothing special. Descriptors of nouns (adjectives) can also be included in this picture. For example, for black widow spiders it’s only the females that are poisonous due to their long fangs. So here I drew eyelashes on the spider and long fangs. Now without an explanation, this anthropomorphization of the spider may not make sense. However once you know that it’s the long-fanged females that are able to penetrate deep enough to deliver the venom, this picture will always be associated with that meaning.

Numerical Relationships (“How much?”)

Blah How Manydan_roam_how_much_spidersExplanations of comparisons of value are best done with graphs. This is obvious as we use this often in our texts. Drawing a bar graphs isn’t difficult either. I don’t think this fact is important enough to include in my video, but if I wanted to depict how many different kinds of spiders there are compared to the number of ants, I could use a bar graph.

Temporal Relationships (“When?”)

Blah Whendan_roam_how_spider_biteTemporal changes are depicted best by a time line. For example the progression of symptoms from a bite by a brown recluse spider progresses from a painless bite initially, then turns into a Bull’s Eye lesion 2 to 8 hours later. It has an erythematous center, an indurated ring and an outer cyanotic circle. Finally 5 to 7 days later, an eschar forms.

The grammatical construct he associates with this is tense.

Other Relationships

Blah Where
Blah How
To describe where things are in relation to others, you use a map. For instance, you could use a map of the US to show where the killer bees live.

Descriptions of how things happen (verbs) are described via a flow chart. We’ve seen many of these. Think of the ACLS guidelines flow charts. Or the management of suspected PE.

Blah WhyMore complex relationships can be depicted via a multivariate plot. This is the “why” question.

I could go on, but it’s probably better to read it from Mr. Roam himself. I’m going to try out some of these ideas. Check out the book and if you have any questions put them in the comments.