One of my favourite papers about medical education was an article Geoff Norman wrote called ‘Medical expertise and mashed Potatoes’. In it he recounts a meeting with the famous chef Albert Roux. Norman uses the encounter to point out the similarities between expertise in what seems like very different domains. Since I have recently  almost lost the will to live  having tried to gorge on an ultimately inedible diet of pseudo-competency based descriptions of what doctors ‘are’ (really, the Danish devote pages to an exegesis of the  CanMEDS, and tweaking of where to put ‘professionalism’ in a schema of what doctors ‘are’!) They all need to get a dose of Wittgenstein to see the folly of their ways..) Anyway I digress.

Medicine was historically an apprenticeship, but our problem (well, actually the students problem) is that in large part this is not mirrored in the way we organise it at the undergraduate level. As Alice Gopnik, the psychologist once remarked, at university we tend to think the way to teach people how to cook, is to lecture then for three years and then, and only then, allow them to crack an egg. Here is a nice video from the NYT of people who understand education much better than we do. The video, and Norman’s article, say more than the ever enlarging girth of the working groups.

 

 

I have never taught in a school, just been a pupil. I do remember the sparring that goes on between pupils and teacher. The kids push ‘to the limit’. They then improvise just under this limit, causing trouble. My thought was that teachers could either define limits carefully or, to be slightly evil, just behave in an inconsistent manner. For the latter, think: random acts of terror! In this scenario, the kids can never quite work out any rules of engagement, and will sit there terrified in silence. Evil, I know.

I wonder whether this approach might be useful for learning outcomes. Rather than taking part in an evolutionary war between the students on one hand who want ever more explicit statements of what they should know, and on the other, the inevitable ignoring of all aspects of knowledge that cannot be explicitly stated, we should aim for a little more disorganisation. We shouldn’t tell the students what they need to know, and we certainly shouldn’t tell them the format of the exam, or even when it is. What do they need to know? Lots. Pay attention. Evil, I know.

Talking the familiar text book as an example,  American researcher David Wiley compares the cost of renting 75,000 movies  ($9.00 a month  fromNetFlicks) or renting  any of 20 million songs from Spotify  ($9.99/month) with the cost of renting a college text book . A single biology text book rents for $12.99 a month from BookRenter.  This cost imbalance is especially vexing in that consumers choose to rent movies or songs, while professors (often in collusion with publisher representatives) choose the textbooks that others (the students) pay for.

 

Terry Anderson writes

Around 20 years ago my father was admitted to a major teaching hospital in Wales. He was in his early 70’s and had heart failure. He was under the care of the ‘general medics’, on a general medical ward. He became mildly confused after admission, and within a couple of days had fallen in the bathroom, and was developing red areas on pressure points, a harbinger of pressure sores. I remember talking to one of the nurses, who was apologetic that there was no possibility of getting a suitable bed (‘there isn’t the money’), and that he had fallen when he should have been supervised. The poor nurse was literally run off her feet, a couple of nurses trying to cope with a score or more of patients. I was probably fairly cross, and not concealing it well—but so was she, reasonably so. She and I both knew how things could be made better. Both of us found it uncomfortable, because both knew that key decisions about care are usually made by people who don’t see patients, or have first hand knowledge of the ‘front-line’ (remember the Ballad of Reading Jail: prisons have walls, not so that convicts can’t escape, but so that God cannot see what goes on inside).
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Is skin cancer an unhelpful term? from jonathan rees on Vimeo.

New York Times

I used to think that medical students understood a lot about learning. They had done well to get to med school, so surely they knew how things worked? Gradually, from experience, I began to think otherwise. I have never opposed asking students questions about how they are enjoying things (Do the staff turn up? What is fun? What is bad? etc) but I have been very suspicious that they innately know what it takes to acquire the knowledge that means that you can ‘think like a doctor’ ( which is what med school should be about). Sometimes — and only sometimes — political correctness or plain lazy thinking gets in the way. Much as it does in the clinical arena when commentators misunderstand what information patients bring to a consultation: patients may have their views on wave-particle duality, but I do not attach must weight to them; other views matter more, as do sometimes the views of others.

There is of course a reasonable literature on how good (or bad, in reality) we are at assessing our own competence (for doctors, as well as students). I think some are much better than others, but as I type, I am aware I am entering the ‘All Cretans are liars’ paradox. My reading is that being aware of this issue is not sufficient to alleviate the problem. But the more educational psychology I read the more I find myself falling into a vortex of uncertainty about teaching and learning. I would like to laugh a lot of the experimental findings away. Perhaps, the findings are only true in particular experimental situations (remember these digits, recall them backwards etc); or true only for secondary or primary school levels; or fail to take enough account of motivation, and behavioural issues. Perhaps. But I suspect I and others have been living a fiction.

This most dangerous idea is that much self-assessment and reflection is bogus. That attempts to teach various types of meta skills doomed. And what matters most is knowledge: good doctors know more about patients and the way patents present with their diseases. Paraphrasing George Steiner, facts and memory, are consciousness’ ballast. Introspection doesn’t tell us too much about them, nor is it therefore a reliable guide to action.

In other words, one bank’s executive bonuses equalled a third of the cost of all university teaching, for more than 2 million students in the sector in 2010.

 

 

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Eczema in almost 5 minutes from jonathan rees on Vimeo.

 I have argued elsewhere that if you are using the word “textbook” you are probably looking in the rear-view mirror and not thinking clearly about what students need. The word “textbook” drags behind it a collection of obsolete assumptions about how knowledge should be organized and transmitted and learned.

 

 

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