It is difficult to reflect back and identify specific examples of transformatice learning throughout my lifetime. I believe they happen slowly over time, and more rarely do they occur as an “a-ha” moment. Certainly college and all of its lide lessons contributed to a transformation. Residency (which took five years), I think, more than any stage of my life contributed to who I am today. I got married, had a child, and also became trained in my profession. Now that I am more attuned to this type of change and possibly aware of it actually happening, I find it more interesting to consider that I am currently in transformative change.
I began taking these classes to become a better teacher for the residents. I basically thought I was pretty good at teaching and just needed a couple of pearls or technique refinements to help me out. I thought my philosophy was essentially the right one (no even knowing what exactly it was or anything about the alternatives), and I didn’t think I could be influenced or it would change.
I did try and keep an open mind, though, and now my perspectives are changing. I am not sure what the timeline is or where exactly my beliefs will end up, but I am sure they are changing. That is a good thing. In my profession, teaching is mired in tradition. A change in attitude is needed to keep up with evolving face of resident education.
A good example of this is mentorship. The results of a rrecent survey of orthopedic resdients showed that residents greatly valued a mentor during training. Unfortunately, very few residents reported actually having one. When I asked our residents who among them believed they had a mentor, not a single one rasied their hand. Disappointing to say the least, but also an area with room for improvement. Change is good.
I have to say that at first I was a little unsure about the value of this inventory, but as I thought about it it began to grow on me…a little. I think it is always better to know your strengths and weaknesses when it comes to just about anything. Most people think they know their strengths and weaknesses, but until you really sit down and take a few minutes to identify them, what good is it? The inventory does this for us. Now I know I am more of an apprenticeship type teacher. Apparently, everyone in the health care field is, but it is still good that I know it. So now I know where my strengths lie, and I also know that social reform is not for me (so much for the career in politics). It also points to some areas where I could improve (nurturing, for instance). While this is helpful, I am not sure to what extent. What I reallt want is for tangible information that will make me a more effective teacher, no matter what my style (I suppose I will have to wait for 602).
What I did find more interesting was Bloom’s taxonomy of learning, and how well it applies to the medical field (it must get old listenng to me blather about the medical field). Anyway, we surgeons (probably unintentionally) cover every level of the taxonomy. First, we teach and learn basic knowledge in a very simple setting (lectures, e.g.). Next, we cover understanding by pimping and discussing topics on rounds or at the bedside/OR table. Then we apply the previous levels when we operate or treat patients in the clinic. For some physicians it stops right there. They simply treat patients without ever analyzing their results, outcomes, or complications. What a nice world that must be; being oblivious to consequences. But for most surgeons, they will take it to the next level and analyze (even at a rudimentary level) their results. In an academic center we analyze our results both good and bad (Morbidity and Mortality conferences, e.g.). You will also see researchers in academic (and some private practice) settings. This is the evaluation level. When you actually scientifically evaluate what has been done in the past or what has been done on the cutting edge. Few surgeons do this and even fewer do it well. Finally, there is the rare physician who will then create novel treatments or mkae grounbreaking discoveries. I took a liking to Bloom’s taxonomy because it applied so nicely to the educational reality I live in. Furthermore, it can serve as a guide to how I set instruction for the residents. I’m not sure I can get them to create something new in the 5 years I have them, but I need to ensure they are well versed in research methods, design, and evaluation so they are prepared to analyze data, methods, and results when they become independant surgeons.
After discussing this topic last week and thinking about it, I beleive it should be used as a framework to guide teaching. Certainly, there is going to be crossover in how different people learn, but (especially in the one-on-one setting) if you can customize your teaching to a particular individual’s learning style you are bound to have better results (has this been proven scientifically? I have no idea, I am assuming it is true, and you know what they say about that). At my job I have opportunities like that, e.g., when I have one resident with me in clinic or the OR. I have never even thought about what style of teaching might suit the learner; I tend to stick with the teaching style that suits me or what I do best (I bet this is a common mistake). That probably works much of the time because we medical types are a pretty predictable, homogenous group, but certainly there have been wasted chances.
The problem is, unless I have some inside information or I am a good geusser, I have no idea which style suits the learner. The solution may be to have each resident take an inventory when they arrive (has been done at other institutions) and then make this information available to all the instructors (attending physicians). That is a fine idea, except they would have no idea what to do with that information.
One thing I have realized since I started these classes is that to effectively improve the resident education I must improve the teaching and, therefore, the teachers. Which means that, in addition to teaching the residents, I need to teach the other attendings how to teach the residents (which means I probably need to learn how to first). Ideally, I would have a group of attendings who had various styles of teaching at their disposal and the knowledge of how each resident learns best. Sounds like a pipe dream, but it is a good goal.
Finally, I have to address the issue of teaching to large groups. It is impossible to make it personalized, so the strategy is to mix it up with many different styles. That is challenging because you don’t want anyone to miss anything,and there is usually a time limit. Might be an instance where we have to pick the important topics, teach them in a varied manner and well, and allow the learners to learn the rest on their own time as they will (which is still better than sitting in a lecture hall and learning nothing for 2 hours, right?).
The training of orthopaedic residents has come a long way since the early part of this century when to become an orthopedist you simply had to do an apprenticeship with an established surgeon. A group of orthopedists established the American Board of Orthopedics in the 1930’s , and they established standards of training and testing. Since that time there have been only minor changes and advances, with the basis of education and training remaining a 5 year residency. However, recently, with the boom of technological (both medical and information technology) advances, orthopedic surgery training has begun to change drastically. This has happened in a background of reduced training hours and increased supervision.
First, medicine and medical research has become a global science. There are valuable contributions made on a daily basis from all over the world. Many of the orthopedic advances are pioneered in Europe or Japan and adopted secondarily in the United States. With the advent of the internet and search engines like Pubmed, this has not created a problem for exposing residents to the appropriate research. It is astonding how much medical research can be found at the click of a mouse. Searching through the stacks for journals is a task not many medical students or residents are very familiar with. In addition, most textbooks have a digital version that ensures easy access without a crowded bookshelf.
The flipside is that the residents have a much larger amount of information to learn. To complicate this, resident work hours have been reduced to 80 hours a week. Theoretically, the residents now have more time at home to read, but testing results since the advent of the 80 hour work week have been less then stellar. Also, residents are legally allowed to be much less hands-on then in previous years when attending supervision was not as regulated. To compound this problem, surgical technique has made major advances (mostly in relation to burgeoning technology). All of this adds up to a medical student who has five years to learn a mountain of information, more complicated surgical techniques with less time, less hands-on training, but improved information technology.
So this is an exciting and challenging time for orthopedic education. Orthopedic surgery is rapidly changing, and education has to adapt. This is difficult because much of the training and educational techniques are entrenched deeply in tradition and very little in proven science. Hopefully, we can adapt and use adavances in IT and education to keep up with the changing face of the profession.
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