Are laptops/ tablets connected to WiFi forces for good or evil in lecutre hall?

This post is in response to several things I've read and heard lately about the use of devices to connect to the internet in medical school large group teaching sessions.  Essentially these posts or comments have been either strongly in favor of the introduction of these technologies, or strongly against.  I haven't found much of a middle ground.

Those against argue from the idea of distraction.  The argument is laid out in several recent research studies looking at the effects of multitasking on cognitive performance.  The basic idea is summarized pretty well here, in an article from the San Fransisco Chronicle.  This is the view held by many basic science course directors who make comments to the effect of, 'if they have their laptops out, they are likely playing solitaire.'  I've also seen some people speaking about generational differences in learning styles who state that the Millenial generation has grown up with multiple electronic devices going.  This falls back on the data that they feel like they have done this for a long time, and should be good at it, but they are not really.  As they don't have any insight into this potential hazard, we as course directors should act to squash this tendency by telling everyone to turn off their electronic devices.  Hence, the common wisdom among these presentations is that it is important to have the learners switch off their devices on entering the classroom for their own good.

On the other hand, there are many potential up sides to having a wired classroom.  First, audience response systems using web-based or local networks are becoming more sophisticated and more robust.  This is much more than the audience clicker system where the audience can push a button to answer usually a multiple choice question (A,B, C, or D).  But there are systems like Twitter that can allow 'back-hallway' discussions or ability to ask questions which can be answered by the presenter in real time.  Newer platforms can collate rich text entries and also collect images.  Many of these allow ability to catch if the audience is out of step more efficiently by than the traditional method of waiting for someone to raise their hand.  Secondly, there is also the ability for the individual learner to go down a 'rabbit hole' right away to pursue a question they may have had.  For example, I interjected a clinical example of hemiballism after a lecturer was talking about subthalamic nucleus anatomy.  I had not shown a video, as I just stood up and extemporaneously gave the discussion.  As soon as I was done talking, a student in front of me had called up a video of hemiballism with a video demonstrating it.  And these are just a few brief examples of the good that can come from online activity during a lecture.

The last point I'd like to bring up, is that this will likely not be a point of discussion soon.  Our med school is considering going to a paperless system where all notes are distributed electronically. Our med school is likely a bit behind the curve on this.  My point is the same devices that allow you to read PP slides, and take notes on them also play Angry Birds.  There's not currently a good way to facilitate one task while blocking the other.  My point is that the ability for a lecturer to demand that everyone turn off their devices.  Thus, this may be analagous to a record company trying in the late Nineties to divert attention from digital devices playing their music and focusing only on
CD's.  Who's bought a CD recently?

So, where do we go from here?  As I look over the neuroscience course this morning, most electronic devices (except mine) are showing slides on epilepsy treatment (which is the lecture we're having today).  So most people are using the technology wisely.  However, with email only a click away, the temptation is strong for attention to wander?  What are your thoughts?

What I learned from the cerebellum yesterday about timeliness

*Note - photo is archived, and not from the lecture mentioned

My fellow course director yesterday gave what was actually a very nice lecture on the cerebellum to our second-year medical school neuroscience class.  It was clear, and it was logical.  But it caused a bit of trouble.  The trouble was that it included a lot of detail.  He had an hour and a half, and he covered 65 slides which for one of my lectures is usually more than I attempt, but I didn't think he was rushed as he went through, so I don't have a problem with that.  he was logical in his presentation and it was all pretty clear, so that wasn't a problem.  It was also organized relatively well.  No, the trouble came from the age-old medical student complaint that the test is today.  And he changed his slides the night before.  And did I mention that the test is today?  And they already had to review brainstem anatomy with cranial nerves and the motor system as well for this test earlier in the week.  And did I mention that the test is today.

I accept part of this is on me as a first-time course director.  There were somethings in the schedule which we purposefully changed in terms of timing to try to improve the flow of the course.  Of course, we have had the typical issues of lecturer availability changing up the timing of a session here or there.  But, some weeks we just kept as it was, as they worked last year.  This is one of those weeks.  I didn't even really revert my mind back to med student mode to realize that putting something as complex as the cerebellar anatomy the day before the test was a bad idea.  It was a bad idea, as basic educational literature supports the idea that concepts are retained more if they are repeated and if they are applied.  We really didn't have time to do either with the cerebellum.  So, next year we will rectify that problem.  This year, the schedule has been set for several months, and there's not much room now to swap things around.

My reason for this post isn't about whether this was an ill-fated lecture or not, it is more about the student reaction to the lecture.  I was in the back of the room as the lecture ended, and the reaction generally from those that sat in the entire auditorium was best described as anger and frustration.  Frustration I can understand.  I can understand that there was a lot of information presented and that this may have been perceived as not being 'fair'.  However, there was also an underpinning of anger that, although I understand where it comes from, I find a little troubling.  I've seen on Twitter some posts by med students after a bad lecture where the venting becomes more of a personal attack on the lecturer themselves.  That is where I think there is a bit of a problem.  This also comes out in the narrative evaluations we receive from students for courses.  There are plenty of comments which are truly helpful, and point out errors which can be corrected.  Then, there are those that don't give much rationale for why the lecture was not good and how to improve it for the future, but they are just downright mean.  I totally realize the the first and second year of medical school is a time of high pressure and stress.  I also understand that processing all that information in the time required is a monumental task.  I understand how a poorly organized talk can make things worse.  I understand that medical students are paying a lot of money for this.  But I also understand that as good as any educational program is, there are going to be times where you try something and it doesn't come off as planned.  I also know for sure that my co-course director's intent was to provide more details to clarify the major points he was making.  His intent was not to harm, but to help.  I think the majority of lectures I went to in medical school, the lecturer honestly wanted to help the students learn about things they are passionate about.  True it is not always presented with great oratory skills or organization, but I think the number of lecturers who truly despise students and purposefully are trying to mess them up is very small.  So, all I'm saying is that part of professionalism we are trying to teach in the medical school curriculum should include how to give reasonable feedback to educators without being judgmental.  Yes, the lecture was ill-timed, and changing slides on dense lecture the day before the test was ill-timed, and that feedback should be given.  It's not OK in frustration to launch an all-out personal assault.  Because, at the end of the day, most medical students still find a way to wade through those messes and learn what needs to be learned.  It's not fun, but as I move forward in the 'life-long learning' cohort, most of the stuff I'm presented with is a huge disorganized pile of information some of which is contradictory, and I need to work it out myself as I have a regular test I take regularly in the exam room of my clinic.  And also, the theory is that the course director's job is partly to take that reasoned feedback and create changes for next year to improve.

Teaching second year students with tag teams

In my view from the back of the neuroscience course, I saw some good stuff today.  We had a four-hour block of time to introduce muscle, neuro-muscular junction, peripheral nerve, and motor neuron physiology and pathophysiology.  For each of these lectures, I invited a pathologist and a neurologist to share the lecture time.  They had not done this before, so there were a few moments where it wasn't clear who was going to present what.  Overall, the pathologists presented the pathological changes in the structure, then the clinicians gave a presentation of what that looks like in patients affected by these diseases.  What I noticed that I thought was super cool, was that in the middle of each talk, the clinician or the pathologist would look over at the other person with a look like, "am I explaining this right?"  The other presenter, then usually stepped in, and gave a nice presentation of the area that was fuzzy for the first lecturer.

I like this model for several reasons.  First, it helps avoid some of the inevitable statements like, "I have no idea what you've been exposed to before about this, but..." or "Have you all seen this before or not?"  Second, it allows points which need clarification to be clarified right at that moment.  Third, I think it helps emphasize to the students that medicine truly is becoming too complex for one person to feel like they can master every thing.  Yes, you can still aspire to be a well-rounded physician, but any field of study moves to fast for you to practically stay up on everything.  Thus, you need to learn to rely on the knowledge and experience of your colleagues.  I think it also practically has the advantage of having clinicians and more basic science facutly mingle a little.

Wondering if others have more experience with a similar model in the basic science curriculum of your medical school?  Please share your thoughts and ideas here.

Paper vs Pixel - Use of On-line or traditonal books in medical education

I was at at team meeting yesterday to orient faculty to the neuroscience course I'm co-directing next year.  We were going through the section where I was relaying to them our required texts for the course.  One of the faculty (who happens to be a physiologist) asked which physiology text we were using for the course.  On the list we have a nice neuroanatomy text, a brain atlas, a psychiatry text, a pathology text, and Harrison's.  He felt the neurophysiology discussions in our clinically minded neuroantomy text were lacking, and the other faculty in the room agreed with him.

So this left me with a dilemma.  Do I have switch from our current neuroanatomy text with a definite clinical foundation a more comprehensive text with neurophysiology covered more completely?  Such a text was used in the past, and was felt to be too dense for the needs of medical students.  Do we have them buy a text that focuses only on neurophysiology in addition to the neuroanatomy text?  I think this would likely just lead to them not buying this text as we'd only need a few chapters, and I'm not sure it would be very useful for them in the future honestly.  It would likely be more dense than the book we already rejected.  Do we just give them the lecture notes to study from?  Or do we search for/develop online references for them to use.

This last point led me to the rebuttal I had to requiring the students to buy another textbook.  My impression from talking to fourth year students is that the majority of them do not buy textbooks any more.  I can actually see good reason for that.  First, textbooks are and always have been expensive.  Textbooks are also notoriously slow to adapt to new information (new editions come out every few years, and take a year or so to develop, so are at best a year out of date, and at worst 2-3 years out of date when they are read).  Compare that to most online resources which are free (or available for free through institutional subscriptions).  Online resources aren't guaranteed to be updated frequently, but at least the possibility is there for them to be updated frequently.  Also, with the advent of more interactive pages, there is a chance for things to be updated as new information is developed through crowd-sourcing.  Hence, my idea that asking students to buy another text is foolish, as I'm not convinced that their all going to buy the first 3 books that are already on my list.

Lessons learned from video conferencing didactic sessions

I've been using two different video conferences platforms over the last few years to beam our didactic sessions on the neurology clerkship to students who are at remote sites - in our case community sites in Bend, and Eugene.  I've had mixed success, and wanted to see if other people have found ways to improve the use of the technology to overcome some of the hurdles I've found.  Our didactic sessions are really set up to be a series of cases which the facilitator works through with the students.  They are usually an hour, and are intended to be very interactive with the students working together as a group to learn about various disease states from a case described by a facilitator.

Here are some things I've learned:

1)  Tech savviness is good.  I'm MUCH more likely to succeed at getting the student to keep coming back to the didactic sessions, and find that they are satisfied with the experience if that student has some technical savvy.  If the student is relatively not as literate with navigation of the web or more in depth programming than a word processor, it is more likely to fail technically.  Also, there is a much lower tolerance if problems start with the less savvy student bailing out earlier.  We're now using Abobe Connect and had used Microsoft LiveMeeting in the past.  Both are decent, but both have a bit of a learning curve, which less computer literate students aren't often willing to overcome.

2)  Better microphones = better experience.  Much more involvement when I spent more money (around $100) on a nice area mic that covers the whole conference room than trying to squeak by with cheaper mics.

3)  Works better with help.  I don't always have help, but I think the whole experience works better if you have some tech help who can monitor the feed, and problem solve for you if issues arrive.  When I'm the only tech help, I try a few things, but often just tell the student to try again the next time, as I can't hijack the whole lecture to spend even 5 minutes finding out what's wrong.  I'm not saying I have help now...

4)  Video feed can just provide a distraction.  Students have said that if the only thing they can see is my head, but there are lots of people talking at a table, it can almost take away from the experience.  I'm going to just sending the slides/whiteboard to try to get around that.  I don't have a whole table cam, and don't have help to run an external camcorder to focus on the person whose talking.  Haven't found a great way around that.

5)  Bigger computers are better.  I recently switched to using my newer, faster, sleeker laptop from an older one we had stowed in the conference room.  Audio has been our main tech issue, and it seemed to run better with the combination of a better computer and a hardwired line on the presenter's side.  We don't always have students hard wired in, but it is harder for them to do that as they have a netbook with them, and are not always in a predictible spot to participate in the lecture.  With that limitation, I'm not sure how to get around the student side of the problem.

What are your insights or experiences?  Have you found other ways to get around the problems I've had?  I hope to be able to improve my abilities to run this over time (as I'm hoping the software will become more reliable, and the hardware will become cheaper and smarter).

Is having residents do most of medical student teaching bad?

It's surprising when a statistic comes out that at face value looks a bit shocking, but if you reflect a little, it's absolutely obvious.  Dr. Vinny Aurora just posted a tweet from a conference she is at about the percentage of teaching medical students on inpatient wards receive from residents.  This was then retweeted numerous times within a few minutes of when she posted it, meaning people felt this was useful and important information.  She followed up with several other tweets about how this makes it imperative that we teach residents how to teach.  I completely agree with this.  What I find a bit odd is that people still are excited to know that the bulk of clinical teaching for our students in the third and fourth year comes from residents, and not faculty.

I would venture that there are probably more junior faculty who populate the ward posts where students are learning than senior faculty.  I have no data to prove that, but if I look at my own department's attending schedule I would hazard to say that over half of the ward attendings are junior faculty.  This is the reality of academic medicine.  Most of the teaching on inpatient wards comes from the junior third of the clinicians in the facility.

I would then argue that it really is not bad.  There seems to be this unstated implication that education provided by residents is somehow less useful, and almost dangerous.  I know the LCME emphasizes having faculty be actively involved in teaching students, and I completely agree that having a completely absent faculty member on an inpatient service is not only a poor learning environment, it can lead to disastrous clinical care consequences.  What I would argue against is the notion that residents have nothing to offer in the realm of education.  Some of the best teachers I worked with as I went through third and fourth year were residents (and even the fourth year sub-intern when I was a third year student on my internal medicine rotation).  I realize that just like faculty, there are some are more engaged in teaching, and some are more knowledgable than others.  On the whole, I think we underestimate the power of resident teaching.  Most students will never go into neurology.  Thus, they really don't need me as a Parkinson's subspecialist to pontificate about the idiosyncracies of what anatomical target to choose for DBS.  They need someone who can show them what a resting tremor looks like, and how to distinguish that from an essential tremor.  Our neurology residents can all do that.

That being said, I again totally agree that our residents are on the whole under-prepared for the teaching role they assume on July 1 of their intern year, and we need to invest much more in teaching them how to teach.  But along the way, we need to appreciate them for what they are.  They truly are the front lines of clinical year teaching for medical students.

The value of teaching and testing medical trivia in 2011

I'm a first year course director for the basic neuroscience course for second year medical students.  With my co-course director, we're gearing up for the course to start in a few months, and are in the process of tweaking the schedule, and looking over who will cover what as the course proceeds.  As we are going over the details of each session, we stop every once in a while to ask what are our main goals with this course.  It's a bit daunting to think about a major course like neuroscience and come up with over-riding goals, but I think it is a useful exercise.

I'm trying to do things better than they were done when I went through medical school.  It seemed to me going through courses like my neuroanatomy course that the goal of the course was recall of very minor details of neurological anatomy, physiology, and pathology.  This was due to the fact that the majority of our assessment was through a multiple-choice test which primarily asked questions about what minutiae. Thus, we all envied our classmates who had the ability to look through notes once and be able to recall all the little details without any trouble.  Those people were always then rewarded with high test grades.  Tests seemed more like a medical "Jeopardy" competition than a review of facts that will actually be useful in caring for patients.  However, life has changed since that time.

The advent of search engines and a whole library of research articles being available where ever you are has made it harder to argue for drilling in facts to the level we used to do.  I was always told that the reason for doing this is that you will likely not remember everything you've learned, so if you oversqueeze information into your head, the important stuff will likely stick.  And, it is true, that every physician I've ever met has moments where they will be presented with a case, and dredge up some unmined factoid from medical school that will help them with a case they are seeing right now.  So, I don't think we can get entirely rid of the feeling that medical training is much like trying to drink from a fire hose of information.  But, I think we can be more targeted in which factoids are required to be known, and I'm not the only one with this opinion.  It's not really important to know what chromosome the defect for Huntington's disease is on, or even the name of the protein affected.  What is important is to know the basic clinical presentation of Huntington's disease, and it's variants.  This is far more useful.  It's also important to know those rare medication side effects so you can monitor if needed for them, and be aware of what medications can do.

I'm not sure I know all the answers to how much is too much detail for a medical school lecture.  But, hopefully in the course I'm directing, the weird stuff the students will be memorizing will all be stuff that one day may percolate up when their seeing a patient.  And, hopefully when that thought percolates up, they'll stop and say out loud, "Thanks, Dr. Kraakevik."