Teaching and Learning in Medicine: Lessons from Beowulf

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Teaching and Learning in MedicineLessons from
Beowulf

• April 16, 2009
• Timothy P. Brigham, M. Div., Ph.D.

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• What are we trying to do?

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MASTERY
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Dreyfus Model

• Novice
• Advanced beginner
• Competent
• Proficient
• Expert
• Dreyfus, HL and Dreyfus SE, Mind over Machine
  the power of human intuition and expertise in the
  era of the computer, Oxford, Basil Blackwell

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• George McClellan

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Brief History of Thomas Jefferson University

• McClellan, and by extension the Jefferson
  Medical College, emphasized clinical
• instruction as an important part of a physicians
  education.
• The schools first home, in the old Tivoli
  Theater on Prune Street, set aside a series of
• rooms to receive patients. This establishment of
  a dispensary to treat patients under
• student observation was the first instituted by
  any medical school in the United States.
• Eventually all medical colleges adopted this
  model of combining lectures with practical
• experience. Later affiliation with the
  Philadelphia Hospital (Blockely) and the
• Pennsylvania Hospital provided students with
  additional facilities for instruction.
• With the growth of Jefferson Medical College and
  increased class size, the school soon
• needed more room. The creation of the Ely
  Building in 1828 provided space for a lecture
• hall in the lower floor and an amphitheater for
  operation in the upper half. After the
• construction of Jeffersons first detached
  hospital in 1877, clinical lectures and surgeries
• were held in the pit.
• This building, Jeffersons first free-standing
  hospital and the second hospital in the nation

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• The Association for Hospital Medical Education
  (AHME), founded in
• 1956, is a national, non-profit professional
  organization involved in the
• continuum of hospital-based medical education
  undergraduate,
• graduate, and continuing medical education.
  AHME's more than 600
• members represent hundreds of teaching hospitals,
  academic medical
• centers, and consortia nationwide.
• The mission of AHME is to
• promote improvement in medical education to meet
  health care needs
• serve as a forum and resource for medical
  education information
• develop professionals in the field of medical
  education and
• advocate the value of medical education in health
  care.

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• Those eligible for AHME membership include
  individuals
• who devote a substantial amount of their
  professional
• efforts to medical education programs directed
  toward
• improved patient care, and individuals employed
  to direct
• or coordinate hospital-based programs of medical
• education at the undergraduate, graduate or
  post-graduate
• level. AHME members include the following
  directors of
• medical education department chiefs medical
  directors
• program directors of undergraduate, graduate and
• continuing medical education administrators, and
• coordinators of medical education.

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• What do we do?

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Personality Characteristics

• Obsessive compulsive
• Overly conscientious
• Pleasure deferring
• Self doubt

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Environment

• 80() hours working
• 24-30() hours awake
• Change
• Little time for family/significant others
• Loneliness and social isolation
• Work overload
• Overwhelming responsibility
• I can never read enough!

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House Officer Syndrome

• Episodic cognitive impairment
• Chronic anger and resentment
• Family discord
• Pervasive cynicism

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Conditions for Mastery

• Supportive, nurturing family
• Motivation/Fit
• Teacher
• Best teachers and role models
• Bloom, BG, Learning for Mastery in All Our
  Children Learning McGraw-Hill 1968/81

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Keys to Mastery

• Instruction
• Surrender
• Practice
• Mental discipline
• Playing the Edge
• Leonard, George, Mastery The Keys to Success and
  Long-term Fulfillment Plume, 1992.

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George Millers Pyramid(upside down)
Knows
Grendel
Knows how
the lair of Grendels mother
Does
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Lecture Grand rounds, etc.

• Knows
• Knows how
• Does

Experiential learning modules Simulation,
role-play, etc.
Grendels mother
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• We keep fighting
• Grendel

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Faculty Development

AGAIN!
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One definition of insanity is doing the same
thing over and over again, but expecting
different results.

• Rita Mae Brown
• Sudden Death, 1983. p. 68

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Entering Grendels Lair

• Swim in deep and scary waters
• Wrestle and embrace Grendels mother
• Drop your sword discover and use your treasure

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Every system is perfectly designed to yield the
result it produces.

• Edwards Deming?
• Donald Berwick?
• Paul Batalden?

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ChangeKurt Lewin - Force Field Analysis
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• Norms
• Formal
• Informal

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• You must swim in deep and scary waters
• Were trained as Educational Leaders/Administrator
  s to love and establish order and control

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4 Room Apartment
Contentment
Renewal
Denial
Confusion/chaos
Claes Janssen 1982
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Embrace Grendels Mother

• Dance with the chaos
• Move away from order and control toward
  coordinating the chaotic ingenuity in your system

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Hrunting
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• Drop your sword
• Experts
• Best practices
• Gurus, gurus, gurus
• Discover and use your treasure the system at
  your feet

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• Drop your sword discover and use your treasure
• You
• The system at your feet

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Awareness
Management
Self
Group
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• What dose of
• you is therapeutic
• How much of you is toxic?

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• Like Beowulf, were really lousy at
• self - assessment

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Tragic
Competence
Dangerous
Confidence
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•  

Public
Blind
Unaware
Secret
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Self Awareness
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• Perceptions of
• reality
• are more
• real than reality

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Myers-Briggs Personality Types

• Normal differences between people
• Persistent tendencies, do not change once
  established
• Comfort zone
• Requires less effort than the opposite
• Not a measure of intelligence
• Not a limitation
• No negative aspects no psychopathology

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E ______ I S ______ N T
______ F J ______ P
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E ______ ISensing Perception
IntuitionT ______ FJ ______ P
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Sensing (S) vs. Intuition (N)

• What information do you pay the most attention
  to?
• Sensing Types give their attention to specifics.
• Intuitive types give their attention to the big
  picture.
• Everyone does both, but only one is preferred.

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S NThese characteristics
often develop from S and N preferences. Some of
them may be true of you

• SENSING
• Details
• Present
• Practical
• Facts
• Sequential
• Directions
• Repetition
• Enjoyment
• Perspiration
• Conserve
• Literal

• Intuition
• Patterns
• Future
• Imaginative
• Innovations
• Random
• Hunches
• Variety
• Anticipation
• Inspiration
• Change
• Figurative

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E ______ ISensing Perception
IntuitionThinking Judgment FeelingJ
______ P
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Thinking (T) vs. Feeling (F)

• How do you react to new information?
• Thinking types consider the logical implications.
• Feeling types consider the impact on people.
• Everyone does both, but only one is preferred.

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T FThese characteristics
often develop from T and F preferences. Some of
them may be true of you

• Thinking
• Head
• Justice
• Cool
• Impersonal
• Critique
• Analyze
• Precise
• Principles

• Feeling
• Heart
• Harmony
• Caring
• Personal
• Appreciate
• Empathize
• Persuasive
• Values

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E ______ ISensing Perception
IntuitionThinking Judgment
FeelingJudging Life orientation
Perceiving
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Judging (J) vs. Perceiving (P)

• How do you manage your life?
• Judging types seek the joy of closure.
• Perceiving types seek the joy of discovery.
• Everyone does both, but only one is preferred.

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J PThese
characteristics often develop from J and P
preferences. Some of them may be true of you.

• Judgment
• Organized
• Structure
• Control
• Decisive
• Deliberative
• Closure
• Plan
• Deadline
• Productive

• Perception
• Flexible
• Flow
• Experience
• Curious
• Spontaneous
• Openness
• Wait
• Discoveries
• Receptive

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Extraversion Energy IntroversionSensing
Perception IntuitionThinking Judgment
FeelingJudging Life orientation
Perceiving
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Extraversion vs. Introversion

• How do you do your best thinking?
• Extraverts think best by talking it out.
• Introverts think best by thinking it through.
• Everyone does both, but only one is preferred.

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E IThese characteristics
often develop from E and I preferences. Some of
them may be true of you

• Extraversion
• Active
• Outward
• Sociable
• People
• Many
• Expressive
• Breadth

• Introversion
• Reflective
• Inward
• Reserved
• Privacy
• Few
• Quiet
• Depth

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• Treasure is right in front of you
• People in your system

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Four Useful Guidelines

• Assess the potential for action
• Get the whole system in the room
• Focus on the future
• Structure tasks people can do for themselves

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Assess the potential for action

• Committed leadership
• Im willing to take a risk, too
• Were in this together
• Energized people
• Support
• Mobilizing energy
• Conditions for motivation
• Express resistance out loud
• Pockets of innovation

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WORK

• Satisfaction
• Meaning

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Douglas McGregors XY Theory

• Theory x ('authoritarian management' style)
• The average person dislikes work and will avoid
  it if he/she can.
• Therefore most people must be forced with the
  threat of punishment to work towards
  organizational objectives.
• The average person prefers to be directed to
  avoid responsibility, is relatively unambitious,
  and wants security above all else.

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Douglas McGregors XY Theory

• Theory y ('participative management' style)
• Effort in work is as natural as work and play.
• People will apply self-control and self-direction
  in the pursuit of organizational objectives,
  without external control or the threat of
  punishment.
• Commitment to objectives is a function of rewards
  associated with their achievement.
• People usually accept and often seek
  responsibility.
• The capacity to use a high degree of imagination,
  ingenuity and creativity in solving
  organizational problems is widely, not narrowly,
  distributed in the population.
• In industry the intellectual potential of the
  average person is only partly utilized.

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Get the whole system in the room

• Do-able
• Team
• Represents key roles and functions
• Highly credible
• Experienced
• Open-minded
• Time

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• 1900 Taylorism
• experts solve problems
• 1950 Lewin colleagues
• everybody solves problems
• 1955 Experts improve whole systems
• 2000s Everybody improves whole systems
• Weisbord, 1987

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Focus on the future

• Focus on problems depress
• Visualize preferred futures - energizes

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Structure tasks that people can do for themselves

• Timeframes
• Expected output
• Create a learning climate

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What to do in each room
Renewal
Contentment
We have too many good ideas
I like it just as it is
Leave people alone (unless the buildings on fire)
Offer help for implementation
Confusion/chaos
Denial
What, me worry?
What a mess!! Help!!
Ask questions, give support, raise awareness
Focus on the future, structure tasks, get people
together
Weisbord, 1987, p. 220
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Summary
Weisbord, 2002
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Do not fear mistakes. There
are none.

• Miles Davis

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MacIsaac, 1995
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OOPS
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Youre the Heroes
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If you think youre too small to be effective,
you have never been in bed with a mosquito.

• Betty Reese (American officer and pilot)