General Medicine Life & HealthMarch 14, 2014

Can the lecture

By James Salwitz, MD

Medical students frequently see patients with us in our office.   Their presence is welcome, if for no other reason than it makes us think young.  A second year student has been coming to our office for over a year and is excited about a future taking care of cancer patients.  She just completed the Hematology and Oncology section of lectures at the med school.  I asked her how it went.  “Frankly, “ she said, in the articulate way of the highly educated, “it sucked.”

I was astonished. How could such an exciting, complex and rapidly evolving field, yield teaching that would cause a motivated student to take such umbrage?   Too much information?  Too complex a topic?  Too much difficulty in the exams?  “No,” she said, it lacked “too” of anything.  It was not organized, not at the appropriate level, rambling and incomplete.  Without reviewing the critical information in texts and online, she would have learned little and the entire class would have failed the subsequent tests.

In a huff, wanting to assure that we not lose a crop of budding oncologists, I swore to find the cause of this didactic discord.  Surely, it must be possible to put together a set of clear, complete, cancer and blood lectures, so that the students were not only taught, but inspired.   Somehow, we would fix those lagging lectures.  But, then it occurred to me, why?

There are 141 medical schools in the United States, 2372 in the world. They teach 20,055 students in North America and hundreds of thousands around the globe.  In every school, every state, and country, they all teach about cancer.  In every school, cancer is the exact same disease.  On every continent, the possible treatments are the same.  Therefore, why in the world do students listen to different lectures by different teachers on the exact same subject?

Why use the lecture hall format in medical school?  Why not find a few super-experts to write one perfect lecture, and then record that lecture one perfect time, given by a brilliant, inspiring, articulate educator (with translations)?  Done, once and perfect for every medical student to hear, at any time, at any pace, as many times as they need or wish.

Of course, this is just the beginning.  Watching that “perfect” lecture on a DVD or even a video stream is so 20th Century.  Each lecture should be placed into an interactive computer program, interlaced with examples of real biology, physiology and pathology, and the software should track each student’s understanding, re-teaching to weakness and reinforcing key concepts.   This would allow students to learn not only the vital basics, but assist exceptional or inspired students to delve deep into esoteric concepts.

There are already thousands of examples of high quality digital learning. Dr. Bryan Vartabedian, MD in his blog 33Charts this week, introduced ReelDx.  This is a semi-interactive video teaching tool for pediatrics. It shows actual patients and builds lessons around their experience in the context of their illness. Such instruction encourages retention by showing examples of each disease and allowing the student to collaborate with the program to learn about illness and treatment.

The TED series of online speeches shows what can be achieved when gifted instructors teach difficult topics.  The Ulm School in Germany teaches a two years Masters in Oncology, 80% of which is online.  Emmi produces interactive online teaching for patients, covering hundreds of different conditions and treatments. Research to Practice keeps practicing oncologists informed with innovative online mini-conferences, which are available in the evening after office hours.  The UpToDate medical database is the go-to-source for professional health information.  Surgeons learn robotic surgery on robotic simulators, even as airline pilots learn in to fly, solidly on the ground before rising an inch into the sky. You can learn conversational Italian, or 33 other languages, in a couple weeks, an hour a day, using Rosetta Stone.  With YouTube, you can find someone to teach you anything.

Computer assisted teaching will transform all of education.  It allows immediate adjustment to each student’s needs, as apposed to a lecture format, which if there is more than one student listening, is already ahead or behind at least half the class.  E-learning can guarantee that nothing of value is missed. It can detect gaps in knowledge quickly, not needing to wait for a quickly forgotten test, weeks too late. It can be modified easily and universally with advances in knowledge. It is cost efficient, effective and would allow senior physicians to spend their teaching time focused on analysis, real world decisions, the physician-patient relationship and critical manual skills.

Medical teaching must be of the highest possible standard.  Therefore, it should lead the charge to digital learning. We cannot afford to waste energy, time and dollars, boring our brightest students with inept education.  It is time to can the lecture.

 

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15 Comments

  • Liz
    Replacing BAD teachers - which is what it sounds like what the problem is here - with online/computer/recorded lectures is NOT the solution. Replacing BAD teachers with GOOD teachers is the solution. GOOD teachers access each of those "tools" as appropriate, along with a number of teaching and learning techniques/tools that can't adequately be replaced by pre-recorded lectures and interactive computer programs. That being said, replacing a BAD teacher with these things would be an improvement (and probably a significant improvement), but it would also be inferior to a GOOD teacher who has access to those same tools and uses them along with other "tools" (electronic or not), as appropriate, in the classroom. Computer programs, including interactive ones with good embedded lectures, are not REPLACEMENTS for a good classroom teacher. They should be used as a adjunct to a good classroom teacher. Using digital teaching/learning as a TOOL, IN COMBINATION WITH, other tools (other forms of teaching) makes sense. Online learning is NOT a substitute for face to face interaction with skilled teachers. It can be (if designed well) a decent adjunct to and certainly adds to learning when a student is engaged in independent study (which effectively what much of the online learning currently is, even though some classes have the added component of very weak online discussion in an asynchronous way - that increases everyone making a comment, but decreases actual discussion of issues in depth where everyone at least hears the discussion even if they don't participate - most online students log on the minimum required and then never read the entire discussion - you can watch the number of page views decrease dramatically as the week progresses). It takes a GOOD teacher to use each mode of delivery of material to its best advantage, integrating them, using them appropriately, taking advantage of the learning that also comes from the teachable moment, discussions, questions from students, group experiential activities, etc… all things that are less possible to do well using the tools of pre-canned lectures, interactive computer programs... I have a PhD, teach at the undergraduate and graduate level, and when I am employed (and at the moment I am not - I am job hunting - cancer played a huge role in my current financial catastrophe, I post on this blog and cancer lists under a nickname to protect my privacy and job search - see http://www.gofundme.com/78d3nc for more of my disaster where, unfortunately, I was forced to use my real first name and real photos - also if this is inappropriate to post this here, please go in and delete it, I am desperate at this point in time), have taught online only classes, hybrid classes and face to face classes. Each has strengths and weaknesses. In my person opinion, backed up by some research (although much of the research out there on this is shoddy) each mode of delivery best meets only a subset of needs in teaching and learning. Using a variety of modes of delivery of information appropriately can definitely strengthen a class significantly. A one or two mode of delivery class, however, generally has weaknesses regardless of how well designed those particular modes used are and/or how good the teacher is.
    Reply
  • Kathleen Denny
    Liz, I agree with you completely. My own experience with both good university and graduate level teachers and with online classes says that the latter are in no way a substitute. Your observation of those pathetic online "discussions" is right on the mark. Most students stuff the thread early with whatever meaningless comment is required to demonstrate that they were "present" and the nature of the "discussion" itself becomes both inefficient and greatly diminishes its value. Most online classes for credit are good training in jumping hoops. If someone enjoys TED lectures for enrichment, that's another matter entirely.
    Reply
    • Liz
      TED lectures, etc can be a good addition to a course. Can they stand alone? I doubt it anymore than replacing a doctor with smart computer programs will work in many cases. While good computer programs can help find small calcifications in a mammogram that a tired radiologist might miss, etc. I am not so sure they are going to make a good doctor obsolete any time soon - anymore than smart computer programs and taped good lectures will make a good teacher obsolete any time soon. THe human factor (presuming they are competent/good at what they do) adds value. The tools are just a means to an end and a poor teacher is still not going to create as good a class as a good teacher even with access to the same tools.
      Reply
      • Kathleen Denny
        Exactly. In my opinion, most of the enthusiasts for online learning have never had to take a class that way on a matter of substance. And I do loads of research online etc. The loss of give-and-take, real discussion, was the loss I felt most deeply.
        Reply
    • meyati
      The computer programs record how many comments a student makes, as part of the grading system. I've known many, myself, included that read, and just fired off comments, often of no value, but they get a good passing grade for participation. Then I had the prof that was teaching how to use Spanish on the Internet, so we could double up on PC skills and required cultural sensitivity training. She was twisting her tongue around-we all had blank looks on our faces. Finally I said, "La red". In Spanish she asked what a fishing net had to do with a computer. Her assistant told her that 'la red" is Spanish for the Internet. At the next class, I realized that I didn't have a chance to pass this course with this prof. When I left- I told her the book store had a dictionary of Spanish computer terms, formal and slang. I had to rub it in.
      Reply
  • Liz
    Hey Dr. Salwitz - sorry I have been somewhat critical. I recognize that your underlying issue was that poor teaching ruined the opportunity to interest an entire class of students (or as it sounds like each year the class of students) in hematology/oncology. That is a problem. Perhaps you can volunteer to be a guest lecturer and try to get them interested? The solution to the underlying problem, of course, is a better teacher for the subject. Everything else is a bandaid on something that needs stitches unfortunately. Better than nothing though...
    Reply
    • James Salwitz, MD
      The core to my thinking goes to the nature of medical education. The first two years of medical school, which consists of well over a thousand hours of lecture, is focused on data and factual material. This sort of information is ideally conveyed with interactive IT based education. The variation which occurs when it depends on individual professors writing and presenting myriad lectures results in gaps in teaching and irratic results. Perhaps this is best supported when one notes that most med school lectures are attended by less the 1/4 of the students. As apposed to data oriented lectures, true teaching should be personal, in small groups, and focused on more challenging concepts, such as decision making, communication, ethical reasoning, leadership and the physical practice of medicine. I have taught Physical Diagnosis, Death & Dying and business at the med school level, for over 20 years, and they require an interactive format. I have also taught various cancer and hematology courses, and they would lend well to digital teaching.
      Reply
      • Kathleen Denny
        I have had a very different impression of the nuts and bolts of medical school. So what's going on when less than 1/4 of med school students attend lectures? And this is the basis for much that follows? Or is it? And what happens with the other 3/4 of med students? Dr. JS, you are definitely trying to grapple with problems in medical education. Med student in my own family considers science to be the ground, and from then on building a base of experience from which to apply the art. And seems to learn most from assignments in which the supervising doc is open and accessible, but takes a very light hand.
        Reply
      • Liz
        I do not want a doctor who does not go to class. What other corners do they cut? Yes the lecture model has some major problems. The other problem is that students these days expect the faculty to be an entertainer. The trouble is that lectures are an efficient way to transmit a lot of info quickly and students who insist on being entertained tune out. I have had some classes (genetics comes to mind) where the enthusiasm of the person who lectured to about 90 of us helped make the material come alive (mind you I as interested to begin with). I also had a lecture class (environmental geology) that the lecturer was boring, but the content was valuable. It was my responsibility as the person learning to pay attention and learn regardless of how good or poor the lecturer was. I don't think all that many students these days think that way. Calculus, physics, chemistry, organic chemistry… 300+ in the lectures with one small group session a week with TA's. Most of us went. We learned. Could it be improved. Of course. But it is also on the student to show up for class and get the most they can out of however the class is taught. It is also on the teacher to figure out the best wayS to deliver the different material. Lecture is useful but so are other methods and all methods are just tools. The good teacher matches the tool to the needs.
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        • Dan
          I only went to the basic sciences classes maybe 5-6 times the entire first two years of medical school, but have done very well thus far, and am at the top of my class at the end of my 3rd year. Unfortunately, basic science lectures in medical school are inefficient and are a poor way to spend the limited time we have. The best students in my class didn't attend lecture. I'd probably rather have a doctor who used critical thinking skills to determine which was the best way to study, than to have one who blindly followed protocol. Fortunately, all of the material is given to us in the form of notes, which can be read 2-3 times as fast as a lecturer can teach, and many lectures are recorded. I did watch quite a few that were taught by our best professors.
          Reply
          • D Someya Reed
            I'm a bit confused...you said you went to basic science classes "maybe 5-6 times the entire first two years" but you also said you "did watch quite a few (recorded lectures) that were taught by our best professors." Were these other lectures, not basic sciences? Were the ones you watched the 5-6 lectures you attended? Why did you choose to attend the 5 or 6 lectures that you did? Are you recommending that basic sciences lectures be removed and just books and "notes" (acting as, in my opinion, Cliff Notes) be the only thing given to medical students? Your method will not be appropriate for all medical students, of course, but would you say that it is appropriate for the 75% or more that don't attend lectures (past and present)? I'm not agreeing, disagreeing or being disagreeable with you. I just want to understand this from someone who is currently in the process. As I said below, if med school lectures are so poorly performed perhaps students should just subscribe to a medical database that is, at least, being consistently updated.
  • D Someya Reed
    Why do you believe that with over 75% lack of attendance at "live" lectures that the same non-attending 75% would be willing to sit (and when & where?) for a "digital" lecture no matter how engaging, brilliant, inspiring, articulate, famous (not to mention perhaps biased and certainly dated as soon as it is recorded) the chosen lecturer would be? Who would decide who would be best for the task? Wouldn't this simply lead to memorization for the test? Your 75% non-attendance statistic is no different than my experience 40 years ago. Unfortunately then, and perhaps still now, students were paying others to attend in their place so as not to get dropped from their classes. In my opinion, it is unfortunate that many of those students with sufficient discretionary income for this practice of substitution are now physicians, themselves. Learning the basics is never the most popular part of any educational path. Live instructors will know (or should know) when they've lost their audience and can adapt. The best live instructors will engage their students in the lecture even with the dry basics. You, yourself, have said you don’t script a lecture and that you use only an outline. I’m sure that is so you can adapt to the circumstances and because of this, no two of your lectures are ever exactly the same. Yet, I doubt that you leave any student feeling short-changed from any given lecture. Right now, digital instructors can only give the appearance of adaptation and engagement based solely on what is scripted in the lecture program, if it has one. If digital is the way to go for "the basics," which is what is usually meant by lending itself to digital instruction, then why not have every student simply purchase a subscription to the 'UpToDate' Medical Database and let them learn things on their own time, at their own speed. At least this database is being monitored and updated on some sort of schedule with some 5,000 contributors and an army of editors. It isn’t without its own biases, of course, based upon rules of inclusion such as “evidence-based,” “peer-reviewed” etc. Anyone with sufficient motivation and a good command of the language it’s written in should be able to teach themselves. After all, isn’t self-education what digital instruction, currently, is really all about? UTD advertises that they sell subscriptions to the public (patients & caregivers). If digital is the best way to learn the basics of medicine maybe every sufficiently motivated individual can learn medicine, as well, regardless of their background. Lastly, If you take personal instruction out of medicine and put it in the hands of a select few are you not removing 1) proof of understanding (if you can’t teach an idea, then you don’t really know it yourself) and 2) the rapport building and social skills needed by all doctors to communicate effectively with those who know less about the subject matter than they do themselves? Wouldn’t this hurt more than help the patient/physician relationship? Perhaps not…if the overall plan is to ultimately convert medical education to all digital instruction and medical practice to all telemedicine. How do you suppose that world will look where we might never have to have a true face to face with anyone?
    Reply
  • meyati
    Well some of the lectures are done by practicing private physicians. They often teach at night, while students are working-often in the hospital, and their mentor wants the student to be available. I also had a classmate that worked in the coroner's office, helping do autopsies. A high news murder- the staff rolled out-everything else was dropped. Another was in an organ harvesting team. Somebody died- he dropped the lecture and rolled out with the team. His job was to remove skin from backs, so it could be used for skin grafts.
    Reply
  • Dan
    I should have clarified. I only went to class a few times other than required, just because I sometimes felt guilty for not going so thought I'd give it a shot again. Every time I realized, like most of my classmates, that going to class was very inefficient. The recorded lectures I watched were played at 2x speed. I watched a few of them because the teachers were great, but I still felt that going to them live was, at least for me, too time consuming for the benefit. As for recommending basic sciences lectures being removed, I'm not sure because a few of my classmates felt that going to class was best for them. However, a lot of the people who went to class have told me this year that they wish they would've skipped. I like the way it's currently set up where notes with all of the material is given ahead of time, and lectures are recorded. This at least gives each student a choice to choose the style that suits them the best. I can definitely see the benefit of the model described by Dr. Salwitz, but as others have mentioned, a good teacher can adapt to the needs of an individual class. I'm not sure med students need this individual attention during the first two years though. These classes are fundamentally different than what I experienced in undergrad, and are composed of hundreds of facts per lecture with unfortunately little explanation given.
    Reply
    • D Someya Reed
      So things are a bit different now than it was for me. We had attendance requirements or we’d be dropped from class except for certain non-conformist professors. “Bruce” comes to mind (as he would tolerate no other title) and who always reported 100% attendance. He gave out the course material, assignments and the dates of the tests on the first day. He felt that we were all adults, if we had better things to do but could still pass the tests without showing up, more power to us. He ended with “I get paid the same whether you’re here or not.” Technologically, it’s all different too. If I put your, my and over 75% of everyone else’s similar lecture experiences together with Dr. Salwitz’s model…If we find the super-lecturer(s) to record the lecture(s)…If we find the super-programmer to create this customized/individualized program and keep it continuously relevant…then won’t we really have succeeded in making the learning environment of the world’s most personal occupation as impersonal as possible? Between your and my experiences, across decades, nothing has really changed about attendance at these lectures. Now almost everyone is “bored” with basic information relayed without explanation and perhaps unwanted or unneeded. Everyone has said that med school takes too long. Everyone now says that all this information can be learned in far less time on one’s own from sources that exist now but were unheard of before. That’s most likely true. Why not go all out then and drop the first two years. Make it a requirement that all this information has to be known in order to GET INTO a medical school program. If nothing else, it would certainly show the determination of the potential candidate. In hindsight, would you have traded those two years for self-study to pass a few tests on the basics and start from where you are now? Do you feel you would have missed anything?
      Reply

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