Rethinking Medical Education

Questions, observations and recommendations toward reform of the process and content.


An inescapable hazard of meaningful learning

An inescapable hazard of meaningful learning

A man learns to skate by staggering about making a fool of himself.
Indeed, he progresses in all things by making a fool of himself.
George Bernard Shaw (1856-1950)
A lesson about learning (from an unlikely source) For several years, while we lived in Florida, we traveled to Colorado in the winter, where we spent time with close friends from California and went skiing together. Like me, our friend Bill had grown up in Montreal and we both had been skiing for many decades. But neither of us had taken any ski lessons. During one of our Colorado trips, Bill excused himself from our little group and headed off to take a ski lesson. When we met up again at the end of the day, Bill announced that he had been hugely impressed by his instructor, Gary. With his characteristically generous impulse, Bill had hired Gary to be available to all of us for ski lessons the following morning.
Well, I immediately had a visceral understanding of Winston Churchill’s telling observation, “Personally, I am always ready to learn, although I do not always like being taught.” My trepidation about the coming ski instruction was substantially reduced after watching Gary work with Marcy and Jane. With each of them he did something we have tried for years to get medical teachers to do, with only marginal success: he began by being diagnostic. He talked to each of them about their sense of their capacities as skiers and then watched them as they did some skiing. He nicely customized his subsequent coaching to what they seemed to need most.
Then came my turn. After learning that I hadn’t missed a ski season in more than 40 years, and that I was reasonably content with my capacities for handling the sorts of mountains we choose, he watched me ski. Then the fun began. Gary’s first comment was, “When were they teaching that stuff you do with your shoulders? Was that in the 1930s or the 40s? We’ll have to get rid of that habit. And the way you move your knees toward the slope. Am I right that that was fashionable in the 50s? That’s got to go also.” After two more questions and comments of the same type I was beginning to doubt my capacity to stand up on skis, let alone negotiate challenging runs ever again. I turned to Gary and asked, with a smile, “Tell me, is all this meant to be helpful, as it surely isn’t feeling that way?”
To his credit, Gary laughed and immediately apologized quite sincerely. He explained that he should have known better, that he and the other instructors at their ski school are warned about situations like this and that he had neglected to act on what he knew. He went on to explain that whenever they were teaching someone who wanted or needed to make reasonably substantial changes in their accustomed ways of doing things, the learners needed to be cautioned that they would be going through a phase of feeling “functionally grotesque”! Oh, my, how that resonated for me! That was exactly how I was feeling. That day, thanks to Bill’s generosity, I learned a great deal about becoming a better skier, but I learned even more about learning.
A companion of meaningful learning As George Bernard Shaw recognized (above), meaningful learning demands that we start doing things, or start thinking, in ways we’ve not done before. And, inescapably, as we undergo the transition from where we now are to where we want or need to be next, we are often faced with some unwelcome feelings. The process of making worthy progress in learning often brings with it a sense of feeling awkward, unsure, perhaps like being a beginner again. Sadly, many of us, and many of our students, are no better prepared for the unpleasant sense of feeling functionally grotesque than I felt on that ski hill a few decades ago. Programs that seldom or never push learners beyond their current capabilities sufficiently to cause them to feel functionally grotesque aren’t serving those learners well.  And most learners, not understanding the need for this process or its value, will typically do what they can to avoid straying too far from their current comfort zone.
The process of meaningful learning When education is effective, it takes learners through a continuously escalating spiral, involving the sequence: diagnosing their current competence identifying those activities and tasks these learners most need right now for moving to a meaningfully higher level of competence active engagement by the learners with those activities and tasks at the new, higher level sufficient practice, reflection and feedback at the new level for achieving stable effectiveness offering new challenges to help the learners move to the next higher level, and so on. If meaningful learning is to occur, there is no avoiding the hazard along the way of feeling the uneasiness we associate with being a stumbling beginner. We are continuously needing to climb beyond our stabilized comfort level to an unfamiliar higher level. If learners are being appropriately stretched by their program, the feeling of being newly functionally grotesque is unavoidable. In well-functioning educational programs, that feeling is transformed from being an unwelcome set of sensations that are to be avoided, into being a welcome sign that some appropriate stretching is happening, from which meaningful — and desired — learning can grow. 
Making the uncomfortable acceptable, even welcome Several conditions are needed in an educational environment if learners are to be helped to feel that being stretched is constructive and desirable, rather than abhorred or ineffective. Most prominent among these conditions are:
  • a sense of trust between learners and teacher
  • an atmosphere of good humor  throughout the process
  • a continuous process of ensuring that the levels of challenge each learner confronts is appropriate to his/her level of need and readiness.
Insufficient challenge, which enables learners to remain within their existing comfort zone, isn’t helpful. Excessive challenges can cause learners to retreat, to become self-protective. Ultimately, excessive challenges are more hurtful than helpful to learning. 
In future postings I will discuss the process of determining and titrating the levels of challenge we offer, and the processes of earning and sustaining authentic trust.
Some questions for your reflection and possible comments:
  • Do you have a reasonably clear sense of your learners’ entry levels and their readiness for challenges that will stretch them sufficiently, without being excessive?
  • What steps do you and your colleagues take to prepare learners for feeling functionally grotesque at times and for supporting them through this phase of meaningful learning? (As GBS might ask, do you help them deal with the experience of feeling they are making fools of themselves?)
  • Have you and your colleagues developed any approaches to diagnosing and challenging your learners that you are willing to share with us? Your contributions here will be most welcome.
Thanks,
  Hill Jason 
Hilliard Jason, MD, EdD
First posted 10/27/08
Updated 11/27/08
From Rethinking Medical Education goto:http://rethinkmeded.org

2 Comments

  1. I don’t een know how I ended up here, but I thought this post
    was great. I don’t know who you are but certainly you’re going to a famous blogger if you aren’t
    alrady ;) Cheers!

    • Thanks so much! Sorry that this came to my attention so very late. Great of you to write your kind comment.

      – Hill

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A little about me

A little about me

Hilliard ("Hill") Jason, MD, EdD I've spent more than a half-century doing what I could to understand and help enhance the medical education process, mainly in the US, but occasionally in 36 other countries. I was responsible for the 2 largest multi-institutional studies of medical teaching ever done. My wife, Jane Westberg, PhD, and I have collaborated in writing 7 academic books and creating 60 educational videos on aspects of health professions education. Among other positions, I was Founding Director of the Office of Medical Education Research and Development at Michigan State University and Founding Director of the Division of Faculty Development at the Association of American Medical Colleges (AAMC). For 2 years I was Scholar in Residence at the National Library of Medicine. I've been a professor at 5 US medical schools. (Happily, all my departures were voluntary.) ;-) Since 1990 I've been Clinical Professor of Family Medicine at the University of Colorado Denver Health Sciences Center. • To view a fuller biography (CV), please click here. • To view an interview of me done for Education for Health, please click here. • To view an interview of me done for Advances in Health Sciences Education, please click here.
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