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Explore This IssueSeptember 2013
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The only thing that interferes with my learning is my education.
As a child, I never liked the month of September. Not because of the weather, which is actually quite pleasant as the long, hot summer days have passed and the afternoons are breezy and the evenings are cooler. To me, September signified the start of the school year, which meant having to deal with new classroom placements and new teachers. What a drag! I much preferred November, when routines were established, friendships were blossoming, and teaching styles were finally deciphered. As a student, “cracking your teacher’s code” was of paramount importance. After all, once you figured out who ruled the class with a firm or soft hand and who graded exams with a penchant for failing students or inflating grades, your time and effort expenditures could be allocated accordingly. After all, there were so many competing distractions, from playing sports to listening to rock n’ roll music to watching your favorite television shows, and, at some point, to flirting with girls.
Fast forward a couple of decades later. As a first-year medical student, I am sitting, actually fidgeting in my seat, trying to follow an anatomy lecture. Today we are studying the course of the pudendal nerve as it slips between the piriformis and coccygeus muscles. Its location in the pelvis is being meticulously drawn on the blackboard in a bright canary yellow color by our highly distinguished anatomy professor. Anatomy lectures were as exciting as listening to a talk on international tax treaties, so having an artistic talent was a requisite for success as an anatomy instructor. I arrived late to class and there were just a few remaining empty seats far off to the side of the lectern that afforded a limited view of the drawings. How am I ever going to remember all this excessive detail about just one of many pelvic nerves? To my dismay, I noticed that several more ambitious classmates had already sketched the drawing in their notebooks. For different reasons, neither I, nor my seatmates, Tom and Nancy, drew anything in ours. I had absolutely no artistic talent, and each anatomy lecture forcefully reinforced that point. Once again, Tom and Nancy (not their real names) were oblivious to the lecture. They were far too busy cuddling each other. I am not sure what became of Nancy, but Tom went on to become the dean of a medical school.
When I recounted this vignette to a colleague, he recalled a classmate who was renowned for being stoned during most of his preclinical training. Years later, despite this state of altered consciousness (or maybe because of it?), he was able to solve some thorny problems in medicine for which he was awarded a Nobel Prize. Is there a moral to these stories? Hopefully not.
Fast forward a few more decades, and I am the guy standing at the front of the lecture hall gazing out at a sea of mostly empty seats. Where have all the second-year medical students gone? Clearly not to class. I estimate that the room is less than half filled, meaning there are only 80 students in attendance. Some appear to be focused on my lecture slides demonstrating the histopathology of leukocytoclastic vasculitis, while others are busy, no doubt checking their Facebook pages or tapping out text messages. A few of them don’t seem to mind using their hard plastic desktops as pillows and are using the time to catch up on their sleep. At least I don’t see any entwined bodies out there.
The Lecture Hall Is Dead
What has happened to the medical school lecture hall? For those of you who have been absent from class, some fairly dramatic changes are taking shape. First, let’s review a bit of history. In the 1970s and 1980s, as student enrollments mushroomed and physical facilities that were mostly built in the postwar era became cramped and antiquated, universities went on a tear, building numerous state-of-the-art facilities. Lecture halls started resembling movie theaters, full of plush seats, quality acoustics, and state-of-the-art imaging technology. They served their purpose extremely well, until the start of this century. It was around this time that our world became even more interconnected, first through wires, then via wireless systems that grew exponentially with the proliferation of mobile devices such as smart phones and tablet computing. Who needed to lecture students using a 35-mm carousel slide projector when PowerPoint presentations could be easily assembled and electronically transmitted to virtually anyone anywhere? What about those massive lantern slide projectors that were needed to crisply project the intricate detail of histology slides? Bill Gates killed that industry, too!
How Disruptive Technologies Changed the Way We Teach
The transformation to digital devices in medical education was fairly dramatic. For example, in September 2011, only three Year II Harvard Medical School students owned iPads. A mere two months later, as we started our rheumatology teaching block, nearly 95% of the class had purchased one.1 What triggered this whirlwind shopping spree? My informal survey of students confirmed their view of the iPad as the ideal multitasking device. Unlike its computing ancestors, it could simultaneously serve as a web browser, book reader, word processor, movie screen, camera, video recorder, and messaging device—all with amazing speed. In the race for computing speed, if the desktop computer is the turtle and the laptop is the hare, the iPad is the gazelle. As M. Eric Johnson, dean of the Owen Graduate School of Management at Vanderbilt University in Nashville, Tenn., observed when commenting about the changing face of business schools, “Technology used to be all about installing expensive equipment that we’d show off to you if you visited us. Now everyone brings [their] own iPad. It’s all very personal now. It requires students to take ownership of their education in ways they haven’t in the past.”2
Similar to its predecessor, the iPhone, the iPad is a prime example of how a disruptive technology can transform users’ behavior. Yet the tablet is just one of several innovations that have upended our old ways of teaching.
Perhaps one of the most intriguing developments has been the creation of massive, open online courses, better known by the acronym, MOOCs. These courses offer a wide array of topics ranging from behavioral economics to systems biology. To date, they have attracted more than 5 million students worldwide due to the MOOCs’ distinguished faculty, high-quality video format, low cost (often free), and ability to set one’s own viewing and studying schedule. What distinguishes this form of teaching from previous online efforts is its integration of social networks that serve as conduits for peer-to-peer learning. For example, there are discussion forums for each course where students can chat with and assist each other, and collaboration via Facebook, Google+, and Twitter is strongly encouraged.
Though MOOCs are better suited to undergraduate-level teaching, there is a growing interest in using this format for medical school teaching as well. Catherine R. Lucey, MD, vice-dean for education at the University of California at San Francisco School of Medicine, predicted that, “online content delivery will be commonplace within about five years in medical school.”3 Dr. Lucey recently led a very popular MOOC on clinical problem solving that has so far attracted an enrollment of over 28,000 students.4
MOOCs serve as a better way to prepare undergraduates for medical school. Currently, most premed courses are fairly didactic and dense with information that needs to be acquired based on the fixed timetable of the particular course. In contrast, with MOOCs, the learning time crunch is eliminated since students can replay any lecture as often as necessary. Keep repeating until it sticks.
Perhaps one of the most intriguing developments has been the creation of massive, open online courses … To date, they have attracted more than 5 million students worldwide.
The Sticky Classroom
If MOOCs gain widespread acceptance in medical education, won’t students be missing out on useful face-to-face interactions with their professors? Is there a way for medical educators to incorporate hands-on clinical teaching into this new realm? This is where the concept of the “flipped classroom” can help out. Charles Prober, MD, senior associate dean for medical education, and Chip Heath, PhD, professor of organizational behavior, both at Stanford University in Palo Alto, Calif., suggest that medical education can be improved by making lessons more comprehensible and memorable—that is, “stickier.”5 They argue that teaching points or messages are stickier when they are unanticipated and thus tend to capture our curiosity. Messages also become stickier when they come in the form of a story that elicits emotion in readers or listeners. Isn’t this why we use clinical cases as tools to instruct our fellows, residents, and students about the finer points of rheumatology?
Although they serve as the scaffolding on which facts and concepts can be organized and reinforced, most medical school lectures proceed without even the briefest example involving patients. There is no glue in the message, so the story may not stick for long.
Attention to stickiness would make medical school lectures more engaging and memorable, but they would still be lectures. Drs. Prober and Heath offer a solution for this dilemma, called the flipped classroom. In this model, students first absorb an instructor’s lecture in a digital format as homework, freeing up class time for a focus on applications, including emotion-provoking simulation exercises. For example, we are starting to incorporate case-based studies of patients with rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) as a way to capture our audience’s attention. This approach is preferred to the old style of teaching where students were given handouts on the basic science of either RA or SLE, but without any clinical anchors. The majority of students chose not to bother showing up to class. Instead, they would wait until a few nights before the exam, view the lecture on video, memorize some key concepts, regurgitate them on the exam, and then shut their minds to rheumatology.
In a similar vein, the Stanford educators cite the example of the core biochemistry course that was redesigned following a similar model. Rather than using a standard, lecture-based format, the instructors provided short online presentations. Class time was used for interactive discussions of clinical vignettes highlighting the biochemical bases of various diseases. The proportion of student course reviews that were positive increased substantially from the previous year and the percentage of students who actually attended class more than doubled from 30% to 80%, even though attendance was optional. Sticky molecules, indeed!
A teaching experiment recently conducted at the University of British Columbia in Vancouver, Canada, had one group of undergraduate students taught by a Nobel laureate physicist using the traditional lecture format, while the other group employed a flipped-classroom approach that was led by several teaching assistants.6 The researchers found increased student attendance, higher engagement, and more than twice the learning in the latter group. The moral of this story must be: Keep your Nobel laureates in the lab and out of the classroom.
How One Kid’s Math Problems Revolutionized Teaching
His work received a huge boost when Bill Gates, the founder of Microsoft, touted the “unbelievable” 10- to 15-minute Khan Academy tutorials that he had been using with his own kids. As Gates dryly observed, “I’d say we’ve moved about 160 IQ points from the hedge fund category to the teaching-many-people-in-a-leveraged-way category. It was a good day [when] his wife let him quit his job.”7 Thankfully, Khan’s wife, Umamia, is a rheumatologist, a specialty renowned for its altruism.
Brave New World
The Khan Academy videos have moved beyond explaining elementary school math principles to children. Though there is a burgeoning medical section, including some helpful videos that outline fundamental principles of immunology and an interesting overview of cervical spine radiology, there are few rheumatology-focused offerings.8 To an extent, this void is being addressed by the highly useful “Resources & Tools” section of the “Education & Careers” tab on the ACR website (www.rheumatology.org), which hosts an interesting array of self-teaching resources. It also has the world’s greatest collection of freely available rheumatology teaching slides. Stay tuned for some exciting new developments regarding the ACR’s online teaching presence.
It’s an exciting time to be a learner, though some readers may be hesitant about entering this brave new world of education. May I suggest another learning strategy that may sound more appealing? It has long been known that music can serve as a mnemonic device on learning and memory and the underlying plasticity of neural networks. Researchers working at the Center for Biomedical Research In Music in Fort Collins, Colo., have found evidence that melodic-rhythmic templates in music may drive internal rhythm formation in the cortical networks involved in learning and memory, and thus enhance memory acquisition.9 Pearl Jam playing in the background seems to effectively synchronize the learning centers deep in my entorhinal cortex, although experts in the field have considered Mozart to be a superior music choice for effectively enhancing spatial–temporal reasoning.10 Either way, don’t forget to bring your musical accompaniment with you to class. After all, you may learn more when listening to Eddie Vedder or Wolfgang Amadeus than from the Nobel laureate lecturing to the class.
Dr. Helfgott is physician editor of The Rheumatologist and associate professor of medicine in the division of rheumatology, immunology, and allergy at Harvard Medical School in Boston.
- Jason Alvarez, director of educational technologies, Harvard Medical School, personal communication November 2012.
- Meglio F. A “disruptive” dean eyes technology changes at Owen. Published July 19, 2013. Available at www.businessweek.com/articles/2013-07-19/a-disruptive-dean-eyes-technology-changes-at-owen. Accessed August 14, 2013.
- Harder B. Are MOOCs the future of medical education? BMJ 2013;346:f2666.
- Lucey CR. Clinical problem solving. Available at https://www.coursera.org/course/clinprobsolv. Accessed August 14, 2013.
- Prober CG, Heath C. Lecture halls without lectures —A proposal for medical education. N Engl J Med. 2012;366:1657-1659.
- Deslauriers L, Schelew E, Wieman C. Improved learning in a large-enrollment physics class. Science. 2011;332:862-864.
- Kaplan D. Sal Khan: Bill Gates’ favorite teacher. Published August 24, 2010. Available at http://money.cnn.com/2010/08/23/technology/sal_khan_academy.fortune/index.htm. Accessed August 14, 2013.
- Khan Academy: Immunology. Available at www.khanacademy.org/science/biology/immunology. Accessed August 14, 2013.
- Thaut MH, Peterson DA, McIntosh GC. Temporal entrainment of cognitive function. Ann NY Acad Sci. 2005;1060: 243-254.
- Rauscher FH, Shaw GL, Ky KN. Listening to Mozart enhances spatial-temporal reasoning towards a neurophysiological basis. Neurosci Lett. 1995;185: 44-47.