Monthly Archives: October 2016

Closing the Circle: How being faculty at a liberal arts college made me a better medical physiologist

Happy Halloween!

As I look back upon my career as a faculty member at both a liberal arts college and several medical schools, I’ve come to the realization that this holiday is not a bad analogy for some things we all are familiar with—surprises both good and bad, sometimes a little scary… and at the journey’s end, a reflection of our perceived world and ourselves.

Example: 20 years ago last month, I started my first faculty position as an Assistant Professor of Biology at a small liberal arts college. Walking into that first classroom on the first day of classes was pretty frightening, because I did not know it all. As a graduate of a medical-level physiology Ph.D. program I had a solid background in the teaching of physiology, having taught it in lecture and/or lab to students in dental hygiene, nursing, dental, medical, and graduate programs. But I’d never taken gross anatomy or histology. So in that first Anatomy and Physiology class I was going to have to be an “expert” in both topics to students who had no reason to think I wasn’t. The horror of it all to me.

I spent a good deal of my first semester staying one week ahead of the students in those weak areas. In the next semester, it was Microbiology in which I was deficient. I had only taken one undergraduate microbiology course 14 years before, and unlike anatomy or histology there had been little cross-learning of this topic with physiology in graduate school, so I was on my own. I had help of course, including experienced faculty and excellent teaching resources that came with the textbooks. But it was a long way out of my comfort zone. In fact, it was downright frightening! As the years went by, I put on many other hats, some of which were better fits than others. I taught general biology, biochemistry, genetics, cell biology, and personal health, among other courses offered to a dozen biology majors and a few hundred non-majors. From being trained as a Physiologist, I had become a Biologist.

So what were the lessons I learned at this liberal arts college? The first was this: That it is possible to teach what many medical schools of the day would have been considered an insane teaching load of 16-20 contact hours with students per week instead of 16-20 contact hours per year. Second, it is not necessary to be THE expert on a topic in order to teach it well. Third, to achieve this adequacy required being very flexible and willing to learn new things. For example, while I couldn’t actually replace an ecologist in the planning and leading of field trips, I could teach enough of the basic principles to satisfy the needs of students in a Biology II class. This involved working with the ecologists on the staff, even following them into the field to see and experience how they looked at the biological sciences. The final lesson I learned, though I learned it late, was that there are always opportunities to be a scientist. That not all research takes place in the laboratory or the clinic. That being a teacher and being a scientist need not be an either-or career choice. That the principles of science could be applied to the science and art of teaching itself.

After several years at this liberal arts college, I made the life-changing decision to start medical school on a part-time-student-part-time-teacher basis, at a Caribbean location. While I never did get an M.D., my faculty experience at this medical school led to other full time faculty positions at both allopathic and osteopathic medical schools. And out there, working up from smaller medical schools to larger ones, I learned still more. For two years before I joined my current institution, I taught medical physiology from 8-10 a.m. five days a week, assisted in the anatomy lab another four hours, and lectured in a premedical prep course for another 8-10 hours per semester. Completely unlike anything I had done before, I had to teach a medical physiology course three times per year as the sole instructor. By necessity I relearned physiology as an entire discipline to a level close to what I’d known as I was finishing up my first year as a graduate student. I became able to teach any physiology topic at the medical level with little to no advance prep, again adequately but not necessarily at the research specialist level. The flip side was that as the only physiologist, there was essentially no time off for anything else including travel, conferences, or research.

From this experience I learned that it is possible to be a sole medical physiologist with the same teaching load as that taught at the undergraduate level. If necessary, one can have at least 14 contact hours per week to medical students and an additional 1-2 hours over several weeks each semester to premedical students and still teach well. I firmly believe that had I not had seven years of teaching experience as a multidisciplinary biologist at the undergraduate level, I would have found it much harder be able to teach all aspects of physiology at the medical level at such an intense pace. Just as I had had to do at the liberal arts college, I worked 16-18 hour days that first semester to stay two weeks ahead of the students. Each semester after that I worked 12 hour days to try to keep up with the demand of keeping lecture content and other materials updated, write 75 new exam items every three weeks, and perform all the other duties required of an associate professor at a tiny school. Along the way I finally overcame the self-concept built in from graduate training that I was an “endocrine physiologist” or a “reproductive physiologist” or a “gastrointestinal physiologist” or any other specialist physiologist based on the research I was doing. And in so doing I did acquire a specialty after all… I became a specialist at being a “generalist” whole-body physiologist, as well as a specialist in physiology education!

It was these specialties, honed from the lessons in adaptability first learned at the liberal arts college, which I brought to both my current medical school and to an osteopathic medical college in the United States. But my lessons weren’t done. Both of these medical programs use an integrated curriculum, which was far different from anything I had experienced before. Prior to helping design the integrated curricula of both schools, I had never had significant teaching-level interactions with either histologists, biochemists, pathologists, or clinical medicine faculty despite our having been colleagues for years. Now not only was I going to interact with them, I was going to have to be able to discuss pathology with medical students with enough competency to help explain how the physiology dovetailed into it and both of them into clinical conditions/presentations. I was going to have to do the same thing with microbiology, anatomy, histology, biochemistry, and pharmacology to appreciate the whole-system approach to medical education.

So once again, I dove into the new challenges of adapting to this integrated organ-system driven curriculum. For the first time, I came to understand across several organ systems how the clinical medicine was driven by pathology and that driven by the four foundations of gross anatomy, microanatomy, physiology, and biochemistry. But the focus of any integrative approach would always be first and foremost the clinical aspect of these four foundations in disorders and compensations because that’s what our students were ultimately trying to master. Bringing the balance in teaching the appropriate level of physiology in such a systems-based curriculum while ultimately keeping the clinical focus was a challenge I had never before faced.

And this is what brings me back almost full circle to my days as a young assistant professor at a tiny liberal arts school. Instead of having teaching resources located in a set of supplements to a textbook, I have access to several specialists in each discipline, all of whom are focused on the same tasks for their respective fields. And yet, in a curious sort of way I have become a Biologist again, albeit a medical biologist.

To illustrate this, I’ll give a short example. At my current institution we have a curriculum in which organ systems are split into a first-or-second semester component and a third-or-fourth semester component. In one lecture I deliver in second semester Endocrine Systems, I deliver a significant portion of the basic science content for the hypothalamus and pituitary gland. In the initial preparation for this lecture, I incorporate materials prepared by our module’s microanatomist (a neuroscientist by training) and from our module’s pathologist which mentions those pathologies most appropriate for students at this level to learn. When I then stand before the class as the lecture presenter, I deliver not only physiology content but this other content as well. As I do so, I am reminded of those times so many years ago now when I was just as far out of my field, delivering the details of dense connective tissue to biology majors, the presentation of viral gastrointestinal disorders to nursing students, or the principles of public health to non-majors.

The story is the same really. We are all alike now, the physiologists of the undergraduate and the medical teaching world. We have much to share with one another, and much to learn from one another. And you know, that’s not really a scary thought at all. Happy Halloween anyway.

Bruce Wright is a professor in the Department of Physiology at Ross University School of Medicine in the Commonwealth of Dominica, West Indies. Bruce received his doctorate in Physiology from Louisiana State University Health Sciences Center in New Orleans. Following two postdoctoral fellowships he taught at Thomas University in Thomasville, GA. He also taught at the Medical College of the Americas in St. Kitts and Nevis, West Indies, the University of Sint Eustatius School of Medicine in the Netherlands Antilles, West Indies, and the Alabama College of Osteopathic Medicine in Dothan, AL. Bruce has been a regular member of the APS for 22 years, most of those with the Teaching section as his primary affiliation. Bruce has served as Treasurer/Events and Awards Coordinator of the APS Teaching of Physiology Section since 2015. He has presented work at EB and the APS ITL on APS learning objectives, novel teaching strategies and item objective formats, integrated curriculum design and implementation, and challenges in preserving physiology content in integrated curricula.

Putting More Physiology into A & P

It’s tough being an undergrad student nowadays. It’s expensive. State funding has cut into the budgets that used to go to offset tuition, and buildings for new classrooms have been on hold forever. Still they keep coming, paying higher and higher fees and tuition, crowded into larger and larger classroom sizes, getting shut out of labs: these are just the surface to larger problems in general. What kind of education are students getting now? I ponder this as I teach A & P again after teaching physiology at a medical school for the last six years and A & P in smaller class sizes four years before that at universities and community colleges. Things have changed, and not for the better. I’ll toss around some ideas that may or may not resonate with you, but these are things I feel we need to improve upon.

How can we get class sizes smaller so we can teach and communicate? The depth of what students know goes not far beyond binge and purge. We can have small group discussion, more TBL and other models for active learning (if they read the pre-class material) and we’ll always have the good students, but for many lectures have become something to avoid. I get students who ask for my PPTs beforehand and use them as note templates, yet many rely on those as a sole source. The chances to integrate material become less frequent as we teach to the room and decrease the amount of material students can absorb. The long term rewards to learning are not being reinforced. I have students submit corrections for points in paragraph form, making them compose answers.

Students need learning skills. Something I learned the hard way, but even in the prehistoric 1970’s note taking was essential. I implore students to do this as a way to create schemas even providing handouts with study skills that I have collected over the last thirty years. Of course the good students use this info, while the middle of the packers might but only after the first exam. We have more students who are being advised that health professions are good careers but not telling them how steep the competition is and how much is expected. Do I want an ED nurse who might forget that NaCl is not the same as KCl? Maybe I don’t have to weed them out, but I want their expectations to be parallel to the challenge and this should be considered the beginning of their career.

Lastly, I propose perhaps a new approach to A & P; let’s separate the classes. Some institutions do this having advanced anatomy and general physiology classes for exercise science, why not do these for pre-health majors as well? The texts nowadays for A & P are humongous, with tons of information that skims the surface without enough integration. Let’s teach physiology with a chance to do more hands-on experiments and not have lab just being anatomy. I poll my students about whether they have seen frog muscle or heart experiments or any Mr. Wizard styled presentations. Few have, maybe from the more affluent secondary schools, therefore descriptions of diffusion or tetanus become an abstraction without the physical connection. They do ECGs and FEV₁s in the second half of A & P, why not have that be the whole year?

Personally my career in physiology began when I walked into a behavioral neuroscience lab and ran my own independent study experiments for undergrad credit, all the while learning about the other research going on. I was happy that one of my biology students worked over the summer on an Integrative and Organismal NSF summer fellowship (that I know from my APS Porter Committee membership go underutilized) because statistics show that these students will go on in science. I’d like to see our future caregivers have that depth as well.

William Johnson received his Master degree in Education from Johns Hopkins University in 1990. After teaching high school on the Dine reservation, he then pursued and obtained his PhD in Biology from Northern Arizonan University, studying angiotensin in desert anurans. After teaching physiology at University of South Florida Colleges of Public Health and Medicine, William has returned to his alma mater to teach anatomy and physiology and human physiology, as well as being involved in the summer program for Journey for Underrepresented in Medical Professions HRSA grant at NAU.

More detail = More complex = Less clear

The question that I’m going to tip-toe around could be expressed thus:

“More detail does not clarity make. Discuss.”

I’m not going to write an essay but I am going to offer a few different perspectives on the question in the hope that you realise that there might be a problem hiding a little further down the path we’re all walking. In doing so I’m going to scratch an itch that I’ve had for a while now. I have entertained a rather ill-defined worry for some time and this post provides an opportunity to try pull my concerns into focus and articulate them as best I can.

One of the first things I remember reading that muddied the water for me was ‘Making Learning Whole’ by David Perkins (Perkins, 2009). He argues that in education we have tended to break down something complex and teach it in parts with the expectation that having mastered the parts our students would have learned how to do the complex thing – playing baseball, in his example. The problem is that baseball as a game is engaging but when broken down into little bits of theory and skill it becomes dull – a drudge. So, do we teach science as the whole game of structured inquiry, or do we break it down into smaller chunks that are not always well connected (think lecture and practical)? That was worry number one.

Let me broaden this out. I see a direct link between the risks of breaking down a complex intellectual challenge into smaller activities that don’t appear to have intrinsic value and ‘painting-by-numbers’ – as a process, it might create something that resembles art but the producer is not working as an artist. If you indulge me a little, I’ll offer an example from education; learning outcomes. In his 2012 article, The Unhappiness Principle’, in the UK’s Times Higher Education magazine, Frank Furedi argues that learning outcomes distort the education process in a number of ways. He worries that learning outcomes provide a structure that learners would otherwise construct for themselves and the adopted construct is rarely as robust as a fully-owned one. He also worries that learning outcomes by their nature attempt to reduce a complex system in a series of statements that are both simple and precise. Their seeming simplicity of expression gives students no insight into the true nature of the problems to be tackled. I don’t imagine that Socrates would have set out learning outcomes for his students.

I see similar issues in the specification of the assessment process; the detailed mark scheme. Sue Bloxham and colleagues recently published the findings of a study of the use of marking scheme, entitling it ‘Let’s stop the pretence of consistent marking: exploring the multiple limitations of assessment criteria’. The article is scholarly and it contains some uncomfortable truths for those who feel it should be possible to make the grading of assessments ‘transparent’. In their recommendations they say, ‘The real challenge emerging from this paper is that, even with more effective community processes, assessment decisions are so complex, intuitive and tacit that variability is inevitable. Short of turning our assessment methods into standardised tests, we have to live with a large element of unreliability and a recognition that grading is judgement and not measurement’ [my emphasis] (Bloxham et al., 2016).

The idea that outcomes can be assured by instructions that are sufficiently detailed (complex) is flawed but it appears to have been adopted outside education as much as within. The political historian, Niall Fergusson, makes this point well in one of his BBC Reith Lectures of 2012. In relation to the Dodd-Frank Act, he says, ‘Today, it seems to me, the balance of opinion favours complexity over simplicity; rules over discretion; codes of compliance over individual and corporate responsibility. I believe this approach is based on a flawed understanding of how financial markets work. It puts me in mind of the great Viennese satirist Karl Kraus’s famous quip about psychoanalysis, that it was “the disease of which it purported to be the cure” I believe excessively complex regulation is the disease of which it purports to be the cure.” Niall Ferguson: The Darwinian Economy (BBC Reith lecture, 2012).

One of the problems is that detail looks so helpful. It’s hard to imagine how too much detail could be bad. There is are examples of where increasing detail led to adverse and unintended outcomes. I have two examples, one from university management and another from education and training. A colleague recently retold a story of a Dean who was shocked that, should a situation arise in an examination room, staff would themselves often decide on an effective course of action. It turned out that the Dean had thought it more proper for the staff to be poring through university regulations. He was also shocked to discover that the regulations did not contain solutions to all possible problems. The example from education and training can be found in article by Barry Scwartz, published in 2011. The article, called ‘Practical wisdom and organizations’, describes what happened when the training of wildland firefighters was augmented from just four ‘survival guidelines’ to a mental manual of very nearly 50 items. He writes. ‘….teaching the firefighters these detailed lists was a factor in decreasing the survival rates. The original short list was a general guide. The firefighters could easily remember it, but they knew it needed to be interpreted, modified, and embellished based on circumstance. And they knew that experience would teach them how to do the modifying and embellishing. As a result, they were open to being taught by experience. The very shortness of the list gave the firefighters tacit permission—even encouragement—to improvise in the face of unexpected events. Weick found that the longer the checklists for the wildland firefighters became, the more improvisation was shut down.’ (Schwartz, 2011). Detail in the wrong place or at the wrong level flatters to deceive.

By writing this piece I hoped to pull together my own thoughts and, speaking personally, it worked. I now have a much clearer view of what concerns me about how we’ve been pushing education but that clarity has made my worries all the more acute. Nevertheless, in order to round on a positive note I’ve tried to think of some positive movements. I have always found John Dewey’s writing on education and reasoning to be full of promise (Findlay, 1910). Active learning, authentic inquiry, mastery learning and peer-learning seem to me to be close cousins and a sound approach for growing a real capacity to conceive of science as a way of looking to understand the unknown (Freeman et al., 2014) seem to me to have Dewey’s unspoken blessing. I also think that Dewey would approve of Edgar Morin and his Seven complex lessons in education for the future (Morin, 2002). There is a video of Morin explaining some aspects of the seven complex lessons that I would recommend.

I’m off to share an hour with a glass of whisky in a dark room.

References

Bloxham S, den-Outer B, Hudson J & Price M. (2016). Let’s stop the pretence of consistent marking: exploring the multiple limitations of assessment criteria. Assess Eval High Edu 41, 466-481.

Findlay JJ, ed. (1910). Educational Essays By John Dewey. Blackie & Sons, London.

Freeman S, Eddy SL, McDonough M, Smith MK, Okoroafor N, Jordt H & Wenderoth MP. (2014). Active learning increases student performance in science, engineering, and mathematics. Proceedings of the National Academy of Sciences 111, 8410-8415.

Morin E. (2002). Seven complex lessons in education for the future. Unesco.

Perkins DN. (2009). Making learning whole : how seven principles of teaching can transform education. Jossey-Bass ; Chichester : John Wiley [distributor], San Francisco, CA.

Schwartz B. (2011). Practical wisdom and organizations. Research in Organizational Behavior 31, 3-23.

Phil Langton is a senior teaching fellow in the School of Physiology, Pharmacology and Neuroscience, University of Bristol, UK. A biologist turned physiologist, he worked with Kent Sanders in Reno (NV) and then with Nick Standen in Leicester (UK) before moving to Bristol in 1995. Phil has been teaching GI physiology for vets, nerve and muscle physiology for medics and cardiovascular physiology for physiologists. He also runs a series of units in the second and third (final) years that are focused on the development of soft (but not easy) skills. He has been interested for years in the development of new approaches to old problems in education and is currently chasing his tail around trying to work out how fewer staff can mentor and educate more students.