Category Archives: Teaching Strategies

Student Preparation for Flipped Classroom

Flipped teaching is a hybrid educational format that shifts lectures out of the classroom to transform class time as a time for student-centered active learning. Essentially, typical classwork (the lecture) is now done elsewhere via lecture videos and other study materials, and typical homework (problem solving and practice) is done in class under the guidance of the faculty member. This new teaching strategy has gained enormous attention in recent years as it not only allows active participation of students, but also introduces concepts in a repetitive manner with both access to help and opportunities to work with peers. Flipped teaching paves the way for instructors to use classroom time to engage students in higher levels of Bloom’s taxonomy such as application, analysis, and synthesis. Students often find flipped teaching as busy work especially if they are not previously introduced to this teaching method. Pre-class preparation combined with a formative assessment can be overwhelming especially if students are not used to studying on a regular basis.

When I flipped my teaching in a large class of 241 students in an Advanced Physiology course in the professional year-1 of a pharmacy program almost a decade ago, the first two class sessions were very discouraging. The flipped teaching format was explained to students as a new, exciting, and innovative teaching method, without any boring lectures in class. Instead they would be watching lectures on video, and then working on challenging activities in class as groups. However, the majority of the students did not complete their pre-class assignment for their first class session. The number of students accessing recorded lectures was tracked where the second session was better than the first but still far from the actual class size. The unprepared students struggled to solve application questions in groups as an in-class activity and the tension it created was noticeable.  The first week went by and I began to doubt its practicality or that it would interfere with student learning, and consequently I should switch to the traditional teaching format. During this confusion, I received an email from the college’s Instructional Technology office wondering what I had done to my students as their lecture video access had broken college’s records for any one day’s access to resources. Yes, students were preparing for this class! Soon, the tension in the classroom disappeared and students started performing better and their course evaluations spoke highly of this new teaching methodology. At least two-thirds of the class agreed that flipped teaching changed the way they studied. This success could be credited to persistence with which flipped teaching was implemented despite student resistance.

I taught another course entitled Biology of Cardiovascular and Metabolic Diseases, which is required for Exercise Science majors and met three times per week. Although students in this course participated without any resistance, their unsolicited student evaluations distinctly mentioned how difficult it was to keep up with class work with this novel teaching approach. Based on this feedback, I set aside one meeting session per week as preparation time for in-class activities during the other two days. This format eased the workload and students were able to perform much better. This student buy-in has helped improve the course design significantly and to increase student engagement in learning. Flexibility in structuring flipped teaching is yet another strategy in improving student preparation.

While one of the situations required persistence to make flipped teaching work, the other situation led me to modify the design where one out of three weekly sessions was considered preparation time. In spite of these adaptations, the completion of pre-class assignment is not always 100 percent. Some students count on their group members to solve application questions. A few strategies that are expected to increase student preparation are the use of retrieval approach to flipped teaching where students will not be allowed to use any learning resources except their own knowledge from the pre-class assignments. Individual assessment such as the use of clickers instead of team-based learning is anticipated to increase student preparation as well.

Dr. Chaya Gopalan earned her Ph.D. in Physiology from the University of Glasgow. Upon her postdoctoral training at Michigan State University, she started teaching advanced physiology, pathophysiology and anatomy and physiology courses at both the undergraduate and graduate levels in a variety of allied health programs. Currently she teaches physiology and pathophysiology courses in the nurse anesthetist (CRNA), nurse practitioner, as well as in the exercise science programs. She practices team-based learning and flipped classroom in her everyday teaching.
Fastballs, houses, and ECG’s

As adults of ever increasing age, I am sure almost every one of you has had a conversation lamenting your loss of physical abilities over the years. “I used to be able to do that.” “I used to be good at that.” As a parent to two young, energetic, fearless boys I hear (and think) these sentiments almost daily. While watching children play on a playground, sprinting for hours, hanging upside down, contorting their bodies into nearly impossible positions, jumping (and falling), twisting and turning, and literally bouncing off walls, parent conversations almost always include incredulous statements about children’s’ physical capacity followed immediately by a statement of the parents’ lack thereof. More than once I’ve heard a parent say, “If I did that, I’d be in the hospital.”

But have you ever actually thought, “Why can’t I do that anymore?” The answer isn’t just “I’m too old”. Obviously the physiologic changes of age are undeniable, but it’s a more complicated reason. At some point in your life, you stopped playing like children play. You stopped running and jumping and twisting and turning. You move in straight lines. You sit for hours. You don’t try that new move. It looks too hard. You might hurt yourself. As physiologists, we all know about homeostasis and adaptations, and it’s no surprise that our lifestyles have contributed to our physical inability in adulthood. Of course you would hurt yourself if you tried ‘that’, but only because you haven’t tried anything like that in years. Start trying ‘that’ though, and over time you’ll find yourself much more physically capable despite the aging process.

This childhood to adulthood performance decrement is not exclusive to physical capacity though. We are doing much the same to our mental capacity with age. A child will take physical risks on the playground, much as they also take mental “risks” in the classroom. Ask a group of 3rd graders a question, any question, almost all of them raise their hand hoping to answer…even if they don’t know the answer. And the student who got it wrong, will raise his hand again after the next question. Give them a challenge or a mystery to solve and they will dive right in. Let them touch and feel and manipulate. They don’t hesitate. They are on their mental playground. This is how they learn. As adults though, we aren’t going to the mental playground, because that’s not what adults do. We sit in chairs. We watch lectures. We make notecards. We read papers. We study the learning objectives and the PowerPoints.

Just as adults could physically benefit from some time on the playground every day, adults (and I’m including college students in this category) can also benefit from time on a mental playground. Even as educators of other adults, we need to remember this. We often forget the multitude of ways that we can put our students on the mental playground. We don’t do an activity, because the students might think it’s ridiculous. It might waste too much time, and there is too much material to cover today. I have found in my classrooms though, that activities that would work with kindergarteners can work equally well for college students.

To give examples of ways to put college students on the mental playground, I would like to share two activities that I have done in a physiologic assessment of health course that have been very effective. The course consists of juniors and seniors who have already taken several biology, chemistry, and physiology courses beyond anatomy and physiology. The first assignment that I give them is to work with a partner to draw a picture of a person with as many health risk factors as they can think of. I have found that most students who take this class (instructor included) are horrible artists, but this adds to the fun of the assignment. The students love it and come up with thousands of creative ways to represent health risk factors. We have a discussion over which drawings have incorporated the most “official” risk factors (as designated by national organizations like ACSM, AHA, etc.) and why some of the others are certainly not healthy (setting off fireworks indoors), but not listed as official risk factors.  Something about taking the time to draw silly pictures on a specific topic really aids in student understanding (anecdotally in my class, but evidence exists that this is effective (Ainsworth S, Prain V, Tytler R. Drawing to Learn in Science. Science. 333 (6046),1096-1097, 2011.).

Another assignment I’ve had good results with to get students onto the mental playground is half mystery for the students to solve and half drawing pictures. I tell the class that we are going to learn about how the heart works and talk about the electrocardiogram. The first thing I ask them to do is to get out of a sheet of paper and to draw a picture of the house they grew up in as if they were looking at it from the road. Normally confusion ensues and the students want to know if it’s for a grade (yes), and why they’re doing it (trust me, it’ll make sense later). After giving the students time to sketch their house, I ask permission to show each to the class, and then ask the question to the class. “Whose house is bigger?” Ultimately the students come to the conclusion that it is nearly impossible to tell without knowing the perspective and distance from the artist and the other views of the house (the front view is only one of multiple views that would be needed to construct the 3-dimensional size of the house). Then, still without talking about the heart, I ask them to draw a picture of a baseball (just the baseball) being thrown. Once again I show the drawings to the class. All usually agree that everyone probably knows the approximate size of a baseball, but then I highlight how different people drew different sizes on the paper. Once again I discuss perspective and how large a baseball looks when it’s about to hit you in the face, because it takes up your entire field of vision, but if it were thrown at you, it would look smaller relative to your field of vision at the start. If you’re watching people playing catch equidistant from both, the ball might move back and forth without appearing to change size relative to the visual field. But all the baseballs are still the same size!

Finally, after the house and baseball drawings I ask, “what did all of that have to do with the heart and electrocardiograms?” After a few minutes, most students understand the theory behind the electrocardiogram without ever having analyzed one. I’ve even had a strong student who was finishing her clinical exercise testing degree that semester say that even though she had taken several courses on ECG analysis and knew how to read them to get good grades on ECG tests, this was the first time she truly “got it.”

Thousands of other ways to engage students on the mental playground are out there as well. Discussing muscle physiology? Hand out rubber bands before class starts and ask them to think about how muscles and rubber bands are remarkably similar yet not the same at all. Teaching about bones? Pass out a few models to let them hold and manipulate. Then ask the students to pretend they’re cavemen and they need to build all of their tools out of bones, which bones would make a good hammer? A good bowl? Spoon? Fork? Weapon? Teaching about brain physiology? Have the students invoke thoughts, memories, feelings or movements and then tell them which part of the brain is responsible. Be creative and remember that just like our bodies, our minds work best when they’re stretched and twisted and used in different ways on a regular basis.

I do not know enough about educational psychology to understand the underlying mechanisms by which these types of activities work (my PhD is in Kinesiology after all – a content expert told to teach well!).  And admittedly most of my evidence that they work is anecdotal or comes by way of gradually improved student scores on final exam and practical questions related to my course objectives over several semesters in which I certainly adjusted more than one variable. However, I do know that in learning, students attend to touch and feel, emotion, and mystery. The same thing you’ll witness at an elementary school playground. Incorporating these into your lessons, even in the simplest of ways can be beneficial for all different types of learners. I’m asking you to turn your classrooms into intellectual playgrounds. Encourage risk taking. Validate atypical approaches. Make it fun. Make it engaging. All the memorized note cards might be forgotten by next semester if it’s not.

   Ed Merritt is an assistant professor in the Department of Kinesiology at Southwestern University in Georgetown, Texas. Ed received his doctorate in Kinesiology from the University of Texas at Austin and completed a postdoctoral fellowship in Cellular and Integrative Biology at the University of Alabama at Birmingham. Ed was a faculty member at Appalachian State University until family ties brought him back to central Texas and Southwestern University. Ed’s research focuses on the molecular underpinnings of skeletal muscle atrophy after trauma and with aging, but he is also equally involved in the scholarship of teaching and learning and melding educational outreach activities with service learning.
Stress and adaptation to curricular changes

 

 

 

…there was a teacher interested in enhancing the learning process of his students. He wanted to see them develop skills beyond routine memorization. With the support of colleagues and the education team at his university, he succeeded and chose a semi-flipped classroom approach that allowed him to introduce novel curricular changes that did not generate much resistance on the part of the students.

The change was made. The students apparently benefited from the course. They worked in groups and learned cooperatively and collaboratively. Students evaluated peers and learned to improve their own work in the process. They not only learned the topics of the class, but also improved their communication skills.

At some point the institution asked the teacher to teach another course. He happily did so, and based on his experience introduced some of the changes of his semi-flipped classroom into the new course. The students in this course were slightly younger and had not been exposed to education in biomedical sciences. To the teacher’s surprise, the students showed a lot of resistance to change. The sessions moved slowly, the test scores were not all that good, and students did not reach the expected outcomes. It was clear that the teacher and the students were going through a period of considerable stress, while adapting to the new model. Students and teachers worked hard but the results did not improve at the expected rate.

Some time ago this was my experience and as I wandered looking for solutions, I started to question the benefits of active learning and the role of stress in educational practice.

Advantages and challenges of active learning

Evidence says that active learning significantly improves student outcomes (higher grades and lower failure rates) and may also promote critical thinking and high level cognitive skills (1, 2). These are essential components of a curriculum that attempts to promote professionalism. However, it may be quite problematic to introduce active learning in settings in which professors and students are used to traditional/passive learning (2).

Some of the biggest challenges for teachers are the following:

  • To learn about backward design of educational activities
  • To think carefully about the expected accomplishments of students
  • To find an efficient way to evaluate student learning
  • To spend the time finding the best strategies for teaching, guiding, and evaluating students.
  • To recognize their limitations. For example, it is possible that despite their expertise, some teachers cannot answer the students’ questions. This is not necessarily bad; in fact, these circumstances should motivate teachers to seek alternatives to clarify the doubts of students. At this point, teachers become role models of professionals who seek to learn continuously.
  • To learn about innovations and disruptive technologies that can improve the teacher role.

Some of the challenges for students include:

  • Understanding their leading role in the learning process
  • Working hard but efficiently to acquire complex skills
  • Reflecting on the effectiveness of their learning methods (metacognition). Usually reading is not enough to learn, and students should look for ways to actively process the information.
  • Trusting (critically) on the methods made available by the teachers to guide their learning. For example, some tasks may seem simple or too complex, but teachers have the experience to choose the right methodology. A work from our team showed that strategies that seem very simple for the student (clay modeling) have a favorable impact on learning outcomes (3).
  • Seeking timely advice and support from teachers, tutors and mentors.

Working to overcome these challenges may generate a high level of stress on students and teachers. Without emphasizing that stress is a desirable trait, I do find that some disturbance in the traditional learning process and risk taking motivate teachers and students to improve their methods.

Intermediate disturbance hypothesis and stress in education

In the twentieth century, the work of Joseph H. Connell became famous for describing factors associated with the diversity of species in an ecosystem (4). Some of his observations were presented in Charles Duhigg’s book “Smarter Faster Better” which discusses circumstances related to effective teamwork (5). Duhigg reports that Connell, a biologist, found that in corals and forests there might be patches where species diversity increases markedly. Curiously, these patches appear after a disturbance in the ecosystem. For example, trees falling in a forest can facilitate the access of light to surface plants and allow the growth of species that otherwise could not survive (5). Connell’s work suggests that species diversity increases under circumstances that cause intermediate stress in the ecosystem. In situations of low stress, one species can become dominant and eradicate other species, whereas in situations of high stress, even the strongest species may not survive. But if, an intermediate stress where to appear, not very strong and not very weak, the diversity of species in an ecosystem could flourish.

I propose that the hypothesis of the intermediate disturbance can also be applied in education. In traditional learning, an individual (ecosystem) learns to react to the challenges presented and develops a method for passing a course. In situations of low stress, memorization (evaluated at the lower levels of Miller´s pyramid) may be enough to pass a course. In high stress level situations, students may drop out or feel inadequate. However, courses that involve active learning may include moderate challenges (intermediate disturbance). These well-managed challenges can motivate the student to develop more complex skills (diversity of species) that lead to effective learning and a broader professional development.

 

 

 

 

 

 

 

 

 

Figure 1. Intermediate disturbance hypothesis in education.

 

In the book “Problem-based learning, how to gain the most from PBL”, Donald Woods describes the challenges and stresses associated with the incorporation of active learning (PBL) in a curriculum (6). He describes the stages of grief that a student (and I add, a teacher) must go through while adapting to the new system. This adaptation can take months and generally is characterized by the following phases:

  • Shock
  • Denial
  • Strong emotion (including depression, panic and anger)
  • Resistance to change
  • Acceptance and resignation to change
  • Struggle to advance in the process
  • Perception of improvement in the expected performance
  • Incorporation of new habits and skills to professional practice

 

 

 

 

 

 

 

 

 

Figure 2. Performance adjustment after curricular changes. Adapted and modified from (6).

 

Properly managing stress and finding strategies to advance in the process are rewarded by achieving better performance once the students become familiar with the new method of active learning. However, to better adapt to curricular or pedagogical changes, it is important for all the education actors to recognize the importance of deliberate work and to have clear goals. In addition, students and teachers should have access to institutional strategies to promote effective time, and anger and frustration management.

Stress is not ideal, but some stress may motivate students and teachers to reevaluate their methods and ultimately work together for a classroom focused on professional excellence. The critical question is how big is the intermediate disturbance needed to improve learning outcomes. As is commonly concluded in papers, more research is needed to answer this question, and we can learn a lot from the theories and methods from our colleagues in Biology.

References

  1. Freeman S, Eddy SL, McDonough M, Smith MK, Okoroafor N, Jordt H, et al. Active learning increases student performance in science, engineering, and mathematics. Proc Natl Acad Sci U S A. 2014;111(23):8410-5.
  2. Michael J. Where’s the evidence that active learning works? Adv Physiol Educ. 2006;30(4):159-67.
  3. Akle V, Pena-Silva RA, Valencia DM, Rincon-Perez CW. Validation of clay modeling as a learning tool for the periventricular structures of the human brain. Anat Sci Educ. 2017.
  4. Connell JH. Diversity in Tropical Rain Forests and Coral Reefs. Science. 1978;199(4335):1302-10.
  5. Duhigg C. Smarter Faster Better: Random House; 2016.
  6. Woods DR. Problem Based Learning: How to gain the most from PBL. 2nd. ed1997.
Ricardo A. Peña-Silva M.D., PhD is an associate professor at the Universidad de los Andes, School of Medicine in Bogota, Colombia, where he is the coordinator of the physiology and pharmacology courses for second-year medical students. He received his doctorate in Pharmacology from The University of Iowa in Iowa City. His research interests are in aging, hypertension, cerebrovascular disease and medical education. He works in incorporation and evaluation of educational technology in biomedical education.

He enjoys spending time with his kids. Outside the office he likes running and riding his bicycle in the Colombian mountains.

Teaching Backwards

 

Generating new ideas and cool learning experiences has always been natural and fun for me. My moments of poignant clarity often came during a swim workout or a walk with my dog as I reflect on my classes. As I visualize this activity, my students are as enthusiastic as I am and are learning. Then, reality returns as I grade the next exam and see that less than half of the class answered the question related to that activity correctly. Accounting for the students who learn despite what I do, I quickly see that I only reached a quarter of my students with this great activity. Why did this happen? What can I do about this?

Well, my life as an instructor changed the day I walked into my first session of University Center for Innovation in Teaching and Education (UCITE) Learning Fellows at Case Western Reserve University.  This program is a semester long session on how learning works where the focus is on evidence-based learning practices and provides an opportunity to discuss successes and failures in teaching with peers.  It was here that I learned about “Backwards Design”1.

What is Backwards Design?

Essentially, it is designing your course with the end in mind. I think of it as “Teaching Backwards” – that is, I visualize my students 5-10 years from now in a conversation with a friend or colleague discussing what they learned from my class. I ask myself these questions:

  1. How do I want them to describe my class? Hansen refers to this as the “Big Idea” or broad objective. An example from one of my classes is provided in Table 1.
  2. What do I want them to be able to tell their friend or colleague that they learned from the class in 5 to 10 years? Hansen has termed this as “Enduring Understanding” (see Table 1).

The next phase is to write learning objectives for each of the enduring understandings (see Table 1). We continue the journey backwards into linking learning objectives to assessment methods and developing the details of each class session. During this process, we must always take into account the student’s prior knowledge (refer to How Learning Works2).

Table 1: Example of Backwards Design Concepts for “Exercise Physiology and Macronutrient Metabolism” class.

Class: Exercise Physiology and Macronutrient Metabolism
Big Idea Enduring Understanding Learning Objective
Exercise-Body Interaction Substrate utilization during exercise depends on type, intensity, and duration of exercise. Students will be able to describe substrate utilization during exercise.
Fatigue during exercise has been associated with low glycogen levels, but scientists are not in agreement as to the underlying cause of fatigue. Students will be able to debate the theories of fatigue.

What did backwards design do for me?

Backwards design provided me focus. It allowed me to step back and ask myself: What are the key take-aways? Does that cool, creative idea I have help to achieve my end game for the course? Is there a better way to do this? Overall, the framework has helped me develop a higher quality course. With that said, I still run into exam questions where I thought I did better at teaching the material than represented by the students’ responses.  So, while there is always room for improvement, this has definitely been a step in the right direction for better learning by my students.

References:

  1. Hansen EJ. Idea Based Learning: A Course Design Process to Promote Conceptual Understanding. Sterling VA: Stylus Publishing, LLC; 2011.
  2. Ambrose SA, Bridges MW, DiPietro M, Lovett M, Norman MK.How Learning Works: 7 Research Based Points for Teaching. San Francisco CA: Jossey-Bass, 2010.

 

Lynn Cialdella-Kam, PhD, MBA, MA, RDN, LD joined CWRU as an Assistant Professor in Nutrition in 2013. At CWRU, she is engaged in undergraduate and graduate teaching, advising, and research. Her research has focused on health complications associated with energy imbalances (i.e. obesity, disordered eating, and intense exercise training). Specifically, she is in interested in understanding how to alterations in dietary intake (i.e., amount, timing, and frequency of intake) and exercise training (i.e., intensity and duration) can attenuate the health consequences of energy imbalance such as inflammation, oxidative stress, insulin resistance, alterations in macronutrient metabolism, and menstrual dysfunction.  She received her PhD in Nutrition from Oregon State University, her Masters in Exercise Physiology from The University of Texas at Austin, and her Master in Business Administration from The University of Chicago Booth School of Business.  She completed her postdoctoral research in sports nutrition at Appalachian State University and is a licensed and registered dietitian nutritionist (RDN).
Thinking Critically About Critical Thinking

 

A few mornings ago, I was listening to a television commercial as I got ready for work.  “What is critical thinking worth?” said a very important announcer.  “A whole lot” I thought to myself.

But what exactly is critical thinking?  A Google search brings up a dictionary definition.  Critical thinking is “the objective analysis and evaluation of an issue to form a judgement.”  The example sentence accompanying this definition is “professors often find it difficult to encourage critical thinking among their students.” WOW, took the words right out of my mouth!

Have any of you had the following conversation? “Dr. A, I studied and studied for this exam and I still got a bad grade.  I know the material, I just can’t take your tests!”  The student in question has worked hard. He or she has read the course notes over and over, an activity that has perhaps been rewarded with success in the past.  Unfortunately re-reading notes and textbooks over and over is the most common and least successful strategy for studying (4).

In my opinion, as someone who has been teaching physiology for over 20 years, physiology is not a discipline that can be memorized.  Instead, it is a way of thinking and a discipline that has to be understood.

Over the years, my teaching colleague of many years, Sue Keirstead, and I found ourselves during office hours trying repeatedly to explain to students what we meant by thinking critically about physiology.  We asked the same probing questions and drew the same diagrams over and over.  We had the opportunity to formalize our approach in a workbook called Cells to Systems Physiology: Critical Thinking Exercises in Physiology (2).  We took the tough concepts students brought to office hours and crafted questions to help the students work their way through these concepts.

Students who perform well in our courses make use of the workbook and report in student evaluations that they find the exercises helpful. But we still have students who struggle with the critical thinking exercises and the course exams.  According to the comments from student evaluations, students who struggled with the exercises report they found the questions too open ended.  Furthermore, many of the answers cannot be pulled directly from their textbook, or at least not in the format they expect the answer to be in, and students report finding this frustrating.  For example, the text may discuss renal absorption and renal secretion in general and then the critical thinking exercises asks the student to synthesize all the processes occurring in the proximal tubule.  The information is the same but the organization is different.  Turns out, this is a difficult process for our students to work through.

We use our critical thinking exercise as a type of formative assessment, a low stakes assignment that evaluates the learning process as it is occurring.  We also use multiple choice exams as summative assessments, high stakes assessments that evaluate learning after it has occurred.  We use this format because our physiology course enrollment averages about 300 students and multiple choice exams are the most efficient way to assess the class.  We allow students to keep the exam questions and we provide a key a couple of days after the exam is given.

When a student comes to see me after having “blown” an exam, I typically ask him or her to go through the exam, question by question.  I encourage them to try to identify how they were thinking when they worked through the question.  This can be a very useful diagnostic.  Ambrose and colleagues have formalized this process as a handout called an exam wrapper (1).  Hopefully, by analyzing their exam performance, the student may discover a pattern of errors that they can address before the next exam.  Consider some of the following scenarios:

Zach discovers that he was so worried about running out of time that he did not read the questions carefully.  Some of the questions reminded him of questions from the online quizzes.  He did know the material but he wasn’t clear on what the question was asking.

This is a testing issue. Zach, of course, should slow down.  He should underline key words in the question stem or draw a diagram to make sure he is clear on what the question is asking.

Sarah discovers that she didn’t know the material as well as she thought she did, a problem that is called the illusion of knowing (3). Sarah needs to re-evaluate the way she is studying.  If Sarah is cramming right before the exam, she should spread out her studying along with her other subjects, a strategy called interleaving (3).  If she is repeatedly reading her notes, she should put her notes away, get out a blank piece of paper and write down what she remembers to get a gauge of her knowledge, a process called retrieval (3).  If she is using flash cards for vocabulary, she should write out learning objectives in her own words, a process called elaboration (3).

Terry looks over the exam and says, “I don’t know what I was thinking.  I saw something about troponin and I picked it.  This really frustrates me. I study and study and don’t get the grade I want.  I come to lecture and do all the exercises. I don’t know what else to do.” It is a challenge to help this student.  She is not engaging in any metacognition and I don’t claim to have any magic answers to help this student.  I still want to try to help her.

I feel very strongly that students need to reflect on what they are learning in class, on what they read in their texts, and on the activities performed in lab (3).  I have been working on a project in one of my physiology courses in which I have students take quizzes and exams as a group and discuss the answers collaboratively.  Then I have them write about what they were thinking as they approached the question individually and what they discussed in their group.  I am hoping to learn some things about how students develop critical thinking skills.  I hope I can share what I learn in a future blog posting.

  1. Ambrose SA, Bridges MW, DiPietro M, Lovett M, Norman MK. How Learning Works: 7 Research Based Points for Teaching. San Francisco CA: Jossey-Bass, 2010.
  2. Anderson LC, Keirstead SA. Cells to Systems: Critical Thinking Exercises in Physiology (3rd ed). Dubuque, IA: Kendall Hunt Press, 2011.
  3. Brown PC, Roediger HL, McDaniel MA. Make it Stick: The Science of Successful Learning. Cambridge MA: The Belknap Press of Harvard University Press, 2014
  4. Callender AA, McDaniel, MA. The limited benefits of rereading educational text, Contemporary Educational Psychology 34:30-41, 2009. Retrieved from http://ac.els-cdn.com/S0361476X08000477/1-s2.0-S0361476X08000477-main.pdf?_tid=22610e88-61b4-11e7-8e86-00000aacb35e&acdnat=1499281376_e000fa54fe77e7d1a1d24715be4bbf50 , June 22, 2016.

 

 Lisa Carney Anderson, PhD is an Assistant Professor in the Department of Integrative Biology and Physiology at the University of Minnesota. She completed training in muscle physiology at the University of Minnesota. She collaborates with colleagues in the School of Nursing on clinical research projects such as the perioperative care of patients with Parkinson’s disease and assessment of patients with spasticity. She directs a large undergraduate physiology course for pre-allied health students.  She also teaches nurse anesthesia students, dental students and medical students.  She is the 2012 recipient of the Didactic Instructor of the Year Award from the American Association of Nurse Anesthesia.  She is a co-author of a physiology workbook called Cells to Systems: Critical thinking exercises in Physiology, Kendall Hunt Press. Dr. Anderson’s teaching interests include teaching with technology, encouraging active learning and assessment of student reflection.
Who’s Teaching Tomorrow’s Teachers?

Have you ever had a colleague say to you:

 “They want me to teach in this new integrated physiology course, but no one has ever taught me how to be an effective teacher!  I’ll be so nervous and probably make embarrassing mistakes, like saying the “love hormone”, oxytocin, is synthesized from cholesterol in the adrenal medulla.”

Being asked to teach first year medical students can certainly be intimidating, but that assignment is not actually akin to being thrown to the wolves. It is true that medical students are often over-achievers, but it’s been my experience over many years that these students are respectful and anxious to learn.

 

Maybe I can offer you a few tips that will help you avoid or prevent these first time  ‘teaching jitters’:

  • Know your subject and relevant scientific facts inside and out
  • Take advantage of teaching skills, workshops, and faculty development programs at your institution or through professional organizations
  • Ask your colleagues for constructive criticism of your first presentations
  • Remember that practice makes perfect, at least most of the time
  • Remember that a good sense of humor goes a long way, but bad jokes rarely help the situation
  • Don’t be afraid that you will make a couple of mistakes- we all make them but not all of us learn from them
  • Work to create effective visuals which may include human interest stories, physiology in the news, and even masterpieces by your favorite artist

Another more proactive approach is to offer programs that will encourage students to pursue their interests in teaching and help them develop the communication skills and understanding of different learning styles and pedagogies that are so essential to becoming an enthusiastic and dedicated educator. Many medical students want to ultimately incorporate teaching into their future careers as clinicians, either by formally teaching in an academic medical center or more informally through their communication with patients and with the community at large.

Here at the Carver College of Medicine at The University of Iowa we encourage our students to pursue one of our specific distinction tracks, which include research, teaching, global health, service, humanities and healthcare delivery science and management, while they are pursuing their medical degree. Although the whole concept of “teaching medical students to teach” is certainly not unique to my institution (ref 1), I do believe that our Teaching Distinction track is unique and has succeeded in terms of achieving the desired outcomes.  I’ve been very fortunate, not to mention honored, to serve as the faculty mentor for several of our previous and current students who have selected to pursue their MD with a Distinction in Teaching. It has been very exciting for me to have the opportunity to impact a student’s learning, not only in the classroom, but also in terms of their own experiences and development as educators. It has also been very gratifying when a former mentee tells me that they learned so much from me- not just endocrinology and cell biology, but also how to convey passion and enthusiasm as a teacher.  Certainly this has been a win-win experience because I’ve learned so much from these students!  Maybe Henry Adams was right when he concluded that “A teacher affects eternity; he/she can never tell where his/her influence stops.”

In order to graduate with a Distinction in Teaching our students must meet a number of requirements that include a minimum of 60 hours of relevant teaching experiences that may include: tutoring and didactic teaching; creating new educational materials; serving as a small-group facilitator; and participation on medical education committees (ref 2).  These students are also required to develop a teaching portfolio and to successfully complete a 4-week teaching elective with a capstone project (ref 2).  Since this distinction track was fully implemented in 2010, approximately 60 students, or 7-8% of all graduates, have graduated with a Distinction in Teaching.  We’ve also heard anecdotally that some students have decided to attend medical school here at the University of Iowa because they specifically wanted to pursue this track, and that having this distinction track on their resume gave them a competitive advantage during their interviews for residency positions.

Great teachers are not always born with that potential, but frequently discover their passion at some point in their careers.   I hope that through this Teaching Distinction track we’ve trained and inspired some excellent teachers who will have major impacts on all of their future students.

References

  1. Soriano RP, Blatt B, Coplit L, CichoskiKelly E, Kosowicz L, Newman L, Pasquale SJ, Pretorius R, Rosen JM, Saks NS and Greenberg L. Teaching medical students to teach: a national survey of students-as-teachers programs in U.S. medical schools. Acad Med. 2010;85:1725-31.
  2. Schmidt TJ, Ferguson KJ, Hansen HB and Pettit JE. Teaching distinction track for future medical educators. Med. Sci. Educ. 2015;25:303-06.
Thomas Schmidt is a Professor in the Department of Molecular Physiology and Biophysics at the Carver College of Medicine, The University of Iowa. He is a Fellow of the American Physiological Society and has served on the Education Committee and the Career Opportunities in Physiology Committee.  He has been the recipient of numerous teaching awards including: The President and Provost Award for Teaching Excellence (The University of Iowa); Master Teacher Award (International Association of Medical Science Educators); and most recently the Arthur C. Guyton Educator of the Year Award (American Physiological Society).  He has served as a mentor for a number of medical students who have graduated with a Teaching Distinction.
What makes a good teacher?

I was intrigued to read this PECOP blog post on what makes a good teacher from December 2016. The post recommends that we reflect on our teaching at the end of the semester, and begin the process of understanding our teaching perspectives through the Teaching Perspectives Inventory. What makes a good instructor is something that is extremely relevant to me, because teaching happens to be my job and my passion.

I was recently prompted to think about this very question as I made contact with my former secondary school in Liverpool, U.K about being featured as a former pupil of theirs (I feel more than slightly uneasy about being featured together with John Lennon however!). I was stimulated to think about my former teachers and what I had learned from their teaching. I left the school over 20 years ago but can to this day recall specific teachers, moments in class, and things I learned inside and outside the classroom. Certainly, that’s the kind of learning I’d like my students to have 20 years after I’ve taught them!

As I reflect on the teaching that I had, several aspects popped out to me.

A love of teaching: My best teachers clearly loved teaching students. They enjoyed interacting with students, creating a rapport with us, which made the subject matter come to life and facilitated our engagement with the material. I have come to the realization that perhaps the most important aspect of teaching is to enjoy connecting with your students in order to create an effective learning environment. The saying of “they won’t care what you know until they know that you care” is somewhat cliché but it has a lot of truth to it. As a soccer coach in my spare time, I frequently reflect on the fact that if you don’t like kids, you shouldn’t coach youth soccer. In the same way, our teaching is unlikely to be as effective as it could be if we don’t like interacting with our students and enjoy teaching them.

Meeting students at their level: My English literature teacher taught us Pride & Prejudice, a text that many in my class found somewhat boring. My teacher perceived the boredom, and attempted to understand why it could be perceived as boring to my classmates. He then adapted his teaching to this in order to emphasize why the text was important. He attempted to bring the text to his students and make it relevant to them, rather than merely expecting students to engage, understand and enjoy the text automatically.

Adaptable: The best lesson I ever had was a history lesson. My teacher was a few minutes late, and as we all sat inside the classroom waiting for him, a dispute arose amongst two students in the class. The teacher came into the classroom and upon encountering the dispute, proceeded to set up a court to judge the basis of the evidence of the ‘crime’, as an example of the history of trials and determining justice. I have no idea if that was his intended lesson, but I was in awe of how the teacher adapted his lesson so perfectly to something that had just happened in the class. It is a reminder to me to be observant and adapt to issues that our students may be experiencing.

Practical: One of the most salient things I learned came from a teacher who was supervising me as I visited potential colleges. We were looking for somewhere to eat dinner one evening, and as we walked past various eating establishments, he gave me the advice of “never eat in an empty restaurant”. This has stuck with me ever since and I apply it frequently when deciding where to eat. It was practical advice on something that I had never before considered, and the ‘light bulb’ lit up for me. Reflecting on this, I see our role as teachers to help our students see beyond the immediate – to analyze and think critically about what we see with our eyes, and to help them consider what things mean. Finally, what we teach them must also be practical and relevant.

From these reflections, I have come to the realization that a good teacher is someone who is able to adapt to where our students are in terms of the knowledge that they come with, and take them to higher levels of learning that they cannot get to on their own.

What is your definition of a good teacher?

 Hugh Clements-Jewery PhD is currently Visiting Research Associate Professor and M1 Course Director in Physiology at the University of Illinois College of Medicine in Rockford, IL, starting in November 2016. Prior to moving to the University of Illinois, he taught medical physiology at the West Virginia School of Osteopathic Medicine from 2007 to 2016. He is a certified trainer-consultant in Team-Based Learning.

The Surprising Advantages Retrieval Practice

Retrieval practice,  retrieval __________,    _________ practice,  testing effect……wuh?!?!

Retrieval practice simply means to actively recall information following exposure (e.g., studying). Because tests are a particularly common and effective means by which to prompt the retrieval of specific pieces of information, the learning benefits of retrieval practice are also known as the testing effect. That is, effective tests can do more than simply assess learning; they can strengthen learning by prompting retrieval. It is important to clarify that the key to the testing effect is the retrieval and not the test per se. Therefore, the testing effect pertains to not only traditional assessments like tests and quizzes, but also to free recall. So, silently answering questions in your mind (e.g., self-testing) is an example of testing that promotes learning.

Landmark study by Roediger and Karpicke in 2006a

Figure 1. Repeated testing lead to better long-term recall when compared to repeated studying. Roediger and Karpicke, 2006a.

Although the testing effect has been described by studies that date back more than a century, researchers and articles often cite a 2006a study by Roediger and Karpicke as the source of renewed interest in the strategy and effect. In that study, the investigators asked three groups of undergraduates to read passages that were about 250 words long. One group of students learned the passages by studying (i.e., reading) them four times (SSSS group). A second group learned the passages by studying them three times and then completing a test in which they were prompted to retrieve information from the passages (SSST group). The last group studied the passages just one time and then performed the retrieval test three times (STTT group). All three groups were given a total of 20 minutes to learn each passage, following which their retention was assessed via free recall either 5 minutes or 1 week later. As you can see in Figure 1, there was a modest advantage with the SSSS strategy, as well as a modest disadvantage with the STTT strategy, immediately after learning the passages. However, the exact opposite pattern was observed one week later, as the STTT group’s recall scores were about 5% higher and 21% higher than those of the SSST and SSSS groups, respectively. The results of this study demonstrated that testing/retrieval practice can be a powerful means of improving long-term memory. These advantages to long-term recall have subsequently been confirmed by many different researchers and investigations (see Roediger and Butler 2011; Roediger and Karpicke, 2006b for review).

Retrieval practice and the ability to make inferences; it isn’t just about simple recall

Figure 2. Retrieval practice resulted in higher scores on verbatim and inferential questions. Derived from Karpicke and Blunt, 2011.

One might be concerned that retrieval practice is just a form of drill and practice that merely teaches people to produce a fixed response to a specific cue. Karpicke and Blunt (2011) addressed this concern by comparing the effects of retrieval practice and concept mapping on meaningful learning, which includes the ability to draw conclusions and create new ideas. The investigators chose concept mapping for this comparison because it known to promote elaborative (i.e., complex) learning. In one experiment, one group of students learned a science text by repeatedly reading (i.e., studying) it, another group studied the text and then used it create a concept map, and a third group studied and then recalled the text two times. The total amount of time the concept mapping and retrieval practice groups were given to learn the text was standardized. The students returned the following week and completed a short-answer test that included both questions that could be answered verbatim from the text and questions that required inferences. As is displayed in Figure 2, the retrieval practice strategy resulted in superior scores on not just the verbatim questions, but also on the inference questions. That is, the advantages of retrieval practice extended beyond simple recall and to meaningful learning. These findings are supported by numerous other investigations (see Karpicke and Aue, 2015 for review), including a subsequent study by the same authors (Blunt and Karpicke, 2014).

Okay, so retrieval practice has been shown to enhance recall and meaningful learning, but does it work with the types of information that are relevant to APS members?

Figure 3. The testing strategy resulted in superior performance on both sections of the six month assessment. Derived from Larsen, Butler and Roediger, 2009.

Yes………numerous studies support this claim. One notable example was a study by Larsen, Butler and Roediger (2009) in which two groups of medical residents first attended lectures on the treatments of both status epilepticus and myasthenia gravis. Immediately after the lectures, and then again about two and four weeks later, the residents studied (i.e., read) a review sheet pertaining to the treatment of one of those diseases and they completed a retrieval test that included feedback on the other treatment. Roughly six months after the lectures, the residents completed a final assessment that covered the treatment of both diseases. As you can see in Figure 3, the testing strategy resulted in scores that were about 11% and 17% higher than those associated with the studying strategy on the status epilepticus and myasthenia gravis sections, respectively. It is also worth noting that the overall effect size pertaining to those differences was large (Cohen’s d = 0.91). The same group of researchers went on publish similar findings with groups of first-year medical students (Larsen et al, 2013). In that follow-up study, a testing-based strategy produced superior recall and greater transfer of learning of four clinical neurology topics six months after the students first encountered them.

Our lab has also recently published numerous studies with relevant materials, and we observed several advantages with retrieval practice compared to more commonly-used reading and note-taking learning strategies. For example, we found that retrieval-based strategies resulted in superior recall of exercise physiology (Linderholm, Dobson and Yarbrough, 2016) and anatomy and physiology course information (Dobson and Linderholm, 2015a; Dobson and Linderholm, 2015b), including information that consisted of concepts and terminology that were previously unfamiliar to the students (Dobson, Linderholm and Yarbrough, 2015). We have also observed advantages to independent student learning that resulted in higher scores on course exams (Dobson and Linderholm, 2015a), as well as to the ability to synthesize themes from multiple sources (Linderholm, Dobson and Yarbrough, 2016), which is a skill that requires higher orders of cognition.

Just give me the take home messages.

  • Dozens of studies have demonstrated that retrieval practice can promote superior recall and meaningful learning when compared to more commonly-used strategies like reading. (Karpicke and Aue, 2015; Roediger and Butler, 2011; Roediger and Karpicke, 2006b).
  • Although some studies have provided evidence that essay and short answer (SA) questions can lead to a greater testing effect than multiple choice (MC) questions (Roediger and Karpicke, 2006b; Butler and Roediger, 2007), a recent study by Smith and Karpicke (2014) indicated that MC and SA questions are equally effective.
  • Multiple repetitions of retrieval practice promote more learning than a single retrieval event (Roediger and Butler, 2011; Roediger and Karpicke, 2006b)
  • The benefits of retrieval practice are enhanced if learners receive feedback after they retrieve (Roediger and Butler, 2011; Roediger and Karpicke, 2006b).

Great, but how do you apply retrieval practice in the classroom?

  • Summative assessments. Tests prompt retrieval, so one way to incorporate more retrieval practice into your classes is to have your students complete both more exams and more cumulative exams.
  • Formative assessments. There are numerous reasons to use low-stakes assessments like quizzes instead of tests. Quizzes may be just as effective at prompting retrieval, and they provide valuable feedback about performance to both instructors and students, but they typically elicit less anxiety and encourage less cheating. Suggested applications include starting class meetings with a short quiz that prompts students to retrieve information that will be developed during the lecture and/or end class meetings with a short quiz to get students to retrieve the important take home messages of the lecture.
  • In-class retrieval assignments. A great way to break up the monotony of lectures is to have students complete retrieval assignments during class meetings. For example, have individuals or groups of students retrieve information and then present it to the rest of the class.
  • Encourage students to use retrieval practice outside of class. One of the greatest benefits of retrieval practice is that it easy to use; all one needs to do is to recall information from memory. I encourage my students to use retrieval practice by first presenting to them some of the evidence of its effectiveness (described above), and then by suggesting some methods they may use to employ the strategy that (e.g., take turns quizzing or teaching fellow students, quiz one-self, or simply freely recall portions of the information). Again, it is important to emphasize that multiple retrieval events are more beneficial, and that each or most of those should include feedback. For example, have students study then retrieve then study again to receive feedback, etc.

 References

  1. Dobson JL, Linderholm T, Yarbrough MB. Self-testing produces superior recall of both familiar and unfamiliar muscle information. Advances in Physiology Education 39: 309-314, 2015
  2. Dobson JL and Linderholm T, The effect of selected “desirable difficulties” on the ability to recall anatomy information. Anatomical Sciences Education 8: 395-403, 2015.
  3. Dobson JL, Linderholm T. Self-testing promotes superior retention of anatomy and physiology information. Advances in Health Sciences Education 20: 149-161, 2015.
  4. Butler AC, Roediger HL. Testing improves long-term retention in a simulated classroom setting. European Journal of Cognitive Psychology 19: 514-527, 2007.
  5. Blunt JR, Karpicke JD. Learning with retrieval-based concept mapping. Journal of Educational Psychology 106: 849, 2014.
  6. Dobson JL, Perez J, Linderholm T. Distributed retrieval practice promotes superior recall of anatomy information. Anatomical Sciences Education DOI: 10.1002/ase.1668, 2016.
  7. Karpicke JD, Aue, WR. The testing effect is alive and well with complex materials. Educational Psychology Review 27: 317-326, 2015.
  8. Karpicke JD, Blunt JR. Retrieval practice produces more learning than elaborative studying with concept mapping. Science 331: 772-775, 2011.
  9. Larsen DP, Butler AC, Roediger HL. Repeated testing improves long-term retention relative to repeated study: A randomized controlled trial. Medical Education 43: 1174-1181, 2009.
  10. Larsen DP, Butler AC, Lawson AL, Roediger HL. The importance of seeing the patient: Test-enhanced learning with standardized patients and written tests improves clinical application of knowledge. Advances in Health Sciences Education 18: 409-25, 2013.
  11. Linderholm T, Dobson JL, Yarbrough MB. The benefit of self-testing and interleaving for synthesizing concepts across multiple physiology Advances in Physiology Education 40: 329-34, 2016.
  12. Roediger HL, Butler AC. The critical role of retrieval practice in long-term retention. Trends in Cognitive Sciences 15: 20-27, 2011.
  13. Roediger HL, Karpicke JD. Test-enhanced learning: Taking memory tests improves long-term retention. Psychological Science 17: 249-255, 2006.
  14. Roediger HL, Karpicke JD. The power of testing memory: Basic research and implications for educational practice. Perspectives in Psychological Science 1: 181-210, 2006.
  15. Smith MA, Karpicke JD. Retrieval practice with short-answer, multiple-choice, and hybrid tests. Memory 22: 784-802, 2014.
 John Dobson is an Associate Professor in the School of Health and Kinesiology at Georgia Southern University. John received his M.S. and Ph.D. in Exercise Physiology at Auburn University. Although most of his research has focused on the application of learning strategies that were developed by cognitive scientists, he has also recently published articles on peripheral neuropathy and concussion-induced cardiovascular dysfunction. He teaches undergraduate and graduate Anatomy and Physiology, Structural Kinesiology, Exercise Physiology, Cardiovascular Pathophysiology courses. He has been an active member of the American Physiological Society since 2009, and he received the Teaching Section’s New Investigator Award in 2010 and Research Recognition Award in 2011.
Boredom, the Evil Destroyer of Motivation vs. Inquiry, the Motivation Maker

Students have an innate desire to learn and more learning takes place when doing rather than when listening. (4)  This begins in pre-school and kindergarten when children have fun while learning by playing with blocks, coloring, drawing, etc.  This is their first experience with active learning.  But then as education progresses through grade school, high school and college, something bad happens.  That is, fun learning activities are slowly replaced with often very boring listening activities filled with inane factoids, and consequently, students often become disinterested.  The disinterest is seen in the form of poor class attendance, and the lack of motivation is palpable through continual yawns, bobbing heads, and walking to the back of the classroom and looking at student laptops to see how many are streaming Netflix or shopping for shoes.  As educators that take part in this process, we actively destroy their innate desire to learn.  We do not do this intentionally, as all of us want our students to learn as much as possible.  However, with the ever increasing and endless mountain of information, we cannot teach them everything, and often feel that we should be actively teaching, rather than letting them actively learn. (3)  Thus, after hours, days and years of sitting in class “listening”, the traditional “sage on the stage” can slowly chip away at the inner desire to learn.  But, if this internal motivation can be decreased by boring activities, can it also be increased by fun or intriguing activities?

 

As educators, we hold an awesome power that has the potential to inspire and increase student motivation.  Student-centered learning activities that include but are not limited to collaborative group testing, inquiry-based learning, team-based learning and laboratory exercises (5) provide students with the opportunity to apply their minds, to have fruitful discussions with their peers (2) and to see and appreciate the complex beauty that science and medicine are.  If we can provide our students with learning activities that open their imaginations and make them feel excitement, we can actively increase their innate desire to learn, and improve their chances of success. (1)  In doing so, the awesome potential power that we hold can become fully realized in the form of life-long learners.

 

References

  1. Augustyniak RA, Ables AZ, Guilford P, Lujan HL, Cortright RN, and DiCarlo SE. Intrinsic motivation: an overlooked component for student success. Adv Physiol Educ 40: 465-466, 2016.
  2. Cortright RN, Collins HL, and DiCarlo SE. Peer instruction enhanced meaningful learning: ability to solve novel problems. Adv Physiol Educ 29: 107-111, 2005.
  3. DiCarlo SE. Too much content, not enough thinking, and too little fun! Adv Physiol Educ 33: 257-264, 2009.
  4. Freeman S, Eddy SL, McDonough M, Smith MK, Okoroafor N, Jordt H, and Wenderoth MP. Active learning increases student performance in science, engineering, and mathematics. Proc Natl Acad Sci U S A 111: 8410-8415, 2014.
  5. Goodman BE. An evolution in student-centered teaching. Adv Physiol Educ 40: 278-282, 2016.

 

 

Robert A. Augustyniak is an Associate Professor and Physiology Discipline Chair at Edward Via college of Osteopathic Medicine- Carolinas Campus, Spartanburg, SC. Rob received his Ph.D. in Physiology at Wayne State University School of Medicine, Detroit, MI, and subsequently completed a post-doctoral fellowship at the University of Texas Southwestern Medical Center, Dallas, TX. A cardiovascular physiologist by training, his studies have focused on the blood pressure regulation during exercise and in heart failure and hypertensive states. In 2009, Rob became a founding faculty member at Oakland University William Beaumont School of Medicine where he began to focus on the scholarship of medical education. These research interests continued to grow when he moved to Spartanburg, SC in 2013. He is profoundly interested in how medical student motivation impacts learning and in finding best practices in teaching and assessment that can increase motivation. For the past several years, he has been and continues to be active within the leadership of the APS Teaching Section.

Critical thinking or traditional teaching for Health Professions?

“Education is not the learning of facts but the training of the mind to think”- Albert Einstein”

A few years ago I moved from a research laboratory to the classroom. Until then, I had been accustomed to examine ideas and try to find solutions by experimenting and challenging the current knowledge in certain areas. However, in the classroom setting, the students seemed to only want to learn facts with no room for alternative explanations, or challenges. This is not the way a clinician should be trained- I thought, and I started looking in text books, teaching seminars and workshops for alternative teaching methods. I quickly learned that teaching critical thinking skills is the preferred method for higher education to develop highly-qualified professionals.

Why critical thinking? Critical thinking is one of the most important attributes we expect from students in postsecondary education, especially highly qualified professionals in Health Care, where critical thinking will provide the tools to solve unconventional problems that may result. I teach Pathophysiology in Optometry and as in other health professions, not all the clinical cases are identical, therefore the application and adaptation of the accumulated body of knowledge in different scenarios is crucial to develop clinical skills. Because critical thinking is considered essential for patient care, it is fostered in many health sciences educational programs and integrated in the Health Professions Standards for Accreditation.

But what is critical thinking? It is accepted that critical thinking is a process that encompasses conceptualization, application, analysis, synthesis, evaluation, and reflection. What we expect from a critical thinker is to:

  • Formulate clear and precise vital questions and problems;
  • Gather, assess, and interpret relevant information;
  • Reach relevant well-reasoned conclusions and solutions;
  • Think open-mindedly, recognizing their own assumptions;
  • Communicate effectively with others on solutions to complex problems.

However, some educators emphasize the reasoning process, while others focus on the outcomes of critical thinking. Thus, one of the biggest obstacles to proper teaching of critical thinking is the lack of a clear definition, as observed by Allen et al (1) when teaching clinical critical thinking skills. Faculty need to define first what they consider critical thinking to be before they attempt to teach it or evaluate student learning outcomes. But keep in mind that not all students will be good at critical thinking and not all teachers are able to teach students critical thinking skills.

The experts in the field have classically agreed that critical thinking includes not only cognitive skills but also an affective disposition (2). I consider that it mostly relies on the use of known facts in a way that enables analysis and reflection of conventional and unconventional cases for the future. I have recently experimented with reflection in pathophysiological concepts and I have come to realize that reflection is an integral part of the health professions.  We cannot convey just pieces of information based on accumulated experience, we have to reflect on it. Some studies have demonstrated that reflective thinking positively predicted achievement to a higher extent than habitual action. However, those may not be the key elements of critical thinking that you choose to focus on.

How do we achieve critical thinking in higher education and Health Professions? Once we have defined what critical thinking means to us, it must be present at all times when designing a course, from learning objectives to assignments. We cannot expect to contribute to development of critical thinking skills if the course is not designed to support it. According to the Delphi study conducted by the American Philosophical Association (3), the essential elements of lessons designed to promote critical thinking are the following:

  1. “Ill structured problems” are those that don’t have a single right answer they are based on reflective judgment and leave conclusions open to future information.
  2. “Criteria for assessment of thinking” include clarity, accuracy, precision, relevance, depth, breadth, logic, significance, and fairness (Paul & Elder, 2001).
  3. “Student meaningful and valid assessment of their own thinking”, as they are held accountable for it.
  4. “Improving the outcomes of thinking” such as in writing, speaking, reading, listening, and creating.

There are a variety of examples that serve as a model to know if the course contains critical thinking elements and to help design the learning objectives of a course. However, it can be summarized in the statement that “thinking is driven by questions”. We need to ask questions that generate further questions to develop the thinking process (4). By giving questions with thought-stopping answers we are not building a foundation for critical thinking. We can examine a subject by just asking students to generate a list of questions that they have regarding the subject provided, including questions generated by their first set of questions. Questions should be deep to foster dealing with complexity, to challenge assumptions, points of view and the sources of information. Those thought-stimulating types of questions should include questions of purpose, of information, of interpretation, of assumption, of implication, of point of view, of accuracy and precision, of consistency, of logic etc.

However, how many of you just get the question: “Is this going to be on the test?”. Students do not want to think. They want everything to be already thought-out for them and teachers may not be the best in generating thoughtful questions.

As an inexperienced research educator, trying to survive in this new environment, I fought against the urge of helping the students to be critical thinkers, and provided answers rather than promoting questions. I thought I just wanted to do traditional lectures. However, unconsciously I was including critical thinking during lectures by using clicker questions and asking about scenarios with more than one possible answer. Students were not very happy, but the fact that those questions were not graded but instead used as interactive tools minimized the resistance to these questions. The most competitive students would try to answer them right and generate additional questions, while the most traditional students would just answer, no questions asked. I implanted this method in all my courses, and I started to give critical thinking assignments. The students would have to address a topic and to promote critical thinking, a series of questions were included as a guide in the rubric. The answers were not easily found in textbooks and it generated plenty of additional questions. As always, it did not work for every student, and only a portion of the class probably benefited from them, but all students had exposure to it. Another critical thinking component was the presentation of a research article. Students had a limited time to present a portion of the article, thus requiring analysis, summary and reflection. This is still a work in progress and I keep inserting additional elements as I see the need.

How does critical thinking impact student performance? Assessment

Despite the push for critical thinking in Health Professions, there is no agreement on whether critical thinking positively impacts student performance. The curriculum design is focused on content rather than critical thinking, which makes it difficult to evaluate the learning outcomes (5). In addition, the type of assessment used for the evaluation of critical thinking may not reflect these outcomes.

There is a growing trend for measuring learning outcomes, and some tests are used to assess critical thinking, such as the Classroom Assessment Techniques (CAT), which evaluate information, creative thinking, learning and problem solving, and communication. However, the key elements in the assessment of student thinking are purpose, question at issue, assumptions, inferences, implications, points of view, concepts and evidence (6). Thus, without a clear understanding of this process and despite the available tests, the proper assessment becomes rather challenging.

Another issue that arises when evaluating students critical thinking performance is that they are very resistant to this unconventional model of learning and possibly the absence of clear positive results may be due to the short exposure to this learning approach in addition to the inappropriate assessment tools. Whether or not there is a long term beneficial effect of critical thinking on clinical reasoning skills remains to be elucidated.

I tried to implement critical thinking in alignment with my view of Physiology.  Since, I taught several courses to the same cohort of students within the curriculum, I decided to try different teaching techniques, assessments and approaches at different times during the curriculum.  This was ideal because I could do this without a large time commitment and without compromising large sections of the curriculum. However, after evaluating the benefits, proper implementation and assessment of critical thinking, I came to the conclusion that we sacrifice contact hours of traditional lecture content for a deeper analysis of a limited section of the subject matter. However, the board exams in health professions are mostly based on traditional teaching rather than critical thinking. Thus, I decided to only partly implement critical thinking in my courses to avoid a negative impact in board certification, but include it somehow as I still believe it is vital for their clinical skills.

 

References

  1. Allen GD, Rubenfeld MG, Scheffer BK. Reliability of assessment of critical thinking. J Prof Nurs. 2004 Jan-Feb;20(1):15-22.
  2. Facione PA. Critical thinking: A statement of expert consensus for purposes of educational assessment and instruction: Research findings and recommendations [Internet]. Newark: American Philosophical Association; 1990[cited 2016 Dec 27]. Available from: https://eric.ed.gov/?id=ED315423
  3. Facione NC, Facione PA. Critical thinking assessment in nursing education programs: An aggregate data analysis. Millbrae: California Academic Press; 1997[cited 2016 Dec 27].
  4. Paul WH, Elder L. Critical thinking handbook: Basic theory and instructional structures. 2nd Dillon Beach: Foundation for Critical Thinking; 2000[cited 2016 Dec 27].
  5. Not sure which one
  6. Facione PA. Critical thinking what it is and why it counts. San Jose: California Academic Press; 2011 [cited 2016 Dec 27]. Available from: https://blogs.city.ac.uk/cturkoglu/files/2015/03/Critical-Thinking-Articles-w6xywo.pdf

 

 

 

 

 

Lourdes Alarcon Fortepiani is an Associate professor at Rosenberg School of Optometry (RSO) at the University of the Incarnate Word in San Antonio, Texas. Lourdes received her M.D. and Ph.D. in Physiology at the University of Murcia, Spain. She is a renal physiologist by training, who has worked on hypertension, sexual dimorphism and aging. Following her postdoctoral fellowship, she joined RSO and has been teaching Physiology, Immunology, and Pathology amongst other courses. Her main professional interest is medical science education. She has been active in outreach programs including PhUn week activities for APS, career day, and summer research activities, where she enjoys reaching K-12 ad unraveling different aspects of science. Her recent area of interest includes improving student critical thinking.