The topic is sufficiently captivating and the presenter is an acknowledged expert…and yet your eyes begin to close and the heads nodding in the room are not because their owners are expressing agreement. What is happening? The presenter has formulated the learning experience in a way that doesn’t encourage participation, says Dr. Jesse Jupiter, a renowned hand surgeon and educator at Massachusetts General Hospital in Boston.
Dr. Jesse JupiterDr. Jupiter, a student of the educational process, spent years mastering the elements involved in teaching. He states, “We are increasingly recognizing that busy professionals learn differently than college or high school students. It has also become clear to us that to provide excellent continuing medical education (CME) we must not only deliver information, but deliver it in formats that are better received and understood. And according to published research, the lecture format is the least effective form of communication as far as the retention of information.”
The wave of the future, says Dr. Jupiter, is the somewhat old fashioned “Case Based Learning.” “This is education that occurs in either small or large groups and during which there is a great deal of learner participation. Case based learning has been shown by those who study such matters to have excellent results. In a sense, this approach takes much of the randomness out of education. In the past CME courses were coffee clubs where there was no real means of assessing how information was delivered or received. That is changing. Pressure is growing from several parties, including state medical societies, to document how information is given and what the outcomes from that education are.”
You might characterize this “new” educational modality as one that creates an actual connection between the giver of information and the receiver of information—which, in turn, forms a greater bond between the learner and the topic at hand. Dr. Jupiter says,
Teaching and learning are two different things. You can seem to be a good teacher by giving a well illustrated lecture complete with witticisms, but the learner has to put in some effort in order to benefit. Small group discussions involving cases are very successful at delivering information because they require the learner to join in and they also bring to the learner information they can relate to.
The former head of the international education board for the AO Foundation, Dr. Jupiter notes, “Let me first say that while these events may appear to be freeform, they actually involve a lot of organization. Those who taught me, and who I believe do these events best, are from the AO Foundation. Working alongside professional educators I looked at every aspect of instruction including, for example, the learning environment. In a traditional lecture the lights are typically lowered, encouraging fatigue, and there is little to no means of addressing people’s questions. One thing we have found to be effective is to arrange participants in a horseshoe so that they can have continuous eye contact with the leader and with each other (encouraging active participation).”
Elaborating on the strategy, Dr. Jupiter says, “Sometimes one or two people try to dominate the group. The last thing you want to do is embarrass them; you can, however, seat someone like this to your left so that you are no longer making eye contact with him (and he will feel less inclined to have constant input). With regard to the session’s structure, the cases must be in a format such that the topic and how you want to handle it are worked out ahead of time. Specifically, you should establish the needs of the participants and then identify your learning objectives.”
Whether it’s a torn ACL or meniscal injury, Dr. Jupiter makes good use of the much abused knee to illustrate his lessons. Dr. Jupiter: “First, determine your objectives in terms of what information the participants need or want to learn (of course this varies depending on whether these are medical students or established surgeons). Then you design the course based on a particular case, the format of which is an introduction with visuals, followed by treatment options. You finish up with what was actually done in that case. For comparison purposes you could take a different case, show complications and have a discussion with regard to why the knee didn’t heal properly. Again, preparation is required…as the leader I would have had to prepare all of this in advance. And ideally you would want the participants to have read related articles beforehand—you don’t want them to be passive learners. You wind up the session with an evaluation, one which includes a summary of the key learning points and conclusion regarding the treatment and outcome of the specific case.”
Ah, they make a beautiful couple…theory and practice, that is.
Whether you’re ‘just’ doing a case based presentation or you’re holding a full event with a cadaver lab, the beauty of the structure is that learners can integrate what they learn in books with what they learn in practice.
“This makes for a more engaged learner who, as a result, retains more information. Such an approach is increasingly important given that we are finding that young people don’t often attend lectures because they are available on the internet. They will, however, go to case discussions because they are stimulating and because the format allows them to clarify learning points. ‘This is what I thought I understood…is this correct?’ Contrast this with a lecture environment, which is diffuse and does not promote an open exchange of ideas. In a lecture there is no chance to say, ‘You know, I read such-and-such article and I don’t think the data was sufficient.’”
In the event of a large group, states Dr. Jupiter, there are also ways to encourage active participation. “In a bigger gathering, ask that people move up to the front of the room (otherwise you lose the ability to have eye contact). Get people involved by reviewing a case and asking what their experience has been with similar cases. Early on during the session ask, ‘Can I get a show of hands as to how many of you have found problems with this?’ Doing that will allow you to get a sense of what type of audience you have.”
Emphasizing the dynamism involved in case based learning, Dr. Jupiter notes, “During the course you can ask the participants what they thought they knew well and didn’t know before they came. Then after the course you will have a more objective way of understanding the program. You can change the direction of the discussions and even cases based on the response of the participants.”
Although enthusiasm abounds for case based learning, there are some whose personality issues prevent them from jumping on board. “One type of individual who may not like such an environment is the expert him or herself. He is asked to participate and is set to give a lecture that shows off his skills; he doesn’t want to prepare much because he already has his lecture. If he is told, ‘I want you to come for two days, but there will be no lecture, ’ then he’s just another guy. Also, let’s say this is a case based event with a panel and Dr. X is asked to sit on the panel. He is now in a position where he will be asked questions, something he may not be comfortable with.”
An interested—and varied—demographic that at times requires special forethought are those clinicians who arrive for training from outside the U.S.
“There can be language issues when you have participants from other countries. This can be overcome in many instances by not only speaking slowly but identifying those in the group who can help as interpreters. Also, in some parts of the world you encounter deferential behavior to one’s older colleagues. This means that if you call on a younger colleague who is seated next to a senior person in his department the last thing he wants to do is say the wrong answer. To help with this issue, I recommend a pre-course seminar on cultural customs that is geared toward the faculty. I have seen a bit of a shift in Asian cultures, however, with younger students appearing more headstrong these days.”
The active exchange of ideas, an increased focus on evidence, and an audience that doesn’t appear anesthetized are all the clear benefits of using the case based learning methodologies. Dr. Jupiter: “The case based environment is pivotal in helping learners think more deeply and integrate practice and knowledge. Continuous learning is one of the things that my colleagues and I enjoy most about orthopedics. Why not have a learning experience that is as dynamic and memorable as possible?”
Why not indeed! For more information, Dr. Jupiter may be reached at jjupiter1@partners.org.
