So our objectives, we're going to, after this, I hope you can describe at least three active forms of teaching and learning. I hope you can understand something you may never have heard of before, forgetting curves. And describe how you can use the lectern as a problem. So you'll understand that when we get there, but it'll be the second to the last slide where I'm going to tell you this entire setup is wrong. So I'm going to shoot ourselves in our own foot. So a teacher is a whole bunch of good things that you see listed here. It didn't matter that the image went off the slide. It covered my purpose of trying to show you that these are lots of qualities that are in a good teacher. So that then raises the question, well, are we talking teacher or are we talking mentor? Since a lot of the conversations today have been mentor. I don't want to go into the detail here because I want to get back to the art of teaching more. But I wanted to point out there are significant differences between a coach and a mentor. And most teachers are in the coaching role, not in the mentor role. They may be an advisor and a coach. They may be a supervisor and a coach. But they could be a mentor, but they're not just because they happen to be a teacher or happen to be a teacher. And the other thing that gets commonly confused here is role models. So, again, I just give you that as a reference that's embedded in the material. So the old way of teaching was passive, and we're doing a lot of that today. Sage on the stage. I know everything. Y'all don't. I'm here to tell you most of what I know. Then I'm going to leave, and then I'll redo that somewhere else. That's the concept. It's really the old way. It's not the new way of doing things where education and learning is a much more engaged and active process. And we'll flesh that out a little bit more as we go. You may wonder where this whole idea about how much percentage of what you read and how much percentage of what you hear you actually retain. It comes from Edgar Dale back in the early 1900s. And very simply, the top of this stack are the passive learning. So reading, hearing, seeing, and hearing and seeing are all passive learning. And you can see you retain much less of than what you do under active learning, where we force you to say things or ask you to say things or ask you to do things if that's what's required. So this would be much more workshop-oriented as opposed to lecture-oriented if we were paying attention to Dale's cone of learning. And if you want to be a better teacher, then you want to think about how can I be more active in what I do. I've given grand rounds in an amphitheater, and people say, how can you be active and interactive in that environment because it's designed so poorly for engagement? And I would say it's more difficult, but it's not impossible, right? I can say, here's a case. Now, I want everybody to take 30 seconds. Have you seen the case just like this, or have you seen a case similar to this? I can ask even in an amphitheater setting. Everybody turn and find somebody next to or behind or in front of you and have a 30-second conversation about what's the differential in that case. We can ask two or three people in the amphitheater to stand up and to say, what did they get out of that conversation with other people? People say, I can't do active teaching in an amphitheater. It's going to take time away from my talk. We just did three forms of active education, active learning, and it added a minute and a half, minute and a half. So you can do and want to strive to do active teaching. This has been called sage on the stage, what we're doing right now. People began to say, well, what you really want is a facilitator. You want a guide on the side. And we've actually grown to understand what you sort of want is a meddler in the middle. They do a little bit of sage on the stage. They do a little bit of guidance and facilitation from the side, and then they instigate. They ask challenging questions to the group, or they give a variable that changes the entire discussion and makes the group think on its feet to see how well they can adapt and adopt. You may have heard this phrase, flipped classroom. Strange story. One day I was on an airplane flying back from overseas, and the group that had flown me overseas had paid for business class, and the individual sitting next to me was the individual who wrote the book, Flipped Classroom. It's like, wow, how does that go? Do you have one on you? Can you sign it for me? What is a flipped classroom, to make it clear? The way most of us were educated is you went to class, okay? They taught you some principles, and then you went home and you did homework out of a book or in a workbook of some sort, and then you came back and you may have been graded or judged on what you got right or wrong in that workbook. That was the standard approach. The flipped classroom is I give you exercises to go home and read or do, and then you come to the class and I learn what you got right or you got wrong, and then I focus what I educate on what you need to be developed and improved, not I teach a standard quantity, then you go home and try to use it on your own. That's the flip that happens. That creates an active learning environment, right? Because now the learner is in the position of demonstrating what they know or not know, and the educator can learn from that and then guide the therapy, guide the education. I wanted to give you something that gave you a whole example. So you start down here on the bottom left at simple, and there are all sorts of forms of active education that go from simple all the way up to the very complex that you can use and leverage. And I would encourage you to try to use three, four, five in almost all lectures that you give, no matter what the classroom looks like. So education principles. To improve it helps to know some basics. So let's just learn a few basic things about education. First, pedagogy. That's to lead the child is what it means, but what it really is is the art and science of teaching. So it's for children and adults. But adults have some special aspects about how we learn, and that's called andragogy, and that's to lead man. And those are learning strategies focused at adults. And this came out of first Alexander Kapp, but Malcolm Knowles is the most known individual around this topic. And look at these following bulleted items. Adults need to know the reason for learning. So they need you to explain at the beginning, I'm giving this talk because of. I've had this occur in my life, or I've seen patients, or have you seen patients, et cetera. Medical providers want to have experience be part of the discussion of what they're learning. So including error in the basis for learning activities. You don't tend to teach error to children. You tend to teach positive how to get from here to forward, and you don't teach error. Adults want to learn from experience. Adults have to have some degree of responsibility in their decisions on that education. That can be a survey. That can be they've chosen to come to that particular course, et cetera. But if they're not responsible, then they're likely not going to pay any attention. Adults are most interested in learning subjects having immediate relevance to their work or personal lives. So it's nice to talk about things that you might see one day, and we don't mind doing that, but it doesn't really lead us to learn and change significantly. What we really want to do is say, I'm having RSV grow in my institution. Can you give me a series of lectures and educational opportunities and workshops and engage me with active learning on RSV? The adults are problem-centered. So this is case-based. They're problem-centered learning is active learning, and adults do much better with. And adults respond better to internal, not external motivators. So for the C-suite that wants to mandate that we learn or do certain things, it's actually much less effective than finding out what we think is of value and then helping guide that discussion of what's of value and then having us educate down that pathway. What I've done is changed the order of those and merely took the first letter and pointed out it spells peer. So hopefully that's a simple mnemonic sort of way for you to remember adult education is better when it's problem-oriental, the internal motivators, experiences included, the audience knows the reason that they're learning something, the audience has some degree of responsibility in it, and they can easily recognize the relevance to their work. And I just wanted to show you this is out of the Army. They've taken these principles and formed them into a tool that can be used for the educators to learn from. So we think about people that learn, and we think that on this scale that's sort of on its side here, right, where they start off as a novice and they go through some form of intermediate stage of proficiency and then they get up to expert. And there's a couple of problems on this page. The first is for an educational tool, it's way too busy. The second problem on the page is that it leads us to believe something that's false, that when we finish training we know more than we're ever going to know and that we are an expert. You're on the pathway to becoming an expert. The end of fellowship, no matter what the field is, that equivalent, okay, you are proficient. This has been a mistake that we've assumed all along. By calling ourselves experts from day one, it means that my educational needs are very different and very limited and I can show up in a grand rounds, do no active learning, no active education, and I just maintain that. And that's the third part. Where's the down arrow that shows that we can drift from expert back to proficient if we don't pay attention to ongoing learning and ongoing personal development? So it's missing, importantly, the potential for the down sweep. So how about some quick little tools that can help you think about teaching? Well, there's a learning maturity piece, right? The most novice people need to learn by rote. There's nothing wrong with that, but that's where that is, and it goes all the way through pattern recognition into applying what you learn into constructing additional meaning and creating new insights. So this can be very important for you as an educator to take a step back before you put the slides together and say, which of these am I trying to accomplish today? Mnemonics are very helpful, like how many feet are in a mile? That's five tomatoes, number of feet in a mile, five, two, eight O's. Or this one, my favorite one in medicine. Rightward shifts in the oxygen-hemoglobin dissociation curve are caused by the R is for right, I is for increases, G is for DPG, H is for hydrogen ion concentration, and T is for temperature. So rightward shifts are the word right. These are great tools for learning. Chunking is a great tool for learning. Chunking is merely breaking it into subsegments so that people can more easily learn and then showing how those pieces fit together. These are tools you can use tomorrow. They will improve the education you give. Now, for every yin there's a yang. What I mean by that is that if there's a learning curve, then there's a forgetting curve. And Ebbinghaus showed us this and pointed this out in the late 1800s. So let's look at this and just think about it for a second. On the y-axis is some event occurs and you have memory. You have some sort of learning that happens. And then there's a decay. And then the next upward sweep is you can get exposed to it again and you learn to the same end point, but now notice the decay is slower. And then you do that again a third time. So part of what's important is to think about multiple exposures to the content for the learnee. The best CME courses will drive us crazy in medicine because the best CME courses would be that you do some pre-work, potentially reading articles, potentially whatever that might be, pre-work. You would come not to a series of didactic lectures, but you would come to interactive workshops. And then two months later you would receive a series of a link to a website that would have cases that show that you've retained what you've learned and that you can apply. Physicians are really good, and many people in health care that are not physicians were trained through science, so we're very good at doing what? Remembering and regurgitating. We're not so good at applying. Go to a CME activity and listen to the questions up front. So you gave a great talk on hypertension today, Dr. Dorman. I loved it. It was wonderful. What do I do for my patient who has hypertension? It's 82, it's a Wednesday, they got Guillain-Barre, and there's a solar eclipse. We're not as good at applying the information, and so we don't use the time. We use the time to teach the facts that people can learn on their own. So this gets at exposure density. How many times do you need to be exposed? What's the distance between those exposures? Many of these variables are still being studied and are not perfectly clear, but if you think about multiple exposures using multiple media and multiple technologies over a period of time, you will learn much more and you will retain it much longer. This is work by Dave Davis. Dave asked some simple questions. Took a bunch of physicians and providers and said, how well do you think you can do something, and then let's see you do it and see how well you do it. They found that most of the people in the middle match pretty well. They're pretty good at being able to say what they're good at, but over here a bunch of people are really poor at self-assessment. They have unbelievable high confidence and very low performance, and we all recognize them as the potential quality and safety nightmare because, oh boy, they are really certain they are doing it right, but they're not. They're doing it wrong. I would point out that although it gets very little press, the upper end is also problematic but for an interesting reason potentially. The upper end, the people who are not very confident but do very well. There may be many of us in this room that turn away from, you know, leave the room after a test and go, I didn't do so good, and then you get your score and you got a 98. You might say, how could those people hurt patients? If they can't trust their ability and have confidence in their ability, then they begin to over-test, and we all know tests lead to more tests, tests lead to biopsies, biopsies lead to procedures that aren't necessary, and et cetera, and so both ends of the spectrum are problematic. We need to recognize that and try to help people identify that lack of capability so they're not overconfident. Style points are important. This is the second to the last slide that I promised you where I was going to go through more about what's wrong. So first off, never talk behind a lectern if you can avoid it. There's no ability for me to move around, for me to communicate with you. I stop using hands. I'm not using body language anymore. Several of us were talking about this earlier today. When there's science behind something that's very weak, the speaker will naturally withdraw from the audience. We're really concerned and we're not certain, and when the data is clear, they will automatically walk forward and say, and you can trust that this analysis, we remove that completely when we do this. This forces me to stare at a certain slice of the audience. I have to force myself to try to make sure that I keep scanning the audience and make sure everybody is involved. This is placed in such a way that for me to know what the next slide is, I have to look down and everybody in the room immediately sees. That means I stop being engaged with the audience. This should be a TV screen down there so my eyes glance down and everybody appears that I'm looking at the first row, not that I'm ignoring you. I don't have a clicker with a pointer. I'm not circling words like the old show Sing Along with Mitch that people do. All of that's distraction. It shows I have a tremor. You watch people and you watch the thing. And then some people are going, do you have an arrow? Is it pointing at something? I can't even see it on the screen, depending upon if they're colorblind or not and the color of the arrow in the background, et cetera. So all of those are ways you can improve your teaching. The last couple, the last important one that I want to mention is if you have to say that the slide is too busy and I want to apologize for that, it shouldn't be in your slide deck. If it has important information on it, don't draw red bars around that line on the table. If they couldn't read it before the red bars, they surely can't see it after the red bars. Remake the table and only have the three points out of the full 25-point table that's actually making the point you're trying to go to. And it's much easier to see and much easier to communicate. Try not to point at graphic slides. Describe them. The x-axis here is time. The y-axis is catecholamine concentration. And as you can see, norepinephrine comes down over five days. Epinephrine returns to normal within 12 days. The visual learner already got there by looking at it. The auditory learner doesn't get anything by you pointing and circling at things. They're waiting for you to explain the graph. So I hope those are some quick, easy tools that will help you be more practical and be a better educator from that standpoint. Thank you. applause

active teaching

flipped classroom

adult learning principles

ongoing learning

effective teaching