Interactive Instruction In Otolaryngology

Otolaryngol Clin N Am 40 (2007) 1203–1214

Interactive Instruction in Otolaryngology Resident Education John M. Schweinfurth, MD Department of Otolaryngology and Communicative Sciences, 2500 North State Street, Jackson, MS 39216, USA

Today’s academic faculty were typically trained under an education system based entirely on didactic lectures. Because the choice of teaching method is usually based on familiar methods, didactic lectures have persisted. However, if the aim is to teach thinking or change attitudes beyond the simple transmission of factual knowledge, then lectures alone, without active involvement of the students, are not the most effective method of teaching [1]. The goals of teaching as described by Isaacs are to (1) arouse and keep students’ interest, (2) give facts and details, (3) make students think critically about the subject, and (4) prepare students for independent studies by demonstration of problem solving and professional reasoning [2]. Isaacs notes, however, that only two of these purposes are well suited to didactic lectures. The problem then is how to organize lecture material so that individual student’s learning needs are better addressed. Gibbs suggests that lecture sessions contain a variety of activities designed to stimulate individual students to think, including small-group discussion, working problems during lecture time, questions included in the lecture, and quizzes at the end of lecture, among others [3]. The current article examines the feasibility of using these types of interactive learning techniques in an otolaryngology residency program. Other possibilities include standard interactive lecturing, facilitated discussion, brainstorming, small-group activities, problem solving, competitive largegroup exercises, and the use of illustrative cliff-hanger and incident cases. The feasibility of these methodologies being effectively incorporated into a residency curriculum is discussed.

E-mail address: [email protected] 0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otc.2007.07.002

oto.theclinics.com

1204

SCHWEINFURTH

Adult learning theory As adult learners, physicians have many different learning styles, and any planned education intervention should account for these differences. Malcolm Knowles is best known for the theory of andragogy, the art and science of helping adults learn, as contrasted with pedagogy, the art and science of helping children learn [4]. Knowles assumed that adults and children learned differently based on five humanistic assumptions [4]: 1. As a person matures, his or her self-concept moves from that of a dependent personality toward one of a self-directing human being. 2. An adult accumulates a growing reservoir of experience, which is a rich resource for learning. 3. The readiness of an adult to learn is closely related to the developmental task of his or her social role. 4. There is a change in time perspective as people maturedfrom future to immediate application of knowledge; thus an adult is more problem centered than subject centered in learning. 5. Adults are motivated to learn by internal factors rather than external ones. Compared with children, adults have significant experience and prior knowledge from which they draw connections and parallels that help to define and categorize new knowledge. The more alike new knowledge is in organization and content to old knowledge, the more easily this knowledge can be assimilated. On any given topic, learners differ greatly in the depth and accuracy of prior knowledge. More than likely, the knowledge will be fragmented and incomplete. In a standard didactic lecture, there is no opportunity for the lecturer to gauge prior knowledge of the learner and, therefore, the class’ learning effectiveness may be quite diverse. Some students may reinterpret what they hear to fit preexisting misconceptions. It will be necessary for some students, therefore, to unlearn some of what they already know and reorganize their knowledge base. Thus the assessment of prior knowledge is critical to the lecturer. As adults grow and change in the learning experience, these changes should be recognized, making feedback essential. The basis of andragogy is often used in the teaching of adults. Putting this theory to work in the classroom involves an awareness of the basic principles that underlie these assumptions. The classroom should be a safe, comfortable environment where facilitation, rather than lectures, is used as a teaching style. The facilitator should promote understanding and retention along with the application of the material to the life experience of the students. The curriculum should be problem centered whereas the learning design should promote information integration. Life situations of physicians have a critical impact as well. McClusky, who introduced the ‘‘theory of margin,’’ believed that adulthood involved

INTERACTIVE INSTRUCTION IN OTOLARYNGOLOGY

1205

continuous growth, change, and integration, in which constant effort was required to manage the energy available for meeting the normal responsibilities of living [5]. He envisioned margin as a formula, which expresses a ratio or relationship between ‘‘load’’ (of living), and ‘‘power’’ (to carry the load). Load is ‘‘The self and other demands required by a person to maintain a minimal level of autonomy’’ and power ‘‘the resources, ie, abilities, possessions, position, allies, etc., which a person can command in coping with load.’’ For the learner to meet the demands of life, combined with learning needs, power must exceed load. Thus, margin enables the individual to take on more stimulating activities, such as educational opportunities, and integrate them into his or her lifestyle. McClusky’s theory is appropriate because it deals with events and transitions common to all adult learners. Educators aware of this theory can more effectively create a learning environment suited to the needs of the learner. Increased load due to unrealistic work assignments, undue stress caused by uncertainty, and unresolved social issues can affect how well the learner can cope. At the same time, learning can provide surplus power, which can be a significant impetus in achieving various goals. Knox’s (1980) [6] proficiency theory also deals with an adult’s life situation. He defines proficiency as ‘‘the capability to perform satisfactorily if given the opportunity.’’ This performance involves some combination of attitude, knowledge, and skill. The purpose of adult learning is to ‘‘enhance proficiency to improve performance.’’ Central to this theory is the belief that a discrepancy exists between the current and desired level of proficiency. This discrepancy is the impetus that motivates the adult to seek a learning experience that will increase proficiency. A model that represents the theory would include the following interactive components: ‘‘the general environment, past and current characteristics, performance, aspiration, self, discrepancies, specific environments, learning activity, and the teacher’s role [7].’’ Specific educational needs of otolaryngology residents and potential barriers Medical knowledge Spread over 4 years, the otolaryngology residency is tightly packed with didactic and self-directed learning in basic science and medical knowledge and procedural skills training. A recent review of the American Board of Otolaryngology’s medical knowledge content requirements revealed over 300 topics to be mastered before board certification. The requirement for medical knowledge is tempered by the development of clinical skills through other means such as practical experience as well as other obligations, including research and community service. Owing to the nature of residency training, didactic instruction time in residency programs is limited. With the

1206

SCHWEINFURTH

advent of work-hour restrictions, most training programs lack sufficient lecture time to thoroughly cover the curriculum mandated by the Accreditation Council for Graduate Medical Education in the available training period. Otolaryngology didactic sessions are therefore content heavy and must be performed in a time-efficient manner to accommodate still further content in other areas. Motivation for change and learning Much has been written about innovative teaching and learning techniques in undergraduates. Physicians in training represent a substantially different group of learners than undergraduates, however. Once a strong professional identity has formedd usually after the first year of trainingd resident learning may be described similarly to that of practicing physicians by the ‘‘change model’’ of Fox and colleagues [8]. In interviews with over 300 practicing physicians, the authors found that the desire to learn and change can come from professional, personal, and social reasons. In their experience, the most common reasons for change included a desire for general competence or the recognition of a changing practice environment (eg, competition, improved patient self-education, and Internet access). Resident physicians are likely similarly motivated by a desire to strengthen professional roles and identity, gain competence, and deal with expected clinical challenges. Geertsma and colleagues [9] identified three stages to learning in practicing physicians: deciding on whether to take on a learning task to address a problem, learning the knowledge and skill anticipated to resolve the problem, and gaining experience in what has been learned. Residents differ from practicing physicians under Geertsma’s model in that they do not have the luxury of choosing whether to take on a new learning task: all learning is new and therefore necessary. The limitation of the change model is the mismatch between real and perceived learning need areas, an observation that applies equally to both resident and practicing physician learners. The instructor must nevertheless be aware of the need to link learning experiences to the residents’ future practice in order to obtain the necessary ‘‘buy-in’’ for whole-hearted participation. Development of other skills in residency training Part and parcel to residency training is functioning within a team, professional identification, and developing rapport with patients and other health care workers. Thus, learning exercises that emphasize team building, interpersonal skills, and leadership skills further the professional development of young practitioners. Finally, upon graduation residents leave the nurturing training environment and go off into distant areas to practice and become local and regional experts. Residents need to be encouraged, therefore, to make the transition from passive to independent learning, study, and professional development.

INTERACTIVE INSTRUCTION IN OTOLARYNGOLOGY

1207

Needs assessment: focus group results A focus group was conducted with otolaryngology residents in training to discuss innovative learning strategies. In summary, residents (1) expressed a desire to maintain the status quo and avoid complex exercises given the available lecture time, (2) considered attempts at innovation as ‘‘too experimental’’ or a ‘‘waste of time,’’ and (3) were concerned about extending the topic outside the available lecture period into personal time. Finally, residents requested the inclusion of pictures, illustrations, and videos where applicable, as well as hands-on techniques. The general consensus was that lectures should build on what has been seen or experienced clinically; residents may have difficulty learning in the abstract but are greatly interested when they have experienced a clinical problem for which they are unaware of or unable to find a solution.

Instructional methods Didactic lectures Lectures are the most widely used and accepted method of education. As a tried-and-true method, lectures have many inherent advantages and benefits. Lectures are time and resource efficient and cost effective, as a large number of learners can be taught simultaneously with the same amount of effort from one teacher. Lectures are familiar and comfortable to both teachers and learners: owing to the lack of interaction neither is ‘‘put on the spot’’ and the lecturer remains in complete control of the learning experience. In a survey of faculty at a large Australian university, Isaacs identified the reasons for the use of lectures: making students think critically about the subject, demonstrating professional reasoning, making students enthusiastic, explaining difficult points, and providing a framework for self-directed learning [2]. The primary advantage of the use of didactic lecturing for otolaryngology core resident education is that the faculty member is a content expert in his or her respective area and is able to distill the most salient points from the textbooks and literature and demonstrate professional reasoning with an admixture of valuable realworld experience not readily available elsewhere. As a group, the faculty firmly believed that the presence of the teacher in the classroom, communicating and interacting with the students, is essential to the educational experience [2]. Learning takes place along three dimensions: knowledge, skills, and attitudes. The lecture format is appropriate only for addressing knowledge. Development of skills and attitudes by the learner requires more participation, practice, and discussion than are available in the lecture format [10]. Within the domain of knowledge there are different levels according to Bloom’s taxonomy [11]. Realistically, lecturing can reach only the lowest two levels

1208

SCHWEINFURTH

of ‘‘knowledge’’ and ‘‘comprehension.’’ Higher levels of knowledge that involve problem-solving skills (ie, analysis, synthesis, and evaluation) require greater participation and practice and should be considered unattainable from the lecture format [10]. From a practical standpoint, lecture preparation is time intensive for the instructor, and the learner may be overloaded by content or bored and subsequently ‘‘check out’’ or stop learning early on in the course of a lecture. The ‘‘one-size-fits-all’’ approach of lectures is therefore insensitive to the individual needs of the learner. From the teacher’s standpoint, non-interactive lectures lack feedback. The teacher is unaware of the student’s real-time needs, reception, and degree of learning. One-way didactic lecturing does not prepare learners for independent, self-directed learning and fails to wean learners from passive roles. Finally, the lack of interactivity does not promote interpersonal communication skills, leadership, and team building. Interactive/active learning Ramsden [1] and others in the area of teaching and learning in higher education distinguish three, essentially hierarchical, views of teaching: the transmission of information, keeping the students active, and facilitating change. The first of these views dovetails nicely with the idea that students must, in the main, remember facts. The second takes a more instrumental view of teaching: as long as students are active something good will happen. The third is consistent with the idea that learning is personal to the student and in a formal setting arises in the interaction with the teacher, student, and subject matter, leading to learning for understanding or ‘‘deep’’ learning. The common wisdom is that deep learning requires that the student participates actively whereby they ‘‘construct’’ knowledge for themselves [10]. Of course, this process cannot take place in the absence of knowledge; hence students will need to have learned some facts. Interactions allow higher level of understanding, higher ability in the analysis and synthesis of material, easier transfer of material presented to other situations, and more effective evaluation of the material presented [10,12,13].

Specific interactive techniques and their potential application Questioning Questioning the audience is the most commonly applied interactive technique (the Socratic Method) and is typically commonly used by many otolaryngology faculty in the form known colloquially as ‘‘pimping.’’ In general, questions can be used to achieve several results (Box 1). An essential role of questioning at the beginning of a lecture is to assess the learners’ prior knowledge. This is an opportunity to identify specific gaps in knowledge and misconceptions and bring all members of the audience

INTERACTIVE INSTRUCTION IN OTOLARYNGOLOGY

1209

Box 1. Using questions as an interactive technique           

Focus attention Arouse interest Enhance inclusion by drawing out the reluctant learner Obtain feedback on the progress of the lecture Assess the level of understanding Assess the ability to apply learned concepts and knowledge Stimulate and guide thinking and reflection Explore different viewpoints Promote discussion and sharing Keep the discussion on track Summarize and consolidate learning

onto the same page before beginning the lecture. Intermittent questioning can serve as a formative assessment of learning and the lecture modified accordingly in real time to ensure that instructional goals are being met. Questioning in a residency environment should be sensitive to the hierarchical structure of the training program and should avoid demonstrating weakness in the knowledge base of senior residents in front of juniors. Therefore, questions should be posed to the group as a whole and not to individuals. It is also important to allow learners to question the teacher during the lecture rather than waiting until the end. Questions may also be posed to learners before the lecture. Learners will avoid not knowing the answers to questions they are given in advance as there is little excuse for not having tried. This technique serves to pique interest, focus learning, and help the learner build on prior knowledge. Preparatory questions further serve to stimulate the development of new patterns of self-directed learning such as reference and resource management which residents will continue after graduation. Discussion Discussion is one of the most powerful tools of teaching and learning. The transition from ‘‘lecturing to questioning to discussion’’ represents roughly the move from the didactic to the rhetorical and then to the dialectic mode of teaching and learning. All three modes are important, but for adult learners, it is obvious that the latter two modes are more significant. Discussion can be based on a provocative question, a case presentation, or a patient management question, or can be learner initiated. To conduct a fruitful discussion, the lecturer should  Avoid imposing an opinion or conclusion on the class  Listen actively

1210

SCHWEINFURTH

 Encourage participation with body language and verbal cues  Keep the discussion on track and prevent domination by one or two members  Maintain a balance of differing viewpoints  Correct factual errors  Provide a wrap-up at the end of the session Brainstorming Brainstorming integrates aspects of both questioning and discussion. Employed at the beginning of a lecture, brainstorming can be used to invite everyone in the group to participate and put them at ease [13]. The teacher can then alter the lecture based on the generated list (as a type of formative feedback) because it demonstrates the learners’ previous knowledge and educational needs. Brainstorming at different points in the lecture allows learners to apply knowledge obtained earlier in the session or as a summation of the learning experience. Small-group exercises Most otolaryngology residency programs are already small groups. Yet residents can be further divided by level of training or in half by juniors and seniorsdor a mix of each. An innovative use of small-group activities devised by the author involves pitting groups of residents against one another. The competitive nature of surgical residents makes the use of ‘‘contest’’-oriented group exercises a good fit. Each postgraduate-year level can serve as a two-person group, or for larger groups, junior versus senior residents. Potential ‘‘prizes’’ include immunity from future questions, reduced demands for activities in the future, or the power to determine tasks other residents must perform. The clinical orientation of cliff-hanger and incident cases makes them an ideal jumping-off point for small-group breakout sessions. In the former, residents are given a case outlining a complex situation that stops at the point where a decision has to be made; in the latter, multiple correct decisions must be made to obtain further information [10]. Residents can work against the clockda diagnostic and management total-cost limitd or each other to resolve each case. These are but a few examples of interactive small-group activities that can be implemented within a residency training environment. Interactive small-group activities and learning theory The small-group structure outlined above can serve as the basic unit of participation in the following types of activities: experiential and cooperative learning, problem solving, case study, simulations, role playing, peer

INTERACTIVE INSTRUCTION IN OTOLARYNGOLOGY

1211

teaching, independent study, and computer-based simulations [10,14–16]. The ‘‘expository model’’ creates a bridge between traditional and interactive lecture styles. Content experts present material in a carefully organized, sequenced and finished form. The major aspect in constructing the lecture is to provide a framework to enable students to receive the most usable material in an efficient manner, organizing knowledge into hierarchical and integrated patterns, from general to specific, and completing the lecture through reinforcement of the cognitive schema [17,18]. In one model of cooperative learning treatment described by Slavin [19], learners are assigned to teams; each member is assigned a portion of the material to be learned and designated as an ‘‘expert’’ for that portion. Each is then responsible for teaching that material to the rest of the group. The benefit of this activity is that it promotes team building through trust and interdependence between members. Gulpinar and Yegen [20] demonstrated that the use of an advance organizer, followed by a presentation of new material and reinforced by an intermittent, interactive task, best captured students’ attention and allowed for recall of previous information, repetition of the material, and integration of newly presented and previous information. Furthermore, they reasoned that if new learning is not based on some prior knowledge, students may learn new information as ‘‘isolated’’ bodies of knowledge and may therefore face difficulties in applying and transferring the new knowledge in novel situations. On the other hand, activation of prior knowledge promotes reconstruction of already existing schemas and provides students with a more fruitful conceptual framework for particular contexts [21]. ‘‘Best-fit’’ techniques According to Frederick [22], the lecture is here to stay. Although adult learners may be eager to embrace change, faculty are not so readily retooled. Therefore, interactive techniques that can be adapted to existing strategies are most likely to be successfully adopted over the long-term. Of the aforementioned techniques, questioning is the most readily usable by most faculty, and minor modifications to most curricula will greatly improve the execution of this strategy. Some of the potential problems encountered by the introduction of interactive techniques are listed with suggested solutions in Table 1. Although not an exhaustive list, these problems are the most commonly encountered ones when incorporating interactive techniques. Slightly more involved techniques, such as discussion and brainstorming, would be the next most adoptable solutions given their use in other formats (eg, the multidisciplinary tumor conference or the morbidity and mortality conference). Although likely to be disorganized initially, discussion empowers the residents (or other physicians) to direct their own learning and, in turn, take responsibility for the conduct of the session, thus greatly reducing the burden on the facilitator.

1212

SCHWEINFURTH

Table 1 Interactive lecturing problems and solutions Challenges

Possible solutions

Time available for lectures is reduced Residents may feel cheated

Reducing content may be useful  Lecturer can make clear lecture notes available  Explanation of approach to learning and teaching is important  Keep advance work expected to minimum  Can read short passages in the session together Choice of task may be important

Residents may feel overloaded if they are asked to do some work in preparation Residents may find it hard to participate if they do not know enough There may be a loss of clarity or focus Lecturer may fear loss of control

Lecturer may be anxious about ability to answer questions

Lecturer may be required to have particular skills to construct appropriate interactions and respond to comments Some individuals may dominate Residents may lack confidence in speaking in large groups Residents may be used to a culture of passive learning in lectures

Residents want clear notes for examinations

Give a ‘‘map’’ to activities interactive elements can be planned to enhance focus  Can use bell or other device to change mode  Requires balance within session between lecturing and interaction  Residents can be referred to sources  Unanswered questions can be dealt with in a later lecture or through Web systems  Can be viewed as part of a new culture of learning  Will need to develop skills by practice  Start with simple interactions  Can learn from others  Ensure a variety of views are heard  May need ground rules regarding air time Can use paired work to build confidence (or allow time to think on their own, then share ideas in pairs)  Need to build new culture (eg, by reducing physical distance between lecturer and students)  Prepare students  Explain importance of learning through repetition of notes  Lecturer can produce notes (eg, on the Web)

Adapted from Young P. Interactive lecturing: problems and solutions. Social Policy and Social Work Subject Center of the Higher Education Academy, November 2001. Available at: (http://www.swap.ac.uk/learning/interactive3.asp).

The use of small-group breakout sessions poses more of a departure for most otolaryngology faculty. However, the use of problem-solving and clinical cases will greatly facilitate this transformation and improve the likelihood of acceptance and ultimate success. According to Tough’s [23] theory of self-directed learning, the best results come from the skillful integration (with concerted efforts both by the teachers and learners) of self-directed learning within formal instructional

INTERACTIVE INSTRUCTION IN OTOLARYNGOLOGY

1213

programs. Therefore, techniques that combine the use of an advanced organizer (from simple prelecture questions and outlines to the preparation of formal presentations to be given to the rest of the group) with interactive techniques integrated into the lecture session are most likely to provide the best results. This format may be used with didactic, medical– knowledge-based lectures as well as problem- or case-based sessions with equal effectiveness. Summary The ideal teaching techniques for use with residents or other physicians should combine the goals of development of medical knowledge, team building, or leadership skills with self-directed learning that provides a period for reflection and personalization of learning goals for individual needs. This approach would empower learners such that they are in control of their own learning and allow them to pursue topics of interest. It would also promote independence and the means to discuss and defend one’s own ideas. In short, the ultimate goal is internalization of the curriculum such that faculty are merely facilitators of the learning process, and not its directors. References [1] Ramsden P. Learning to teach in higher education. London: Rutledge; 1992. [2] Isaacs G. Lecturing practices and note-taking purposes. Studies in Higher Education 1994; 19(2):203–17. [3] Gibbs G. Lecturing to more students. Oxford (UK): Polytechnics and Colleges Funding Council; 1992. [4] Knowles MS. The modern practice of adult education: from pedagogy to andragogy. 2nd edition. New York: Cambridge Books; 1980. [5] Merriam S, editor. An update on adult learning theory. San Francisco (CA): Jossey-Bass Inc; 1993. [6] Knox AB. Proficiency theory in adult learning. Contemp Educ Psychol 1980;5(4):378–404. [7] Merriam SB, Cafferella RS. Learning in adulthood. 2nd edition. San Francisco (CA): JosseyBass Inc; 1999. [8] Fox RD, Mazmanian PE, Putnam RW. Changing and learning in the lives of physicians. New York: Praeger Publishers; 1989. [9] Geertsma RH, Parker RC, Whitbourne SK. How physicians view the process of change in their practice behavior. J Med Educ 1982;57:752–61. [10] McLaughlin K, Mandin H. A schematic approach to diagnosing and resolving lecturalgia. Med Educ 2001;35:1135–42. [11] Bloom BS, Krathwohl DR, Masia BB. Taxonomy of educational objectives: handbook I. cognitive domain. New York: Mackay; 1956. [12] Bonwell CC. Enhancing the lecture: revitalizing a traditional format. In: Bonwell CC, Sutherland TE, editors. New Directions for Teaching and Learning. San Francisco, CA: Jossey-Bass Inc; 1996;67:31–44. [13] Steinert Y, Snell LS. Interactive lecturing: Strategies for increasing participation in large group presentations. Med Teach 1999;21:37–42. [14] Keyser MW. Active learning and cooperative learning: understanding the difference and using both styles effectively. Research Strategies 2000;17:35–44.

1214

SCHWEINFURTH

[15] Legan SJ. Multiple-format sessions for teaching endocrine physiology. Advances in Physiology Education 2001;25:228–32. [16] Micheal J. In pursuit of meaningful learning. Adv Physiol Educ 2001;25:145–58. [17] Chung JM, Huang SC. The effects of three aural advance organizers for video viewing in a foreign language classroom. System 1998;26:553–65. [18] Ivie SD. Ausubel’s learning theory: an approach to teaching higher order thinking skills. High School Journal 1998;82:35–42. [19] Slavin RE. Cooperative learning: theory, research, and practice. Englewood Cliffs (NJ): Prentice Hall; 1990. [20] Gulpinar MA, Yegen BC. Interactive lecturing for meaningful learning in large groups. Med Teach 2005;27(7):590–4. [21] Biemans HJA, Deel OR, Robert-Jan Simons P. Differences between successful and less successful students while working with the contact-2 strategy. Learning and Instruction 2001;11: 265–82. [22] Frederick P. The lively lectured8 variations. College Teaching 1986;34:43–50. [23] Tough A. The adult’s learning projects: a fresh approach to theory and practice in adult learning. 2nd edition. Toronto: Ontario Institute for Studies in Education; 1971.