Untitled

Robert Karp, MD

Avrahom Gurwitz, MPH

Department of Pediatrics

SUNY-Downstate Medical Center

Brooklyn, NY

Darwin Deen

Department of Family Practice

Albert Einstein College of Medicine

Pre-test for Part VI Section 3 (detailed explanations at the bottom):

A Medical student is given a list of Vitamins and Minerals said to be deficient in a set of 10 nutrition related disorders (Iron, Thiamin (B1), Vitamin D), etc along with a set of disease states. She is told she will be quizzed on the correct correlations.

Q1. Which vitamin or mineral is deficient in Iron Deficiency Anemia

A. Iron

B. Thiamine

C. Vitamin D

D. They are all deficient

Q2. and Q3. The same question and choices for Beri-Beri and Rickets.

Q4. What would engage the student best in retaining information about these conditions?

A. A simulated patient experience

B. An interactive discussion of applying principles of nutrition assessment.

C. A lecture series covering each of the nutrients

D. A lecture reinforced by a simulated patient, and an interactive discussion.

Objectives

On completion of this section, residents will be able to:

Describe differences among short term, long-term, and working memory
Appreciate the importance of affective, experiential (e.g., "active") learning in developing a working memory for information and a set of skills needed to use it.
Use active learning techniques in their own teaching

Introduction:

A major concern in medical education is that material be presented in an experiential and effective way: if students do something that touches his or her own consciousness, that something "sticks." That is, it enters into one's long term memory. This observation, first made by John Dewey and affirmed by Jerome Brunner, has support in both psychological and neuroscience studies. For example, language that stimulates heightened activity in the left prefrontal and temporal cortices has been associated with prolonged memory (Wagner et al, 1998). The same is true for actions. [Don't we all remember socially awkward experiences from our youth?]

Long term memory includes general principles that are retained through life. They include substantial skills related to how to gain information rather than the specifics

It is a natural phenomenon that uncompleted or interrupted tasks are retained in "working memory" better than completed ones. The general theory, called the "Zeigarnik" effect, suggests that a sequential learning process with a series of incomplete tasks leads to better retention of information than discreet, completed one. It also explains the success in learning when material is case-based or where there is peer teaching. By contrast, much pre-clinical education fails in developing working memory or retention of information, long term.

Working memory includes information necessary to complete clinical tasks. They include having skills, techniques and specific factual material for patient care in the settings where these are in need.

Class learning unsupplemented by clinical experience, however, tends to be lost. Much of medical education consists of a series of tasks completed in preparation for examination. Residents will remember information specific to their rotations (e.g., neonatal intensive care, emergency care, etc.) while they are on service, but once that rotation is completed, specific material learned is deleted. There is "short term" memory, but is not retained sufficiently to be securely remembered.

Short term memory includes any or all factual material as well as skills needed to conduct tasks that are completed in a defined time-frame.

Case Study #3

This case focuses on distinguishing among a need for "Short-term," "Working," and "Long-term" memory.

Mirelle is an 18-year-old pregnant teen-ager who has come to you for a health check. She says, "I've heard that taking a vitamin will prevent birth defects. Is that true?"

Q1. What elements of the nutrition history taking should enter long-term, working and short-term memory?

A1. Here are a few examples:

Long-term: The importance of

1. Taking a detailed history,

2. Knowing about the culture of the families

3. Appreciating the impact of food cost and cultural impediments on obtaining adequate nutrients.

4. You need to remember that folic acid is exceedingly important in pregnancy to prevent neural tube defects, maintain fetal growth, and prevent pre-term delivery.

Working: The process of taking a history

1. Actual elements of the culture(s) seen

2. The need for B vitamins B12 and folate to be taken together

3. The foods that contain different nutrients

4. The role of food support, food fortification and nutrient supplementation in providing these essential nutrients

Short Term: The mechanism of action

1. Specific vitamins such as folate.

2. How vitamins work to achieve a healthy outcome.

Q2. How can we develop working memory in residents and pediatricians?

A2. Achieving long-term memory has been a goal of undergraduate medical education and general pediatric residency training, but we, the teachers, have not been doing very well. A more appropriate goal for undergraduate training, drawn from the work of ED Hirsch, Jr. would be to create a structure for learning that is constantly reinforced and broadened through experience. Hirsch lists the following three keys to creating a matrix for successful learning:

1. Is the material presented sufficient in quantity and quality to achieve a domain of understanding?

2. Is there a fluency developed to enable the learning process to be maintained?

3. Is there an ability to use the information in a context different from that in which it is originally presented?

An essential element of the teaching experience is for learners to question and teachers to answer. Answering a question forces a teacher to reformulate his or her own understanding of the subject. This process reinforces understanding for both teacher and student. Thus, the process of teaching used is an important contributor to retention. A pure lecture format for teaching will not include the "give and take" necessary for reformulation and reinforcement. An appropriate goal of teacher training is to insist on limitations in the time spent providing material in didactic format. Rather, using a combination of question and answer and "role-play" [residents assuming the role of patients, parents and provider] will be more effective in sustaining learning. [Silberman, 2006]

Here are Silberman's eight keys to active learning:

1) Engage

2) Be brain friendly

3) Discuss

4) Encourage questions

5) Students learning from each other

6) Do it

7) Integrate technology

8) Unforgettable end

You are conducting a small group session for 3rd year medical students. The students are starting their pediatric clerkship. You are going to teach them how to take a nutritional history.

Q1. What are some ways you can engage the students?

A1. A popular method is called an icebreaker. Icebreakers are techniques used at the first session to reduce tension and anxiety, and also to immediately involve the class in the course. An icebreaker in this case can consist of having everyone in the group tell everyone else of a food that reminds them of a childhood event and why.

Q2. What are some ways you can be "brain friendly" - encourage thinking?

A2. One way you can encourage thinking is by opening the lesson with a short nutritional story that is dramatic and interesting both factually and educationally. You can present a short problem, ask an opening question or give a highlight to coming attractions. All these are designed to make the students brains wake-up to make them receptive to learning.

Q3. What are some ways you can encourage lively and focused discussion?

A3. First you should get a survey of the student's opinion. Students ask more questions when their opinion are elicited first. Then distribute a compelling document such as an article or even a picture. Then provide a contrasting opinion even if the opinion is not his own. This will stimulate discussion and it will also get the students to think about other possibilities.

Q4. What are some ways you can urge students to ask questions?

Here is a photo from a wedding. Ask the residents what they see. Their observation relates very much to Mirelle's concern.

TEACHING CAPTION: It is a photo of an Orthodox Jewish couple just or about to be married. There is a clue shown. The left hand of the bride is resting on an aluminum armrest. Why?

The bride and groom are in wheel chairs as they both have spina bifida. This could probably have been prevented (~80%) by having adequate folate in the diet to compensate for a C677C>T transformation of Methyl TetroHydro Folic acid Reductase (MTHFR). This evolved in much of European ancestry populations because it deprived Salmonella of their source of folic acid and lead to population survival advantage for the TT mutation. [See module on folic acid and nutrition in pregnancy]

A4. A lively discussion usually leads to questions. However, if the students fail to ask questions here are some tips to get them to ask questions. Hand out a list of questions as a reference. Then ask students to develop a question with the person sitting next to them. If they fail to come up with good questions, you can teach them how to ask a good question. You can teach them that a question is a way of resolving information and making it fit with other information already gained elsewhere. Modeling a good question may also be helpful.

The picture they are looking at is the marriage of a young man and woman with neural tube defects.

Some questions they might ask relate to the prevention of NTD's using folic acid, the clinical care of NTD patients, and the social ramifications of a couple with spinal cord dysfunction.

Q5. What are some ways you can let students learn from each other?

A5. The most important thing is to keep the learning unit small. Anywhere from 2 to 6 people in a unit is small enough to facilitate students learning from each other. Units larger than 6 students do not foster such an environment. Let students assign themselves to which students they want to work with. This allows students that already feel comfortable with each other to learn from each other. Compose the groups of diverse and heterogeneous students. This fosters different opinions and discussion between students, allowing student to gain perspectives from each other. Lastly, allow students to pick their own topics. This will foster interest in the topic between the students.

Q6. What are some ways you can enhance the students learning with experiencing and doing?

A6. Role-playing is one of the most powerful ways of learning information, second to actually doing the real thing, by experiencing the information. The group can break up into small dyads with one person being the "physician" and the other person being the "patient". The "physician" then takes a nutritional history from the "patient". After the "physician" is finished the students reverse roles and the other student becomes the "physician" and interviews the "patient". The students later discuss what it felt like to interview someone and what it felt like being interviewed.

This material provided by HB Karp, PhD.

An alternate to dyads is the use of triads, which is usually preferable.

A. One participant is the "Patient", one the "Physician" one the "Observer".

B. You provide all the players with an Observer form and a brief instruction on how/what to observe.

C. You rotate through three rounds rather than two. All feedback goes to the "Physician".

D. At the end of each round feedback is given as follows:

1. The "Physician" answers these two questions: A. "What did you like best about what you did? B. "What if anything would you change?"

(This provides Internal Subjective Feedback)

2. The "Patient" responds to the same to questions giving the Physician the feedback directly. (This provides External Subjective Feedback)

3. The Observer reads back the observations s/he has made which provides the Physician with External Objective Feedback

Feedback goes to the "Physician" at the end of each round. The Physician gets three different types of feedback for a single set of behaviors. You can also ask the "Patient", "What was it like being in this position?" You can also ask the "Observer", "What was it like watching the process from the outside with no personal involvement?" Remind all "You'll never have this opportunity again.'"

Q7. What are some ways you can blend technology into the learning process?

A7. One of the most useful technological advances is the Internet. By providing students with informative web sites, providing search tips and utilizing web quests one can enhance learning and provide a place for students to find more information on a topic. Another technological advance that can be used is slide presentations. A good slide presentation with graphics can be a great visual aid to learning.

Q8. What are some ways you can make an ending that reinforces what has been learned - an unforgettable ending?

A8. Inviting students to summarize the entire unit is a good way to for students to incorporate the information. Asking students to perform a skill is also a good way to end. Having students rate themselves, identify what they have learned and assess how they have changed is also an effective way of ending a session. Have students plan for the future. This adds an element of reality to the unit.

For more information on active learning:

Silberman M. (2006). Teaching Actively: Eight steps and 32 strategies to spark learning in any classroom. Needham Heights, MA. Allyn & Bacon.

Merrill H, Melanie T. (2006). Inspiring Active Learning: A Complete Handbook for Today's Teachers. (2nd Ed) NY, NY. Assn for Supervision & Curriculum.

Summary

The most important beginning for the development of a curriculum is to start at the end. Ask, "Do I have an evaluation protocol in place that will tell me whether I am achieving my goals, or alternatively, take corrective action?" Effective evaluation guides the learner and teacher alike. However effective the evaluation may be, the curriculum will fail unless it takes the teachings of classic and contemporary critiques to heart. Build structures of understanding (Hirsch), make learning experiential (Dewy and Brunner), and make learning active, rather than passive (Silberman).

Evaluation

We practice what we preach. Rate the qualities of this module with respect to the listed objectives on a scale of 1 (very poor) to 7 (superlative). Your feed-back is very important to us. We would appreciate your sending a copy of this section to rkarp@downstate.edu.

Part V

Have we:

1. Put elements in place for effective evaluation of nutrition (or other) teaching programs?