Dave's Whiteboard

Lena H. Sun of The Washington Post, who often reports on health-related topics, has an article in today’s paper about the use in medical training of “standardized patients” — healthy people portraying patients.  (Here’s how Johns Hopkins Medicine describes its standardized patient program.)

Developing the capabilities of doctors, nurses, and other practitioners is a clear example of complex learning.  You have a wide range of skills.  Some are primarily procedural: when you draw blood, do it like this; when you’re checking vital signs, do it like that. Follow this process for obtaining and recording data.

Most of what we think of as medical training, though, involves skill for situations where there’s no single correct approach to a given problem.  So the standardized patient is an individual who’s portraying a particular type of patient–in other words, someone who’s acting as a realistic learning task.

Many [of the standardized patients] are actors, but actors don’t always make the best patients, clinical directors said. Improv is not allowed. People trained to portray a particular type of patient must work from the same facts and deliver responses in the same way to the students examining them.

“They can’t overact,” said Kathy Schaivone, clinical instructor and director [of the Clinical Education and Evaluation Laboratory] at the University of Maryland at Baltimore. “If I can’t guarantee that all five will cry, the ones that I know that can [cry], I have to ask them not to.”

(Here’s an overview of the standardized patient curriculum at U-Maryland Baltimore.)

One challenge for the standardized patients is to provide a structured debriefing: “Did the student palpate the sinuses? Listen to the heart in all four places? Wash hands before and after touching the patient?”

In this setting, I see two interconnected sets of skills:

• Those needed by the medical practitioners to relate to patients, interact with them, and arrive at a reasonable diagnosis based on limited information.
• Those needed by the standardized patients in order to believably and consistently portray someone with a particular condition.

Behind both of these, of course, is an intensive effort to design, develop, and implement the training.  Beyond the somewhat obvious (what conditions are both useful to have portrayed and suited to the standardized patient approach?), there’s the multilevel skill required of the patients: how do I portray the condition?  What do I share readily?  What do I tend to withhold?  What am I incorrect about?

In addition, the patients need to debrief the students, both via checklists and via face-to-face feedback. Program directors like Schaivone, meanwhile, need to monitor the performances of both the patients and the students.

To illustrate the complexity of behavior, the online version of Sun’s article has a link to this May 2011 article on how doctors struggle to show compassion, by Manoj Jain, an infectious disease specialist and professor at Emory University.

‘Standardized medicine’ image adapted from the CC-licensed original by Ben Weston (Tek F).

Kevin Kelly, in this week’s New York Times Magazine, writes about home-schooling his eighth-grade son.  He balances a nothing-special tone (“one of more than a million students home-schooled” last year) with crisp examples like the boy’s decision to learn to make fire the old-fashioned way.

He was surprised by the enormous amount of bodily energy required [to use the bow method]… and how a minuscule, nearly invisible bit of fuel… can quickly amplify into a flame and then a fire.  Chemistry, physics, history and gym all in one lesson.  And, man, when you are 13 years old and Prometheus, it’s exhilarating!

(Probably took a little while longer than this demo I found on YouTube.)

Kelly and his wife had a goal: to provide an ideal learning environment.  Their son had gone to school for 7 years, and planned to attend an “intense” high school.  He was the one who asked if he could be home schooled.

What stands out for me is Kelly’s statement that technology was not a major factor in the success of this year.  Yes, lots of online materials and research.  But the computer was only one tool among many.

Kelly sees “technological literacy” as yet another proficiency children need to acquire.  It supplements but isn’t the same kind of critter as critical thinking, logic, or the scientific method:

Technological literacy is…proficiency with the larger system of our invented world.  It is close to an intuitive sense of how you add up, or parse, the manufactured ralm.  We don’t need expertise with every invention; that is not only impossible, it’s not very useful.  Rather, we need to be literate in the complexities of technology in general…

What kinds of literacy is he talking about? These stood out for me:

• Technologies improve so fast you should postpone getting anything you need until the last second.  Get comfortable with the fact that anything you buy is already obsolete.
  • This aligns with a tongue-in-cheek watchword: never buy a low serial number.  More seriously, it’s allowed me to happily skip at least 1 out of 2 OS  upgrades.

• Before you can master a device, program or invention, it will be superseded; you will always be a beginner.  Get good at it.
  • “You will always be a beginner.”  It sounds like you’re being sentenced.  It’s more like having a gate opened: you’re not the only one here.
    
• Be suspicious of any technology that requires walls.  If you can fix it, modify it or hack it yourself, that is a good sign.
• Nobody has any idea of what a new invention will really be good for.  The crucial question is, what happens when everyone has one?
• The older the technology, the more likely it will continue to be useful.

That last point truly resonated with me.  Among other things, it recalled a somewhat dry but oddly compelling book I’ve been rereading: The Coming of the Book: the Impact of Printing, 1450-1800.

Kelly’s website announces the coming of his latest book, What Technology Wants.  Here’s part of what he says about the book as a book:

I suspect this will be the last paper-native book that I do. The amount of work required to process atoms into a sheaf of fibers and ink and then ship it to your house or the local bookstore is more than most of us are willing to pay anymore. And of course the extra time needed upfront to print and transport it is shocking. This book was finished, designed, proofed, and ready to be read four months ago. But atoms take time, while bits are instant.

What about Kelly’s son?  I think he’ll do fine in that demanding high school, based on this anecdote near the end of the NYTM piece:

On one particularly long day, with books piled up and papers spread out, my son was slumped in his chair.

“Is everything O.K.?” I asked.

“It’s hard,” he said.  “I not only have to be the student, I also have to be the teacher.”

“Yes!  So what have you learned about being a teacher?”

“You have to teach the student — that’s me — not only to learn stuff but to learn how to learn.”

“And have you?”

“I think I am doing better as the student than the teacher.  I’m learning how to learn, but I can’t wait till next year when I have some real good teachers — better than me.”

I was surprised to learn–from my wife, no less–that I unconsciously assess things (especially edible things) on a personal scale with almost as many degrees as a thermometer.

It’s an understatement scale, I guess, because even as my approval increases, the terminology is…less than exuberant, as in these examples:

• That’s okay.  (Barely acceptable.)
• That’s not bad.
• Not half bad.  (Well above average.)
• Not bad at all.
• That’s all right. (At least one Michelin star.)
• Pretty good.  (At least two.)

There’s a theoretical maximum, “really good.”  It’s like absolute zero, only warmer; you don’t find it much in nature.

I asked my children whether they’d ever heard me apply these terms.  They couldn’t say, because it’s hard to talk when you’re convulsed in laughter.

The purpose of a scale is twofold: measuring and evaluating.  Measuring is a comparison with some standard: you’re this tall (in inches, in cubits, in stacked-up poker chips).  You typed 268 characters in 3 minutes and made 4 errors.

Evaluating is forming a judgment, usually by means of a further comparison.  You’re tall for a 14-year-old boy.  You meet the minimum speed required for this job.

Thanks to Stephen Downes’s OLDaily, I came across Clarence Fisher’s connecting assessment.  It’s a rubric he created for middle schoolers “to help students think about the connections and global understandings they are establishing.”

He doesn’t plan to assign grades based on where students are–this is a conversation starter, he says.  To me, it’s a way to say to the student, “This is how it might look if you’re at a beginner level of skill.  This is more-than-beginner.  This is how it looks if you’re accomplished.”

Fisher offered another rubric in an earlier post–one to help grade student blog posts.

What I like about these is that Fisher shares what he’s come up with for a particular situation.  He even provides Google doc versions (blogging rubric, connecting rubric) in case someone wants to use them as starting points.

Pretty good, I’d say.

“Approval scale” image adapted from this CC-licensed photo by mag3737 / Tom Magliery
(images are his; cartoon balloons are mine).

This morning’s Washington Post has an article about college professors banning laptops from their classrooms.  (The first example is from a Georgetown Law lecture on “democracy and coercion.”)

Similar bans, the article claims, exist at William and Mary, the University of Virginia, and other big-name schools.

It’s been years for me since college, so my own notions are just notions.  That rarely stops me from musing.

• That law lecture occurred in a room with a hundred students.  Ipso facto, it seems to me, the average student didn’t get to say ten words.  Not that you have to say something to rework, reconsider, connect what’s new to what’s known–but talking about new material is at least as helpful as writing notes on paper.
• It’s not as if a room without laptops is a room without distractions (or a room that suddenly has interesting lecture).  As a U-Va professor says, “If students don’t want to pay attention, the laptop is the least of your problems.”
• One comment added to the Post story reminds us of all the people who doodled, crossword-puzzled, or just read the sports pages while safely and quietly lodged toward the back of the lecture hall.

I don’t mean to seem one-sided.  No matter how cool your keyboard, even ten people in a room going clickety clickety clickety can be distracting–just as Worlds of Warcraft can be when it’s on the screen of the person in front of you during Conflict in Nineteenth-Century East Asia.

Stepping completely outside things I know about: maybe the tried-and-true formal education approach isn’t always ideal.  A law professor in a lecture hall might not be so impartial about his methods as to concede their shortcomings.  Is a lecture to 100 people an optimal way to achieve whatever the goal is for “democracy and coercion?”

Maybe not–because formal systems like law school have a built-in time and exposure constraint, culminating in not just the law degree but the bar exam.

Mostly I think the question hinges on specifics: what’s the purpose of this (presumably in-person) class?  Why is it in-person?  Am I as the professor dispensing knowledge (the Font of Wisdom approach)?  Am I encouraging people to explore issues, grapple with implications, bring in things from the outside?

Consider the approach of another Georgetown law professor (who does allow laptops).  He told his class that Chief Justice John Roberts was stepping down from the Supreme Court.

That was untrue, as the professor knew–but the news flew out.  It seems the real point of the lesson was: credibility. (Much more on this story at Above the Law, including a follow-up.)

CC-licensed image of lecture notes by Kevin Lawver.

My driver’s ed instructor told my class:

You never have the right of way.
You can only yield the right of way.

Recalling this precept got me thinking about driver education / driver training, and that got me thinking about how people have very different readings for “training,” “education,” and “learning.”

Learning to drive is a good example of a complex skill (the kind van Merrienboër and Kirschner grappled with in Ten Steps to Complex Learning).  We tend to think we know what the outcome of the education or training will be: a good driver.

But what’s that?

On the formal side, it’s really about passing requirements.  If you’re an adult who moves to Maryland, for instance,  you have to:

• Pass a vision test
• Have had an out-of-state license within the past year (no suspensions)

And if your out-of-state license expired a year ago, you have to take “the knowledge and skills tests,” which I take to mean a road test and what was once known as a written test.

I’ve been driving for more than 40 years and have had licenses in four states, but I don’t recall taking more than one road test.  Not that I’m eager to do so, but you do get the impression that if you pass it once, still drive, and haven’t lost your license, you’re doing okay.

Some of what vM&K would call constituent skills for driving are recurrent ones–how to start the car, how to stop, how to steer, how to recognize signals and respond to them.  But there are many non-recurrent skills (things we do differently in each situation).  The other day I was exiting a strip-mall parking lot, wanting to turn right onto the highway.  An oncoming car on that highway had its right turn signal on.

Did that mean he’d be turning into the lot I was exiting?  How could I tell?  How could I help a novice driver figure that out?

My old instructor’s advice about right of way was a kind schema or mental model, like the two-second rule–one way to help new learners acquire cognitive strategies.

In writing about this, I’m seeing more clearly that there’s also an overlap of stakeholders: the general public (represented by the state) wants the roads to be safe; new drivers want to be able to drive; parents want their children to drive safely.

They might not even agree on the outcome.  Is it “status as skilled driver” or simply “holder of a driver’s license?” Is “skilled” the same as “safe?”

(I can answer that one: no.  Just take a drive through heavy traffic with someone who prides himself on what a skillful driver he is.)

Maryland’s Motor Vehicle Adminstration publishes a skills log and practice guide “to help the new drives gain valuable experience in operating a motor vehicle in a variety of conditions and highway environments.”  Maryland now requires 60 hours of supervised driving prior to taking the tests, with 10 of those hours at night.  The parent, guardian, or mentor of the new driver must sign a statement attesting to this, in addition to the 6 hours of behind-the-wheel instruction in the mandatory driver education course.

I like the guide (other than the mid-60s bureaucratic tone of the writing).  A “planning guide” (on the right; click for a larger version) summarizes skills; individual sections amplify them with descriptions, examples, and checklists.

Because of the state’s interest in having competent drivers, it makes sense for the state to have created this.  Is 60 hours the right amount?  Are these skills the right skills?  Will parents or guardians follow the guide, or simply certify that they had?

I can’t say–and, frankly, neither can you.  This is a complex skill; there’s no one right answer.  I think you can make a case that most of the skills in the guide are basic ones for a competent driver.  At the same time, no test is going to guarantee that a new driver, or even an experienced one, will never have an accident.  (I’d settle at times for “will not talk on the phone while driving.”)