MOOCs and things

by reestheskin on 16/12/2016

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Video is cool. Text isn’t.

Houston, we have a problem.

OEB16 musings

by reestheskin on 13/12/2016

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I went to the OEB meeting for this first time this year. I was not certain how much I would like it, but found it really enjoyable. Not a meeting I would go to each year but, if you are interested in teaching and learning in the broadest sense, it is well worth a visit. I would go again.

One of the sessions I enjoyed most was a fairly small concurrent session with the title ‘The value and the price: discussing Open Online Courses’, chaired by Brian Mulligan (IoT, Sligo), and with panellists Stephen Downes(NRC, Canada), Nina Huntermann (edX), Diana Laurillard (UCL), and KonstantinScheller (European Commission). It was all wonderfully informal, with not too many people there and plenty of time for questions and discussion. I got involved too, rather than just listening. The discussion ranged widely over MOOCs (c or x), online learning, ‘conventional teaching and learning’ and other topics, but that is to be expected. You cannot discuss online learning without thinking about offline learning; you cannot discuss new tech, without discussing old tech; you cannot discuss scale without discussing one-to-one; you cannot discuss value without talking about money and non-money.

I didn’t take notes but the thoughts going round in my head (prompted no doubt by the panel were):

  • You cannot hide from the question of value. You can think about this is terms of money, time, inner wealth or job prospects, but the calculus has to exist somewhere. If the learning takes place in an institution that performs other tasks and has other goals (research, outreach, engagement, certification), this value has to be factored somewhere. Cross subsidies will be under challenge, whether they are they are sensible, or not. Sensible for whom?
  • I am, to use somebody else’s phrase, a libertarian paternalist when it comes to higher education. I really do think I can guide people through difficult terrain. But putting glorious autodidacts to one side, to what extent do many students need coaches, and under what conditions. The answer, at least in some of the domains I know about, is far less than we like to think. And, those who require least guidance are, in many senses, those we want most.
  • Content. What is the content, how is it presented, how does it hang together, how tested is it, how has it been curated, how personal is it? I will start ranting about this soon, so I will shut up now. Except to say, it is not a rant: this is so important.
  • How important is place? Where is the community? How do you maximise the sense of place?
  • How do you balance private study with communal learning. What is the right balance, and how does the answer influence costs?
  • I can see differences between MOOCs and other forms of non-institutional learning, but only of degree. Penguin books, and BBC OU broadcasts were open to many of us, and used by many of us. But they only allowed local conversations, rather than networked learning. We can — or at least –could do a lot more now.

Thoughts crossing in the night

by reestheskin on 01/12/2016

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I am at the OEB16 meeting in Berlin. As ever, thoughts cross. If you go around the stands you have to ask about the relation between learning — a personal act — and all that you can sell to go with it. Software, hardware etc. And you have to wonder about the balance of goods and dreams.

Marcia Angell reviews Alice Gopnik’s ‘The Gardener and the Carpenter’ in the NYRB (November 2016)

‘Among the book’s strengths is that Gopnik leaves no doubt about where she stands on the peculiarly American way of leaving families on their own in an increasingly unequal society. “Middle-class parents are consumed by the pressure to acquire parenting expertise,” she writes.

(Gopnik quoted text)

“They spend literally billions of dollars on parenting advice and equipment. But at the same time, the social institutions of the US, the genre at originator and epicenter of parenting, provide less support to children that those of any other developed country. The US, where all those parenting books are sold, also has the highest rates of infant mortality and child poverty in he developed world.”

Making new ideas

by reestheskin on 22/11/2016

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Another great video of Alan Kay, explaining how intellectual revolutions occur ( ‘appoint people who are not amenable to management’)

You have the MOOCs and bla-bla-bla

by reestheskin on 19/11/2016

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“You have the MOOCs and bla-bla-bla – you can quote me on that,” he says, laughing, “but the real revolution that has happened is in YouTube, Wikipedia, Minecraft, and people publishing things on the internet.”

I think MOOCs are interesting, mainly because of the light they cast on dated and inadequate models of university mass education, but he is right.

Mark Surman of Mozilla.

Classroom learning, engagement and oxymorons

by reestheskin on 10/11/2016

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Undergraduates frequently complain that they don’t have enough contact hours. But a major study in the UK suggests that students develop skills better out of – rather than in – the classroom.

I do not find this claim too surprising, but if you read the article and go to the HEA ‘engagement report’, I find it hard to know how they claim to have established this as a fact. Confounding and hidden variables all around. But as has been said before, classroom learning has the air of an oxymoron. Contact hours are both relevant and  irrelevant. Context matters most.

The importance of tails for clinical expertise

by reestheskin on 07/11/2016

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There is a nice piece by Nassim Nicholas Taleb in Medium. It is from a forward to a book (I think) on physical / strength training. If you have read Taleb you will know this is not too surprising.

You will never get an idea of the strength of a bridge by driving several hundred cars on it, making sure they are all of different colors and makes, which would correspond to representative traffic. No, an engineer would subject it instead to a few multi-ton vehicles. You may not thus map all the risks, as heavy trucks will not show material fatigue, but you can get a solid picture of the overall safety.

Likewise, to train pilots, we do not make them spend time on the tarmac flirting with flight attendants, then switch the autopilot on and start daydreaming about vacations, thinking about mortgages or meditating about corporate airline intrigues — which represent about the bulk of the life of a pilot. We make pilots learn from storms, difficult landings, and intricate situations — again, from the tails.

In one sense he is saying something that is easy to agree with. But if you delve a little deeper, it is not what we always do in medical education.

The structures we create to enable learning in a clinical discipline are not mirrors of what goes on in the real world. Pace the airline example. We shouldn’t expect teaching time to mirror disease prevalence; we don’t spend most of our time in dermatology teaching students about viral warts, or dandruff, or toxic erythema. When you try to recognise objects, you do not just study those particularly objects. Rather, you have to study all the other objects. If you want to be able to ‘call out’ whenever you see a dog, you have to study cats. And chimps, and wolves and so on. This is one of the reasons why just learning about the top ten conditions makes little sense, if acts of recognition are involved. Most things are defined by what they are not. To think in the box, you have to know what is outside the box. This is what makes medical education a hard problem.

There are implications for clinical practice for the expert, too. Everyday practice appears to minimise the role of the statistical tails. Your learning about common condition may be ‘everyday stuff’ requiring little formal study. But for rare conditions, or odd presentations of common conditions, everyday practice, may not be sufficient — simply put, you do not see rare events frequently enough to consolidate and strengthen your memories. Everyday practice rarely provides enough critical mass, you might say. A practical example.

When I was a trainee in Newcastle if we saw an ‘interesting patient’ or a patient in which the diagnosis was unclear, we pressed a buzzer. The buzzer and flashing light went off in all the clinic rooms, the laboratories, the professor’s office and the seminar room. What happened then, resembled the Stepford wives. All descended on the particularly clinic room, as though under some malign influence. There were times when this was quite funny, although some patients might have told this differently.

This simple tool was just an implementation of another one of Rees’s rules: routine clinical practice is not sufficient to consolidate or acquire the skills you need to provide routine clinical practice. This seems like a paradox, but it isn’t. “A sailor gets to know the sea only after he has waded ashore.”  Rather, I always view it as a solution to the forgetting curve that Ebbinghaus described (although I think there may be other justifications)

There is a simple learning point here. The acquisition or maintenance of clinical competence requires much more than seeing patients (and by this, I do not just mean reading research papers). Software, and virtual worlds that we control, might help. But the Rees maxim remains: routine clinical practice is not sufficient to consolidate or acquire the skills you need to provide routine clinical practice

In your final year, you get to crack eggs

by reestheskin on 31/10/2016

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“Imagine if we taught baseball the way we teach science. Until they were twelve, children would read about baseball technique and history, and occasionally hear inspirational stories of the great baseball players. They would fill out quizzes about baseball rules. College undergraduates might be allowed, under strict supervision, to reproduce famous historic baseball plays. But only in the second or third year of graduate school, would they, at last, actually get to play a game. If we taught baseball this way, we might expect about the same degree of success in the Little League World Series that we currently see in our children’s science scores.”

Alison Gopnik

‘You Americans have the best high school education in the world. What a pity you have to go to college to get it.’ In Alan Kay

We don’t need no teachers

by reestheskin on 24/10/2016

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‘People pay a lot for a great education now, but you can become expert level on most things by looking at your phone.’

Sam Altman quoted in the New Yorker

It is just nice to see it in black and white. So simple. BTW, the quote came via the wiser (not ‘smarter’) Nick Carr, who commented: ‘By “a really good life,” Altman means a virtual reality headset and an opioid prescription’.

ed.derm.101 update and more SoundCloud tracks added

by reestheskin on 21/10/2016

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I have been busy updating some teaching stuff. It is never finished but there is time for a little pause. I have completed all the SoundCloud audio answers to the questions in ed.derm.101 (Part C) and there is a ‘completed’ version of ed.derm.101 Part C half way down the linked page. Not all the links have been checked, and a lot had to be redone because the superb New Zealand Dermnet site changed their design (the best source of dermatology images, IMHO). An example of the sort of audio material is below.

Rankings matter! But what matters in rankings?

by reestheskin on 18/10/2016

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Apart from money, that is.

HigherEd is awash with rankings. Governments like them, and so do publishers. Just look at the THE, with its myriad of bullshit scores. The allure of bogus numbers, over judgment. A feel-good frenzy of metrics. When rankings of US colleges first came in, the assessors used to actually live on campus for a while, go to lectures, and talk to students. There was an attempt at face validity. Not any more. All you need is GIGO data, and you can sell it, or use it to buy power and kickbacks like the politicians. There was even a time when the notion of common sense mattered, but then came the RAE/REF. Then the TEF. Larry Lessig’s comment is worth repeating, again.

The best example of this, I am sure many of you know are familiar with this, is the tyranny of counting in the British educational system for academics, where everything is a function of how many pages you produce that get published by journals. So your whole scholarship is around this metric which is about counting something which is relatively easy to count. All of us have the sense that this can’t be right. That can’t be the way to think about what is contributing to good scholarship.

Anyway, at the back of last week’s Economist I came across a single page advert in the ‘Courses’ section, about IMD (shown below).


I suspect I would have passed over it, except that I used to meet up from time to time with a Professor of finance who lived in Edinburgh and worked at IMD. We had many conversations about teaching, and what impressed me was the focus on ‘education and teaching’ and thinking hard how to do it better. There is a lot about MBA programs that I do not understand, and a fair bit I am suspicious of, but I have little doubt they offer something medicine could learn from.

It piqued my interest enough to follow it up, so here is some more text from the IMD page.

At the end of September, we were informed that IMD would be included in the 2016 MBA ranking, despite the Economist’s initial agreement. This is surprising as we had not supplied any information and our participants and alumni had not been surveyed for this ranking. This contradicts the paper’s statistical method, which requires a minimum 25% survey response rate to be ranked.

Needless to say, IMD has serious reservations regarding the Economist’s methodology and its outcomes. In 2015, relative to the previous year’s ranking, LBS & IESE fell 9 ranks, IMD fell 11, and ESMT fell 23. Meanwhile, IE, Warwick and Macquire all jumped up 19 scores. As a result, Queensland, Warwick, Henley were ranked better than Cornell, London Business School, Carnegie Mellon and IMD!

They then go on to argue that the Economist ranking is scale dependent, and will discriminate against small schools (and, as we know small universities like Cal Tech are terrible…).They finish off with:

Again, IMD was not surveyed for the 2016 ranking and did not actively participate. Given this, we do not know which data the Economist will use to establish our position. What we do know is that the Economist ranking has just lost its last bit of credibility. Unfortunately, there is little IMD can do to stop the Economist from proceeding.

Says it all. Wake up. At least the Economist accepted the money (for the advert).

The Heavenly Emporium of Dermatological Knowledge

by reestheskin on 12/10/2016

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In my ‘online’ textbook of ‘rashes’ (ed.derm.101), that is the non-cancer bits of dermatology, I have a chapter called ragbag. I used to have two ragbag chapters, but now by combining them, the subject has been made simpler and easier, even though the content is unchanged. I am sure students agree. I put in this chapter all the things I do not put elsewhere. I thought I should now fess up a little, as Gödel would not have said.

In ‘John Wilkins’ Analytical Language’, Borges refers to the work of Franz Kuhn and his work on the the Chinese encyclopaedia the ‘Heavenly Emporium of Benevolent Knowledge’ (John Luis Borges, Selected Non-fiction, ISBN978-0-14-029011-0). This work is a classification of the world. For instance, you can classify the world into various groupings or categories. For animals we have:

  1. Those that belong to the emperor
  2. Embalmed ones
  3. Those that are trained
  4. Sucking pigs
  5. Mermaids
  6. Fabulous ones
  7. Stray dogs
  8. Those that are included in this classification
  9. Those that tremble as if they were mad
  10. Innumerable ones
  11. Those drawn with a very fine camel hair brush
  12. Et cetera
  13. Those that have just broken the flower vase
  14. Those that, at a distance, resemble flies

All very straightforward stuff, as any medical student will agree. I also like the system proposed by the Bibliographical Institute of Brussels (after Borges). It parcelled the universe into 1000 subdivisions with number 262 corresponding to the Pope, 268 to Sunday Schools, 298 to Mormonism, and 179 to cruelty to animals, duelling and suicide.

We have lots of similar systems in medicine, some of which seem less fit for purpose than those described above. My incomplete categorisation of categorisation (the grant was turned down) is as follows:

  1. A minority are generative — you get more out than you put in. We work hard to avoid these.
  2. Some are overtly vexatious.
  3. Soem are covertly vexatious.
  4. Some require more input that you get out (like fees).
  5. Some require so much learning to understand the nuances of the classification, that learning the ‘facts’ is a relief.
  6. Some reflect career enhancement on the part of the teacher.
  7. Some are designed to allow a subject to be examined in a MCQ.
  8. None of the above.
  9. All of the above.
  10. Ichthyoses.

Dreyfus and Dreyfus, the US philosophers and students of AI, pointed out that although we like to use rule-based systems in teaching, experts quickly forget them, and do not appear to use them (From Socrates to Expert Systems:The Limits of Calculative Rationality, 1984). We just inflict them on the young either because that is the only way we know how to encourage learning, or because we repeat what happened to us earlier in our career without good reason. Quoting Dreyfus and Dreyfus:

The beginning student wants to do a good job, but lacking any coherent sense of the overall task, he judges his performance mainly by how well he follows his learned rules. After he has acquired more than just a few rules, so much concentration is required that his capacity to talk or listen to advice is severely limited.

They were not writing about medical students. But I recognise what is going on. I can remember it too. Classifications may or may not be useful in learning a subject, and in chunking, may provide a guide to action. But the more experience you get, the less the clinician uses them. Academics, of course, play by different rules, and get to write the rules.

Marvin Minsky once quipped “Every educational reform is doomed to succeed”. He meant “with some students”.

Alan Kay

One principle about learning

by reestheskin on 07/10/2016

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“If I had to reduce all of educational psychology to just one principle, I would say this: The most important single factor influencing learning is what the learner already knows. Ascertain this and teach him accordingly.”(Ausubel, 1968 p. vi). Via Dylan Wiliam.

Wie sagt man das…

by reestheskin on 06/10/2016

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When I was a child, growing up in Wales, my father would express puzzlement that I didn’t seem to know how to pronounce certain words. He didn’t get that since Welsh was his equal first tongue — but not mine— knowing how you pronounce Welsh words was obvious to him, but not to me. For my part, it was only scores of years later that I realised some of his verbal mannerisms were not just odd idiosyncratic English or slang, but Welsh, although the meaning was clear to me. I  had just not realised these were Welsh words or phrases, and of course I too would use them.

I have noted in the past, that when students mispronounce some of these dreadful dermatological terms, it was a signal that they had read about a disease, but had never been taught on that disease. It signalled to me how much they were acquiring on their own. English is like that, certainly in comparison with German: until you hear the word spoken, guessing how you say it, is tricky. More so, when you chuck in the various languages that contribute to the dermatological lexicon — and when they are then spoken / bastardised by English speakers.

But today, a student today pointed out that it would be helpful to include how words are pronounced in our course material. I am not certain how to do this yet, but I can believe that not knowing how to pronounce a term might ‘inhibit’ thinking and ‘silent talking’ about the topic (I do not know whether there is any research to back this opinion up).

Hotel California, and who pays for the education of doctors?

by reestheskin on 05/10/2016

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I wrote a post on this topic awhile back trying to map out the territory of funds going in and out of undergraduate medical education. It was a bit too rambling but more thought out I feel than Jeremy Hunt’s latest slant on statistics that the Guardian (and others) reported. So here are some bullet like points on this issue, together with some questions. The backdrop is the article I wrote before, and the issue of ‘we paid for their training so we can seize their passports’ (Phil Hammond’s, ‘Hotel California clause’: ‘you can check in but you can never leave’.) And because, somebody asked me to spell things out a little more.

In England medical students pay 9K fees. HEFCE (Higher education funding) add another 10K. Lets round up and call it 20K. HEFCE also adds money beyond fees for other expensive degrees (engineering, for example) although I do not know if it is 10K or less. This 20K goes through the universities

Medical students do not pay their final year fees in England, but must meet all their living costs, and 9K fees for the other 4 or 5 years. Government loans attract interest and, as others have commented, the government alters the conditions in a way that would be illegal for any bank (Gee! The government makes even the bankers look like saints). So say 40-45K fees, plus living costs. I doubt much change from a 100-120K. The money attracts interest and will be much larger by the time it is paid back, and will also feed into the debt of students who do not earn enough to pay back their fees.

The other funding stream is via the NHS. In England this is called SIFT, in Scotland it is called ACT. This is probably in the region of 20K per student per clinical year, and is designed to meet the costs of the ‘students on the wards’ and pay for all the NHS staff time for those involved in teaching. This money stays within the NHS, and the universities have essentially no access to it.

If you add there two streams together you are talking about close to 30K of ‘state funding’ plus 10K from the students. Living expenses are on top, and I will ignore opportunity costs of what students defer from earning.

The problem with the 30K state funding figure is it fails the reality test. These sums add up to a figure (40K) close to what Stanford charges its small medical student cohort, and yet it is clear that our UK medical students get a much worse deal. Or just compare what this sort of money buys you at an expensive private school. There is a (fat) rabbit off somewhere. Nobody with any knowledge of medical education, and who isn’t playing politics, believes that is what we spend on each of our students.

Above, I said 20K goes through the universities, but I did not say that universities spend that 20K on delivering undergraduate teaching. The obvious issue is that medical research is big business, and most research in general loses an institution money — this is especially true of charity funded research, the main funder of medical research in the UK (although there is an attempt to make up this deficit from QR funds but it is grossly inadequate). Peacocks tail, and all that. So, teaching fees are used to subsidise this loss. There are good costings for this in some US schools, but they use endowments to meet the costs; in the UK we get students to pay for this. To what extent? I do not know. Do not ask, is the mantra. This will run and run. And then unwind.

What about the NHS money. Well, nothing is transparent in the NHS, but we know most of the this money is not used to support teaching, but siphoned off to pay for clinical care. What proportion? I would start at saying 70% (i.e. only 30% goes for what it is intended for). So I think 18K over the whole course. But I know of no convincing data in this area, just the sort of bumph Hansard repeats, which is not reality based. Do not ask, is again the mantra.

My previous post added in come complexities. And there are more, that I have not mentioned.

The key points are:

  1. We do not know how much undergraduate medical education costs, just that the available figures are not credible.
  2. Much of the money said to support medical education is used for other purposes (this is a generally accepted argument across many research universities throughout the world).
  3. Costing is opaque and multiple parties have little interest in transparency.
  4. Money (as in staff) is a key determinant of teaching and learning. Until you follow the money, you cannot seriously think about improving medical education. Some of us even think it is possible to reduce costs and improve learning at the same time. This is why all this  matters — and not just to students.
  5. Institutional and student interests are not completely aligned.
  6. Certification is a monopoly business. To paraphrase Derek Bok, a distinguished former President of Harvard, if institutional survival (money)and morality conflict, morality goes out the window.
  7. Current models of medical education are based on what made sense in the immediate post-war world. It really should be done so much better.
  8. People often ridicule arts students, saying how little contact time they have. Meaningful contact time in medicine not what it was, nor what it should be — talk to medical students across the UK.
  9. Hospitals perform worse than GPs in delivering teaching. There is a moral here.

Anyway you can still listen….

‘Innovative’ educational practice is more fashion-driven than those who attend the catwalks are.

Distance learning and the unbundling of education approaches its 200th birthday

by reestheskin on 02/10/2016

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Interesting post from Tony Bates on the history of distance learning, and the University of London External Programme, which started in 1828.

Unfortunately I have no knowledge of the individuals who originally created the University of London External Programme back in 1828. It’s a worthy research project for anyone interested in the history of distance education.

I was once (mid-1960s) a correspondence tutor for students taking undergraduate psychology courses in the External Programme. In those days, the university would publish a curriculum (a list of topics) and provide a reading list. Students could sit an exam when they felt they were ready. Students paid tutors such as myself to help them with their studies. I would find old exam papers for the course, and set questions for individual students, and they would send me their answers and I would mark them. Many students were in British Commonwealth countries and it could take weeks after students sent in their essays before my feedback eventually got back to them. Not surprisingly, in those days completion rates in the programme were very low…

But I am fascinated by (and was ignorant of) the following:

Note though that teaching and examining in the original External Programme were disaggregated (those teaching it were different from those examining it), contract tutors were separate from the main faculty were used, and students studied individually and took exams when ready. So many of the ‘new’ developments in distance education such as disaggregation, self-directed learning, and many of the elements of competency-based learning are in fact over 150 years old.

Online or paper

by reestheskin on 30/09/2016

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Nick Carr writes about e-textbooks, quoting research that students don’t like them, or at least they prefer conventional textbooks. Seems reasonable to me. We know a lot more about the design of conventional textbooks, layout, indexing, and interaction and so on. But for dermatology it seems to me e-textbooks offer a way forward. If you want to learn dermatology, you have to look at images, and to do this well, you need access to lots and lots of images. One of the conclusions of a paper we published several years ago was how few instances of a particular disease students are exposed to. Seeing only n of 1 for a particular lesion type is just not enough: imagine your sole idea of what a ‘dog’ is, was based on only seeing one poodle. Current publishing models and norms mean that most dermatology textbooks are short on images — and often the images they contain are poor. E-textbooks are one way round this, and it is difficult to look at an iPad and not wonder what a good dermatology text would like like on it. What will be really interesting is what will happen to the legacy publishers given the price sensitivity of undergraduate students and the lower barriers to entry.

Annotation and memory of position on the page are important issues, but I doubt invention will not improve things. Just look at the way the ‘clunky’ Kindle allows you to highlight text, then retrieve it on the Amazon web site and go back to the text at the various bookmarks. A scholars dream for encouraging accurate referencing and citation.

In the meantime keep reading skincancer909^^ and my online material! Lots of room for improvement however.

^^ Skincancer909 is currently being rewritten and the future version will incorporate video with a new design.

Students are not fish

by reestheskin on 26/08/2016

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This is such a brilliant graphic from an article by Doc Searls posted on Medium and here.  A sort of universal metaphor (recursion intended) for universities, education and much else. Data rich, attention limited.

doc searls

doc searls



“It’s no accident that only 11% of the US workforce is passionate about their work. This is a sign of great success. This is exactly what these institutions were designed to do – suppress passion. It starts with our schools that seek to prepare us for all the other institutional environments seeking people who can reliably follow instructions and execute in a predictable manner. Think of our current institutions as powerful chisels, relentlessly chipping away at our edges until we fit neatly into the tightly defined roles that our institutions have create.

John Hagel

The most important thing in learning is copying how other people think. I don’t think learning by doing really gets one to emulate how other people think. Marvin Minksy

A learning objective I approve of

by reestheskin on 08/08/2016

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“Classics are written by people, often in their twenties, who take a good look at their field, are deeply dissatisfied with an important aspect of the state of affairs, put in a lot of time and intellectual effort into fixing it, and write their new ideas with self-conscious clarity. I want all Berkeley graduate students to read them.”

Reading the classics by Christos Papadimitriou. [As in maths / computing classics, so includes Euler’s paper on the Konigsberg bridges etc, but also Vannevar Bush’s ‘As we may think’.

We can only grasp reality by metaphor.

by reestheskin on 07/08/2016

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This is a quote from a review of Alice Gopnik’s most recent book, ‘The gardener and the carpenter’. I have enjoyed Gopnik’s previous work, and this quote could, with some latitude, be applied to medical school and medical education (where students become competent despite the best intentions of the medical educators…).

It assumes that the ‘right’ parenting techniques or expertise will sculpt your child into a successful adult. But using a scheme to shape material into a product is the modus operandi of a carpenter, whose job it is to make the chair steady or the door true. There is very little empirical evidence, Gopnik says, that “small variations” in what parents do (such as whether they sleep-train) “have reliable and predictable long-term effects on who those children become”. Raising and caring for children is more like tending a garden: it involves “a lot of exhausted digging and wallowing in manure” to create a safe, nurturing space in which innovation, adaptability and resilience can thrive.

We can only grasp reality by metaphor.

‘The Socratic slogan: “If you understand it, you can explain it’, should be reversed: Anyone who thinks he can fully explain his skill, does not have expert understanding’. Hubert Dreyfus.


Students: Why virtual is best

by reestheskin on 05/08/2016

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There is sometimes a prejudice in medical education that somehow teaching at the bedside is always best. Of course most medical encounters are not at the bedside (any more) simply because most clinical encounters are not on wards, but in offices, whether the offices are in hospitals or elsewhere. The arguments for the bedside include tradition, but also reflect the fear that medical education will be expropriated from the clinical context. I have a lot of sympathy with the latter view, but it will sometimes lead to error.

Yesterday, I talked about the Dermofit App, to which I contributed. One of the rationales for this whole approach almost a dozen years ago now, was my belated realisation that clinical exposure — however intense — in dermatology might not be as efficient as a learning environment in a virtual world. In dermatology, simulation is over one and a half centuries old, and the history of this simulation, tracks the development of technology. It is just that this simulation relies on something we have got used to because it is all around us: high quality graphics. Pictures of lesions.

Several years later we published a paper, exploring this. We wrote:

“The overwhelming majority of students 82% (n = 41) did not see an example of each of the three major skin cancers (BCC, SCC, melanoma) and only a single student (2%) witnessed two examples of each. The percentage of students witnessing 1, >3 and >5 examples is given for each of the 16 lesions and demonstrates that there was not only a lack of breadth but also of depth to the students’ exposure.”

In one sense this is all very obvious. We know that (perceptual) classification tasks require practice, and that practice requires multiple training examples. The training signal: noise ratio can be higher in the virtual world, and it is easier to manipulate events in the virtual world. If the quip is that technology is everything that gets invented after your teenage years, we don’t recognise the obvious technology here simply because it is has been around so long. It is just that silicon really allows it to be done so much better. The caveat is whether the business model allows this.

Students will prefer the clinic, for reasons I understand. But they will often be to wrong to do so.

Just in time foundations

by reestheskin on 01/08/2016

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Roger Schank is speaking at OEB 2016, and there is a post from him here on the OEB site.

His second sentence is:

Sorry to be a downer, but technology will change nothing if what is meant by technology is that we have new ways of delivering the same old material.

His suggestions include:

  • Eliminating all lectures. No one can listen to someone talk for an hour and get much out of it.
  • Creating a data base of stories (a minute and a half maximum length) that are the kinds of things people tell each other in natural conversations that produce recognition in the listener about the potential use of that advice.
  • Creating virtual experiences where learners get to pursue their interests in a world that reacts to what they do. If you want to be a fireman when you are ten years old, then you should get to be one (virtually) for as long as you like it. If you think you want to become a doctor, practice when you are ten on virtual patients and get advice from real doctors (in the form of video stories told just in time) when you make a mistake or ask for help.
  • Understanding that real teaching involves mentoring. When you have an idea or are trying something out, it is always a good idea to have someone available to ask a question. My daughter ran up the stairs to ask me a question when she was five. After I answered she said “I will be back when I need you again.” And she always has come back when she needs me again. Good parents are natural mentors. They never sit their kids down and give them an hour lecture. Teachers cannot be mentors typically because they have too many students to deal with at the same time and these students are typically not pursing goals they have chosen for themselves.

He goes on to argue how AI / tech can help.

I can agree with much, if not all of this (excepting the ten year old bit, if taken too literally). And building simulators of the ‘real world’ is where we need to be. But I still wrestle with what is foundational and how much preloaded material students need in order to allow them to make sense of the real world (‘preloaded material’, yes, I can hear the hackles…)

You might divide learning into ‘just-in-time’ and ‘foundational’. Foundational rightly has a bad name because most foundational learning is not foundational at all, but often reflects the prejudices of those who benefit from selling particular content. Medical degrees are stuffed full of foundational stuff that is nothing of the kind.

In medicine, you learn your craft by doing it, by seeing patients and diagnosing their ailments in the company of experts, and seeing what happens to them (supplemented by learning about what has happened to others); and by going back to the books and foundational concepts continually. But there is a framework that creates the clinical worldview, and that worldview has a language, that requires immersion.

One (and only one)  key goal of medical school is to enable to you to function in a clinical environment such that you can make sense of it, and learn from it. But that is not available to a novice, however bright, without a lot of ‘preloaded’ baggage. The question is about what the balance is between ‘preloaded’ and ‘just-in-time’. I think we obsess over the former and need to shift much more to the latter. But I do not know exactly how it will look in the end, although I know the direction of travel that is needed.

And yes, tech can help this, but not when PowerPoint is involved. He is right there, and has been for a long time.

[Alice Gopnik, in one of the John Brockman edited books (I think), remarked that although  she had spent much of her professional life studying how babies make sense of the world, little of any of these learning insights made it into how she delivered material to her university students or how they learned. Three years of lectures on cracking eggs, and then in the fourth, you get to do it.]

Morality 101

by reestheskin on 21/07/2016

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Derek Bok states that some of those who were found guilty of criminal acts in the recent waves of corporate malfeasance in the US, scored very well on their ethics modules at Harvard. It is easy (and facile) to imagine that somehow doing a ‘course’ on a particular topic will produce a change in behaviour that is permanent and withstands countervailing forces (culture eats strategy,and culture eats morality etc, I hear you say). Those in universities should of course know better — producing changes in behaviour in response to an environmental stimulus is a paraphrase of one definition of learning. But the message doesn’t get through, largely because the academy has increasingly chosen to turn its professional tools away from examination of its own purpose. It is deemed rude to ask for evidence when everybody knows the sun goes round the earth.

Nor, if we are to believe Timothy Wilson, should we go in with the ‘null’ hypothesis that courses wishing to eradicate ‘isms’ may only be beneficial. The evidence points in a different direction: they make some people’s behaviour worse. I sometimes wonder if anybody is really too worried about whether these interventions work — they just want to tick boxes to comply with yet more rituals of verification (to use Michael Power’s phrase from the Audit Society).

Anyway these ramblings were by way of introduction for what is for me one of the clearest expositions of morality and the human condition. I have no idea why I cannot keep it out of my mind but maybe putting it down in writing might help. It comes from a short article by Jacob Bronowski, in a posthumous collection of his essays, ‘A sense of the future’. The article is “A moral for an age of plenty”  and it includes an account of the death of the physicist Louis Slotin.

Louis Slotin was a physicist in his mid thirties, working at Los Alamos in 1946. Bronowski described him so: ‘Slotin was good with his hands; he liked using his head; he was bright and a little daring — in short, he was like any other man anywhere who is happy in his work’. Just so.

Slotin was moving bits of plutonium closer together, but for obvious reasons, not too close. And as experts are tempted to do, he was using a screwdriver. His hand slipped. The monitors went through the roof. He immediately pulled the pieces of plutonium apart, and asked everybody to mark their precise positions at the time of the accident. The former meant he would die (9 days later, as it turned out); the latter allowed him to prognosticate on what would happen to the others (they survived).

Bronowski writes:

There are two things that make up morality. One is the sense that other people matter: the send of common loyalty….The other is a clear judgement of what is at stake: a cold knowledge, without a trace of deception, of precisely what will happen to oneself and to others if one plays the hero or the coward. This is the highest morality: to combine human love with an unflinching, a scientific judgement.

I actually think we are more lacking in the second than the former. Worse still,  we are less tolerant of evidence than we once were: we prefer to wallow smugly in our self-congratulatory goodness. We have been here before. Medicine only became useful when physicians learned this lesson.

[ And yes, people remarked that Slotin hadn’t followed protocol…]


by reestheskin on 18/07/2016

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I didn’t know.

Two Stanford graduate students, Jerry Yang and David Filo, saw opportunity. Working from a trailer on campus, they began compiling websites into a list, organized by topic. They eventually named it Yahoo, an acronym for ‘Yet Another Hierarchical Officious Oracle.


I now have a new term for ‘learning outcomes’. Yahoo. Although ‘hideous’ competes with hierarchical