From didactic to TBL an exercise in transformation

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					From didactic to
          TBL:
      an exercise in
     transformation

     Lindsay Davidson
        Associate Professor
      Department of Surgery
         Queen‟s University
           davidsol@kgh.kari.net
Plan

    Introductions
    The course in question
    Identify problems
    Create a solution
    Sense making
    Change theory and complexity
    Wrap up
Who I
am and
what I
do
Then…….
What analogy would you
use to describe what
implementing educational
change feels like?
Musculoskeletal course
   Mandatory component
    undergraduate M.D. program
   Multi-departmental composite
   Relevant anatomy taught in first term
Administrative constraints

    4 weeks long in the middle of 4+ month
     term
    18/35 instructional hours/wk available for
     MSK lectures
    Shares curricular time with 3 parallel
     courses administered separately
     – Clinical Skills
     – Problem based learning
     – Medicine in Society
    Evaluation: all courses participate in MCQ
     and SA exams at end of term (100%
     grade)
People

   100 first year medical students, second
    term
    – The average medical student has >4 years
      undergraduate experience prior to
      commencing M.D.
    – Heterogeneous group
   19 different faculty members participate in
    lectures
   Botterell B139
        the
TEMPLE OF KNOWLEDGE
 “The role of the medical
school is to produce doctors
who have the basic building
blocks (pluri-potential
students) to allow them to
differentiate into mature
physicians that can populate
multiple professional lines.”
             Medical Education for Tomorrow‟s Doctor
      University of California, Davis School of Medicine
                                          January, 2003
RCPSC CanMEDS roles
   Typical week in traditional course
            Monday           Tuesday          Wednesday        Thursday     Friday


830-930         Path:Bone           Adult       Anatomy         Shoulder    Rehabilitation
                 structure       fractures       review:        problems       (Dr H)
                  (Dr A)           (Dr C)      upper limb        (Dr C)
                                                  (Dr F)


930-1030        Path: Bone    Path: Bone        Anatomy         Anatomy        Anatomy
                  healing       healing          review:         review:    review: lower
                  (Dr A)        (Dr A)         lower limb      lower limb    limb (Dr F)
                                                  (Dr F)          (Dr F)



1030-1130   Osteoporosis         Children's        Imaging        Knee      Other courses
               (Dr B)            fractures        principles    problems
                                   (Dr D)           (Dr G)       (Dr C)


1130-1230       Study time        Multiple    Study time
                                  Trauma
                                   (Dr E)


            L                U                N                C            H
1330-1630   Other courses
Group introductions

    Who you are
    What you teach
    Analogy
    Share
You are now instructional design
consultants

    Given what you know about the
     course…
    Are there problems with existing
     format?
    Make a list using the flip chart
    As a group, pick the top 2 things you
     want to change
    Be prepared to share
Problems that I identified

    Information overload
     – Absence of key themes/concepts
    Poor connections between sessions
     – Many faculty involved in course
     – Unrelated “horizontal” course
       components
    Disconnect between published
     objectives/classroom content
     – Sample of class surveyed every lecture
Problems that I identified


    Evaluation
     – No formative evaluation High-stakes,
       multiple choice and short answer end-of-
       phase exams
     – Little opportunity to demonstrate analytic
       processes
    Poor long-term retention of course
     concepts
     – Surface vs. deep learning
What does research tell us about how to
encourage students to adopt a deep approach
to learning?

      Ensure that the students' workload is
       manageable,
      Design out information overload,
      Ensure that the students have a clear
       understanding of what is required of them,
      Ensure that the assessment regime rewards
       critical thinking and risk taking,
      Require active participation,
      Ensure that students have as much choice
       as possible,
      Bolster self-esteem.


                   http://www.ucd.ie/teaching/good/flex3.htm
Recognizing concerns with the traditional model
of instruction, which of the following would be
your priority to change in order to facilitate
increased “deep learning”:

A.   Revision of objectives, development of themes
B.   Faculty development – classroom techniques
C.   Faculty development – pedagogical concepts
D.   Introduction of pedagogical concepts to students
E.   Introduction of different learning opportunities
F.   Alteration of grading scheme
G.   Other
Recognizing concerns with the traditional model
of instruction, which of the following would be
your priority to change in order to facilitate
increased “deep learning”:

A.   Revision of objectives, development of themes
B.   Faculty development – classroom techniques
C.   Faculty development – pedagogical concepts
D.   Introduction of pedagogical concepts to students
E.   Introduction of different learning opportunities
F.   Alteration of grading scheme
G.   Other
Blended Learning

  “courses that combine face-to-
  face classroom instruction with
  online learning and reduced
  classroom contact hours (reduced
  seat time)”
 Dziuban, C. D., Hartman, J. L., Moskal, P. D. (2004).
 Blended Learning. Educause Research Bulletin, 7, 2-12.
   Active learning model

                    Active learning
Passive
                             Reflective dialogue
Learning       Experience    with:

Receiving
                Doing              Self
information
and ideas.


               Observing         Others
pre-TBL initiatives (2003-4)

    Schedule similar but less teachers
    Learning goals inventory pre-course
    Classroom activities introduced in sessions I
     taught
     – Lecture bingo
     – “Muddy points”
     – Role playing
    Online activities
     – Self-study
     – Quizzes
    Evaluation
     – Group and individual projects - 10% grade
     – Final exam - 90%
Externally imposed change

    Course moved from Feb to April by
     Phase director
    MSK now last course before final
     examination period
Pre-TBL: course evaluation

    Self-directed learning close to exams
     problematic
    Inadequate feedback from online
     quizzes
    “Anatomy difficult to remember” by
     end of winter term (was taught in fall
     term)
    Some sessions: excessive detail
Presented by the UG Dean
at Education Journal Club
Group task

  Develop a new schedule for the
   sample week using TBL
   principles
  Consider the problems that you
   identified previously as you
   generate your solution
  Share
Year 1: TBL

     Course divided into four thematic units
     Use of WebCT to present preparatory
      material including graded (low stakes)
      quizzes
     Introduction of RATs and structured
      classroom group activities in existing
      lecture hall)
Year 1: TBL


     30.9% instructional hours set aside for
      individual study
     Course moved to start of term
Year 1: TBL - program evaluation
strategy

    Comment cards
    CTL observational study (2 TL, 2
     lecture)
    Classroom engagement survey after
     TL sesion
    End-of-course survey
    CTL focus groups
My impressions after year 1 TBL

    Students better prepared in class
     – Less need to define terms, explain simple
       concepts available in references
    More classroom discussion, questions
    Classroom cramped, hard to move around
    Although RATs and Team Exercises
     encouraged studying students seemed
     frustrated by them and complained that
     their time would be better used in lecture
My impressions after year 1 TBL


    Peer evaluation created a significant
     amount of anxiety and (even) hostility
My impressions after year 1 TBL


    Some student responded very positively
     in person
     – Emails
     – Spontaneous conversations after class
Student feedback year 1

    “I did more reading and understood
     the subject”
    “I enjoyed the mixture of didactic and
     self-directed learning”
My impressions after year 1 TBL
    There was a vocal group of students
     who actively resisted the new methods
    Peer evaluation created a significant
     amount of anxiety and (even) hostility
Student feedback year 1

    “I think that the majority of the class
     came to this school because they
     WANT a didactic style of learning. I
     am one of these individuals.
    I feel that organized lectures are
     best.”
    “I cannot foresee why prospective
     students would want to come to a
     medical school that has such poor
     instruction.”
Student feedback year 1
    “Never before have I been so utterly
     bewildered as to what was happening in
     school. The group work .. was not helpful in
     any respect. The time wasted in these
     exercises could have been used much more
     effectively with lectures or with self-directed
     learning. Constructive criticism and comments
     pertaining to the inefficacy of the course
     director‟s approach have been repeatedly
     ignored and dismissed…..she is clearly
     deluded. I am extremely disappointed in the
     caliber of coordination thus far. When potential
     students ask me about the weaknesses of the
     medical program in the future, the course
     coordinator of the MSK block will be the first
     and only failing I would bring to their attention.”
Faculty responses to student
comments
    “Juvenile”
    “Spoiled brats”
    “The changes took guts”
“Resisters” - Hargreaves and Fullan (1998)

    May have good ideas
    You ignore them at your peril if they
     stay around for implementation
    In other words… there are good
     technical and political reasons for
     taking resisters more seriously
    “Annoyance is often a signal of
     opportunity”
“Understanding why most attempts
at educational reform fail goes far
beyond the identification of specific
technical problems … (E)ducational
change fails partly because of the
assumptions of planners, and partly
because solving substantial
problems is an inherently complex
business.”
Michael Fullan (2001), Understanding
Educational Change, p.96
What went wrong?
Things that I think contributed
to poor result:
    Poor classroom for TBL
    My learning curve
     –   Open book RATs
     –   Inexperience with developing team exercises
     –   Suspicious of using MCQ format
     –   More than “mini-lectures” to debrief
    Combination with other modalities
     – Online modules, quizzes
     – Group, individual project
What is the most important “next
step” in planning year 2?


 A.   Resume traditional course format
 B.   Increase faculty development
 C.   Find a different classroom
 D.   Revise RATs and application
      exercises
 E.   Revise course evaluation structure
Year 2: TBL

   Class sessions moved to hospital
    gymnasium
   I attended TBL conference
    – TBL implementation corrected
    – Better cases/exercises developed
    – Learned technique for making groups
   New website for content delivery
    – Financial support from administration to hire
      assistant to transform lecture content into
      online resource to be used as background
    – Limited capability for interactivity
Year 2: TBL

   Introductory session to course with
    practice RAT
   Pre-course survey of student impressions
    of group work
   Improved linkages with “horizontal
    courses
    – Joint sessions with Epidemiology and
      Geriatrics
    – No PBL for first two weeks
   Coursework = 50% grade
   Alteration in peer evaluation strategy
Feedback year 2

    “Team learning was great.”
    “The team learning was excellent and
     well prepared/organized. I hope the
     other blocks incorporate this learning
     style.”
    “I really liked the group learning
     method (I am dreading returning to
     lectures next week!).”
    “The team learning was extremely
     helpful and the quizzes also improved
     my understanding on the topics.”
Feedback year 2

    “I really enjoyed the team learning format
     – it is helpful to work through problems
     and test our knowledge.”
    “In general I loved this block. I‟m biased
     because I enjoy group learning, but I
     think it was good for everyone, even if
     they don‟t appreciate it yet. I think that
     many people that make it into medical
     school are trained book learners + they
     take offense when people challenge their
     set style.”
Feedback year 2

   “I didn‟t like the group work at the
    beginning, but I learned to like it
    during the course. I do still prefer
    lectures, and I feel that I still learn
    best this way.”
Feedback year 2

   Students hated the gym
   Students reacted negatively to
    course website which was not „in
    sync‟ with the school‟s main online
    portal
“The following is offered as a position
statement form the Aesculapian Society (AS)
on the matter of TBL and its implementation
in the MSK course of the Queen‟s
undergraduate medical curriculum.”

“There are numerous implementation-based
and logistical concerns that must be
addressed before the AS can support further
application of TBL throughout the Queen‟s
undergraduate medical curriculum.”

  Christopher Barnes, VP, Academic Affairs, Aesculapian Society
  May 10, 2006
          Typical week - year 3 TBL
            Monday             Tuesday       Wednesday        Thursday    Friday


                 Path:Bone
                                                 Anatomy
                  structure
                                             review: upper
                   (Dr A)           Adult                      Shoulder
830-930                                        limb (Dr F)                 Rehabilitation
                                 fractures                     problems
                                                                              (Dr H)
              Path: Bone           (Dr C)                       (Dr C)
                                                Anatomy
            healing    (Dr
                                             review: lower
                   A)
930-1030                                      limb (Dr F)
                                 Children's     Imaging
                Osteoporosis     fractures   principles (Dr
                                                              Knee
1030-1130          (Dr B)          (Dr D)          G)
                                                            problems      Other courses
                                  Multiple
                                                             (Dr C)
                               Trauma (Dr
1130-1230       Study time           E)       Study time
            L                  U            N             C               H
1330-1630                                   Other courses
Year 3: TBL
What analogy would you
propose to describe what
implementing educational
change feels like as a
teacher?
                                                            2004     2005     2006 2007
1. Overall, this is an excellent course.                      29.7     50.0    55.8 94.4
2. I learned a great deal from this course.                   70.3     53.9    76.9 94.4
3. This course was helpful in developing new skills.          69.8     67.3    64.1 86.5
4. I felt that this course challenged me intellectually.      68.8     67.3    70.5 93.2
5. My interest in the subject has been stimulated by this     42.2     63.4    44.9 84.9
course.
6.This course included components that addressed my                           53.8   86.4
personal learning style
7. The objectives of the course were adequately               53.2             50    77.7
explained.
8. This course covered the right amount of material.          28.6    65.3    47.4   86.5
9. The workload in this course was reasonable and             25.5    46.1    39.7   61.3
appropriate.
10. The course material was presented at a satisfactory       52.0    67.3    70.5   95.4
level of difficulty.
17. The team learning exercises in class helped me to                         73.1   84.4
learn and better understand the course material
“Change is a leader‟s friend, but it has a
split personality: its nonlinear messiness
gets us into trouble. But the experience
of this messiness is necessary in order
to discover the hidden benefits - creative
ideas and novel solutions are often
generated when the status quo is
disrupted.”

     Michael Fullan (2001), Leading in a
     Culture of Change, p. 107.
Course development

 A.   Revision of objectives, development of
      themes
 B.   Introduction of different learning
      opportunities
 C.   Alteration of grading scheme
Course development

 A.   Revision of objectives, development of themes
 B.   Introduction of different learning opportunities
 C.   Alteration of grading scheme
 D.   Faculty development – classroom techniques
 E.   Faculty engagement – pedagogical concepts
 F.   Introduction of pedagogical concepts to
      students
Course development

 A.   Revision of objectives, development of themes
 B.   Introduction of different learning opportunities
 C.   Alteration of grading scheme
 D.   Faculty development – classroom techniques
 E.   Faculty engagement – pedagogical concepts
 F.   Introduction of pedagogical concepts to students
 G.   Appropriate classroom
 H.   Sufficient independent work time
 I.   Integration of horizontal components
Course development

 A.   Revision of objectives, development of themes
 B.   Introduction of different learning opportunities
 C.   Alteration of grading scheme
 D.   Faculty development – classroom techniques
 E.   Faculty engagement – pedagogical concepts
 F.   Introduction of pedagogical concepts to students
 G.   Appropriate classroom
 H.   Sufficient independent work time
 I.   Integration of horizontal components
 J.   Ongoing course evaluation
 K.   Reflection on the process
Understanding the Change
Process
    The goal is not to innovate the most
    It is not enough to have the best
     ideas
    Appreciate the implementation dip
    Redefine resistance
    Reculturing is the name of the game
    Never a checklist, always complexity
          Michael Fullan (2001), Leading in
          a Culture of Change, p. 34.
Fullan‟s framework for
leading complex change
    Moral purpose
     – “acting with the intention of making a positive
       difference”
    Understanding change
     – Respect complexity
    Relationship building
     – Diverse people/groups
    Knowledge creation + sharing
     – “turning information into knowledge is a social
       process”
    Coherence making
         Leading in a culture of change (2001, p. 4)
            Thank you

             davidsol@kgh.kari.net
http://meds.queensu.ca/course/msk

				
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