Factors in Instructional Design:
Training versus Education
Andrew L. Carney, MD. Clinical Associate Professor
Radiology, Neurosurgery and Orthopedics
ITL Seminar – Spring 2003 - March 17-18.
Training differs from education in that it seeks to impart a set of established facts
and skills and to obtain a uniform predictable behavior from the trainees without
the necessity of their understanding why they should act is the prescribed
manner. To a great extent, such learning is primarily passive and incorporates
conditioned reflex action within a time constraint. Education, on the other hand,
seeks to have the student learn skills and to understand why actions are taken or
not. That means the student must learn to observe, analyze and question, to
formulate hypotheses and make conclusions and then to act, live and modify
their actions according to these conclusions. Furthermore, the educator may
accommodate individual talents in students and even encourage competition
between students. Such learning is an active process. However, all education
must include training especially in the acquisition of factual information. Training
is built around rote memory, repetition and conditioning reflexes ala Skinner.
Education is built on the organization of knowledge, mastery of the detail and
active analysis ala Socrates.
Computers in education can be a blessing. But powerpoint can destroy
communication between teacher and student, between speaker and audience.
It can embolden the inarticulate to believe they possess a golden tongue. Public
speaking, debating and a stage presence facilitates teaching and presentation.
The sense of timing is critical for an effective presentation. At many powerpoint
presentations, the speakers refuse to answer questions out of sequence and this
raises doubts about their capability and undermines their status.
The requirements for the teacher in each process are different. The trainer may
be required to follow a tight syllabus and presentation material and may possess
very little option to deviate from a proscribed format. For some, computer
designed instruction, especially powerpoint, has become a crutch for the
inadequate speaker, a mask to conceal ignorance and the lack of understanding.
For others, the rigid format provides a means of avoiding questions,
active discussion or interaction, a way to avoid learning to speak and
and discuss ideas, a way to read without facing the audience.
The educator must possess the knowledge and skill to teach the subject, the
ability to write coherent sentences and to speak effectively in public. The
educator must be able to convey knowledge to the student audience, hold their
interest and incite active participation. Ultimately the student must demonstrate
retention of the knowledge and some application of that knowledge, usually by
examination. The computer may aid in education by making challenges to the
student much more dramatic and available, by broadening the imagination
and stimulating creativity.
POWERPOINT can destroy communication between teacher and student
between speaker and audience. It can embolden the inarticulate to believe
they possess a golden tongue. Public speaking, debating and experience in the
theater facilitates teaching and presentation. The sense of timing is critical for
an effective presentation. At many powerpoint presentations, the speakers
refuse to answer questions out of sequence and this raises doubts about their
capability and undermines their status.
There are two situations which I wish to contrast (1) the training of corpsmen
for the US Army in San Antonio and (2) leading medical students to actively
Analyze medical images.
Training of corpsmen at Fort Sam Houston in the 1960s illustrates
some of the techniques which can be useful in the classroom. Young men
selected to be corpsmen were usually highly motivated and capable. The military
realized that these men would be the primary care for the wounded soldier.
In hot San Antonio, classes began at 8:00 AM and extended to 6:00 PM. The
classrooms are kept so frigid that sweaters were routinely worn. The room was
fully lighted so eye contact could always be maintained. Projections were rear
view so there were no distractions in the classroom. The assumption was made
that the attention span of many students was from 15-20 seconds, hence the
necessity to refocus attention often, sometimes by use of a foot switch to dim the
image, sometimes by a change of image. The instructor never spoke when the
image was displayed. Students were not permitted to spend time reading and
rereading. Repetition was accomplished by changing images. The blackboard
was never used, because of the loss of student-instructor contact. The retention
of critical course material was measured at end of course, at 6, 12 and 24
months. If retention rates in a specific subject falters, the instructor on probation
1x, then replaced for a second failure.
How do you hold the attention of students for ten hours a day. First, the students
must be able and well motivated which they were. The extensive use of images
was superior to text. Images had more emotional impact and were retained
longer. Concepts would be repeated by the use of different images.
Teaching Medical Students - Imaging of Basic Orthopedic Problems
This is one of the first lectures given to medical students on their radiology
rotation. The objectives were first to overcome fear, then to develop the ability to
recognize the different types of imaging and achieve competence in identifying
images and content. All images are stripped of labels because students prefer to
read rather than think. The objective is to approach images with an open and
inquiring mind. The method is to begin with the obvious and defer the
ultimate, because the biggest problem is getting started and being overwhelmed
with the fear of failure. Once basic abilities are developed, then the significance
of the details can be stressed.
Medical education tends to destroy creativity and there are some serious
problems with medical students. They can become heavily reliant on rote
memory, suffer from information overload and have been programmed for exam
taking. Many are obsessed with extracting examination questions from a
presentation. The objective is to develop their ability to see what is really there
before their eyes, and to develop confidence in their ability to do so.
Sometimes shock therapy is useful - to introduce images not related to medicine.
Finally, students need someone to model their lives and behavior on.
One such model cited Paul Orfalea. Orfalea founded Kinko’s and when he sold
out the system had 25,000 employees and 1100 stores, he was a billionaire. The
fact is that Mr. Orfalea has severe dyslexia and still cannot read well. He
achieved success by focusing on his strengths – the ability to see the obvious
and look at the bottom line. Surely if Orfalea could do it, they could. The students
have a handout available to them on this man and his philosophy.
Initially, the organization of this presentation is covered. The credentials of the
speaker, the objectives and the organization of the presentations are stated
followed by the general approach to interpreting images. The modalities of
imaging are identified and it is stressed that the presentation focuses on the
common problems of orthopedics encountered by all physicians regardless of
specialty. Focusing on highly esoteric orthopedic problems sparks gross
disinterest in some students.
The role of the physician is to observe, to see what is really there and to
document the findings whether related to anatomy, deformity, function or
behavior. Furthermore, the physician must teach and inform both his patient and
society by words, numbers and images and to influence society when it is
appropriate. The word authority is derived from the word author.
Images are integral to our society and profession. The art of verbal description
has been largely loss outside of the fiction writers and laywers. The medical and
social world is dominated by images, drawings, illustrations, paintings,
sculptures, photographs. In medicine we often have means of assisted viewing
such as by the microscope or arthroscope. The full panoply of photography
include still, cine and digital images. Recent additions include computer
enhanced images, animation and virtual reality. Imaging is not to be confused
with illustration. Imaging often contain excessive detail; while illustration edits the
detail presents a perspective, a selected feature.
The field of orthopedics and its development as a whole and its specialties and
subspecialties are defined. The term orthopedics means to straighten the child.
Prior to World War II, most fractures were cared for in the US by general
surgeons. But by administrative fiat, the orthopedic surgeons were given
responsibility for all trauma involving bone during that war. The student must
recognize the difference between the trauma and the spine surgeon, the pediatric
and the tumor surgeon, the hand surgeon and sports medicine specialist.
The basic modalities of imaging in radiology are radiography, computed
tomography, nuclear medicine, ultrasound and magnetic resonance imaging
are described. Appropriate illustrations of normal and abnormal images are
The major presentation focuses on eighteen conditions commonly
encountered by all physicians at some time in their professional lives.
Congenital hip dysplasia, compartment syndrome and carpal tunnel
Syndrome are but three of the eighteen conditions covered.
The major advantage of a presentation based on images is that there are so
many available that acquisition is relatively easy. However, an underlying story
line must be created which gives continuity and logic to the overall work.
The answer to every question asked of the students can be found in the
projected image at hand. The idea is to start with the obvious. Participation is
encouraged early in the lecture and interaction can usually be achieved as the
demand for thought and insight increases.
The computer enables the handling of both images and text in a most remarkable
manner. While the understanding of the material is a sine qua non, the ability to
tell a story, write a coherent sentence and have a great sense of timing can
dramatically enhance a performance. Training for many is a requirement of
society. Education will only be available to a few because of many constraints on
the process. But teaching the young to understand, to analyze and create new
ideas is the only way progress can occur. No progress can be made without the
computer, but its use is both time consuming and demanding.