MARCIA DAY CHILDRESS: Good afternoon.
I'd like to welcome you to today's Medical Center
Hour, which also doubles as Medical Grand Rounds.
I'm Marcia Day Childress from the Center
for Biomedical Ethics and Humanities
here in the school of medicine.
Whether we are students, teachers, or clinicians,
we're all learners.
That's one reason we're all here today.
And to a great extent, if we recognize
that learning frequently entails imparting as well
as taking in new knowledge and skills, we are all educators.
As educators, our work includes maintaining
awareness of how we do what we do,
from our own ongoing preparatory efforts and critiques
of effectiveness, to assessments of outcomes, review
and revisions of methods, and renewal of our performance in
and commitment to the educational process.
Along the way, we grow and change.
The people we work with grow and change.
The context and content of our endeavors change.
Sometimes we can discover that our stated assumptions
and principles are at odds with our actual practices.
When, as educators, teachers, and learners,
we reflect on and examine what we see, what we feel,
what we say, what do we find in the way
of guiding assumptions, principles, values,
and practices?
What do we do then?
How do we best address any asynchrony
in these and set things aright?
In this Brodie Medical Education Award lecture, all of us here
today--
learners of all stripes and seniorities--
will practice some foundational skills, such as cultivating
a beginner's eye and more accurate data collection,
in order to uncover and examine habits
and thought patterns that may no longer serve us.
Understanding our own assumptions and the values
they reflect will allow us to be more intentional in designing
our educational programs and our learning
in clinical practice environments,
so that they are more principle-driven,
and that they better meet the needs of patients, learners,
and caregivers.
We'll do this today under the expert and lively tutelage
of Dr. Elizabeth Gaufberg, who's associate professor of medicine
and psychiatry at the Harvard Medical School,
the Jean and Harvey Picker director of the Arnold P. Gold
Foundation Research Institute, and director of the Cambridge
Health Alliance, Center for Professional
and Academic Development in Cambridge, Mass.
She's also a core faculty member in the Harvard Macy Institute's
program for educators in the health professions.
One of the best educator of educators
that we know, Liz comes to us as the University
of Virginia's 2018 recipient of the Brodie Medical Education
Award, a citation which is all about consummate teaching,
intentional pedagogy, and educational excellence.
We're delighted that today's program doubles,
as I mentioned, as Medical Grand Rounds.
We thank the Brodie Medical Education
committee and its chair, Evan Heald, and the Academy
of Distinguished Educators for supporting this program,
and also for sponsoring Medical Education Week for 2018, which
is going on all this week with lots of activities
we hope you're taking advantage of.
Please join me in welcoming Liz Gaufberg,
and I think we're in for an active hour.
[APPLAUSE]
ELIZABETH GAUFBERG: Wow.
Thank you, Marcia, and thank you all.
Thank you to the Brodie Committee.
If someone can simultaneously be treated
like royalty and like one's best, oldest friend,
that's how I've been treated since I arrived here on Monday.
This is just such a warm, lovely community.
Back in January, when I was at the Harvard Macy
program for educators in the health professions,
I sat down with my friend and mentor, Gene Corbett,
and asked him what he thought I should do for this hour.
And he said, I just want to say one thing--
the Brodie committee is all about stirring the pot.
So I listened to that, and we decided
I would do something on assumptions
about teaching and learning and make it active.
But last night, being someone who tries to do a good job,
I just Googled "stirring the pot,"
and the first thing that came up was the definition
from the Urban Dictionary.
And this is what it reads--
"Someone who loves to proliferate the tension
and drama between two or more feuding people or groups
in public to get a rise out of people,
in hopes of starting a storm of drama
and uncomfortable conflict, sometimes for personal gain,
but oftentimes just for the thrill of confrontation."
No, no!
I planned it all wrong!
But luckily, the second entry under Phrase Finder
asks us to picture a pot of soup.
A lot of ingredients have settled to the bottom,
out of sight until stirred.
Metaphorically, a lot of issues, assumptions, and tensions
can drop out of sight when nobody mentions them.
One can stir the pot to bring issues to the surface,
to create awareness and effect change.
Phew.
I think that's what you meant, Gene, right?
So I've designed a session today that's
a briefer version of something we do at the Harvard Macy
to get people to think about the assumptions
that they bring-- those deeply held assumptions they bring--
to teaching and learning.
But a lot of what we'll talk about today
is really relevant to practice and to life.
I want to start out with a story.
A lot of my stories come from my kids.
I have four daughters who are now
in their teens and early 20s.
But from the time they were little,
they would say things in the course of everyday conversation
that would cause me to see things in just a different way.
And that makes them some of my best teachers.
So this story dates back about 15 years ago
when my daughter Eva was in kindergarten.
She's a junior at Northeastern now.
But she came home from school, and I asked her,
how did it go today?
And she said, well, we heard a story in school.
And I said, tell me.
So she told me a story about a little boy whose job it
was to sit on the side of a mountain and watch the sheep.
And his job was incredibly boring.
There was no one to talk to, and he was lonely,
so he pretended like there was a wolf coming
to attack the sheep.
And when he called "wolf," the townspeople all came.
And when they discovered there was no wolf,
they got really mad at him, and they stormed away.
And as young children do, she repeated endless cycles
of the boy crying "wolf," and I listened, until that day
that there really was a wolf.
And when the little boy cried "wolf," nobody believed him,
and nobody came.
And the wolf ate all the sheep and ate the little boy too.
And at that point, Eva just stopped.
Well, maybe she had to go to the bathroom at that point,
but she stopped, and that was the end of the story.
So I waited, and I said, you know, Eva,
that's a really, really upsetting story.
Was there any lesson to that story, any moral?
And she considered and then responded, yes.
The lesson is, no matter how many times your kids trick you,
you should still believe them.
So I laughed too.
I think I called my husband at work, and he laughed.
I have to admit, though, there was this little place
inside of me of worry that Eva got the wrong answer.
And then, that was around the time
when I was beginning to develop an identity as an educator.
And so I started thinking about that very well-worn path
of an Aesop's Fable that was so familiar to me,
and what some of the assumptions about learning
were that underlay that.
I also was thinking more about just the little boy,
and what was he doing all by himself
on the side of the mountain?
And why wasn't he in school?
And what about child labor laws?
And after the third time that this happened,
couldn't that town have predicted it and figured out
a way to help the sheep to graze,
and the kids to stay alive?
And there could have been some really useful problem-solving
that came out of this dilemma.
And what about the pedagogical strategies that are valued,
embedded in that story?
So using fear to stimulate learning--
that's a really scary thing for a five-year-old to hear about.
Then again, using stories to stimulate learning, which we've
done a lot of in the last couple of days
with the Brodie experience--
or what about having an entire educational experience drive
just to one right answer, rather than a multiplicity
of possibilities?
And so part of what I hope to accomplish today--
this is not a tie-it-up-in-a-neat-box kind
of talk.
It is a stirring-the-pot and getting some things
to rise to the surface.
But I hope that you will begin to think
about your own well-worn paths and habits,
your automatic behaviors as educators, as learners,
and maybe consider perhaps there's
another path that could be viable,
another means of transportation, or even another destination.
And you may end up recommitting yourself to your old ways,
but it's that process that I'm hoping to engage us in.
And we will be doing--
I'll talk for a little while, and then I
have some interactive exercises that I
would love to engage you in.
So this is a quote by Einstein.
"It's a miracle that curiosity survives formal education."
And I just love this, because it suggests
that there are certain things that we can unlearn
in the process of becoming health professionals
or learning anything new, and we really
have to be tuned in to those unintended byproducts.
What does our process of education
do to curiosity, to empathy, to other valuable traits
that we bring with us?
And so why are we doing this?
One thing I've just told you is to try
to identify habits and patterns that no longer
or do not serve us.
To learn from and to work effectively
with others whose assumptions might differ from our own.
And sometimes when we find ourselves
in conflict or disagreement, you can get into conflict
at a more superficial level, when you really
discover that it's at a deeper level of assumptions
that you might differ in.
And really being curious about others' assumptions, I think,
helps you get past that.
And then, to be intentional in designing
both educational programs and cultivating
both learning and practice environments that
are principle-driven.
I think of principles as tried-and-true assumptions
that we've really looked at and we've
elevated to guidelines for action and practice.
And these are 50,000-foot questions that we look
at at the Harvard Macy educators program,
and I'm going to ask you to think a little bit about today.
Some of us have never really thought about these things.
What is learning?
Is it an informative process--
literally lifting the lid off something
and pouring information in-- or do you
think of learning more as a transformative process,
where the shape of the container or the connectivity
is actually changing?
Does learning happen in an individual,
or does it happen within a community?
What's the difference between teaching and learning?
I know that when I first started out,
I felt like if I delivered content
that learning would happen.
It was like when I used to pack my kids' lunch in the morning,
and I would put in examples of the five food groups
and feel really good about my nutritious input,
until the day that I opened the lunchbox at the end of the day,
and the only thing that was eaten was the cookie.
So too in a lot of what we do-- that there is a difference
between teaching and learning.
And some of our efforts now at competency-based education,
I think, really are a recognition of that.
Is the teacher a content expert, a coach, a guide, a co-learner?
How do we think of ourselves as educators,
and do we stick with one format when the context might
do better with another?
Assessment-- are we looking for short-term results
or longer-term outcomes?
And a lot of times, when we say assessment,
we think of particular formats that we're
familiar with, like multiple-choice tests or OSCEs.
And what we're trying to get at here
is education that is more--
to move from format-driven to principle-driven.
And if you're thinking about, what are our ultimate goals?
Peggy and others here are working on wisdom,
but what is the point of this endeavor?
And our assessment should follow from that.
And then goal of education-- are we
passing on traditional values or helping learners
adapt to and make change?
Very different assumptions underlying these efforts,
and building from there would mean
we'd be building radically different kinds
of environments.
And so these are about education,
but if you think about practice environments,
do we think about health care as a good or a service?
Is it a product?
If it's a product that we make in our laboratories
or in boardrooms and we then deliver it
to patients who use it, it's very
different than thinking of health care as a service,
because services are intentionally
co-designed by the people that consume those services
and the people that provide them.
Even using words like consuming and providing
have assumptions at their root.
But what do we feel in practice about--
who is the good doctor or nurse?
Are they people that never make mistakes?
If that's an assumption that's at the root of what we believe
about the good clinician, what does that
mean when somebody invariably is going to make a mistake?
How do we respond to them?
So just really getting at these very deep-seated questions.
All right.
So this is a talk about assumptions,
and I think it's only fair to give
you some of my own assumptions-- my own conceptual
underpinnings-- in thinking about this.
I ascribe to a social constructivist way of thinking
about knowledge, which is that individuals construct new
understandings-- new knowledge-- through the interaction of what
they already know and believe-- their own conceptual lenses--
and the ideas, events, activities
that they come in contact with.
And this is reinforced by neurobiology.
And we're tribal creatures, and especially in situations like
this where you're being welcomed into a community--
a profession--
social constructivism can be a very powerful force.
And knowledge often ends up in those--
held in those social groups.
Just as an aside, it's very interesting
to think about social constructivism
in the age of the internet, and I
think most of you-- who's familiar with the phrase
"the filter bubble"?
Anybody?
Have you heard of that?
We get most of our news from our news feeds--
through our social media--
but there are these algorithms that
feed us information that often ends up just reinforcing
what we already believe.
If you looked at my news feed, you
would think that every medical student in the country is--
that trained in art museums and has certain advocacy beliefs.
And we're constantly fed information
in this way, which ends up--
another way of saying a filter bubble is an echo chamber.
And so this incredible tool that has the potential
to expose us to so many diverse opinions, viewpoints,
frameworks ends up often insulating us.
And the other conceptual underpinning
is that human beings, by nature, have limited perspective.
And we have limited perspective partly
just because we have sensory limitations.
Our eyes and our ears only have a certain range and acuity.
And we have this remarkable ability
that we call selective attention, which
is what allows you to walk across the street
without getting killed or study for the MCAT
and focus exclusively on something
and block everything else out.
Right?
It's remarkable.
At the same time, when you're selectively
attending to one thing, you're necessarily
blocking other things out.
And then we also have limited perspective because
of social constructivism.
We have certain deeply held constructs that--
and we're going to talk a little bit more
about this-- that really influence what we pick out
in the environment.
And I like this cone in the box example.
It's a simpler version.
How many of you know the six blind men and the elephant?
Yeah, most of you are nodding.
But this is just a cone in a three-dimensional box.
And if you're person A looking through that peep hole
on the top, what do you see?
Circle.
And if you're person B?
Triangle.
And you are convinced that it's a triangle,
and the other person is convinced that it's a circle,
and that's because they don't have
a more expansive understanding of what's in the box.
And it's just a metaphor for how we all walk through life.
We have a piece of the picture, and getting
us to zoom out when we need to-- or can
or need to-- and zoom in when we need to is really important.
So sometimes just remembering this can help.
So gosh, if I had time to switch out the slide,
I would have put a pot of soup up.
But this is really just to make the point that some
of our assumptions--
I think that assumption is something we
take to be true without proof--
the minority of them we can explicate and--
but much is under the surface.
And so we need to come in through a side
door in our assumptions.
And the way that we're going to do this today
is sort of three routes.
The first is just to expose you to the idea
of the ladder of inference.
Is this a familiar term to anybody?
OK, good.
A couple of people, but--
and then we're going to go for a metaphorical walk together,
and then we're going to dig in the sand--
metaphorical sand-- for assumptions.
So let me just see if I can do this.
So this ladder of inference is a concept
that ties much of what I've shared as a preamble together.
And here we go.
This is about a--
I think it's about a four- or five-minute section of a video.
OK.
So was that at all familiar to any of you?
Nothing like that has ever happened, huh?
And I'm from Boston, and--
MARCIA DAY CHILDRESS: Turn on your mic.
ELIZABETH GAUFBERG: Oh, my mic is off?
It is on.
Can you hear me now?
Is it just that it got dislodged?
And this is a multiple-times-a-day sort
of occurrence.
And I would just ask you to take a moment and, in your own mind,
imagine just changing--
these were bland cartoon figures--
but change the type of car, or the gender of the driver,
or the age of the driver.
It's a young millennial, or a very old person, or their race
or ethnicity, and just see--
imagine yourself in that situation,
and see if anything changes.
I can tell you just another quick example.
So this kind of thing, as I said,
happens all the time in Boston, and we all
suffer from a little bit of road rage.
But in another transportation experience,
my husband and I love to drive two hours north of Boston
to this lake, Squam Lake, where we have a little cabin.
And when you're out on the motorboat,
people are so friendly on Squam Lake.
They smile and wave.
It's so different than Boston traffic.
And if there's another boat, you slow down,
and you smile and wave.
Or if there's a kayak or a canoe,
you make special care not to make a wake,
and you smile and wave.
And last summer, I was with some friends,
and I said, god, people on Squam Lake are so nice.
And without missing a beat, my friend Mark said, Liz,
you realize those are exactly the same people that
are giving you the finger in Boston traffic.
Right?
So it's the error of attribution,
and there's just a lot that goes on with us cognitively.
So this ladder, it isn't really a ladder.
It's a loop.
And it goes around very quickly, very instantaneously.
You see this one loop here, that our beliefs--
our mindsets-- actually influence what we see.
If I expect the people in traffic to be rude,
suddenly I'm noticing a lot of rudeness.
And if I expect them to be nice on the lake,
I think I probably see more niceness.
And then there's another loop that I don't have here,
but that our actions actually feed back something.
We've been talking a lot about who's responsible for culture
here over the last couple of days.
But our actions within the cultures and systems
in which we work actually feed something back
and change reality.
So it's a fairly instantaneous process--
and literally, we end up just jumping to conclusions.
But the beauty of the ladder metaphor
is that it allows us to stop on any rung
and notice where we are.
So one place to stop-- and we're going to do this just
in a moment with an exercise-- is to notice
what data we're selecting.
The world just is, and it's--
I can't remember who said it--
blooming and buzzing.
Who's the literary person?
You probably know.
Joyce, or-- the world just is, and we selectively
attend to what we need to in the environment.
But are there ways to more expansively be open to what is?
And some people who use mindfulness
practice or other practices to cultivate
the beginner's mind, that's a little bit of what
they're getting at.
And there are other ways, as well.
Or you can notice, if you remember
in the video, that moment of feeling that emotion.
That anger was a clue that an assumption was underneath it.
So being able to stop that round-and-round activity
is part of why we use this ladder metaphor.
Stopping the hamster wheel.
I had an epiphany.
So sometimes you can just stop.
And the ways that we do this, just briefly,
are honing our skills of close looking.
That's through observation.
And some of the things Marcia does in the art museum
are really about honing observation skills--
just bringing more in.
Being more aware of your own assumptions and reasoning,
explicating your assumptions to others
and inquiring into others' assumptions
in a non-judgmental way.
By the way, this is something I meant to say at the beginning.
There's no hidden agenda here, in terms
of assumptions that I want you to get at, at the end.
It really is about learning more about yourself.
And it's not to label other people's assumptions.
It's really just a process of exploration.
So I want to tell you about this book that--
actually, there's a reference on the hand-out
that Marcia put together.
But I'm excited about this book.
A group of us heard this woman speak at a conference at MoMA
last year.
She's a cognitive psychologist who
wrote a book called Inside of a Dog that
was beautifully written and on the best seller
list for a long time.
But she's a New Yorker, and she describes
walking her dog around the block and the space-out
that she was often in when she did this.
Her mind was elsewhere.
The whole point was for the dog to do his thing,
and she'd come back in.
But she often just didn't even notice her surroundings,
until she had a little kid.
And when her son was about 17 months old,
and he started to walk, his beginner's eyes
opened her up to things that were going on.
It could have been some trash--
a trash bag-- on the sidewalk or the fact that there
were letters of B's and O's embedded in the fences
around the buildings.
And it gave her an idea.
And when she started tuning into what her son was saying,
she realized how much she was missing.
So she decided to go for a walk with experts,
and she ended up going for a walk with 11 experts,
starting with a geologist, who showed her
the limestone facade of the buildings
and the fossils embedded in them.
And after she went for a walk and learned
from this geologist, she never saw the block in the same way.
And then she went with an urban wildlife expert.
Who knew there was something like that?
They can actually show you where the rat holes are,
and where the pigeons roost.
And what were some of the other folks?
Oh, someone who--
MARCIA DAY CHILDRESS: Entomologists.
ELIZABETH GAUFBERG: Entomologists--
so about bugs on the underside of leaves.
Or a font expert--
so they went around, and they looked at signage.
And then there was somebody who was a body language expert.
AUDIENCE: Sociologist.
ELIZABETH GAUFBERG: Sociologist.
So how much space do you leave when you're walking down
the street between people?
And every time she took a different walk,
she learned more from the expertise,
but she also realized it was infinite.
There were worlds within worlds on that block,
but she couldn't hold onto them all at once.
But they ended up informing her understanding
and enriching her understanding of her own neighborhood.
So what I'm going to ask you to do now
is I want you to think about your own learning and practice
environments-- just one of them, because I
know you're all over the place.
But one of your own learning and practice environments.
Just conjure it up.
A place that you come frequently,
a place maybe that you are on automatic behavior, some
of the time.
And imagine inviting somebody to go for a walk with you.
And imagine who that person would be
and what you might want to learn from them.
You can't know what you're going to learn,
because you haven't taken the walk yet.
You can do that after the talk.
But think broadly.
It might be, if you're an attending,
it might be a learner.
Or it might be somebody completely
from outside of health care, somebody with a different role.
Who would you take a walk with?
And we're just going to take a minute or two
to talk to the person next to you.
Who would you take a walk with who has different expert
eyes than you?
And then we'll harvest some of the ideas, and then move on.
Why don't we come back to the group.
So I'm just wondering, can folks just shout out
some of the people that came to mind-- some of the expert eyes
that might inform you?
Yeah, Evan.
AUDIENCE: So I thought it would be fun in UMA clinic
to have a folklorist.
ELIZABETH GAUFBERG: A folklorist.
Interesting.
Tell us a little more about that.
AUDIENCE: Just because our patients have
a different biopsychosocial spiritual model of health,
and to better understand what they think
is going on with them.
ELIZABETH GAUFBERG: Very interesting.
Thank you.
Other experts you'd like to walk with?
Yeah, over here.
AUDIENCE: We talked about walking with our patients,
seeing what emotions the environment that they were
in the hospital setting, [INAUDIBLE],,
what they're getting [INAUDIBLE]..
ELIZABETH GAUFBERG: Wonderful, thank you.
AUDIENCE: [INAUDIBLE].
ELIZABETH GAUFBERG: Oh, yeah.
So walking with patients.
And did you say inside or outside
of the hospital setting?
Inside.
So how does this environment actually impact the patient?
And that's something that really is accessible to do, right?
Others?
Yeah, over here.
AUDIENCE: We were thinking about taking
a walk around the University with Thomas Jefferson.
ELIZABETH GAUFBERG: With Thomas Jefferson?
I love the fact that you have somebody from history.
That would be--
AUDIENCE: [INAUDIBLE].
ELIZABETH GAUFBERG: Yeah.
You'd have a hard time explaining
what an iPhone is to him, I bet, but that's
really very interesting.
And how are his founding principles
translated to the modern day?
Really interesting.
And there was somebody back here I saw.
Hi.
AUDIENCE: So my office is in the oldest part of Hospital West,
and I would love to walk through the complex
with someone who knew the history of the architecture
of the building, because the building I'm in dates back
to the late 1800s, early 1900s.
So there are all these buildings that
have been connected over the years
at different functions in the past
that I walk through every day and have no idea.
ELIZABETH GAUFBERG: So interesting.
The history of the architecture--
and you named an architect as somebody you could walk with.
And I think that's fascinating.
Is the way that our teaching and care space is designed--
does that actually support our goals?
Marcia was telling me when we came
in that there used to be this big stationary panel desk here,
and then the podium, which belies
a sense of how learning should happen in the very design.
Maybe just a couple of other walks that you would take?
Yep, back here.
AUDIENCE: A non-medical family member.
ELIZABETH GAUFBERG: A non-medical family member.
Great.
Thanks.
AUDIENCE: They interpret what we do
and what the environment is differently than we do.
ELIZABETH GAUFBERG: Yeah.
Thank you.
So sometimes we need an English-to-English interpreter,
right?
Anybody else here?
OK, great.
So you get a sense--
and you can keep your wheels turning and--
I don't know if it's going to be possible to get
Thomas Jefferson to go on a walk,
but there might be people that really
could expand your horizons.
OK, so as I said before, one way down here
is to use mindful practice and some of these ideas of getting
other perspectives.
But then there's this nexus when we jump to conclusions,
and often that's when we feel an emotion-- when
we have a reaction.
It could be anger, frustration, surprise.
And when you have a reaction, it can be useful just
to dig a little deeper.
And this is a guy--
I don't think it's the exact guy,
but when I was a little girl, I used to visit my grandparents
in Florida.
So this was maybe 40-plus years ago,
when my grandparents had a house on South Beach, which
was pretty dingy back then.
My grandma had the prediction it was
going to be really fancy and glitzy,
and that's why they invested, but they never
got to see it turn into that.
But I used to follow a guy that looked a lot like this,
because I was fascinated.
This is a little metal detector, and it
would go click, click, click, click, click,
and then he would dig, and there would be treasure.
And so I'm going to ask you to do the same thing.
I'm going to ask you to notice your emotional reactions--
that's your click, click, click, click, click.
And this is, through the course of watching
a video in a teaching and learning environment,
it's a parody.
And there is no way-- there's a lot going on in this video--
that you're going to see everything or respond
to everything.
But I just want you to notice your own reactions,
and then the next step is what does my reaction tell me
about a fundamental assumption I hold
about teaching and learning?
OK, so watch the video.
What are your reactions?
And then we're going to debrief together and just
start to get at some of our assumptions.
All right.
So a lot was happening there.
And we're short on time, so normally I
would have you just do a pair share
but I'm going to ask for people--
brave people-- to share just your reactions
to any aspect of this.
And it's good to try to be specific,
like when he said this, or when this happened,
this was my reaction.
And then we'll convert it to what
that might say about your fundamental assumptions
about teaching and learning.
So reactions?
Yep, back here.
AUDIENCE: Less specific, but just in general,
just overwhelmed-- that heaviness in your stomach.
ELIZABETH GAUFBERG: OK.
You're having flashbacks, maybe, to your own training,
so overwhelmed.
And so noticing that reaction, what
does that say about an assumption
that you hold about how people learn best?
AUDIENCE: Well, for me, it's saying
that a slower pace or more piecemeal might be--
ELIZABETH GAUFBERG: So a slower pace or a--
AUDIENCE: More open tour--
not get that visceral, oh, my god.
ELIZABETH GAUFBERG: Thanks, Marcia.
Yeah?
AUDIENCE: I don't have anything else.
ELIZABETH GAUFBERG: If you could just repeat it,
because I don't know that the other--
AUDIENCE: Yeah, so I was saying that it was a very visceral--
overwhelm-- pit-in-the-stomach kind of feeling.
And what that would say about me is that maybe a more piecemeal
approach to getting the information--
because I feel already like there's
no way I could do all this, before I even started--
ELIZABETH GAUFBERG: Gotcha.
AUDIENCE: --type of feeling.
ELIZABETH GAUFBERG: Some time to absorb and process, perhaps.
Other reactions?
Yeah, over here.
AUDIENCE: It seemed like one specialty was very prejudiced
against other specialities and wanted to convey that attitude.
ELIZABETH GAUFBERG: Yeah.
And what does that say about an assumption?
Can you convert that to an assumption
you hold about teaching and learning or practice?
AUDIENCE: We assume our specialty is the superior one,
I guess.
ELIZABETH GAUFBERG: And how might that impact our learners?
And it doesn't have to be--
it can be negative or positive or--
AUDIENCE: Well, clearly, it's going
to set up prejudice in the learners
before they've actually obtained any data to make
their own independent decisions.
ELIZABETH GAUFBERG: Yeah.
Thank you.
Other-- I saw another hand.
Yeah, over here.
AUDIENCE: I think I related a lot to the IV teaching,
specifically, and that feeling of-- oh, my gosh,
I'm supposed to understand this, and I have no idea what he just
said, but I'm going to have to figure it out and pretend.
I think that that plays into the need for ongoing feedback
in a loop between a teacher and a learner
and making sure there's actual understanding, because a lot
of the time, in that fast-paced kind of an environment,
there isn't time for that-- or at least
you don't think there is, but it's obviously critically
important that there is.
ELIZABETH GAUFBERG: So time and opportunity to ask questions
and to assess whether learning has happened.
Great.
Thank you.
Yep, over here.
AUDIENCE: I was going to say, there
was clearly some intentional intimidation
to belittle the med students and to get
them to get the message that they don't really
know anything, or try to convey a message that they don't
know or have any practical knowledge,
compared to a resident.
ELIZABETH GAUFBERG: And what does that say-- so yeah,
I think a lot of us picked up on that.
But what does that say about a fundamental assumption you hold
about teaching and learning?
AUDIENCE: Being intimidated is not
going to be good for the learner.
ELIZABETH GAUFBERG: But then again, there
might be an edge between a certain amount of challenge--
what is that right balance between challenge and ease?
But intimidation, when it crosses that line,
it sounds like that's something you assume
isn't going to be helpful.
Other-- yeah, Tim.
AUDIENCE: I just want to say, too, that--
MARCIA DAY CHILDRESS: Give him the mic.
Yeah, there's a mic right there.
AUDIENCE: We teach the way we were taught.
And that assumption there is that because we
were taught that way, we're going to teach that way.
And it's a rite of passage.
We were belittled, and we were beaten down,
and we worked all these hard hours,
so we're going to make those under us
experience it the same way.
ELIZABETH GAUFBERG: Yeah.
Yeah, thank you.
So that is often what underlies our practices-- is just,
this is the way it's always been done,
and this is what we're going to continue.
So yeah, back up here.
AUDIENCE: So I noticed that, as I was watching it,
I immediately was following Carter and Ben,
and I was following their action.
But because you had primed me, I started
looking at the things that were happening around them, as well.
But had you not primed me, I would
have missed the cop walking through the OR suite, which
was like the gorilla video.
ELIZABETH GAUFBERG: Yes.
AUDIENCE: And so--
ELIZABETH GAUFBERG: If we had more time,
that was going to be one of my slides, but we didn't.
AUDIENCE: Oh, I just ruined it for you.
Sorry.
But the idea that there's an opportunity, just
by a subtle hint, that you can actually bring out
a lot more that you could lose.
ELIZABETH GAUFBERG: Yeah.
I don't think I've ever seen--
I've watched this many times, and I don't know
that I've ever seen the cop.
So thank you for that.
So it really makes the point about selective attention.
Great.
Other reactions?
Maybe we'll just take a couple more, and then we can wrap up.
Yeah.
We have two.
Oh, hi, Preston.
AUDIENCE: I was struck with--
every bit of information appeared to have--
every bit of information provided
appeared to have the same level of importance.
So everything from, don't shake his hand; he's--
whatever the issue was, to this is the most important number
you ever need, this is the most important-- everything just
was deluged onto him with-- you got to know it all,
and it's all equally important.
And probably not the case.
ELIZABETH GAUFBERG: So it's probably not the case,
and so if you can convert that into maybe a principle,
it's that the learners need some--
AUDIENCE: Guidance on what's important.
ELIZABETH GAUFBERG: --guidance and--
OK.
Great.
Yep.
Preston, and then--
AUDIENCE: There's a fine line between wonderful confidence
and arrogance.
And here is a phenomenal resident
who's excellent in his shoes, but yet is a bit cocky.
And here is his chief of department
celebrating his skills, but also cautioning this student
to not assume some of those other qualities
of his behavior.
ELIZABETH GAUFBERG: Yeah, yeah.
That was a beautiful moment, because it
was a recognition of complexity, and that as a learner
you can choose what aspects of a role model--
and it's a very mature idea that people
can have wonderful qualities and challenging qualities,
and it's all embodied in the same person, and how can--
hold that.
Maybe one more, and then--
one more reaction and assumption.
Yeah.
MARCIA DAY CHILDRESS: So I'm realizing
that we bring to what we see our own tendencies,
and my takeaway from that is it's 6440
to call the operating room.
I have an ear for numbers.
ELIZABETH GAUFBERG: Ah.
6440.
Right.
That was like a--
AUDIENCE: I can't get rid of it.
ELIZABETH GAUFBERG: --it was a fire hose.
I hope you don't have to call the operating room here,
because I think it is a different number here.
So we only have just a few more minutes.
We had a backup video.
What I'm going to encourage you to do as we move forward
is actually to remember the ladder,
and to get to know your own ladders-- the conclusions
that you automatically jump to-- to actually make a commitment
to take some walks, or even just inquire of somebody
you're already with how they see things.
And then to notice when you're responding and dig for what's
underneath.
I honestly never get bored anymore
when I'm in a lecture or a teaching and learning setting,
because I do that thing where I try to figure out
what it is that I'm responding to what it
says about my own assumptions.
It's really fascinating to be an anthropologist
of medical education culture.
And just a closing quote, and a little advocacy
for exploring assumptions.
And the next stage is really taking your assumptions,
and then elevating them to principles,
and moving maybe from more format-driven models
of education to principle-driven.
And we have about two minutes if there are any--
MARCIA DAY CHILDRESS: We actually
have a few more than that, because we
started a little late.
ELIZABETH GAUFBERG: OK.
And if people need to leave, we certainly understand.
Any reflections, questions, ways you
think this could be operationalized at UVA?
Yeah, over here.
AUDIENCE: Well, I just have a quick question, again,
I'm Matt from the internal medicine residency program,
and thanks for all the time and energy
you spent with us over the past couple of days.
I was wondering what your thoughts on how much
time should--
the timing around formal education.
Right now, we have two 45-minute sessions, or medical school
classes, or from 8:00 to 1:00, and it always
seems just like droning on with not much diversity in the style
of the lecture or the style of what the teacher is
trying to do for the learners.
And in terms of time limits, what's
the best way to make sure that you're
making sure you're covering all the information without just
putting it one after the other and making it--
because now we're having med students--
when I was in med school, no one went to class.
They did it on their own time, because the timing
of the lectures and having to pay attention
for that long wasn't suitable to their learning style.
ELIZABETH GAUFBERG: Yeah.
That's a great question.
I guess my response is that learning is always happening,
and teaching is always happening.
I say to faculty, every time you walk down the hall,
you're teaching or modeling something.
It sounds like you're making the distinction
between the formal curriculum that might happen in classrooms
versus the on-the-fly learning.
Is that correct?
AUDIENCE: Yeah.
Say, in morning report, what would you
say the appropriate duration of these classes should be?
ELIZABETH GAUFBERG: I would move away from the duration
question and think a little bit more about principles of adult
learning and whether the methods of education
are rooted in how people learn best.
And we know certain things about adult learners--
that they learn when something is relevant to them.
So to the extent that you can make things connected
to a case, an actual patient, and then link the information--
the content knowledge-- to that, it's often relevant.
Giving people the opportunity to actually work with information,
rather than just--
now, in the technological age, a lot of the content--
we have something called the flipped classroom, where
you can watch a really excellent lecture in two-
or three-timed speed in your pajamas, but then you come in,
and the important stuff is working with that information.
So thinking about what helps adults
to learn and make it relevant, I think,
is more important than actually how many minutes
the session is, because it really should be quality time.
Was that helpful?
Yeah, back up here.
AUDIENCE: Thank you very much.
I was wondering, how does one help sensitize colleagues
to the fact that they may be functioning based
on their assumptions, when they haven't
had the privilege of sitting here for the last hour?
ELIZABETH GAUFBERG: So one of the things
that we actually do as--
because this is a half-day at the Harvard Macy--
we learn some skills with something called humble
inquiry, which is learning to ask questions--
to actually listen to your colleague, and maybe just say,
tell me more, or tell me about--
and the attitude of the questioner
hopefully could be or should be one of really genuine openness
and curiosity, to try to get at the other person's underlying
assumption.
And also a willingness to be humble and vulnerable
in sharing your own.
And so there are ways of--
there are peer-coaching skills that allow us to do that.
But it takes a little time and a safe space
to be able to explore, because again, it can be touchy,
because people can often feel like you're
trying to get them to get to a right assumption
or a different assumption.
But I think the first step is really just
to be open to the fact that there's a diversity of, often,
assumptions that are driving people.
AUDIENCE: I have a bit of a follow-up to that,
and that would be whether creating some team teaching
opportunities might be one way in which
that kind of engagement can happen as you're working
in preparation for doing something together in ways that
are new to both of you.
ELIZABETH GAUFBERG: Yeah, and really
making explicit that, when you're doing team teaching,
part of it is preparing and talking about--
if it's a co-facilitating situation, and then de-briefing
afterwards, and having those de-briefing conversations.
And again, with genuine curiosity about what went well,
what could have been done differently.
And I think, often, we really expand our perspective.
Any other-- I'll be here for at least a few more minutes
before we have to move on to the next thing,
so I'm happy to talk with people down here.
MARCIA DAY CHILDRESS: Well, I'd like
to thank Liz for getting us started on our walks.
And I would recommend the Alexandra Horowitz book to you.
You can just read it chapter-by-chapter
as she takes her different walks through a very
familiar and suddenly unfamiliar neighborhood.
I invite you to join us next week
for a program in conjunction with the Virginia
Festival of the Book.
We have Martina Scholtens here from British Columbia,
from Vancouver, talking about her book
that came out last year, Your Heart
Is the Size of Your Fist, A Doctor Reflects on Ten
Years in a Refugee Clinic.
So please join us then, and now please join me
in thanking Liz Gaufberg.
ELIZABETH GAUFBERG: Oh, thank you.
This is great.
Thank you.