"Spoon feeding in the long run teaches us nothing but the shape of the spoon."
E. M. Forster
"The perfect method of learning is analogous to infection. It enters and spreads."
Leo Stein
John Q. Resident strolled into the program director's office and expressed surprise when he was told that he scored in the eighth percentile on the American Board of Surgery In-Training Examination (ABSITE). "Oh," John whined, "I studied but I just don't test well."
"I am sick and tired of this apathy," said a professor as she walked out of the operating room and slumped into a chair. "How am I supposed to teach when the resident doesn’t bother to read up on the patient or procedure?"
"Residents expect to be spoon-fed," moaned a surgery professor. "I spend the bulk of my time explaining simple anatomy and procedural steps that they should already understand, and then they get frustrated when they don't get to do the case!"
These are not unfamiliar stories. Similar scenarios as they relate to undergraduate collegiate experiences are discussed in a classic book called Turning Teaching into Learning 1. This article highlights a few of the book’s main points regarding the importance of learner responsibility and offers thoughts on how we can promote resident accountability and commitment in surgical education.
According to author Robert Case, learner responsibility for their own learning is important for four reasons. First, learner responsibility is the key to growth in one’s knowledge base. Decades of research suggest that academic outcomes are correlated to the effort that learners put into their work and the degree to which they are engaged in their studies. Much lip service is given in residency programs suggesting our goal is to prepare residents to become lifelong, self-directed learners. Socrates said that responsibility can only be taught by example. If you accept this truth, then we acknowledge our obligation to craft policies and teaching strategies that actively promote learner effort. In other words, we have an obligation as a faculty to teach in a manner that provides opportunities for residents to involve themselves in their studies and (key point here) make them accountable for their own learning.
The second reason why learner responsibility is important is because irresponsible learners negatively diminish our collective academic life; frankly, they take the fun out of teaching. Passive, disinterested, reactive (do what they are told but rarely think ahead for themselves) learners can drag a residency rotation down to its lowest common denominator. It seems that faculty members give up when working with these types of residents and either ignore them or just direct them on what to do so the work gets accomplished. There is little motivation to invest time teaching them because it feels like wasted effort. It only takes a few irresponsible residents to weaken the fabric of faculty enthusiasm for teaching. If we spent as much time discussing how we can enhance challenges for the self-directed and highly motivated residents we do have in our programs, instead of those who are less responsible learners, who knows what heights the real adult learners could reach?
The third reason why learner responsibility is important is because the habits of responsible civic and personal life are sharpened and refined in higher education institutions. Our aim is for residents to assume responsible positions in their communities, profession, and in other facets of the world in which they live. For us to fulfill this important purpose, we must nurture a climate in which residents are ultimately responsible for what they glean from their education, develop a deep structured approach to learning, and are uncomfortable doing anything without fully understanding why as well as the consequences.
Finally, responsibility has important implications for public policy toward education. Medical schools and residency programs want to maintain public trust, not graduate students who are insufficiently moved to independence. As plainly noted by Pace:
"Much of the current rhetoric about institutional accountability and Consumerism in… education is one sided. If students don't Graduate the institution is accountable. If students don't learn, the Teacher is accountable. If graduates don't get good jobs the Institution is to blame." 2
Learning is a joint proposition. Medical school and residency program faculty need to be better prepared to take action on learners who do not assertively accept their responsibilities as active self-directed learners and who have demonstrated such, as they should not expect to graduate!
Faculty need to create policies that emphasize these issues. Steps to consider in the residency programs that reinforce the importance of the joint relationship in teaching and learning include the following:
A. Establish clear expectations. Faculty are responsible for defining as well as negotiating the expectations in each rotation by insuring that what is expected is reasonable and feasible given the time allotted. The tendency to hand the students/residents a list of objectives that are not tied to the curriculum or are too large in scope for the given rotation period does not make for an accountable clinical rotation.
B. We need to create a supportive environment. Programs need to adopt an educational philosophy that moves learners to independence. The educational philosophy needs to emphasize the role of learner accountability for the learner’s own progress and in order for residents to make the most of their residency experiences.
C. The school and faculty are accountable for providing first-rate resources and facilities. They are responsible for designing curriculum that is up to date and relevant. They are also responsible for teaching in a way that promotes learner responsibility. Teaching practices that promote surface rather than deep learning include the following3:
- Conveying a lack of enthusiasm or interest in their role as teachers and/or the content being learned
- Not investing sufficient time in teaching
- Allowing residents to be passive and spoon-feeding information
- Rushing to cover too much material
- Emphasizing coverage at the expense of depth
- Creating undue anxiety or low expectations of success by making discouraging statements or assigning excessive workload
- Presenting material in whatever setting so that it can be perceived as a series of unrelated facts
Deep learning is encouraged by faculty when they do the following:
- Show personal interest in the subject being studied as well as the learner
- Concentrate and ensure the necessary time for key concepts
- Confront learners’ misconceptions, which can only be revealed with teaching strategies that make learners’ thinking visible
- Using assessments (whether day-to-day questions or a test) that require thought and the demonstration of higher-level thinking (instead of rote facts)
- Relate new information to what the resident already knows
- Reinforce resident efforts when showing appropriate movement to independence
- Be consistently fair in assessment and feedback, which fosters mutual trust
- Hold residents responsible for self-directing thinking and learning
D. Follow up. If we plan to hold the residents accountable for their own deep learning, then we need to verify with sufficient follow-up. The rationale for being an intellectually curious and self-directed learner should be discussed explicitly as needed, and consequences for being a passive transient in a residency program need to be spelled out.
E. Feedback. It would be in the resident’s best interest if we were to provide positive and negative feedback when they do something well or when we note that they did not do something well. Lack of feedback is the number one complaint of students and residents. Both positive and negative feedback should be provided and with appropriate documentation on a more frequent basis.
F. Evaluations. We need to provide fair and judicious performance ratings and examinations that assess quality of effort. If a resident can “get by” in a rotation or program by simply doing well on the ABSITE, it suggests that the only quality of effort that is being reinforced is memorization of facts and the ability to apply knowledge on a multiple choice examination. We need to take a step back and look at our evaluation systems and ensure that we are recognizing and reinforcing behaviors that demonstrate resident responsibility and self-directed learning.
This is not meant to be an exhaustive list of what can be done to promote resident responsibility for their own learning, but hopefully it jump-starts faculty thoughts about what is being done in their programs that hinders or reinforces high standards and expectations for self-directed learning and learner responsibility.
Surgery residency programs typically attract the cream of the crop. Yet being smart alone doesn't constitute a good surgeon. How residents readily apply themselves as learners will likely correlate with their future approach to learning. Our curriculum, teaching methods, and evaluation strategies need to keep this consideration in the forefront.
"Much education today is monumentally ineffective. All too often we are giving young people cut flowers when we should be teaching them to grow their own plants."
John Gardner
"Feed a person a fish and you've fed him a day, teach a person to fish and you've fed him for a lifetime."
Anonymous
"Give a person a fish and he can eat for a day, but teach a person how to fish and he'll be dead of mercury poisoning inside of three years." (Ha)
Charles Haas
