You have just finished your shift with one of your best senior residents. You’ve had a good bit of acuity and pathology today and she did a great job managing all of the cases. After the shift, she pulls you aside and says, “Can I tell you something without you getting mad?” Puzzled, you say of course. She says, “I didn’t really feel like I learned anything from you today.” Immediately, you become defensive in your mind. You think to yourself…
- Has she been blind to the teaching I’ve been doing today?
- What about the time we spent talking about the patients and what to do for them?
- And talking about the times I had similar patients to the ones we saw today?
Surely, she is incorrect in her assessment of how the day went! However, if she is saying something about it, could it actually be true? And if so, what did she expect me to do differently?
In all of education, there is an inherent feeling that a teacher is supposed to teach and a learner is supposed to learn. Depending on the level of the learner, learning can come in different forms. One thing that any teacher will tell you is that the goal of teaching is not just retention. There are multiple levels of learning including conceptualization and comprehension. One concept that not a lot of people understand is the correlation between teaching and learning. A large majority believe that teaching and learning go hand in hand. If there is teaching, then there must be learning. Obviously, the learner must be engaged with the teaching to learn. So if the learner is asleep or playing on their phone, they are not learning from the teaching.
In reality, teaching and learning are not as correlated as people think. Think about it. Can a learner learn without teaching occurring? Of course, they can. Therefore, the opposite is also true: a teacher can teach without learning to occur. This is what troubles educators. If educators spend all of this time preparing to teach, is it all for nothing if the learners aren’t learning? The goal, although lofty, is to get every learner present to learn the material. The problem is the engagement. Educators must find a way to engage every learner to achieve the lofty goal. The problem is that this is nearly impossible to do in lecture form. So what invariably happens is educators settle for the 75% rule. If at least 75% of the class understands, the educator is content that they’ve done a good job.
In medical education, the same is true. During the pre-clinical years, the focus is on retention. However, retention alone is almost never sufficient as there are varying presentations for every disease process, varying drug dosages, varying diagnostic modalities, etc. Therefore, it is almost insulting to suggest that lecture-based teaching, the age-old method for teaching retention, is the best modality for medical education.
Consequently, during the clinical years, there is a bit of a paradigm shift away from lecture-based learning. The focus now is a lot on pattern recognition in the form of patient interactions. There are some lectures as well, often in the form of noon conferences or resident didactics. However, there is a significant opportunity here to focus on engagement. There are often smaller groups of students in the clinical environment and there is a lot of opportunity for teaching and learning. Sadly, the majority of educators focus on teaching and not if learning is occurring. In other words, the focus is on the teachable moment instead of the learnable moment.
So what is the difference between the two? The teachable moment is any moment an educator is, say, educating. For example, let’s say you and your resident are in the room resuscitating a patient in atrial fibrillation with RVR. You ask which medication does she want to give and she tells you diltiazem. You ask her the dose and she correctly says 0.25 mg/kg. You decide at that moment to teach her and say that if that dose doesn’t work, then the next dose is 0.35 mg/kg and to consider a drip after that. She nods and says, “Yep, sounds good.” Now focusing on that moment, did she learn anything from the teachable moment? You might not know that she has taken care of 10 atrial fibrillation patients in the last week, all with different treatment variations based on different practice styles. So she didn’t learn a thing from your little teachable moment. No wonder she said you didn’t teach her anything.
So what is the learnable moment? The learnable moment is any moment that the learner has learned something that they will retain for a prolonged period. And this moment is really what we should be searching for and striving to achieve with all of our learners.
So how do educators know when a learnable moment is occurring? If you ask a learner, they will tell you it is often an uncomfortable feeling when they recognize that they just heard something for the first time that they need to remember or something they have learned previously but had forgotten and is being refreshed in their brain. It will often elicit a gasp or an agape jaw. A smile. A whimper at times. A “huh…” Or an “oh, yeah!” Or a feverish jotting down. The learnable moment is truly a wonder to behold and is what drives educators to teach. When you see it, you know it. And so does your learner.
So let’s go back to your resident and the atrial fibrillation patient. She gives you the dose of diltiazem perfectly. You decide to teach and ask, “What if she is allergic to diltiazem?” She has only used diltiazem and is unaware of any other medications. So you inform her that metoprolol is another option. Her eyes light up with a small smile upturning on her lips as she replies, “Oh yeah, I have heard of metoprolol being used for a fib.” Learnable moment mic drop.
So how do we achieve this magical moment, especially in our busy clinical environments? We oftentimes let the bustle of our clinical environments get in the way and we try to educate on the fly, frequently poorly. We often resort to short lectures and lose the engagement that has been gifted to us. What I hope to do over this series is focused on techniques you can use to find that learnable moment in all of your learners. Whether it be through pimping (I hate that name and will call it “RFQ” when you see the post), “what if” questions, gaming, VR, simulation, you name it. It is our task as educators to discover that learnable moment.
So before your next shift, think of ways you can find that learnable moment in your learners. Stay tuned.