Category Archives: comparing medicine and education

Helping Professions: The Doctor-Patient Relationship (Joel Merenstein)

Relationships are at the core of the helping professions: teaching, medical practice, psychotherapy, nursing, and social work. Yes, expertise is important and skills are essential but the bond between student, patient, client and the professional is crucial for improved health, solving problems, understanding one’s self, and learning. Joel Merenstein, M.D., understands this at the core of his being. Merenstein has written posts for this blogs before. His most recent (see here) is about relationship with patients after he retired in 2010.

This post–taken from his recent co-authored book, The Human Side of Medicine: Three Generations of Family Physicians Share Their Storiesunderscores the centrality of the doctor-patient relationship. Obviously, there are differences among the helping professions but what draws them together is precisely this relationship, a bond that too many health, social policy, and educational policymakers seeking efficiency, increased productivity, and faster, and better outcomes, too often forget or ignore.

Mary Ann and I had a long and intense relationship as patient and doctor. She was bright, resourceful, and determined. She had her own ideas about medical management and did not hesitate to share them with me. We usually disagreed–until she was dying.

Actually, for many years our conflicts centered around her role as mother rather than patient. I believe, and still do, that both the doctors’ and the parents’ responsibility for children should be to aid and encourage independence. Mary Ann believed in total protection and guidance. So many of her phone calls would start, “I know that you think I’m an overprotective mother, but ….”

Real crises were no problem for her. When the second of her four daughters had acute glomerulonephritis [serious inflammation of the kidneys], she did not panic or become hysterical but remained calm. supportive, and caring. However, despite her daughter’s complete recovery, Mary Ann would forever ask, “Shouldn’t we check again to be sure her kidneys are still all right?”

As the girls grew older and less controllable, more of Mary Ann’s questions and concerns focused on her own symptoms. Once again we had our disagreements. She was not a bothersome patient. In fact she would often wait weeks or months with a particular set of symptoms before calling or making an appointment; but when she did call or come in, she would always want more answers than I had, more explanations than I was capable of–and at the same time, she offered more suggestions than I knew how to handle.

She recognized some of her symptoms as depression and would start medication, only to discontinue the visits and the therapy before they could be effective. At other times she would request tests to evaluate her joint and muscle pains and then want to know why they were normal when she was so uncomfortable.

She never criticized me personally for the lack of answers but was often hard on herself. She came in for an urgent visit with severe ear pain. When I found a small furuncle [a boil] in the external canal, she was upset that she had overacted and that the visit was unnecessary.

Whenever I recommended some referral or alternate form of therapy, she would counter, “That’s not the answer,” or “Do you really think that it will work?” When she finally agreed to see a rheumatology consultant, it seemed to be more to prove no one could diagnose her than to really get an answer. She was vindicated when the consultant could find nothing wrong.

Then a markedly elevated sedimentation rate was reported [blood test that shows inflammation in the body]. This prompted an extensive hospital evaluation, but again no answers. Six weeks later she developed chills, fever, and lymph nodes so large that it was hardly necessary to biopsy them to diagnose her lymphoma.

As she began to do battle with the first of two oncology groups, the strengths of our relationship surfaced. In response to the oncologist’s complaints, I noted that she had always been difficult. I told her and her husband that the oncologist should have been more open and informative. I was being truthful in both instances.

The second oncologist provided a little better communication but not much improvement or satisfaction. She failed to show any response to all of the radiation or chemotherapy.

There was much for me to deal with too: the lack of communication by the oncologists and their difficulty with her demands to know everything, a period of blaming her husband and then herself, and the oldest daughter’s guilt over her independence battles with her mother.

The oncologist reported that there was nothing more he could offer. Mary Ann accepted this and prepared herself.

Then came the house calls. We talked about the home visits I made when the girls were younger and we were all just starting out. We reminisced and bantered, and then she nodded toward her husband and said, “You have to make him understand.” So we stopped talking about the past and concentrated on the future.

Other home visits were to meet the visiting nurses and set up a regimen for pain medication and to see how things were going. There were no complaints and no disagreements. She made suggestions regarding adjustment of her medication and how the nurses might help. She was usually right, or at least she seemed to respond. There were no calls outside the regular visits until the end.

It was a cool but bright Sunday morning in March,and her husband called and asked if I could be there by noon. Her blood pressure had dropped,and they were afraid to give her the narcotic injection that was due then.

She was quiet but seemingly comfortable when I arrived. She said the priest had been there and given her the last rites and “everything was set.” I asked one of the girls if perhaps they had last comments to discuss with their mother. She informed me her mother had already taken care of that.

Her daughters, her husband, and her sister were all around in the large master bedroom. We all talked together almost lightheartedly. She seemed to doze,and I said to the family, “Maybe she doesn’t need the shot.” We all laughed when she immediately admonished me,”You said the wrong thing.”

I gave the morphine and reminded her husband that the injections were not killing her but relieving her pain. I told her to put in a good word for me in heaven and said goodbye. At the front door I wanted to hug her husband but was only able to put my arm around his shoulder.

As I drove away I had a sense of loss but yet felt good that it went well. Then I had an uneasy feeling and pulled the car off the road and thought maybe it had gone well because we did things her way this time. She died at 6:00 AM the next day, quietly and peacefully at the age of 48.

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Doctors and Their Relationships with Patients (Joel Merenstein)

Over the years I have written this blog, I have posted comparisons of medical clinicians and public school teachers. The substantial differences between the two helping professions (e.g., doctors work one-on-one, teachers in groups; doctors’ decisions can have immediate consequences for life and death, much less so for teachers; differences in salaries; social status, etc.) seemingly made comparisons far-fetched. What I focused on, however, was the centrality of the relationship between teacher and student, doctor and patient, as the core of both helping professions, one for learning in school and the other maintaining good health for patients (see here and here).

In this post and others to come, I offer examples of such a relationship between doctor and patient that captures the depth, breadth, and importance of that relationship  to both clinician and patient. Such accounts are uncommon in medical literature.

Joel Merenstein retired in 2005 from his family medicine practice in Pittsburgh (PA). He wrote this article for The Journal of Family Practice in 2010. He and two colleagues have recently published essays about family practice in The Human Side of Medicine.*

Being in practice for 42 years was like running a marathon. Things seem easy and pleasant at first, but then as time goes by, you hit the “wall” and you feel like you can’t go on. “It’s just too hard,” you think. And you wonder: “What am I doing here?”

In an actual marathon, you hit that wall somewhere around the 20-mile mark. (At least that’s what my son tells me.) But in my family medicine practice, I hit the wall at the 10-year mark.

If, like me, you decide not to quit, the endorphins kick in. You feel a high and know you could go on like this forever. You wonder to yourself: “Can life really be this good?”

And then, as the years pass by, you and your patients change and you know the race is coming to an end. It’s time to stop running. Yet, there are many losses in giving up practice. After spending nearly a lifetime as a doctor, it’s hard to give up that identity. That’s who you are, and who you have been.

In my case, I saw the doctor-patient relationship as a “covenant, not a contract,” as Gayle Stephens, MD, described it, and my role as a physician was to prescribe myself as my most potent therapy, as taught by Michael Balint.1

David Loxterkamp has written about “being there” as the prime service of the family doctor.2 But in retiring you are not there—at least not the way you once were.

How about lunch, doc?

When I retired 5 years ago, many patients wanted to “go out to lunch” or in some way maintain our relationship. I avoided this, saying that I thought it was important for them to develop a relationship with their new doctor. This was (and is) true, but I’ve come to realize that it is not the most important reason to pass on such invitations.

Lovers breaking up say they can “still be friends,” even though they know that is impossible. They can neither give up the special feelings they have had, nor the memories of those feelings that will always be a relevant part of their lives. Similarly, I have too much invested in these relationships to “just be friends.”

Moving on
I have moved on. My wife of 52 years and I travel and visit our children and grandchildren. I take and teach classes at a program for retired people. I have more free time than I have ever had, and I don’t miss the constant sense of responsibility for others, or the time spent agonizing over mistakes. But it was the right time to leave practice when technological advancements were accelerating at lightning speed, and my energy level was no longer keeping pace.

Mixed emotions when I talk to patients.

I must confess that I periodically call patients to see how they’re doing. It’s really more for me than for them—but I try not to make that obvious.

Despite not wanting to have lunch with my former patients, I must confess that I periodically call some of them to see how they are doing. I realize that it is really more for me than for them—but I try not to make that obvious. Our conversations leave me with such mixed emotions.

Feeling guilty
Bob and his family were patients of mine almost from the day I started. I attended their daughters’ weddings, shared in their tragedies, cared for multiple illnesses, and counseled the children. When Bob was diagnosed with Alzheimer’s disease, I told him it was very early and we would go through it together and learn from each other. Then I retired.

I know through my conversations with him and his family that he has gone on with good care. But he has gone on without me.

I feel guilty.

I realize that some of this is ego—a loss of importance. But mainly I feel badly that I am not fulfilling that promise I made to him. And I have “cheated” myself out of the pleasure of learning and giving.

Feeling incomplete
I was particularly close with Marylou and her family. I attended birthday parties, cared for her and her husband’s chronic illnesses, supported them through the illness and death of their daughter, and listened when that’s all I could do. Last year, Marylou called me when she was diagnosed with breast cancer. I stayed in touch and expressed my pleasure when she did well. But, I wasn’t involved in the therapy decisions and I wasn’t there when it was time to cry or talk to the family.

It made me feel incomplete.

Feeling humbled
Recently I got a letter from a urologist regarding a former patient of mine, Robin.

Robin was diagnosed with prostate cancer about 10 years ago, when I was still his physician. Obviously, the new urologist didn’t know that I had retired. So I forwarded the note to Robin’s new family physician and called Robin to see how he was.

I still felt a tremendous sense of responsibility for Robin’s diagnosis. I had never screened him for prostate cancer. But as he reminded me at the time of his diagnosis, he and I had discussed screening. It’s just that Robin, who knows much about medicine and was always involved in his own decisions, had chosen not to pursue it.

Now 10 years later, Robin and I were catching up. As we talked, Robin revealed that he had multiple complications requiring permanent catheters and that he’d had to give up work.

“I wish you were still in practice,” he said to me. “I miss our talks.”

With that, I felt humbled.

Talking to Robin got me thinking. As doctors, we spend so much time worrying about doing the right thing and giving the right advice that we sometimes forget that we need to have confidence in our patients and their ability to make their own decisions. We need to know when to let go.

“Being there”
Jane was another person who emerged from my professional past. I had known her for years. Not only was she my patient, but I saw her when she came in with her father, sister, and mother for their appointments. Together, we had cared for her family members through their illnesses and deaths.

One day after my retirement, she called to get some advice for a problem she was having with her stepson. I listened, gave some suggestions about whom to see, and offered to stay in touch. She thanked me, saying she didn’t know who else to call.

I hung up thinking how hard it is to “be there” when you are not there.

Jane’s call reminded me of a lesson I’d given years ago to a class of first-year medical students. I had brought in a patient of mine and together, in front of the class, we discussed the doctor-patient relationship.

I asked my patient what was most important about our relationship. She said that when she was diagnosed with diabetes, I gave her my private home phone number.

I responded, “Mrs. E, in our 15 years together, how many times have you used that number?”

“None,” was her reply.

Med students, take note

I really don’t know if my retirement has been easier for my patients than for me. I certainly hope so. Part of my job was to encourage their independence and self-sufficiency. My emotional dependence on them is my problem and I suspect one that is not that uncommon among doctors. I am still teaching and doing some research. Some of my retired friends still go to grand rounds and travel to medical meetings, even though they don’t see any patients.

I have few regrets in retiring from my practice. It was the right thing to do at the right time. Do I miss it every day? Yes, but I also feel so lucky to have worked as a family physician for 42 years.

I once heard a British family physician define the family doctor as someone you can go to and talk to about anything you want. To me, the family doctor is someone who knows you—really knows you—in a way that no one else does. A family doctor is someone who can cry with a patient about a loss, not because the physician can appreciate the loss, but because the patient’s loss is the physician’s loss, too.

I wish more young medical students understood the depth of the connections we make as family physicians, and just how rewarding the work can be. If they did, there would certainly be more students choosing a career in family medicine.

References

  1. Balint M. The Doctor, His Patient and the Illness. 1st ed. London, England: Pitman Medical; 1957.
  2. Loxterkamp D. Being there: on the place of the family physician. J Am Board Fam Pract. 1991;4:354-360.

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*Joel Merenstein is a life-long friend. We met at ages 14, were in the same Jewish boys club, went to Pitt, and since then have stayed in close touch through family events including vacations, visits to one another, and weekly phone calls. We have often had conversations (and continue to do so) about doctors and teachers, technologies in both professions, politics, religion, families, and many other issues. Our friendship has become family.

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Why Have Instructional Technologies Been an Add-on to Classrooms?

My primary care doctor is an early adopter of technology. He is a believer that new hand-held computers can replace the stethoscope, record EKGs, and other functions. These are labor-saving devices that make him more efficient, he told me. They give him more time to spend with the patient (although the HMO I belong to mandates 20-minute appointments with longer visits allowed when special requests are made).

One of the few physicians in the HMO who volunteered to use Google Glass when it was being sold, my doctor asked me if it is OK for our conversation to be recorded as we talked. He does not use the video function of Google Glass when meeting with patients. When I asked him why he is using Google Glass, he said that with a scribe located elsewhere in the building taking down what we talk about and producing a transcript later, while I am with him, he does not have to constantly switch back-and-forth looking at the computer screen and then me. We converse about my health, answer questions, and discuss issues bothering me.

These visits with my doctor got me thinking about how teachers and physicians have encountered new technologies as they practice the art and science of teaching and ministering to both the healthy and ill. From what I encountered in schools over the past three decades when computers have been used by teachers for instruction and doctors for diagnosing and treating illnesses, I began to wonder why doctors so easily integrated new devices–either as early adopters or even “laggards”–into their daily encounters with patients while it has been a long slog with getting computers integrated seamlessly into daily lessons.

Why  has “technology” in education been considered separate, an add-on, when that has not been the case when technological tools have been applied to business, medicine, architecture, engineering and other professional work. For some reasons in these other workplaces, high-tech tools are part-and-parcel of the daily work that professionals do in getting the job done well and efficiently. As the conversation between my doctor and me over Google Glass illustrated, hand-held devices that do EKGs and monitor heartbeats, machines that do CAT-scans–help physicians figure out what’s wrong with a patient. Not, however, in schools and higher education. There, use of efficiency-driven tools is both the subject and predicate. The instructional problem to be solved is secondary. Why, then, unlike other professional work, has educational technology monopolized discussions about improving schools, changing teaching, and preparing students for the labor market?

There are, of course, some easy answers to my question. Initially, for teachers access to desktop and, later, laptops and now Chromebooks and iPads was an issue. Too few shiny new devices were available. School boards and superintendents had to find scarce dollars to buy hardware and software, establish wireless networks, provide on-site and district assistance, and set aside even more funds to build teachers’ capacities to use new technologies. Limited access helps to explains the slow-motion use of new devices in classrooms. In the past half-decade, however, allowing for some exceptions, access is no longer an issue in the nation’s classrooms. One-to-one laptops and Chromebooks and iPads on classroom carts, BYOD programs, and giving students a device to take home have largely replaced computer labs and media center machines.

The issue now is teacher use or the seamless integration of devices into daily lessons much as doctors have done to varying degrees when they work with patients. Instances of integration, that is, using hardware and software as part-and-parcel of the lesson and not as an add-on tacked onto activities during the school day. Examples of smooth and continuous integration cross grade levels and subjects occur in classrooms, schools, and districts. But as yet such easy use of the new technologies as essential tools like paper and pen are not as widespread as advocates want. Why not?

Any answer to the question has to take into consideration the differences between the practice of teaching and the practice of medicine. Teaching is a group process, one adult working with 15-30 students at a time while the latter is commonly one-to-one. Moreover, the age-graded school gives teachers located in self-contained classrooms a degree of autonomy; yet the structure also isolates them from colleagues. It is hard for teachers to collaborate within the school, much less the district level, and to become part of a culture where constant improvement is the norm, not the exception.

While doctors do practice in organizations driven by efficiency criteria, they retain a great deal of autonomy. After the physician knocks and enters the exam room to see you, it is just you and the doctor. Access to research literature, collegial advice, and direction from the HMO often, but not always, create a culture that embraces change and continuous improvement.

Those differences in organizational structures and culture between medicine and schooling become the initial framework for any in-depth and nuanced answer to question:  why have new technologies have been seen as add-ons in schools and classrooms? A second related question comes quickly on the heels of this one: If technology has been an add-on to schooling, how does integration into classrooms, schools, and districts occur at all? That is what I will try to answer in my next project (see here).

 

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A “Zombie” Reform: Outcome Based Education (OBE) in Medical Education and K-12 Schools

Outcome Based Education (OBE) rolled through U.S. public schools in the 1980s and 1990s. Yes, OBE (a.k.a “mastery learning,” “competency-based education”) is still around (see here). But the drum-beating policy talk and promises of turning around “failing” U.S. schools, well, those claims have evaporated for K-12 schools.  Except for university medical education. Thus, a “zombie” reform returns.

On the 100th anniversary of the Flexner Report (1910) which did, indeed, alter medical education a century ago, another gaggle of reforms aimed at transforming current medical education has swept across U.S. medical schools in the past decade. I say “another” because like K-12 U.S. schools, university medical education has had cycles of reform aimed at the original Flexnerian model of medical education–two years of basic sciences (e.g., anatomy, biochemistry, genetics) and two years of clinical practice in hospitals and clerkships in various specialties (e.g., surgery, internal medicine, obstetrics).  OBE–sometimes called “Competency-Based  Education” (CBE)–has become the “reform du jour” in this cycle of change in medical education. Yet its shortcomings and missing elements applied to medical education have already been documented fully  (see 2013_OBE).

OBE in either K-12 or medical schools is all about educators identifying concepts, knowledge, and skills that students must have in the “real world,” teaching both, and then measuring  performance to see whether students have acquired the requisite knowledge and skills.

In OBE, how long it takes for each student to master the content and skills is not tied to a prescribed time such as a quarter, semester, or year. Nor is any pedagogy privileged. Moreover, assessment is not only a one-time snapshot, it is ongoing.  Mastery depends upon individual students’ grasp of the material and their demonstration of skills. Thus, in K-12 schools embracing OBE would give up an age-graded system–1-8, 9-12. Students would not be compared to one another. Teachers would be free to use varied pedagogies matched to student differences as each one masters prescribed outcomes. Yet OBE, even with the stamp of Presidential approval (Bill Clinton and George W. Bush) barely made a dent in U.S. schools in the 1980s and 1990s.  It is in the dust-bin reserved for once-hyped school reforms.

For medical education, however, CBE has come back from the dead. As had occurred in K-12 OBE, definitional problems have arisen often. For medical education, a recent definition is:

Competency-based education (CBE) is an approach to preparing physicians for practice that is fundamentally oriented to graduate outcome abilities and organized around competencies derived from an analysis of societal and patient needs. It de-emphasizes time-based training and promises greater accountability, flexibility, and learner-centredness.
Defining what CBE is also means specifying what outcomes have to be mastered before medical students can become doctors. One report summarized the seven roles that physicians must become competent in: “medical expert, communicator, collaborator, manager, health advocate, scholar, professional.” In addition, according to the report, physicians must master 28 general competencies and 154 “enabling and sub-competencies.”
But even definitions and detailed outcomes cannot get around one of the fundamental lapse in K-12 OBE and currently faces those leaders in medical education who seek to implement CBE. And that lapse has haunted not only these reforms but any major change seeking to alter structures and cultures in educational organizations: inattention to the capacities of teachers and, in this instance, medical school professors to both understand the reform and implement it fully. As one report put it, albeit delicately (see: 00001888-201110000-00017-1 )
Faculty in medicine are expected to teach, yet most faculty enter their academic positions underprepared for their roles as medical educators—even when they assume education leadership positions. This lack of formal training in teaching may be due, in part, to a lack of recognition of the complex skills (from techniques in microteaching to metaskills in program evaluation) necessary to succeed as a medical educator. Without formal educational training, most faculty members undergo ad hoc training, selecting from a local/national menu of programs, that they hope will enhance their skills—after they assume their teaching roles. Developing a better understanding of the skills necessary for success as a medical educator would be an important advance for medical education, resulting in the improved quality of teaching and enhanced learner outcomes.
Less delicately, I would say: If those who are expected to put CBE into practice lack the know-how in helping students master the specified outcomes, how in the world can learners become competent in their roles as doctors? Like so many promised reforms in K-12 schooling, teachers have to implement the reform and in doing so acquire the knowledge and skills that will aid students. The same is true for CBE in medical education. Putting an end to “zombie” reforms begins with recognizing that teachers and medical faculty are the gatekeepers to any meaningful classroom change be it OBE or CBE.

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“Good” Doctors and Teachers (Part 2)

1. Has the definition of “good” teachers changed over time as has the one about “good” physicians?

2. Are there many different versions of “good” teaching as there were for “good” doctors?

3. Even with the differences in definitions over time and setting, are their core characteristics that transcend both as there were among “good” doctors?

4. Are “good” teachers dependent for success on their students, as doctors are on their patients?

The answer to each of the four questions is yes.

1. Has the definition of “good” teachers changed over time as has the one about “good” physicians? 

From the 1960s, researchers laid out the following personal traits and behaviors that “good” teachers exhibit:

[E]ffective teachers carefully monitor learning activities and are clear, accepting and supportive, equitable with students, and persistent in challenging and engaging them.

In the 1980s and 1990s, researcher findings added up to the following attributes of “effective” teachers. They:

*are clear about instructional goals;

*are knowledgeable about their content an strategies for teaching it;

*communicate to their students what is expected of them and why:

*make expert use of existing instructional materials in order to devote more time to practices that enrich and clarify the content;

* are knowledgeable about their students, adapting instruction to their needs….;

*address higher- as well as lower-level cognitive objectives….;

*accept responsibility for student outcomes;

*are thoughtful and reflective of their practices.

Then there are the features of “good” teachers that progressives then and now hold dear:

*A classroom that is student-centered:

*Teaching methods that are inquiry driven and organized around problem-solving and investigation:
*Instructors who are passionate about their subject’s real world significance.
*Metacognition—critical reflection about content
and pedagogy—is an integral part of the classroom
experience.

Lists of attributes and behaviors of “good” teachers appear every decade. Some lists overlap, some do not.

good-teacher-mind-map-Medium

 

 

 

 

 

 

 

 

2. Are there many different versions of “good” teaching as there were for “good” doctors?

Surely, there are. Consider that since the 1990s, policymakers have rushed to raise academic standards, hold teachers and administrators accountable for student outcomes, and expanded testing. In that push, a narrowed view of what constitutes “good” teaching has unfolded that focuses more on direct instruction and teacher-centered behaviors.

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Yet there are students who see “good” teaching as different than this current mainstream view (e.g., “What makes a great teacher is being kind,” “A great teacher is someone that cares for his or her students,” “Someone who can make learning fun and someone who can be funny and focused at the same time”).

And for many, but not the majority, there are parents, practitioners, and researchers, who define a “good” teacher as going beyond high test scores. They want their children’s teachers—reflecting another age-old tradition of teaching—to work daily for the well-being of the child, see students as whole human beings, believe in active learning, create structures for students to collaborate and explore. In short, these folks embrace a progressive ideology of teaching believing with supreme confidence that students exposed to this tradition of teaching will do well on tests, graduate and go to college. They would point to Los Angeles teacher Rafe Esquith, kindergarten teacher Vivian Paley, and Foxfire teachers in rural Georgia as “good” teachers who nurture, inspire, and connect to students.

3. Even with the differences in definitions over time and setting, are there core characteristics that transcend both as there were among “good” doctors?

Yes, there are. Just as when medical staff, patients, professionals and non-professionals define “goodness” in physicians, two essential features crop up again and again for teachers: competence and caring.

the.modern.school.teacher

4. Are “good” teachers dependent on their students as doctors are on their patients for success.

Yes. they are. To see how the dependence works, one has to sort out the notion of “good” from the idea of “successful.” They are often seen as equivalent terms. They are not. Once sorted out, it becomes clear that both teachers and doctors depend on their students and patients to learn and heal.

Keep in mind that doctors and teachers using “good” practices do not automatically yield “good” results. Following the best practices in either job leads, from time to time, to failure, not success. Why? Because motivated students and patients have to participate fully for “good” teaching to turn into “successful” learning and the same is true for doctors and their patients.

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Here is how the distinction works for teachers. Good” teaching pursues morally and rationally sound instructional practices. “Successful teaching,” on the other hand, is teaching that produces the desired learning. As Gary Fenstemacher and Virginia Richardson put it:

“[T]eaching a child to kill another with a single blow may be successful teaching, but it is not good teaching. Teaching a child to read with understanding, in a manner that is considerate and age appropriate, may fail to yield success (a child who reads with understanding), but the teaching may accurately be described as good teaching. Good teaching is grounded in the task sense of teaching, while successful teaching is grounded in the achievement sense of the term.”

Another way to distinguish between “good” and “successful” is when a 8th grade teacher teaches the theory of evolution consistent with the age of the child and best practices of science teaching (the “good” part) and then has her students complete three written paragraphs filled with relevant details and present-day examples that demonstrate their understanding of the theory of evolution (the “successful” part). These teaching acts are not the same nor does one necessarily lead to the other.

For the past quarter-century, however, policymakers and politicians have chopped, grated, and blended the goals of schooling into a concoction seeking to make education an arm of the economy. They scan international test scores, focus on achievement gaps, and boost teacher pay-for-performance plans. This policy direction has shoved the notion of “good” teaching into one corner of the ideological debate and thoroughly erased the distinction between the “good” and “successful” in teaching. Now “good” teaching means test scores go up and students go to college. A big mistake.

Why a mistake? Erasing the distinctions between “good” and “successful” teaching muddles policy prescriptions seeking to improve how teachers teach and what students learn. Best example of that muddle is evaluating teacher performance on the basis of student test scores. Consider, for example, the stark differences between Houston’s pay-teachers-for-performance and Denver’s ProComp plan.

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The answers to the four questions are monotonously “yes.” The string of “yes” answers reveals that policymakers have, as so often they do, ignored the history of diverse teaching traditions and different ways of teaching that parents, practitioners, and researchers prize resulting in an unfortunate monopoly on only one way of teaching while students—in their glorious diversity–learn in many different ways.

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*The quote marks are there to signal that “good” (or “great,” “excellent,” “effective”) is an adjective that varies in meaning among parents, teachers, students, researchers, and policymakers.

 

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“Good” Doctors and Teachers* (Part 1)

During the 1930s, my grandmother saw a specialist about a melanoma on her face. During the course of the visit when she asked him a question, he slapped her face, saying, ‘I’ll ask the questions here. I’ll do the talking.’ Can you imagine such an event occurring today? Melanomas may not have changed much in the last fifty years, but the profession of medicine has.  Eric J. Cassel, 1985[i]

Today, a stinging slap to the cheek of a patient who asked a question of her doctor could lead to an assault charge. Doctor-centered practice–paternalistic authority is no more. Shared decision-making between doctor and patient has become the ideal. In short, the definition of a “good” doctor has changed dramatically in the past half-century.[ii]

Even with this 180 degree shift in defining “goodness,” there remains much variation even among former TV doctors Welby and Kildare and today’s Dr. House. All are seen as “good” in different ways as times change.

And that is why I put “good” in parentheses. Personal features (e.g., communication skills, empathy), expertise (e.g., credentials on walls, medical specialty), what others say, and context matter greatly in judging how “good” a doctor is.

Here is how one doctor puts the issue of defining “goodness” among physicians.

In my view, there are many ways a doctor can be good, so it’s difficult to know what someone means when he or she says a doctor is good.

For some people, being a good doctor is all about bedside manner, personality and communication skills. Other people value smarts, technical skills or expertise in a particular condition. Still others rely on credentials, such as where a doctor went to medical school or residency training. I’ve even known patients who care little about these other factors and instead care most about how the office runs, how quickly the phone is answered or how friendly the receptionist is.

The type of doctor may also determine how a person defines a good doctor. For example, many people I know say they don’t care about a surgeon’s bedside manner as long as his or her patients have outstanding results. Yet those same people might say that a good bedside manner is much more important for their primary care physician.

Then there are those magazines that list “best” doctors in their cities annually. How do they compile such lists? New York magazine, for example, depends upon a private firm that polls doctors for their recommendations:

The idea is that medical professionals are best qualified to judge other medical professionals, and if one recommendation is good (think of your doctor referring you to a specialist), multiple recommendations are better. Licensed physicians vote online (castleconnolly.com/nominations) for those doctors they view as exceptional.

So if the notion of a “good” doctor varies by time–doctor-centered then and patient-centered now– it also varies by what patients and doctors, each having quite different perspectives, value most in medical practitioners (e.g.,competence,  empathy, bedside manner). In short, there is not one single definition of a “good” doctor that covers all settings, perspectives, and times.

Yet even with all of this variation over what constitutes a “good” doctor, even with all of those lists of personal and technical features that patients want in their doctors, two generic characteristics emerge from the flow of words time and again. These basic features: competence and caring–turn up in studies (see here) and public opinion polls among both physicians and patients.

Keep in mind, however, that even the most competent and caring doctor depends upon the patient for any success in diagnosis and treatment. The truth is that expertise and caring are necessary ingredients for any definition of “goodness” in medical practice but, overall, insufficient in the helping professions without the patient’s cooperation.

While doctors can affect a patient’s motivation, if that patient is emotionally depressed, is resistant to recommended treatments, or uncommitted to getting healthy by ignoring prescribed medications the physician is stuck. Medical competence and empathy fall short when patients cannot or do not enter into the process of healing.

This basic predicament in the helping professions of being dependent upon the cooperation of the patient for any success–often unremarked upon–hobbles any definition of a “good” doctor.

Does the historical shift in definitions about “good” doctors and the fundamental dilemma they face apply to teachers? I answer that in Part 2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[i]Epigraph story in Christine Laine and Frank Davidoff, “Patient-Centered Medicine,” JAMA, 1996, 275(2), p. 152.

[ii] Ronald Epstein, Md., et. al. “Communicating Evidence for Participatory Decision-making,” JAMA, 2004, 291(19), pp. 2359-2366; Simon Whitney, Md., et. al., “A Typology of Shared Decision Making, Informed Consent, and Simple Consent,” Annals of Internal Medicine, 2003, 140, pp. 54-59.

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*Synonyms for “good” are “best,” “great,” “effective,” “stellar,” etc.

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Evidence Based Education Policy and Practice: A Conversation (Francis Schrag)

 

This fictitious exchange between two passionate educators over making educational policy and influencing classroom practice through careful scrutiny of evidence–such as has occurred in medicine and the natural sciences–as opposed to relying on professional judgment anchored in expertise gathered in schools brings out a fundamental difference among educators and the public that has marked public debate over the past three decades. The center of gravity in making educational policy in the U.S. has shifted from counting resources that go into schooling and relying on professional judgment to counting outcomes students derive from their years in schools and what the numbers say.

That shift can be dated from the Elementary and Secondary Education Act of 1965 but gained sufficient traction after the Nation at Risk report (1983) to dominate debate over innovation, policy, and practice. Although this is one of the longest guest posts I have published, I found it useful (and hope that viewers will as well) in making sense of a central conflict that exist today within and among school reformers, researchers, teachers, policymakers and parents.

Francis Schrag is professor emeritus in the philosophy of education at the University of Wisconsin, Madison. This article appeared in Teachers College Record, March 14, 2014.

A dialogue between a proponent and opponent of Evidence Based Education Policy. Each position is stated forcefully and each reader must decide who has the best of the argument.

Danielle, a professor of educational psychology and Leo, a school board member and former elementary school teacher and principal, visit a middle-school classroom in Portland Maine where students are deeply engaged in building robots out of Lego materials, robots that will be pitted against other robots in contests of strength and agility.  The project requires them to make use of concepts they’ve learned in math and physics.  Everything suggests that the students are deeply absorbed in what is surely a challenging activity, barely glancing around to see who has entered their classroom.

Leo:  Now this is exciting education. This is what we should be moving towards.  I wish all teachers could see this classroom in action.

Danielle:  Not so fast.  I’ll withhold judgment till I have some data.  Let’s see how their math and science scores at the end of the year compare with those of the conventional classroom we visited this morning.  Granted that one didn’t look too out of the ordinary, but the teacher was really working to get the kids to master the material.

Leo:  I don’t see why you need to wait.  Can’t you see the difference in level of engagement in the two classrooms?  Don’t you think the students will remember this experience long after they’ve forgotten the formula for angular momentum? Your hesitation reminds me of a satirical article a friend showed me; I think it came from a British medical journal.  As I recall the headline went: “Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized controlled trials.”

Danielle:  Very cute, but let’s get serious.  Spontaneous reactions can be misleading; things aren’t always what they appear to be, as I’m sure you’ll agree.  I grant you that it looks as if the kids in this room are engaged, but we don’t know whether they’re engaged in the prescribed tasks and we don’t know what they’re actually learning, do we?  We’ll have a much better idea when we see the comparative scores on the test.  The problem with educators is that they get taken in with what looks like it works, they go with hunches, and what’s in fashion, but haven’t learned to consult data to see what actually does work.  If physicians hadn’t learned to consult data before prescribing, bloodletting would still be a popular treatment.

Suppose you and I agreed on the need for students to study math and physics.  And suppose that it turned out that the kids in the more conventional classroom learned a lot more math and physics, on average, as measured on tests, than the kids in the robotics classroom.  Would you feel a need to change your mind about what we’ve just seen?  And, if not, shouldn’t you?  Physicians are now on board with Evidence Based Medicine (EBM) in general, and randomized controlled trials (RCTs) in particular, as the best sources of evidence.  Why are teachers so allergic to the scientific method?  It’s the best approach we have to determine educational policy.

Leo:  Slow down Danielle.  You may recall that a sophisticated RCT convincingly showed the benefits of smaller class sizes in elementary schools in Tennessee, but these results were not replicated when California reduced its elementary school class size, because there was neither room in the schools for additional classrooms nor enough highly skilled teachers to staff them.  This example is used by Nancy Cartwright and Jeremy Hardie in their book on evidence-based policy to show that the effectiveness of a policy depends, not simply on the causal properties of the policy itself, but on what they call a “team” of support factors (2012, p. 25).  If any one of these factors were present in the setting where the trial was conducted but is lacking in the new setting, the beneficial results will not be produced.  This lack of generalizability, by the way, afflicts RCTs in medicine too.  For instance, the populations enrolled in teaching hospital RCTs are often different from those visiting their primary care physician.

Danielle:  I have to agree that educators often extrapolate from RCTs in a way that’s unwarranted, but aren’t you, in effect, calling for the collection of more and better evidence, rather than urging the abandonment of the scientific approach.  After all, the Cartwright and Hardie book wasn’t written to urge policy makers to throw out the scientific approach and go back to so-called expert or professional judgment, which may be no more than prejudice or illicit extrapolation based on anecdotal evidence.

Leo:  You seem to be willing to trust the data more than the judgment of seasoned professionals.  Don’t you think the many hours of observing and teaching in actual classrooms counts for anything?

Danielle: If your district has to decide which program to run, the robotics or the traditional, do you really want to base your decision on the judgment of individual teachers or principals, to say nothing of parents and interested citizens?  In medicine and other fields, meta-analyses have repeatedly shown that individual clinical judgment is more prone to error than decisions based on statistical evidence (Howick, 2011, Chap. 11). And, as I already mentioned, many of the accepted therapies of earlier periods, from bloodletting to hormone replacement therapy, turned out to be worse for the patients than doing nothing at all.

Now why should education be different?  How many teachers have “known” that the so-called whole-word method was the best approach to teaching reading, and years later found out from well-designed studies that this is simply untrue?  How many have “known” that children learn more in smaller classes?  No, even if RCTs aren’t always the way to go, I don’t think we can leave these things to individual educator judgment; it’s too fallible.

And you may not need to run a new study on the question at issue.  There may already be relevant, rigorous studies out there, testing more exploratory classrooms against more traditional ones in the science and math area for middle-schoolers.  I recommend you look at the federal government What Works website, which keeps track of trial results you can rely on.

Leo:  I’ve looked at many of these studies, and I have two problems with them.  They typically use test score gains as their indicator of durable educational value, but these can be very misleading.  Incidentally, there’s a parallel criticism of the use of “surrogate end points” like blood levels in medical trials.  Moreover, according to Goodhart’s Law—he was a British economist—once a measure becomes a target, it ceases to be a good indicator.  This is precisely what happens in education: the more intensely we focus on raising a test score by means of increasing test preparation to say nothing of cheating—everything from making sure the weakest, students don’t take the test to outright changing students’ answers—the less it tells us about what kids can do or will do outside the test situation.

Danielle:  Of course we need to be careful about an exclusive reliance on test scores.  But you can’t indict an entire approach because it has been misused on occasion.

Leo: I said there was a second problem, as well.  You recall that what impressed us about the robotics classroom was the level of involvement of the kids.  When you go into a traditional classroom, the kids will always look at the door to see who’s coming in.  That’s because they’re bored and looking for a bit of distraction.  Now ask yourself, what does that involvement betoken. It means that they’re learning that science is more than memorizing a bunch of facts, that math is more than solving problems that have no meaning or salience in the real world, that using knowledge and engaging in hard thinking in support of a goal you’ve invested in is one of life’s great satisfactions.  Most kids hate math and the American public is one of the most scientifically illiterate in the developed world.  Why is that?  Perhaps it’s because kids have rarely used the knowledge they are acquiring to do anything besides solve problems set by the teacher or textbook.

I’m sure you recall from your studies in philosophy of education the way John Dewey called our attention in Experience and Education to what he called, the greatest pedagogical fallacy, “the notion that a person learns only the particular thing he is studying at the time” (Dewey, 1938, p. 48).  Dewey went on to say that what he called “collateral learning,” the formation of “enduring attitudes” was often much more important than the particular lesson, and he cited the desire to go on learning as the most important attitude of all.  Now when I look at that robotics classroom, I can see that those students are not just learning a particular lesson, they’re experiencing the excitement that can lead to a lifetime of interest in science or engineering even if they don’t select a STEM field to specialize in.

Danielle:  I understand what Dewey is saying about “collateral learning.”  In medicine as you know, side effects are never ignored, and I don’t deny that we in education are well behind our medical colleagues in that respect.  Still, I’m not sure I agree with you and Dewey about what’s most important, but suppose I do.  Why are you so sure that the kids’ obvious involvement in the robotics activity will generate the continuing motivation to keep on learning?  Isn’t it possible that a stronger mastery of subject matter will have the very impact you seek?  How can we tell?  We’d need to first find a way to measure that “collateral learning,” then preferably conduct a randomized, controlled trial, to determine which of us is right.

Leo:  I just don’t see how you can measure something like the desire to go on learning, yet, and here I agree with Dewey, it may be the most important educational outcome of all.

Danielle:  This is a measurement challenge to be sure, but not an insurmountable one.  Here’s one idea: let’s track student choices subsequent to particular experiences.  For example, in a clinical trial comparing our robotics class with a conventional middle school math and science curriculum, we could track student choices of math and science courses in high school.  Examination of their high school transcripts could supply needed data.  Or we could ask whether students taking the robotics class in middle school were more likely (than peers not selected for the program) to take math courses in high school, to major in math or science in college, etc.  Randomized, longitudinal designs are the most valid, but I admit they are costly and take time.

Leo: I’d rather all that money went into the kids and classrooms.

Danielle:  I’d agree with you if we knew how to spend it to improve education.  But we don’t, and if you’re representative of people involved in making policy at the school district level, to say nothing of teachers brainwashed in the Deweyian approach by teacher educators, we never will.

Leo:  That’s a low blow, Danielle, but I haven’t even articulated my most fundamental disagreement with your whole approach, your obsession with measurement and quantification, at the expense of children and education.

Danielle:  I’m not sure I want to hear this, but I did promise to hear you out.  Go ahead.

Leo:  We’ve had about a dozen years since the passage of the No Child Left Behind Act to see what an obsessive focus on test scores looks like and it’s not pretty.  More and more time is taken up with test-prep, especially strategies for selecting right answers to multiple-choice questions.  Not a few teachers and principals succumb to the temptation to cheat, as I’m sure you’ve read.  Teachers are getting more demoralized each year, and the most creative novice teachers are finding jobs in private schools or simply not entering the profession.  Meanwhile administrators try to game the system and spin the results.  But even they have lost power to the statisticians and other quantitatively oriented scholars, who are the only ones who can understand and interpret the test results.  Have you seen the articles in measurement journals, the arcane vocabulary and esoteric formulas on nearly every page?

And do I have to add that greedy entrepreneurs with a constant eye on their bottom lines persuade the public schools to outsource more and more of their functions, including teaching itself.  This weakens our democracy and our sense of community.  And even after all those enormous social costs, the results on the National Assessment of Educational Progress are basically flat and the gap between black and white academic achievement—the impetus for passing NCLB in the first place—is as great as it ever was.

Danielle:  I agree that it’s a dismal spectacle.  You talk as if educators had been adhering to Evidence Based Policy for the last dozen years, but I’m here to tell you they haven’t and that’s the main reason, I’d contend, that we’re in the hole that we are.  If educators were less resistant to the scientific approach, we’d be in better shape today.  Physicians have learned to deal with quantitative data, why can’t teachers, or are you telling me they’re not smart enough?  Anyhow, I hope you feel better now that you’ve unloaded that tirade of criticisms.

Leo:  Actually, I’m not through, because I don’t think we’ve gotten to the heart of the matter yet.

Danielle:  I’m all ears.

Leo:  No need to be sarcastic, Danielle.  Does the name Michel Foucault mean anything to you?  He was a French historian and philosopher.

Danielle:  Sure, I’ve heard of him.  A few of my colleagues in the school of education, though not in my department, are very enthusiastic about his work.  I tried reading him, but I found it tough going.  Looked like a lot of speculation with little data to back it up.  How is his work relevant?

Leo:   In Discipline and Punish, Foucault described the way knowledge and power are intertwined, especially in the human sciences, and he used the history of the school examination as a way of illustrating his thesis (1975/1995, pp. 184-194).  Examinations provide a way of discovering “facts” about individual students, and a way of placing every student on the continuum of test-takers.  At the same time, the examination provides the examiners, scorers and those who make use of the scores ways to exercise power over kids’ futures.  Think of the Scholastic Assessment Tests (SATs) for example.  Every kid’s score can be represented by a number and kids can be ranked from those scoring a low of 600 to those with perfect scores of 2400.  Your score is a big determinant of what colleges will even consider you for admission.  But that’s not all: Foucault argued that these attempts to quantify human attributes create new categories of young people and thereby determine how they view themselves.  If you get a perfect SAT score, or earn “straight As” on your report card, that becomes a big part of the way others see you and how you see yourself.  And likewise for the mediocre scorers, the “C” students, or the low scorers who not only have many futures closed to them, but may see themselves as “losers,” “failures,” “screw-ups.”  A minority may, of course resist and rebel against their placement on the scale—consider themselves to be “cool”, unlike the “nerds” who study, but that won’t change their position on the continuum or their opportunities.  Indeed, it may limit them further as they come to be labeled “misfits” “ teens at-risk,” “gang-bangers” and the like. But, and here’s my main point, this entire system is only possible due to our willingness to represent the capabilities and limitations of children and young people by numerical quantities.  It’s nothing but scientism, the delusive attempt to force the qualitative, quirky, amazingly variegated human world into a sterile quantitative straight-jacket.  You recall the statement that has been attributed to Einstein, don’t you, “Not everything that can be counted counts, and not everything that counts can be counted.” I just don’t understand your refusal to grasp that basic point; it drives me mad.

Danielle:  Calm down, Leo.  I don’t disagree that reducing individuals to numbers can be a problem; every technology has a dark side, I’ll grant you that, but think it through.  Do you really want to go back to a time when college admissions folks used “qualitative” judgments to determine admissions?  When interviewers could tell from meeting a candidate or receiving a letter of recommendation if he were a member of “our crowd,” would know how to conduct himself at a football game, cocktail party, or chapel service, spoke without an accent, wasn’t a grubby Jew or worse, a “primitive” black man or foreign-born anarchist or communist.  You noticed I used the masculine pronoun:  Women, remember, were known to be incapable of serious intellectual work, no data were needed, the evidence was right there in plain sight.  Your Foucault is not much of a historian, I think.

Leo:  We have some pretty basic disagreements here.  I know we each believe we’re right.  Is there any way to settle the disagreement?

Danielle:  I can imagine a comprehensive, longitudinal experiment in a variety of communities, some of which would carry out EBEP and control communities that would eschew all use of quantification.  After a long enough time, maybe twenty years, we’d take a look at which communities were advancing, which were regressing.  Of course, this is just an idea; no one would pay to actually have it done.

Leo:  But even if we conducted such an experiment, how would we know which approach was successful?

Danielle:  We shouldn’t depend on a single measure, of course.  I suggest we use a variety of measures, high school graduation rate, college attendance, scores on the National Assessment of Educational Progress, SATs, state achievement tests, annual income in mid-career, and so on.  And, of course, we could analyze the scores by subgroups within communities to see just what was going on.

Leo:  Danielle, I can’t believe it.  You haven’t listened to a word I’ve said.

Danielle:  What do you mean?

Leo:   If my favored policy is to eschew quantitative evidence altogether, wouldn’t I be inconsistent if I permitted the experiment to be decided by quantitative evidence, such as NAEP scores or worse, annual incomes?  Don’t you recall that I reject your fundamental assumption—that durable, significant consequences of educational experiences can be represented as quantities?

Danielle:  Now I’m the one that’s about to scream.  Perhaps you could assess a single student’s progress by looking at her portfolio at the beginning and end of the school year.  How, in the absence of quantification, though, can you evaluate an educational policy that affects many thousands of students?  Even if you had a portfolio for each student, you’d still need some way to aggregate them in order to be in a position to make a judgment about the policy or program that generated those portfolios.  You gave me that Einstein quote to clinch your argument.  Well, let me rebut that with a quotation by another famous and original thinker, the Marquis de Condorcet, an eighteenth century French philosopher and social theorist.  Here’s what he said:  “if this evidence cannot be weighted and measured, and if these effects cannot be subjected to precise measurement, then we cannot know exactly how much good or evil they contain” (Condorcet, 2012, p.138).  The point remains true, whether in education or medicine.  If you can’t accept it, I regret to say, we’ve reached the end of the conversation.

References

Cartwright, N & Hardie, J. (2012). Evidence-based policy:  A practical guide to doing it better.  Oxford and New York: Oxford University Press.

Condorcet, M. (2012). The sketch. In S. Lukes, and N. Urbinati (Eds.), Political Writings (pp. 1-147). Cambridge: Cambridge University Press.

Dewey, J. (1938/1973). Experience and education.  New York: Collier Macmillan Publishers.

Foucault, M. (1995).  Discipline and punish: The birth of the prison. (A. Sheridan, Trans.) New York: Vintage Books. (Original work published in 1975)

Howick, J. (2011). The Philosophy of evidence-based medicine. Oxford: Blackwell Publishing.

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Filed under comparing medicine and education, school reform policies