Mistakes among Doctors and Teachers

I had a conversation with a dear friend* a few years ago that has stayed with me. We had been talking about something I had written detailing my failures as a teacher with students I have had over the years. He had practiced Family Medicine for over a half-century in Pittsburgh and for years helped resident physicians in doing medical research and improving communication with their patients.  He pointed out to me how similar teachers experiencing failures with students is to physicians erring in diagnoses or treatments (or both) of their patients.

I was surprised at his making the comparison and then began to think about the many books I have read about medicine and the art and science of clinical practice. In my library at home, I had two books with well-thumbed pages authored by doctors who, in the  first dozen pages, detailed mistakes either they had made with patients or errors committed by other physicians on them or their families.

In one, Jerome Groopman, an oncologist, described what occurred with his 9-month old child after a series of doctor misdiagnoses that almost caused his son’s death. A surgeon, who was a friend of a friend, was called in at the last moment to fix an intestinal blockage and saved his son’s life.

In the other book, surgeon Atul Gawande described how he almost lost an Emergency Room patient who had crashed her car when he fumbled a tracheotomy only for the patient to be saved by another surgeon who successfully got the breathing tube inserted. Gawande also has a chapter on doctors’ errors. His point, documented by a paper in the New England Journal of Medicine (1991) and subsequent reports  is that nearly all physicians err.

If nearly all doctors make mistakes, do they talk about them? Privately with people they trust, yes. In public, that is, with other doctors in academic hospitals, the answer is also yes. There is an institutional mechanism where hospital doctors meet weekly called Morbidity and Mortality Conferences (M & M for short) where, in Gawande’s words, doctors “gather behind closed doors to review the mistakes, untoward events, and deaths that occurred on their watch, determine responsibility, and figure out what to do differently (p. 58).” He describes an M & M (pp.58-64) at his hospital and concludes: “The M & M sees avoiding error as largely a matter of will–staying sufficiently informed and alert to anticipate the myriad ways that things can go wrong and then trying to head off each potential problem before it happens” (p. 62). Protected by law, physicians air their mistakes without fear of malpractice suits.

Nothing like that for teachers in U.S. schools. Sure, privately, teachers tell one another how they goofed with a student, misfired on a lesson, realized that they had provided the wrong information, or fumbled the teaching of a concept in a class. Of course,  there are scattered, well-crafted professional learning communities in elementary and secondary schools where teachers feel it is OK to admit they make mistakes and not fear retaliation. In the vast majority of schools, however, no analogous M & M conferences exist (at least as far as I know).

Of course, there are substantial differences between doctors and teachers. For physicians, the consequences of their mistakes might be life-threatening, even lethal. Not so, in most instances, for teachers. But also consider other differences:

*Doctors see patients one-on-one; teachers teach groups of 20 to 35 students four to five hours a day.

*Most U.S. doctors get paid on a fee-for-service basis; nearly all full-time public school teachers are salaried.

*Evidenced-based practice of medicine in diagnosing and caring for patients is more fully developed and used by doctors than the science of teaching accessed by teachers.

While these differences are substantial in challenging comparisons, there are basic commonalities that bind teachers to physicians. First, both are helping professions that seek human improvement. Second, like practitioners in other sciences and crafts, both make mistakes. These commonalities make comparisons credible even with differences between the occupations.

Helping professions.

From teachers to psychotherapists to doctors to social workers to nurses, these professionals use their expertise to transform minds, develop skills, deepen insights, cope with feelings and mend bodily ills. In doing so, these helping professions share similar predicaments.

*Expertise is never enough. For surgeons, cutting out a tumor from the colon will not rid the body of cancer; successive treatments of chemotherapy are necessary and even then, the cancer may return.

Some high school teachers of science with advanced degrees in biology, chemistry, and physics believe that lessons should be inquiry driven and filled with hands-on experiences while other colleagues, also with advanced degrees, differ. They argue that naïve and uninformed students must absorb the basic principles of biology, chemistry, and physics through rigorous study before they do any “real world” work in class.

In one case, there is insufficient know-how to rid the body of different cancers and, in the other instance, highly knowledgeable teachers split over how students can best learn science. As important as expertise is to professionals dedicated to helping people, it falls short—and here is another shared predicament–not only for the reasons stated above but also because professionals seeking human improvement need their clients, patients, and students to engage in the actual work of learning and becoming knowledgeable, healthier people.

*Helping professionals are dependent upon their clients’ cooperation. Physician autonomy, anchored in expertise and clinical experience, to make decisions unencumbered by internal or external bureaucracies is both treasured and defended by the medical profession. Yet physicians depend upon patients for successful diagnoses and treatments. If expertise is never enough in the helping professions, patients not only constrain physician autonomy but also influence their effectiveness.

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. Autonomy to make decisions for the welfare of the patient and ultimate health is irrelevant when patients cannot or do not enter into the process of healing.

For K-12 teachers who face captive audiences among whom are some students unwilling to participate in lessons or who defy the teacher’s authority or are uncommitted to learning what the teacher is teaching, then teachers have to figure out what to do in the face of students’ passivity or active resistance.

Failure and error occur in both medical and teaching practices.

Both doctors and teachers, from time to time, err in what they do with patients and students.

Patients can bring malpractice suits to get damages for errors. But that occurs sometimes years

after the mistake. What hospital-based physicians do have, however, is an institutionalized way

of learning (Mortality and Morbidity conferences) from their mistakes so that they do not occur

again. So far, among teachers there are no public ways of admitting mistakes and learning from

them (privately, amid trusted colleagues, such admissions occur). For teachers, admitting error

publicly can lead directly to job loss).

So while doctors, nurses, and other medical staff have M & M conferences to correct mistakes, most teachers lack such collaborative and public ways of correcting mistakes (one exception might be in special education where various staff come together weekly or monthly to go over individual students’ progress).

Books and articles have been written often about how learning from failure can lead to success. Admitting error without fear of punishment is the essential condition for such learning to occur. There is no sin in being wrong or making mistakes, but in the practice of schooling children and youth today, one would never know that.

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* Dr. Joel Merenstein and I have been close friends since boyhood in Pittsburgh (PA). He passed away in 2019.

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 Stories—underscores 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.

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.

How Measurement Fails Doctors and Teachers (Robert Wachter)

“Robert M. Wachter is a professor and the interim chairman of the department of medicine at the University of California, San Francisco, and the author of “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age.” This post appeared in the New York Times on January 16, 2016

 

Two of our most vital industries, health care and education, have become increasingly subjected to metrics and measurements. Of course, we need to hold professionals accountable. But the focus on numbers has gone too far. We’re hitting the targets, but missing the point.

Through the 20th century, we adopted a hands-off approach, assuming that the pros knew best. Most experts believed that the ideal “products” — healthy patients and well-educated kids — were too strongly influenced by uncontrollable variables (the sickness of the patient, the intellectual capacity of the student) and were too complex to be judged by the measures we use for other industries.

By the early 2000s, as evidence mounted that both fields were producing mediocre outcomes at unsustainable costs, the pressure for measurement became irresistible. In health care, we saw hundreds of thousands of deaths from medical errors, poor coordination of care and backbreaking costs. In education, it became clear that our schools were lagging behind those in other countries.

So in came the consultants and out came the yardsticks. In health care, we applied metrics to outcomes and processes. Did the doctor document that she gave the patient a flu shot? That she counseled the patient about smoking? In education, of course, the preoccupation became student test scores.

All of this began innocently enough. But the measurement fad has spun out of control. There are so many different hospital ratings that more than 1,600 medical centers can now lay claim to being included on a “top 100,” “honor roll,” grade “A” or “best” hospitals list. Burnout rates for doctors top 50 percent, far higher than other professions. A 2013 study found that the electronic health record was a dominant culprit. Another 2013 study found that emergency room doctors clicked a mouse 4,000 times during a 10-hour shift. The computer systems have become the dark force behind quality measures.

Education is experiencing its own version of measurement fatigue. Educators complain that the focus on student test performance comes at the expense of learning. Art, music and physical education have withered, because, really, why bother if they’re not on the test?

At first, the pushback from doctors and teachers was dismissed as whining from entitled and entrenched guilds spoiled by generations of unfettered autonomy. It was natural, went the thinking, that these professionals would resist the scrutiny and discipline of performance assessment. Of course, this interpretation was partly right.

But the objections became harder to dismiss as evidence mounted that even superb and motivated professionals had come to believe that the boatloads of measures, and the incentives to “look good,” had led them to turn away from the essence of their work. In medicine, doctors no longer made eye contact with patients as they clicked away. In education, even parents who favored more testing around Common Core standards worried about the damaging influence of all the exams.

Even some of the measurement behemoths are now voicing second thoughts. Last fall, the Joint Commission, the major accreditor of American hospitals, announced that it was suspending its annual rating of hospitals. At the same time, alarmed by the amount of time that testing robbed from instruction, the Obama administration called for new limits on student testing. Last week, Andy Slavitt, Medicare’s acting administrator, announced the end of a program that tied Medicare payments to a long list of measures related to the use of electronic health records. “We have to get the hearts and minds of physicians back,” said Mr. Slavitt. “I think we’ve lost them.”

Thoughtful and limited assessment can be effective in motivating improvements and innovations, and in weeding out the rare but disproportionately destructive bad apples.

But in creating a measurement and accountability system, we need to tone down the fervor and think harder about the unanticipated consequences.

Measurement cannot go away, but it needs to be scaled back and allowed to mature. We need more targeted measures, ones that have been vetted to ensure that they really matter. In medicine, for example, measuring the rates of certain hospital-acquired infections has led to a greater emphasis on prevention and has most likely saved lives. On the other hand, measuring whether doctors documented that they provided discharge instructions to heart failure or asthma patients at the end of their hospital stay sounds good, but turns out to be an exercise in futile box-checking, and should be jettisoned.

We also need more research on quality measurement and comparing different patient populations. The only way to understand whether a high mortality rate, or dropout rate, represents poor performance is to adequately appreciate all of the factors that contribute to these outcomes — physical and mental, social and environmental — and adjust for them. It’s like adjusting for the degree of difficulty when judging an Olympic diver. We’re getting better at this, but we’re not good enough.

Most important, we need to fully appreciate the burden that measurement places on professionals, and minimize it. In health care, some of this will come through advances in natural language processing, which may ultimately allow us to assess the quality of care by having computers “read” the doctor’s note, obviating the need for all the box-checking. In both fields, simulation, video review and peer coaching hold promise.

Whatever we do, we have to ask our clinicians and teachers whether measurement is working, and truly listen when they tell us that it isn’t. Today, that is precisely what they’re saying.

Avedis Donabedian, a professor at the University of Michigan’s School of Public Health, was a towering figure in the field of quality measurement. He developed what is known as Donabedian’s triad, which states that quality can be measured by looking at outcomes (how the subjects fared), processes (what was done) and structures (how the work was organized). In 2000, shortly before he died, he was asked about his view of quality. What this hard-nosed scientist answered is shocking at first, then somehow seems obvious.

“The secret of quality is love,” he said.

Our businesslike efforts to measure and improve quality are now blocking the altruism, indeed the love, that motivates people to enter the helping professions. While we’re figuring out how to get better, we need to tread more lightly in assessing the work of the professionals who practice in our most human and sacred fields.

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.

Testing in Medicine, Testing in Schools (Abigail Zuger, M.D.)

The following article appeared in the New York Times on April 13, 2015. I have often compared primary care physicians to teachers; sometimes the comparisons worked and sometimes they did not. This article looks at testing in both arenas, medicine and schooling.  Abigail Zuger compares school-based standardized tests and her work one day of spending five hours seeing 14 patients and ordering 299 diagnostic tests. Do you agree with the analogy she draws? Why?

I spent the usual long afternoon at work doing little but ordering tests, far more than I honestly thought any patient needed, but that’s what we do these days. Guidelines mandate tests, and patients expect them; abnormal tests mean medication, and medication means more tests.

My tally for the day: five hours, 14 reasonably healthy patients, 299 separate tests of body function or blood composition, three scans and a handful of referrals to specialists for yet more tests.

Teachers complain that primary education threatens to become a process of teaching to the test. They wince as the content of standardized tests increasingly drives their lesson plans, and the results of these tests define their accomplishments.

We share their pain: Doctoring to the tests is every bit as dispiriting.

Some medical tests, like blood pressure checks, are cheap and simple. Some are pricier and more complicated, like mammograms or assays for various molecules in the blood that correlate with various diseases. We order them all at prescribed intervals, and if we happen to forget one, either by accident or design, electronic medical records nag us mercilessly until we capitulate.

As in education, our test-ordering behavior and our patients’ results increasingly define our achievements, and in the near future our remuneration is likely to follow. Still, like all test-based quality control systems, ours can be gamed. Our tests can also inflict unnecessary psychic damage, and occasional physical damage as well.

Most distressing: Ordering tests, chasing down and interpreting results, and dealing with the endless cycle of repeat testing to confirm and clarify problems absorb pretty much all our time.

It is all in the name of good and equitable health care, a laudable goal. But if you reach age 50 and I cannot persuade you to undergo the colonoscopy or mammogram you really don’t want, am I a bad doctor? If you reach age 85 and I persuade you to take enough medication to normalize your blood pressure, am I a good one?

I am not the only one who wonders.

A cadre of test skeptics at Dartmouth Medical School specialize in critically examining our test-based approach to well adult care. If you are confused about mammography, colonoscopy or the PSA test for prostate cancer, these folks deserve much of the blame: They have repeatedly demonstrated that these tests and many others do not necessarily make healthy people any healthier, any more than standardized testing in grade school improves a child’s intellect.

Dr. H. Gilbert Welch, a Vermont physician who is part of the Dartmouth group, has a new book that might serve as the test skeptic’s manifesto and bible. Its title, “Less Medicine, More Health,” sums up his trenchant, point-by-point critique of test-based health care and quality control.

In medicine, “true quality is extremely hard to measure,” Dr. Welch writes. “What is easy to measure is whether doctors do things.” Only doing things like ordering tests generates data. Deciding not to do things and let well enough alone generates nothing tangible, no numbers or dollar amounts to measure or track over time.

Dr. Welch points out that doctors get to become doctors because they are good with tests, and know instinctively how to behave in a test-focused universe. Rate them by how many tests they order, and they will order in profusion, often more than the guidelines suggest.

They will do fine on assessments of their quality, but patients may not do so well. Even perfectly safe tests that are incapable of doing their own damage may, given enough weight, trigger catastrophe.

Yes, little blood pressure cuff over there in the corner, that means you. The link between very high blood pressure and disease is incontrovertible, and the drugs used to control blood pressure are among the cheapest and safest around.

Even so, as Dr. Welch pointed out in a recent conversation, systems that rate doctors by how well their patients’ blood pressure is managed are likely to invite trouble. Doctors rewarded for treating aggressively are likely to keep doing so even when the benefits begin to morph into harm.

That appears to happen in older adults, at least in those who avoid the common complications of high blood pressure and continue on medication. One study found that nursing home residents taking two or more effective blood pressure drugs did remarkably badly, withdeath rates more than twice that of their peers. In another, dementia patients taking blood pressure medication with optimal results nonetheless deteriorated mentally considerably faster.

Yet no quality control system that I know of gives a doctor an approving pat on the head for taking a fragile older patient off meds. Not yet, at least. Someday, perhaps, not ordering and not prescribing will mark quality care as surely as ordering and prescribing do today.

Children go to school to learn. Adults go to the doctor … why? If they are sick, to get better, certainly. But for the average healthy, happy adult, let’s be honest: We really haven’t completely figured out why you are in the waiting room. And so we offer a luxuriant profusion of tests.

 

“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.

 

 

 

 

 

 

 

 

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.

 

 

 

 

 

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.

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.

 

 

 

 

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.

 

“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.

Best Practices and Bad Habits (Part 2)

Transfer of learning appears to be a simple concept. What you learn in the family or learn in school  can be applied in different situations outside of the family and the classroom. Learning Spanish, for example, helps later in learning Italian. Learning to get along with an older brother or sister helps in learning how to get along with others later in life. Learning math in middle school helps one in high school physics. It doesn’t always work that way, however.

In Part 1,  I described how I taught a two-week unit on specific critical thinking skills useful to understand history and use in daily life in the early 1960s. My theory was that teaching these thinking skills directly one after the other at the very beginning of the semester would lead to students applying them when I began teaching units on the American Revolution, Immigration, Sectionalism and the Civil War, and the Industrial Revolution.

The response of students to the stories and subsequent discussions and debates almost made me swoon. I was energized by students’ enthusiasm as we went from one specific skill to another using contemporary stories drawn from newspapers,  student lives, and Glenville high school. The two week unit was from all indications a success with student engagement high and even scores on the unit test were higher than I had expected.

Then, when I began my U.S. history units on the American Revolution through World War I, the skills I believed that I had taught my students weeks earlier were missing in action. Root canal work was easier than getting students to distinguish between a biased source and one less so or explain why certain statements were opinions, not facts. I was puzzled.  What had happened?

Years later, I discovered from reading psychologists a great deal about the ins-and-outs of transfer of learning (see, for example, here). Teaching specific critical thinking skills and expecting students to apply what they learned to different situations depended upon many conditions that were, I learned later, missing in my lessons. Even the concept of teaching these skills isolated from the historical content–as I did–undermines the very goal I wanted to achieve (see CritThink).

Nonetheless, puzzled as I was by the absence of students applying what they had learned in the later history units I taught, for the next few years I continued to teach that two week unit on critical thinking at the beginning of the semester, marching through the lessons one skill after another. I repeated again and again this unit because the students were engaged, loved to apply what they learned to their daily lives, and I felt good after each of the five periods I taught. An uncommon experience for a veteran teacher.

Even had a colleague I trusted grabbed me by the shoulders then and told me how I was way off in thinking that my students would transfer the skills they learned in the two-week unit to subsequent history units, I would not have believed that colleague.  I would have continued with what I considered a “best practice” that, in reality, had become a “bad” habit.

Like Dr. Danielle Ofra, I would have given reasons to myself why what I was doing helped students. As I look back, I kept doing the same unit year after year and ignored the signs–the mysterious tug I felt every semester seeing repeatedly that students failed to apply the skills in subsequent history units that they had supposedly learned weeks earlier. I persisted even in light of the evidence of little transfer of learning.

Such “bad” habits, of course are common. From over-eating to smoking to excessive Internet surfing to watching far too much television, “bad” habits–destructive to one’s health and well-being–persist among substantial numbers of youth and adults.

Such habits are like ruts in road that get deeper and deeper through repetition of the behavior. It is hard to get out of the well worn groove. Yet people do break “bad” habits by replacing them with “good” habits that begin a new groove, and get practiced over and over again. It can be done and does occur.

As for me, my “bad” habit of ignoring evidence of my students not applying what they learned in that two-week thinking skills unit, eventually changed. The baffling lack of application got me to read more and talk to colleagues about what occurred in my teaching. I stumbled into new knowledge about transfer of learning. I made many attempts, some failed badly, to build new units in history where these thinking skills were embedded in the historical content. Eventually, I got into a new groove and created different units and taught them (e.g., Colonization, American Revolution, Causes of the Civil War, The Industrial Revolution, The Kennedy Assassination). See here.

But understanding transfer of learning was a hard road to travel in getting out of that rut I had made for myself as a history teacher many years ago.

Best Practices and Bad Habits in Practicing Medicine and Teaching Students

Listen to Danielle Ofri lamenting a fact she discovered about her work in New York City’s Bellevue hospital as a physician: “we often ignore good advice when it conflicts with what we’ve always done.”

Ofri was referring to the latest clinical guideline issued by the Society of General Internal Medicine that recommended against annual physical exams for healthy adults. The scientific evidence shows “the harm of annual visits — overdiagnosis, overtreatment, excess costs — can outweigh the benefits.”  These guidelines become  “best practices” for physicians to follow with patients; they are based upon analysis of many clinical studies.

Keep in mind that the body of evidence producing clinical guidelines for how doctors should practice is based on cumulative research and meta-analyses often involving tens of thousands of patients in control and experimental studies. “Evidence-based medicine”–even with all of the criticism of reversals in the advice doctors receive-is a reality at the fingertips of every doctor tapping keys and watching the computer screen as they take a patient’s history and conduct an annual exam.

Yet Ofri continues to have her patients return every year for an annual exam. How come?

She says: After the research was initially published last year, I grappled with the evidence, or lack thereof, reaching a conclusion that I mainly still supported the annual visit, if only because it establishes a solid doctor-patient relationship. But seeing these new, strongly worded recommendations, I may have to re-evaluate. At the very least, I should take a moment to think before I reflexively recommend the annual visit. But I know that I might still end up doing the same thing, despite the evidence.

She concludes: Humans are creatures of habit. Our default is to continue on the path we’ve always trod.

For some physicians, habit trumps evidence or what was once a “good” habit–annual exams for all of her patients–becomes a “bad” habit. True as well for K-12 teachers.

No such clinical research base, however, exists for recommending “best practices” in teaching reading, math, science, or history. Sure there are single studies, even groups of studies that point in a direction that teachers might consider in teaching long division or teaching six year-olds how to parse vowels and consonants. But for most teachers, “best practices” is a meld of what researchers say practitioners ought to do, what “experts” say should be done in classrooms, lessons learned from personal experiences in teaching, deeply-ingrained beliefs–call it ideology–about how best to teach and how students learn, and, yes, you guessed it: habit.

All of these ways of defining “best practice” for teachers came into play when I taught history to high school students many years ago. Let me explain.

In the fifth year of my teaching at Cleveland’s Glenville high school–it was the early 1960s–I had already introduced materials to my classes on what was then called “Negro history” (see here and here). I then began experimenting with the direct teaching of critical thinking skills. I believed that such skills were crucial in negotiating one’s way through life and understanding history. I wanted my students to acquire and use these skills every day. So I began teaching my U.S. history courses with a two-week unit on thinking skills. My theory was that the students learning these skills at the very beginning of the semester would then apply them when I began teaching units on the American Revolution, Immigration, Sectionalism and the Civil War, and the Industrial Revolution.

In the two-week unit, I selected skills I believed were important for understanding the past such as: figuring out the difference between a fact and opinion, making a hunch about what happened and sorting evidence that would support or contradict the hunch, judging how reliable a source of information is, distinguishing between relevant and irrelevant information in reaching a conclusion.

For each of these, I would go over the specific skill with the class and they and I would give examples from our daily lives, school events, and family happenings. Then,  I chose a contemporary event–a criminal case in the local newspaper, a national scandal that was on television, and occurrences in the school–and wrote out a one-page story that would require each student to apply the particular skill we were discussing such as making an informed guess, collecting evidence to support their hunch, and reaching a judgment. I also gave the class additional sources from which they could (or could not because of biases) select information to support their conclusion.

For the two weeks, each period–I was teaching five classes a day at the time–was filled with engaged students participating in flurries of discussion, debates over evidence, student questioning of each others’ conclusions, and similar excitement. I was elated by the apparent success of my critical thinking skills unit.

After the two weeks of direct instruction of skills, I plunged into the Coming of the American Revolution and subsequent history material. From time to time, over the course of the semester, I would ask questions that I felt would prompt use of those thinking skills we had worked on earlier in the year. Blank stares from most students with occasional “Oh yeah” from others. I designed homework that explicitly called for use of these thinking skills; few students applied what they had presumably learned.    I was thoroughly puzzled.

Which brings me to the concept of transfer. Why did students taught discrete thinking skills directly with a high degree of engagement and apparent learning for two weeks have a difficult time transferring those very same skills to history lessons later in the semester? I take up this issue and my “bad” habit in the next post.