From didactic to TBL: an exercise in transformation Lindsay Davidson Associate Professor Department of Surgery Queens University [email protected].

From didactic to TBL:

an exercise in transformation

Lindsay DavidsonAssociate Professor

Department of SurgeryQueen’s University

[email protected]

Plan

Introductions The course in question Identify problems Create a solution Sense making Change theory and complexity Wrap up

Who I am and what I do

Then…….

What analogy would you use to describe what implementing educational change feels like?

Musculoskeletal course

Mandatory component undergraduate M.D. program

Multi-departmental composite Relevant anatomy taught in first term

4 weeks long in the middle of 4+ month term 18/35 instructional hours/wk available for

MSK lectures Shares curricular time with 3 parallel

courses administered separately– Clinical Skills– Problem based learning– Medicine in Society

Evaluation: all courses participate in MCQ and SA exams at end of term (100% grade)

Administrative constraints

People

100 first year medical students, second term– The average medical student has >4 years

undergraduate experience prior to commencing M.D.

– Heterogeneous group 19 different faculty members participate in

lectures

Botterell B139Botterell B139

the the

TEMPLE OF KNOWLEDGETEMPLE OF KNOWLEDGE

“The role of the medical school is to produce doctors who have the basic building blocks (pluri-potential students) to allow them to differentiate into mature physicians that can populate multiple professional lines.”

Medical Education for Tomorrow’s DoctorUniversity of California, Davis School of Medicine

January, 2003

RCPSC CanMEDS roles

Typical week in traditional course Monday Tuesday Wednesday Thursday Friday

830-930 Path:Bone structure

(Dr A)

Adult fractures

(Dr C)

Anatomy review:

upper limb (Dr F)

Shoulder problems

(Dr C)

Rehabilitation (Dr H)

930-1030 Path: Bone healing (Dr

A)

Path: Bone healing

(Dr A)

Anatomy review: lower

limb (Dr F)

Anatomy review:

lower limb (Dr F)

Anatomy review: lower

limb (Dr F)

1030-1130 Osteoporosis (Dr B)

Children's fractures

(Dr D)

Imaging principles (Dr

G)

Knee problems

(Dr C)

Other courses

1130-1230 Study time Multiple Trauma (Dr

E)

Study time

L U N C H

1330-1630 Other courses

Group introductions

Who you are What you teach Analogy Share

You are now instructional design consultants

Given what you know about the course…

Are there problems with existing format?

Make a list using the flip chart As a group, pick the top 2 things you

want to change Be prepared to share

Problems that I identified

Information overload– Absence of key themes/concepts

Poor connections between sessions – Many faculty involved in course– Unrelated “horizontal” course

components Disconnect between published

objectives/classroom content– Sample of class surveyed every lecture

Problems that I identified

Evaluation– No formative evaluation High-stakes,

multiple choice and short answer end-of-phase exams

– Little opportunity to demonstrate analytic processes

Poor long-term retention of course concepts– Surface vs. deep learning

What does research tell us about how to encourage students to adopt a deep approach to learning?

Ensure that the students' workload is manageable,

Design out information overload, Ensure that the students have a clear

understanding of what is required of them, Ensure that the assessment regime rewards

critical thinking and risk taking, Require active participation, Ensure that students have as much choice

as possible, Bolster self-esteem.

http://www.ucd.ie/teaching/good/flex3.htm

Recognizing concerns with the traditional model of instruction, which of the following would be your priority to change in order to facilitate increased “deep learning”:

A. Revision of objectives, development of themesB. Faculty development – classroom techniquesC. Faculty development – pedagogical conceptsD. Introduction of pedagogical concepts to studentsE. Introduction of different learning opportunitiesF. Alteration of grading schemeG. Other

Recognizing concerns with the traditional model of instruction, which of the following would be your priority to change in order to facilitate increased “deep learning”:

A. Revision of objectives, development of themesB. Faculty development – classroom techniquesC. Faculty development – pedagogical conceptsD. Introduction of pedagogical concepts to studentsE. Introduction of different learning opportunitiesF. Alteration of grading schemeG. Other

Blended Learning

“courses that combine face-to-face classroom instruction with online learning and reduced classroom contact hours (reduced seat time)”

Dziuban, C. D., Hartman, J. L., Moskal, P. D. (2004). Blended Learning. Educause Research Bulletin, 7, 2-12.

Receivinginformationand ideas.

Active learning model

PassiveLearning

Active learning

ExperienceReflective dialoguewith:

Doing

Observing

Self

Others

pre-TBL initiatives (2003-4)

Schedule similar but less teachers Learning goals inventory pre-course Classroom activities introduced in sessions I

taught– Lecture bingo– “Muddy points”– Role playing

Online activities– Self-study– Quizzes

Evaluation– Group and individual projects - 10% grade– Final exam - 90%

Externally imposed change

Course moved from Feb to April by Phase director

MSK now last course before final examination period

Pre-TBL: course evaluation

Self-directed learning close to exams problematic

Inadequate feedback from online quizzes

“Anatomy difficult to remember” by end of winter term (was taught in fall term)

Some sessions: excessive detail

Presented by the UG Dean at Education Journal Club

Group task

Develop a new schedule for the sample week using TBL principles

Consider the problems that you identified previously as you generate your solution

Share

Year 1: TBL

Course divided into four thematic units Use of WebCT to present preparatory

material including graded (low stakes) quizzes

Introduction of RATs and structured classroom group activities in existing lecture hall)

Year 1: TBL

30.9% instructional hours set aside for individual study

Course moved to start of term

Year 1: TBL - program evaluation strategy

Comment cards CTL observational study (2 TL, 2

lecture) Classroom engagement survey after

TL sesion End-of-course survey CTL focus groups

My impressions after year 1 TBL

Students better prepared in class– Less need to define terms, explain simple

concepts available in references More classroom discussion, questions Classroom cramped, hard to move around Although RATs and Team Exercises

encouraged studying students seemed frustrated by them and complained that their time would be better used in lecture

My impressions after year 1 TBL

Peer evaluation created a significant amount of anxiety and (even) hostility

My impressions after year 1 TBL

Some student responded very positively in person– Emails– Spontaneous conversations after class

Student feedback year 1

“I did more reading and understood the subject”

“I enjoyed the mixture of didactic and self-directed learning”

My impressions after year 1 TBL

There was a vocal group of students who actively resisted the new methods

Peer evaluation created a significant amount of anxiety and (even) hostility

Student feedback year 1

“I think that the majority of the class came to this school because they WANT a didactic style of learning. I am one of these individuals.

I feel that organized lectures are best.”

“I cannot foresee why prospective students would want to come to a medical school that has such poor instruction.”

Student feedback year 1

“Never before have I been so utterly bewildered as to what was happening in school. The group work .. was not helpful in any respect. The time wasted in these exercises could have been used much more effectively with lectures or with self-directed learning. Constructive criticism and comments pertaining to the inefficacy of the course director’s approach have been repeatedly ignored and dismissed…..she is clearly deluded. I am extremely disappointed in the caliber of coordination thus far. When potential students ask me about the weaknesses of the medical program in the future, the course coordinator of the MSK block will be the first and only failing I would bring to their attention.”

Faculty responses to student comments

“Juvenile” “Spoiled brats” “The changes took guts”

“Resisters” - Hargreaves and Fullan (1998)

May have good ideas You ignore them at your peril if they

stay around for implementation In other words… there are good

technical and political reasons for taking resisters more seriously

“Annoyance is often a signal of opportunity”

“Understanding why most attempts at educational reform fail goes far beyond the identification of specific technical problems … (E)ducational change fails partly because of the assumptions of planners, and partly because solving substantial problems is an inherently complex business.” Michael Fullan (2001), Understanding Educational Change, p.96

What went wrong?

Things that I think contributed to poor result:

Poor classroom for TBL My learning curve

– Open book RATs– Inexperience with developing team exercises– Suspicious of using MCQ format– More than “mini-lectures” to debrief

Combination with other modalities– Online modules, quizzes– Group, individual project

What is the most important “next step” in planning year 2?

A. Resume traditional course formatB. Increase faculty developmentC. Find a different classroomD. Revise RATs and application

exercisesE. Revise course evaluation structure

Year 2: TBL

Class sessions moved to hospital gymnasium

I attended TBL conference– TBL implementation corrected– Better cases/exercises developed– Learned technique for making groups

New website for content delivery– Financial support from administration to hire

assistant to transform lecture content into online resource to be used as background

– Limited capability for interactivity

Year 2: TBL

Introductory session to course with practice RAT

Pre-course survey of student impressions of group work

Improved linkages with “horizontal courses– Joint sessions with Epidemiology and

Geriatrics– No PBL for first two weeks

Coursework = 50% grade Alteration in peer evaluation strategy

Feedback year 2

“Team learning was great.” “The team learning was excellent and

well prepared/organized. I hope the other blocks incorporate this learning style.”

“I really liked the group learning method (I am dreading returning to lectures next week!).”

“The team learning was extremely helpful and the quizzes also improved my understanding on the topics.”

Feedback year 2

“I really enjoyed the team learning format – it is helpful to work through problems and test our knowledge.”

“In general I loved this block. I’m biased because I enjoy group learning, but I think it was good for everyone, even if they don’t appreciate it yet. I think that many people that make it into medical school are trained book learners + they take offense when people challenge their set style.”

Feedback year 2

“I didn’t like the group work at the beginning, but I learned to like it during the course. I do still prefer lectures, and I feel that I still learn best this way.”

Feedback year 2

Students hated the gym Students reacted negatively to

course website which was not ‘in sync’ with the school’s main online portal

“The following is offered as a position statement form the Aesculapian Society (AS) on the matter of TBL and its implementation in the MSK course of the Queen’s undergraduate medical curriculum.”

“There are numerous implementation-based and logistical concerns that must be addressed before the AS can support further application of TBL throughout the Queen’s undergraduate medical curriculum.”

Christopher Barnes, VP, Academic Affairs, Aesculapian Society May 10, 2006

Monday Tuesday Wednesday Thursday Friday

830-930

Path:Bone structure

(Dr A)

Anatomy review: upper

limb (Dr F)

930-1030

Path: Bone healing (Dr

A)

Anatomy review: lower

limb (Dr F)

1030-1130Osteoporosis

(Dr B)

Children's fractures (Dr D)

Imaging principles (Dr

G)

1130-1230 Study time

Multiple Trauma (Dr

E) Study timeL U N C H

1330-1630 Other courses

Adult fractures

(Dr C)

Shoulder problems

(Dr C)

Rehabilitation (Dr H)

Knee problems

(Dr C)Other courses

Typical week - year 3 TBL

Year 3: TBL

What analogy would you propose to describe what implementing educational change feels like as a teacher?

2004 2005 2006 2007 1. Overall, this is an excellent course. 29.7 50.0 55.8 94.4 2. I learned a great deal from this course. 70.3 53.9 76.9 94.4 3. This course was helpful in developing new skills. 69.8 67.3 64.1 86.5 4. I felt that this course challenged me intellectually. 68.8 67.3 70.5 93.2 5. My interest in the subject has been stimulated by this course.

42.2 63.4 44.9 84.9

6.This course included components that addressed my personal learning style

53.8 86.4

7. The objectives of the course were adequately explained.

53.2 50 77.7

8. This course covered the right amount of material. 28.6 65.3 47.4 86.5 9. The workload in this course was reasonable and appropriate.

25.5 46.1 39.7 61.3

10. The course material was presented at a satisfactory level of difficulty.

52.0 67.3 70.5 95.4

17. The team learning exercises in class helped me to learn and better understand the course material

73.1 84.4

“Change is a leader’s friend, but it has a split personality: its nonlinear messiness gets us into trouble. But the experience of this messiness is necessary in order to discover the hidden benefits - creative ideas and novel solutions are often generated when the status quo is disrupted.”

Michael Fullan (2001), Leading in a Culture of Change, p. 107.

Course development

A. Revision of objectives, development of themes

B. Introduction of different learning opportunities

C. Alteration of grading scheme

Course development

A. Revision of objectives, development of themesB. Introduction of different learning opportunitiesC. Alteration of grading schemeD. Faculty development – classroom techniquesE. Faculty engagement – pedagogical conceptsF. Introduction of pedagogical concepts to

students

Course development

A. Revision of objectives, development of themesB. Introduction of different learning opportunitiesC. Alteration of grading schemeD. Faculty development – classroom techniquesE. Faculty engagement – pedagogical conceptsF. Introduction of pedagogical concepts to studentsG. Appropriate classroom H. Sufficient independent work timeI. Integration of horizontal components

Course development

A. Revision of objectives, development of themesB. Introduction of different learning opportunitiesC. Alteration of grading schemeD. Faculty development – classroom techniquesE. Faculty engagement – pedagogical conceptsF. Introduction of pedagogical concepts to studentsG. Appropriate classroom H. Sufficient independent work timeI. Integration of horizontal componentsJ. Ongoing course evaluationK. Reflection on the process

Understanding the Change Process

The goal is not to innovate the most It is not enough to have the best

ideas Appreciate the implementation dip Redefine resistance Reculturing is the name of the game Never a checklist, always complexity

Michael Fullan (2001), Leading in a Culture of Change, p. 34.

Fullan’s framework for leading complex change

Moral purpose– “acting with the intention of making a positive

difference” Understanding change

– Respect complexity Relationship building

– Diverse people/groups Knowledge creation + sharing

– “turning information into knowledge is a social process”

Coherence makingLeading in a culture of change (2001, p. 4)

Thank you

[email protected]://meds.queensu.ca/course/msk