Intentionally Role Modelling Pattern Making

diabetes mapPattern Making is an essential requirement of long term memory. When children stop counting on their fingers and start remembering something called addition, they are experiencing pattern making. Patterns can also be experienced as physical memories; bike riding is an example. Patterns are a key element in retrieving information from long term memory and experienced physicians have 100s of thousands of medical patterns. Patterns are what help you to know what is wrong with a patient when they walk in the room. Patterns let you perform procedures automatically without thinking about the steps. The down side of this automaticity is that you forget how you developed the pattern and, therefore, it can be difficult to explain the steps to novices because you no longer think about the steps, you just do them..

Many medical students don’t start medical school with good pattern making skills. Like other critical thinking skills, pattern making can be taught and isn’t innate.
Here are some ideas for helping students create their own patterns.

Teaching Input Interrogation

medmapAs students are reading articles, viewing videos or listening to lectures, asking the right questions will help students understand the relationships between what they are reading and what they have previously learned. Questions should focus attention on key elements. Novices don’t know what questions to ask and need guidance from you, so here are some suggestions for questions you can include in your teaching. In flipped classrooms, providing questions with pre-class assignments that will be discussed in class will increase compliance and better prepare students for application activities.

  1. Use 5 WH – Who, What, When, Where, Why and How to dig out key elements
  2. Use specific pattern questions such as
    • What do you need to learn from this?
    • What are the key takeaways?
    • How does this content form patterns with what you learned last week?
    • What is this evidence of?
    • What questions do I still have?


Opportunities to encourage reflection occur during simulation and case debriefing, critical incident discussions and feedback sessions. Here are 5 key questions to encourage reflection:

  1. What do you think about …?
  2. Why do you think this (data used for decisions and cognitive error identification)?
  3. How do you know this (appropriateness of evidence)?
  4. Can you tell me more?
  5. What questions do you still have?

Create Problem Solving Opportunities

Complex case based and clinical thinking teaching are all based on problem models that encourage recall of knowledge and critical thinking about interconnections.

Demonstrate Your Thinking Process

Novices need to see how different disciplines and different people create patterns. Radiology has different patterns from surgery and novices need to understand those differences. Sharing how you think through problems, either by explaining or drawing on a white board, will help novices realize the value in creating their own approach.
Each individual organizes information to meet their unique needs. Look at the examples used to illustrate this article; some people like to use text, others images, others talk through their process. (The images are links to more information). Once the pattern is created the physical representation is no longer needed, but until that time physical interpretations can be revisited over and over.

Encourage Recall

Each time a student brings a pattern into working memory, they are improving the links to that pattern in long term memory. Clickers questions and cases are easy ways to do this in medical classrooms; referencing previous experiences and supervised practice can be used in clinical settings.

Designing the Flipped Classroom: Part 3 – In class activities


Learning is viewed here as developing a way of thinking and acting that is characteristic of an expert community. Such a way of thinking consists of two important elements:

  1. the knowledge that represents phenomena in the subject domain
  2. the thinking activities that construe, modify and use this knowledge to interpret situations in that domain and to act in them.
Billet, 1996
Situated learning: bridging sociocultural and cognitive theorizing
Learning and Instruction, 6

Long Term MemoryIn Part 2, we looked at outside the classroom activities; in this article we will look at using the classroom to move information forward into long term memory.

Let’s start with the process outlined in the image to the right.

Input Interrogation

Input interrogation is a term originating in the electrical sciences which is used in education to mean using higher order questions to transform information into patterns. When groups of people do this interrogation together through discussion, cases and problem solving, the resulting patterns are better developed. Classrooms are an ideal location for input interrogation unlike memorization which is best done alone. Learning takes place when you have a teaching plan that includes both.


Patterns are the schema retained in long term memory that makes understanding and retrieval of knowledge easier. Experts have millions of patterns that make diagnostic reasoning and management planning easier.

Information Retrieval

We know that “practice makes perfect” in terms of skill development but it also improves development of patterns. The more time students spend checking  that what they believe to be true is true, the better their patterns therefore the better their retention will be.

Use these design elements to plan in class activity

  1. Look at your objectives again, verbs such as analyze, compare, manage, evaluate lend themselves to this design approach.
  2. Look at any questions you asked as part of the outside class activity, what is the best way to get answers for these questions (quiz/discussion)? This becomes your lead off activity. (Retrieval/Input Interrogation)
  3. Pick an activity that furthers your objective (Input Interrogation) (Pattern Making)
  4. Ask students to identify gaps in their knowledge and discuss how those gaps will be met in future classes or through self-directed learning. (Pattern Making)

Designing the Flipped Classroom: Part 2b Videos

KhanOne of the areas that is problematic for people who want to try flipping their classroom is the common idea that all you have to do is record your lecture and ask students to watch it ahead of time or as part of an online course. BIG MISTAKE promoted by lecture capture companies! Recorded lectures are not interactive, they are too long to meet peoples’ attention needs and they often focus on talking heads which is very poor input (unless your head illustrates the topic being discussed.) Cognitive overload is very common in this type of flipping and retention of content is poor.

Look at the beginning of this Behavioural Genetics lecture capture video of 1 hr 38 minutes. Three minutes in the instructor explains the basic concept using his voice only, combined with an image of the speaker pacing back and forth (a useful technique for engaging your live audience but distracting in a video). How much of the basic concept would the novice retain by lecture end? For the auditory learners in the class, he was probably a very entertaining speaker, but his brief use of the whiteboard is poorly shown by the capture technology. This lecture would have been better captured in a podcast without the visual distractions of his image.

Here are some tips for flipping videos to help people memorize:

  1. Keep them short -under 15 min.- and focused on one key concept (Attention)
  2. Chunk videos into no more than seven concepts per session (Cognitive Overload)
  3. Start with a story (Relevance)
  4. Use a graphic organizer at either beginning or end if there are important interconnections (Scaffolding)
  5. Use images of presenter at beginning and end if instructor presence is needed.
  6. Use clear, simple visual illustrations of all key concepts (input).

If you are teaching a skill:

  1. Demonstrate the complete procedure, including patient and team interaction
  2. Repeat the actual procedure progress by chunking videos into numbered steps (Cognitive overload and Scaffolding)
  3. Use still photos in the video to illustrate complex movements (Scaffolding).

Designing The Flipped Classroom: Part 2 Design the outside class activity

Working Memory

Prerequisite Learning Design Knowledge

In the previous section, you analyzed information about your students and your objective. Now we are going to look at how working memory (the brain’s immediate experience) can be best utilized to improve learning in a flipped classroom. As you can see from the image at the top of the page, there are 5 aspects of learning that you have to initially consider.

I. Attention
Obviously, in order to learn, people have to pay attention, however, there are many distractions that can take students’ attention away. There are three aspects of attention that you have control over:

  1. Because people can’t listen and read at the same time, they often find it annoying when presenters read the text on their slides.  If you are preparing a slide show as your flipped component, put key points and relevant images on your slides and write a script for uwhat you need to say. Don’t make your head the focus of the video unless you are using your image to teach a key point.
  2. People have trouble paying attention for more than 15 minutes. Flipping allows you to chunk content into more manageable pieces. If you are recording lectures, aim for 8-12 minutes per show and organize content around 1 objective at a time.
  3. Use questions. Our students have a Pavlovian response to being asked a question, so use questions to focus attention on what to look for in article and videos.

II. Relevance
The more relevant content is to student’s current lives, the more focused their attention will be. Information that can be incorporated into current schema (an organized pattern of thought or behavior) will be easier to retrieve from long term memory. This is why you analyzed who your students are in the previous section. Some of the ways to improve relevance in a flipped classroom are:

  1. Tell patient stories – There are some excellent online resources such as Stories from the Saskatchewan Health Region.
  2. Ask students to remember a relative or friend with health issues.
  3. Begin illness scripts that students will build on over time. Start with the common diagnoses.
  4.  Use graphic organizers that link what participants learned previously to keypoints they will learn next.

III. Scaffolding
Novice learners don’t have the patterns that you have, so they need structures that help them see relationships. Once they have created schema of their own, the scaffolding isn’t as useful or necessary. Some examples of scaffolding are:

  1. Guidelines
  2. Mnemonics
  3. Numbers
  4. Steps
  5. Concept maps/graphic organizers/illness scripts

IV. Inputs
Content primarily enters working memory in 4 forms: images, sounds, movement and emotions. Movement is the most poorly understood of the input tools but writing, typing, drawing and manipulating instruments are common examples. Smell is less useful in classroom settings, but can be very relevant in clinical settings. When planning your flipped classroom, try to include at least two of the inputs in every activity.

V. Cognitive Overload
Cognitive overload is the barrier that stops information from reaching memory. As a rule of thumb, about 7 items is the limit of how much information working memory can hold at any one time. Beyond that point, either earlier steps, ideas and facts will be lost in order to access the new learning or the brain will stop paying attention and new content will not be retained. Fatigue and hunger decrease the amount of material accessed, which is why you need to know about students’ overall work load. If information isn’t accessed by working memory, it can’t be stored in long term memory. If students cram information for exams, it often doesn’t get processed into long term memory and is lost post-exam.


Design The Outside Class Activity

  1. Start with an objective or learning step that you would like the students to learn before class which requires them to memorize X. Spend some time thinking about how this objective might be best learned. (There are some ideas here.) Pick three or four methods that fit the objective.
  2. Set some criteria the method has to meet, such as cost, time to construct, technology availability, availability of outside resources, etc. and narrow the choices to two. Pick one that appeals to you (start small).
  3. Create the resource, considering the 5 points in the prerequisite section.
  4. Ask someone else to look at the resource with fresh eyes and give you feedback.
  5. Pilot the content and ask for student feedback.

Stay tuned for next post on Creating Videos and on Designing the Flipped Classroom Time.


Designing the Flipped Classroom: Part 1 Analysis

We have to articulate that process publicly, so that the people following new processes are not mistaken for cowboys or illiterates.
Mike Caulfield

There has been lots of talk recently about Competence by Design and about new technologies not contributing what people expected to learning. I am going to try to answer one issue of the latter with the former. Flipped classrooms are either the next wonder of technology or a total disaster depending on who you listen too. As always I answer “It isn’t the tool, it’s the pedagogy.” I am going to use the ADDIE approach to Instructional Design to inform my writing. So what can the pedagogy of design, bring to flipping.

What does it mean to Analyze?

There are two components I am going to explore

  1. The learners
  2. The objective

Medical Education Learners

No, I’m not going to talk about “kids these days”. There are several questions to consider here:

  1. What level of education can you assume this group of student has achieved?
  2. What does that tell you about their memorization, higher order thinking, clinical reasoning skills?
  3. What milestones can you assume the student has achieved as a result?
  4. What prerequisite knowledge and skills is it problematic to assume the student has (problem solving, study skills)?
  5. What cognitive load are the learners presently carrying (other classes, exam schedules)?
  6. Are there holidays or other events that would restrict how much time they can prepare for class?

For example: some medical students who have a traditional science background are very good at multiple choice learning but may have had little exposure to critical thinking, while some arts students have more experience with critical thinking but not memorization. Understanding this diversity can help with planning small group experiences or study groups when planning activities.

The Objective
Start by examining the verb used in the objective. Verbs such as:

  1. describe, list, define, name, explain, compare, identify and label all require lower order thinking (memorization)
  2. analyze, appraise, investigate, solve, determine, diagnose, synthesize require higher order thinking.
  3. apply, calculate, demonstrate, model, perform require application skills.

Memorization skills lend themselves well to flipped classroom learning because students can view lessons multiple times and practice retrieving knowledge.

Higher Order Thinking is best done at least initially in the classroom or small group where the diversity of student experiences improves problem solving skills. However there are frequently prerequisite or foundational skills that can be reviewed before class.

Application skills are best learned through practice and feedback from peers and experts, but they also have prerequisite information such as basic science facts or steps in a procedure that need to be held in working memory: either previously learned (and remembered) or reviewed before practice.

The Verb and Assessment
The verb also tells you how students should be tested, so finally you need to analyze the match between how and what students will be tested on with what you are teaching.

Stay tuned for Part 2 Design Phase

Is the End of Lecturing, the End of Teaching?

Lecturing humourOver and over for the last 10 years, I have heard people say online learning will kill the teaching profession, learning objects will kill the teaching profession and now flipped classrooms will kill the teaching profession. I think I bring a unique perspective to this argument because I came to teaching through an unusual teacher training program in the 1970’s. My teacher training was focused on small group learning, problem solving, discovery learning and individualized curriculum to bring up basic skills. Then, in my 30’s, I discovered computers as an individual teaching tool.
I wasn’t confronted with lecture based teaching methods until I went to graduate school in my 40’s. I deeply hated the experience, but I conformed to the university culture where every conference and every large classroom experience is exclusively lecture based.
To my deep shame, lecturing has now become a deeply ingrained habit, but I still hate it. If the job of teachers is to help students learn, then lecturing is an incredibly inefficient way of doing that. I feel like a horse buggy driver among spaceships. So let’s look at alternative definitions of teaching.

Teaching at a Distance – MOOC’s vs. Videoconferencing vs. Desktop Collaborative Learning

To date, I have participated in two Stanford MOOCS with over 500 people and been deeply disappointed. There was minimal interaction with teachers, poorly developed curriculum and mass chaos as 500 people tried to organize themselves into task groups. Clearly these course needed good teachers desperately.

My university has invested heavily in videoconferencing programs that project lectures to distant locations. I have participated in and observed many of these sessions and I have never seen an engaged audience at the other end. I see students eating, talking to their friends and engaging with their computers but I don’t see them engaging with the faculty or home-based students even when the instructor is interacting well with the f2f students.

I used to participate in online desktop sessions using a tool that allowed participants to communicate through audio, chat, small group rooms and whiteboard tools. I saw people deeply engaged. Contrary to the myth that you don’t need a teacher, it was the teacher presence and interaction with the audience that made these classes so engaging. I don’t understand why medicine is one of the only training programs not using this technology.

Flipped Classroom

The best examples of flipped classes in medicine that I have seen involve students using a variety of resources to learn the knowledge component of a course. Teachers create that content, teachers curate resources created elsewhere. Teachers decide what reasonable workloads outside the classroom are. Teachers have office hours to meet with students who are struggling with fuzzy concepts. Yes, it’s a different role from creating and reading PowerPoint slides, but it is clearly all about helping people learn.

The role of the teacher freed from listing facts in a lecture becomes a facilitator of Higher Order Thinking. Learning through cases, experiences, patient stories, problem solving, resource sharing and formative assessment will engage your brain as well as the students when you enter the flipped  classroom.

Curation as Social Learning

Curation means gathering, evaluating and providing access to X. One of the cutting edge roles of teachers is to curate knowledge resources online to share with students. Dr. A.M. Cunningham has one of the best examples of this here. The next level of curation is to make the students your curators by having them share resources with other students. This is called Social Curation and it still requires a teacher to facilitate, and assess the process.

Teaching is one of the oldest professions. It just needs a new wardrobe for the twenty first century. So medicine, let’s shed the 16th century lecture robes. Help me break a bad habit!

Flipped Classroom Workshop

Participants in our flipped classroom workshops are asked to do a series of pre-readings, in order to have a better understanding of what it means to be a student in a flipped environment.

Before the workshops on June 25th and 26th, please read:

  1. Why flip the medical classroom? As you are reading this article, please think about at least 1 reason not mentioned for why you might want to flip your class.
  2. Flipped Classroom As you are reading this, pick one technique you might want to explore further.
  3. The Flipped Classroom Goblin  As you are reading, think about what you might do about student concerns with the flipped methodology.
  4. Using the Flipped Classroom Group Time  As you are reading this, pick one technique you might want to explore further.

Thank you.

How Do People Learn to Do X?

In my basic teaching classes, I talk about the “5 Step Approach to Teaching Skills and Procedures” but I don’t usually talk about why this technique works better than simply telling someone how to do X. I recently was looking at an article about flipping the classroom that asked can you learn to fold an origami crane by watching a video once. The answer of course is no. Try it by watching the linked video above. Why is it impossible? Does previous origami experience make the doing easier?


Unless you are one of the unique individuals with an eidetic memory, the video moves too quickly for you to remember the steps as distinct units in the process. This is a similar issue if you are told how to do X verbally, most novices will not be able to remember a series of steps after leaving the room even if it seems very clear to them when they are told. Even if you have folded cranes previously, the majority of people who don’t do origami regularly will have forgotten the steps.

The advantage of video instruction over verbal instruction is you can watch the video numerous times in order to practice as you go along. If you prefer the big picture, you can watch the entire video before trying the individual steps. If you are a trees person, you can stop it at each step and make notes or practice the first time you watch.

Novice vs. Expert Memory

When experts demonstrate X, it looks easy (because it is to the expert) and novice minds are often fooled into thinking that they can do it as readily. The problem is that most procedures physicians do involve both intellectual and muscle memory, only repeated supervised physical practice creates muscle memory. Someone with previous experience doing similar tasks has a jump start on the muscle memory. In the crane example, someone with previous origami experience will find the basic folds easier to follow. Muscle memory seems to take longer to lose than intellectual memory. For example, you will often remember how to do an origami fold longer than you will remember the name of the fold.

Supervised Practice

Novice practitioners don’t know what they don’t know and can repeat errors over and over without knowing why they are wrong. This group needs regular feedback until they are minimally efficient. Supervision can be gradually withdrawn after that.

People with some experience need initial supervision because there may be required terminology or steps they have forgotten especially if they haven’t done X in a while. For example, when I watched the video I had forgotten what a mountain fold was and how to do it. Watching the video didn’t help and I needed to either ask someone or look it up in a different milieu.



The Flipped Classroom Goblin

I just sat down with a group of 1st and john_henry_fuseli_-_the_nightmare2nd year medical students to hear horror stories about their experiences with flipped classrooms. Although many of them liked the idea behind the strategy, these experiences had been overwhelmingly negative.

The stories mainly consisted of 4 categories:

  1. Too Much Content

      1. A three hour lecture is boring in the classroom but it is unwatchable as an unedited video
      2. Asking students to read several articles written for medical professionals not medical students because the faculty member doesn’t have time to edit the content or doesn’t understand the knowledge level of med students leaves them confused and embarrassed by their lack of understanding. Worse it can mean avoidance of article reading once they graduate.
      3. Asking students to read articles without guiding questions so they know what to focus on
      4. Anything that takes more than 1 hour to complete (see Flipped Classroom for ideas)
  2. No Follow Through Between Homework and Class Time

      1. Asking students to do homework but not following up and helping students make the connection between the time spend studying and classroom activity
  3. Using Class Time for Lecturing

      1. The educational theory behind the flipped classroom is that content that must be memorized is best learned independently while higher order thinking is best done thru group activity. Flipping the classroom provides an opportunity for students to develop both factual and clinical reasoning. (see Using Classroom Time)
  4. Not Attending Faculty Development

      1. The underlying issue seems to be with faculty who I know have never attended a single workshop on how to flip a medical classroom. Students have positive stories about what active participants in faculty development are doing.

    image (C) Henry Fuselli

Why Guidelines are an Important Part of Medical Education

The Problem

Like women a year after childbirth who have fuzzy memories of the experience, preceptors don’t remember what it was like not to know X. Their fingers don’t remember the inability to tie knots and they are unable to list the steps in a procedure because it is performed automatically, both mentally and physically. Therefore guidelines seem too simplistic or obvious to experts. Even changes to guidelines are rapidly assimilated if they fit into the medical patterns that experts already have.

Medical Students Don’t Have Patterns

Medical students leave the university with vast chunks of information, but only practice in the real world forms those chunks into the patterns that denote medical expertise. Both their bodies and their minds are awkward participants in the new learning process that forms the clinical years.

Clinical Guidelines

Guidelines promote clinical learning for the following three reasons:

  1. memorizing steps is a familiar learning process for students, it’s concrete in an environment that may feel nebulous and unpredictable to recent graduates
  2. guidelines act as a bridge to pattern making, with increasing practice and confidence the student begins to understand the links to deeper knowledge and understanding
  3. guidelines are a concrete tool for feedback. Instead of the nebulous “great job”, preceptors can ask the clerk or resident how well they followed a particular guideline.

Just for fun, take a look at how one physician is encouraging the use of guidelines. How might you promote the use of guidelines?