Teaching the Hidden Curriculum

Today I’m going to talk about seven methods that you can use as a clinical teacher to assist students to learn the hidden curriculum – in other words the skills and attitudes we expect doctors to demonstrate, but in most cases don’t teach and don’t assess as part of the medical curriculum. Some of the methods you will already be familiar with, others will be easily implemented, some will be more difficult to implement, but all of them will help reveal the hidden curriculum to medical students.
I’d like to begin this session by telling you a story about why I keep returning to my family doctor even though his practice is so busy that I’ve waited weeks for an appointment.
Several years age, my daughter was diagnosed with a serious illness and as he was telling her about the diagnosis, without a break in his eye contact with her, he laid his hand on my shoulder. That brief contact told me that even though his focus had to be on my daughter, he knew that I was in pain as well. Without a word, he had conveyed his empathy.
Empathy, professionalism, multicultural sensitivity, communication, team work, office management are just a few of the skills that we expect graduates to have when they become physicians. So let’s look at how we teach these skills and attitudes.
1. Consciously Role Modeling
Role modeling is a standard expectation but conscious role modeling requires daily thought about what part of professionalism you are going to demonstrate today. At the same time each day think about not demonstrating the dehumanizing of patients and staff.
2. Use Deliberate Reflection
What aspect of professionalism are students not being exposed to in your teaching? Maybe its patient advocacy, maybe its teamwork; how can you rectify that missing element? Have a coffee with the student and ask them what they think makes a good doctor.
3. Tell the Stories
Provide students with an opportunity to explore doctors’ impact on patients’ lives. If you don’t have time or are uncomfortable with storytelling, provide them with opportunities to watch movies like Wit or The Doctor, or read excerpts from books such as the Tennis Partner, The Vagina Monologues or The Spirit Catches You and You Fall Down.
4. Provide Humanistic Problems
Humanistic problems include questions such as “How difficult is it for this diabetic to eat properly?” or “Are their cultural implications to the patient accepting this treatment?” which provides students with opportunities to explore cultural and economic reasons behind non-compliance.
5. Involve Your Patients
Select one or two of your regular patients and ask them ahead of time if they would be willing to work with one of your students directly including giving the student feedback on how they did. In some cases, you might want to arrange a home visit or informal discussion time for the student to explore a fuller picture of the patient’s viewpoint.
6. Involve Your Staff
Medical students have in some cases been isolated from other medical practitioners and haven’t had the opportunity to explore interdisciplinary teams or other aspects of medical management. Your staff is a good starting point. Ask them to teach the student a specific skill, and then ask them to provide feedback on how the student interacted with them as professionals, either to you or directly to the student.
7. Involve Your Community
Provide your students with a project that explores larger community issues such as “How healthy is this community?”, “What resources are available for handling bereavement issues?” or “What resources are available for patients who have chronic pain?” Projects of this kind allow the students to meet other professionals while at the same time increasing their knowledge.
Thank you for participating in today’s broadcast. I hope these seven methods will prove useful in your practice. Please feel free to contact me directly or participate in the comments section of my Blog.

Email Etiquette- Dos and Donts

The internet has radically changed the way we communicate. With it comes comes a new set of behaviors, expectations potentially sticky situations. The following is a brief list of
the Dos and Don’ts of email. Listen in on the rules of engagement for effective email communication.
Do use business letter writing basics. Use appropriate salutations, formatting and sign-off. Always err on the side of formality.
Don’t make email too long. Be concise and to the point. It will be more valuable to the recipient and will elicit a better response.
Do not use multiple punctuation marks – like question, question, question. It comes across as emotional and irrational.
Don’t consider email to be secure. Keep your personal comments and confidential matters for a private conversations. Consider where the email might end up.
Do be selective when CC’ing – ask yourself if others really need to be included?
Don’t use BCC except for broadcast emailings such as newsletters etc… protecting the
privacy of everyone in the list, especially if they do not know each other.
Do take your time to respond to email, especially ones that might incite emotion. Savvy
emailers let their emails age several hours and often over night before they reread them
and send them on their way. Always ask yourself “How might this be interpreted by others?”
Don’t not reply. Even if you can’t help someone, let them know you are listening and
Do be polite. Imagine that when you are speaking, you are speaking to a crowd of people. Your audience may be larger that you expect and your choice of words may easily offend.
Don’t use email to discuss sensitive or embarrassing subjects. It might come back to bite you.
Do use humor sparingly. It the appropriate intonation associated with speech can be easily misinterpreted.
Don’t mark all you correspondence as urgent. Ever hear of the little boy who cried wolf?
Do avoid read/delivery receipts. They are annoying and most recipients eventually learn to turn them off or not answer them.
Don’t get into protracted email conversations. Decide ahead of time when you need to pick up the phone.
Do sensitive about relationships you have with your recipients and their relationships with one another. Are you sending a request to a colleague and their boss giving the impression that putting the squeeze on them? There’s a time and a place for that.
Do use case appropriately. Using upper case letters (all caps) comes across as if you are YELLING! Do you want to be yelled at?
Finally, Do keep your missives and quips to a minimum. They can be fertile ground for miscommunication, unpleasantries and worst yet, legal action. Consider the following email related legal cases compiled by CNN:
# a Massachusetts class-action suit over the dangers of the diet drug combination
Phen-Fen, the court allowed this e-mail from a company executive to be admitted: “Do I
have to look forward to spending my waning years writing checks to fat people worried
about a silly lung problem?”
# Chevron settled a lawsuit for $2.2 million that involved an interoffice e-mail giving 25
reasons why beer is better than women.
# Former star investment banker Frank Quattrone was convicted of obstructing federal
investigations into stock offerings at Credit Suisse First Boston. Central to the case was
an e-mail Quattrone forwarded telling employees it was “time to clean up those files”
after he learned of the investigation.
# More than 500 of former West Virginia Gov. Bob Wise’s intimate e-mails with a state
employee were obtained under the Freedom of Information Act and made public in 2003. The employee’s husband filed for divorce and Wise didn’t seek re-election in 2004.
I encourage you to read some of the myriads of articles written on the subject. Like any other modes of communication, Email says a lot about you.

Active Learning Strategies for Your Classroom

According to Pat Wolfe – “No matter how creative, colorful or exciting a lesson is, if the teacher’s brain is the only one interacting with the material, the teacher’s brain – not the student’s brain – is the only brain forming dendrites.”
Hi, I am Kalyani Premkumar, Curriculum and Faculty Development Specialist of the College of Medicine, University of Saskatchewan. Today, I would like to reflect on Active learning.
The traditional lecture, where the lecturer talks and the student listens, is the most common teaching method used in most college classrooms. But does this method promote student learning? Think back about your own learning – how did you learn? What do you remember best?
Evidence indicates that students learn better when they are actively involved in the learning process. It is therefore important for Instructors to understand what active learning is, the benefits of active learning, the barriers that prevent the use of active learning processes and examples of a few techniques that can be used.
What is active learning?
Many argue that learning in any form has to be active, and the traditional lecture too constitutes ‘active learning.’ A review of the literature indicates that students need to do more than just listen. Active learning is any well-structured, teacher-guided, student-centered activity that “substantially involves students with the course content through talking and listening, writing, reading and reflecting.” More importantly, the student has to be engaged in higher order thinking tasks such as analysis, problem-solving, synthesis and evaluation. Instructional activities that involve students in doing things and thinking about what they are doing constitute active learning.
Why active learning?
There are a number of benefits and reasons for using active learning. Students prefer active learning strategies in classrooms to traditional lectures. It stimulates higher order thinking and skills. The techniques promote learning in students with different learning styles. In addition, students are motivated when they are actively involved in the learning process. Active learning facilitates participation by the entire group. Here, the student takes responsibility for his/her own learning. Improved interpersonal skills, increased retention and transfer of new information are other benefits seen.
Barriers to adoption of active learning
Despite the evidence to the benefits of active learning, many instructors are reluctant to use active learning techniques. Many of the instructors have been taught in the traditional manner and are hesitant to adopt new techniques and undergo the anxiety that usually accompanies any kind of change or risk. Even at the college of medicine, there is often little faculty incentive to change.
The most common barrier cited is the lack of time to ‘cover’ all the material. There is also the perception that using active learning strategies may increase preparation time. How can active learning be managed in large classes? is another question asked by teachers. Some identify lack of resources and equipment as barriers.
In active learning, students take responsibility for the learning. As such, instructors are reluctant to loose control. What if the students do not participate? Do I have the necessary skills to try a different teaching method? are other questions that plague some instructors.
But each of the barriers can be overcome by thoughtful and careful planning in the part of teachers. It is also important for instructors to use active learning techniques that suit their personalities and comfort level. A variety of active learning strategies – from simple to complex, exist and teaching methods can be chosen according to suitability.
Some strategies
Students can be engaged in individual or small group activities both in small and large-sized classes. Simple techniques that can be adopted with very little preparation include: pausing to enhance recall; think-pair-share – where the student is given time to think, then turn to their neighbor and share their thoughts); question and answer pairs; one-minute-paper; focused listing (students are given time to list key points) and buzz groups. Other strategies that require more planning include scenarios/case studies, reading assignments, simulations, interactive computer programs and problem-based learning. Simple active learning methods that could be easily used with technology, such as PowerPoint games are also freely available. Today, I would like to expand on the simplest of techniques that require least preparation.
Let me describe an interesting study on the technique of pausing – if you can call it a technique, and convince you that it works. Here, the instructor paused for two minutes every 12-18 minutes of lecture. That means, it was done on three occasions during a lecture. This was done on each of five lectures. During the pauses, the students worked in pairs to discuss and rework their notes without any interaction with the instructor. At the end of the lecture, the instructor gave three minutes time for students to write down everything they could remember from the lecture. The students were tested on the information 12 days after the last lecture. A control group received the same information (but without the pauses) and were similarly tested. This study was done in two separate courses repeated over two semesters. The researchers found that students who participated in lectures with pauses did significantly better in the test – the difference in mean score between the two groups was two letter grades.
These findings have important implications and are consistent with research that suggests that the ability to retain information decreases substantially after 10-20 minutes. Inclusion of pauses, or short active learning activities into the lectures improves student learning and this happens despite the reduction in lecture time!
One may then argue: If the lecture time is reduced, how can I teach everything? – there is too much content to ‘cover.’ Concerned about this issue, other researchers did a study on 123 medical students randomly distributed into three groups. The three groups were similar in the cumulative GPAs and knowledge base. Three different lectures on the same subject, with varying density (90%, 70% and 50%) of new information in the lectures were prepared and administered to the groups. The lecturer spent the remaining time reinforcing the material. The researchers found that students attending the ‘low density’ lectures learned and retained the lecture information better. This implies that the amount of new information learnt by students in a given time is limited and instructors may be defeating the purpose when this limit is exceeded. Instructors may be better off presenting only the basic material needed to achieve the learning objectives and spending more time reinforcing facts and concepts in order to promote student learning.
So, try it yourself. For a start – just pause for 1-2 minutes every 12-18 minutes.


The philosophy behind the active learning strategy is that students “learn best by doing, not by watching or listening”. There are a number of benefits to adopting active learning strategies in the classroom. Yet, the barriers that exist among instructors have to, and can, be overcome by careful and thoughtful planning. A variety of active learning strategies, from simple to complex, exist and the instructor should choose one that is most suitable for the objective in question, taking into consideration his/her own comfort level.
The success of an active learning methodology does not depend only on the methodology but, ultimately, on the “constantly evolving relationship between methodology and learners”, facilitated by the educator.
According to Carl Rogers, The only learning that really sticks is that which is self discovered.

The Content Jungle

The overgrown content of undergraduate medical education creates a jungle in which teachers and students alike become entangled and where some even meet their death. Many of you may have had a near-death experience as students. In this Pod Cast I will outline the pathophysiology of the overcrowded content jungle, the resulting syndromes, and some effective treatments.
I am Marcel D’Eon, Director of Educational Support and Development. I completed my PhD in Educational Administration at the U of S in 1997 and immediately joined the College of Medicine. I had a short career as a naval officer and then worked as a classroom teacher for 16 years. My interests are in faculty development, educational change, and how people learn.
Overcrowding in the curriculum has been with us for decades. Even Abraham Flexner at the turn of the twentieth century noted the debilitating effect of cognitive stuffing and educators since him have added their voices to the common lament: there’s too much to learn. However, we must do something about it. Students, when faced with an overwhelming amount of material to learn initiate a survival mechanism known as cramming (cognitive stuffing) which produces Bulimic Learning. They stuff as much in as they can for a short period of time and after the examination their brains empty. Clearly this is a waste of time and effort on the part of students and teachers.
Effective and efficient learning occurs as new information is connected to existing knowledge networks within the brain. In fact, nothing can be learned that is not in some way connected to what is already known. To commit something to memory it must have some connection to what is already in memory. The more significant the connection is the better and more durable is the learning. When our capacity is overwhelmed through overcrowding we do not have time to make the necessary connections to existing knowledge networks that will allow us to remember what we have studied. Our metaphoric knowledge receptors are overwhelmed. Little bits of information float freely in the virtual knowledge space within our minds and are rapidly lost. Students hope they do not escape until at least after the exam!
Students apply themselves to the task of learning a mountain of information, (a little like trying to take a drink from a fire hydrant) but do not seem to be learning. They cram untold amounts of information into their brains and think they are learning but they are not. They suffer from an illusion of learning because they merely recognize a term. They remember having seen it once but they can’t quite remember what it means or how it related to medicine. In the most extreme form students may not even remember ever seeing the word before!
The solution to Bulimic Learning is to teach less and hence create the conditions by which our students will learn more. Less is more. What happens when we attempt to ease content overcrowding and deny cognitive stuffing? First, students have more time to make the necessary connections and practice their new understandings through application to cases and exercises provided by astute teachers. This results in firm and lasting learning. Then, these newly modified and enhanced knowledge networks become anchors, hooks, and connections for further learning which might happen in class or through self-directed learning. In the end, the students will remember more for longer periods of time and be able to pick up additional knowledge skills and attitudes more effectively and efficiently. Though we have taught less and worry that we have done our students a disservice we have actually helped them to learn more and to be in a position to build quickly and easily on that foundation.
Don’t let the content jungle trap you and your students. Trim down the amount of material you try to teach in a session to a reasonable amount based on the prior knowledge of your students. Meet them where they are and help them to build solidly on the existing learning that is already in place. Engage them in active learning exercises such as case discussions in teams where they can integrate their new knowledge with what they already know and avoid giving your students any reason to turn to Bulimic Learning that will trap them in the content jungle.

Pass/Fail Grading System

Welcome. I’m Sheila Harding, the Associate Dean of Medical Education in the College of Medicine at the University of Saskatchewan. For the next few minutes, I’ll be speaking with you about the Pass/Fail grading system that was implemented in our undergraduate MD program with the Class of 2007. It has been phased in year-by-year with that class, which has just begun the clinical clerkship phase of the program. I’ll provide some of the historical reasons for the change, and describe some of the hypothetical advantages and concerns of the Pass/Fail grading system when compared and contrasted with the traditional system. I’ll tell you about our experiences and observations to date, and look to the future.
The literature addressing the dissatisfaction of teachers and students with traditional grading systems goes back decades. It was recognized as early as the 70’s that a medical student’s performance in traditional evaluation systems was unrelated to that student’s subsequent performance in internship, what we now call PGY-1, or the first postgraduate year of training. Thus, traditional grades have been given more weight than they should carry in making promotion and recruitment decisions. By the 90’s, many North American medical schools had switched to some version of Pass/Fail, either in the pre-clinical years alone, or throughout the MD curriculum, and this has become the norm in Canadian medical schools.
There are many hypothetical advantages in a Pass/Fail approach to the evaluation of medical students. To quote the literature, this approach seeks “to establish a partnership of trust between educators and students in a joint educational effort to foster excellence through the creation of mature and sophisticated physician learners.” It shifts students from competition to collegial cooperation. It provides flexibility for self-directed learning and the use of different learning styles. It emphasizes the attainment of durable learning directed toward good patient care, rather than the attainment of short-term learning directed toward good grades through the unhealthy practice of “academic bulemia”. It eases student’s anxiety.
Many express the concern that a Pass/Fail grading system will erode standards; that instead of working hard and striving for excellence, medical students will settle for mediocrity. Another concern is that the lack of finely tuned grades will prevent the appropriate recognition of academic excellence. Some worry that this will make the graduates of a Pass/Fail program less competitive in the pursuit of postgraduate positions. Happily, both the literature and our own experience demonstrate that students in a Pass/Fail program continue to work hard and to earn their core competencies at least as well as they did in a traditionally graded program, by any available measures. Programs have been creative in finding ways to recognize both academic excellence and excellence in other qualities that characterize exceptional physicians. Now that Pass/Fail systems have become the norm, there is no evidence that students in such a system are disadvantaged in the pursuit of postgraduate positions, except in individual programs where the local program personnel remain convinced of the importance of grades despite the evidence to the contrary.