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Continuing medical education — a wilderness of its own
Journal of Wilderness Medicine, 5,248-250 (1994)
EDITORIAL·
Continuing medical. ~ducat10J1- a wilderness of its own Call it free association or the linking of two dissimilar concepts through a common thread of thought. There are times when a provocative approach to one topic carries the reader or listener to make an observation to a different, seemingly unrelated subject. That is one of the reasons for publication of the manuscript by Kahn and Yardly in this issue of the Journal. On the surface, "Relationship of client attributes and guides' techniques to client satisfaction at a climbing school" is not greatly about medicine but more about the psychology of the relationship between climbing guides and their clients. While it certainly is that, on closer inspection, it can be used to provide remarkable insight into one of the thorniest issues in medicine-that of continuing medical education (CME). This is particularly relevant for wilderness medicine, which carries a content that begs for innovation in the educational process. CME in the United States is rarely more than a stand-up in-person real-live doctor or panel of doctors talking about what interests them in front of an auditorium full of physicians who need to accumulate credit hours for recertification or to satisfy an institutional requirement. The choice of content may have been based on a prospective needs assessment but rarely is modified en route to adapt to the changing needs or manifest boredom of the participants. With as much as we know about educational techniques, it is quite astounding that we continue to endure hour after hour of darkened rooms, blue diazo slides and scant interaction. For all of the interactive multimedia technology that is available to guide young children through mazes of dinosaurs, it is astounding how unimaginative are the approaches available to physicians and other healers. Wilderness medicine has a jump up on the rest of the profession. Virtually any way you slice it, the subject material is intrinsically interesting; indeed, it can be wildly entertaining. In the midst of medicine is adventure and exploration, tales of heroic rescues, mountains summitted and jungles traversed. CME programs which have been sponsored by the Wilderness Medical Society, the University of California at San Diego and others draw large crowds and generate enormous satisfaction among the attendees. But I wonder, could we do better? I think so. If one reads Kahn and Yardley carefully, the strategic generic concepts about education become clear, as does their application to wilderness medicine education. There are many points to be made, so I will approach them in the same sequence as have the authors. First, the title itself carries useful information. Learner attributes must be matched by the appropriate educational techniques for education to be maximally effective and satisfying. In business circles, they call it "knowing your customer." Action-oriented persons respond differently than do bookworms, and neophytes differently than seasoned clinicians or researchers. Those of us who have been teaching for a while know how tough 0953-9859 © 1994 Chapman & Hall
Editorial
249
it is to engage a "mixed crowd"-you're always talking "up" to one person and "down" to the fellow sitting in the next seat. The level of education must be matched to the level of the students. That means that the technique for information transfer must let the student seek an equilibrium of learning, or that the student body must be carefully segmented. The enthusiasm of the instructor is plainly apparent and can carry or lose the day. Regardless of the educational technique chosen, one must be "into it," or the students will soon be flocking "out of it." If for no other reason than people are entitled to get what they paid for, educators cannot take their responsibilities lightly. Spoon-feeding pupils is not necessarily desirable, but neither is an obsession with the Socratic method. In wilderness medicine, there is much technique, ranging from tried and true medical precepts to more free-ranging episodes of improvisation and search and rescue. Being technically sound implies being technical. While there is certainly room for armchair enthusiasm, this is not a viable approach for an educator. If a teacher wishes to do more than read from a script, he or she must have some first-hand experience in the environment. Students are better than we imagine at rating our technical skills. Medicine has a long tradition of being hard on its initiates-witness internship, the "grilling" which occurs on ward rounds, and expectations of high level performance from the greenest interns and students. That approach may toughen up a few individuals but is probably more dysfunctional than inspirational. In wilderness (medical) education, we need to separate the transfer of knowledge from conditioning for the environment. Sure, you can't treat a victim of profound hypothermia in a blizzard if you don't know how to put your mittens on, but that's apples and oranges. We should use the wilderness experience to enhance student self-confidence, not to display our muscles. In fact, I would argue that wilderness medicine favors the wily, not necessarily the triathlete. Furthermore, many observers have noted that persons who lead by domineering diminish interactions (if you don't count mutiny) among their constituents. To be effective educators, we should reinforce collaborative behavior that introduces control into a chaotic setting. As instructors, we should try to make our students better than we are at all of the skills we are trying to teach. The wilderness setting poses a unique challenge to physicians and other health care providers. The rugged individualism that is so much a part of medical education must become subservient to the needs of the group. There is no silver platter upon which to serve anything, much less a textbook to which to refer. The education we offer our students must teach them not only to rely upon themselves, but how to create an atmosphere of teamwork in which everyone can playa meaningful and sustainable role. What then of the evaluation process? Traditionally, comments are collected at the end of a CME experience which only remark upon the very best and the very worst that the program had to offer. The feedback is nonanalytical and serves little purpose to improve the teaching skills of the instructors. Part of CME must be a process whereby the instructors can be taught and evaluated by professional educators-people who teach other people how to teach. I cannot recall any course offered to me as a faculty member which was designed to enhance my teaching abilities or methods. I would like to see the Wilderness Medical Society work with education professionals to assess the best educational techniques available, both the tried and true and the "cutting edge," and figure out a way to disseminate this information to the persons who can best use it. This by no means has to be limited to medical professionals, but it is a good place to start. Our demonstrations need to have impact, and our lectures do more than convert
250
Editorial
travelogues into lullabies. Wilderness medicine has every content advantage going for it that one could possibly imagine, so it would be a shame to see it go the way of other specialties and wind up with conventions, coloring books and multiple choice. What Kahn and Yardley have so clearly demonstrated, perhaps unintentionally, is a framework by which we can begin to measure ourselves as educators. This can only be done in the eyes of our students, not in a reflection from the mirror. PAULS. AUERBACH, MD
Stanford, California USA
EDITORIAL·
Continuing medical. ~ducat10J1- a wilderness of its own Call it free association or the linking of two dissimilar concepts through a common thread of thought. There are times when a provocative approach to one topic carries the reader or listener to make an observation to a different, seemingly unrelated subject. That is one of the reasons for publication of the manuscript by Kahn and Yardly in this issue of the Journal. On the surface, "Relationship of client attributes and guides' techniques to client satisfaction at a climbing school" is not greatly about medicine but more about the psychology of the relationship between climbing guides and their clients. While it certainly is that, on closer inspection, it can be used to provide remarkable insight into one of the thorniest issues in medicine-that of continuing medical education (CME). This is particularly relevant for wilderness medicine, which carries a content that begs for innovation in the educational process. CME in the United States is rarely more than a stand-up in-person real-live doctor or panel of doctors talking about what interests them in front of an auditorium full of physicians who need to accumulate credit hours for recertification or to satisfy an institutional requirement. The choice of content may have been based on a prospective needs assessment but rarely is modified en route to adapt to the changing needs or manifest boredom of the participants. With as much as we know about educational techniques, it is quite astounding that we continue to endure hour after hour of darkened rooms, blue diazo slides and scant interaction. For all of the interactive multimedia technology that is available to guide young children through mazes of dinosaurs, it is astounding how unimaginative are the approaches available to physicians and other healers. Wilderness medicine has a jump up on the rest of the profession. Virtually any way you slice it, the subject material is intrinsically interesting; indeed, it can be wildly entertaining. In the midst of medicine is adventure and exploration, tales of heroic rescues, mountains summitted and jungles traversed. CME programs which have been sponsored by the Wilderness Medical Society, the University of California at San Diego and others draw large crowds and generate enormous satisfaction among the attendees. But I wonder, could we do better? I think so. If one reads Kahn and Yardley carefully, the strategic generic concepts about education become clear, as does their application to wilderness medicine education. There are many points to be made, so I will approach them in the same sequence as have the authors. First, the title itself carries useful information. Learner attributes must be matched by the appropriate educational techniques for education to be maximally effective and satisfying. In business circles, they call it "knowing your customer." Action-oriented persons respond differently than do bookworms, and neophytes differently than seasoned clinicians or researchers. Those of us who have been teaching for a while know how tough 0953-9859 © 1994 Chapman & Hall
Editorial
249
it is to engage a "mixed crowd"-you're always talking "up" to one person and "down" to the fellow sitting in the next seat. The level of education must be matched to the level of the students. That means that the technique for information transfer must let the student seek an equilibrium of learning, or that the student body must be carefully segmented. The enthusiasm of the instructor is plainly apparent and can carry or lose the day. Regardless of the educational technique chosen, one must be "into it," or the students will soon be flocking "out of it." If for no other reason than people are entitled to get what they paid for, educators cannot take their responsibilities lightly. Spoon-feeding pupils is not necessarily desirable, but neither is an obsession with the Socratic method. In wilderness medicine, there is much technique, ranging from tried and true medical precepts to more free-ranging episodes of improvisation and search and rescue. Being technically sound implies being technical. While there is certainly room for armchair enthusiasm, this is not a viable approach for an educator. If a teacher wishes to do more than read from a script, he or she must have some first-hand experience in the environment. Students are better than we imagine at rating our technical skills. Medicine has a long tradition of being hard on its initiates-witness internship, the "grilling" which occurs on ward rounds, and expectations of high level performance from the greenest interns and students. That approach may toughen up a few individuals but is probably more dysfunctional than inspirational. In wilderness (medical) education, we need to separate the transfer of knowledge from conditioning for the environment. Sure, you can't treat a victim of profound hypothermia in a blizzard if you don't know how to put your mittens on, but that's apples and oranges. We should use the wilderness experience to enhance student self-confidence, not to display our muscles. In fact, I would argue that wilderness medicine favors the wily, not necessarily the triathlete. Furthermore, many observers have noted that persons who lead by domineering diminish interactions (if you don't count mutiny) among their constituents. To be effective educators, we should reinforce collaborative behavior that introduces control into a chaotic setting. As instructors, we should try to make our students better than we are at all of the skills we are trying to teach. The wilderness setting poses a unique challenge to physicians and other health care providers. The rugged individualism that is so much a part of medical education must become subservient to the needs of the group. There is no silver platter upon which to serve anything, much less a textbook to which to refer. The education we offer our students must teach them not only to rely upon themselves, but how to create an atmosphere of teamwork in which everyone can playa meaningful and sustainable role. What then of the evaluation process? Traditionally, comments are collected at the end of a CME experience which only remark upon the very best and the very worst that the program had to offer. The feedback is nonanalytical and serves little purpose to improve the teaching skills of the instructors. Part of CME must be a process whereby the instructors can be taught and evaluated by professional educators-people who teach other people how to teach. I cannot recall any course offered to me as a faculty member which was designed to enhance my teaching abilities or methods. I would like to see the Wilderness Medical Society work with education professionals to assess the best educational techniques available, both the tried and true and the "cutting edge," and figure out a way to disseminate this information to the persons who can best use it. This by no means has to be limited to medical professionals, but it is a good place to start. Our demonstrations need to have impact, and our lectures do more than convert
250
Editorial
travelogues into lullabies. Wilderness medicine has every content advantage going for it that one could possibly imagine, so it would be a shame to see it go the way of other specialties and wind up with conventions, coloring books and multiple choice. What Kahn and Yardley have so clearly demonstrated, perhaps unintentionally, is a framework by which we can begin to measure ourselves as educators. This can only be done in the eyes of our students, not in a reflection from the mirror. PAULS. AUERBACH, MD
Stanford, California USA