2018 TEACH Education Day

Good morning everybody thank you so much for coming and committing and dedicating time to your roles as faculty members this is wonderful and even worse importantly dedicating their time to improving the education for your learner's you are so good at killing as a reminder we have a receive in this session at noon through probably two are unable to attend this morning we also this evening have our big annual reception at which point we'll have a little welcome from the Dean we'll also have our annual teach awards presented and all of our posters for folks who have done anything innovative education wise throughout the year and also to podium presentations for folks who have been really great things for the past year they did too so this morning I'm sorry thank you for playing that so the this morning and noon are both in this room however the reception is over in the simulation center the new simulation center which is 15 old woods which is really just behind the Starbucks Starbucks and mode so you go with time and then you go over to the left with a train tracks you'll see it's the old trolley garment the brick building with the klaxon so I hope that you all there will be a wonderful event food and beverages not produced in 20 years ok so welcome this morning and I'm thrilled to be able to introduce dr. for operating after Larry brought me here today government's professor in the Department of learning health sciences at the University of Michigan Medical School where he directs the competency-based and Health Professions education program his research interests center around the development of expertise knowledge and performance assessment self-regulated learning and educational leadership development he has held the office of president of the Society of directors of research in medical education and chair of the WMC central group of educational affairs who is also the founding chair of the EE MCS Medical Education Research certificate program so that's Murphy also part of our first program dr. Kaufman has over 135 peer-reviewed publications on a variety of topics in medical education and has been recognized for career productivity by the mm C c/g a CTE a medical education laureate award the 2015 John T Hubbard award from the national board of medical examiners and the marrow player award from the donor MC group on educational centers quite big accomplishments dr. garland earned his bachelor's in psychology from Calvin College in both his master's and PhD in psychology from the University of Michigan we are so grateful to have him with us today to engages in thoughtful conversation regarding the master adaptive learner please come very proud so it's a it's a real pleasure for me to be here I spent in the summer of the Blue Ridge Parkway working at a gas station Magnus said he's so coming back to Virginia always a treat although if I am getting a little bit apparently because I was in Richmond during Hurricane Florence and I was in Atlanta during Hurricane Michael and now I'm here during the LCME so disaster even though almost immediately precedes me it's over though that's I'm going to be the case at least in this presentation so what I'd like to do today is to describe for you this is larger in a context of Education and education principles which of course will they'll see if you're thinking about a lot this framework which we are calling the mastered active learner which combines a variety think it's just almost like a big hotel where with pegs that you can hang on many of the issues that we wrestle with in teaching and particularly in learning and thinking about the learning process for our for our students I want to highlight the fact that although I'm making the presentation the model itself really comes from a very large collaboration that the American Medical Association has funded the accelerating change in education we're 11 schools have been sharing about 10 million dollars to try to develop innovations to promote education and this model to master that learner is one of the products of that so witzy it is a child with many parents of scholars educators clinicians who are contributing to our understanding to our thinking about learning in the context of medical education so it really centers around what and again the LC me is a great context for this what is the purpose of a Medical School of medical education well part of it is that we want to develop people who are experts in their field we want expert pathologist we want expert internist we wanted people we want people who can be skilled practitioners we also want people who are just good thinkers regardless of their discipline but we want people who are abroad who can think critically about things in which they are experts but also in things in which they may not be but they have to make decisions even when they're not experts but in the long run and I'm sure this is in your document as well what we're doing in a medical school we're trying to develop lifelong learners we want people who will learn here but we also want them to learn when they leave and the ongoing learning that takes place in practice is really what makes the difference we can teach them a lot of things in medical school but we know the type of date as soon as they leave so they have to continue to learn and it's this last one the ongoing learning that is so much challenging because it is all up to you it's up to the individual there's no curriculum you know there's no faculty member holding you to account there's more but not much assessment to give you guidance so it really is a focus to try to develop lifelong workers people who can self direct their own learning and pursue that process on their own so this is what has given rise to this idea of a master depth of learning that we want more than just learning for now which is just retrieving what you've been told and more than just next year's application but we really want to focus on the learning that takes place over the next couple of decades so there are I don't know if there are handouts here or if you had to print them out but I'm giving you a handout kind of a program to keep track of all characters that are coming in and out of this drama to illustrate this segment that we're calling to master to learner in this case I want to point you to the lower left-hand corner which is the identification of the main movers in this little build limit rare and Don Moore who really were the spark plugs for developing this project but highlight again that it is a fairly recent development by a lot of people it's published in academic medicine last year so this diagram is used with their permission let me give you an orientation to the different parts that we'll spend some time on as we go through this okay so at the top we have the fact that even though we're talking about the individual learner learning loss takes place in the community so we're representing that by having multiple people here but we're really focusing on the learning that is in one person's life so at the end of social context but we're really focused on the individual learning in this case and this environment is a critical part because the learning is taking place usually in the context of work so the problems that you're dealing with what you're learning is often driven by what working on so the environment is a major component of that but the crux of it is these four interlocking gears because these are the four components of the self regulated self-directed learning process and each of these goes in in excitement through the learning process and each one has specific characteristics in the community excuse me the requirements people the talking about a little bit more detail but overall the idea is that there is a cycle of learning that takes place in the context of oh excuse me of a workplace environment with other people engaged in the process of providing that context for that so wanted to start with the broader psychological phenomena better TV place as the context as a psychological context for this learning process and we have four of these elements that you for these phenomena that are really important for understanding this larger process of learning the first is self monitoring the fact that self directed so regulated learning requires that you are really in a sense monitoring yourself you're paying attention to what you're doing what you're thinking self examining why you came up with that decision critically appraising your own decisions your judgments try to get feedback on what you've done and whether it turns out to be correct so this self monitoring is kind of like the second one the metacognitive you're thinking about your own thinking and this is something that we typically don't do as experts part of what makes us skilled and valuable and and special is that we can do a lot of things without need a lot more expertise is automatic it's unconscious we just do it we do it we don't have to think about it so this metacognition this self monitoring is really a challenge for a lot of experts to take that step back and think about what you're doing as it usually you're thinking is very automatic so reflection of understanding and appreciating what you've done and why you've done it and the critical thinking are all more very closely related constructs that really are essential as an overall underpinning for this process you don't think about your thinking you're not going to really be an effective learner outside of formal educational context so it's also important to recognize that in formal education this gets short-circuited because as we've got faculty and we've had exams that we've had lots of other things telling you waitress won't work and how you're supposed to think and if we concern is that because this is our goal does medical school supressing does it prevent or cause all of these kinds of activities to Africa in addition to this larger context we've got some individual characteristics that we've identified as being important so it like the metacognitive context for this this is a series of individual characteristics that again are not its sound not limited to this learning process but it's part of the psychological context for making it work and these are things like curiosity if you have high levels of curiosity it's going to facilitate the learning self-regulated learning process same with motivation you're motivated by a variety of things some of them are very adapted for you know trying to be competent trying to demonstrate expertise solve these problems other motivation is is not adaptive drumming for grades trying to do things because you're told to do them but without understanding a purpose for mindset mike-set refers to some psychological research that is has identified that people can approach learning within two different mindsets one is they think about knowledge and you're good Lauren as being a fixed quantity and then you're either smart or you're not and if you're smart you can learn a lot if you're not you can't but it's fixed it's good buying for it in you're kind of a victim of faith the other wines that is a is a more than adaptive a growth mindset where the understanding your perspective on what you're doing is that you can always continue to learn that there's always capacity to learn more to continue this process and the research suggests that people who have this attitude about learning that is something I can continue to grow in tend to engage in self regulated learning to a much higher degree and are more effective at it so the mindset the way you're thinking about learning itself makes a difference as those resilience resilience is a kind of a hot topic that lots of issues about trying to promote resilience in students and residents and faculty to combat burnout and stress but it's also one of these things that we think feeds into the learning process as well people with high levels of resilience can deal with uncertainty and setbacks and being wrong more effectively than people who are more fragile so these batteries are characteristics of the end that we think fits into this model but there's also the opportunity for teaching to make a difference so this is all about the learner but the teacher is still an important aspect of this where the idea of coaching as someone who can both nurture this process but also provide feedback about the performance and guidance in the form of coaching provides an opportunity even for you who are very you know are well into the independent self-directed learning phase of your career can still get advice to get feedback still benefit from you interacting with colleagues so those are kind of contextual factors so now we'll go into the core of the learning process for the self-regulated learning process and it has these four phases that are all interlocking sort of moving wand booths the others and within them there are various characteristics various components that I'd like to describe in a little bit of detail but I want you to think about them in the context of the environment here the learning environment here and the extent to which things are supportive or obstacles to this kind of learning because that's what we've been doing for Michigan LCD is year half what two years so we're starting to think about this and we're starting to Russell with how do we deal with the fact that we want learners to continue to learn not become dependent on what they're told to have to do lose our environment really supported that so this is one of the uses we're making of this framework is a way to guide our thinking so the first one starts with the planning phase the way it's described here it really centers on the critical phase of recognizing that there's a gap that you personally have a gap in knowledge or in performance or understanding something that should be different than the way it is now that gap is what we say guides the opportunity for learning so recognizing that there's an opportunity of her improvement this is necessary to start the learning process and in part of that process is identifying the gap and what might give you the information to address that gap so let's look at that one a little bit more detail we think that in this larger planning process we've got four components questioning goes back to the the larger context of curiosity so asking lots of questions always having that mindset of curiosity of asking what go and I understand what can I learn in this process is pins into this aspect of learning and learning process searching for information in the environment just trying to find out what's what's happening what's going on and then setting goals for learning that you have a part that guides this whole process this change magnitude is one of the intriguing parts that part of what you do when you identify gap that you need to fill is to come to some determination of whether this is management is this a small enough goal small enough gap that I can accomplish or is it going to require any change in the whole system so your initial judgment about whether this is manageable becomes part of the space often not very explicit but I think it is psychologically something that enters into the decision-making process so talk a little bit more of details of this one recognition I think personally is the most challenging part of this whole process because so much what we do we do as routine you know patients come in we're seeing them for many of the same problems it's another person with diabetes and we just we've seen this over and over again so that it's not very often that we even recognize that there's a gap there there's something we can learn from this and usually that it comes when your routine expertise fails so the way you've always been doing things doesn't work anymore there's a patient who doesn't respond there's a problem that pops up others know where apparently in the learning process starts with those problems so it's when you recognize that something's not working they slow down stop the automatic unconscious part of your expertise and you realize that you maybe have the borders of what you're really competent at and if that's the case then there's an opportunity for learning sometimes this comes from other people sometimes it comes from your own practice but unless you identify a gap you don't do anything no gap whole learning so this part me is underappreciated because we don't really know how this happens because that moment a psychological moment when you recognize that there's a gap is a very brief period of time from when you're confident that you know everything that's going on and now do you recognize that there's something that isn't right when puppets have witness what happens mentally to identify that gap or whatever the conditions under which those emerge so this is an area that I think have a lot to learn about and it's a very difficult area but one that is absolutely critical to get this process started if a lot of the research on continuing adaptation for practitioners you can identify you can get individuals to identify in a given day half a dozen or more gaps things that they would like to know about but they don't understand laudamus you know literature based was what is the current research current information but there are always more things that we don't know as we could spend time out then there is time so the challenge is how do we prioritize how do you decide of all the things that I would like to know I would like to understand that I have a gap or deficient or a problem but I spent time and how those priorities is set so one of the incentives around this are you doing it for your own benefit does it have a direct impact on patient care is it going to excuse me will be easy to to address and I call up buddy then ask a question and get the answer and I've done or is this going to require an intensive investigation of the literature so among the gaps that you might identify you need to prioritize which ones they're going to be most effective and part of this comes the challenge of identifying and cat puppet bullet is that when we're dealing with our uncertainty we have this challenge of not knowing what that really means is our uncertainty is Howard out there are questions is this a reflection of me and my ignorance or is this a reflection of the feeling and the part of this early process of gap identification is trying to figure out where the gap is so we have the Johari Window here which is widely known as a way to think about how we share uncertainty and many of the things that we see we spend most of our time in this area where we know things and we know that others know and this is the shared understanding that we have as expert practitioners we've been we have areas of uncertainties this area here that not known to sell so if you identify gap the question is is this something that other people know about it's just my problem or this is also they have true unknown that other people don't know about as well obviously trying to address the gap in the upper corner is going to be easier because you got experts you've got resources you've got the answer out there as detracted to nobody no spotter now some of you will recognize this as being doubles around front Donald Rumsfeld's yeah we know there are some things that are known that everybody knows but it's for him it was the unknown unknown so things that nobody knows that are out there to catch us and these are the ones this is where we do research this is where to try to advance our knowledge so for an individual the question is which one is things that other people know or things that require research so it's the vendor before this this part this boom here in the diagram is really where things start all the where things run off the rails by the way because we don't take off to take advantage of the opportunities that are there for learning but let's assume that we identify again we have a deficiency that we I would like I need to know more about or I need to find a way to address this problem so we've identified a gap and now the challenge comes how do we learn about it what's the process of really addressing a gap so engaging and learning notice that it is not a necessary consequence of identifying the gap many gaps are never addressed because there's no learning attached to it and in the learning phase we really identify - there's the critical appraisal evidence-based medicine how do we find evidence in a systematic way to address the problem and then there variety of learning strategies that we can use to try to take advantage of the resources that might be out there people literature now literature various kinds all of which might be resources to fill our gaps so there are a lot of learning strategies and a lot of many schools have offices of learning support or various other names that are there to help learners get over some adverse learning strategies that they've acquired through college and in early years of medical school some of these are what we see students doing and maybe we do as well rereading highlighters you just highlight everything in the book becomes to be important and I've got highlighted it I've learned it masks practice cramming and a friend will learn everything I can and this one moment because I'm going to need it tomorrow for an exam these are all and we've got evidence to demonstrate that all of these are not ineffective completely but there other strategies so there are some inappropriate maladaptive learning strategies that students and us can fall into and trying to address these gaps what we're really looking for is learning as deeper and more lasting a couple of things that I can highlight for these I'll spend here that there are lots of this is a whole area of Education of developing effective learning strategies but part of what we have to factor into this is the assessment because assessments in a formal education are usually if they're used more as the dipstick to try to figure out is how much someone knows rather than a learning opportunity and good and effective assessment can be a very powerful tool for helping people learn partly because it identifies what they don't know and using that the guide there the subsequent learning but we tend not to use it effectively that and instead we use it to to do this quick measurement and then we all forget about it so one of the learning strategies that is has been demonstrated to be effective is spacing for learning over time I'm not sure what your curriculum is but we've had many iterations where his special moon was departmentally based we would teach everything about pediatrics in six weeks and then you can forget about a lot of students then they kind of empty their brain and prepared to get filled with something else so massing the practice of learning in a short period of time is less effective than spacing it out so it's a difference between the kind of rote memorization that tends to happen in the in the crunch eyes and just distributing it so this is one cluster to occur of what happens during typical situations where the learning takes place over a period of time number of events within this period period of time in the learning is fairly quick but the problem is that the forgetting is he was quicker yes I didn't know whether it was to raise pans or not but I absolutely yeah I have been discharged you're using the word learning I've literally guess it seems to me the more important concept is understanding the goodest attention yes it's so much better if you understand and we test only the memory of factual stuff back about acute memory which may you know wink not length items a and B but the winters may provide them the real are absolutely right and I and I stand corrected or clarified that really we should be talking about understanding and all of us learning is necessary not sufficient I think and I worry about and I think understanding gaps I worry today that we have less and this is the topic others have heard me comment about our electronic communications does it lend itself to identifying gaps as readily um--and I taught interchange yeah I think that as a learner we're working with the residents in clinic this becomes one sitting over there I learned my gaps a lot quicker and feel better and then don't understand that yeah and stays with me yeah and you're right I tend to drift into more of a fact-based presentation because we've got Hillary if you don't know something factual I mean that's an easy gap to identify of grief I don't know how this works I need to study up okay but it's not understand how it works if yeah so the understanding is much more complex because with understanding you may be able to infer just by understanding how everything else okay tears I don't understand how it was just working but I think I know why it should be or what it should be so I think you're absolutely right understanding is a richer and I think the model applies to the understanding as well but I think in many ways it's it's more complex much more nuanced less time I'm sorry I think the learn means is less exercise than what we do today yes yes I think we tend to use learning for a lot of factual we're not up stitute yeah yeah understanding no that's a very important point and I appreciate that that that clarification they were kind of fuzzy when we talk about learning people who develop this or thinking of everything it's like getting any kind of acquisition but a lot of it is for medical students is that kind of factual is it you and learning well you're much better doctor yeah yeah and if you understand it and not prime axis or so if you're understanding it a lot of this is this not the issue but you're not forgetting specifics mr. Pathak oh yeah good one very good thank you so in this case so the event is that if you mass all your learning into a specific period of time and never come back to it again is interior losing especially if it's factual information so the idea is that if you space the learning over a longer period of time the that makes the memory more resistant so learning things over and over again coming back to it is by itself a benefit just distributing the practice over a longer period of time part of it comes because of another learning strategy which we can talk about is intervening where we're not focused on one topic to the exclusion of everything else but we're interleaving intermingling other content and I am this is this looks like a lot of medical school curriculum where we take a discipline based curricula that had blocks and now we're dividing them up into interspersed weeks or different phases or modules or components that are trying to do more integration so on this integration idea as a curricular design fits into this aspect where we are learning to the way we've learned things this large the artificial reflection of the way that we've organized medical schools organized scientific knowledge this isn't reality reality comes and as an abbess everything is connected to everything so the idea that we are interleaving is kind of reflecting the way we we encounter reality we encounter problems that are drifting across these in these disciplinary boundaries so the argument here is that by learning you learning in this interconnected way you will see connections or understanding of how things are related across the spectral buckets in ways that will enable you to learn better and remember more and these two work together because if your interspace if you're intervening you're usually spreading out the time on a given given topic or a different outcome so these kinds of learning strategies can be used to structure formal education these actually have curricular implications but there are also important strategies for learners for all of us to recognize that there are better and worse ways for learning in connection to a gap that we might have identified so the learning process is what we spend a lot of time on as faculty because that is the part of the week we kind of define the gaps for the learner and we tell them what they need to learn we don't really talk as much about how your money learning I don't know maybe maybe you do that with with residents more or some of us as experience expected teachers will recognize that it's more about we need to talk to our learners about how they learn as well as what and this is trying to emphasize that so the third year in this cycle is what happens when after you've done the learning because learning is incomplete unless you apply it and this year is really the kind of the back tech feedback of putting it into practice and seeing if it works this one has two aspects to it both of related to feedback so you have the importance of external feedback that you get from the environment you get from other people and you have a self-assessment where you are going to be back watching yourself there are the important but the learning which may be factual may be understanding is really consolidated when you put it into practice and usually this is in the same context and would that generated the original question so we have a patient with diabetes not responding to treatment you identify this is something I need to look into you do that solve the code enter monologist or whatever the case may be then you go back to try to address the same problem same patient see if they respond differently now so this check on the knowledge on the learning is whether it has been successful or not takes place in this space because self-assessment is part of this process or to identify that this is a very quality that we rely on self-assessment sometimes almost exclusively because when we're at practice we don't get feedback in the form of tests we don't get feedback in the determine in terms of somewhat like Atul Gawande who had a colleague watch him do surgery and give him feedback on what he did most of the time we're just saying that's in people pretty well where I had a problem their patient was not very cooperative so we tell our own stories to ourselves these stories are often not very accurate a lot of evidence out there that we have we have a link with on problem how many are our lawyers drivers here so we could all be below average the challenges when we're assessing ourselves we had what was our standard Perkins I'm sorry I thought ourselves going out in the juice way like this you know there's a how I feel about myself and the problem is that that's focusing on this dimension here am i conscious of what I can do or what I can't do or am i unconscious and I think you probably seen this before that we have this disciple where we start off incompetent but we don't know where it but we know we figure I want to be a doctor I know I don't know anything about being a doctor I need to go to a medical school so I make a decision to start addressing my incompetence and what happens is that the first phase of learning fills in a lot of these gaps but when were very conscious of it and often it retains all of our consciousness to to fill these after learning we move from incompetent to competent and that's where many learned a medical students and a lot of residents are they're very conscious of what they go and then they have to think about it and then applying it but then we get to the unconsciously competent which includes most of the people in this room where you over learning this you know what works you've done this before you don't need to think about the challenge with the self-assessment is that we become unconsciously competent you are not thinking very explicitly about what you don't because it's obvious and we've read risk of becoming overtime changes in the healthcare system of treatment of modalities lots of reasons over time we move from being competent and confident but we're still unconsciously because it's always worked this way before so this is just a way to highlight the fact that your self-assessment your confidence that things are fine is probably a bad sign it's probably might well be an indicator that you're up in this area they need to start identifying some divisions once we adopted him our television you're like this something foolish yeah I think that gets you're raising the issue I'm focusing this on saw has a psychology this is the individual that's what I'm really focusing on here is how the individual learner you're bringing up the fact that this environment which will still get to really put some challenges in because you're addressing the fact that most of the time our practice is not as an individual we're practicing within the system and we developed this competence that hub which were unconscious now in one domain one system one airhead and now we try to transfer it into a different life so you've hired somebody into a system and change the environment in which they were previously competent now you're putting them in a different situation and they're not as confident for the problems they may not be aware of that I'm sorry is that that's a fact of life it's a fact of life then I think the argument here is that when those changes happen that's when your gap detector needs to be activated that you need to go into it say okay I'm being hired to now do this here what's different and these differences aren't things to paper over but these may be things that I need to adapt it's not particularly so big changes like that are all been easier to deal with because we recognize that I've had on a puddle of water park I don't know how this place works I mean I got a lot of things I need to learn it's when the changes are incremental and you can tend to drift from that compounds in understand and its ongoing gap range that's ongoing yes we don't have gap recognition all the time we're in trouble right but then it goes back to the slide about priorities because there are infinite number of gaps of people really small really big so you have decided which ones matter and but you're absolutely right that without the gap you just this is very comfortable this is the routine this is what we would really strive for and then the lot of systems too if you can if you can weed out all the errors like a Six Sigma get down to a refined process that will work the same way every time is great until the environment changes that doesn't work as you do the choice of the categories that confident versus him content implies aesthetics yes okay and if the categories were not improving in approving then you cut a continuous loop going on more readily than in mind because people's self-esteem ties into the unconfident and so there's this huge resistance to recognize them in some areas no I'm not confident you're absolutely right yeah yeah yeah that's why there is a deficiency of that oh so yeah we could we can provide external assessments about other people's confidence without much difficulty what the literature indicates is that we can still use self-assessment as long as it's tied to some external feedback so some mechanism by which you can check yourself against some extra standard a colleague Hospital metrics you how becomes data anything that we can find that and help us refocus and recalibrate our self-assessment is really really important so yeah if you can get someone who will accept your judgment about their then becomes coaching and that's great there's wide again lots of evidence that coaching is really hard especially for people who are out in formal educational setting so getting that external information that feedback is critical but it's also very expensive medical schools to provide this on a routine basis but students paying a lot of tuition for that privilege so we need to find ways to change our environment to support that so coming around to this last part of the cycle where we've identified the gap we try to fill the gap we've checked the gap by by putting it into practice then they have to decide whether this learning is our understanding let's put it that way but this understanding is sufficient to change my practice so right up until now it's been kind of it's always kind of cognitive thing but now you're going to change your habits so you're going from this you know the routine are from the adaptive part into a routine and in this one this year we have two aspects one is deciding whether this requires a change in my behavior because it's a routine part of my day I do this all the time so it's really important than to actually translate the needs mood changes in my behavior or endured this is a change for me or change for the system because those are clearly different scales of trying to change but unless this phase happens there's no lasting change in behavior you may have read about something but that's kind of intriguing you know I remember reading something about a flipped classroom but if you've never done it you don't do a routine basis you don't have any understandings so this is really the adoption of innovation and those of you who are familiar with with that framework know that this adoption takes place in stages so the first time you learn about something and try to put it into practice you're still early in those those phases of going from knowledge to knowing that it exists to persuasion knowing that is our having the motivation make convinced that this is a good thing to a decision to actually do it putting it into practice and then the confirmation that it works and this is worth pursuing it's been done demonstrated over and over again but Rogers mean the name most commonly associated with this but is based on data that goes well back into the 30s when they were looking at farmers adopting new hybrids of corn and they would identify the fact that this was a fairly common curve and you have in the introduction not many people re are planting is high rate and that stays pretty flat but what almost you know six years before people really started to adopt it and then you have a fairly steep [Music] rate of adoption for several years and then it levels off and we you've heard about the early adopters who will try anything new maybe because it's new but these are the ones that will be at this this part of the curve then you have the lathe adopters once it will not change unless there's no alternative and you have probably a good chunk of people who will only adopt it when they see other people doing it but this is can also be translated into your own personal by hand so at what point are you willing to be to take a risk and try this out because it's new to me or with the idea of this being part of a larger understanding larger context maybe it is something that you'll about more rattling mathematics research and phase 2 and phase 3 studies face for studies and then as you learn because it's not just adopting for us as positions because it affects yes in the drug-free Kent Brantly right so the I had to curb it'll be similar to doubt but I'm just thinking oh yeah apply to it right so this is the research and a weapon for moines public evidence do you eat before you adopt it where the FDA approves right right so all of those authoritative all those authorities have said this is a good thing my colleagues are going the hospitalist language equal kindness and then of course you'll always have people who it's more they have the review agent base where they should have been doing this 15 years ago they're out the top they're all right and prey so this this adaptive this implementation can be supported by the environment in various ways that a supportive environment that really highlights the value of adaptation the risk of trying something new that might not work or that might have its own consequences tolerant bears are just good environments and then going back against what we've said about feedback and providing data on whether your adoption of this this new learning is really working so you're not relying on just my gut feeling that this is I feel good about it but it actually is producing the results that we want that again is part of the environment that we can is to support that so you go through that you adopt it and of course then there's a new gap so you continue to cycle sometimes it's a continuous process especially in the process of understanding than just back to learning you both deeper and deeper into nuances and if it's an area you are particularly interested in or part of your work that gap identification and remediation and application just continues repeatedly over and over again to wrap up we wanted a couple of comments about the environment who talked movement about how an effective environment can support us but it can also injury flirting environments another hot topic why the concern about it with LCD visits with clear visits for residency programs what does the environment doing as a place where learning in practice is it creating express contributing to burn out suicide identified area of abuse so how this relates to the master day learning process is something that has not been examined to any great detail but there are some things that you might expect you later one is that if you encourage people to follow this adaptive learning cycle you are in a sense inoculating them from some of the impact of the environment because you are enabling them strengthening them giving them those tools to learn in spite of the environment because they are defining internally in an adaptive way their deficiencies how they respond to it so how my students are who only listen to what happens in class everything else is irrelevant you are recognising through this process that learning is something that happens all the time I can influence it I can control it I can contribute to it I can use the environment effectively to try to address these Niemann if it's not set up to be an ideal environment but obviously what we hope is that we set up environments that are supportive environments that encourage recognition of uncertainty then encourage questioning that make learning easy provided resources to go through this process get a feedback all the things that we talked about can be facilitated environment so this context is another part of the larger model that we need you spend big more attention to it we're working on as part of them screwed to develop it so right that time I have time for a couple of questions if you want signaling something sorry thank you very much several questions I think I'm gonna step on one the minds yeah probably know from other ways that other ways to diagnose people's fix versus growth mines thinking about not only through the admissions prosecutor but maybe later because it seems to me that's a really neat party yes there are methods for trying to distinguish these this is Michael Emma because I started off like this personality psychologists where you individual differences for everything you would want to classify people introverts and extroverts sick mindset growth mindset and when I was in getting my PhD they decided that it was no such thing and I had to find a different to study because our behavior we like to talk about as if doing you're an extrovert or an introvert for granted your behaviors determined as much by the environment situation the people you're working with lots of things besides whatever which will keep the characteristic in my head so long story short story is that you can identify these things vibratory settings and they may eat sees that people have how they actually translate into your behavior is something I'm not gonna make strong claims but I think it's a you know it's a battery it's heavily contributed to the energy in the whole system but I'm not sure it's guiding the people of the specific Gators so I'd be very very about identifying the students as being a fixed mindset zoo because and the environment played such a role environments there yeah I think that's one of the things well yes yes I got that I so three times when you get to learning something heavy reinforcements college critical part and yeah I think that most men misunderstand even where lots of actual shop by listening to a recorded lecture understand you have to you have to bounce off other people Hyundai channel you put the team back them up well I'm not sure Blanchard was very good at that and I'm not sure a lecture was a very good format promoting that begin you everybody showed up but they were all focused on you know you know a personal experience between a win away from the luxuries sort of win over things with other people happens the contents yeah you're not gonna be that fun well what we find and I suspect your students do too that they have these kind of subversive selves well students they get together and that you get because they recognize there's mark students they know that study together this is effective it is help but these we've kind of gone to a model where that was kind of an actual thing to happen because we're all leaving this room at the same time let's go get a cup of coffee we can talk about the support they have to do it more intentionally so I think we can have environments that are more or less supportive that yeah we're dealing with all of the same problems we're finally getting faculty to recognize that maybe we need wide lectures to 12 students to the waste of their time because it's the same lecture limited latitude right so there there's war with tendency to just adopt the fact that everybody's going to be doing this and start off on their own time whatever schedules and try to supplement that by having no discussion sections instead of finding the more thoroughly I there's no quality so the environment certainly promotes that I'm really very these these generation all the differences and kids nowadays because Socrates was saying so every environment and dispirited when things continue to change when you put that to it so I'm not sure that to say the students are more isolated there's probably different opportunities for them to interact and the lecturer just want to look anymore but they can be we're building I'm not sure about facility but we're talking about a new education power that's going to be all about small green room so we're recognizing and trying to promote in the environment the opportunities for students to get together and whereas that was at the International Conference on residency education and there was I wouldn't understand it myself but all this talk about social media and whatsapp that we have for the students to mess feather and that this was taking place all the time that they were talking about cases never seen each other but was always virtual communication that's you mentioned that I mean aren't the students self-select entire at ten percent or thirty unoffending come to lecture actually one that I guess yes and I don't agree this it's a waste of a faculty members time to be there I've gotten over the fact that only ten or twenty percent in there well as those who come are interacting I think we need to change an expectation that okay I'm doing they we shouldn't even call the lecturer we need to pour something like this but it's going to take place here and maybe they don't have it in this big empty electrical so I think that part of what the wrestle with is that fact you still have the expectation I'm going to have a hundred seventy students hanging out of my every word where they never best ever sleep pay attention to the grocery shopping never read what I want to do on an iPad we're here to prevent this report right we think that the interaction that's a really important why it's great we discussed last month too is it's not about the lecture or the strategy it's how we implement the strategy so being interactive doing things you're your audience I think it's really important or I think the dr. govern has talked a lot about environment so the way in which we create the environment that the face versus the growth mindset is something I mean at least superficially we can see that my daughter says no I'm I'm horrible math so you're just gonna have to accept that grade no you're not there yet so it's working I it's maybe putting a little bit more energy into that and I know that we see that a lot with our medical students what I see with you all from my perspective is that you all are outstanding at least in teaching an extra adaptive murmurs you are identifying the gaps they don't know all there is to know about teaching so and I know that all of you in this room are already really great features so you've identified a gap you are coming here to fulfill the gap you're identified now we need to go and try to practice and try to implement those things email goes and then if it doesn't works which something else' that's why what we try to provide through teach and I hope that it helps in a lot of ways I hope to see you all that at five o'clock over at the simulation center and please encourage the colleagues to come with me so thank you doctor [Applause]