Motivation to learn

'The two main functions of a teaching organisation should be first to enable students to learn how to learn and secondly to motivate them to want to do so.' -Russell Ackoff

When we prepare to teach, we spend a lot of time on the content, but perhaps not enough thinking about how to make it stick. Russ's insights from bringing reading skills to illiterate students from a socially deprived neighbourhood have an important lesson for us all.

In the 1960's Mantua was one of the most violent neighbourhoods in Philadelphia. A poor community of 22,000 people, gangs ran the streets and education into adulthood was rare. Most children left school with no ability to read or write. Russell Ackoff and his Operations Research group at the University of Pennsylvania were approached by a group of community leaders after educationalists had failed to tackle the problem of illiteracy.

Three community members were employed by the University to research the problem and develop solutions. The academics didn't have the answers, only the community could solve community problems - helped by the resources and skills of the university.

Children didn't read because reading wasn't done at home, their family didn't read and their friends didn't do it. More than half of the households in Mantua didn't contain a book and the street culture was verbal, not written. At age 12 it was compulsory to join a gang for survival. If you were caught carrying a book, you were beaten up, as doing so was seen as a capitulation to a dominating white culture. The children may have been illiterate, but they were smart and they didn't read because they didn't want to.

The research team bought a set of Charlie Caplin films. These played in the auditoriums of the schools in the neighbourhood all day, every day. Any child was allowed to come and watch them at any time, without needing permission from teachers. And by the end of that semester, every child in the school could read.

How did they achieve this? The children wanted to read the subtitles. They couldn't understand what was going on and they wanted to, so they learned. They were motived.

Mantua has since received 17 national awards for self-development efforts, it was the subject of 7 major television documentaries and multiple leadership awards.

What motivates the people you’re trying to inspire?

Core skills for success in work and life

I believe there are three core skills and attributes that we need to work on for life success. It doesn’t matter whether you’re a working professional, year 11 student or in primary school. These attributes have always been important, but the complexities of modern life mean they are more critical than ever.

Our world is described as volatile, uncertain, complex and ambiguous. The term VUCA was first used in The US Army War College in the late 1990s, but really became cemented into leadership literature after the terrorist attacks in the US on September 11, 2001. If nothing else, the coronavirus pandemic has shown us how quickly things can change. The ability to respond to the challenges of VUCA is central to work and life success for all of us. So, what does this look like?

My teaching at undergraduate and postgraduate level focuses on 3 core attributes in students:

1. Agency

2. Mental flexibility

3. Meta-learning

Of course, I have subject-specific content to embed, but these are the most important skills to nurture in the process.

Agency

Agency is simply the ability of an individual to make their own choices and act accordingly. Having agency means having a sense of self, particular values and cultural identity, and being able to pursue self-determined goals through strategic action. A sense of agency tells you that you can make a difference in the world and that it’s your responsibility to do so. It supports independent thinking and encourages people to seek innovative solutions to problems they encounter.

Through agency, people devise ways of adapting flexibly to remarkably diverse geographic, climatic and social environments; they figure out ways to circumvent physical and environmental constraints, redesign and construct environments to their liking… By these inventive means, people improve their odds in the fitness survival game.

- Albert Bandura

Mental flexibility

Our perception of the world isn’t how it really is. It’s an interpretation based upon our previous experience, developmental history, culture and evolution. This is why we all experience the world differently, even if we are in the same room or even the same conversation. Our brain develops these mental models of how the world works because of the need for efficiency. There are far too many inputs from all our senses, much redundant information, and any alternative would quickly lead to cognitive overload. The resultant mental moment that we experience is based upon perceived relevance. Our brain is always trying to make unpredictable circumstances predictable.

When I was training to be an obstetrician, I came across women who declined medical input into high-risk pregnancies, who chose to home birth or free birth (with no trained attendant) despite the obvious risk to the life of themselves or their baby. These experiences were incompatible with how I understood the world. But of course my understanding was based upon the experience of an educated male who had been through the standard course of medical training. My mental models were limited. I took the opportunity to read texts about home birth and to hear why women choose this option. I read the online discussion forums and came to understand a new perspective. This didn’t always change my advice when I reencountered similar situations, but it gave me an understanding of motivations, the ability to empathise and a language to help me engage more genuinely in shared decision-making options.

Mental flexibility in response to VUCA

In a VUCA environment, prior mental models and predictions are a poor guide for the future. A healthy response would be to adjust the weighting of our previous assumptions, guided by feedback from the environment. This feedback is acquired through usual methods but in particular active listening and curiosity. We would then act and update our mental models accordingly.

An individual’s response to uncertainty is determined by several factors, such as prior experiences, our state of mind - e.g. stress, boredom, fatigue - and environmental context, for example, if we feel under threat. Also, people who are less anxious about change, unpredictability, and conflicting mental models will naturally perform better in changing environments.

Uncertain environments lead to arousal, and the biological response of arousal frees up cognitive resources in preparation for the adaptive change outlined above. If this doesn’t occur, long term arousal is harmful and leads to reduced performance as well as diseases such as high blood pressure, depression and suppression of our immune system. The stress many have experienced in response to the challenge of COVID-19 is testament to this.

Cognitive biases

If an individual is unable or unwilling to respond adaptively to uncertainty, they often succumb to cognitive biases and ‘sculpt and select’ sensory inputs to be more consistent with established mental models and predictions. Without self-awareness and mental flexibility, outdated models can lead to poor decision-making that is out of touch with the current world. Sometimes people respond to uncertainty with rigid frameworks to maintain a sense of control and decrease their own anxiety. Trying to avoid uncertainty isn’t a good long-term strategy in the modern world.

Humans, however, can be very adaptive to change, with high intrinsic motivation to deal with uncertainty and to learn the skills to manage unpredictable situations. These are the skills we need to teach and nurture in our students. Adapting mental flexibility is challenging, but it isn’t impossible.

Meta-learning

Unfortunately, learned skills have a limited short-life in a changing environment, so the ability and drive to learn continuously is the only solution for success. Meta-learning is defined as ‘...being aware and taking control of one’s own learning’ (Biggs J, 1985). This includes the principles and strategies that make learning more efficient, including retrieval practise, spacing, interleaving, feedback, elaboration and testing. Self-regulated learning leads to a valuable sense of agency and improvements in academic outcomes and life success.

Learning and self-efficacy

From an educational perspective, it’s essential to recognise that agency is enhanced when learners appreciate that shortfalls in achievement are primarily due to things they can do something about, rather than an underlying lack of capacity to learn. Humans cannot avoid difficulties such as failure, criticism and inequity, nor can we avoid the usual emotions that go with them: disappointment, anxiety and fear. Those who have previously experienced the ability to rise above setbacks will be more able to see themselves doing so once again. Enabling students to experience success will contribute positively to meta-cognitive skills and personal sense of agency.

Summary

It is very unlikely that the VUCA norm of the modern world is going to change anytime soon. The attributes of enhanced agency, mental flexibility and having the knowledge and motivation to continually learn will provide a foundation for lifelong success whatever career or path is chosen.

Recommended resources

Systems Thinking - Russell Ackoff
This presentation from 2015 remains a fascinating critique of modern-day educational approach and discusses the importance of motivation, agency and meta-learning.

‘Your future depends upon your capacity to learn and your motivation to do so’

‘ Teaching is an obstruction to learning’

‘In school we kill creativity. Examinations encourage students to think about what examiners expect. To provide known answers. This systematically kills creativity.’
Link to video

Encouraging agency in others
The influence of teaching: beyond standardised test scores: Engagement, Mindsets and Agency. A summary of the practical steps to help students develop agency is listed from page 10.

10 Steps to Agency - summary

The summary table is linked above. What works for kids works for adult learners too.
Full document here (PDF).

Meta-learning
The Learning Scientists blog has a huge range of resources, based around their six evidence-based strategies for the most effective ways to learn.
Link: Six strategies
Link: Frequently asked questions

Mental flexibility
James Clear authored a series of articles about decision-making and mental models.
Link to website

Shane Parrish’s Farnam Street
Link to website

References

Frost D. The concept of ‘Agency’ in Leadership for Learning. Leading & Managing. 2006; 12: 19-28
Biggs J. The role of meta-learning in study processes. Br J Educational Psychology, 1985; 55: 185–212.
OECD: Future of Education and Skills 2030: Curriculum Analysis. Preparing humanity for change and AI: Learning to learn as a safeguard against VUCA. 2018

Know your CoronaZone!

You're being told to wash your hands regularly, but exactly when and how often? Here's a guide for health professionals that works for everyone. We live our lives in 3 zones and when you know these, the actions to take while you're there and when you move between them, it's easy.

Red (Risky) zone:
The dangerous one. Wash your hands regularly, don't touch your face and wash hands immediately before eating or drinking in public areas. In supermarkets, use the provided trolley wipes and hand sanitiser, etc. Health professionals will practice the usual 5 moments of hand hygiene when directly caring for patients. If you're in the clinic, put on non-sterile gloves and take 5 minutes to wipe your environment with alcohol wipes before you start: tables, telephone, chair handles, exam couch, blood pressure cuffs, stethoscope and door handles. You might consider wearing nitrile disposable gloves in very risky environmental situations, e.g. on a plane or public transport if the community infection rate is very high.

Orange (OK) zone:
These are areas that few other people use or places you transition to green zones, e.g. your car. Keep hand sanitiser and antibacterial wipes in your car and sanitise hands when you come from a red zone. Hand hygiene isn't needed when you move from orange to red, but remember when you fill-up the car, you're back in the red zone again! Consider how often you need to wipe down regular orange zone touchpoints such as steering wheels, door handles, personal keyboards & your office phone. It may be daily or every other day. If you eat in an orange zone, still wash your hands first.

Green (Good) zone:
This is your home. Keep handwash near the entrance and wash your hands as soon as you arrive. Take care when you handle items that you bring from other zones. Still wash your hands before meals.

Special items:
Your mobile phone is probably your most dangerous item for infection transmission. You will touch it regularly throughout all 3 zones and put it next to your mouth. Wipe it down with an antibacterial wipe when you enter your green zone and you should be using hands-free in the car.

Your office swipe card will be handled throughout the day and you might need it in the car, so wipe it down at the end of the day and leave it there. Make an effort to keep pens out of your mouth and ladies need to think about where handbags go at home, and what's taken in and out. It goes without saying to avoid placing it on the floor in public restrooms - Coronavirus can be passed via the faecal-oral route and flushing toilets disperse a mist of infection.

If you teach your family and kids about the CoronaZones and establish good habits, you'll keep everyone safe. Together, we can beat this!

Click to download this information as a one-page PDF.

The relentless pursuit of Patient Safety

When I saw this today, the concept of 'relentless' safety resonated. Patient safety isn't just about the exhaustive investigation of the rare, but significant, 1% of adverse events. Patient safety is an approach to leadership, culture and staff support that is 'always on'. It's about the 99% of the times that we get it right, understanding why and creating an environment that's safe for both patients and our teams.

Patient safety is supporting staff to:

➡ Monitor for risk and variations
➡ Anticipate when things might go wrong
➡ Respond at the right time
➡ and Learn, constantly.

Safe environments for patients are ones where:

1. Leaders seek to understand the work of on-the-floor staff, as it is done, not as it's imagined.

2. Myths are dispelled and everyday adjustments to practice are recognised as a positive event.

3. The culture of blame is tackled, rudeness and incivility are not tolerated, and fear and shame are addressed.

4. Leaders prioritise psychological safety within their teams, so people are comfortable questioning, responding and discussing variations and errors, as they occur.

5. Teams feel cared for and kindness flows down from the top.

Easier said than done perhaps, but starting from number 5 and working up is a good place to begin. And we all have our part to play in that.

Learning at work

“The physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.”

― P. Kalanithi, When Breath Becomes Air.

Paul Kalanithi was a gifted neurosurgical trainee and his memoir describes his own journey after a being diagnosed with metastatic lung cancer. During his career, he learnt that there is much more to being a brilliant doctor than merely knowing all the facts. But what exactly did he mean by this?

We experience two types of learning: firstly, incremental learning – we study a ton of new facts, medical knowledge, technical skills and learn how to get sh✯t done as a Doctor in Training. Through incremental learning, individuals align habits with established norms, conform to ideals laid out by experts and reinforce existing power structures. Incremental learning involves the process of deliberate practice.

Mezirow introduced the concept of transformative learning. This is a deeper, developmental shift, where situations and dilemmas challenge our underlying assumptions and beliefs about the world. We grow through reflective engagement with our experiences as a clinician, the people we meet - particularly our patients - and by testing new mental models of how the world works. Transformative learning changes perspectives and relationships, laying the foundation for personal growth and innovation. It requires curiosity, attention, and courage.

Incremental learning is well known to us, but what practical steps can we take to encourage and inspire transformative learning for Doctors in Training? Here are a few examples:

1. An indigenous patient self-discharges from hospital against medical advice. The supervising consultant asks their Senior House Officer to spend time with the ward social worker and Indigenous Liaison Officer to understand more about this patient’s situation. They work with the patient to find a compromise to ensure ongoing care is provided within the individual’s context of holistic health.

2. A specialist has a relationship with a national patient organisation and involves their training registrar in the activities. During the year, the registrar orientates a patient advocate into a hospital working group, authors an article for patients about how to navigate the health care system and helps review information available online.

3. A team-building exercise is planned between midwives and obstetric registrars. They debate ‘Caesarean section on demand should be freely available in public hospitals.’ The midwives must present the affirmative argument and the obstetricians the negative.

Transformative learning more commonly comes from everyday activities too, but the key is to recognise the opportunity as it presents, to slow down and make space for it. Steps of transformative growth include 4 stages:

1. Note the experience. How did it make you feel? What happened when you reacted differently, or your prior beliefs were challenged?

2. Voice what happened. Discuss with others and see what their response is. What patterns do you notice? Reserve judgment and just describe it, keeping your mind curious.

3. Interpret the experience. Why did it go the way it did? Avoid usual thinking, e.g. ‘because we’ve always done it that way’ or traditional relationships and structures. What novel interpretations could explain it? What are the implications for future situations: both similar and dissimilar? What did you learn?

4. Own it. How does the experience fit with your own personal prior beliefs? Now bring the past and the future into the conversation. What does it mean for the relationships involved and the team culture? How can you build confidence in new ways?

From: Learning for a living. G Petriglieri. MIT Sloan Management Review. 2019

As supervisors, it’s up to us to create the conditions for transformative learning. We must role model the reflective process, examine our own perspectives and consider where we might challenge our assumptions and beliefs. We need to encourage autonomous thinking, allow time for this reflection to take place as part of every day, on-the-job teaching.

Gradually, as we make room for deliberate practice and reflective engagement, our teams will master both ways of working and learning and see the benefits it brings for our relationships, workplace culture, and patient care.

Trauma-informed care

Exposure to traumatic events is ubiquitous, even in high-income populations. Trauma-informed care is a form of 'universal precautions' health providers can use to mitigate further harm and help with healing.

Adverse childhood experiences (ACE) and intergenerational trauma are linked with chronic pain, obesity, cancer, substance abuse and mental illness. But training for health providers on ACEs and harm prevention is less common. Trauma-informed care is for everyone.

Trauma-informed care needs an environment of calm, safety and compassion. Care is respectful, cultivates trust, resilience-building and a sense of control. Gerber describes the 4Cs of the practical approach of TIC: Calm, Contain, Care and Cope.

1. Calm
   Be self-aware, breathe deeply to calm yourself. Reduce chaos where possible and promote a calm, patient attitude to yourself and others. Cultivate an understanding of trauma and how resilience, justice, and equity lead to peaceful, calm communities.

2. Contain.
When enquiring, limit trauma detail & give support without requiring disclosure of trauma. Earn trust by behaving reliably and monitoring emotional/physical responses to education and enquiry about trauma. Work closely with others to minimise risk of trigger or re-trauma.

3. Care
Share messages of support when trauma is disclosed, normalise and destigmatise trauma symptoms and harmful coping behaviours. Practice cultural humility, minimise power differentials and promote self-care, compassion and equity for all.

4. Cope
Emphasise positive relationships and interventions that build resilience, document a 'coping strategies' list as well as a 'problem list'. Increase social support, identify and treat mental health, substance use and other sequelae of trauma.

Trauma-informed practice is a journey of learning for all clinicians - about how trauma affects our patients, and a strengths-based approach to provide the support they need. We can make a difference. More full-text resources here: http://bit.ly/tic-resources

Trauma-Informed Healthcare Approaches. Gerber M. 2019. Link | Review

Originally published by Danny Tucker on LinkedIn and as a Twitter 'Tweetorial’ (link).

Powerful presentations

I read a book last week that included some great advice about how to give powerful professional presentations. We can all remember back to school or university and examples where the presentations we had to endure were just shocking. The monotone voice, ugly, text-heavy slides in tiny font that left us day-dreaming about being anywhere but there. We need to do better than this.

Research from the field of educational neuroscience gives us clear, unequivocal advice on how to give a presentation that engages your audience and imparts knowledge in a way that truly sticks and impacts others. And isn’t that what we want, both presenter and audience?

Jared Cooney Horvath is a neuroscientist at the University of Melbourne and his latest book ‘Stop talking, start influencing’ contains 12 insights that are backed by a solid evidence base. I’m going to summarise five of his recommendations here, because they are so important when speaking in front of others – something that comes naturally to very few of us.

Insight #1 Speaking and reading: never both
JC starts his story by demonstrating that humans cannot understand more than one person speaking at a time. We can listen and flip between 2 voices, absolutely. But the part of the brain that processes oral speech – the Broca/Wernicke network – can only deal with one stream at a time. The left inferior frontal gyrus actively blocks one voice, while the other is allowed to pass through. The most common voice we hear is the sound of our own silent reading voice and in fact, the brain processes this in a manner almost identical to the way it processes an out-loud speaking voice.

The implication of this is that it’s impossible to understand something you are reading, while simultaneously trying to understand a voice you are listening to. Read that sentence again because it’s key.

When a lecturer uses text heavy slides, your brain is madly trying to both listen to the speaker’s voice as well as the internal voice reading the text on the screen. If you selected one of the two, you could understand just fine. But we generally try to take everything in. We fool ourselves into believing we can do it – but we really can’t. And that’s why you come out of those lectures more confused than when you went in.

Implication: No (or minimal) text on slides.

As a presenter, it’s tempting to use PowerPoint slides as a crutch, in case you forget what to say. But this is the number one cause of brain-numbing presentations.

Let’s wind this back even further - what is the role of presentations anyway? Are you trying to impart a large volume of knowledge in a long 30- or 40-minute talk-fest? If we need our audience to take in that much detail about a topic, we would be much better providing a relevant paper, guideline or review article for them to read in their own time. The benefit of being physically in front of a room of people is to be able to influence thinking, clarify difficult to understand concepts or to inspire action. When charged with giving a presentation, try to reframe your plan in these terms, because the unique opportunity of face-to-face speaking is wasted on attempts to transfer volumes of factual knowledge.

Coming back to our slides – are just a few words OK? It seems that up to 7 keywords on a slide don’t require the brain to enter vocalisation mode and the meaning is accessed directly.

Insight #2 Use (predominantly) images on slides
Not only can visual images and oral speech be processed simultaneously, but the combination is proven to help with understanding and learning. Memory can increase by up to 20% when images and speech are combined. The use of images has been shown to enhance audience engagement, receptivity, and judgments of likeability. One image per slide is optimal – more is not better.

Graphs and tables don’t count as images, because our brains can’t immediately comprehend them. If you need to include graphs or tables, lead your audience through the information. Building up the image piecemeal is one way to do this – e.g. showing the axes first to explain their meaning, and then overlaying the data in turn. This ensures the audience is following your speech and not wasting precious cognitive resources trying to decrypt a complicated figure (and ignoring you).

Be aware of the type of image you are using and the effect it might have on your audience. Cute, amusing or shocking images will enhance engagement but not lead to learning. Relevant images that support verbal content has been shown to help audiences build deeper connections and ultimately increase learning, but to potentially decrease engagement. Remember this when selecting images: you might start with less relevant images to ensure your audience is on board and keen to learn and later in the presentation relevant images will enhance their learning.

Finally, use (predominantly) images on handouts. If you include large amounts of text, audiences will need to choose between listening and reading. Extra articles, reviews or guidelines should be given after the presentation.

Insight #3 Slide design: Consistency is key
Slides need to have a consistent design, with keywords and images in the same location and size across the presentation. This allows prediction to take place, which reduces cognitive load, so they can concentrate on understanding your material. Spatially consistent formatting increases memory by up to 35%.

If spatial layout fails to match prediction, it causes the audience to abruptly pay attention to what’s on the screen. This can be useful to force attention, but can only be used once the layout has been learned and prediction formed.

Signaling is another technique that is underutilised. Simply use a laser pointer or arrows on a slide to point out relevant material in graphs or tables being discussed.

Contextual cueing should be applied to handouts and other printed material – comprehension is enhanced by consistency of design.

Insight #4: Don’t invite multitasking

‘Anyone who can drive safely while kissing is simply not giving the kiss the attention it deserves’ –Anon

Human beings cannot multitask – what we do is, in fact, task-switching and it has 3 major negative consequences: time, accuracy and memory. The irony is that the people who believe they are good multitaskers perform worse during task-switching than people who rarely multitask. To make matters worse, frequent multitasking strengthens people’s confidence in their ability to task-switch!

If you have control over your audience’s use of computers or mobile technology during a presentation, encouraging them to cease using it will improve their memory retention. There is even evidence that students sitting next to computer users during a lecture have reduced concentration and recall.

Every time we mention a web address, distribute a practice problem or display a complex graph, we invite task-switching which can impair comprehension, memory and performance. Each learning task we present to our audience needs to have a clear focus, stepwise trajectory and devoted time for engagement and completion.

Make sure that you, your slides and your handouts deliver one message at a time. If there is any loss of clarity, use signaling to guide attention and curb multitasking. Examples of this are reducing transparency on unimportant areas of your slide, cropping, using arrows, boxes or pointers to guide listeners to the exact point you are trying to get across.

Humans hate (or rather love) unsolved puzzles. Our brains are prediction machines and they see incomplete problems as failed predictions that need to be solved. During presentations, if we accidentally leave concepts or ideas half finished, people will feel compelled to complete them while trying to listen to you – multitasking in action!

Insight #5 Open with a story
Finally, compelling and relevant stories can be a powerful way to prime an audience and guide how people interpret and remember new ideas. Stories put your audience at ease and make them willing to learn from you. They boost engagement and desire to learn and improve understanding when followed up with solid teaching. Stories create a bond between storyteller and audience. When you tell your story well, the audience will feel how you feel.

There are a range of types of stories that can work in medicine, but our daily lives are full of them. You might choose the origin of the issue at hand, where it came from in history. Controversies make good stories. Application of facts in real-life scenarios are powerful and can drive creative problem-solving. Personal stories from your own experience will serve to build connection. Cliff-hangers work with every type of story; we all love a good mystery.

Hopefully some of these ideas have resonated with you and you can begin to use the techniques in your own teaching sessions. Once you understand the neuroscience of learning, it will become truly surprising to you how often poor presentations are done. The extra effort in planning is worth it. You’ll never be able to go back – and your audience will thank you.

The failure of Medical Education?

Are medical schools and specialty training programs adequately preparing doctors for the complexity of modern medical practice? The Health LEADS Framework is shown here. This is a framework for professional development in healthcare that has been widely adopted in both Canada and Australia. A template for the types of professional skills we need in healthcare. Domains include Leads self, Engages others, Achieves outcomes, Drives innovation, Shapes systems.

When we map assessment criteria for medical graduates at intern, RMO and registrar training level, approximately 60% of these relate to the ‘Leads self’ and ‘Engages others’ domains. Almost 50% do in senior doctor performance reviews.

If we value professionals who have skills such as self-awareness, articulate communication, and graded assertiveness, who are strong collaborators, adaptable and empathic - how are we actually training for these qualities? Are medical schools doing a good job? Do the curricula of structured specialty training programs reflect this? On the job training? Or do we largely stick to medical knowledge and procedural skills?

From my own experience as a clinical leader looking to appoint a new specialist, I don’t care if you’ve done 100 or 1000 hysterectomies. Of course, your Fellowship and safe practice are expected. But I want to know that you’ll get on well with your colleagues, support the doctors in training, be self-aware, engage harmoniously with the wider clinical team and be compassionate with your patients. The rest you can learn - these core skills are critical to a successful department and safe clinical care.

I just sense there’s a gap between what medicine trains for, and what it expects from its doctors.