By James Leonard, PharmD, Clinical Toxicology Fellow, University of Maryland School of Pharmacy
“Medicine
is black and white.”
This is a phrase not commonly uttered in medical practice.(1) Diagnoses are based on
probabilities; therapeutic decisions are based on balancing the benefits (number
needed to treat) with the risks (number needed to harm). Medicine is fraught
with controversy, but we teach students, residents, and new practitioners that
they need to be practicing guideline directed care. There are many fields of
medicine (cardiology, infectious disease, epilepsy) that have practice
guidelines based on robust data and large studies. We teach these topics as
right and wrong, asking students to go down the steps of adding
antihypertensives based on JNC-8 or adding the “correct statin” based on a
patient’s risk profile. On the other hand, my area of practice, toxicology, has
a limited evidence base and practice is highly based on experience and small
studies. This means that the field if full of controversy. This blog post will
cover educating learners on topics filled with controversy.
What
is controversy?
Controversy is a type of conflict
where one person’s understanding and conclusions are incompatible with
another’s.(2,3) It is incredibly easy find
controversy in issues rooted in ethical, r
eligious, or political beliefs.(3) Most of these issues are more difficult to study with hard science and are dependent on emotional and experiential arguments. On the other hand, medical practice is primarily based on experimental “facts” and practicing outside of those facts is often deemed unreasonable. With our history of medical reversal (disproving what is “known” about a medical practice through completion and publication of superior trials; think about beta-blockers as contraindicated in heart failure prior to the 1990s), it is important to question the facts and learn to practice with an understanding that there is always controversy in medicine.(4)
How
can we use it to teach medicine?
We can use controversy to teach
medicine more thoroughly than most other methods. In their article “Energizing
Learning: The Instructional Power of Conflict,”(2) Johnson and Johnson describe using
controversy to teach by a few simple steps. First, you assign students either
alone or in small groups to learn “their” side of a controversy. Next, both
sets of students present their arguments in a situation that is not a
conventional debate; there is no winning. The instructor plays devil’s
advocate, chimes in with experience, and acts as mediator. Next there is an
open discussion with students presenting facts, supporting their positions, and
engaging with each other. The fourth step requires students to swap
perspectives and learn and argue the other side of the issue or other aspects
of treatment. Finally, students get together to devise a new, integrated
solution. The authors hypothesize that this method provides a higher level of
understanding of their original side of the controversy, challenges their
understanding, and then sparks their epistemic curiosity, leading to seeking
out new knowledge. I think of this process as very similar to forcing students
along the Dunning-Kruger curve by challenging their understanding of a topic by
immediately introducing healthy doubt (Dunning and Kruger presented the idea
that people often do not know what they do not know, but will be confident in
their abilities regardless of their knowledge. The graphs from their seminal
article have been combined as shown and elaborated on by some authors).(5) Additionally, more experienced
practitioners can step in to remind learners that patients do not read
textbooks to know how they should present or react to therapies. The teaching
certificate course utilizes different teaching theories and use of controversy
in combination with other theories can add to our arsenal of teaching methods.
What
problems occur with controversy?
The setting needs to be right and
rules need to be put into play. Learners need to have the emotional quotient to
poke holes in only ideas and not attack others personally. Additionally,
learners need to recognize that their opinions are being challenged. There is a
fear that emotions can get heated in the classroom and things may get “out of
hand.” Warren and Center provided a series of tools to manage students that get
heated and to encourage learning despite controversy.(6) Some of their most useful tools
include only letting students attack ideas and if the conversation gets too
heated, intervene and have students leave the conversation temporarily. If
students do not have open minds, they can misunderstand the exercise and get
emotionally attached to their side of the topic.
Has
controversy been used to teach medicine before?
In short, the answer is yes. The
Social Media and Critical Care annual conference utilized debates in medicine
taking on hot topics like code status, use of c-collars, and the evolution of emergency medicine. These are debate style discussions,
but often assign speakers to promote the side they have been publicly against.
Medicine is full of controversy
whether we like it or not. Teaching students underlying evidence and presenting
their summaries with opposing opinions can enhance the learning of everyone
involved. Preceptors can act as mediators, play devil’s advocate, and offer
experiences that stimulate conversation. This method of teaching, while
time-intensive, encourages learners to get excited about topics and has
potential to revolutionize education.
References:
1. Simpkin AL, Schwartzstein RM. Tolerating
Uncertainty - The Next Medical Revolution? N Engl J Med. 2016 Nov
3;375(18):1713–5. Full Text
2. Johnson
DW, Johnson RT. Energizing Learning: The Instructional Power of Conflict.
Educational Researcher. 2009 Jan 1;38(1):37–51. Full Text
4. Prasad
V, Cifu A. Medical reversal: why we must raise the bar before adopting new
technologies. Yale J Biol Med. 2011 Dec;84(4):471–8. PMC3238324
5. Kruger
J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing
one's own incompetence lead to inflated self-assessments. J Pers Soc Psychol.
1999 Dec;77(6):1121–34. Full
Text
No comments:
Post a Comment