Self-Regulated Learning and Forgetting

Young man with a book We go through school without realizing if our learning strategies are inefficient even more so when some assessments support these practices as opposed to discourage it. Unfortunately, exams and graduation run the risk of giving us a sense that learning is over, that what we have learned does not change, or that there are not more effective ways of learning. There is no way of unlearning what we have learned in the past, so it’s always a sensible practice to reassess our knowledge on a constant basis. 

Zimmerman defines self-regulated learning when students actively participate in their own learning using feedback, behavior, motivation, and metacognitive skills for effectiveness [1]. The problem is that active participation is not enough, learners also need effective learning strategies to acquire and maintain information highly retrievable and long-term retention. In a recent meta-analysis Dunlosky and colleagues[2] identified a number of effective and non-effective learning strategies practiced by students. Although learning strategies are useful, their effectiveness might not reach their potential in a curriculum without frequent testing, interleaved practice, formative assessments, distributed practice.

Studying Technique
Effect on Learning
Practice Testing High
Distributed PracticeHigh
Interleaved Practice Moderate
Elaborative InterrogationModerate
Self-explanation Moderate
RE-reading Low
Highlighting Low
Keyword mnemonic Low

Table adapted from BigThink

In a recent lecture at Harvard University Dr. Robert Bjork, an educational researcher from UCLA, talked about learning strategies and their implications in self-regulated learning. The title of the talk is quite intriguing and appropriate: Forgetting as a friend of learning: Implications for teaching and self-regulated learning.

These are a few of the concepts he addressed:

  1. Active retrieval is a learning process and a skill unto itself; so it requires practice.
  2. New theory of disuse: storage strength vs retrieval strength
  3. Performance is measurable and observable, learning is not.
  4. Conditions that reduce retrieval strength can, therefore, enhance learning.
  5. Practice retrieval, rather than looking things up, as often as possible.
  6. Mass practice shows rapid learning, but no benefit for long-term retention.
  7. Spaced practice shows forgetting, but helps long-term retention.
  8. Desirable learning difficulties: conditions of instruction that appear to create difficulties for the learner, slowing the rate of apparent learning, often optimize long-term retention and transfer.
  9. Induction: the ability to generalize concepts and categories through exposure to multiple exemplars. Block/Mass allows the learner to notice characteristics that unify category. Interleaving makes it difficult.
  10. The image below depicts active research and where learners can go wrong when managing and assessing their learning [3].

Self regulated learning graphic

This is a great panel discussion with Dr. John Dunlosky, Dr. Robert A. Bjork, Dr. Pooja K. Agarwal, Dr. Dan Robinson, Dr. Elizabeth Marsh, and Dr. Geoff Norman held at McMaster University last year.

These are a few of the points discussed:

  1. Effective and not effective learning strategies (mass learning, retrieval practice, etc)
  2. Myths in education (e.g. learning styles, MBTI personality types)
  3. Evidence-based education
  4. Desirable difficulties
  5. Cummulative exams
  6. Bloom’s Taxonomy
  7. Identification and emphasis of core knowledge
  8.  Technology might be helpful in learning (also consider cost)

 

References

  1. Zimmerman BJ. Self-regulated learning and academic achievement: An overview. Educational Psychologist. 1990;25, 3-17.
  2. Dunlosky J et al. Improving Students’ Learning With Effective Learning Techniques: Promising Directions From Cognitive and Educational Psychology. Psychological Science in the Public Interest. 2013;14 (1), 4-58 DOI:10.1177/1529100612453266
  3. Bjork RA, et al., (2013). Self-regulated learning: beliefs, techniques, and illusions., Annu Rev Psychol, 64:417-44 PMID: 23020639 

 

Further Reading

Retrieval Practice: 10 benefits of testing

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Author information

Javier Benitez, MD
Javier Benitez, MD
ALiEM Featured Contributor

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Trick of the Trade: Making your own homemade ultrasound gel

UltrasoundKenyaExpertPeerReviewStamp2x200You are spending a month in rural Kenya, doing an ultrasound teaching course. Your enthusiastic participants have been ultrasounding every chance they get. Unfortunately, this has caused your ultrasound gel supplies to dwindle. It will be a month before a new shipment of gel arrives from Nairobi. This gel will cost about $5 per bottle, which is a considerable expense for the local hospital’s budget.

Trick of the Trade: Homemade ultrasound gel

With a few simple and ubiquitous ingredients, you can make your own ultrasound gel to use. 

PIC1

Equipment Needed 

  • Corn starch
  • Water
  • Pot or pan
  • Heat source
  • Empty and clean bottle 

PIC2

Technique

  1. Combine 1 part corn starch to 10 parts water in a pan. Here, we use ¼ cup corn starch to 2 ½ cups water to make about 2 gel bottles full.
  2. Heat this mixture while stirring constantly at medium heat for 5-10 minutes.
  3. When the substance begins to boil, turn off the heat and allow the mixture to cool.
  4. Pour the mixture into a clean, preferably sterilized, container. Here, we use an old commercial ultrasound gel bottle which we placed in boiling water for 10 minutes first.
  5. Ultrasound away! Note that the gel should be used within 48-72 hours for best results. After that, it may begin to separate a bit.

PIC3

Word of Caution

This homemade gel does not have the same bacteriostatic ingredients that are in commercial ultrasound gel. Therefore we do no recommend its use for skin and soft tissue infections.

Expert Peer Review

April 11, 2014

For anyone who has spent time working abroad in a low resource area, you are likely familiar with the utility of ultrasound. It has a wide range of applications, it is easy to use, and there is an increasing number of portable machines available. There are very few ongoing costs associated with the use of ultrasound machines. The exception to this is ultrasound gel.

There is very little published about ultrasound gel alternatives. The 1995 WHO Manual of Diagnostic Ultrasound [1] contains a recipe for making your own ultrasound gel which requires many chemicals not available in most low resource settings. Olive oil has been studied as a feasible alternative [2] but is messy and provides less surface contact between the patient and the probe. Water baths have been looked at but are only applicable to extremity ultrasound [3].

In our recent pilot study [4], we found that a cornstarch-based alternative is at least comparable to commercial gel. Our study, which is a randomized blinded trial (abstract forthcoming at SAEM 2014) found no statistically significant difference between commercial gel and the cornstarch alternative in terms of image quality. The cornstarch-based alternative is an easily created, easily used, extremely inexpensive option that will hopefully make ultrasound more feasible and accessible in low resource settings.”

Reference

  1. Manual of diagnostic Ultrasound [PDF 3.6 MB], 2nd Edition. World Health Organization. 2011. Retrieved Aug 13, 2012 
  2. Luewan S, Srisupundit K, Tongsong T. A comparison of sonographic image quality between the examinations using gel and olive oil as sound media. J Med Assoc Thai. 2007 April; 90(4)624-7. Pubmed
  3. Blaivas M, Lyon M, Brannam L, et al. Water bath evaluation technique for emergency ultrasound of painful superficial structures. Am J Emerg Med. 2004 Nov;22(7):589-93. Pubmed
  4. Binkowski A, Riguzzi A, Fahimi J, Price D. Evaluation of a Cornstarch-Based Ultrasound Gel Alternative for Low-Resource Settings. J Emerg Med. 2013 Nov 12. pii: S0736-4679(13)01064-0. Pubmed
Allison Binkowski, MD, Emergency Physician, Ventura County Medical Center

 

Top image

 

Author information

Christine Riguzzi, MD
Christine Riguzzi, MD
Ultrasound Fellow
Department of Emergency Medicine
Highland General Hospital-Alameda Health System

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Understanding Phenytoin Equivalents

fosphenytoin image 1 (1)Sometimes, in an effort to make things simpler, we actually make them more confusing. Such is the case with phenytoin equivalents. 

Fosphenytoin is a water-soluble prodrug of phenytoin. After IV administration, much of the fosphenytoin is metabolized to phenytoin within 15 minutes. Advantages over phenytoin include the option for IM administration and less cardiotoxicity allowing for faster infusion rates. Even the potential for hyperphosphatemia from the release of phosphate is generally inconsequential. 

So, where is the confusion? 

If you want the patient to receive 500 mg of phenytoin, then you simply order fosphenytoin 500 mg PE (where PE stands for phenytoin sodium equivalents).

But… if you turn the vial around and look at the side, you’ll notice it says that each 10 mL vial contains fosphenytoin sodium 750 mg. Wait, so do we need to order fosphenytoin 750 mg to make sure the patient receives phenytoin 500 mg?

fosphenytoin image 2 (1)

Phenytoin Equivalent: Keeping it simple

Most, if not all, institutions have the process set up so that fosphenytoin is ordered as phenytoin equivalents. So, keep it simple.

  1. Choose your favorite phenytoin dosing calculator
  2. Calculate a dose
  3. Order that amount of fosphenytoin in PE units

I would have preferred to just learn a new weight-based dose for fosphenytoin, completely separate from phenytoin. But, this is what we have. Don’t over-think it. That’s where the confusion sets in.

Author information

Bryan Hayes, PharmD
Bryan Hayes, PharmD
ALiEM Associate Editor
Clinical Assistant Professor, University of Maryland (UM)
Clinical Pharmacy Specialist, EM and Toxicology

The post Understanding Phenytoin Equivalents appeared first on ALiEM.

Understanding Phenytoin Equivalents

fosphenytoin image 1 (1)Sometimes, in an effort to make things simpler, we actually make them more confusing. Such is the case with phenytoin equivalents. 

Fosphenytoin is a water-soluble prodrug of phenytoin. After IV administration, much of the fosphenytoin is metabolized to phenytoin within 15 minutes. Advantages over phenytoin include the option for IM administration and less cardiotoxicity allowing for faster infusion rates. Even the potential for hyperphosphatemia from the release of phosphate is generally inconsequential. 

So, where is the confusion? 

If you want the patient to receive 500 mg of phenytoin, then you simply order fosphenytoin 500 mg PE (where PE stands for phenytoin sodium equivalents).

But… if you turn the vial around and look at the side, you’ll notice it says that each 10 mL vial contains fosphenytoin sodium 750 mg. Wait, so do we need to order fosphenytoin 750 mg to make sure the patient receives phenytoin 500 mg?

fosphenytoin image 2 (1)

Phenytoin Equivalent: Keeping it simple

Most, if not all, institutions have the process set up so that fosphenytoin is ordered as phenytoin equivalents. So, keep it simple.

  1. Choose your favorite phenytoin dosing calculator
  2. Calculate a dose
  3. Order that amount of fosphenytoin in PE units

I would have preferred to just learn a new weight-based dose for fosphenytoin, completely separate from phenytoin. But, this is what we have. Don’t over-think it. That’s where the confusion sets in.

Author information

Bryan Hayes, PharmD
Bryan Hayes, PharmD
ALiEM Associate Editor
Clinical Assistant Professor, University of Maryland (UM)
Clinical Pharmacy Specialist, EM and Toxicology

The post Understanding Phenytoin Equivalents appeared first on ALiEM.

Neuraminidase Inhibitors for Influenza – The Truth, The Whole Truth, and Nothing But the Truth Finally

InfluenzaOver the last 5 years, the use of neuraminidase inhibitors for the treatment of influenza has skyrocketed. Emergency physicians have been pushed to prescribe these medications under the belief that they reduced symptoms, the risk of complications, hospitalizations, and transmission. However, the recommendation for the use of these drugs has never sat on firm evidence-based ground. So what did we know then, and what do we know now?

Background

A prior Cochrane review published in 2012 noted that much of the data was unavailable for them to review as it was not released by Roche pharmaceuticals [1]. The available data only supported a reduction in symptoms but marketing focused on reduction in complications and transmission. Many physicians have remained skeptical of the utility of these drugs. Why? Well, what we’ve always known is that the complete set of data and studies was never released.

What’s New?

Last week the BMJ published two systematic reviews on these drugs (via the Cochrane Acute Respiratory Infections Group) along with a number of editorials on the topic. With full access to the data, the blinders are off. We have a full picture of the data, and it doesn’t look good… at least not for oseltamivir (Tamiflu) and zanamivir (Relenza). Let’s take a look at each systematic review.

Article #1: Oseltamivir (Tamiflu)

Jefferson T, Jones M, Doshi P, Spencer EA, Onakpoya I, Heneghan CJ. Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. BMJ 2014; 348: g2545. [2]

Design: Systematic review of RCTs on adults and children

Main outcome measure: Time to alleviation of symptoms, complications, hospital admissions and adverse events

Outcome measure
Finding
Alleviation of symptomsShortened by 16.8 hours with oseltamivir
Admission to hospitalNo difference
Reduction in confirmed pneumoniaNo difference
Other complicationsNo difference
Transmission in prophylaxis groupNo reduction
Side Effect
Results
NauseaIncreased (NNH 28)
VomitingIncreased (NNH 22)
Psychiatric eventsIncreased (NNH 94)
HeadacheIncreased (NNH 32)

* NNH = Number needed to harm  

Summary: Oseltamivir led to a minor decrease in time to symptom alleviation with no benefit for complications, hospitalization or transmission. Side effects were common.

Article #2: Zanamivir (Relenza)

Heneghan CJ, Onakpoya I, Thopson M, Spencer EA, Jones M, Jefferson T. Zanamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. BMJ 2014; 348: g2547. [3]

Design: Systematic review of RCTs on adults and children

Main outcome measure: Time to alleviation of symptoms, complications, hospital admissions and adverse events 

Outcome Measure
Finding
Alleviation of symptomsShortened by 14.4 hours with zanamivir
Admission to hospitalNo data
Reduction in confirmed pneumoniaNo difference
Other complicationsNo difference
Prophylaxis1.98% reduction in symptomatic influenza (NNT 51)
 

Summary: Zanamivir led to a minor decrease in time to symptom alleviation with no benefit for complications or hospitalizations. There was a small decreased in transmission. Zanamivir was well tolerated without any major side effects seen in this data set.

Conclusions from these articles

Oseltamivir and zanamivir treatment showed modest decreases in time to symptom alleviation in comparison to placebo. However, there was no comparison made to standard supportive therapy for reduction of symptoms. A little acetaminophen or NSAID may be just as effective. Additionally, neither medication reduced the risk of complications or any other clinically important outcomes. Oseltamivir frequently led to side effects that may be worse than influenza itself. Lastly, prophylaxis was ineffective with oseltamivir and showed only modest benefits with zanamivir.

Editorial

In addition to the two Cochrane Acute Respiratory Infections Group publications, the BMJ published an accompanying editorial [4]. The authors discuss a number of issues but focus on the fact that despite this drug being approved for use for the last 15 years, we’ve never had access to the full data set. Roche pharmaceuticals left scores of data unpublished and, more insidiously, selectively published the studies that supported the use of the drug. The result is that billions have been spent on these drugs for treatment of influenza, prevention in close contacts of patients with influenza, and in creating stockpiles of medications in the event of an epidemic or pandemic. These issues have been picked up in the mainstream media (The Guardian editorial) as well.

We, as clinicians should demand more transparency. It would seem reasonable for regulatory organizations to require the disclosure of all data, not just published data, before approving a drug.

 

References 

  1. Jefferson T, Jones MA, Doshi P, Del Mar CB, Heneghan CJ, Hama R, Thompson MJ. Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children (Review). Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No.: CD008965. DOI: 10.1002/14651858.CD008965.pub3.
  2. Heneghan CJ, Onakpoya I, Thopson M, Spencer EA, Jones M, Jefferson T. Zanamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. BMJ 2014; 348: g2547.
  3. Jefferson T, Jones M, Doshi P, Spencer EA, Onakpoya I, Heneghan CJ. Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. BMJ 2014; 348: g2545
  4. Krumholz HM, Hines HH. Neuraminidase inhibitors for influenza: The whole truth and nothing but the truth. BMJ 2014; 348: g2548.

Image

Author information

Anand Swaminathan, MD MPH
Assistant Professor Emergency Medicine
Assistant Residency Director
Bellevue/NYU Emergency Department

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Behaviorism: Is punishment or reward more effective in education?

Behaviorism_2Every person involved in teaching and learning has a philosophy on how people learn. Implicitly, explicitly, legitimate or not this mental construct of learning affects the way they impart instruction and assess learning. One of the oldest and most commonly used educational theory of learning is behaviorism.

This theory, differentiated from cognitivism, constructivism, and others, was extensively studied by psychologists Jason B. Watson, Edward Thorndike, B.F. Skinner. Behaviorism has been applied not only in education, but also in business, parenting, politics, and psychological therapy to name a few. Its initial subjects were animals as explored by Ivan Pavlov, who studied classical conditioning, and his famous studies on dogs (Pavlov’s dogs) and Thorndike who studied operant conditioning in cats. Soon after its intricacies were described, this theory was applied to the field of education.

What is behaviorism?

The learning process, in general, is quite a challenge to describe let alone define. Some view it as an all-or-none phenomenon, while others view it as a continuum process. In behaviorism, learning is seen as a change in behavior due to an external stimulus. Behaviorist, such as B.F. Skinner, do not take into account mental models as it is more difficult to assess or control. This might be a bigger challenge in competency-based education as some of what’s being assessed in this setting are based mental models that may differ from person to person. While behaviors might seem clear-cut in behaviorism, assessing if something has been learned or not presents a difficult endeavor to non-behaviorists educators. 

Behaviorism operates under the assumption that organisms will increase or decrease their behaviors if adding pleasant or taking away noxious stimuli, coined as The Law of Effect by Edward Thorndike. The type of stimulus found in behaviorism can be controlled, as seen on studies conducted by Skinner on experimental animals in cages. The Wikipedia diagram below depicts the difference between reinforcement and punishment as employed in a behaviorist’s learning environment. 

In his experiments Skinner had hungry rats in a box and gave food pellet (positive reinforcement) each time the rat pressed on the lever. The assumption in this case is that food will increase the probability that the behavior (pressing the lever) will increase due to the positive reinforcement. In another experiment a satiated rat was placed in a different box and was given electric shocks until the rat pressed the lever. The reinforcement in this case (withdrawing the electric shock) increases the probability that the rat will press the lever (behavior). The experiment can be seen in this 1948 recording.

 

Skinner’s view of behaviorism in education

Although Skinner was a pioneer and viewed behaviorism as an educational theory, he was not in favor of how it was applied in the school system during his time. His criticisms alluded to the fact that the school environment was riddled with aversive control rather than positive reinforcement. His belief was that positive reinforcement was much more effective in developing the student’s behavior for lifelong learning. Here’s a quote from a YouTube interview with Richard Evans in 1964:

 “Aversive techniques are immediate, they work when you have one person stronger than another… This is an easy thing to account for because the results are immediate. The results of positive reinforcement are often deferred and it’s very hard. It’s often true in education, the teacher wants the student to be quiet and study can threaten him and get that result. But of course the student only studies under that pressure and once you release it he’ll never study again. But if you can induce him to study for other reasons, which is much more difficult and requires a much better understanding of human behavior you have a permanent result because you’ll be using consequences which continue in his life as he goes on in the world.”      

Derek Muller (@veritasium), a physics educator recorded a video “Is punishment or reward more effective” which quotes a study performed by Daniel Kahneman, where flight instructors were under the impression that by giving negative feedback, in the form of punishment, the fighter pilots would perform better while positive feedback would do otherwise. After a statistical analysis was performed via regression analysis it was found that the punishment had no effect on their performance.

 

Praise the behavior, not the person

Interestingly a Wall Street Journal article, based on a book, appeared last year where a music teacher was praised for teaching strategies in the classroom which seemed closer to aversive control and punishment rather than positive reinforcement. In the article the teacher is quoted as calling the students “idiots” and saying “Who eez deaf in first violins?”. The article goes on to say that he corrected students’ behaviors by poking them in the hands and arms with a pencil.

Although, some teachers identify with the philosophy of being “tough teachers” there are others who think otherwise. In an article in Education Week Teacher, a music teacher and author Nancy Flanagan cites the work of Carol Dweck  to illustrate her theory of growth and fixed mindset. Dweck studied this phenomenon in adults and children, and found that when learners are praised for their learning process, it fostered a “growth mindset” as opposed to praising the person which fostered a “fixed mindset”.

  • A learner with a growth mindset seeks challenges, does not see talent as a fixed trait, is enthusiastic about learning.
  • A learner with a fixed mindset sees intelligence and talent as fixed characteristics and do not venture out of their comfort zones.

In related findings, a video by Dylan Wiliam, an educator and researcher who studied formative assessment, discussed that when feedback is task-involving rather than ego-involving, students showed more effective improvement. On the other hand ego-involving feedback was not as useful.

Dr. Brent Thoma (@Brent_Thoma) and ALiEM Book Club recently reviewed the book “Drive” by Daniel Pink (@DanielPink) which focuses on motivation. The book is based on Self Determination Theory, a theory developed by Edward Deci and Richard Ryan. This theory states that the learner needs a sense of mastery, autonomy, and purpose for intrinsic motivation. The contrast between SDT and behaviorism is that intrinsic motivation is not taken into account in behaviorism, as stated by Richard Ryan in this video of his keynote lecture at the 5th Conference on Self-Determination Theory. There are important interactions between motivation and feedback which need to be considered seriously when helping learners develop into lifelong learners.   

Conclusion

More worrisome is a learning culture based on aversive control that’s conducive to a high-shame, low-participation environment (video by Frank Coffield). I think it is important to consider the work of Skinner and his views on behaviorism, if employing a punishment/reward system. Furthermore, the new work by the authors cited above should also be taken into account for the benefit of learners and teachers. Positive reinforcement in the form of task-involving feedback seems to be more effective than aversive control in driving students’ motivation and promoting lifelong learning. 

Can this positive reinforcement also be misused?!

You get a star for getting to the end!!!  ;-)  

What are your thoughts? 

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Author information

Javier Benitez, MD
Javier Benitez, MD
ALiEM Featured Contributor

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