Brazil on Evidence-based Education

Victoria Brazil, perennial star of the SMACC conference, tackled another education topic at smaccGOLD last March.

Yep, evidence and education – are those too words meant to go together?

She asks ‘what works?’ and comes up with two valid answers: EVERYTHING and NOTHING.


Listen in and consider what outcomes we should really be measuring in medical education.

Here is the audio:

Here are the slides:

Here is the video:

To listen to all the smaccGOLD talks as they are released subscribe to the SMACC podcast on iTunes.

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Are You a Good Educator?

The iTeachEM Podcast is back with an interesting episode on a topic that is not that well understood….how do know if you are actually any good at teaching? Sounds like a simple question with perhaps an even simpler answer, doesn’t it? Well, three prominent educators, Simon Carley, Anand Swaminathan (Swami), and Natalie May will make you question what you think you know about this topic. Recently these three brilliant minds got together to discuss this topic that is pertinent to all educators. If you want to be a better educator then you MUST listen to this episode. We welcome comments and questions from the social media world. If you want to even be on the podcast, record an audio file pertaining to this topic and send to me.


iTeachEm educators




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The Global Classroom

There has been lots of discussion recently about the “flipped classroom” in medical education and how this is changing the face of education. Rob Cooney from iTeachEM and FlippedEM has done some great work with flipped classrooms. Well, this post isn’t really about the flipped classroom at all. It’s about the Global Classroom. More specifically, the Global EM Classroom.

Salman Khan, author of The One World School House, discusses his vision for learning out of the classroom with video instruction. In this book he discusses his thoughts on a “one world school house.” What he means by that is a vast network of online videos that are used to instruct students all over the world. Class time can then be spent discussing things that will help students in the real world and not just dishing out Power Point after Power Point.

khan book

My vision for how to teach is pretty similar to Khan’s. My vision, The “One World Emergency Department,” is all based on FOAM. The FOAM world of blogs, podcasts, websites, etc. is already a rich collection of educational materials that “students” all over the world take part in. This is the global classroom. The key is YOU can be one of the teachers in the classroom.

What is the Global EM Classroom?

The Global EM Classroom is the total sum of the audience for the educational products you develop and deliver online. Essentially, it’s the group of people affected by what you teach. It’s your “reach” in the world of social media. It’s your impact factor. If you are active on Twitter, have 12,000 followers, and routinely send out board review pearls then your global EM classroom is potentially huge.  Your impact can be enormous. If you watch people on Twitter and barely interact then your classroom is small. On the other hand,  In addition, all of those wonderful things you have created for the flipped classroom can be used in the global EM classroom. Go global with your flipping! Why confine your teaching to your local environment? Go global, share it with the world, and get your name and message out there.

Global Classroom

How can the Global Classroom help others?

This is pretty obvious. Teaching with social media can help learners from all over the world. Engaged people all over the world are on Twitter, Google+, etc. (sometimes too much) and learn from educators who contribute to “the classroom”. A lot of educational exchange takes place on social media. I have personally been contacted twice by physicians (outside the US) thanking me for teaching them an important pearl on Twitter. One case was a doctor who thanked me for sending out a pearl on Twitter that helped him successfully intubate an obese patient. I had tweeted out a picture of an obese patient ramped up on multiple pillows–thus bringing the ear level with the sternal notch. This “ear to sternal notch” positioning has been mentioned by Rich Levitan many times and is talked about rather extensively in his airway course. The second case was from a physician who thanked me for helping him “save a life” by tweeting out a pearl about how to diagnose atypical cases of acute aortic dissection. These are only two cases, but these two educational tidbits that I sent out made a difference in the global classroom. Don’t think your contribution to the classroom doesn’t make a difference.

How can the Global Classroom propel your career?

Social media can help you grow your career in a number of ways. Preparing and delivering educational materials online is one thing, but interacting with the recipients of this material is another. The Global EM Classroom is part of the larger concept of engagement. A few months ago I sent out a tweet asking people to list what twitter had done for their career. The response was overwhelming. Many good things happening to folks in the FOAMed world can be attributed to social media involvement.

  • I first met Chris Nickson and Mike Cadogan on Twitter. Yep, you heard me correctly, Twitter. This has led to invites to SMACC (Social Media And Critical Care) and collaboration in multiple other projects, including this blog, iTeachEM. Both of these guys are now good friends of mine. Mike Cadogan, who lives in Perth, Australia, has stayed at my house before and has even been to my kids’ soccer games! Chris Nickson, faculty for our Teaching Course in Maryland and a member of the Teaching Institute “think tank,” is a good friend of mine. We met on Twitter. No joke. Bottom line: engagement in social media leads to friendships that you can’t imagine. It works!
  • Social media will lead to project involvement that will boost your career.
  • Engagement and making new friendships in the FOAM world will make you happier. It’s true.
  • Your contribution to the classroom (blog posts, podcasts, etc.) makes the world a better place. People helping people. It’s very powerful.

Mike Cadogan trying to corrupt my kids…


Mike at my daughter’s soccer game…

How can you cultivate  your own EM Classroom and make a global impact?

Some tips for increasing your global impact:

  • If you aren’t on Twitter and contributing, why not? Get yourself setup and don’t be a “watcher.” You won’t regret it. A must read is Chris Nickson’s post on Top 10 Tips for FOAM Beginners
  • Get involved with contributing to the global education discussion: blogging, podcasting, etc. You don’t have to create your own blog or podcast. Talk to someone who already has one and get involved. Involvement leads to good stuff.
  • Start following people on Twitter who have the same interests as you. As an example, let’s say your interest is in endocrine emergencies. This is your clinical area of interest and you would like to grow and cultivate this within the framework of your career. Start following people with the same interest. Start following organizations that discuss this topic. Start contributing to the discussion. With enough energy and passion for your topic, the next thing you know you are on a guideline committee, speaking at a national or international meeting, and growing your CV and career. Yes, this message is for your, George Willis.
  • Create videos and share  with the world. Watch this quick little video by Sal Khan on how video is the future of education.
  • Engage, engage, engage with the world of social media and education.
  • Promotion and Tenure committees are slowly starting to pay attention to your impact. Sometimes very slowly, I realize that. But some committees have started paying attention to things like Google Analytics. If your blog has thousands of hits per day, and your podcast has over a million downloads (I know, we can’t all be Scott Weingart), schools and institutions will start paying attention to “the numbers.” This will likely become more common as old P&T committees turn over and the new guard takes over. I can dream can’t I?
photo (5)

Me with Stella Yiu and Ken Milne (from SGEM). What’s in the water supply in Canada? They have some excellent educators!!




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The Interplay of Emotions & Learning

Our goal should be to create a student who moves up the knowledge axis, along an “excelsior spiral that climbs the tree of knowledge” – Barry Kort

Rob & Chris’ debate about whether learning styles exist (or not)  touches upon a subtle, but important point. Forcing a student to come out of their comfort zone is important in the educational journey, in fact, there is likely a strong interplay between emotions & learning.  Many have attempted to identify the healthy amount of discomfort that’s necessary in the learning process, but I thought this paper by a group from M.I.T. highlighted some very important concepts.

In an attempt to engineer a computer application that could identify a student’s emotions, Kort highlights some theoretical concepts that are highly adaptable to medical education & other STEM courses.  The underlying principle of this paper is that there is a necessary cycle in learning that requires making mistakes, evaluating/reflecting about what went wrong, deconstructing false beliefs, discovering a potential solution, and ultimately repeating the cycle until the problem is solved.

Dr. Kort begins with the establishment of a static model that plots Positive/Negative emotions on the horizontal axis against Learning/Unlearning on the vertical axis. (below).

Emotions & Learning Model 1

Let’s briefly review this model and how it applies to medical trainees:

Students will often begin in the upper quadrants (I or II) – with a clinical question, interest, or endeavor.  This could be the result of an interesting patient, failed resuscitation, missed questions during a “pimping session” or whatever – but something that sparked an interest.   Quadrant III often is reached during a period of research or self-reflection.  During this time, the learner will likely identify knowledge gaps or misconceptions that currently exist.  The reflection, deconstruction, & unlearning process that ensues is likely the most critical.

After a period of failure, the learner will eventually progress to Quadrant IV where a new potential answer is identified, or a true solution is realized or understood.  Ultimately, the idea is that the student should traverse a series of both positive and negative emotions on their path to truly understanding the answer to their question.

So where does the educator exist within this process?

The authors contend that the instructors role is to help the student continue their path around the loop, as well as teaching them how to propel themselves especially after a setback.

Fluid Emotions & Learning Model

The last variable to consider is time, which can be added as a third axis (z-axis).  By incorporating time, the authors define the educator’s  role as that of a mentor, where the student progresses in an orbital fashion along an, “excelsior spiral that climbs the tree of knowledge.”  Essentially, building their knowledge base as they travel through this cycle of failure and success.


Some key pearls to take away from this paper include:

  • Learning is an active process that incorporates some degree of struggle.
  • Expert teachers are very adept at recognizing and addressing the emotional state of learners, and even more importantly – are able to effectively guide them through this learning cycle again and again.
  • Much of this theory focuses on the individual learner, however it is possible to incorporate these concepts into a lecture if necessary – see, “Make Your Audience the Hero”

Teachers who incorporate the cycle of learning and unlearning into the educational constructs of their classroom are (in my opinion) more effective educators.

Finally, there is something important about what this journey teaches students outside of the intended lesson plan, something that we’ll address next time – the value of GRIT.

Some parting questions to the educators out there:

      • Do you think some form of negative emotion is important to the learning process?
      • Is there actually value in allowing students to struggle?

Leave your thoughts below!


References [Free full text]

  1. Massachusetts Institute of Technology Affective Computing Lab
  2. Kort B, Reilly R, Picard RW.  An Affective Model of the Interplay Between Emotions and Learning.
    Download Paper Here.

    Contact me on Twitter @JohnGreenwoodMD

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Learning Styles Do Exist!

This post is a response to Learning Styles Do Not Exist

“Absence of evidence is not evidence of absence.”

Chris, say it isn’t so!

Learning styles most certainly exist!

Before I dig into some important points, I agree with you about the lack of validity of the kinestetic/auditory/visual breakdown as discussed in the video. Different learning tasks will require learners to activate different sensory pathways and any learner can be successful in learning content or procedures given enought time and exposure. Falling into the “I can’t do it because I’m a ________ learner” is simply the learner being lazy.

What I must disagree with is the overall statement that, “Learning Styles Do Not Exist.” It seems that learning styles have recently come under fire, as they do every few years. The article by Pashler et al is but one in a series of articles that attempt to debunk learning styles. Their conclusion, however, is interesting:

“we conclude therefore, that at present, there is no adequate evidence base to justify incorporating learning styles assessments and general educational practice. . . However, given the lack of methodologically sound studies of learning styles, it would be an error to conclude that all possible versions of learning styles have been tested and found wanting; many have simply not been tested at all. Further research on the use of learning-styles assessment in instruction may in some cases be warranted, but such research needs to be performed appropriately.”

The latter part of their conclusion is quite important. Any teacher who has taught long enough recognizes that students learn in different ways. Think back to when you first learned to suture. Were you a learner who had to watch the teacher? Or did you read a book first? Or perhaps you had to get hands-on with the pig’s foot, needle driver, and suture? Did you need to wrestle with the content alone or did you need to discuss with your friends? Did you need a checklist worthy stepwise approach or did you “just do it?” Perhaps you had to do one of the above when you preferred a different method of learning?

Recognizing that learners do vary in their preferences, I do not believe that we should dismiss learning styles outright. Richard Felder, professor of physics and co-creater of the Felder-Silverman Learning Styles Index recently wrote a thoughtful response to the Pashler study. In it he identifies some critical questions:

  • Do students with different assessed learning styles respond differently to specific forms of instruction?
  • Does instruction that matches a student’s learning style lead to greater learning?
  • Can instruction be improved by taking learning styles into account? If so, how?

Important points made in response to the first two questions include:

  • Learning styles are a continuum, and are not exclusive to one extreme or the other
  • Learners with any style can still be successful
  • Students taught in a style discordant with their preferred style perform worse than students matched to a learning style

As instructional designers, the third question is the most important. Felder makes the point right away that attempting to design instruction matched to each learner is, “for all practical purposes, impossible.” Optimizing one learner will lead to mismatched instruction for other learners. A point not stressed by Felder that directly ties into optimizing learning is that optimal learning requires stress. As I discussed in Neurobiology and Medical Education, too much stress leads to anxiety and too little leads to boredom. It is plausible that being perfectly matched will detract from learning by decreasing the stress threshold. So what should we do instead?

  • Choose one learning style index to apply and try it out.
  • Seek balance in your teaching. Try to provide instruction that varies between matched and mismatched in order to allow students to experience stress and growth, as well as develop skills to learn in uncomfortable settings.
  • Teach your students about their preferences. This will allow you to coach them in the development of coping skills (introverts will dislike group projects and will benefit from reflection time).
Bottom Line: Don’t throw out the baby with the bathwater! Reflect on what preferences you have (and likely use in your instructional design) and determine where alternate content presentation techniques could be easily applied.

References and links

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Neurobiology and Medical Education

Insights from neurobiology can be applied to medical education right now.

Key concepts from neurobiology that we can use include:

  • the need for repetition
  • reward and reinforcement
  • visualisation
  • active learning
  • optimal stress
  • avoiding fatigue
  • avoiding multi-tasking
  • learning styles
  • revisiting

This is explained in the brief screencast below:


  • Ericsson, K. Anders, and Paul Ward. “Capturing the naturally occurring superior performance of experts in the laboratory toward a science of expert and exceptional performance.” Current Directions in Psychological Science 16.6 (2007): 346-350.
  • Friedlander, Michael J., et al. “What can medical education learn from the neurobiology of learning?.” Academic Medicine 86.4 (2011): 415-420.
  • Sexton, J. Bryan, Eric J. Thomas, and Robert L. Helmreich. “Error, stress, and teamwork in medicine and aviation: cross sectional surveys.” Bmj 320.7237 (2000): 745-749.
  • Surani, Salim, et al. “Sleepiness in medical residents: impact of mandated reduction in work hours.” Sleep medicine 8.1 (2007): 90-93.

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