President Larry Millstein called the 2,260th meeting to order at 8:22 pm November 13, 2009 in the Powell Auditorium of the Cosmos Club. The minutes of the 2,259th meeting were read and approved after a short discussion.
Mr. Millstein introduced three new members of the Society. He then introduced the speaker of the evening, Mr. Donlin M. Long of the Johns Hopkins Medical Institutions. Mr. Long spoke on “Competency to Mastery: How We Learn and Apply Knowledge.”
This topic is somewhat different, Mr. Long began. It is about basing education on competency, rather than time and place. It is a new concept, perhaps 20 years old. It is being taken very seriously in medical education, especially post-graduate. It also involves the concepts of mastery and the question of how we ensure lifelong learning.
Currently, the goal of medical education is competency. Competency is gained by a specific progression of learning. Competency is not the final goal; it is a way station required to progress to mastery.
The progression to competency begins with a novice, who has to learn facts and skills under direction with immediate feedback. The novice begins to apply facts and skills by rules, which are still given to him by others. Next, the advanced beginner begins to understand the need for self directed learning. He learns the rudiments of analysis and begins to expand the rules. Finally, he achieves competency, which is characterized by self directed learning and use of rules expanded and developed by experience and analysis.
A few practice continuous improvement, pursue learning independently, assess themselves regularly, and progress toward mastery. That, however, is a small group.
Competency based learning is the new goal of education. With competency based learning, time requirements are eliminated. There are no freshmen, sophomores, juniors. Progress is determined by goals and milestones. Goals are decided by the students. They prove they have learned and progress as rapidly as they can.
There is a movement to make this the standard of medical education. It is being done mostly in post graduate study at present, but Mr. Long says there is commitment to it and several countries have made steps to apply it in medical school education.
Is it practical? There is precedent. In the past in the United States, when we were short of physicians, pre-medical school has been reduced to two years and medical school to three years. Recently a demonstration of the practicality was done in Canada, where a famous orthopedic surgery program was reduced from seven years to four. The European Union has adopted competency based physician training as a policy.
Mr. Long believes the main problem in education is not not learning facts, but that we don’t program the brain to learn. This requires ongoing study and deliberately engaged practice. It does not happen by experience alone.
As practitioners gain experience, they increasingly develop, modify, and expand rules. Eventually, rule-following becomes knowledge based. With practice, they develop skills to apply their own rules quickly, which is often important. Use of the same information in a variety of venues is also important.
There are oral learners, visual learners, and there are some who learn by doing. Repetition turns out to be extremely important. Great musicians practice as much as ten hours a day. The ones who lose their abilities with age are the ones who stop practicing. 10,000 hours seems to be about what it takes to gain mastery in many fields.
The key to avoiding a plateau is deliberate learning, working toward getting better every day. The cognitive skills need to be continually fostered. Practice must be deliberate and systematic in order to have the best effect. One great problem in neurosurgery training is that most situations do not provide frequent enough opportunity for practice on difficult problems. Achievement of true mastery is unlikely to occur without extensive practice, and useful discoveries come primarily from people who have achieved mastery.
What is known in cognitive science? We need to take that kind of information and use it in education. No current theory is adequate, and that means education will have to adapt as information develops, and that is not characteristic of education.
There is much to be learned. Some aspects of cognition, such as decision making and fact gathering, seem to be understood fairly well; others are not. People seem to reach, with enough practice, a level where they make knowledge based decisions without analysis. We do know that learning progresses from the simple to the complex. Eventually, if continuous learning is practiced long enough, people make complex decisions by a perceptual process. They see a problem; they immediately know a solution; they act on it.
He ended with some philosophy, noting that he was speaking to the Washington Philosophical Society.
Aristotle told us we only know what we experience. David Hume held that the self was just connected to experiences. William James postulated a stream of consciousness based on experience, but thought there was something more in the process but he wasn’t sure what it was. His student, John Dewey, said that that “something more” occasionally produced thoughts of great importance. This was best expressed by Josiah Royce, who said that many important thoughts and conclusions occur without analysis and without experience, and this is the fundamental basis of perceptual knowledge. Descartes said there must be some important aspect of mind that is not physical. Bishop Berkeley told us no experience is real; everything is in our stimuli, in the mind. Daniel Dennet wrote that the brain itself is biological, but thought and consciousness are not.
Perceptual research strongly favors the biological theories, but it tells us that experience is not the only process. Much elaboration occurs in the brain, without obviously thinking about it. We don’t have neurological explanations for this.
He recalled a recent study (Kiani & Shadlen, Science, 2009) that showed that individual nerve cells in the parietal lobe gave animals reliability of interpretation, accuracy of choice, and confidence in decision. This discovery of such a graded response in individual cells is astounding, implying that individual cells can estimate probabilities. It denies the proposition that brain cell function is all-or-none, which has been a standard assumption.
Mr. Long concluded saying this is a very brief look at a new concept, competency based education. He hopes that it will spread from medicine throughout the education field. He expects that as it develops, we will increasingly rely on knowledge about how the brain learns.
He offered to answer questions.
One question was about the assumption that hoofbeats indicate horses and not zebras. Does this represent a hindrance by common teaching patterns to the kind of development he advocates? Mr. Long said such assumptions reflect perceptual learning. If you are in Washington, hoofbeats most likely do indicate horses.
Several questions dealt with concerns about what might be lost from by focus on demonstrable capabilities and what is left out from people’s training. Mr. Long’s answers indicated that care must be taken to keep the relevant skills and knowledge in the program, but he gave examples that indicated that substantial efficiencies can be gained with little or no loss.
One question dealt with motivation. Mr. Long observed that nobody knows how to motivate people. In his field, medicine, in general, there is a lack of focus on outcomes. The contributions and capabilities of a few people are known, because they are published, but for most practitioners, they are not.
Another person asked if statistical analyses might help focus on outcomes. Mr. Long gave one example where just such an approach had a dramatically positive effect in survival after heart surgery. But that is not common.
Another person pointed out that, although Mr. Long had spoken of neuroscience in connection with education, his examples were based entirely on behavior. Mr. Long acknowledged the point, and said, essentially, that is the current state of the field of neuroscience.
After the talk, Mr. Millstein presented to Mr. Long a plaque commemorating the occasion. He welcomed Mr. Long to membership in the Society. He announced the next meeting and presentation. He made the parking announcement and other housekeeping announcements. Finally, at 9:45 pm, he adjourned the 2,261st meeting to the social hour.
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