Motivation in basic science teaching William Pryse-Phillips, md, frcp[c],
Simpson,1 in his catalytic book "Med¬ ical Education A Critical Approach" wrote of the "Myth of the Basic Sciences" and quoted the old (1944) Goodenough Report as follows: "There is an urgent need in every school for a new viewpoint on the part of the teachers of the pre-clinicai subjects and for the drastic elimination from the curricula and therefore from the ex¬ aminations in these subjects of a mass of detailed information which serves only to deaden his interest in subjects that can and should make the liveliest appeal to him". Other points made by Simpson in¬ cluded the reminder that we believe that if a thing is nasty it must be doing some good; that because relevant as¬ pects of the sciences are basic to the critical thinking of the skilled clinician, so we have assumed they must also be basic and primary for the medical student; that basic sciences are rejected by many students; and that there is no evidence that laboratory instruction is of greater teaching value than a lecture .
or a
.
.
slide-tape presentation.
Some other comments about basic sciences are germane. First, the vital necessity of instructing students in, for example, Laurell electrophoresis is only recognized when a protein chemist hap¬ pens to be appointed to the staff. Sec¬ ond, unless original learning is reinforced repeatedly, such learning will inevitably be lost. Third, for adequate learning, contextual relevance is essen¬ tial, as is motivation; and with many aspects of basic science the only mo¬ tivation is the need to pass examina¬ tions in order to progress to the relevant and beckoning subject of clinical medReprint requests to: Dr. William Pryse-Phillips, Faculty of medicine, Memorial University of Newfoundland, St. John's, Nfld. A1C 5S7
mrc psych
icine. The term "basic science" assumes too much. Science undoubtedly it is, but unless it supplies a need at a clinical level it is not a bit basic, but simply irrelevant. But to attack it threatens
have cake. At last, one begins to under¬ stand Marie Antoinette. But why should a medical student be hindered in realizing his wish to participate in the fight for the fortunes of the diseased by a substratum of tenuously relevant data selected for him in general by clinicians but specifically by nonclinicians? Are such people really able to assess the validity of their contribu¬ tions? And since most of us clinicians and teachers were not so trained, can we? To each question, I proffer a doubting "No". Who then should select the basic science to be taught and how should motivation to recognize, retain, recall and reproduce such data be provided? Sandok,4 at Mayo Medical School, and Barrows,5 at McMaster University, by coupling basics with clinical immediacy, by provoking students to seek
those academic scientists whose raison d'etre in a medical school is their curricular time allotment. To quote Weed,2 "The only protection the student then has against the misconceptions of the faculty is reality". I have no simple answer as to how to make medical education relevant. But I have a suggestion that goes part of the way. Just as medical audit from charts by peer review and by oneself is sadly inadequate perhaps useless and just as patient-derived audit (for example, by giving the patient his own medical record) is being approached as a more valid method, so might one turn from classic to operant conditioning of motivation. Pirsig,3 in his most startling answers to patient-derived questions book "Zen and the Art of Motor Cycle and by providing selective reading with Maintenance", achieved this. (If I quote its halo effect, went far in solving the from him it is because I doubt whether problem. Pirsig3 perhaps went even this book is well known and because further, in two contemporaneous stages. Pirsig achieved, in a milieu that is more First, in Pirsig's grade-free course liberal than in most medical schools, one of the students might go to his what I believe is a prototype of de¬ initial class, get his assignment, sirable education, at least at adult and probably do it out of habit. He level.) What Pirsig did was to withhold might go to his second and third as well. grades during one university English But eventually the novelty of the course ansemester. The classic nonplussed, would wear off and because his academic noyed reaction of the students was life was not his only life, the pressure of summed up by one of them: "Of course other obligations or desires would create you can't eliminate the degree and circumstances where he just would not be able to get an assignment in. Since there grading system after all that's what was no degree or grading system he would we're here for". Not often, but some¬ incur no penalty for this. Subsequent lectimes, I detect that terrifying myopic tures which presumed he'd completed the opinion underlying a student's remon- assignment might be a little more difficult strance. Some of our students regard to and this difficulty understand, medical preclinical education as a in turn, might however, weaken his interest to the means to the end of being allowed clin¬ point where the next assignment, which ical education. They remember that he would find quite hard, would also be they must eat bread before they can dropped. Again, no penalty. In time, his ...
CMA JOURNAL/FEBRUARY 8, 1975/VOL. 112 295
0tomotiI® slows the gut fast COMPOSITION: Each tablet and each S ml of liquid contain 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine sulfate. INDICATIONS: Acute and chronic diarrhea; whether functional, or associated with conditions such as gastroenteritis, irritable bowel syndrome, regional enteritis, ulcerative colitis, infectious diarrhea and diarrhea following drug therapy. Also may provide effective intestinal control in patients following gastric surgery, ileostomy or colostomy. CONTRAINDICATIONS: Jaundiced patients or patients hypersensitive to the components of Lomotil. PRECAUTIONS: Lomotil should be used with extreme caution in patients with severe cirrhosis or advanced liver disease and in those patients receiving barbiturates or addictive narcotics. Administer with extreme caution to known atropine and diphenoxylate sensitive individuals. Do not exceed the recommended dosage. WARNING: Keep out of reach of children; accidental overdose may cause severe respiratory depression. ADVERSE REACTIONS: Are relatively uncommon; most frequently, nausea; less frequently, drowsiness, dizziness, vomiting, pruritus, skin eruption, restlessness, insomnia, bloating and cramps have been reported; and rare incidences of numbness of the extremities, headache, blurring of vision, swelling of gums, euphoria, depression and general malaise have occurred. Many of these might be symptoms of disease being treated; accurate differentiation is often impossible. DOSAGE AND ADMINISTRATION: ADULTS: S mg (2 tablets or 2 x S ml liquid) 3 or 4 times daily. Usual initial adult dose is 2 tablets. CHILDREN: 5.0 3 - 6 months 7.5 6 - 12 months 10.0 1 - 2 years 12.5 2 - 5 years 15.0 5 - 8 years 20.0 8 - 12 years (5 ml equals 1 teaspoonful.) NOTE: THIS IS TOTAL DAILY MEDICATION. GIVE IN DIVIDED DOSES.
ml ml ml ml ml ml
AVAILABILITY: TABLETS 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine sulphate in bottles of 100, 500. LIQUID 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine sulphate/S ml in 60 ml (2 oz.) bottles.
Full prescribing information available upon request, or in C.P.S.
Searle Pharmaceuticals Oakv,IIe Ontario
weaker and weaker understanding of what the lectures were about would make it more and more difficult for him to pay attention in class. Eventually, he would see that he wasn't learning much; and facing the continued pressure of outside obligations, he would stop studying, feel guilty about this, and stop attending class. Again, no penalty would be attached. But what had happened? The student, with no hard feelings on anybody's part, would have flunked himself out. Good! This is what should have happened. He wasn't there for a real education in the first place and had no business there at all. A large amount of money and effort had been saved and there would be no stigma of failure and ruin to haunt him the rest of his life. No bridges had been burned. Other students, of course, would turn in acceptable work and be allowed to proceed to the next course. Second, a student who can only work if pushed to do so by grading will, if not graded, leave and either find his own reduced level of function outside the university or succeed to a certain extent, limited, however, by theoretic ignorance of his subject. The obstacles in his quest to do a more satisfying job would, one hopes, stimulate him to return to university to remedy his theoretic deficiency. But his new approach would differ from his former one; no longer would he be a grademotivated person, but a knowledgemotivated one. He would need no external pushing to learn: his push would come from inside. He'd be a free man. He wouldn't need a lot of discipline to shape him up. In fact, if the instructors assigned him were slacking on the job, he would be likely to shape them up by asking rude questions. He'd be there to learn something, would be paying to learn something, and they'd better come up with it. Motivation, once it catches hold, is a ferocious force, and in the gradeless, degreeless institution where our student would find himself, he wouldn't stop with... ordinary clinical information. Take the case of a patient with a tremor. The student would need to know about the cause of the tremor, its anatomic and pharmacologic features, its therapy, the peripheral dopaminergic effects, hepatic coma, electroencephalography... one could go on and on. The student motivated from within probably would. One need not, however, drop out of a gradeless course in order to achieve this result. It can be otherwise preplanned so that practice is made to reveal principles. The student's wish to "do medicine" is doubtless a genuine, if only a partly informed wish. He seeks the end result, and that status and theoretic responsibility is his distant motivating goal. Term papers are steps to this. But because all are pre-
requisites to that final goal, all must be equally important. Again the student becomes grade- and not knowledgeoriented. A medical student who was once a nurse cannot be taught irrelevancies unless the grading requirements are rigid, for such a student has seen clinical practice, can recognize what theoretic bases physicians have relied upon, and will relate everything taught to clinical situations he himself has already experienced. It is not possible to exercise sacred cows in the meadows of his mind, nor is it likely that superficial explanations will satisfy. His appetite for understanding will have been born of low-level, passive clinical experience, and that appetite will be satisfied only by specific, and in this case clinically relevant food. I would like to leave the choice of the relevant in basic science teaching to those who have not just seen but have actually felt the need for it. Such students would have been trained first in the techniques of medicine and would, for perhaps their first medical year, have been clinical apprentices to practising physicians. The first-year course thus might be called "The appearances of disease". Their exposure to sickness would suggest to them all those areas of background knowledge in which they were deficient; their lack of understanding would motivate them to seek it. Is this not a better way of inducing motivation from within? Has anyone ever done a study of the later clinical abilities of nurses-turned-physicians? I have only seen a few such individuals; I have never seen one fail a course. Those I have seen have high motivation indeed, overcoming even the frustration produced by courses needed for graduation but not for practice. If we as clinicians will not keep only those courses we recognize as appropriate, should we not at least enable the students to generate their own informed opinions about what is needful in basic science teaching? References 1. SIMPSON M: Medical Education: A Critical Approach. London, Butterworths, 1973 2. WEED L: in Problem Oriented Record, edited by HURST JW, New York, Medcom, 1972 3. PIRsIG RM: Zen and the Art ol Motor Cycle Maintenance: An inquiry into Values. New York, Morrow, 1974 4. SANDOK B: Presentation to the Third Neurological Education Workshops, Daihousie University, Halifax, 1974 (in press) 5. Bkaaows: Ibid
CMA JOURNAL/FEBRUARY 8, 1975/VOL. 112 297
Simpson,1 in his catalytic book "Med¬ ical Education A Critical Approach" wrote of the "Myth of the Basic Sciences" and quoted the old (1944) Goodenough Report as follows: "There is an urgent need in every school for a new viewpoint on the part of the teachers of the pre-clinicai subjects and for the drastic elimination from the curricula and therefore from the ex¬ aminations in these subjects of a mass of detailed information which serves only to deaden his interest in subjects that can and should make the liveliest appeal to him". Other points made by Simpson in¬ cluded the reminder that we believe that if a thing is nasty it must be doing some good; that because relevant as¬ pects of the sciences are basic to the critical thinking of the skilled clinician, so we have assumed they must also be basic and primary for the medical student; that basic sciences are rejected by many students; and that there is no evidence that laboratory instruction is of greater teaching value than a lecture .
or a
.
.
slide-tape presentation.
Some other comments about basic sciences are germane. First, the vital necessity of instructing students in, for example, Laurell electrophoresis is only recognized when a protein chemist hap¬ pens to be appointed to the staff. Sec¬ ond, unless original learning is reinforced repeatedly, such learning will inevitably be lost. Third, for adequate learning, contextual relevance is essen¬ tial, as is motivation; and with many aspects of basic science the only mo¬ tivation is the need to pass examina¬ tions in order to progress to the relevant and beckoning subject of clinical medReprint requests to: Dr. William Pryse-Phillips, Faculty of medicine, Memorial University of Newfoundland, St. John's, Nfld. A1C 5S7
mrc psych
icine. The term "basic science" assumes too much. Science undoubtedly it is, but unless it supplies a need at a clinical level it is not a bit basic, but simply irrelevant. But to attack it threatens
have cake. At last, one begins to under¬ stand Marie Antoinette. But why should a medical student be hindered in realizing his wish to participate in the fight for the fortunes of the diseased by a substratum of tenuously relevant data selected for him in general by clinicians but specifically by nonclinicians? Are such people really able to assess the validity of their contribu¬ tions? And since most of us clinicians and teachers were not so trained, can we? To each question, I proffer a doubting "No". Who then should select the basic science to be taught and how should motivation to recognize, retain, recall and reproduce such data be provided? Sandok,4 at Mayo Medical School, and Barrows,5 at McMaster University, by coupling basics with clinical immediacy, by provoking students to seek
those academic scientists whose raison d'etre in a medical school is their curricular time allotment. To quote Weed,2 "The only protection the student then has against the misconceptions of the faculty is reality". I have no simple answer as to how to make medical education relevant. But I have a suggestion that goes part of the way. Just as medical audit from charts by peer review and by oneself is sadly inadequate perhaps useless and just as patient-derived audit (for example, by giving the patient his own medical record) is being approached as a more valid method, so might one turn from classic to operant conditioning of motivation. Pirsig,3 in his most startling answers to patient-derived questions book "Zen and the Art of Motor Cycle and by providing selective reading with Maintenance", achieved this. (If I quote its halo effect, went far in solving the from him it is because I doubt whether problem. Pirsig3 perhaps went even this book is well known and because further, in two contemporaneous stages. Pirsig achieved, in a milieu that is more First, in Pirsig's grade-free course liberal than in most medical schools, one of the students might go to his what I believe is a prototype of de¬ initial class, get his assignment, sirable education, at least at adult and probably do it out of habit. He level.) What Pirsig did was to withhold might go to his second and third as well. grades during one university English But eventually the novelty of the course ansemester. The classic nonplussed, would wear off and because his academic noyed reaction of the students was life was not his only life, the pressure of summed up by one of them: "Of course other obligations or desires would create you can't eliminate the degree and circumstances where he just would not be able to get an assignment in. Since there grading system after all that's what was no degree or grading system he would we're here for". Not often, but some¬ incur no penalty for this. Subsequent lectimes, I detect that terrifying myopic tures which presumed he'd completed the opinion underlying a student's remon- assignment might be a little more difficult strance. Some of our students regard to and this difficulty understand, medical preclinical education as a in turn, might however, weaken his interest to the means to the end of being allowed clin¬ point where the next assignment, which ical education. They remember that he would find quite hard, would also be they must eat bread before they can dropped. Again, no penalty. In time, his ...
CMA JOURNAL/FEBRUARY 8, 1975/VOL. 112 295
0tomotiI® slows the gut fast COMPOSITION: Each tablet and each S ml of liquid contain 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine sulfate. INDICATIONS: Acute and chronic diarrhea; whether functional, or associated with conditions such as gastroenteritis, irritable bowel syndrome, regional enteritis, ulcerative colitis, infectious diarrhea and diarrhea following drug therapy. Also may provide effective intestinal control in patients following gastric surgery, ileostomy or colostomy. CONTRAINDICATIONS: Jaundiced patients or patients hypersensitive to the components of Lomotil. PRECAUTIONS: Lomotil should be used with extreme caution in patients with severe cirrhosis or advanced liver disease and in those patients receiving barbiturates or addictive narcotics. Administer with extreme caution to known atropine and diphenoxylate sensitive individuals. Do not exceed the recommended dosage. WARNING: Keep out of reach of children; accidental overdose may cause severe respiratory depression. ADVERSE REACTIONS: Are relatively uncommon; most frequently, nausea; less frequently, drowsiness, dizziness, vomiting, pruritus, skin eruption, restlessness, insomnia, bloating and cramps have been reported; and rare incidences of numbness of the extremities, headache, blurring of vision, swelling of gums, euphoria, depression and general malaise have occurred. Many of these might be symptoms of disease being treated; accurate differentiation is often impossible. DOSAGE AND ADMINISTRATION: ADULTS: S mg (2 tablets or 2 x S ml liquid) 3 or 4 times daily. Usual initial adult dose is 2 tablets. CHILDREN: 5.0 3 - 6 months 7.5 6 - 12 months 10.0 1 - 2 years 12.5 2 - 5 years 15.0 5 - 8 years 20.0 8 - 12 years (5 ml equals 1 teaspoonful.) NOTE: THIS IS TOTAL DAILY MEDICATION. GIVE IN DIVIDED DOSES.
ml ml ml ml ml ml
AVAILABILITY: TABLETS 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine sulphate in bottles of 100, 500. LIQUID 2.5 mg diphenoxylate hydrochloride and 0.025 mg atropine sulphate/S ml in 60 ml (2 oz.) bottles.
Full prescribing information available upon request, or in C.P.S.
Searle Pharmaceuticals Oakv,IIe Ontario
weaker and weaker understanding of what the lectures were about would make it more and more difficult for him to pay attention in class. Eventually, he would see that he wasn't learning much; and facing the continued pressure of outside obligations, he would stop studying, feel guilty about this, and stop attending class. Again, no penalty would be attached. But what had happened? The student, with no hard feelings on anybody's part, would have flunked himself out. Good! This is what should have happened. He wasn't there for a real education in the first place and had no business there at all. A large amount of money and effort had been saved and there would be no stigma of failure and ruin to haunt him the rest of his life. No bridges had been burned. Other students, of course, would turn in acceptable work and be allowed to proceed to the next course. Second, a student who can only work if pushed to do so by grading will, if not graded, leave and either find his own reduced level of function outside the university or succeed to a certain extent, limited, however, by theoretic ignorance of his subject. The obstacles in his quest to do a more satisfying job would, one hopes, stimulate him to return to university to remedy his theoretic deficiency. But his new approach would differ from his former one; no longer would he be a grademotivated person, but a knowledgemotivated one. He would need no external pushing to learn: his push would come from inside. He'd be a free man. He wouldn't need a lot of discipline to shape him up. In fact, if the instructors assigned him were slacking on the job, he would be likely to shape them up by asking rude questions. He'd be there to learn something, would be paying to learn something, and they'd better come up with it. Motivation, once it catches hold, is a ferocious force, and in the gradeless, degreeless institution where our student would find himself, he wouldn't stop with... ordinary clinical information. Take the case of a patient with a tremor. The student would need to know about the cause of the tremor, its anatomic and pharmacologic features, its therapy, the peripheral dopaminergic effects, hepatic coma, electroencephalography... one could go on and on. The student motivated from within probably would. One need not, however, drop out of a gradeless course in order to achieve this result. It can be otherwise preplanned so that practice is made to reveal principles. The student's wish to "do medicine" is doubtless a genuine, if only a partly informed wish. He seeks the end result, and that status and theoretic responsibility is his distant motivating goal. Term papers are steps to this. But because all are pre-
requisites to that final goal, all must be equally important. Again the student becomes grade- and not knowledgeoriented. A medical student who was once a nurse cannot be taught irrelevancies unless the grading requirements are rigid, for such a student has seen clinical practice, can recognize what theoretic bases physicians have relied upon, and will relate everything taught to clinical situations he himself has already experienced. It is not possible to exercise sacred cows in the meadows of his mind, nor is it likely that superficial explanations will satisfy. His appetite for understanding will have been born of low-level, passive clinical experience, and that appetite will be satisfied only by specific, and in this case clinically relevant food. I would like to leave the choice of the relevant in basic science teaching to those who have not just seen but have actually felt the need for it. Such students would have been trained first in the techniques of medicine and would, for perhaps their first medical year, have been clinical apprentices to practising physicians. The first-year course thus might be called "The appearances of disease". Their exposure to sickness would suggest to them all those areas of background knowledge in which they were deficient; their lack of understanding would motivate them to seek it. Is this not a better way of inducing motivation from within? Has anyone ever done a study of the later clinical abilities of nurses-turned-physicians? I have only seen a few such individuals; I have never seen one fail a course. Those I have seen have high motivation indeed, overcoming even the frustration produced by courses needed for graduation but not for practice. If we as clinicians will not keep only those courses we recognize as appropriate, should we not at least enable the students to generate their own informed opinions about what is needful in basic science teaching? References 1. SIMPSON M: Medical Education: A Critical Approach. London, Butterworths, 1973 2. WEED L: in Problem Oriented Record, edited by HURST JW, New York, Medcom, 1972 3. PIRsIG RM: Zen and the Art ol Motor Cycle Maintenance: An inquiry into Values. New York, Morrow, 1974 4. SANDOK B: Presentation to the Third Neurological Education Workshops, Daihousie University, Halifax, 1974 (in press) 5. Bkaaows: Ibid
CMA JOURNAL/FEBRUARY 8, 1975/VOL. 112 297
