Generation Why – Challenges in Medical Education at #NSWMET

This blog post is based on a talk I prepared for the New South Wales Medical Education and Training Conference in Sydney, August 2016.
Generation Why stemlyns @_nmay

I’d like you to imagine something with me.
4It’s 08:00 on a Thursday morning and you’ve just arrived in the Emergency Department. Waiting for you is a brand new group of medical students and junior doctors. It’s a quiet day in the ED (I did say imagine…) and there are no patients waiting to be seen.

Being a medical education enthusiast, you spot an ideal opportunity to do some teaching. What better topic than trauma? You whip out your laptop and load up an old powerpoint, one you used when you last instructed on an ATLS course.

stemlyns keen student mobile phones

Before you are two slides in, all but one is looking at their mobile phone. Still, because you seem to have the attention of one junior doctor, you plough through the presentation, dutifully reading it all out word for word. 90mins and 220 slides later, you ask if there are any questions.

“Just one,” she says:

stemlyns will this be in the exam Is this familiar? So let’s take a step back and think about some other things which might be familiar.

If you know how these two things are related…

11 12

 

 

 

 

 

 

 

Or if you look at this picture and immediately want to shout “Bueller!”…

 @emmanchester @docib @_nmay stemlyns ferris bueller

4Well, that makes me happy. It makes me happy because I know you’re just like me.

I, like you, am a member of Generation X – I was born in 1980 and I am independent and self-reliant and I love facts (I love a pub quiz especially if I get to argue with the question master, which has been known to happen). These are the typical values of Generation X; born between around 1966-1981 we are rule-driven with a linear relationship between work and money (work more, get paid more).

Generation WHY?-3Maybe some of you are older than this; maybe you are looking at me and wondering if I’ve really finished my training and whether I could possibly be old enough to know anything about medical education (thanks!).

Maybe some of you are baby boomers, that glorious generation born between 1946-1965 who own everything in the world; the world owes you nothing. What you have, you’ve earned through hard work; and you know that when the boss says jump you should simply ask “how high?”

But our learners are not the same as us. They are self-obsessed, selfie-obsessed, narcissistic, impatient, demanding little upstarts with an overinflated sense of entitlement – right? They don’t want to learn, they’d rather be playing Pokemon Go… And every time you’re asked to teach them you die a little inside because you know that when you walk into the lecture theatre you’re going to be faced with this: (Ed – this is what they think an orchard looks like)

macbook-air-12-retina-release-date-2015_0

Well… no.

Yes, they are different from us and yes, they want different things. This can be uncomfortable for us because it’s unfamiliar, and medicine of all things can be extremely rigid and resistant to change. But I personally think we need to re-frame the way we consider our trainees if we want to teach them anything at all.

Generation Y: The Millennials

stemlyns generation Y

  • 1982-1994 – our junior doctors, getting to be our senior colleagues
  • Digitally fluent
  • Love collaboration, less focus on winning/losing (parents will have stories of medals for participation)
  • Detatched from institutions, networked with friends
  • Delayed rites of passage: live at home, marry later, have kids later
  • Consumers of education – “we’re paying for it, give us what we’ve paid for”
  • Dislike giving up their time even if offered money – that linear relationship no longer exists. They want work/life integration, not balance.
  • Dislike supervision and control, dislike hierarchy. Raised to believe their voice matters – when the boss says jump, they ask “why?”, which might prompt a powerful response in you, such as “how dare he?!” or “who does she think she is?!”
  • They’ve always had computers at home and are fluent in instant messaging, social networking, customisable tech – they are tech savvy
  • The world is at their fingertips, literally; low tolerance for boredom and for poor wifi
  • They are proactive learners: they want to know WHY, not what

Generation Z

stemlyns generation z

  • 1995-current, just turning 21 – these are our medical students
  • True digital natives
  • Grown up in a world of global threat
  • Clean living; lower alcohol and drug use (at least in the UK)
  • Serious and concerned about the future
  • Diverse and fluid, about gender, race and sexuality
  • Proactive online
  • We don’t know much more about them as adult learners because they’re not quite there yet

 

What do they want from education?

Let’s think about three settings. I’m basing my thoughts on generalisations, typical traits and stereotypes, but that can be helpful in informing our education strategies.

The formal learning environment

  • They want you to teach them things they can’t Google. Lane and Yamashiro looked at educational technology use at the University of Washington and found that students were 2.5x as likely to think course websites should be used and 4x as likely to use instant messaging in their education as their teachers were
  • They want education to be social – classroom time is for working together and collaborating
  • They want active learning. They have to be engaged, that boredom threshold and the rapid availability of a world of more interesting things they will tune out if you don’t keep them interested
  • They want “just in time” learning; similar to the flipped classroom: online, web-based learning at home with class time to make sense and contextualise; answers fed to instructors who can tailor teaching to the individual
  • Visually driven: functional MRI studies show that in undertaking simple tasks, younger participants had more occipital lobe activity.
  • Most up-to-date information and pitfalls when it comes to learning medicine

Face-to-face with you as their supervisor

  • The ideal boss of a Gen Y employee is equal parts mentor and leader. They’d prefer not to have a boss but if they have to have one, they dislike hierarchy; dictatorial approaches won’t work
  • They like to explore their thoughts out loud and they want to be able to do this non-judgementally – a far cry from the traditional grilling or pimping some of us might remember (if you do this nowadays you can be certain it will be construed as bullying in the complaint letter written about you – YES, Generation Y will write a complaint letter. Although it will probably be an email)
  • Recognition of the fact that they are an individual – their world is customisable, they are used to defining and branding themselves and their preferences

Online learning

  • Like it or not, many of our junior doctors and trainees are going online for their medical education. Blogs, podcasts and teaching video channels on YouTube are increasingly popular
  • Learners want to go online to find the most recent information and they know to an extent how they can do that
  • They may also perceive peers to be more credible than teachers, particularly if you’re not online or familiar with looking for up-to-date information
  • The average age of my Twitter followers is 29 years old: we know that the younger generations are online and hungry for learning

 

What does this mean for us as educators?

The formal learning environment

  • The formal lecture is dead: long live the lecture! Downloading the contents of a textbook into a powerpoint presentation and reading it out to an audience in the hope that some of it sticks has never really worked, so let’s rethink it. Replace bulletpoints with pictures, textbook content with practical applications and illness scripts, monotonous speeches with interactivity
  • Utilise workshops and games for interactivity. Simulation ticks these boxes and both Generation Y and Generation Z learners love it. Blog post on how to design a workshop up soon!
  • Use moderated small groups to help your learners apply their knowledge; be the wise expert. For learners who are resistant because they’re not interested in your specialty reframe the context (“as the admitting surgical doctor, what would be your approach to this patient?”)
  • Make sure whatever you’re teaching is relevant, giving your learners what they actually need
  • Focus on construction of ideas, not instruction: be a choreographer of learning
  • Teach critical appraisal; in our world of information overload, equip our future docs with the skills and knowledge to make sense of the world of published literature and how to translate it into clinical practice (the link takes you to Ken Milne’s fantastic interactive lecture on teaching EBM at TTCNYC15 – you can also direct them to our new Critical Appraisal Nuggets series)

Face-to-face with you as their supervisor

  • Spend time getting to know your juniors and students
  • Work together to look after patients, particularly in the Emergency Department
  • Be non-judgemental; Generation Y in particular is desperate for feedback but you will need to signpost it (“I’m going to give you some feedback”) and use advocacy with inquiry, both in simulation and real-life clinical encounters. They don’t take what they perceive as negative feedback very well.
  • Be a role model – be the boss who does the work, who sees patients and gets stuck in
  • Be a mentor; show an interest
  • Facilitate critical thinking and reflection, perhaps helping learners to craft a Personal Development Plan

Online Learning

  • Understand the world of FOAM resources out there
  • Be a part of the conversation (you’re a lifelong learner too)
  • Be a filter in the world of information overload (as Chris Nickson says, “there’s no such thing as information overload, only filter failure.”)
  • Give your learners a FOAM prescription
  • Think about how you can use asynchronous learning to suit your learners (we have a lot of ideas about how you can do that – get in touch!)

 

It’s hard to know what works in medical education because evidence is hard to demonstrate – perhaps made harder because we try to teach to our own learning framework and preferences. Consider that the majority of major medical education literature we take as the cornerstone of what we do was written between 1960-1990; by baby boomers, about baby boomers (and possibly Generation X). It’s no wonder that it doesn’t seem to fit our current learners.

Yes, of course it’s exhausting and hard work to rethink our education strategies – it’s much easier to stick up a two hundred slide lecture and read it from the screen but we owe the next generation of doctors more than this. And if we stick to teaching the way that worked for us, we are forcing them to do the hard work of trying to fit into our schema – and isn’t that against the very essence of education?

So what should I have done with those keen learners?

stemlyns activity medical educationWe talked through the principles of primary survey for the trauma patient. I gave them a trauma scenario and they decided who should be in their trauma team, where each team member should stand, then what they should do – then later in the day they saw it happening for real and we were able to debrief to relate back to the morning’s teaching.

 

So it’s possible. In fact, it’s pretty easy really if you can bring yourself to invest time in it, you’ll get a handsome return. Our learners are smart and motivated and they truly value education. And if, after all that, your learners are still asking if it’s going to be in the exam? Well, the answer is always YES.

Nat

@_nmay

 

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21 Comments

  1. Derek Louey

    Attending The Teaching Course last month reinforced my belief that the greatest educational challenge facing Gen Y/Z is the overwhelming volume of information they are now faced with. This gives both the illusion of knowledge yet at the same time impairs their ability to learn effectively.

    Nevertheless, it was argued that their capacity and motivation to learn is no different from previous generations. Our hyperdistracted learners are virtually paralysed by the multiple inputs from the Internet in which education is only one part of its usage.

    As teachers, I think we have a role as curators of knowledge and to guide students through the process of how to manage and filter knowledge in a logical way. Teach them how to learn in the modern information age.

    Reply
    1. Natalie May (Post author)

      I couldn’t agree more, Derek. Our learners are different from us but they are dynamic and enthusiastic, if only we can adjust our teaching to harness it. And what is brilliant is that they really value education. As I say in the post and said during the talk itself, teaching our learners to understand critical appraisal and practice EBM is probably the most valuable skill we can equip them with in order to meaningfully face the overwhelming volume of published literature. Thanks for your thoughts!

      Reply
  2. Jon Smart (@JonDSmart)

    Very insightful points in this post Dr. May!

    As a current Gen-Y intern, just a few thoughts in case you wanted more confirmation of being on the right track:

    1. “Is this an efficient way to learn the material long term?” is essentially what we are looking for.

    It links back to what you say about how we value our time the most.
    We genuinely don’t mind putting in time or hard work, but there has to be a reason for it.
    We don’t want to just punch a clock saying “Well, we sat through 8 hours of lecture today, almost no one fell asleep…good work team.”

    The rudest thing an instructor can do is read a PowerPoint to me. It makes me wonder if they know I am capable of reading myself.

    We hate wasting time in inefficient, poorly planned lectures that could be spent in more effective learning.

    2. I slightly disagree that the lecture is dead. Maybe it is simply finding a better medium for itself, namely podcasts and asynchronous curriculum as you mentioned.

    I think we all know those in our programs who go above and beyond to plan excellent lectures. I really appreciate those who make the steps beyond “death-by-PowerPoint” slide sets and turn lectures into stories or scenarios that capture our attention.
    There are certain lecturers that I would gladly listen to for hours because they are THAT good at what they do.

    But, even better when I can hear these lectures ahead of time on my own and know the basic knowledge/framework they think I need to know.
    Then I can spend the group time working through the material practically either in simulations or group discussions to further solidify my understanding.

    It takes that basic, shallow knowledge gained from simply listening and makes it my own personal knowledge that I am much more likely to remember when I need it.

    I don’t think the issue is that we are these “ADHD, self-entitled, narcissists” that we constantly are characterized as (thank you for moving past that stereotype by the way!).
    But rather we value our time and want to use it effectively so that we can both become excellent physicians as well as have lives outside of the hospital that we enjoy.

    Just a few thoughts from a millennial (Since I am in the generation that likes to share our thoughts in excess at times). Thanks again for bringing attention to this!

    Reply
    1. Natalie May (Post author)

      Hi Jon,

      Thanks so much for your thoughts! We are always particularly happy when people take the time to comment on our blog posts.
      1. I love your clarity – thank you!
      2. I suppose what I should have said was “the traditional lecture is dead… Long live the lecture!” We know from the popularity of TED talks (and those from smacc) that there is a role for the on-stage presentation – but it’s not for downloading the contents of a textbook into the audience’s collective consciousness via a powerpoint karaoke experience. Exactly as you’ve outlined, these are great opportunities to explore, rethink and above all to inspire. Happy to take any feedback on today’s presentation if you feel like being specific 🙂
      And thanks for not taking the stereotype too literally – I was worried that I might have predicted the generational make-up of the audience incorrectly and risked offending lots of Gen Y but obviously that was tongue in cheek and designed to get the audience onside in order to try to get them to change their mindset. I also tried to add a meta-level of role modelling a Gen Y friendly lecture – I hope that worked too!
      Natalie

      Reply
      1. Natalie May (Post author)

        In fact, I’m going to add a link to Simon’s Medutainment series of blog posts as I think that they really explain how the traditional lecture has evolved into something more meaningful!

  3. andrewjtagg

    A very timely post for me, Nat, as I have taken over the role of intern and resident supervision in my ED.

    It can be challenging to teach when we have the time contsraints that we do have but as Cliff Reid pointed out (http://resus.me/humblingreminder/) we can have a profound impact on those around us. Our role as educators is also to inspire as well as to teach. I think the best way to inspire is to set a good example. Ending the idea of pimping and belittling as a pedagogical technique and learning how to use effective feedback to drive learning on the floor.

    Reply
  4. Derek Louey

    A lecture can also be a useful way to provide the basic scaffolding and organising principles that underpin a complex subject. The expert can also provide context, insight, perspective and emphasis on what are the key aspects that should be borne in mind. A good lecture isn’t always the one that uses parochial rhetoric. There is plenty of room for the expository form that presents both sides of an argument for the listener to consider and explore.

    Reply
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  6. Simon McCormick (@DrSimonMc)

    Really helpful piece with lots of challenging material. Has taken me years to try and get my head round the cultural differences between myself and the trainees that have come along behind me. Starting to think of them as different rather than wrong was the first step and now trying to understand their culture is the next and this blog has been really helpful in clarifying some of the things I’ve worked out by trial and much error!.

    On the flip side, do you think learners have any responsibility to understand their teachers and the culture they have come from? Just because you don’t like how somebody delivers teaching (lecture, montonous voice, paper based) doesn’t mean that what they are teaching isn’t valuable. This may be the most brilliant clinician but not a gifted teacher and maybe you need to work a bit harder to access some of that brilliance? Part of being an adult learner has surely to be understanding that it can’t always be just how you like it?

    Reply
    1. Simon Carley

      Excellent thoughts and I see your point, but it’s more efficient for the teacher to change to the learners rather than the other way around.

      Learner centred education and all that.

      It’s deeply saddening when I see a great clinician finding themselves unable to engage with their audience because they have not moved with the times.

      I also run into problems with senior educators who appraise junior ones and because it does not fit the trad model they get criticised.

      A complex situation, but at the end of the day it’s about learning and we must use whatever tools we have to try and help that happen.

      S

      Reply
      1. Derek Louey

        As passionate teachers we can do more to empower young students to acquire the maturity to capitalise on learning opportunities from even the most trying of circumstances than try to convert our older colleagues who have ceased any interest in improving their abilities.

  7. John Cronin

    Thanks Natalie that’s really excellent insight and analysis. I personally find it v challenging when you walk into a lecture and everyone has their laptops open in front of them. It’s like they are saying “you better be good or my eyes will start to drift down!”

    Reply
    1. Derek Louey

      Because experience tells them that only a few lecturers are able to deliver information more clearly than other sources. In the past we had no choice but to put up with sub-standard teachers. Today the options are virtually endless. If you are confident and competent in your ability as an educator, they soon will be captivated by your lesson, not obligated.

      Reply
  8. Derek Louey

    Perhaps Gen Y/Z are just a product of the technological environment.

    What we interpret as

    1) ADHD, is simply their strategy of managing the volume of information traffic that converges upon them
    2) Disloyalty, is the natural skepticism developed when so many ‘authoritative’ (and sometimes contradictory voices) clamour for their attention
    3) Narcissism, is their protective response from the imposing demands that exist in a hyper-connected world
    4) Consumerism, is the result of a greater range of competitive and quality educational products on the market.

    Gen Y/Z are not desperately in need of someone who has complete authoritative knowledge, but a mentor who teaches them to choose wisely from amongst those who claim they do.

    Reply
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