More on What the Best College Teachers Do

In this entry I return to the work of Ken Bain, whose book on the best college teachers (1) was the basis of his presentation to Palmer Davenport faculty a couple of years ago. In his text, there is a chapter on how the best teachers prepare to teach. And in this chapter he discusses a set of questions he finds that the best teachers ask when involved in course planning.

1. What big questions will my course help students answer, or what skills, abilities or qualities will it help them develop, and how will I encourage my students’ interest in these questions and abilities?
What this means is, we start with the results we hope to foster and work backward. What is it we want out students to do- do we want them to reason, to recall or to comprehend? When we look at the questions we want to ask, do we delve behind that question to see if there are larger questions? Do we test our fundamental assumptions?

2. What reasoning abilities must students have or develop to answer the questions the course raises?
We want more than to ask students to memorize information. We want them to be able to reason out the answers, and we want to get them to do so both collaboratively and by themselves in problem-solving settings.

3. What mental models are students likely to bring with them that I will want them to challenge? How can I help them construct that intellectual challenge?
How do these models impact, either positively or negatively, the learning students need to undergo to answer the questions we have set before them? Can we then plan to use this knowledge to help them do just that?

4. What information will my students need to understand in order to answer the important questions of the course and challenge their assumptions? How will they best obtain that information?
This revolves around what students need to learn, and not what we might intend to do in the classroom or clinic. Our focus is on helping people learn to reason, to think. It moves us away from being purveyors of knowledge, dropping content into student heads and brains. It makes learning far more active, and engaging for the student.

5. How will I help students who have difficulty understanding the questions and using evidence and reason to answer them?
This is sort of a question of tactics; do we answer questions, provide explanations, develop exercises, or what? How do we then develop new skills in our students when challenges arise?

6. How will I confront my students with conflicting problems (maybe even conflicting claims about the truth) and encourage them to grapple (perhaps collaboratively) with the issues?
How true this is in chiropractic, where there are numerous and often contradictory fundamental approaches to chiropractic, to management, to concepts and constructs such as subluxation. What methods can we use to address conflicting information that may arise both inside the educational program and outside it? Addressing conflict in ideas needs to be built into the fabric of our coursework and our teaching methods.

7. How will I find out what they know already and what they expect from the course, and how will I reconcile any differences between my expectations and theirs?
We all understand this, but we still often teach in a way that controls the questions, sets the agenda and so on; we are, after all, the experts here. But how do we reconcile this with a need to provide more self-directed and active learning opportunities?

These are only some of the questions that Bain asks, and there are a good number more, but the point here is to open the teaching window and consider the students whom we teach- look to make this a more active and engaging process in which the student actively helps to construct learning. Our best teachers often do this, and may not even understand why. Bain helps to answer that question.

References
1. Bain K. What the best college teachers do. Cambridge, MA; hardvard University press, 2004:48-57

Anatomy of a Scholarly Article

In general, scholarly research articles are divided into the following sections: Introduction; Methods; Results; Discussion; Conclusion (sometimes referred to as the IMRAD format), though each main heading might have subsections. There will also be an abstract, usually in a structured format, and a reference section; articles missing any of these pieces are likely flawed in some manner. Keep in mind that research reports have structures that differ from case reports or literature reviews, which themselves have unique structures.

Abstract: This is a brief summary of the article limited to a paragraph or 250 words, providing a synopsis of the article. Typically, this is what a reader views before making a decision to read the full article. Today, structured abstracts are most common; these have subheadings for each part of the paper. These are preferred because they do a better job than the traditional prose abstract did. The abstract should present the purpose of the study, and allow the reader to screen for possible bias.

Introduction: This provides a rationale for the study and conveys the article’s purpose. It will usually provide a brief review of the literature, highlighting important research on the topic and giving context for the research. It should stimulate the reader’s interest. It should conclude with a clear statement of the study’s purpose- indicating the hypothesis to be tested or the question to be answered. Thus, an appraisal of the introduction should look to see if the purpose is presented and the context given.

Methods: This provides details about how the study was carried out. It will tell you how subjects were selected and assigned to groups, will describe the equipment used, and will thoroughly describe the procedures used. It will define its experimental design. A standard for the methods section is that it should give you enough information so that an interested researcher could repeat what was done. There should be a statement about the ethical safeguard used for both human and animal research. And there should be a statement about how the data will be analyzed. When you appraise the methods, ensure that the research design is appropriate for the study’s purpose and question, that the population and samples are identified, and that the methods of data collection are described in detail.

Results: This presents the findings of the study. Data is summarized, tables and graphs prepared and information is presented in a comprehensive and convincing manner. Ensure that you see that all data is presented; missing data may be a sign the author is ignoring data contradictory to the study’s hypothesis. All statements should be supported by the data. You should also look to see that all the demographic data is presented, and that statistical tests are described.

Discussion: This section points our new or important features of the study, and compares the study’s results with previous reports. It should help tell whether the data supports the hypothesis, note any limitations and provide alternate explanations for findings. The discussion should follow logically from the study data, leading to conclusions that support the study objectives.

Conclusion: This points out the importance of the study findings, and points to new directions for future research. This is not a place for any speculation.

References: Should be complete and accurate, mainly from peer-reviewed journals and only relevant citations used and cited. They should be up-to-date and from high-quality evidence sources.

Reporting Statistics in Healthcare I

Tom Lang is seen by many as the dean of statistical reporting in healthcare. His book on statistical reporting (1) is a leading text to the guidelines used for this purpose, and for novice writers following his recommendations is de riguer. His book opens with a chapter that reviews the reporting of statistics in each part of a scientific research report. This bears your attention.

FOR THE INTRODUCTION

1. State the purpose of the study. Identify the relationships that were studied and the reasons for studying them. All too often the purpose for the research is left unsaid. In clinical trials, it helps to know if the study is explanatory or pragmatic. Explanatory studies, also known as efficacy studies, are designed to help understand a disease or therapeutic process; as a result, they are best conducted under optimal conditions with extremely tight controls over what occurs during the course of the study. Pragmatic studies, also known as effectiveness studies, are designed to help answer or provide information about clinical decision making. Thus, these are conducted under what might be considered “real world” or normal conditions, representing the reality of working in a clinical environment. Thus, it helps to know the purpose of the study, and in general a study should be one or the other, but not both. Lang states that you will more typically see heterogenous samples in pragmatic studies, but more homogenous samples in explanatory studies, and this makes sense given the above definitions.

2. If the study was designed to test one or more a priori hypotheses, state the hypotheses. This is because good science requires a “clear statement of a testable question.” When we know this in advance, it is called an a priori hypothesis, and the results can then be interpreted in light of that question. When we develop the question after we collect the data, that is termed a post hoc analysis, and this is a more speculative form of analysis because the data was not originally collected to answer the questions being asked “after the fact.”

3. State how the original data may be obtained for reanalysis and the format in which the data are stored. It should be an industry standard that the data collected in scientific studies should be made available upon request. Indeed, several journals require authors to sign a statement that they will provide the data when the editor asks for it. This can help to provide a check on data analysis, as well as scientific misconduct. Authors should report the format in which the data are stored, so as to ensure that those interested will be able to work with that data.

This is an introduction to how we can use report data properly. I will later look at other parts of scientific papers to provide an overview of reporting research designs and activities. I note and recommend that for those interested in conducting research Lang’s book is a must have. Highly recommended.

References
1. Lang T, Sekic M. How to report statistics in medicine: annotated guidelines for authors, editors and reviewers. 2nd edition. Philadelphia, PA; American College of Physicians, 2006

The Challenges of International Research

Over the past few months, I’ve fielded a number of questions from faculty members interested in conducting scientific research while on a Clinic Abroad trip. In each case, I have had to discuss the challenges of doing so, because the conduct of human subject research in foreign settings is fraught with legal, moral and ethical issues. And as much as I truly hate being the bearer of bad news- for after all, my role is in part to enhance research scholarship- there are good reasons to raise those challenges. I thought I would use this entry to briefly discuss the ethics of international research.

As human activity globalizes, there has been increasing concern about international research ethics since a significant amount of drug research now occurs in third-world and developing nations. Not all of this has been without controversy. In the United States, our research ethics has been guided by the Belmont Report (1), which itself was based on the Declaration of Helsinki (2) [which was itself based on the Nuremburg Code (3) that developed immediately after the end of World War II]. While these codes and accords began with the protection of subjects involved in non-therapeutic research (that is , research that provided no benefit to the subject), it has been universalized to those who also participate in therapeutic research ( where there is a potential for subject benefit, not a guarantee). Arising from this is the key bioethical precept of informed consent. Quoting my former instructor Dr. Erin Egan, “Informed consent in research is a complex issue even in the United States, and research in other countries adds several levels of complexity.”(4) Beyond that, other areas of concern include (a) Vulnerable populations issues, (b) Informed consent issues, and (c) Social justice and societal benefits issues.

Vulnerable Populations: Major pharmaceutical companies look to overseas regions because it is cheaper and they might be able to use study designs that would not be approved for use in the United States. Costs are lower because potential participants are likely to accept far less monies that subjects in the US would, and because poverty may ultimately override their normal caution in considering participation. If you obtain participants because of poverty and desperation, this can be problematic; it is not unethical in and of itself to simply offer lower costs and payments. And consider this: if you do an AIDS trial in, say, Mozambique because the design you are using is not ethical in the US, and you are not offering any care once the trial is done, and the people of Mozambique will not be able to use the drug under development because it will cost too much; you are taking advantage of the population since they will never benefit from the results, and you are then using them to help develop a drug to be sold in the US alone. I think we can see the problem here. The current standard is that all research participants are entitled to the worldwide best standard of care (as opposed to the standard of care as offered in that country, said standard of which may be no care at all).

Informed Consent: This is hard to address in the USA as it is; it is even harder when you factor in language and cultural issues, as well as lack of education. How can we translate our English language consent forms into another language and retain the nuances of the document, and ensure it is written at an appropriate level? How well do we understand the culture itself? Do we need to involve community leaders or tribal elders? How do ensure that women are not coerced, without our knowledge, into participating or not participating?

Social Justice and Societal Benefits: There now exists both national and international guidelines about what comprises acceptable research in foreign populations. These are designed to help limit the concerns we might have about using one population of subjects for the primary benefit of another more advantaged population. Thus, one stipulation of this consensus is that the research must benefit the population studied; it makes sense, for example, to study Malaria in a country where it is endemic, though it might be less ethical to study the effects of a new drug for obesity in such populations. A second issue is that of subsequent care- you should not come into an area, conduct research and then leave without considering providing some consideration of the subsequent health needs of the community. This may seem less critical for chiropractic care, since it is not generally addressing life-threatening diseases, but it is still no less true. In countries with poor infrastructure, how do ensure this happens?

There is also one other consideration, and that is ethics review. We have a Palmer IRB which reviews research conducted by Palmer faculty and researchers. When working in another country, we need to follow their laws as well as our own, and this means we need to have IRB review done by both the Palmer IRB and a local IRB in the country of interest. We need to be sensitive to the health ministry and its regulations as well. This needs to be studied, since it varies by country. The National Bioethics Advisory Committee has said this on this issue: “Recommendation 5.2: The U.S. government should not sponsor or conduct clinical trials in developing countries unless such trials have received prior approval by an ethics review committee in the host country and by a U.S. Institutional Review Board. However, if the human participants protection system of the host country or a particular host country institution has been determined by the U.S. government to achieve all the substantive ethical protections outlined in Recommendation 1.1, then review by a host country ethics review committee alone is sufficient.” (5)

Given all these considerations, I hope you can see why I have been so cautious about the development of foreign-based projects during Clinic Abroad trips. This is not to say we cannot consider such research, but it will take significant planning to be able to develop such a project successfully.

References
1. http://ohsr.od.nih.gov/guidelines/belmont.html, accessed April 27, 2010
2. http://www.wma.net/en/30publications/10policies/b3/index.html, accessed April 27, 2010
3. http://ohsr.od.nih.gov/guidelines/nuremberg.html, accessed April 27, 2010
4. Egan E. Course notes, week 11, Research Ethics. Loyola University, Nieswanger Institute of Ethics, 2009
5. National Bioethics Advisory Committee. Ethical and policy issues in international research: clinical trials in developing countries. Bethesda, MD, 2001

Single Subject Time Series Designs

The single subject time series design (SSTSD) is a form of a case report that uses a more formal process to track the response of a single patient over time. One of the challenges physicians face is the knowledge that it is never really possible to know, for a given single patient, that what we have done to the patient has resulted in the response we see. There can be many reasons a patient responds after therapy, such as natural history, the intervention, placebo effect, and so on. However, the SSTSD provides us with a better window into the usefulness of our intervention, since it tracks a single person over time.

In an SSTSD, you would initially establish a baseline on your patient over a period of at least 3 visits. Here, you would collect data on the patient’s status. For example, perhaps we were working with a patient who has chronic low back pain, and our outcomes measures include an Oswestry Disability Index as well as a Visual Analogue Scale. Taking these three measures gives us a stable sense of the patient’s status. Then, we begin treatment, and during the period of treatment we continue to take these same outcome measurements. We do so for the same length of time as we did for the baseline period. We might see a change in scores when we do this, a reduction in both disability and pain. This can help establish a relation between our intervention and the patient response. Now, let’s add one more period of measurement, a follow-up period where we cease therapy again, and instead measure the outcomes over a similar period of time. If we see the scores rise or return to where they were before we started treatment, this is even better data demonstrating the impact that our therapy has. This is known as an ABA design for a SSTSD.

Conditions ripe for study as SSTSDs need to be stable and chronic; acute conditions vary too quickly for a physician or researcher to be able to establish a meaningful baseline for comparison, because as you can see, the patient acts as his or her own control during the treatment and follow-up time. These kinds of studies are useful for helping a patient to understand change over time, especially for conditions where change in made only incrementally and slowly (for example, frozen should or adhesive capsulitis).

Variations in this design exist. For example, an ABA design can be repeated over time as an ABAB design, also known as a withdrawal design since it withdraws and then restores therapy several times. There can be an ABAC design, where C represents a second, alternative intervention. We can also consider a multiple baseline design, in which at least 3 individuals are tracked like this, but with the caveat that we do not begin treatment on the second patient until after we see a response in the first, and we do not begin treatment on the third patient until we see a response in the second. The differing baselines here are a means to reduce effects of confounding influences. There is also a simultaneous baseline design in which we do the same as in a multiple baseline approach but gather all our patients at the same time; in a multiple baseline approach it is not necessary to do so.

This methodology can be useful in a practice setting, and can be a means for a chiropractor to collect data for future publication. It also is a means to strengthen the results drawn from case reports, which tend to fall lower on an evidence hierarchy. I do not neglect case reports, though; they are often the papers clinicians turn to first, and they can offer direction for challenging patients.

Theoretical Frameworks for Academic Dishonesty

An interesting chapter by DiPietro in the new book “To Improve the Academy, Volume 28” (1) discusses a variety of theoretical frameworks used to explain academic dishonesty. He lays out five such theories, and then places student behavior in their contexts. These theories include deterrence theory, rational choice theory, neutralization theory, planned behavior theory and situational ethics.

1. Deterrence theory: this theory proposes that cheating is a function of the severity of the consequences. Thus, if we want to prevent or stop certain behaviors, we need to punish them with consequences so severe it will act as a discouragement. Such punishments might include failing the assignment or course, probation or expulsion. This is based on past research demonstrating that when people believe they can engage in a behavior with no or minimal consequences, they are likely to do so. One of the chief challenges here is that, due to the increased time and effort involved, instructors may not wish to report the behavior. There are also cultural determinants; Western students fear expulsion, while Asian students seem to fear public humiliation.

2. Rational Choice theory: Here, this theory treats dishonest actions as the result of decisions that we make as rational agents; that is, we weight pros and cons of an action, and based on how we assess the alternatives, we make our choice. We might look at this as a kind of cost-benefit analysis: is the effort necessary to cheat worth the cost of getting caught and being punished?

3. Neutralization theory: This theory hypothesizes that students are able to engage in morally inappropriate acts without damage to their self-esteem if they are able to rationalize the act and consider it morally neutral rather than wrong. I think of a recent news report about a young author charged with plagiarizing from an existing text who stated that she was using the material as a “mash-up”; that is, taking someone else’s words and placing them into he rown work as part of her creative process. If we can convince ourselves that what we are doing is not morally wrong, we may then proceed with doing the actual act. Thus, efforts to prevent cheating should work on deneutralizing it, emphasizing the moral incorrectness of the act. We should focus on personal responsibility.

4. Planned Behavior theory: This theorizes that cheating happens because of the opportunity as well as the intention to treat. Thus, we need to take efforts to reduce the opportunity to cheat, perhaps be increasing our vigilance during exams, using additional proctors and exam versions, and by increasing education on the value of integrity and honesty. Example: place open seats between students; this reduces opportunity.

5. Situational Ethics: This appears to be related to rational choice theory and is a direct outgrowth of John Stuart Mills and his initial utilitarianism. That is, each student has to weight the specifics of his or her situation; could I cheat here because of these reasons? Can I accept the risk knowing the potential benefit? What are the issues I am concerned with here? If I do poorly, I could lose my scholarship and be sent home; thus, maybe I need to do something to increase my chance of passing, and this might include cheating. It is hard to address this because each student will bring his or her specific issues to the consideration.

These approaches help us understand something about why students cheat, but we do need to ensure consistency in our approach and in our investigations of possible cheating. None of us are naïve about this; we know it happens and we take what measures we can. Moral training and a focus on the integrity of being a doctor may help us to diminish the cheating that undoubtedly occurs.

References.
1. DiPietro M. Theoretical frameworks for academic dishonesty. In: Nilson LB, Miller JE. To Improve the Academy, Vol. 28. San Francisco, CA: Jossey-Bass, 2010:250-262

Innovation in Education- Amazing Examples

I would like to begin this entry in my blog by asking you to watch the following video:

http://www.youtube.com/watch?v=3mZ1zV1l2KQ

When you do, focus on the following. Note how the children involved are engaged in the process of what they are doing, how safe they have to feel in order to express themselves in the way that they do, what it must have taken to get a group of children in a public school to work that hard and to work together, and the commitment of the young man playing the piano, who leads these children in their singing. That man, Gregg Breinberg, came to music education and decided that maybe there was a new way to engage children, one that did not rely upon the so-called “school band” sound that pervades music training for young children. The standard pedagogy focuses upon old standards, such “America the Beautiful” and “Michael, Row Your Boat Ashore.” And while these are indeed fine songs, they may no longer really speak to children as well as they might. So Breinberg tried something new; he decided to develop vocal harmony in modern rock and soul songs. This meant teaching his kids to sing songs by Talking Heads, Rihanna, Lady Gaga, Stevie Nicks, Tori Amos, and in the case of this video, the rock band Phoenix.

Imagine being a kid in Staten Island, where these kids are located. Imagine learning to sing a song by someone like Tori Amos, likely a singer you might never have heard of, but who is a modern pop singer. So you learn the song. And then you are asked to travel across the river to sing a short set of songs in New York City, and lo and behold, when you get there, so does Tori Amos, who then sings with you! http://ps22chorus.blogspot.com/2007/05/ps22-chorus-featuring-tori-amos.html

This is innovation in action. Mr. Breinberg had formal training as a music educator, knew the standard methods for teaching music, and out of that created a new way of teaching children to sing in choir that stood the world on its head. Yet his success is undeniable and reading his blog, linked immediately above, can make you feel much better about education in general.

Then, look at this little clip of MD Weathers teaching math at Biola College:

http://www.youtube.com/watch?v=blOrY-nEGaE&feature=player_embedded

Think about how long it must have taken him to set this up. How committed he has to be to his students to invest the time and the creativity to his teaching efforts. Yet again, this is an example of a teacher moving beyond standard pedagogy, trying something new and novel, something humorous and yet engaging. In both of these teachers we see efforts to keep students engaged, to keep them just a little bit off balance, to ensure they participate with what is going on in the classroom. And the question for all of us, what can we do that might shake up a standard classroom setting? Can we bring in media? I am experimenting with using the TV program House to teach examples of bioethics (or in House’s case, usually, violations of bioethics). Can we try new methods? What might those methods be? Think about it, and give it a shot; it will be enjoyable for you and exciting for your students.