RAGBRAI and Education?

I’ve just returned from riding my 5th straight RAGBRAI. For those who do not know what this is, it is the Register’s Annual Great Bicycle Ride Across Iowa. This is the nation’s largest and oldest cross-state bicycle ride, attracting between 12-13,000 riders per day each day of its week-long length, along with another 12,000 support personnel. The ride wends its way from the west side of Iowa at the Missouri River (this year beginning at Council Bluff, and ending at the east side of the state and the Mississippi River (this year at Burlington). I ride with a couple of other Palmer faculty and administrators as part of the larger Bicyclists of Iowa City. But as I rode those long miles (449 this year), it gave me time to think of some lessons from RAGBRAI which could equally apply to education.

1. Training matters. When I first began riding this year, back in March, I felt sore and uncomfortable during my initial rides. But I kept plugging away, riding 12 or 14 miles per day, not too much, and within a few weeks my legs felt better, my derriere was not hurting, and my wind got better. Now, I can ride for miles on end and I was able to finish the daily rides, even those of 80 miles, by just past noon each day. I am not skinny, for sure but I never ended up feeling too tired. Point being, the more we engage ourselves in what we do, the more comfortable we get at it, whether it is teaching, engaging in clinical practice, or our other work. Practice really does make perfect.

2. Working with a group matters. I think we see this best in the peloton of the Tour de France. In the peloton, it has been found that the energy need to keep riding at race pace is 40% less than that of a break-way group of smaller riders. Over the course of a 100-mile ride, that leaves the peloton with a huge energy surplus compared to the lead group as the race comes to its final miles, and invariably the peloton swallows up that lead group a few miles from the end, leaving the race wide open for sprinters who have huge amounts of energy left for the final 500 meters. Same in education, collaboration with your colleagues can lessen your own work load, can provide you assistance and can leave you with energy to devote to your own interests. We have a great wealth of talent in this institution, and collaborating with our colleagues is but one way to help you actualize your own abilities and talents.

3. Planning matters. RAGBRAI is a daily grind leading to a good result: completion of the ride. It requires a rider, especially one like me who is at best modestly competent on a bike, to think about the best way to complete the ride. Each day is marked by benchmarks- towns are so far apart, and nutrition is important. Do I eat first and ride, or ride for 10 miles and then eat? Should I get out early and avoid heat and wind or ride a bit later and avoid crowds? Even my thinking matters- if I start out thinking, wow, I have 76 miles to ride today, it sounds daunting. Maybe it is better to think, it is 12 miles to the next town; then, when I get to that town, I think now it is 10 miles to the next town. Breaking it down that way can reduce the larger tension of knowing I will be in saddle all day long. The obvious corollary here is in the work we do- when we look at the larger picture it can stop us cold and we might never even get started because what we plan to do is so complex. But looking at smaller pieces of our plan, and meeting each part, leads to small success but helps keep momentum.

4. You can do the impossible. This is some of what I saw this year on the route: a man riding RAGBRAI on a bicycle without a seat, so that he had to stand and ride the entire distance. People riding RAGBRAI on unicycles- how do they get up the hills? People roller blading RAGBRAI. A woman who was running the entire route, on a daily basis- that averages to 70 miles per day! A man riding a bicycle with a sail on in, the so-called Pterosail. People on single, fixed gear bicycles. 80-year old women riding the route. A 5-year old riding. If you set your mind to something and you work to make it happen, more often than not it will, it will.

I know the above may seem banal, but in fact I find that it posits a nice mechanism for helping me to accomplish my goals and to keep continually updating my abilities. It is a microcosm of a larger worldview, but one I find helpful. It helps me have faith in myself.

Ride on!

The Six Secrets of Change

A new book by Michael Fullan (1) looks at how leaders help organizations go through change. The six processes he described address what he refers to as large-scale reform, wherein the goal is to change whole systems or organizations. He notes that these six “secrets” are synergistic, feeding upon one another, and that they are heavily nuanced. By this he means that they require thought and consideration before being used. He suggests a need for motivational embedding, in order to motivate people to invest time and energy to get results. Finally, he notes the presence of tension, wherein a good leader will keep all of these six secrets in balance.

His secrets, in short are:

- Love your employees. An institution or organization should invest as much energy toward its employees as it does its customers. Translated to an educational setting, this would mean as much energy toward the faculty and staff as it does toward its students. And he places great importance on continual learning, so that people also continue to find meaning in their work and to their relation to their company or institution.

- Connect peers with purpose. Fullan discusses what he calls the “too tight – too loose” dilemma. This is the attempt to find balance between how much you delegate power during times of change; people may feel constrained if you tighten requirements too much, but if you let power devolve too far you may get uneven results. He suggests that it is necessary for leaders to build strategies that encourage what he calls purposeful peer interaction. People enjoy working with their peers and this can foster learning that leads to results.

- Capacity building prevails. This is where leaders invest in developing individuals and group efforts to enhance the efficacy of the group as a whole. People learn new skills and competencies and as a result undergo new motivation. Doing so requires a leader to avoid intimidation and negative judgment, but also to rely on peers to help drive the process.

- Learning is work. He feels that there is too little learning going on in formal training courses that institutions offer, and not enough that occurs while actually doing the work. He feels that good institutions link working and learning very effectively.

- Transparency rules. It is necessary for institutions to have clear and regular discussions of results, and continual access to practice. He states that continuous improvement is not possible without good data, which is part of being transparent. Finally, he suggests that transparency creates positive pressure to do better.

- Systems learn. He feels that systems can learn, and that using these processes you will increase both knowledge and commitment. But to do so, people need to have their motivation constantly stimulated so that it is deepened.

His text goes on to expand upon each of these ideas, and I found it a fascinating read that suggests new approaches we can all use in addressing change.

NOTE: I will be off campus next week so the next post will occur the week after. RAGBRAI beckons.

References
1. Fullan M. The six secrets of change. San Francisco, CA; Jossey-Bass, Inc., 2008

Team-Based Learning

Team-based learning is “an instructional strategy that is “based on procedures for developing high performance learning teams that can dramatically enhance the quality of student learning.” (1) Put another way, it is the use of small groups in college teaching. Most of us are familiar with small-group learning at some level, either by being a member of a small group in our education, or by fashioning them for use in a class that we teach. Why are we seeing a growth in such forms of teaching?

In part, I think it is due to the fact that younger learners are more conversant with technology, are less tolerant of lecture settings, and are tired of passive learning settings. Small groups not only enhance learning, but they also foster interpersonal skill development. And finally, small groups can be an exciting new method for teachers to use to help engage their learners. According to Fink, small-group learning is transformational, driving four separate kinds of transformation:

- Transforming small groups into teams
- Transforming technique into strategy
- Transforming the quality of learning
- Transforming the joy of teaching

Further, Fink also notes that there are three different ways to use small groups: casual use, cooperative learning, and team-based learning. Casual use represents the first use by an instructor, where perhaps after delivering a short lecture the instructor then asks students to pair up with the person sitting next tot hem to discuss a question or solve a problem. After allowing a short period of time to pass, the instructor then calls on some of those students to provide a response. Cooperative learning is a bit more complex. It requires advance planning, regular use of small groups, role assignment, and so on. However, it does not require any significant change in the current structure or format of the course in which it occurs. The small group activities simply are fit into that structure. The pinnacle, then, is team-based learning. Here, the structure of the course in changed in order to most effectively take advantage of what are now called learning teams. These teams require commitment from students and a desire to solve problems beyond the abilities of any single member. (1, p. 7)

Fink notes that for learning teams to be used, a course need only have a body of information that students need to understand, and that the students learning how to apply the content by solving problems or resolving issues. A classic example of this approach could be embodied in the small group process of problem-based learning in healthcare education. Lastly, Fink defines team-based learning as “a particular instructional strategy that is designed to (a) support the development of high performance learning teams and (b) provide opportunities for these teams to engage in significant learning tasks.” (1, p. 9)

It is likely we all use at least a small measure of team-based learning in our teaching; the question is how to systematize doing so at a higher level. The text by Michaelson, Knight and Fink provides a detailed examination in how to do so.

References

1. Michaelson LK, Knight AB, Fink LD, editors. Team-based learning: a transformatice use of small groups in college teaching. Sterling, VA; Stylus Publishing 2004:vi

The American Public Health Association

I’ve been a member of the American Public Health Association for nearly 15 years now, and am among only perhaps a few hundred people from our profession to join and participate. I’d like to take a little time here to describe APHA and advocate for you to consider joining as a member of the Chiropractic Health Care section. Information I present here can also be found on the APHA website, at http://www.apha.org/.

APHA is the oldest and largest public health organization in the world, and has been in existence since 1872. As the website notes, “the Association aims to protect all Americans and their communities from preventable, serious health threats and strives to assure community-based health promotion and disease prevention activities and preventive health services are universally accessible in the United States.” Amongst its members are practitioners, educators and health care professionals of an amazing diversity, and this diversity includes several hundred chiropractors. The vision of APHA is a healthy global society, and it has worked ceaselessly to that end for more than a century. Its mission is to “Improve the health of the public and achieve equity in health status.” APHA gives voice to the underserved and the forgotten, ensuring that our efforts at improving national health leaves no one behind.

Advocacy is a major activity of APHA, and it regularly publishes legislative updates of its actions; the latest can be read at http://www.apha.org/NR/rdonlyres/74574D4F-4FC8-4920-8526-8B58259C2CF0/0/May2009LegislativeUpdate.pdf.

APHA has 25 sections, each comprised of major public health disciplines. Sections are the primary professional unit of APHA, and it is through its sections that much of its work is accomplished. I am pleased to note that one of the 25 sections is the Chiropractic Health Care section. As it is described on the website, the CHC “enhances public health through the application of chiropractic knowledge to the community by conservative care, disease prevention and health promotion.” The existence of this section is a result of the work of a number of people, but none more so than Dr. Rand Baird, who has been an APHA member for more than 25 years and was instrumental in growing the chiropractic membership. Palmer College has an active number of faculty and administrators among the members of this section.

It is important that we have this voice. Chiropractors serve on APHA’s Governing Council, and have made important input into public health policy. But our numbers are few and more should join. Please consider it. The investment of money pays off in influence, and our influence needs to be heard at the highest levels of our government. APHA can help make that happen.

Organizational Culture in Higher Education

In the business community, the focus on organizational culture really took off in the 1980, with the publication of books like Peters and Waterman In Search of Excellence. But since that time, there has been little agreement on how to view culture, and a number of theories have evolved. What is incontrovertible is that culture does play a role in aiding and resisting change. Change is, of course, inevitable in education.

Institutions are influenced not only by outside forces (ie, the economy) but by inside forces as well. This internal dynamic “has its roots in the history of the organization and derives its force from the values, processes, and goals held by those most intimately involved in the organization’s workings.” (1) Decisions and actions are a reflection of the organization’s culture. For those that have been in the culture for some time, the cultural values are part of the air they breath, not often considered consciously but almost always followed nonetheless. It is only when we break the codes of our culture that we find ourselves aware that they are there. But culture is a driver in educational organizations, and as our challenges become more difficult that there is a need to look at culture as a means to help address these challenges.

Tierney notes that organizational culture encourages members to:
- Consider conflict in the broad canvas of organizational life
- Recognize contradictions that create organizational tension
- Implement decisions with an awareness of their role on the culture
- Understand the symbolic dimensions of decisions and actions
- Consider why different groups have different perceptions about performance

Thus, Tierney offers a framework for looking at culture. In this framework, he considers:

- Environment: how does the organizational define its environment and what is its attitude toward that environment?

- Mission: how do we define the mission, articulate it, and use it for decision making? How much agreement is there?

- Socialization: How do new faculty (or staff or administrators) becomes socialized? How do we find out what we need to know to survive and thrive in our new environment?

- Information: What is information, who has it, and how do I get it?

- Strategy: How are decisions made? Who makes them? What happens if I make a bad decision?

- Leadership: What does the organization wants from its leaders? Who are they? Are there informal leaders as well as formal ones?

Our culture is conveyed in the relationships we have with our colleagues, and how we view what we see happening. No organization can be immune to the effects of culture, and understanding it is critical to aiding in innovation and change.

References

1. Tierney WG. The impact of culture on organizational decision making: theory and practice in higher education. Sterling, VA; Stylus Publishing 2008:24

Likelihood Ratios

Imagine that in trying to gather information about a particular patient you are seeing you come across an article that describes a diagnostic test that may help better confirm your suspected diagnosis. For example, let us assume that your patient is suffering from back pain, and you suspect that she might have a herniated intervertebral disc. You believe this because your work-up for that patient has found that there is pain in the low back which radiates down the leg and into the lateral side of the foot, that certain motions are quite painful, that this came on after a doing physical labor, and that it has worsened over the past three days. In addition, you have a number of positive diagnostic tests which have occurred, but they seem mildly contradictory and you feel that it may be due to the severe pain the patient is experiencing. What can you do to get a better handle on what is happening?

You can look at the likelihood ratio for one of the diagnostic tests you did. Why look at this? Well, the main reason is that doing so will help move you from your estimate of the likelihood the patient has a disc herniation (also called the pre-test probability) to a more accurate estimate (called the post-test probability of the target disorder). The likelihood ratio is a tool which moves us from pre-test probability to post-test probability.

Consider: the presence of a positive straight leg raise test is seen as indicative of a disc herniation. But it is not conclusive and there may be other possible explanations for its presence. But certainly, with the other information you have collected from your patient, a large likelihood ratio will likely move to you a more positive confirmation of disc herniation, and also may lead you to consider either diagnostic imaging or to a particular management protocol.

A likelihood ratio is the relative likelihood that a given test would be expected to be positive (or negative) in a patient with a disorder as opposed to one without (1). Likelihood ratios can be calculated easily from 2x2 contingency tables used to calculate sensitivity and specificity; a likelihood ratio is actually [Sensitivity/(1- Specificity)]. For the actual math involved, please see http://w3.palmer.edu/lawrence/RSCH841/Reliability%20and%20Validity.doc.

But here is the key to understanding a likelihood ratio. It indicates the extent to which a diagnostic test will increase (or decrease) the pretest probability of the target disorder. LRs of 1 mean that the pre and post-test probabilities are exactly the same; if greater than 1, it indicates an increase in the probability that the target disorder is present (and the greater this number, the greater the probability), while the converse is true for likelihood ratios of less than 1. With a likelihood ratio, you can use a nomogram (such as the one found at http://www.cebm.net/index.aspx?o=1161) to convert the pretest probability to a post-test probability.

In our case, let’s begin by assuming that the pre-test probability of the presence of herniated disc is 50%; this is based on our own clinical expertise plus any literature we may have read. From the paper we found, we see that the likelihood ratio for a straight leg raise is 12. Plugging this into the online nomogram shows us that the post-test probability of a disc herniation is now 94%. One could feel quite comfortable that this patient does indeed have a disc herniation, and can proceed accordingly.

You can find tables of likelihood ratios derived from the scientific literature, such as those seen in the Rational Clinical Examination series from JAMA. They are the most valuable test we have for the use of diagnostic tests.

References

1. Guyatt G, Rennie D, Meade MO, Cook DJ. Users’ Guides to the medical literature: a manual for evidence-based clinical practice, 2nd edition. New York, NY; McGraw Hill, 2008:426-430
2. Sackett D, Rennie D. The science of the art of the clinical examination. JAMA 1992;267:2650-2652

Preparing Tables in Your Journal Articles

One the great problems that journal editors face today is that anyone with a computer and a word processing program can create their own tables and graphics to accompany their journal submissions. But most who do so are unaware of the typesetting protocols that go into proper table preparation and make tables that are too complex, too large, too poorly organized or too large. With a little bit of thought, it is possible to construct tables that easily convey information; that is, of course, the entire reason to have one.

Tables need to be prepared so that the information they contain are accurately understood. Tables should be used for the presentation of only certain kinds of information, including information where the numerical values are important, where there is a large amount of numerical data in a compact form, where a summary of information is needed, or where the information cannot easily be summarized in text form. The 6th edition of Scientific Style and Format (1) offers the following guidelines for tables:

- Make them complete enough that the reader does not need to continually refer to the text.

- Make them as simple as possible, and if it is not possible to make them simple, make them logical and orderly.

- There needs to be a logical basis for how you organize columns and rows.

- The units used in a table should be consistent with those in the text (which I note is a common error we find in tables).

- Do not provide the same information in both table and text format.

- Don’t make a table if you can easily explain the findings in a few lines of text.

When you prepare tables for publication, in general they are placed at the end of the manuscript, and are placed on individual new pages of the manuscript, no matter how small any given table might be. If you have 5 tables, that would take at least 5 pages to print. Each table should have a title, which is coordinated to the table number in the text. Each table should be numbered consecutively according to order of occurrence, and each should have its own call-out (that is, words that direct the reader to look at that particular table, ie, “See table 1.”). Do not use numbering where you have variants (Table 1a, 1b, 1c, etc). It is okay to use abbreviations in a table, but you should also use a footnote to let the reader know what the abbreviation means. Doing so saves space, which makes the table less costly to print. You do not need to use more than 2 significant digits in printing numerical data, and you should always provide the unit for the table so the reader knows exactly the meaning of the numerical data. Each column of entries should be aligned with its respective heading, either flush left or centered. If you have no number larger than 9999, you do not need to separate the digits with a comma, but if you go above 9999, you will have to do so (ie, 10,350). If you use decimal points, you should align on the decimal. Footnotes are used when the information they contain does not fit into the logical order of the table. Superscripts are recommended now, as numerics, not as symbols (such as asterisk, dagger, etc.). People understand the order better this way.

A lot of thought goes into table construction and it is not quite as easy as it may initially seem. Style guides such as the one referenced here can provide guidance, as can reference to the Vancouver Accords of the International Committee of Medical Journal Editors (2).

References

1. Style Manual Committee of the Council of Biology editors. Scientific style and format: the CBE manual for authors, editors and publishers, 6th edition. New York, NY; Cambride University Press, 1994:677
2. http://www.icmje.org/