Friday, September 4, 2009

The class as a microcosm of the course

The survey results from Wednesday's class are pretty much in. I'll have the results posted by this afternoon. The general conclusion seems to be that we interacted better with the new rules, but perhaps the discussion didn't go to the depths it might. I'll elaborate on that further below.

Professors like to hear themselves talk. I'm no exception. At an intellectual level I do understand that it is you students who have to do the learning for yourselves. I can't do it for you. So working through things on your own is for the good. Nonetheless, I found myself wanting to jump in several times and had to consciously and uncomfortably for me hold back to let your conversation flow.

To be clear about things, while I did plan from the outset to do these little surveys to get anindicator of how the sessions went, I in no way planned for Monday's class (and perhaps the classes the first week too) to have little sense of flow to them and that progress is being made, requiring some adjustments to make the sessions better. I am not smart enough to design our early sessions to be suboptimal so that we can collectively make them better. But given that the situation has presented itself, it is interesting to ask whether we can use ourselves to gain insight into how to design for effective change.

I face the following conundrum in thinking about how we should move forward. Using a metaphor of swimming in a pond, there was very good swimming to be had in the center of the pond. But collectively you didn't find it. Instead you stayed in the reeds, where progress is slow and you get scratched up. I don't understand why. Perhaps upon reading this some of you can offer a response that would shed light on the situation.

In Better, the designer for effective change is the health care professional, for the most part doctors. We spent very little time in the discussion on the doctor who designed the vest and was responsible for making his Center perform well above the average. We touched on him, but mostly talked about other things. We might have spent more time talking about patients. In a not very precise analogy but one for getting us started, if teacher is to doctor then student is to patient. As students, you may have reasonably identified with the patient. (More on that below). But instead, we spent a good chunk of time on the family decision to move or stay in Cincinnati once the Center there released the information about its poor performance.

There was a reason to bring up the point, since it speaks to the issue of how credible Gawande was in discussing the benefits of being open about failure. But it is in no way the central point in the chapter on the Bell Curve. Why did our discussion linger there?

Suppose you had made the identification between student and patient. In what ways are they the same where the identification is useful in helping you to understand what is going on? I'm not sure whether it came up in that session or not, but I've heard it mentioned several times by a variety of you that in at least some of your courses, the subject matter is obscure and the assignments you are required to do appear to be make work. When that is the case, it seems reasonable enough to expect the student to feel imprisoned. That feeling, in turn, creates a sense of frustration and can lead to angry responses, behavior that might not seem rational when thinking long term but is very easy to understand on the ground.

At least some of you had knowledge of that coming into the course. For those who did, how hard is it to make the identification that a teen with cystic fibrosis also feels imprisoned? Making that sort of identification is what I mean by transfer. On the survey many of you said transfer did occur in this session. But I didn't see anyone make this identification.

An insightful doctor will understand this about his patients. He'll come to this understanding by taking an anthropological approach - having ongoing conversations that give evidence of what is going on. Not taking the treatment is an angry response. Seen this way, the vest is interesting because it empowers the patient to do the treatment on her own. She doesn't have to depend on another. The vest isn't a technological miracle. It is a testament to the doctor's empathy for the patient and that he has the insight to act on that empathy.

Right in front of us is all there is to what I believe can be said about designing for effective change. It requires a strong sense of empathy, an anthropological approach to gain understanding of what is going on, and an intelligence to act based on these things. The empathy itself may come from the notion that people deserve to feel like human beings and not like prisoners. I'm not sure everyone possesses that notion but for those who do it may be fundamental or part of ones core beliefs that our families instill in us. The other two, I believe, are learned elsewhere, mostly through the doctor's own explorations. They can't be the stuff taught in medical schools, however, because if they were then there wouldn't be a Bell Curve, though maybe it should find its way into the medical school curriculum.

If you view it this way several other things get explained fairly easily. The doctor's ongoing motivation to innovate follows from the reality that the treatments are for coping; they are not a cure. Absent a cure, someone with cystic fibrosis will feel imprisoned from time to time, no matter how effective the treatment is. (We did spend some time discussing the motivation but we didn't have a good explanation for it.)

I do think this is the only way to read this chapter. Gawande is not writing a classic work of fiction where scholars debate the interpretation. He writes to make his meaning plain. So there is a puzzle for me about why our discussion didn't tread on these waters. Perhaps for some of you the chapter wasn't fresh in your memory, having read it in early summer. And maybe for others the life experiences weren't there to be able to make the needed connections. I'm guessing for still others all the ingredients were there but you didn't put it all together, perhaps because some of your other beliefs blocked you from doing so.

I would really like to understand the explanation. If you can get to the middle of the pond on our own in class conversation, I'm fine on being non-directive, wanting to hear myself speak notwithstanding. If you can't, we need to find Plan B for our approach through the rest of the course, though I'm not sure what that would be.


  1. Just to address the long discussion on the family's decision to remain in Cincinatti...

    I was the person to pose this question, and I definitely did not mean for it to last as long as it did. I (and I think others as well) did think that the discussion should move on to a different topic, however we were getting good input and discussion. I think because it was the first time we had this "student led" discussion, we (or at least I) weren't sure how much to control the discussion and how much to just let it flow. I think another thing that may keep us from flowing into more important topics sometimes is that when students raise their hands sometimes it is long before they get called on, and so what they had to say may not relate to the topic at hand anymore.

    With that said, I think it is important to bring up the important subject matter, so maybe we continue on student-directed discussion with interjections of directing from you if we are not moving in the right direction...

  2. Thanks, Tiffany. We have the long weekend to consider how much of one and how much of the other we should do.

  3. I admit that I was glad when you (Professor Arvan) had us move to another topic after we spent a long time on the family decision question. What I really liked about the Wed session was how students addressed each other. Some even posed their own questions after their responses. It is still essential that we keep moving at a good pace. Not everyone will be interested in discussing every topic that is brought up, so we shouldn't linger so much on one, especially if it isn't the central idea. I feel that's a role that you can really fill for us in this class. You do have more knowledge and insight than many of us. You know more about what are the ideas that are important in these readings. Like Tiffany, I agree that we do need direction from you during the class time, though not through asking every question posed in our discussions.

    I am not really sure yet what the solution is or what the balance should be, but I have seen good aspects in both types of sessions we have done so far.

  4. While I agree that as a class, we should be able to "reach the middle of the pond" on our own, I feel that we are still all a little unsure as to your ideas for the class. Said another way, I don't feel that we have a good enough idea of your "discussion goals" from the first few class sessions to be able to do it ourselves, hence the reason we floundered on Wednesday. It might be good to take a step back and have you lead the discussion for a day or two so that we can all learn what you would like us to do "on our own" in the future.

  5. Greg - I think that is a good suggestion. I'm going to try a hybrid tomorrow where there is some direction, then let you guys go, then conclude and start the cycle again. Afterwards I hope we have some time to critique.