Tuesday, September 1, 2009

Gawande - Bell Curve + Apgar

Consistent with changing the approach we take during the class discussion, I will change the lesson plan to a narrative format. I prefer narration to lists, but seemingly have fallen into a trap feeling a need to produce them. So this is an attempt to get out of that.

The good part of what we've accomplished in the first three classes is that everyone has had a chance to speak up and it seems that most students are comfortable participating. Also, I have the general sense that the readings and the subject matter are to people's liking. But the participation is uneven and we are not getting a conversation. Instead we are getting students giving their two cents on a question I've posed and with possibly a diversity of views, but no real way that one expressed view informs the other, instead a set of snippets that don't add up to a conversation. There are probably a bunch of subsidiary issues that flow from that main one. Furthermore, I'm driving the bus way too much. We need to get the students to drive. That is a goal. A big one.

So I've asked that students plan questions in advance of class. When they have the chance to ask their question, they should drive, select people to respond and then it's this next part that probably still needs a fair amount of tweaking but what I will make a start here with the aim to make our discussion more like a conversation.

If student A is the one originally posing the question and student B is the first respondent and gives an answer, then A should have some discretion at that point, depending on B's response. Some possible things A could do are:
(1) Say, "Great response B. That is sensible and provides a really good answer to my question." or
(2) Say, "Thanks, B. Very interesting. But what about xyz, how does that fit?"
(3) Say, "Thanks, B. But I'm not sure I understood what you were saying."
modifications of any of these that I will not enumerate further.

If (1) happens, it is time to move on. If A had a second question, then A should proceed with that. If not, the role of questioner should move to another student. When either (2) or (3) are the case, we can't leave it there and move on. There needs to be further response. At that point A needs to decide whether B should be given another chance or a third student, C should get a turn. This has a better chance of producing a sense of conversation than what I had been doing previously. It means that not everyone will get to answer each question that is posed. But if we rotate the role of A, B, and C, and people do have questions prepared in advance, we should get broad participation overall. At least I hope so. Some repetition of ideas may come out this way because people might come up with questions that are similar but not identical. The repetition is ok to me as long as the questioner genuinely still feels there are some things unanswered that the questioner is curious about. If the questioner feels the prior discussion has covered the question, the questioner can pass. That's ok too.

If that works reasonably well then I will try not to interfere much if at all when the flow seems like it is going well and might assist the questioner in identifying a student to play the role of B in case nobody volunteers for that. (I hope that is a rare occurrence.) Then when the set of questions has concluded I'll have to make some determination where we are on the topic. If you've gone beyond what I had wanted to cover with some interesting points of the class' creation, I'd want to make note of that then and there. If I feel something important has been missed, I might then play Socrates at that point for a bit to extract the missing ideas. And if you've done the job I'd wanted to do, I might jut leave it at that or make a summary sentence or two just to wrap up.

So those are process change ideas I hope we can try. Let's switch to content coverage. The Bell Curve chapter, and to a certain extent the preceding chapter called The Score, and the one that follows it called For Performance are each about the following idea. Best practice needs to be constantly reinvented. During the process of reinvention one necessarily goes beyond known science. One tries things in a quasi-experimental (or even less experimental than that) manner, mindful of results and with an eye on performance but not caring much if at all whether there are proper controls, so potentially mis-identifying causality. The aim is not primarily to understand causality (though in retrospect that would be nice). The aim is to improve performance. If there is belief that a newly tried practice should be able to improve performance, then the practitioner should feel impelled to implement that practice. This, as much or even more so than diligence, is how we get...better. It makes a significant part of the practitioner's job finding that next thing which improves performance and turns the practitioner into a type of experimenter qua tinkerer.

The Bell Curve Chapter looks at this in the case of Cystic Fibrosis treatment, which is a good place to look because there are specialized centers for that treatment and they have substantial variability in their performance in keeping patients in good health.

Time permitting we will then talk about Apgar and her scoring system for the health of a new born baby. It is instructive how the simple measuring system completely changed obsterics. Reading that chapter about Apgar is what inspired creating the little survey we've implemented.

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