Direct Observation, Perfection, and Imposter Syndrome
7-10 Minute Read
Author: Bruce Morgenstern, MD
Purpose
To provide a framework for clincal educators to understand the best practices, the jargon, and the fundamentals of medical student education so that current and future students can maximize their learning.
Learning Objectives
Describe the importance of direct observation in feedback and assessment.
Appreciate the impact of “perfection” on health professionals.
Describe the impact of impostor syndrome, burnout and shame on health professionals.
Describe the issues presented by cognitive load to learning in a dense curriculum.
Understand, at a high level, the concepts of adult learning theory and active learning.
If you skipped over the learning objectives, as at least one of the authors is prone to do, look them over again: this module is a potpourri of topics that can be forced to fit under the general rubric of Goals and Objectives. Not appreciating the issues discussed here will clearly impact the ability for students to learn the material covered in a curriculum’s goals and objectives.
I. Direct Observation
It’s impossible to assess a skill unless you observe it. This is also true for attitudes in the big three categories of knowledge, skills and attitudes – which is why medicine has developed such a reliance on testing knowledge. Objective knowledge assessments are relatively cheap to develop (although sitting for them is not always for the student), easy to administer, easy to prove they’re valid and reliable from a psychometric standpoint.
You can’t know if a student can present a case unless they do that in your presence. BUT – if they present a case and you didn’t observe them doing at least part of what they’re presenting to you, how do you know they did it, did it correctly, or interpret what they did accurately?
Take, as a non-clinical example, piano practice. If you send someone off to a sound-proof room to practice and they come back to tell you how it went 45 minutes later, what does either party actually gain from that exercise? Can one get better at piano without some observed work? Why is medicine any different?
If you are going to help a student learn and improve, the students need formative feedback; feedback that’s specific and actionable. How can that happen if the student has not been observed? There are validated tools that allow for observation of students without a major imposition on patient flow and are critical to the success of a practice.
II. Perfection
If you ask any health care professional what constitutes a “bad” day for them at work, most will tell you that if they recognize that they made an error, they’ve had a bad day. Ponder this for a moment: what personal standard/expectation does this engender? A good day is one in which one’s performance was flawless – perfect. A personal standard of perfection is perhaps one explanation for the sad over-representation of suicide in our fields. It’s also difficult to apply that standard to oneself and not expect it of one’s learners. Learners, in a safe setting, are going to make mistakes. We as teachers need to develop ways to accept error in our learners (and of course ourselves) so that we can learn and continue to improve. Remember, there is a competency around practice-based learning and improvement. The national QI trend is geared towards learning from errors (of course there is the recent case of a Tennessee nurse that may have a huge impact on how QI works, but that impact remains to be seen). (1)
III. Highly performing people, burnout, shame, and impostor syndrome
Medical students in general are a unique group. They are elite (having almost always been at the top of their classes), increasingly of upper socioeconomic status, (2) and have often stood out for their academic performances while demonstrating a commitment to volunteering and service. Once in medical school, they often suddenly find themselves to be “normal” in comparison with their (also elite) colleagues. This leads to a precarious psychological state ripe for the symptoms of burnout, (3) shame,(4) and impostor syndrome. (5)
Fundamentally, this means that medical students want to excel, and are horrified if they do not. They appear to crave constructive feedback (6). However, we as faculty need to be cognizant that there’s a fragility that we need to recognize as we attempt to assist students. Practically, this means being clear and as objective as possible when providing feedback. (6)
IV. Adult learning theory/Active learning
Now a giant leap back up to a 30,000 foot view: remember, most medical students, at least chronologically, are adults. Because educational psychologists have their own jargon, adult learning theory is also known as andragogy (as opposed to pedagogy). Key elements of andragogy, per Wikipedia, include:
a. Adults must want to learn.
b. Adults will learn only what they feel they need to learn – This really doesn’t apply to medical students. Between licensing exams and curricula, the students really can’t guide their learning objectives the way someone who, for example, has been in practice for a decade can.
c. Adults learn by doing – Active learning!
d. Adult learning focuses on problem solving.
e. Experience affects adult learning
f. Adults learn best in an informal situation – not sure the evidence for this is as clear as the other elements.
g. Adults want guidance and consideration as equal partners in the process - Feedback! (7)
A bit more about active learning. From Wikipedia, by way of Bonwell and Eisen, and the school of circular definitions comes this: “Active learning is ‘a method of learning in which students are actively or experientially involved in the learning process and where there are different levels of active learning, depending on student involvement.’” Still, you likely get the concept; sitting passively in a lecture is not as effective a method to secure learning as to have the students actively engage with the materials. (8)
It’s somewhat odd that active learning is considered to be a component of adult learning theories. Kindergartens practice active learning (and even adult learning) techniques regularly.
V. Cognitive load
You may, if you actually read the objectives for this module (and we did ask you to, didn’t we?) and added them at least to your working memory, have noticed that we’ve skipped cognitive load (We also will bet [it’s Las Vegas after all!] that the reference to the learning objectives actually prompted you to look at them, perhaps for the first time.) Well, welcome to cognitive load, which we’ve likely exceeded with this potpourri – and it’s not even three full pages yet!
We’ll rely on Wikipedia for much of this, as we often have. Cognitive load refers to the used amount of working memory resources (discussed in the module Human Memory 3). It has implications for instructional design, of course, why else would we cover it? And there’s some jargon: there are three types of cognitive load:
a. Intrinsic - inherent level of difficulty associated with a specific instructional topic.
b. Extraneous – is generated by the manner in which information is presented to learners, under control of instructional designers.
For example: teaching about a square. A square is a figure and should be described using an image. An instructor could describe a square verbally, but it takes far less effort for the learner to see a square.
c. Germane - the processing, construction and automation of schemas. In other words, it’s the work the student uses to consolidate a concept into a memory. It’s easier to learn what a square is than to learn elements of particle physics. Easier still to learn about a square with minimal extraneous cognitive load (Yes, we know we have provided a bunch of extraneous load!). (9)
Last thing, from the sacred cows make the best hamburger (if you want to know, here’s a dive into that expression). (10)
VI. Learning Styles
There is little more comfort to many teachers than the concept that they can maximize their teaching by playing toward their students learning styles. Many of you have likely heard of (or been “diagnosed” with) a style based upon the VARK schema – which is one of 70 or so different schemas. VARK is an acronym for sensory elements: Visual, Aural, Verbal [Reading/writing], and Kinesthetic. The face validity of this schema is so strong that many of us buy into it. Of course, as people with a background in science, we might want to see some evidence.
Well, there isn’t much. Check out this paper: Learning styles: Where’s the evidence? The authors conclude “In summary, there presently is no empirical justification for tailoring instruction to students’ supposedly different learning styles. Educators should instead focus on developing the most effective and coherent ways to present particular bodies of content, which often involve combining different forms of instruction, such as diagrams and words, in mutually reinforcing ways.” (11)
References
1. Guilty verdict for former nurse in death of woman accidentally given wrong medication sets “dangerous precedent,” nurses warn - CBS News. Accessed July 26, 2023. https://www.cbsnews.com/news/radonda-vaught-nurse-guilty-death-wrong-drug-dangerous-precedent-nurses/
2. Shahriar AA, Puram VV, Miller JM, et al. Socioeconomic Diversity of the Matriculating US Medical Student Body by Race, Ethnicity, and Sex, 2017 - 2019. JAMA Netw Open. 2022;5(3):e222621. doi:10.1001/jamanetworkopen.2022.2621
3. Thun-Hohenstein L, Höbinger-Ablasser C, Geyerhofer S, Lampert K, Schreuer M, Fritz C. Burnout in medical students. neuropsychiatrie. 2021;35(1):17-27. doi:10.1007/s40211-020-00359-5
4. Whelan B, Hjörleifsson S, Schei E. Shame in medical clerkship: “You just feel like dirt under someone’s shoe.” Perspect Med Educ. 2021;10(5):265-271. doi:10.1007/S40037-021-00665-W
5. Khan M. Imposter syndrome—a particular problem for medical students. BMJ. Published online December 9, 2021:n3048. doi:10.1136/bmj.n3048
6. Bing-You R, Hayes V, Varaklis K, Trowbridge R, Kemp H, McKelvy D. Feedback for Learners in Medical Education: What Is Known? A Scoping Review. Acad Med. 2017;92(9):1346-1354. doi:10.1097/ACM.0000000000001578
7. Andragogy. In: Wikipedia. ; 2023. Accessed July 26, 2023. https://en.wikipedia.org/w/index.php?title=Andragogy&oldid=1145820700
8. Active learning. In: Wikipedia. ; 2023. Accessed July 26, 2023. https://en.wikipedia.org/w/index.php?title=Active_learning&oldid=1163110197
9. Young JQ, Van Merrienboer J, Durning S, Ten Cate O. Cognitive load theory: implications for medical education: amee guide no. 86. Med Teach. 2014;36(5):371-384. doi:10.3109/0142159X.2014.889290
10. Sacred Cows Make the Best Hamburger – Quote Investigator®. Accessed July 26, 2023. https://quoteinvestigator.com/2016/12/12/cows/
11. Rohrer D, Pashler H. Learning styles: where’s the evidence?: commentaries. Med Educ. 2012;46(7):634-635. doi:10.1111/j.1365-2923.2012.04273.x