Pediatric anesthesiology 2016 reviews

Sunday Session II: Education - Teaching and Learning Across the Generational Gap

Reviewed by Kamie Yang, MD
University of Michigan and CS Mott Children’s Hospital

Millennials are defined as people born 1980-2000 and thus include most of our residents and fellows.  Do they learn differently than their predecessors?   The first part of this session debated this very question. 

Jonathan Tan, MD (Children’s Hospital of Philadelphia) argued that different teaching methods were necessary when teaching Millennials, while Mary Landrigan-Ossar, MD, PhD (Boston Children’s Hospital) argued that Millennials do not learn differently. 

Dr. Tan started by discussing how different generations have different learning preferences.  While baby boomers (those born 1946-64) and Generation X-ers (born 1965-1980) preferred lectures, handouts, note taking, study guides, and programmed independent learning, Millennials prefer something very different: simulations, group activities, creative interactive exercises, and game style learning (Kurup, Int Anesth Clin 48(3), 2010).   The rise of technology and the ability to obtain instant communication and feedback through the internet and cell phones are thought to be the drivers of this noted change in learning preferences.  

In response to these differences, Stanford University Medical School restructured its biochemistry course from a standard lecture-based format to short online didactic presentations and chose to utilize class time for interactive discussions of clinical vignettes instead.  Class attendance remarkably shot up from 30% to 80%, even though attendance was optional (Prober, NEJM 366:18, 2012). Industries in business and medical education have also begun to treat and teach Millennials uniquely.   New medical education textbooks and review materials are appearing that claim to be exclusively tailored for the "visual learning style of Millennial students, touting that they provide unique “rapid-reference, visual approach[es] to learning”.   Online anesthesiology education has also grown in recent years.  Learnly, an online anesthesiology learning “ecosystem” created by the Stanford Anesthesia Informatics and Media (AIM) Lab, aspires to be a “comprehensive and integrated model of teaching anesthesia that addresses the unique learning preferences of today's Millennial learners”.  More than 40 anesthesia residency programs and 1,200 residents have enrolled into Learnly and utilize its mobile video podcasts, short readings, and knowledge assessments on a daily or monthly basis ( 

Dr. Tan then discussed how the brains of Millennials have been found to function differently in other respects as well.  Functional MRI studies have shown that “Net Savvy” and “Net Naïve” people have different patterns of cerebral activation when asked to do internet searching tasks. (Small, Am J Geriatr Psychiatry 17:2, 2009).  Also, according to the Nielsen Norman Group (An Evidence-Based User Experience Research, Training, and Consulting company), “Digital Native” Millennials approach reading web pages differently when compared to their older, “Digital Immigrant” counterparts.  Seeking to gain information in a rapid manner, Millennials tend to skim content much more quickly, often just reading headings rather than approaching the text of a web page methodically and line-by-line (Nielson, How users read on the web., 1997).

Dr. Tan closed his interesting talk by recommending Millennials be taught with interactive methods that utilize technology which can be obtained remotely and on-demand.  Millennials also have unique teaching needs in medicine, including maintaining basic clinical skills (that can often be circumvented by technology like basic IV skills vs. ultrasound placement of an IV), appropriate use of social media, and avoidance of distraction by technology.  He also highlighted that this is the first time in history where four generations occupy the workforce and that effective healthcare delivery relies on effective interactions between all of these generations.  In the end, he believes the tremendous diversity that exists across the generations and cultures of today’s workplace gives us an unprecedented opportunity for innovation in medicine.

Dr. Landrigan-Ossar countered that Millennials do not learn in a different way, but are young people simply growing up in an era of new technologies.  As seen in prior eras, new technologies are inherently mistrusted and she contends that it is our job as educators to understand these new technologies so that we may harness their educational power.

Fears about the Millennial generation’s reliance on digital technology can be found starting from the 2000’s.   An article about how workers distracted by phone calls, emailing, and text messages lost IQ points surfaced on  During an Annual Meeting of the UK Royal College of Psychiatrists, concerns were raised that people of the Facebook and MySpace generation could not form lasting relationships, had a “distorted view of the world and their own identity” and were “at increased risk of behaving impulsively.”  In the New York Times, a Harvard psychiatrist also published an article discussing that technology’s influence on attention span, creativity, and focus was like that of taking methamphetamines and expressed his concerns that using technology was even addicting. 

In history, the fear of new inventions is certainly not new.  Socrates in 400 BC reportedly disliked the written word because he thought it would “produce forgetfulness” since things would no longer need to be memorized.  In the 1800’s placing children in organized classrooms was thought to be a “follie” and was feared to “exhaust the children’s brains”, leading them to become suicidal and homicidal.  The television was also feared in the past and was thought to be associated with juvenile delinquency, delayed verbal development, and reduced academic effort. 

More recently, the positive effects of the technological innovations of the Millennial generation have surfaced.  Though the American Academy of Pediatrics has recommended limiting passive screen use in young children under two, in certain situations, “interactive” children’s programing has been shown to yield positive effects in language development.  Other technologies like video game play that simulates laparoscopic surgery have also been shown to be useful in the training of surgeons.

Dr. Landrigan-Ossar closed her thought provoking lecture by recounting that though Millennials are often described as being narcissistic and constantly distracted by technology, all people are more narcissistic in their younger years and this quality fades over a given person’s lifetime.  She feels that Millennials are “not a new species” and that they learn in the same way as other generations do and act like everyone else did when they were young.  In essence, our job as educators is not to figure out how to teach a unique cohort of students, but to learn how to best implement this era’s new technologies so as to improve the education of learners of all ages. 

Edward Nemergut, MD (University of Virginia, Charlottesville) then spoke about the Technological Innovations of Teaching and Learning. In his informative lecture, Dr. Nemergut discussed 3 basic concepts in learning: (1) Spaced learning vs. massed learning (2) Test-enhanced learning (3) Targeted learning systems.

Spaced learning and massed learning
Dr. Nemergut started by introducing the difference between spaced learning and massed learning.  Spaced learning utilizes short learning sessions separated by breaks over a longer period of time (ex. hearing a song on the radio occasionally over many years).  Massed learning is the concentrated learning of material (with no intervals or short intervals between successive bouts of learning) (ex. cramming to memorize glycolysis the night before an exam during medical school).

The method of learning that yields the best results depends on the timing of learning assessment.  If immediate assessment is performed, massed learning yields better results.  However, these positive effects wane over time, with delayed assessments showing poor long-term retention. (ex. you passed your glycolysis exam in medical school, but can’t remember the steps today).  Conversely, if delayed assessment is performed, spaced learning is better (ex. you can the recall the lyrics of the song even 20 years later).  This positive effect on long-term retention occurs regardless of the subject or assessment method. 

However, we tend to utilize massed learning methods in medicine.  ACLS is taught in a single long, intense session and immediate testing of achievement yields reassuring data.   Nevertheless, our ultimate goal in training ACLS techniques is to achieve long-term learning (i.e. good ACLS performance months later during a code), rather than good immediate performance (i.e on the ACLS test done right after the session).  Therefore, spaced learning is an inherently better method of structuring lessons. 

Dr. Nemergut then discussed studies that illustrated the benefits of spaced learning in medicine.  When teaching microvascular anastomosis to surgical residents, spaced learning subjects were taught with one session per week over four weeks while massed learning subjects received four sessions per day.  Ultimately, the spaced learning subjects performed significantly better on retention tests performed one month later and were better able to translate their skills to live rat anastomosis tasks.  (Moulton, Ann Surg 244(3), 2006).

Test-Enhance Learning
What about giving tests? Can testing a student help them to acquire new knowledge and does test-enhanced learning exist?   Retrieving information in a testing situation is thought to promote better long-term retention and consolidation of learned material than simply restudying materials alone. Furthermore, the simple act of taking a test and getting answers wrong exposes the test taker to questions that allows them to refine their understanding of concepts that are deemed important by their teacher. 

Another method that tests may enhance learning is by exposing students to their “fluency illusions”. Fluency illusion is a learner’s tendency to misjudge their depth of knowledge and assume that facts, formulas, or arguments that they remember right now will remain so in the future.   For example, our false impression that we “know” the capital of country X is clearly exposed when we are faced with a multiple choice question asking for the capital of country X and realize we don’t know which choice to pick.  When these fluency illusions are recognized during testing, further study can be focused on those deficient areas.

The positive effects of testing were highlighted in an article in Science that showed that repeated studying after learning had no effect on delayed recall, but repeated testing produced a large positive effect.  This particular study focused on the straight forward task of learning 40 Swahili words and knowledge was tested 1 week later.  (Karpicke, Science 319(5865), 2008).  Interestingly, even giving a pretest prior to any instruction has also been found to improve final exam performance when similar (but not identical) questions were presented to undergraduate psychology students on the first day of class.  (Bjork, Am J Psychology (in press), 2016).

However, some educators do not believe that testing alone enhances the learning process and instead think that the positive learning effects imparted by testing is actually due to the active learning that occurs to prepare for the test.  Many educators aim to enhance their student’s ability to encode knowledge into memory by focusing on creating more active methods of getting that knowledge into the student’s memory.  More recently, however, retrieval practice, the mere practice of retrieving and reconstruction knowledge as it is learned has been shown to produce greater gains in meaningful learning.   In a study on teaching complex science concepts, the simple act of practicing recall of information during the studying period resulted in more learning even when compared to complex active learning methods. (Karpicke, Science 331(772), 2011). 

Nevertheless, it is important to realize that both learners and teachers are notoriously bad a anticipating which learning methods are really working.  He quoted D. Stephen Lindsay, a professor of psychology at the University of Victoria, to say “Conditions of instruction that appear to create difficulties for the learner, slowing the rate of apparent learning, often optimize long-term retention and transfer to real life situations, whereas conditions of instruction that make performance improve rapidly often fail to support long-term retention and transfer to real life situations.”

Targeted learning systems
In the final part of his talk, Dr. Nemergut continued by discussing how, in real life, we know that students are individuals and that we all learn differently.  He proposed that if we could individualize learning modules, we could greatly improve performance and learning efficiency. 

He then showed a series of mathematical curves that appeared to be similar to the O2 hemoglobin dissociation curve.  The equation for these curves use estimates of a student’s knowledge (x axis) to predict their likelihood of answering a question correctly (y axis).  Adjustments of their knowledge factor (k) could be made based on their performance on a series of questions, allowing for the further refinement of the equation’s ability to estimate the student’s true probability of getting a question right. 

Dr. Nemergut closed his talk by discussing how if these equations can be calculated and areas of deficiency correctly predicted, individualized educational interventions could then be employed to address the deficient areas.  Thus, just like Pandora, Amazon, and Netflix use adaptive algorithms to select products or songs based on your prior purchases and “thumbs up”, educational programs of the future will no longer treat all students the same, but will instead be able to adapt based on each student’s individual, real-time learning needs. 

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