Instruction Without Lecture: Losing the Crutch

Despite being an inefficient way to educate people, the lecture has remained the most commonly employed method for delivering course material in medical schools. The educator Edgar Dale, creator of the “Cone of Experience,” has been quoted as stating that we retain 20 percent of what we hear, 70 percent of what we discuss with others, 80 percent of what we experience, and 95 percent of what we teach others. Adult learning theory (andragogy), as described the educator Malcolm Knowles, teaches us that adults learn best when the learning process is collaborative and problem-based.

Yet, we consistently retain the lecture as the most common form of “teaching.”

In 2013, Tulane University initiated the Health Education Adaptive Learning Experience (HEAL-X) for PhDs in the biomedical sciences desiring an MD degree. This 42-month curriculum includes 18 months of preclinical education that is based entirely on adult learning theory and active learning principles; that is, we do not lecture these students.

In this curriculum, normal and abnormal structure and function are combined within each organ system block. Traditional department-based teaching (Anatomy, Physiology, Pharmacology, etc.) is eliminated in favor of weaving departmental instruction throughout the curriculum. As one of the primary people responsible for HEAL-X and the director of the hematology and neoplasia blocks, moving away from passive lecture-based teaching was a welcome challenge.

What We Did
In place of traditional course lectures, we applied three teaching modalities:

  • Team-Based Learning (TBL)
  • Higher-Order Thought Questions
  • Drawing Exercises

TBL is an active learning strategy that takes advantage of the diversity of participant skill sets to solve problems. Prior to a TBL exercise, participants are assigned readings, Web captures, textbook chapters, or other material that they are responsible for reviewing ahead of time.

TBLs are typically divided into three parts:

  • Part 1: an Individual Readiness Assessment Test (IRAT) that involves 10 multiple-choice questions derived from the readings that are answered and scored individually.
  • Part 2: a Group Readiness Assessment Test (GRAT) in which teams of four or five participants answer the same multiple-choice questions using a lottery-style scratch-off. Points are deducted for multiple scratch-offs. During the GRAT, active learning occurs during the subsequent group discussion regarding selection of answer choices.
  • Part 3: a Group Assessment Exercise (GAE) in which teams answer higher-order questions followed by audience response and discussion of the correct answers among all students.

For the HEAL-X curriculum, we employed both a Coagulation TBL and a Leukemia TBL.

We also replaced lecture with posing higher-order thought questions to the class. As with TBL, learners are expected to review materials prior to class; these questions are then discussed in class, in lieu of lecture.

For example, we might ask learners, “If you were going to design a new drug to target diffuse large-cell lymphoma, what would you target, and why?” or “Why do illicit cyclists abuse erythropoietin? What advantages does it provide?”

Such questions foster discussions in class, allow learners to learn from each other, and are active rather than passive. Finally, we ask our students to engage their “right brains” through drawing exercises. When we draw, we notice subtleties that are lost with mere observation. While the right brain communicates through imagery, the left brain communicates through words. Yet, language cannot always express the wealth of information conveyed by images.

Da Vinci once said, “Writer, what kinds of words will you fetch to awkwardly describe what drawing can instead perfectly represent?” Van Gogh put it even more succinctly: “Drawing is the root of everything.”

Keeping those principles in mind, we asked our students to draw histologic and pathologic images. We also asked them to draw the coagulation cascade and encouraged doodling in class. Such engagement was intended to improve observational skills, foster active learning, and – frankly – to be fun.

Abandoning the Safety Net of Lecture
Although it is too early to robustly assess the success of our active learning curriculum, so far students in HEAL-X have performed similarly on National Board of Medical Examiners subject exams when compared to students following a traditional curriculum.

We have used our HEAL-X experience to modify the entire hematology curriculum and plan to offer a similar active learning product to all of our students. We are in the process of moving our hematology course to iTunes U, in a course that will include an iBook written by our faculty and Web captures and assessments that we produced.

Although active learning requires more preparation by the learner, we believe this preparation is worth the time spent. After all, one description of the teacher’s role is to make the act of decision-making challenging, so that the learner can only escape by learning. We hope we have met
this lofty goal.