Hard Times: a Transmission Perspective on Medical Education

What does education mean to you? This is the first of five posts which look at different answers to that question, and explore the implications for teachers and learners.

 

Teach these boys and girls nothing but Facts.  Facts alone are wanted in life.  Plant nothing else, and root out everything else.  You can only form the minds of reasoning animals upon Facts: nothing else will ever be of any service to them.

All quotes: Charles Dickens, Hard Times

What do you think happens when you learn? Do you have a mental model of what is actually going on? When I say that I’ve learnt something new today, am I talking about an adjustment inside my head—perhaps in the way that synapses interconnect in a particular part of my brain? What about learning that seems to fall outside the bounds of head knowledge: intuitively felt heart knowledge or tacitly embodied practical skill? Or is learning a more generalised alteration in a disseminated network—a process not limited to, or even principally focused on changes within me? Am I describing a restructuring of my relationships with particular artefacts, people or groups; or a reorienting of my relationship with the wider world?

We are all learning, all the time. And the way that we conceive of learning matters, because it affects every aspect of how we approach a given situation, as learner or teacher, or indeed whether we should even make that distinction.

In the first chapters of Hard Times, Charles Dickens introduces us to three educationalists: a government official, a school superintendent called Mr Gradgrind, and a newly qualified teacher, Mr M’Choakumchild. All three share a belief in the importance of filling students’ heads with facts.

[They] swept with their eyes the inclined plane of little vessels then and there arranged in order, ready to have imperial gallons of facts poured into them until they were full to the brim.

Daniel Pratt calls this approach to teaching and learning a Transmission Perspective. The underlying metaphor is one of telecommunications. The aim is for a sender to parcel knowledge into small packets ready for transmission to a receiver, who will then be able to un-package and store the data.

The picture shows this perspective graphically. The trainer’s knowledge is represented by a large sphere containing the stuff that they have previously learned. Their remit is to wrap up parts of that stuff and broadcast it into the trainee’s much smaller sphere. As the trainee receives and stores these packets of data, their sphere will grow; eventually, they may contain nearly as much stuff as their teacher.

Dickens beautifully illustrates, and satirises, many of the the key features of a Transmission Perspective. Firstly, that the stuff of learning exists within our heads.

His bald head…all covered with knobs, like the crust of a plum pie, as if the head had scarcely warehouse-room for the hard facts stored inside.

Secondly, that the nature of that stuff is such that we can explicitly describe each and all of its component parts.

With a rule and a pair of scales, and the multiplication table always in his pocket, sir, ready to weigh and measure any parcel of human nature, and tell you exactly what it comes to.

It assumes that these germs of ideas can be defined, refined, then inoculated into the learner, where they will grow into a replica of the stuff in the teacher’s head.

The little pitchers before him, who were to be filled so full of facts.

And that once this has been achieved, they will have learnt all they need.

He seemed a kind of cannon loaded to the muzzle with facts, and prepared to blow them clean out of the regions of childhood at one discharge.

Malcolm Gladwell talks about the way that satire—intended to bring about change in the world—often serves only to perpetuate the very things it is trying to undermine. When faced with Dickens’ stereotypes it is easy to distance ourselves. We can enjoy the absurdity of Gradgrind’s mindset and celebrate our modern outlook—so much more enlightened—and yet continue, at heart, to see the world in precisely the way that he does.

Over the course of a century, and more, Medical Education has flirted with many alternative perspectives on teaching and learning. But I would argue that a Transmission Perspective remains the underlying, default worldview for many of those who are involved in the education of doctors.

Let’s start with the atomisation of knowledge into explicit parcels. Benjamin Bloom’s work to divide the stuff of learning into a taxonomy of knowledge, skills and attitudes—and their many sub-domains—remains fundamental for many. His project has helped the vast edifice of competency based learning to develop: every subject must be dissected and defined, taught and tested in ever smaller aliquots. Not only must teachers pre-define what students should learn from any interaction, they must declare these intended learning outcomes, so that student minds won’t stray beyond the approved territory.

Meanwhile, the juggernaut of evidence based medicine—with its focus on proven facts as revealed by randomised controlled trials—provides further support.

‘You are to be in all things regulated and governed,’ said the gentleman, ‘by fact… You must use… for all these purposes, combinations and modifications (in primary colours) of mathematical figures which are susceptible of proof and demonstration.

The very language of postgraduate medicine—Trainer, Trainee, Training Programme, Annual Review of Competence Progression—provides powerful evidence of the dominant worldview. The popularity of Training the Trainers courses speaks volumes about the mindset of both organisers and aspirant teachers.

So, Mr M’Choakumchild began in his best manner. He and some one hundred and forty other schoolmasters, had been lately turned at the same time, in the same factory, on the same principles, like so many pianoforte legs.

Many medical teachers have found ways to pay lip service to alternative paradigms, without actually changing their underlying Transmission Perspective. For example, a learner centred approach—“Look, the green sphere is at the centre,” even if the red sphere retains all the power—or assessment of prior learning:

He went to work in this preparatory lesson, not unlike Morgiana in the Forty Thieves: looking into all the vessels ranged before him, one after another, to see what they contained. Say, good M’Choakumchild. When from thy boiling store, thou shalt fill each jar brim full by-and-by, dost thou think that thou wilt always kill outright the robber Fancy lurking within — or sometimes only maim him and distort him!

My picture provides a way to visualise some of the problems with this model.

The trainer can only transmit stuff that is already inside their own head, and from that only those parts that they can explicitly exteriorise as discrete packets of knowledge.

‘Bitzer,’ said Thomas Gradgrind. ‘Your definition of a horse.’
‘Quadruped. Graminivorous. Forty teeth, namely twenty-four grinders, four eye-teeth, and twelve incisive. Sheds coat in the spring; in marshy countries, sheds hoofs, too. Hoofs hard, but requiring to be shod with iron. Age known by marks in mouth.’

Michael Polyani argues in The Tacit Dimension that there is an implicit aspect to all areas of our learning: “we can know more than we can tell.” From a Transmission Perspective, however, the learner can never progress beyond what their teacher can articulate. Their final shape, size and configuration must alway remain within the sphere of their teacher.

The teacher’s claim to educational credibility resides entirely in the size of that sphere: they must ensure that their heads are stuffed ever tighter with subject knowledge, often at the expense of thinking about how others might learn and develop:

Ah, rather overdone, M’Choakumchild. If he had only learnt a little less, how infinitely better he might have taught much more!

Transmission certainly has many appeals to those charged with developing and maintaining a system of education: it is a process that can be monitored and measured; learning objectives are simply stated and disseminated; achievement of well demarcated competencies is effortlessly assessed; quality control is manageable. Organising education becomes somewhat akin to running a factory: a clearly imposed and well policed system of checks and balances is needed to keep the machines running true. The governments and regulatory bodies of today are in many ways no different from those in Dicken’s time:

A government officer; in his way (and in most other people’s too), a professed pugilist; always in training, always with a system to force down the general throat like a bolus.

In essence, a Transmission Perspective provides an efficient and measurably effective method—on its own terms—of ensuring that doctors attain baseline levels across many domains of clinical knowledge. However, it is very poorly suited to the full development of most aspects of clinical expertise and professionalism; and it is antithetical to curiosity, imagination and creative exploration.

He would go in and damage any subject whatever with his right, follow up with his left, stop, exchange, counter, bore his opponent (he always fought All England) to the ropes, and fall upon him neatly.  He was certain to knock the wind out of common sense, and render that unlucky adversary deaf to the call of time.

Transmission is an informational approach to teaching and learning whose sole aim is to add stuff to the student vessel.

But you mustn’t fancy,’ cried the gentleman, quite elated by coming so happily to his point. ‘That’s it! You are never to fancy.’

In the following posts, I’ll be surveying four paradigms of learning that are transformational, each aiming to nurture changes in the nature of the vessel itself.