PROBLEM SOLVING IN MEDICAL EDUCATION
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- PROBLEM SOLVING IN MEDICAL EDUCATION
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Pvaluauon anil the Health Profc^v’t' / December !’9R0
416
| "J cccntly (here has been growing interest in (he problcmJs. \ solving ability of medical students and its effects on per
formance in medical school. It has long been recognized that
problem-solving is a modus operand! in medical school, and it
was suggested that the main objectives of medical education are
to help students utilize the scientific method in approaching medi
cal problems and to acquire skills in problem-solving during (heir
educational experience (Miller, 1961). Students at all levels often
reveal difficulties by their performance on examination items
or ease studies involving problem-solving abilities. Further, with
traditional' medical curricula" deficiencies in problem-solving
often are not discovered until late in the clinical training (Helfer
and Slater, 1971). In an attempt to resolve these problems, nu
merous studies have sought to determine what processes and
skills are required for solving medical problems, how these skills
can betaught, and how deficiencies can be detected early in medi
cal training. Research findings in the area of medical problem
solving to date, however, are difficult to integrate, since studies
have used different terminologies and various definitions for
problem-solving ability. In addition, individual studies have
investigated different parts of the problem-solving process, and
consequently, comparison of the results is difficult..
The purposes of this report are to review and attempt to
integrate ail previous findings and to discuss the following
questions:
What is traditionally considered a problem-solving task in medi
cal school?
(2)
What arc the main processes that characterize problem-solving?
(J) What arc the different specific skills involved in each of those pro
cesses?
(4)
Can these processes and skills also be taught?
(5)
What techniques arc used to train students to solve problems and
how successful arc they?
(6)
Can students with potential deficiencies in pfoblcm-solving
ability be identified early in the medical curriculum?
(7)
What predictor instruments arc used for this purpose, and how
effective arc they?
(I)
MOIH1S AND DESCRIPTION 01 MEDICAL
I’HOiU.EM-SOl.VlNG
Medical problem-solving is synonymously referred to ns
diagnostic or clinical problem-solving, clinical or diagnostic
process, or clinical judgment. As the nomenclature suggests,
medical problem-solving ability Ims usually been studied within
the context of clinical diagnosis. In order to describe, teach, or
predict clinical problem-solving, several diagnostic models or
frameworks have been developed. A summary of these models
will provide a general, comprehensive description of (he processes
and skills involved in medical problem-solving and will indicate
the directions governing some of the research. In general, existing
models have attempted to define one or more of the following
aspects of medical problem-solving: (a) the different processes
that compose clinical problem-solving, (b) the skills that con
stitute the processes, and (c) the variables that affect both.
Corry (1970) described the processes of diagnosis as-three
major interactive components: genera! medical experience, infer
ence function, and test selection function. Through these pro
cesses, a diagnostic decision is made.
In a similar manner, F.lstcin (1974) defined the processes of
medical inquiry as cue acquisition, hypothesis generation, cue
interpretation, and hypothesis evaluation. Decision-making oc
curs both during and at the conclusion of each of these processes.
Andrew’s model (1974) specifics six interdependent and se
quential processes: problem-sensing, hypothesizing, searching
and defining, identifying, resolving, and verifying, lie further
defines these processes as consisting of several cognitive skills,'
such as the ability to gather, analyze, evaluate, and synthesize.
data, to know and evaluate health care strategies, and to make
adequate changes when possible.
In contrast with the models described above, Koziclccki (1972)
views the processes in a different perspective. Because of Koziclccki’s
unfamiliar terminology, his model will be discussed in some
detail, in his model, the processes arc labeled as the "environment
information block," the “goal block," the "operational block,"
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and the "psycho-information block." ! he goal and operational
blocks arc contained in the short-term memory and serve mainly
to determine the structure of the diagnostic process, i he goal
block is composed of the diagnostic golds which select informa
tion both from outside (environment information block) and
from long-term memory (psycho-information block). I he diag
nostic goals guide the diagnostic process in (he operational block;
the goals determine what information from (he outside environ
ment and from long-term memory will be introduced, and what
data will be criminated. The operational block then reviews the
data selected in order to derive a set of hypotheses, and establishes
the levels of probability for each hypothesis being verified.
Repealing this process leads to a final conclusion: the hypothesis
that has the highest probability. Koziclccki (1972) adds a new
dimension to his model by classifying the processes into different
parts of litiman memory. In other words, he explains the
processes in terms of where and how information is retrieved.
Because most models describe medical problem-solving per
formance in a very general manner, Visonhalcr ci al. (1975)
suggest a “meta-lhcory” that is “sufficiently general to accommo
date a range of more limited theories.” They postulate that
competence in problem-solving depends on certain general skills.
plus skills that arc required by a particular problem. They suggest
that clinical decision-making involves a decision maker (c.g., a
physician), a decision ease (c.g., patient or patient record), and an
informational interaction governed by rules leading to clinical
decisions. They further maintain that the clinical decision is
dependent on the decision maker’s clinical memory and decision
making strategy. The mcla-thcory, then, attempts to provide not
only a description of clinical problem-solving activity in a general
situation, but also in specific eases.
Similarly, Schwartz and Simon (1976) assume ip their model
that medical diagnosis is part of a medical problem guided by the
physician’s hypothesis pool, affected by the way the physician
structures his or her medical knowledge, and dependent on the
medical context. They further elaborate the maimer with which
different variables influence a physician’s diagnosis through their
definitions of the operation processes: “the cognitive state," “the
criteria for action on a diagnosis." “the identification of evidence
related to hypothesis pool," and “the information gathering."
While these processes arc similar to the ones described in the
other models, they incorporate some aspects not covered in those
models. First, the model specifics the activities that govern and
underlie each process and provides a framework within which
specific hypotheses can be investigated and evaluated. Second, it
examines factors that may affect medical problem-solving pro
cesses, such as individual knowledge, area of medicine, and
medical context.
From a somewhat different perspective. Bashook (1976)
suggested that the appropriate approach for investigation is to
define the domain within which the clinician functions, rather
than to model the process that governs the diagnosis. He
proposed a conceptual framework that simultaneously considers
the problem-solving process, the area ofclinical medicine, and the
context of care. Bashook’s model implies several assumptions: (a)
that the clinician may not know the solution, but nonetheless
makes a series of decisions which may lead to an acceptable
resolution of the problem; (b) that the problem-solving process
hits three main components —problem-sensing, problem-defining
(diagnosis), and problem resolution (management)- each of
which requires certain cognitive skills that may or may not be
necessary in the others; and (c) that different medical specialties
and different clinical contexts affect and imply limits on accept
able resolution. Similar to Visonhalcr cl al. (1975) and Schwartz.
and Simon (1976), Bashook (1976) described clinical problem
solving as resulting from a complex interaction of several factors:
processes, skills, content, and context of care.
In summary, all of the above models have attempted to
describe the processes in clinical problem-solving, the skills
within the processes, and the factors which affect the processes
and skills. Although the terminology differs, the processes
generally consists of the following activities: problem-sensing,
hypothesis generalization, and evaluation. These processes, in
turn, arc affected by several factors, such as clinician's medical
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knowledge, men of medicine, and clinical context of the problem
solving. Most of the models reviewed sought to provide a
framework within which the process of medical problem-solving
and the faclorsthal influence it could be investigated and verified.
To date, none of these models have been investigated in their
entirely, rather, different parts of the processes involved in
clinical problem-solving have been studied in isolation. Hence,
there arc no complete and integrated data on which a compre
hensive description of medical problem-solving can be based.
t here is. however, a good deal of information contained in the
literature about those portions of medical problem-solving
models that have been investigated. A review of the research
investigating the processes of clinical reasoning is necessary to
synthesize available data. Using the framework outlined above —
problem-sensing, hypothesis generation, and evaluation—this
review will summarize current research into the processes of
medical problem-solving.
Based on the studies on the problem-sensing process, the
author has distinguished three main skills: collecting, interpret
ing. and integrating data (cues). Most studies have investigated
one or more of those skills. Berner ct al. (1976) found that when
sccond-ycar medical students were presented with a case prob
lem, they were able to identify an adequate number of cues but
had difficulty forming the cues into conclusions. Elstein et al.
(1978), in observing 24 physicians interpreting cues, found that
physicians generally tended to classify them as confirming, not
contributing to, or disconfirming a hypothesis. Like Berner ct al.
(1976), they found that cue acquisition and cue interpretation arc
independent, but diagnostic accuracy is related to both. An
inaccurate diagnosis can result from mistakes in data collection
and/or in data interpretation. In an attempt to explain how data
collection influences diagnostic accuracy, Neufeld (1977) mea
sured the data-gathcring process by its thoroughness (the propor
tion of available findings elicited by the student) and its efficiency
Vu / Medical Problem-Solving
(ratio of number of findings elicited to time taken in the
encounter), lie found that diagnostic accuracy was related to how
thoroughly, but not how efficiently, (he cues were collected. In
the same study, Neufeld (1977) found that failure to diagnose
accurately resulted from an inability Io recognize important cues,
inadequate definition of recognized cues, and incomplete use of
clinical data generated for problem solution. In addition, Ekwo
(1977) found that errors in diagnosis result from mistakes in cue
interpretation caused by small memory capacity, level of knowl
edge, and amount of prior experience.
In general, skills in data-gathcring and data interpretation
appear to be independent of one another, but each of these
influences the degree of accuracy of diagnosis.
HYPOTHESIS CENEKATION AND EVALUATION
Based on existing studies, it was found that more research has
been done on hypothesis generation (han on hypothesis evalua
tion. In addition, since the data concerning the hypothesis
evaluation process are closely tied to those concerning hypothesis
generation, both arc reviewed here.
In studying the process of hypothesis generation, Norman ct al.
(1974) compared the performance of preclinical students, clinical
students, and practicing physicians in solving a medical problem.
Given identical cases, physicians and students in the clinical years
generated the first hypothesis after 60 seconds, while freshman
students generated hypotheses after an average time of 35
seconds. Neufeld (1977) found that both the number of hypothe
ses and the speed of their generation appeared Unrelated to
successful outcome, educational level, or problem-solving ability.
Ek wo (1977) found that early hypothesis generation was more
frequent with familiar problems than with unfamiliar ones, and
became more specific as a function of educational level. Em
example, physicians make less use of the general hypotheses
favored by beginning students, instead using a number of
hypotheses of about average specificity, and from them deriving a
more specific diagnosis (Norman ct al., 1974). In observing the
physicians. i'islcitj et al. («97K) found tlisit hypotheses aie
retrieved from memory, ami the number of hypotheses consid
ered at any one time is limited, averaging from four to five and
reaching an upper bound of six or seven. As the number of
hypotheses considered at one time is limited due to limited short
memory capacity, Idstein cl :il. (1978) have concluded that this
capacity could be increased effectively by nesting the hypotheses
or by substituting one for another in a reformation, so that the
number of hypotheses remains unchanged, in addition, Idstein cl
al. (1978) discovered the following with respect to hypotheses
generation:
(1) The frequency of disease seems more important than I he serious
ness of disease.
(2) The generation of hypotheses appears to derive from a matching
pattern, in other words, hypotheses arc derived or triggered by
salient cues of combinations of cues that arc matched or associ
ated back to long-term memory. 1 he same finding was obtained
by Neufeld et ai. (1975), who suggested that the origin of hypoth
eses appears to he related to the individual’s previous patient ex
periences.
(3)
During the early work-up of a patient, physician's problem for
mulations arc not unidimcnsional. Rather, they can be cliaracterized by (a) hierarchical organizations —from general tospccific formulations, (b) competing formulations - alternative sets of
formulations which explain a group of symptoms, (c) multiple
subspaces- problem formulations including subsets (hat pertain
to different types of diagnostic categories, and (d) functional
relationships-- hypothesized relationships between certain prob
lem formulations.
(4)
Once a list of possible hypotheses has been generated, the process
of selective search appears to start with the most probable.
Concerning this last aspect, it has been shown that the number
of hypotheses and the time of generation are not related to
effective problem-solving (Neufeld ct al., 1975). Rather, effective
problem-solving is characterized by generation of specific hy
potheses, a search strategy, and use of specific questions to elicit
significant findings. This last feature especially discriminates the
physician's performance from that of a student. I he former
appears to engage in well-defined strategies aimed at gathering
confirming data to rule in or out particular hypotheses, while the
latter docs not (l-eightncr, 1977).
WHAT CONSTITUTES EITK'IEN I M EPICAL
i’llOtll.EM-SOl.VINt;?
In looking al the overall problem-solving process, several
studies have attempted to determine what processes or skills
distinguish an expert from a nonexpert problem solver. I o date,
however, observation of which processes and skills arc associated
with accuracy of diagnosis has provided only the frustrating
answer that performance by both physicians and medical stu
dents varies from one problem to another. In other words,
performance is inconsistent (Elstein el al., 1978: McGuire and
Page, 1973) and appears to be ease-related. Donnelly ct ai. (1974),
in analyzing student performance on patient management prob
lems, also found that while information-gathering ability may
generalize from ease to ease, decision-making ability (diagnostic
and management) appears related to the content of the ease.
Further studies have demonstrated that differences in perfor
mance may result not only from the content of the problem but
from the interaction between the problem and the problem
solver's ability (Hogan et al. 1977). I his last observation is further
supported'by the finding that problcm-solvingskills diffcr among
individuals (Berner et al., 1977) and, consequently, may affect
their performance. Efficient problem-solving appears to depend
on both the individual’s acquired skills and his or her mastery of
the content of the problem to be solved. At present, there is only
general information about this interaction process, and more
detailed analyses arc needed. Such analyses may help to deter
mine:
(I) whether there ate generic skills required by all medical eases as
well as specific skills which are needed in some problems but not
in others;
(2) whether some problem-solving skills are more easily acquired
than others; and
rvahH.iion and ihc Ikntlh I'rofr^hnB I Dcccmbc. IQRO
content knowledge, memory capacity, prior experiences, anti
individual differences in skills.
HUTBLEM-SOI.VTpKJ: THAINING OF
MEOK AL STUDENTS
As described above, identifying ibc processes or skills which
characterize an efficient problem solver is a complex and difficult
task. Therefore. determining how to teach these processes and
skills most effectively and efficiently is also a complex one.
Present attempts to train students or help them develop problem
solving ability can be classified as using cither a specific teaching
technique or a comprehensive teaching program.
St’ECH-tr Tf.aciiw; techniques
One of the techniques is to allow students to practice and wot k
through various types of clinical problems or simulated patient
physician encounters. The simulations used as teaching tech
niques include written simulations such as patient-management
problems (McCarthy and Gonnclla, 1967), card decks such as the
Portable Patient Problem Pack (Barrows and Tambiyn, 1977),
and computer-based (Friedman et al., 1978; Murray ct al., 1977).
With the exception of Murray ct al. (1977), none of the studies
provided any objective data on the effectiveness of the above
described simulations for helping students develop medical
problem-solving ability. To determine the instructional value of
Computer-Assisted Learning (CAI.), Murray ct al. (1977) com
pared the performance of a group of undergraduate students who
had received CAL instruction with a group who had not. It was
found that the use of CAL improved both the students' factual
knowledge and their ability in making patient-management
decisions.
In addition to using the different types of simulations described
above, several studies incorporated other types of training
techniques. Allal and Shulman (197'1) developed a training
technique for second-ycar medical students to generate diag
nostic problem formulations. In general, a set of problem
formulations helps define the dimensions of the problem for
which a physician's search for diagnosis is conducted. The
formulations arc based on the cues that the students obtain in (he
initial minutes of a clinical encounter. Training consisted of two
main components’: "generating initial problem formulations
under a condition that simulates the early part of the clinical
encounter." and "providing the student with feedback based on
the performance of this task by cxpciienccd physicians" (Idstein
ct a'., 1978). The simulation consisted of color films presenting a
physician’s view of the early minutes of the clinical encounter.
Two types of feedback were provided to the students: “feedback
on the outcome of physician’s problem-formulation activity
during the earliest part of the work-up, and feedback on the
processes by which physicians arrive at these outcomes" (filstein
ct al.. 1978).
Sixteen sccond-ycar medical students were randomly assigned
to each of the two treatment groups and to the control group.
Both treatment groups included the two components of the
training model (simulation and feedback), with one difference:
One group was provided outcome feedback only, while the other
received both outcome and process of feedback. Training con
sisted of thrcc-weck sessions. In the posltcst, subjects were
evaluated on four variables: problem formulation, cue utiliza
tion, classification of cues, and degree of relationships among
problem formulations. The results showed a significant difference
between the trained groups and the control group bn problem
formulation, but not for the other dependent variables. 7 he
results also revealed that the training model was just as effective
for second-ycar medical students when it provided oidy outcome
feedback, as when it provided outcome and process feedback.
Gordon (1974), in a similar attempt, taught diagnostic prob
lem-solving through the applications of heuristics. Thirty-two
fourth-ycar medical students were asked to develop a diagnosis
for each of several simulated medical cases. Sixteen students were
provided with a heuristic to apply to their cases, while the other
(OMi’KI'.IIENStvE lHACKING PROGRAMS
In addition to the specific teaching techniques described above’
several comprehensive teaching programs have also been devised
in an attempt to provide instructional environments conducive to
the development of medical problem-solving skills. These pro
grams have been termed comprehensive because they incorporate
more than one instructional format in their teaching.
One such program is the Focal Problems course (I’armctcr ct
al.. 1975; and Wavs ct al., 1973). The course centers on patient
problems discussed in small-group learning settings with faculty
preceptors. The instruction involves several techniques: use of
study eases, small-group discussions which incorporate related
clinical, biological, and behavioral science concepts as well as the
problem-solving process, and the Problem-Oriented Medical
Record as it relates to the eases presented. Cases arc designed to
present data sequentially. As the.ease develops, students are
asked to generate hypotheses, interpret cues, and arrive at a
diagnosis. In spite -of the interrater differences in evaluating
student performance, students, as a result of the course, arc
generally rated highest “on their ability to interpret data,
demonstrate a comprehensive approach to the patient, recognize
the degree of seriousness, evaluate the viability of the work-up at
different stages, and apply consistency in reasoning" (Parmeter ct
al.. 1975).
Another program devised to teach problem-solving is that of
Barrows and his colleagues (1977). Based on several findings
(Barrows and Bennett, 1972; Elstcin ct al., 1978; Feightner and
Norman, 1976; Panker ct al., 1976), Barrows (1977) generated a
set of objectives that can be implemented in a curriculum in order
to foster problem-solving ability. Given the objectives and
students' general observed weaknesses in the medical problem
solving process, he suggested I hat the students should be provided
with (a) continual exposure to patients, so that they have the
opportunity to practice and develop sound technique and good
habits in problem-solving approach; (b) simulation experiences;
and (c) printed materials, so that their experiences with a
simulated patient can be complemented with printed or computer
devices (hat help them practice and evaluate the cognitive aspects
of their problem-solving process. According to Barrows (1977),
the components of this approach “have been used with many
students in different schools and the consistent effect it has in
terms of student motivation, enthusiasm and growth in personal
skills endorses its effectiveness.” The approach, however, has not
been yet systematically evaluated for its effectiveness in fostering
and developing clinical problem-solving skills.
Berner and Trcmonli (1976) studied the effectiveness of various
learning environments (presence or absence of structured classes,
staff teaching expertise, amount of instruction, and types of
learning experiences) on students' acquisition of problem-solving
skills. They assigned 161 students to various hospital settings for
eleven weeks. They found that when students were provided with
objectives, the otics in structured programs (i.c., with regularly
scheduled classes) did better on multiple-choice questions and
management problems assessing their ability in interpreting data
and in formulating diagnoses than the ones in the unstructured
programs. No speculations were offered to explain this finding.
Taylor cl al. (1978) devised a five and one-half week course to
help 61 first-ycar students develop their ability to formulate early
diagnoses. I he course included lectures, small-group sessions,
independent learning, and several simulated patient problems for
students' practice. Based on postcoursc performance on twenty
multiple-choice questions and two patient management prob
lems, it was found that most students satisfactorily recalled
factual information and identified and interpreted information
needed for hypothesis-testing, but performed less well at forming
and revising hypotheses.
Last, in an attempt to validate measures assessing factual recall
(multiple-choice) and problem-solving skills (ease management).
44*
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Freeman and Byrne (1977} pre- anti posltcsfcd 80 general
practitioners who attended jhrec-vear (raining courses al dillcrc.nl leaching centers. Basic to these courses, though, was the
attachment system, in which the trainees worked in a close
personal relationship with the tutor. It was found (hat the
trainees’ scores in (actual knowledge and problem-solving skills
had improved significantly at the end of their thrcc-ycar training
course. Ihis improvement was particularly noticeable with
students who were initially poor in the area of problem-solving
skills. Although trainees attended different training centers,
marked improvement of poorer students in clinical problem
solving skills was seen to result from (he interaction of the trainees
among themselves, and the emphasis in group interaction on
patient-management skills. These results, though, as suggested by
the authors, need to be interpreted carefully, due to method
ological problems including possible contamination of the results
caused by the teachers’ awareness of the study, the test designers'
knowledge of the teaching methods and course content, the
limitation of the test procedure, and the problems in test-scoring.
SUMMAHV
Although several studies have investigated the effectiveness of
various clinical problem-solving teaching techniques and pro
grams, the conclusions which can be drawn are limited because of
(a) the scarcity of objective data in these studies (Barrows ct al.,
1977; Sprafka ct al., 1974; Ways ct al., 1973), and (b) the lack of
uniform definitions of clinical problem-solving and its measure
ment.
For example, while some studies designed their technique or
program to teach a range of skills involved in history, problem
solving, and clinical judgment (Freeman and Byrne, 1977), others
attempted to teach abilities to utilize and classify cues and to
formulate problems (Elstcin ct al., 1978; Altai and Shulman,
1974), to interpret data and formulate diagnoses (Berner and
Trcmonli, 1976), or simply to develop diagnoses (Gordon, 1974).
In addition, the results of these studies were also difficult to
Vtt / Medical Pinblcm.Solving
<1-19
interpret. Since most of the studies did not include a control
group or a pretesting and a delayed posttesting of the subjects’
initial and long-term ability to solve clinical problems, no linn
conclusions can be made about the effectiveness of their teaching
techniques or programs.
Based on most of the studies reviewed (Alla! and Shulman,
1974; Gordon. 1974; Murray etai., 1977, and Taylor e! al., 1978),
it has been demonstrated that successful learning of problem
solving skills depends on the acquisition of both process and
content knowledge. But the studies to date have not permitted a
separation between the effects of process and content on medical
problem-solving ability, due to the variability in the factors
included in those studies, such as: length of training or program,
students' level of (raining (first-year versus fourlh-ycar), instruc
tional formal (single versus combined), and instrument used to
assess clinical problem-solving. A more systematic control of
these factors across st tidies may provide a better understanding of
the effectiveness of the training or program, ns well as the effects
of the interaction between process and content on medical
problem-solving ability. Presently, it appears that the process
allows an effective acquisition of content which in turn enables
the students to apply their process to solve medical problems. i\
better understanding of the interaction may allow one to
determine how problem-solving training can be successfully
implemented in the medical curriculum.
PREDICTORS OF MEDICAL
PROBLEM-SOLVING ABILITY
After reviewing various studies on clinical performance, it is
clear that since problem-solving ability is essential to the
competency of a physician, clinical problem-solving should
constitute a main part of medical education. Further, it is
apparent (hat lack of this ability may cause difficulties in
adequate performance in medical school. With findings about tbe
possibilities of teaching problem-solving skills, the following
question must be addressed: How docs one identify students who
450
I wliulhm ami lire llcatlh IWcwions 1 December l»«0
lack those skills in order to provide them necessary guidance and
training'.'
Elstcin ct al. (1978). in order lo assess the relations between
processes of clinical reasoning and selected personality charac
teristics. used one measure ol logical reasoning and four person
ality measures. The logical reasoning measure consisted of three
problems developed by Riinoldi and his associates (Erdmann.
1964). I he personality measures included a measure of cognitive
complexity by Bieri cl al. (1966), a dogmatism scale by Rokcach
(I960), a flexibility scale of the California Psychological Inven
tory (Gough, 1957), and a scale of the Omnibus Personality
Inventory (1968). In the first analysis, Elstcin ct al. (1978) studied
the personality variables and their correlation with physicians’
capacity to interpret medical data. Capacity to interpret data was
defined by four clinical process variables in hypothesis genera
tion. The variables were the number of hypotheses considered
one-quarter and halfway through the work-up, total number of
generated hypotheses, and point of generating the first hypoth
esis. It was found that the association between personality
variables and the clinical problem-solving measure was inconsis
tent. i his finding, they suggested, could derive from the fact that
physician's performance across problems was inconsistent. It was
also found that there was no significant correlation between
measures of logical problem-solving and clinical problem-solv
ing. Elstcin ct al. (1978) explained that the lack of correlation
between performance on logical and clinical problem-solving
could be due to two main facts: (1) Logical problems are highly
formal and lack meaningful content, while clinical problems have
a. high content component. (2) Clinical problems depend on
probability inference, while logical problems do not.
Krupka ct al. (1977). in an attempt to determine new predictors
to be used as a screening process for admission to medical school,
have used various batteries of cognitive tests and validated them
against peer and faculty ratings of students’ performance in
clinical clerkships. I he cognitive tests they uscd wcrc: the SRA
Pictorial Reasoning Test (McMurphy and Arnold, 1973), the
Remote Associates lest (Mednick and Mednick, 1967), and the
Watson-Glaser Critical Thinking Appraisal (Watson and Glaser,
1964). Krupka ct al. (1977) validated these tests against six
measures of performance: peer problem-solving ratings, faculty
problem-solving ratings, number of courses deferred in the first
two years of medical school, number of clerkships deferred in the
clinical years, scores on a multiple-choice test, and a score derived
from a series of diagnostic management problems administered
during a clerkship. As the above cognitive tests were used in
combination with the Study Habits inventory Test (Wrenn,
194 I), the State Trait Anxiety Inventory (Spiclbcrgcret al., 1970),
and the Anxiety Seale Questionnaire (Krug ct al., 1976), the
predictive effects of the cognitive tests alone are not well defined
iii the prediction analysis. Although a clear pattern was not found
from the analysis of test score, it appears that conceptual fluidity
(measured by the Remote Associates Test) is less important, while
critical analytic skill (measured by the Watson-Glaser Critical
Thinking Appraisal) seems recurrently relevant.
Mawardi (1978), using the Group Embedded Figures Test
(GEFT) by Oilman et al. (1972) in conjunction with other
personality tests, found a small but positive correlation between
GEFT and the ratings of students’diagnostic problem-solving (r=
.1723, p<. 10) and synthesis ability (r= .1672, p<.IO). Although
(he .10 level of significance is disappointing, theauthor explained
that this small correlation might be due more to the nature of the
clinical ratings than to the efficacy of the tests used.
.SUMMARY
i
The summary and results of the predictive studies (Elstcin ct
al„ 1978; Krupka ct al., 1977; Mawardi, 1978) reviewed arc shown
in I able I. As the table suggests, broad generalizations or
comparisons concerning the predictive effectiveness of (he tests
used arc almost impossible. All four studies not only used
dtffcrcnt predictors but also defined their criteria differently.
Vn / Medical Problem-Solving
45J
This variety in test choice implies that medical problcin-sotvinn
is a complex behavior; as a result, it is difficult to agree on what
would predispose an individual to solve problems effectively.
Further definitions of the criteria themselves show little general
agreement. While one study measured medical problem-solving
ability in terms of capacity to generate hypotheses and interpret
data (filstcin ct a!., 1978), another study measured it in terms of
peer and faculty pfoblcm-solving ratings, or scores derived from
diagnostic management problems (Krupka cl al., 1977). The
choice and definition of the criteria arc crucial for deciding which
battery of tests is most appropriate. For example, if the criterion
is defined as lite ability to generate hypotheses and interpret data,
cognitive tests would appear to be more appropriate predictors
than personality tests. On the other hand, if problem-solving
ability is measured indirectly through peer and faculty ratings of
problem-solving, or number of clerkships deferred, personality
tests used in conjunction with cognitive measures appear to bean
appropriate combination of predictors, since peer and faculty
ratings arc likely to be influenced by personality characteristics.
In general, the difficulties in predicting problem-solving ability
derive from several sources:
(I)
The medical students’ small range of abilities may render
the prediction of their problem-solving skills difficult. The
predictive value of the tests could be better determined if (hey
were used to predict for or to distinguish only the upper and lower
25% of the students, instead of the whole class.
(2)
The choice of instruments used as predictors and their
related criteria in the studies have at times been inappropriate.
Elstcin ct al. (1978) used a battery of four personality measures
and a logical reasoning measure to predict specific problem
solving ability, such as hypothesis generation, which may well be
inorc related to cognitive than to personality measures. In
addition, unless the construct validity of the predictors is
provided, prediction of medical problem-solving is not only
complex bul difficult to interpret.
(3)
The definition of effective problem-solving is not com
monly agreed upon. For example, while one study defined
454
i'tand tht
I’iofrwnn* ! December 19X0
effective ptoblcm-solving as generating hypotheses and inter
preting data (i’lstein et al., 197B). another defined it in terms of
faculty or peer ratings oi problem-solving and scores on Diag
nostic Management Problems (Krupka et al., 1977). A common
defined criterion would allow possible comparisons on test
effectiveness.
(4)
Although the general processes and skills of medical
problem-solving have been assessed, it has not . been clearly
established how stable they arc within an individual, or how they
influence the effectiveness of problem-solving. Such results
would provide answers concerning how to predict problem
solving more accurately. For example, if content is one factor
which may affect problem-solving performance, is it necessary to
measure the skills of incoming students independently of their
knowledge? On the other hand, if skills are also a factor, it is
important to determine how they affect performance and how
they interact with other factors. For example, is effective
problem-solving the result of a complete matching of an indi
vidual’s acquired skills with the specific skills required by the ease
to be solved? Do medical problems require both general and
specific skills? Are some skills acquired by most individuals when
they enter medical school, and some with learning? These ques
tions not only would help to show how one can predict problem
solving ability, but also how one should design a medical
curriculum in order to develop and foster this ability.
CONCLUSIONS
The prevailing problems in all areas of medical problem
solving research stem from the lack of a comprehensive under
standing of the cognitvc processes and skills characterizing
medical problem-solving, and the variables which affect them.
Although recent (indings have shown that nyoblem-solving
performance is affected by several skills, content knowledge, and
clinical context, the roles played by these variables need to be
investigated further. Existing data, however, could be used to
Vti / Medical Piablcin-Solving
455
develop a preliminary model (hat would provide researchers with
a more comprehensive and a clearer framework within which the
knowledge of problem-solving could be described and system
atically evaluated I his framework could be described in terms of
a medical problem-solving typology that would consider the
different types of processes and skills, the areas of content
involved, the subjects’ levels of knowledge and training, and the
various degrees of difficulty of the diagnostic problem. Such a
preliminary typology provides a comprehensive framework al
lowing future studies to start from a common basis investigating
various aspects of clinical problem-solving. Il would also allow
the study of the effects of some variables on clinical problem
solving ability while holding other variables constant.
A common problem of the above teaching and prediction
studies derives from the methodology anti instruments with
which they have assessed medical problem-solving ability. The
effectiveness of the problem-solving teaching techniques or
programs and the effectiveness of the personality and cognitive
measures used for predicting medical problem-solving ability are
measured mostly by assessing the subjects' performance on
medical problem-solving assessment instruments. Since the va
lidity and the reliability of most of these instruments have not yet
been completely demonstrated (Vu, 1979), the results obtained on
the teaching and prediction of medical problem-solving arc
unintcrprctable. In order to obtain more usable data, future
studies need (a) to take into account the limitations of their
criterion instruments, and (b) to devise a better controlled and a
more comprehensive evaluation of the subjects’ ability to solve
problems, since this is affected by amount of content knowledge,
clinical context, level of training, and difficulty of the clinical
problems. For example, a subject’s ability to solve clinical
problems could be more accurately assessed with different types
of problem units at different times during training.
Although the results on various aspects of the diagnostic
process are still difficult to integrate, they do hold promise. As
long as problem-solving ability remains important for optimal
functioning of a clinician, research must provide more effective
4,(.
Vu / Medical Problem-Solving
<AOlu,unn nml .he tknhh Vr«(e
45/
present need is for a common and comprehensive definition in
which previous and future data can be integrated and interpreted.
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IAYI OR. ?
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VJSOXHAI I R..I. I ...S. W CHAN. C WAGNER, and A. S. EI.STE.IN (1975) ”Con>-
Arthur Levine
WHY
INNOVATION
F AILS
State University
of New York Press
ALBANY
Published by
State University of New York Press, Albany
1980 State University of New York
All rights reserved
Printed in the United States of America
No part of this book may be used or reproduced
in any manner whatsoever without written permission
except in the case of brief quotations embodied in
critical articles and reviews.
For information, address State University of New York
Press, State University Plaza, Albany, N.Y, 12246
Library of Congress Cataloging in Publication Data
Levine, Arthur.
Why innovation fails.
Bibliography: p.
Includes index.
1. Universities and colleges—United States.
2. Educational innovations —United States. I. Title.
LA227.3.L46
378.73
80-14950
ISBN 0-87395-412-2
ISBN 0-87395-421-1 (pbk.)
CHAPTER 1
Innovation
and Failure:
Some Questions
In 1969 the faculty of Brown University voted to replace, in toto,
their traditional program with a progressive, new student-centered
curriculum. The change was widely noticed in the educational com
munity and was the subject of much praise. Commenting on the
program 5 years later in an article entitled, “Brown University Trend:
Back to Old Curriculum," Robert Rheinehold said, “Today the reforms
which were hailed as the most flexible and progressive undergrad
uate curriculum to be found in any major American university are
struggling for survival against heavy odds” (New York Times, Feb
ruary 24,1975, p: 47). He went on to chronicle the de facto collapse
of the program.
Across the continent, Stanford University, in 1969, introduced a
major curriculum change that included two experimental programs.
After more than a year of operation, John Weingart and I reviewed
those programs and were so impressed with their success that we
recommended they be profiled as part of a planned network television
documentary on higher education. On January 14, 1975, Stanford
announced that it was terminating both programs (San Francisco
Chronicle, January 15, 1975, p. 3).
One thing the new curriculum at Brown and the experimental
programs at Stanford had in common was that they were both inn;/. v
Sons. The key words to describe them or any innovation might be new
and different. Innovation combines the elements of reform and change;
reform implying new and change implying different. Innovation can
Questions and Answers About Innovation
operationally be defined as any departure from the traditional prac
tices of an organization. As a result, the element of newness inherent
in innovation is a relative phenomenon—what is new in one place is old
in the next. The same might be said of time. Much that we call
innovation is in fact renovation, trying the ideas of the'past once again.
For instance, the University of California at Santa Cruz was consid
ered one of the most innovative schools of the 1960s for its use of the
cluster college concept, a departure from the traditional pattern of
mass education adopted at UCLA and Berkeley. Clustering involves
dividing the university into smaller, more liveable, residential liberal
arts colleges. This is an example both of renovation and the relative
character of innovation. As it turned out, the Claremont Colleges near
Los Angeles had been using the cluster arrangement since 1925. And
the idea itself dates back almost 800 years to the colleges of Cam
bridge and Oxford in England.
What’s Known About Innovation
We know a lot about innovation. We know about its forms. Differ
ent people slice innovation up in different ways and so there are a
cornucopia of typologies to choose from. This author divides organiza
tional innovations into five basic tvpes.^new organizations, innovative
enclaves within existing organizations, holistic changes within exist
ing organizations, piecemeal changes within existing organizations,
and peripheral changes outside of existing organizations^Each form
has its own advantages and disadvantages as well as its own rationale.
For example, in colleges and universities, the form of organization this
author is most familiar with, this means:
The establishment of new colleges. A new college is the easiest way
io establish a nontraditional institutional mission. For example, Ben
nington College in Vermont was a product of the desire to extend the
progressive, philosophy of education into the college years where it
was absent in the late 1920s. And Metropolitan State University in St.
Paul, Minneapolis, was designed to develop a nontraditional program
especially for older adults who fit uncomfortably into existing institu
tions. The creation of a new college avoids the expenditure of enor
mous amounts of time and effort that would be required to transform
Innovation and Failure: Some Questions
an established institution and reorient its staff and students. Creating
a new college, however, is by no means a guarantee of success for a
nontraditional mission. New schools rarely fulfill all of the expecta
tions of their founders. There are external pressures as well as inter
nal ones to revert to the tried and true. There is also a tendency for
participants to force their own dreams and hopes on a new institution
whether or not these conform with the college's mission. Creating a
new college is expensive and when colleges are underenrolled as at
present and existing institutions of higher education have unused
capacity for lack of students, it is a high-risk, inefficient form of
innovation.
Innovative enclaves within existing colleges. The development of
new enclaves involves setting aside a specific location within the
institution for change. It may be an experimental subunit as at Stan
ford, an experimental period during the calendar year, or any other
innovation separate from the mainstream of traditional campus activ
ities. Innovative enclaves are relatively inexpensive and easy to
implement. They, can serve as institutional laboratories for change
and as sources of institutional self-renewal if the practices are adopted
elsewhere around the school or involve large numbers of people
faculty and students-who participate in both the enclave and the
rest of the institution. The disadvantages of enclaves are that they
can become appendages isolated from the rest of the campus, sanctu
aries for dissatisfied faculty and students, and a means of preventing
an institution from making needed organizational changes.
Ihilisfic changes wiIIuh existing colleges, if lislic change involves
the adoption of a major institutional innovation cl aracterized by a
unified and coherent purpose. The curriculum change at Brown Uni
versity is a good example. Of all the forms of change, holistic reform
is the most defensible .when major change is necessary: the most
efficient since it in.olves substituting new programs for old rather
than new additions; the most difficult to ge ad pted; the 1 ast ik \
to succeed, particularly in large rgani itions; and the k tcommon.
It is risky because it involves ahead • - : blis ed institutions with
built-in resources, habits, and staff—and a staff at that usually lack
ing in consensus about institutional purposes. But holistic change is
especially risky because it replaces the old with the new. If the change
Questions and Answers About Innovation
Innovation and Failure: Some Questions
does not succeed, nothing is left to fall back on.
Piecemeal changes within existing colleges. Piecemeal change in
volves minor innovations such as the use of a new piece of equip
ment, the adoption of a new course, or a procedural change in per
sonnel practice. It is the most common form of change, the easiest to
implement, and a series of such changes can, in sum, produce holistic
change, but this is unlikely since piecemeal changes tend to rely
more on political negotiation than on coherent and unifying purposes.
Peripheral changes outside existing colleges. Peripheral change
involves the establishment of institutions or changes within institu
tions that are not traditionally associated with higher education, but
that have an effect on the activities of existing colleges and universi
ties. A recent example is the establishment of college-degree-granting
programs by several commercial corporations such as Xerox and
American Telephone and Telegraph. As Sir Nevil Mott said “The
infallible recipe for stirring up a university is to set up a rival” (Hefferlin, 1969, p. 3). Peripheral programs can alert existing schools to
unmet students needs as well as potentially profitable program addi
tions. They can also compete with colleges and universities by draw
ing away their clientele.
Be that as it may, all of the studies and this author’s own research are
consistent, as shown in Table 1.1, with a process having four fundamental steps: 1) recognizing the need for change—it is realized that
some organizational need is not being satisfied; 2) planning and for
mulating a means of satisfying the need-a concrete plan i devel
oped; 3) initiating and implementing the plan-the plan is
Into
operation on a trial basis; and 4) institutionalizing or terminating the
new operating plan-either the operating plan is routinized and inte
grated into the organization or it is ended.
The fourth stage is the period described in the accounts of Stan
ford and Brown. It is less familiar than the earlier three stages and
Table 1.1
Levine
1. Recognition
of need
Stages in the Innovation Process
.Mann and
Hage and
Aiken
Rogers
Smelser
1. Evaluation
1. Awareness
1. Dissatis
faction with
sense of
opportunity
1. State of
organiza
tion before
change
2. Interest
2. Symptoms
of dis
turbances
2. Recognition
of need for
change
3. Evaluation
The strengths, weaknesses, and reasons for these five types of
innovation are paralleled in nonuniversity organizations as well.
We are also aware of the times when innovation is most likely to
occur. Marvin Bressler (Levine, 1978, pp. 431-432) of Princeton Uni
versity finds a^close connection between environmental conditions
and innovation. The likelihood of change is enhanced when there is a
crisis in the environment, when people have a shared interest in
change, when there is a power imbalance in the environment, when
the environment lias experienced structural changes, and finally when
it is consistent with the Zeitgeist or spirit of the times?
We know, too, about the process of innovation. It involves a series
of predictable, sequential stages. So say a number of organizational
studies (Hage and Aiken, 1970; Mann and Neff, 1961: Rogers, 1962;
Rogers and Shoemaker, 1971; Smelser, 1959). Unfortunately, there is
little in the way of concensus among the studies about how many
steps there might be in the sequence or what the individual steps are.
6
3. Handling
distur-
4. Channeling
2. Planning
and forma-
solution'
3. Initiation
and implempnlnlinn
of plan
5. Attempts to
. .■
3. Planning
change
,
. .
-• Ill it ‘..tl -Il
3. ImplemJj
t. 1 rial
6. hnplementation by
entrepre-
4.
alization or
1 R.r.mniza-
5. Adoption?
7. Roulinizalion
5. ?:ab: izing
change
xinc
steps to
make
Svurce: Hage and Aiken. 1971| p. 113.
Note: This table contains exm
he better known the.
Zaltnian i-t al. (1973. p. 61-f>2t
nilar exercise with eleven the* .its.
. a ' -1 ... ,\ ■;
he above tahk ' i heir own model hais two stagesand live
s. It differs from this
in that the process of recugniziing need is omitt<id. The implementat
include a process comparable to institution;! izntkim ur termination, hov
Questions and Answers About Innoration
that brings us co what we don’t know about innovation. There is a
tendency to think of the third state of the process (implementation) as
! •—
its conclusion. The goal of innovation or change is to adopt something
'' • new and different. At the end of the third stage, that is done. The
innovation is in place, there is apparent closure to the story, and there
is a presumption of success. It is not dissimilar from the way fairy
tales are told. Most involve something akin to the first three stages of
the innovation process. Take Cinderella for instance. In that story we
have a prince who recognizes a need, which is the loss of his extraordi
nary’ dance partner of the night before. That’s stage one. He develops
a stage two plan to marry her that involves taking a slipper the young
woman left at the dance, transporting it all over the countryside,
asking every women to try it on, and marrying the person it fits.
., Stage three of the plan is put into operation, Cinderella is found, and
y
the story ends happily ever after. The reader never wonders whether
> the marriage was a good one. We assume it all worked out and are
quite shocked when we hear differently from People Magazine.
■K
This is approximately what has happened with the research on inno
vation and change. It concentrates almost exclusively on stages one
through three. This literature is far too extensive for casual discussion
here, although key works are examined in the concluding chapter of
|
this book. The interested reader might also turn to one of the excellent
'' .
annotated bibliographies on the topic, such as that prepared by Research
.
/
for Better Schools, Inc., entitled Administering for Change (Maguire,
Tompkin, and Cummings, 1971). Stage four, institutionalization or
termination of the innovation, 1970, has received only scant attention
in published research (Hage and Aiken, 1970, p. 104; Johnson, 1969).
Notable are case studies by Selznick (1949) on the Tennessee Valley
Authority, C rwin 1974) >n the Ti tcher Corps, Zald (1963) on the
Young Men's Christian Association, Gusfield (1963) c th .• '.’.hinvr.’s
Christian Temperance Union, Grant and Riesman (1980) on experi
mentation in higher educatir>n, and Erikson (1966) on Puritan America.
Yet even these studies shed little light on the institutionalization
termination stage. Though the authors focus on events that occurred
during this period. :t was not their intent to describe the process of
institutionalizing or terminating innovation. As a result, very little is
known about what happens after an innovation is adopted.
Innovation and Pailurc: Some Questions
This is unfortunate, particularly so because the institutionalization
termination stage is a critical period for any innovation and the„organization adopting it. During 1970-71 John Weingart and I conducted a
study of the innovative undergraduate programs of the 1960s at 26
colleges across the United States. In the years since, a number of the
schools have been revisited to see what fate has brought them.
Through it all, we discovered that during the institutionlizationtermination stage, innovations are usually transformed or.dje,_and
many of the universities and colleges housing innovations, which will
be called host organizations, change. As at Stanford and Brown, most
innovations declined, some have eroded away, as at Brown, and oth
ers are terminated, as planned at Stanford.1 Only one innovation was
able to move the host organization substantially in its direction. Sub
sequent research has confirmed these impressions time and time again.
The 1960s was a decade of widespread change. A great deal of
excitement and energy were expended on efforts like those at Brown
and Stanford. In the ensuing years we have learned that much of that
change has dissipated and we shall hear in the future that much of
the change of the 1970s has disappeared as well. In many cases tire
loss is desirable. There is nothing intrinsically good about innovation
for innovation’s sake. Yet, in some cases, thejpss is unfortunate and
unnecessary. It is too often largely a result of what we didn’t know
about innovation.\
That is the subject of this book. This volume focuses on the
institutionalization-termination phase of change and attempts to
explain why innovation fails—that is, why it declines prior to achiev
ing its intended purposes. In understanding how and why innova
tions fail, we gain an understanding of what it takes to make them
work. This book tries io answer four questions:
Questions and Answers About Innovation
The text is divided into three parts. Part One, entitled “Questions
and Answers About Innovation," sets the stage for the rest of the
book. It consists of Chapters 1 and 2. Chapter 2 is concerned with
innovations in organizations and provides a detailed description of
the fourth stage of the innovation process—the institutionalization
termination phase. A model is presented of the ways in which inno
vations prosper, persist, decline, and fail after they have been adopted.
The reasons for this are explained and examples are provided of how
the model works in the case of three similar innovations that met
very different ends.
Part Two, “A Study of 14 Innovations,” applies the institutionaliza
tion-termination model in a study of structurally similar innovations.
All were experimental colleges at the State University of New York
at Buffalo. The model presented in Chapter 2 is deficient in two
respects: It lacks empirical confirmation and it is sketchy, meaning it
fails to describe fully the associated events, interactions, and processes.
Part Two is intended to respond to these deficiencies. Chapter 3
discusses the character of the State University of New York at Buf
falo, the origin and development of the 14 innovations, and their
early institutionalization-termination. Chapter 4 concentrates on the
subsequent results of the institutionalization or termination stage.
A methodological note is contained in Appendix A.
Part Three is entitled “Conclusions.” Chapter 5 answers the ques
tion that this volume, began with—how and why do innovations fail
and succeed? The final chapter provides context. It discusses the
already existing literature on innovation and change in terms of what
has been learned from this study.
10
CHAPTER 2
Organizations
and Innovations:
Some Ansivers
The Four-Stage Innovation Process
All kinds of organizations have been chronicled—service organiza
tions, community organizations, voluntary organizations, complex
organizations, formal organizations, social organizations, and work
organizations of many stripes, to mention just a few. They are all
different, yet they all share three characteristics—norms, values, and
goals. Norms are the commonly prescribed guides to conduct in the
organization—means of communication, patterns of authority and con
trol, rules of membership, and all of the other characteristics that
describe the way people should interact. Values are the commonly
shared beliefs and sentiments held by people in the organization.
And goals, which are reflective of organizational values and ar-..attained according to organizational nonns, are the commonly accepted
purpose and direction of the organization.
Every organization has a different set of norms, values, and goals.
Even similar types of organizations differ in this respect. No
colleges, for example, are exactly alike. And this is important I icause
the unique set of norms, values, and goals that an oi'gani ation
possesses constitutes its character or personality. That personality is
very much the same as an individual’s personality. It is an essential
aspect of the organization and just as integral to its well-being.
Accordingly, organizations guard their perst nalities against poten
tially entropic forces both within the organization and in the external
11
Questions and Answers About Innovation
environment. The tools they use are called boundaries. Kai Erikson
describes boundaries as a "symbolic set of parentheses” which con
trol an orgainization’s social space in order to retain “a limited range
of activities and a given pattern of constancy and stability within the
larger environment” (Erikson, 1966, p. 10). This means simply that
boundaries circumscribe or stipulate the personality appropriate to
^the organization. Their function is to strictly maintain the status quo.
Any change in an organization's norms, values, and goals requires a
. comparable change in its boundaries.
In the bounded organization, innovation is likely to occur when
environmental change makes existing boundaries unworkable, when
the organization fails to achieve desired goals, or when it is thought
that goals can better be satisfied in another manner. Each of these
conditions may trigger the first step in the four-stage innovation
process. That is, only if the condition is recognized as a failing or need.
As a matter of fact, the labeling of need and subsequent innovation
does not have to be the response to any of these conditions. Recogni
tion of need can take quite a while. It may not occur until there has
been an extensive internal or external examination or it may, in fact,
never occur. There are limits to how long inaction is possible, though.
Organizations that continually neglect to respond to goal failure or
environmental change are likely candidates for extinction. Problems
can be ignored only so long without “paying the piper”. Nonetheless,
once a need is recognized and the organization seeks a vehicle for satis
fying it, no matter what the vehicle, it represents an innovation for
that organization. It is a departure from its traditional practices.
The actual contact between an innovation and an organization can
occur during any of the first three stages of the innovation process.
During the first stage (recognition of need) and the second stage
(planning and formulating a solution) the innovation is, at its point of
greatest development, nothing more tangible than an idea. Participa
tion in these two stages may vary from an organization-wide to an
individual phenomenon. The possessor of an innovative idea need be
only a single individual, and possibly even an individual external to
the organization. For example, at colleges and universities, one per
son, the entire university community, or even an outside source such
as the U.S. Department of Labor may identify the failure of the
university to consider the problems of women as a need. The plan
ning and formulation of the solution can vary from an individua
designing an independent study; to the faculty, students, and admin
istration of the university forming a joint committee to create a wom
en’s studies program; to the U.S. Department of Labor imposing
affirmative action guidelines upon the university. In any case, when
the innovation or solution is implemented, which is the third stage of
the innovation process, there is necessarily contact between theorganization and the innovation, whether or not the organization approves
of the innovation.
The third stage is a trial period. During this time the innovation is
tested as a solution to the unsatisfied need. Every organization has
one or more mechanisms for approving innovation or change. In a uni
versity, the function might be the purview of the senior faculty or
curriculum committee at the departmental level, and at the institu
tional level the job of a senate, university administrators, or trustees.
(If the organization has formally approved the innovation and thereby
permitted its implementation, it usually grants the innovation some
degree of initial autonomy, a grace period of sorts, in order to work
out unresolved questions and solve unanticipated problems. There
after, the organization begins to send a gradually increasing number
of cues to the innovation—initially subtle, subsequently unsubtle—
about how it should begin fitting in with the organization. These cues
are intended to begin the fourth stage of the innovation process
institutionalization or termination designed to make the innovation
just a routine part of the organization, a necessary' occurrence if the
organization is to achieve a common set of goals.
If the innovation is not approved by the organization, the grace
period prior to instiims-mtlization or termination described above is
unlikely. Autonomy is a prize that an organization grants only after it
has legitimized an innovation, and formal approval is the way in
which it confers legitimacy.
Because innovations are by definition departures from traditional
organizational practices, the innovation and the host organization
have at least a somewhat different set of goals, norms, and values.
and, as a result, a differing set of boundaries. This is apparent in the
unapproved innovation soon after its adoption and in the approved
and Answers About Innovation
innovation by the end of the (rial period, which is of variable length
and dependent entirely on the grace period granted by the host. The
presence of two separate and divergent boundary systems combines
to provide multiple or blurred definitions of organizational character.
■ An organization cannot function in this manner because each bound
ary system pulls it in a different direction. This results initially in
disagreements and ultimately in conflict between the host and the
innovation. The conflict can only be resolved by making the diverg
ing boundaries congruent, which is essential for organizational health.
Otherwise the organization expends its resources on internal conflict
rather than the attainment of its goals, the raison d’etre for organiza
tional existence.
Conflict resolution and boundary”convergence are the functions of
the institutionalization or termination stage. There exist two mecha
nisms for accomplishing these ends. The mechanism selected is
largely at the discretion of the host organization since the innovation
is typically dependent upon it for resources and the people associated
with the innovation have likely developed a survival wish. The first
..•mechanism is called boundary expansion and involves the adoption of
. the innovation’s personality traits by the host, or more simply an
acceptance by the host of some or all of the innovation’s differences.
Owing to the dominant position of the organization, there is very
rarely a complete acceptance of innovation differences; far more com
mon are mutual changes in both host and innovation personalities,
agreed upon through joint negotiation and resulting in a hybridiza
tion of the two. In boundary expansion, the convergence of organiza
tion and innovation boundaries and conflict resolution occur when the
. organization legitimizes some or all of the innovation's differences
and agrees to live with or absorb those differences. Acceptance or
<
pti >n can invol e establishing the innovation as an enclave or
diffusing it throughout the organization. Diffusion is the process
whereby innovation characteristics are allowed to spread through the
host organization, and enslaving is the process whereby tiie innova
tion assumes an isolated position within the organization.
lhe second mstijjitionalization-termination mechanism is called
boundary contraction and involves a constriction of organizational
boundaries in such a manner as to exclude innovation differences.
Organizations <md Innovations: Some Answers
The innovation, which is then outside organizational boundaries, is
viewed as illegitimate and labeled “deviant’’. The deviant label serves
to define and highlight the organization’s boundaries by singling out
previously not unaccepted norms, values, and goals as now clearly
inappropriate for the organization. Having identified the presence of
a deviant subpart, the organization has two available sanctions. A
sanction must be applied in order to formalize and reinforce the
organization’s legitimate boundaries and end the internal conflict.
This necessitates a showing that deviance of the innovation’s variety
will not be tolerated. The.two sanctions of boundary contraction are
resocialization or termination of the innovation. Resocialization occurs
when the innovative unit is made to renounce its past deviance and
institute the acceptable norms, values, and goals it failed to incorpo
rate previously. Termination occurs when the innovation is eliminat
ed. Boundary contraction, then, fosters boundary convergence and
conflict resolution by excising contested innovation differences. This
process is shown in Figure 2.1.
Compatibility Versus Profitability
In order to gain a rudimentary understanding of the factors deter
mining the four outcomes of the institutionalization-termination stage
—diffusion, enclaving, resocialization, and termination—a study (un
published) was conducted of two similar innovations in comparable
organizations that resulted in quite opposite institutionalization
termination results. The innovations were experimental colleges, the
organizations were large universities, and the opposite results werboundary expansion via diffusion and boundary contraction via ter
mination. An analysis of innovation differences with respect to the
university environment.yieldcd a series of characteristics or indica
tors that broke down primarily along two dimensions—compatibility
and profitability. The diffused innovation was found to be profitable
for the host and compatible with its personality, while the terminated
innovation was incompatible and unprofitable.
Subsequent inve ligation into the literature of .. . field re . tied
that the wheel had been rediscovered, as both compatibility and
profitability have long been prominent considerations in the literature
on innovation diffusion. That literature is especially poignant because
Answers About Innovation
the institutionalization-termination deci: n is very similar to the acceplance rejection choice involved in the di tsion of innovation; however,
the findings of the research are far fron rystal clear. Griliches (1957)
found profitability to be the cause of farmers adopting a new hybrid
sorghum breed. Bradner and Straus (1959), in a reexamination of
the Griliches data, found congruence (synonymous with compatibil
ity) a more influential factor. Fliegel and Kivlin (1962) found relative
advantage (dose kin of profitability) and compatibility the attributes
most significantly related to innovation adoption; however, most fol
lowup research has failed to confirm one or the other (Rogers and
Figure 2.1. The Institutionalization or Termination of innovation in Organizations.
innovation Boundaries
Organization Boundaries
16
Organizations nntl Innovations: Some Answers
Shoemaker, 1971, pp. 140-141). Compatibility tends to be supported
less often than profitabilityA major difficulty with this literature is that three forms of research
bias confound the issues—researcher’s world view, research setting,
and research methodology. With regard to researcher's world lew,
anthropologists and sociologists—scientists of culture—are prone to
emphasize compatibility, while economists and psychologists—scien
tists of the individual-tend to stress profitability.
^Concerning the research setting, research conducted in indiistrialI ized Western countries has emphasized profitability, while that conouctea in nonindustrial, non-Western countries has emphasized
compatibility. This results in large measure because most innova
lions studied have been Western and industrial in origin, making
them more likely to be incompatible with non-Western, nonindus
trial countries than their own. For instance, a new breed of beef cattle
is more likely to be rejected in the United States because of profit
ability than compatibility considerations. On the other hand, in India,
where the consumption of beef is taboo, the rationale for rejection
would undoubtedly be compatibility. Unfortunately, a good deal of
diffusion research has been based on an American rural agricultural
setting, and therefore minimizes the importance of compatibility.
With regard to research method bias, studies utilizing in-depth,
long-term, participant-observation Case studies have stressed com
patibility more often than survey research methods, especially when
conducted in a post facto fashion and when designed only to gauge
the acceptance-rejection choice. This is because all innovations lack
ing cultural compatibility are not rejected, but are often manipulated
in a manner designed to make them more congruent with culturally
shared orienta ions. Pri filability. ?.
is net as easily adapted.
Survey research studies have altn< mt ur.ifi-i miy missed such compat
ibility manipulations. Given all of this, one w mid have to conclude
that both compatibility and profitability play an important part in the
institutionalization or termination of an innovation.
Compatibility may be thought of as the degree to which the norms,
values, and goals of an innovation are congruent with those oi tire
host. Profitability cannot be so easily defined. In the rural agricul
tural studies mentioned, profitability was treated as an objective and
17
Questions and Answers About Innovation
solely economic variable. Under no circumstances can it be construed
as an objective phenomenon; profitability is subjective. To illustrate,
because a new crop was shown to have a very high economic return
in 1958 does not mean that the farmers who adopted it in 1959 did so
for financial reasons. Others have taken exception to this inference as
well. Rogers and Havens (1961), for instance, note that "profitability
as any other item of information about an innovation must be dif
fused. ... It is our contention that what really counts is an adopter’s
perception of profitability, and not objective profitability” (p. 414).
The solely economic concept of profitability encourages the objec.. ' tification of it. There are a multitude of noneconomic profits available
to the innovation adopter, such as security, prestige, peer approval,
growth, efficiency, and improvement in the quality of life, to name
only a few. Different organizations have different needs, so that an
unpopular or unaccepted organization might overlook an innovation
.' ,, promising financial profit in favor of another offering peer approval.
/ An innovation may then be defined as profitable so long as it satisfies
the adopter’s needs or satisfied them better than the existing mech
anism. This definition incorporates both the subjective and noneco
nomic elements of profitability in emphasizing simply adopter needs.
-t . A state of profitability exists when needs are effectively satisfied.
/ The greater the satisfaction, the higher the profitability.
There are two forms of profitability—self-interest profitability and
general profitability. Self-interest,profitability is that which motivates
the individual subunits and the individual staff within an organiza
tion to adopt an innovation. General profitability is that which moti
vates an organization to choose or maintain an innovation, but is such
that neither subunits nor individuals would adopt it themselves. For
instance, an innovation.adopted at ;• university by one department in
response to declining revenues that results in increased enrollments,
more faculty lines, and a large foundation grant might motivate other
indivicuals ano departments with similar needs to adopt the innova
tion. 1 his is self-interest profitability. On the other hand, an example
of general profitability might be a learning skills center which was
ashed because students lacked basic reading, writing, and arithskills. The success of such a center would obviate the need for
nts or individuals to adopt similar programs. Such an innovation
Ommuations and Innovations: Sonic Answers
would be profitable becau ;e it satisfied a recognized need aid allowed
the college to pursue its goals without the prior encuiiirance of
students lacking basic skills.
With this background in mind, compatibility and probability can
be placed in their roles as the determinants of the institutieializationtermination outcome. Compatibility is a measure of the appropriateness of an innovation within existing organizational bomdaries. It
is a measure of. dissatisfaction. Compatibility does not determine
whether an innovation will work; it indicates the degree ti which an
innovation is inconsistent with the norms, values, and gals of the
organization. In seeking compatibility, an organization atempts to
maintain its personality, to protect the status quo, are; to avoid
changes in established boundaries. Organizations contimally moni
tor and seek to preserve cherished boundaries. The wad mainte
nance is a key to compatibility. The greater the compatiSity of an
innovation with the organization, the lesser the degree of cssatisfac
tion within the organization that will be aimed at the innoation. , (
In contrast to compatibility, profitability is a measure i satisfac
tion. It is a measure of the effectiveness of an innovation insatisfying
adopter needs. In measuring profitability an organizationevaluates
whether the innovation;'!) satisfies the specific need for wiich it was
created, and 2) positively (+) or negatively (-) affects therestof the
organization. Unlike cortipatibility considerations, which am at pre
serving a particular array of organizational boundaries, profitability
concerns deal strictly with a pragmatic assessment of gair irrespec
tive of the boundary system.
Questions and Answers About Innovation
Organizations and Innovations: Some Answers
able. This plus or minus evaluation scheme is shown in Figure 2.2.
A few illustrations may be helpful. For simplicity's sake each is
based upon a similar innovation in a similar organization—an exper
imental college in a major university—but in each of the illustrations,
the outcome of the institutionalization-termination stage is different.
subunit, New College. The faculty senate of the College- of Arts and
Sciences voted to table the recommendation, teehng the college would.
usurp arts and sciences prerogatives and thinking the cost of the
venture excessive. Despite the opposition, David Matthews, presi
dent of the University of Alabama, established the college one month
later. He appointed Neal Berte as its dean.
Berte and his staff began by' trying to create a positive image for
the experimental college. They spoke at civic clubs, on television,
and at high schools across the state. Berte also reached out to the
University of Alabama faculty. He explained the purpose of the col
lege to opponents and invited them to participate in it. They did so as
advisors, guest lecturers, and members of a review committee.
Berte and his staff also structured the college in a manner that was
designed to reduce discord. Students admitted to the college were
representative of a cross-section of the university rather than being
either all honor students or all way-out types. The number of stu
dents admitted to New College was limited to a few hundred despite
the fact that a large number of applications were received. In addi
tion, all New College students were encouraged to take two-thirds to
three-quarters of their courses in the existing departments of the
university. Faculty appointments at New College were of two types—
joint appointments with existing university departmentsand a small
number of full-time appointments within New College. Full-time New
College instructors had credentials comparable to those of other uni
versity .faculty. Furthermore. New College was planned to be a tern-
Boundary expansion via diffusion. In 1970, after two years of prelimi
nary study, a student-faculty-administration committee at the Uni
versity of Alabama recommended the creation of an experimental
aid of David Matthews, Berte also built an endowment for New
College and obi it
. ge found; ioi grams, including a $250,000
Ford Venture Fund (Irani targeted tor the whole university, not just
value .
u
... .. Tin .. ulty of New C<
like the faculty of the- university; the New College student was like
the university student; the faculty of the university helped to shape
the New College curriculum; and, must of the courses New Coileg
20
21
Questions and Answers About Innovation
Organizations and Innovations: Some Answers
students took were in the existing departments of the university.
New College also proved to be of self-interest profitability for Uni
versity of Alabama faculty. New College managed to obtain grant
money and an endowment at a time when funds were tight. It also
attracted large numbers of applicants at a time when enrollments
were declining in several departments. And the innovations at New
College were the basis of lay and professional kudos.
Compatibility and self-interest profitability are the conditions asso
ciated with boundary expansion via diffusion, which is what occurred
at the University of Alabama. A large number of New College pro
grams, practices, and even administrative procedures diffused through
out the university. For instance, departments such as physics, and
colleges such as Business and Commerce, adopted more individual
ized programs that they attributed to New College. In addition, the
arts and sciences college adopted the student-designed major’s pro
gram which originated at New College. The College of Business and
Commerce adopted internships from New College and the School of
Education hired a New College student to act as a consultant in the
development of a program based upon her independently designed
major.
whom already had appointments with other university departments,
were certainly compatible with the University of Minnesota faculty.
The only way in which the General College seemed at all incom
patible with the university was in respect to students. The General
College never became a place for the excellent student who was
unhappy with the university program. Instead, it attracted primarily
the student who would not otherwise have been admitted to the
university, and this is what made the college profitable in the manner
that was earlier described as general profitability. The General Col
lege kept the selective university open to all students, which was a
social necessity. In taking primary responsibility for educating the
nontraditional student, the General College permitted the university
to continue its own programs with few changes, which would not
have been the case if other units of the university were made to adopt
the General College mission.
Because the General College was compatible with the norms,
values, and goals of the university and exhibited general profitability,
it was institutionalized by boundary expansion via enclaving. Even
from its earliest days the college was somewhat peripheral to the
University of Minnesota and was never fully integrated into its social
structure. Obtaining resources from the university, for example, often
involved a struggle. The. General College developed a faculty sepa
rate from that of the rest of the university. The joint faculty appoint
ments of the first year ran into opposition from university departments
and began decreasing as early as the late 1930s. Today, the General
College has a separate faculty, very few of whom have joint appoint
ments with any other university department, even though the major
ity with positions of assistant professor or higher have Ph.D. degrees.
General College students were not fully integrated into lhe univer
sity either. Although they are permitted to, take courses in the uni
versity, they are not automatically granted upper-division admission
to the university for satisfactory performance. Instead General Col
lege graduates must apply for upper-division admission just as stu
dents from any other institution outside the university. In short,
General College is an enclave or isolated island within the University
of Minnesota.
Boundary expansion via enclaving. In 1932 a dean’s committee with
enthusiastic support from University of Minnesota President Lotus
Coffman recommended the establishment of the General College. It
was a two-year, lower-division, open-admissions liberal arts program
intended for students who had interests that could not be satisfied
elsewhere in the university, students without time for a four-year
degree, students wanting a broad general education, and students lack
ing the qualifications to be admitted to other units of the university.
The best instructors at the University of Minnesota were recruited
to teach in the General College when it beganoperation in the fall of
1932. Emphasis was placed upon creating interdisciplinary general
education courses.
,
lhe college proved compatible with the university. Its mission of
interdisciplinary' general education and quality teaching was compat
ible with and, in fact, improved upon the university’s own lowerdivision program. The initial faculty of the General College, all of
22
Questions and Answers About Innovation
Organizations and Innovations: Some Answers
Boundary contraction via termination. In 1926 a senior faculty and
administration committee identified weaknesses in the University of
Wisconsin’s educational programs in the areas of instruction, advis
ing, and the relationship between the university and secondary schools.
To combat the weaknesses, Alexander Meiklejohn, a member of the
committee, proposed an experimental college that was approved by
the university faculty and the state regents. Meiklejohn was made
director of the college.
The college began operation in 1927. Its staff consisted of parttime faculty loaned by the university departments. The college offered
an unusual two-year course of study that focused on fifth-century B.C.
Athens during the first year and contemporary America during the
second year. There were no course or subject matter divisions in the
curriculum.
The college proved incompatible with the norms, values, and goals
of the university. The curriculum was quite unlike anything else on
the campus. In addition, the college violated accepted university pol
icy by withholding student grades until the end of the second year.
The Experimental College students differed sharply from the rest of
the students at the university as well. Very early the college and its
students acquired a reputation for being radical, causing local high
schools to discourage their students from applying to the Experimen
tal College. As a result, most of the Experimental College students
were from out of state and a majority were Jews. In an age of overt
antisemitism this was incompatible with the social make up of the uni
versity Indeed, the composition of the Meiklejohn student body also
raised the ire of both the state legislature and campus fraternities.
Another consequence of the college's reputation was a decline in
enrollments at the height of the depression, which made the underen
rolled college very costly to the university. Moreover, the college
failed to satisfy one of the needs for which it was created—it wors
ened the relationship between the high schools and the university,
and brought the university bad local press as well. In addition, the
college utilized financial resources and new university facilities that
other academic departments or more traditional students would like
to have used. The short of it is that the Experimental College was
unprofitable to the university.
Meiklejohn’s college then was both incompa ible with the univt r
sity and unprofitable for it. Accordingly, it was terminated in 1932,
only five years after it began.
Boundary contraction via resocialization is conspicuously omitted
from these illustrations. It’s not for lack of examples; merely as a
courtesy for the reader. Boundary contraction via resocialization is
the principal focus of Part Two of this book.
CHAPTER 5
How and Why
Innovation Fails
The aim of this volume is to discover how and why innovation fails.
Toward that end, a model of the institutionalization-termination process
of innovation was tested in a study of the colleges at the State Uni
versity of New York at Buffalo. The task of this chapter is to analyze
the findings of that study.
The institutionalization-termination model was shown to be valid
in a study of 14 innovations.1 Each of the four modes of institutional
ization-termination was isolated in the course of the study, and the
conditions of profitability and compatibility postulated for each were
shown to be correct. Boundary expansion via diffusion occurred under
conditions of compatibility and self-interest profitability. Boundary
expansion via enclaving occurred when the innovation was compati
ble and generally profitable. Boundary contraction via resocialization
occurred under conditions of profitability and incompatibility. Boun
dary contraction via termination occurred when the innovation was
unprofitable and incompatible. Il is likely that it would occur under
conditions of compatibility and unprufitability, as unproi'itability was
shown to be the key determinant. No other forms of or alternatives to
boundary expansion and boundary contraction were discovered.
'Bear in mind that this
i- based ,
single case study, it is possible that
'the model is valid for only S.U.N.Y.A.B. furthermore, it is possible that there are
exceptions to lhe model, though none were located in this study.
155
Hou> and I! iiy Innovation runs
JE'iy Innovation Fails
According to the mode';, innovation failure is defined as a premature
decline in the planned level of impact or influence of an innovation on
the host organization. Some innovations, such as compensatory edu
cation programs, are planned only as innovative enclaves. There is
never any intention of diffusing the innovation. Other innovations,
like tire colleges at Buffalo, are intended for diffusion. Enclaving for
the colleges represented a decline in status. Martin Meyerson and
the Ketier committee planned the colleges to be a major feature of
the university. They were to be expanded vastly beyond their modest
beginnings, which was quite a contrast with the Stern prospectus
goal of limited enclaving. This is to say that the position an innova
tion holds can only be judged successful or unsuccessful relative to its
planned goals. On the other hand, no innovation is created with the
hope of boundary contraction, that is, resocialization or termination.
If termination is planned, it is a goal only after the innovation has
fulfilled its purpose. Under other circumstances, termination would
be considered premature or a sign of failure. The two modes of
boundary contaction would then normally represent a decline in status
for an innovation.
The range of possibilities for an innovation—from extreme bound
ary expansion to extreme boundary contraction—represents a con
tinuum from total diffusion to complete termination. Termination,
resocialization, enclaving, and diffusion are ideal types or points on
the continuum; varying from substantial impact by the innovation on
the host to substantial impact on the innovation by the host. The
emphasis in boundary expansion is upon impact by the innovation on
the host while boundary contraction concentrates upon host impact
on the innovation. The treatment of the colleges at Buffalo—between
the Stern prospectus which sought boundary expansion via enclaving
anti th Reichert : < . tus whidi advocated boundary*contraction—
showed how very close boundary contraction and boundary expan
sion really are. Though the colleges were technically being enclaved,
the continued evaluations encouraged the colleges to conform or
become more compatible with the university if they were to get a
good rating. This involved an informal renunciation of some of their
past behavior and the adoption of some university-valued traits, which
amounts to a weak form of resocialization. All of this is to say that at
their edges, the four modes of institutionalization-termination begin
to meld together, as do boundary expansion and boundary contrac
tion, to form a continuum.
Movement down the continuum always constitutes failure if it
occurs before the innovation has accomplished its purpose. Passage
of an innovation downward in institutionalization-termination stages
involves an institution wide decision and is marked by a formal deg
radation ceremony. After the Stern prospectus, which represented
downward movement for the collegiate units, colleges were forced by
the university administration to conform to a series of demands. The
winners were allowed to make the rules for the losers. After the
Reichert prospectus, which was a sign of further downward move
ment, the colleges were made to go through a public hearing that
bore a certain similarity to a criminal court trial, while the chartering
committee and presidential review were not dissimilar from a parole
board. In any case, the colleges were forced to acknowledge the fact
that they had been vanquished, and rightly so, for they were bad. This
follows from the description of boundary contraction in Chapter 2.
In contrast, passage upward from the institutionalization-termination
stage-to-stage from,termination to diffusion is informal and occurs in
an unit by unit and in a person-by-person fashion rather than involving
the whole oganization. This was true in the diffusion of the colleges
among S.U.N.Y.A.B. faculty and departments. Should the colleges rise
from their current resocialized position to one of boundary expansion
via enclaving, this would involve simply a change in attitude by indi
viduals and departments regarding profitability, not a formal cere
mony. And that, in fact, appears to be exactly what is now happening.
With three factors in mind—the definition of failure, that institu
tionalization-termination is a continuum, and that movement down the
continuum represents failure—the question of why an innovation fails
can now be answered. Failure results from an innovation ’s decline
in profitability, compatibility, or both. Compatibility was previously
defined as the degn e 1 congruence I etwee n the personality--norms,
values, and goals—ol an ini >vati< n and its host. Indicators f om
patibility were found to be the attitude of the innovation toward the
How and Why Innovation Fails
host, the past history of the innovation, anti the actual congruence of
the innovation and host norms, values, and goals. The first two indi
cators are fudge factors that indicate the degree of examination and
amount of suspicion and distrust appropriate in evaluating the inno
vation's compatibility with the host.
Profitability was previously defined as the degree to which an
innovation satisfies the organizational, group, and personal needs of
the host. Several different indicators of profitability were discovered.
Two forms of profitability were identified as well: positive and nega
tive profitability. Negative profitability exists when it is desirable to
continue an innovation because treating it in any other manner would
undermine already satisfied organizational, subunit, or individual
needs. The likelihood of arson and campus unrest were the source of
negative profitability at Buffalo in 1970. Positive profitability exists
when an innovation is desirable in itself, and that is a stronger form
of profitability. Indicators include clients, enthusiasm, unio.ueness,
reputation, money, outside funding, and the like.
Compatibility is a screen for measuring the organizational inappro
priateness and dissatisfaction related to boundary change associated
with an innovation. Profitability is a measure of the satisfaction and
effectiveness of an innovation in meeting organizational needs. A
decline in compatibility means that an innovation has become less
appropriate and more unsatisfactory for the host. Similarly, a decline
in profitability indicates that an innovation is less satisfactory and
less effective.
Compatibility and profitability are the twin wheels that run the
institutionalization-termination model. As compatibility declines, in
novations move from boundary expansion to boundary contraction.
specifically resocialization. Under normal circumstances resocializa
tion is that brand of boundary contraction reserved for dealing with
incompatibility. An innovation that attempts to serve as an alterna
tive to the host rather than a supplement would always be extremely
incompatible. Refusal to become a supplement would constitute un
willingness to become compatible. The members of College E, that
preceded Cora P. Maloney College, sought to create a college that
would serve as an alternative to the university. They realized that fail
ure to become a supplement to the university would mean termination.
so many key staffers left. The same was true of the College of
Modern Education. Extreme incompatibility and an unwil in
become more compatible means that the host organization is required
to spend a good deal of time attempting to curb “inappropriate”
behavior by the innovation. Curbing the innovation begins to take so
much time that the host organization is unable to satisfy its more
basic needs, which makes the innovation unprofitable and termina
tion is the result. In such instances, unprofitability is the cause of
termination; incompatibility is only an indirect cause. The negotia
tions between Women’s Studies College and President Ketter ebbed
back and forth. Women’s Studies College rewrote its charter in early
summer 1975, but not to the satisfaction of the president. He felt that
the charter was incompatible and that the college was getting to be
too much trouble, so he refused to sign the charter—which amounted
to termination. Fortunately for Women’s Studies College, it was very
strong in the profitability realm and that saved it from termination
and allowed instead a resumption of negotiations of the college’s
future. The basic facts in the case point to a link between profitability
and compatibility, such that when an innovation becomes too incom
patible, it then becomes unprofitable.
A decline in profitability, like a decline in compatibility, moves an
innovation from boundary expansion to boundary contraction, except
that unprofitability results in termination rather than resocialization.
Termination is the vvariety of boundai y contraction associated with
unprofitability. Profi tability would seesn to be more important than
compatibility in inno
iis is not surprising in that it is
hkeiv easier to c»un
action associated with incompatibility than to ger
.ion associated with profitability. The importance ot urotitabmiv is shown in that the colleges at
s’u.N.Y.A.B. with hi
?iv given greater latitude with
regard to compatibilIky‘than less pro!atable colleges. This is especially interesting in i
ring boundary contraction via
resocialization, whic
liefly with compatibility. The
importance of profits
ity. Faculty clUe' < underlined bj the behavior
of S.L’.N.Y.A.B. face
to participate more heavily in
departments than th< . clleges because departments were more profitable. This was true
'.embers who felt the colleges
158
159
Conclusions
How and Why Innovation Fails
more compatible wit!-, their personal life-styles than their depart
ments. Profitability is of concern to both the innovation and the
host. As was indicated, an innovation must be profitable to the host,
but the host must also be profitable to the innovation. For example,
the College of Progressive Education was terminated by the host
for being unprofitable, while College Z decided to terminate itself
because it found the host unprofitable. Similarly, many old college
people left their colleges because they felt that continuing a rela
tionship with the host to be unprofitable. A reciprocal relationship
between the host and the innovation was not found for compatibility,
however.
The answer to the question, Why innovation fails? would then be
because it is either unprofitable or incompatible. The degree of fail
ure is greater if it is unprofitable.
the accepted appeal body, both because of its collective expertise and
because it was more representative of the university than the execu
tive. The rationale for the differences in U.S. and S.U.N’.Y.A.B.
law-making was that the university is a community of scholars where
it is assumed that the most reasonable ideas will prevail. The elab
orate network of checks and cross-checks would seem unnecessary
in such an environment. As the university has become more a mir
ror of society in recent years, its legal machinery has become more
and more elaborate, perhaps someday achieving the complexity of
that of the society. Certainly litigation at the university is booming.
A 1978 survey by the Carnegie Council found that law suits were
up at three out of four of the nation’s most prestigious research
institutions—the Yales, the Harvards, Michigans, and Berkeleys of
the country. By the way, the elaborate machinery' of institutionali
zation-termination is unlikely to exist in many other types of organi
zations.
The form of institutionalization-termination selected by the host
is determined by people and times. In times of plenty, the planned
mode of institutionalization for the colleges was boundary expansion
via diffusion. In times of steady state, the actual mode of institutional
ization was boundary contraction. Similarly, the form of institutional
ization that was selected varied from Martin Me;-arson to Robert
Ketter. The desired form of institutionalization-termination varied
from faculty senate chairman to faculty senate chairman. Good times
as opposed to bad times, and innovators like Meyerson in contrast to
consolidators like Ketter. tend to favor more generous terms of insti
tutionalization-termination. The reasons were explored in Chapter 3.
In any case, the university appears a rather generous organization
in its reluctance to terminate innovations. The attitude of innocentuntil-proven-guilty, winch permits an imiovation to continue until it
proves it is unworkable, rather than being made to prove itself wor
thy of continuing, was found to be widespread at S.U.N.Y..A.B. The
outcome of such an attitude, however, is continued skeptic!.- .. in lite
host regarding the imiovation aftei institutionalization-termination.
In order to increase its share of university resources, an innovation
must then prove it is a legitimate activity of the host. At steadystate S.U.N.Y.A.B., the colleges were being required to prove they
Hou) Innovation Fails
Institutionalization-termination decision-making is a political process.
This is so because institutionalization-termination occurs in times of
strife and is concerned with creating laws that will resolve the issues
leading to the strife and thwart its future occurrence. In any law
making procedure, some people win and others lose; that is, laws are
vehicles for controlling behavior, so that any law will limit the behav
ior of some individuals. Even in a society that chooses to make mur
der a crime, there must be some people who gained fame, fortune,
and power because of their success at murder. Such people lose the
source of their livelihood—they are the losers.
The- law-making procedure of institutionalization-termination deci
sion-making looks much like our national system of law-making.
There were operating subcommittees that reported to a legislature.
in this instance the Buffalo faculty senate. The faculty senate laws
were subject to the approval or veto of the executive, the president of
the university. There were also lobbies, pressure groups, and proce
dures for appealing unjustly perceived laws'. Lacking in the process
was the U.S. system of checks and balances. The legislature was
only advisory to the president and the body of appeal was the faculty
senate, the same group as the legislature. The senate was probably
160
Conclusions
Ilotv and Why Innovation Fails
are better than existing departments to get their fair share. This is
quite surprising. Normally one would expect a sense of legitimacy to
precede the decision not to terminate an innovation.
Two characteristics of university organizations might explain the
prevalence of the innocent-umil-proven-guilty philosophy. First, the
university has no obviously measurable criteria for success. For
instance, a company that makes pens can see if a new product
increases monetary profit. If it does, or has the potential to do so, it
is profitable; if it does not, it is unprofitable. This is a bit simplistic,
but the university has nothing even remotely approaching such a
r.n-nsurc. ?l.> ^oals
abstract and so are its measures of profitabil
ity. As a result, it is harder for a university to justify the termination
of a program or activity;
Second, the modem or practiced concept of academic freedom
makes justification of termination even more difficult. Academic
freedom has come to be the right of faculty to teach in strict pri
vacy and to do their research in isolation. In fact, student course
evaluations have been criticized by faculty for violating their aca
demic freedom. The problem then is that autonomy has become
popularly linked with academic freedom, encouraging existing pro
grams and activities simply to continue because scrutiny of any sort
is inappropriate.
Nonetheless, colleges and universities do practice boundary con
traction and sometimes even termination, but likely at a lower rate
than other organizations. 1 he degree to which a host organization is
capable of making a negative institutonalization-termination decision
is dependent upon the degree of internal solidarity with regard to
shared orientations—norths, values, and goals. As campus wide
shared orientations coalesced at S.U.N.Y.A.B., institutionalization
termination grew harsher and harsher even though the colleges were
more tame in later years. The greater and more widespread the host
divisions, the more rancorous the institutionalization-termination and
the less likely a permanent solution will he reached. In such an envi
ronment. multiple modes of mstiiutiimalizati-awa’mination are pro
posed and gain constituent backing. The 1970 institutionalization of
the colleges that occurred on a campus divided over norms, values,
and goals was characterized by rancor, temporary solutions, and
support for a multitude of institutionalization-termination solution-.
Interestingly, there is never total agreement. Even in 1974, when
agreement was rather widespread, several modes of institutionali
zation occurred at the same time. While the colleges were being
subjected to boundary contraction, boundary expansion was also
occurring. The reason is that there were administrative subunits and
individuals within the host organization whose needs differed from
the rest. But, as would be expected, boundary contraction—which
coincided with the more commonly shared orientation—rather than
boundary expansion was the predominant fate of the colleges.
In instances of political division, the innovation is given an increas
ingly important role in negotiating an institutionalization-termination
solution. Institutionalization-termination becomes a matter of negoti
ating an acceptable solution. The colleges were more influential in
1970 in prospectus development and acceptance than in 1974, when
the campus was more united. The actual negotiation process can best
be seen in the discrepancy between the 1970 faculty poll favoring
strong controls on the colleges and the vote of the faculty senate for
the lenient Stern prospectus. Under conditions of political division,
more emphasis is placed on control procedures than an innovation
substance because there is little common ground between the most
extremely divided groups. Procedures can be agreed upon more easily than the substarice of an innovation. The 1970 Stem prospectus
was concerned prii narily with proccdirral aspects of the colleges,
such as the numbe r of credits a suidei it could take per term, the
procedures for approving experimental <:•ourses, and soon. This was
;ctus, which demanded connot nearly as true o f the Reichei
siderable faculty ini vehement and end*?d the experimental course
option. When there? are puiitic.il divisi<ms, extremists are able to
decide the course o f insiilnliunalization-itermination, but are ineffeclive or excluded uiuder conditions of p olitical solidarity. Dissident
elements of the factilty and student bodj had to be appeased during
1970 jnst'itutionaliz; diui’•termination or t here was a danger of unrest
extremist elei:iicnts were ineffective both
being resumed, in
during the faculty < icoates ami in tne c.bartering committee. Under
uionali iti >n t mination results in greater
all circumstances ii
formalization of inricvalion procedures;such as governance, hiring,
162
How and Why Innovation Hails
and the like; but under conditions of political division, the degree of
formalization is less. The colleges became more formalized under
the Reichert prospectus than the Stern prospectus. This is because
greater host solidarity results in greater scrutiny of the innovation
and less in-fighting within the host.
Despite the conditions under which institutionalization-termination
occurs, it may be repeated several times. If, as mentioned, it occurs in
a politically divided host, it is more likely to be repeated at least once
after the host stabilizes; however, even in a nonpolitically divided
host, changes in times and personnel, host and innovation, can trig
ger another institutionalization-termination phase. The difficulty with
repeated instituticnuiizati. ns is that they are a drastic and gross way
of adjusting the relationship between an innovation and the host.
They are very time-consuming, require months to be completed, and
necessitate a mobilization of host membership.
An easier mechanism is regulation. This involves controlling the
flow of host resources to the innovation, the internal procedures of
the innovation, and the autonomy of the innovation from the host.
Both the Stem and Halstead prospectuses advocated boundary expan
sion via enclaving. By means of regulation, the status of an innovation
under any mode of institutionalization-termination can be increased
or decreased. The Halstead document, by imposing greater regula
tions, brought the colleges closer to boundary contraction.
Regulation is a function of the host. It has the advantage of being
quick, razor-edged. and lacking in the machinery that makes institutionalization-terir.m.mi';;’. cumbersome. Regulation increases as an
ingly compatible. which means that the innovation is perceived in
some way to be iliegitimt.'v by the host. The lack of legitimacy is
of innovation abuses are perceived to increase. Regulation began
at Buffalo as a half-hearted effort by administrators, and became
increasingly tough, wider in scope, and greater in amount as time
passed. The enforcement of regulations is selective. For instance,
departments at Buffalo were not punished for failing to have their
courses approved as were the colleges. When the number of regula
tions increases sufficiently, they are incorporated into a new insti
tutionalization-termination document. The Halstead prospectus was
such a document.
As regulation increased, the colleges at Buffalo complained louder
and more often about violations of their autonomy. As with institu
tionalization-termination appeals, the faculty senate served as the
ultimate judge of the correctness of the regulations. The senate was
an excellent body for carrying out that function in that it had to guard
itself against the executive as well. To permit the executive to over
step his or her boundaries with regard to the innovation was to invite
similar activity with regard to the faculty. All organizations do
have such established and readily available appeal procedures. The
university is a particularly democratic organization.
When the host—through institutionalization-termination or regula
tion—required changes of the colleges, they usually reacted to the
demand by complaining and complying. Most innovations develop a
desire to continue and are dependent on the host for sustenance. At
times, accepting a change meant the loss of characteristics associated
with the purpose for creating the college. For instance, some colleges
had created academic communities for students or excellent centers
of identificati on, yet were r<.•organized in a mrinner that undermi:ned
those com muinifies. Such ch amzes sometimes resulted in a conur
tion of the p usilion fonyer! \ held bv an inn*.jvatinn on the mst
tionalizalion- termination coritinuum rather tha n a decline.
Innovation ? .' < n f mnd « o have complied •with the host in thtree
ways. They i a chided: piecerneal change, holist ic change. and men
Two ways of not buckling to the host were ence runtered as well. St »me
y to stay as they wi
colleges took a passive staru
In all cases such a decisiui i was ultimately i •eversed or subjec
i. The more succes:
negotiation —
way of refusi ug to comply w;it h host demands v
The only coi eve that was i ^compatible with ithe university that did
not change siignificanily wa* College Z. which pissed.
165
Conclusions
The failure of an innovation involves several steps:
1. A need is perceived by the host for institutionalization or termi
nation of the innovation after its trial period. If the innovation is
successful, an institution wide and formal institutionalization
termination process does not occur. Under such conditions, in
formal institutionlization-termination and regulation are suffi
cient to align the innovation with the host.
2. One or more plans for institutionalization-termination are formu
lated and one is approved.
CHAPTER 6
Implications:
A Literature
Review
3. The plan is implemented and initiated.
4. The innovation is subsequently regulated by the host as per
ceived necessary. The process is repeated as many times as
necessary, with the innovation moving down the boundary
expansion-boundary contraction continuum with each repetition.
Chapter 1 boldly proclaimed that a great deal is known about
innovation. A few tantilizing morsels were dangled before the reader.
But to be quite candid and to provide a rationale for writing this
book, it was pointed out that there are also serious gaps in our knowl
edge. So far this volume has attempted to fill a few of these holes—
at least that was the hope for Chapters 2 through 5. With that done,
it’s now time to pull together what we knew at the outset and what
we learned in the course ■■ tl ■
In the quest to discover why innovation fails, this volume empha
sized two related subjects - organizations, universities in particular.
as locations for innovation and innovations themselves. For the re
mainder of this chapter each will be examined in turn. The three
purposes for Join.' this ata: 1>
see if the institutionalizationtermination model pre.- :’-vd j:> Chapters 2 to 5 is consistent with the
existing liter;:li:re > ■:. ::mat ion. and change: 2) io see if the existin'
literature adds tm> :.:.t'..ei explanation to the institmi nalization
This entails a research review of sorts—a review of majoi findi
in the literature :. i!:er ilmn a review of the full range of publica
tions of the subject.
pn cvdure will be to present conclusions
from key research pertaining to colleges and universities as well as
organizations in general, and to examine the implications in terms of
the institutionalize ion-termim.I ion model.
166
Conclusions
implications: A Literature Renci’.1
Let's begin -.vith organizations since that is how this book began.
The author is aware that "consistency is the hobgoblin of little minds,"
but argues in turn that symmetry in defense of scholarship is no vice.
This is the finding of JB Lon Hefferlin (1969). lie examined the
correlates of innovativeness or, as Hefferlin called it. dynamism in, of
all places, colleges and universities. His research, published under
the title Dynamics of Academic Reform, involves a study of a repre
sentative sample .of 11.0 colleges and universities. Hefferlin found
instability to be the critical ingredient for the innoration producing
organization. He reported that colleges without gradoate programs—
and thus more chance for instability or change—had a greater rate of
change than universities. Academic reform was also more prevalent
at colleges and universities with changing faculties owing to expan
sion and turnover, low rates of tenure, junior staff members influen
tial in educational policy-making, rotating department chairpersons,
and trustees and educational leaders oriented more toward change
than stability. Student-centered institutions—that is, colleges and uni
versities financially dependent on attracting studentsand their tuition
money—and those located in metropolitan areas also exhibited a pro
clivity for change, due, as were other factors, to greater instability.
Hefferlin’s thesis goes beyond the institutionalization-termination
model. The kind of college he describes as innovative is one that
might be classified (using the language of the model) as lacking in
rigid boundaries. Owing to changing leadership, a changing staff. a
changing marketplace, a changing environment or locale, and the
absence of a static graduate school ethic, such schools are more flexi
ble and open. Ifwe analogize an organization’s boundaries to the belt
holding up a pair.of pants, we might say that Hefferiin’s colleges are
circumscribed by a loose belt with a few extra notches for breathing
room. If the \veareir of such a belt puts on a few ex:tra pouncIs, the belt
need not be adj us ted. Similarly, if an organization deparl:s from its
norms, value s, and
• >e made in
its boundary•s U i?:e boundaries are flexible or n< rnrigid. Tu a certain
extent boundlary e:xpansion occurs automatically. It is just ii matter of
taking up tin.
Dropping 1.he be■it analogy (to the pleasure of t he author• and < .lost
eater likecertainly the readet'. th snide boundaries means I
lihood of boa ndar\ expansion when tin otganizalion is faard with an
innovation. '1 'he oprpositc is true of rigid boundaries. In thatl case, it is
more likely
imovatio , difk recces with th C h:i>t will be per
ceived as de•\ ian. . resulting in boundary contraction. 1 il ucr sucn
conditions, innovations are unlikely to be adopted or to persist if
already adopted. AH o! this is to say < u in stabii r rigi i >rgani: a
tions, innovations are more likely to be perceived as incompatible.
unprofitable, or both.
168
169
Organizations
Aside from innovation, and perhaps change, organization is the key
concept of this volume. The term was prominent in each of the last
five chapters, and detailed (some might say minute) attention was
given to the case study organization, the State University of New
York at Buffalo. The irony is that organization is a relatively unim
portant part of the institutionalization-termination model. It is what
might be called “a given.”
The model starts with the organization. Regardless of its varia
tions, there is no change in the model. It is the innovation that must
vary. No matter what the nature of the organization, the innovation
must be compatible and profitable with it if the innovation is to
succeed. Otherwise, failure is always the consequence. As a result,
this discussion of organizations can do little in the way of confirming
or disconfirming the model. What it can do,-though, is to amplify and
elaborate upon both the current literature on organization and change,
and the institutionalization-termination model.
The fact of the matter is that innovation is more likely to occur in
some types of organizations than others. Shepard (1969) refers to
the extreme examples of this phenomenon as “Innovation-Resisting
and Innovation-Prodqcing Organizations." At the risk of laboring the
obvious; these are the organizations at opposite ends of the resist
ance continuum. There are certain systematic differences between
them, three in particular. And that is the subject matter that this
discussion of organizations will deal with.
1.
Jimuimtioii Resistance Is Related to Orgaiiizalional Stability
Conclusions
It is interesting to note, though, that rigid boundaries do not neces
sarily make for a stuffy or traditional organizaton. Burton Clark (1970)
sends this message via his book, The Distinctive College, a study of
the “organizational sagas” of three innovative colleges—Antioch,
Reed, and Swarthmore. Each was a school that struck out on its own
to achieve a nontraditional or exceptionally innovative mission. Such
endeavors are always subject to what John Weingart and I have
called the centripetal force of inertia. That is, all kinds of forces
inside and outside the organization press to make it more like tradi
tional organizations of its type. The only protection for such organiza
tions is rigid boundaries. In the case of Clark’s three colleges, this
meant a small, little-changing core of personnel; a little-changing
program; clearly articulated clientele and financial support groups; a
student subculture for socializing entering students to appropriate
norms, values, and goals; and a true, ideology. In combination, these
elements preserved the three experiments. At the same time, they
ruled out other types of innovation, which more than likely would
have been the traditional practices of other institutions. For the three
colleges, such practices would indeed have represented innovations,
but undesirable ones from the point of view of their innovative missions./And that is the function of boundaries—to preserve the status
quo. It seems quite reasonable to think that the more the status quo is
valued or the external environment feared by an organization, the
more rigid its boundaries?}
2. Innovation Resistance Is Related to a Variety of
Or",iiiizaiio>:al Variables
£fiage and Aiken (1970. chapter 2) offer an awfully good summary
of the principal organizational variables that most past researchers
have said influence the innovation-producing or resisting qualities of
an organizati(.n.^Bear in mind, however, that this research is not
without its critics. For instance, Zaltman, Duncan, and llolbek (1973)
argue that the relationships postulated by Hagfe and Aiken do not hold
throughout the innovation process, but rather at particular stages.
Their criticism appears apt and similar criticisms of this variety may
be wholly justified, but they do not diminish the value of the Hage
and Aiken work for our present discussions! What Hage and Aiken
Implications: A Literature Review
offer the reader are postulates concerning the likelihood of change
associated with seven different organizational variables. So far as the
weight of present research is concerned, it supports Hage and Aiken.
provided the postulates are taken to refer to general tendencies or
directions for change or innovatoin. The postulates do not necessarily
apply to particular organizations, specific periods of time, and defi
nitely not to each of the individual stages of the innovation process.
The Hage and Aiken postulates are:
The greater the formalization (i.e., the greater the degree of codification
of jobs, the greater the number of rules specifying what is to be done,
and the more strictly rules are enforced), the lower the rate of organiza
tional change.
The greater the complexity (i.e., the greater the number of occupational
specialities of an organization and the greater the degree of professional
ism of each), the greater the rate of organizational change.
The higher the centralization (i.e., the smaller the proportion of jobs
and occupations that participate in decision-making and the fewer the
decision-making areas in with they are involved), the lower the rate of
organizational change.
The greater the stratification (i.e., the greater the disparity in rewards
such as salaries and prestige between the top and bottom ranks of an
organization), the lower the rate of organizational change.
The higher the volume of production (i.e., emphasis on quantity versus
quality in organizational outputs', the lower the rate of organizational
change.
The greater the emphasis on efficiency (i.e.. concern with cost or re
source reduction), the lower the rate of organizational change.
The higher job satisfaction (i.e.. betw e". organizational morale), the
greater the rate of organizational change.
These'seven postulates flo w directly from the institutionalization
termination model. The first three postulates are matters of com
patibility and the next four are concerned with profitability.
Conclusions
Implications: A Literature Review
With regard to Compatibility, it is not surprising that increased
formalization reduces change. This is the phenomenon just discussed
—rigid boundaries. The more rules, jobs, or other aspects of organiz
ational life that are codified, 1) the more rigid are organizational
boundaries 2) the more limited the range of acceptable norms, val
ues, and goals, and 3) the less likely innovation is to persist.
—''Complexity and centralization are opposites in terms of compatibil
ity. Complexity increases tire number of autonomous decision-makers
or decision-making units in an organization. That is the essence of
specialization and professionalization. By definition, centralization
reduces both the number of decision-makers and decision areas. As
regards compatibility' then, complexity tends to increase the range of
acceptable norms, values, and goals of an organization by increasing
both the number of people whose opinions matter and the number of
.areas in which those opinions matter. Centralization does just the
mpposite and thereby reduces the range of acceptable norms, values,
land goals. This means that the complex organization is likely to have
0 wider range of acceptable norms, values, and goals than the less
complex organization.) And the centralized organization is likely to
have a narrower range of acceptable norms, values, and goals than
the less centralized organization. So as complexity increases, the
likelihood of an innovation being incompatible with the organization
declines. As centralization increases, the likelihood of incompatibility
increases. The result is more boundary expansion in the more com
plex organization and more boundary contraction in the more central-
an innovation satisfies adopter needs. If the potential adopter of an
innovation either has no need because productivity and efficiency are
high, or defines the need very narrowly in terms of productivity or
efficiency alone, the likelihood of innovation is significantly reduced
—most potential innovations will appear unprofitable.
Finally, job satisfaction is a very basic need. Until that need is
satisfied, it is highly unlikely, as mentioned earlier, that solutions to
more advanced needs will be sought. This also reduces the potential
forjnnovation. Most innovations will appear unprofitable.
^JJy way of conclusion, one might say that established organiza
tional characteristics—like complexity, centralization, formalization,
stratification, efficiency, productivity, and job satisfaction—dictate the
degree to which innovation in general will be compatible and profita
ble with an organization. '{The likehhoqd of innovation incompatibility
is increased in an organization that is low in complexity and high in
formalization and centralization. Universities, by the way, tend to be
high in complexity and low in formalization and centralization. The
likelihood of innovation unprofitability is increased in an organization
that is low in job satisfaction, efficiency, and productivity. Here again
universities have the opposite mix of characteristics. Accordingly,
institutions of higher education might be classified as low in innova
tion resistance relative to organizations in general.
certainly discourage innovation. Decision-makers tend to be people
in the higher echelons of an organization, and for them innovation is
threatening. It involves jeopardizing their status. To change things
requires risking their goodies to some degree. That is unprofitable.
and unprofitability always leads to boundary'contractioii. Were deci
sions made by people at the bottom of the,organizational hierarchy,
the likelihood of innovation would undoubtedly rise.
Productivity and efficiency are examples of a narrow range of
profitability. Recall that profitability is defined as the degree to which
3. Innovation Resistance Is Related to Organizational Character
Organizational character, the gestalt or total complexion of a par
ticular organization, is one of those topics that is best explored by
careful study of a specific organization, so we will fall back on the
university here.
The 1960s and early 1970s produced a flurry, probably cl
avalanche, of publications about the organization of American col
leges and universities. 11 was ;■ transm.iy interest spurred largely by
student unrest.
with the apparent return of quiet to the nations
campuses, this brand of research has become passe, though the rise
■of collective bargaii
and faculty unionism in recent years ave
kept some interest in the subject alive and a trickle of literature in
the pipeline.
Implications: A Literature Review
The legacy of this effort is a hodgepodge of the good, the bad, and
the ugly. What stands out are a variety of alternate descriptions of the
university as an organization. Particularly noteworthy are John Mil
lett's (1962) characterization of the university as a collegial organiza
tion in his book The Academic Community, Herbert Stroup's (1966)
depiction of the university as a bureaucratic organization in his vol
ume Bureaucracy in Higher Education, and J. Victor Baldridge’s
(1971) portrayal of the university as a political organization in his
case study of New York University entitled Power and Conflict in the
University.
Each description seemed to bear a grain of truth. The image of the
collegial organization is readily apparent in the decision-making of
college faculties, who collectively determine the promotion of staff
and the direction of educational policy. This would be an apt descrip
tion of the way the Buffalo ■‘faculty senate performed in the case
study. The picture of the university as a bureaucracy is observable in
the hierarchical ordering of university personnel with a chain of com
mand that includes department chairpersons, division heads, school
deans, academic vice presidents, presidents, and trustees. Indeed,
the lack of such organization was considered one of the failings in the
case study colleges by the State University of New York at Buffalo.
The political portrait of the university was confirmed daily in the
newspaper accounts of campus unrest in the late 1960s. It was cer
tainly one of the most prominent features of the Buffalo case study.
The fact of the matter is that each of these descriptors does an
excellent job of characterizing some aspects of college or university
organization, but none describes it fully. In general, they call to mind
the parable of the blind men and the elephant. Each blind man
touched a different portion of the animal and took that for the whole.
Just as the elephant is not a snake as the blind man who touched its
tail said, so the university is not wholly a bureaucratic, collegial, or
political organization.
,
With the hope of building a better elephant, it’s useful to consider
just what went wrong with past writings. Several things come imme
diately to mind. The Millett and Stroup volumes are essays intended
to describe the university as a particular type of organization, rather
than to impartially assess the organizational character of the umver-
sity. Both authors were quite successful in their endeavors. They
convincingly demonstrated that a number of college activities are
governed by a single form of organization, but neither book, nor both
taken together, provides the basis for a comprehensive theory of the
entire university as an organization.
The Baldridge thesis grows out of a solid research base, but the
research is of the type that David Riesman has called ’’firehouse re
search—the alarm bell rings, the researcher slides down the greased
pole, rushes to the fire, and begins collecting data" (Keniston, 1973,
p. xv). In Baldridge’s case, the fire alarm was a cornocopia of assorted
troubles at New York University. His research was concerned with
how these troubles were resolved. His case study is remarkably good,
but his conclusions suffer from weaknesses germane to all firehouse
research. To change metaphors in midstream, Baldridge took a snap
shot when what was needed was a motion picture. His snapshot
caught only a portion of the university and caught it at only one
moment in time. It missed the organization in its entirety and it
missed the historical perspective. The current organization of higher
education is a product of almost 350 years of evolution in which the
university has grown by increasing the number and kind of activities
in which it engages. The snapshot of recent troubles fails to capture
the rich pattern of elaboration, change, and interaction of the old
with the new that have provided the continuity over time of college
and university organization.
In short, cun-ent literature about the university as an organization
has had three basic weaknesses:
1.
It has failed to consider the university as a whole. dealing
instead with selected activities.
2.
It has failed to regard the university as a historical entity, focus
ing instead upon the university at a single moment in time, usually a
time of crisis.
3.
It has failed io regard the organizational character of the ■
versity as pluralistic, emphasizing instead a single type or form of
organization.
In the next few pages an alternate analysis or typology of the
university as an organization will be offered. It grows directly out of
the past writings and seeks to improve upon them by responding to
Conclusions
the weaknesses that have just been pointed out. The typology is
historic in origin. It is b'ased upon the three functions that comprise
the mission of American institutions of higher learning—teaching,
research, and service. The typology offers a comprehensive analysis
of higher education organization since all of the activities associated
with colleges and universities in this country have grown from the
teaching, research, and service functions, and are to the present day
designed to support and pursue those functions. Finally, the product
of the typology is pluralistic in its depiction of college and univer
sity organization.
A Typology of University Organization
The mission of the American university has not always been trifunc
tional. The earliest American college, established in 1636, was a
single-purpose institution and that purpose was teaching. Only grad
ually over the next 275 years did American colleges grow to include
the research and service functions. The growth occurred by expan
sion rather than substitution. That is, colleges adopted new functions
one at a time by adding them to their existing function or functions
rather than by substituting the new function for the old. Different
schools adopted the new functions and the activities associated with
them in different ways, and the newly adopted functions and activi
ties were emphasized in varying degree at different schools. The
typology that follows draws upon these differences, based as it is
upon institutions that, for a time, emphasized one function far more
greatly than others. The typology describes the forms of organization
that govern university/ and college activities emphasizing each of
higher education’s primary functions and combinations thereof.
Activities Associated with the Teaching Function
We think of teaching as a cooperative endeavor, a communion of
sorts between student and teacher, student and student; and teacher
and teacher. Expressions like living and learning are intimately assoc
iated with it. Accordingly, activities associated with the teaching func
tion of universities tend to be organized in a collegial or communal
manner. This, according to John Millett (1962, p. 235),
176
Implications: A Literature Review
. . presupposes an organization in ■•■.Inch functions are differentiated
and in which specialization must be brought together in a harmonious
'..’hole. But this process of bringing together, of coordination if your will,
is achieved not through a structure of superordination and subordina
tion of persons and groups, but through a dynamic of consensus.
The key elements of the Millett definition are differentiation of
function, a sense of wholeness, nonhierarchical structure, and con
sensus of opinion. They are all found in the American colonial college
and its predecessor, the medieval college. Both were exclusively
teaching institutions. The colonial college was small in size, popu
lated by a homogeneous group of people, and modeled after the Cam
bridge colleges in England. It has been described as “a large family
sleeping, eating, studying, and worshipping together" (Rudolph, 1962
p., 88). The roles in this family were differentiated. The faculty
acted as moral guardians or parents, and the students, who were
often considerably younger than contemporary college students, were
treated as children. The family was nonhierarchical. There were no
faculty ranks and no administration to speak of. The sense of whole
ness and consensus of opinion grew out of a shared religious com
mitment. College-presidents were ministers, the majority of faculty
were ministers, and until the middle of the eighteenth century, 50
percent of the students became ministers after graduation (Brubacher
and Rudy, 1976, pp. 8,10).
The continental medieval college was larger than the colonial col
lege, but similarly communal.1 The University of Paris, for instance,
was divided into "nations,” four cooperative and nonhierarchical
groups, that were created to protect faculty and students who were
strangers in foreign university towns and to provide them with class
room space, dormitories, and other forms of assistance including
burial service. The larger size of the medieval college made reaching
a consensus more difficult for it titan the colonial college. However,
consensus was reached, but only because daily life at these “selfgoverning and self-respecting" institutions was much consumed by
.meetings (Haskins, 1967, p. 50).
'For a brief description of the medieval college and '’nanons," see Schachner.
Conclusions
Activities Associated with the Research Function
When people think of research, the image that comes quickly to
mind is the philologist, looking like Monte Wooley, laboring alone late
at night in his ill-lit room, hunched over a partially legible ancient
manuscript with magnifying lens in hand; or the solitary scientist,
played by Paul Muni, feverishly mixing chemicals as dawn’s early
light streams through his small laboratory window. Research tends to
be individual or small-group work, and the university activities assoc
iated with it are anomically or atomistically organized. This form of
organization, not previously discussed, has frequently been attribu
ted to the university by angry parents, politicians, and law officers,
but it has not been incorporated into the serious organizational litera
ture. Anomic organization is a state of relative normlessness that
exists when individual desires predominate in a college rather than
commonly agreed-upon norms. Anomic is too strong a term, being
inimical to the notion of organization, but gives a sense of the entropy
associated with the research mission of the university. Atomistic is
perhaps the better term.
In any case, atomistic organization provides an apt description of
life at Johns Hopkins University, America's first research university,
which was founded in Baltimore in 1876. Hopkins had both a teach
ing and a research function, but the emphasis was decidedly upon
research. For example, the first entering class included 54 graduate
students and only 12 matriculated undergraduates (Hawkins, 1960
p. 90). Hopkins was built firmly on the foundation of the German
research university. The two key concepts of lernfreihcit. which
granted students the right to attend school when they wanted and the
ability to take whatever-'courses they wished, and lehrfreiheil, which
gave faculty the right to teach and publish research of interest regard
less of findings, were imported directly from Germany. At Hopkins
the commitment to lehrfreiheit meant that faculty and departments
were given the freedom to design their own courses and workloads.
The commitment to lemfreiheit gave students the freedom to take
whatever pr rgrams they chose. The result of the new freedoms
was “extreme specialization” by faculty, the development of “semiautonomous'' departments, and an individually isolated student body
(Fn nch, 1946, pp. 45, 335). Meetings of the entire Hopkins faculty
178
Implications: A Literature Review
were “rare and without authority" (Hawkins, 1960, p. 213). The first
Johns Hopkins president "compared the members of the university
to a hive of bees each storing up honey in a narrow cell unobserving
and unobserved” (pp. 308-309). An assistant commented that most
Hopkins men had “little real knowledge of what others are doing”
(p. 309).
Activities Associated with the Service Function
When people complain about the long lines, having to go from
office to office for information, and speaking to supervisor after super
visor, more often than not they are talking about the university ser
vice function. Activities associated with it tend to be organized in a
bureaucratic fashion. Herbert Stroup (1966, p 14) defines bureau
cracy:2
as a large-scale organization with a complex, but definite social func
tion. It consists moreover, of a specialized personnel and is guided by a
system of rules and procedures. In addition, a carefully contrived hier
archy exists in which the social function of the burearcracy is earned out
impersonally.
All of the elements of the Stroup definition can be found in the
most well-known American experiment in service that originated
at the University of Wisconsin in 1904. Charles Van Rise, then
president of the university, declared that the entire state of Wis
consin. was the campus of the university. The service function
involved the university with the state legislamre, keai government
civic groups, and the office of the governor. Numerous faculty ap; . their scholarly expertise to state problems. The senice function also
encouraged the university to extend education into the commit^-through the development of off-campus study and off-campus co;
As part of this < fort the university sent ■
short, popularized courses in the large towns and cities, offered tech
nical and how-m-d . it instruction on campus, and established large
2Sir<nip will be used as the source here rather than Mr. •: Wi-lxr. the father
bureaucracy, since Stroup deals specifically with in.s:itut:'.n-.itliigcer education. >'>rcover, the Stoup dvfil.r.ion
kusly gn us out of Went:
179
Conclusions
extension and correspondence programs. The service effort was so
broadly conceived that one Wisconsin booster went so far as to say
that the cow was one of the by-products of higher education in Wis
consin “for the-university saved the dairy industry” (Rudolph, 1962,
p. 364). As a result of the commmitment to the service function, the
University of Wisconsin became a larger and more complex organiza
tion.3 New services were added and the university was reorganized
into schools which were subdivided into departments. The university
also became more hierarchical in structure. The faculty meeting
declined in prominence and the power of high level administrators
increased. Furthermore, specialization of roles grew as the number of
middle management deans proliferated. Given the massive growth of
staff and activities associated with the service mission, rules, regula
tions, and impersonality grew more abundant as well.
Activities Associated with Multiple Functions
Activities associated with multiple functions are often politically
organized. According to Baldridge, political organization involves
strategic conflict in which campus interest groups are, at the same time,
struggling with one another and cooperating. QTtTc essence of political
organization is “negotiation and the exchange of advantages, and
favors.” The objective of participation in political organization is to
“wring concessions and advantages” from the college or university
community without destroying it (Baldridge, 1971, pp. 203-204).
Political organization differs from the other three forms of organi
zation in that there is no historic ideal type from which it descends. It
occurs only when there is conflict within a college or university about
which forms of organization or whose opinion should govern activi
ties that serve more than one of the teaching, research, or service
functions. Activities with multiple functions are likely to result in
conflict because the research, teaching, and service functions call for
three different form of governance that make'competing and irrecon
cilable demands upon college personnel. Atomistic, collegial, and
bureaucratic organization each cede decision-making power to differ•Fvr a discussion of changes at Wisconsin as a result of the service function, see
Curti and Carstensen (1949. p. 105-107).
180
Implications: zl Literature Review
ent campus groups. Atomistic organization grants the individual stu
dent and faculty member the power to make decisions. The voice of
each is the voice that counts. Collegial organization grants decision
making power to a collectivity of students and faculty, with no one
individual able to make decisions for the entire group. It is the collec
tive voice that matters. Bureaucratic organization places differing
amounts of decision-making power in the hands of different campus
groups. However, it is the voice of the person at the top that is heard.
This means the chief administrator, who is not given any decision
making power in atomistic organization, is given the most power in
bureaucratic organization. Quite an interesting situation!
For this reason, when the people in a college community’ disagee
about the nature of an activity and the form of decision-making that
should govern that activity, the community divides into smaller com
peting groups. Each group is composed of people with shared defini
tions of how the disputed activity should be construed, and each
applies pressure to have its definition of the situation accepted by the
entire community.
Conclusions
Implications: A Literature Review
functional activities and organizing different parts of the activity in
different ways. With regard to courses, for instance, doctoral disser
tation guidance, w.uch emphasizes research, might be organized
atomistically while introductory or survey courses, which emphasize
teaching, are often organized collegially.
Nonetheless, universities are always politically organized. It is the
degree of political organization that varies. At Buffalo, for instance,
political organization appeared to be the dominant form of organiza
tion during 1969-1970. Despite the obvious harmony on campus in
1974, there was still political organization, but it was so small as to be
discountable as a force in governing the university.
Similarly, the mix of the four organizational forms would be expec
ted to vary from college to college. This is so because different col
leges pursue slightly different activities, have different functional
emphases, and probably classify the activities they engage in some
what differently with respect to teaching, research, and service.
In a like manner, the mix of the four organizational types at any one
university would be expected to vary with time. For example, after the
U.B. merger with the State University of New York, there was an or
ganizational change to match the change in mission. In its transition
from a local, private service university under Clifford Furnas and the
presidents preceding him to a public university stewarded by Martin
Meyerson, the organizational character of U.B. decreased in the degree
to which it was bureaucratic and increased to the extent it was anomic.
Innovalion or Organizational Character
Enough said about universities for the moment. Despite their unique
characteristics as organizations (see Perkins, 1972), several conclu
sions can be drawn from the discus'sion about organizational charac
ter in general and about resistance to innovation in particular.
The character of a specific organization is a product of its history
and the various organizational forms or types of which it is composed.
The character of the university, for example, was said to be a product
of nearly 350 years of history and four organizational types (bureau
cratic, anomic, collegial, and political organization). In the univer
sity’s case, tb.e organizational types were mission-related and may be
in other organizations as well.
The character of few, if any organizations, can be accurately
described as being wholly of one type. Even if one type appears
dominant, other types generally exist in its shadow. By the way, the
four types found in the university are not exclusive. Other types,
such as coercive organization, may be found in different organiza
tions, such as prisons.
The mix of types in a particular organization will likely vary with
lime, circumstance, and organizational mission.
As organizational character changes, so does the innovation
producing or resisting character of that organization. The reason is
that each organizational type incorporates a different level of innova
tion resistance. For example, collegial organization builds in a high
level of innovation resistance through its decision-making process.
Decisions are based on consensus. Consequently all or most people
must agree to adopt an innovation. Even if the majority favor an
innovation, a minority can veto it. Ironically in such organizations,
once an innovation is adopted, it persists practically forever since a
consensus is needed to terminate it. In contrast, anomic organization
incorporates a low level of innovation resistance to small innovations.
Only the consent of a single individual is necessary to adopt an
innovation. For larger innovations, resistance is greater. Since each
member of the organization is autonomous, it is difficult to get agree
ment on organizationwide innovations. The situation is not dissimilar
from trying to grasp sand —it trickles away grain by grain.
Given the mix of organizational types in most organizations, dif
ferent activities and decisions within an. organ!;: ttioti are 1. tely to be
governed, at least to a sm;:!l extent, by different organizational types.
as was the case in the university. This means that innovation resist
ance is likely to vary throughout an organization.
As a consequence of the mix of organizational types, the individ
uals and groups that are involved in decision -making throughout the
organization will vary. The reason is that e.-.cii • rgmiuatmnal type, as
shown in the university, invests decisi m-making in the hands of a
different assortment of people. The result is a certain variation in the
standards of compatibility and profitability used thr-sig!:- the organ
ization,. The less visible the innovation and the fewer people or
groups involved, the wirier the variation is likely to be. Phis is s
because the fewer the aett •- invt B d it decis r making, tl e 1< -likely they arc to be representative of the orgatiizaimn.
The conclusion that would have t< bt Irawi fr m th t scussi nis
182
183
Conclusions
that an organization is not a monolithic whole. This is especially the
case in large complex organizations. Standards of compatibility and
profitability may vary somewhat throughout the organization, which
means that innovation resistance is likely to vary throughout the
organization as well. While boundary expansion and innovation accep
tance may be the response to an innovation in one part of an organi
zation, boundary contraction and innovation rejection may result
throughout the rest of the organization. With this happy news in
mind, it is time to consider the innovation side of the ledger.
Innovations
Chapter 1 described the literature on innovation as extensive—that
might be called the calm and understated assessment. In actuality,
the publications verge on the incomprehensible by their sheer num
ber, cutting across the fields of agriculture, anthropology, business,
economics, education, history, psychology, sociology, the sciences, the
professions, and most other subjects that one can think of.
For the sake of the current discussion, three types of literature
need to be distinguished from the rest of the morass: 1) the literature
on innovation characteristics and innovation success, 2) the litera
ture on how to carry out successful innovation or change, and 3) the
literature on obstacles to innovation success. This, in sum, is the
literature most germane to the institutionalization-termination model,
so this is where opr discussion will begin, looking at each of the three
types in turn.
1. Literature an hiuoration C’l'i'ccleristirs uiiil biwratiuu Success
Innovation characteristics literature is comparable to the organiza
tional variable literature already discussed. It is concerned with the
specific features of an innovation—any innovation —that enhance or
detract from its likelihood of being adopted or persisting. It is impor
tant
note that adoption and persistence are,the most common
measures i.f innovation success, which is different from the definition
associated with the institutionalization-termination model, where suc
cess is defined negatively as the absence of downward movement on
the inst I'.utionalizalion-lcrmiiiation continuum prior to the innovation’s
184
accomplishment of its purpose. The implications of this will be dis
cussed 'e'er.
Current research varies considerably on the number, even the substance, of the characteristics that determine an innovation's success
or failure. Zaltman and his colleagues (1973) are at the high end of
the spectrum suggesting some 19 attributes. Many of the sugges
tions are new and there is little evidence in the literature to dem. ca
strate their validity.
Nonetheless, if one surveys the literature as Rogers and Shoe
maker (1971) have done, basing their conclusion onmore than 1500
empirical and nonempirical studies, five critical ciiaracteristics emerge:
relative advantage (“the degree to which an innovation is perceived
as being better than the idea it supercedes”); compatibility (“the
degree to which an innovation is perceived as consistent with the
existing values, past experience, and needs of the receiver”), com
plexity (“the degree to which an innovation is perceived as relatively
difficult to understand and use”), trialabilily, elsewhere called tri
ability and divisibility (“the degree to which an innovation may be
experimented with on a limited basis”), and observability, also called
communicability (“the degree to which the results of an innovationare visible to others”).
Rogers and Shoemaker (pp. 350-352) say the following relation-
Conclusions
ported by 69 percent of the empirical studies.
“The observability of an innovation, as perceived by members of a
social system, is positi vely related to its rate of adoption." Seventy-eight
percent of the empirical studies of observability support such a conclu
sion.
At first blush, there does seem to be a certain disparity between
tire Rogers and Shoemaker conclusions and the institutionalization
termination model. Rogers and Shoemaker find four characteristics
—relative advantage, compatibility, trialability, and observability —
to be positively related to innovation success, while the model indi
cates that success is a consequence of only' two characteristics—
compatibility and profitability.
On further examination, this numerical disparity disappears. It should
be noted that Rogers and Shoemaker are concerned with the adop
tion of innovation in contrast to the institutionalization-termination
model which deals solely with the period after they are adopted. In
Chapter 2, it was pointed out that the decision to institutionalize an
innovation is much the same as the decision to adopt or initiate and
implement one. But there are important differences as well. That is,
the adoption of an innovation also involves the prior two steps or
stages of 1) recognizing the need for an innovation, and 2) the plan
ning and formulating of the innovation itself. And this accounts for at
least two of the characteristics omitted in the institutionalization
termination model—trialability and observability.
Trialability is a matter that precedes the decision to adopt an inno
vation, but becomes inconsequential thereafter. It is concerned with
the ability of an organization to try an innovation on the installment
basis. There is a certain risk in trying anything new. If it doesn’t
work, there is some comfort in knowing that the situation is reversi
ble without undue harm to the organization. Recall that this was one
of the major drawbacks mentioned for holistic change. If it fails to
work, there is nothing left. Be that as it may, once, an innovation is in
place, holistic or not, the question of trialability becomes moot. It is,
as a result, a subject not even considered in the past adoption period.
As for observability, this is a concern largely of the second stage of
the institutionalization-termination process—planning and formulating
186
a solution. If an innovation is unobserved and, as a result, unknown,
it is quite unlikely to be thought of as a solution to the organization’s
need. Observability is, for this reason, a critical innovation character
istic during the preadoption period. During the postadoption period,
observability remains a concern of the innovator, but it is a concern of
a different sort. It becomes a matter of rumor control, making sure
that the rest of the organization has an accurate picture of the innova
tion. And this, though apparently a problem of observability, is more
fundamentally an issue of compatibility and profitability. That is,
preventing the innovation from appearing incompatible or unprofit
able. Observability is by no means a necessary innovation character
istic in terms of insuring success during the postadoption period. In
fact, in the case in which an innovation is actually incompatible or
unprofitable, it would be advantageous from the point of view of the
innovator for the innovation not to be observed by the rest of the
organization.
This leaves Rogers and Shoemaker with two characteristics—rela
tive advantage and compatibility—and the model with two charac
teristics—profitability and compatibility. The two sets are much the
same. Relative advantage is a measure of profit. Rogers and Shoe
maker (1971, p. .139) describe it as an indicator of the intensity of
reward or punishment resulting from the adoption of an innovation.
Disparities in the definitions of the characteristics are, however,
instructive. As for compatibility, both Rogers and Shoemaker, and the
model are referring to precisely the sai
an innovation and the organization. The difft ren :e in d< finitions here
is trivial. It can be chalked up to the model’s reliance or. traditional
sociological terminology, and Rogers and Shoemaker’s use of a more
popular phraseology.
The situation is similar for profitabilitv and relative advantage.
Both are measures of gam. materia', and nonmaterial, based on the
perceptions of the adopter. Profitability is a sharper concept to the
extent that it relies upon the needs of the adopter rather than the
generalized notion of betterment. This difference allows for finer
discrimminatiqps of the concept of profitability into "eneral.
:■
interest, negative, and positive forms.
187
Conclusions
Implications: A Literature Review
To .summari.e then, the innovation characteristics associated with
the institutionalization-termination model are consistent with the
existing literature on innovation characteristics and innovation suc
cess. The construct of profitability, however, may represent a refine
ment over the more commonly used concept of relative advantage.
The human problems or human relations school is therapeutic ■
educational in orientation and brings about change through alter,
tions in the personality and motivations of organizations, groups, and
individuals. Among the well-known members of this school are Rensis
Likert, Warren Bennis, Ronald Lippitt, Chris Argyris, Walter Sikes,
F. J. Roethlisberger, and Douglas McGregor to mention just a very
few. The assumptions made by the human relations school about the
world are, not surprisingly, quite different form those of the rational
school.
2.
Literature on How to Carry Out Successful Innovation or Change
These writings, collectively called the literature of planned change,
are a jumble of theories, research of varying quality, folk wisdom,
reminiscences, and snake-oil remedies that are intended to help the
potential innovator understand what steps must be taken to enhance
the likelihood of an innovation’s success. Four schools or ways of
thinking about planned change can be identified, however. They
might be called the rational school, the human problems or human
relations school, the power school, and the eclectic school, which
includes each of the other three and the kitchen sink, too.
The rational school emphasizes change through research and utili
zation of knowledge and other expert resources. The most familiar
names associated with it are probably Everett Rogers and Ronald
Havelock. The philosophy of the school rests on several basic assump
tions:
One fundamental assumption is that men are rational. Another assump
tion is that men will follow their rational self-interest once this is revealed
to themi. A change is pr oposed by some person or group which knows of
a situat ion that is desireible, effective, and in line with the self-interest of
the per:•son. erouD. orcra nizati<>n, or community which will be affected by
the change. Because th'e person (or group) is assumed to be rational and
moved by self-interest. it is assumed that he (or they) will adopt the
propose?d change if it cain be rationally justified and if it can be shown by
the proposer(s) that he (or they) will gain by the change [Chin and
Benne, 1969, p. 34],
The emphasis is decidedly upon enlightened s61f-interest and gain.
For this reason, the rational school might be. described in the lan
guage of the institutional-termination model as the profitability school.
It seeks to increase the likelihood of innovation by raising the per
ceived profitability of change.
188
[The human problems or human relations school holds that patti ms
of action and practice are supported by sociocultural norms and by
commitments on the part of individuals to these norms. Sociocultural
norms are supported by the attitude and value systems of individuals—
normative outlooks which undergird their commitments. Change in a
pattern of practice or action, according to this view, will occur only as
the persons involved are brought to change their normative orientations
to old patterns and develop commitments to new ones. And changes in
normative orientations involve changes in attitudes, values, skills, and
significant relationships, not just changes in knowledge, information, or
intellectual rationales for action and practice [Chin and Benne, 1969,
P- 34],
This, to be sure, is the compatability school. By changing the norms
and values of the people in an organization, the human problems/
relations school hopes to increase the likelihood of innovation success.
The power school brings about change by means of coercion. It
holds that those with less power will comply to the will of those with
more power. Consequently, decision-making elites are often capable
of imposing the changes they wish. The political model of organiza
tion advanced by J. Victor Baldridge, which was discussed earlier, is
an outgrowth of this school, but is a more civilized and democratic
version in which competing coalitions arc substituted for competing
elites.
/' All three of the schools Examined so far—the rational school, the
\ human problems/relations scl.... 1. and the power sd
) thing in common. They all have poor track records-each is incc-m\plete. The rational school neglects innovation compatability: the
'human problenis/relations;school neglects innovation profitability;
189
Conclusions
and, the power school ignores both. The power schools , by the way,
has the worst track record. The problem is that planned change as
dictated by the power school “has a remarkable tendency to solve one
set of problems only to generate another set; to give advantage to one
group, but to disadvantage another; to eliminate one structural strain,
but to create another (Baldridge, 1971, p. 96). As Lindquist (1978, p.
9) perceptively notes, “Losers of today’s battles do not give up. They
mount a new demand." Change may get adopted in this manner; but
it is unlikely to persist. The example of New College at the Univer
sity of Alabama, discussed in Chapter 2, which was established by
the president of the university despite faculty objections, is a truly
exceptional exception.
The limitations of the three schools may explain why the fourth,
the eclectic school, is currently in vogue. It is a pragmatic school
lacking in the ideology of the others. It goes with what works. Per
haps in its most ideal sense, the eclectic school can be described as
seeking to overcome the weaknesses of the others by combining their
strengths along with other successful change strategies. The result,
unfortunately, too often comes out looking like a recipe put together
by a committee, and there are enough such recipes to make an
impressively sized cookbook.
To save the reader the trouble of purusing such a volume, several
of the recipes (Bennis, 1973; Conrad, draft; Lindquist, 1978; and
Martorana and Kuhns, 1975) have been collapsed or synthesized.
The result is a new 12-ingredient recipe for successful change. The
details of its derivation can be found in Appendix B; a shorter version
1.
2.
Create a climate, even a demand, for change
Diminish the threat associated with innovation and avoid hard-
Implications: A Literature Review
9,
10.
11.
12.
Build an active base of support
Establish rewards
Plan for the postadoption period
Other'
To be quite candid this recipe, like much of the eclectic literature, is
a confusion of procedures (e.g., engage in information dissemination
and evaluation), goals (e.g., build an active base of support and get
organizational leaders behind the innovation), postures (e.g., avoid
being timid), and innovation stages (e.g., item number 1 points out
the importance of the first stage of the innovation process—recogni
tion of need—and item 11 cautions not to forget the final stage). None
theless, the two determinamts o.t.tlK.institudonalizadP'iAermination
model—profitability^and compatibility—are prominent throughout.
CompatibiliFy isa theme in items 1, 2, 4, 5, 8, and 9. And profitability
is dire’ctlyTouched upon in items 1, 2, and 10. This recipe, then, is
consistent with the institutionalization-termination model in empha
sizing the importance of compatibility and profitability in innovation
success. However, it does not make it clear that these are the only
criteria for success; neither, on the other hand, does it preclude that
possibility, as her other determinant leaped forth from the recipe.
By way of conclusion, it might be said that the literature on planned 1
change indicates that profitability and compatibility are probably '
both necessary if an innovation'8 tosucceed'.’ The lack of success of
the rational, human problems,'relations. and power schools may be a
consequence of the neglect by each of compatibility, profitability, or
both. The currently more popular eclectic school was found to include
both profitability and compatibility prominently among its prescripli.msfo! imtoxt.lioil stucessA'
• .if
being timid
4. Appreciate timing
5. Gear the innovation to the organization
6. Engage in information dissemination and evaluation
7. Communicate effectively
8. Get organizational leaders behind the innovation
190
191
;■
issue of successful change from the opposite direction; that is, the
l’rt>b£cn^n mnoyatjon must_overcome *r’s t0 succeed.
Die hicratpre here■'ruing with
organizations and larger social systems in general, and that concerned
with particular types of organizations. In the next few pages an exam
ple of each will be examined.
As for organizations in general, one of the most thoughtful pieces
of writing is an article by Godwin Watson (1969) entitled “Resistence
to Change.” In it, he identifies five obstacles to innovatiorTwithiri
ejostlng social systems. They are:
1.
Conformity Io norms
“Members of organizations demand of themselves and of other
members conformity to institutional norms . . . because norms are
shared by many participants they cannot easily change; (p. 493).
Watson points out that conformity or rejection of the nonconformist
are the usual outcomes.
2.
Systemic and cultural coherence
No innovation can be considered an island unto itself. Changes in
one part of an organization will necessitate changes throughout the
organization. But “innovations which are helpful in one area may
have side effects which are destructive in related regions” (p. 494).
3.
Vested interests “The most obvious source of resistance is some threat to the eco
nomic or prestige interests of individuals" (p. 495).
4.
The sacrosanct •
. .
“The greatest resistance concerns matters which arc connected
with what is held sacred... . The closer any reform comes to touch
ing tome of the taboos or rituals in the community, the more likely it
is to be resisted" (p. 495).
5.
Rejection of outsiders
“Most change comes into institutions from ‘outside.’ ... A major
problem ... is to secure enough local initiative and participation so
that the enterprise will not be vulnerable as a foreign importation”
(p. 496).
These obstacles are problems that persist throughout the innova
tion process—from the time a need is first recognized to the time an
innovation is institutionalized or terminated. All five barriers can be
be described as potential problems of incompatibility or unprof
ability. Conformity to norms, protecting the sacrosanct, and rejects ..
of outsiders are all matters of incompatability. The first two obstacles
are concerned with preserving the existing norms, values, and goals
of an organization, and the third involves rejecting that which is
inconsistent with an organization’s personality.
Unprofitability is the trouble with the other two barriers-vested
interests and systemic and cultural coherence. As mentioned in the
discussion of organizational stratification, for individuals and even
subunits that are well endowed relative to the rest of an organization,
most change is threatening. It is for this reason that vested interest
makes innovation unprofitable. As for systemic and cultural coher
ence, recall that in Chapter 2 profitability was said to be a measure of
whether an innovation both satisfies the need for which it was cre
ated and whether it positively or negatively affects the rest of the
organization. What Watson describes as the coherence barrier is actu
ally a case of innovation that has a negative effect on tire remainder
of the organization. It is in this sense an unprofitable innovation.
Before offering any conclusions about Watson’s work, let’s turn to
the literature on barriers in a particular type of organization. And for
the sake of novelty, make that organization a university. Once again the
best source is ITefferlin (1969). He first notes five obstacles common to
innovation success in all types of organizations, universities included:
1. Organizations are inherently passive. This means “they exist
for the routinization of behavior,” preserving the status quo (p. 10).
2. Voluntary organizations attract members who agree with their
activities. That is. "organizations are self selective" and recru? mem
bers "who appear compatible with them" (p. 10).
3.
Organizations tend toward institutionalization and ritualism.
This is quite similar to Watson’s m non < f the sacrosan;:.
4.
Organizations that are livelihoods for people tend to come to
exist only as livelihoods fot those people. Here llefferlin is concerned
with the problem u vested interest.
5.
Maintenance it 'litu ion tl effe tit ent
remer is ' ■
one problem that organizations must face in order to survive,
er
problems take precedence ®yer it. This refers to the question of
timing noted in the literature on planned change.
bnplica I ions: A Literature Review
All of Hefferlin’s five barriers. like Watson’s, can be described as
problems of innovations being potentially incompatible or unprofit
able with their host organizations. There is even some overlap in
the two men’s analyses. In any case, item 4 on Hefferlin’s list deals
with passible unprofitability and all of the rest are concerned with
incompatibility.
What makes Hefferlin’s (1969) work unique is the next seven bar
riers he proposes. These are barriers peculiar to the university. They
include the following:
1. The purposes and support are basically conservative. Hefferlin
describes colleges and universities as devices essentially for the “per
petuation of culture’’ with a “long tradition of custom and precedent”
(p. 13). Innovation is not especially compatible with such an organi
zation.
2. The educational system is horizontally fragmented. This means
that colleges are wedged between secondary education and graduate
school, both of which dictate what colleges should do. Hefferlin says
modification of college programs beyond accepted boundaries “would
be as risky-as for a typewriter manufacturer to market typewriters
with an arrangement of keys different from that of the standard
keyboard” (p.14). Consequently, universities might be described as
organizations with a very narrow range of acceptable norms, values,
and goals.
3.
Within higher education, institutional reputation is not based on
innovation. That is. "the accepted roads to academic prestige and
advancement are not those of unconventionality” (p. 15). So innova
tion is consid-. . W .". .ather unprofitable endeavor.
!. Faculty members have observed their vocation for years as
students before joining it. Socialization runs deep within the univer
sity and innovation that runs against the grain is more likely to be
thought of as deviant.
5. The ideology of the academic profession treats professors as
independent professionals. This means both variation in the norms,
values, and goals within a diversity, and impressive power of pas
sive resistance among members. Establishing the compatibility of an
innovation is no picnic under these conditions.
6.
Academics are skeptical about the idea ol efficiency in academic
life. Hefferlin refers here to the rejection of educational measurement
by many faculty. In such an organization, common needs are hard to
demonstrate and varied standards of profitability abound.
7.
Academic institutions are deliberately structured to resist pre
cipitant change. Procedures for approving change are elaborate and
slow. A relatively large number of people and groups tend to partici
pate, so that an innovation is likely to be subjected to quite an assort
ment of varied standards tor judging profitability and compatibility.
As pointed out in their descriptions, each of these seven barriers,
like those examined before them, are profitability and compatibility
related. What is remarkable though, particularly given the context of
this book, iq Hefferlin’s distinction between the barriers to successful
innovation in universities and those of organizations in general. The
university barriers all follow from the organizational barriers. Each is
a specific case of the general rule. It is as if the organizational proto
type had been applied to the university, it had not, by the way. The
similarity merely confirms one of the basic tenets of the social sci
ences. A specific organization, like the university, is supposed to be
different from all other particularistic organizations, but if social
research is to have any meaning it should be exactly like all other
organizations in-general.
This has been'a bit of a digression, and it is necessary to return
to the principal concern of the moment —the literature on barriers
to innovation success. So far as the institutionalization-termination
model is concerned, this literature is consistent with the notion f. •
innovations which me compatible and profitable with their orga:
tions tend to succeed; and those that are not fail. All of the ban <rs
described by Watson and Hefferlin could be fully accounted for in
terms of the constricts <>l compatibility and profitability alone. The
terms barrier and obstacle may be misnomers, however. The elements
identified by Hefferlin and Watson might better be thought of as
innovation limiting factors. 1 hat is. they are the itemsthat determine
the kinds of innovations an organization cannot adopt. To this extent
they are right oi. in- boundary. 1'hry are natural snags. It an innova
tion is to trip over an organizational crack, the barriers identified are
simply the most likely spots. 4
19-
195
Implications: A Literature Review
Conclusions
I
ii
H
By necessity the discussion to this point has been somewhat diffuse,
concentrating in turn on discrete portions of the literature on innova
tion and change, it is now time to pull together all of the various pieces
and see just what they add up to. Recall that there were three stated
purposes for this chapter:
1. to see whether the institutionalization-termination model is con
sistent with the existing literature on innovation and change,
2. to see whether the institutionalization-termination model adds
any explanatory power to the existing literature, and
3. to see whether the existing literature adds any explanatory power
to the institutionalization-termination model.
As to the first purpose, the institutionalization-termination model
was consistent with all of the literature examined, including the inno
vation and change literature on both institutions of higher education
and organizations in general. This should not be interpreted to mean
that the model was proven correct or valid, however. It simply means
that no literature was discovered that is at odds with the model. It
means additionally that the findings of the literature examined on
innovation characteristics and innovation success, planned change
and innovation success, and barriers to innovations success could all
be explained in terms of the model.
The institutionalization-termination model has three basic elements:
outcomes is also different from that of the model. As for outcomes,
the current literature speaks generally of only two possibilities—
success and failure. Success, as noted earlier, is defined primarily in
terms of innovation adoption and persistance. Failure is nonadoption
or nonpersistence.
The situation with the switch is just the opposite. The possibilities
seem nearly limitless with some researchers talking of a score or
more factors determining the innovation outcome.
To this extent the institutionalization-termination model does add
explanatory power to the literature on innovation and change. First,
it offers a needed explanation of the process whereby innovation suc
cess and failure occur. In so doing, it makes the phenomenon of
innovation more comprehensible.
Second, the model specifies a very few variables—two to be pre
cise, compatability and profitability —that determine innovation suc
cess and failure in the postadoption period. These variables alone
were found to be all that was necessary and sufficient to explain
failure and success on the basis of the literature examined. The
model might then be described as adding parsimony to existing
explanations of innovation success and failure. By so simplifying,
relationships that were formerly hidden have become more obvious.
For example, it became possible to offer a hypothesis for why only
the eclectic school of planned change might be successful. Moreover,
in concentrating on only two variables, it has also been possible to
‘'relative advantage." which is comparable- in meaning. Profitability
was also found to be a more complex phenomenon than previously
self-interest profitability. This shedding of additional light on pt
ability has the poundal ;■> make the inine.atioi; process more tin
standable io its students and perhaps its practitioners.
Third, the institutionalization-te;miami.m model lies innova
success to the purpose for which the innovati, ,n was intended. This is
an advance over gearing success to adoption and persistence. By way
Implications: A Literature Review
of example, the Buffair roll es .vere adopted and persisted; yet
they were by no stretch of the imagination a success in their early
years. The reason is that the colleges'were intended to be diffused
throughout the university but remained only an isolated enclave. In
terms of the goals for the colleges, their position constituted failure.
However, if success were measured by persistence, they would have
to be called successes, which flies in the face of reality. The model’s
contribution here is in providing a more relative, innovation based
definition of success.
Fourth, the model goes beyond the rather gross concepts of suc
cess and failure with regard to the outcomes of the innovation process.
It specifies four outcomes and a continuum of results varying from
total innovation impact on the host organization (innovation diffu
sion) to total host impact on the innovation (termination). The lack of
research on outcomes has been a serious gap in the innovation litera
ture. Particular outcomes such as diffusion have been well documented
(Rogers and Shoemaker, 1971). The others—enclaving (Leeds, 1969),
resocialization (Kennedy and Kerber, 1973), and termination (Erik
son, 1966)—are also discussed in the literature, but they have not
been linked as possible and continuing consequences of the innova
tion process.
Fifth and finally, the model offers a complete explanation for what
occurs during the innovation process and why.. This has not been
characteristic of the innovation literature.
With regard to the third and last purpose of this chapter, the exist
ing literature makes an important contribution in terms of under
standing the role of the organization in inn.r.atinn success and failure.
'■
model. as.obs,-:
treats the organization as a given. It lias no
formal place in explaining the success or failure of a particular inno
vation. In the final analy ■ is this is still the case. However, the organ;zation cannot be ignored. The literature makes clear that as a rule
organizations vary in the degree to which they resist innovation. In
terms of the model, this means that some organizations are more
prone to respond to innovations with boundary contraction anti others
with boundary expansion. Ik-fK-rlin's study on organizational stabil
ity showed that organizations with flexible boundaries are more likely
to respond with boundary expansion. Such organizations have built
198
in relatively wide ranges of compatibility and possibly even profit
ability. In contrast, the Hage and Aiken (1970) review of organiza
tional variables indicated that organizations with a narrow range of
acceptable norms, values and goals, or a restricted definition of prof
itability, are more likely to respond with boundary contraction.
The literature on organizational character also showed that com
patibility and profitability standards within an organization vary with
times, circumstances, and the issues being considered. Moreover,
organizations are likely to have at least some deviation in compatibil
ity and profitability standards throughout. This means that resist
ance to innovation will vary across organizations as well, and that
innovation may be easier in some parts of an organization than oth
ers. The variation also indicates more fundamentally that in some
organizations, the unit of analysis might better be a subunit or part of
the organization than the whole, depending on the sizeand nature of
the innovations, not to mention tee organization.
The existing literature also nrakes clear that there is probably
variation in the factors that determine the outcome of each of the
four stages of the innovation process. Zaltman et al. (1S73) made this
statement directly and Rogers and Shoemaker (1971) provided addi
tional evidence in pointing out innovation characteristics—observ
ability and trialability -that were necessary for innovation adoption.
but not in postadoplion persistence. Accordingly, there may also be
times in the innovation process when compatibility and profitability
are not critical, but there is as ye! no evidence to suggest such a
conclusion.
In short, the vwy
./
: w the existing Teralin e
was in pointing out the .variations associated with innovation —
variation in organizations, variation within mganizatkes. and varia
tion throughout the innovation process.
A Problem-Solving x^pproach to Teaching Basic Sciences
NFME*DM 14/85
EIHAIxJEPQRI
Submitted by John Nolte. Ph J).
Associate Professor of Anatomy
University of Colorado School of Medicine
1.
Qpals and Activities.
Overview. During academic year 1985-86, a sequence of three courses, collectively
entitled “Anatomy by the Case Method", was taken by thirteen first-year students at this
schcrij a replacement. for t!v.wd. core coarec.? In hirtreogy, oruhryolegy rsa
neuroEnatomy. The method used was. in principle, fairly simple. Students learned the
content of the three usual core courses by working in small groups on. clinically based
problems. The focus of the problems was explaining normal structure and function and
its disruption, not discussing clinical medicine. They received a set of learning
objectives at the beginning of the year, listing all the material they were expected to
1
■
' they also received the same slides and other learning materials as regular
studen ts). At the conclusion of each problem, they received a list of the objectiveswhich
they ought to have covered during that problem. The two small groups (one group of six.
one of S3ven) met separately, tvrice a week. with a facilitator to discuss the current
problem: additional time was spent either individually or in groups to work on aspects of
the problems.
The goals of this project were to evaluate: £ whether students can learn an
adequate amount using this technique; 2, whether this tachniq ue encourages students to
spendreore thio thiakiug rev
.j
re: v.rerere: a amply memorising; 2,
whether this technique restores some of the enthusiasm for teaming which is often felt
to be licking; 4, whether the perceived need for extensive faculty time in
problem-based learning can be partially offset by using fourth-year medical students as
facilitators: and £ whether long-term retention is superior using this technique. The
answer to the first four, as indicated in this report, appears to he a qualified "yes"; the
fifth item has not yet been evaluated.
Selection of Students. Thirty-three (of 132) students applied for the program, An
interview by one faculty member was required of ail applicants, to be sure all students
understood the nature of the program thoroughly. In addition, the academic records of
all applicants were reviewed. Three studentswithdraw during the interview phase, and
two were eliminated by us because of concern about their suitability for the course. The
remaining 28 applicants appeared to be a representative academic sample from the
firs t-year class (average undergraduate GPA 3-51. vs. 3.55 for the whole class: average
MCA1 10.1. vs. 9.x for the whole class). Fourteen participants were selected by a stratified
random sampling process, so that sexes and minorities were represented in the
proportions in which they applied. Two students withdrew early in the quarter and
returned to the standard track. They were replaced by two students randomly selected
from the remaining 14. One student withdrew later in the quarter, too late, we felt, to be
replaced, the students organized themsslvesinto two groups (initially seven per group).
which were maintained throughout the year.
Anatomy by Uie Case Method - Page '2
Faculty. Seven faculty members (including me), from 6 different departments.
ultimately agreed to serve as facilitators for student groups. In addition, six fourth-year
medical students (of seven invited by me. based on personal knowledge) agreed to serve
as facilitators. Three faculty members from the University of New Mexico School of
Medicine conducted a two-day training workshop for all these individuals in August,
1935. acquainting them with techniques of problem-based learning. Each facilitator
worked with one group of students for a period of four to six weeks, except for me: I
worked with each group for six weeks (the first and second halves of the fall quarter).
Cases. We considered "borrowing" cases from New Mexico or other schools using
problem-based learning. However, we decided to develop our own. since our aims were
somewhat more restricted than those of other schools, i.e.. we were attempting to focus
mainly on selected basic science areas. Therefore, we developed a series of 25 cases
(listed in Appendix I) designed to lead students into these selected areas of interest. Most
of the cases were based on patients saoo. at University Hospital, although some were
either derived from journal articles or fabricated.
2.
Formative Evaluation
This project included no systematic formative evaluation plan. Students and
facilitators were asked to have a brief evaluation discussion at the conclusion of each
■group session (i.e., twice per week), and to report any problems to me. I met with all 13
students as a group at least once per quarter, and made minor adjustments (e.g..
occasional formal lab sessions were scheduled). The only objective formative evaluation
was exams and these, as described in the next section, were satisfactory.
3.
Stimulative Evaluation
Measures of Learn in g. Twicc-per-quarter exams (passing score 70%) for Case Method
students included 65 questions used on 1985-86 histology exams, and 21 questions used on
1985-86 neuroanatom.y exams. Questions from 1984-85 embryology exams were also used,
but these were not examined quantitatively .since s different group of control students
was involved. Case Method students did significantly better on the histology questions
than did students in the regular track (37% vs. 82.5%, p<.G2). However, this comparison is
flawed, in part because dental students were included in the histology course. This could
have been circumvented by examining the performance of only the experimental and
control students (i.e., those who applied and either were or were not accepted), were it
not for a more serious problem. A new histology course director was appointed between
the time my proposal was submitted and the time the program began: the new course
director declined to distribute learning objectives to students in the regular course.
Therefore, any detailed comparison between the performances of the groups would be
difficult to interpret. However, a valid comparison was possible for the neuroanatomy
questions, and there was no significant difference in performance (82% vs. 85% ). This.
together with the histology results, convinced both (he Department and the Curriculum
Committee that learning was at least comparable using the Case Method approach.
Measures of the Learning Process. Measures of students' enthusiasm and of the methods
used for learning are somewhat less objective, but are suggestive nonetheless. Anecdotal
reports from facilitators uniformly indicated high enthusiasm and diligence, as well as
surprising retention when atopic came up a second time. Neurobiology reference books
placed on reserve in Che medical school library by me were used 2-f times by Case Method
Anatomy by the Case Method - Page 3
students (shout 2 uses/student) and 74 times by students in the regular neuroanrlomy
course (about 0.6 uses/student).The small numbers make firm conclusions impossible.
but this does suggest, that Case Method students relied less on standard texts and more on
library research.
Student Evaluations. Student evaluations also provide some indications of the
effectiveness of the course. All students fillout an evaluation form including 13
standard questions at the conclusion of each core course. Figure 1 shows the evaluation
scores averaged over all regular first-year core courses, and the averages for Anatomy
by the Case Method; a hypothetical “ideal" evaluation profile is shown for comparison.
and a list of the 13 questions is included as Appendix II. It can be seen that Anatomy by
the Case Method was generally evaluated more favorably than were other first-year
courses.
Figure 1
Certain, of these questions seem particularly relevant to this project, and are
shown in Figure 2. These indicate that Case Method students, relative to first-year
students in other courses, were more likely Co attend, more enthusiastic, and felt that
they used what they learned. They did feel that this entailed more work than other
courses, but anecdotal evidence indicates that this was “work'' they enjoyed. All
participants stated that they would they make the same choice again, and this group of
students has in fact convinced the pathophysiology course director to offer a similar
course, on an elective basis, far sophomores.
Anatomy by the Csse Method - Page 4
Selected evaluation questions
2”attendance
3“relativo work
S'velevance
6=objectives defined
7“objectives met
8"facilitated problem-solving
13“'l liked this course"
question
Figure 2
Effectiveness of Facilitators. As indicated in an earlier section, selected fourth-year
medical students served as facilitators for part of the year. I met with these students
weekly to discuss their progress, and they tad no unusual problems to report At the
end of the year, Case Method students were ashed to evaluate all their facilitators, in
terms of one rating of "effectiveness- on afourtpoint scale. The small numbers make
firm conclusions difficult but, as indicated in Figure 3. there was no major difference, if
any at all. between the effectiveness of faculty and that of seniors, as perceived by the
students (mean 1.44 for faculty. 1.64 for seniors).
Figure 3
Anatomy by (he Case Hethod - Psge 5
Future Plans. All students will be given a histology pretest at the beginning of the
sophomore pathology course, and a neuroanatomy pretest at the beginning of the
sophomore neuroscicnces course. These pretests will emphasize major organizing
principles. end are intended to look for differences in “long-term" retention between
control and experimental students.
Based on the promising results of the 1985-86 pilot study, both the Department of
Anatomy (now the Department of Cellular and Structural Biology) and the Curriculum
Committee recommended enthusiastically that the program be continued. The
Department will provide the needed funds, and all of the 1985-86 faculty facilitators
have agreed to serve again. The program will be essentially the same as last year.
involving H students and the same three courses. I will be the course director, but an
advisory subcommittee of the Curriculum Committee will assist. Forty-six (of 125)
incoming first-year students volunteered for this year's program, and 1-4 have been
selected, using the same stratified random sampling process.
4.
Failures/Negative Results
There were no negative results, although there were many inconclusive results.
There were no failures, since all 13 students passed the course. We hope to obtain more
conclusive results, and to continue to avoid failures, in 1986-87.
5.
Publications
While the results described above are. for the most part, inconclusive, they do
demonstrate that it is possible to establish a problem-solving track within a traditional
basic sciences curriculum with limited manpower, and that students learn enough, and
have fun doing so. in such a setting. In a pilot project like this, there is no way to decide
whether the students responded to the novelty, the small groups, the problem-solving
techniques, or some other variable. Nevertheless, simply knowing that the process
works should be helpful to other educators (it would have been helpful to me).
Therefore, I hope to find am appropriate journal in which to publish a descriptive
account of the program. Reprints will be sent to NFME when available.
Anatomy by the Case Method - Page 6
' APPENDIX I
PROBLEMS DONE DURING ANATOMY BY THE CASE METHOD, 1985-86
1. McArdle's disease. Topics covered: structure of skeletal muscle; fiber types; excitation.
contraction; upper and lower motor neurons end causes of weakness; myopathy vs. neuropathy.
2. Large-fiber peripheral neuropathy. Topics covered: somatosensory pathways; peripheral nerve
3.
histology and fiber types; stretch reflex; types of ataxia.
Bony abnormality pressing on spinal cord. Topics covered: spinal meninges; corticospinal tract;
4.
5.
spinal cord anatomy and bleed supply.
Meckel's diverticulum. Topics covered: gut histology and embryology.
Cervical carcinoma, with renal failure. Topics covered: uterine histology; kidney histology and
6.
general physiology.
Congenital abnormalities of the male uregenitai system. Topics covered: histology of male
reproductive system; spermatogenesis; hernias; embryology of kidney and male reproductive
7.
system.
Alzheimer's disease. Topics covered: neuronal histology; memory; language, dom fnance and
higher cortical function in general.
8.
Kearns-Sayre syndrome (a mitochondrial myopathy). Topics covered: mitochondrial structure
and function; cardiac muscle and conduction system; oculomotor, trochlear, abducensand facial
nerves; auditory system; light reflex and near reflex; control of eye movements.
Kertagener’s syndrome. Topics covered: fertilization; heart development; middle ear mechanics;
olfaction; lung histology.
10.
Congenital CHS abnormalities affecting cranial nerves. Topics covered: cranial nerves and
general brainstem anatomy; CNS embryology; CNS blood supply.
11.
Pituitary prolactinoma. Topics covered: visual system; histology and embryology of pituitary;
hormones and male reproductive system.
12.
/'cute myelogenous leukemia Topics covered: bleed, retlculo-endothellal system.
13.
Crohn's disease. Topics cove-rod: regional 61 anatomy and physiology, anemia, abdominal pain.
9.
14.
15.
16.
17.
Adenocarcinoma of ths heed of the pcncreas. Topics cxvared: digestive endocrine glands, liver &
gallbladder, pencreatic histology & embryology. ■
Congenital heart disease (tetralogy of Fallot). Topics covered: cardiac & vascular embryology. •
Osteoporosis. Topics covered: maintenanca & remodelling of bone, Haversian system, thyroid
histology & embryology.
.Addison'sdisease. Topics covered: adrenal histology, skin history, general endocrine review.
18.
Idiopathic vertigo. Topics covered: labyrinth, auditory & vestibul -r CNS connections, eye
19.
20.
movements & nystagmus.
Breast carcinoma. Topics covered: exocrine glands, adipose tissue, en. ~vology of breast.
Toxic shock syndrome. Topics covered: kidney review, blood review, vt ’1 histology.
21.
22.
Pemphigus. Topics covered: skin embryology, epithelial histology.
Xeroderma pigmentosum with CNS manifestations. Topics covered: motor system review,
ectodermal embryology, DNA repair, skin histology, peripheral nerve histology.
23.
Kluver-Bucy syndrome. Topics covered: limbic system, higher cortical function, ■■•’ntricles
24.
and CSF.
Osteogenesis imperfecta. Topics covered: eye. ear. tooth and connective tissue histology and
25.
embryology.
Syringomyelia. Topics covered: spinal cord anatomy, somatosensory pathways.
APPENDIX II
WINTER QUARTER 1905-86
PRE-CLINICAL CORE COURSE EVALUATION
Use only No. 2 Lead Pencil. Make marks heavy and black. Erase totally
all erasures. Enter Course Name and Number on answer sheet where ’'Course"
is requested. Enter Date where requested. Return to the departmental
office or other location designated by the course director or course
representative. Written comments should be a useful and meaningful
record of student ideas and concerns.. It is our professional responsi
bility to make only valuable and constructive comments. Should you feel
response outside of a professional scope concerning the course or the
instructorCs) is necessary, discuss it with the Student Advisory Office.
If an item is not applicable to this course, leave it blank, for example,
if this course had no small group meetings, you would leave n-2 blank.
1.
What portion of the Lectures in this course did you attend?
a)
hlcl
d)e)
2.
< 20%
20-49%
50-69%
70-89%
> 90%
What portion of ’Che small group meetings Clabs, seminars, etc.') did
you attend?
al
bl
cl
e)
< 20%
20-49%
50-69%
70-89%
? 90%
ii relation to rhe amount of curriculum time given to the course, how
tard did you work on this course compared with other core courses?
Much Less than usual
Some less
About the- same
Soma more
Much more
Timing of this course, ideally, should be:
a)
b)
c)
d)
5.
Earlier in the sequence
Later in the sequence
About the time it was given
Not at all
Do you think the subject matter of this course is relevant, to your
-2-
ions:
Please choose one letter to indicate your evaluation of each
aspect listed.
oa
c <□
o <u
cn <
a
2
M
CJ
£•
I
>> 0)
r-l 0J
tO c
c Sj
O <Ti
<n
cn Q
<u
<n
Q
(B)
CO
CD)
CB)
co
(0)
CE)
CE)
6.
The course objectives t■rere well defined.
CA)
7.
Course objectives were effectively met.
(A)
8.
The course facilitated my ability to apply
its content in problem solving.
(A)
CB)
co
CD)
CE)
9.
There was overall good continuity between
presentations.
(A)
CB)
co
CD)
CE)
10.
14.
In this course, there was little unnecessary
repetition of material covered in other
courses.
CA)
CB)
CO
CD)
CE)
The repetition which, existed within this
course was not excessive.
CA)
CB)- CO
CD)
(E)
The exams Cor other evaluations) were "fair”
and were a reasonable measure of ray" knowledge.
CAI. CB)' co
CD)
CE)
1 liked this course-
CA)
co
CD)
CE)
What were the:
a) Strong points of the course?
b)
Weak’ points of the course?
We hope you will add any comments or suggestions here..
CH)
Ann. Conz. Res. Med. Educ., vol. 27, 1988, in press
~
SHIFTING TOWARD PROBLEM-BASED LEARNING IN A MEDICAL SCHOOL
NEUROBIOLOGY COURSE
John Nolte*f, Ph.D., Pamela Eller*, M.S. and Steven P. Ringel M.D.
Departments of Cellular and Structural Biology* and Neurology r
University of Colorado Schoolof Medicine
Denver, Colorado 80262
The current widespread interest in problem-based learning typically centers around programs
in which small tutorial groups of students work with individual faculty members. Tne advantages of
such systems include am increased tendency for students to seek deeper understanding of the subject
matter (Coles, 1985; Newbie and Clarke, 1986), and often a more enjoyable learning experience
(e.g., Obenshain, 1983). One impediment to wider implementation of problem-based learning is the
perception that large numbers of faculty are required (Barrows et al., 1986). Some preliminary
attempts to incorporate techniques of problem-based learning into large-group courses, without
drastic increases in faculty, have been largely successful (Barrows et al., 1986; McMillan and
Wenger. 1987; Schwartz, Fiddes and Dempster, 1987). We therefore sought to determine whether
such techniques could be made a major part of a large-group neurobiology course, whether
responsibility for learning could be effectively transferred to the students in such a course, whether
students would learn and retain as much using such an approach, and whether their learning process
would be more enjoyable.
Prior to academic year 1984-85, the standard neurobiology course taken by medical students
at this institution was a fairly traditional lecmre/laboratory course. It was indifferently received by the
students (see below) and the laboratory sessions were poorly attended. Beginning with the 1984-85
academic year, we totally revamped the course with the above considerations in mind. We report
here on three years' experience with the new format.
Methods.The faculty for the course included members of both clinical and basic science
departments. Our overall concern in redesigning the course was to encourage students to be actively
involved in all its aspects. Since we hoped to transfer responsibility for learning to the students, it
was crucial to compile a concise set of educational objectives, so that the students would have
adequate guidance. Tnis was accomplished in a series of weekly meetings extending over several
months, in which the course material was pared down to its core elements which were then specified
as objectives.The number of lectures was reduced from 35 to 19. Those remaining were designed to
emphasize general organizing principles rather than facts. The time made available by this reduction
was devoted to problem-solving sessions. This was done in a graduated way, so that early parts of
the course were totally lectures and laboratory sessions, and later parts of the course were
exclusively problem-solving sessions. Laboratory ume was reduced to what we felt was the
minimum required for the students to view the necessary anatomical material. Some students did this
in a traditional fashion using gross brains and photographic slides of sections, while in recent years
others used a computerized videodisc system (Nolte et al.. 1987).
We devised a format for the problem-solving sessions that afforded students the opportunity
to work in small groups but nevertheless required no additional faculty. Most of the cases were
based on videotaped examinations of real patients, edited to demonstrate each patient's findings but
provide no explicit information about the nature or location of the disorder. One week before a case
was scheduled to be discussed the videotape was shown in class, after which it was made available
in the library. At die time the case was shown a brief Hess than one page) handout was distributed,
posing a series of questions designed to guide students' discussion of the problem. All students wen
encouraged to work through the problems, but three students volunteered or were assigned to serve
as the facilitators for a group of about 20 classmates. (Our students have desks and laboratory space
m 6 separate Unit Teaching Laboratories (UTLs), so thev are already divided into groups ot about
)
20.
Each student served as a facilitator twice during the quarter. On the day the problem was to be
addressed, the students spent the first hour of the session in small-group discussions led by peers.
The second hour was spent in the lecture hall, where a team of at least two faculty members (one
basic science, one clinical) led a general class discussion of the problem. Faculty members were
specifically instructed not to lecture during these periods. Students and faculty were told that the
object of the problems was to understand die basic science underpinnings of neurological disorders,
and not to leant diagnosis or treatment. The educational objectives were divided into blocks, so
students had a reasonably accurate sense of the minimum material they needed to learn from each
problem session.
At the end of the course, students led a series of small-group review sessions. These were
divided up so drat each pair of students was responsible for presenting a specific subset of the
material to their small group. Faculty members circulated through the UTLs during these periods to
answer questions.
We also tried to devise ways to make the examinations part of the educational experience.
The importance of making examinations consistent witii the learning format has been emphasized
(Newbie and Entwhistle, 1986). Accordingly, exams had a closed-book part, derived stricdy from
the educational objectives, and an open-book part, based on one or more new cases. In addition, in
order to emphasize the small-group format, to encourage students to complete their understanding of
the material, and to provide ourselves with feedback about the quality of our questions and our
teaching, we adapted a technique suggested to us by Drs. Scott Obenshain and Henry Silver.
Students were allowed to retake each exam as UTL groups and to submit a group answer sheet that
counted for 20% of the grade of all participants. This was an optional activity, and there was no
penalty for not participating.
Results and Discussion-Numerous anecdotal data indicate that this approach was successful The
enthusiasm of the students surpassed our most optimistic hopes. The large-group discussions were
remarkable for the degree of student participation and for the depth of the discussions; we often
found that the students had conducted literature reviews, and they sometimes uncovered facts
unknown to the faculty. One clinical faculty member who participated in a session stated afterward
that he felt as if he had been talking to residents. The pattern of library usage changed dramatically.
For example, use of the reference books annually placed on reserve for the course went up more than
twentyfold. One of us (IN) annually helps with a second-year neuropathology laboratory, a year
after the neurobiology course, in which students review normal neuroanatomy. He had previously
been struck by tire fragmented way in which second-year students seemed to recall bits of the
nemobiology course; each student seemed to remember a few important items and some minutiae,
with no apparent partem. A year after tire revised neurobiology course was initiated, most students
appeared to remember a substantial amount of the core material identified in the neurobiology
educational objectives. Two years after tire revised course began, attending neurologists reported to
the the neurobioldgy course director that the students seemed to have a better fund of knowledge,
and to be more enthusiastic, at the beginning of the neurology clerkship than had previously been the
case. An added benefit, not entirely anticipated, was that faculty as well as students found the
problem-solving sessions intellectually stimulating. Furthermore, little advance preparation was
required on the pan of faculty once the materials were developed.
More objective data are available in die form of student evaluations. All students are required
to complete an evaluation of each core course (compliance is typically at least 90%); all evaluations
include 13 general questions in common. Records from all core courses from 1983 to 1987 are
currently available, and it was possible to do a ycar-by-year comparison of evaluations of the
neurobiology course with the average evaluation of the eight non-neurobiology courses examined
(the Introduction to Clinical Medicine (ICM) Course was excluded from this comparison, since its
purpose and format are substantially different from the other courses.) Items particularly pertinent to
our goals in the revised course are discussed here.
Self-reported attendance at laboratory and small group sessions increased from about 65% in
1983-84 (far below average) to about 90% (average) in 1984-85, the first year of the revised course.
As indicated in the following graph, students also felt that the course met its objectives - that they
learned the core material of the revised course much more effectively than they did in the average first
year course. (This and other similar figures in this report compare the average evaluation score of the
neurobiology course to that of other first-year courses with the exception of ICM. Significance levels
are t, p<.05;
p<.001.) Furthermore, they felt that the course began to encourage more than rote
memorization, that they began to apply the information and solve problems with it much more than in
other first-year courses.
course
changes
course
changes
The results of evaluation questions dealing with examinations and with the enjoyability of the
course are shown in the next figure. Presumably because the examinations were designed to be pan
of the learning experience, because their format was consistent with the format of the course, and
because the stated educational objectives were adhered to rigorously, students began to agree that the
examinations were an accurate measure of their achievement in the course. Finally, the.course went
from being less Liked than tlie average course to being one of the most popular in the basic science
years. In the spring of 1988, Medical Student Council instituted an award for what the sophomore
class felt to be the best basic science course at this medical school. The 1986-87 neurobiology course
received die first such award.
changes
changes
One common objection to evaluation data such as these is that they represent a nonselective
favorable response to change or increased attention (i.e., the Hawthorne effect; Roethlisberger and
Dickson, 1939). In the present case, there are at least three indications that the more favorable
evaluations are a reflection of a genuine, selective change in attitude. The first indication is that the
evaluation changes have been sustained for three years, and in some cases have become even more
favorable. The second is that the changes have been selective. All items in ±e standard evaluation
have become more favorable, but not to nearly the same degree. For example, the changes mentioned
thus far were nearly a full point on a five-point.scale. In contrast, the change in an item that asked
about the amount of repetition within the course changed by an average of only about 0.1 points
during the same period The third indication comes from a concomitant experiment done at this
medical school. In 1986-87 nearly the entire first-year curriculum underwent an extensive
reorganization: gross anatomy was moved from the winter to the fall quarter, and other courses were
rearranged to allow biochemistry, embryology, microanatomy and physiology (all previously onequarter courses) to be presented in parallel throughout the winter and spring quarters. The hope was
to achieve greater integration and to give the students more time to assimilate this material. For the
most part, all these courses continued in a traditional lecture/laboratory format. As indicated below,
tire changes in student evaluations of their non-neurobiolog;.' first-year courses were relatively minor
and in most cases not significant
agree
strongly
N.ON-NEURO COURSES
It seems clear, therefore, that students had a more enjoyable learning experience in
neurobiology as a result of these changes. The anecdotal data mentioned above, as well as the
students' own perceptions, also indicated that they learned more effectively. Changes in National
Boards performance are at least consistent with this idea.
We examined performance on questions from Part I of the June administrations of the
National Boards of 1985, 1986 and 1987 (corresponding to students who took the neurobiology
course in 1983-84, the last year before the change, and in 1984-85 and 1985-86, the first two years
after the change) Questions were divided into two groups based on key-word item analyses supplied
by the National Board of Medical Examiners. The first group consisted of all questions from the
anatomy and physiology subtests dealing with material covered in the neurobiology course. The
second group consisted of all remaining questions from the anatomy and physiology subtests. (This
sorting was fraught with uncertainty, in part because of the limited information provided by key
words and in part because of the overlapping coverage of topics by different courses. It was,
however, done with no advance knowledge of our students' performance on individual questions.)
Performance on neurobiology questions was inferior to that on non-neurobiology questions for
students who took the neurobiology course before the change; after the course changes, the relative
performances reversed. These were fairly small differences, and the neurobiology/non-neurobiology
difference in average score, corrected for changes in national performance, was only significant for
those students who took the course in 1985-86 (p=.001). However, if these performance data are
plotted using the national average on each question as a threshold measure, showing the percent of
questions on which our students scored higher than the national average, then the year-to-year
changes are striking.
Changes in National Board Performance
1986
Year of NBME, part 1
Conclusions and Implications.We concur with others that techniques of problem-based learning can
be used successfully in large-group courses, that the responsibility for learning can in large part be
transferred to students, and that this can result in a learning process which is 1) at least as effective as
the traditional lecture/laboratory process and 2) more enjoyable for both students and faculty.
Since these techniques can be implemented, once the materials are developed, with no
increase in faculty' time or numbers (see also Mennin and Martinez-Burrola, 1986), they should have
wide applicability.
Acknowledgements. We thank Tom Finger and Clyde Tucker for their helpful comrppnts dp the
manuscript, and Ned Calonge for advice on data analysis.
\ j
References
Barrows, ELS., Myers, A., Williams, R.G. and Moticka, E J. Large group problem-based learning
a possible solution to the ’2 sigma problem', Med. Teacher 8:325, 1986.
Coles, C.R. Differences between conventional and problem-based curricula in their students’
approaches to studying. Med. Ed. 19:308, 1985.
McMillan, D.E. and Wenger, G.R. Effects of curriculum and format changes in a medical
pharmacology course, 1983 to 1987. J. Med. Ed. 62:836, 1987.
Mennin, ST. and Martinez-Burrola, N. The cost of problem-based vs. traditional medical education
Med. Ed. 20:187, 1986.
Newbie, D.I. and Clarke, R.M. The approaches to learning of students in a traditional and in an
innovative problem-based medical school. Med. Ed. 20:267, 1986.
Newbie, D.I. and Entwhistle, NJ. Learning styles and approaches: impheations for medical
education. Med. Ed. 20:162, 1986.
Nolte, J., Eller, P. and'Trynda, R.S. Stalking the wild asparagyrus: learning neuroanatomy using an
interactive video system. Proc. Conf. Res. Med. Ed. 26:193, 1987.
Obenshain, S.S. Old wine in new skins: teaching the new biology. In The new biology and medical
education, C.P. Friedman and EF. Purcell (eds.), Josiah Macy, Jr. Foundation, New York,
1983.
Roethlisberger, F.J. and Dickson, W.J. Management and the worker. Harvard University Press,
Boston, 1939.
Schwartz, P.L., Fiddes, T.M. and Dempster, A.G. The case-based learning day: introducing
problem-based learning into a traditional medical curriculum. Med. Teacher 9:275,1987.
.p^> <
PRIMARY CARE CLERKSHIP
Community Project--6th year
INTRODUCTION:
The
Health
Survey/Communi ty Epidemiology projects that are re
quired during the Sixth Year Primary Care Clerkships are not
designed
to
transform physicians into epidemiologists.
They are designed
to
train
the
primary
care,
community oriented clinician to
think
in
epidemiological
(population based) terms and to
plan,
execute,
and
analyze a limited community health survey.
LEARNING OBJECTIVES:
At the end of the projects,
the student should be? able
2,
define cases and controls and to quantitate exposure to
real
and suspected risk -factors;
make
reasonably accurate statements about the community -from
which these samples were drawn;
4
hypothesize
and test hypotheses about
causes
of
illness,
benefits of treatment, and the natural history of a disease.
EPIDEMIOLOGY AND THE PRIMARY CARE PHYSICIAN:
It
goes
without
saying that physicians in
the
clinic
do
not
traditionally deal with cases,
controls,
populations, relative risks
and
all
of those other epidemiological things.
They do not
choose
their patients,
do not select "exposed" and "unexposed"
individuals,
and
do
most
of their hypothesizing in their heads
rather
than
on
computers.
They examine,
diagnose,
treat and prescribe medications
for one'individual at a time.
However a community—oriented
physician
must
realize
that every individual seen in clinic or in hospital
is
really a representative of a larger population which shares with
that
given individual certain health problems or certain health risks.
The
individual patient might be an INDEX CASE— the first person
with
a
specific problem that has surfaced
in
the
community.
That
patient
should
alert the physician (and the rest of the health
care
system) that the problem might appear later in larger numbers and might
even
be the beginning of an epidemic.
In this
respect,
familiarity
with
epidemiological principles and survey methods might be
the
key
tool
for rapid intervention and control before extensive sickness and
suffering spreads through the community.
The
individual patient presenting to the clinician is usually
a
SAMPLE of a population with similar symptoms and/or similar
exposure
to health risk factors.
He could,
for example,
represent a certain
age group,
or a dozen people bitten by the same dog, or people living
in
a
certain
location,
or
an
occupational
category.
He
could
represent a group of individuals who share a certain life style,
or a
group of returning tourists, or diners who ate in the same restaurant.
The
other members of the group(s) might or might not be seen
by
the
same
doctor
or
in
the
same
clinic.
The
clinician
with
an
epidemiological orientation and survey skills will be able to identify
a potential rafOblem while it is still controllable and will be able to
alert the public health authorites.
The patient seen by the physician in clinic is sufficiently aware
of
his
symptoms
to
have
sought
professional
help.
The
epidemiologically
oriented
physician knows that
for every
case
he
sees,
any
number of milder cases or subcl i-ni cal cases
are
probably
also
present
in the same community,
and that they will not
usually
seek assistance unless they get worse.
On the other hand, in the case
of many infectious diseases, these SUBCLINICAL/UNDIAGNOSED individuals
might
act
as reservoirs of infection.
Proper survey skills ahd
the
ability
to define case character.! sti cs will permit the
clinician
to
provide
the
necessary therapeutic and preventive Services needed
in
the community to prevent the disease from spreading.
any physician, working in any clinic, and
In the final analysis,
is "doing" epidemiology whether or not
examining patient* ; one by one,
The normal daily,
weekly,
or annual patient
load
s/he intends to.
attended
to by a given physician (as long as more than one patient is
involved)
is really a DEFINABLE POPULATION whose collective
personal
health (OUTCOME)is affected,
positively or negatively, by EXPOSURE to
the doctor's skills, knowledge, and abilities (or lack of them).
It
should be emphasized that the community epidemiology projects
are
training exercises and are not intended to be "research
projects
suitable for publication" in the scientific literature.
The fact that
some of these projects,
in the past,
were actually good enough
for
publication
is a tribute to your colleague's skill,
luck,
and
very
hard work.
This, however, is not the purpose of these projects.
On the other hand,
it could be noted, parenthetically, that some
of the greatest breakthroughs in Medicine were achieved by
physicians
in
clinical
practice,
working with population
groups
considerably
smaller than the ones you will be studying, and without computers:
For
example,
the
first
identification
of
an
occupationally
related
cancer (Percival Pott 1790),
the recognition that
puerperal
fever
could
be
controlled by handwashing
(Semmelweiss’ 1847),
the
asociation
of
congenital
cataracts with
Rubella during
pregnancy
(Gregg 1941), the relationship of Diethylstilbestrol to vaginal cancer
(Herbst 1971), and the discovery of Legionellosis (1976) — were all a
result
of careful observation and simple epidemiological
surveys by
primary
care physicians who kept accurate clinical records,
who were
alert to trends,
who were basically curious, and who knew how to test
hypotheses.
MENU OF SUCCESSFUL SURVEY PROJECTS 1983-1987s
17. Hospitalization relative to year and season.
IS. Effect of age and diagnosis on prescription patterns.
19. Levels of glucose, Tg, Cholesterol in diabetics as a function
of diet and insu1in.
Patient's understanding of physicians instructions.
Tea drinking, anemia and iron deficiency.
Distribution of intestinal infection causes.
23. Hypertension prevelance in different populations.
24. Nonfatal accidents and injuries.
25. Hearing and vision problem prevelance.
26. Mental Health problems encountered in clinic visits.
27. Use of new drugs for CVA patients prescribed by primary care
physicians.
28.
Survey of body mass among Kibbutz males admitted to Soroka.
29.
Hemoglobin/height/weight
comparisons of Beduin children
in
Rabat clinics compared to Ethiopian children in Matzada clinic.
30.
Causes for presentation to Emergency room.
31.
Hypertension among patients presenting to clinics for various
32.
Character!sties of patients presenting to clinics with chest
pains.
Elevated temperatures among adults.
Does
information
and
instruction initiated
by
physi ci an
satisfy needs of patient and family?
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what to look tor in groups
In al! human interactions there are two major ingredientS^-rt-ontesit and process. The
nrst deals with the subject matter or the task upon which the group is working. In most
interactions, the focus of attention of all persons is on the content. The second ingredient, process,
is concerned with what is happening between and to group members while the group is working.
Group process, or dynamics, deals with such items as morale, feeling tone, atmosphere, influence,
participation, styles of influence, leadership struggles, conflict, competition, cooperation, etc.
In most interactions, very little attention is paid to process, even when it is the major cause
of ineffective group action. Sensitivity to group process will better enable one to diagnose group
problems early and deal with them more effectively. Since these precesses are present in all
groups, awareness of them will enhance a person’s worth to a group and enable him to be a
more effective group participant.
Below are some observation guidelines to help one process analyze group behavior.
Participation
One indication of involvement is verbal participation. Look for differences in the amount
of participation among members.
1.
Who are the high participators?
2.
Who are the low participators?
3.
Do you see any shift in participation, e.g., highs become quiet; lows suddenly become
talkative. Do you see any possible reason For this in the group’s interaction?
4.
How are the silent people treated? How is their silence interpreted? Consent? Dis
agreement? Disinterest? FearP.etc.
5.
6.
Who talks to whom? Do you see any reason for this in the group's interactions?
Who keeps the ball rolling? Why? Do you see any reason for this in the group’s
interactions?
Influence
Influence and participation are not the same. Some people may speak very little, yet they
capture the attention of the whole group. Others may talk a lot but are generally not
listened to by other members.
7.
Which members are high in influence? That is, when they talk others seem, to listen.
8.
'Which members are low in influence? Others do not listen to or follow them. Is there
any shifting in influence? Who shifts?
9.
Do you see any rivalry in the group? Is there a struggle for leadership? What effect
does it have on other group members?
Styles of Influence
Influence can take many forms. It can be positive or negative; it can enlist the support
or cooperation of others or alienate them. Hou; a person attempts to influence another may be
the crucial factor in determining how open or closed the other will be toward being influenced.
Items 10 through 13 are suggestive of four styles that frequently emerge in groups.
10.
Autocratic: Does anyone attempt to impose his will or values on other group members
or try to push them to support his decisions? Who evaluates or passes judgment on
The 1972 Annual Handbook For Croup Facilitators
21
other group memlx'rs? Do any mcmljers blcx.-k action when it is not moving tJie
direction they desire? Who pushes to “get the group organized’’?
11.
Peacemaker: Who eagerly supports other group members’ decisions? Does anyone
consistently try to avoid conflict or unpleasant feelings from being expressed by
pouring oil on the troubled waters? Is any member typically deferential toward
other group members — gives them power?. Do any members appear to avoid giving
negative feedback, i.e., who will level only when they have positive feedback to give?
12.
Laissez faire: Are any group members getting attention by their apparent lack of
involvement in the group? Does any group member go along with group decisions
without seeming to commit himself one way or the other? Who seems to be withdrawn
and uninvolved; who does not initiate activity'., participates mechanically and only in
response to another member’s question?
13.
Democratic: Does anyone try to include everyone in a group decision or discussion?
Who expresses his feelings and opinions openly and directly without evaluating or
judging others? Who appears to be open to feedback and criticisms from others?
When feelings run high and tension mounts, which members attempt to deal with
the conflict in a problem-solving way?
Decision-Making Procedures
Many kinds of decisions are made in groups without considering the effects of these
decisions on other members. Some people try to impose their own decisions on the group,
while others want all members to participate or share in the decisions that are made.
14.
Does anyone make a decision and carry it out without checking with other group
members? (Self-authorized) For example, he decides on the topic to be discussed and
immediately begins to talk about it. What effect does this have on other group
members?
15.
Does the group drift from topic to topic? Who topic-jumps? Do you see any reason
for this in the group’s interactions?
16.
Who supports other members’ suggestions or decisions? Does this support result in
the two members deciding the topic or activity for the group (handclasp)? How does
this effect other group members?
17.
Is there any evidence of a majority pushing a decision through over other members
objections? Do they call for a vote (majority support)?
18.
Is there any attempt to get all members participating in a decision (consensus)?
What effect does this seem to have on the group?
19.
Does anyone make any contributions which do not receive any kind of response or
recognition (plop)? What effect does this have on the member?
Tusk Functions
These functions illustrate behaviors that are concerned with getting the job done, or
accomplishing the task that the group has before them.
20.
22
Does anyone ask for or make suggestions as to the best way to proceed or to tackle
a problem?
c1972 University Associates
21.
Does anyone attempt to summarize what has been covered or what has been going
on in the group?
22.
Is there any giving or asking for facts, ideas, opinions, feelings, feedback, or searching
for alternatives?
23.
Who keeps the group on target? Who prevents topic-jumping or going off on tangents?
Maintenance Functions
These functions are important to the morale of the group. They maintain good and
harmonious working relationships among the members and create a group atmosphere which
enables each member to contribute maximally. They insure smooth and effective teamwork
within the group.
24.
Who helps others get into the discussion (gate openers)?
25.
Who cuts off others or interrupts them (gate closers)?
26.
How well are members getting theirideasacross? Are some members preoccupied and not
listening? Are there any attempts by group members to help others clarify their ideas?
27.
How are ideas rejected? How do members react when their ideas are not accepted?
Do members attempt to support others when they reject their ideas?
Group Atmosphere
Something about the way a group works creates an atmosphere which in turn is revealed
in a general impression. In addition, people may differ in the kind of atmosphere they like in a
group. Insight can be gained into the atmosphere characteristic of a group by finding words
which describe the general impressions held by group members.
28.
Who seems to prefer a friendly congenial atmosphere? Is there any attempt to
suppress conflict or unpleasant feelings?
29.
Who seems to prefer an atmosphere of conflict and disagreement? Do any members
provoke or annoy others?
30.
Do.people seem involved and interested? Is the atmosphere one of work, play
satisfaction, taking flight, sluggishness, etc.?
Membership
A major concern for group members is the degree of acceptance or inclusion in the group.
Different patterns of interaction may develop in the group which give clues to the degree and
kind of membership.
31.
Is there any sub-grouping? Some times two or three members may consistently agree
and support each other or consistently disagree and oppose one another.
32.
Do some people seem to be "outside" the group? Do some members seem to be
“in"? How are those “outside” treated?
33.
Do some members move in and out of the group, e.g., lean forward or backward in
their chairs or move their chairs in and out? Under what conditions do they come in
or move out?
Feelings
During any group discussion, feelings are frequently generated by the interactions
between members. These feelings, however, are seldom talked about. Observers may have to
The 1972 Annual Handbook For Group Facilitators
23
make guesses based on tone of voice, facial expressions, gestures, and many other forms of
nonverbal cues.
34.
What signs of feelings do von observe in group members: anger, irritation, frus
tration. warmth, affection, excitement, boredom, defensiveness, competitiveness, etc.?
35.
Do you see any attempts by group members to block the expression of feelings,
particularly negative feelings? How is this done? Does anyone do this consistently?
Korms
Standards or ground rules may develop in a group that control the behavior "of its
members. Norms usually express the beliefs or desires of the majority of the group members
as to what behaviors should or should not take place in the group. These norms may be clear
to ail members (explicit), known or sensed by only a few (implicit), or operating completely
below the level of awareness of any group members. Some norms facilitate group progress and
some hinder it.
24
36.
Are certain areas avoided in the group (e.g., sex, religion, talk about present feelings
in group, discussing the leader’s behavior, etc.)? Who seems to reinforce this
avoidance? How do they do it?
37.
Are group members overly nice or polite to each other? Are only positive feelings
expressed? Do members agree with each other too readily? What happens when
members disagree?
38.
Do you see norms operating about participation or the kinds of questions that are
allowed (e.g., “If I talk, you most talk"; “If I tell my problems you have to tell your
problems")? Do members feel free to probe each other about their feelings? Do
questions tend to be restricted to intellectual topics or events outside of the group?
c/972 L’rnccntfy Associates
budner's intolerance of ambiguity
Date:
Name:
Please indicate your honest feelings about each of the following
placing a circle (O) around a letter or letters using this code:
SA = Strongly agree
A
= Agree
AS = Agree slightly
DS = Disagree slightly
D
= Disagree
SD = Strongly disagree
1.
An expert who doesn't come up with a definite
answer probably doesn't know too much.
SA
A
2.
I would like to live in a foreign country for a while. SA
A
3.
There is really no such thing as a problem that can't
be solved.
SA
A
4.
People who fit their lives to a schedule probably
miss most of the joy of living.
SA
A
5.
A good job is one where what is to be done and-how
it is to be done are always clear.
SA
A
6.
It is more fun to tackle a complicated problem than
to solve a simple one.
SA
A
7.
In the long run it is possible to get more done
by tackling small, simple problems rather than
large and complicated ones.
SA
A
8.
Often the most interesting and stimulating people are
those who don't mind being different and original.
SA
A
What we are used to is always preferable to what is
unfamiliar.
10.
People who insist upon a yes or no answer just don't
know how complicated things really are.
SA
A
11.
A person who leads an even, regular life in which few
surprises or unexpected happenings arise, really has
a lot to be grateful for.
SA
A
12.
Many of our most important decisions are based upon
insufficient information.
SA
A
13.
I like parties where I know most of the people more
than one where all or most of the people are complete
strangers.
SA
A
14.
Teachers or supervisors who hand out vague assignments SA
give a chance for one to show initiative and originality.
A
15.
The sooner we all acquire similar values and ideals
the better.
SA
A
'S P--G
ROLE OF THE TUTOR/GROUP FACILITATOR
The tutor/faci 1'itator is a university educator who leads a task
oriented group to successfully achieve the objectives of a teaching
programme.
in playing this role, the tutor/faci1itator has to Fulfill
several responsibilities and is accountable to the teaching programme
for the satisfactory completion of them.
These responsibilities require
i t i es/sk i1 Is which the tutor/faci itator would display with various
degrees of proficiency.
These abilities include
principles and practice of problem based
group dynamics
assessment of student learning
pr i nci p1es
use of different methods
design of evaluation tools .
learning resources
use
principles
des i gn
managerial skills
curr i cu1um des i gn
WORE SPECIFICALLY
The tutor/faci1 Itator should haves
an understanding of the overall
goals for the teaching programme;
2.
an understanding of the objectives and logistics of the spec i f i c
component of the programme For which the tutor/fac i 1 i tator is
"tutor i ng;
3.
a knowledge of various educational
these individuals appropriate1y;
4.
a knowledge of the respective
resources and educational events;
5.
a knowledge of some basic principles and methods of evaluation;
6.
a knowledge of the steps necessary to promote problem based
learning, problem solving and critical thinking in students;
7. a
knowledge about
the
roles and an ability",to use
usefulness
rationale and
of various
learning
------------
techniques of self directed
B.
Personal
Attributes
The tutor/faci1itator should demonstrate an acceptance of:
1.
the problem based approach as an effective method for acquiring
information and-for developing the ability to think critically;
2.
the se1f-d i rected 1 earn i ng geBtoach, i.e. the student
pr’i marl Fy respons i b I e for the student's own education;
3.
the sma!£ group tutorial
and feedback;
as
a
forum for
integration,
The tutor/faci1itator will demonstrate fulfilling
in the tutor/faci1itator role by:
being
direction
responsibilities
1.
attending the orientation/training workshops and meetings;
2.
arranging the persona] schedule during the
order to be adequate 1y available;
3.
being prepared to
required;
4.
supporting the efforts of the coordinators of the programme by
ensuring that student evaluations are completed, contacting
planners about problems or suggestions for improvement;
have
individual
meetings
~
teaching period
with
students
----- t
throughout
in
as
the
in facilitatory teaching,
i. Skill
i.e.,
quest ions,
asking non-directive, stimulating
students as appropriate;
student
presenting consequences
views, cues as needed;
of
indicating when additional
external
challenging
cone 1 usions,
opposing
information is required;
referring students to resources as appropriate;
avoiding lecturing the student(s) unless an except ion that
jus fTFTecT'ahd recogn i zed.
2. Skill’s in promoting group problem solving and
by helping students:
critical
to examine a range of phenomena, from the molecular
the fami ly and community level ; s,■(
is
thinking
level
to
to assess/appraise critically evidence supporting hypotheses;
to define issues and synthes i ze
3. Skills
.
information.
in promoting efficient group function by:
assisting the group to set early goals and a tutorial plan
which may be modified later including an organizational
framework and an evaluation plan;
sensing problems in tutorial
group to dea’l with them;
making students
progress;
serving as
feedback.
aware
a model
of
the
functioning and
need
to demonstrate
helping the
to monitor the group's
productive ways of giving
4.
5.
Skills
in promoting
individual
learning by:
helping students to develop a study plan,
goals of the student and the programme;
considering
the
helping students improve study methods
selection of appropriate learning resources.
including
the
Skilis in student evaluation
students by:
reviewing and
tutorial group;
and
clarifying
coordinating the
programme
helpi-ng students define personal
goals
evaluation of
with
the
objectives;
helping students select appropriate evaluation methods;
reviewing demonstrated learning achievement and ensuring that
the student gets feedback;
preparing the report on the individual student, learning
progress, including a decision as to whether the student has
or has not completed, the objectives of the programme;
contact ing, if app1 icable, the student's advisor at the
beginning of the programme and at the end of it (as a
mini mum).
3: TEACHING IN SMALL GROUPS
INTRODUCTION
This chapter assumes you have been asked to teach a small
group. It also assumes that the group you are to take will meet
on more than one occasion and therefore will present you
with the opportunity to establish and develop a productive
group atmosphere. Small group teaching can be a most re
warding experience. However, to achieve success you will
need to plan carefully and to develop skills in group manage
ment. You should not fall into the common error of believing
that discussion in groups will just happen. Even if it does, it is
often directionless, unproductive, unsatisfying and perhaps
threatening, lb-avoid these problems you will need some
understanding of how groups' work and how to apply a range
01 smaii group techniques to achieve the goals you set out to
achieve.
THE IMPORTANCE OF SMALL GROUP TEACHING
Teaching in small groups enjoys an important place among
the teaching methods commonly found in medical education
for two rather different reasons. The first of these can be des
cribed as social and the other as educational. For many
students in the university, and especially those in the early
years of their studies, the small group or tutorial provides an
important social contact with peers and teachers. The value of
this contact should not be underestimated as a means for stUr
dents to meet and deal with people and to resolve a range of
matters indirectly associated with your teaching, such as diffi
culties with studying, course attendance and so on. Such
matters will, of course, assist with the attainment of the more
strictly educational objectives of your course.
Among the educational objectives that you can best achieve
through the use of small group teaching methods are the
development of higher-level intellectual skills such as rea
soning and problem-solving, the development of attitudes
and the acquisition of interpersonal skills such as listening,
speaking, arguing, and group leadership. These skills are im
portant to medical students who will eventually become in
volved professionally with patients, other health care pro
fessionals, community groups, learned societies and the like.
The distinction between social and educational aspects of
small group teaching is rather an arbitrary one but it is import
ant to bear it in mind when you plan for small group teaching.
INTRODUCTION
This chapter assumes you have been asked to teach a small
group. It also assumes that the group you are to take will meet
on more than one occasion and therefore will present you
with the opportunity to establish and develop a pioduciive
group atmosphere. Small group teaching can be a most re
warding experience. However, to achieve success you will
need to plan carefully and to develop skills in group manage
ment. You should not fall into the common error of believing
that discussion in groups will just happen. Even if it does, it is
often directionless, unproductive, unsatisfying and perhaps
threatening. To-avoid these problems you will need so'me
understanding of how groups' work and how to apply a range
ot smaii group techniques to achieve the goals you set out to
achieve.
THE IMPORTANCE OF SMALL GROUP TEACHING
Teaching in small groups enjoys an important place among
the teaching methods commonly found in medical education
for two rather different reasons. The first of these can be des
cribed as social and the other as educational. For many
students in the university, and especially those in the early
years of their studies, the small group or tutorial provides an
important social contact with peers and teachers. The value of
this contact should not be underestimated as a means for stu
dents to meet and deal with people and to resolve a range of
matters indirectly associated with your teaching, such as diffi
culties with studying, course attendance and so on. Such
matters will, of course, assist with the attainment of the more
strictly educational objectives of your course.
Among the educational objectives that you can best achieve
through the use of small group teaching methods are the
development of higher-level intellectual skills such as rea
soning and problem-solving, the development of attitudes
and the acquisition of interpersonal skills such as listening,
speaking, arguing, and group leadership. These skills are im
portant to medical students who will eventually become .in
volved professionally with patients, other health care pro
fessionals, community groups, learned societies and the like.
The distinction between social and educational aspects of
small group teaching is rather an arbitrary one but it is import
ant to bear it in mind when you plan for small group teaching.
WHAT IS SMALL GROUP TEACHING?
Much of what passes for small group teaching in medical
schools Unis out to be little mere than a lecture to a small
number of students. Nor is size, within limits, a critical feature
for effective small group teaching. We believe that small
group teaching must have at least the following three
characteristics:
^active participation
face-to-face contact
purposeful activity.
Active participation
The first, and perhaps the most important, characteristic of
small group teaching is that teaching and learning is brought
about through discussion among all present. This generally
implies a group size that is sufficiently small to enable each.
group member time to contribute. Research and practical ex
perience
has
established that between five and
eight
students is ideal for most small group teaching. You will know,
from experience, that many so-called small groups or tutorial •
'groups are very much larger than this ideal. Although a group
of over twenty students hardly qualifies as a small group it is
worth remembering that, with a little ingenuity, you can use
many of the small group teaching procedures described in
this chapter with considerable success with larger numbers
of students. Generally speaking, though, you will be looking
for a technique which allows you to break the number down
into subgroups for at least some of the time.
Face-to-face contact
The second characteristic of small group teaching is that it
involves face-to-face contact among all those present. You will
find it difficult to conduct satisfactory small group teaching in
a lecture theatre or tutorial room with students sitting in roves.
Similarly, long boardroom-type tables are quite unsuitable
because those present cannot see all other group members,
especially those seated alongside. Effective discussion re
quires communication which is not only verbal but also non
verbal involving, for example, gestures, facial expressions,
eye contact and posture. This will only be achieved by sitting
the group in a circle.
&
Purposeful activity
The third characteristic of small group teaching is that the
session must have a purpose and must develop in an orderly
way. It is certainly not an occasion for idle chit-chat although,
regrettably, some teaching in groups appears to be little more
than this. The purposes you set for your small group can be
quite wide. They include discussing a topic or a patient prob
lem and developing skills such as a criticizing, analysing,
problem-solving and decision making. It is highly likely that
you will wish the small group session to achieve more than
one purpose. In medical schools, most groups are expected to
deal with a substantial amount of content. However, you yvill
also wish to use the small group approach to develop the
higher intellectual skills of your students and even to in
fluence their attitudes. In order to achieve these various pur
poses you will need considerable skills in managing the
group and a clear plan so that the discussion will proceed in
an orderly fashion towards its conclusion.
MANAGING A SMALL GROUP
Small group teaching is considerably more difficult to’man
age than a lecture because you must take a closer account of
the students’ behaviour, personalities and difficulties. To
achieve success with a small group you must also have a clear
understanding of how a group operates and-how it develops.
You have particular responsibilities as the initial leader of the
group but your role will vary considerably, both within a
session and from session to session. For instance, if you adopt
an autocratic or authoritarian style of leadership (not an
uncommon one among clinical teachers') you may well have a
.of o* purposoiul activity but there will be a limited amoum qi
spontaneous participation. You should preferably adopt a
role which is a more co-operative one where you demon
strate an expectation that the students will take responsibility
for
initiating
discussion,
providing
information,
asking
questions, challenging statements, asking for clarification and
so on. A successful group is one that can proceed purpose
fully without the need for constant intervention by the teacher.
This is hard fox most teachers to accept but is very rewarding
if one recognizes that this independence is one of the key
goals of small group teaching and is more important than
satisfying one’s own need to be deferred to as teacher and
content expert.
In managing a group there are two main factors that have to
be considered. These are those relating to the task of the
group and those relating to the maintenance of the group. In
addition there must be a concern for the needs of each
student within the group.
The tasks of the group: These must be clearly defined. This is
something that must be high on the agenda of the first
meeting. The reason for the small group sessions and their
purpose in the course must be explained. In addition, you
must initiate a discussion about how you wish the group to
operate, what degree of preparation you expect between
group meetings, wh'-it role you intend to adopt, what roles you
expect the students to assume and so on. Because such
details may be quickly forgotten it is desirable to provide the
student with a handout . The following list of headings may be
helpful:
A>^ALL
ff^DlNOS
HANDOUT
°
Course title, description and aims'
®
Teacher's name and availability
p
List of students' names
3
How the group is to run (e.g. teacher's role, students’roles, !
®
Work requirements (e.g. assignments,' case presenta
tions)
"|
o
Assessment arrangements
©
Reading matter
'■?*
method to be used)
.
Maintenance of the group: This refers to the achievement of a
good 'climate' for discussion. It must be one 'that is open, trust
ful and supportive rather than closed, suspicious, defensive
and competitive. It is important to establish that the responsi
bility for this factor rests with the students as well as with the
teacher. The firm but pleasant handling of the loquacious or
dominating students early in the session or the encourage
ment of the quiet student to contribute are obvious examples
of what must be achieved to produce the required environ
ment, for effective group discussion.
rat!
-
The successfully managed group will meet the following
criteria:
®
:cjT&p4A AT A
GpCTp
-\rTcT ft(U. , :^0Z-)
Prevalence of a warm, accepting, non-threatening group
climate.
o
«
Learning approached as a co-operative rather than a
■ competitive enterprise.
Learning accepted as the major reason for the existence
of the group.
o
Active participation by all.
o
Equal distribution of leadership functions.
<2
Group sessions and learning tasks are enjoyable.
s
Content adequately and efficiently covered.
© Evaluation accepted as an integral part of the group's
activities.
o
Students attend regular#
©
Students come prepared.
STRUCTURE IN SMALL GROUP TEACHING
We mentioned earlier the need to have a clear plan so that the
group discussion will proceed with purpose and in an orderly•
fashion. A structured approach to the task and the allocation
of the time available is a useful tool for you to consider. An
example of such a structured discussion session is illustrated
in Figure 3.3..
3-3
?
F’I^LirtfNAFUE5/ft^(4cepi(^ MATpSgS
Tms
g
ARDENT FT6SSNTS-THS INITIAL f+lfPKy'
AND 5-M^IHAVW FIND INS Op ONp Op fN&
PATENTS
'
T/TIN?
®
ftrftnHese?anp
■4“
/Nr^FFfATlOFl FfWIpEp pjv
5TD£NT
(ANPj^NSPDTANT) THOUGHT (VASTrtEPlA^NaSKy
(A/ffAl
Wiql (fs!yg$n6ATK7NS
GRTPS?. dgpyp
f^y
lOMlN^
&
4TVPSNT PRESENTS f^FTW- PAlA ON INVESTI
GATIONS ANP PFOSfzess .’G’jzovp P|$O(/SSES
ANY PISPAPITIES
IONINS
Ggt>ur- i-^APFg. opptrgs OofMOpjPi® gfeTlAFXS
ANO t?PP4>RT(tN(TY Fttp OlARFI^nSN
OP
^riipis
TOTAL
^0 MINS
This is a structure of a discussion based uu a case presenta
tion. Note that the structure lays out what is to be discussed
and how much time is budgeted. Such a scheme is not intend
ed io encourage undue rigidity or inflexibility, but to clarify
purposes and tasks. This may seem to be a trivial matter, but it
is one which creates considerable uncertainty for students.
Keeping to a time budget is very difficult. You need to be alert
to how time is being spent and whether time from one part of
the plan can be transferred io an unexpected and important
issue that arises during discussion.
Another structure, not commonly used in medical education
is illustrated in Figure 3.4.
3.^-
A 5N0WBALUN& <S>pZ)UF’
pocunwr
ewer
dN'Pf’IC'/
bA&d’FAWY
ffisppy ANp
PROUTS •'
3®
IN PAIK£ I
tW-NoS/S
l/f P/rFlOVt-T<^/MAf<&
AN P&C1PS- PM fWTHSfS. T^STS
H/hS
] WPAS fN 6MAI-L
PMPS
**=*'
, IOMINS
T?
prfy^P^£5 ANO
A^PP5-P]PNT OZ 61ARIFY1N&
['f2gft>P-T7N6 "&&<%. 1? d/HgLg
pis-
■
FAIWT fof
A^pFeMFNpvvftpps &poup
2P A!ns
(
^MALp
p^pppT,lEACHeR
NOTSS C4AiN ppiNTStPN <pOXW, gUTPh&ps f>Af£g
Op. Oh&AA-AP
-A< OppupS C5NANO Wp^NTS ppppp. COftMFNT5 •
PF- -TV P&NTS ATTEMPT *()n~
M/W ^F ft>(NT^ PA1AEP amp
■
pOFM 4f
This structure includes tlfe principle of 'snow-balling' groups.
From an individual task, the student progresses through a
series of small groups of steadily increasing sice. There are
special advantages in using this structure which are worth
noting: it does not depend on prior student preparation for its
success; the initial individual work brings all students to
approximately the same level before discussion begins; and
it ensures that everyone participates, at least in the prelimi
nary stages.
DEALING WITH DIFFICULTIES
You will undoubtedly have a variety of difficulties to deal with,
in your group sessions. For example, you might decide to
ignore a sleeping student or an amorous couple in a lecture
class, providing it was not disruptive, but it would be
impossible to do so m a small group. How you resolve
problems with the working of the group is critical. An authori
tarian approach would almost certainly destroy any chance
of establishing the co-operative climate we believe to be
essential. It is generally more appropriate to raise the prob
lem with the group and ask them for their help with a solution.
One of your main roles as a •Group leader is to be sensitive to
the group and the individuals within it. Research has identi
fied a number of difficulties that students commonly exper
ience. These are connected with:
making a contribution to the discussion
understanding the
conventions
of , group work
and
acceptable modes of behaviour
knowing enough to contribute to the discussion being
assessed.
These difficulties frequently get in the way of productive dis
cussion. They tend to be due to genuine confusion on the part
of students combined with a fear of exposing their ignorance
in front of the teacher and their peers. It is therefore essential'
for you to clarify the purpose of the group and the way in
which students are to enter into the discussion. Their previous
experience of small group sessions or ward teaching might
lead them to see the occasion as only a threatening questionand answer session. They must learn that ignorance is a rel
ative term and that their degree of ignorance must be recog
nized and explored before effective learning can begin. A
willingness by the teacher to admit his own ignorance and
demonstrate an appropriate way-'of dealing with it will be
very reassuring to many students. -
Confusion in the students' minds about how they are bein®
assessed can also cause difficulties
Generally speaking.
assessing contributions to discussion is inhibiting and should
be avoided if possible. If you do not have discretion in this
matter then at least make it quite clear what criteria you are
looking for in vour assessment. Should you be able to deter
mine your own assessment policy then- the following are
worth considering:
.
(
require attendance at all (or a specified proportion of)1
group meetings as a prerequisite;
set formal written work, e.g. a major essay, a series of
short papers, a case analysis;
set a group-based task, e.g. keeping an account of the
WOlk Quilt: by tut: ylOup.
The teacher's perceptions of group difficulties may not nec
essarily match those of the students. A discussion with the
group about how tuey tytnk things arc going or the.administra-
tion of ?. short questionnaire aye ways of seeking feedback.
Once the grbup is operating it is important to be continually on
the look out for trouble. You must be sensitive to the emotional
responses of the group- and to the behaviour of individual;
students. Bion has categorized group responses into fight,
flight, pairing and dependency. These categories serve to
highlight some of the common features in groups which;
hinder their successful operation.
Fight: this appears in several forms. It may be. easily recog
nized as overt hostility and aggression but equally damaging
can be misplaced humour, quibbling over semantics, point
scoring and attempting to establish intellectual superiority.
Teachers are as frequently guilty of such activities as their
students.'
Flight: students become very adept at avoiding difficult sit
uations. In our experience this is one of the biggest problems;
in small groups. It may take the form of withdrawal from active
participation, by distracting behaviour, or by attempting to
change the direction of the discussion without the resolutionof a sticky problem.
Pairing: a pair within the group may carry on a more.or less
personal conversation for considerable periods of time. All
too often the teacher is one of them. A good group wall not
allow this but in many groups the majority of the discussion'
may be carried on by only a small minority of students.
42
Dependency: this is also a common problem and is one
which may be present in a whole group. The group avoids
tackling problems by getting someone to do it for them. This
may be the brightest student or most frequently the teacher
who may even be flattered into it. Medical students seem to
be particularly adept at this and their teachers particularly
susceptible.
INTRODUCING STIMULUS MATERIALS
A very useful means of getting discussion going in groups is to
use what.is generally knCwn as 'stimulus material'. We have
seen how this was done in the snowballing group structure
described previously. The range of stimulus material is really
very large indeed. It is limited only by your imagination and
the objectives of your course. Here are a few examples:
®
a short multiple-choice test (ambiguous items work well in
small groups)
©
a case history
® • a trigger film or video (e.g. short open-ended situation,
such as a patient's reaction to a doctor)
®
a patient
o
observation of a role-play
o
visual materials (e.g.' X-rays, photographs, slides, speci
mens, real objects, charts, diagrams, statistical data)
®
an audio recording (e.g. an interview, heart sounds, a
segment of a radio broadcast)
°
a student's written report on a project or a patient
®
a patient
management
problem or modified essay
question (see Chapter 6)
®
a journal article or other written material
One of the most innovative approaches we have encountered
vvqS ujql GcVciOpcu. ajj iviOOIc atrthc UiiiVOISity Oi.
He used extracts from literary works to help students under
stand the broader cultural, philosophical, ethical and pen-.'
sonal issues of being a doctor. Examples of sources for these
extracts include Solzhenitsyn's Cancer Ward and Virginia
Woolf's On Being Ill.
ALTERNATIVE SMALL GROUP DISCUSSION
TECHNIQUES
As with any other aspect of teachina it is heloful to have a
variety of techniques at one's fingertips in order to introduce
variety or to suit a particular situation. Such techniques
include:
fa One-to-one discussion
nUZZ "'"OU’"'®
fa' Brainstorming
fa Plenary session
fa Evaluation discussion
One-to-one discussion
1.
This is a very effective technique which can be used with a
group of almost any size. It is particularly useful as an ‘ice
breaker' when the group first meets, and is valuable for en
hancing listening skills. It can also be used to discuss con
troversial or ethical issues when forceful individuals with
strong opinions will be prevented from dominating the
discussion. They will also be required to listen to other
opinions and express them to the whole group.
A
Procedure
o group members (including the teacher) divide into
pairs and each person is designated 'A' or 'B'.
o
person A talks to person B for an uninterrupted
period of 3-5 minutes on the topic for discussion.
<s
person B listens and avoids prompting or questioning.
o roles are reversed with B talking to A.
<2
at the conclusion the group reassembles.
o each person introduces himself, -introduces the
person to whom he was listening and then briefly
paraphrases what that person said.
Use as icebreaker
© group members are asked to respond to a question
such as ‘tell me something about yourself'.
General use
« group members respond to appropriate questioning. ■
e.g. 'what is your opinion about... ?'
It is important to insist on the no interruption rule (though not so
much when used as an icebreaker). Prolonged periods of
silence may ensue but person A will be using this time for
uninterrupted thinking, a luxury not available in most situa
tions. Often the first superficial response to a question will be
changed after deeper consideration.
2.
Buzz groups
These are particularly helpful to encourage maximum partici
pation at one time. It is therefore especially useful when
groups are large, if too many people are trying to.contribute
at once or, alternatively, if shyness is inhibiting several
students.
Procedure
A BUZZ
ss^- the group is divided into sub-groups of 3-4 students
discussion occurs for a few minutes (the term 'buzz'
comes from the hive of verbal activity!)
a clear task must be sdi
each group reports back to the whole group
3.
Brainstorming
This is a technique that you should consider when you wish to
encourage wide and creative thinking about a problem. It is
also valuable when highly critical group members (including
perhaps yourself?) appear to be inhibiting discussion. If used
frequently, it trains students to think up ideas before they are
dismissed or criticized. The key to successful brainstorming
is to separate the generation of ideas, or possible solutions to„;
a problem, from the evaluation of these ideas or solutions.
r&UFZ ?-7
Procedure
zt" explain the rules of brainstorming to the grpup:
<= criticism is ruled out during the ido? generation stage
all ideas are welcome
o quantity of ideas is the aim (so as to improve the
chances of good ideas coming up)
® combination and improvement of ideas is sought
•'£**’ ctoto Old >-> vrsVsl
a period' of silent thought is allowed during which
students write down-their ideas
7^ ideas are then recorded (in a round robin format) on a
blackboard, overhead transparency or butcher’s paper
for all to see
w^en
ideas are listed, and combination and improve
ment of ideas are comolete, discussion and evaluation
commences.
4. Plenary session
In many group teaching situations, and indeed at medical
conferences, subgroups must report' back to the laraer
group. This reporting back can be tedious and often involves
only the subgroup leaders who may present a very distorted
view of what transpired. The plenary session method may
help you get round these problems.
Procedure
'■
.CWOCTlNk A Pl-EWY
a
subgroups sit together facing other subgroups
SSS&IPN
a
the chairman of subgroup A briefly reports the substance
of the discussion in his group
®
the chairman of subgroup B then invites members of sub
groups B, C, D etc. to ask questions of any member oi
group A
&
after 10 minutes chairman B reports on the discussion in
subgroup B and the- process is repeated for each
subgroup
®
the 10 minute (or other) time limit must be. adhered to
strictly.
:
.
5. Evaluation discussion
From time to time during a course it is desirable to review the
progress of your small group, both in regard to the teaching
and in regard to the material you are covering. There are a
number of ways you could collect information about these
matters, one of which is the technique called the evaluation
discussion.
FI6Uf<& S-q '
CONPOCT(Ne> AN
&VARJATION
p(5<Ug5fpN
Procedure
prior to the group meeting students are asked to write a
1-2 page evaluation of the group's work focussing
equally on their reactions to the processes of teaching
and what they are learning.
each student reads this evaluation to the group
each member of the group is then free to ask questions,
.. agree or disagree, or comment
For success you must be sure (to create an atmosphere of
■acceptance where negative as well as positive information
can be freely given.
1
i
EVALUATING SMALL GROUP TEACHING
Evaluation implies collecting information about your teaching
and then making judgements based bn that information.
Making judgements based on what one student says, or on
rumour or intuition, is simply not good enough. You must col
lect information in a way that is likely to lead to valid judge
ments. However, constant evaluation of small group activities
is not recommended as it may inhibit the development and
working of the group. Evaluation may be of two types:
informal or formal.
Informal evaluation: this can proceed from your careful re
flection of what happened wiring your time with the group.
You may do this by considering a number of criteria which
you feel are important. For example, you may be interested in
the distribution of discussion among group members, the
quality of contribution, the amount of your own talk, whether
the purpose of the session was-achieved and so on. Of course,
your reflections will be biased and it is wise to seek confirma
tion by questioning students from time to time. However, the
importance of informal evaluations lies in your commitment to
turn these reflections into improvements; If you are con
cerned with your own performance, the assistance of a
trusted and experienced colleague sitting in on the group,: or
even just discussing with him your own feelings about the
group, may be very helpful.
Formal evaluation: one formal approach to evaluation has
already been described, the evaluation discussion. Other
approaches include the use of questionnaires and the analy
sis of video recordings of the group at work, ‘oicuiucuu
cmsstionnsirss ATA
tKrhiMi coo'l/ ctnHont
to
a set number of questions. An example is shown in Figure
3.10.
Although such standard questionnaires can be useful you
may find it more beneficial to design one that contributes
more directly to answering questions which relate to your
own course and concerns. As questionnaire design is a tricky
business it is recommended that you seek the assistance of a
teaching unit. The analysis of videotapes of your group al
■work is also a task which would require the expertise of some
one from a teaching unit.
p-f6UlsE >•(£>
CWlM (JrTbWIAL
T
- - -----------------------------------------------------------------------------------------Name................................... .-................... . Course.......... ......ty;'.................. H
Please .indicate your thoughts about the tutorial given by this
particular tutor. Your responses are anonymous
(xU^TtONNAIKE
(ADViSu^r CENTReTDf^,
UNIV6gStTf BpPCATtQM/
Indicate your present thought;: by means of a tick on the four-point
scale.
(A) The tutor
good group leader ------ poor group leader
.(Wf^SITY Op A>&LAIP&)
fits into the group ------ too forceful
discoursgss ths
questioned —— questioning of opinions
patient ------ impatient
sarcastic ------ never sarcastic
I
lively ------ monotonous
pleasant manner ------ unpleasant manner
------ not interested in students
interested in my ideas ------ not interested in my ideas
interested in me as an
individual ------ does not know me
encourages'me to
unable to discuss
discuss problems -T-- problems
treats me as an equal ------ treats me as a.subordinate
clearly audible ------ mumbles
stresses important
all material seems
’ material ------ the same
makes good use of examples
and illustrations ------ never gives examples
explanations clear and
understandable ------ quite incomprehensible
appears confident ------ not confident
(B) The tutorials
well organized ------ muddled
good progression ------ poor prbgression
well prepared ------ not well prepared
time well spent ------ a waste of time
merely repeat lecture
new material Covered ------ material
have thrown new light on
irrelevant to understanding cf
lecture course ------ lecture course
overcome difficulties
difficulties not
encountered in lectures •------ dealt with
(C) The student's response
I am fully aware of my
I seem to be 'working in
progress ■----- the dark^ijf
1 enjoy contributing -—-- I try to say nothing .
I would prefer not
I look forward to the
tutorials ------ to attend
I have learnt a lot ------
-
1 have leamt nothing
I am more inclined to
I have developed an aversion
.
continue with the subject ------ to the subject
Advice or suggestions for the future.sh’ould be written on the back.
GUIDED READING
For a wide ranging discussion of the purposes and techniques
of small group teaching we suggest you turn to M. L.J. Aber
crombie's Aimsand Techniques of Group Teaching, Society
for Research into Higher Education (fourth edition), Guild
ford, Surrey, 1979. This monograph also provides a good
introduction to the research literature on small groups.
If you are looking for a brief, practical guide to the use of dis
cussion in small groups, you might find it helpful to obtain a
copy of W.F. Hill's Learning Thru Discussion, Sage, Beverley
u;nr.
1000 The ~utlines in this book w:” u-1—
get started if you are new to small group tpaching You will, of
course,, need to adapt some of the strategies to the circum
stances of your own teaching.
Books and journals referred to in this chapter:
Experiences in Groups by W.R. Bion, Tavistock, London,
.1968
Medical Humanities - A New Medical Adventure by A.R.
Moore, Nev/England Journal of Medicine, 29 5,1976,1479-80
Learning Through Discussion at the Open University by A.
Northedge, Teaching at a Distance, 2, 1975, 10-17
NP -
F •& , .
purpose of this section is to have an understanding of study habits and
itudes toward studying. Please answer the following statements usinc the
below. Use the response which most closely corresponds to how you feel.
is, put an "P.", "S", "P", "G", or "A" on the line following the statement.
When my assigned homework is extra long or unusually difficult, I either cult
in disgust or study only the easier parts of the lesson.
My dislike for certain teachers causes me to neglect ray school work.
When I get behind in my school work for some unavoidable reason, I make up
back assignments without prompting from the teacher.
,
I feel that I would study harder if I were given more freedom to choose course:
Daydreaming about dates, future plans, etc., distracts my attention from my
lessions while I am studying.
Even though I don't like a subject, I still work hard to make a good grade.
Even though an assignment is dull and boring, I stick to it until it is
I lose interest in my studies after the first few days of a new semester.
I keep all the notes for each subject together, carefully arranging them in
some logical order.
I believe that teachers truly want their students to like them.
When I am having difficulty with my school work, I try to talk over the trouble
with the teacher.
I feel that students are not given enough freedom in selecting their own topics
for themes and reports.
I lay aside returned examinations, reports, and homework assignments without
bothering to correct errors noted by the instructor.
Lack of interest in my school work, makes it difficult for me to keep my
attention on assigned reading.
I keep my place of study business-like and cleared of unnecessary or cistractin
items such as pictures, letters, mementos, etc.
' R - RARELY means from 0 to 15 per cent of the time.
* S - SOMETIMES means from 16 to 35 per cent of the time.
2 F - FREQUENTLY means from 36 to 65 per cent of the time.
4 G - GENERALLY means from 66 to 85 per cent of the time.
C A - ALMOST ALWAYS means from 86 to 100 per ce- -f the '
16.
Telephone calls, people coming in and out
friends, etc., interfere with my studyir",
17.
I feel confused and undecided as to '
should be.
'
r-
^-sessions" with try
■ •, --ducational and vocational goals
18.
It takes a long time for me to get '. '.rmed up to the task of studying.
19.
Some of ray courses are so uninteresting that I have to "force” myself to do
the assignments.
20-
I am unable to concentrate v/ell because of periods of restlessness, moodiness,
or "having the blues."
21.
I believe that having a good time and getting one's full chare of fun out of
life is more important than studying.
23.
I believe that teachers tend to avoid discussing present-day issues and events
with their classes.
24.
When I sit down to study I find myself too tired, bored, or sleepy to study
efficiently.
25.
I feel that my grades are a fairly accurate reflection of my ability.
26.
I waste too much time talking, reading magazines, listening to the radio
watching TV, going to the movies, etc., for the good of my studies.
27.
I feel that it is not worth the time, money, and effort that one must spend
to get a college education.
28.
My studying is done in a random, unolanned manner—is impelled mostly by the
demands of approaching classes.
29.
Some of my classes are so boring that I spend the class period drawing
pictures, writing letters, or daydreaming instead of listening to the
teacher.
.
30.
"Extracurricular activities"—dating, clubs, athletics, fraternity and sorority
activities, etc.—cause me to get behind in my school work.
31.
I feel that I an taking courses that are of little practical value to me.
32.
I utilize the vacant hours between classes for studying so as to reduce the
evening's work.
R - Rarely means from 0 to 15 per cent of the time.' 'I
S - SOMETIMES means from 16 to 35 per cent of the time.' !F - FREQUENTLY means from 36 to 65 per cent of the time, r d
; - GENERALLY means from 66 to £5 per cent of
*J~e.
- t|
A - ALMOST ALWAYS means from £6 to 100 per c■. time.
35.
I strive to develop a sincere inte't ■; 11
36.
I complete my homework assignments cn time.
37.
The prestige of having a college education provides my main motive for going
to college.
38.
I like to have a radio, record player, or television set turned on while I’m
studying.
39.
X believe that a college's football reputation is just as important as its
academic standing.
40.
With me, studying is a hit-or-miss proposition depending on the mood I'm
41.
I think that It might be best for me to drop out of school and get a job.
42.
I study three or more hours per day outside of class.
43.
I feel that the things taught In school do not prepare one to meet adult
problems.
44.
I keep my assignments up to date by doing my work regularly from day to
45.
Prolonged reading or study gives me a headache.
46.
I prefer to study my lessons alonj! rather than with others.
47.
I feel like cutting classes whenever there is something I'd rather do or
whenever I need to cram for a teat.
48.
At the beginning of a study period I organize my work so that I will utilize
the time most effectively.
49.
I believe that grades are based upon a student's ability to memorize facts
rather than upon the ability to "think" things through.
< •. every course I take.
Tn p'3F-
Scoring and Interpreting the Intolerance of Ambiguity Scale
Introduction
The Intolerance for Ambiguity was developed by Stanley Budner in 1960
(Sudner, 1962).
Budner defined intolerance for ambiguity as a general
tendency to perceive ambiguous situations as threatening.
Conversely,
tolerance of ambiguity was defined as a tendency to perceive ambiguous
situations as being desirable.
Ambiguous situations were defined as
situations characterized by novelty, complexity or insolubility.
Indi
cators of the perception of threat were identified as phenomonological
submission (dislike), phenomenological denial (repression), operative sub
mission (avoidance behavior) and operative denial (destructive or reconsructive behavior).
More generally the ambiguous situation is defined as one
which cannot be adequately structured or categorized by the individual due
to a lack of sufficient cues.
Scori ng
The Intolerance for Ambiguity Scale is made up of sixteen Lickerttype i terns.
1.
The eight odd items are positively stated and therefore express
one's intolerance for ambiguity.
Thus in scoring the positive items,
SA=7, A=6, AS=5, DS=3, D=2, and SD=1.
Omissions are scored a 4.
2.
The eight even items are negatively stated and therefore express
one's tolerance for ambiguity.
In order to score these negative
items so they are expressing intolerance for ambiguity, the numbers
assigned to responses are reversed.
Therefore, for the even items,
SA=1, A=2, AS=3, DS=5, 0=6, and SD=7.
Again, omissions are scored
4.
A single score summarizing one's intolerance for ambiguity may be
obtained by summing the values on each of the sixteen items.
The
scores possible on the scale range from 16 (very tolerant) to 112
(very intolerant).
Budner, Stanley
1962.
"Intolerance of Ambiguity as a Personality Variable."
Journal of Personality.
30:29-50.
KELLNER'S SYMPTOM QUESTIONNAIRE
1v|p-3P-|O.
DATE
NAME................................................................................
Please describe how you have felt DURING THE PAST WEEK and make a small check
mark like this
.
For example, the word NERVOUS is on the first line: if you have felt nervous
check YES like this:
/
W
NO
/
If you have not felt nervous, check NO like this:
YES
NO
A few times you have the choice of checking eith TRUE or FALSE.
Do not think long before answering. Work quickly! Please answer ALL questions!
1.
Nervous
YES
NO
24.
Feeling unworthy
YES
2
Weary
YES
NO
25.
Annoyed
YES
NO
3
Irritable
YES
NO
26.
Feeling of rage
YES
NO
4
Cheerful
YES
NO
27.
Cannot enjoy yourself
TRUE FALSE
5
Tense, tensed up
YES
NO
28.
Tight head or neck
YES
NO
Sad, blue
YES
NO
29.
Relaxed
YES
NO
7
Happy
YES
NO
30.
Restless
YES
NO
8
Frightened
YES
NO
31.
Feeling that people are
friendly
YES
NO
9
Feeling calm
YES
NO
10
Feeling healthy
YES
NO
•
12
Losing temper easily
YES
Feeling of not enough
air
TRUE FALSE
NO
32.
Feeling of hate
YES
NO
33.
Choking Feeling
YES
NO
34.
Afraid
YES
NO
35.
Patient
YES
NO
NO
Feeling kind to people
YES
NO
36.
Scared
YES
NO
Feeling fit
YES
NO
37...
Furious
YES
NO
Heavy arms or legs
YES
NO
38.
Feeling friendly
YES
NO
16
Feeling confident
YES
NO
39.
Feeling guilty
YES
NO
17
Feeling warm to people
YES
NO
40.
Feeling well
YES
NO
18
Shaky
YES
NO
41.
Feeling of pressure in
head or body
YES
NO
19
No pains anywhere
TRUE FALSE
42.
Worried
YES
NO
20
Feeling aggressive
YES
43.
Contented
YES
NO
44.
Weak arms or legs
YES
NO
NO
13
14
'
-
NO
Arms and legs feel
strong
YES
22
Appetite poor
YES
NO
45.
Feeling desperate, terrible
YES
23
Feeling peaceful
YES
NO
46.
No aches anywhere
TRUE FALSE
21
NO
PLEASE
TURN
OVER-
SCORE KELLNER'S SYMPTON RATING SCALE
File Name = KELLNER
Yes = j
No
For items:
1,2,3,5,6,8,11,12,15,18,20,22,24,25,26,27,28,30,32,33,
34,36,37,39,41,42,44,45,47,48,49,52,53,54,55,56,57,58,
= Q
59,60,61,62,63,64,65,66,67,68,69,70,72,73,74,75,76,77,
79,80,81,82,84,85,86,87,88,90,91,92
Yes = 0
No
= 1
For items:
4,7,9,10,13,14,16,17,19,21,23,29,31,35,38,40,43,46,50,
51,71,78,83,89
(Anxiety Symptom) Score - Sum of Scores for items:
1,5,8,18,30,34,36,42,49,54,59,62,63,64,68,86,87
R(RELAXED) Score - Sum of Scores for items:
9,16,23,29,50,89
A(Anxiety) Score - Total Sum of Scores for AS and R
DS (Depression Symptom) Score - Sum of Scores for items:
2,6,24,27,39,45,47,58,60,61,66,67,73,75,76,84,91
C (Contentment) Score - Sum of Scores for items:
4,7,40,43,51,71
D (Depression) Score - Total Sum of Scores for DS and C
SS (Somatic Symptom) Score - Sum of Scores for items:
12,15,22,28,33,41,44,52,53,57,65,72,74,77,79,85,92
SW (Well Being) Score - Sum of Score for items:
10,14,19,21,46,78
S (Somatic) Score - Total Sum of Scores for SS and SW
HS (Hostility Symptom) Score - Sum of Scores for items:
3,11,20,25,26,32,37,48,55,56,69,70,80,81,82,88,90
F (Friendly) Score - Sum of Scores for items:
13,17,31,35,38,83
H (Hostility) Score - Total Sum of Scores for HS and F
Total Score for SQ Scale = Total Sum of Scores for A, D, S, and H
LEARNING STYLE INVENTORY
•
The following questionnaire, the Learning Style Inventory, is intended as a
starting point for reflection and analysis of the way you learn best.
It is
intended to help you identify those learning situations and resources that will
maximize your effectiveness as a learner.
Following the inventory there are
scoring instructions and an explanation of the learning theory on which it is
based.
INSTRUCTIONS
There are nine sets of four words listed below.
Rank order each set of
four words assigning a 4 to the word which best characterizes your learning
style, a 3 to the word which next best characterizes your learning style, a 2
to the next most characteristic word and a 1 to the word which is least
characteristic of you as a learner.
Be sure to assign a different rank number
to each of the four words in each set.
Ro not make ties.
a
discriminating
receptive
feeling
accepting
intuitive
abstract
present-oriented
experience
intense
FOR
SCORING ONLY:
CE
TTTTT3
tentative
relevant
watching
risk-taker
productive
-Observing
reflecting
observation
reserved
practical
___ impartial
doing
aware
questioning
active
pragmatic
experimentation
responsible
___ involved
analytical
thinking
evaluative
___ logical
concrete
"future-oriented
conceptualization
rational
RO
136789
AE-RO
■
A?
LEARNING STYLE INVENTORY
The following questionnaire, the Learning Style Inventory, is intended as a
starting point for reflection and analysis of the way you learn best.
It is
intended to help you identify those learning situations
’ounces that will
maximize your effectiveness as a learner.
Following t~
scoring instructions and an explanation of the learning
jO
.
y there are
which it is
based.
INSTRUCTIONS
There are nine sets of four words listed below.
Rank order each set of
four words assigning a 4 to the word which best characterizes your learning
style, a 3 to the word which next best characterizes your learning style, a 2
to the next most characteristic word and a 1
characteristic of you as a learner.
to the word which is
in each set.
Oo not maxe ties.
tentative
relevant
watching
risk-taker
’’
-/
.4.
"A.
discriminating
receptive
feeling
accepting
j
*
involved
analytical
thinking
evaluative
5.
intuitive
productive
y
logical
kl.
least
Be sure to assign a_ different rank number
to each of the four words
y___ practical
1
impartial
y
9.
doing
aware
questioning
active
abstract
,
observing
concrete
present-oriented {,
reflecting
future-oriented y___ pragmatic
experience
observation,- ,
conceptualizatic y
experimentation
y
responsibl e
intense
•
reserved
*
rational
FOR
SCORING ONLY:
5.
7.
i.
CE
.
RO
2 3 4 5 7 8
AC
1
3 6 7 8 9
’2'y 4 5 8’9'
SCORING THE LEARNING STYLE INVENTORY
To score the inventory sum each column including only those words whose
item number appears under the place for the total score.
For example, for
CE total the ranks for words, 2,3,4,5,7 and 8 in the first column.
For RO
total the ranks for words 1,3,6,7,8 and 9 in the second column and so on.
To get the combination scores subtract CE from AC and RO from AE.
Preserve
negative signs it they appear.
(NOTE:
The non-scored words in each mode have
been randomly assigned to other columns to disguise the pattern.
Ignore them.)
Reprinted and adopted form David A. Kobl, Bulling a Learning Community
(Washington, D.C.:
National Training and Development Service, T574).'
The words that comprise each scale are listed with it to aid you in inter
preting the personal meaning of your raw score.
When you score high on a given
scale, you tended to rank the words in that scale as most characteristic of your
learning style.
The combination scores AC-CE and AE-RO can be used to get an indication of
which of the four dominant learning style types is most characteristic of your
method of learning, as indicated below.
-
High abstract/high active = Converger
High abstract/high reflective = Assimilator
High concrete/high active = Accommodator
High concrete/high reflective - 111 verger
You may now want to briefly answer the following questions as a way of
reflecting on the meaning of your 12ST scores:
1.
Do you feel that your Learning Style Inventory scores are valid indicators
of your learning style?
How would you characterize the way you learn?
What is your greatest strength as a learner?
Your greatest weakness?
2.
What are your learning to learn objectives?
What modification of your learning
style seems necessary for you to master new material you may wish to learn?
Do you want to alter your learning style in any way?
3.
Given your learning style and learning objectives what kind of environment
do you need to learn best?
Do you learn best alone or interacting with
others?
Do you need discipline of freedom?
Does competition help or hinder
your learning?
What teaching methods are best for you--theoretical discussions,
reading, experiential exercises and games, practical application oriented
cases, etc.?
Abstract
1
Concrete
AC-CE
Active
1
Reflective
AE-RO
Concrete
Experience:
Receptive
Feeling
Accepting
Intuitive
Present-Oriei
Experience
Reflective
Observation
Tentative
Watching
Observing
Reflecti ng
Observation
Reserved
Abstract
Conceptual Tzation:
■Analytical
Active
Experimen
tation:
Practical
Thinking
Evaluative
Logical
Conceptualization
Rational
Doing
Active
Pragmatic
Experimentation
Responsible
j.. ; /Acsc simulations provide
spund faculty to explore the
In traditional management
aid practitioner learning styles
is filtered through the learning
s presentation and analysis of
' analysis because his data is
ential learning approach, this
both teacher and student are
x>th interpret according to their
i, the teacher's role is that of a
self-directed. He helps students
'j the phenomena in his field of
les and perspectives from which
<y with alternative theories and
i his observations into his own
■he implications of the student’s
•o test these implications through
Irning process. One is a goal to
itter. The other goal is to learn
' a learner—i.e., learning how to
jorks well, managers finish their
[Hectual insights, but also with an
I This understanding of learning
lomc application of what has been
Suing learning on the job. Day-toJr.d exploring new ideas. Learning
us classroom, but becomes an in-
pips between a manager's loaming
now about his current behavior on
pg styles approach problem solving
ically, the answer to this question
a solving are not different processes
{viewed from different perspectives.
figure 3 a typical model of the probfon the experiential learning model.
‘in a problem-solving sequencegenhrengths of the four major learning
pF's problem-solving strengths lieTn
Idem finding_based on some goaf or
^verger’s problem-solving strengths lie
Problems and opportunities that exist
;rsnd “!denffiy~dTficrences”). The asi.nJdmg~tha'Tis necessary to choose a
F1GURE 3
Comparison of the Experiential Learning Model
with a Typical Model of
ths Problem-Solving Process (after Pounds. 1965)
priority problem and alternative solutions. The converger’s strengths lie in
evaluation of solution consequences and solution selectionTo date, two studies have been conducted to discover whether there is a
thing to this theoretical model. The first study was conducted by Charles Sta
(Stabell, 1973) in the Trust Department of a large U.S. midwestern bank. ■
aim of his study was to discover how the learning styles of investment port!
managers affected their problem solving and decision making in the manager
of the assets in their portfolios. While his study involved only thirty-one r.
agers, he found a strong correspondence between the type of decisions t
managers faced and their learning styles. More specifically he found that n<
all of the managers in the Investment Advisory section of the depanmehigh-risk, high-pressure job (as indicated by a large percentage of holdin
common stock, a large percentage of discretionary accounts, and a high perf
ancc and risk orientation on the part of clients), had accommodative leai
styles (scoring very high on the AE and CE LSI scales). On the other hand
men in die Personal Trust section, where risk and performance orientation
low and where there were few discretionary accounts and fewer holdin
common stock, scored highest on reflective observation. This finding sup
TO USE STANDARDIZED PATIENTS
TABLE OF CONTENTS
PAGE
DEFINITION....................... ................................................................. 1
WHY NOT REAL PATIENTS?.................................................... 2
WHY STANDARDIZED PATIENTS? ............................... ............... . • 3
WHEN TO USE A STANDARDIZED PATIENT............................ 4,5
HOW TO USE A STANDARDIZED PATIENT................... ,..............6-8
"TIME IN and
TIME OUT" ............................................................ 8
FORMATS............................................. ....................................... ..
9-13
WRITTEN MATERIALS WHICH ACCOMPANY THE
STANDARDIZED PATIENT. .........................................................
14-17
IMPORTANT INFORMATION...................................................... ....18-19
ACCOMPANYING MATERIALS...................
20
m standardized pattent
DEFINITION:
The Standardized Patient (SP) is a healthy person who has been carefully
trained to realistically reproduce the history, physical and emotional
findings of an actual patient.
The SP offers a readily available and standardized tool for teaching and
evaluating student performance.
This allows for teaching and assessment of
clinical skills in a patient oriented and problem based manner.
Presented with a realistic patient problem, the student is forced to determine
what kind of person or problem is represented and allows him/her to experience
the personal responsibility of assessing, managing and dealing with a
patient's problem(s).
S7AT0S OF THE STANDARDIZED PATIENT PROGRAM
Total Membership (approximately 81) consists of 48 active patients and 33
patients reserved for special events. The available age levels and sexes are
listed below:
60+
50"s
40’s
20-30’s
adolescent
11 males
1 male
5 males
11 males
7 males
7 females
8 females
10 females
17 females
4 females
2
TOY KOT REAL PATIENTS?
Tlie use of real patients has a variety of drawbacks if considered from an
educational point of view. It nay be difficult to accept that there are
alternate and often better sources of patient problems than real patients, but
the disadvantages need to be considered.
DISADVANTAGES OF REAL PATIENTS IN Afl EDUCATIONAL SETTING
AVAILABILITY:
The appropriate real patient may not be available when needed for effective
student learning.
Patient availability and overuse is a major concern for
medical institutions in many parts of the world.
When real patients are available, they are available only in certain locations
such as hospitals, clinics or private practice. These restrictions may generate
logistical problems for the student learner.. Often these locations are not
suitable for group discussions, repeated study and examination and are not
accessible to learning resources. In addition, patients in these settings have
to have their care and diagnostic studies interrupted, and are often discharged
before the full educational benefits are elicited from their problem.
Many patients are complex or urgent and are therefore not available for student
learning because urgency, seriousness or sensitivity of the problems require
immediate and complex care.
ADAPTABILITY-.
Discussions are limited in front of a real patient. The educator must monitor
the type of information revealed to a patient during the discussion period with
the student(s).
REPEATABILITY:
Patients often feel like they are being used as guinea pigs, in the students
education.
The length of tine a student takes, the repeated'questions and
discussions nay fatigue, or bo of inconvenience to the patient.
CONTROLLABILITY:
A real patient may present complexities or unrelated problems that can distract
or confuse the learner. The real patient is often variable, and these variables
such as unco-operativeness, hostility, changing physical signs are uncontrollable
and may limit educational uses.
A patient may become "mechanical" after repeated examinations and "work-up”.
The history becomes automatic and the affect is no longer genuine or spontaneous
(the real worries and concerns have been dealt with and so the patient no longer
expressed these); he becomes passive and "educated” to the types of questions
and answers that are expected.
REDBACK:
A real patient will not or does not have the skills to provide the student(s)
with objective feedback.
!7KY STANDARDIZED PJfimS?
J
ADVANTAGES OF USIHG STANDARDIZED PATIENTS IM AK EDUCATIONAL SETTIHG
As an alternative to real patients, the SP can offer several advantages.
AVAILABILITY:
The SP is available anytime or any place.
The educator need not be
inconvenienced by hospital schedules, the appropriateness of available patients
or location of the patient.
The SP can be arranged for weeks in advance at the point in time when the patient
experience is important for student learning. It is easy to plan patient-student
experience for greater effective and efficient learning.
Using SP's, it is not necessary to rely on real patients who may not be willing
or available at the appropriate time, and, therefore, eases demands on the
hospital patients.
ADAPTABILITY:
The SP is adaptable and allows for monitoring in areas of great sensitivity or
risk, where opportunities for direct student participation are not often
possible. With the use of "time in" and "time out" (described in detail later) ,
the educator can discuss various problems the students are encountering in front
of the SP - he can clarify direction, reactions, problem definitions, etc. with
no risk to the patient's welfare.
REPEATABILITY:
There is minimal variation with the SP from student to student or session to
session. The SP is repeatable.
The presenting problems are standard and consistent - the only variance is the
SP’s reaction to the student's approaches and interpersonal interactions.
Because of this repeatability, the student is allowed to repeat a task over and
over until it is mastered.
THE SP IS STANDARDIZED
CONTROLLABILITY:
The SP offers a controlled situation.
"he SP can bo trained for the amount of information freely offered to the student
and what information must be specifically asked for.
A simulation can be "adjusted" to the level of the student.
Similar to the
volume control on a television, the SP's "affect" can be adjusted. For example,
if the SP is simulating a Manic, the real manic may be frightening and difficult
for the first year student and therefore an inappropriate experience. However,
the level of the anxiety and irritability of the SP can be adjusted to suit the
educational goals of the educator - making the encounter beneficial to the
student learning.
4
The outcome of the patient problem is predictable - known and documented, lab
results are available, and progress of the actual patient case available for
further study.
The student -■ patient encounter can be dissected to meet educational goals.
The educator can select one aspect of the patient encounter (i.e. history,
physical examination, etc.) and concentrate on the selected aspect.
Unlike role playing, the SP maintains the role of the patient, which increased
the realism for the student. The student must respond to the SP as he would a
real patient when there is no familiarity, or preconceived determinants of the
patient.
.FEEDBACK:
Feedback is immediate. The educator and the SP can jointly provide immediate,
constructive and honest feedback to the student.
The educator can guide the
student, helping him to shape and develop hypotheses, problem formulation and
examination skills at a critical point in the learning process - they need not
worry about speaking in front of the SP with this feedback.
The SP is trained to provide feedback from the patient's point of view:
commenting on the student's professional manners, attitudes and interpersonal
skills.
STUBKHY ACTIVITT:
There is HO rick to the SP, therefore student anxiety levels decreases.
THERE ARE WO TIKE RESTRICTIONS:
The student need not worry about fatiguing the patient.
Unless imposed for
educational purposes, there is no time restrictions when using a SP.
TOEH TO USE A STANBAEBIZEB PATIEbT
During the early development of clinical reasoning skills and interpersonal
skills it nay be productive to use a SP with the tutorial group (5-6 students).
This will allow the students to observe and try out a variety of approaches to
a patient problem as well as decreasing student anxiety.
Later, when the
students have developed certain techniques and approaches to -patients, the
productivity of the group discussion and feedback is improved when each student
has a separate opportunity to interview and examine the SP while remaining
members watch behind a one-way glass.
The SP can be used specifically:
TO TEACH OR EVALUATE CLINICAI> REASON SKILLS
These skills would include clinical judgement, problem solving and
medical inquiry skills.
TO TEACH OR EVALUATE CLINICAL EXAMINATIOS SKILLS
All aspects of the students skills such as interviewing (history
taking), physical examination, interpersonal communication, problem
solving and management can be assessed or taught.
TO CHALLENGE THE STTOENTS KNOWLEDGE BASE
Is the student able to transfer the knowledge and skills he gains
from his studies into work with the patient.
70 OETSa STUDWrS DIFFERENT PATIENT TYPES
As an educator,
experience.
it
is
possible
to
plan
the
type
of
patient
6
HOW TO USE A STANDARDIZED PATIENT
The SP used and trained properly presents a high quality realistic
simulation which is a valuable learning resource for students.
When these four steps are followed, the SP encounter will better
meet your objectives and needs.
STEP 1, SELECTION OF PROBLEMS
The first step in using a SP is to identify the objectives of the encounter.
Is the problem being studied for clinical skills?
Interpersonal skills?
Diagnosis, differential diagnosis or problem formulation and treatment? Basic
mechanises? Concepts? Information from sciences areas related to the problem?
You may identify one, or a combination of several of the above objectives that
you wish to accomplish during the encounter. Once the objectives are identified,
problems may be selected from a list of available simulations obtained from the
Standardized Patient Program Office upon request.
This list provides brief
descriptors of all available simulations, and the key educational features of
each simulation. This allows the educator to select the exact problem relevant
to his/her educational goals.
an appropriate simulation is not found, please contact the Program Office.
THIS I,IS? IS h'OT AVAILABLE FOP. CIRCULATION TO STUDENTS
Please Note: The training of a SP is-based upon a real patient problem and is
a duplication of the picture that patient presented. Under NO circumstances is
the simulation to ho changed - only modification or "adjustment" of the affect
is permitted.
STEP 2. TEE TUTORS ROLE Ltj PREPARATION OF THE STUDENT(S) TO USE A
STANDARDIZED PATIENT
Ground rules for the educational use of the SP need to be identified to the
student(a). The student(s) need to be aware that:
a)
The SP is faithful to the picture of the real patient.
b)
There is no need for concern about making mistakes,’ or asking
questions or performing examinations that nay upset/ hurt the SP.
c)
Interaction can be interrupted for discussion by the group by calling
"time out" (see section on "time in and time out" for details)
d)
The group objectives when using this problem
o)
The time allotment for each interview and the time outs
f)
The format of the session (see section on "Format" for details)
g)
The setting in which they are confronting the SP (i.e. emergency
room clinic, etc.)
h)
The S? will expect his treatment while in simulation will be the
same as if ha were a real patient and will interact accordingly
1
PLEASE NOTE;To maintain the realism of the simulation, it is important the
students should not have contact with the SP prior to the encounter - the SP .
must not be seen "out of role".
STEP 3.
TEg TCTORS ROLE TH PREPARATION OF THE SP PRIOR TO THE SESSIOW
The SP will be able to meet identified goals of the session if 3-5 minutes are
taken to "brief” the SP prior to the session.
This briefing period should
cover:
a)
The goals or purpose of the simulation
Teaching?
Evaluation?
Physical examination?
To concentrate on interviewing?
Interpersonal skills? Etc.
b)
The perception of the students abilities, problem areas of the
student and the areas the students have had identified as needing
most study. How this simulation will help in these areas.
c)
The level of the student ( i.e.’ Year 1 and 2 medical students,
nursing students, occupational therapy students, physiotherapy
students, etc.)
d)
Format of the session {see "Formats")
e)
Review the high points of the simulation with the Standardized
Patient: the important information on history, physical examination,
psychosocial features.
f)
Review with the SP how this simulation has been used with other
groups for ideas on how to best meet your own goals.
g)
Time allotment for interview, time outs, and feedback.
h)
Review with the SP any problem areas they may have in the simulation
that must be reviewed or "finely tuned". This is an area the SP will
identify, for example it may be necessary to fine tune a physical
finding for the SP so that the finding is realistic.
STEP 4.
THE TUTORS ROLE IH DEBRIEFIRG THE STANDARDIZED PATIENT AFTER THE
SESSION
FEEDBACK:
PROS THE STANDARDIZED PATIENT TO THE STUDENT(S)
An important feature in using a SP is the opportunity it provides for objective
feedback from the patient’s point of view. Feedback is given at the end of the
session. Hie SP should be allowed to "recover" (3-5 minutes alone) and to become
himself. Each SP is extensively trained in the techniques of giving feedback.
Feedback is constructive, critical comment on "how he felt as the patient",
covering interpersonal communication and professional manner of the student.
There is some confusion regarding feedback: feedback is given from the patient's
point of view only. These are personal feelings and perceptions of the SP while
ia the role of the patient. The SP is not sophisticated in his medical illness
8
and is not prepared to provide feedback on specifics of the students' techniques
and diagnosis.
If verbal feedback is not required due to tine restraints or format of the
session, the SP is prepared to supply and complete a PATIENT FEEDBACK FORM for
review at a more convenient tine.
These feedback forms were developed to
categorize the SP’s responses to the students' professional manners, attitudes,
etc.
FEEDBACK: FROM TUTOR TO THE STANDARDIZED PATIENT
Once the feedback by the SP to tho student (s) is complete, it is helpful to
review privately with the SP the following:
a)
Problems found with the simulation
b)
How this simulation met defined education goals
c)
How the simulation could be better used with future groups
PLEAS?; HOTS:
This is extremely helpful to the SP. BUT this session is not
a substitution for completion of the REPORT OH USE Form
supplied by the SP. This form provides the SP Office a record
of how the SP is used and more importantly, helps to monitor
the quality of each individual simulation and simulated
patient.
"TIME IH AT7D TIES OUT"
"Time in and Tira out"
refers to the period which distinguishes active
interaction time with the SP from discussion time within the group. "Time out"
can be called by student examine?, tutor or group when issues, techniques,
direction, problem definitions, possible hypotheses, clinical intervention or
issues for later studies need to ba discussed or clarified.
During "time out", the SP will remain in role but in a "suspended" state, not
interacting with the student(s) until a member of the group calls a "time in".
The SP performance will not be altered or modified on the basis of"the time out
discussion.
9
There are several formats which have been found to be useful when using the SP.
Some suggestions fallow.
FORMAT 1.
The-? SP i's interviewed: in a: group - using " t ime . out's:": .but:
only one-student interactswith. the patient throughout the
session:.
. . STUDENT. A
.-.-. TIME OUT
: DISCUSSION:.:
STUDENT A:.. .
proceeds. with the interview,
.: incorporating: the: time, out discussion
FORMAT 2:
The S?. is interviewed 'in 'a'. group’ using time outs but
.continues:: with. dif ferent, interviewers : af ter the time out
■period.! ; :•:
.
•
'
■
. ' STUDENT' A
TIME OUT
- .-DISCUSSION
'STUDENT B:
proceeds with the interview,.
■ : incorporating. time out discussion
10
••••.•
•
:'
•: •-FORMAT 3:
When-.-initial approach, .ta the .patient , is an important
:gpa-l.;::: .the. ..group may--.wish to:. begin, the., simulation. over
.again: several'• times with different -interviewers:
STUDENT: A-: :
-..-
■
■
TIME OUT
DISCUSSION
STUDENT: B: begins- the simulation with
the:, presenting complaint
FORMAT 4 AND 5:
Self Assessment Units: These procedures allow the students to evaluate his own
skills, strengths or weaknesses dealing with a specific patient problem along
with the underlying knowledge he/sho nay have in that area.
.-/:<•■'
- ..-FORMAT .4^' '
^individual . student -/works with/ a. SP
while, .being./video-taped:
for
30 minutes
■JSvaljiutori completes//evaluation : form - behind
glass'
....
one-way
Student: writ es consultation re:.- findings, impressions,
/plan •:■:•:
:- ■: :- - - :■:•:• ■-/:•:•/ /:-: ■:
Student/: than, '/refers. / to ' consultations
professiorial.':whp. saw: the patient: .
Student completes .MCQ.
written
by
EORMAT :5:
Ihdiyiduai;:s't'udent: works; with SP f or: .30 .'minutes while :
.beihg;..video.--taped.
... :■ :
;
Studeut' writes consultation.
Student comp]ntee MCG
Student books time, ni.thtutor ar: group at: a later date
•Reyieri :tape : and--eyaliiation: •
■FORMA.'? .6:
;The: S.?;±s;:alsd-.a.yailabie; to; accompany P4 ^Portable. Patient.
Problem. Pucks).
In. this case.r the.SP: is interviewed,
using; the ; :
:. in;, 'and. .time. out technique.
Once-; the
skudeiifcls);: f eel: ;the? -interview- is:;complete-, work with :-the
Vi. :Deck.. begins.In ,working, with the ?:4, the student (s)
omits, .the. history .' ( white.) cards and physical . examination
.(.blue-)-:: cards
co.hcentrati-ng; on : the-.- treatment: (orange)cards:, : management:-, (pink): cards and- consultations (green)
cards . Once complete work- with :-the: "patient’’ ; /th-e;student.
cari. -fpllot.* ;the:: patient ’ s' progress, with the buff cards -
F0RM1T 7:
During evaluations, the SP is used because a S? problem may be presented in a
consistent manner. The students should not take time in and time out during an
evaluation session. The evaluator views the interaction through a one-way glass
(direct observation) and completes an evaluation form. The session may be video
taped, but this is optional, and reviewed at a later date.
.FORMAT-. 7 :
SP .^a's. if : .a: > clinical session, and
Student :-A;: interviews
interview.
.
;
Student: k TOitestcpiisuitatiah re:
plan while!'.
:
findings, impressions,
.Student B -: interview . Si-': as if a clinical session, and
interview,:'/starting: from? presenting: complaint
Once complete, the ovaluator reviews student
evaluation form and areas that need work.
progress
and
discusses
the
FORMAT 8:
13
A second method for evaluation, the SP is used in conjunction with lab data.
In this format the individual student spends time with a SP taking a history,
and examining if appropriate.
He then leaves the SP and joins two observers
(usually a tutor and a supervisor).
They discuss the students findings, the
student is questioned on his approach and thoughts and asked what his next step
would be.
He is then given a result of appropriate investigations which he
identified would be ordered. He is then sent back to the SP where he completes
the interview, incorporating the information from the lab data and his
interpretations, management, etc.
The session is video-taped and may be used for various purposes including
allowing a tutorial group to see different approaches of the same problem using
the tape for instant recall to ascertain the thought process of the student or
concentrating on the examination or history taking approach of the student(s).
The video-tape may be kept as a record of what the student has done, and compared
to later tapes to monitor his progress.
FORMAS 8:
Student A'/interviswa:’SP:' as'.'if:' a .clinical:session. and.
interview-
Student' leaves 'the S? to join observers and evaluators
Student/ is 'questioned:’ to thought process >
next step
etc.
Student is. given: laboratory information •
Student: rejoins : SP to complete :: interview
irit'orndtion? obtained- from observers ?'.
(Student .wraps, up- interview
using
14
WRITTEN MATTOTaLS WHICH ACCOMPANY THS STANDARDIZED PATIENT
1.
FACULTY CHECK LIST: A list was developed to assist in the preparation of
the SP for caah session.
The SP has been trained to provide a highly
realistic simulation of the actual patient. To maintain the quality of
their performance and to help them understand your needs and expectations,
it is essential that the items on this list are discussed with the SP.
2.
QUALITY REPORT ON STANDARDIZED PATIENT FORMS: As a formal evaluation on
the SP and their presentation of the problem, a control form was developed,
a "FACULTY REPORT Oil TEE BSE OF THE STANDARDIZED PATIENT" form (see
example).
This form ensures the maintenance of good, high quality
simulations and determines the uses of the simulations. The SP will supply
this form to the student and faculty after each session for criticisms,
comments, suggestions etc.
3.
ETIQUETTE FOR THE STANDARDIZED PATIENT: There are certain requirements
that must be observed by the SP to ensure quality and realism in the
simulation. These requirements are outlined for the SP - ETIQUETTE FOR
THE STANDARDIZED PATIENT and is included here for your reference only.
4.
FESDDACZ FORMS:
These forms were developed to categorize the SP's
responses to the students' professional manners, attitudes, interpersonal
rapport, and the comfort during the physical examination.
The SP will
supply these upon request.
5.
A STANDARDIZED PATIENT FEE AND EXPENSE REPORT accompanies each patient.
Uhen the session is completed, the SP will ask the tutor to verify the
hours worked by signing the Fee and Expense report (see example).
15
FACULTY CHECK LIST ON THE USE OF THE SIMULATED PATIENT
The Simulated Patient will have greater flexibility and will be able to help meet
your educational goals if you carry out.the following activities.
A
BRIEFING OF THE SIMULATED PATIENT PRIOR TO THE TEACHING EPISODE
I.
The goals or purposes of the simulation:
Evaluation?
Teaching?
for example:
interviewing skills, physical
exam, interpersonal skills, and
clinical reasoning skills.
2.
Your perception of the students abilities.
3.
Problem areas the students have had and how this simulation will help in
these areas.
4.
Format of the session,
for example:
- each student will individually interview the Simulated Patient
- the group as a whole will interview the simulated patient
- individual students will interview the patient - each starting from
the beginning
- use of "time in" and "time out"
5.
Review the simulation with the Simulated Patient - history, physical findings
psychosocial problems, emotional picture etc.
Each Simulated Patient will
present a card which identifies their situation which will assist you in
introducing the Simulated Patient.
6.
Review with the Simulated Patient how this simulation has been used with
other groups for ideas on how to best meet your own goals.
B•
FEEDBACK TO STUDENTS AFTER THE SIMULATION IS COMPLETED
1.
Allow the Simulated Patient to "recover" and to become himself before the
feedback session.
2.
Feedback from the Simulated Patient should cover:
- interpersonal qualities
- professional manner of the student
Any other feedback should be intercepted as inappropriate.
(Note:
we have had some confusion regarding feedback:
feedback should be given
from the point of view of the patient that is being simulated)
C•
DEBRIEFING OF THE SIMULATED PATIENT AFTER THE TEACHING EPISODE
1.
Review with the Simulated Patient any problems you found with the simulation
2.
Review with the Simulated Patient how this simulation met your educational goals.
3.
Review with the Simulated Patient how this simulation could be better used with
future groups.
16
QUALITY REPORT ON STANDARDIZED PATIENTS
STANDARDIZED PATIENT NAME
SI MULAT I ON
USER'S NAME
PROGRAMME
_
__________.DATE---- --------------------
__ _____----- -------------- ------ ---------------- -------------------
__
Supervisor ( 1
Student [ ]
... ______-—- --------------------- -EXT •
RATING SCALE:
1 » Needs to be retained
2
- Needs to be reviewed
3
=* Pew ninor changes necessary
4
n Good
5
= Excellent
PLEASE RATE THE QUALITY
THE ABOVE SCALE:
b-
OF THIS STANDARDIZED PATIENT USING
Realism of the Standardized Patient
low
1
Clinical signs shown by Standardized Patient
12345
Feedback given by Standardized Patient
1
2
2
3
3
4
hlgji
?
4
(If you gave this standardized patient a (3) or below in Question
1 please Identify the specific "problem areas" that should be
reviewed with
the
Standardized
Patient
for
realism or
consistency):
COMMENTS:,
2.
Was the Standardized Patient suitable
for your particular goals?
yes
no
The Standardized Patient feedback covered:
a.
Interpersonal qualities
__
c. Clinical Skills_
b. Professional manner
__
d. Diagnosis or
management
COMMENTS :
____________________
_________
3.
4.
5.
If I had this simulation again, I would like the following
available:
a. Labdata/database
____b. Other:
Did this Standardized Patient arrive ON TIME?
DATE:
yes
no_
SI GNATURE
PLEASE RETURN COMPLETED POEMS TO: Millie Perritt, HSC 3N51g
Thank you in advance for completing. Your input is important for
maintaining quality and develonment of the nrograisEis.
-Revised 2/88
5
fefflj faSEofUhemthLciences
STANDARDIZED PAT8ENT PROGRAM
FEE AND EXPENSE REPORT
HAMILTON. ONTARIO
PLEASE PRINT
REPORTS MUST BE SUBMITTED WITHIN 14 DAYS OF ACTIVITY to Millie Perritl - 3N51G
Yas i I
NAME:___________
______________
CHANGES ONLY ON DATA RECORDS:
Telephone:
_______________ LEVEL:_____________
Prevtously patd by Program?
D.O.B
(j
C™: !o b3 pjcbcri up al
Street Address:
Province:
•TRAIN. SIMULATE. T A
SIGNATURE OF SIMULATED PATIENT:
Nq
to be mailed
DATE SUBMITTED:
Postal Code:
LJ
18
IBFORTAHT INFORMATION
This Catalogue provides a description of each simulation available alphabetically
and categorically. A copy has been made available in the Health Sciences Library
and in the general office of your descipline. Each simulation is numbered for
quick reference..
When booking a Standardized Patient, please refer to these
numbers.
BOOim.'G
To book Standardized Patients, please contact Millie Perritt, Standardized
Patient Program Office, Health Sciences Centre, 3N51G, or call 525-9140, Ext.
2388, between 8:00 a.m. and 4:00 p.ra. from Monday to Friday. A minimum of 3
days notice is required when booking individual simulations.
Clock bookings
can be organized through the Program Office (SEE EXAMPLE).
CANCELLATION
24 hours noticed is required re cancellations.
FEES
Usage
is
regulated
by
your
program
administrator
and
billed
accordingly.
Approval must be obtained prior to booking simulations (external users need to
discuss additional costs for travel, accommodation and training).
INSTRUCTIONAL MATERIALS
These simulations offer challenges that were created by the trainers of each
simulation and are offered as guidelines only. Additional information can be
obtained from the Program Office on the different styles of teaching with
simulations.
TORISHOPS
Instructional workshops will be held each year for all health professionals
interested in learning more about the use of simulation in teaching.
ADMINISTRATION
Director:
Halyna Pierco-Fenn
Program Administrator: Millie Perritt
Training Consultant: Gayle Gliva-HcConvey
HOW TO CONTACT US
Standardized Patient Program
McMaster University
Health Sciences Centre
3N51g
1200 Main St. Heat
Hawaii ton, Ontario
L8N 3Z5
Telephone:
(416) 525-9140, Ex. 2388
(416) 52S-914O Ext. 2388
Director: Pierce-Fenn 575-2507
Bookings: Ms. Millie Perritt
father Billing Ir .
NAME:_____________
< J on (Organizat '.on/ ? :io t J. tut iori/riospi t
, etc . I: .......... ..
-
”
'
’
I
ADDRESS:_________________________________________________ •____________________________ ________________
J
ICITY:__________ __________________________________________ POSTAL CODE______________ _________ TELE._____________________________ !
(CONTACT PERSON ________________ ___________________
TELE
.
I
......
MCMASTER (HSC)
USER
Please use one requisition per user} .
DATE
REQUIRED
CATALOGUE NAME
TELE.
TIME
FROM
TO
LOCATION
PROGRAMME
/DEPT.
(office use only)
SIMULATOR TIME
VERIFIED
Return completed forms to: Millie Perritt, Standardized Patient Programme, (HSC-USsisg)
McMaster University, Faculty of Health Sciences, 1200 Main St. West, Hamilton, Ontario,
Booking forms will be mailed on request.
L8N 3Z5
ACCOMPANYING MATERIALS:
VIDEOTAPE:
If there is a need to see a tutorial group interviewing a SP with a tutor, there
is a cassette tape available in the McMaster Health Sciences Library AV area:
"A TUTORIAL SESSION UITH A SIMULATED PATIENT"
PUBLICATIONS:
A list of publications concerning the Simulated (Standardized)
available through the Standardized Patient Programme Office.
SUGGESTED READING:
Problem-Based Learning: An Approach to Medical Education
Barrows, H.S. and Tanblyn, R.M.
Springer Series on Medical Education Volume 1
Spring Publishing Company
New York, Mew York
Patient
is
np'-
MEHTA
ORATION
1991
THEME
REBUILDING THE FOUNDATIONS
RE-EXAMINING PRE-CLINICAL MEDICAL EDUCATION
RAVI
NARAYAN
COORDINATOR
COMMUNITY HEALTH CELL
IIETY FOR COMMUNITY HEALTH AWARENESS, RESEARCH AND ACTION
BANGALORE - 560 034
INTRODUCTION
I feel greatly honoured by the Alumni Association for having
invited me to deliver the Late Dr. H.J. Mehta Oration for 1991.
At a personal level this honour is particularly meaningful to
me since I knew Dr. Mehta very well,
having been associated
with him not only as his pre-clinical student but also in many
capacities and college activities as General Secretary of the
students association and a student representative on the medical
education committee of the College.
He was an inspiring,
deeply committed and value oriented
professor greatly involved in medical education.
He was a key
member of the pioneering team that laid the foundation for
high quality pre-clinical education at St. John's and as a
tribute to this contribution,
I decided to explore the changing
role and scope of pre-clinical undergraduate medical education
as the theme of my oration.
I am sure that had he been granted more years,
he would have
been keenly involved in the radical reorientation of medical
education that is emerging as the urgent goal of the 1990's.
ACKNOWLEDGEMENTS
I would like to acknowledge the peer group support
-■ of Dr. C.M.Francis, Thelma Narayan and Shirdi
Prasad Tekur of CHC in the development of this
oration,
- of Magiroal Pragasam, Shirdi Prasad Tekur and
Krishna Chakravarthy in the visual animation of
the oration,
- and of M. Kumar and V.N. Nagaraja Rao
in the typing of multiple drafts as well as
this final manuscript.
BACKGROUND TO ORATION
h^y own personal involvement in this growing concern and dialectics
about medical education in India began two decades ago as a young
intern during a three month experience in a Bangladeshi refugee
camp.
As a graduate from one of India's top 10 medical schools,
I was shocked to find how unprepared I was to meet the professional
and emotional challenges of the practice of medicine in conditions
of poverty.
My gut-level critique of medical education at the
first student seminar of the Indian Association for Advancement of
Medical Education in 1972 has found a place in Parks Textbook of
Preventive and Social Medicine ever since. (8)
After my postgraauation at London School of Hygiene and Tropical Medicine and
AIIMS (New Delhi) at both of which medical education was the
subjects of my dissertations, (9)
I participated for a decade
in the social and community orientation of medical education at •
this institution being involved with a series of innovations
including the Mallur Health Cooperative, the rural orientation
programmes, the epidemiological field projects and the village
based and plantation internships. (11)
Finding that all our
efforts in exploring the new 'community oriented social biology1
had little impact on the career choices of our graduates primarily
because of the 'medical model1 orientation of the rest of the
departments I moved beyond the college to provide technical support
to grassroots community health work, $s a member of the medico
friend circle - a national network of community physicians and
health activists we put together a critique of the existing system
and e.-olved the framework of an alternative curriculum (12) which
has just been published.
This found echo and some resonance, in the
recent efforts of many medical colleges and it brought me back full
circle to spend the last 18 months working on a training manual
for innovations in the 1990's.
This oration draws inspiration
from the process of this study and is the first of a series of
_formal presentations of the project results. (13).*123458910
11
FRAME WORK
I
I
1.
PREAMBLE
2.
PRE—CLINICAL MEDICAL EDUCATION s AN EVOLUTIONARY HISTORY
3.
PRE-CLINICAL PHASE s A NATIONAL ORIENTATION
4.
PRE-CLINICAL PHASE ; WHAT'S WRONG
5.
6.
FEEDBACK FROM GRADUATES IN PRIMARY HEALTH CARE
BEYOND ORTHODOXY s NEW APPROACHES
7.
FROM 'HOSPITAL' TO COMMUNITY FOUNDATION
8.
INNOVATIVE TRACKS AND EMERGING ALTERNATIVES
9.
RECOGNISING THE PARADIGM SHIFT s TOWARDS THE NEW BIOLOGY
10.
IN CONCLUSION
11.
REFERENCES
IT
PREAMBLE
Training of the right type of Doctor for' India has been a subject
of concern and committed reflection since the Bhore Committee
blue-print of 1946, which identified'the aim of medical education
as the production of 'the Social Physician1 - who would be 'a
scientist and social worker ... a friend and leader of the people'. (1,3)
This goal was re-emphasised by the Mudaliar Committee of 1961, which
laid the foundations for the current M.B.B.S. Course, geared to
produce the 'socially oriented general practitioner as well as the
specialist, teacher and researcher'.(1,3)
The Patel Committee of 1971 defined the 'Basic Doctor' with clarity
and realism (4) and the Shrivastava Report of 1975 spelt out the
vision of the 'community and family oriented' general practitioner
with social responsibility. (5)
The ICSSR/ICMR study group on Health"for All - an alternative
strategy (1981) outlined the alternative community based health
care strategy that required the leadership of community oriented
physicians. (6)
And more recently the draft National Education Policy for Health
Sciences (Bajaj Report, 1989) currently being circulated has
summed it all up by reiterating the goal of producing 'Community
Physicians1 - 'who are basic doctors, astute clinicians, good
communicators and educators and sound administrators ... effectively
leading an ever expanding health team for positive health action'. (41;
While the goals have been very clear,
been clearly understood as yet.
‘how to reach there?' has not
The Shrivastava Report (1975) which made a situation analysis soon
after India celebrated the Silver Jubilee of independence and
national planning identified atleast five reasons why the process
of medical education introduced by us had failed to meet the
expectations.
These included
-
An inherited system of medical education
Exclusive orientation towards the teaching hospital
Training irrelevant to community needs
Increasing trend towards specialization/postgraduation
Lack of incentive/recognition for rural work
Attraction of export market for medical manpower"
(5)
Twelve years later the WHO-SEARO Report on Reorientation of Medical
Education (
) reviewed the situation in South East Asia including
India in 1988 and was more explicit on the dilemmas of the region.
In a rather candid analysis it identified a host of reasons for the
growing gap between goals and realities.
These included
-
Transplanted European-American models with colonial
inappropriateness in their clinical, scientific, and
administrative systems.
Aspiration to 'international' i.e., often irrelevant
standards.
Medical students selected from upper middle class with
career aspirations towards urban practice.
Training in high technology curative, biomedicine.
Exposure to science and values of the old biology."
.. 2
2.
In the overall analysis there has been a growing dichotomy between
urgent social goals and the actual realities of medical education
development.
2.
PRE—CLINICAL MEDICAL EDUCATION :
AN EVOLUTIONARY HISTORY
The history of medical education in the world goes back several
centuries BC with the well documented records of the growth of
Ayurveda in the vedic period and the development of systems of .
training doctors.
Atleast three forms were described : apprenticeship
to renowned physicians; gurukulas or forest ashrams under expert
preceptors; institutes- of higher learning such as Taxila, Nalanda
ancT'Kasb-i .
Authoritative textbooks were studied including the
Charaka and Sushruta Samhitas, and the training was basically
integrated bedside teaching supplemented by' lectures and practicals
Selection of
SZJDE which included human body and animail dissections.
teachers and students stressed both cognitive and affeotive domains.
However no compartmentalization into pre-clinical and clinical
phases was recorded.(14)
With the advent of the Buddha (500-600 AD)
a systems of hospitals developed but human body dissection and
surgery received a setback.With the Moghul invasion in 12th century
AD the Graeco-Arabic systein was introduced which cross fertilised
Ayurveda"and developed as the Unani tradition.
For the first time
private practitioner linked schools and schools attached to big city
hospitals developed where medical students were trained under famous
scientists and physicians.
The Daru Shifa of Hyderabad and the
textbooks of Hakim Ali Gilani and others are famous.
While human
body dissection were, taboo in Islam causing a setback in surgery
development, medical ethics teaching gained much importance.
Bedside teaching and discourses gave students anatomical knowledge
covered by limited observations and speculations of eminent
teachers.(15)
&
&
0
In Europe the renaissance in 1500-1700 began a new era marked by
'the liberation of intellect frofti the shackles of traditional
dogma and established authority1 (22).
The famous book Fabrica
Humanis Corporis of Andreas Vesalius - Professor of Anatomy—and
Surgery at Padua University and""Leonardo da Vinci's dissections
and descriptions were symbolic of this- period.
Anatomy and
Physiology developed rapidly and the emphasis on pre-clinical
SLIDE foundation began. The 'public anatomies! of the company of
Barber Surgeons and the evolving courses at Oxford, Cambridge and
many leading German Universities further emphasised the need for
'basic knowledge' for medical training (16). while the British
hospitals stressed clinical bedside teaching
' the German
Universities stressed 'scientific medical teaching' through
scientific departments.
The Flexner report (17) laid the foundations for the development of professional units, compartmentalization of
systems and divisions ot phases of teaching in medical, jschooljs.
in'
U.K., the Goodenough committee, 1944 further established this
tradition as well as outlined the process of state and university
support’and coordination of medical education. (16, 18)
?
By the early twentieth century this standard and orthodox model
of medical education was established all over the world.
It included:
Su OP
-
Subject based block teaching
Basic Sciences preceding clinical, studies
Little vertical/horizontal integration
Lectures.as the preferred way of teaching
Severehospital and clinical orientation
.. 3
- Dasic sciences primarily theory and laboratory oriented.
(16,
18)
In Indi? the European tradition of medicine and medical education
was introduced in 1703 by the Portuguese in Goa Royal Hospital
which had a 3 year course in Medicine and' Surgery under Miranda
and. Alm.feiThe British, brought in western medicine through
'the East India Company and trained local ‘dressers1 and
‘compounders1 to help the' expatriate British army doctors of the
IMS.
In 1822 the first 'Native medical institution' was setup
in Calcutta and European medical textbooks were translated into
-vernacular by government order .,
Initially in a spirit of dialogue
textbooks included Charaka, Susruta, Avicenna and'European texts.
However William Bentinck's Committed on Medical Education- 1833
laid the foundation for the now well-established,. 1 colonial
transplant1 by recommending only 'English medium training of .the
European tradition'.
While paying tribute' to Dr. Goodeves the first principal and
Professor cf Anatomy; Vaidya Madhu Sudan Gupta the first vaidya
teaching who broke Brahmanic reservations and undertook and taught
Anatomy dissection and the first four medicos of India Uma Chandra
Seth. Dva:cka_ Nath Gupta, Rai'Kristo Dey and Nobin Chunder Mitter,
who established this tradition-,- -it- is important to note that most
of - the development’s' there after--were-preconditioned by.developments
in Britain so that by the time of independence the_Indian" Medical
Education and 'Pro-C]inical1 Education as well was” a’ 'faithful'
fol lower- of the UK traditions though about a decade behind- ‘ it. •( 9, 18)
PRE-CLTNICAL', PHASE
;
A NATIONAL ORIENTATION
While it is true that the Indian medical education system in the
twentieth century is substantially modelled on British/American
lines.it would be unfair to our national planners and experts
in medical education, if vie do not acknowledge that from the Bhore
•Committee report of 1946,' when the" Concept-of the Social Physician'
was developed, attempts have been niade to modify the -system of
education to suit our own national needs -and aspirations even if
these modifications in hind sight; are now assessed as being very
’superficial or inadequate to reorient medical education to greater
social/community relevance, which is now the urgently accepted need
in the 1990's.
An overview of the recommendations Bhore report (1946)
andithe. Mudaliar report (1961) leed to the development of the current
model of Pre-Clinical teaching in India which may be outlined as
follows s
'
PRE-CLINICAL - NATIONAL ORIENTATION - I
BASIC
SUBJECTS
DURATION
:
18 Months
SUBJECTS
s
Anatomy including Histology and Embryology
Physiology including Biochemistry and
Biophysics.
GENEPAL
PRINCIPLES.
;f* Minutiae/Details reduced
Didactic lectures curtailed
Practical/Clinical applications
Demonstrations/Practicals increased
Staff Student Ratio
1 : 15
BHORE/MUDALIAR REPORTS, 1946 - 1961
(source :
1,2,3)
4.
It -is significant that both these reports while setting the social
goal for medical education also brought in the additional found2t2.cn
element which distinguishes Indian medical'education from most of
its European counterparts
i.e., the development of the Preventive
and Social Medicine / Community Medicine department and the
pre-clinical phase of its teaching through this department.
It is
important to emphasise that an early attempt was made from the very
beginning to ensure that this additional foundation or orientation
element was both 'clinical and community in it;.- scope and orientation.
PRE-CLINICAL - NATIONAL ORIENTATION - II
PRE-CLINICAL PHASE OF PSM
COURSES
I
Psychology
Statistics
Elementary Pha rm ac ology/P ath/Micr0
PSM TEACHING
;
History of Medicine
Human Ecology
Genetics
Nutrition
Demography
Growth & Development
CLINICAL
.ORIENTATION
;
History Taking
Signs
First Aid
Ambulance Work
Lectures /Tutorials/Demonstrations/Visits/Survey
Bhore/Mudaliar Reports
1946 - 1961
(Source :
1,2,3)
While judging by standards of medical education anywhere in the
world, this element of both vertical and horizontal integration
and the early introduction of the young medico to clinical and
community realities was a very progressive, even radical step,
it must be conceded that this additional orientation phase was
more or less completely ignored and the pre-clinical phase obsession
with the basic sciences of Anatomy, Physiology and Biochemistry
due to -the exploding knowledge in these areas, became firmly
established, thus, increasing not only the work load of the young
medicos but effectively cutting them off from the social / cultural/
technical realities of clinical / community medicine practice in
the years ahead.
In probably 110 out of the 125 medical colleges
or 160/175 (recent estimates) this obsessive compulsive neurosis
'with cadaver dissection, frog experiments and laboratory experiments'
is well established.
As an expression of this 'obsession' it has been computed recently
that Anatomy, occupies 52% of I-'M.B.B.S. Course, and 16 out of cvov100. hours of M.B.B.S. Course.
In other words we spend 10 - 12% cf
medical life in a dissection hall. (20)
The Medical Council of India curriculum recommendations of 1981,
currently in force further builds on the Bhore/Mudaliar recomme
ndations but considering that the 1946/1961 recommendations are
still to be implemented the fact that the 1981 is far ahead of
its time and has been shown little consideration need not come
-.5...
as a surprise to us.
The goals and general principles outlined were as follows :
MCI RECOMMENDATIONS - 1981
;
GOAL :
PHYSICIAN OF FIRST CONTACT
'
PRINCIPLES
INTEGRATED-INTER DEPARTMENTAL TEACHING
EMPHASISE'FUNDAMENTALS/AVOID DETAILS
REDUCE DIDACTICS/lNCREASE GROUP LEARNING
LOGIC/INDEPENDENT JUDGEMENT/SELF EDUCATION
COMMUNITY BASE MORE THAN- HOSPITAL BASE
(Source :
10)
The recommendations on pre-clinical phase were equally interesting.
Based on concerns about the Jstressful nature' .and growing -irrelevant
of expanding pre-clinical aontent and its obsession with detail, the
MCI made a series of recommendations (10) and provided 'caution'
some of it having been offered' since the Bhore report (1946) itself.
MCI RECOMMENDATIONS - 1981
Pae-Clinical Phase
Basic Sciences
;
15.months
FUNDAMENTALS/BASIC PRINCIPLES
applied/clinical aspects
COLLABORATION WITH OTHER DEPARTMENTS
ANATOMY
-
LIVING/APPLIED
PHYSIOLOGY
-
HUMAN/CLINICAL
BIOCHEMISTRY
-
HUMAN/APPLIED
(Source ;
10)
Echoing Bhore/Mudaliar recommendations, the MCI also suggested an
increasing content of health and community orientation by introducing
a more comprehensive pre-clinical phase of community medicine (SPM
or PSM) which is summarised-in Table
MCI RECOMMENDATIONS - 1981'(ill)
- Pre-Clinical PSM
(Community Orientation)
DURATION
COURSES
;
3 months
t History of Medicine ' Health/Health Care
Behavioural Science
Ecology/Uibanization
Population/Demography Community behaviour
Health Economics
Nutritional Dietetics
PRACTICAL;Hospital and Clinical Orientation - Foundation
skills, Field visits-and Community Orientation
(source :
10)
While in terms of content/focus this was a significant step, in
actual practice there was little involvement of other departments
both pre-clinical and clinical, in this foundation phase of SPM/
Community Medicine.
This lead to the building up of a parallel
track under the department of PSM so that students experienced
community medicine as. in opposition to and alienated from mainstream
pre-clinical and clinical” subjects..,..
The addition of pre-clinical-PSM was not seen as a broadening of the
'foundation1 but as an additional burden, at best an unavoidable
phenomenon,
Pre-Clinical faculty perceivedsit mainly as a cause for
an unwelcome reduction in time earlier allotted to them.
The
consequences of this attitude inevitably prevented the much need
collaborative and creative integration and involvement.
In most
colleges the 3 months of additional foundation was too spread out an hour a week or sometimes even an afternoon a week making little
impact on the; students or the pre-clinical faculty.
4.
PRE-CLINICAL PHASE ?
WHAT'S WRONG
In the last two decades both in India and .abroad there has been a
growing concern and dissatisfaction with medical education in all
■.
its dimensions - in the context of its overall focus, development,
relevance and its social orientation., The pre-clinical phase has
quite understandably also come under vigorous scrutiny and multiple"tecckcproblems have been recognised.
In general terms these 'include :
Ox_c../r'
i)
ii)
iii)
Medical education is seen as being-too long and with the
explosion of knowledge too much in detail causing a
phenomenal stress on the average medico.
There is too much teaching and most of it teacher oriented
and teacher-determined and little time for critical, reflective
and. interactive learning which is student centred or student
determined.
With the rapid growth, reassessment and review of basic and
■ applied knowledge much of what is taught from textbooks 'has '
already reached the verge of obsolescence.
So quantity must
give place to quality and that too selectively.
tv/jan.'
(
).
1.
ivj There is growing evidehce that there is a sudden drop in
social/motivational indicators in students in the pre-clinical
phases due to; laqk of human/patient c.QDfcact and the overall
stress on irrelevant minutiae apart from a certain degree of
dehumanization as well.
v) Due to established tradition and growing inflexibility caused
by compartmentalization and vested intere-■Es~ in the context
of time allotted, and areas allotted, inclusion of any form
of vertical or horizontal integration or any forms of 1 experi
ential1 learning or_any new additional,topics.for study have
all been resisted ... or e-f f e'c-tively marginalised.'
vi) Educational theory__ahd pedagogical reform have finally managed
entry into the professional bastions of education and have led
to critical introspection o’f the ongoing rather unimaginative
and top-down methodologies.
All this has been ^further compounded by the development of the new
biology and the deeper understanding of health and health care
systems - though about that later in this oration.
5,
FEEDBACK.-FROM GRADUATES IN PRIMARY HEALTH CARE
As part of a study this year, we reached a sample of young doctors
who had graduated in the 1980's and asked them to reflect on their
medical, education in the-context •of' the more than 'two years of
professional experience in a small..peripheral hospital or rural
health centre.
While we have received serious reflections on more
than 35 topics/subjects and aspects of medical education, (21) I
would like to present a short overview of what they felt about the
pre-clinical subjects.. What emerged was a creative summary of what .
policy makers, medical education and socially sensitive pre-clinical
faculty have been saying more recently in professional conferences,
expert committees, ’.IAAME conferences and other fora.
The interesting
fact was that none of the respondents had touch with 'medical education'
expert documents or journals but their 'common sense' review and
reflection was most., revealing.
The main feedback for Anatomy,
Physiology and' Biochemistry was as follows ;
CHC - GRADUATE SURVEY - 1991
I
ANATOMY REORIENTATION
STRESS CLINICAL/APPLIED ASPECTS.
;
INVOLVE/INTEGRATE WITH CLINICALS
LIVE/SURFACE ANATOMY
.
TEACHING AIDS - SURGERY/VIDEOS
'BAN GRAY'S ANATOMY1
STRESS HAND/FOOT ANATOMY/NEUROLQGY/ANGIOLOGY
(Source s
21)
3.
CHC - GRADUATE SURVEY - 1991
II
PHYSIOLOGY REORIENTATION
REDUCE ELABORATION/DETAILS
MORE CLINICAL/HUMAN ORIENTATION
LESS THEORY MORE PRACTICAL-CLINICAL
'DISPENSE WITH FROGS'
CONTRAST .HEALTHY VS DISEASE PHYSIOLOGY
FOLLOW UP IN CLINICAL PHASE
(Source 5
CHC - GRADUATE SURVEY -.1991
21)
III
BIOCHEMISTRY REORIENTATION
EMPHASISE CLINICAL BIOCHEMISTRY
EMPHASISE CLINICAI* APPLICATIONS
ENSURE LAB-SKILL DEVELOPMENT
DROP COMPLICATED FORMULA/CYCLES
& STRUCTURE/UNNECESSARY DETAILS
(Source ;
21)
The overall consensus was that one year or two semesters was more
than enough to cover a shortened curriculum that was oriented to
applied aspects,in•clinical/community work.. With greater involvement
of clinical teachers and some- reinforcement of principles and
relevant details during clinical phase - the pre-clinical would
not only be more meaningful but also gain in importance and
relevance from the student point of view and npt be such an
unmitigated cause for stress and tension as it had, become today.
It may be worthwhile recalling today that more than 45 years ago,
the Goodenough Cbmmittee in UK had exhorted pre-clinical faculty
,to do what our recent graduates are saying.
GOGDENOUGH COMMITTEE - UK
&
©
(1944)
Appeal to Pre-clinical faculty
"Urgent need ....
.....
for drastic elimination from curriculum.
from examination .... mass of detailed information
.... which serves only to clutter up the students mind
and deadens his interests in the subject that can make
the liveliest appeal to him".
-------7-65)
in
9.
6.
BEYOND ORTHODOXY :
NEW APPROACHES
The survey of feedback from young graduates has highlighted some
of the key directions that reforms in pre-clinical medical education
should take if it has to gain in social/clinical/community relevance.
Our survey of literature of the last four decades has shown that,
though there has been a growing 'vested interest' against reform
and a deep seated inertia in general some innovative ideas, amidst'
all the 'rhetoric' have evolved in some colleges and some 'newer
approaches' going beyond the prevalent 'orthodoxy' have been voiced
and are beginning to take shape. (25-37)
To emphasise the key
concepts I have classified them into the following ten processes
which are not mutually exclusive.
A. Humanization
Increasing focus on human observation, measurement and .
experimentation on healthy subjects (including the medical
students themselves), patients in hospital wards and outpatients
and community volunteers is recommended.
Surface Anatomy and
radiological demonstrations need to replace cadaver dissection.
Experiences of Human- biology teaching in schools of Madhya Pradesh
(the Kishore Bharati and Ekalavya experience) is of special
significance to this process.
B. Integration
This is the need of the hour and could take many forms,
which would help student learning.
all of
i) The three disciplines of Anatomy, Physiology, Biochemistry
should move increasingly towards an integrated course in
Human Biology where 'structure and function, growth and
behaviour' are all presented as an integrated whole.,(28)
ii) Increasing integration (perhaps greater coordination begin
with) with para-clinical and clinical subject teaching to
emphasise, corelat.ion and interrelationships.(27)
. C. Clinical Orientation
There is need to locate pre-clinical teaching in the clinical
context so that e.g., Me Gregor takes over from Gray's and
Simson Wright from Best and Taylor.
This will and has shown
to, (wherever it has- been given a serious trial) to enhance
the interest of the student in the 'theory' and its application.
'
■
NrJiD. Functional Approach
•
--------------------------------- ------------------
'
The function of parts of the body, organs systems and even
cellular systems should be the overriding message, so that
structural details do not get over emphasised.While the
earlier emphasis was on disease in a clinical setting, the
'functional approach' encompasses the range of 'healthy function'
and could integrate clinical and community settings looking at
both.health and disease situations and functioning of the human
being in all these siutations.
x
/,
\ J7
E. Primary Health Care Orientation
"
Contents of the curriculum need to be reprioritised by national
10
needs, local mortality and morbidity patterns and national health
programme priorities.(29)
At JTPMER., the Anatomy curriculum has been restructured to empha
sise maternal and child health, family planning, leprosy and TB,
blindness and deafness.(25)
Physiology too could emphasise MCH, nutrition, immunology,
infectious diseases and reproductive physio; ogy.(26)
Living Human Biology
The contextualization of orthodox pre-clinical teaching in the
context of 'human beings living in Society1 is an increasing
need so that from cadaveric orientation we move to an active
interaction with societal realities.
This means e.g., Not only
,would 'anthropometry' become more relevant but its application
in clinical and community situations, in schools and balwradis
vand its use to measure healthy growth and underdevelopment would
all become integral part of the learning experience.1 Pre-Clinical
faculty would need to increasingly move into the hospital and
community situation to identify and prepare such learning
experiences.
New Pedagogy
The efforts of the National Teacher Training Centres at JIPMER
and PGI have been laudable in orienting medical college faculty
to the newer pedagogical concepts of group dynamics, teaching learning concepts, method and media, curriculum development,
institutional and instructional objectives, self-learning
innovations and so on. (30)
The NTTC's and more recently the
CMET of AIIMS have also trained faculty in newer assessment/
evaluation techniques like SAQ{ MCQs, OSPE, OSCE and attitudinal
assessments and so on(31)While pre-clinical faculty have activelyparticipated in these efforts it is not yet possible to review
how effectively these new ideas have been operationalised.
However much more efforts are required so that large-scale
orientation can take place.
Health Clinics
A suggestion to start health clinics to promote positive health
concepts and non-drug oriented approaches in health including
Ayurvedic concepts, Pancha Karma and Yoga have been suggested.(36)
The clinics could focus on health monitoring of children,
.antenatal women and aged as well as provide nutritional advise,
and foster anti-addiction programmes.
Pre-clinical teachers
wculd then be seen as, active participants.in Health Care-and not
be marginalised as ‘theoretical, lab oriented' people as at present.
Community Biology
Many colleges are experimenting with community live-in programmes
that give medicos in the pre-clinical phase a real-life experience .'.
of the socio-cultural-economic-politics of life in rural India
and an opportunity to interact with community realities and develop
skills of relevance to community work.
'Social Anatomy and Social
Physiology1 are.observed and experienced and a deeper understanding
of 'community biology- is achieved.. The COP's of CMC-V and the
ROP of SJMC are examples of these programmes.(_3y.|p
'
..11
J. Health Education
w
>
A national workshop organised by CHEB on integration of Health
Education in the medical curriculum has recommended that
pre-clinical faculty join efforts to.make medical students
adept in explaining 'in the language used by patients, 6th
grade school children and Or first aid volunteers', the structure/
function and important concepts and principles relevant to
different systems of the body.
This dimension would include
communication techniques, rapport building, folkways of thinking
-and perception, low cost media etc. (34)
Taken together, these 10 processes applied to the existing curriculum
structure and content, could move towards a gradual metamorphosis
from the existing cadaver/disease/hospital orientation of pre-clinical
academics to the new human/health/community oriented new biology.
7.
FROM’HOSPITAL'
TO
'COMMUNITY' FOUNDATION
With the overall shift in emphasis from hospital based curative/
clinical medicine to an increasing focus on community medicine
and community based health care, the overall nature of pre-clinical
education'is beginning to change drastically.
The name itself will
be a misnomer soon, as pre-clinical consists of subjects of relevance
beyond clinical medicine.
With community health in mind the
pre-clinical-phase ofPSM teaching already includes such diverse
subjects as psychology, sociology and other behavioural sciences,
biostatistics, human ecology, population dynamics and demography,
genetics, human growth and development and nutrition and dietetics all these taken together along with early community and hospital
experience are now essentially a part of community orientation or
foundation for community based health work.
In more recent years there are recommendations to include more
topics and areas of community interest including medical ethics,
management and communication skills, health education, team
leadership skills, social analysis, political economy of health,
value orientation, social history of medicine, self learning skills,
culture and health interactions, gender bias in medicine, research
and training skills, urban health, personality development,
humanistic psychology, evaluation skills, community development issues-ideologies and approaches etc.(12)
Much of this will be
in the pre-clinical phase and much of it .during the increasing
block postings or live-in experiences in the community.
There is
therefore an increasing’need to call this phase 'Foundation Phase'
rather than pre-clinical which has in the. newer context a narrower
connotation.
The greatest challenge however will be to locate' this
change in the context of the career aspirations of medicos.
If the
orientation he gets from various departments is, the glorification
of the Jaslok/Apollo culture then much of the new curriculum will
continue to be classified as irrelevant.
If Aroles and Baba Amte,
become the new heroes &the professional challenges of medicine/health
in conditions of poverty become focussed'in his aspirations, than
all of the 'new' will get the 'relevance' label.
The challenge is
not therefore only of 'content' but 'ethos' and 'values' as well.
12
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INNOVATIVE TRACKS - THE INTERNATIONAL RESPONSE
A year after the Alma Ata declaration on Primary Health Care and
the evolution of the concept of Health for All by the year 20.00,
nineteen training institutions which have been developing
experimental/alternative curriculum for health manpower development
came together with WHO collaboration to form the International
Network of Community Oriented Educational Institutions for Health
Scienpes.
This network meets regularly to strengthen member
institutions in achieving community orientati m and problem based
learning and assists new institutions to introduce innovations in
training.
Two studies of these innovative schools and 'tracks'
bring together the key experiences of these institutions.(23,24)
In the context of the 'Pre-Clinical Phase'
studies show the following developments ;
of education these
'Integration of basic and clinical science in pre-clinical
year is a major feature of the innovative track'.
Community experience was a frequent vehicle for this • integration.
Most of the learning is problem-based.
Innovations are introduced ~in th-e- early years of the course
during the students most impressionable years-.------
v) All of them employ tutorial groups which ranged from 2-5
meetings' per week and 5-25 students per group.
Important learning criteria were the opportunities to reason
and think, to be stimulated by the learning environment and
to build a close relationship with faculty role models.
All of them introduced their students to a community component
in the first year and prepared their students for this experience
with training in clinical skills so that students could provide
a useful community service during their learning experience.
-It was reported that 'while problem based learning tends to rely
on.simulated clinical problems, community based learning carries
problem based learning a step further.
It places students in
confrontation with real-life health problems, while providing
them with sufficient professional tools to reinforce scientific
learning with meaningful health care' (23,24)
8B.
EMERGING ALTERNATIVES IN INDIA
Medical Education in India is often seen to be handicapped due to
the absence of the concept of 'autonomy' in education and because
of the exam/subject classification and phasing imposed by the MCI
recommendation.
However this is notional.
While autonomy is
necessary, it must be acknowledged that MCI curriculum recommendations
of 1981 also give enough space and scope for innovation.
There have
only been a few good examples but these emphatically endorse that
the constraint is largely hypothetical.
. .13
13.
i) The CMC-Vellore model of community oriented medical education
consisting of three block postings of 2-3 week duration in
pre-clinical, first'year clinical and second year clinical•
has been put to collective scrutiny by the medical colleges
;
affiliated to MGR University and adopted as curriculum
recommendation.
Pre-clinical faculty are involved in the- live in
experiences and rural camps like all other faculty.(39)
J
V
ii) The Kdttayam experiment (1972-1976) was a pioneering
fore-runner of an alternative curriculum involving integration
both vertical and horizontal in a community based setting.
Pre-clinical elements’ formed part of the integrated community
based problems teaching in the programme.(30)
The experiment
was instrumental in stimulating.B.Sc., Human Biology course
at Osmania-geared to teaching Health as a Science subject in
schools.
. //rTiiij -The mfe —.an ■informal network of community physicians and health
,
’
activists have after a series of group/individual reflections
have brought out an anthology of articles also compiled into a
anthology-of ideas towards an alternative curriculum which... is
specifically geared to a community oriented Primary Health Care
Doctor exposed -to -;a- -social/societal understanding of Heal.th. and
Disease.
This alternative has’be’e'h submitted by CMC-Ludhiana
with its application for an experimental parallel curriculum
•to Punjab University and the\green signal has been given.(38)0
iv) A consortium of,four key institutions facilitated by a WHO
Resource Centre' in Educational' Development. (CED Illinois)
have initiateci a propess called Decision based approaches
to evaluation’and innovation'since 1987.
The emerging
innovations in the pre-clinical context inclpde(40)
- Pre-clinical syllabus reoriented as. core abilities with
clinical orientation.
- Foundation course to help process of transition from school
to college.system which will- include behavioural sciences,
value education, history of medicine, communication skills’
etc.
- Early exposure of students to patients, problem based learning
modules, restructured assessment', systems etc.
v) Many other centres of innovation are appearing on the Indian
scene.
CMC-Ludhiana has initiated a process of gradual
orientation'of all faculty to.problem solving approaches in
teaching and small group tutorials and self learning techniques
with a strong community orientation.
CMC-Miraj has evolved the Miraj Manifesto a plan for a denovo
community, oriented medical college which explore integrated,
problem solving approaches.
JNU - Department of Social Medicine and- Community Health has
called for a health manpower development strategy that is
oriented to the 'new public health1 deeply located in the
socially paradigm.
Institutions such as St. John's, Bangalore, JIPMER, Pondicherry.
MGIMS, Sevagram are also trying cut community based experiments
of increasing significance.
All these are indications that the 1990's will be a decade of
'creative innovation' towards our social goals.(38)
9.
RECOGNISING THE PARADIGM SHIFT
: TOWARDS THE NEW BIOLOGY
In 1948 the WHO defined health as ‘physical, mental and social well
being'.
Thirty years later in the 'Alma Ata Declaration' it went
further and'evolved the concept of Primary Health Care and the
Goal of Health for All by 2000 AD.
Ten years later the World
Conference on Medical Education organised by the World Federation
for Medical Education, WHO., UNICEF, UNDP and others passed the
Edinburgh Declaration on Medical Education which some of you -may
be familiar jwith.
All of them have grappled with the radical' changes in our
understanding of human biology tha.t has taken place in the last
two decades.
These changes can be presented as a paradigm shift from the
bio-medical model of medicine to a bio-psycho-social model of
health which includes the following shifts.
Medicine
Health
Individual
Community
Pathophysiology
Behaviour
Microbes
Environment
Disease Process
Social Process
Treatment
Care System
Intracellular Research---------
Societal Research
Provision of Services
Enabling/Empowerment
Patient as Participant
Patient as beneficiary
' •
Doctor/Nurse
-I*
Health Team
Medical Education has to keep pace with this change and as the
Edinburgh Declaration has emphasised it has to metamorphose radically
This metamorphosis is multidimensional and will include -the
following. : (7)
Primary Care Community base
Tertiary Care Hospital based____
■■
Disease Orientation
Discipline Orientation
<
________ >»,
Health Orientation
Problem Orientation
Teacher centred and teacher
directed teaching and
evaluation
Learner centred and student
directed self learning
Theoretically oriented
teaching
Experiential‘learning
Are we ready for '■.his shift?
11
. .15
15
10.
IN CONCLUSION
I would like to end by bringing to you the Goals of 1990 that
has been set collectively by the Medical College representatives
of South East Asia recently.
MEDICAL EDUCATION IN SE-ASIA
Goals in 1990's
Graduate/Specialist doctors
Social/Societal need responsive
Appropriate ethical, social, technical,
Scientific and management abilities
Ability to work effectively
in PHC Oriented comprehensive
Health Care System .
—WHO—SEARO,
1988
The time for fence setting, superficial reforms and 'cosmetic
changes' in the quality of medical education is over.
Colleges, such as our Alma mater have to be in the forefront of this
radical reorientation.
The Pre-Clinical Phase of medical education has therefore a double
challenge before it in which all pre-clinical faculty have to be
actively involved.
The first to the integration of their disciplines towards the new
Health Oriented Human Biology.
The second the preparation/orientation/motivation of the students
(whom they meet before all the other faculty) towards the new Social
biology and the skills and attitudes for the Community Health Care
response.
I would like to end by quoting the Edinburgh Declaration which
requested all of us to join in the organised and sustained programme
to alter the character of medical education so that it truly meets
the defined needs of the society in which it is situated.
The stage is set; the time for action is upon us.
THANK
YOU
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