Dr. T. Hiruki - Teaching

• Training and supervising pathology residents (doctors who want to get specialty certification in pathology) and other medical specialty trainees
• Organizing and delivering university courses about pathology to undergraduate students in medicine and the allied health sciences (e.g. nursing, physiotherapy, pharmacy, etc.)
• Organizing and delivering continuing medical education courses for practicing pathologists

Click here to see what teaching I did during my last full-time job at an academic centre.

My current part-time position is entirely service oriented, but it is at a teaching hospital and my work brings me into regular contact with pathology trainees. Though I have no formal teaching responsibilities at the moment, this partially detached perspective has allowed me to observe what works and doesn't work, reflect on my own experience as a learner and teacher, and set out a personal Teaching Philosophy (Thanks to fellow pathologists-on-the-Web Mitch and Maria for this idea).

Teaching Philosophy

The State of Medical Education

Medical education is in a state of flux, halfway in transition:

The didactic model worked fine in the early days of medicine and pathology, when the amount of knowledge to master was small and relatively static. But today, we are constantly discovering more about the human body and the diseases that affect it. Information growth will only accelerate as the Human Genome Project starts to yield dividends. And yet the duration of medical school and pathology residency has not changed. Some of the new information will invalidate the old -- the halflife of information will become shorter. Rather than be told as many facts as possible (that may soon be out of date) during their training, learners will be better served by becoming information literate: by finding out how to gather, evaluate and synthesize information. Non-medical fields of human endeavour recognized some time ago the importance of such lifelong learning.

The Pathology Learner

General - People in medical school and pathology residencies are adults working on their second and third higher education degrees. One presumes they are highly motivated to succeed and have high personal standards of academic and professional performance.
Medical Students - Medical schools in many cases still select candidates on the basis of their didactic learning and memorization ability rather than aptitude for problem-based learning (see above). However, North American medical students at least are increasingly exposed PBL as part of their curriculum.
Pathology Residents - There is a dearth of North American applicants to most pathology residency programs these days. Rather than shut down, most programs fill their trainee ranks with international medical graduates, doctors who have done their training outside of North America. They may face many more challenges than the typical North American medical graduate:

• They may be unaccustomed to the North American medical system.
• They may come from a different cultural norm, e.g. where expression of personal opinions is frowned upon.
• They may be in pathology as a "residency of convenience"; may thus have less aptitude for and/or interest in pathology.
• They may be older, and as a result:
  • May have done their medical school many years ago
  • May not have been in a learning environment for many years
  • May not have been exposed to problem-based learning
  • May have more complicated personal lives, e.g. marriage, parenting, immigration
• English language ability may be an issue.

Note the word "may" above, i.e. "sometimes". I have had the privilege of training with and under many excellent IMGs. Still, the possibility that these factors may impact on training must be taken into consideration. Some of these challenges may also apply to "typical" North American medical graduates (who, because they chose to do pathology, are actually not so typical), as well as "re-entry" trainees, North American medical graduates who decide to do pathology after many years of practice in a non-pathology field.

The Pathology Coach

I am a pathology coach, as opposed to a traditional pathology teacher who simply conveys facts. Coaching entails helping trainees identify their strengths and weaknesses, offering lots of feedback, and delegating challenging assignments to help trainees grow beyond their comfort zone. It also means clearly stating where one stands and what one expects.

Focus - I am interested in long-term results (instilling a skill set for lifelong learning), while emphasizing sound practices that will deliver short-term performance results as well. I will give suggestions and hints, facilitate, but not dictate -- spoon feeding is detrimental to a trainee's development. I believe and have seen that coddling leads to a loss of self-respect and independence.

Feedback: I do not skimp on feedback. Most people wait until a problem is so big they can't ignore it. I believe problems are best dealt with early or, even better, pre-empted.

Four Levels of Learning 1. Incompetent, and unaware of incompetence 2. Incompetent, but aware of incompetence 3. Consciously competent 4. Unconsciously competent (internalized knowledge)

It was once thought that people learn things by getting them right, not wrong, and that mistakes were to be avoided. With the advent of humanistic approaches, the basic premise is that people learn through mistakes, and so mistakes are good. Feedback is crucial to help the learner progress through the Four Levels of Learning (see box). Most pathology trainees I have encountered, even senior ones, are still at Level 1. Once at Level 2, trainees can use their information-seeking skills to get to Level 3. Level 3 is a matter of knowing and using an externalized decision-making process. The rest is practice, practice, practice.

At its core, coaching is positive: it means having faith in the maturity and ability of the trainee to rise to the level of expectations. My coaching approach is still not very common in pathology, so many trainees are unaccustomed, even uncomfortable with having this level of responsibility for themselves. Usually this is because under other teaching methods they never received truthful feedback and never had to develop their information-seeking skills. But residency is practice for Real Life After Residency (yes, it exists) -- better to learn how to cope sooner than later, and in a supervised situation.

Goals

• Curiosity: The lack of this is one of the biggest barriers to the acquisition of knowledge. Ask "Why?"
• Self-sufficiency: Acquire a minimum skill set to allow one to function as an independent practitioner of pathology. This includes:
  • Vertical and Lateral Thinking
  • Information Literacy: Be able to navigate all available sources to gather information, evaluate the reliability and relevance of information, synthesize and apply information appropriately.
• Self-awareness: Know your limits; realize when a case is too complex for your level of knowledge.
• Irrelevant staff person: Produce high-quality work, such that the staff person's co-signature is simply a formality (An informal measure of work quality: How much of your work has to be redone to get to the final product?).

From 1993 to 1998 I taught a few things about pathology to some of the students at the University of Toronto, and in return I got to call myself an assistant professor.

• My Curriculum Vitae

• My Resume

• Faculty of Medicine
  • Undergraduate (M.D.) Program
    • Pathobiology of Disease, 2nd year
      I was a Small Group Facilitator for a course with a blended didactic / problem-based learning (PBL) curriculum.
  • Department of Laboratory Medicine and Pathobiology
    • Residency Program
      Nothing novel here - the U of T trains the next generation of pathology specialists in much the same way it did the last generation of pathologists. A few didactic lectures and the occasional small group unknown case session, but mostly supervision of doing routine pathology work.
    • Surgical Pathology Fellowship Program
      More of the same, with less supervision if warranted by the ability of the individual. These extra "finishing" years are becoming increasingly popular among new graduates of pathology residency programs everywhere, whether it is because of a lack of job opportunities or simply a lack of confidence. Others use the year to subspecialize and/or do some research.
  • Department of Medical Imaging
    • Residency Program
      Radiologists need a break from their daily routine of black-and-white pictures. I used to co-present a teaching session which correlated the shadows they were seeing with the pathology that produced them, in all its glorious colour.
  • Department of Surgery
    • Colorectal Surgery Fellowship Program
      At the subspecialist level, the need for accurate interdisciplinary communication is heightened. I used to present a session showing the pathology of the colon and rectum, and discussed the therapeutic implications with those trainees who were concentrating on surgery of the large intenstine.
  • Department of Physical Therapy
    • Undergraduate Program
      I used to be asked to present a didactic lecture on viral hepatitis in this course. I'm not sure why it was in the curriculum -- maybe it was to show the students what could happen if they got a needlestick injury while thumping some inpatient's chest...

• Faculty of Pharmacy
  • Undergraduate Program
    • Pathophysiology and Clinical Biochemistry for Pharmacists, 3rd year
      I was Course Co-coordinator for this series of didactic lectures covering the full range of medical problems. The speakers showed the pathological processes causing diseases and the therapeutic entry points for the medications that the pharmacy trainees will someday dispense.

Medical school, residency, and -- until recently -- even having a faculty appointment do little to teach one about teaching, other than to provide opportunities for trial-and-error experimentation.

While I was at the University of Toronto, the
Centre for Research in Education was established to provide faculty members with some formal instruction on teaching and to investigate various aspects of teaching. I was able to attend several of the CME courses they offered:

• Asking Questions
• Small Group Teaching
• Needs Assessment