Kulamakan (Mahan) Kulasegaram
The renowned sociologist Fred Hafferty conducts a workshop on the hidden curriculum entitled Cats, Sheep, and Barnyard Animals. The central activity is a poll of the participants: is your medical school training students to become the ultimate followers (Sheep) or the ultimate non-conformists (Cats)? This is a profound question for training in the health professions and indeed, any profession where both technical expertise and a larger commitment to societal responsibility are valued. At the heart of the question is a fundamental tension between conformity and disruption. While the question takes as its subject the students who are trained within the curricula, in the intellectual tradition embodied by the late Del Harnish, I argue that there is a more pressing question to be asked: are our teachers Sheep or Cats? Moreover, what implications does the answer have for how we train health professionals? My own answer is that our teachers (at least the truly exemplary ones) are Cats by disposition and discipline but are forced to act as Sheep in the service of increasing standardization.
When Teaching as Subversive Activity was published in 1969, the prevailing mood was disruption in the social and political landscape. Fittingly, the goal of the book was to outline a pedagogy that would empower and transform students with the ability to question, critique, and change society and educational practice. Despite half a century, health sciences and health professions education still struggles with how to train students who have an array of abilities to question and reform the institutions that train them. The ‘forms’ of education have been readily adopted, including inquiry learning, problem-based learning, and several other ‘BLs’. Whether the resulting pedagogical processes and outcomes are actually inculcating students with the capabilities advocated by Postman and others, however, is an open question. The enthusiasm for ‘new’ thinking and challenging received wisdom has not waned. Every so often, a laudable journal like BMJ or Academic Medicine will publish an editorial or commentary from medical pundits or thought leaders arguing that students must be prepared to challenge, critique, and provide new viewpoints to healthcare concerns. Doing so is not just good pedagogy—it is imperative if the future challenges of healthcare are to be met. Critical thinking (whatever that is), along with a whole host of allied ideas, are cited as essential components of a subversive and innovative cohort of students.
Our desire for subversive pedagogy must inevitably contend with an equally strong discourse: standardization of practice and outcomes. In health professions, clinical practice is subject to increasing standardization, and it is no surprise that health professions education has assimilated this discipline. There is nothing inherently wrong with standardization (a point acknowledged by Postman & Weingartner, 1969). Curricula are driven to standardization by a number of processes, including accreditation of professional programs, offices of faculty development that promulgate ‘best practices’, and a growing ‘evidence’ base that identifies ‘efficacious’ strategies for teaching. While these endeavours are well meaning in that they aim to create reproducible and reliable quality in education, they also have unintended consequences. Of relevance to us, standardization serves to stifle meaningful interactions between teachers and students. Increasingly, the vehicles—and I argue the victims—of the standardization of educational practices and metrics are teachers.
How do students learn to challenge received wisdom? From whom do they understand the skills required to question the system and their own assumptions? And significantly, from whom do they learn that there is value to this orientation towards learning and practice? Teachers. An effective teacher is not only the communicator of skills and knowledge but is also a role model for attitudes and values. While a teacher may actively work to communicate skills and knowledge, their implicit and intuitive way of being can teach attitudes and values. The medium is the message, and the teacher is the text. This is a long recognized social fact in studies of the hidden curriculum. If teachers are part of a curriculum organized around questioning and critique—be it evidence, power, values—their actions, attitudes, values, and embodiment of teaching practice must so be aligned. Sometimes this may entail blatant contradiction of the formal curriculum and of the ‘truths’ that underlie health professions practice. The most memorable and impactful teachers are the most subversive. The iconoclasts, the curmudgeons, and the skeptics. We have all benefited from close interaction and inspiration from exemplary scientists. Common across all of them was an anarchic streak and a desire to question what they knew. Indeed, this was what made them successful scientists and subsequently role models for many of us as scholars.
In the past, teachers had the space to operate as dictated by their own expert judgements, disciplinary traditions, and (dare I say) personalities and quirks. For them, the classroom was a creative space to tell stories of science and scholarship. They made interesting and sometimes risky choices when teaching. As an example, my first statistics professor explained what a normal distribution was by using a graph of an international survey of penile length. This was a slightly shocking and perhaps juvenile way of presenting an important concept, but it communicated important ideas beyond the meaningfulness of the concept of a ‘distribution.’ It subverted our prior notions of how statistics are used and the nature of learning statistics, and it engaged us in a playful attitude towards what could have been a dry and difficult subject. And frankly, it was entertaining. As Marshall McLuhan said, “Anyone who tries to make a distinction between education and entertainment doesn’t know the first thing about either.” I was fortunate that the intellectual climate of education permitted a wide range of frivolous, entertaining, creative, and ultimately educational choices by teachers. From unethical marketing campaigns in pharmacology to combatting terrorism in cell biology, our teachers made weird and wonderful choices. They also created an environment of inquiry that permitted us to subvert other aspects of our education, including our values and choices.
These teachers modelled an inspirational attitude that had a formative impact on our careers and personal lives. They could do so because, in the classroom, they had the academic freedom to engage with their students as they saw fit. That freedom provided privilege—and responsibility—that was, to some extent, insulated from evaluation and assessment concerns. This meant that learning was deliberately challenging, that it veered away from the formal curriculum, and that it was unpredictable—and ultimately rewarding. In short, it mirrored the process of scholarship and critical thinking. Marks and assessments were secondary to understanding how to think using a particular set of concepts and ideas.
Not all teachers took advantage. Not all teachers were, nor were they required to be, subversive mentors. And indeed, some abused this freedom. However, most understood their responsibility, especially in workplace and experiential learning. Many teachers communicated the subversion of standards and guidelines as a necessity of day-to-day practice in the health professions. Reality rarely matches the randomized control trial. Clinical teachers play an important role in explaining this to naïve students who have memorized protocols and guidelines. This is subversion from one perspective. From another, it is the adaptive and flexible application of expertise that we want role modelled.
Unfortunately, those who were once encouraged or even permitted to be subversive agents within the curriculum are now the black sheep—and a vanishing breed at that. An excessive zeal for standardization has seen to that. Standardization exerts pressures in a few different and synergistic ways. Firstly, there is standardized curricular content and, more significantly, standardized assessment approaches mandated by thought leaders and institutionalized by accreditation processes. Secondly, there are standards and guidelines for how teachers should teach, including pedagogical principles and practices derived from research. These are often derived from good evidence but are translated into inflexible policies and procedures to which faculty must adhere. In my own field, aligning faculty with the new curricula based on these models is a major priority. Thus, faculty development is a ubiquitous obsession with most medical schools I’ve encountered. And, inevitably, when curricula fail to deliver on lofty promises, the blame is assigned to teachers who failed to be ‘developed.’ The so-called ‘best principles’ and ‘best evidence’ can trump years of hard-won experience and inspiration. Thirdly, there are ubiquitous standards for evaluation of teaching by students. These evaluations are demonstrably unreliable and tend to measure ease of course material and student satisfaction rather than true learning. These evaluations also form the basis of academic merit despite good evidence showing that standardized evaluations of ‘teaching effectiveness’ neither assess teaching nor effectiveness. All of these pressures force teachers to toe the line despite their own inclinations. There is little room for questioning the science behind the cholesterol hypothesis in first year physiology when the tutor guide and assessment materials dictate the pace and speed of what is to be covered. Teachers who display their Cat-like creativity are culled. We are left with only Sheep to guide sheep.
At this point, I will confess that I, too, am part of the problem. As a health professions education researcher and advocate of ‘evidence-based education,’ much of the academic work I engage in has the effect of narrowing the range of options to teachers. This is not intentional—the work my colleagues and I engage in is about broad principles of learning rather than any one particular form or format of pedagogy. Still, the uptake of theoretical principles is only through concrete instantiations that become conflated with underlying evidence. Education is an activity with a broad range of possibilities. And yet, the tendency to embrace the ‘best evidence’ has the result of narrowing our options. The consequence is a limiting of the ability of teachers to challenge and inspire subversion in students.
If we can agree that we want independent, creative thinkers who can challenge and advance the health professions, then we have no choice but to accept that our curricula must allow room for challenge, critique, and countervailing viewpoints. In other words, we need to create room for subversion. Empowering students to question knowledge and their teachers is an act of professional self-preservation. Students need mentors, role models, and exemplars in this endeavour. They need to be able to identify with their teachers if we want them to develop a critical disposition to practice. However, as long we put in place processes and structures that reward teachers who are Sheep-like, we will train Sheep-like students.
Cats can be unpredictable and anarchic. This is a scary thought for administrators and accreditors. But on one account, the pundits are right: the future challenges of healthcare will not be solved by Sheep-like thinking.
Postman, N. & Weingartner. (1969). Teaching as a Subversive Activity. New York, NY: Delta Publishing Co., Inc.