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THE METHODS

When faculty members talk about education, one of their first considerations is how to teach. Though obviously an important aspect of instruction, it is of relatively minor importance when viewed in the entire context of education. Before one can decide whether a lecture is a better method to teach a specific topic than a group discussion or whether slides, a chalkboard, or computer-assisted instructional software should be used to facilitate making a concept clear, it is essential to understand the student, the student's needs, the purpose of the education, and the content to be taught.

Too often, the instructional methodology, which is easy to consider, receives the major emphasis, whereas the difficult questions about education, such as what is its rationale, are glanced over or never even considered. After the fundamental questions about educational philosophy are answered, selection of a particular instructional technique becomes critical. The specific teaching method selected is intended to be the one best suited to the specific educational goal desired.

The use of simulation games is a good example of how the method satisfies the educational goal. In cardiopulmonary resuscitation training, a simulated cardiac arrest is an exercise in which students play the resuscitator roles and use all the real-life equipment in a real-time setting. The involved students, as well as other students and the teacher or teachers who observe the simulation, review and critique the resuscitation to point out correct actions and those that could have been performed better. The goal of the exercise is to teach students to coordinate the entire cardiopulmonary resuscitation effort by bringing together the facts and skills in an atmosphere in which reasonable attitudes are exhibited despite the tense nature of the emergency situation, all without jeopardizing any patient. A lecture, a slide show, or even a small group discussion could not achieve this goal.

Simulation is becoming an integral teaching methodology in anesthesia education.^[43] Borrowed from flight simulation, which is an essential part of the training and certification of commercial and military pilots, anesthesia patient simulators have been developed and used to educate individuals in the discipline of anesthesiology in two major ways: (1) for specific recognition and management of critical events and (2) in the general comprehensive education about all aspects of anesthesia patient care. By coupling a mannequin with a computer and anesthesia patient care equipment, a simulation setting is created that so closely mimics real life that it is a virtual reality. Physiology, pharmacology, pathophysiology, and crisis management are a few of the curricular areas that can be most effectively taught by the anesthesia simulator approach, that is, modeling a real patient scenario for students to manage with zero risk to the simulated patient and no real risk to the student (except for the trainee's self-imposed stress to achieve). Use of this technology is limited only by the ability of the educators and students to create and "live" the scenarios.^{[43] [44]} Additional advantages of human patient simulators include their use in teaching all types of students (e.g., medical students, student nurse anesthetists, allied health professionals in a wide variety of disciplines, practitioners in continuing education programs) and the ability to conduct educational research and to collect "simulated" patient management outcome data.^{[43] [44]} Undoubtedly, the field of human simulator education and research will continue to grow exponentially in the next few years.

An in-depth study of individual teaching techniques is appropriate after the links between the questions about educational philosophy and rationale and the methods of teaching have been established. Lectures, small group discussions, the use of questions, clinical problem solving at the bedside or in the classroom, psychomotor skill learning at the bedside or in the classroom, and the use of adjunctive educational media such as slides, chalkboard, videotape, audiotape, overhead projector, computer, and teaching models are all at the teacher's disposal for effective use in the proper situation. Each of these techniques can be used more effectively and efficiently when the method is studied and understood.

Effective use of questioning, for example, occurs when the teacher understands the difference between closed and open questions.^[45] Closed questions are used when the teacher is interested in having the student remember facts. Because the range of responses to closed questions is limited, students answer with facts and have limited opportunity to delve into more complex cognitive learning (i.e., problem solving). A teacher who wishes to direct the teaching/learning activity toward the application of knowledge to new settings or analysis of information for conceptual learning, rather than mere regurgitation of facts, uses open questions as the teaching device. There is a considerable difference in the learning that might occur when a question such as "What might explain postanesthetic stupor in a patient operated on for head trauma?" is asked of a student versus asking a question such as "What are the signs and symptoms of increased intracranial pressure?"

Developing a psychomotor skill lesson is another example of how understanding instructional methodology can lead to effective teaching and learning. The old adage about teaching psychomotor skills in medicine is "see one, do one, teach one." The absurd nature of this approach has been highlighted in the following way: "This is akin to a piano instructor playing 'The Minute Waltz' for a beginner and then saying, 'Now, try it yourself.'"^[45] Rather than using the repetitive trial-and-error approach to teaching/learning psychomotor skills, a systematic methodology can be used.^[45]

1. Analyze and separate the skill into its component parts and determine which aspects of the skill are most difficult to perform.
2. Provide students with a model of the skill, demonstrated effectively in its entirety, that they are expected to perform.
3. Make provisions for students to practice until the expected behavior is mastered.
4. Provide adequate supervision and an evaluation of the final performance.

Anesthesiology instructors need only think of the protocol that they are using to teach, for example, pulmonary artery catheterization by the internal jugular venous route,

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Figure 85-2 Diagrammatic representation of a model to conduct educational outcome analysis. The six components are joined in "chain-link" fashion to signify that the outcome analysis is as strong as its weakest link. Essential to the model, therefore, is sound development and implementation of the educational plan and process. This includes definition of the educational objectives, understanding of both the teaching faculty and student participants, and execution of the instructional activity. Having established the educational experience, its outcome can be assessed by applying an appropriate evaluation design^[46] and using the measurement techniques to collect the data for analysis. The final step in the analysis is to apply the results to the program objectives and instructional activities to enhance future desired learner outcomes. (From Hutchins EB: Unpublished lecture notes: Evaluation Methods in Professional Education. Course ED668, Graduate School of Education. University of Pennsylvania, 1981.)

A final example of an answer to the question of how to teach comes from review of the effective use of audiovisual aids. Although it is true that "a picture is worth a thousand words," the anesthesiology teacher must be sure that this image is the "text" that the teacher wishes the students to read. Slides, for example, focus the viewer's attention on an idea or ideas that the lecturer wishes to amplify in some manner. By definition, the entire lecture cannot be put on slides. Only a few important portions of the presentation are conveyed by slides, and these points are emphasized in some specific way by the visual image or images, which add to the verbal presentation. Slides are not the TelePrompTer, although they are often used this way.

Even more basic is the need to understand the proper production formatting of slides so that the message on a 35-mm transparency or a PowerPoint computer image can be clearly seen when projected onto a 12-foot-high screen in a large 800-seat lecture hall. If format is not considered, the slide is not visible and undoubtedly detracts from rather than enhances the lecture. Finally, even the best-produced slide is useless if nobody, including the lecturer, knows how to troubleshoot a nonfunctional projector. Surely, the thousands of hours that have been devoted to slide lectures about anesthesiology could have benefitted from the teachers taking more responsibility in the preparation of effective visual aids.