The images should take the place of the patients and the text should take the place of the teacher (von Hebra)

Some resources I have produced for teaching are shown immediately below (with links). For some of my earlier thoughts about teaching, scroll down the page further.

  • My open access textbook on skin cancer, skincancer909 is here.
  • My open access skin cancer atlas with ~600 high quality images is here. [this site as at top of page]
  • Some videos designed to help students learn dermatology are on my Vimeo page [or better still start with the teaching page at the top of this page or look in skincancer909]
  • My blog chiefly about medicine and education is here.

Some mild mannered views on teaching.

What follows is quite old, and I have resisted the temptation to change it. I would probably make it more nuanced if I were writing it now, but it is what I thought when I began to think about these issues seriously, around 2010

Derek Bok on University Teaching:

‘some faculty members will cry foul, claiming that teaching is simply not comparable to a piece of merchandise. But protestations of this kind cannot hide the fact that very few universities make a serious, systematic effort to study their own teaching, let alone try to assess how much their students learn, or to experiment with new methods…’
[Universities in the Marketplace, Princeton University Press, 2003]

Bok is right. The standards of teaching and learning in higher education are far from reasonable. This is not just a problem in the UK, but is also true of most of mainland Europe and the USA. Of course, there are lots of staff passionately concerned with student learning, but then there were lots of passionate physicians who went around for hundreds of years killing their patients rather than making them better. Good intentions are not sufficient.

Medicine presents some special problems, partly because Universities often do not want to admit that students (in Flexner’s words) need to be taught in medical schools and second, because of the often pernicious influence of the NHS and the dead weight of the regulatory bodies.

I have had a long interest in how to teach medicine and dermatology. Almost twenty years ago I wrote in my first inaugural lecture:

Feinstein, in a memorable but neglected phrase, described a clinician as somebody who ‘depends not on a knowledge of causes, mechanisms or names for diseases but on a knowledge of patients’. Can this view be correct? And if so, where does this leave llic teaching of natural science in medicine. Is the idea that clinical care must be based on a hierarchy of disciplines, with clinical practice being based on fundamental biological science, mistaken? Is there any point in teaching undergraduates the anatomy and physiology of (say) skin? Will the reported explosion in basic biomedical science, the human genome project and so on, be of any relevance to the practising clinician? Or should we capitalise on our students’ distrust of natural science, train them in ethics and accounting, ready moulded to fit into the new reformed NHS: semi-autonomous replicons, skilled at following protocols and algorithms, whose guide to practice will be audit cycles and pragmatic meta-analyses.

I think I hit on some of the key problems, but my answers now would differ wildly from the ones I would have provided then. The central concerns are the relations between the following:

  • the body of accumulated knowledge,
  • how that knowledge was accumulated,
  • how you impart that knowledge,
  • what is relevant, and how much of the accumulated knowledge is relevant to the practitioner.
  • how do we impart useful knowledge
  • how do we define and assess competence
  • how do we define the bounds of knowledge for different practitioners

It seems to me that there are a number of issues that are worth thinking about. Some are specific to medicine, others will affect the Universities more generally

  • I like Eli Noam’s essay (Electronics and the Dim future of the UniversityScience, 1995) on how technical change will influence historical norms in universities. Technology is just so disruptive and we have moved from an apprentice scale to a much larger one. The Open University really was so prescient.
  • As William Baumol has reminded us of, the cost of teaching (and healthcare) haven’t scaled downwards with many commodities. There are differences between baked beans and university education, but tuition costs do not represent good value for many. In the UK, as has been pointed out elsewhere, teaching is massively subsidising research. The best form of tech transfer of science, is properly educated students as the late Roger Needham pointed out
  • I don’t think the conventional UK honours degree makes much sense considering the number of people who go to University. Universities work better with more advanced tuition, but the ‘value’ provided to many honours degree students in not what they need. I also think there is nothing sacrosanct about the first few years of medical school. And while we are at it, why is medicine 5 years here and 4 in the US. Does it need to be this long? Do students need to be at a residential university for all of this time?
  • Rich DeMillo quotes that there are over 30,000 new colleges opening up in India. It is foolish to believe that the apparent superiority of countries such as the UK is going to remain that way without a lot of change, and I see little evidence that there will be such change. The UK used to make great cars: the UK once upon a time had many great Universities……
  • Paul Romer who enjoys a worldwide reputation for his economics research—and who is often talked about as a being a future Nobel laureate—also has a reputation as a teacher. He provides some economist like insights into the difficulties university education faces:

“In the old model, a teacher had to be so engaging that he inspired students to put in the effort that is necessary for learning,” Romer explains. “The problem is that that is not a scalable model. There simply aren’t enough inspiring teachers and inspirable students.”

For me the key issue here is ‘scalability’. Romer’s solution, a company he founded called Aplia is, I think, the direction we should be going in. He goes on:

“What we have right now is a reputational model for universities rather than an outcome model,” Romer says. “The presidents at the elite institutions know that if the competition were to be based on some credible measure of output or value added, they would lose.”

  • Medicine has particular problems. We do not really know what we want students to learn, there is little rigour to standards and assessment (what you mean, you set and then mark the exam for your own students?). The NHS is also often a pernicious influence. Large amounts of funding is allocated for teaching but most of it is consumed by central non-teaching health care provision, and the NHS often behaves like, and thinks like a monopolist, imagining doctors as interchangeable widgets produced in an educational factory.  What really do we expect of students at the end of their course? Why no national exams? Medical schools were called just that by Flexner for a very good reason (and not colleges of biocellular-translational science…)

In terms of what we do about some of these problems I like Carl Wieman’s summary:


1. Establish what students should learn

This means faculty members laying out learning goals for the programs and all the individual courses in operational terms of what students should be able to do if they learned what the departmental faculty would like them to. These goals should include EVERYTHING the faculty hope students to learn, from concepts to vocabulary to specialized skills to habits of the mind, …
Establishing clear goals informs the design of curriculum, teaching, and evaluation methods.

2. Determine what students are actually learning

Systematically gather data on students’ problem-solving ability, conceptual understanding, attitudes, and skills in the areas where faculty members have identified learning goals.
Methods for measuring student learning include:

— in-depth interviews to reveal student understanding

— observing problem-solving in the particular course of interest

— review of suitable research literature

— surveying current students and alumni

— analyzing exam results (particularly open-ended questions)

— using validated assessment instruments, and/or developing new ones to probe all those areas of learning that the department cares about

3. Improving student learning

This is primarily where teaching comes in and is addressing the question of “how do we now move the students from where they are to where they meet the goals we have set?”
Strategies include:

— adapting proven practices

— introducing and testing new research-based practices

— ensuring course sequences and goals are properly aligned to student preparation and capabilities

— continuously evaluating effectiveness using methods detailed in Step Two

— Reviewing and revising learning goals as appropriate

In medicine we need to look to what the physicists have achieved in terms of studying learning within specific domains. In medicine we have far too many educationalists who want to talk about professionalism and endlessly change the curriculum / waffle on about individual learning styles and problem based learning etc rather than focus on how to improve learning and make it cheaper. Chief among the problems are a complementary set of fallacies: just because you can do something, you can teach it (‘the curse of knowledge’), and second, just because you have a Masters in Education, and you were sick once, you understand how medicine works. Is there anybody I haven’t upset ?

And where to start, now that the rant is over? Look at Geoff Norman’s work.

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