Ben White

Learning & The Transfer Problem

12.09.20 // Medicine, Reading

There’s a classic quote that gets attributed to a whole bunch of people, and it goes like this:

“In theory, there is no difference between theory and practice. But in practice, there is.”

This is the transfer problem, and it’s a real thorn for how we learn (and especially how we learn to perform in high-stakes roles like medicine).

When a medical student says, “I know all the information and can explain it but I just don’t do well on the multiple-choice test,” this is the transfer problem at work.

When someone else can do well on the multiple-choice test but can’t apply their knowledge to actually helping patients, that’s the transfer problem too.

The more different the learning methods are from the evaluation, the harder it can be to succeed. The more different the learning and evaluation methods are from the real-life goal, the less useful they are.

Here are some passages from Ultralearning: Master Hard Skills, Outsmart the Competition, and Accelerate Your Career:

Given a century of research showing the difficulties of transfer along with proposed solutions that have failed to provide lasting results, any student must take seriously the notion that transferring what has been learned between very different contexts and situations will be treacherous.

The answer is that learning directly is hard. It is often more frustrating, challenging, and intense than reading a book or sitting through a lecture. But this very difficulty creates a potent source of competitive advantage.

The best way to prepare for taking a high-stakes multiple-choice exam is to do lots of multiple-choice questions (e.g. How to Study for Step 1). The best to learn to do a procedure (other than actually doing the procedure) is to do a good simulation of said procedure.

If you can judge yourself only on how much you improve at the overall task, it can lead to a situation in which your improvement slows down because you will be getting worse at the overall task while becoming better at a specific component of it.

This is the treacherous problem of stagnant or decreasing qbank performance during dedicated review for some students. More time to trying to memorize low-yield minutia or shore up knowledge gaps doesn’t always yield upfront measurable gains. But, that doesn’t mean that when once again incorporated into a broader approach and after refreshing your core knowledge against the forgetting curve that it won’t ultimately yield results.

This practice of starting too hard and learning prerequisites as they are needed can be frustrating, but it saves a lot of time

Sometimes it’s best to just dive in because you’ll rapidly figure out exactly what you need to know.

I agree with this, and it argues for the early incorporation of question-based learning. This is actually how I learned pathology, by slogging through the question book and largely ignoring the larger text.

Human beings don’t have the ability to know with certainty how well they’ve learned something. Instead, we need to rely on clues from our experience of studying to give us a feeling about how well we’re doing. These so-called judgments of learning (JOLs) are based, in part, on how fluently we can process something. If the learning task feels easy and smooth, we are more likely to believe we’ve learned it. If the task feels like a struggle, we’ll feel we haven’t learned it yet.

No pain, no gain.

Imaging is the great equalizer

11.27.20 // Radiology, Reading

Imaging is the great equalizer. When we look deep into ourselves from the vantage of this fundamental level, with exterior barriers and labels removed, we just might just see ourselves, other people, and our lives in a whole new light.

From Dr. Cullen Ruff’s Looking Within: Understanding Ourselves through Human Imaging, currently an Amazon Black Friday deal for a whopping $0.99 on Kindle.

When I see patients these days, it’s usually because I’m about to put a needle somewhere, but Ruff is old enough that he has decades of stories from an era where radiologists got (relatively speaking) a lot more patient facetime.

And yet, what a strange job we have, bypassing everything externally visible to study people’s insides.

To be home is to be known

11.16.20 // Reading

If anyone was looking for a summary of a core problem in American society, from former Surgeon General Dr. Vivek H. Murthy’s lovely book, Together: The Healing Power of Human Connection in a Sometimes Lonely World:

While loneliness engenders despair and ever more isolation, togetherness raises optimism and creativity. When people feel they belong to one another, their lives are stronger, richer, and more joyful.

And yet, the values that dominate modern culture instead elevate the narrative of the rugged individualist and the pursuit of self-determination.

To be at home is to be known. It is to be loved for who you are. It is to share a sense of common ground, common interests, pursuits, and values with others who truly care about you.

In community after community, I met lonely people who felt homeless even though they had a roof over their heads.

And, when people are desperate for community, the ones most emotionally convenient or accepting may not be ones that provide meaningful uplift.

Communities that focus on us vs. them distinctions, scapegoating, and villainization aren’t about bringing people together. They’re about frustration and fear.

Tomorrow is a new day

11.11.20 // Reading

Finish every day and be done with it. You have done what you could; some blunders and absurdities no doubt crept in; forget them as soon as you can. Tomorrow is a new day; you shall begin it well and serenely, and with too high a spirit to be cumbered with your old nonsense.

—Ralph Waldo Emerson, in an 1854 letter to his daughter.

It’s my birthday today, and this is something I think about when considering my relentlessly increasing age.

The best day for a new positive change is always today. But we’re very fallible human beings and I’ve been stress eating for about six months, so barring that, let’s not discount tomorrow either.

Bigger isn’t always better

10.19.20 // Reading

From Company of One: Why Staying Small Is the Next Big Thing for Business by Paul Jarvis:

I like reading things that are not about medicine and seeing what lessons cross domains and apply. The premise of Jarvis’ book is that growth for growth’s sake is a terrible business model for many businesses and especially the many people that run them. It’s okay to be big, but any decision to grow the enterprise should be an active choice considering all factors and not just the default MO taken from the recent start-up culture of silicon valley.

My wife left her employed university position last year to start a solo private practice, and it’s been wonderful. It’s not hard to see how there are so many downsides to being part of large company or expanding your own business too much. On the former, no control. On the latter, so much time managing the machine that it’s easy to completely lose track of why you started the practice and what you liked about it.

But here are four passages that also resonated with me as a physician and educator:

Miles Kington, a British journalist, reportedly said that “knowledge is knowing that a tomato is a fruit. Wisdom is not putting it in a fruit salad.” We should never assume that having an abundance of knowledge is the same as having an abundance of wisdom.

This is the problem with equating performance on a knowledge assessment like a high-stakes multiple-choice examination with real-life competence. Knowledge is important, but it doesn’t mean you can perform in your field.

More isn’t better—better is better. There are advantages to putting in the time and effort to master a skill, but there’s also a great need for balance.

“More isn’t better” is a real truism for so many things in our world. We should question whenever something or someone simply wants more of us: more hours, more years of training, more free labor, more notches on the CV belt. It’s not necessarily that the “more” is inherently bad—it almost never is—but that doesn’t mean it’s worth it.

Sukhvinder Obhi, a neuroscientist at McMaster University, coined the term “power paradox” to describe what happens when we gain power through leadership: we subsequently lose some of the capabilities we needed to gain it in the first place—such as empathy, self-awareness, transparency, and gratitude.

The power paradox explains much of the bullying we see within strict hierarchies: how excrement rolls downhill from the top of a poorly-run organization all the way to the youngest least experienced students who are just doing their impressionable best to insulate themselves from the worst of indoctrination as they grow.

[Cal Newport, author of So Good They Can’t Ignore You] believes that we need to be craftspeople, focused on getting better and better at how we use our skills, in order to be valuable to our company and its customers. The craftsperson mind-set keeps you focused on what you can offer the world; the passion mind-set focuses instead on what the world can offer you.

There are some people who in life (or medical school), are confident they know exactly what they want. They are passionate about dermatology and orthopedic surgery. That’s great.

But I don’t think there’s anything wrong with the rest of the world, those who simply don’t know or seem to be missing that “passion.” I agree with Newport that passion is something you can grow through competence and the craftsmen mentality. There are no perfect jobs or fields. There are good and bad aspects to everything, and suggesting otherwise drives so much anxiety in the specialty and residency-selection process.

Success has more to do with you, your goals, and your perspective than it does with exactly what box you place yourself in.

 

What Money Buys

10.14.20 // Finance, Reading

From How to Think About Money by Jonathan Clements:

First and foremost, money buys time and autonomy. Secondarily, it buys experiences. Last, and least, it buys stuff, and more often than not, the stuff we buy makes us miserable.

Most people live their lives with these in the opposite order, but Clements is absolutely right.

You don’t have to be a FIRE-fanatic to realize that setting up your professional life, spending, and saving to optimize for number one is the winning strategy.

Simple Sabotage

10.12.20 // Miscellany, Reading

Simple Sabotage: A Modern Field Manual for Detecting and Rooting Out Everyday Behaviors That Undermine Your Workplace is a book inspired by a real World War II CIA field manual called “Simple Sabotage” that was written to help “guide ordinary citizens, who may not have agreed with their country’s wartime policies towards the US, to destabilize their governments by taking disruptive action.” You can read the declassified original document at that link.

It’s short and fascinating and much of it is timeless. Operationally, it functions as a “how-not-to” for creating an efficient organization. The CIA’s top 3 takeaways:

1. Managers and Supervisors: To lower morale and production, be pleasant to inefficient workers; give them undeserved promotions. Discriminate against efficient workers; complain unjustly about their work.

2. Employees: Work slowly. Think of ways to increase the number of movements needed to do your job: use a light hammer instead of a heavy one; try to make a small wrench do instead of a big one.

3. Organizations and Conferences: When possible, refer all matters to committees, for “further study and consideration.” Attempt to make the committees as large and bureaucratic as possible. Hold conferences when there is more critical work to be done.

These points were once felt to be a great way to sabotage Nazi Germany, but they seem to have been voluntarily taken up by most modern American businesses.

A good example from the book is the “obedient saboteur,” someone who—by doing exactly what he’s told to do—is actually making things worse:

This problem can be particularly acute in organizations with a culture of “continuous improvement.” Continuous improvement is a business philosophy created by W. Edwards Deming in the mid-twentieth century. This philosophy thinks of processes as systems and holds that if each component of the system constantly tries to both increase quality and reduce costs, efficiency and success will follow. But taken to an extreme, even continuous improvement can lead to sabotage.

One company we know had a call center manager driving his team to move from an average pickup speed of 1.4 rings to 1.2 rings. The division head asked, “How often do callers abandon us after only 1.4 rings?” “Almost never,” he was told. “Virtually no callers who actually intended to call us hang up before the third ring.” Yet the call center manager persisted in trying to ensure that all calls were answered more quickly each year. Why? Because getting the phones answered quickly was his job—by definition, quicker was better. He never thought to question whether he had crossed the threshold where process had overridden outcome. He had become one of the Obedient Saboteurs. If you asked him why he was trying to lower pickup times, he would tell you that faster pickup means improved customer experience. That’s true—but the threshold is three rings. Once you get below three rings, faster pickup times don’t continue to improve the customer’s experience anymore.

The problem we see, time after time, is that nobody bothers to go back and tell the call center managers of the world to go continuously improve something else.

To keep this kind of sabotage out of your group, step back and conduct a formal review of any continuous improvement programs you have in place. If they aren’t relevant anymore, pull the plug.

Also see: measure what matters.

To fight back, ask yourself:

What is the stupidest rule or process we have around here?

What are the three biggest obstacles you face in doing your job?

If you could rewrite or change one process or procedure, what would it be and why?

A lot of quality improvement isn’t real:

It’s adding clutter. It’s replacing content with process.

We should be just as ruthless when evaluating quality measures and metrics as we are with the fail points that inspire them.

Status Quo Bias

10.07.20 // Miscellany, Reading

From Machine, Platform, Crowd: Harnessing Our Digital Future by Andrew McAfee and Erik Brynjolfsson:

Research in many different fields points to the same conclusion: it’s exactly because incumbents are so proficient, knowledgeable, and caught up in the status quo that they are unable to see what’s coming, and the unrealized potential and likely evolution of the new technology.

This phenomenon has been described as the “curse of knowledge” and “status quo bias,” and it can affect even successful and well-managed companies.

There are a lot of bad actors in healthcare that I would love to see fall prey to the curse of knowledge.

When “value” became shorthand for “economic worth”

10.05.20 // Reading

From Doughnut Economics: Seven Ways to Think Like a 21st-Century Economist by Kate Raworth (emphasis mine):

Despite such misgivings from the twentieth century’s two most influential economists, the dominance of the economist’s perspective on the world has only spread, even into the language of public life. In hospitals and clinics worldwide, patients and doctors have been recast as customers and service-providers.

There may be no perfect frame waiting to be found, but, argues the cognitive linguist George Lakoff, it is absolutely essential to have a compelling alternative frame if the old one is ever to be debunked. Simply rebutting the dominant frame will, ironically, only serve to reinforce it. And without an alternative to offer, there is little chance of entering, let alone winning, the battle of ideas.

But when political economy was split up into political philosophy and economic science in the late nineteenth century, it opened up what the philosopher Michael Sandel has called a ‘moral vacancy’ at the heart of public policymaking. Today economists and politicians debate with confident ease in the name of economic efficiency, productivity and growth—as if those values were self-explanatory—while hesitating to speak of justice, fairness and rights. Talking about values and goals is a lost art waiting to be revived.

I love that.

And the example of healthcare I think is exactly right. Everything is a business—that’s unavoidable. It isn’t even a bad thing. Lose money and you won’t be in business very long. But not all businesses need to be organized with the primary purpose of optimizing productivity and growth.

Good patient care is inefficient. Talking to people—understanding their perspective and helping them become active participants in their health—takes time. A patient visit was never meant to be an assembly-line 15-minute med check.

It’s not that we should applaud or celebrate inefficiency. There is plenty of waste to trim in any enterprise. It’s that these ideas—efficiency, productivity, and growth—should be tools to achieve meaningful ends, not the primary endpoint. Measure what matters.

And if some of that extra “value” makes it to the actual workers? Much of our economy is predicated on individuals misallocating their income away from savings and away from optimizing their time:

As economist Tim Jackson deftly put it, we are ‘persuaded to spend money we don’t have on things we don’t need to make impressions that won’t last on people we don’t care about’.