Carrot or stick? On training medical students

Like many of my colleagues, I teach and supervise students, residents, nurses, and respiratory therapists. I’m also the medical director of a PICU. Overall, I’ve been teaching and doing administration for over 30 years. And, like most of my colleagues, I never received any formal instruction at all in how to do these things. To some extent I got help from my own mentors, primarily by watching what they did, but basically I learned on the job. I hope I am reasonably good at it, but really, I have little way of knowing if I am. So I’ve always had an interest in whatever tidbits I could pick up in teaching theory that might be useful. One particular topic that’s always interested me is the opposing pros and cons of reward versus punishment. I use those tools to train my horse – rebuking bad and praising good behavior. What do we know about applying them to people?

The practical problem, one faced by most teachers, is what to do when a student does a poor job. The tradition in medical teaching, certainly when I was in training, was to lean heavily on the rebuking, punishing side of the equation. Public ridicule was common, and there was more than a little yelling involved. Did fear of that help me avoid doing the wrong thing next time?

Recently I was reading one of my favorite group blogs, Crooked Timber. Most of the contributors are professors of one sort or another, and the topic of effective teaching comes up now and then. This whole reward/punishment tension was the topic of a recent post there. The situation it describes involves military flight instructors, who universally believed that yelling at fledgling pilots when they made mistakes was much more likely to make their next attempt better than was praising a good action. Here’s what one instructor had to say about it:

“On many occasions I have praised flight cadets for clean execution of some aerobatic maneuver, and in general when they try it again they do worse. On the other hand, I have often screamed at cadets for bad execution, and in general they do better. So please don’t tell us that reinforcement works and punishment does not, because the opposite is the case.”

It’s a military example, but training doctors has traditionally been done using that sort of get tough model. I was aware of a statistical principle called the regression to the mean, but this example applies it to teaching in a way I hadn’t thought about. The argument goes like this.

If a given student does a bad job at something, that is more likely to be a low point for them, below their average. Statistically speaking, they are more likely to do better on the next attempt no matter what the teacher does. So the teacher is likely to think whatever he or she did – screaming, for example – as causing the improvement. On the other hand, if a student does an exceptionally good job, the same regression to the mean makes it likely the next attempt won’t be as good, so whatever the teacher does – in this case praising – tends to cast doubt on the usefulness of praise.

For myself, I think praising, in the long run, works much better. I’d be interested in what any professional teachers think about this.

In the comment trail to the article, the classic The Art of Raising a Puppy was cited as a useful source. That was interesting.


4 responses to “Carrot or stick? On training medical students”

  1. I’ve never formally taught, but of course I’ve been taught many things. Motivationally, I hate to say it, but a bit of negative pressure works on me. For maintaining or improving a well-mastered task, only praise will do.

  2. I’ve never done well with yelling and ridicule, either. Most teachers in the medical world who use those things do so, I think, because it was done to them. It’s all they know.

  3. Hey Chris,
    isn’t that one of the great things about bein a Doc?? Getting to call yourself a “Professor” without goin to Professor-School like those loser Ph.Ds…
    Hard as it may be to believe, I to, was a Professor for a short while, till they noticed I only taught
    female students, make that attractive female students, make that Stunningly-Attractive-Super-Model-Quality-Female-Students. Oh, I had Male students, but they usually bailed out after sittin in the OR for 10 straight hours without a break, hey, they said they wanted to be treated like residents…
    And if it wasn’t for being rebuked/punished/humiliated for most of my 2 years of 3rd year Med School I probably wouldn’t have gone into Anesthesia,
    which only losers/FMG’s/antisocial Ass-burgers went into in the mid 90’s…
    In fact, I still remember that the murmur of tricuspid stenosis is increased with a Valsalva maneuver after being humiliated Oliver Twist Style for not knowing that fact-oid on Internal Medicine rounds
    OK, probably not knowing what the Tricuspid Valve,Stenosis, or Valsalva Maneuver was probably didn’t help either…
    In fact I still remember some haughty Internal Medicine Resident sarcastically “Congratulating” me on “Matching” into Anesthesia…
    Still see the guy around occasionally on my way out of the hospital at 4, I mean 3:30pm(on my “long” days), doing his “Hospitalist” thang, looking like one of those Laboratory Rats on his Hamster Wheel of endless rounding/consults/admissions…:)
    So don’t be afraid to set some Snot Nosed Med Student straight, some people need Tough Love…


  4. Hi Frank:

    I did some peds anesthesia as part of my critical care training. What I recall is the “hours of boredom — moments of terror” thing. I found I preferred something in between.

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