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Editorial |
1 From the Department of Diagnostic Radiology, Dana-Farber Cancer Institute, 44 Binney St, Boston, MA 02115-6084. Received August 10, 2004; accepted August 11. Address correspondence to the author (e-mail: kitt_shaffer@dfci.harvard.edu).
For years, radiologists have been doing their teaching correctly. From residency onward, most current practitioners can recall personal experiences of the classic noon conference teaching method known as the hot seat conference. This conference can be thought of as a slightly less intimidating form of the teaching method displayed in such movies as The Paper Chase. The "cold call" of law school seminars puts an individual learner on the spot and forces him or her to perform in front of the entire class. In a similar manner, the hot seat is both a challenge and an opportunity for each learner to show what he or she knows.
The origins of this teaching method are unclear, and little has been written about it from the educational point of view. It is just the way we have always done things. If we attempt to dissect what potential benefits this teaching style might have, some interesting features emerge that correspond precisely with current paradigms of educational theory.
The hot seat is a case-based teaching method. Case-based methods are much in vogue in business schools, law schools, and medical schools (1,2). The hot seat is interactive. This is considered essential to optimal learning (3). It is also stressful. This is a two-edged sword. A mild degree of stress undoubtedly aids in memory and retention (4). Too much stress can interfere with performance (5,6). The hot seat encourages engagement by other audience members, sometimes requiring them to answer questions that the hot seat holder cannot. This fosters active listening or "vicarious learning," which is another positive attribute (7,8).
In an ideal hot seat session, the instructor has a very difficult but very rewarding role. A well-run conference of this type allows learners to direct the teaching to a modest or large extent, depending primarily on the skills of the instructor. Having learners set their own agendas and direct their learning greatly enhances any educational experience (9). Of course, the hot seat can be abused, and we have all seen examples, hopefully rarely, of sessions where learners were demeaned or made to feel inadequate. The hot seat must be used judiciously, and various methods have been proposed to relieve this potential stress (10,11).
A skillful hot seat conference leader can choose from many images to show, depending on questions raised by the audience or areas of confusion that become evident on the basis of the discussion at hand. Additional examples can be shown to clarify difficult points, and the conference may take a very different direction based on what the learners want or need at any given moment. No two hot seat conferences are ever the same, even if the instructor has brought in the same radiographs.
Many hot seat instructors like to draw on radiographs. A picture is truly worth a thousand words, and simply pointing to the right paratracheal stripe on a radiograph does not convey a fraction of the information that is available by drawing that stripe and graphically depicting its relationship to the azygos vein. Structures on radiologic images, particularly conventional radiographs, are often subtle and complex in contour. Simply pointing is often inadequate.
If one attends conferences or reads articles about theories of medical education, it is amazing how often the topics raised and suggestions for best practice seem to be describing a hot seat teaching session (12). Interactive, learner-directed, case-based teaching is the ideal toward which medical educators are striving, and we have been doing this all along.
We are, however, at risk of losing this valuable advantage. In the conversion from radiographs to picture archiving and communication systems, the emphasis in many noon conferences has been toward use of slide-based didactic teaching presentations. There are many reasons for this, most of them having to do with the easy accessibility of digital images, the familiarity of most radiologists with the most common presentation software, and the satisfaction of preparing an elegant and complete set of teaching images for future use.
The downside of this is obvious. We are changing from learner-centered teaching to instructor-centered teaching. We are focusing on delivery of information rather than exploration of learners’ thought processes (13). We are working hard to put together a talk so that we will not have to modify it in the future and so that it will be very easy to deliver. By their very nature, most slide-based talks are linear, with topics delivered in fixed order, and we are sacrificing image quality and the ability to delineate subtle structures graphically on the fly as particular questions arise.
There are many ways to preserve some of the good things about film-based hot seat teaching. Slide-based teaching need not be purely didactic. Cases can be assembled into slide shows, with the intent of having learners discuss them in a hot seat format. Even purely didactic presentations can be made more engaging by including effective animations and creative annotation to delineate subtle findings or by maintaining a case-based organization (14).
Technologic advances may soon allow routine audience participation through the use of keypads or wireless interfaces, which could lend even more of an interactive element to didactic talks (15). The inherent linear nature of slide presentations, however, limits freedom to move among cases on the basis of student needs. The necessity to store images in a compressed format at a size that is not cumbersome also limits the quality of the projected image and does not allow magnification on demand.
The Web can offer interactive teaching solutions if used creatively. Web sites that merely show a series of radiographs or computed tomographic images with every possible anatomic and pathologic finding labeled are not of great educational value. Reading through a series of these images is about as entertaining as reading the encyclopedia. More thought must be given to Web site design in an attempt to emulate an interactive hot seat experience (16).
Web sites should provide small chunks of information that are repeated several times in several possible clinical settings, in the same way that a topic might be explored in a hot seat teaching session (17). Typical questions, such as "What if the patient were 30 years old instead of 60 years old?" "What if this were a man instead of a woman?" "What if the patient had a history of human immunodeficiency virus?" might come up in an effective hot seat conference to force a learner to explore the connections of a particular bit of knowledge to other knowledge they might already have. It is these "semantic networks" that allow learners to remember and apply what they have learned and, in particular, apply it to new and unfamiliar settings (18).
In noon conference settings, we must explore more creative methods than simply showing the slides we prepared for some other conference to our eager residents. It takes time and effort, but it is feasible to do everything that was done in the "old-fashioned" film-based hot seat conference with digital methods.
A folder of digital images on a laptop can substitute for a folder of film-based images. A digital drawing tablet can substitute for colored markers. A computer with enough video memory can be used to display a separate screen to the learners; this allows the instructor to keep notes and other information about the cases, such as the diagnosis, away from the eyes of the learners. Full-resolution images can be directly displayed and zoomed in real time by using photograph editing software. In this way, the view for each learner is actually better than that in a film-based teaching session (19).
We as radiologists have been doing medical education correctly for a long time. We are in danger of losing this advantage through a limited vision of what the digital revolution means to teaching. We should look closely at the new tools at our disposal to find innovative ways to enhance our teaching, while preserving the essential elements that made it so good in the first place. We owe it to our students, residents, and fellows.
FOOTNOTES
Author stated no financial relationship to disclose.
REFERENCES
This article has been cited by other articles:
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  B. Hassan, R Jacobs, W. Scarfe, and W. Al-Rawi A web-based instruction module for interpretation of craniofacial cone beam CT anatomy Dentomaxillofac. Radiol., September 1, 2007; 36(6): 348 - 355. [Abstract] [Full Text] [PDF]
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