Portal de Periódicos da CAPES

16th Annual Pauline Cerasoli Lecture Life Lessons: Teaching for Learning That Lasts

2013; Lippincott Williams & Wilkins; Volume: 27; Issue: 3 Linguagem: Inglês

10.1097/00001416-201307000-00003

1938-3533

Elizabeth Mostrom,

Empathy and Medical Education

Education Section President Peggy Gleeson, Cerasoli Lecturer Elizabeth Mostrom, and APTA President Paul Rockar.In rivers, the water that you touch is the last of which has passed and the first of that which comes. Leonardo Da Vinci It is with great humility and trepidation that I stand before this audience of physical therapy educators today. I can only hope to fulfill the promise and meet the expectation associated with the honor of presenting the Polly Cerasoli lecture for 2013. I was never fortunate enough to count Polly as a close personal or professional friend and colleague, but I have read and heard much about her accomplishments and characteristics over the years. As I read tributes about Polly, most notably those shared by her colleagues Bette Ann Harris1 and Colleen Kigin, 2 it was clear that Polly was an esteemed educator and leader who possessed many characteristics that Colleen and Bette Ann referred to as the 5 Cs: (1) she was committed to others, her profession, and to her ongoing learning and development; (2) she was caring and considerate— these were key elements of her mentoring and leadership style; (3) she was collaborative and adept at building teams; (4) she was comfortable with change, albeit not without some nervousness, wisely recognizing that change is never easy for most; and (5) she was comfortable with herself—with who she was and the paths she was following. That's a tall order! I most certainly do not posses all of those characteristics, but I'm honored to be a recipient of this lectureship in her memory. If we strive to share some of Polly's attributes, we will all be better for it. Let me say a few words, however, about my interactions with Polly over the years. As a novice physical therapist educator, I was able to observe and admire Polly's contributions and commitment to the profession during my first decade of learning to be a physical therapy faculty member, and as I began to engage in a variety of activities in our professional organization and the Education Section. Then, in the early 1990s, a few years before the brutal attack in 1996 that changed her life—and ours—forever, I got to meet Polly more personally when she came to Central Michigan University as a CAPTE candidacy reviewer. Of course, this was a "high stakes" visit—one that can engender uncertainty if not full-blown anxiety. And there she was: tiny Polly with her red hair and infectious smile, full of energy, enthusiasm—clearly committed to the advancement of physical therapy education and the development of future practitioners, supportive of our efforts, and full of excellent consultative insights and recommendations, borne of experience, which proved to be immensely valuable on our path to initial accreditation. Thank you, Polly. In preparing for this lecture, which I always look forward to at every CSM, I read through the previous Cerasoli lectures, most of which I had the privilege of listening to with eagerness— always leaving with new inspiration. So many previous lecturers are individuals whom I have admired and respected over the years; they have been exemplars of excellence and extremely important role models to me as I sought to craft my identity as physical therapist, educator, and as a person. As I read the wise words of those that have gone before, the immediate metaphor that came to mind was that of "standing on the shoulders of giants"— as in the canopy of a beautiful stand of Aspen trees—but the height invoked by that image made me very uncomfortable. Thus, my next image was that of a little mushroom pushing up through the rich loam below towering trees that have dropped their leaves for the season, only to enrich the soil and foster new growth in the spring. So that is the starting point for my lecture. I do want to take a moment to thank the individuals who nominated me for this recognition. I was most honored and surprised to learn that they were former students: Thank you to Don Straube and Keir Ringquist who initiated the nomination, and thanks also to my friends and colleagues who wrote letters of support for the nomination. The title of my talk today is "Life Lessons: Teaching for Learning That Lasts." A wise teacher once told me that when making a presentation I should share my take-home message early and clearly, while listeners are still with me. So here it is: My message today boils down to the conclusion that the intersubjectivity and relational stance between teachers and learners is of critical importance in fostering learning that is lasting and meaningful in the lives of both teachers and learners. Now, I'd like to walk through some of the waypoints in the intellectual, professional, and personal journey that brought me to this place. For many years, like so many of you, I have had an abiding curiosity about what makes for "good" teaching and "good" learning, learning that is not just for the moment or a particular situation but learning that has staying power, learning that is deep and has the power to transform learners and carry forward meaningfully with them into their professional and personal lives. These leaders could be patients, students, fellow therapists or other professionals, friends, or family members. This interest has led me, along with other colleagues and several of my graduate students, toward investigations that have had various forms and foci—investigations of the nature of expertise in clinical practice and clinical teaching, of the learning of individuals who worked with outstanding clinicians and clinical teachers, and the learning of PT students, including my own, as they progress through the professional curriculum and enter their early years of practice. Most recently, my able coinvestigators, Gail Jensen, Jan Gwyer, Laurie Hack, and Terry Nordstrom, and I have turned our attention more broadly to trying to uncover and understand what constitutes excellence in physical therapist education in academic and clinical environments through our study, "Physical Therapist Education for the 21st Century." Today, however, I really want to focus on the teacher and the learner—on the teaching and learning that may, or may not, be fostered and nourished by that relationship. In doing so, I'll share some findings from my studies and life experience, but also draw on the work of other educational researchers, theorists, and philosophers. Over the years in my own qualitative studies of expertise and teaching excellence,3,4 when I have asked outstanding clinicians and teachers to share an exemplar—a story about a memorable event that shaped who he or she is as a therapist or teacher—the stories inevitably turn to descriptions of a memorable teacher (be they a patient, instructor, or other colleague) and his or her personal qualities, attributes, and the teacher's relational stance to them as learners. So let me share a story of one teacher and leader as it was told by Christopher Clark, PhD, a highly regarded educational psychologist and researcher, who served as my dissertation advisor many years ago. This a story about a submarine captain—not a physical therapist —but listen closely to see and you may hear some connections with your own experiences as teachers and learners. I thought this would be an appropriate story to tell in this beautiful port city of San Diego that is home to so many Naval service men and women. Those of you who have served in the military, especially on submarines like Chris and my 103-year-old father, may have more direct connections. At the time of this story, Dr. Clark was a lieutenant and chief engineer on the submarine. Here is his telling as recounted in his book titled, Thoughtful Teaching5: Captain Carlin is 12 years older than I am…. As captain of the submarine he was a man of good humor, profound competence, and high expectations for his officers and men. He was a good teacher. A submarine is a complex and intense place to live and learn. The 3 different submarines in which I served were, basically, steel cylinders 16 feet in diameter and 300 feet long, crammed with all manner of equipment and people. It is an extremely intense learning environment. The safety of the 75 crew members depends, to a great extent, on how well everyone learns to operate and repair every electrical, hydraulic, mechanical and pneumatic system on board. Everyone has a personal interest in everyone else's learning. Our lives depend on the competence of the newest crew member. This makes for a highly motivated learning community. In this exotic context, what made Captain Carlin a good teacher? In part, it was his affirmative personality, good humor, and encouragement by example. He was very knowledgeable about all aspects of submarine operations, and he was also open to learning new ways of doing things. He was eager for deeper understandings of the ship, the sea, and of the people with whom he worked and lived. He recognized that the unique character of this particular submarine must be learned patiently over time. He also taught me that the character of the crew could be cultivated but not imposed from above. He knew that building on the strength of each individual crew member is crucial, and that expressing respect for and interest in each person was one of the keys to his leadership. In part, he managed by wandering around the submarine, collecting each of our stories. But lest you think Captain Carlin was larger than life, he also showed us his human frailties and vulnerabilities. He did all of the grocery shopping for his family of 6. He mowed his own lawn. He was uncertain about how to raise his 4 children, and, as a father of pre-adolescents at the end of the 1960s, he had many reasonable fears about what could befall his boys and girls. He had car trouble, and he chewed his fingernails. He not only collected stories from each of us, he also told stories of his own life, his childhood, his weekend, and of his chilling feelings when he was a missile officer on a Polaris submarine during the Cuban missile crisis. One other fact about Captain Carlin will help you appreciate him as a leader and a teacher: he put great energy into promoting and publishing the accomplishments of our ship and our crew to the Division Commander and the Squadron Commander. Our captain was our advocate; he was the teller of good news, the one who made us proud to be on the USS Amberjack. We rose to the occasion; we fed his need to tell good news by creating more of it…. One morning we were returning from 2 weeks at sea, and I was to be the Officer of the Deck, to bring the ship upriver and moor alongside the pier. Shiphandling in this situation is a difficult and hazardous team effort, and I was a relatively inexperienced 25-year-old shiphandler. The captain stood behind me as I navigated the river, came through a narrow drawbridge, and gave orders to helm and engine room that brought us smoothly alongside the pier. It was a very good landing. What was the captain's role in this good landing? First, he kept silent throughout, letting me know that I was in charge. Second, he was present and alert, giving me reassurance that, if the situation became especially difficult, I could call on him for help. And third, he was sufficiently aware of the particulars of solving this complex piloting problem, on this particular day, that his congratulations to me and our debriefing afterwards carried great meaning, credibility and instructional value. I still remember his first words of that conversation 25 years ago. The captain said, 'Lieutenant Clark, that was a fine landing. It cost me only three fingernails.'5(pp7-9) So here we have a portrait of a good teacher, in a setting quite different from school or the clinic—but how different is it? What emerges in this story is a picture of a dedicated teacher who is, yes, credible, competent, knowledgeable, and has high standards for himself and his crew, but also one who is a gatherer and teller of stories—those of his learners and those of his own—through which a bond of humanity, concern, vulnerability, and mutual respect and trust is formed. One who is thoughtful, alert, and present. One who knows when to assist, guide, and support and when to let go, to pass the baton, as it were. One who is an advocate for his learners and celebrates their accomplishments. This is a portrait of a good teacher and a good person, a teacher who leaves his learners with "life lessons." Dimensions of Good Teaching I'd like to explore each of these dimensions of good teaching with you a bit further today. But first let me point out that these are personal qualities, perhaps I should call them gifts, which I have heard about many times before in my studies of exceptional clinical teachers and the students with whom they worked. You might also recognize these as attributes of the expert physical therapist clinicians that Gail Jensen, Jan Gwyer, Laurie Hack, and Kay Shepard have so elegantly described.6 Listen now to the words of an outstanding clinical teacher describing the influence of a former clinical instructor (CI). I'll call this teacher Kathy. Here are Kathy's recollections of this memorable CI as she uses this memory to inform her everyday practice as both a therapist and clinical teacher: It wasn't necessarily her clinical skills that made me think she was such a good clinical instructor … she had very good clinical skills but they weren't the key; it was more her personal skills. She treated me as a peer. She found learning opportunities for me, but she treated me as a peer in front of patients, in front of other staff members, in front of physicians, nurses, other team players. She gave me feedback and the confidence to continue with what I was doing …. She had a lot of qualities—she was very thorough and she was very dedicated to her patients; she was a strong patient advocate and student advocate. So some of those skills have affected me in positive ways as a clinician, but you also need those skills with a student. She was dedicated to my learning and she was very thorough and thoughtful with my own learning.4(p159) Does this description resonate with that of Captain Carlin? Thoughtful Teaching So let's explore this notion of being a thoughtful teacher. Here, I will draw first on the work and writing of Clark5 and Max van Manen.7 These authors have pointed out that the use of the term "thoughtful teaching" highlights 2 aspects of thoughtfulness. First, that teaching is indeed an intellectual enterprise; it requires that an individual is steeped in his or her disciplinary knowledge and able to determine how to adequately represent, or translate, disciplinary knowledge and skill in a way that allows others to come to understand. As Clark5 points out, "teaching demands a great deal of thought … problem solving, and decisionmaking."(p xv) Second, thoughtfulness is about the way we use the word "thoughtful" in everyday parlance. When you think of someone who you would describe as thoughtful, what image does that evoke? For most, we may think of someone who is considerate and kind, tuned in to the moment and to another's perspectives and feelings, such that they can be empathic and respond in ways that are supportive or encouraging when necessary. They are mindful. They are tactful. It is sometimes challenging to define what we mean by everyday words like "thoughtful" or "tactful," although we know it when we see it—and we certainly miss it when it is absent! In his treatise on tact in The Tact of Teaching: The Meaning of Pedagogical Thoughtfulness, Max van Manen7 claims that pedagogical tact is a "special case of general social tact."(p137) He urges reflection on the meaning of tact and identifies several aspects of general social tact: (1) Tact means the practice of being oriented to others—the practice of otherness; (2) To be tactful is to "touch" someone, and such touch can be more powerful than a thousand words; (3) Tact cannot be planned and a corollary to this aspect; (4) Tact knows no rules—yet tact is not unruly. That is, tact governs praxis (as in "thoughtful action") but it cannot be reduced to rules—it requires a careful reading of social situations to determine what action or words are most appropriate in the moment. Finally, (5) Tact is governed by insight while relying on feeling— it is a practical intelligence that is caring; such embodied knowledge is enabling knowledge.7 Van Manen7 goes on to explore how pedagogical tact manifests itself and why it is important in teaching. Although his original work is oriented toward the teaching of children, I think you will see that tact also is critical in the teaching and learning of adults and, specifically, future health professionals. His tenets are shown in Table 1 and elaborated on below; see if you envisioned these manifestations of tact in the story of Captain Carlin or the voice of Kathy as she described her clinical instructor:Table 1: Manifestations of Pedagogical Tact as Described by Max van Manen 7 Tact shows itself as holding back; sometimes the best action is nonaction— knowing what to leave unsaid, when not to notice, or when not to step in. Tact shows itself as openness to the learner's experience; tact asks "What is this experience like for the learner?" Tact shows itself as attuned to subjectivity; it treats the other as a subject, not an object. Tact shows itself as subtle influence; it does not always jump out at you, but it is omnipresent. Tact shows itself as situational confidence; it is a tone or a stance in unpredictable or uncertain encounters. It is not fake or false confidence. Tact shows itself as improvisational gift; teaching and learning require constant improvisation. What does pedagogical tact do, according to van Manen?7 Tact preserves a learner's space; growth and learning require space. Tact protects what is vulnerable. Our learners—patients or students—are vulnerable. Tact prevents or mediates hurt; it lessens scarring from experiences. Tact makes whole what is broken; it can heal. Tact strengthens what is good; to be tactful and believe in a learner is to strengthen that person. Tact recognizes and enhances what is unique about the learner. Tact sponsors personal growth and deep learning. Van Manen7 concludes by claiming that the significance of tact is that it "gives new and unexpected shape to unanticipated situations—it turns incidence into significance."(p187) Thus, it is the ability of gifted teachers to "see pedagogical possibilities in ordinary incidents, and to convert seemingly unimportant incidents into pedagogical significance that is the promise of tact for teaching."(p187) Finally, van Manen reminds us that "a touch of tact may leave a mark on the learner—this touch can work wonders."(p189) What Is the Experience of Tact and Pedagogical Thoughtfulness? How have you experienced "tact" in your encounters with teachers and learners? Did you hear and feel it in the stories of Captain Carlin and Kathy? Have you had experiences when you knew that tact was missing? I know that some of my own students have been touched by tact— or "pedagogical thoughtfulness"— in a way that has marked who they are becoming as therapists and people. I learn this by listening to their descriptions of "life lessons" as they conclude semester-length internships during the final professional year of our curriculum. As they end their internships, I ask them to share a "life lesson" with other members of a regionally based dialogue group who have met face-to-face and virtually as the semester proceeded to exchange and discuss their learning experiences in the clinic. These life lessons are described as "take-home messages," which they will carry forward with them into their professional and personal lives. Here are just 2 examples: I learned that it is good to be emotionally involved in your work. This is difficult to do, especially since you need to have a balance so you aren't drained on a daily basis, but it needs to happen to get that connection with your patient …. I learned that treating the whole person, not just the pain or dysfunction, but really investing in the patient, listening to their stories, letting them cry during the session, really trying to understand them as a whole before and after whatever it is that brings them to you—is what the healing process is about. I can do everything in my power to treat them, but without that component, true healing doesn't happen. My CIs were healers. This life lesson reminds me of the words of Abraham Verghese, physician and author of Cutting for Stone,8 who notes that one can be cured but not healed; and that we can heal in the absence of curing. In my view, this observation seems especially applicable to physical therapy. One other student described a lesson learned through the actions and words of her CIs, and herself: … the biggest lesson I have learned … is to expect the unexpected and to learn to remain calm in all circumstances. This has played out a lot in my last clinical and in my life …. As I continue forward, this is an area I plan to focus on because I like to have plans, and instead I must realize that very few things actually follow an exact plan. I feel that learning to handle these instant changes with grace and quiet confidence will be one of the most beneficial lessons for me in all areas of my life. So these 2 students had worked with CIs who modeled several of the aspects of pedagogical tact described above: They were attuned to their patients' and learners' experiences, they exhibited situational confidence in the face of uncertainty, they demonstrated the gift of improvisation, and they sought to mediate hurt and to heal. But their teaching also was intentional. Like the excellent CIs in my studies, their teaching was guided by their knowledge, skills, and teaching philosophy— but also individualized according to the unique level and needs of their patients and students. Let's return to another characteristic that we see in our portrait of a good teacher: a gatherer and teller of stories. An individual who uses narrative to connect teachers and learners not only with each other's experiences and shared humanity, but with professional or disciplinary knowledge. Let's briefly take a narrative turn. The Role of Narrative in Teaching and Learning I suggest that narrative can be an important tool for expressing pedagogical thoughtfulness and tact. I have to admit that I use the term "narrative" cautiously due to the extraordinary overuse and misuse of the term in public discourse today. It seems that everything is a "narrative" these days; however, it is not. The history of narrative begins with the history of humankind. Our lives are filled with stories and we all live storied lives. Even so, the use of the narrative form as a way of "coming to know" and gaining insight into human experience and understandings has not always been privileged or respected, especially in 20th-century positivist traditions and the world of biomedicine. We have all heard, read, and told illness narratives. In early work on the nature of medical discourse, Elliot Mishler9 suggested that such narratives direct our attention to the "voice of the lifeworld" of our patients. And yet, even today, when a great deal of focus has turned toward the importance of patient-centered care and even "narrative medicine,"10 it is frequently challenging to balance the voice of biomedicine with the voice of the "life-world."9 On a more promising note, over the last 3-4 decades, a number of influential individuals from a variety of disciplines began to advocate for what is referred to as a "narrative" or "interpretive turn" in our thinking and approaches to understanding human intention, action, and interaction.12-23 This list of authors is by no means exhaustive, and I can't touch on the contributions of all these writers today; but I do want to point out the plurivocality of the group. Here, we have individuals from numerous disciplines and professions— psychology, sociology, anthropology, medicine, nursing, occupational therapy, and education—all urging this turn. Many of these authors drew on the works of a variety of philosophers, including early and powerful theoretical works by John Dewey24,25 and Jerome Bruner.26,27 So what is narrative and what does it do? How can it serve teaching and learning? There is no single definition or binding theory of narrative, but authors do agree that narrative has characteristic features and functions that help us make sense of human experience in its socio-historical-cultural context. In the 1980s, Jerome Bruner, an influential educational psychologist, posited 2 modes of thought—each providing distinctive ways of ordering experience and constructing reality.26 Bruner suggested that these 2 modes, which he called the paradigmatic or logicoscientific mode and the narrative mode, were complementary but irreducible to the other (Table 2). My focus today is on narrative.Table 2: Two Modes of Thought as Posited by Jerome Bruner 26For Bruner,26 stories serve more than one purpose: They can be informational and transformational, descriptive and explanatory. Bruner also claimed that narrative was particularly powerful for understanding the human condition. When constructing or hearing a story, we enter into 2 "landscapes": the landscape of action—the situated action that involves an actor or agent, intention or a goal, events, and the sociocultural surround of that action and event—and the landscape of consciousness—what those involved in the story know, think, or feel. Thus, key features of narratives are that they bind agents and actions together in some pattern, creating coherence and connection and placing events and actions in unique contexts. Narratives have both distance (the narrator as an observer, taking a reiterative stance) and intimacy (the narrator as an actor). Furthermore, stories have a profoundly moral dimension; they bind tellers and listeners in reciprocal, joint meaning-making, and they can encourage communal reflection and create communal understandings and bonds. Today, many educational researchers and philosophers—Carol Witherell and Nel Noddings,23 Jean Clandinin and Michael Connelly,15 and Huber et al28 among them—have underscored the value of narrative as a tool for making sense of, and co-constructing meaning in, teachers' and learners' lives and practice. In addition, they have answered the clarion call of Lee Shulman29 for a rich case literature in teaching. Some of you are likely familiar with the work of Robert Coles, a thoughtful and prolific writer, who is also a physician, child psychiatrist, teacher, and editor. He is author of the book, The Call of Stories: Teaching and the Moral Imagination,16 and many others. I want to share a story from Coles' life experience where he describes the use of stories as ways of "teaching by heart" and "taking learning to heart."30(p39) This story was captured in the Foxfire interviews, conducted in the early 2000s, with influential educators from around the globe "who have made a difference in the way we perceive teaching and learning."31(p4) Like my interviews with exceptional clinical teachers, the Foxfire interviews started with a question about memory: These gifted teachers were asked about a memorable learning experience and the way that experience shaped who they were becoming and their work today. In Coles' interview, he recounted the memory of an experience he had in a fifth-grade classroom with a teacher named Bernecia Avery. The lesson was about American history, the tragedy of the Civil War, and Abraham Lincoln. This tragedy and the memory of Lincoln may be fresh in our minds for those who have had the chance to see the recently released Steven Spielberg movie and the remarkable depiction of Abraham Lincoln by Daniel Day Lewis. Here is a part of Coles' memory: I remember her telling us about Lincoln, and then I remember seeing her crying, as did others in the class. We all sat there fixed and silent, not restless as we sometimes were. She was in tears telling us about Lincoln and telling us about his decency, the way he felt for others, even as he was trying to advance himself. She made that distinction clearly to us—that the important thing in life was not only to do well but to think of others …. She urged us to think of Lincoln's example so that we might become more like him in our own lives.30(p36) Coles goes on to remember Avery telling her students that the important thing was not the dates of the Civil War or where Lincoln was born or died, rather, "the important thing was what kind of person he was, what kind of character he had, and how we might learn from him." In other words, she turned the Civil War into a melancholy look at history and insisted that we ought to think about history not only in the abstract but in the concrete."30(p36) That evening, Coles went home to talk with his parents about this experience. He realized that Avery "had given us a dramatic, personal, moral moment. She had told us not only about someone, a president, but also about something and someone who mattered to her; and she had brought history alive and connected it to personal introspection and storytelling in a very urgent and compelling manner. The result was that I remember that moment to this day, and it was well over half a century ago."30(p36) For Coles, this was a "surprising kind of instruction that clung to us in heart, mind and soul …. it shows how memory can connect to storytelling and to moral reflection in the listener's mind, as well as in the storyteller's mind."30(p37) As teachers, we have a responsibility to instruct in our respective content areas, but we also are moral and philosophical guides. Coles, along with many others, including those from our own field (Herm Triezenberg,32,33 Carol Davis,33,34 Ruth Purtilo,35,36 among others)