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Interactive Teaching (JiTT & PI)

“Don’t let your education get in the way of your learning.”

-Mark Twain

How can we match the way we teach with the way our brain learns?

Modern educators have created a series of principles that can accomplish this important goal:

1. Two way communication between the teacher and students combined with active learning increase processing and rehearsal by the working memory, increases understanding, and amplifies meaning.

2. Establishing a cooperative environment where students work together allows learning to continue after the class session. Students teach each other. The most effective way to learn is to actually teach, because this requires the highest degree of mental processing and greatly increases the likelihood that  long-term memories will be produced.

3. Teachers must have high expectations of their students. This provides motivation and emphasizes that the teacher feells what he or she is teaching is important. It has meaning and when the teacher convinces the student the lesson has meaning it has a greater likelihood of being incorporated into long-term memory.

4. Respect diverse talents and ways of learning. Some individuals learning best by listening and speaking, others learn best by diagrams and pictures, still others learn by writing and reading. Therefore it is important for each teacher to use diverse techniques and formats to reach all their students.

5. Rapid feedback to allow the students to understand their errors quickly. Rapid feedback also allows the student to experiment with new techniques for learning and to quickly decide if these changes are of benefit.

PowerPoint Lectures and Lecture Notes Do Not Accomplish These Goals

Because professors know that past national board examinations have covered  preclinical medical sciences in frightening detail, they feel obligated to include excessive detail in their oral presentations. In order to cover such large amounts of material, and allow the majority of students to pass the course, PowerPoint lectures are reproduced as notes with the understanding that students will only be responsible for the facts included in these documents. Tests consist of multiple-choice questions that primarily require the recognition of specific facts. When basic medical sciences are taught in this way, students find these subjects overwhelmingly complicated, and unappealing.

This approach ignores the basic tenets of the modern effective learning. PowerPoint lectures establish the professor as an authoritative expert, rather than as a collaborative coach, and are a form of one-way communication that minimizes active learning. These static lectures also fail to create conditions for cooperative leaning among students. Use of PowerPoint notes and multiple choice questions sets low expectations for students to simply memorize facts, rather than develop a deep understanding of the field. This approach fails to respect the students’ diverse talents and ways of learning. Finally and most important standard lectures have been shown foster few long-term memories (See long-term memory pyramid below)

Long-term Memory and Different Forms of Teaching

Long-term Memory and Different Forms of Teaching

New electronic teaching methods
Small class rooms, and small group interactive sessions can accomplish all of these goals; however in medical school and many higher education environments, classes tend to be larger, and there is insufficient time for professors to teach multiple small groups. Fortunately advances in computer science and electronic communication systems now allow educators to accomplish these goals in large group settings.

Our scientific colleagues in physics with the support of the National Science Foundation have created two methods that together have consistently improved student performance on objective tests that measure understanding. These same methods have now also been applied successfully to the teaching of mathematics and biology. We believe they should also be applied to the teaching of the medical sciences in conjunction with edited reference sources, small group discussions, and assessment by essay questions in addition to multiple choice formats.

Just-in-Time Teaching (JiTT)
Before each large group session, students are required to email the answers to three warm-up questions, two designed to emphasize key principles that are to be covered during the upcoming teaching session, and a third open-ended question “What didn’t you understand about this material? Or if you understood everything, what did you like or dislike about the material?” (See Teaching diagram below).  Questions are included as part of the syllabus. Answers can be emailed to a common site and downloaded onto a spreadsheet, allowing the instructor to review the answers several hours before the large group session. The instructor can copy and paste examples of ideal answers, wrong answers, and specific comments about the material onto their PowerPoint slides, and discuss their content. This exercise encourages students to prepare ahead of time, usually the night before, and allows them to sleep on these ideas, increasing the chances of creating preliminary long-term memories. To properly answer these questions students have to read and discuss possible answers. However, if students obtain answers from those who have previously taken the course, the purpose of JiTT is defeated.

By preparing the night before, the students have created a network of facts and ideas that can be linked to the content of the large group session, increasing meaning and understanding (the key conditions for establishing long-term memories). By reviewing the answers before the session, the instructor can tailor the discussion to the specific needs of the students. All misunderstandings can be clarified during the teaching session ie. just-in-time (see

Typical Large-Group Interactive Session

Typical Large-Group Interactive Session

Peer Instruction (PI)
This method converts conventional lectures into interactive sessions requiring the students to actively participate. Before each major section of the lecture, a  multiple choice conceptual questions is presented (See  Figure 1). Each individual student first takes 1 minute to decide on an answer, and then confers with the 3-4 other students on his or her team for 2 minutes. The group comes to a consensus and electronically answers the question. A computer program compiles the answers and creates a bar chart that is projected on the screen. The students actively work with the material and teach each other. The instructor then goes over the answers, and explains why one answer is correct and others are not. At this point students should be encouraged to ask questions.  It is important that the instructor maintain a supportive empathetic tone, and encourage students to actively think about why one answer is most appropriate. Usually 3-4 concept questions (one every 10-15 minutes)  are included, and monologues by the instructor never last longer than 10 minutes. The interactive questions allow the working memory to rest and allows attention span to reset and sensory input from the immediate memory to again be efficiently transfer to the working memory. (See the graph of attention below)

Peer Instruction Lowers Working Memory Fatigue

Peer Instruction Lowers Working Memory Fatigue

Whenever possible, sessions should illustrate how understanding the pathogenesis of disease can explain the clinical manifestations. Questions related to the diagnosis and management of real medical cases are particularly motivating to the students. When possible questions on differential diagnosis should be included at the end of the session to allow the students to apply what they learned (transferance). Students enjoy questions related to this form of problem solving. Furthermore, diagnostic reasoning tends to be ignored in large group sessions, despite the fact that this skill is required in virtually all fields of clinical medicine.

Peer instruction encourages two-way communication, and active collaborative learning. This method reduces the factual content, thus minimizing working memory fatigue. Understanding and meaning are emphasized, establishing the ideal conditions for creating long-term memories.

Further Reading:

  1. Mazur E. Education. Farewell, lecture? Science; 2009 Jan 2;323(5910):50-1.
  2. Mazur E. Peer Instruction. Upper Saddle River, NJ: Prentice Hall; 1996. 253 p.
  3. Southwick FS. Spare me the Powerpoint and bring back the medical textbook. Transactions of the American Clinical and Climatological Association. 2007;118:115-22.
  4. Zemelman, S, Daniels, H, Hyde H. Best Practice: Today’s standards for teaching and learning in America’s schools, Portsmouth, NH, Heinmann; 2005. 336 p.