All of us have experienced those rewarding times in learning when something clicks and the light goes on in our brain. Something we’ve been struggling to make sense of is finally resolved! These light bulb experiences are sometimes preceded by long periods of mental sweat, but on occasion we can trace resolution to a brief window we call a teachable moment.

Teachable moments may seem serendiptous, and some times they are; however, they can be catalyzed by a well-timed question. The question can occur to us personally as we finally realize where the cognitive conflict lies. But the question can also come from an outsider, a teacher or a peer, who correctly diagnoses (or suspects) what we understand and where our thinking is flawed.

The teachable moment phrase can lead a teacher to think that it signals that it is time to deliver the relevant fact(s). That would be to misuse this golden opportunity. Perhaps we should call this a “learnable moment.” It is a moment of openness for the learner and it is the learner’s needs that must be paramount. A question is being hinted at, if not actually voiced as we pause on the threshold. Questions of consequence require true understanding to move to an answer, not the supply of a missing fact. This is the time to lead the learner from what he or she knows to the blocking misconception, or to a missing idea, or to the missing, but crucial connection to another concept not yet brought to bear.

What follows is an approximate transcript of an interview with hospitalist Dr. Adam Smalley. We discuss how he recognizes and leverages teachable moments in a chaotic medical environment where the opportunity is almost literally a moment. As the best physician is a skilled diagnostician of where the patient’s problem lies, so the skilled educator/learner has learned to gently expose misunderstanding with well-placed questions. Read on to discover how to develop this crucial skill:

[00:04] Mike Gray: Everyone has heard of the elusive teachable moment, that instant of openness when a cognitive lightning bolt can strike without warning. Doctor Adam Smalley's audience is medical students and residents, and the venue is the often-chaotic medical environment. Teachable moments are priceless here. What's at stake is potentially the life of a patient as medical students and residents wrestle to achieve deep understanding and enhanced problem-solving abilities. Join me as we seek to maximize teachable moments in every area of life. Well, today I'm talking with hospitalist physician Adam Smalley about the importance of recognizing and utilizing teachable moments. Welcome to the podcast, Adam.

[01:02] Adam Smalley: Thank you for having me on.

[01:04] Mike Gray: If I remember right, you're married to a physical therapist, is that right?

[01:09] Adam Smalley: That is correct. A physical therapist who also remembers your class as well.

[01:14] Mike Gray: I won't ask why. You know, trauma can make some deep grooves in the brain.

[01:20] Adam Smalley: That's right. I can reliably inform you that modified true false has been discussed in my household within the last one week.

[01:28] Mike Gray: Oh, no. Well, I haven't thought about it within the last year. So, there we go.

[01:35] Adam Smalley: Very good.

[01:36] Mike Gray: You have how many children?

[01:39] Adam Smalley: We have five daughters.

[01:40] Mike Gray: Five? Wow. Yeah, we had five too, but not five daughters, so, yeah, that's been good. Age range is what?

[01:50] Adam Smalley: Well, once tomorrow hits, that's our last birthday of the year, they will range from 12 to 4.

[01:58] Mike Gray: Okay. That's pretty tight.

[02:02] Adam Smalley: Yeah. And they're all just about two years apart, so 12,10,8, 6, 4.  

[02:09] Mike Gray: Well, blessings when they get to be marriageable age. We had three daughters. And I always wondered how I was going to pay for three weddings. You know, of course, the sons, I did some paying too, but not the same extent. But God will provide.

[02:24] Adam Smalley: Yes, he will.

[02:26] Mike Gray: So, you're a hospitalist, and I think a number of people may not know what a hospitalist is. It's not somebody who tries to keep the hospital functioning correctly. What does a hospitalist do?

[02:44] Adam Smalley: So, I'm internal medicine trained, so adult medicine, physician. Within internal medicine, there's a lot of directions a physician can go, including primary care. But these days, there are a lot of opportunities to focus on inpatient practice, meaning patients admitted to the hospital for medical reasons and just only have a practice in the hospital. I'm even perhaps slightly unusual within the hospitalist crowd. I blur over into critical care territory. I'm on the higher acuity side. But a lot of the typical things you might think about with a hospitalist would be true again, think medical patients that need to be in the hospital for one reason or another. If you think about admissions and discharge work and discharge planning, and being a part of the functioning of the hospital is, it really gets a starting idea of what the focus is.

[03:43] Mike Gray: Okay. And, of course, that didn't exist when I was your age. You know, we had a patchwork of things, including your primary care physician who would try and show up and take care of you as well as running his practice. So, the game's a bit different now, for sure. So, could you briefly outline your educational journey that got you to where you are now?

[04:13] Adam Smalley: Certainly. So, my journey, of course, included undergraduate training with you, exposure to your teaching and training methods, and we'll dive into that, I know. From there, I was able to get into medical school at East Tennessee State, that's in Johnson City, Tennessee. Got a good medical training there and decided to do internal medicine. As my specialty training ended up moving for that. And I'm originally from the Midwest, so came to Indiana University and the program in Indianapolis, that would have been in 2014, and we've been in Indianapolis ever since. So, I finished internal medicine training at IU in 2017, and then I kind of went across the street, took a job as a teaching hospitalist at one of the other major systems in town at St. Vincent hospital system in Indianapolis, and I've been with them ever since.

[05:07] Mike Gray: Okay, well, that's a short version, and we'll talk about some of the pieces of it, for sure. We're kind of focusing today on teachable moments, and sometimes people think in terms of those being magic, and they may feel like it in the moment when, in the classic sense, the light bulb goes on for somebody. Do you remember some of those personal teachable moments, either high school, college?

[05:40] Adam Smalley: Yeah, absolutely. And I think some of them could be called light bulb moments, where in the moment, I knew something was going on. I think there's plenty of moments that you look back on, you reflect on and say, that was a really important moment. Even if I didn't fully appreciate it at the time, there are sometimes moments that I thought were really important at the time, and hindsight says they were maybe less important than I initially assigned. But perhaps that's just getting older and trying to gain wisdom and trying to reflect, and you start to see things in perspective. But a few that really stick out for me. I had a high school math and science teacher. It didn't hurt that he was my soccer coach as well, but who really helped me to gain an awe for the created world, for the created order. I remember walking into his classroom, and on the wall, he had a quote that mathematics is the language with which God has written the universe. It's a great week to be reflecting on that, because Monday [April 8] here in Indiana, we got to appreciate a total eclipse, total solar eclipse. And that was a wondrous moment. And the mathematics in order that went into being able to calculate that and enjoy that, I think that's a cool moment just to reflect back on. But he helped me to understand that there was a lot more out there, that God had created a wonderful order that was worthy of admiration and worthy of study. When I came to undergrad, I will say my educational career is probably more characterized by overconfidence than anything else. But I started to get echoes that there was more out there. I heard of the great Doctor Gray by reputation before I entered his classroom. But there was something I knew I heard there was something going on there, and then got into your classroom and started to be challenged with teaching from a different angle than I had, than I had previously appreciated. I guess I would say I knew something was going on. I knew I really enjoyed it, that it felt deeper, it felt more meaningful, that my mind was being challenged across the whole spectrum of its function, as opposed to just kind of working in a little corner here or there. But it's taken a long time to really reflect on the importance of those conversations and what you were really trying to do in those. And I expect that there will still be more that I sort out over the years as well. But I do remember pretty much day one, Gen Bio One with your concept map front and center, upfront, and a signal that something bigger is going on here, some deeper thinking is going on here. And I think there's a lot more I could say about the undergraduate experiences. I took every class that you offered that I could fit into the calendar, which I think included everything available at the time and benefited vastly. But again, I don't think I knew something was going on at the time. I knew that I really appreciated it, that it was making me a better learner, that it would pay dividends later on. But I also know in hindsight, that I didn't fully adopt the kind of expert thinking or mentality that you were demonstrating. There were more lessons to be learned about how to get there down the road. That would take time, that would take experiential lessons for me to turn back around and go, okay, how do we get back to where that was going into medical school? Medical school went just fine, except that in the first year, I got to Step One [exams] and did not perform as I thought I should and not even being overconfident, just saying that the output was not where I needed to be. And that was a self-discipline issue. That was something that I needed to address internally. And so really picking up from there, by God's grace, I was able to take more responsibility for my own education and really aim towards being the kind of doctor that God had called me to be. Being the kind of doctor my patients needed me to be. That's one of the most important things, is the person looking at me from across the bed. What do they need me to be today? And have I prepared to be that person today, to be that physician today? But that's a process. I think I'll pause there, see where you want to take it.

[09:58] Mike Gray: Yeah. The idea that you have personal responsibility for your learning, as opposed to the curriculum being the driver and the people who are charged with delivering that curriculum, I think is a watershed for real learning to take place, because nobody can learn for you. In spite of the old country thing, “I'll learn you, boy.” It's not possible that I can manipulate somebody else's cognitive processes to the point where real learning is taking place. So, it's always personal when real learning is taking place. And there are environments that can help that process to go to much higher levels, and there are environments where the joy of learning doesn't enter the equation, that it's dry and dusty and unmotivating. But there's at least a grade to be had in this course, so we'll play the game. So, what I'm hearing to this point is kind of this broad perspective that led to the idea that you're capable of learning on a different level than you had previously learned, but you caught it by atmosphere first, and then maybe consequences, as you mentioned with your step exam, from medical school. So, a broadening of the cognitive horizons is really the ultimate goal here, that we don't get stuck in. Sometimes a light bulb moment is defined in such a way like, oh, now I understand that some particular angle or concept, maybe, that I didn't really put all the pieces together until just now. And that can be satisfying, but really what we want, I suppose, is a succession of teachable moments like that, where things are being put together in a way that satisfies and that allows me to build something that continues to gain complexity, not for the sake of complexity, but because of the power of that structure to explain other things that I care about.

[12:38] Adam Smalley: Well, let me pick it up from there, because I think one of the tie ins that really helped. So, as I reflect back on undergraduate courses with you and with some others, but especially with you, I felt like I got a minor in metacognition, and those threads would pick up as I move forward into medicine. One area that we think about thinking a lot in medicine is diagnostic reasoning. There's a lot of thinking about how that process happens. I felt very at home, very much at home, when diagnostic reasoning started to be discussed and taught and could apply those principles readily to diagnostic reasoning. Med school has a bad rap, as just drinking from the fire hose, as the analogy is, it's not necessarily false, and it's not that I didn't have any good threads happen there. But really, in residency, again, when I'm looking at patients, those pieces start coming together. When we're actually working through, how do I think about a patient presentation? How do I think about diagnostic reasoning? And then I had the opportunity to benefit from some people that really lived. It could teach. It could show you how that worked in real time. To me, that was exciting. That was enlivening. It was a thrilling experience, and it would have been even more thrilling if it hadn't been so terrifying as an intern, but just a really exceptional experience. And again, those pieces came together and helped me to really dive in headfirst in the field where I ended up training for residency.

[14:12] Mike Gray: Yeah. So really what you gained along the way was an ability, I would say, to think like a physician. So, in my classes, we really were aiming to create the thinking of a biologist and more specifically, in various courses of a microbiologist or molecular biologist. What are the tools? What are the problems that these people are called upon to solve? And so, I think it's important that a physician turns the corner from the information deluge that tends to be the first two years, which I still decry as kind of a horrible waste of an opportunity that could have been leveraged to a better extent. But there is a sense in which colliding with the reality of dealing with patients and needing to diagnose what's going on in front of me here calls out the need to start thinking like you've used the word diagnostics. So, we're talking about, really what you pay a physician for is not all of the factual information that they've cataloged in their brain or can access readily through their computer. What you're paying a physician for is their ability to get to the point quickly, but by listening to the patient. I think you're a fan of Osler, and he once said something to the effect of if you talk to the patient long enough, they'll tell you what's wrong with them. So, there's a sense in which listening, which is in short supply because of the way medicine is structured, combined with asking good questions and ordering the right diagnostic tests, can allow you to home in efficiently on a diagnosis that's hopefully going to be helpful to the patient, or at least relieve some suffering from the patient. So, I think that in many ways the goal is learning how to put that together so that I can try and solve this problem in front of me for this person. That's what they're asking me to do. Is that the way you see your practice of medicine?

[16:43] Adam Smalley: I think what you just said is reflective of how I feel. I was going to say I completely agree with Osler in that quote and have found that to be true on many occasions. Granted, not every time do you get to take a detailed history on every patient, depending on the clinical scenario. So, very much I agree with the way you stated that. Can I roll you back to med school? Not that we have to fix med school in this podcast. I don't pick curriculum at all for anybody in medical school, but I think the question of how much content is going to be a living question for a long time. So certainly, medical education in particular, but education in general is very fact oriented and very recitation of fact oriented when it comes to testing. But as I move forward in the practice of medicine, there's a lot of knowledge that has to be present. I use secondary resources all the time, which would be like your up-to-date type thing. I can look up a drug dose for sure, but if I don't know the drug exists or I don't make the right diagnosis on the front end, I can't possibly get down to picking the right drug dose to treat that. It's tough because there's a lot of factual information that is actually relevant, particularly for those that practice a broad spectrum of medicine. You could argue in some subspecialty fields, you could cut it down pretty effectively. Anyway, I think that you've asked the question well, you've pushed the line well, as far as we shouldn't be stuffing our lectures so full of content that the concepts are missing, that the thinking is missing. And yet, on the flip side, you don't want a doctor who lacks factual knowledge. So how we navigate that, how we acquire that to get to a point of effectiveness, I think is going to be an ongoing question. How would you interact with that slight pushback because, largely, I agree with you, but a little bit of pushback that you do need factual knowledge to be effective in a field.

[18:52] Mike Gray: That's a common pushback. When we talk about higher order learning, reasoning, like, you have to have a fact base to reason from. So, the shorthand way of saying it is facts are something that was arrived at by somebody else's higher order learning in the past. Okay? That's the way I look at it. Like, particularly when you're looking at something that's not just an obvious physical reality, like the bird in the tree outside your window, knowing that it is a bird and knowing which bird it is and so forth. Somebody else did that work before you ever encountered that bird, and you're accessing their thinking. So not everybody who sees that bird is interested enough in birds to become a bird watcher, to be able to know the difference between the male and female of that species and. And so forth, but it's there. And I would say, you know, if you were more interested in birds, you'd have less trouble recognizing that bird, either physical appearance or the song of the bird or whatever. So, I think a lot of times we substitute fast access to facts to a way that would allow us to interact with concrete realities. That's what facts are that are justifiable to getting those as part of a bigger network of ideas, like bird watchers have to do. And they do it joyfully because they're interested in birds. So, I think maybe another way to say a similar thing. You use the word content, and I think my view on content, which I've expressed in previous podcasts, nobody ever accused me of dumbing down my courses. So, in terms of the factual base that people came away from having learned, from having had, the course, is demonstrably a larger fact base and not a smaller one than I experienced as an undergraduate when I was taught by more traditional means. The same thing came up when we started moving our department in that direction, like, whoa, wait a second. There's still the MCAT medical college admission test that these students have to take. And so you're playing a risky game when you're playing with curriculum. And I think med schools are caught in that same conundrum, as it were. But I think the fact base is meaningful and useful when you approach the learning from a standpoint of what question does this help me to answer? As opposed to like, so here are 15 beta blocker drugs, you know, and you need to learn the names and the nuances of the differences between when you'd use one, and when you'd use another is not a real helpful, efficient way. I don't think it's an impossible way to get to some level of retention, but I don't think it's a helpful way. So, the word content to me is always a trigger word. And people have recently, because of artificial intelligence, started to use it the way I have historically used it. So I read an article just this morning about people decrying using AI to generate quote unquote content, and that writers, for instance, when they were on strike, wanted some assurances from Hollywood producers that they were going to be sparing in their use of artificial intelligence to generate quote unquote content, because AI is potentially going to take their jobs away and they would like to think that they're writing on a higher level than AI can write on and that they're not just generating quote unquote content. So, you know, another word for content would be stuff, you know, and there are a lot of courses that are stuffed with stuff. So how much of it do you remember percentage wise from being exposed to the stuff? So, I think acquisition of a fact base, in my mind, comes through an inquiry of what question are we trying to answer and what role does that fact play in getting us to an answer that we can defend? So anyway, that's my thought.

[23:54] Adam Smalley: Well, that's really good. And you could even add the assumption that a lecture-based fact giving is effective, right? Well, there's data that 20%, 10% of a lecture, content wise, is going to be retained. And I forget the exact timeframe, but that was presented earlier in your podcast, one of the other seasons. So, we're assuming the default is effective, but it's perhaps a faulty assumption. But picking up where you put that, for me, content really stuck much, much better, particularly in residency. Not to skip over your lectures or the style, I do believe that Socratic question-based lecture is more effective, much more helpful in developing those concepts. But really that case-based learning, which is residency's really high intensity case-based learning, you see a patient, you round, you talk about the plan, you follow up the results of your plan and of your interventions and see how that person does, how that case proceeds. And you get that direct feedback loop. When we talk about adult learning and experiential learning, having a direct feedback loop is really critical to maximally benefiting from your experiences. So, moving into that kind of an environment in residency really kicked things into gear for me.

[25:16] Mike Gray: So maybe you can pick apart a little bit what you mean by the direct feedback loop.

[25:22] Adam Smalley: So, there's a couple places in medicine where you see this lacking. So, a classic one, and not to pick on them, but just a classic one, is emergency medicine. Do the first 15 minutes on average of a case, and they often initiate, particularly for a sick person, they're going to initiate a lot of interventions that they don't necessarily get to follow up the outcome of those interventions, their decision to intubate, their decision to order a certain blood test, order a certain antibiotic, call a consultant, those kinds of things. So, unless they go seek out how did Mister Smith do, Missus Smith do, they lack a feedback loop to know how their decisions performed in real time?

[26:06] Mike Gray: Is this kind of flowchart driven then, that it's typical if you took any two emergency room physicians with the same patient that they would probably chart the same flow pattern. That's just, this is what we do. 1st, 2nd, 3rd, fourth, and I don't know if this is really effective, it's just what we do.

[26:30] Adam Smalley: Well, if you allow me the word similar, I think they'd be similar. Definitely have a respect, high respect for the field. The job they do is difficult. There would be certain parameters within these parameters. You know, 99% or 90 plus percent of emergency trained physicians are going to do this kind of thing. You know, exact order, exact dose. Those kinds of things may vary somewhat, but how you really find out, did I pick within the accepted range? Did I really pick the best thing? I know that I believe my patient was septic, and therefore early antibiotics are proven to be really helpful in reducing mortality in sepsis. So, they may be acting on really good data, but knowing whether the actual spectrum that they picked for that individual patient was effective, I think is another level as well. So, I would contrast that to somebody who has the opportunity to follow up on patients longitudinally. So, you could take your classic primary care provider, they pick an anti-hypertensive. They follow that patient longitudinally over years, and if they stay with it and the patient stays with them, they may get feedback about did they really reduce the risk of heart attack and stroke? As an inpatient rounding physician, I do get at least short term follow up on my patients, but getting that longer term follow up is harder. But in the metacognition world, which has been one of the threads that your teaching has gotten me interested in, having a strong feedback loop on your decision making is a critical piece to expert thinking or to becoming a professional. Or you could alternately say a top performer in your field. You've got to know in real time how your decisions are affecting things. So, you can continue to hone those, to make the best decisions in the individual circumstance?

[28:19] Mike Gray: Yeah, absolutely. I think that's true everywhere, really, that we only change our thinking when we bump up against reality. That says that thinking really isn't working like you think it was; like you anticipated. Look at the payoff here, as opposed to, of course it's right. That's the way I was trained, and that's that. That's what works in this situation. So, in medicine, you talked about rounding and the feedback that faculty and students can get from seeing real patients. How do you recognize, in the midst of contact with a patient and their current status, how do you recognize a teachable moment? Is it rare? Is it something that happens that you can't control, but you can take advantage of? Is it something that you might be able to position a few pieces next to each other and make it happen in a particular context, although it's not, you know, as obvious. So, let's talk a little bit about that and the education of medical students and residents. Right.

[29:39] Adam Smalley: So, the answer is going to be kind of a yes, things happen to you in the hospital as the attending physician, and then you can certainly facilitate learning environments around you. And some of both, I think, is going to have to be happening at all times. So, what we're alluding to is part of my job is rounding on teaching services at the main hospital where I work at, and getting to work with third and fourth year medical students, and then both beginner residents and then even senior residents in a teaching environment. So, we'll be rounding on a group of patients. We will have a number of patients that are our responsibility, and then as we take care of them, as the attending physician, I'm responsible to make sure the quality of care is where it should be and also to be providing education during rounds. I think the best educational opportunities have a few components to them, and I kind of think of this as a Venn diagram. One. What are my learners interested in? So, if I have somebody interested in a field that is unrelated to our patients, that can be a challenge. But I try to get people on board to be interested in the patients that we have to see, and [2] if that can be paired with actually taking care of a patient who has that issue. A classic example was, well, I don't know much about liver failure. And then, lo and behold, we're taking care of a patient with cirrhosis. We have a golden opportunity. And then the third part of the Venn diagram is, what am I actually good teaching at, because sometimes there are interests and patients that have issues that I'm not as good at teaching at. And sometimes I have to have the wisdom to say, hey, that's a great topic, but I really think you need to seek that experience with such and such kind of physician or a different kind of person. But usually, the kind of services I'm on have pretty sick patients, and we can talk about respiratory failure, sepsis, heart failure, antibiotics, infections. Like I said, liver failure, kidney failure. We have a wide gamut of topics and usually have plenty to teach medical students and residents.

[31:47] Mike Gray: So, you have lots of things you could teach, but how do you make your choices about what you think is going to be most effectively taught with this particular patient?

[32:04] Adam Smalley: Some of those are conscious and some of those are subconscious. Certainly, if we have a sicker patient, somebody who's more acute, then I'm going to have the team respond to the bedside. We'll often start our teaching rounds at the bedside for that patient. Then as the more active patient, the more interesting patient is being presented, I'm listening to whoever's presenting. Hopefully a student, a medical student who's been prepared by the resident is presenting and then looking for that opportunity. So, I usually come in. I've basically listed my favorite teaching topics already, so I kind of know my patient population at this point. And so, I'm bringing us to the bedside, and I'm looking for what is the point of contact between their educational gap and what's going on today and where we can really put that piece in. And so, if I've got a patient who has a need today, then I'm going to line that up with, where are my learners at? Where are they at? In the process of understanding what we're doing for this individual patient. And so, for example, it could be a patient with respiratory failure who's come in, has been put on a BiPAP machine, which is a non-invasive ventilator. And I'd really like them to tell me about the blood gas from overnight. I'd really like for them to present that to me and interpret it to me, because that's going to tell me a lot about their foundational understanding about what is going on with the patient, what are we trying to achieve with the intervention, and then what are we even looking for? Trying to get anticipatory on the blood gas that we have or maybe the next blood gas that we're going to get. And so, as the student is presenting, I'm really wanting to hear how far is their thinking getting and then a few things may happen when they start to run out of steam because the student's going to. They don't come ready to present that patient in full. It's our job to teach them to pick them up where they are and get them farther. So, they're going to run out of steam on the plan. And depending on the learning dynamic, their resident may bail them out and finish out the plan, or they may have an agreed upon plan ahead of time. But what I'm looking for is where did we first encounter ignorance or lack of knowledge? What was that next step? And that's where I'd really like to hit the teaching point. So, was it blood gas interpretation? Was it basics of noninvasive ventilation and the physiology and the pathophysiology involved in that. I'm looking for that opportunity to meet the learner right at the edge, right at the limit of their knowledge and understanding, and then add the teaching on right there and in the environment. You know, I've got. I may have a gold star student who's really far, but I may. I may notice there was a more junior student who's just completely lost at the point we're talking about there. And then I may have a senior resident who's completely bored at the point of learning for the medical students. So, I'm trying to manage that environment, trying to hit that most important point on rounds. And really while we're rounding, it's got to be a minute or two. There's not time to necessarily. You can't spend ten minutes developing the point. You've got to hit it right where it's at. Okay, this is the most important concept for this thing. And then we're going to back off. We're going to see whether that resonated. And then if we need more time, I may try to find an afternoon for more time on that topic, but I hope that kind of gives an example of really the most ideal teaching topic. And then, of course, you have to understand there's going to be interruptions, there's going to be changes in the patient's clinical condition. We're going to have 15 other patients that need to be seen that day as well. So, the amount of time we spend on one presentation and one teaching topic gets to be pretty limited.

[35:42] Mike Gray: Yeah, one of the concepts that you just mentioned really is something gets a bad rap in terms of learning, and that's assessment. And there has to be a trust relationship with assessment. And I put it that way because the natural human tendency is to kind of bluff when I get to the edges of my understanding, or lack of understanding, like, particularly if it looks like I am way out in left field on this, I don't want to appear to be that deficient in front of whoever else is involved here in the learning scenario. So there has to be a sense in which if I expose my ignorance, that I'm trusting that this person will handle my ignorance in a way that is not going to be dehumanizing to me. And I know that's a—It doesn't always happen that way. In medicine there is a sometimes a hierarchy where somebody likes the idea of showing somebody else how dumb they are under these circumstances.

[36:56] Adam Smalley: Yeah, I'll throw medicine under the bus. So historically, over the last 50 years, medicine does not have a good reputation as being a quality learning environment, often generating a hostile learning environment. And I'll hesitate to throw individual specialties under the bus, but the hierarchy lives more strongly in some specialties rather than others. But regardless, none of us wants to be exposed as ignorant of something in public—that's painful. So how that scenario is managed is super important. And really that's something that I've had to learn even more about, particularly over the last five or six years. When we talk in medicine, we talk about the learning environment. You have to have a healthy and inviting learning environment where exposing ignorance, where exposing even mistakes is a welcome thing, that there's not punitive damages attached to that. We're not here to be punitive. We're here to help you. So that learner has to believe deep down, having met me 1 hour before, maybe that I have their best interest in mind and I'm not just trying to shame them in front of the patient, the family, the nurse, the respiratory therapist, whoever else may be observing us, not to mention the rest of the hierarchy of the team, the residents and on, but that I'm going to create a safe learning environment where we can expose our ignorance and then work through that and build from there together. So, I would say that is a topic that I have found to be more and more important with every year, is maintaining that safe learning environment.

[38:33] Mike Gray: Yeah, I absolutely agree, because you can shut down somebody to where all they're doing is trying to defend themselves or to minimize the damage in the moment, which is really the opposite of the idea of a teachable moment. The teachable moment is a posture from.

[38:53] Adam Smalley: The learner that I want to be.

[38:54] Mike Gray: Taught in this situation because my ignorance about this is going to cost me or going to cost the patient down the road. And so, it's a kindness for this to be an opportunity for me to learn. A teachable moment is not something where the teacher gets a chance to demonstrate how smart they are and how dumb the students are. So, this has to be. This is a word that a lot of people don't like, but it has to be learner centered, that this is all about learning, creating a learning environment that's optimal, as opposed to a place for me to show everybody my mastery of the dynamics of problem solving in this arena.

[39:40] Adam Smalley: Well, I'd like to pick up that point, but I'll just reiterate, even if you don't enter a learning encounter with the intention of being malicious, you can unintentionally. I have unintentionally created awkward situations for my learners just because I wasn't paying attention to the factors that mattered to them.

[40:00] Mike Gray: Yeah.

[40:00] Adam Smalley: And so, yeah, that you have to be learner centered, trying, always trying to put your mind back into how insecure they feel in this moment, because I do remember, you know, I'm getting a little farther out there, but I do still remember how insecure and fragile you feel as a learner in that environment. But, you know, the clinical environment is complex. And part of that I enjoy, it gets. It gets difficult because I do need to be learner centered and very much agree with that. But I will say I have somebody who takes priority to my learner, and that is the quality of my patient care. That's a lesson that I've had to learn over the last eight years in teaching, is that I came out of residency with approximately one good way to do everything. And since then, I've had to learn the other five and be okay. There's a range of plan that the residential can present to me. That's okay. That's good. I may try to tune that up in conversation, try to say, hey, that works. But did you think about the side benefits of doing it this way but learning a range of acceptable, but having that line, your plan is not good enough for our patient. And therefore, as the attending physician, we are going to tune it up, we're going to change it and go this way because we do have a patient in the middle. So how to do. If I go into a full override on their plan A, there has to be good rationale, not just, you know, I didn't eat breakfast this morning. There has to be a good reason for why I'm overriding. And the point is, has got to be, well, the patient needs this, not just eh, I like this other antibiotic better. What if the plan that they presented is good? Then I need to leave it alone and go from there. So there's some wisdom there. But that's where a traditional teaching environment doesn't necessarily have a patient in the middle. And so, there is a lot of social dynamics, but keeping the patient first, then after that, okay, have I maintained a quality learning environment? Have I met those factors? You know, every scenario is different, and then you throw a family member in, you throw. It's just, it's fun because it's never the same two days in a row.

[42:11] Mike Gray: So, when you talk about modifying or overriding what the student or resident was proposing, there needs to be a rationale behind that rather than. Well, it's not what I usually do in this situation. And the rationale is really based on an understanding that's been arrived at about one or more ideas that are central to this particular case or this particular decision point in this case. So, what we get to, I think, is what's often called conceptual learning and the power of a concept when it's rightly understood to unlock solutions to problems. So how do you understand the idea of a concept in regard to one of these teaching opportunities that reveal themselves clinically? Where is the concept in the learning that you're trying to facilitate?

[43:23] Adam Smalley: Well, I hope I understand concept, the term concept, as you use it adequately for this, and I'm sure I blur it with other concepts, with other topics as well. But I do believe understanding a concept and the critical nature of concepts is important for clinical learning in a hospital type environment. And just the short time window by itself means that only the most important teaching point has that opportunity to get through. So, one thing that I've been challenged with over the years is to make my own thinking clearer and clearer and clearer, because I don't get to say it five ways, I have to say it the best way first and maybe explain it a couple different ways as time allows. And what I really want to get into that moment is a teaching point that's going to be able to be applied in multiple directions. So, the image I like to think of for a concept is an engine. An engine is, you use the word power, and I like that idea. So, an engine that you can power up and it'll power your car to go into multiple different applications, multiple different directions. And the most helpful things that I can do for my learners is introduce them to the most central concepts that will help them apply the point in multiple directions. Now, that's not always the learning point of the day. Sometimes we get into more esoteric knowledge as we need to for a patient situation. But I really, over the years, have liked that image of an engine, and there are critical concepts that you may not envision as an engine. They're more foundational concepts. So, when I teach acid base disorders in medicine, I'm really only accessing the surface level concepts that are required to apply those to a clinical situation. I'm not necessarily going back to a gen chem one or gen chem two concept for acid base chemistry, but to me that's a helpful image that I'm trying to give them, an engine that can be applied in many directions.

[45:31] Mike Gray: So, I know one that you often are involved in that you've mentioned previously today is sepsis. And maybe you want to define sepsis and why that's a central idea in the environments you are working in.

[45:48] Adam Smalley: Yeah, and sepsis is huge, and there's a lot of stakeholders. So, I'll stick with the sepsis three panel definition. The short version, which is sepsis, is a combination of, well, let me rephrase. Sepsis is a dysregulated host response to an infection, and they came down on that for a variety of reasons. We're not here to talk about the sepsis three definition, but a dysregulated host response, that is its own syndrome centering around essentially what would be a severe infection. So, you have infection as the trigger, and then you have a lot of host factors and other factors going on. And when you look at what are the bad things that can happen as a consequence of sepsis, it helps to understand that there are a lot of host factors involved. So, people who have a low immune system or are on immune system modulators are at high risk of the more severe forms of sepsis. And when you understand that immunology and host factors play a critical role in the development of sepsis, that starts to make perfect sense. And then when you understand that this is driven by infection, and we start talking about how do you treat sepsis? Well, yes, it's its own thing, but we are going to want to go hit that infection hard, as hard as we can, appropriately for the scenario. So, we can talk about major infection, infectious disease concepts like source control. If you don't have source control, you're not going to win this with just antibiotics. But of course, then early appropriate broad-spectrum antibiotics are going to make perfect sense because this is driven by the underlying infection. So, treating that initial underlying infection is critical. So hopefully, I've at least in small, in brief, defined sepsis and then driven it in a couple different directions. Because immune system matters, host factors matter. The infection, the severity of the infection, treating the infection matter, and there's a lot more applications. Even if I just give them that, there's a lot more applications and details that they can build into that as they encounter more patients with sepsis, with time.

[48:03] Mike Gray: Yeah, that's helpful. So, sepsis is a trigger word, in a sense, that, you know, behind that, there are a host of connected ideas that have everything to do with the status of this patient and where things might be headed in the near future. As I recognize that that's what I'm dealing with here. So, it's not simply a word, it's not simply an item on a chart, but it connects to a whole bunch of other things that may have a powerful say over where this patient is tomorrow, if they're even still here tomorrow. So, let's just generalize. Concept maybe is a word that gets misunderstood. A concept, in terms of cognition is a pattern regularity. That is, there's a series of things that are all captured with this label. Sepsis, we were just talking about. So, sepsis always involves an infectious agent if you're truly septic, as opposed to, I just have an immune system dysregulation problem going on, an autoimmune sort of thing that wasn't triggered, as far as we can tell, by an infection, at least we were not able to detect the infection. So, there's an idea that there, and for many people, just powerful idea as a substitute for the word concept might be helpful. But I think that powerful ideas are what drives deep and durable learning, and that some of the most powerful ideas are not necessarily recognized for the power they contain. It's easy to gloss over them and not spend the time cultivating a deep understanding of those. So, in general, then, in talking about learning, how do you understand the idea of a concept as crucial to real learning, to deep and durable learning?

[50:16] Adam Smalley: I think that's a tough question to answer to you, because I know my thinking around what exactly a concept is is not as developed, and I would not necessarily disagree with your alternate terminology you supplied there. A powerful idea that not every piece I'm teaching is exactly a concept as defined in this conversation, but I'm still aiming for the most potent idea that can be fit in a clinical scenario.

[50:46] Mike Gray: So maybe. Maybe it's helpful to take this out of medicine and out of metacognition, per se, and just talk about a situation that you encounter outside of those arenas, maybe more pedestrian, that will show the power of being able to use one of these central ideas and cultivate it to the point where you open up your understanding that you create learning opportunities for yourself. I think there are other arenas where that has surfaced in your life, and that certainly the intent of deep and durable learning is to harness this approach to learning to other areas of life that I'm curious about. And I might actually become very enmeshed in helpful ways that broaden my horizon. So, any of those for you?

[51:50] Adam Smalley: Certainly. And one of the as a Christian, as a believer, one of the areas in which in my life, in which I think all of us would immediately want to apply deep and durable learning is to the learning of God's word. And so, as a learner of God's word, as a student going in deep looking for those patterns, and if you've gone in deep and looked for patterns, looked for themes, they're all over the place, and they're there to be discovered, they're there to be enjoyed and learned from. And much has been written, of course, over the years as well, but really to dive in for yourself. And then over the years, I've had opportunities to teach at small group tables for both of my churches over the years. And having to learn it in depth myself, having to clarify down to the key patterns, the key ideas, and then turn around and try to communicate those back to others, has yielded a lot of fruit in my life, great fruit in my life. And I know others have echoed this theme even through this season of the podcast, and I would echo it myself. One maybe more off the beaten path track that I enjoy is I have found that I love ancient history, I love ancient literature, even ancient wisdom. So, I recently finished reading the complete and unabridged Plutarch's parallel lives and did that primarily. I love the history of it, but also as a looking for patterns in ancient wisdom, ancient wisdom, literature, and of course, having a great biblical background, I have a long history studying Proverbs and Psalms and Job and seeing how these themes are echoed even through pagan authors. I find that really interesting. I love history. I love looking backwards in time and trying to analyze how decisions were made and how they turned out. And was the outcome incidental to the decision, or was the decision instrumental in the outcome, and how the historians argue over it, and whether the historiography is accurate to the actual events. Those are interesting questions. Those have been additionally fun questions to me.

[54:15] Mike Gray: Yeah, well, for me, part of what I'm anticipating in heaven is the opportunity to have unfettered opportunity to explore all of the amazing patterns that are in God's universe. You know, things that I'm not equipped for right now, like lacking opportunity or time or resources or whatever. There's so much to learn that can bring a deeper level of appreciation for who God is and give me joy in the process of having the ability to appreciate God from another angle that I had not previously even known was out there, that there is a real sense in which that's what we're created for, that bringing glory to God is also a personal kind of thing. It's opening the eyes of my understanding. And Paul prayed that for his listeners. And it's not simply the biblical text, but it's, you know, the Bible says the heavens declare the glory of God, but I think so does the molecular world and the microbial world and the physiological world. And, you know, we go on and on and on because, you know, from him and to him and through him are all things, and everything testifies to the power and wisdom of the creator God, who made it all. So maybe, in summary, what have you learned about yourself as a learner and how you can approach learning differently at this stage in life than you were equipped for at 18?

[56:19] Adam Smalley: There's just so much. But from what you were just saying, it reminds me how key curiosity is in learning. That's not something I understood or appreciated at 18 or even through medical school. I did not rightly leverage curiosity, which has just been amazing. And it's part of that glory. It's part of the joy in the created order that we are meant to enjoy. We're meant to be curious. We're meant to go and pursue that in right ways. But the biggest thing I've learned is that I can learn. Even though the early part of my story has a veneer of overconfidence, overconfidence and pride really has an undercurrent of doubt of can I really cut it? Am I really going to make it? And so leveraging God given abilities to learn is refreshing. It's comforting. And then really, once you get to the end of that, and I don't know if I explained it well, but once you get to the end of that, you realize the main question is just where does God want me to put this effort? What direction does he want this to go? And that's so liberating. It's so freeing. And not to say that I get it right every time we're still in a fallen world. I'm still in my old self, in a sense, anyway. There's still much more to learn, but it's freeing to say, okay, Lord, you've given abilities, you've given opportunity, you've given time. And then what direction do you want me to take this? Oh, opportunity to teach an adult Sunday school class. Great. Let's go. Opportunity to learn more about your word. Okay, let's go. Opportunity to teach and to lead the next generation in medicine. Hey, let's go. That sounds great. And these are just some examples of the ways in which God can lead us to be participating in his work during this life. And of course, we know the list of potential options of how we can be laboring to glorify him. It's so vast and varied, it almost dazzles us. And yet it's such a blessing to be able to be a part of it.

[58:22] Mike Gray: Yeah, maybe we can even circle around to home life, like being a husband and a father. And so, is there learning taking place there?

[58:34] Adam Smalley: Every moment of every day there is learning. And when they're little, there are different techniques. And yet, interestingly, you can. There's a lot, obviously, books, and books have been written, but on this topic, you can start to paint the picture of quality thinking, of looking more observationally, looking with curiosity. And then instead of just feeding the answer, well, what do you think? And waiting as an adult, waiting for a child to give an answer to that question can be infuriating at times, but it also can be extremely valuable. And while I'm thinking, I'm remembering that you have quality time with your grandson, where you've experienced this yourself. Sometimes you ask a question, you think, there's no possible way that I'll get the answer I'm going for. And that's fine. They/ve got time to grow. And then sure enough, they say something and you're like, wait a second, they okay, this is exciting. It's fun. So, it's been a lot of fun.

[59:41] Mike Gray: Indeed, it has. Well, thanks for joining us today, Adam. Appreciate your participation, your insight and ability to apply this to a variety of contexts. God bless you and your work.

[59:58] Adam Smalley: Thank you so much for having me. And you too.

[01:00:00] Mike Gray: Thank you. This is the last episode of season eight. I'm going to take a break until August as I lead the 20th summer of SITS. The Summer Institute in Teaching Science (SITS) is a faculty and curriculum development program for higher education that develops and applies the ideas we talk about here on deep and durable learning. It is really the incubator where many of my principles of learning were developed.

Let me get personal. I really need to hear from you listeners to find out where you get stuck as an adult learner. How can I make this approach to learning more concrete? What do you need in order to adopt this as your new learning paradigm? Are there topics or issues you'd like me to apply the principles of deep learning to or ways to make these principles more practical and applicable to your life? I'd love to hear from you. You can reach me with your suggestions questions at this email address: Podcast at deep and (a n d) durable.com that's podcast@deepanddurable.com. That's an email address. While the podcast is paused for the summer, this might be a good opportunity for you to get some context by listening to the first four seasons of this podcast. My blog posts@deepanddurable.com are also a helpful resource that have links to other resources.

Don't settle for a mere vacation this summer. To vacate is to escape. Life is still waiting for you when you return. There's nothing more rewarding than personal transformation. Use your discretionary time well this summer. Immerse yourself in the wonders of God's creation. I hope you'll experience joy this summer through your growth as a learner. See you in August.