Problem finding in clinical medicine

Problem finding is the creative ability to define or identify a
problem. The process involves consideration of alternative views or
definitions of a problem that are generated and selected for further
consideration. Problem finding requires individuals to set
objectives, define purposes, decide what is interesting, and
ultimately decide what they want to study.
1 Comment »
Research indicates that problem finding elicits
negative responses from students
Jul 28th, 2009 by Frank LaBanca, Ed.D.
from: www.bath.ac.uk
My good friend and colleague, Krista Ritchie, recently defended her
dissertation at McGill University. I was able to attend via distance
using Skype. During her defense, I had the opportunty to hear
about her research on problem finding. She conducted her study
longitudinally, observing students over the course of a year from
various Connecticut high school science sites. Each site she studied
had students in a “traditional” course (e.g., biology, chemistry,
physics) and an applied science research course. Both the
traditional and research courses were taught by the same teacher at
each site.
As she was presenting her data, one thing stood out to me as a
practitioner. She discussed the negative responses often associated
with problem finding: anxiety, nervousness, fear. These responses,
she discussed, were often not found in the traditional science
education classes, yet were prevalent in the applied research class.
This immediately got me thinking.
Of course, the proximate interpretation is for an applied science
teacher to know that there is anxiety assocaited with the problem
finding phase of research, and he or she should do whatever is in
his or her power to support the students. Yet, I wonder – what is
the necessity of the anxiety to push the student forward to facing
and conquering the challenges associated with creative problem
finding?
For more of a holistic view of the educational enterprise, I am
thinking more about the place of problem finding within
educational structures. While I am an advocate of problem finding,
I am not so Pollyanna as to realize that creative behaviors like
problem finding are often stifled and supressed in education. As
much as teachers say they want their students to be creative
producers – so many really don’t. I can hear the voices now . . .
“Just do what I say.”
Or from the students, “Just tell me what to do
and I’ll do it.” There is TOO much culture of lock-step-do-as-theteacher-says-and-don’t-push-the-creative-envelope culture
prevalent in education. I don’t even claim this to be a one-way
street. Teachers and students just want to do as told: solve/teach
well-known questions that have well-known answers. I am often
disgruntled about how few teachers and students are willing to take
a risk and work with ill-defined problems. I think that’s where
really powerful learning takes place. My challenge as an
instructional leader is to bring more students, parents, teachers,
administrators – all the constituents – to this place.
A place where we transcend the logical and analytical processes of
problem solving and challenge students to engage in creative
problem finding behaviors.
one bit!
And I’m not anxious about saying that
Csyksentmihaly and Goetzels
Exploratory activities of artists make a difference in quality and originality
CTSciNet
Perspective: Problem Finding
and the Multidisciplinary
Mind
By Linda Austin
February 20, 2009
Great problem finders are able to make conceptual leaps,
applying solutions and techniques from other disciplines to
problems of their own.
A single day in the life of a clinician presents innumerable problems worthy of
investigation. An example: Vascular insufficiency of the lower extremities is a
devastating condition commonly diagnosed in diabetic patients, smokers, and the
elderly. It's a single disease, yet it offers many problems that a researcher might
address. How can the condition be prevented? Could an existing mechanical aid
such as an elastic support stocking be improved? If amputation is required, what
wound-healing issues will arise? Could stem cell injection into the affected leg
offer therapeutic benefit?
Which of these--or other--problems a researcher chooses, and how those
problems are defined and pursued, determines the course of a scientific career.
Choose a problem that's especially rich and you'll be doing important work for
decades. Choose a problem of limited scope and you've limited the scope of your
research career.
This article was developed in collaboration with the American Federation for
Medical Research (AFMR).
So, how do you choose well? Great problem finders are able to make conceptual
leaps, applying solutions and techniques from other disciplines to problems of
their own. But even people who aren't predisposed to such intuitive, creative
leaps can achieve similar results by taking steps to approach problems--or
solutions--with a multidisciplinary mind.
Problem finding
Psychologists Jacob W. Getzels and Mihaly Csikszentmihalyi have studied
problem finding--"the way problems are envisaged, posed, formulated, created,"
[1] in their words--as a key component of achievement. Whether working in art,
business, or clinical investigation, great problem finders can look at the same
phenomena that others have observed--sometimes for centuries--and perceive
gaps of understanding and offer new perspectives that lead to a creative solution.
Getzels and Csikszentmihalyi identified psychological attributes of artists who
were particularly creative problem finders: This group typically demonstrated a
willingness to switch direction when new approaches suggested themselves.
They were open to reformulating problems as they experimented with different
perspectives. They were slow to judge their work as absolutely finished, and they
were able to evaluate critically the probability that improvements were
achievable. Artists who rated high in these areas were judged to be exceptionally
creative, and follow-up studies of their work 18 years later demonstrated that
they achieved a higher degree of professional success than did their less
creative colleagues [2].
Another study, this one of artists and scientists, compared those who were
critically acclaimed with others who were professionally merely competent. This
study found that the former spent more time and energy on problem finding [3].
The multidisciplinary mind
Broadly, scientific investigation may start in two ways, either of which may be
fruitful. A "problem focused" approach begins with a question that stimulates
studies to look for answers. Sometimes, however, new solutions to a specific
problem appear that suggest potential application to other problems. Examples
include stem cell injection for lower limb vascular insufficiency, gamma-knife
irradiation for obsessive-compulsive disorder, endoscopy for brain tumor
resection, and deep-brain stimulation for depression. Repurposing solutions for
new clinical problems requires a multidisciplinary mind; that is, scientific curiosity
about other disciplines and the time to learn about progress in specialties outside
of one's own.
A clinical, contemporary example of a multidisciplinary mind is Judah Folkman,
the pioneer of angiogenesis research. Even as a student, Folkman was
innovative: He developed a new technique for hepatectomy for liver cancer and
the first atrioventricular implantable pacemaker. Later, he and a colleague
reported the use of implantable polymers for the sustained release of drugs,
which allowed the development of Norplant. In 1971, Folkman proposed that all
tumor growth is angiogenesis-dependent, a theory that was originally met with
ridicule and disbelief among his surgical colleagues. Before his death, Folkman
began to explore treatments with angiogenesis inhibitors for conditions as
seemingly disparate as myocardial infarction, diabetes, macular degeneration,
and even obesity [4].
If Folkman is a prototype of the multidisciplinary, problem-finding mind, his
example suggests the personality traits that promote creative clinical
investigation: curiosity and exposure to areas of medicine outside his own
specialty, radical thinking, an ability to take a risk, the capacity to persevere
despite ridicule and failure, exceptionally high energy, and the ability to inspire
and collaborate with colleagues. Until the end of his life, he evidently was willing,
if not eager, to remain on the steep part of the learning curve, reaching out to
areas far outside of his core discipline.
Problem finding in clinical medicine
The challenge of problem finding is that scientific discovery usually develops in
slow, incremental steps, not leaps--and in clinical medicine, the process is
especially slow. National Institutes of Health funding, the gold standard of
research achievement, rewards proposals based on small, forward additions to a
carefully constructed base of scientific achievement. Academic promotion
rewards those who develop deep focus in a narrow niche.
Likewise, academic medicine has traditionally existed within well-demarcated
specialties. Specialty boards and academic societies further isolate specialists,
and generalists are often not highly valued. Although these silos allow specialists
to achieve great experience with specific clinical conditions, they may also limit
our ability to progress in leaps. The current movement toward multidisciplinary
centers of clinical care and support for translational research is critically
important to speed the process of discovery.
Yet, to an extent, it shouldn't matter if the labs are on the same floor as the
hospital ward. The critical moment occurs when a clinician can think across
disciplines about how a cellular process may be active in many different
diseases, as Folkman did. Further, that conceptual marriage is meaningless
unless the thinker is able to see and appreciate the significance of the problem.
To achieve proof of concept requires emotional and professional investment in
the idea, institutional or collegial support, funding, commitment of time and
energy, and the willingness to tolerate the risk of failure.
Developing a problem-finding, multidisciplinary mind
Although some minds seem more innately predisposed to creative,
multidimensional thinking, there are ways to stimulate a problem-finding,
multidisciplinary mind:
Exposure to unusual stimuli: A truly unique, original idea is very rare and may not
even be necessary for creative productivity. Instead, creativity is often a matter of
exposure to new stimuli and repurposing ideas and techniques already used in
another field. To do this, the clinical investigator should talk to colleagues, read
journals or listen to podcasts, attend meetings, and watch for new developments
and ideas in other disciplines.
Listen to silence and observe the 'negative space': Artists speak of the negative
artistic space created by the positive images painted on a surface. Psychiatrists
listen for what is not being said in therapy as a clue to repressed material. Part of
the process of human acculturation is an unconscious collusion to remain blind to
the most obviously observable phenomenon, if it lies outside the realm of how we
always do things. Yet the seeds of innovation and progress often lie within the
domain of that which is ignored or even denied. For instance, specific clinical
interventions are often developed for a single demographic group, defined by
gender, race, or age. Interesting scientific questions arise from considering the
intervention for other groups. As an example, HPV vaccination is currently
recommended only for girls, but epidemiologists and clinicians are beginning to
comment on the consequences of allowing males to function as an unchecked
reservoir of the virus.
Recognize the problem after the answer has been found: The history of the
discovery of penicillin is a fascinating example of a solution that was discovered
over and over again for many centuries before its importance was appreciated.
For more than 1500 years, observations had been made about the ability of fungi
to inhibit the growth of bacteria [5]. Reportedly, Arabian stable boys stored their
saddles in damp, moldy areas because the moldy saddles prevented the
development of saddle sores. In 1852, J. R. Mosse published a report on the use
of yeast to treat infection, followed by Joseph Lister's unpublished observation in
1871 on the ability of Penicillium glaucum to inhibit bacterial growth. In 1897,
French medical student Ernest Duchesne published the results of an elegant
series of experiments; however, he did not publish further and his discovery lay
neglected for decades thereafter. Alexander Fleming rediscovered penicillin in
1928, but it was not until 1942 that Chain, Florey, and Jennings identified patulin,
the antibiotic produced by P. glaucum [6]. One can only wonder how the course
of history might have changed if the value of penicillin had been appreciated
earlier. Undoubtedly, there are many other solutions confronting each of us every
day--if only we can find the problem!
Reformulation and revision: Great problem finders resist premature closure of the
process of exploration. Scientific investigation is best served by a restless, selfcritical mind. Gaps of understanding, disconnection between theory and clinical
results, or anomalies in results can all stimulate new problems. Clinical scientists
rarely reverse their opinions or point out their own mistakes because prestige,
funding, and organizational power are at risk. Such forces may limit creative
investigation. Great personal and scientific integrity is required to elevate new
findings that weaken the theory on which one's reputation has been built. Yet
without that acknowledgement and subsequent "course adjustment,"
investigation may continue down a blind alley and result in a career that is
respectable but quickly forgotten.
Stay curious
Problem finding is an essential skill of clinical investigation, and the definition of a
great problem sometimes occurs long after the solution has been observed.
Relentless curiosity, the capacity to see the invisible, a willingness to reach
outside one's own disciplinary silo, and continuous revision and reformulation are
all components of the kind of problem finding you need to adopt to assure an
important scientific career.
References
1. J. W. Getzels, M. Csikszentmihalyi, The Creative Vision: A Longitudinal Study
of Problem Finding in Art (Wiley, New York, 1976).
2. M. Csikszentmihalyi, "The Domain of Creativity," in Theories of Creativity, M.
A. Runco, Ed. (Sage, Newbury Park, Calif., 1990), pp. 190-212.
3. S. Rostan, Problem finding, problem solving, and cognitive controls: An
empirical investigation of critically acclaimed professional productivity. Creativ
Res J 7, 97-110 (1994).
4. A. Park, Judah Folkman, Cancer Pioneer. Time Magazine. Jan. 16, 2008.
5. S. Duckett, Ernest Duchesne and the concept of fungal antibiotic therapy.
Lancet 354, 206 (1999).
6. E. Duchesne, thesis, Contribution a l'etude de la concurrence vitale chez les
microorganisms: Antagonisme entre les moisissures et le microbes. Faculte de
Medecine et de Pharmacie de Lyon (1897).
Linda Austin, M.D., is associate dean for communication development and a professor of psychiatry at the M
of South Carolina.
10.1126/science.caredit.a0900024
Jasper Tomkins is the author and illustrator of eleven books (with
many more waiting in the wings). Among them, The Catalog, winning
the International Children’s Book Award, the Pacific Northwest
Booksellers Award, and the National Children’s Choice Award. Nimby
received the Washington State Children’s Choice Award and The
Hole in the Ocean, the National Parent’s Choice Award. For his The
Sky Jumps Into Your Shoes At Night he received the National
Children’s Choice Award.
Jasper grew up in the Pacific Northwest. Every summer his parents
whisked him away to the wilds of nature to experience mountains,
rivers, lakes, forests, bears, porcupines, and snakes. And then
oceans, islands, whales, rocks, sand, ants, and eagles. Every
September it was time to go back to school where Jasper was a quiet
student usually hiding in the back of the room working on secret
science projects he had hidden in his desk (in second grade he had
so many projects, his teacher gave him two desks). If you peeked
over his shoulder, you might have found him making funny drawings
that he wouldn’t show to anyone. He thought they were terrible and
wished he could draw like his mother.
BLC 11 Big Take-Away? Problem-finding is the Next
Big Thing
One of the threads to emerge out of a number of terrific presentations at November Learning’s Building
Learning Communities 2011 conference in Boston was the idea that we are shifting to a new pedagogy.
We might describe the old model of teaching–let’s call it “education 1.0″–as a problem-solving pedagogy.
In it, students are asked to solve hundreds of trivial problems in textbooks and worksheets. Page-tall
columns of algebra equations come to mind immediately, but we find equally dull work in other subjects,
too: book reports in language arts classes, listing provinces and their capitals in Social Studies classes, for
example. I realize I’m being a bit hasty here. There is a good argument for drilling in order to build skills.
There is also great value in just knowing things. However, it’s not hard to see that if this is all we do we are
in danger of creating a classroom of highly skilled but not very imaginative or creative students. This is the
lament of China’s education leaders.
Education 1.0 was replaced by a problem-based learning model–let’s call this education 2.0. Here, curricula
and student work are driven by relatively complex problems meant to give purpose to the sort of drilling
that went on in vacuo before. In order to solve a problem, students–it’s believed–will naturally search for
and hone the skills they need to solve it. The critique heard at BLC 11, quite loudly from Ewan McIntosh,
is that these problems are artificial. The answers are already known by the teachers or some other authority
so the problem is not in fact a problem to be solved at all. More importantly, as Dr. Eric Mazur and Dr.
Steven Wolfram pointed out in their keynotes, this sort of contrivance does little to prepare students to be
the life-long learners schools universally claim they are creating. Again, I’m aware I’m taking some
liberties. It is indeed well worth the effort to walk through some old problems just to see how others went
about solving them, to study their methods, as we say. This is what Newton meant when he said he stood
on the shoulders of giants. He did not mean, however, that the purpose of that study was to add another
hammer in the problem-solving toolbox. He meant the purpose of that study was to find where old methods
were insufficient for cracking open knew knowledge.
So here at BLC 11, the buzz is about giving education 2.0 another turn turn to create a problem-finding
pedagogy. Let’s call this education 3.0. Here we want students to engage with problems to which even the
teachers do not know the answers, to engage with the “unknown unknowns” as Ewan McIntosh says.
It’s there in the terra icognita of knowledge that learning gets exciting. Discoveries in this area have
genuine value not just to the student, but to everyone. I’ve heard many teachers express chagrin at the way
students toss out their notebooks at year-end. But if those notes aren’t much more than a record of drills–
the equivalent of a record of the pushups one has done all year–I can hardly fault the students. Indeed, I
think we have a serious moral problem if we are compelling students to attend classes and don’t help them
produce something of intrinsic worth.
Something else exciting happens when we pass the edge of the knowns, too, I think. Students are
encouraged to work at a very high level of thinking when they are asked to analyze a collection of data,
judge it’s worth, synthesize it and draw out a question for further study. (I wonder if structure of education
itself inhibits, even excludes, higher-order thinking. That would make the efforts of teachers to encourage
students to think more deeply and richly largely misplaced. If we want to change behaviour, we have to
make sure the environment supports the new behaviour. It’s a study I’d like to pursue.)
Wolfram created his fabulous apps to relieve the students of the burden of trivial calculations so that they
can apply there mental energy to finding the new problem in set of data. Marco Torres looks at apps
like Thumbjam and Hex OSC Full the same way, as tools that let the non-piano player get on with making
a soundtrack for a video, for example. (Hans Rosling, not at the conference, created
his Gapminder software for the same reason.) I am proposing a model workflow for a problem-finding
school that could employ these tools and get on with finding new problems:
This is a sketch. I need to spend some time thinking about what this looks like in practice, especially across
all the grades. But I’m suggesting that as the students consider the questions in the diamonds, they must do
some hard thinking. They would also have to think carefully–critically–about where to get help. I can see
links to building social networks and teaching social search here.
I am especially interested in the final question–”is it worth keeping?” That question, essentially, replaces
the final exam. (There’s probably another loop in here that asks if we ran another iteration of the problem
would we find a better answer.)
Students also have to consider how they will store that data for later use. I favour a bucket to hold huge
piles of unstructured data that users can can reorder as they need, hence my note to tag rather than file. It
seems the semantic web, which would be ideal here, is still a ways off, but there are ways to set up
unstructured data collections even primary students could use. We had a custom-built prototype bucket at
my previous school and I am pretty sure one can build a good workarounds using a combination of off-theshelf tools. (More on that later.)
I’ll spend the next few weeks of summer tinkering with this plan and have it ready to run with my students
when school starts in the fall. In the meantime, I’d appreciate any thoughts.
Cross-posted in my own blog, A Stick in the Sand.
This entry was posted on Sunday, July 31st, 2011 at 4:27 pm and is filed under BLC. You can follow any responses to this entry through the
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7 Responses to “BLC 11 Big Take-Away? Problem-finding is the Next Big
Thing”
1.
Ewan McIntosh Says:
August 1st, 2011 at 5:36 am
2.
I’m putting the keynote and a few other things together as a new book, finished this week,
published for BLC11-ers first of all, entitled The Problem Finders, after the opening to the
keynote. I hope it helps people begin that journey of finding a new way of framing learning.
Brad Ovenell-Carter - Guest Blogger Says:
August 1st, 2011 at 10:00 am
3.
I saw your tweet! Looking forward to the book, Ewan. My plan is to have a model ready to deploy
in my IB TOK class this fall. I’ll let you know how it goes.
Thea Nielsen Says:
August 7th, 2011 at 9:32 pm
Looking for unsolved problems and finding ways to unravel its mystery is the best education you
can get, but only if you are familiar with most of the basic things around you. Or else, you would
only be solving something that has already been tackled before.
4.
Nancy Lockhart Says:
August 16th, 2011 at 12:05 pm
5.
To give students problems whose answers are unknown passes the edge of the knowns!
Administrators have to teach teachers to let go of some of the control and let discovery begin!
Jeanne Duran Says:
September 11th, 2011 at 10:42 am
6.
This is all very exciting and I agree with the need to develop collaborative, creative problem
solving skills in our students. My struggle is with the balance between this and the Common Core
frameworks that predetermine what needs to be learned. Can one find problems with unknown
answers that will ‘lead’ students to discover what we have decided they need to know?
Bruce Deitrick Price Says:
September 16th, 2011 at 4:51 pm
7.
Who is Thea Nielsen and why is she so smart? “…Looking for unsolved problems and finding
ways to unravel its mystery is the best education you can get, but only if you are familiar with
most of the basic things around you.”
I worry that all the talk in this column is going to be abused as a sophistry for further dumbing
down the classroom. Just watch. The defense against that is to make sure young students do learn
basic skills and basic facts. Only on that solid foundation can you move–slowly but increasingly–
toward more creative and original work.
This weird fetish for bringing college into the 4th grade was first seen in New Math. It was a
disaster because it did not teach knowledge in an appropriate and ergonomic way.
Bruce Deitrick Price
Improve-Education.org
Jane Doe Says:
September 30th, 2011 at 11:35 am
There is a place for drills and practice. Most of my algebra students cannot add or multiply
fractions without a calculator. They have no idea how to do it.