How Do We Train, How Do We Measure, Is This for Everybody?

Educating educators:

If anyone is going to teach they are going to need to know who they are teaching, what they are going to teach, and how to teach it. Therefore, those who are teaching poor students are going to have to know and be able to identify in their students the ways their students are poor, how this effects their thinking and the hidden rules of their culture, and how to work with them to learn and incorporate the hidden rules of the middle class. A Framework for Understanding Poverty would be a starting point and incorporating the curriculum that Ms. Payne has devised in her AHA process[1] as part of standard teaching curricula would make be helpful as well.

Non-cognitive skills again are things like perseverance, self-control, social intelligence, curiosity, gratitude, enthusiasm, and optimism. These can be incorporated into the standard academic curriculum[2] and taught at any age[3]. This is critical for academic achievement to translate into lifetime success. Training in this skill set will be critical for current and future teachers. 

In addition to academic classes as part of teacher training and continuing teacher education it would be imperative to have on site peer reviews on a regular basis to talk about and solve problem situations.  In order to do this effectively I would favor cameras in the classroom[4] so that issues to be addressed could be captured in real time and discussed among colleagues in regularly scheduled review sessions. With every profession, medicine, engineering, law, one goes through school to get the basics but hones their craft through experience.  For teachers to share their experience and develop their craft with the help of their peers on an ongoing basis would help to ensure that continual improvement in that craft.

It is true in any service profession but probably more so with teaching that the attitude of the teacher has a lot to do with their effectiveness. Teachers deal with children so providing a caring nurturing environment is crucial to the success of their teaching. Peer review of the type I described can spot problems in this area and more importantly provide support and feedback to help educators maintain the high standards we want them to aspire to.

Measuring achievement with students:

The end points are softer in the area of cultural intelligence and non-cognitive learning but they are measurable and they can be incorporated into academic testing. Testing for cultural intelligence could involve role-playing exercises. (How do I balance my checkbook? How do I budget for the month with this income?) Testing non-cognitive skills could include tests of perseverance and cooperation. (How does this student solve problems and work with their team in building a robot for their science project?)  Identifying these skills as learning objectives and measuring their attainment is key to making education more complete.

The other 60%:

Will all this extra schooling with emphasis on hidden middle class rules and non-cognitive learning help the middle class and upper class majority provide something vital that is missing in the current curricula? I think there is something vital that is missing and addressing that with a curriculum change could provide it.

6.7% of Americans are clinically depressed.[5] But that rate is 35% among college students[6] and 27% among medical students, [7] those who would be considered among the most academically successful in their age group.

I think the following additions to the academic curriculum would be helpful for all socioeconomic classes but particularly important in addressing this problem.

Teaching meditative practice:

Victor Frankl said, "Between stimulus and response, there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” Among other things meditation trains the brain to expand that space so that those who become proficient in it can respond to the world in a more thoughtful and rational way.  This is helpful in both emotional and intellectual health.

Teaching emotional intelligence:

Emotional intelligence is the capacity to be aware of, control, and express one's emotions, and to handle interpersonal relationships judiciously and empathetically.[8] Emotional intelligence is a subset of non-cognitive skills that can be taught and contribute significantly to personal and academic success.[9]

The other non-cognitive skills:

It is hard to be anxious or depressed if a student is enthusiastic and optimistic. Of course, sometimes the going is hard and that takes perseverance.  That said even with the best attitude, talent, and effort one can muster sometimes we just don’t succeed. Failure may not be an option if you are member of Special Forces but it is inevitable for the rest of us and also an opportunity. We learn and can grow from our mistakes. How we deal with failure is as much a measure of our character as whatever makes us successful. Teaching children to accept responsibility and to learn and grow from their mistakes would unburden them from an unnecessary sense of failure and give them the capacity of resilience.  

Adding meditative practice, emotional intelligence, and non-cognitive learning skills to the cognitive academic curriculum would help all students across the socioeconomic spectrum to have the cognitive skills emotional intelligence and strength of character to be happy, healthy, and successful as adults.

In the next blog I will talk about how we would pay for all of this. I didn’t think I would write so much about something about which I know so little but I guess that is what this whole experiment is all about.

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[1] AHAprocess.com

[2] http://www.nber.org/papers/w20749

[3] http://www.creativitypost.com/psychology/can_non_cognitive_skills_be_taught

[4] I can imagine some push back on this. On the one hand, the object is not at all punitive but educational. On the other, as far as big brother in the classroom, we are talking about public schools with up to 25 witnesses for anything that goes on in the room.

[5] https://adaa.org/about-adaa/press-room/facts-statistics#

[6] http://www.apa.org/monitor/2013/06/college-students.aspx

[7] https://www.amsa.org/anxiety-and-depression-the-risks-of-medical-school/

[8] https://en.wikipedia.org/wiki/Emotional_intelligence

[9] http://ei.yale.edu/who-we-are/mission/

What comes out depends on what goes in – and how it gets there

The object of education for anyone is to provide something that’s missing – how do I read, how do I paint, how do I interpret Plato? Regardless of the exact curriculum or method of teaching there are social, emotional, and cognitive skills that poor children are missing and need to be taught if they are going to successfully escape poverty.

According to their website, KIPP schools aspire through their teachers to create a rigorous academic environment that also provides role models and support systems, characteristically missing in poor families, as Ms. Payne has pointed out[1], to help their students out of poverty.

Children in poverty, particularly generational poverty, literally come from an alternative culture. They need someone to model the different cultural norms so they know how one thinks, talks, and acts in the culture they aspire to. Perhaps more importantly, by providing a nurturing relationship that teacher or series of teachers can be the key relationship that transports children out of poverty.

Support systems provide the how-tos of the new culture. How do you do this algebra assignment when you don’t understand it; how do you balance a checkbook; how do you dress for a college or job interview? Having the time and taking the time to identify and focus in on the needs of the students and providing this kind of support, again in a nurturing manner, will help students bridge the gap to the middle class.

I have no first hand knowledge of how well KIPP schools achieve these goals but they are goals all schools should aspire to. Being aware of these differences and being able to provide resources to overcome these differences should be a crucial part of the education of teachers and the task of teaching. Schools and teachers should be judged on how well they provide this kind of service.

With respect to curriculum, regardless of what cognitive skills are taught non-cognitive skills should be embedded into the course work and/or taught as separate class work. Non-cognitive skills include perseverance, self-control, social intelligence, curiosity, gratitude, enthusiasm, and optimism.[2] These character traits are as important to scholastic and life success as any cognitive learning skill. Furthermore, while they are most easily instilled at an early age they can be learned even later on in a scholastic career.[3]

With respect to the academic curriculum my only suggestions are the following.

I would recommend ensuring that all students are bilingual by the time they enter first grade. This would be accomplished by immersion in English in preschool for children for whom this is a second language and immersion in a second language in preschool for children fluent in English. This is when brains are optimally designed to learn language. A former classmate of mine has run a Montessori school outside of Chicago and English-speaking 3 year olds are immersed in one of 3 languages and come out at age six fluent in the immersion language.

I would consider introducing students to a musical instrument at around age six. There are a host of cognitive and non-cognitive skills that can be learned in the practice of a musical instrument.

In my next entry, I take a stab at how we might educate teachers, how we might measure achievement, and how we would pay for all this.

In addition, while one in five children live in poverty (compared to 1 in 8 adults) and 44% live in low-income families, that still leaves a majority of children who are middle class or above. In my next entry I will also take a stab at what if any benefit this structure might have on the majority of students.

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[1] I reference my own blog. http://geoffhberg.blogspot.com/2018/03/a-framework-for-understanding-poverty.html

[2] Again KIPP schools are exemplary is that this is part of their mission and curriculum http://www.kipp.org/approach/character/

[3] In the early 90’s Nobel Prize winning economist James Heckman noted that students who took the GED to earn a high school equivalent diploma studied an average of 32 hours. In subsequent studies he found that compared to high school graduates they tended to do poorly in jobs, the armed services and marriage. What they lacked were non-cognitive skills. I came across this idea in the following This American Life segment.  It is very worthwhile to listen to. https://www.thisamericanlife.org/474/back-to-school

Improving Public Education - More is better

This discussion of education is based on the following assumptions.

1.     Democracy should afford its citizens equality of opportunity.

2.     Education, both historically and actually, is a vehicle – probably the principle vehicle for democracy to afford equality of opportunity.

3.     Financial status affords middle class and wealthy students material and cultural advantages that tend to tilt the playing field in their favor.

4.     Changes in the way we educate our children can provide better outcomes for everyone[1] and at the same time help to level playing field for the socially and economically disadvantaged. That said, I am going to principally focus on leveling the playing field. At the end I will make some comments on how this specifically may help the more materially advantaged classes.

As noted in A Framework for Understanding Poverty people are poor in more ways than a lack of money. These include deficiencies in emotional resources, knowledge resources, spiritual resources, support systems, and role models. In addition, people living in poverty learn hidden rules that help them survive in poverty but are different than the hidden rules of the middle class and keep them from moving up the socioeconomic ladder.

I would contend that school can provide these non-financial resources and provide an environment to learn the hidden rules of the class they aspire to but only if children start younger and go to school for more hours/day and more days/year. That would mean children would start school at age three, have a 9-5 school day, and go at least 200 days per year with no school break longer than 3 to 4 weeks.

The model for this can be found in KIPP schools. These are publicly funded K-12 charter schools. Their typical school day is 7:30 to 4:00. Because they are publicly funded they operate on the public school calendar although they offer summer school. Nearly 90% of their students are poor [2] but perform academically at or above grade level when compared with conventional public schools[3]. I would suggest starting this model for preschool, starting the school day later for health and academic reasons[4], and extending the school year to avoid summer learning loss[5].

The principle object of these extended hours days and years is provide an immersion experience in literally an alternative culture from the culture of poverty so that poor children can successfully move out of poverty and into the middle class and possibly beyond.

Of course, if the academic quality of those extended hours, days, and years of schooling is subpar then expanding this time will be a waste of it. That quality will depend on the quality of the methods, the teachers, and the curriculum. I know nothing of teaching methods and close to nothing about teacher standards or curriculum. However, with respect to the latter two I would like to suggest some parameters and I will do that in my next entry. 

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[1] The United States is below average in math and about average in reading and science compared to 34 OECD countries https://www.oecd.org/unitedstates/PISA-2012-results-US.

[2] http://www.kipp.org/results/national/#question-1:-who-are-our-students

[3] http://www.kipp.org/results/national/#question-3:-are-our-students-progressing-and-achieving-academically

[4] https://www.cdc.gov/features/school-start-times/index.html

[5] Summer learning loss is the phenomenon that students regress and lose up to a month of learning after the 10-week summer vacation. This is especially true of socioeconomically disadvantaged students. https://www.brookings.edu/research/summer-learning-loss-what-is-it-and-what-can-we-do-about-it/

A Framework for Understanding Poverty – no really

In 2016 J. D. Vance’s book, Hillbilly Elegy: A Memoir of a Family and Culture in Crisis was published to critical acclaim. Of the book, the Economist said, "You will not read a more important book about America this year." It the story of one family of the Appalachian diaspora that moved out eastern Kentucky and poverty after WW II, fell back into it in the 70’s and 80’s and how the author escaped but left behind the poverty that still haunts the Midwest.

This entry is not about Hillbilly Elegy. It is about a book that, in an organized and systematic way, explains every facet of the origins of poverty that J.D. Vance experienced, the patterns of culture and family structure that he experienced in poverty, and offers instruction in how to break those patterns and where Vance’s escape from poverty is a prime example.

The book is A Framework for Understanding Poverty by Ruby K. Payne.[1] Ms. Payne is a educator and she wrote this book as a workbook for teachers and guidance counselors to help them not merely deal with poor students but help them develop skill sets to get them out of poverty. More than 20% of children in this country live in poverty.[2] This is not only a disproportionate part of our population but we are 34^th out of 35 developed countries[3] with respect to the percent of children in poverty.

A patient of mine who is a retired police officer and runs a shelter for homeless women and children told me about the book and for me I did “not read a more important book about America” in 2016 and I read it on the heels of reading Hillbilly Elegy.

In the introduction she has “Key points about Poverty” and some statistics, about poverty.  Most important in this are the factor that get people out of poverty. These are that it is too painful to stay, a vision or a goal, a special talent or skill, a key relationship.

In chapter one she enumerates the factors that define poverty. Poverty is more than a lack of money. People who are poor also lack:

1.     Emotional resources, the ability to withstand hardship and persevere. She considers this the most important resource

2.     Mental resources, ability to process information

3.     Spiritual resources when present help the individual to not feel hopeless or useless.

4.     Physical resources, People with disabilities lack the ability to be self-sufficient

5.     Support systems, people or groups who provide physical, financial, or emotional support for the person in poverty

6.     Role model/mentor to model the hidden rules of the class (the middle class) to which you should be aspiring if you want to get out of poverty.

7.     Knowledge of the hidden rules of class

 

 

In chapter 3 she enumerates the hidden rules of poverty, middle class and the wealthy. People in these different classes have different relationships to very fundamental aspects of our life. The following are some examples:

	POVERTY	MIDDLE CLASS	WEALTHY
Money	To be used and spent	To be managed	To be conserved and invested
Education	Valued and revered as abstract but not as reality	Crucial for climbing success ladder and making money	Necessary tradition for making and maintaining connections
Time	Present most important. Decision made for moment on feelings and survival	Future most important. Decisions made for future ramifications	Traditions and history most important. Decisions made partially on basis of tradition and decorum

The point she makes here is that first people in poverty aren’t making “bad” choices because they are stupid; they are making the choices they make because that is what allows them to survive in poverty. Second, in poverty crises arise in the moment so time is compressed and everything is about the current moment so middle class skills like perseverance and delayed gratification are hard to master in this environment. Third the object of education (and perhaps by extension any anti-poverty program) is to educate the poor to the hidden rules of the middle class so that when they enter the middle class world (at work or school) and can find success there and hopefully find their way out of poverty.

In chapter four she delineates generational poverty, defined as two generations living in poverty.  Unlike situational poverty in which one has fallen out of the middle class into poverty, in generational poverty the hidden rules of the middle class are unknown and the hidden rules of poverty are more deeply ingrained. In addition, the family structure, discipline, and language (as presented in chapter 2) are such that they only reinforce the hidden rules of poverty.

The last half of the book consists of strategies for educators to use to address these issues. Furthermore, this book is a publication of an organization Aha Process that offers education of these strategies.

Virtually every aspect that Vance described about poverty from the multiple aspects of poverty, to the hidden rules, to the family trees. For me what was so important about this book was that while Vance's personal saga is about Appalachian poor, she make crystal clear, that poverty regardless of race color or creed regresses to the same mean and the path out is identical for all who are born or fall into poverty.

Vance suggestion that the government throwing money at poverty has largely been a waste may be because we are not focusing in on the other co-conspirators in the cause of poverty.

J. D. Vance credits his grandmother’s mentoring as his salvation from poverty and doesn’t think government can reproduce that. Of the factors that get people out of poverty (see above) the only one outside the individual is a mentor to lead them. Ms. Kane suggests that this is a piece of the puzzle that education might provide if the teaching community embraced it.

In my next blog I am going to give my thoughts on education and how to change it. Since this is something about which I know nothing there will probably be a lot of dogma. (Although I will try to reference my dogma as much as possible.) However, I would very much like to hear your thoughts (and corrections).

 

 

 

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[1] The version I read is the 2003 edition. This can be purchased used on Amazon for under $10. The version I bought is pictured above.

[2] http://www.nccp.org/topics/childpoverty.html

[3] https://www.unicef-irc.org/publications/pdf/rc10_eng.pdf

Fixing Healthcare Part 3C: Odds and Ends

Here are some other issues that would come up in a transition from our current health care system to a Guaranteed Healthcare Entitlement (GHE).

Where does the money come from? Well to begin with the money is already coming from somewhere so we could start by identifying the current sources and creating a system around that.  For instance, there could be corporate tax at approximately the rate they pay currently for health care which, from talking to at least one business owner, they would embrace in a heart beat knowing that that rate would be fixed for at least a decade.  However, it should be structured in a way that it is not based on the number of employees so as not to discourage hiring.  Medicare contributions from salaries could still be collected. A small 1 – 3 % tax on non-wage income again fixed for at least a decade could be created to cover any shortfall. 

Where does the money go? Of the $3.3 trillion we spend on health care 80 – 90% would go directly to ACO’s for patient care.   However, there would be additional cost outside of direct patient care. These would include . . .

There would be administrative cost. These would include computing the actuarial tables on which premium payments would be based.  The distribution of these payments to ACO’s would be an expense but much less than current Medicare costs because it would be a monthly lump sum payment for lives covered not a payment for each individual procedure.  Establishing what is covered and standards of care would be required and periodically updated. These would be covered.

The current bill for health care includes government agencies such as the National Institute of Health, the Food and Drug Administration, and the Center for Disease Control.  These would continue to be fully funded.

           

What to do about malpractice: If medical groups are to be open and transparent the malpractice system should be scrapped.

Malpractice is the system we have to identify medical errors and compensate people who are hurt by those errors.  The problem is that malpractice is not a system and it does a very poor job of identifying those errors and providing compensation for the errors. 

Malpractice grew organically out of the fact that there are doctors who make mistakes and there are lawyers to sue them so on a case-by-case basis we have a huge industry that awards payments to around 150,000 plaintiffs annually.[1] It is demonstrably true that there are many more medical errors than this.[2] It has been suggested that this is a reason for even more litigation[3] but the problem is that malpractice itself inhibits the investigative process that would identify individual and systemic problems, formulate corrections, and provide reasonable compensations to the injured.

Malpractice is litigation and to paraphrase Clausewitz litigation is dueling by other means. In addition, when one gets sued, their lawyer immediately advises them that they are only allowed to talk to their counsel, their spouse, or their clergy. In this secretive and adversarial atmosphere in which virtually every physician feels threatened[4] it is virtually impossible for an open and transparent dialogue to take place.

Furthermore, because especially those who, in the current system, are labeled plaintiff and defendant can’t have a dialogue a large part of the healing process is lost.

Finally every discipline has its own system for establishing truth. The legal and medical epistemologies are very different.  Medicine is disinterested, rational, and cooperative; litigation is partial[5], emotional, and adversarial.  In my limited experience legal judgments are hit or miss when they come to accurately reflecting the medical facts. 

This is not to say that medical errors don’t occur. They, of course, do but these errors would be far more likely to come to light in a system if malpractice were replaced with a no fault compensation system for medical errors.  Such a system could be run by the states by strengthening their board of medical licensure and discipline.

In summary the current malpractice system does not allow for the open investigation of medical errors, does not allow for reconciliation between the provider and the patient and family, and in general does not give justice a good name. Health professionals and patients need a better system.

There are of course a lot of other issues that I have not thought of which would effect the implementation and effectiveness of such a radical change in health care delivery.  I would certainly welcome any thoughts from readers on the matter.  If you don’t like this system you don’t have to worry because . . .

1.     I am not emperor.

2.     Most people don’t recognize the long-term deleterious effect the medical industrial complex has on the economy.

3.     Those who are concerned put the blame for health care problems on the insurers or government and not on providers.

4.     Currently, the federal government spends $1.2 trillion dollars on healthcare.[6] With the GHE that number would be 3 times that. Again We the People are already spending that on healthcare but there would still be a significant (I would say knee jerk) reaction to this “socialization” of medicine and corresponding increase in the federal budget.

5.     Since such a system threatens doctors, insurers, lawyers, and drug manufacturers it may be a good thing but the powers (read money) that would oppose it would be all but insurmountable. 

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[1] https://www.npdb.hrsa.gov/resources/npdbstats/npdbStatistics.jsp

[2]https://www.hcp.med.harvard.edu/sites/default/files/methodsmakarydaniel_2016_bmj%20%281%29.pdf

[3] https://centerjd.org/content/briefing-book-medical-malpractice-numbers

[4] 

 

http://www.nejm.org/doi/full/10.1056/NEJMsa1012370

[5] The fact that medical testimony for both litigants comes experts who are paid by those parties is the antithesis of disinterested and counter to the principles of best medical inquiry practices. 

[6] http://www.taxpolicycenter.org/briefing-book/how-much-does-federal-government-spend-health-care

Fixing Healthcare Part 3B: Changes in the delivery of care

The changes I proposed in the organization of health care would bring down the cost significantly. However, I think changes in the delivery of health care beyond what is done anywhere else could have further benefits in reducing the medical industrial complex starting with . . .

Health maintenance: When you first walk in to your doctor’s office the first thing that happens is  - data entry.  You give your demographics and your insurance information and now in a new wrinkle they ask if you are anxious or depressed, if you smoke or if you drink. This happened to me at my orthopedist’s office. None of this data collection requires the skill of a doctor.  Furthermore, the most effective solutions involve specific programs or providers that address those specific problems – the mental health counselor for those who are anxious or depressed and substance cessation programs for patients who drink or smoke.  Adding some simple vital signs and basic blood work would identify problems and direct patients to resources that would actually help them.  All of this could be done with an app without the input, and cost, of a high priced health care provider with an advanced degree.

Computer medicine: Doctors do two things; diagnose, which is pattern recognition, and treat, which always involves risk/benefit analysis.  Both of these processes are precisely what computers are good at and very probably could supplant the clinician.  For a variety of real technical as well as emotional issues that could be a stretch. However, at the very least computers could render a second opinion. As an example, radiology is all about pattern recognition. In England mammograms are read by two radiologists.  In a study they had a computer do the second reading and got results comparable to two radiologists. [1]

Technical care: Sometimes diagnoses or treatment require procedures or surgery.  Sometimes these procedures require operator discretion such as a lot of general surgery and neurosurgery. For example, a surgeon doing exploration and excision in the abdomen for cancer must identify the cancer and its extent and decide what and how he must remove what he has found. However, a lot of procedures and surgeries are routine repetitive. I would submit that technicians trained for the specific task could do a lot of these.

For example, back in the 90’s when sigmoidoscopy was the standard screening procedure for colon cancer Canada had trained nurses do the procedure with results, as would be expected comparable to doctors.[2]

I would submit that there are a large number of surgical procedures that are chronically repetitive could be done at least as well by trained technicians as it is by doctors with nearly a decade of training past medical school.

Surgical outcomes are most highly correlated with operator experience[3], and manual dexterity.[4] [5] Neither of these qualities are screened when candidates are judged by standardized testing. 

I would suggest that procedures such as colonoscopies and arthroscopies and surgeries such as cataract operations and joint replacement could be done by technicians based on their manual dexterity and their demonstrated expertise over time. Training and even a healthy low six figure salary would be a fraction of the cost of the current arrangement.

To the best of my knowledge no developed country does any of this but that isn’t to say that it can’t be done and in a fixed cost health care system there would hopefully be the motivation to experiment in this direction.

In my next installment I will talk about some odds and ends but mostly about malpractice.

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[1] http://www.nejm.org/doi/full/10.1056/NEJMoa0803545

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4071908/

[3] https://www.ncbi.nlm.nih.gov/pubmed/23932603

[4] http://www.nejm.org/doi/full/10.1056/NEJMsa1300625

[5] https://well.blogs.nytimes.com/2013/10/31/a-vital-measure-your-surgeons-skill/