Reward or punishment in medical training

Like many of my colleagues, I teach and supervise students, residents, nurses, and respiratory therapists. I’m also the medical director of a PICU. Overall, I’ve been teaching and doing administration for over 30 years. And, like most of my colleagues, I never received any formal instruction at all in how to do these things. To some extent I got help from my own mentors, primarily by watching what they did, but basically I learned on the job. I hope I am reasonably good at it, but really, I have little way of knowing if I am. So I’ve always had an interest in whatever tidbits I could pick up in teaching theory that might be useful. One particular topic that’s always interested me is the opposing pros and cons of reward versus punishment. I use those tools to train my horse – rebuking bad and praising good behavior. What do we know about applying them to people?

The practical problem, one faced by most teachers, is what to do when a student does a poor job. The tradition in medical teaching, certainly when I was in training, was to lean heavily on the rebuking, punishing side of the equation. Public ridicule was common, and there was more than a little yelling involved. Did fear of that help me avoid doing the wrong thing next time?

A while ago I was reading one of my favorite group blogs, Crooked Timber. Most of the contributors are professors of one sort or another, and the topic of effective teaching comes up now and then. This whole reward/punishment tension was the topic of a post there. The situation it describes involves military flight instructors, who universally believed that yelling at fledgling pilots when they made mistakes was much more likely to make their next attempt better than was praising a good action. Here’s what one instructor had to say about it:

On many occasions I have praised flight cadets for clean execution of some aerobatic maneuver, and in general when they try it again they do worse. On the other hand, I have often screamed at cadets for bad execution, and in general they do better. So please don’t tell us that reinforcement works and punishment does not, because the opposite is the case.

It’s a military example, but training doctors has traditionally been done using that sort of get tough model. I was aware of a statistical principle called the regression to the mean, but this example applies it to teaching in a way I hadn’t thought about. The argument goes like this.

If a given student does a bad job at something, that is more likely to be a low point for them, below their average. Statistically speaking, they are more likely to do better on the next attempt no matter what the teacher does. So the teacher is likely to think whatever he or she did – screaming, for example – as causing the improvement. On the other hand, if a student does an exceptionally good job, the same regression to the mean makes it likely the next attempt won’t be as good, so whatever the teacher does – in this case praising – tends to cast doubt on the usefulness of praise.

For myself, I think praising, in the long run, works much better. I’d be interested in what any professional teachers think about this.

In the comment trail to the article, the classic The Art of Raising a Puppy was cited as a useful source. I found that very interesting. After all, to those of us with more than three decades in medicine, medical students are a little like puppies. We want to give them a sound foundation and train them without hurting them.

Christopher Johnson is a pediatric intensive care physician and author of Your Critically Ill Child: Life and Death Choices Parents Must Face, How to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments.  He blogs at his self-titled site, Christopher Johnson, MD.

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