An Effective Team: Active Learning Also Needs the Sage on a Stage

Abstract

As a faculty member at a medical school, I have had experience with a variety of different teaching methods. Lecturing, sometimes ridiculed as “sage on a stage,” has been to some extent replaced by active learning approaches, including in medical science education. However, some academics have defended the lecture format, and if one accepts the importance of diversity of thought and opinion in academia then this should also include diversity of teaching methods and of learning experiences. Thus, academic freedom should include content delivery and not only of the content itself. Briefly examining arguments made in one prominent defense of the lecture approach, and based on my own practical experience, I believe that the “sage on a stage” should be included as a component of the educational toolkit, as an important contributor, along with active learning approaches, to an effective educational team. I also note that students have a responsibility in making the best use of any educational approach, including lecture.

Plain Language Summary

Lecturing as an Important Tool for the Effective Educational Team

As a faculty member of a medical school, I have used a number of different methods to educate students. I have lectured students, a traditional form of teaching that has fallen into disfavor among some in academia, who ridicule lecturing as “sage on a stage.” In other words, lecturing is seen as being performed by an arrogant self-absorbed faculty member (“sage”), on a podium (“stage”), with the focus of attention being on the professor rather than on the students. In contrast, active learning approaches are being increasingly favored in higher education. However, based on my experiences as a medical school faculty member, as well as published work by others, I believe that lecturing—the “sage on a stage”—retains an important place in higher education. I contrast the stereotype of a negative lecturing experience to what an engaging positive lecture can be and favorably contrast that to an active learning-only approach, which itself can have problems. Further, I discuss how lecture can be effectively combined with specialized active learning designed by individual faculty members based on their own material, as opposed to problematical general team approaches. I also discuss how students have a responsibility for maximizing their learning experience, regardless of teaching method. As part of academic freedom, faculty should have the right to design their educational material as best they see fit to help the students understand the material and not be forced to accept team-based active learning as the newest “fad” in higher education. This need not be a “zero-sum” argument; both active learning and lecture have their places in an optimized educational environment. I oppose the attitude in which lecture is a priori rejected and mocked as “sage on a stage.” The most effective and open-minded approach is to use the tool best suited for a particular educational objective. Thus, a defense of lecture is not an attack on properly conducted active learning. I conclude that we need to bring back the “sage on a stage” as part of an effective education team that couples both lectures and active learning approaches.

As a faculty member at a medical school, I have had experience with a variety of different teaching methods such as lecturing and team-based active learning. Lecturing has to an extent fallen out of favor in some areas of academia, including medical education, and is sometimes ridiculed as being a “sage on a stage.” ¹

Replacing lecture in certain institutions are such approaches as team-based active learning and the flipped classroom, in which students accumulate knowledge, including from faculty-produced podcasts, before class, while the actual in-class experience with faculty involves student driven self-directed active learning exercises. Other active learning approaches include case-based learning (CBL), peer-assisted learning, problem-based learning (PBL), team-based learning (TBL), observational learning, and simulation-based learning.^2,3 As regards frequency of use of delivery types, although lecture is still used in many American medical schools,^4,5 the proportion of its use is declining. Thus, as a proportion of content delivery, lecture declined from 60.66% in 2012-2013 to 51.10% in 2018-2019, while hours invested in simulation has increased. ⁴ Further, 97% of American medical schools use CBL and 54% use TBL. ⁶ Other data suggest up to 74% of medical education hours include some type of active learning method. ⁷ And, while still rare, some schools are eliminating lecture completely ⁸ ; the number of such schools may increase in the future. The quantitative trends are clear, but more important to this essay is the negative attitude toward lecture summed up by the derisive slogan “sage on a stage.” Therefore, although lecture is still heavily utilized, this teaching method is in decline and is being increasingly criticized as inefficient. ⁸

The available educational methods may be better or worse fits for particular forms of medical school curricular content. For example, year 1 basic science information may be the material best suited for in-class lecture, although pre-recorded podcasts coupled to in-depth problem-based active learning (“flipped classroom”) could be another option. My personal experience is that lecture works best for delivering basic science curricular content. I understand active learning has been found to be highly effective in teaching basic science at the undergraduate level. ⁹ My experience may differ for 2 reasons. First, the medical school and graduate school content that I currently teach is typically of a higher level of complexity and difficulty than that found in undergraduate education, and it may be possible that lecture is more effective for this greater information density and difficulty. Second, and even more likely, effectiveness depends on how active learning is being performed at a given institution. Thus, I find that 1h lectures on a given topic, with students being able to ask questions live, followed by problem-solving designed by myself specific to my material, presents the material more optimally, in depth, than do podcasts limited to ∼ 30 min, followed by team-taught active learning where 1 or 2 questions per 30 min of material are utilized as a retrieval technique. The experiences of other faculty under other systems may of course differ, but it is also likely that some faculty at other institutions may have similar experiences to mine. Context is important. In summary, I believe that lecture, combined with more control over how I deliver my material, provides a more optimal learning experience for the student with respect to material on postgraduate cell and molecular biology. For example, in my one-on-one interaction with students, answering their questions on my material, my impression is that they had a deeper understanding after lecture than after active learning. A direct quantitative comparison of student performance between the 2 teaching methods is not feasible in my case due to changes in the curriculum and exams, as well as the transition of USMLE Step 1 to pass/fail. However, my (subjective) opinion, my impression, my perception is that the students get a more comprehensive understanding of my material with lecture coupled to focused problem sets.

What about other types of curricular content? Observational and simulation-based learning is likely best suited for clinical skill training. CBL is well-suited for teaching such items as differential diagnosis, summary statements, disease mechanisms and pathophysiology, testing and management; thus, the curricular content geared to more direct medical knowledge would be effectively approached with a team-based CBL/TBL-style learning modality.

With respect to Bloom's Taxonomy, ¹⁰ lecture would fit best with the understanding domain, which is a pre-requisite for the other domains. Remembering would fit well with a form of PBL that is comprehensive enough in its coverage of content that the students actually practice retrieval of a significant portion of the learned material. Simulation and CBL would fit well with applying, and analyzing could be effectively achieved with CBL and PBL. Many of the active learning techniques would be suitable for evaluating. CBL as well as simulation may be best for the creating domain. Thus, active learning has its place, but without a foundational understanding of the material, the remembering, applying, analyzing, evaluating, and creating domains would be ineffective. If lecture is, or can be, an effective component of understanding, particularly for postgraduate basic science material, then lecture should have a place in the curriculum. I also note that the students could do all of the steps inherent in Bloom's Taxonomy on their own even in a pure lecture format, which has been the case until relatively recently.

Given some of the advantages of active learning with respect to particular components of the medical curriculum, as well as domains of Bloom's Taxonomy, it is not surprising that there are data to support the utility of active learning approaches in medical education.^11,12 For example, active learning has been shown to help lower achieving students to close the performance gap to those higher-achieving, without harming the latter. ¹³ In general, active learning is suggested to lead to better student engagement and has been associated with improved understanding and application of the relevant medical information, as well as improved clinical reasoning and interpersonal skills. ¹⁴ In particular, CBL and PBL seem especially effective as active learning approaches in medical education. ¹⁵

However, some academics have pushed back against the trend to critique lecture and have defended the lecture approach. ¹⁶ Thus, data also support the utility of the lecture approach in medical education, such as a preference of first year students for lectures, ² and, in particular, problem-based lectures have shown to be useful in enhancing student understanding and satisfaction. ¹⁷ It has been argued that lectures are optimal for the efficient of information transfer to students ¹⁸ ; further, while some surveys indicate that students do not find lectures to be time efficient, they still find value in attending. ¹⁹ Interestingly, one study suggested that students prefer “passive” lectures as opposed to active learning, while faculty prefer active learning; thus, students are more likely than faculty to believe that more content should be delivered by lecture. ²⁰ Of course, one reason that students perceive that they are learning more and thus prefer lecture is because lecture exerts a lesser cognitive load on students as compared to active learning. ²¹ Despite student perception, data support improved performance with active learning; thus, the students learn more even though they believe that they learn less.^9,21 Thus, student perceptions alone cannot be the deciding factor. Lecture versus active learning needs to be fairly evaluated with respect to results at every institution, as each institution may do active learning in their own way, with particular strengths and weaknesses. What applies for physics classes at Harvard University ²¹ might not necessarily apply to the particular approaches taken at specific medical schools. Further, student preferences and student satisfaction, while not a deciding factor, do need to be considered. Improving the ability of lecture to deliver content could enhance both student learning as well as student satisfaction. If lecture can be improved without significantly adding cognitive load, then student perceptions of learning, and satisfaction about lecture, can be maintained while at the same time providing better student performance.

Therefore, there have been calls to revise and enhance the lecture format to keep lecturing as a viable and useful component of medical education. ^{16 22–24} Despite positive aspects of lecturing, this mode of information delivery continues to be viewed with considerable disfavor by some in higher education.^16,25,26

At this point, I would like to examine some arguments made in one comprehensive defense of lecturing, ¹⁶ ponder my own practical experiences and conclude that lecture (“sage on a stage”) does indeed have an important role in medical education and can assist the students to develop skills of use in medical practice. This is not a “zero-sum” argument; I do not suggest that lecture should replace active learning but instead believe that lecture, along with active learning, can be a valuable member of an optimal education team. Thus, we should promote cooperation, not competition, between lecture and active learning.

Lecturing has been condemned as mere processing of information by the student as a passive consumer of content, an approach in which students blindly memorize information without full understanding or synthesis of the material; on the other side, the lecturer has been accused of running a monologue, dispending information in the absence of meaningful communication with the students. ¹⁶ The enthusiasm for podcasts, or similar “pre-work learning,” in flipped classroom approaches is somewhat puzzling, as all the alleged problems, mentioned above, with lectures would apply just as much to podcasts. Indeed, an argument can be made that podcasts are worse; after all, in the lecture format there is, or can be, direct interaction between faculty and students, the students are in the physical presence of the lecturer, who in turn can study the faces and body language of students to gauge how well they seem to be understanding the material. ¹⁶ When I lectured, I monitored the reaction of the students to my presentation and the students had the opportunity to ask questions during and after the lecture. In fact, there is nothing to stop the lecturer from engaging in “give and take” with the audience of a live lecture, which would begin to blur the line between lecture and some types of active learning preferred today. The lecturer should talk with, not at, students, as part of mutual reflection on the facts and arguments that are being presented. ¹⁶

Thus, the lecturer has the responsibility to make the lecture engaging in order to stimulate active listening. Indeed, one of the positive aspects of lectures is for the students to develop effective listening skills, ¹⁶ which is fundamentally important for the practice of medicine. This leads to another important point—the students, as well as the faculty, have significant responsibility in making the best use of any educational approach, including lectures. Students cannot be passive consumers of content but must engage in active listening and reflective thinking to synthesize the material. ¹⁶ In this respect we observe the value of individual responsibility, as opposed to collectivist team-based approaches. Indeed, a purported weakness of lecturing, the “isolation” of the student in the mass audience, can instead be viewed as a strength, as the “existential” experience of “aloneness” and solitude can stimulate deeper thinking and reflection. ¹⁶ This is another facet of student responsibility, to take charge, as an enlightened individual, of their learning experience, as opposed to always being a “cog in the machine,” dependent on others in a group learning format.

The literature suggest that active learning approaches are more effective when students take more responsibility for being engaged in the process,^27–29 which make sense as one of the fundamental premises of active learning is that it is a student-centered exercise and that students must be responsible for their own learning. While there has been less discussion of student engagement in lecture, ¹⁶ apart from complaints that the student role is typically unacceptably passive, the advantages of problem-based lecturing ¹⁷ may be in part derived from more student engagement. Thus, proposals to enhance lecture delivery have included “pause techniques” to stimulate more student engagement. ²³ Findings suggest that student confidence in the material is enhanced when interaction is included in lecture ³⁰ ; therefore, increasing student responsibility in this regard can optimize their learning experience. The consensus in the field therefore seems to be moving in the direction of student ownership of their educational success, for both active learning and lecture. My personal experience has been that CBL is expected to be a student-driven exercise with minimal input from the faculty facilitator. In lecture, I expected student engagement as part of their obligations for the course. In summary, both faculty and students have responsibility and accountability for effective learning.

At this point, we can compare the negative stereotype of lecturing to what a more positive outlook and approach would be. In the former, we have an arrogant, self-indulgent “sage on a stage” standing on a podium, droning in a monotone at bored and disengaged students, who in turn are nothing but human tape recorders listening to a monologue, documenting and attempting to memorize, in robotic fashion, a series of disconnected facts in the absence of any real understanding. In contrast, a positive view of lecturing would be of faculty interacting with the students, who in turn are utilizing active listening and reflective thinking to understand and synthesize the material, and link it to previously understood knowledge. In addition, the student can then leverage this fully synthesized information in future learning experiences, integrating all of it into a broader conceptual framework. This positive form of the lecture is what I strived to embody when I was lecturing.

As an example, envision a lecture on gene expression, a topic that I have practical teaching experience with. The lecturer can present atomized facts on different cellular and molecular processes and glaze-eyed students can attempt to memorize each isolated fact without understanding how they are linked or what their biomedical relevance is. In contrast, the material can be presented as facts and principles that comprise an integrated whole related to cellular function and related medical relevance, and the students can synthesize the information and actively reflect upon how the presented facts and principles fit into a larger picture. Later, these actively engaged students would be able to understand how the process of gene expression fits with human health and morbidity. This would seem to compare favorably to students being bombarded with facts in multiple podcasts, without the opportunity to engage with the faculty during this learning experience. The positive lecturing experience would also compare favorably to students coming to class to do problem-based student–team workshop versions of active learning that review only a small fraction of the prelearned podcast material, as they watch faculty spend the time walking back and forth (“teacher on a treadmill?”). In practice, what percentage of faculty podcast material is covered in these types of active learning exercises? If, say, only one or 2 questions are derived from a 30 min, information-dense, podcast, to what extent are the students effectively practicing “retrieval?” In this case, are specific types (eg, team-based student workshops) of active learning sessions the most efficient approach for the students to understand the material, or are they being performed because that is the “current fad” in academia? ²⁵ If we have an obligation to optimize lecture (or as some say dispense with lecture entirely), don’t we have an equal obligation to optimize active learning?

Of course, there is a place for various forms of active learning sessions and perhaps one strategy that can be considered is to combine lecturing with active learning; with the former presenting the facts in a manner that facilitates active listening and then subsequently allowing the students to work through problems (ie, active learning) to reinforce what has been learned. However, in order to practice real retrieval, active learning sessions should be individualized for each faculty member; thus, each faculty should be able to design their own active learning sessions dedicated to their material, so that the students can have significantly dedicated time allotted for each topic. In this manner, many key concepts can be worked on, rather than the 1 or 2 questions per faculty per topic occurs in “team-based” sessions. Indeed, of the many problems with a team-based educational approach, ⁶ is the dilution of faculty effort when multiple topics taught by multiple faculty are “crammed” into a single active learning session.

Further, a “one size fits all” “cookie cutter” approach to active learning sessions may not be the most effective strategy, since different types of material (eg, basic science vs clinical) can be best understood through various types of questioning. Some types of knowledge may be best retrieved by students through multiple choice, others through long answer, others through role-playing, etc. Each faculty member should have the freedom to design the appropriate active learning for their material. As stated above, in my experience, my material was best understood by students through lecturing with respect to imparting knowledge, and then by self-designed focused problem sets as regards active learning. In this sense, the “sage on a stage” can be an appropriate vehicle not only for imparting basic knowledge via lecturing but also via active learning designed by individual faculty members, specifically for their own lecture material.

While in theory academia should be associated with a diversity of thought and opinion, from my perspective, and that of others, the reality is of an increasing tendency for conformity of academic sociopolitical thought as well as of teaching methodologies.^25,31 I have previously discussed how the politicization of the medical curriculum leads to rejection of traditional modes of learning such as lecture, ²⁵ potentially harming students, and how forcing faculty to engage in specific types of teaching styles is not consistent with academic freedom, which should be a bedrock value in the educational environment. ³² Academic freedom is crucial with respect to educational content delivery; thus, extending my previous discussion of this topic, I consider the work of Reichman ³³ and how it can apply to choice of educational content delivery. A statement (pp. 69–70) from that work ³³ is relevant to the topic of academic freedom for teaching in which Reichman states that academic freedom applies to teaching approaches and should not be subject to the veto of administration. However, in team-taught courses there may be a collective responsibility for teaching that limits individual academic freedom; such decisions should involve discussion by all involved. ³³

I fully agree with Reichman's advocacy of academic freedom of teaching. If education is a significant portion of faculty responsibility, then it stands to reason that academic freedom must include teaching methodology, and not only, for example, research and scholarship. However, the issue of “collective responsibility” has to be carefully considered. Reichman states that academic freedom to teach in an appropriate manner should not be subject to the “veto” of departmental or institutional leadership. However, that leadership could do a “run-around” on academic freedom by forcing faculty to join a collective team-teaching approach, so that the educational methods used by all members of the “team” are consistent. Thus, if it is decided that the “team” is going to do pure active learning and if an individual faculty member instead believes that lecture is most appropriate for their material, then that faculty member's freedom to teach will be, as Reichman states, “limited by the collective responsibility of the faculty for the institution's curriculum.” ³³

Who decides on how the curriculum will be delivered and to what extent a collective approach will be used? If the decisions are made by leadership and by committees of select faculty appointed by leadership, the situation conflates to administrative control of faculty teaching and limited academic freedom. Thus, we see the importance of part of Reichman's statement: “deliberations leading to such decisions should involve substantial reflection and discussion by all who teach the courses under review.” ³³ All faculty stakeholders in the process must be able to equally participate in the process. Otherwise, faculty will question the legitimacy of a decision-making process from which they were effectively excluded. Further, there needs to be a balance between the practical requirements of “collective responsibility” and the reality that different educational methods may be more or less appropriate for particular material. If faculty can effectively defend why one content delivery method is superior for their material then they in theory should be allowed to use it. Institutional faculty representation (“Faculty Council” or “Faculty Senate”) should defend academic freedom in this regard and such freedom should be explicitly stated (and followed) in the Faculty Handbook. AAUP policies on academic freedom, including teaching style, could be enforced under contract law. ³⁴

Of course, there can be some practical issues with this ideal. Schools may devise “team-based” content delivery and there may be a desire for consistency of educational methodology across the curriculum. If the majority of faculty are doing active learning and one or a few faculty want to do lecture, this may be disruptive to the curriculum and to the students themselves, who seem to prefer consistency and predictability in content delivery. It may be useful to offer students a distinct choice between a traditional lecture-based curriculum and one based on active learning approaches, ²⁵ so individual students are not disrupted by inconsistent delivery formats, although this may run into limitations of faculty time and institutional resources; implementing a dual track is not trivial.

In summary, probably the best course of action is to create a balanced curriculum from the beginning and have all faculty stakeholders who teach in the program design the curriculum from the ground up, including a degree of flexibility of content delivery in at least certain sectors of the program; thus, I would suggest that as much flexibility for individual initiative as is possible be incorporated into “collective responsibility.” Having the curriculum be imposed top-down by administrative diktat or by a small select curriculum committee composed solely of like-minded individuals is likely to result in the academic freedom issues noted here. In this manner, incorporating appropriate flexibility and representation in curriculum design, the 2 halves of Reichman's statement ³¹ will be in better accordance, and academic freedom will be as maximized as possible even with a team-based approach. Perhaps academic teams should be viewed more akin to sports teams, in which different players have various skills and play different positions, all working in their own way to achieve collective objectives. A team does not have to imply that all members help to achieve the objectives in the exactly the same manner.

I conclude that the “sage on a stage” should be an important component of our diverse educational toolkit; there is nothing inherently wrong with lecturing, a teaching approach that, when done properly, can be of considerable value to the educational enterprise. The politicization of education and its consequent focus on nonlecture approaches must not be allowed to obstruct us from using the best methods for teaching. ²⁵ Further, it is important to again stress that this need not be a “zero-sum” argument; both active learning and lecture have their places in an optimized educational environment. I am not suggesting that active learning approaches should be eliminated and replaced by lecture; as far as I am aware, no defender of lecture ¹⁶ have suggested anything that radical. Instead, I oppose the opposite attitude in which lecture is a priori rejected and mocked as “sage on a stage.” ¹ The most effective and open-minded approach is to use the tool best suited for a particular educational objective. A defense of lecture is not an attack on properly conducted active learning; a sound approach to teaching should welcome the “sage on a stage” as a member of the educational team. Finally, as part of the education experience, students should observe and experience academic freedom as embodied by faculty who design and deliver material in the manner that they see fit to best educate those students. ¹⁶ Faculty should not be forced to engage in teaching methods that they believe are not optimal for student learning in specific topics.

To summarize, I suggest that that we should not “throw the baby out with the bathwater”—lecture remains an effective approach to deliver certain kinds of material, and the “sage on a stage” can be a cooperative “teammate” to various active learning approaches that may be more effective for other types of content. I would also suggest that childish derisive caricatures of lecture—“sage on a stage” being one example—should be eschewed; there is an implication there of a selfish, attention-seeking academic who prizes their own ego over student learning. As suggested above, akin to negative attitudes about lecture, derisive names (eg, “teacher on a treadmill”) can also be invoked for certain active learning approaches. This behavior should be rejected, and there should instead be increased tolerance for different teaching and learning styles. Finally, medical schools and other institutions of higher learning should take their ostensible commitment to academic freedom seriously, extending into the domain of content delivery and not only the content itself.