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The Surgeon's Tools & Educational Standardization

In a recent post, I suggested that standardization is a good thing at the more coarse "grain sizes," but that administrators should leave substantial room for professional autonomy when it comes to the finer-grained choices teachers make. Today I want to address the same issue from a different angle.

Micromanaging is not a virtue, and teachers appreciate it when administrators stay out of the fine-grained decisions that comprise their daily practice. But it's not as if this level of practice is inscrutable magic. When you look at what the best teachers do, you see something that might be surprising: many of them are making exactly the same fine-grained "moves" as each other. There are many specific tools and strategies that the best teachers tend to use in remarkably similar ways.

The key element, though, is autonomy to exercise professional judgment: the best teachers are using these moves if and when they judge it to be appropriate, not when an administrator walks into the room with a clipboard.

A lot of people tell me they oppose any kind of standardization on the grounds that individual creativity results in the best teaching. But again, this is an issue of grain size, and the specific ways in which autonomy can actually be exercised.

Consider a surgeon doing a difficult but common procedure, such as removing a tumor. The goal is clear - a healthy patient - and so are the standards for success. Fully remove the tumor, don't leave any gauze inside, and so forth. The exact series of steps to take can't be laid out in a textbook or dictated by a hospital administrator, because a real patient is complex and unique, and doesn't always match the picture in the book. This is where professional judgment is essential, and analogously, this is why "teacher-proof" scripted curriculum doesn't "work" in the sense of circumventing a lack of skill.

But many of the tools, steps, and processes will be the same from surgeon to surgeon, and the best surgeons are those who observe others and seek feedback on their own practice, at all grain sizes. Surgeon Atul Gawande wrote about his experience with coaching in this outstanding New Yorker piece featuring educational coaching expert Jim Knight.

Professional practice is composed of numerous variables operating in concert—the task itself, skill, knowledge, technique, tools, data, input from colleagues, rules and procedures (such as "scrub in"), adapting to the circumstances, and more. Standardizing the soup-to-nuts process of teaching is unwise and probably impossible, but enormous gains can be realized by using each grain size as a nucleation site for improving practice.

To correct what I said in my earlier post, productive standardization can occur at any grain size. There are good and bad ideas at every level of professional practice, and there's nothing wrong with outright banning destructive practices, like deciding not to wash your hands before surgery. Where autonomy becomes absolutely crucial is in putting everything together, orchestrating the countless factors that contribute to success.

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