Vol 2 No 4
April, 1998
    ISSN 1097-9743
    ASEPNewsletter is devoted to informative articles and news items about exercise physiology. It is a monthly magazine of news, opinions, exercise physiology professionals, and events that shape exercise physiology. While it contains views and opinions of the Editor who oversees the ASEP Internet Websites, visitors can have a voice as well. We welcome interested practitioners, researchers, and academicians to e-mail the Publisher their thoughts and ideas or to respond directly via the ASEP Public Forum.

    May, 1998

Just Thinking....
Learning how to think vs what to think!
Tommy Boone, PhD, MPH

To anyone who clicks on the ASEPNewsletter, please bear in mind that this medium is open to you. Don't assume only the members of ASEP have the opportunity to publish their thoughts or state their mind on whatever issue that is exciting or troubling to them. We are reconciled to publishing most any theme, particularly if it has some underlying principle or value to exercise physiologists today and tomorrow. We have only a short time to live, why not get excited and serious about expressing your thoughts, ideas, dreams, hopes, and frustrations here on the ASEPNewsletter website. I can see the web clickers thinking that the script is written, but it isn't. This is not and should not be a singular experience, however motivated a person's mission. So, in keeping with the opening statement, assume some responsibility, interest, and involvement in helping this organization to succeed. Step forward and state your case, offer your ideas, or your commitment to something, and don't apologize -- just get involved. We are not in a changeless society. We can make a difference! Your thoughts are important to us and to those among us who have not started to think yet. Share your ideas with ASEP members and world by sending in your ideas via e-mail to me and I will copy and paste your comments in the next ASEPNewsletter. Until then, I have two final thoughts to share with you: (1) something Bruce Barton said, "Sometimes when I consider what tremedous consequences come from little things.....I am tempted to think there are no little things. AND, (2) to stretch your thinking, I have written a little piece to help us face up to the need to learn "how to think" versus "what to think." 

The Teacher's Accountability for Classroom Content: 
An Interdependence Ethics Perspective
Tommy Boone, PhD, MPH
ASEP President
Professor and Chair
Department of Exercise Physiology
College of St. Scholastica
Duluth, MN 55811 

WHILE WALKING BY A CLASSROOM, I heard the teacher tell the students that they could prevent a heart attack by lowering cholesterol. A compelling and popular notion, but is it true? Perhaps, the answer lies in college classrooms where the future teachers regard textbooks and professors as bearers of "truth." If cholesterol doesn't cause heart attacks, why is there the discontinuity between rhetoric and reality? Several scholars have recognized this deficiency and have attempted to remedy it by creating classroom opportunities to develop certain critical thinking capacities (Browne et al., 1995).

Indeed, all of our upbringing, suggests that we have made many decisions and have acted on them without the critical thinking skills to reduce our vulnerability to manipulation. In that "ethics" is about giving guidance regarding the rightness and wrongness of an action (Nephew, 1996), it would appear unethical to teach in a manner that would adversely affect someone's well-being. That is, an ethical way of teaching ought not to ignore the importance of respect for students, and their means for distinguishing the reasonable from the unreasonable.

In his novel, Brave New World, Aldous Huxley suggests that we live in a perpetual state of ignorance (Huxley, 1989). So, is it appropriate to concede that future teachers can't be held accountable for the accuracy of their lectures if the information they were given as students was not reliable or because they have not thought critically to gain an understanding of the cholesterol and heart disease knowledge? The short answer is "no" and, therefore, the paucity of rational thought and the mindless absorption of ideas without merit deserves our attention.

When students understand the relationship between cholesterol and heart attacks, they are empowered to make correct decisions. They are, to argue from an ethical point of view, free and fully functional human beings. Then, why do cardiologists, epidemiologist, and health educators continue to endorsed the belief that, in light of the Interdependence Ethics theory (Nephew, 1996) that individuals are interdependent, continue to stifle provocative questions about cholesterol and heart disease? Just as every person depends on every other person, and just as no person can cut the ties binding all of us in interdependence, then it follows that we must have consideration for each other's beliefs, actions, and lifestyle.

Simply stated, is it in the best interest of the students to present mis- information? No! The fact that we are interrelated does not make it right to commit an action out of fear of lack of information. What makes life worth living is our relationship with each other (Nephew, 1996). To be sure, whatever the reason within the teacher to have the students believe heart disease is caused by cholesterol, the students' education is incomplete. Most fundamentally, the students' are not being helped in asking critical questions to define specific issues, explain relationships, or evaluate the teacher's argument. In short, the students' fundamental need of a full and complete cognitive development isn't being met. It isn't the students' fault, to be sure, it is the teacher's fault. The teacher is responsible for the situation, and the non-satisfaction of the fundamental need of the joy of discovery.

The main flaw with the teacher's lack of provocative questions of scientific information is that the students are not given a chance to make any decisions. Everything is, in essence, forced onto the students. The result is frustration and a truncated looked at cholesterol. Therefore, from the students' perspective, their irresponsible behaviors result in bad health such as when they fail to modify lifestyle factors thought to contribute to the prevention of coronary artery disease (CAD). Although this concept of personal responsibility for health is deeply embedded in our educational system, much of what society believes may be little more than wishful thinking (Oliver, 1986).

This lack of an understanding and getting beneath the mere obvious suggest that the teacher was either poorly prepared to lecture on CAD or failed to look at all the scientific data. As I determined later, the teacher firmly believed that cholesterol causes CAD. I tried to introduce the notion that CAD is a multifactorial problem not monofactorial, and that its complexity requires the willingness to understand that individual prediction for CAD (or heart attack) is very weak. The teacher's comment was, "It's my class, and I'll teach it the way I want to." While that was the end of our conversation, I continued to think about what had happened.

I don't have a problem with taking care of one's self. It makes sense that we do have some influence on the quality of our health, although admittedly less than generally believed. There is a problem, however, when statements are made to students (and even the public at large) as though they are 100% agreed upon by all interested thinkers, researchers, and educators. The implied message behind such statements is simply, "Well, if you don't listen to me and you have a heart attack, it's your fault." This sort of moral dogma would appear to be inappropriate in classrooms. Without human caring for what one presents, given our absolute interconnectedness, the message floats to the surface as being more important than the audience; hence, the notion of rights gone mad (Nephew, 1996). Yet, there is no justification in setting up students to be victimized by the presentation of health related materials where fear becomes the motivator. Without a straight forward and critical analysis of the entire subject matter, society demonstrates lack of caring in fostering and maintaining relationships.

It is the teacher's responsibility to discuss health issues critically, to intelligently contrast theories and research data, and to avoid using the classroom to confirm personal bias while failing to seek disconfirming evidence. Students are owed a measure of consideration, and thus can assert a claim on every teacher to present their lectures with honesty and fairness to the different sides of an issue (however sensitive). Teachers, therefore, are accountable for class content. They cannot present inaccurate information and unwarranted generalizations simply because no one is monitoring what they teach.

Since proof has not been obtained for most health related problems, particularly the risk factors for CAD or its manifestations (chest pain or heart attack), and since a great many people have heart attacks with no known risk factors for CAD, there is reason for caution (especially when expectation exceeds reality). To determine the extent to which other teachers considered CAD a preventable disease, I asked them about the likelihood of preventing a heart attack by modifying just one risk factor -- cholesterol. Their response was, "Of course CAD is preventable." They thought I was joking with them or involving them in some trick.

Apparently they did not know that there is no absolute assurance that low cholesterol protects against CAD, that CAD therefore cannot be prevented, and that it cannot be predicted per individual because the cause(s) is still unknown (Gotto, 1985). The notion of multivariate thinking versus univariate thinking in regards to causes(s) had not hit home. They had little understanding of the limitations of population-based statistics (as in the case of epidemiological research), and that they are used to compute averages and probabilities (Vogt, 1983).

Students may not realize that they have rights, but they do nonetheless. They have the right to articulate the claim that health information is presented "without deception by omission." Teachers should not be part of the problem in understanding the threadlike connections between health and disease. It is their duty to recognize limitations in scientific analysis and, if they choose not to, then they must be held accountable for the mixed messages. Why? Because all teachers are obligated to do what is right, given the interdependent relationship between teachers and students. When the teachers fail to distinguish truth from falsity, insight from prejudice, and accurate concepts from misconception (Paul, 1993), then everyone suffers.

Clearly, while cholesterol may contribute to CAD in some individuals, the "prevention" of CAD or a heart attack by lowering cholesterol (as a general statement to all students) is either a misunderstanding of the literature or a desire to teach whatever a teacher deems appropriate. Neither example should be allowed to occur. The teacher is responsible to the institution, the students, their parents, and society at large to examine and present all relevant and scientific information. The content of the lecture must be accurate and complete. It must not be politicized or presented in a biased manner. The evangelical approach to health and disease is not an education. It is indoctrination that leaves the student confused and anxious (Boone, 1995).

Lectures on health issues must be based on sound scientific data. Teachers must be nonjudgmental and slow to structure a rigid perspective on health topics. They should not personalize information just because they consider it in the best interest of the students. Healthy choices mean just that! How else can students decide the appropriateness of one style of living versus another if not given a choice. The answer is they cannot and, too often, the "believe it because I said so" way of relating to students results in unnecessary fear and anxiety.

Students need informed and educated teachers. They need open- minded teachers for continued reflection and growth about essential health matters. They need more access to a variety of ideas on any given topic. They need exposure to the research community, particularly journal publications, and then they need to read the articles. If it is too challenging for the student, it should be the teacher's responsibility to clarify the authors' purpose and conclusions, particularly since concluding remarks are often suspect.

Take the measurement of cholesterol. Most teachers would not suspect that a problem exist with the measurement itself, which would certainly make the interpretation more difficult if not incorrect. Yet inaccuracy in the measurements of LDL-cholesterol is a problem of some significance. As an example, the College of American Pathologists surveyed 5004 laboratories and found a range in cholesterol responses from 101 to 524 mg/dl (Current Status of Blood Cholesterol Measurement in Clinical Laboratories in the United States: A Report, 1988). The actual value submitted to the laboratories was 263 mg/dl, which was confirmed by the Centers for Disease Control. How can researchers conclude a relationship between cholesterol and CAD when the measurements vary so greatly? This is not a new problem.

There are other problems, too. Single measurements of total cholesterol and HDL-cholesterol may not be reliable for diagnosis or therapy (Roeback et al., 1988). There are seasonal patterns that exist for cholesterol of which there are no clear-cut reasons (Gordon et al., 1987). The hopeful benefits of high HDL-cholesterol are still encapsulated in an unresolved "hypothesis" that remains largely a mystery (Miller and Miller, 1975).

Given these concerns (and there are others), teachers must be critical thinkers. It is the only way to avoid what is known as the Post hoc ergo propter hoc fallacy (i.e., following-after-therefore-caused-by). It is also an excellent way to get rid of the negative labeling associated with specific risk factors. This is an important point for students with poor self-esteem, yet who are told to be concerned about their cholesterol and CAD. As these students become better thinkers, they will very likely experience less physical complaints, less anxiety, and less depression.

Bear in mind that within the medical-scientific community there are researchers and academicians who believe that too many changes in lifestyle have been suggested without sound medical and scientific documentation (Becker, 1987). So where to from here? The way forward is to tell the truth that, although certain scientific findings appear to demonstrate an important relationship between cholesterol and CAD, the data are woefully inadequate.

Students need to know that the relationship is a statistical relation, which is true on the average for the population. It may not be true for each individual in the population and, as stated earlier, even the absence of risk factors does not mean that CAD will not occur. A person does not have to smoke or have high cholesterol or blood pressure to develop CAD. This is the complexity of the disease and, therefore, any teacher's intent to embrace causation via one factor is difficult if not impossible.

Maybe teachers at all levels should consider presenting health issues in a way that is less frightening to students. Consider, for example, the common tendency to present the ratio of risk of CAD in one group with low cholesterol to the risk of CAD in another group with high cholesterol (i.e., relative risk) versus the actual number of individuals who are likely to get CAD, called absolute risk (Boone, 1992).

The stage is set for increasing the students' anxiety and apprehension, particularly if the cholesterol related risk for development of CAD is viewed in relative terms. As an example, while I did not hear the teacher say, "even a slight elevation in cholesterol doubles the risk of dying of CAD in the next six years" -- it is logical that it occurred. If so, I can see the students sitting in their chairs sweating about having doubled their chances of dying from CAD. But, is the concern valid and should the data be presented in relative terms. I do not think so.

Had the teacher made the statement in terms of absolute risk, it would have been considerably less frightening and less misleading. In fact, given the same theme with my age group (between 35 and 57 years of age with a cholesterol of 170 mg/dl) my chances of dying of CAD in the next six years is 4 in 1,000. If my cholesterol were to increase to 230 mg/dl, my chances of dying of CAD in the next six years is 8 in 1,000. The absolute (annual) probability of dying is increased from 0.00067 to 0.00133 -- not much of a reason to be anxious and scared.

The crucial point is that teachers should not have the right to create a false belief upon which an action may be predicated, thus compromising free behavior (Nephew, 1996). Consequently, a misleading statement or misrepresentation of scientific conclusions is deception and is not morally acceptable. The worry is that too often teachers have considered misinterpretations as reasonable and in the best interest of students. But, when students are persuaded to believe something that is not true, the end result is an uneducated population without the ability to critically evaluate what they read or experience. Their mental and emotional unpreparedness leaves them with little hope of building the capacity to engage in higher-order thinking, and there is little to no satisfaction of their fundamental human needs to avoid undue suffering.

What is the answer? We need critical thinking teachers who are held accountable for the scientific accuracy of their health related lectures, and we need more constructive discontent thinkers who require an analysis of all the evidence before accepting on face value claims made by a particular researcher or educational program. The students' derived obligation is not developed, and they have little knowledge of choosing paths to bring about consequences that are sought (Nephew, 1996).

Given this view, teachers should avoid teaching practices that result in a type of personal aggrandizement (with all of its limitations and pitfalls) and, instead, teach with an attitude of friendship and love as obligations to their students. While doing so, they will simultaneously preserve their professional integrity as well as uphold the doctrine of beneficence. Also, as the teachers engage in critical thinking, they (and their students) will develop a sense of wonder, questioning, and skepticism. The result will be an increasingly more sophisticated and accurate understanding of what constitutes being healthy. This morally right action will give rise to increased opportunities to challenge assumptions, negotiate ideas, visualize perspectives, evaluate the correctness and quality of health related information.

Becker, M.H. (1987). The cholesterol saga: Whither Health Promotion? Annals of Internal Medicine, 196: 623-625.
Browne, M.N., Hoag, J.H., & Berilla, B. (1995). Critical thinking in graduate programs: Faculty perceptions and classroom behavior. College Student Journal, 29: 37-43.
Boone, T. (1992). Coronary artery disease predictions from epidemiological research: Some critical reflections. The Journal, 12: 2-24.
Boone, T. (1995). What critical thinking may mean to the student and the teacher. College Student Journal, 29: 30-33.
Current Status of Blood Cholesterol Measurement in Clinical Laboratories in the United States: A Report From the Laboratory Standardization Panel of the National Cholesterol Education. (1988). Clinical Chemistry, 34: 193-201.
Gordon, D.J., Trost, D.C., Hyde, J., Whaley, F.S., Hannan, P.J., Jacobs, D.R., & Ekelund, L. (1987). Seasonal cholesterol cycles: The Lipid Research Clinics Coronary Primary Prevention Trial Placebo Group. Circulation, 76: 1224- 1231.
Gotto, A.M. (1985). Some reflections on arteriosclerosis: past, present, and future. Circulation, 72: 8-17.
Huxley, A. (1989). Brave New World. New York: Harper & Row, Publishers.
Miller, G.J. & Miller, N.C. (1975). Plasma-high-density-lipoprotein concentration and development of ischemic heart disease. Lancet, January 4: 16-19.
Nephew, A. (1996). Interdependence Ethics. Duluth, MN: CSS Publishing.
Oliver, M.F. (1986). Prevention of coronary heart disease - propaganda, promises, problems, and prospects. Circulation, 73: 128-136.
Paul, R.P. (1993). Critical Thinking: How to Prepare Students for a Rapidly Changing World. Santa Rosa, CA: Foundation for Critical Thinking.
Roeback, J.R., Christenson, R.H., Watson, T.E., & Hla, K.M. (1988). Reliability and cost effectiveness in a clinical setting. Clinical Research, 36: 717A.
Vogt, T.M. (1983). Making Health Decisions: An Epidemiologic Perspective on Staying Well. Chicago, Illinois: Nelson-Hall, Inc., Publishers.

Final thoughts......

I believe it was Oliver Wendell Homes who said, "What lies behind us and what lies before us are tiny matters compared to what lies within us." In your mind's eye, can you walk the walk I did in the above paper or is your walk altogether different AND WHY?

As a bonus, if you are willing to write your version of what I said in the above paper and publish it in the ASEPNewsletter, ASEP will send to you a very nice, smooth ink flowing, high quality pen with a rich lacquer finish. The pen is a gift of hours of work by the employees of Myron Manufacturing Corporation. Mike, the President, tells me that it is the gift of good taste for every occasion. Naturally, it will have the American Society of Exercise Physiologists engraved on it in crisp and permanently etched letters.

Why not give it a try? Publishing your thoughts, and thus a paper in the ONLY online electronic exercise physiology newsletter in the world! Your efforts will become part of what is now becoming the "end of the beginning" as the history of Exercise Physiology" is being literally rewritten. 

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