Teaching and Learning in Medical and Surgical Education

Lessons Learned for the 21st Century

Linda H. Distlehorst, Gary L. Dunnington, J. Roland Folse, Linda H. Distlehorst, Gary L. Dunnington, J. Roland Folse

• Publisher: Routledge
• Year: 2000
• eBook ISBN: 9781135659769
• Edition: 1
• Topic: Education
• Subtopic: Education General

The idea for this book was originally conceived by Terrill Mast in conversations with Roland Folse. Dr. Mast was dedicated to the belief that all medical teachers should be generalists with skills and knowledge in all aspects of the field. Before his untimely death, he recruited most of the prestigious contributors to this important new book. This comprehensive volume features a review of the major topics in medical and surgical education by today's leading authorities in the field. The assembled authors represent a "Who's Who" in medical education around the world. Each chapter provides a state-of-the-art overview of the topic along with the projected changes most likely to occur over the next decade. A "must-have" for anyone responsible for educating students, residents, and physicians in the medical and surgical fields, this new book addresses the critical medical educational issues of the next millennium, in one, comprehensive volume.

PART I
THE EVOLUTION OF MEDICAL AND SURGICAL EDUCATION

CHAPTER ONE
Medical Education: The Testing of A Hypothesis

Stephen Abrahamson
University of Southern California

There are many ways to consider medical education. In this chapter, medical education is conceptualized as the complex of processes by which a medical student is changed from a medical school applicant to a medical school graduate—with all that is implied: from unknowing to knowing, from unskilled to skilled, from layman to professional—in summary, from medical student to physician. The complex of processes includes the following: learning by the medical students, teaching by the faculty members of a medical school, and governance by the administrators of the medical school. How these three processes are interwoven to form medical education as we know it today warrants critical review.

THE SCIENCE OF LEARNING

Education can be thought of as a profession, and as such it includes a set of practices and a body of sciences underlying those practices. Those who have studied education maintain that the sciences provide the basis for the practices. Thus, a brief review of some principles of learning should precede any discussion of practices of teaching.

Time and space do not permit the presentation of learning theory in detail. Indeed, there are different theories of learning, each with a body of research supporting it. But extant learning theories all agree on some basic principles which the good teacher knows and attempts to apply.

Learning is an Individual Matter. No two students learn in exactly the same way. What may help one student to learn may not help another. What may help one student may even hinder another’s learning. Some students report that when they are intimidated by the teacher, they cannot learn well. Others report that such a stimulus “forces” them to learn. Some students cannot listen to a lecture and take notes at the same time. Others find note-taking to be a necessary aid to their concentration.

The application of this basic principle of learning suggests that the teaching program should include a variety of teaching techniques. It suggests further that the good teacher tries to get to know his or her students as individual learners. Of course, if the teacher is merely a lecturer to a large group of students, the opportunities to treat students as individual learners is quite limited. But even in this case, the skilled teacher prepares lectures and delivers them in such a way as to maximize the opportunity for students to be active participants rather than passive listeners: through rhetorical questions, through question-and-answer periods, through “programmed” lectures, through “six-by-six” discussions—in other words by abandoning the “55-minute lecture” in favor of varying the learning activities in an attempt to meet different learning styles of different students.

In fact, there are “learning styles” conceptualized by educational psychologists concerned with learning. Different students have different “styles” of learning, and helping students discover their respective learning styles may itself be a significant aid to their education. When students are aware of how they learn, their learning is facilitated.

Learning is More Efficient and More Effective When the Learners are Motivated. Motivation is difficult to define but generally is “regarded as a process internally seated which, once aroused by an appropriate stimulus, leads to more intensive (learning) activity than otherwise would have been present (Miller, Abrahamson, Cohen, Graser, Harnack, et al, 1961). Motivation, in other words, is something within the learner: his or her drive to learn, desire to learn, need to learn. The teacher cannot “motivate the student.” Instead, the teacher can offer incentives—positive (rewards, praise, recognition) or negative (failing grades, reprimands, ridicule). In other words, the teacher can take advantage of the student’s motivation. Of course, the teacher needs to know what that motivation is and how to use that information in planning and conducting the teaching-learning exercise. Once again, there is this connection between the art of teaching and the science of learning—in this case, planning learning activities which capitalize on the student’s motivation.

It has been postulated that it is not possible to prevent a person from learning what he or she is motivated to learn—up to, of course, physiologic limits to that learning. The challenge for the teacher—the good teacher, that is—is to discover the motivation of individual students and work from there, rather than to demand that the student learn what the teacher thinks he or she ought to learn. The key for the teacher is to find ways to help the student develop that motivation by recognizing the need for learning. In other words, the teacher should start with students’ perceived needs and help the student recognize other needs—which then, in turn, become perceived needs of the students.

Learning is More Efficient When the Learning Experience Has Meaning to the Learner. In some ways, this principle of learning is so obvious as to obviate the need for elaboration. Students become “lost” when what is to be learned is so foreign to them that it has little or no meaning to them. Sometimes, teachers assume that students are at a certain level of understanding of a given topic, only to discover that they, in fact, are not nearly up to that level. When that situation occurs, the good teacher backs up and ensures that students become familiar enough with the subject to move ahead. The poor teacher forges ahead with the apparent assumption that “it’s not my fault that they’re not ready.”

In a related manner, plunging students into a learning milieu which is totally foreign to them will slow the learning process, if not inhibit it totally. For students who have never seen the inside of an operating room, a learning experience scheduled there may pose serious learning blocks. Their first experience in that setting should be an orientation, not a “training run.”

Learning is More Efficient When There is “Feedback” for the Student. Research is very clear on this matter: students learn far better when they receive feedback from the teacher: information about how well they—the students—are doing, how much they are learning, whether they are achieving the desired goals of the learning exercise.

Application of this principle of learning demands that the teacher know what those goals and objectives are and, in addition, how well individual students are achieving. The teacher then has the obligation to let the student know those same facts: what the goals are and how the student is doing. All too often in medical education this obligation is met by giving each student his or her test score, rather than by meeting with the student and reviewing how he or she did and in what ways he or she met or did not meet the goals.

The challenge for the teacher goes beyond merely understanding these principles. The real challenge is to apply these principles in planning and carrying out teaching-learning activities.

THE ART OF TEACHING

As just mentioned, education can be thought of as a profession. Thus, the practices constitute the “part of teaching,” and they are amenable to examination by students of education processes. These practices include, or should include, both familiar and less well-known techniques of teaching. In medical education, the familiar practices, of course, are lecture, seminar, laboratory supervision, ward rounds, conferences, and case presentations, among others. The less well-known or less frequently used (or even considered for use) practices include problem-based tutorials, student-led discussions, and self-instructional programs designed by faculty for purposes of student learning.

For each of the techniques of teaching, there are skills which teachers develop throughout their careers. These skills are learned by teachers, although there is very seldom a systematic effort to teach them to new faculty members. It is generally assumed that the acquisition of an advanced degree automatically qualifies a person for the role of teacher in higher education. If nothing else, it is expected that the new graduate—MD or PhD—will emulate his or her own teachers and thus become a “practitioner” of education. This avoidance of systematic preparation of a teacher for his or her teaching role in a medical school ensures that good teaching will appear by chance and that bad teaching often will serve as a model for new teachers.

To defend the lack of teacher preparation, false premises often are advanced and assumed by the medical education establishment to be true. One such false premise is that “good teachers are born that way.” The fallacy here is patent! Teaching involves a set of skills which can be learned and therefore are not innate. The false premise simply obscures the need for teacher preparation and, further, provides a defense for bad teaching. It also obviates the need for medical school teachers to devote more of their academic time to preparation for teaching—time which can then be used on higher priority institutional goals which, in their turn, mandate that medical school teachers concentrate on clinical practice and/or research, and not on teaching. After all, it is clear that the careers of medical school teachers depend on their productivity in practice and/or research, not on their excellence in teaching.

Another false premise is related to Abrahamson’s Myth #1: It doesn’t matter what curriculum a medical school uses (Abrahamson, 1996). This time, however, the false premise would be: “These students are so damned smart that it doesn’t matter what kind of teaching they get!” In fact, medical students are so intelligent and so highly motivated that the premise is almost true! (It would be true if it were stated: “These students are so intelligent and so motivated that they might learn despite the bad teaching.”) In this case, however, there is an important corollary: Medical students would learn more effectively and more efficiently with good teaching.

In addition to these false premises, there are several misconceptions about teaching which should be explored. The first of these is “Teaching=Learning.” That is, if the teacher has “taught” something, the student must have (or should have) “learned” it. The misconception is heard in the expression: “We have already covered that ground.” (There are only two occupations which use the expression, “cover the ground”: farming and teaching!) The expression is clearly a misconception. Just because something has been “covered” in class (i.e., included in a lecture) does not necessarily mean that it has been learned.

The second of these misconceptions is “Lecturing=Teaching.” All too often, the lecture is the only method of teaching considered. Although lecturing is one technique of instruction, it is but one of many and not nearly so effective as apparently assumed by medical school teachers. The severest critics of the lecture describe it as a process by which information is transmitted from the notes of the teacher to the notes of the student without going through the minds of either! But most critics, not so severe, are not condemning the lecture or advocating that it not be used. They are simply raising questions about the excessive number of lectures used in medical education and their assumed effectiveness in producing learning. But because the lecture is used so much, they are also concerned with the substantial number of lecturers who are not skillful in using the technique.

But what is “teaching,” anyway? Teaching is providing activities, materials, and guidance which facilitate learning. The teacher is the person who provides the “activities, materials and guidance which facilitate learning.” Thus, although lecturing is one of the “activities,” there are many others. Whereas slides or transparencies are one form of “materials,” there are others, and “guidance” is often a neglected area of the teacher’s art. Using this definition of teaching, we must shift our thinking from the teacher to the learner because the outcome, learning, is the raison d’etre for the input, teaching.

With this definition of teaching, it would be expected that teachers plan for their teaching with the student in mind. How do they learn? What will help them learn? What can I do to facilitate that process for them? Sometimes the activities will be teacher centered....

Table of contents

• Dedication
• Contents
• Foreword
• ACKNOWLEDGMENTS
• Contributors
• PART I THE EVOLUTION OF MEDICAL AND SURGICAL EDUCATION
• PART II THE ART AND SCIENCE OF MEDICAL EDUCATION
• PART III MAJOR CURRICULUM MOVEMENTS
• PART IV CHALLENGES FOR MEDICAL EDUCATION
• Author Index
• Subject Index