Medical Teacher

ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20

Active learning in medical : Strategies for beginning implementation

Ben Graffam

To cite this article: Ben Graffam (2007) Active learning in medical education: Strategies for beginning implementation, Medical Teacher, 29:1, 38-42, DOI: 10.1080/01421590601176398 To link to this article: http://dx.doi.org/10.1080/01421590601176398

Published online: 03 Jul 2009.

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Download by: [Tulane ] Date: 12 July 2017, At: 06:10 2007; 29: 38–42

Active learning in medical education: Strategies for beginning implementation

BEN GRAFFAM University of South Florida College of , USA

Abstract Medical educators often deliver complex material in a format that does not allow the positive learning engagement recommended by cognitive researchers and theorists. Intentional engagement and active learning change the nature of learning, while simultaneously improving knowledge gain and recall abilities. Students find the work more interesting and thereby put more effort into it. Historical perspective reveals that medical faculty need to make changes in their teaching methodologies. However, transforming pedagogical practice is difficult, as medical faculty have not had much exposure to pedagogical theory or training. While simple steps can be taken to alter basic lecture formatting, these steps may be unfamiliar to medical faculty. Seven methods for adapting parts of lectures are described. Practice with such methods may engender exploration of epistemological and cognitive aspects of deeper understanding.

Introduction medical faculty behave like most higher-education faculty and approach teaching as the information-imparting instructor A growing literature extols the benefits of active versus passive (Kember 1997). This simplistic understanding stems from the learning in medical education (Carlin 1989; DesMarchais et al. mistaken belief that, to be a good teacher, one only needs an 1990; DesMarchais 1993; Richardson & Birge 1995; Rich et al. exceptional grasp of the material (Fang 1996). 2005; Foord-May 2006). Since the introduction of problem- Clearly, an expanded view of teaching needs to be based learning (PBL) nearly three decades ago (Moust et al.

embraced by some medical faculty. Considering the two 1997), to the more recent appearance of team-based learning contrasting literatures just mentioned, what might assist (TBL) in the past few years (Hunt et al. 2003), active learning medical faculty to develop more active learning pedagogies? has become a buzzword for medical educators. This makes First, medical faculty may need a primer on active learning. sense, as cognitive science and learning theory have shown This paper will describe active learning pedagogies, based on active learning to be a superior experience in classrooms, the findings of cognitive and education science. Second, creating a deeper understanding of content material faculty may need to compare teaching styles. This paper will (Fink 2003). describe a set of basic, significant learning activities specially Ironically, a concurrent literature is also growing, though designed to begin the process of transforming lectures into this one bemoans the lack of pedagogical change in medical active learning frameworks. Admittedly, these steps are small education (Rudland & Rennie 2003; Cohen 2004; Hurst 2004; Iedema et al. 2004; Rajan 2006). Teachers in medical schools, lacking pedagogical training, generally teach as they were Practice points taught in undergraduate and graduate school (Hurst). Though  Transforming medical is a necessary step for the science of medicine has changed tremendously over the improving learning environments in medical education. past 50 years, the same cannot be said for teaching in medical  Pedagogical transformation for medical faculty may be classrooms. They are still lecture driven, with little critical difficult due to no prior pedagogical training. engagement occurring between students and faculty (Cohen).  Strategies for engendering a more active approach to At issue is the mechanism of change. Medical faculty learning are accessible and applicable to existing content understand the complexity of scientific change, regarding it as modules. of paramount importance. When research uncovers evidence  Lectures (passive learning) can be adapted into active for a particular biological function and/or treatment, that learning engagements with no loss of content material. knowledge is directed toward patients and students. This  Active Learning involves both the instructor and the change is a natural function of medical education, meeting students working cooperatively. with little resistance.  Active learning pedagogies engages the learner so that On the other hand, pedagogical change is not a natural knowledge gain and recall are increased. function of medical education (DesMarchais et al. 1990; Foord-May 2006). With no pedagogical background, most

Correspondence: Ben Graffam, PhD, Education Specialist, Office of Educational Affairs, University of South Florida College of Medicine 12901 Bruce B Downs Blvd, Tampa, FL 33612, USA. Tel: 813-974-7294; email: [email protected]

38 ISSN 0142–159X print/ISSN 1466–187X online/07/010038–5 ß 2007 Informa UK Ltd. DOI: 10.1080/01421590601176398 Active learning in medical observation

in the development of active learning paradigms. Yet component, is just experience, and it is not clear that beginning the transformation on a scaffold of method experience by itself does little more than confirm previously establishes a clearer path toward change. Once methods are held prejudices (MacLellan 2005). understood, a more philosophical look at teaching can ensue. In these ways, active learning is different from passive This paper will conclude by speculating on that process. learning, though passive learning is important to the learning process, and its role should not be downplayed (Fink 2003). However, as a method it fails to connect students directly with Active vs. passive learning the knowledge and skills they need to learn. Passive learning Contemporary views of learning posit that people construct occurs when students read an assigned article, chapter or knowledge based on previously held beliefs and experiences. book; when they attend a lecture; when they watch a film. This process is an ongoing interaction between the learner and Active learning occurs when each of those activities is the experience (Bransford et al. 2000). In this sense, active combined with engagement, observation and reflection. learning is metacognitive, giving the individual a picture of The difference is not just observable, it is ideological. how she/he learns. Whereas passive learning presupposes that knowledge Bonwell & Elison define active learning as ‘anything that can be transferred from one person to another, active involves students in doing things and thinking about the things learning presupposes that all knowledge is constructed they are doing’ (1991, p. 2). In other words, for learning to be by the learner. Each offers a very different kind of active, learners not only need to do something but also need to epistemological underpinning. Passive learning perceives reflect on what they are doing. Active learning is learner- knowledge as a commodity, whereas active learning perceives centered, where the individual’s needs are more important knowledge as experience created by the individual’s meaning- than those of the group (Duckworth 1987). Once needs are making processes (MacLellan 2005). Contemporary learning discerned, teachers devise learning opportunities that advance theory extols active learning as the significant process of student understanding in the content area (Vye et al. 1998). human understanding (Bransford et al. 2000). Designing active learning engagements means finding ways Designing active learning engagements means discerning to merge what the students will do with what the teacher will ways to activate the learners’ experiences so their previous do (Chickering & Gamson 1987; Brown & Campione 1994). world comes into direct contact with the new world being Not to consider the latter is to remain in paradigms that explored. This juxtaposition, when followed by significant disconnect the teacher from the student, negating the power of reflection, builds frameworks upon which new learning learning relationships. Active learning pedagogies change the functions. teacher–student relationship to a learner–learner relationship. In active learning environments, teachers are less con- Active learning falls under many taxonomies (Piaget 1978; cerned with content, and more concerned with stimulating Bonwell & Elison 1991; Lehrer & Chazan 1998; Fink 2003; reflective critiques of the nature of knowledge. Learning Bulpitt & Martin 2005; Kimonen & Nevalainen 2005). For ease situations are designed so students grapple with ill-structured of understanding, we will discuss it as made up of three problems or evaluate a discipline’s inquiry patterns. Active interrelated components: intentional engagement, purposeful learning pedagogies develop, evaluate, and revise mental observation and critical reflection. models and schema used to understand the world. Intentional engagements are experiences where learners perform what we want them to learn. These performances may be set in real or simulated contexts: learners take a medical Strategies for moving from passive history; they perform a physical exam; they communicate the to active learning in lectures bad news of a particular condition to a patient. Purposeful observations are experiences where learners Transforming teaching methods is a difficult process. watch or listen to someone doing what we want them to learn. According to Hativa (2000), it involves not only a modification These observations can be real or simulated. Students observe of classroom practice but also an exploration of beliefs, a procedure; they observe instructors modeling the especially those about learning. Concerning beliefs that deter thought processes applied to understanding symptoms; they teaching modification, many faculty: observe interactions between a and a patient where . regard the adaptation of instructional practices as equivalent the patient speaks a different language from the physician. to lessening academic quality (Hativa 1998); Critical reflection experiences round out the triad of active . believe that teaching is transferring knowledge from one learning components. Reflection is defined as thinking about person to another (Fang 1996); how meaning is made. People make meaning based on their . believe their job mandates covering all pertinent and experiences and on the information and ideas they encounter available material (Smith 1995). (Fink 2003). Much of meaning-making remains unconscious if it is not reflected on. However, significant research (Minstrell 1989; Bonwell & Active learning combines engagement and observing with Elison 1991; Cashin & Downey 1995; Barron et al. 1998; reflective experiences. Students perform or observe a certain Bransford et al. 2000) demonstrates these beliefs to be activity, and then they reflect on the way that experience has detrimental to good learning. Suffice it to say that one major activated specific learning patterns. Intentional engagement obstacle to developing active learning pedagogies is teacher or purposeful observation, done without the reflective belief. 39 B. Graffam

Much has been written on teacher beliefs, so this paper will answer. A better method is to select a student and then ask not delve there. Rather it will present ways for medical faculty the question. Selecting the student changes the nature of the to begin transforming pedagogical style. This section will question. Suddenly it is a question that needs to be describe simple strategies for medical faculty who are willing answered. The conversation is transformed from the ‘one- to take on pedagogical change but, for some reason, lack the speaking-to-many’ to a ‘one-on-one’ type immediately. An background knowledge to begin the process. intimacy is created in what may have been a fairly informal place. Such a transformation engages the student quite Breaks as action moments differently, and the reflection possibilities are great. In medical education, this is important because students will As the predominant in is be having very intimate conversations with their patients, the lecture (Fink 2003), it is safe to assume that most medical conversations that transform themselves quite quickly faculty probably use this method to a great extent. Accepting depending on the knowledge being shared. that faculty are comfortable in that stance, and that it will . Follow-up Targets: After some practice with targeted maintain its role of prominence, these first two adaptations questioning, or concurrent with its beginning, a good only barely change the nature of the lecture model. However, addition involves asking a second student what she/he both effectively create moments where students are differently thinks of the first student’s response. Again, the student is engaged with the material, thereby offering opportunities for selected before the question is asked: ‘Samantha, what critical reflection and interaction. did you think of John’s idea that pink eye is the most . Pause Procedures: During the course of the lecture, the diagnosed condition?’ Samantha can now answer in several instructor makes regular pauses of three to four minutes ways, all of which should inform the instructor of the nature during which the students work in pairs to make of her knowledge. Follow-up targets can begin a conversa- collaborative notes on the major issues of the lecture up tion between students; they can begin larger discussions to that point or since the last pause. These pauses need to and/or debates. They can involve more students as it is occur regularly, with lecture intervals not exceeding 18 even possible to follow up the first follow-up target, though minutes (Ruhl et al. 1987). Essentially, this simple adapta- diminishing returns come at about the third person in. tion involves a low level of doing and reflecting into the . Connection Questions: We want students to pay attention to process of listening to a lecture. our lectures. Questions help us get that attention. We also . Bulleted Breaks: Considering that most lectures are organ- want them to be critically engaged. Connection questions

ized around some kind of outline, the instructor can take can help to this end. In a nutshell, connection questions parts of the lecture and move them from oral delivery to recognize knowledge systems. No knowledge is ‘out there’ print format. At some point in the lecture, the instructor on its own but rather is connected in myriad ways to other distributes a set of unordered bullet points. These points knowledge. This is no surprise to medical faculty. Students, make up what would be five or six important issues in the though, often need reminding. Connection questions can be lecture. Students work in groups of three or four to as simple as ‘what are the similarities between tinea capitis categorize and order the points, as well as to generate and hand–foot and mouth disease?’. These are issues that one or two questions to be asked of the instructor. This are generally thought of as facts easily placed in a work takes approximately 25 minutes, including the asking presentation. Treated as a question, though, the nature of of questions to the instructor. Essentially, this adaptation learning that fact is changed. Connection questions can also involves a higher level of doing and reflecting, though it be used as precursors to the next material to be covered in maintains the basic status of the lecture. the lecture. ‘Samantha, after dealing with this case of roseola, and considering I want us to stay in the same age group, is it possible we’ll be dealing with hand–foot and mouth disease Questioning techniques next?’ Again, such questions can help instructors diagnose Many lecturers pepper their presentations with an assortment their students’ strengths and weaknesses as well as create an of questions to their students. Questions change the tone of the atmosphere of full group involvement. presentation, for more than just the time that the question is ‘out there’ looking for a responder. When members of an audience know that questions may be asked of them, they Case scenarios listen differently. Medical education is not unfamiliar with case-based learning. Questions allow instructors to diagnose the level of student PBL has made its name through this method, and TBL is doing understanding, while simultaneously involving the students the same. Yet case-based decision-making is often overlooked in the construction of knowledge. There are several ways to when instructors organize their lecture material. This is too consider the use of questioning in teaching, and each of these bad, because material not processed through the decision- would do a good deal to change the nature of lectures. making functions of the mind is less likely to be recalled after . Targeted Questioning: Many instructors ask open questions an extended period of time (Fink 2003). Reworking minor and of their students: ‘What is the condition pediatricians major points of the lecture into cases that engender instructor/ diagnose most often?’ These questions often become student interactions can be a powerful transformation to the rhetorical as soon as it is clear that no one is offering an learning environment. 40 Active learning in medical observation

. Cases for student decision-making: Turning lecture material medical faculty will be unable to enact such change. Primers into cases is generally an easy process. Rather than like the examples offered here do not create immediate active presenting the data on the clinical manifestations, treatment and significant learning experiences, but they do acknowledge and control measures of a childhood rash, the instructor the need for more interactive approaches to learning in could describe a hypothetical case and then engage the medical education. students by getting them to establish (or raise questions Once such an acknowledgement occurs, once medical about) the pertinent characteristics of each area. This simple faculty begin the work of transforming passive into active alteration intentionally engages the students in a topic on learning experiences, the epistemological concerns of medical which they can critically reflect, conjoining two aspects of pedagogy can be explored. Faculty who move away from the active learning. Plus, it gets them using the kind of simplistic view that teaching is merely transferring knowledge thoughtful analysis they will need as . begin to rethink knowledge itself. Future pedagogical work . Cases for modeling: Cases can also be used to model the will include helping medical faculty explore the different kind thinking and analysis medical professionals actually use. of knowledge demands that are put upon medical students. After presenting the hypothetical case to the students, the These differences require different styles of active learning, instructor can then take some time and think aloud about as well as different frameworks for how medical knowledge is the aspects that will reveal the case’s significance. By constructed by the individual learner. speaking aloud the cognitive process used to identify the At that time, learning frames can be completely redesigned, clinical manifestations, symptomatic characteristics, poten- as instructors will have transformed their understanding of tial treatment plans and long-term control measures, the learning writ large. Knowing that students need to engage, instructor serves as a model students can observe. Thus, as observe and reflect in order to be actively involved in the with the student decision-making cases, this activity learning informs instructors how better learning engagements combines two components of active learning. Cognitive might be constructed. modeling is a far too little used strategy, and one that is Ideally, the primer offered here will begin the process of within the grasp of nearly all medical faculty based on their exploring those epistemological concerns. Each activity content area expertise. Students rarely get an opportunity engenders interactions between instructor and student, man- to observe the cognitive processes of decision-making, ifesting behaviors befitting the active learning components of especially in classes that merely deliver the ‘facts’ of a intentional engagement, purposeful observation and critical condition/case to them in lecture. reflection. While not a panacea, these steps may be a beginning for faculty to explore the idea of active learning in

All of the activities/methods shown here are easily placed their classrooms. If so, they are worth the experiment. within the context of an already designed lecture. In many ways, the format could still be called a lecture, though certain elements within allow for a changed engagement. Active Notes on contributor pedagogies change the nature of the learning experience, but BEN GRAFFAM is the Education Specialist at the University of South Florida they do not always require wholesale changes of the material College of Medicine. With degrees in Gifted (MA) and to be delivered. Simple changes in the presentation can begin (Ph.D.) he is presently observing and assessing educational reforms at the process of developing a more active learning pedagogy. that college.

Discussion References Most instructors in higher education believe they promote Barron BJ, Schwartz DL, Vye A, Moore A, Petrosino L, Bransford JD. 1998. Doing with understanding: lessons from research on problem and critical thinking and active learning but, in fact, only 9% project-based learning. J Learning Sci 7:271–312. engage in these activities regularly. Only 8% can identify active Bonwell CC, Elison JA. 1991. Active learning: creating excitement in the learning in practice (Paul et al. 1997). These same instructors classroom. Ashe-Eric Higher Education Report 1. Washington, DC: report on the positive nature of their lectures when, in fact, George Washington University. lectures consume an inordinate amount of class time (Fink Bransford JD, Brown AL, Cocking RR, editors. 2000. How people learn: brain, mind, experience, and school. Washington, DC: National 2003), do little to assure that content material is well learned Research Council. (Meister 1998), and offer information in a singular style when Brown AL, Campione JC. 1994. Guided discovery in a community of evidence points to a broad range of learning styles among learners, in: K. McGilly (Ed.) Classroom Lessons: Integrating Cognitive students in higher education, including medical schools (Curry Theory and Classroom Practices, (Cambridge, MA, MIT Press). 1999). All of this emphasizes Cohen’s comment that: Bulpitt H, Martin PJ. 2005. Learning about reflection from the student. Active Learning in Higher Education 6:207–217. [a] majority of educators within medical education Carlin RD. 1989. Survey results and a recommendation for a change in employ teaching methods that knowingly fail to US medical curricula. Acad Med 64:202–207. Cashin WE, Downey RG. 1995. Disciplinary differences in what is taught change physician behavior and thus cannot be and instudents’ perceptions of what they learn and of how they are expected to improve the quality of care physicians taught. New Directions for Teaching and Learning 64:81–92. provide to their patients. (2004, p. 2) Chickering AW, Gamson ZF. 1987. Seven principles for good practice. AAHE Bull 39:3–7. To address this situation, pedagogical transformations are Cohen JC. 2004. Instituting improvement in medical education. Reporter needed. However, with little pedagogical training, many 13(11):2 (publication of the AAMC). 41 B. Graffam

Curry L. 1999. Cognitive and learning styles in medical education. Meister JC. 1998. Corporate : Lessons in Building a World-Class Acad Med 74:409–412. Work Force (New York, McGraw Hill). Desmarchais JE. 1993. A student-centered, problem-based : Minstrell JA. 1989. Teaching science for understanding, in: L. Resnick, 5 years’ experience. Can Med Assoc J 148:1567–1572. L. Klopfer (Eds) Toward the Thinking Curriculum: Current Cognitive Desmarchais JE, Jean P, Delorme P. 1990. Basic training program in medical Research (Alexandria, VA, ASCD). pedagogy: a 1-year program for medical faculty. Can Med Assoc J Moust JHC, Vanberkel HJM, Schmidt HG. 1997. Signs of erosion: reflections 142:734–740. on three decades of problem-based learning at Maastricht University. Duckworth E. 1987. The Having of Wonderful Ideas, and Other Essays on Higher Educ 50:665–683. Teaching and Learning (New York, Teacher’s College Press). Paul R, Elder L, Bartell T. 1997. California Teacher Preparation for Fang Z. 1996. A review of research on teacher beliefs and practices. Instruction in Critical Thinking: Research Findings and Policy Educ Res 8:47–65. Recommendations (Sonoma, CA, Foundation for Critical Thinking). Fink LD. 2003. Creating Significant Learning Experiences (San Francisco, Piaget J. 1978. Success and Understanding (Cambridge, MA, Harvard Jossey-Bass). University Press). Foord-May L. 2006. A faculty’s experience in changing instructional Rajan TV. 2006. Making medical education relevant. Chronicle of Higher methods in a professional physical therapist education program. Phys Educ 52(19):B20. Ther 86:223–235. Rich SK, Keim RG, Shuler CF. 2005. Problem-based learning Hativa N. 1998. Lack of clarity in university teaching: a case study. High versus a traditional educational methodology: a comparison of Educa. 36:353–381. preclinical and clinical periodontics performance. J Dent Educ Hativa N. 2000. Becoming a better teacher: a case of changing the 69:649–662. pedagogical knowledge and beliefs of law professors. Instructional Sci Richardson D, Birge B. 1995. Teaching physiology by combined passive 28:491–523. (pedagogical) and active (andragogical) methods. Adv Physiol Educ Hunt DP, Haidet P, Coverdale JH, Richards B. 2003. The effect of usingteam 268:66–74. learning in an evidence-based medicine course for medical students. Rudland JR, Rennie SC. 2003. The determination of the relevance of basic Teac Learn Med 15:131–139. sciences learning objectives to clinical practice using a questionnaire Hurst JW. 2004. The overlecturing and underteaching of clinical medicine. survey. Med Educ 37:962–965. Intern Med 164:1605–1608. Ruhl LL, Hughes CA, Schloss PJ. 1987. Using the pause Iedema R, Degeling P, Braithwaite J, Chan DKY. 2004. Medical education procedure to enhance lecture recall. Teacher Educ and Special Educ and curriculum reform: putting reform proposals in context. Med Educ 10:14–18. Online 2004 9:1–15. Available at: http://www.med-ed-online.org Smith RA. 1995. Reflecting critically on our efforts to improve teaching and Kember D. 1997. A Reconceptualization Of the research into university learning, in: E. Neal (Ed.) To Improve the Academy (Stillwater, OK, academics conception of teaching. Learning and Instruction 7:255–275. New Forums Press). pp 129–153. Kimonen E, Nevalainen R. 2005. Active learning in the process of Vye NJ, Schwartz JD, Bransford BJ, Barron LZ. 1998. Smart environments educational change. Teaching and 623–635. that support monitoring, reflection, and revision, in: D. Hacker, Available online at: http://www.elsevier.com/locate/tate J. Dunlosky, & A. Graessner (Eds) Metacognition in Educational Lehrer R, Chazan D. 1998. New Directions for Teaching and Learning Theory and Practice (Mahwah, NJ, Erlbaum).

Geometry (Hillsdale, NJ, Erlbaum). Vygotsky L. 1978. Mind and Society: the Development of MacLellan E. 2005. Conceptual learning: the priority for higher education. Higher Psychological Processes (Cambridge, MA, Harvard University Br J Educ Studies 53:129–147. Press).

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