Effective Education in Medical Practice
John M. Schweinfurth
Graduation from a residency training program and entry into surgical practice represents an abrupt and often permanent change in learning styles. Professors are fond of telling the graduate, “This is just the beginning of your education, not the end.” The divide is dramatic. Nothing in didactic form approaches the learning experience of the real world, where there is no textbook, no lesson plan, and no instructor to fall back on. Indeed, many early decisions are based on the teacher’s transplanted wisdom. Often the transition is abrupt; the educational process up to graduation is based on a teacher-directed model of learning for which there is no direct continuity in practice. Currently, there are multiple, instructor-led resources for long-term learning including opportunities for continuing medical education (CME) from annual national and regional professional meetings, home study courses, audio digests, and online reviews.
This chapter, however, is not about formal, teacherdirected learning activities such as lectures and CME. The reality is that instructor-led CME activity, while valuable, represents not only an artificial learning environment but a relatively ineffective one at that (1). Active engagement in self-planned learning activities tends to be more effective than the passive learning, which commonly characterizes formal CME. The vast majority of postgraduate, or lifetime, learning is problem specific and occurs in the context of real experience: the clinic, on an Internet search engine at night, or over the phone with a colleague; those conversations that invariably begin, “I have this patient….”
Lifetime learning involves finding and implementing solutions to everyday problems encountered in the clinic, in the emergency room, in the operating room, and on the wards. The process by which much of this education occurs is via self-directed learning (SDL). According to Gibbons, a paradigm shift in instruction is “teaching students to challenge themselves to pursue activities that arise from their own experiences, employing their own emerging styles to find patterns of meaning and processes of productivity that lead them to a high level of achievement and fulfillment. The prime imperative… is not to enhance teacher-directed learning, but to develop a more student-directed model” (2).
WHAT IS SELF-DIRECTED LEARNING?
Initially described by Malcolm Knowles, in its broadest meaning “self-directed learning” is a process
“… in which individuals take the initiative… in diagnosing their learning needs, formulating learning goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies, and evaluating learning outcomes” (3).
Knowles argues that proactive learners learn more things better than do passive, or “reactive,” learners. They enter into learning purposefully with greater motivation and better long-term retention. Finally, because of rapid changes in our understanding of the world, it is no longer realistic to define education as the transmission of static knowledge but to develop instead skills of inquiry.
Hammond and Collins (4) describe SDL as “a process in which learners take the initiative, with the support and collaboration of others. For increasing self- and social awareness; critically analyzing and reflecting on their situations; diagnosing their learning needs with specific reference to competencies they have helped identify; formulating socially and personally relevant learning goals; identifying human and material resources for learning; choosing and implementing appropriate learning strategies; and reflecting on and evaluating their learning.” This humanistic characterization of SDL implies a sense of social awareness, self-actualization, and the acceptance of personal responsibility for one’s own learning.
TABLE 203.1 SKILLS AND COMPETENCIES OF THE LIFELONG LEARNER | |
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The acquisition of SDL is a complex process, involving numerous skills and competencies relied upon to complete challenges such as medical school and residency. Unlike the classroom setting, where the emphasis is on mastery of content, SDL emphasizes personal action taken to become more productive. Testing is no longer an issue, but performance certainly is. Many authors have identified SDL as essential to continuing education efforts in adults (5,6).
Not everyone is ready to accomplish SDL, however; this is because certain traits are essential for becoming a successful, productive individual. Candy (7) synthesized an essential character list from over 100 such traits (Table 203.1).
Barrows called for the application of SDL in medical education because “the curricula of many medical schools put too heavy an emphasis on memorization of facts and little stress on problem solving or self-directed study skills necessary for the practice of medicine. Problem-based SDL is a teaching-learning method specifically designed to emphasize these skills and to increase the retention of facts and their recall in the clinical situation” (8). Generally, SDL is not limited to specific settings but can occur as a part of any process and include formal learning activities as well. Among Tough’s factors are three common patterns in independent study: a specified learning need, curiosity, and a general desire to learn (9). Houle (10) described three groups of adult learners: goal oriented, activity oriented, and learning oriented based on their immediate educational needs, not necessarily on individual learning styles. Of these, most practicing physicians clearly fall into the first category, as they embark on a learning project to acquire new procedural skills, to become familiar with new medications, or updates in coding and reimbursement schedules, for example. Activity-oriented learners participate for social interaction and learning-oriented for the sake of knowledge itself.
THE CHALLENGE MODEL OF SELF-DIRECTED LEARNING
Possibly the most influential essay on SDL is The Walkabout by Maurice Gibbons published in the 1974 edition of the Phi Delta Kappan. At the heart of the essay is the movie of two children lost in the desert wilderness of the Australian outback. Facing certain death, the two are found and cared for by a young aborigine on his walkabout, a 6-month long endurance test during which he must survive alone in the wilderness and return to his tribe an adult. Gibbons surveys the ramifications of the story from a societal standpoint:
“The movie is a haunting comment on education. What I find most provocative is the stark contrast between the aborigine’s walkabout experience and the test of adolescent’s readiness for adulthood in our own society. The young native faces a severe but extremely appropriate trial, one in which he must demonstrate the knowledge and skills necessary to make him a contributor to the tribe rather than a drain on its meager resources. By contrast, the young North American is faced with written examinations that test skills very far removed from the actual experience he will have in real life. He solves familiar theoretical problems; he does not apply what he knows in strange but real situations…. His preparation is primarily for the mastery of content and skills in the disciplines and has little to do with reaching maturity, achieving adulthood, or developing fully as a person.”
The walkabout model is quite applicable to the learning required by the practicing physician. First of all, it should be experiential and the experience should be “hands-on.” Second, it should be a challenge that extends the capacities of the learner. Third, it should be a challenge specific to or, better, designed by the learner. A productive learning experience depends on the learner’s ability to make appropriate choices, but in most teacher-directed situations the student is not called upon to make any meaningful choices. “The test of the walkabout, and of life, is not what (the learner) can do under a teacher’s direction, but what the teacher has enabled him to decide and to do on his own” (Gibbons, 1974). Most importantly, the trial should be an important learning experience in itself and should involve not only the demonstration of the student’s knowledge and skill but also his or her self-awareness, flexibility, and nature as a person.
