Elizabeth G. Armstrong

How can physicians' learning styles drive educational planning?

As changes in health care delivery systems and in the global burden of disease call for a reassessment of how tomorrow’s physicians should be educated—indeed, for a reconsideration of the diversity of roles the physician should play—there is an immediate need to produce continuing medical education (CME) programs with real impact. Curriculum planners are questioning both the content of medical education and the methods of instruction and training. The product, or content, and the mechanism for its delivery have been defined and discussed, but a significant body of literature has shown that new knowledge does not necessarily lead to new behavior. Ample evidence exists in the CME literature to support the implementation of more active and self-directed learning strategies to promote the desired change in behaviors. The question, then, that is the focus of this article is how educational planning might be better guided by an understanding of how physicians learn within the continuing medical education domain. Revisiting the principles of David Kolb’s Learning Styles Inventory, the authors propose applying his experiential learning model to overall curriculum design work. The authors argue that promoting the application of all learning styles in sequence in an educational encounter is a most desirable approach, and that this approach to learning could extend far beyond individual learners to influence how every component of medical education is designed, from the individual lecture or class activity to entire courses or programs.

What Can Medical Education Learn From the Neurobiology of Learning

The last several decades have seen a large increase in knowledge of the underlying biological mechanisms that serve learning and memory. The insights gleaned from neurobiological and cognitive neuroscientific experimentation in humans and in animal models have identified many of the processes at the molecular, cellular, and systems levels that occur during learning and the formation, storage, and recall of memories. Moreover, with the advent of noninvasive technologies to monitor patterns of neural activity during various forms of human cognition, the efficacy of different strategies for effective teaching can be compared. Considerable insight has also been developed as to how to most effectively engage these processes to facilitate learning, retention, recall, and effective use and application of the learned information. However, this knowledge has not systematically found its way into the medical education process. Thus, there are considerable opportunities for the integration of current knowledge about the biology of learning with educational strategies and curricular design. By teaching medical students in ways that use this knowledge, there is an opportunity to make medical education easier and more effective. The authors present 10 key aspects of learning that they believe can be incorporated into effective teaching paradigms in multiple ways. They also present recommendations for applying the current knowledge of the neurobiology of learning throughout the medical education continuum.

Medical education as a process management problem.

With complaints that new doctors are less prepared for residency and practice than expected, are burdened with debt, and then take even longer to complete their specialty training, the authors ask whether medical education can be designed more effectively. Curriculum redesign and pedagogical reform efforts to date address fragments of medical education—the content of particular courses or clerkships or the way in which the courses or clerkships are conducted. However, these reforms do not typically address the relationships among the various elements, that is, in what order skill sets should be sequenced, how communication should occur between disciplines, and by what mechanisms skills or knowledge should be mastered and assessed by the end of one phase so students are prepared adequately for the next. In failing to address these systems issues, current reform efforts may forgo some opportunities to convey and properly insure greater mastery of knowledge and skills in less time, at less cost. A case study of a typical students third- and fourth-year clerkships illustrates how focusing only on educational elements leads to the exclusion of opportunities to systemically facilitate the relationships among them. This situation is contrasted with how other demanding, high-tech, knowledge-intensive industries with outstanding operations have learned to achieve superlative performance by managing and designing both the elements and the interactions among them within complex work and learning systems. The authors’ exploratory research offers suggestions for medical education reform and frames additional opportunities for further discussion.

Using an Outcomes-Logic-Model Approach to Evaluate a Faculty Development Program for Medical Educators

Purpose This study used an outcomes-logic-model approach to examine the impact of participating in a nontraditional professional development program. Building and using a logic model provides a structure for the program to examine the degree that the desired learner outcomes, the program delivery methods, and the measurement approaches are aligned. Method Structured telephone interviews were conducted in 2001 with 16 Harvard Medical School (HMS) participants in the Harvard Macy Program for Physician Educators (HM-PE): five who completed the program in 1998, five in 1999, and six in 2000. Interviews were also conducted with four Faculty Scholars, alumni of the HM-PE program who taught in subsequent programs. In 2004, online questionnaires were sent to the 16 participants and four Faculty Scholars. Immediate outcomes, such as greater use of active learning principles, and intermediate outcomes, such as commitment to medical education, were examined. Results Of those interviewed in 2001, 80% responded to the 2004 online questionnaire. Thirteen of 16 (81%) HMS respondents reported increased knowledge about and confidence using learner-center teaching methods; 10 of 16 (63%) said they gave fewer lectures and added alternative educational methods. Thirteen of 16 (81%) reported a stronger commitment to the field of medical education: almost one third felt the HM-PE program was a turning point in their careers. Conclusions The outcomes logic model provided data to judge how well the program mission and plan were implemented, and whether outcomes had been attained.

Can a simulated critical care encounter accelerate basic science learning among preclinical medical students? A pilot study.

Purpose: To explore whether a simulated critical care encounter can accelerate basic science learning among preclinical medical students. Method: Using a high-fidelity patient simulator, we “brought to life” a paper case of a myocardial infarction among a convenience sample of first-year medical students (n=22 [intervention]). Students discussed the case as part of a routine tutorial session, and then managed the case in the simulator laboratory. Using an identical six-item test of cardiac physiology, students were evaluated immediately after the simulator session and at 1 year (n=15). Performance was compared with controls (case discussion but no simulator session) at both baseline (n=37) and 1 year (n=48). Results: Performance among simulator-exposed students was significantly enhanced on immediate testing (mean score 4.0 [control], 4.7 [intervention], P = .005). Gains among the simulator cohort were maintained at 1 year (mean score 4.1 [control], 4.7 [intervention], P = .045). Multivariable analysis confirmed that the intervention was a significant determinant of performance across time (P = .001). Conclusion: Compared with controls in this pilot study, an additional simulation exercise improved immediate performance on a short written test of cardiovascular physiology. Enhanced performance was again seen at 1 year, raising the possibility that the extra teaching session produced accelerated and sustained learning compared with the routine teaching method. Given the preliminary nature of this investigation, further study is required to distinguish transient from lasting effects of simulation versus alternative teaching approaches in the basic medical sciences.

Faculty development for ambulatory teaching

This paper deals with helping faculty members and others learn to teach more effectively in ambulatory settings. First it suggests ways to help clinicians expand and update their knowledge and skills in ambulatory medicine as a foundation for teaching. Next it identifies six skills — establishing mutual expectations, setting limited teaching goals, asking questions, stimulating self-directed learning, giving feedback, and capitalizing on role modeling — that are basic to effective ambulatory teaching. Then it presents strategies for developing and maintaining such skills: Assessment of teaching, consultation with experts in education, and participation in programs such as workshops. The paper ends by discussing aspects of institutional support and calling for research on the impact of faculty development efforts on teaching and learning in medicine.

An Online Spaced-Education Game to Teach and Assess Medical Students: A Multi- Institutional Prospective Trial

Purpose To investigate whether a spaced-education (SE) game can be an effective means of teaching core content to medical students and a reliable and valid method of assessing their knowledge. Method This nine-month trial (2008–2009) enrolled students from three U.S. medical schools. The SE game consisted of 100 validated multiple-choice questions–explanations in preclinical/clinical domains. Students were e-mailed two questions daily. Adaptive game mechanics re-sent questions in three or six weeks if answered, respectively, incorrectly or correctly. Questions expired if not answered on time (appointment dynamic). Students retired questions by answering each correctly twice consecutively (progression dynamic). Posting of relative performance fostered competition. Main outcome measures were baseline and completion scores. Results Seven-hundred thirty-one students enrolled. Median baseline score was 53% (interquartile range [IQR] 16) and varied significantly by year (P < .001, dmax = 2.08), school (P < .001, dmax = 0.75), and gender (P < .001, d = 0.38). Median completion score was 93% (IQR 12) and varied significantly by year (P = .001, dmax = 1.12), school (P < .001, dmax = 0.34), and age (P = .019, dmax = 0.43). Scores did not differ significantly between years 3 and 4. Seventy percent of enrollees (513/731) requested to participate in future SE games. Conclusions An SE game is an effective and well-accepted means of teaching core content and a reliable and valid method to assess student knowledge. SE games may be valuable tools to identify and remediate students who could benefit from additional educational support.

Questioning the 'big assumptions'. Part II: recognizing organizational contradictions that impede institutional change

Background Well‐designed medical curriculum reforms can fall short of their primary objectives during implementation when unanticipated or unaddressed organizational resistance surfaces. This typically occurs if the agents for change ignore faculty concerns during the planning stage or when the provision of essential institutional safeguards to support new behaviors are neglected. Disappointing outcomes in curriculum reforms then result in the perpetuation of or reversion to the Status quo despite the loftiest of goals.

Questioning the "big assumptions". Part I: addressing personal contradictions that impede professional development.

Background The ultimate success of recent medical curriculum reforms is, in large part, dependent upon the facultys ability to adopt and sustain new attitudes and behaviors. However, like many New Years resolutions, sincere intent to change may be short lived and followed by a discouraging return to old behaviors. Failure to sustain the initial resolve to change can be misinterpreted as a lack of commitment to ones original goals and eventually lead to greater effort expended in rationalizing the status quo rather than changing it.

Crafting cases for problem‐based learning: experience in a neuroscience course

Clinical cases for problem‐based learning should capture the relevance of patient encounters, and not serve merely as a ‘take‐off’ point for scientific study. As a vehicle of learning, the case should drive the science and the science should drive the case. Decision points elicit intellectual commitment, and help to raise the level of inquiry. Our cases are focused, avoiding clinical complexity and reliance on pattern recognition. We emphasize formulation of evidence‐based mechanistic hypotheses. The case does not stand alone, but must suit its position in the course and curriculum.