Active Learning Strategies in Undergraduate Medical Education of Pathology: A Saskatoon Experience

INTRODUCTION

Post-secondary education is changing; the postmodern generation wants fun, power in their own hands, clear expectations and explanations, personal rapport with their instructors, honesty, and uninhibited use of technology.¹ Students are “becoming more diverse in ethnic background, age, and participation patterns.”² Current research on learning indicates that using a wide variety of teaching strategies in the classroom increases student buy-in and learning, but “because employing this emerging knowledge challenges the historic structure of the universities, we ignore it”³ “This raises the question of whether it has already become immoral to teach without extensive use of active learning techniques that so enhance performance.”⁴ Learning and participation are inseparable.⁵ In response to findings such as these, the professoriate is being encouraged to adapt and alter their teaching methods to address the new generation of postmodernist students.¹

More specifically, there is a shift in medical education toward educating physicians who can work as team members; an ideal medical education would produce physicians who, as part of a health team, practice “patient-centered medicine.”⁶ This education has remained elusive, perhaps, because it requires a change of philosophy from a disease-centered approach to an illness-centered approach, as well as an expectation for physicians to be members of health care teams (medical and non-medical trained personnel) responsible for patient management. Being a member of a team requires effective interaction and communication with all members of the team. Physicians-in-training require opportunities to develop these interpersonal skills that will be used throughout their careers with both patients and team members as part of their hitherto traditional rigorous medical education.^7,8

Active learning strategies are instructional tools that can address both content and process objectives that include the development of interpersonal, communication and problem-solving skills within the current framework and tradition of lecture-based classes. Dealing with the same content, students have an opportunity to both increase their grasp of the content while using processes that encourage interpersonal communication, teamwork, and problem solving. Active learning strategies are widely used in both elementary and secondary educational settings and in some post-secondary and adult education because they promote learning through the active participation of the learner; “teaching strategies and learning tasks used in university classrooms foster intellectual passivity because they focus on presenting knowledge, rather than constructing analyzing, synthesizing, or evaluating knowledge.”⁹ Teaching styles in medicine have remained fairly pedantic with traditional modernist classrooms structured around faculty authority and visual learning. Such traditional teaching continues to promote an individualistic, competitive environment rather than fostering the skills of cooperation necessary to function effectively as part of a team.

A vision for a progressive team approach to the management of patients has called for the active involvement of medical students in their own education and training. This promotes and provides opportunities for the development of the thinking skills and interpersonal skills needed to function effectively in this new environment. Active learning strategies that emphasize small group activities reinforce the content for which medical students are responsible by using strategies that address a wider variety of individual learning styles, and promote the development of effective team work and interpersonal skills through the processes of active learning.

The design and format of the study contribute unique ideas to the field of medical education; there is a collegial relationship between a medical faculty member and an education expert in an on going collaborative process, and students are experiencing strategies that will both presumably enhance their immediate learning and will provide them with techniques to use with patients in their future medical practices. More specifically, the purpose of this study was to evaluate the inclusion of three methods of active learning strategies (encouraging collaboration, using analogy and metaphor, and summarizing techniques) in the general pathology course of the undergraduate medical curriculum.

METHODS AND MATERIALS

The active learning strategies of using metaphor, collaboration, and summarization techniques including the fishbone technique were incorporated into a General Pathology Course. The specific teaching strategies chosen addressed both process and content of:
a) Developing and practicing interpersonal and communication skills;
b) Promoting a more cooperative atmosphere among individuals;
c) Providing opportunities for group problem solving;
d) Introducing and modeling a technique for conveying complex medical concepts in an accessible simple way for students to use in the future with their patients; and
e) Incorporating a wider variety of strategies linked to learning styles to help students understand the content more thoroughly.

The course ran from the end of August to the middle of December meeting 43 times in total, three times per week. This is a 6-credit course with 57 contact hours taught by 8 different instructors over the term. There were 88 students enrolled in this course: 60 2nd year medical students, 26 2nd year dental students, and 2 Masters in Pathology graduate students. This study was initiated and carried out by the course coordinator who was an instructor and taught 13 of the 22 classes; these sessions formed a block series of lectures occurring from the beginning of the course to the midterm exam thereby maintaining continuity of teaching style. Working with a doctoral student in Educational Administration, this instructor developed lessons that met the content and process objectives to be addressed by increasing the amount of active learning. The instructor and the coach worked together using action research cycles of plan, act, observe, and reflect 10 to decide which active learning strategies might be most effective in meeting the process and content objectives set by this instructor for her portion of the course. It was finally decided to use metaphor, collaboration and various summarization techniques including the fishbone technique. The instructor, an accomplished lecturer, excited by workshops offered for faculty in the College of Medicine to encourage more active learning in medical education, was keenly interested in developing a larger repertoire of instructional methodologies. The coach was interested in seeing if these methods could be used to advantage in medical education. Organizationally, the scholarship of teaching was encouraged in the College.

During the introductory session, students were informed that active learning strategies would be included in their familiar lectures in this instructor’s classes. As an incentive beyond the benefits to their own learning and the development of skills that would stand them in good stead with future colleagues and patients, students were informed that participation in these activities would garner 10% of their final grade.

Rather than “buying” a completely new educational style, the instructor and the coach chose to start slowly by “renovating” the old traditional lecture with small bits of active learning strategies that usually took no more than 10 minutes in a 50-minute class. Lectures were punctuated and augmented with active learning strategies that often included working in pairs or small groups. Groups were formed randomly with proximity usually being the deciding factor; students turned to the person sitting closest, generally someone they already knew. Students were asked to discuss key points of portions of the lecture or formulate responses to questions posed throughout the lecture. This provided a break in the flow of lecture information, and gave students an opportunity to reflect and interact with their peers.

At other times, students were asked to develop visual or verbal metaphors that linked the pathology concepts being presented in the lecture to a common visual or verbal concept. The instructor modeled first and gave examples, and then provided an opportunity for students to develop their own metaphors in small groups or pairs. Figures 1a,b,c and 2 provide examples of how students used this technique to advantage. Exploring how various complex medical concepts compared to and are different from familiar concepts helped to cement the medical concepts for some and provided a model that could be used to clarify complex concepts with patients in the future. For some students, the visual metaphors had more impact, and for others, the verbal metaphors resonated more effectively. In both cases, there was an opportunity for the instructor to clear up any misconceptions about the medical concepts that may be illuminated as students developed metaphors. Working in pairs throughout the course, students used a variety of methods to review and summarize lecture information including the fishbone technique (Figure 2a and 2b). Students also had an opportunity to use a simple concept map to summarize a clinical case (Figure 2c and 2d). These had been modeled by the instructor for one of the previous topics and for the next lecture the students were asked to participate in developing one of their own working in a small group within the confines of the classroom. In most cases, the students handed in their work as they left the class for the day as a record of their participation in active learning and towards their final grade. Throughout the course, the instructor continued to use PowerPoint presentations and distribute handouts based on these presentations. In this way, some of the traditional lecture structure remained the same as more active learning strategies were added.

Student work was collected over the course of the term. The entire class (88 students) participated in the classroom activities with varying degrees of enthusiasm. There appeared to be engagement in the activities and a good deal of productive “buzz” in the lecture theatre during the activities. The instructor and coach continued to modify the activities throughout the course based on the perceived reactions of the students to the activities. The objectives were not for the students to become proficient with the different activities and they were not graded on the quality of the assignments they handed in at the end of class; they were merely awarded a percentage of their grade for handing something in. A sampling of the student responses to the activities was often shared with the large group at the beginning of the next class. Students requested to hear how others had responded and sharing these responses seemed to spark enthusiasm.

The instructor had no further teaching responsibilities in this course after the mid-term so students’ perceptions of the active learning strategies were gathered through an anonymous questionnaire administered as a component of the mid-term exam; it was worth 2 marks toward the mid-term grade (Table 1). The questionnaire was the last page of the exam and was torn off to preserve the anonymity of the students. The questionnaires were collated and analyzed on a semi-quantitative and qualitative format. The student performance at the midterm was also used as a performance assessment as the question content was predominantly from the material covered by this instructor.

RESULTS

The student performance at the Midterm exam was slightly better in comparison to the previous years; there was no regression of marks in comparison to the previous years (Figure 3). This reassured the instructor’s guiding medical philosophy of “Do no harm.”

The overall feedback from the students to the midterm questionnaire was generally favorable. Table 2 indicates the responses to the three yes-no questions. In the comment section, the students generally enjoyed the interaction with peers and liked to participate in these classroom activities. Some indicated that they did not perceive that these changes in teaching methodology actually helped them learn more easily. For some students, however, the summarization techniques and the metaphors and analogies were helpful in clarifying concepts and provided tools to review the concepts over the longer term. In that respect, all objectives were met to some extent. Of the total number of 256 responses to the open-ended questions from the students, 170 (67%) were positive about the inclusion of these active learning strategies. Seventy-two responses were negative (28%) while 14 (5%) comments were neutral. The 14 neutral comments were primarily about the time of day the class was offered and observations about the handout package. The negative comments clustered mostly around a concern that activities took away from lecture time (39 of 72-54%) without adding significantly to learning or the development of interpersonal skills. The positive comments, however, indicated that interacting with others and engaging in these activities was useful in clarifying the concepts, it was enjoyable, and the class moved more quickly (Table 3).

DISCUSSION

From the wide variety of strategies that can be used to actively engage students in their own learning, the ones that are chosen depend on the objectives of the course and the needs of the students. Simulations, demonstrations, experiments, debates, role play, small group discussions, creating visual representations and models, problem solving, case studies, research and presentations, and games are all examples of active learning strategies. These strategies are widely employed in primary and secondary classes and in adult education and workplace training.

Although the feedback from students favored the incorporation of active learning strategies overall we found the negative comments about active learning detracting from lecture time confusing given the endorsement of active learning from the literature. The literature is clear on the benefits of active, student-centered learning over a strictly lecture approach. Lecture is not ineffective but active involvement in the learning process is beneficial to students,¹¹ it reduces the density in the lecture thereby increasing retention,¹² and addresses a wider range of objectives over and above the transfer of content from instructor to student. Very simply put, “there is a great difference between imagining that we have done the problem and actually doing it,”¹³ active learning provides an opportunity for students to do the problem.

The College of Medicine at the University of Saskatchewan has been educating faculty about the benefits of active learning, and providing support through workshop sessions and personal assistance to instructors to restructure lessons. The course instructor involved in this study has attended all of these workshops. Incorporating new strategies takes effort, flexibility, and faculty-driven initiative to make changes as well as the drive to try and make them work. The overall feedback in this one course of general pathology medical and dental students indicates that the students are not as receptive to the perceived benefits of the inclusion of active learning strategies in their lecture sessions as we thought they might be. The biggest criticism seemed to be reflected in their comments about “wasted time.” It may be that longer range objectives do not figure prominently in a somewhat myopic view of students to successfully complete their exams. In this context, it is important to remember that the postmodern student who “despises above all theoretical constructs so vague as to be irrelevant to anyone outside the discipline”1 is skeptical of authority and visual learners. These students also have “an entirely different set of values, including an absence of inherent respect for authority, a willingness to demand that information be both relevant and entertaining, and above all else a need for all their interactions to be personal, including those that over the ages have remained strictly professional.”¹ In short, these students demand that the teacher-student interaction be different and, as part of that, that different instructional approaches be used. Awareness and recognition of this led to the incorporation of active learning strategies in the fond hope that it might appeal to their varied ways of learning. Although the students enjoyed the interaction, some of the students did not see a benefit to their learning and felt that it detracted from traditional lecture time. Students, though alerted and prepared for these “new” activities, still felt uncomfortable exploring and breaking new ground as opposed to the traditional lecture format which with they are both familiar and extremely comfortable. The perception of “wasted time” and lack of recognition of learning in group work need to be addressed as these students have to be comfortable in a “team” approach for their future professional careers. This is not atypical; students are resistant to active learning techniques because “they have not been trained to cooperate in the academic environment.”¹⁴ Students may feel that the lecture method is easier for them because they can remain passive in a way they are comfortable with and to which they are accustomed.

This exploration has also raised the question of the organizational climate toward wider instructional methodologies. If some instructors are concerned that they do not have enough time to “cover the content”¹⁵ then any time spent not directly transmitting content from instructor to student may be interpreted as a waste of time, and not recognized as “teaching.” The appearance of anything other than a lecture being not serious teaching¹⁴ hinders the involvement of students in their own learning. Medical education has an historical and traditional texture that is familiar and comfortable to both faculty and students. In addition to taking a great deal of effort on the part of the instructor, changing this seems to raise the level of anxiety among students who think that they may not be getting what they need to “pass the exam.” It is the final exam which seems to drive the students’ involvement with instruction,¹⁶ and this raises the question of the learning styles and study habits of this particular group of students which may be different from an average group of undergraduate university students. Such knowledge of learning styles and study habits may help to choose active learning strategies that enhance the learning experience for the students while addressing content and process objectives. This will be the subject of future study.

CONCLUSION

In summary, active learning strategies can be incorporated in the delivery of pathology education as a renovation of the traditional undergraduate medical curriculum. The adoption of such strategies does need the flexibility, time, and effort of both the instructor and the participating students, and is an embrace of the spirit of exploration. Some students were somewhat resistant to change and some students seemed to equate “teaching” with “lecture” and any other modes were interpreted as non-teaching activities. Some students tolerated the activities rather than being actively engaged in the same. The perceived immediate benefits need to be observed in relation to the extra effort required to teach in this way for the current climate of medical students in our school in addition to designing studies to examine the potential long term benefits of including these strategies in undergraduate medical education. The long-term effectiveness of incorporating metaphor and analogy, and summarization techniques such as the fishbone with interpersonal skill development as objectives along with content objectives, however, may only become apparent when these students function as doctors in team-oriented, patient-centered clinical practices.

REFERENCES

1. Fowler, G. Postmodernism: this changes everything! The Journal of Student Centered Learning. 2003; 1(2): 87-95.
2. Smith, P. Curricular transformation: why we need it, how to support it. Change. 2004; Jan/Feb: 28-35.
3. Smith, P. Curricular transformation: why we need it, how to support it. Change. 2004; Jan/Feb: 28-35.
4. Nelson, C. Student diversity requires different approaches to college teaching, even in math and science. American Behavioral Scientist. 1996; 40 (2): 165-175.
5. Wlodkowski, R. Fostering motivation in professional development programs. New directions for adult and continuing education. 2003; Summer(98): 39-47.
6. Jamshidi, H. and Cook, D. Some thoughts on medical education in the twenty first century. Medical Teacher. 2003; 25: 229-237.
7. Salas, E., Burke, C., Bowers, C., and Wilson, K. Team training in the skies: Does crew resource management training work? Human Factors. 2001; 43: 641-674.
8. Leipzig, R., Hyer, K., Ek, K., Wallenstein, S., Vezina M., Fairchild, S., Cassel, C., and Howe, J. Attitudes toward working on interdisciplinary healthcare teams: a comparison by discipline. Journal of the American Geriatrics Society. 2002; 50: 1141-1148.
9. Wright, W. and O’Neil, M. Perspectives on improving teaching in Canadian universities. Canadian journal of higher education. 1994; XXIV(3): 26-57.
10. Kemmis, S. Action research. In J. Keeves & G. Lakomski (EDS.), Issues in educational research. 150-160. New York: Pergamon. 1999.
11. Terenzini, E. and Pascarella, P. Living with myths: Undergraduate education in America. Change. 1994; Jan/Feb: 28-32.
12. Russell, I., Hendricson, W., and Herbert, R. Effects of lecturing information density on medical student achievement. Journal of Medical Education. 1984; 57: 881-889.
13. Zull, J. The art of changing the brain: Enriching teaching by exploring the biology of learning. Stylus Publishing: Sterling, VA. 2002.
14. Panitz, T. Why more teachers do not use student centered learning techniques and policies needed to encourage positive changes. The journal of student centered learning. 2003; 1(2): 55-60.
15. Nelson, C. What is the most difficult step we must take to become great teachers? The National Teaching and Learning Forum. 2001; 10(4): 10-11.
16. Biggs, J. Teaching for quality learning at university: What the student does? Buckingham, UK: Society for Research into Higher Education and Open University Press, 1999.

NOTE: Please refer to the complete PDF file for all Tables and Figures