Focusing on Learners

Especially in medicine, most of us are most familiar with educational approaches that are instructor centered. The instructor is the single most active person in the learning environment, and bears responsibility for determining what is taught, how it is taught, when it is taught, and how learner performance is assessed. Often underlying instructor-centered approaches to education is the view that learners such as medical students are basically empty receptacles waiting to be filled up with the knowledge the instructor contains.

Despite the great prevalence of instructor-centered models in medical education, however, a great deal of investigation and discussion in the contemporary literature favors a more learner-centered approach to education. This is grounded in the insight that the goal of education is less to exercise instructors than to cultivate knowledge and skills in learners. In other words, education is more about learners than instructors, and it is fitting that educational approaches be more tailored to the opportunities the learner presents.

Many if not most medical educators have little or no formal background as educators. Except by example, no one ever taught us how to teach effectively. We have all but tacitly accepted such insidious educational concepts as the fund of knowledge. Operating on this principle, we suppose that our goal is to increase our learners' fund of knowledge in a relevant subject area. Such a concept is highly instructor-centered, however, and all but inevitably promotes an instructor-centered educational approach. We find ourselves operating as though there were a knowledge level in the mind of the learner, and all we need to do to determine it is insert a dipstick. The higher the level, the more knowledge we have successfully imparted. Yet learners' minds are more than tanks, and knowledge is more than a liquid with which we fill them. If we are to meet the needs of learners more effectively, it is vital that we develop a clearer understanding of what goes on in their minds.

Sometimes the sheer volume of information that medical students and residents face leaves them feeling oppressed or nervous. They quite reasonably deduce that they will not be able to learn everything, and seek out guidance on what they really need to know. In the most stressful situations, this boils down to the effort to discern what will be on the test. Learning comes to be directed by evaluation, and soon learners have lost their focus on what they will need to know to excel as physicians. In the ideal situation, learners are focused on the latter, on what a good physician needs to know. To foster such learning, educators can ensure that learners face problems that closely approximate those they will face in actual practice.

Here using patients and case histories as the focus can be extremely helpful. When a patient presents with a particular problem, what sorts of information does the physician need to seek,which aspects of the history and physical examination are most appropriate, and which tests are most likely to be helpful? When medical students begin their discussion of acid-base balance with a particular patient in respiratory alkalosis or metabolic acidosis, they are able to situate the discussion in a clinically relevant context from the outset. Such problem-based approaches also put students in the role of problem solvers, not mere memorizers. The knowledge they acquire, therefore, tends to be usable, as opposed to the frequently inert form of knowledge that memorization spawns. Learners are not merely trying to recall what they were told, but to use knowledge to solve a problem similar to those they will face in medical practice.

Learner-centered education advances an attitude of respect for learners. Those who choose careers in medicine are usually very bright and capable people, and they enjoy a challenge. They are unlikely to respond to their fullest capability if they are treated like small children and simply told what to do. We should let them know that their own learning needs and preferences have shaped their educational program. They are not like passengers in a car on an amusement park ride, but like members of a team exploring a new geographical region. Their route is not entirely predetermined, and even their destination is to some degree subject to their own discretion. They are not sheets of metal moving along a conveyor belt, about to be stamped into a particular shape. At their best, they are active participants and even collaborators in their own education, and our mission as educators is to enable them to realize that potential.

If we do not respect learners' potential to function as co-investigators and even co-directors of their own education, we may foster an attitude of "learned helplessness," where formerly bright and self-directed learners become increasingly reliant on instructors to tell them what to do. How well would such an attitude prepare them for the challenge of life-long learning that a career in medicine represents? How will they know what books and journals to read, what continuing education courses to attend, and how well they are doing as learners? Will we keep giving them reading assignments and exams their whole lives? No. To prepare them to flourish as learners, we need to give them an active role in determining what to learn and how to go about learning it. We need not begin the class telling medical students what they should want to learn. We can begin the class by getting them talking about what they want to learn and why, and we can tailor the syllabus at least in part to what they say.

Learners do not arrive in medical school or residency as Descartes' blank tablets. They bring with them prior experiences and a desire to help shape their own learning. What do they know already? How might the subject matter of this particular course or clinical rotation fit more dynamically into their current understanding? Even first-year medical students have had experience with healthcare. What "cases" do they bring with them on day one? By bringing to light and making use of what learners already know, we make the relevance of the material much more transparent, because the learners themselves helped to supply much of it. Moreover, we also help learners develop as true learners, not mere memorizers, by challenging them to play an active role in shaping their own educational experience.

Understanding the questions and experiences learners bring to the table can become increasingly difficult, the greater the gap that separates instructors and learners. It is therefore especially important to get to know and understand novices. If we are not careful, we may find ourselves using terms and concepts that are unfamiliar to learners, and instruction ends up going "over their heads." It is simply a mistake to overlook the important differences that separate first-year medical students from fourth-year medical students, or fourth-year medical students from third-year residents. What works well with one group of learners may fail miserably with another, either because it assumes too much knowledge and clinical experience, or underestimates the capability of learners. What bores or insults one group may totally overwhelm another. And sometimes the relevant gradations are measured not in years but in months or, in some cases, even days.

Showing respect for learners makes them want to work harder by paying attention and striving to do well. When learners see that instructors take seriously what they already know, they will do so as well. If learners think that instructors are fiercely on the lookout for every mistake so that we can pounce on it and humiliate them, they are likely to become more and more reticent about asking questions and offering insights. On the other hand, if they sense that identifying and redressing lacunae in their understanding is regarded as an important opportunity, then they are likely to develop into more self-critical and self-directed learners. Sometimes the best response to a learner's question is not the answer, but another question. What learners do not know is not an empty chasm that we must close. Instead, it is fertile soil on which to sow the seeds of additional learning. It is an opportunity for educators to do what we do best—to teach. More importantly, it is also an opportunity to help learners achieve one of their greatest missions, namely, to become more effective learners.

When we work with learners, we want them to understand that we are not merely talking at them, but conversing with them. Our primary mission is not to make ourselves feel more important or advance our careers. We are not showing off how much we know. Rather,we are attempting to help learners learn what they most need to know. Therefore, the most important person in the classroom is not the teacher, but the student. We need to think less about our own performance and more about the performance of learners. Are we challenging them in meaningful ways, not merely to stay awake or to write down everything we are saying,but to think critically and creatively, and to solve problems? When we evaluate students, we need to look beyond mere selection and sorting of students, and focus instead on evaluation as a formative opportunity. Does our evaluation fan the flames of their motivation and help them do a better job of learning? The goal is not to pass some examination, but to become a fine physician.

One thing we know about the maturation of learners is that the more mature we become, the more intrinsically motivated we tend to become. In other words, our learning becomes more and more motivated by our own needs and interests, rather than outside requirements. Grades can become a self-defeating reward system, if they keep us focused on external as opposed to internal motivations and rewards for learning. We must prepare learners for a professional career in which they will no longer receive grades at the end of every term, and when they will have to decide for themselves what to learn and whether they are doing a good job of learning it.

What motivates mature learners? In large part it is pure curiosity, the desire to understand something for its own sake. Another important motivator is the questions that arise during daily practice. Another is the opportunity to help a patient. In these situations, people are trying to learn not because someone tells them they must, or because they want to impress someone else, but because the knowledge itself is important to them. These intrinsic motivators have at their core curiosity and the desire to excel at our craft. Are we becoming the physicians to whom colleagues will turn when they have questions?

The purpose in highlighting learner-centered education is not to suggest that we should be designing individualized and unique curricula for every learner. However, it is possible for many of us to employ a richer and more varied educational approach. Different learners learn best in different contexts and by different approaches, and we can help our learners discover what works best for them by presenting them with different possibilities and encouraging them to reflect on their learning experiences. Some do best learning alone and others in small groups. Some do best reading the material, and others do best when they hear it. Electronic educational media offer additional opportunities to interact with the material in varied ways. Learners are, after all, human beings, and no two are exactly alike. If we treat them as though they were simply carbon copies of a single learner, then we will be doing both them and ourselves a disservice.

On the other hand, if we understand and respect learners, we can help them become more effective and better prepare them for a life of learning. When we do so, they are likely to learn more, and to think more highly of their educational program and their instructors. Such learners can offer us more effective criticism of their learning experiences, and help us improve our programs even more. They are also more rewarding to work with, and thereby help us to remain more actively engaged and committed as educators. Finally, some of them will be better prepared to join the ranks of academic medicine, and help to meet the need for first-rate medical educators in the future. One of the best preparations for teaching is to learn with good teachers. By reorienting our focus to the learners, we enhance the overall quality of medical education and practice.

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