Medical school

Medical students are skipping class in droves — and making lectures increasingly obsolete

By Orly Nadell Farber 

The future doctors of America cut class. Not to gossip in the bathroom or flirt behind the bleachers. They skip to learn — at twice the speed.

Some medical students follow along with class remotely, watching sped-up recordings of their professors at home, in their pajamas. Others rarely tune in. At one school, attendance is so bad that a Nobel laureate recently lectured to mostly empty seats.

Nationally, nearly one-quarter of second-year medical students reported last year that they “almost never” attended class during their first two, preclinical years, a 5 percent increase from 2015.

The AWOL students highlight increasing dissatisfaction and anxiety that there’s a mismatch between what they’re taught in class during those years and what they’re expected to know — or how they’re tested — on national licensing exams. Despite paying nearly $60,000 a year in tuition, medical students are turning to unsanctioned online resources to prepare for Step 1, the make-or-break test typically taken at the end of the preclinical years.

These self-guided med students are akin to a group of American tourists wandering through Tokyo without a map. Like a tour guide hired on the street, the online learning tools — including memory aids, videos, and online quizzes — can enhance the educational journey, or send the students down a dead end.

Lawrence Wang, a third-year M.D.-Ph.D. student at the University of California, San Diego, and the National Institutes of Health, said he relied heavily on these resources during his first two years of medical school.

“There were times that I didn’t go to a single class, and then I’d get to the actual exam and it would be my first time seeing the professor,” he said. “Especially, when Step was coming up, I pretty much completely focused on studying outside materials.”

Wang isn’t alone. According to 2017 data from the Association for American Medical Colleges, 1 in 4 preclinical students watches educational videos — like those on YouTube — on a daily basis. And according to two video developers, tens of thousands of medical students subscribe to their products — one of which costs $250 for two years, the other $370 for one year.

Leaders in medical education have begun to scramble. Some medical schools, like Harvard, have done away with lectures for the most part. Instead of spending hours in an auditorium, Harvard students learn the course content at home and then apply the knowledge in mandatory small group sessions.

Other institutions, like Johns Hopkins, are moving in the same direction, but have yet to make a full switch. Hopkins cut down on lectures and boosted sessions that require active student participation. Preclinical lecture attendance hovers around 30 to 40 percent, according to Dr. Nancy Hueppchen, associate dean for curriculum.

For many students, she said, licensing exam prep begins on day one of medical school: “They have this parallel curriculum going along with what we’re teaching them.”

Step 1, an eight-hour multiple choice test, is a big deal. Performance on the exam, though it’s taken before most students even begin training in a hospital, heavily influences which medical specialties they can eventually pursue after school and at what hospitals they can pursue them.

With medical schools grading pass-fail, the Step 1 score is an increasingly significant piece of information that’s used to sort through residency applications, Hueppchen said. When she took the exam, it was only used as a pass-fail test. Today, residency programs rely on the score more heavily; students and faculty suspect that it’s used as a cutoff for making admissions decisions.

Ryan Carlson, a third-year M.D.-Ph.D. student at the University of Washington, said that his school focused on teaching “what they thought was important for a physician to know.” But medical students have to know more than what is relevant to a practicing clinician to succeed on Step. The exam focuses on rare diseases and other minutiae, said Carlson, who now tutors for the test.

Hueppchen acknowledged that students at Hopkins and elsewhere “express some distrust that they’re getting everything they need — or that we’re being meticulous in pointing out what they need — to study for and excel on the Step 1 exam.”

SketchyMedical produces visual memory aids with elaborate illustrations, like this one of the major drugs targeting the sympathetic nervous system. Stephen Wang at SketchyMedical

 

The medical tour guides

That distrust has spawned a cottage industry of online study aids. Most are a far cry from your high school SAT prep course.

SketchyMedical is one of the most popular guides. The company, built in 2013 by three then-medical students at the University of California, Irvine, produces visual memory aids with elaborate illustrations to help students learn and retain the voluminous material they’re expected to know.

Dr. Andrew Berg and his co-founders, Drs. Saud Siddiqui and Bryan Lemieux, started sketching pictures and pairing them with stories while taking microbiology in their second year of medical school.

“We were just bombarded with different names of bacteria, viruses, and fungi, and we were having a tough time keeping them all straight,” he said.

The sketches helped them, and now other students are using them, too.

Imagine it’s test day and a med student is asked which drug she would use to treat a patient’s postoperative gastrointestinal blockage. The student closes her eyes and mentally enters the world of “Acetyl-Cola,” a bustling port town that’s depicted in one of SketchyMedical’s cartoons. Outside a storefront, the student finds construction workers, motorcyclists wearing brain-shaped helmets, piles of dripping-wet fish, and a man sporting an adrenal gland-shaped beanie.

A colon-shaped mixing truck pouring out cement is an unfortunate, but effective, symbol for defecation, and a worker wearing a name tag reading “Beth” and drinking a cola reminds the student of the drug bethanechol, given to treat intestinal obstructions.

The illustrations are turned into narrated videos, which teach drug names and their mechanisms and side effects. SketchyMedical has also produced videos on microbiology and pathology.

Berg compares the work of Sketchy to hieroglyphics in ancient Egypt. But for many, Sketchy evokes a different technique used a thousand years later in ancient Greece: method of loci, also called a memory palace or journey.

Memory palaces are typically imagined spaces in which a person can store information like a string of numbers or a series of words. Each piece of information is placed somewhere inside the palace. When the palace builder wants to recall an item, she can take a mental stroll through the space to retrieve it. This technique famously enabled Cicero, the Roman statesman and philosopher, to commit his speeches to memory.

“We accidentally stumbled upon these visual learning techniques, but now looking back we see there’s a lot of evidence supporting visual learning,” Berg said.

“That was the biggest learning curve of med school — it wasn’t so much how do I do well in it, it was, how do I use all these crazy resources that are being marketed to me to best meet my goal of passing Step.”

Ryan Carlson, third-year M.D.-Ph.D. student at the University of Washington

SketchyMedical is not the only extracurricular resource students rely on. An entire industry cropped up in the last few years, marketing videos and self-quizzing features to preclinical students. Dr. Jason Ryan, the creator of Boards and Beyond, is a name (and voice) familiar to medical students across the country.

Ryan, a faculty member at University of Connecticut School of Medicine, creates explanatory videos that track along with the content in First Aid, a Step preparatory book that Ryan said is more like “an encyclopedia of terms” than a real study aid. Ask any medical student if they use First Aid, and they’ll point you to their heavily annotated, tattered copy.

While both Ryan and Berg consider their products supplements to regular medical education, many students view them as necessary investments for success. Choosing which ones to use can be a challenge, however.

“That was the biggest learning curve of med school — it wasn’t so much how do I do well in it, it was, how do I use all these crazy resources that are being marketed to me to best meet my goal of passing Step,” Carlson said.

 

The old players react

This expanding corner of the medical education industry is both a product of a new attitude among students — born from anxiety surrounding exam prep — and a disrupter of the traditional classroom education. Med schools now have to think more creatively about how they train their future doctors, Berg said.

In 2015, Harvard Medical School revamped its curriculum for the first two years to enable clinical exposure and boost class attendance with a flipped-classroom model: Students learn the content at home, and then apply it during in-class exercises. Dr. Richard Schwartzstein, director of education scholarship, said the program now emphasizes problem-solving and critical thinking — skills seen as essential to practicing medicine — instead of factual recall.

But while medical schools are de-emphasizing pure memorization, the national licensing exams have yet to reconsider, he acknowledged. Still, Schwartzstein is not a huge fan of external resources, citing their focus on memorization and pattern recognition as major weaknesses.

“You don’t have to actually teach pattern recognition,” he said. “We all are born with the capability of recognizing pattern.” He advises students to stick to Harvard-developed videos and their recommended readings. Like many medical schools, Harvard gives students a dedicated study period — six to eight weeks without coursework — to “prepare in whatever way they deem most appropriate to take the boards,” he said.

Hueppchen said that the outside resources “may have value in day-to-day studying, they may have value in studying for Step 1,” but Hopkins has not vetted them so it doesn’t recommend them to students either.

The National Board of Medical Examiners, which works with state medical boards to set the minimum standards for medical licensing and administers the Step exam, also doesn’t endorse these products — or their use as hard lines for residency admissions, said Dr. Michael Barone, vice president of licensure programs. The group “is aware of some secondary uses of scores,” he said, but the test’s primary purpose is to report licensure alone.

So long as Step still requires intensive rote memorization, companies like SketchyMedical and Boards and Beyond will likely remain in business.

Both Berg and Ryan agree that physicians no longer need to memorize as much as they did in the past. Ryan’s grandmother was one of the first female physicians to graduate from her medical school in the 1940s. Back then, he said, she had to remember everything. “If she had to go to a book every time she saw a patient, she’d never be able to work through the day.”

Today, there’s much more to know, and medicine is evolving so rapidly — with new drugs, guidelines, and practices — that physicians can’t possibly remember it all. Instead, they look information up on their cellphones, using a variety of apps on the clinic floors. But preclinical students still need to commit board-tested material to memory, a task often compared to drinking from a firehose.

Needing to memorize for boards and learn in parallel for their institutions is the breeding ground for anxiety that Hueppchen said “has truly detracted from the joy of learning.” It has even detracted from the joy of teaching, she added.

Berg said he tries to bring joy to memorization: “I think that what I hope to contribute the most is making studying more fun.”

Andragogy vs. Pedagogy

 Selected Moments of the 20th Century

A work in progress edited by Daniel Schugurensky Department of Adult Education, Community Development and Counselling Psychology, The Ontario Institute for Studies in Education of the University of Toronto (OISE/UT)

 Malcolm Knowles publishes The Modern Practice of Adult Education: Andragogy vs. Pedagogy

Although the term andragogy has been in use since 1833, it was Malcolm S. Knowles, who in his 1970 book, The Modern Practice of Adult Education: Andragogy vs. Pedagogy, first popularized the term in North America and organized the concepts into a comprehensive theory. Knowles devised a set of four assumptions that differentiated adults from children as learners. Knowles' four assumptions necessitated an entirely new approach to teaching adults and were hailed as groundbreaking in the field of adult education at the time. The four assumptions are self-concept, experience, readiness to learn and orientation to learning (Knowles, 1970, p.39). This essay will examine how different or new Knowles' theory of andragogy was compared to the progressive education theorists such as John Dewey, Maria Montessori and Alexander Neill. The progressive education theorists were influential in the early part of the twentieth century, long before Knowles, but their ideas centered on children rather than adults. Comparing and contrasting Knowles' four main andragogical assumptions with the ideas of Dewey, Montessori and Neill reveals the extent to which andragogy contributed new approaches to the field of adult education. An in-depth comparison of Knowles' andragogy with the progressive education theorists also reveals the extent to which Knowles' theory is specific to adults. In the end, Knowles' ideas did not offer anything new to the field of adult education nor did they contribute useful information as to how adults learn differently than children. Knowles is often closely associated with andragogy, but in fact, it originated much earlier. Alexander Kapp, a German grammar school teacher, first introduced the term andragogy in Germany in 1833, but it referred broadly to adults as learners rather than to any specific style of learning (Draper, 1998). Pedagogy was the common term used for teaching at the time. Pedagogy means "the science or art of teaching" and a direct translation of the term from the Greek root of "peda" means a "boy" or "child"(Selman et. al, 1998, p.19). Andragogy, as a term, was developed in reaction to pedagogy in order to move away from its close association with children. Andragogy means "the science or art of teaching adults" because the Greek root of "andra" means adults (p.19). Knowles, however, was the first to develop the ideas of andragogy into a detailed strategy for teaching adults and to popularize the term in North America (Draper, 1998). Knowles felt that pedagogy was "based on a now obsolete premise - that is, the idea that the purpose of education is to transmit culture" (Draper, 1998, p.14).

Knowles believed that an andragogical approach to teaching adults was vitally important in order to take the adult's learning needs into account and to "teach adults how to learn" (Knowles, 1970, p.39). The transmissional modes of pedagogy were not considered as sufficient in enabling adults to deal with the rapid change going on in our society. The result of the "timespan of major cultural change" changing more than once in one's lifetime called for a new and more successful approach to adult learning (p.39). Knowles' felt this development necessitated a new approach to learning based on a more accurate set of assumptions of adults as learners. The four assumptions Knowles uses to distinguish adults from children as learners produced a split between andragogy and pedagogy. The self-concept principle reflects the self-directing character of the adult learner rather than dependent nature of the child. The principle of experience simply acknowledges the need to draw on the adult's rich source of experience. In contrast, the pedagogical framework perceives the child as not possessing sufficient life experience to effectively incorporate into the learning environment. Readiness to learn indicates that adults differ from children in their developmental stage and as a result have special learning needs. The assumption implies that adult learning needs tend to focus more towards their social roles. On the other hand, pedagogy claims that the learning needs of children are geared towards physiological and mental development stages. Orientation to learning assumes that adults put more value on being able to practically apply their learning while pedagogy suggests that children naturally focus on postponing immediate application for future needs. These four sets of assumptions establish significant guidelines for creating adult learning environments (Knowles, 1970, p.39). The concept that learning can be made more effective by taking advantage of the innate ability of learners to be self-directed did not originate from Knowles' theory of andragogy in 1970. Montessori, Dewey and Neill had all proclaimed the advantages of recognizing the self-directing capacity of learners and focused their attention on children as learners. Their arguments seriously undermine one of the key assumptions of andragogy; the assumption that adults are more self-directed than are children. Montessori felt that learners were predominantly self-motivated and that they generally learned by themselves (Montessori, 1955). She also acknowledged that the teacher only played a small part in the learner's overall environment (Montessori, 1955). Dewey felt it was important that the educator did not impose a direction on the student, but acted as more of a guide and an assistant (Dewey, The Child and the Curriculum, 1902). Montessori argued that, because of old prejudices, adults fail to recognize the self-directing capacity of children (Montessori, 1955). The oppressive and controlling habits of traditional education prevent adults from observing the child as an individual. Neill also believed strongly in the self-directing capacity of the child. In his experimental Summerhill School in the 1920s, Neill went so far as allowing children to choose whether to attend school (Neill, 1962). Therefore, the progressive education theorists believed that both children and adults are innately self-directing, but that it is our societal prejudices that prevent us from tapping into the self-directing nature of the child. The perception that an adult's experience should be made a central part of the learning process did not derive from Knowles. The progressive education theorists were far ahead of Knowles in developing thoughts on recognizing the learner's experience. Their work also supports the claim that the child's experience is equal to that of an adult's. John Dewey, in particular, was of the opinion that for learning to be effective it needs to be based on the learner's experience (Dewey, 1902). Dewey maintained that learning is merely symbolic if there is no relation to learning and a person's experience. Dewey criticized the tendency of "old education" to ignore the child's experience and to compare the child as immature in comparison to the adult (Dewey, 1902, p.12). Montessori's opinions support Dewey. Montessori argued that "we form a barrier not paying attention to the inner power of the child or what they can teach us" (Montessori, 1955, p.47). A comparison of Knowles' third assumption with the ideas of the progressive education theorists makes it clear that Knowles did not come up with anything original. The progressive education theorists do not specifically focus on the concept of readiness to learn in the same manner as Knowles, but an overview of their writings reveals the similarity of their thoughts on the subject. In Neill's Summerhill School, for instance, some classes were organized according to age, but others according to interests (Neill, 1962). It is logical to agree with Knowles that adults differ from children in their developmental stage, but this does not necessarily entail that adults require a different approach to teaching. The concept that learners learn best when they are able to apply learning did not begin with Knowles. Montessori and Dewey advocated the need for practical application of learning long before Knowles and again focused their thoughts on children as learners. Dewey felt that "the divorce between learning and its use is the most serious defect of our existing education. Without the consciousness of application, learning has no motive to the child." (Dewey, 1966a, p.73) Naturally, the same principles can be extended to all learners regardless of age. Neill also claimed that education should involve real doing (Neill, 1962). Dewey strongly believed that the educational system needed to better represent life. He also criticized the preoccupation with subject centered learning in "old education". He felt that the constant state of change in our society rendered much of subject centered learning obsolete (Dewey, 1966b). Curiously, his ideas of preparing people to deal more effectively with a continuously changing world is similar to Knowles' theory of "helping people to grow in their ability to learn" (Knowles, 1970, p. 34). Dewey thought that the prevalent thinking that adults are more suited to practical application than children reflects the beliefs of the "old education" system more than the actual needs of the learners. According to Dewey the child learner would be perfectly content to apply their learning to specific problems (Dewey, 1966b). We can easily conclude that age is no longer an adequate means of distinguishing andragogical from pedagogical assumptions. Many theorists, including Knowles in his later writings, argue that new definitions are needed to erase some of the confusion in the debate. The most common opinion, now held by Knowles among others, is to portray andragogy as self-directed learning and pedagogy as teacher directed learning (Rachal, 1983). This new and more accurate distinction brings us right back to the progressive education theorists. It was the progressive education theorists who first came up with the idea of distinguishing between progressive education and traditional education. In summary, their idea of progressive education represented self-directed learning and traditional education represented teacher-directed learning. We cannot ignore the impact of Knowles' theory on the field of education, but we can benefit from ignoring the confusion it created and focus on the ideas put forth by the progressive education theorists. UNESCO echoes a similar sentiment and now discourages use of the term andragogy (Draper, 1998). Comparing Knowles' andragogy with the ideas of the progressive education theorists also makes it clear that the main assumptions of andragogy are not specific to adults and that andragogy as a theory explaining adult learning did not contribute anything new to the field of adult education. 

Sources:

Dewey John. (1902). The Child and the Curriculum. Chicago: University of Chicago Press.

Dewey, John. (1966a). "The Dewey School." Dewey's Educational Writings. Ed. by F.W. Garforth. London: Heinemann.

Dewey, John. (1966b). "My Pedagogic Creed". Dewey's Educational Writings. Ed. by F.W. Garforth. London: Heinemann.

Draper, James. (1998). "The Metamorphoses of Andragogy". Canadian Journal of Studies in Adult Education. Vol. 12 (1), May.

Knowles, Malcolm S. (1980) The Modern Practice of Adult Education. Revised and Updated. Englewood Cliffs: Prentice Hall Regents.

Knowles, Malcolm S. (1970). The Modern Practice of Adult Education: Andragogy Versus Pedagogy. New York: Association Press.

Montessori, Maria. (1955). Childhood Education. Translated by Joosten A.M., Chicago: Henry Regnery Co.

Neill, Alexander. (1962). Summerhill. Middlesex: Penguin Books.

Rachal, John. (1983). "The Andragogy - Pedagogy Debate: Another Voice in the Fray". Lifelong Learning: The Adult Years. Vol.6 (9), May.

Prepared by Jay Friedman (OISE/UT)

Preceptoria de Residência Médica

Projeto Desenvolvimento de Competências Pedagógicas para Prática Preceptoria na Residência Médica

Problem-based Learning

Problem-Based Learning: Six Steps to Design, Implement, and Assess

By: Vincent R. Genareo, PhD, and Renee Lyons

Twenty-first century skills necessitate the implementation of instruction that allows students to apply course content, take ownership of their learning, use technology meaningfully, and collaborate. Problem-Based Learning (PBL) is one pedagogical approach that might fit in your teaching toolbox.

PBL is a student-centered, inquiry-based instructional model in which learners engage with an authentic, ill-structured problem that requires further research (Jonassen & Hung, 2008). Students identify gaps in their knowledge, conduct research, and apply their learning to develop solutions and present their findings (Barrows, 1996). Through collaboration and inquiry, students can cultivate problem solving (Norman & Schmidt, 1992), metacognitive skills (Gijbels et al., 2005), engagement in learning (Dochy et al., 2003), and intrinsic motivation. Despite PBL’s potential benefits, many instructors lack the confidence or knowledge to utilize it (Ertmer & Simons, 2006; Onyon, 2005). By breaking down the PBL cycle into six steps, you can begin to design, implement, and assess PBL in your own courses.

Step One: Identify Outcomes/Assessments

PBL fits best with process-oriented course outcomes such as collaboration, research, and problem solving. It can help students acquire content or conceptual knowledge, or develop disciplinary habits such as writing or communication. After determining whether your course has learning outcomes that fit with PBL, you will develop formative and summative assessments to measure student learning. Group contracts, self/peer-evaluation forms, learning reflections, writing samples, and rubrics are potential PBL assessments.

Step Two: Design the Scenario

Next you design the PBL scenario with an embedded problem that will emerge through student brainstorming. Think of a real, complex issue related to your course content. It’s seldom difficult to identify lots of problems in our fields; the key is writing a scenario for our students that will elicit the types of thinking, discussion, research, and learning that need to take place to meet the learning outcomes. Scenarios should be motivating, interesting, and generate good discussion. Check out the websites below for examples of PBL problems and scenarios.

Step Three: Introduce PBL

If PBL is new to your students, you can practice with an “easy problem,” such as a scenario about long lines in the dining hall. After grouping students and allowing time to engage in an abbreviated version of PBL, introduce the assignment expectations, rubrics, and timelines. Then let groups read through the scenario(s). You might develop a single scenario and let each group tackle it in their own way, or you could design multiple scenarios addressing a unique problem for each group to discuss and research.

Step Four: Research

PBL research begins with small-group brainstorming sessions where students define the problem and determine what they know about the problem (background knowledge), what they need to learn more about (topics to research), and where they need to look to find data (databases, interviews, etc.). Groups should write the problem as a statement or research question. They will likely need assistance. Think about your own research: without good research questions, the process can be unguided or far too specific. Students should decide upon group roles and assign responsibility for researching topics necessary for them to fully understand their problems. Students then develop an initial hypothesis to “test” as they research a solution. Remember: research questions and hypotheses can change after students find information disconfirming their initial beliefs. 

Step Five: Product Performance

After researching, the students create products and presentations that synthesize their research, solutions, and learning. The format of the summative assessment is completely up to you. We treat this step like a research fair. Students find resources to develop background knowledge that informs their understanding, and then they collaboratively present their findings, including one or more viable solutions, as research posters to the class.

Step Six: Assessment

During the PBL assessment step, evaluate the groups’ products and performances. Use rubrics to determine whether students have clearly communicated the problem, background, research methods, solutions (feasible and research-based), and resources, and to decide whether all group members participated meaningfully. You should consider having your students fill out reflections about their learning (including what they’ve learned about the content and the research process) every day, and at the conclusion of the process. 

Although we presented PBL as steps, it really functions cyclically. For example, you might teach an economics course and develop a scenario about crowded campus sidewalks. After the groups have read the scenario, they develop initial hypotheses about why the sidewalks are crowded and how to solve the problem. If one group believes they are crowded because they are too narrow and the solution is widening the sidewalks, their subsequent research on the economic and environmental impacts might inform them that sidewalk widening isn’t feasible. They should jump back to step four, discuss another hypothesis, and begin a different research path.

This type of process-oriented, self-directed, and collaborative pedagogical strategy can prepare our students for successful post-undergraduate careers. Is it time to put PBL to work in your courses?

References
 

Barrows, H.S. (1996). Problem-based learning in medicine and beyond: A brief overview. In L. Wilkerson, & W. H. Gijselaers (Eds.), New directions for teaching and learning, No.68 (pp. 3-11). San Francisco: Jossey-Bass.

Dochy, F., Segers, M., Van den Bossche, P., & Gijbels, D. (2003). Effects of problem-based learning: A meta-analysis. Learning and instruction, 13(5), 533-568.

Ertmer, P. A., & Simons, K. D. (2006). Jumping the PBL implementation hurdle: Supporting the efforts of K–12 teachers. Interdisciplinary Journal of Problem-based Learning, 1(1), 5.

Gijbels, D., Dochy, F., Van den Bossche, P., & Segers, M. (2005). Effects of problem-based learning: A meta-analysis from the angle of assessment. Review of Educational Research, 75(1), 27-61.

Jonassen, D. H., & Hung, W. (2008). All problems are not equal: Implications for problem-based learning. Interdisciplinary Journal of Problem-Based Learning, 2(2), 4.

Norman, G. R., & Schmidt, H. G. (1992). The psychological basis of problem-based learning: A review of the evidence. Academic Medicine, 67(9), 557-565.

Onyon, C. (2012). Problem-based learning: A review of the educational and psychological theory. The Clinical Teacher, 9(1), 22-26.

Vincent R. Genareo is a postdoctoral research associate at Iowa State University, Research Institute for Studies of Education (RISE). Renee Lyons is a PhD candidate at Clemson University, Department of Education.