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Introduction
“What I hear, I forget;
What I see, I remember;
What I do, I understand.”
– Old Chinese proverb
More recently this truism has been quantified by Dale (1969) as shown in Table
1. Given that interactive teaching, where both the instructor and
student are actively (and equally) involved in the learning process, is
overwhelmingly more successful than lecturing, one wonders why
physician/teachers devote so much time and energy to preparing and giving the
“perfect lecture.” Table 1. Learning Recall
Related to Type of Presentation
| Type of
Presentation |
Ability
to Recall |
| after 3 hours |
after 3 days |
| Verbal (one-way) lecture |
25% |
10-20% |
| Written (reading) |
72% |
10% |
| Visual and verbal (illustrated
lecture) |
80% |
65% |
| Participatory (role plays, case
studies, practice) |
90% |
70% |
Adapted from: Dale 1969.
Perhaps it’s because most medical faculty
have no formal teacher training. As a consequence,
many of us—myself included for many years—spend
most of our academic careers wondering why
students don’t pay more attention to our profound
utterances if they want to have more knowledge. Or
why behind our backs they often refer to us as
pedantic bores.
As a method for providing information and knowledge,
lecturing has dominated formal education over
the centuries. It has been used for large groups to
convey a lot of content in a short time, keep the
group together on the same points and control time.
Perhaps its biggest advantage is that, in the hands of an
enthusiastic teacher steeped in the subject, it can be
an effective vehicle to impart and infuse learners with
a spirit and vision and love for the subject. Careful
observation, however, shows that lecturing frequently
is without accompanying discussion, questioning or
immediate practice and, even when followed by
testing, is one-way communication and a poor
learning method.
Similarly, one wonders why so many physician/
teachers are tyrants in the operating theater, creating
high-stress situations by using fear in the mistaken
belief that it is an effective learning tool. Clearly, we
must be wearing blinders since all around us effective
learning is taking place without stress or fear being
used. Is learning surgical procedures so much more
difficult than being a skilled tennis player? I think not,
because I learned both. Even reconstructive tubal
microsurgery requires no finer skills than hitting a
topspin backhand. Moreover, learning to hit that
perfect backhand stroke, patiently guided by a coach
who continually gave me constructive feedback,
reassurance and support, was infinitely more pleasant
than being terrified as a resident doctor that I would
make a mistake in the OT when operating with the
“great professor.”
Medical schools around the world traditionally have
avoided examining the way faculty members teach
and why their prevailing practices are faulty. Few
institutions provide substantial, ongoing teacher
training to any faculty members. Those that do make
it clear that teaching is secondary to research and a
host of other activities. Far too often faculty lecture to
their students, believing that their primary role as
teachers is to “cover the subject.” This notion of
coverage suggests that a certain amount of content
must be presented to students in the allotted time.
Students, kept in a passive role by the lecture format,
are expected to absorb the content for later use. But
since they receive little direct instruction in how to use
the content for higher order cognitive tasks, such as
problem solving, they retain little information. Furthermore,
even in classes designed for discussion,
teachers do most of the talking.
If medical education (and this applies to higher
education in general) is to change, faculty members
must be genuinely interested in teaching and they
must be trained in interactive methods. Medical
schools must encourage and support faculty teachers
in adopting teaching practices that actively involve
students on a daily basis. According to Bejaj (1989),
to accomplish this will require development of a new
approach to undergraduate medical education in
which learning activities would be directed towards:
- shifting emphasis from use of teacher-oriented to
learner-oriented methods, including self-paced
learning and assessment (written or using an audio-,
video- or computer-based format);
- changing from narrow, discipline-oriented teaching
to a problem-solving approach;
- moving from lecture-oriented (one-way) teaching
to experiential, interactive learning; and
- changing the medical teachers’ role from the
lecturer who transfers a defined body of knowledge
to that of a facilitator or coach of student
learning.
Before any meaningful change in teaching can take
place, however, medical school faculty must fully
realize the importance of objectively measuring
student performance. In the absence of carefully
designed assessment instruments or any other
verifiable definition of student proficiency, any claims
of effectiveness amount to mere assertion. For
example, at a recent seminar on distance learning, the
chair of the academic standards committee of a
prominent health professional school was asked the
question, “How do you assess the quality of your
teaching?” Without hesitation he responded, “We
don’t have to because our faculty is the best.” In the
coming years, academic excellence will be defined
increasingly in measurable, quantifiable terms, not just
by reputation of the school or a high tuition.
At present, medical schools throughout the world still
have no comprehensive means of assessing students
other than through grades, which are notoriously
poor indicators of student ability. Grades also constitute
a built-in conflict of interest because the person
who does the teaching also assigns the grades.
Moreover, even within academic departments, faculty
seldom have tried to create uniform grading standards
for the same course. As a consequence, faculty
grading often varies widely. To correct these problems,
medical school faculty must begin to specify in behavioral terms what it is they expect their graduates
to know and be able to do and how well they expect
them to do it. Without such standards, it is not
possible to develop reliable and valid assessment
measures.
For the past several years JHPIEGO has been developing
a more effective approach to both classroom
(didactic) and clinical training. It is based on the
assumption that all students at the undergraduate and
graduate levels can master the required knowledge,
attitudes and skills provided sufficient time and
appropriate learning methods are used. This approach
focuses on learning by seeing and doing rather
than by preaching and scolding. Moreover, it is an
approach with which medical faculty can be comfortable
and which does not require learning to become
an “educator” or mastering educational jargon
(McIntosh 1992).
The goal of mastery learning is that 100% of those
being trained will learn the essential knowledge and
skills on which the training is based. While some
students are able to learn new knowledge or a new
skill immediately, others may require additional time
or alternative learning methods before they are able
to demonstrate mastery of the knowledge or skill.
Not only do people vary in their abilities to absorb
new material, but individuals learn best in different
ways—through written, verbal or visual means.
Effective learning strategies take these differences into
account and use a variety of learning methods.
The mastery learning approach enables the student to
have a self-directed learning experience. This is
achieved by having the faculty teacher serve as
facilitator and by changing the concept of testing and
how test results are used. In courses that use
traditional testing methods, teachers administer pre-and
post-tests to document an increase in the
students’ knowledge, often without regard to how this
change affects job performance. The philosophy
underlying the mastery learning approach, however, is
quite different. It is based on continual assessment of
participant learning. To be successful, it is essential that
the instructor regularly inform students of their
progress in learning new information and skills and not
allow this to remain the instructor’s secret.
With the mastery learning approach, a brief precourse
questionnaire is used to determine what the students,
individually and as a group, know about the course
content. This allows the faculty trainer to identify
topics which may need additional emphasis, or in
many cases, require less classroom time during the
course. Providing the results of the precourse
assessment to students enables them to focus on their
individual learning needs. Subsequent testing is
designed to assess the students’ progress in learning
new information. Again, results of this assessment are
reviewed with students.
With the mastery learning approach, assessment is:
- Competency-based, which means the
assessment is keyed to the course objectives and
emphasizes acquiring the essential knowledge and
attitudinal concepts needed to perform a job, not
just acquiring new knowledge.
- Dynamic, because it enables faculty to provide
their students with continual feedback on how
successful they are in meeting the course objectives.
(Teachers using pre- and post-tests often do
not review the correct answers with the participants.
As a consequence, students may leave the
course not knowing important information.)
- Less stressful, because from the outset students,
both individually and as a group, know what they are
expected to learn, where to find the information and
have ample opportunity to discuss it with the faculty
trainers.
Key Features
The key features of the mastery learning approach are
that it:
- is based on social learning theory and behavior
modification (modeling),
- incorporates adult learning principles,
- uses what we have come to call the “humanistic”
training method, and
- is competency-based.
What does social learning theory tell us that will help
us become better teachers and surgeons? In its most
basic terms, it states something we all know but
actively, it seems, try hard to forget—that modeling
(imitating) the behavior of others is the way we all
learn from day one. Recently, I spent a pleasant 10
minutes watching my 5-year-old daughter “teach” a
friend how to ride a bicycle. Verbal communication
was limited to laughter, squeals of delight when her
friend did the right thing and the frequently repeated
phrases, “Let me show you” or “It’s easy.” There
were no lectures on centrifugal force, and how it
keeps rotating bodies such as a bicycle with its
spinning wheels from changing its vertical position (i.e.,
falling over). In no time at all, however, both were
equally skilled in riding the bicycle, and their attention
then turned to sharing one bicycle—an activity with
which 5-year-olds (and some adults) still have great
difficulty.
In 1981 Zemke and Zemke stated this social learning
theory more formally, “...when conditions are right,
we learn most rapidly and effectively from [exposure
to] someone [correctly or proficiently] performing the
desired behavior.” Whether it’s surgery or tennis,
seeing and working with someone who performs the
skill proficiently is worth a thousand words. But what
does “performs the skill proficiently” mean? In the
USA we have a saying about someone who is a good
surgeon—“S/he has good hands.” What is meant by
this is that the surgeon seems to operate effortlessly,
smoothly and with every move so purposeful that s/
he appears to be operating very fast. Moreover,
because each move is well-planned, assisting a good
surgeon is easy for both the assistant and the scrub
nurse.
Analyzing how the skilled surgeon, the one with good
hands, differs from the surgeon who struggles through
each case usually reveals that the former:
- has a standard, well thought out method for
performing the procedure, changing her/his
approach only when the anatomy or pathology
dictates; and
- has practiced (and refined) this standard approach
repeatedly until s/he is unconsciously competent.
This then is a working definition of “performs the skill
proficiently.”
For faculty members (or surgeons with “good hands”)
who aspire to be good clinical trainers, the critical
steps involve learning how to transfer their knowledge
and skills effectively. To do this requires learning how
to facilitate three processes:
- creating a comfortable atmosphere for learning;
- helping the student remember the key steps in the
desired behavior; and
- translating the desired behavior into skilled
performance.
Being able to facilitate these processes will allow the
student to go from being consciously incompetent to
becoming unconsciously competent (Howell 1982).
To successfully do this, the instructor, now trainer,
needs to be familiar with how adults learn—the
second component of our approach to learning.
Adult learners—and medical students qualify as such—
desire that learning be:
- relevant;
- task-oriented;
- participatory (two-way communication);
- friendly (controlled stress, positive feedback);
- varied (demonstrations, case-studies, role play; not
just lectures); and
- built on past experience.
These characteristics are based on the following eight
principles of adult learning (Sullivan et al 1995):
- Learning is most productive when the student is
ready to learn. Although motivation is internal, it is
up to the clinical trainer to create a climate that will
nurture motivation.
- Learning is most effective when it builds on what
the student already knows or has experienced.
- Learning is most effective when students are
aware of what they need to learn.
- Learning is made easier by using a variety of
training methods and techniques.
- Opportunities to practice skills initially in controlled
or simulated situations (e.g., through role play or
use of anatomic models) are essential for skill
acquisition and for development of skill competency.
- Repetition is necessary to become competent or
proficient in a skill.
- The more realistic the learning situation, the more
effective the learning.
- To be effective, feedback should be immediate,
positive and nonjudgmental.
As mentioned earlier, the teaching model with which
most health professionals are familiar is the classroom
instructor lecturing to a group of students who
anxiously take notes so that they can pass a written
examination. This approach to teaching, used by a
skilled instructor, can be effective in providing basic
knowledge. It is, however, a very poor way of
imparting clinical skills such as inserting an IUD,
strengthening problem-solving skills or changing
attitudes towards clinical practice. For example, as
shown in Table 2, only when combined with
demonstration, practice, feedback and especially
coaching, is there significant:
- attainment of the desired skills, and
- successful transfer of the skills to on-the-job
performance (Joyce and Showers 1981).
|
Training Components |
Skills Attained |
Transfer to Job |
Theory
+ |
10-20% |
5-10% |
Demonstration
+ |
30-35% |
5-10% |
Practice
+ |
60-70% |
5-10% |
Feedback
+ |
70-80% |
10-20% |
Coaching
+ |
80-90% |
80-90% |
Adapted from: Joyce and Showers 1981.
The third component of our learning approach
involves using anatomic models and other learning
aids to simulate a real-life situation. Where a clinical
skill, such as inserting an IUD or performing a lumbar
puncture, is involved, this component has come to be
called the humanistic training method (McIntosh 1992).
Medical faculty have used models for demonstration
purposes for many years, but until recently most
medical teachers have been loath to use models for
helping students learn (or practice) the desired
behavior or skill. This reluctance is partly due to the
lack of good models which closely mimic the human
body, or of other learning aids such as interactive
computer-based programs, until the last few years.
For most physicians, however, the reason is more
basic—one that is deeply imbedded in the mistaken
belief that medical or surgical procedures can be
learned only with a patient. Everywhere around us,
however, are examples which contradict this belief—
situations where use of simulators is the norm, not
the exception. For example, for many years commercial
airlines have required that pilots first learn to fly
747s and airbuses in a flight simulator.
The use of more humane teaching methods is an
important factor in improving the quality of skills
training (Delker 1990; Norton 1987). By working
with models (simulators), students can learn (and
repeatedly practice) the steps (and sequence)
required to perform a medical procedure or activity
safely. For example, practicing IUD insertion on a
pelvic model prior to performing the procedure with
a client has many advantages, such as minimizing the
risk of making a learning mistake on a client and
permitting the student to learn the procedure in a
much more relaxed environment. Other important
advantages of learning with models are that their use:
- facilitates skill acquisition and competency (see Table 3);
- decreases the number of cases needed to achieve
skill competency;
- permits clinical skills training to be done in the
classroom and at times when the clinic may not be
open;
- enables training to be done at sites where
caseloads are low; and
- shortens basic training time, thereby making it less
costly.
In using the humanistic training method in IUD
training, for example, two learning activities should
occur before the student attempts to insert an IUD.
First, the essential skills and client interactions should
be demonstrated by the instructor/trainer several
times with the model and other teaching aids (e.g.,
videotape or slide set). Second, the essential skills and
client interactions should be practiced repeatedly by
the student using the pelvic model and actual instruments.
This should be done under supervision and in
a setting which closely simulates the real situation.
Only when skill competency and some degree of skill
proficiency have been demonstrated should the
student have her/his first contact with a client (McIntosh
1992).
| Skills Acquisition |
Knows the steps and their sequence (if necessary) to perform the required skill or activity but
needs assistance |
| Skill Competency |
Knows the steps and their sequence (if necessary) and
can perform the required skill or activity |
| Skill Proficiency |
Knows the steps and their sequence (if necessary) and
efficiently performs the required skill
or activity |
The fourth and final feature of the mastery learning
approach is that it is competency-based. The goal of
clinical training is to help physicians perform their
clinical duties competently. No matter how effective
training is in conveying information, influencing
attitudes and judgment, or stimulating thought, it will
have failed if medical graduates are unable to perform
the tasks assigned to them (McIntosh 1992).
Competency-based training (CBT) is distinctly
different from traditional educational processes
(Sullivan 1995). CBT is learning by seeing and doing.
More traditional forms of instruction, on the other
hand, attempt to educate the student by providing a
broad array of knowledge from which s/he later can
select what is needed, according to the given situation.
Unlike the traditional model, CBT provides
students with those competencies vital to the successful
performance of their jobs. While traditional forms
of training place great value on evaluation of what
information the student has learned, CBT emphasizes
evaluation of how the student performs (i.e., a
combination of knowledge, attitudes and, most
importantly, skills).
To successfully accomplish CBT, the clinical skill or
activity to be taught is first broken down into its
essential steps or units. Each step is then analyzed to
determine the safest and most efficient way to
perform and learn it. This process is called standardization.
Once the procedure has been standardized,
competency-based assessment instruments (learning
guides and checklists) can be developed for use in
training and evaluating trainee performance.
The final steps in the CBT process are:
- identifying medical faculty who are experts in
performing the procedure or activity,
- helping them to learn to proficiently perform the
procedure using the standard approach,
- showing them how to transfer their expert
knowledge and skills effectively to students, and
- assisting them to learn how to use the CBT
learning guides and checklists to assess student
performance.
To date, this learning approach has been applied to a
number of preservice (undergraduate) and inservice
(postgraduate) training situations. For example, in a
recent study conducted in Thailand, a standard (6-
week) IUD training course for nurses was compared
to a 2-week, competency-based course using a
specially designed pelvic model (Ajello et al 1991).
This model closely simulates the female pelvis and can
be used to demonstrate and learn the skills needed to:
- do a complete pelvic exam (speculum, bimanual
and rectovaginal),
- obtain vaginal and/or cervical specimens for
microscopic examination, and
- insert and remove IUDs.
In this study 300 nurses selected for IUD training
were divided into two groups of 150 each—a control
group who attended the standard 6-week course and
a study group who took the 2-week CBT course. The
trainers for the study group were instructed in CBT
techniques while the trainers for the control group
continued to use their traditional training approach. In
addition, a separate group of instructors was trained
to serve as external examiners in order to independently
assess the performance of both groups. The
evaluators used written, competency-based checklists
which had been developed and field-tested prior to
the study. These checklists covered all aspects of IUD
service delivery including initial and method-specific
client counseling, client screening for STDs, medical
assessment, IUD insertion/ removal and followup
care. Limited data also were collected which documented
client, trainee and trainer satisfaction and compared
direct costs.
The results of this study are summarized in the
following tables ( Tables 4–6). As shown in Table 4,
on average, trainees in the study group were judged
to be competent after 1.6 cases whereas the control
group required significantly more cases—6.5.
Table 4. Number of Cases
Needed to Achieve Competency
(N = 150 for both groups)
|
Type of
Training Course | CASES
(Average) | |
Study Group: | Competency-based (2 weeks) | 1.6 | |
Control Group: | Standard
(6 weeks) | 6.5 | | t value = 18.10
(p <.001) |
Moreover, 99% of the study group trainees were
judged to be competent after the fifth client, compared
to only 29% in the control group (Table 5).
Most importantly, 10% of the trainees in the control
group never achieved competence, even after the
sixteenth case (Table 5).
Table 5. Percentage Achieving
Competency by the Nth Client
|
Client
Number | Study Group | Control Group | |
1st | 70% | 0% | |
3rd | 97% | 17% | |
5th | 99% | 29% | |
8th | — | 61% | |
16th | — | 90% |
Finally, direct costs for the 2-week CBT course were
only 54% of those for the standard (6-week) course (Table 6). (Direct costs for the CBT course would
have been even lower if the cost of the models, about
$240 each, could have been dispersed among more
trainees.)
Table 6. Comparison of
Direct Costs by Training Approach
|
Training Approach
|
Per Participant |
Study Group:
Competency-based (2 weeks) |
$383 |
Control Group:
Standard (6 weeks) |
$714 |
The lessons learned from this comparative study are
as follows:
- Both the standard (6-week) and competency-based
(2-week) IUD training courses helped
participants learn the required clinical skills.
- The CBT course:
- led to more rapid achievement of skill
competency,
- increased the proportion of trainees achieving
skill competency,
- provided a humanistic approach to training
which minimized risk to the client,
- diminished training dependency on large
client-acceptor caseloads, and
- was significantly less costly.
- Competency must be assigned on an individual
basis (i.e., there is no magic number of clinical
cases which automatically makes a participant
competent).
- Some trainees may never learn the skills for
providing IUD services unless the training is
competency-based.
- Client satisfaction is much higher when IUD
training uses humanistic methods.
- When the training is based on adult learning
principles and is competency-based:
- Trainee and trainer satisfaction is higher (less
stress with better two-way communication).
- The focus of the trainer shifts from giving a
“great lecture” or designing the “perfect
course” to improving trainee performance.
Despite the positive results of this study, the question
often asked is “Does training really make a difference?”
In this case, the answer is a resounding “yes.” Not
only did the new method improve the quality of
training and shorten training time, but it also led to the
Government of Thailand changing the way IUD
training is conducted. As a consequence, nearly three
times as many nurses can now be trained for about
the same cost as before this study was conducted.
The goal of the mastery learning approach is to equip
medical students and interns with the knowledge and
skills needed to carry out their clinical duties more
safely and efficiently. Since 1990, JHPIEGO has
introduced this learning approach into selected host
country medical schools. To date, it has been well
received by both faculty and students wherever it has
been tried. In addition, when this approach is used,
students learn the essential knowledge and skills in less
time, at less cost and with fewer patients needed for
training purposes.
The mastery learning approach developed by
JHPIEGO is based on four key features. First, it
involves use of behavior modification (modeling) to
facilitate learning a standardized way of performing the
skill or activity. Second, it incorporates use of adult
learning principles, which means it is interactive,
relevant and practical. Moreover, it requires that the
faculty teacher facilitate the learning experience rather
than serve in the more traditional role of an instructor. Third, where possible, it relies heavily on the use of
models and other teaching aids (i.e., it is humanistic)
to enable students to gain confidence in performing
the assigned task or procedure before working with
patients. Fourth, it is competency-based. This means
that the training focuses on how well the student
performs rather than how much has been learned. Finally, this learning approach stresses the importance
of the cost-effective use of limited resources and the
application of relevant educational technologies.
Developing and implementing a learning approach
similar to the one described in this paper requires a
major commitment on the part of medical faculty to
change dramatically the way they view their roles and
teaching responsibilities. To introduce the mastery
learning approach requires that faculty instructors
function as facilitators, trainers and coaches and, most
importantly, that they view their students as partners
in the learning process.
Ajello C et al. November 1991. Field Assessment of a Pelvic Model and Training Package for Use in Conjunction with
IUD Training. Presented at the 119th Annual Meeting of the American Public Health Association: Atlanta, Georgia.
Bejaj JS. 1989. Extracts from National Education Policy in Health Sciences Background Documents, National Workshop
on Medical Education, December 7–9, p. 22. Indian Medical Association: New Delhi, India.
Dale E. 1969. Cone of experience, in Educational Media: Theory into Practice. Wiman RV (ed). Charles Merrill:
Columbus,
Ohio.
Delker PV. 1990. Basic Skills Education in Business and Industry: Factors for Success or Failure. Contractor Report, Office
of Technology Assessment, United States Congress.
Howell WS. 1982. Empathic Communicator. International Thomson Publishing: Belmont, California.
Joyce B and B Showers. 1981. Transfer of training: the contributions of coaching. Journal of Education 163(2): 163–172.
McIntosh N. 1992. Medical Education for the 1990’s and Beyond: An Approach to Clinical Training. Proceedings of The
Need Based Curriculum for Undergraduate Medical Education. p. 21–28. Medical Council of India: New Delhi, India.
Norton RE. 1987. Competency-Based Education and Training: A Humanistic and Realistic Approach to Technical and
Vocational Instruction. Paper presented at the Regional Workshop on Technical/Vocational Teacher Training in Chiba City,
Japan. ERIC: ED 279910.
Sullivan RL. 1995. The Competency-Based Approach to Training. Strategy Paper No 1. JHPIEGO Corporation:
Baltimore,
Maryland.
Sullivan RL et al. 1995. Clinical Training Skills for Reproductive Health Professionals. JHPIEGO Corporation: Baltimore,
Maryland.
Zemke R and S Zemke. 1981. 30 Things We Know for Sure About Adult Learning. Training Magazine (June).
1 Adapted from: Sullivan R et al. 1995. Clinical Training Skills for Reproductive Health Professionals. JHPIEGO Corporation: Baltimore, Maryland.
JHPIEGO Strategy Papers are designed to summarize JHPIEGO’s experience
in reproductive health, with a focus on education and training. The papers
are intended for use by program staff of JHPIEGO, USAID and its cooperating
agencies and other organizations providing or receiving technical assistance
in the area of reproductive health training.
©Copyright 1996 by JHPIEGO Corporation. All rights reserved.
Portions of this paper initially were presented at the workshop on Need Based
Curriculum for Undergraduate Medical Education, organized by the Medical Council
of India, 28–29 August 1992, New Delhi and at the IXth Uttar Pradesh Chapter
of Obstetrics and Gynaecology Annual Conference, 8 October 1995, Varanasi, India.
Financial support for this publication was provided in part by the United States Agency
for International Development (USAID). The views expressed in this report are
those of the authors/editors and do not necessarily reflect those of USAID.
JHPIEGO, an affiliate of the Johns Hopkins University, is a nonprofit organization
dedicated to improving the health of women and families globally.
CREDITS
Editor: Ann Blouse
Production Assistance: Holly Simmons
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