- Educational theory
- Problem-based learning
- Evidence-based medicine
- Faculty roles
- Information technology
- References and publications
The Sydney Medical Program is based on elements of adult learning theory, research in cognitive psychology and student learning research. The Program is designed to avoid an overemphasis on 'covering the content' at the expense of developing process abilities - for example, using "communication skills, collaboration and teamwork skills, and thinking and decision making skills in both creating and using … knowledge" (Sinclair 1996). A naïve 'transmission' theory of learning results in a surface approach to learning (Marton & Saljo 1976), but deeper approaches, as exemplified by problem-based learning, encourage students to participate in an interactive, personal approach to the construction of meaning.
Research in the field of adult learning emphasises the value of concrete experience and identifies a number of important influences. Adult learning is best encouraged when:
- learners are engaged as participants in the design of learning
- they are encouraged to be self-directed
- the teacher functions as a facilitator rather than a didactic instructor
- individual learners' needs and styles are taken into account
- a climate conducive to learning is established
- learners' past experiences are utilised in the classroom and
- learning activities are deemed to have some direct relevance to the learners' circumstances.
Student learning is promoted when there is consistency between curriculum aims and objectives and the teaching and assessment methods used. Biggs (1989) and Gibbs (1992) suggest that there are four key elements of good teaching, each of which encourages students to adopt a deep approach to their learning:
- Creating a motivational context - involving intrinsic motivation and 'ownership' of learning within a positive emotional learning climate
- Encouraging learner activity - active rather than passive learning in which connections are made with past learning and between concepts. The learning activities are planned, reflected upon, processed and related to abstract conceptions
- Encouraging interaction with others - through mechanisms such as cooperative learning, autonomous student groups and peer tutoring, and
- Helping students to develop a well structured knowledge base - involving the linking of new concepts with existing knowledge and experience to provide structure and integration.
Learning is influenced by students' perception about themselves as learners, the nature of the learning task, the outcomes that are considered likely to be rewarded and the context in which learning is expected to occur. Context influences learning outcomes because it is an important determinant of the approach students take to their learning.
Problem Based Learning (PBL) is a key educational approach used throughout the Program. It underlies the curriculum structure and learning experiences of students in a number of ways. Not only does it integrate curriculum content through the presentation of patient 'problems', but also provides the context for students to develop their clinical reasoning skills; and a springboard for collaborative self directed learning. Its use is consistent with recent theories of learning and cognition which are shifting the emphasis on 'individual thinkers and their isolated minds...(towards) an emphasis on the social nature of cognition and meaning'. Theory of situated cognition or situated learning offers a base for developing instructional resources that are more aligned with the realities of professional practice - 'the notion of learning knowledge and skills in contexts that reflect the way the knowledge will be useful in real life'.
The following characteristics of a situated learning environment have guided the design of PBL throughout the Program and provide:
- authentic contexts that reflect the way the knowledge will be used in real life
- authentic activities
- access to expert performances and the modelling of processes
- multiple roles and perspectives
- support for the collaborative construction of knowledge
- time for reflection to enable abstractions to be formed
- articulation to enable tacit knowledge to be made explicit
- coaching and scaffolding by the teacher at critical times
- for authentic assessment of learning within the tasks.
In Years 1 and 2, on-line resources, delivered through the Program’s intranet, support Program goals by giving students access to the key tutorial materials needed to motivate and support their clinical reasoning during the problem week, both during their three, ninety minute PBL tutorials each week; and during their related self directed learning. The problem web page also provides specific, faculty written starting points for independent learning, as well as access to a wide range of other learning opportunities.
The design of these web pages and the materials they present is specifically tailored to meet the needs of the clinical reasoning model (Neame 1989) being used by students to arrive at diagnostic and management decisions during PBL tutorial activity and self directed learning.
Evidence-based medicine (EBM) is a movement which aims to increase the use of high quality clinical research in clinical decision making. EBM had its roots in 19th century Paris, but really got going in the 1990s when the explosion of medical information and information technology made it feasible to search computerised databases easily and rapidly for the best, most up to date evidence. Now, it is also driven by the involvement of consumers in medicine and the move towards shared clinical decision-making.
Practically, EBM is about finding out what the patient wants to know and the best possible evidence on which to base answers. The sorts of questions patients ask have, over time, driven clinically relevant research into (for example):
- the accuracy and precision of diagnostic tests (including the clinical examination),
- the power of prognostic markers, and
- the efficacy and safety of therapeutic and preventive interventions.
The University of Sydney has recognised the importance of producing graduates with skills in EBM and is one of a small number of Universities that teach EBM to undergraduate students. This enables students to develop EBM skills from the outset of their clinical training, and to foster an ongoing desire to practice EBM.
In years 1 and 2 of the Medical Program EBM teaching aims to assist students to formulate focussed clinical questions, to literature search effectively, and to find and appraise clinical research. EBM is integrated into the rest of the students learning so that it is seen as part of the process of acquiring preclinical and clinical knowledge and skills. In the problem-based learning (PBL) process, EBM prompts and activities have been designed to simulate EBM in clinical practice.
This integrated teaching is supplemented by EBM specific teaching – in the form of interactive theme sessions and small group tutorials each block, with a different skill addressed each block. For example, block 1 covers formulating clinical questions, block 2 study designs in epidemiology, and subsequent blocks cover critical appraisal of studies on questions of prognosis, aetiology, intervention and diagnosis.
In years 3 and 4 the students build on the skills learnt in years 1 & 2 and, in addition, begin to apply clinical research to clinical practice. Over the two years students are involved in a range of innovative EBM activities, and have many opportunities to take their theoretical EBM knowledge and put it into practice. One example is ‘PEARLS’, where the students find a patient in their clinical encounters and formulate a clinical question of relevance. In a series of tutorials, they develop their search strategy, conduct the search, find the best quality evidence, appraise it and present it to their colleagues and teachers in a formal presentation. [Note: PEARLS = Presentations of Evidence Abstracted from the Research Literature for the Solutions of real individuals problems.]
The University of Sydney is committed to training doctors for the 21st century – and that means doctors who can deal with information explosion and the increasing demands from the profession, government and consumers for evidence based practice. Sydney University graduates will be well equipped to cope with the challenges of the next century and will be in a strong position to lead the way in evidence based practice and shared clinical decision-making.
In a PBL curriculum, the Medical School play a number of roles:
While this is a familiar role, the method of 'delivering' content may vary. In the Sydney Medical Program, content experts:
- Construct discipline 'maps' which outline the essential knowledge associated with their discipline and where it is 'built in' during the four years of the Program
- Prepare self-directed learning materials which are available to students as learning topics
- Provide summaries of lectures and themes session (these are practical classes in each of the four themes: Basic and Clinical Sciences, Community-Doctor, Patient-Doctor and in Personal and Professional Development)
- Deliver lectures and theme sessions especially in areas which are conceptually challenging
- Supervise options, electives and honours projects
- Construct assessments in collaboration with content experts from other disciplines
- Assist individual students requiring remediation
While the role of the PBL tutor is initially unfamiliar to many academics, most are quick to see the similarities between PBL tutoring and the supervision of higher degree students. Tutors in a PBL group fulfil many roles:
- asking questions
- encouraging students to clarify their ideas
- encouraging students to examine new ideas
- pointing out inconsistencies
- encouraging all group members to contribute
- supporting each member of the group
- ensuring that everyone has a chance to contribute
- testing for agreement between group members
- summarising progress
Students appreciate PBL tutors who promote intrinsic motivation and 'ownership' of learning within a positive emotional learning climate. It is this 'climate' that is a critical element of success for PBL groups.
Clinical tutors combine the qualities described as characterising both content experts and PBL tutors. While they have important information to share with students, clinical tutors promote the active acquisition of both knowledge and skills. Clinical tutors are also very significant role models (Gordon and Lyon, 1998) and for this reason they are never "off duty".. Since students now begin their clinical experience in the first month of the first year, they have many more opportunities to observe clinical teachers in their roles as teachers, but also as providers of medical care. These observations trigger strong intrinsic motivation, as evidenced in their portfolio records of the first six months of medical school.
Health care environments are increasingly reliant on information technology and it is essential that medical practitioners are familiar with IT. The size of the information base that informs the proper practice of medicine requires doctors to be able to perform efficient searches of the medical literature to determine best practice. Throughout the program, information technology is used to deliver the teaching and learning and to provide a means by which students can access medical literature and databases. These resources include text descriptions and outlines of the problems and associated lectures and laboratory sessions, moving and still medical images (radiology, pathology, histology, etc.), clinical data relevant to the problem of the week, Internet sites related to the problem, and on-line self-assessment questions and answers.
Computers are provided in each of the tutorial rooms, the medical library and specialised computer laboratories, as well as in the more traditional practical laboratories and museums. Computers are also provided in the clinical schools to allow students to access all of the learning resources both on and off campus. Communication between students and teachers is facilitated through the use of electronic mail and electronic forums. Some reports and assignments may also be submitted electronically. To ensure appropriate training in the use of these technologies, a guiding principle has been to deploy computers in a way which reinforces their use in current and future clinical settings.
For information about the IT that underpins the Medicial Program see Professional educational services
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