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Archives ofDisease in Childhood 1996; 74: 357-
MEDICAL EDUCATION
Self directed learning
Angela Towle, David^ Cottrell
Why self directed learning? It is now recognised that medical education has to be a lifelong process. The^ practice of medicine and its underlying knowledge base change so rapidly that^ it is essential^ that^ doctors continue to learn throughout their professional career. However, continuing professional edu- cation is not simply a matter of keeping up to date, but also entails reflection on practice in order to incorporate new experiences, to^ relate present situations with previous experiences, and to reorganise current^ experiences based upon this process. Self directed learning enables the learner, whether^ student^ or^ practitioner, to do these important things. As defined by Knowles,1 self directed learn- ing is a process in which individuals take the initiative, with or without the help of others, in diagnosing their learning needs, formnulating learning goals, identifying human and material resources for learning, choosing and imple- menting appropriate learning strategies, and evaluating learning outcomes, that^ is, they^ take responsibility for, and control of, their own learning (see box 1). If self directed learning skills are a prerequi- site for the good doctor, then we should ensure that those entering the profession are encour- aged and helped to develop these skills as part of their education. Medical education has traditionally relied on didactic and teacher dominated methods of teaching, which have done little to help students develop either the skills or the right attitudes for lifelong learning. Although the^ widely accepted definition of teaching is 'helping someone to learn', medical teachers have too often concentrated on what they teach (for example, the urge to 'cover the subject' in^ lectures) rather than how^ to^ help students learn most effectively and efficiently (not to^ mention^ enjoyably). Fortunately progress is now being made to introduce more active, student^ centred methods of^ education, and to focus attention on the needs and aspira- tions of the learners rather than those of the
teachers. The latest recommendations on the undergraduate curriculum from the^ UK General Medical Council specifically state that learning through curiosity, the^ exploration of knowledge, and the critical evaluation of evidence should be^ promoted and^ should ensure a capacity for self education. The medical education literature provides guidance as to what will facilitate learning as well as help cultivate the critical skills of lifelong learning. Schmidt, for example, gives three principles which will make teaching more relevant and effective, based upon what is known about adult learning. (1) Building on prior knowledge: students use the knowledge they already possess to understand and structure new information. (2) Learning in context: the closer the resemblance between the situation in which something is learned and the situation in^ which it is applied, the more likely it is that transfer of learning will occur. (3) Elaboration of knowledge: information is better understood and remembered if^ there is opportunity for elaboration (this includes discussion, answering questions, teaching peers, critiquing). Examples of^ applications that^ are^ currently being used to cultivate skills of self directed learning and reflection are: problem based learning; small group learning; self and peer evaluation; self study materials; library work and (^) projects (both literature reviews and research); learning contracts; profiling; simu- lated (^) patients; and (^) computer assisted learning. Course features which can enhance self directed (^) learning are (^) highlighted in box 2. As examples of how self directed learning can work in (^) practice, we shall focus on two con- trasting methods: problem based learning and self/peer evaluation. We^ will discuss these^ two areas in relation to facilitating undergraduate learning but the principles involved are, of course, equally relevant for postgraduates and for consultants engaged in continuing profes- sional (^) development. A (^) further reading list is provided at^ the^ end^ of^ the^ paper for those wish- ing to get more ideas about teaching and learn- ing methods that foster student centred and self directed learning.
Problem based learning In the introduction to their useful book, Boud
and Feletti identify problem based learning as
the most (^) significant innovation in education
This is the ninth in a series on medical education.
King's Fund Centre for Health Services Development, London A (^) Towle
Academic Unit of Child and Adolescent Mental Health, University of Leeds D (^) Cottrell Correspondence to: Dr Angela Towle, University of British Columbia, Division of Educational Support and^ Development, Office of the Coordinator of Health Sciences, 400- Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada.
Self directed learning activities
- Setting own learning goals
- (^) Identifying appropriate learning resources
- (^) Selecting appropriate learning strategies
- (^) Selecting important from (^) unimportant
- Integrating material from different sources
- Tirne management
- (^) Monitoring achievement of (^) learning outcomes
- (^) Monitoring effectiveness of own (^) study habits
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Towle, Cottrell
for (^) the professions for many years, possibly the most important development since the move of professional training into educational institu- tions.4 The principal idea behind problem based learning is that the (^) starting point for learning should be a problem, query, or puzzle that the learner wishes to solve. There are four broad goals5: integration and relevance of knowledge; development of clinical reasoning; independent learning; and a more interesting curriculum for staff and students. Problem based (^) learning originated at McMaster University in Canada in the mid- 1960s and has since been (^) adopted by perhaps 30 medical schools throughout the world as the sole or major (^) learning method and (^) by several hundred as one of the methods in a hybrid curriculum. In (^) its purest form (for example at McMaster and Maastricht), a problem is presented to a group of students and the group decides what it needs to know in order to solve it. The learn- ing objectives of such an exercise (^) are generated by the students and several groups of students simultaneously (^) encountering the same (^) prob- lem will (^) end up learning different things. A more structured problem based learning system might entail^ a^ list of^ learning objectives generated by the teachers or course organisers to which students are (^) guided gently. Some medical schools (such as Harvard) mix prob- lem based learning with more traditional forms of teaching such as lectures and seminars which are related to the (^) problems being studied. Comparisons of different curricula suggest that students (^) perform as well (^) following problem based courses as students receiving traditional (^) courses, but do indeed (^) acquire a more (^) inquisitive and (^) self directed style of learning. Problem based (^) learning typically occurs in small tutorial groups of five to 10 students. The teacher's role is to facilitate the learning process, not to give the students information. Students are presented with a (^) problem and encouraged to^ ask^ themselves^ questions, the answers to which will (^) help solve (^) the initial
problem and increase their understanding of
the underlying processes involved. Some of the answers will come from the prior (^) knowledge of group members, others^ will^ need^ to^ be researched. In its commonest form in the early years of medical programmes, a problem is (^) progressively unfolded, with additional information becom- ing available.^ The^ problem can^ be^ simple or
elaborate, written^ on^ paper, introduced by a
video or in some combination of formats.
Effective problems can be based on a variety of
questions -^ an^ individual patient, a puzzle in
normal function, an ethical dilemma, or an
issue of community concern. Supplementary
materials may include further written informa-
tion, laboratory data or pathology slides, read-
ing lists, and^ computerised databases.
A typical problem in paediatrics might be as
follows: 'An 11 year old girl has not attended
school for three weeks because of recurrent
episodes of central^ abdominal pain. A full
history, examination and relevant special
investigations have failed to reveal any organic
cause'. Initial discussion of the problem,
usually with a tutor present, is used to identify
gaps in knowledge (^) and learning goals are set for later individual or small group study. This
problem, with some guidance from the tutor,
may lead the students to explore the organic causes of abdominal pain and their appropriate
investigation and management, psychological
and sociological theories concerning the mechanisms of 'non-organic' (^) pain, methods of psychiatric assessment of children and families, the role of services dealing with (^) special educa- tional needs, psychological treatments and many other related areas. In subsequent sessions the tutor will (^) have to be prepared to provide more information to the students
about the problem, for example, the results of
the child's physical investigations or the family background. When planning problem based learning, attention must be given to the resources (^) that will be needed by students in between tutorials to answer the questions (^) they have set (^) them- selves. These will (^) include library and audio- visual materials, but may also include staff who will need to be warned that (^) a group of questioning students may descend on them to seek explanations that will help their (^) learning. While (^) no two problem based learning ses- sions are the same, most proceed through the following stages: (1) Analysis of the problem. (2) Identification of (^) the information required in the form of questions. (3) (^) Study to formulate the answers (^) to ques- tions. (4) Application of the (^) newly acquired knowledge to the initial problem. Thus, much of the work carried out by the students will be in between the tutorial sessions facilitated by the teacher when the group meets to review progress. Teachers are required to operate in very different ways to facilitate this kind of learning: clear (^) learning objectives need to be set (^) for each problem presentation and tutors must learn skills in small group teaching to facilitate the analysis and questioning which should occur in the initial session. (^) They also have to resist the (^) temptation to control (^) the direction of the (^) discussion and to provide information instead of encouraging students to find out for themselves. Studies have shown that tutors with (^) expert knowledge of the problem being discussed^ are more directive, speak more frequently and for longer, provide
Course features that enhance self directed learning
- Clear, advance information about tasks
- Specific performance goals for assignments
- (^) Intrinsic rewards for task completion
- Timetabling that allows sufficient time for task completion
- Trust that (^) learners will remain on task
- (^) Support for student learning, for example, personal tutors, study skills courses
- Formative assessment and feedback that enables students to monitor and modify their own learning
- (^) Appropriate summative assessment, that is, that tests problem solving rather than rote (^) repetition of facts
- (^) Appropriate staff development/teacher training
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