MMiflin BM, Campbell CB, Price DA: A lesson fromthe introduction of a problem-based, graduate entry course: the effects of different views of self-direction. Medical Education 1999; 33:801—807
Miflin BM, Campbell CB, Price DA: A conceptual framework to guide the development of self-directed, lifelong learning in problem-based medical curricula. Medical Education 2000; 34:299—306
Barrows and Tamblyn (
+1) define problem-based learning (PBL) as learning that
begins with problem solving. That is, the problem comes first, and the theory and facts are learned afterward, as they are needed to solve the problem. Thus defined, PBL sounds like an educational principle, one that favors teaching in the context of clinical problems rather than in the context of academic disciplines. However, PBL as it is practiced is actually a collection of educational principles and procedures. A typical PBL curriculum, for example, might include the following elements: small-group learning, student-directed learning, lifelong learning, cooperative learning, contextually grounded learning, patient-centered learning, and community-centered learning. The basic educational principles underlying each of these elements have histories stretching back between 50 and 2,000 years. Each principle has its supporters, its detractors, and a complex practice built around its implementation. Teaching in accordance with a principle requires faculty that have a thorough understanding of the meaning of the principle as applied to their educational context. Some writers, including myself (
+2), have cautioned against the mistaken assumption that teachers need only follow the "PBL formula" to ensure that their students reap the benefits of most of the major principles of learning of the twentieth century.
Miflin, Campbell, and Price (1999) discovered a dramatic instance of this incorrect presumption that PBL is a formula for success. They attempted to understand the origin of the stress experienced by both students and faculty upon introducing a problem-based course at the University of Queensland. A major source of stress was "the differences of opinion about the meaning of self-direction as it was applied in the course." They concluded that there was a conflict between teachers' and learners' expectations, especially with regard to the extent to which students were expected to "direct" their own learning. Self-direction, of course, is one of the pillars of PBL.
Through the use of extensive monitoring procedures including questionnaire surveys, observations of PBL sessions, focus groups, and consultations, the authors documented specific frustrations with self-directed learning. The learning issues identified by the students themselves in their tutorial groups—such as "the anatomy and physiology of the lung"—were too vague to enable them to limit their study to a manageable level. Students "were particularly frustrated" by laboratory classes in which demonstrators were instructed "not to answer student questions or demonstrate specific issues, but to allow students to ‘direct their own learning.’" Some groups spent most of their time trying to figure out "what the school wanted them to learn." Students argued that they had become dependent on the PBL tutors because their tutor was their only route to divining what the university wanted them to learn. Ironically, there were students who withdrew from the PBL tutoring sessions because they preferred to be self-directed. In the absence of guidance, students were unable to discover either the appropriate material or the appropriate depth for their learning. On the other hand, teachers' conception of self-directed learning prevented them from answering students' questions. The teachers believed that students should learn from resources (printed material) that the university provided.
The authors concluded, as Blumberg and Michael (
+3) had earlier, that consistency of interpretation of core concepts is essential to curriculum implementation. They called for a careful and comprehensive preparation of teachers in the concept of self-direction as it affects the teaching and learning process. As a first step toward consistency in the interpretation of the concept of self-direction, they developed a consensus regarding the meaning of the concept of self-directedness. In a subsequent paper (2000), they published this conceptual framework. Self-directed, lifelong learners, as defined in their Graduate Medical Course, would accept responsibility for evaluation of their practice; identify deficiencies in their knowledge, skills, and attitudes; generate a learning program to address these deficiencies; evaluate their learning efforts; and repeat this cycle with each patient and clinical situation. In addition, learners would need the skills to identify, access, and use resources wisely and efficiently.
An examination of the literature led them to the conclusion that self-directed learning was not served by the hands-off approach whereby students learn independently of teachers or organized classes. They concluded that support and guidance actually foster the development of self-directed, lifelong learning. Experienced learners appreciate the value of experts and the wisdom of experience in facilitating their learning by introducing them to the fundamental principles and structures of the discipline. Moreover, access to school learning objectives does not make students more "other-directed." An overview of the curriculum, its objectives, resources, and evaluation methods, such as that used by McMaster University's M.D. program, enables students to appreciate the long-term goal of the curriculum and to adjust their study of each unit accordingly, both in terms of focus and pace.
The authors mapped out a developmental sequence for each of the components of their curriculum: the PBL tutorial process, the case format, the small-group setting, and the tutor. The curriculum "evolves from early school guidance of the learning process to independent, student self-directed learning" (p. 303). For example, the role of the tutor or teaching staff, one of the components of the curriculum, is planned so that it gradually shifts from "other" direction to "student" direction. Teacher functions such as the "provision of knowledge" and "guiding learning" shift gradually from a maximum in first year to a minimum in fourth year, while "demonstrating practice" and "modeling professional roles" shift from a minimum in the first year to a maximum in the fourth year.
Maudsley RF: Role models and the learning environment: essential elements in effective medical education. Academic Medicine 2001; 76(5):432—434
Miflin, Campbell, and Price (2000) addressed the problems of PBL first by creating a consensus among faculty and students regarding the concept of self-direction. Then they analyzed the curriculum components and established a developmental sequence for each component within which self-direction can evolve. One of these components was the "role of the teaching staff," which comprised a number of features, including "modeling professional roles."
The analysis of each of these features could be taken to an even more detailed level. Maudsley has written a brief commentary on role modeling in medical education. He offers a list of methods for improving role modeling, including a number of specific ways in which students and faculty need guidance (pp. 432—433). For example:
I am currently collaborating with a colleague to develop a workshop to improve role modeling. She has read all of the literature on role modeling in preparation for this task. She told me that most of the authors writing about role modeling agree that its importance is undervalued, but no one has specific suggestions for learning strategies and techniques. Maudsley's suggestions for improving role modeling are no exception; they are more like objectives than specific methods.
An important message is buried here about the process of improving education. It's a long road from self-directed learning as an educational principle to the specific kinds of guidance and training that would enable teachers and students to use role modeling to foster self-direction.
Kruger J, Dunning D: Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments. Journal of Personality and Social Psychology 1999; 77:1121—1134
Hodges B, Regehr G, Martin D: Difficulties in recognizing one's own incompetence: novice physicians who are unskilled and unaware of it. Academic Medicine 2001; 76(10):S87—S89
One of the competencies necessary to achieve self-directed learning, according to Miflin, Campbell, and Price (2000) is learners' ability to identify deficiencies in their own knowledge, skills, and attitudes. Self-assessment is a critical skill because without it learners cannot generate a learning program to address their deficiencies. But what of the learners who are unaware of their difficulties?
Kruger and Dunning suggest that unskilled people suffer a dual burden: "Not only do these people reach erroneous conclusions and make unfortunate choices, but their incompetence robs them of the metacognitive ability to realize it (p. 1121)." Kruger and Dunning conducted four studies in areas in which knowledge, wisdom, or savvy was crucial: humor, logical reasoning, and English grammar. Participants, Cornell undergraduates, rated 30 jokes of varying comic value in one study; completed a 20-item test on logical reasoning in another study; and completed a 20-item test of English grammar in a third study. In each case they were asked to compare their general ability with that of other students from their class. Participants who scored in the bottom quartile in any of these areas grossly overestimated their test performance and ability.
In another phase of the study, they tested their hypothesis that lack of self-monitoring skills or poor metacomprehension was the explanation for this overestimation. They invited both the top-quartile and bottom-quartile participants to return to the lab for a session in which they were asked to grade the papers of five of their peers, thus giving them experience with the behavior of others. They were then asked to rate their own ability once again, relative to their peers. Bottom-quartile participants were less able to gauge the competence of others and did not lower their overestimation of their own performance after seeing the papers of other students. In the authors' words, they "failed to gain insight into their own performance after seeing the more competent choices of their peers" (p. 1127).
Hodges, Regehr, and Martin replicated Kruger and Dunning's research in a medical education setting. Family practice residents rated videos of their own performances on a "breaking bad news" scenario, and their ratings were then compared with those of experts. Exposure to benchmark performances did lead to better self-assessments for some of the residents, especially for those in the highest performance group. For the lowest performers, the improvement in self-assessment after exposure to benchmark assessments was inconsistent and minimal. The authors concluded that this finding is particularly important for self-regulating professions such as medicine, where continuing education is left entirely in the hands of individual professionals: "It is only through accurate self-assessment that physicians can identify areas in which they are deficient in order to pursue further learning" (p. S88). They conclude their paper with four concrete suggestions for improvement of the self-assessment ability in medicine, such as the teaching of self-assessment during medical school and residency and the modeling of self-directed learning by teachers.
Once again, it's a long road from self-directed learning as an educational principle to the specification of goals that define self-directed learning, such as the skill of "self-assessment," and finally to the actual techniques necessary to improve this skill. There is an old German saying, Der liebe Gott wohnt im Detail: God lives in the detail. Just as educational principles provide a language and a set of assumptions that give concrete meaning to problem-based learning, the details are essential in implementing the principles.