Numerous models have been proposed for dissecting and categorizing learners' diverse approaches to perceiving, processing, storing, and retrieving information. Some paradigms consider multiple dimensions, from biological to sociological, whereas others concentrate on one, such as sensory input (1). A number of models have been extensively studied and have associated assessment instruments. These can be administered to learners to delineate and describe learners' styles along the dimensions of a given model (2). The work in this field is so prolific that devising organizational systems and reviewing the many styles is the subject of numerous additional publications (3–5). Many of these diverse models have implications for educators, but considering them all when creating educational materials is certainly challenging, if not impossible. For simplicity, this article discusses a single, unidimensional model, VARK, demonstrating the process of understanding its theory, scientific underpinnings (via information-processing), and applicability to the design and delivery of educational materials. Through the examination of this style, it becomes evident that multimodal stimuli within multimedia presentations inherently lend themselves to teaching learners of various styles simultaneously and effectively.

VARK: A Model for Sensory Modality Preference

A common variable included in many models of learning-style is the mode of sensory input through which learners most readily perceive information. This is an important variable for educators to consider, as they can easily manipulate sensory input to the benefit of learners. One commonly discussed model for sensory input preferences is VARK, which was proposed by Fleming and Mills (6). The V in VARK represents Visual sensory mode preferences, in which learners prefer to encounter information in visual forms, such as charts, graphs, diagrams, etc. A stands for Aural, representing learners who prefer to hear new information, such as through a narrated lecture, music, or other auditory stimuli. The R represents a preference for Reading/Writing information, such as seeing words on a screen or page or writing one's own notes. K is for Kinesthetic — for learners who prefer learning through the use and movement of their bodies, which can occur during athletics, hands-on experiments, field-trips, etc.

Fleming and colleagues created a questionnaire with 16 items in its most recent version (Version 7.0), which is available online (7). With this tool, learners self-assess their preferred styles of sensory-modal input and communication. Some learners have a strong preference for a single modality, whereas others prefer multimodal input. Various cohorts have been shown to have different distributions of the four VARK categories or multimodal preferences. Fleming's analysis of the VARK scores for participants completing an online instrument in September 2008 (N=59,869) shows the following distribution: V: 3%, A: 8%, R: 14%, K: 12%; Bimodal: 15%; Trimodal: 12%; All modes: 36% (8).

In two studies, medical students showed a strong inclination toward multimodal stimuli, with nearly 64% of samples expressing a preference for multimodal stimuli, rather than unimodal input (9, 10). This proportion is similar to the online participants choosing multimodal preferences in Fleming's data from 2008. However, among medical students in these two studies with unimodal preferences, the proportion with Kinesthetic preferences were 18.1% and 23.3%, as compared with Fleming's K group of 12%. Also, the medical students had a preference for Reading/Writing in the proportions of 7.8% and 1.9%, whereas Fleming's data yielded 14%. These numbers could suggest that medical students have a greater preference for kinesthetic input and lesser preference for reading/writing than one cohort of Fleming's online participants. Murphy and colleagues reported that a sample of dental students demonstrated more visual and less kinesthetic preference than college student subjects in Fleming's database (11).

Information-Processing Theory Applied

Similarly to the VARK model, cognitive science discusses the relevance of various sensory-input "channels" through which learners perceive information. Information-processing theory teaches that perceived information is then rapidly and involuntarily transmitted to sensory memory. Then information is selected, mostly via directed attention, to pass from sensory memory to working memory, where processing can occur. Next, some of the processed information is stored in long-term memory in order to be retrieved at a later time (12).

Cognitive science has also brought to light variables that have a bearing on each phase of this multi-step process of learning. Attention, for example, is increased by the salience, novelty, and surprising nature of the stimuli (13). Enhanced attention can result in improved transfer to working memory and allow further processing to occur. Attention is also serial, and learners cannot pay attention to everything at once. In fact, too much simultaneous stimulation may actually decrease the likelihood of complete registration of information (14, 15). Once information is attended to and arrives in working memory, it encounters additional limitations regarding how much can be held and processed in working memory at one time. Working memory has been said to have both visual/spatial and verbal/text elements that can work together (dual-coding), without interference, to augment learning and eventual retrieval. The capacity of these two elements is estimated to average four visual/spatial and seven verbal/text chunks of information for any given moment. Beyond these limits, overload can occur, and information can be lost before complete processing and long-term storage is achieved.

Neuroanatomical correlates have been reported for some of these processes and limitations (12, 16–20). Several features of stimuli and how they are presented can contribute to the effective transfer of information from working memory to long-term memory. Such features include, but are not limited to, the organization (e.g., chunking, schema), rehearsal/repetition, familiarity/relevance, and affective/emotional valence of information (17, 21, 22). The organization and strength of long-term memories are essential for the future recall and utilization of learned information.

Pedagogical Implications

The challenge of the "one-room schoolhouse" is often considered when designing curricula meant for an audience of varied levels of expertise, such as a diverse body of medical students who vary in familiarity with a given topic. It may be a useful metaphor when considering the delivery of a single message, via one instructor, to a group of learners with different styles, as well. Some studies show that increased learning occurs when educators match the preferences of their learners (23–25), although others refute such claims (26). Also, some types of information are best presented using certain combinations of modalities for the majority of learners. For example, a computer animation depicting the process of lightning was most effective when the information was presented both visually and with concurrent auditory narration (27).

Multimodal stimuli typically provide increased learning, relative to unimodal stimuli (28). Media with both visual and verbal components can be used readily to incorporate multimodal stimuli. Given that many medical students (and, likely, residents) have a multimodal preference, multimedia presentations are a natural fit for providing them with the stimulation they prefer. Furthermore, multimedia messages can easily incorporate many of the characteristics of information that result in enhanced attention and long-term learning. The surprise, salience, and intensity of stimuli can be easily modulated with multimedia methods to enhance attention. Messages that are relevant, emotionally charged, and built on previous knowledge can also be included in an organized context that includes chunking and repetition of key points to facilitate the creation and consolidation of long-term memories.

A strategic approach that incorporates these features is necessary if optimal learning is to be achieved via multimedia presentations. Simply using media that provide a lot of stimulation can be detrimental to learning if the presentation is not well-planned (29). There is a significant body of work that has investigated the most effective multimedia design principles in terms of stimulus features and organizational principles; these are outlined in Table 1. Also, incorporating multimedia tools, such as video clips, into psychiatric lectures may increase long-term retention of information and increase learner satisfaction (31). Providing opportunities for hands-on experiences, such as group exercises, role-playing, live interviewing, field-trips, etc. can increase the kinesthetic component of learning that many students value. Combining all such techniques could potentially enhance attendance and increase student motivation and engagement in the learning process.

Examples From The Mental Status Exam

One of the fundamental skills that many psychiatric educators hope medical students will graduate with is the ability to perform and present a complete mental status exam. This is often one of the first lectures students receive in introductory courses; it is often readdressed early in psychiatry clerkships; and it is fine-tuned during psychiatry residency training. Many of the concepts of the mental status exam are abstract and difficult to describe by simple written words or auditory narration. However, many of these concepts can be readily described through the use of multimodal stimuli during a multimedia presentation.

Although there is certainly irony in the fact that this article is describing the use of multimodal and multimedia formats, but only uses the written word to do so, we will make an attempt to outline examples of how other media could be employed effectively for teaching some of the core concepts. For example, the topic of a patient's appearance and why this is relevant for a doctor to observe and describe can be discussed by using pictures, written words, and auditory descriptions. An instructor might choose a popular celebrity whom most students would recognize, and show photos in which his or her appearance is strikingly different at two points in time—such as one photo of a neatly groomed, attractive headshot used for publicity and another of the same celebrity's disheveled mug-shot after being arrested while intoxicated. The former could have the label "well-groomed" underneath it, and the latter could read "disheveled." The surprised response to seeing the celebrity can help to engage the students and to heighten attention. Furthermore, the specific features of appearance demonstrated by each photo can be described verbally to explain what is meant concretely by the commonly used labels under each picture. Then, juxtaposing the two images of the familiar celebrity side by side could engage further processing by repeating key concepts, encouraging an emotional response, and organizing related information. It could also illustrate why appearance is an important feature of one's mental status, as it can be a window into an individual's current functioning. In fact, most, if not all, topics in the mental status exam readily lend themselves to multimedia instruction.

The various aspects of speech, such as rate, rhythm, volume, prosody, etc., can be demonstrated by video clips from well-known movies. Thought process can be taught by videos of real patients who demonstrate disordered thinking, such as tangential, perseverative, or grossly disorganized thoughts. Students might be primed with the definition of one of these concepts first, told what to look for, then shown the video with a descriptive label below it (e.g., "tangential"). Afterwards, students can be asked to describe what they saw and heard, and eventually to discuss what makes each concept different from the others. Students can even role-play the neuro-cognitive exam in small-group sessions—taking turns being the "doctor" asking the questions, and the patient answering them.

Although not meant to be a complete list of all of the components of the mental status exam, these examples demonstrate some of the numerous potential ways to include multimodal stimuli through multimedia experiences around this topic. Certainly, these principles and strategies will be useful in teaching other topics in psychiatry and other subjects, as well. Of note, the inexhaustible resources of the Internet provide a vast repository in which educators may find appropriate images and even video clips. Search engines, such as Google images™ (for pictures) and YouTube™ (for video clips) are just two of the many readily accessible databases that supply free, public content. It may take time to find an image or clip that adequately and appropriately demonstrates the desired concept, but the impact can be worth the search. Also, there are some psychiatric educational materials on institutional websites that are free and already organized, such as the one maintained by Newcastle University, www.ncl.ac/nnp/teaching/general, which also has a video clip section using some of these multimedia principles: www.ncl.ac.uk/nnp/teaching/video.

Learners have individualized, preferred styles, through which they most readily acquire new information. A number of models exist that describe learners' styles using different dimensions. These models vary in complexity and focus, and mostly serve to demonstrate differences between individual learners. Learners with significant differences often sit next to one another and receive the same content from educators. Thus, educational planning and tools are necessary to address these differences. Whereas some educators advocate evaluating learners' styles and providing targeted instruction, others have not found this to be helpful or possible in every setting. Incorporating multimodal stimuli and considering principles of information-processing and multimedia design in educational messages can address and, in some cases, supersede learners' variability and promote optimal learning. Medical students and, by default, residents, often prefer multimodal stimuli and, as a result, may significantly and specifically benefit from multimedia presentations.

Many topics in psychiatry readily lend themselves to multimedia presentations, even the basic and important concepts within the mental status exam. There are a number of free, publicly available resources from which educators can draw in order to create higher-impact multimodal and multimedia messages for learners. For higher-order concepts, students often prefer "live drama" in which they are actively engaged with instructors, one another, interactive technology, and standardized or real patients. Although no "one-size-fits-all" solution is possible, a combination of well-designed materials, well-executed presentations, and hands-on, in-vivo experiences will likely engage the majority of learners and increase their learning and satisfaction.