Few physicians involved in medical education have had formal training in teaching or in the educational concepts that underlie pedagogical methods. And yet we develop a teaching style, give lectures, conduct courses, and facilitate small groups. Many of us attend faculty development teaching workshops, but these usually focus on specific pedagogic skills and do not emphasize evaluation of different educational theories or the development of a coherent educational perspective (1). We have initiated, facilitated, or weathered curriculum reform—a process that may call for a shift in educational perspective or theoretical orientation even when it is experienced as simply a change in learning objectives and teaching methodology.
Without formal training, we are overly reliant on other sources for our thinking about medical education. For many of us, our educational perspective may be determined by a set of undiscussed, experientially derived, aggregated beliefs and ideals about the nature of teaching and learning. We teach as best we can, often with success, but find it difficult to describe clearly how or why we teach the way we do.
Improved understanding of educational perspectives can facilitate discussions about teaching, clarify the intent of pedagogical techniques, stimulate our thinking, and enliven the daily experience of teaching. Additionally, in teaching medical trainees to become the lifelong learners that the practice of medicine demands, we teach them (explicitly or implicitly) about learning itself (2). If we as teachers are unclear about what learning is and how teaching happens, it may be harder for our students to develop efficient patterns for lifelong learning that the practice of medicine demands.
In this paper, we present a hypothetical case to demonstrate different educational perspectives and how they might differently influence the daily practice of teaching. Dr. Doe, a junior faculty member, receives feedback on his teaching from three experienced teachers, Drs. A, B, and C, as part of a pilot program in the Department to provide peer review of teaching. Each of the senior educators sat in on two of Dr. Doe's sessions on schizophrenia with third-year medical student clerks. Their job was to critique Dr. Doe's performance and to stimulate his thinking on how to improve his teaching. Each reviewer met individually with Dr. Doe after the sessions.
Dr. Doe teaches from the behaviorist perspective; Dr. A admires cognitive learning theory, Dr. B is a proponent of social learning concepts, and Dr. C focuses on the role of interpersonal inspiration in teaching. These four perspectives do not represent the entirety of current thinking about adult education, but they do embody what we believe to be widespread and common approaches to medical student teaching. We have designed the case to highlight the differences among the four perspectives, rather than exploring their regions of similarity or overlap. In this brief presentation we do not pretend to have represented these four perspectives in all their richness and complexity. We also do not suggest that the feedback styles we have scripted for our fictional educational critics are ones that should be emulated by experienced educators in counseling junior colleagues. The somewhat confrontational or evangelical tones assumed by Drs. A, B, and C are used solely for heuristic intent, to emphasize and highlight the differences in their educational perspectives. Specific genders are used only for convenience.
After presenting the scenario we discuss the importance of educational perspectives, particularly with regard to their impact on individual faculty development and the acquisition of skill and mastery in teaching.
Dr. Doe is a mid-rank assistant professor in the Department of Psychiatry. He takes his teaching responsibilities seriously, volunteering for teaching assignments and making himself available to students. He has attended several faculty development workshops on pedagogical technique and has become an expert in using Microsoft PowerPoint.
Dr. Doe's Description of His Teaching: A Behavioral Perspective
My teaching is based on the principles of behavioral learning theory, the same theoretical paradigm that underlies behavior therapy. Some of the principal developers of behavioral learning theory are John Watson, Edward Thorndike, Edwin Guthrie, Edward Tolman, and B.F. Skinner. The fundamental tenets of behavioral learning theory are these:
These basic principles focus me on observable behaviors in both the teacher and the learner, rather than on internal thought processes that cannot be known, quantified, or reproduced with any certainty. The elements of the environment, including my behavior as a teacher, are what shape behavior and learning, not the characteristics of the individual learner. Contiguity (how close in time two events must be for a bond to be formed) and reinforcement (stimuli that increase the likelihood of an event being repeated) are key features in the learning process (3). These principles are clearly seen in operant conditioning, which in its simplest form tells me to "reinforce what you want the individual to do again; ignore what you want the individual to stop doing" (4). Many of my effective teaching techniques are designed to properly manipulate contiguity and reinforcement.
As a teacher, I focus on using low-inference, observable behaviors that educational research has shown to increase learning. Low-inference behaviors are those that can be specified and are denotable and objective, whereas high-inference behaviors are those that require subjective inference to evaluate (5). For example, I don't teach "with enthusiasm" (a high-inference behavior), but I do vary the volume of my voice, gesture frequently with my hands, change where I stand in front of the class, and make a point of looking directly at a variety of individual students when I speak (all low-inference behaviors).
Other low-inference behaviors that I use include
I have practiced these skills and used videotape review of my own teaching to look for opportunities to increase my use of effective teaching behaviors. Well-designed behavioral research in education, conducted in the classroom laboratory, has proven the association between these low-inference teacher behaviors and improved learning outcomes in students.
I believe that most universally accepted educational techniques can be traced to behavioral learning theory. The systematic design of instruction with behavioral learning objectives is grounded in the concept of measurable, demonstrable outcomes as the benchmarks of learning. I always start my teaching by providing my students with a list of behaviorally defined objectives for them to achieve. For example, instead of a vague high-inference objective of "the student will understand schizophrenia," I specify that "the student will be able to list the symptoms of schizophrenia, describe the major treatment strategies of schizophrenia, and compare the mental status findings of schizophrenia with those of bipolar disorder." I develop goals and objectives for teaching that include knowledge, skills, and attitudes that the student should master or attain by the end of the teaching session.
The emphasis on competency-based education that is being incorporated into graduate medical education by the ACGME and organized medicine is another outgrowth of behavioral learning theory principles. Competency-based education focuses on behavioral skill sets that residents and students must demonstrate to be considered proficient in an area. Even complex skills like patient interviewing and psychotherapy are going to be behaviorally defined. I look forward to developing objective methods of assessment that will measure the acquisition of these skills.
To improve my teaching, I need to identify, practice, and refine the teaching behaviors that are known to improve learning (7,8). Included in these behaviors are other elements of the environment such as the syllabus, the audiovisual presentation, the size and configuration of the classroom, and other elements that promote understanding and retention. If I design the right environment and use the right teaching behaviors, learning will occur. It's been proven.
Dr. A's Comments:A Cognitive Learning Perspective
Dr. Doe, I believe you can further improve your teaching by incorporating teaching principles derived from cognitive learning theory. To help your learners become truly expert physicians, you will need to go beyond external observable behaviors and find out what is going on inside their minds. Student behavior is important because it reflects what the learner is thinking—it is the external representation of an internal process. When I'm teaching from a cognitive learning perspective, I want to get inside the learner's head and do what I can to facilitate the development of clinical expertise. Consider what makes you an expert psychiatrist. Is it only a collection of behaviors? Or does it include the array of sophisticated cognitive structures in your head that you access to diagnose and design treatment interventions? An important challenge for teachers is to figure out how to facilitate learners in the development of these cognitive structures in their own minds.
Cognitive learning theory focuses on the internal processes of perception, insight, and meaning. The locus of control is with the learner, not the teacher. "The human mind is not simply a passive exchange-terminal system where the stimuli arrive and the appropriate response leaves. Rather, the thinking person interprets sensations and gives meaning to the events that impinge upon his consciousness" (4, p. 76). The teacher is only responsible for structuring the content of the learning activity to promote perception, insight, and meaning in the learner. We can understand these mental processes through the contributions of information processing theory, studies of the development of expertise, artificial intelligence, and recent work on memory and metacognition (9—11). Important historical foundations have come from Jean Piaget in understanding the cognitive developmental process in learning and from gestalt psychology in recognizing the importance of insight in solving problems (12,13).
More recently, educators have studied the development of cognitive expertise in medicine (14—17). They have found that learners have their own cognitive stages of development as they progress through medical school and residency training to become expert physicians. Good teachers recognize these stages in their learners and teach accordingly. Consider how we understand learning in children from a developmental Piagetian perspective. We can teach with a sophisticated awareness of where learners are developmentally, what they can and cannot assimilate, and what the next step is for them in becoming expert psychiatrists.
Early learners think very differently from experts (18). How do we get them to the expert proficiency stage? As an example, when you first learned diagnostic skills as a student, you used complicated algorithms based on long lists of possible diagnoses tied to specific symptoms, like the differential diagnosis for psychosis. When you see a patient now, as an attending physician, you don't use long, laborious, algorithms to make diagnoses. You use gestalt recognition of prototypes for schizophrenia or delirium that you carry around in your head. You use a "best fit" or match choice to these cognitive templates to make the diagnosis efficiently and accurately.
I try to package educational content to make it cognitively most useful to the learner. I link new learning to prior knowledge whenever possible, and rely on advance organizers and other cognitive packages to facilitate retention and provide an expert cognitive framework (19—21). Remember one of the techniques that you used to teach the important facts that learners need about schizophrenia? First, you asked the students to recall a patient with schizophrenia they had interviewed on the ward, and then you used that case to develop a prototype for the diagnosis, treatment, and course of the disease. Other organizers might include contrasting the DSM-IV criteria for schizophrenia with those for bipolar disorder to help the learners achieve diagnostic expertise, and explaining the stress/diathesis model to help them understand etiology. Getting learners to focus on clinical cases and patients, and contrasting these with other clinical experiences, helps them develop a bank of prototypes to draw on (22). You can use other cognitive schemata or structures to help organize the learner's worldview and facilitate the processing of new information and experiences.
Additionally, you can do some wonderful research using a cognitive model of learning and teaching. Consider the explosion of knowledge in cognitive neuroscience. We are starting to understand how information is processed in the brain, how learning actually occurs, and what is really happening in the process of teaching and learning. We need to advance this understanding with better models of cognitive processing. Research in teaching will be based on what actually happens in neuronal pathways in the brain, using the models of cognitive neuroscience and information processing.
Dr. B's Comments:A Social Learning Perspective
Dr. Doe, you are clearly a committed educator. I'd like to introduce you to a perspective on learning that will augment what you already do.
Most of the complex behaviors and patterns of interaction that we engage in every day were learned in natural interpersonal or social settings—for example, learning to talk or learning to be efficient on ward rounds. Social learning theory (SLT) focuses on such learning processes (23). When I use SLT-based skills, the students are drawn into the learning because it is situated in live interaction. The pressure for me to be engaging or entertaining as a teacher diminishes as the material and its context take center stage (24). If you set up a safe, reality-based learning environment and establish learning tasks, then learning communities (such as a class) will be largely self-correcting and self-directing.
Your presentation on schizophrenia could acknowledge and utilize other learning modalities. In addition to reading in textbooks and listening to didactic presentations, third-year clerks have multiple other learning experiences to mobilize in learning about schizophrenia. These other modes of learning provide examples of the SLT principles of vicarious learning and legitimate peripheral participation.
Vicarious learning provides students additional opportunities to learn by observing each other's experiences. Observational and participatory learning can be synergistic (25). Let's focus on interviewing patients with schizophrenia as an example.
Knowing the signs and symptoms of schizophrenia is essential, but knowing how to elicit them from a patient is more difficult to learn and teach. How does one learn when to use different interviewing techniques? We often refer to "clinical experience" in order to explain how one gains this kind of knowledge. We can accelerate the process by, for example, having students observe and discuss interviews conducted by other students or clinicians (26). This technique facilitates the gaining of clinical experience by enlarging the learner's pool of experience, and it allows the learner to quickly identify gaps in his or her learning (26,27).
Post-interview group discussions facilitate integration and development of a flexible interviewing style as long as students feel comfortable enough to make mistakes and take chances. For the vicarious learning to reach its full potential, the discussions must feel safe enough to allow a robust group process. Disagreement will result in creative tension, which a trusting and cohesive group will use to develop a working resolution based on shared understanding.
You could increase the impact of vicarious learning in your sessions. Maximize attention by bringing in an articulate patient who has schizophrenia and who is invested in teaching students about the disease. Modulate the tension in the room by asking appropriate questions of the students. Enhance the results of the their attentiveness by telling them what to look for before the patient arrives. Have them take turns asking the patient questions. To further increase their motivation to learn, provide accurate positive feedback directly to the students about their efforts, and also provide positive feedback vicariously by showing and telling the students what you enjoy about working with such patients. Multiple, overlapping written cases, videotaped interviews, and role-playing exercises are helpful if live demonstrations are unfeasible (12). Mobilizing vicarious learning offers an opportunity to learn the complex behaviors inherent in expert interviewing of psychotic patients. Only with those skills will the facts and concepts about the illness have any meaning.
For example, how does one help an intermittently psychotic, pregnant, homeless, alcoholic woman meet her basic needs? Does knowledge of the putative neurotransmitters involved in schizophrenia ensure sufficient treatment in this case? Most of us physicians would insist on a multidisciplinary approach to her treatment. When teaching such a case to students, it isn't enough to say, "Ask the social worker about the nonmedical stuff." They must be taught how to access the expertise of others and how to negotiate responsibilities among members of a treatment team.
Conceptualizing modern-day medicine as imbedded in teamwork shifts the emphasis of our role from being the omnipotent provider to being the integrator of each team member's contributions. The difference cannot be overstated. Teamwork cannot be learned in isolation from a book, or in a dyadic setting. Learning to treat mentally ill patients relies on developing good interpersonal and information-management skills. Effectively mobilizing the learning that comes from social learning does not simply follow from working effectively on one's own (27).
The concept of legitimate peripheral participation highlights the importance of the changes in social setting that are often inherent in an extended learning process. The learner's journey from novice to competent worker to expert may involve many learning settings and the picking up and discarding of many different roles. The roles that a preclinical student, a third-year clerk, a fourth-year subintern, or a resident have in providing patient care are hierarchically different from (i.e., peripheral to), yet legitimately related to, those of the fully trained physician. In your sessions with the third-year students, you want to be cognizant of what their current roles at their clerkship sites are, and you want your sessions to support and develop those roles. Your sessions are a part of the bridge from novice student to licensed physician. The sessions are juxtaposed to second-year lectures, ward rounds, or treatment team meetings, and your goal is to offer a different educational experience that builds on previous experience, complements current learning, and lays the foundation for subsequent roles.
Safety in the group, an essential condition, develops best when group roles are clear but flexible and all members are valued. Inherently supportive, such settings modulate and buffer each member's anxiety (12). Emotional support may be particularly relevant in learning about schizophrenia, since in many ways it is one of the most frightening illnesses students face. Your teaching session occurs outside the context of a treatment team, so you can and should discuss issues that may not be relevant to the team's daily tasks, as other team members may have long ago come to terms with what it is to face schizophrenia on a daily basis.
In summary, you should mobilize all the resources available in your educational setting, starting with the type of learning that is most basic to being human. Just as in the rest of life, learning in medicine and psychiatry involves complex patterns of interpersonal interaction and is affected by its social contexts. Few illnesses carry us farther afield from familiar relationship patterns than schizophrenia. Thus, interviewing and treating patients with schizophrenia requires developing a wide repertoire of interviewing skills and interpersonal sensitivities, and the learning will be different in the classroom, on the ward, or in the mental health clinic. The richness of the illness's phenomenology and of our treatments loses its essence when faced with reductionism. You can't reduce compassionate care to low-inference behaviors. Nor can you expect novice doctors to acquire complex concepts from books alone and then be able to apply them appropriately in unfamiliar complex social settings like inpatient wards. Knowledge must be learned in as naturalistic a setting as possible. Mobilizing vicarious learning is one essential way to develop and broaden learning outcomes. Recognizing the value of legitimate peripheral participation can deepen your understanding and refine your teaching efforts. The tools of SLT help students learn to learn and enable them to perform more effectively in the intersubjective and connected world in which we live, practice, and teach.
Dr. C's Comments:An Inspirational Teaching Perspective
Dr. Doe, I'd like to compliment you on your teaching in general and on your courage in undergoing this review process. Overall, I enjoyed your presentations on schizophrenia. You covered the material well and the level of detail was about right for the class. But while you overtly appeared energetic—you moved purposefully around the classroom, approached the class, and gestured encouragingly to students—there were a couple of times when it seemed like you lost heart. For example, one time was when you apologized to the class for "having to rush through" some of the material you'd planned to cover in the session. You then seemed constrained, perhaps by overadherence to your lesson plan.
The educational perspective that I find most useful is one that focuses on what happens within me as I teach and how that affects my students. My inspiration for my teaching has come from the work of P. J. Palmer, and most of what I'll say has been taken from his writings, although he expands his thoughts beyond my focus here (28).
In order for true deep learning to occur in students, teaching must come from deep within the teacher—it must be inspired. I found myself wondering if you yourself were feeling inspired by your teaching. Do you feel like yourself when you teach? You taught the way many of the faculty in the department teach, but do those methods allow you, personally, to connect with what excites you about teaching medical students, or with what truly fascinates you about schizophrenia?
It's always crucial to teach from within—to teach from your heart. It's straightforward to figure out what to teach. The course director gave you clear direction on that. Thinking about how to teach takes a bit more effort, but even that can become dry and technical, and actually even damaging, if the discussion stops there. I've seen several good teachers—teachers who could enthrall a lecture hall or who could energize a dynamic small group—become lifeless and insipid in class when some well-intentioned but misguided curricular mandate has forced them to adopt a teaching methodology that is not their own.
The deeper question is who we are as teachers. Our ability to connect with students, and to connect them with psychiatry, depends less on the methodology we use than on the degree to which we, as teachers, know ourselves and are willing to make ourselves open to our students and vulnerable in the service of learning. I got the sense that you—or some part of you—was holding back as you taught. Perhaps there is more of an intellectual rather than a personal commitment to the methods you use? You'd have to look inside yourself and see if my hunch is right or not.
Your teaching was good, but it didn't always seem to flow naturally—not that teaching always does. Anytime you try to connect a large and complex body of knowledge like psychiatry with a class of medical students (another large and complex body) there are going to be discontinuities, false starts, and renegotiations. But good teaching comes from the identity and integrity of the teacher, and nothing you do as a teacher will make a difference to anyone if it is not rooted in your nature. The students will not remember facts—those will be forgotten or will change as new ones are discovered. The students will remember you—the quality of your individuality and your relatedness to them. That will be their bridge to learning, to psychiatry, and to their future patients with psychiatric illness.
Teaching is hard work. It's an act of hospitality—welcoming students in—and as such is a daily exercise in vulnerability. Methodology can facilitate or stifle teaching and learning. What is crucial is how your teaching reveals who you are to the students. I didn't get a consistent sense from your presentation of who Dr. Doe is—as a teacher, as a researcher, as a clinician.
My colleagues have probably given you different feedback. They are both excellent teachers, and while they teach from different perspectives, each teaches in a way that is concordant with how that individual sees him/herself and the world.
Don't fall into the trap that reduces teaching to blind technique and assumes that learning will follow. Find out who you are as a teacher. Discover your passions, your vulnerabilities, your strengths and your fears. Teach from there. Look back and think about who inspired you to teach, and what were the lessons, both good and bad, that you took from them. Look at what motivates you now. How does that fit with where you are in your life, where you've come from and where you see yourself going?
Be honest with yourself about your teaching. The methods will then fall naturally into place, and your students will learn.
Dr. Doe might be bewildered and confused by the different perspectives and feedback in this peer evaluation provided by Drs. A, B, and C. Each educator provided a compelling argument for his or her perspective and its application to the teaching setting. Alternatively, however, Dr. Doe may gain new insight into his own perspective on teaching and learning if he is able to contrast and compare his ideas with those of his peers.
One way to assist with this task is to organize different educational perspectives in the context of a general structural model of teaching/learning relationships (F1). Similar models have been proposed by others (e.g., 29,30).
The teacher stands in relation to the learners and the course/curricular content, in a particular physical setting (lecture hall, outpatient clinic, hospital ward), within a particular educational and social context. Different educational perspectives may highlight different elements or groups of elements of the model. Dr. A's perspective, for example, can be seen as primarily focusing on the relationship between learner and content. Dr. B's perspective emphasizes the connections between the learner, the setting, and the context. Dr. C's perspective is more concerned with what happens between the teacher and the learner directly. This rough mapping of different perspectives onto the structural model can serve as a cognitive organizer for talking about, integrating, or reconciling different perspectives.
Educational perspectives are important because they guide how we think and act as teachers. Pratt and associates (30) define an educational perspective as a cluster of actions (what a teacher does), intentions (what a teacher is trying to accomplish), and beliefs (why the actions and intentions are reasonable, important, or just). Actions are the manifest aspects of teaching: how a teacher organizes a class, course, or curriculum, how she or he uses teaching materials, the teaching methods or techniques employed. Intentions encompass more than just detailed learning objectives; they are closely tied to what the teacher sees as the purpose or function of his or her teaching. The beliefs may incorporate concepts from educational research, as in the case of Drs. A and B, and may also be derived from personal, philosophical, or experiential components, as is more explicitly the case with Dr. C's perspective.
There are significant advantages to teachers' being aware of and developing their educational perspectives (3,31—33) so that they become more available for discussion and examination. Well-developed educational perspectives can
Poorly developed perspectives can produce confusion and frustration when the problems, conflicts, and disappointments that normally accompany teaching occur. For example, it would be hard to implement a small-group problem-based-learning curriculum in a school where the faculty had little appreciation of a social learning perspective and were focused exclusively on the measurable educational outcomes of the National Board examinations. Similarly, without clarifying educational perspectives it would be difficult to counsel a small-group leader who saw his small group sessions as "a wonderful chance to talk with and inspire" the students, even though his group was consistently failing the multiple choice final exams.
Developing and broadening our educational perspective can facilitate the development of teaching expertise. Familiarity with one's own perspective and how it structures and enhances one's experience of teaching allows for more effective exploration of the unusual or unfamiliar teaching/learning event that calls for a new response from the teacher. Knowledge of alternative perspectives can help us devise new strategies to respond to such events, and such knowledge also provides benchmarks or external criteria against which to gauge the outcome of our efforts. Finally, an explicit educational perspective provides a structure to organize our own learning about our own teaching and to assist with the efficient incorporation of new experience into old.
In summary, just as in the practice of medicine there are many different specialties and approaches, so it is with the practice of teaching medical students. Our educational perspective guides our teaching. Underdeveloped or unexplicated educational perspectives may permit effective teaching in one instance but may lead to roadblocks in others. Thoughtful development of our own educational perspective and enhanced understanding of the perspectives of our colleagues can improve our teaching and the learning of our students.