Radiology
Editorial Richard B. Gunderman, MD, PhD Kenneth B. Williamson, PhD Mark Frank, MD Darel E. Heitkamp, MD Hal D. Kipfer, MD
Learner-centered Education The discipline of colleges and universities is in general contrived, not for the benefit of the students, but for the interest, or more properly speaking, for the ease of the masters. Adam Smith (1) Many instructors believe, perhaps implicitly, that learning depends primarily on the teacher. The teacher-centered model of education places all responsibility for decision-making about what is taught, how it is taught, when it is taught, and how learner performance is measured squarely on the shoulders of the teacher. This model views teachers as active participants in the educational process and learners as passive receptacles of knowledge. Current educational theory, however, argues for a learner-centered rather than a teacher-centered approach (2). The overarching purpose of education is to produce educated learners, and teaching is a means to this end. With this view, teachers should place less emphasis on what they know and more on what learners bring to the educational encounter.
Index terms: Editorials Education Radiology and radiologists Published online 10.1148/radiol.2271021124 Radiology 2003; 227:15–17 1
From the Education Division, Department of Radiology, Indiana University Medical Center, 702 Barnhill Dr, Rm 1053, Indianapolis, IN 46202-5200. Received September 6, 2002; accepted September 9. Address correspondence to R.B.G. (e-mail:
[email protected]).
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RSNA, 2003
As is typical of medical educators, many radiologists have received little or no formal instruction in how to teach effectively. Much of their past education has been more teacher centered than learner centered, and there is a natural tendency to teach others the way one was taught. For example, the concept of “fund of knowledge” is a teacher-centered notion that derives from standardized testing. Educators who operate on this paradigm act as though they can put a dipstick in a learner’s head and measure the amount of knowledge the learner has acquired (3). To improve the quality of radiologic education, radiology educators must develop a deeper and more complete understanding of what goes on in the mind of the learner. We argue that, in spite of their apparent success, medical students and residents resent learning environments in which they are treated as if they were children and are given little or no responsibility for their own education. As learning environments become better adapted to the needs of learners, we believe that medical students and residents will emerge with a greater degree of useful connected knowledge and a higher regard for what they have learned from their teachers. Because medicine can be only as good as the people who practice it, our whole society benefits when medical education is improved.
Problem-centered Learning Reflecting on the sheer volume of material they must master, medical students and radiology residents frequently they feel overburdened and anxious. Recognizing that no one can learn everything, they eagerly seek clues to what they really need to know. Hence they embrace teaching that helps them perceive how
what they are learning can be used to solve real-life problems they will encounter in clinical practice (4). For example, medical students will find more motivation to learn radiology when they see that what they are learning will enable them to take better care of their patients during internship and residency. A good radiology educator will focus on how medical students can make best use of radiologic resources, including which tests to order in which clinical situations, and how to recognize basic but urgent imaging findings, such as pneumothorax or pneumoperitoneum. To begin by simply presenting a medical student with what a pneumothorax looks like on a chest radiograph without first addressing its clinical relevance is to miss an important learning opportunity. The educator should first address such questions as: How common is pneumothorax? What may cause it? What threats does it pose to a patient? Likewise, radiology residents need to see the practical value of what they learn. By prefacing discussions of particular imaging findings with information about how frequently residents will encounter them in real-world practice or about how not correctly identifying and interpreting those findings can injure the patient, the teacher can dramatically increase the students’ motivation to learn. For example, before teaching radiology residents how to recognize and treat adverse reactions to intravenously administered contrast material, a good radiology educator will help them to understand why they need to know it. An effective means of doing so is to begin with a real-life case of a reaction to contrast material and ask them how they would handle it. Transformation of learners from passive listeners to active prob15
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lem solvers is the desired result, and frequent exposure to actual clinical cases in which they can apply what they are learning is a great strategy for reaching that goal. Testing learners in ways that encourage development of creative thinking and problem-solving skills will help produce this result.
Respecting the Learner People who choose careers in medicine tend to place a high premium on personal autonomy. They resent instructional strategies that treat them as if they were children and tend not to respond well to situations that allow them little or no choice. It is important to them to believe that their own learning needs and preferences have been taken into account. As a result, medical students and radiology residents are likely to learn more effectively in an environment where they participate and collaborate with one another in the learning process. Given enough time, a poor learning environment can undermine learners’ desire to play an active role in their own education. Failure to respect learners fosters an attitude of “learned helplessness.” With this attitude, learners rely entirely on instructors to tell them what to study and place greater emphasis on memorizing what they have been told rather than on truly understanding what they need to know. Such an attitude is antithetical to the habits of lifelong learning that medical educators are charged to instill. Knowledge is not something to be “dumped” or “downloaded” on learners. Rather, learners must be active in determining what they learn and how that learning takes place. Medical students, for example, might be invited to discuss their top learning objectives for a radiology elective, and radiology residents might be invited to participate in reviewing and perhaps revising the format of their daily case conferences. Respect for learners is manifest in attempts to orient education around their own particular needs and abilities. Teachers who make no effort to adapt their instructional strategies to the knowledge and experience of their learners are implicitly dismissing both the learners’ need to participate in their education and the prior experience they bring to the table. For example, medical students or residents might occasionally contribute cases of their own that they have encountered in clinical practice. Such an approach makes the relevance of the material obvious, because learners 16
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themselves selected it. It also gives learners an explicit role in shaping how they structure their educational experience.
Experience-based Learning The earlier the stage of training at which medical students or radiology residents happen to be, the greater the danger that radiology educators will fail to make meaningful connections between what learners already know and what they are learning. For example, in teaching a 1st-year medical student about congestive heart failure, offhand references to concepts such a dyspnea, Starling forces, and cardiothoracic ratio are unlikely to prove helpful. In contrast to 1styear students, 4th-year medical students should possess a serviceable understanding of such concepts, which can be readily integrated into their learning experience. Similarly, 1st-year radiology residents are limited in the imaging findings they can detect, the differential diagnoses they can offer, and the recommendations for further evaluation they can provide. Therefore, problem-centered instruction must be tailored accordingly. On the other hand, 4th-year residents might be bored or even insulted by clinical problems designed for 1st-year residents. Wherever possible, educators should make an effort to get to know learners and to develop an accurate perception of their past experiences. When learners believe that educators respect their past experience and learning, they are more likely to pay attention to what they know and build on it (5). If learners believe that educators are poised to pounce on every indication of ignorance and use it as an opportunity to humiliate them, they are much less likely to acknowledge “lacunae” in their understanding and ask for help with areas of confusion. Great educators regard what learners already know as fertile soil on which to sow the seeds of additional learning. They regard what learners do not know as an opportunity to do what they do best—to teach—as well as to help learners become more effective at learning. As learners become accustomed to thinking about their own education in these terms, they are more likely to develop the habits necessary to learn effectively throughout their careers.
Excelling at Learning It can be very disappointing and demotivating for learners to believe that edu-
cators are merely talking at them rather than talking with them. Good educators enjoy what they do, but they do not use instruction as a vehicle for their own selfaggrandizement. The purpose of education is not to puff up the self-esteem of educators and, thereby, draw attention to how much they know in relation to how much those they are teaching know. Rather, the purpose of education is to foster as much learning as possible about the most important things learners need to know. Learners do better when they believe their teachers care about them. One way of inspiring this sense in learners is to ensure that the learning environment focuses more on the performance of the learner than it does on that of the educator. Learners express the highest and most enduring admiration for those educators who help them recognize what they are truly capable of and who inspire them to achieve that potential. Medical students and radiology residents tend to be high achievers who need to see growth and improvement in their work. Hence, instructors should provide them with meaningful challenges to test what they have learned and give those who are doing a good job an opportunity to shine. Evaluation is not merely about selecting and sorting learners; it is also about providing meaningful feedback that learners can use to do a better job and about motivating them to do their best (6). Some educators might mistakenly suppose that they have done enough by ensuring that students and residents do well on their board examinations. Most learners are capable of accomplishing much more. Great educators approach teaching in a way that inspires learners to pursue new knowledge by inviting them to become involved in research. Likewise, great educators ply their craft in a way that encourages learners to become educators in their own right, and they encourage learners not merely to assimilate information for their own recall but to inspire others to learn as well.
Intrinsic Motivation As learners mature, they tend to become motivated by their own needs and interests rather than by the expectations and requirements imposed on them from the outside. The erroneous but widespread assumption that learners are motivated primarily by the desire for high grades creates a counterproductive educational environment (7). Medical students and radiology residents will spend Gunderman et al
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most of their professional lives in an environment where they do not receive grades. If the only reason they ever open a textbook or journal is to earn a higher grade, they may find that their motivation to learn soon wanes once they move out into independent practice, where they never receive a report card. To facilitate the intrinsic motivation to learn, radiology educators should pay attention to what makes their learners tick. What motivates people to learn? Simple curiosity, the desire to understand something for its own sake, may be the most important motivator of all. The exigencies of real-world practice can be another important motivator, as when medical students become more proficient at detecting cases of pneumothorax on chest radiographs once they have confronted the adverse consequences of missing the diagnosis. Another important motivator is the opportunity to make a difference in the life of a patient; for example, by locating the source of a fever or relieving the fever by draining an abscess, the medical student can truly help the patient. Intrinsic motivators include the desire to excel at one’s craft and the desire to be acknowledged as an outstanding clinical radiologist to whom colleagues can turn for help with their difficult cases. By tapping into these and other sources of intrinsic motivation to learn, educators can energize learners and prepare them to do their jobs more effectively.
Varied Approaches When it comes to education, one size rarely fits all. While it would be logistically impossible to design an individualized curriculum for every learner, it is possible to use a multiplicity of educational approaches to ensure that most learners encounter one or more learning methods that work well for them (8). For example, some learners are visually oriented and benefit from seeing concrete manifestations of concepts with their eyes. This includes not only viewing actual images of radiologic findings, but also seeing slides, handouts, and computer graphics that demonstrate key concepts in a concrete way. Other learners respond well to aural presentation and may find their learning
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substantially enhanced when they hear material presented, in addition to seeing it on a page. Today, we enjoy new instructional technologies, such as the Internet and dynamic electronic media, and a virtual classroom may offer additional opportunities to improve the learning environment in learner-centered ways. For example, an online learning framework could be adjusted by and for each user and provide components of text, audio, still images, and video that are adjusted to how each learner learns best. Some learners may be highly motivated by sheer love of learning, whereas others may take a real interest in material only when they see it as a matter of immediate practical importance. To reach the former group, it might be sufficient merely to help learners realize that they do not know something, whereas to reach the latter group, it might be necessary to indicate why they will need that knowledge in day-to-day clinical practice. It is nearly impossible to incorporate all possible approaches to instruction in a single lecture or learning exercise, but use of a multiplicity of approaches helps to ensure that nearly everyone connects with the material in one way or another.
Conclusion It is a mistake to treat learners as though they were empty vessels that simply need to be filled with knowledge. Learners are, after all, human beings, and they approach learning no differently from the way they would approach any other life task—with a set of motivations, concepts, and personal beliefs. These learner characteristics pertain not only to the particular subject area of study but, more broadly speaking, to knowledge itself. By helping learners perceive the meaning and relevance of new knowledge in terms of their prior knowledge and experience, educators can enhance learning. Not only will learner performance be enhanced but also learners will think more highly of the quality of education they have received. By giving learners a chance to use what they learn in practical situations, educators can help further consolidate their knowledge and prepare them to put their learning to use in real-
life situations. The same principles apply to evaluation of learner performance, where assessment tools require learners not merely to recall information but to apply what they know by making decisions in situations that closely approximate clinical practice. Shifting the focus of radiology education to the learner produces a number of benefits. First, fully engaged learners make important contributions to their departments and schools by performing better clinically, offering constructive criticism regarding their educational programs, and representing their programs well when they leave their institutions. Moreover, highly motivated learners enrich the educator’s experience, and their success helps to alleviate burnout and enhance professional satisfaction. Finally, helping medical students and residents excel as learners inspires some to consider academic careers at a time when the ranks of academic radiology are thin and there is an urgent need to develop new radiology educators. By reorienting much of the focus in radiologic education from the teacher to the learner and by fostering a greater sense of respect on the part of educators for the people they are teaching, we can enhance the overall quality of radiologic education and practice.
References 1. Smith A. The wealth of nations. Book 5, chap 1, pt 3. Chicago, Ill: Encyclopedia Britannica, 1952; 333. 2. Hansen EJ, Stephens JA. The ethics of learner-centered education: dynamics that impede the process. Change, Sept/Oct 2000;41– 47. 3. Feltovich PJ, Ford KM, Hoffman RR. Expertise in context. Cambridge, Mass: MIT Press, 1997. 4. Knowles M. Andragogy in action. San Francisco, Calif: Jossey-Bass, 1984. 5. Rogers CR. Freedom to learn. 4th ed. Columbus, Ohio: Merrill, 1994. 6. Gunderman RB, Williamson KB. Feedback in radiologic education. Acad Radiol 2002; 9:446 – 450. 7. Kohn J. Punished by rewards: the trouble with gold stars, incentive plans, A’s, praise, and other bribes. New York, NY: Houghton Mifflin, 1993. 8. Wilkerson L, Irby DM. Strategies for improving teaching practices: a comprehensive approach to faculty development. Acad Med 1998; 96:387–396.
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