Problem definition by students as a specific technical ...

PROBLEM DEFINITIONBY STUDENTSAS A SPECIFICTECHNICAL DEVICE FOR TEACHINGCOMPLEXCLINICALSKILLS* BY GAEDNEI~ C. QUAttTON, M.D., MICHAEL T. McGUII~E, M.D., AND P E T E E E. SIFNEOS~ M.D.

I. IlVTRODUCTIOlV The entire educational process is now being studied and questioned as never before--by educators, philosophers, psychologists, and concerned nonprofessionmals. As ths much-needed scrutiny is iin,ally extended to American medical education, it becomes clear that a large portion of current medical curriculum has evolved through historical accident, has often remained e~trenched, and has been little influenced by studies in the psychology of learning. There are, of course, understandable reasons why medicine has been slow to examine its educatio~al philo,sophy and methods. In nearly all o,f the main educational institutions, service demands have increased, and, for a variety of reasons--additional administrative responsibilities, interests in research, etc. there has been a shor%age of teachers' time. But by far the most important reason lms beea the ~staggering increase in medical knowledge during the past 25 years. Under gre~t strain faculties have tried ~o provide both didactic coverage and practical training in new medical knowledge. In the main this effort has resulted in students being required to learn more ,and more facts. To make matters worse, or at least more urge,nt, there is neither an end in .sight to the appearance of new facts nor an obvious solution to the problems of information organization and dis.semination which presently co,nfront medical educators. In addition to the problems of teaching and making available what is new in medicine, findings from many ,studies suggest that a significant portion of current curriculum should be changed to improve both the efficiency of learning and the utility of the learned material2 -~ The experimental psychological study of education has most directly concerned itself with matters of efficiency and utility. It emphasize~s that instruction of any type is not simply a matter of o~tlining a list o,f facts which the students should memorize}, ~ Concerning these points, Jerome Bruner has argued that the goals of instruction should be to teach students *This paper is from Harvard Medical School--Massachusetts General Hospital.

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to think, to take initiafLve in identifying problems, to solve real problems, and to carry out the plan~ing of their eduea,tion for both short and long-term goals. Also implicit in Bruner's work is the idea that part of the process of learning is that the ~student m~st develop efficient techniques both fo,r spotting his own ignora.nee and for correcting that ignorance. This paper concentrates on the problem~solving aspect of education. One way in which to lo.ok at problem solving is to argue that if :students eo,ncentrate on solving problems of a specialized type, they will, through M cide,ntal lear,ning, acquire the necessary facts and skills which now eompri~se the body of medical school instruction. If :such M,cide.~tal lear~d.ng is possible, the acquisition of these facts and skills might well be more efficient than it is at present, particularly because learned facts would be anchored through their ~se. These as,sumptions, of cour.se, should not be accepted w~thout e~ideaee. Yet they do appear to be both plausible and reasonable and might well serve as a guide for a program o,f educational research. In this paper, the authors' conception of problem solving is a method of proceeding from a present state o.f knowledge to some %ture :state, which may be called the "goal." In moving between these two points, specific events occur--i.e., ~subordina~e or intermediate problems are identNed a~ad solved. In certain in,stan.ces tactics o~r strategies which will be u,seful elsewhere are learned during the intermediate steps. In the most general sen,se, therefore, problem .solving has four facets: 1. The original staiement of the problem (with the path to the solution to be determined) 2. The full path ~o r solution, including false starts, errors, bad hu~ches, etc., as well as the logic, strategies, and ~acties leading ~o the correct interme4iaVe solutions 3. The solutio~ to the problem 4. Generalizedstrategies and tactics of problem solving which are derived from solving individaal problems a~d which may be used in a variety o,f different problelns Teaching which presents only facts can be regarded as teaching a set of solutions to problems which were both identified and .solved by other;s. If the solution~s to these problems are taught correctly, they may become useful tools to the .student who memorizes them. But with this k 89 of rote learning it. }s unlikely that a student

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will develop either alternative solutions to the same problems or his own techniques to solve other problems, when solutions have no~c been provided. The generalized tactUes and strategies of problem solving~often called he~ristics--~are themselves tools the teacher should give the student. We cap think o,f no place where this point is more isapo.rtant than in teaching medisal students interviewing, dUagnosUs, and patient management. In these three areas of medicine, the studen~t, if he Us to be at all kn~owledgeable, will be a.hnost entirely self taught. However necessary they may be, heuristics have turned out to be elusive entities. A number of provisionul heuristics have been identified by Simon, 7 however. One of the most u~seful is the

ability to clearly define the problem before a sotutio~ is attempted. Without this initial step, the general direction one should take will be only dimly perceived. But there Us more to clear definition than setting off in the right direction. In the investigators' experience, students who fail to clearly define a problem will frequently abandon effort,s at solution. (We do not dispute the idea th.~t much valsable thought and many pew ideas and insight's, even new problems, evolve from attempting to reach dimly perceived goals. But these by-products also appear when one has a well-defined goal. Thas, it is difficult to copdope sloppy thinking on the b asUs that it is either more pr(~ductive or ereative than attempts to reaeh well-defined goals.) A secoud useful heuristic is the abilit~ to mal~e a clear dist~nc-

tio,n betwee~t the fi~al problem to be solved a.nd the problem-solw ~ing activity itself (with its associated strategies and tactics). I t has turned out, however, that making such distinctions is a task of immense complexity, if only because one m~st Mso divorce the implicit strategies contained in any definition of a goal from the actual intermediate step,s which are n o~t contained in that definition. For example, the studeut who defines a goal in economic terms has already limited ~he areas in which he may search for a solution. Operating within these limits should not be confused with the specific intermediate steps. A third heuristic may be added to the previous two: the abihty to recognize inefficiest sub-problem sol~tian. In .any cosaplex problem there are innumerable sub-problems, some of which do not require full solution, and ~still others which require only partial so~lution in terms of the defined goal. To return to the example

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in the previous paragraph, certain readily available details may be irrelevant to the end goal (such as the sequence of particular laboratory procedurels), and others, such as the manner in which patients are booked into a medical clinic, need not even be defined except to be certain that they occur. Problem solving, therefore, is as much an activity of deciding what not to solve as it is a proce.ss of problem analysis~ .solution and synthesis. II. T ~ CovasE The authors have endeavored to .develop an instruction strategy which makes use o.f these three heuristics and to test this strategy in an ,a~tual course. To teach the first heuristic, students were required to design a flexible but effective and efficient medical his~tory (defining the problem). To teach the second heuristic, stu.. dents clo~sely scrutinized the proces~ses of history-taking itself and subjected each irde,a to clinical tests of effecis To teach the third, data nse,d to teach the second were analyzed by different criteria. The choice of subjeot was in part determined by the investigators' wish to present ~students not only with a complex and novel task in which the goals and intermediate steps had to be thought out, but :also with the ]dad of problem wherein s,tudents could see that solution demanded they forego solving a variety .o.f OLther related problems. The authors felt that this latter point should be ur~derstoo~d for practical as well as theo,retical reasons, since our subject was the medical interview--:a process in which students will often mix moral and .ethical questions with technical questions. In order to ,avoid confusion about objective.s, studeats were given almost complete respo,n,sibility for making decisions about goal choiae and intermediate go,al explication. The instruction ~strategy aims both to make explicit and to attempt to teach the~se three heuristics and may be conveniently thought .of aqs comprising three phases. These phases are somewhat arbitrary since they merge in the actual instruction s~tuation and their ;separ~ateness is stressed for the purpo~ses o~f descriptive and conceptual clarity. However, the three-phase separation is not simply arb,itrary but reflects the investigators' observations that learning experiences are somewhat analogous to a natural life history: They have a beginnin~g, a middle, and an e.nd. To the extent that this analogy is apt, it suggests two specific conse-

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quence,s for teaching. First~ there are efficient and inefficient ways to sequence the teaching material i.e., certain information or co~noepts maser be taught before others (a point recently summarized and documented for medical researchers by iVfosel2 Second, optimal structuring of the knowledge to be taught is desirable (independent of sequencing). Thus, the form of knowledge presentatio~n must be considered independently of sequencing-i.e., ideas or facts may be introduced in a way which encourages efficient or inefficient acquisition. In writing this course, we have attempted to present an histo rical viewpoint. That is, we have tried to ,state our original overall teaching goals, our intermediate teaching goals, and the teaching tacti, vs employed. A Results and Discussion Sectio,~ (See Part II) deals with the outcome of therse efforts and provides an interpretation. III. T~AC~I~TG PLAN RA~IONAL~ PHASE I: Students Decide ~tpon Goals of ~nterviewing (The problem to be solved). A. Logistic Considerations. A student seminar group, with a maximum of six students and one or two instructors, vc~s chosen. The Mze was predetermined both to enco.urage and facilitate student participation. It was felt that a number greater than six migh4 lead ~o the n on-participa;tion of certain members rather ~haa a critical interchange .of views among all participants. Conversely, a group of four or less might result either in a single individual dominating the group or in the development of per~son,al rivalries. Students and instructors met each week for two-hour sessions. Assignments for each seminar required two to three hours to complete. B. The Problem to be Solved. The instructor presented fhe students with the problem: %0 define the go,Ms of a medical evaluation ~nterview of approximately one hour's duration. In solving this problem the following limiting rules were to apply: (1) goals had to be clearly defined and comprehensible to ,all members of the gsoup; (2) goals were to be bgsed on information available to all studen;ts (see below); (3) the ~chosen goal(s) had to be specifi~c enough ,so that ~ the 16 hours allotted for the course, methods of achieving or fM]~ng to gchieve the goals could be stu~ed in a clinical setting; (4) goMs had to be justified--i.e., student.s had to provide adequate reasons for choosing one goal

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in preference to o,thers and to present re,asvns why the goal might be important. Thr,oughout the initi,al seminar hours, the instructor acted as a recording secretary by standing at the blackboard and carrying out three separate activities: (1) recording the students' ideas, (2) moderating conflict,s amo,ng stndents, ~and (3) judging whether or no,t the limiting re strictious were observed. Infrequently the instructor would add his own views, but only in terms of possibh~ alternative definitions of already present ideas. C. Time and the Teaching Materials. No ,specific time limit was set on Phase I. However, it was assumed that six hours (6/16) should be ,~he maximum. Bes ,stude,nts ~tttended that first meeting, they were assigned a transcribed medical evaluation interview to read. This allowed all students to have access to the same data from which they could begin their task. During this period go.als were acceptable ,only if they ,could be identified in the transcribed inte:rview--i.e., s:tude~tts who had already had experience in interviewing .could ~ot use their experience,. The choice of material (complex yet finite) was determined by the investigators' belief that %he students' prfor knowledge and experience with dyadic communication (not interviewing) would allow them to make a reasonable a~rmlysis of the materi~l, but provided them with a sufficiently complex task to stimulate interes.t ,and to ~a~ow them to make m~productive attempts at go,al definition. The strict application of the ru~es f~or acceptable data obv~oxlsly limited the amount o~ information available to the ,seminar. It was felt that the restriction was valuable in ~hat it would a~ow time for all goals ~o be Iegitimately questioned by other semhlar members. D. Comme,nts on the F~rst Phase. The instruction objectives of Phase I were to enco,urage stude,nts to state the problem. This process ~started with a body of unorganized teaching material witho~t the aid of existent ordering schemes or concepts. What they o.r~anized w~as to be me~an~gful to the participants ~an.d presented in a clear arid precise form. The aim of organizing the course in th~s man,her was to establish the first heuristic (clear problem de~mitio~) to which the students could relate intermediate step,s during Phase II, when they would make initial ~t~temp~s at problem solution. A second aim was to force students to use actuM data rather than ideas o,r hearsay. Still another aim was to f,o,rce students ~o develop a corn-

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mon voeabularly .so that discus,stoats about the intermediate steps would ,not bog down in the reporting of experience,s in personal terns. There were several aims in having the instructor function as recording secretary. Each instructor could allow and encourage students to develop their owaq vaguely formed ideas by systematically defining the goals and by co.nstantly forcing them back to data available in the tr,anscripts. IIis constant nondirective but structurally-limiting role was also designed to achieve another objective: The instructor insisted that goal definiti~on continue until the goals took a form where they could be tested in the clinical situ.ation. (For example, there would be a relatively good po~ssibility of testing the goal of "assessing patient expectations," but a relatively poor possibility of testing the goal of "doctor-patient rapport.") The authors suspected that students would not grasp the full complexity of the problem definition aspect of the task until the course was well trader way and students had begun to test their idea.s in an actual clinical situation. Hence, precise goal defini'tio.n was imperative so that achievenaent could be measured, Thus, although it was anticipated that there would be a number of goal changes during Phases I I and III, change was less important than clear definition, for the original commitment to specifying go,a}s, testing them, and in some eas~s redefining them, was eoItsidered an essential element of the ixstruction. During this phase, it was hoped that learning would occur in the following ways. From Lhe very first, the student had to engage in decisio,n-making and data-ordering if he were to make sense out of the teaching material. Extensive conceptual ordering would be required because of the intrinsic logical nature of the task and by the logical requirements set by the instructor. Toward this end, the teacher was to constantly insist that students order their ideas. The purpose of impo,sing r~straints of logic o,n the students was based on the belief that it was the only way to insure that ;students think through their ideas thoroughly. Learning by thinking w~s, thereto,re, a major component of Phase I. The second componen?~ was ~o encourage :students to learn thr.ough the use of skills they already possessed but did not realize they possessed. In part this point would apply to data organization, and in part to .drawing inferences about reasonable goals from the interview transcript,s.

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Finally, it is important to emphasize that during Phase I, the instructors tried to communicate to students that there were no intrinsically oorreet ways to order the data. This meant that the teaching data would be s~sceptable to several method, s of ordering which were not predictable in advance. This was done by announcing this f a c / t o students several times. P~ASE II. (First Part) Students Take I,ntermediate Problem-

A.

Solving Steps Logistic Co.nsideratians. Same as tho,se outlined for Phase I.

B. The Problem To Be Solved. With one or more goals having been defined in the previous phase, the problem during the first part of Phase I I was to shift the discussion to the technical methods .of interviewing and their effects on either obtaining or interfering with achieving the goals previously outlined. The ]inlLting requirements for informatio~a which were acceptable in Phase [ were to be especially exnphasdzed during this phase: All intermediate solutions had to be supported by evidence available to all mere. bers of the group. However, the sources of awailable information were expanded, principally by Mlo,wing .students to report (in summary) their attempts to reach the stated go,als in an actuM clinical setting. Thus, certain tecLhniques~e.g., specific types of questions would bring specific types of an.swer~s--were quickly accepted, tested, and used as intermediate steps by students. In other cases, when an intermediate solution was suggested which was not acceptable to all students, it was given the .stattcs of "provisional" and each member of the gr,oup w~s then required to test it in a clin~oal situat~o~ before the ,subsequent meeting, at which thne its relevance would be ~ssessed. 2~n example will clarify the,se points. A goal of interviewing might be to ~s,certaLu the "previous medical history of the patient." A method which was often recommended for obtaining this end would be to start the interview with a non~spe,cific question (an "open-ended" question) and gradually become more specific as the interview continued. Reasonable as this approach might sound, it could no~t be accepted as a technique, if it were neither illustrated in the transcript nor tested clinically and shown to be relevant to solving the problem of obtaining the history. One purpose of

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i~sisting ,on such a requirement is clear enough: It forces the student to examine all concepts, even if they are a priori reasonable. C. Timing c~nd Teachizzg Methods. No specific t~me limit was set for th~s phase, but it was estimated that it would require sevensixteenths of the course. P~ASE II. (Second Part) A. Logistics. Essentially the saJme as the first part of this phase, except that the second part was to begin af%er students (1) had attempted to identify the intermediate steps in problem solution, (2) were actively testing these steps, and (3) were relating their findings to the original go,al(,s). B. The Problem To Be Solved. The problem to be solved in this part was distinct from the first part in the followin~ ways. An independent analysis and ordering of the same data and problems were provided the students (not necessarily the il~structors' analysis). The purpose was to introduce students to another point of view which they could either incorporate into their own evolving concep4 or reject, but either way o~ly with adequate reason and evidence. This served to increase the body of available information. C. Timing and Teaching Material. For the second part of Phase II, :stu.dents were forced to analyze the interrelationship of techniques to stated goals. This continued antil the instructor believed that they were as,ses~sing the relationships between i_ntermediate step,s a~d goals. D. Comments on Phase I I (Both Parts). There were three instruction goals in this phase. First, students were to explicate and test intermediate ~steps--technique.s of in~terviewing. Second, where passible, the instructor ~attempted to draw students' attention to the possibili%y ~hat intermediate solutio.~s were sequence-dependent and that final goals afteu changed as a result .o~ experience and testing. The third instruction goal was to introduce the student to methods of .taking other solutions to similar problems and, through testing, reject or .accept them. It was the in.vestigators' belief that the group size in this phase would be especially importani---small enough to allow students to exchange concepts of evidence, but large enough $o assume a variety os .experiences in testing. As in Phase I, ene side effect of such interchange was felt to be the gradual definition and con-

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ceptaal refinement of numerous 4~ticult and ambiguous terms dealing with problem solving str~tegie~s, classification of techniques, etc. P~ASE III. The Student Digests, Orders, Accepts, Rejects, a~nd Tests His I%termediate Solutio~ns and Compares them to his Orig~ inal Goals. A. Logistics. Same as Phase I. B. The Problem to Be Solved. The main problem to be solved ~as to decide which inte~rmediate steps were most effective in achieving the original goals, which ,steps we.re ineffective, and which steps suggested that the goals were inadequately defined. C. Time and Teaching Material. The teaching material and the requirements for the use of informati~on remained the same throughout 'th~s please as in Phase II. The time was ~stimated at four-sixteenths of the course. D. Comme~nts on Phase IfI. The main goals of this phase were to allow students to order and assimilate their own created and tested problem solution meth,ods, to continue to test their hypotheses outside of instruction periods, to further refine their own criteria for judging efficie~t methods by which to pursue particular go~als, and to grasp how method directly influences the informatio~ received. In outline focm, this phase requires little space. However, ~t was considered essential to ~ e course in that it allowed for solidification of what had been learned. I:~ESULTS

The course as described has now been given to three groups of fi~st-year psychiatric residents .and 12 groups of third-year medical students. Comparing residents to students, two quite different sets of results were obtained. At the most general level (.subjective impressions), the psychi,atric residents were pleased with the course. It was the investigators' impcession that the original objectives were achieved with the group. With but a few individual exceptions the opposite was true with the medical students (even though many of the s ~ e instructors taught both residents and students). Students felt they learned s.omething, but they were not really pleased

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with the course. The instructor.s felt that the goals had not been achieved. Four measures ~ere used to ass,ess the course: (1) The number o.f defined goals, (2) the number of defined techniques, (3) goal.technique ratio., i.e., number o,f goals with defined go~al-related techniques x" total goals q- total teakniques and (4) the number .o,f suggestions for changing the course (derived from a post-co~urse questionnaire). (A) Number of Individually Defined Goals: Medioal students (Av/group) ~ 6.1 major goals, Range ~ (4-9)--5.3 sub go.als, Range ~--- (4-8) Psychiatric residents (Av/group) ~ 8.4 major goals, Range ~ (7-11)--11.7 sub goals, Range ~--- (9-15) (B) Number of Individually Deigned Teclmiques: Me~dical students (Av/group) ~ 4.7, Range (3-8) Psychiatric residents (Av/group) ~--- 10.6, Range (8-14) (C) Goal-Technique Ratio : Medical students (Av/group) ~ .59 Psychiutric residents (Av/group) ~ .78 (D) Number of Suggestions for Changing the Course: Medical students (Av/group) ~--- 5 Psychiatric residents (Av/group) ~ 9 Several additional ,subjective observations were agreed upon by the instructors and might also qualify as refsults: (A) Psychiat~c re,sideats participuted in all three phases of the co~rse; they developed extensive outlines of the relationship of techniques to goal.s and they actively tested their ideas about interviewing. The medical students, on the other hand, were noticeably les~s enthn'siastic about the course, and failed to .show any of ~he sp,ontaneoas interest shown by residents. (B) Following completion of the ,co~rse, residexds felt that their interviewing style had changed, a~d that they were better able to interview. Several months later they felt the same way. ~edical ~students, on the other hand, did not feel that their style w~s appreciably altered, or that they were signifioanfly better interviewer~s because of the col~rse, although almos,t all agreed that some benefit was derived from the ]_6 s.essi:on~s.

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DISCUSSION There are several explanatiojr~s for the results. One .of the most obvio,us and o,ne which could be inferred from medical student comments is that they did not view the technical aspect~s of interviewing (intermediate steps) as important diag~o,stic and therapeutic tools, whereas the psychiatric residents did. Students seemed more concerned about recognizing disease,s---it was the first clinical year--which they had not yet learned at the time the course wa,s given. They thus placed a high prio~rity on diagno,sis and seeing sick patie~ts and a low priority on learning the techniques o,f gaining the information they needed for diagnasis. It is tempting to try t,o explain away the relatively poor results with the medical ,students by saying that they lacked the experience to utilize the course properly. ~owever, thi,s argument is probably ~o~t pertinent because the course v~a.s a.ctt~ally ~n.struction in methods of thinking, which ~should, at least in principle, be applicable at a~y time in a .student career. This line of re,aso~ing suggests the f~ollowing explanation: Learning will not be enthusiastically pursued unless it is viewed ,as relevant to the goals students have set for themselves. (In the paradigm we have outlined for learning, the course paradoxically turns out to, be an intermediate step unrela• to ,a goal.) Put s~omexchat differently, :s.tudent,s must envision. ~some ~ain (real or Zancie,d) from their effort in o,rder to exert themselves. It might also be worth considering the p o,s~sib~ty that ,student,s often think thai courses dealing with non-real entities (~ranscripts, etc.) ,are "phoney" and respond as though the learning exercise wa,s trivial. These arguments touch on two. is,sues of pedagogic pro,cess~the timing and the content of courses, i t ,can be inferred from our findings that both the timing a~d the content were wrong f.or the medical students. Whate~er the inte~tio,ns of the instructors, students appear to be subje.ot to more per:suading influences, such as what they believed were e~ssenti.al skills to beco~r~ing a physician. We would infer, therefo,re, that any co~se should be given a place in the curriculum with this co,r,~s~deration in mind. In line with this idea, it is suspected that had the course been titled something like "Strategies in Diagno.s~s," the medical students might have been more receptive, for as already suggested, they saw diagnosis as essential.

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These .considerations perhaps shed some light on why the measures used to asses,s the course inHeate that the psychiatric residents learned arid benefited more than did the medical students. Residents came up with more major (logically Hs~inct) goals as well as sub-goals tbran did medical .students. The same was true for techniques. The goal-technique ratio als,o can be interpreted in the same way. For, as we understand the f.ormula, the closer the ratio approaches unity, the more teclmiques were being assessed us possible intermediate steps to achievhag defined go,als. Thus ,a list of goals would be takea to indicate Simon's fir,st heuristic (problem definition). A list of techniques which were apparently related to the gouls would be taken as ,an indication of exp~eating intermediate steps (the second heuristic). The fourth measure, that of averaging the suggestio,ns for changing the course, can be interpreted in either of two ways. We cho,se to take the greater a.umber of ~sug'ge.stio~s both as a mea~sure of participant interest and indirectly as an indication of having run into nontrivial problems in an attempt to stay within the limits set by the eoFur, s e .

In af.tempting to assess if students and residea.ts ~etually learned (or were taught) the three heuristics, a number of diffieulties ,arose. For example, the clear definition of a problem (the first heuristic) is complicated by additional factors. First, in .actual practice, goals usually undergo redefinition once an attempt is underway to ,actually achieve the ~o,als. It .appear,s that the experienced physiei,an first begin.s an interview with what he believes are reasonable go.als for the imitial interview, only to accept a reduction in the total number as well as a redefinition of other,s o~ee the interview is underway, and he has assessed the possibilities inherent in the sit.u,atio~.. These alterations appear to be purely pragmatic and determined by what the physician believes he can achieve with the toots (intermediate steps) available to him in the time he allots himself for the interview. Thus he may decide that certain techniques (for example, forced choice questions) do not gain reliable informatioa. He may believe that the use of ,certain other techniques (open-ended questio,ns), while they work, cause particular patients to respond with more details than the physician is actually seeking. The sa~ne sequence of events appears to have occurred in these ,studies. What both students and residents felt was important during, the first hours of the seminar

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TEAC]~II~G CO~IPLEX CLINICAL SKILLS

seeaned to change in importance as the meetings went on. It was the authors' impression that the r estrictiorLs pl.aced on admis,sible eviden,ce actually enhanced this redefinition process and the active pursuit of related intermediate steps, since similar .aour~ses, where restrictions have not been set down, have often deteriorated into discussions o~f individual differences among participants. Perhaps, however, it is mere important to realize that these two heuristics interact in the sense that intermediate goal solution ser~es to lead to redefinition of the final goal(s). We were satisfied that the psychi~atric residents made sortie steps toward learning Simon's two heuristic principles. This was particularly apparent when the residents were able to demor~strate to their own satisfaction tha~t specific techniques which were good fo,r achieving certain goal,s almo.st automatically precluded the pursuit of others. We were considerably less certain, however, when we attempted to assess the ~ability of residents and student,s to, identify intermediate ,steps which had a,o apparent value in solving pro~blems-i.e., to identify inefficient sub-problem solution (third heuristi,c). Neither from the students nor residents we.re the results satisfying. Residents seemed to ,set forth their go,als and then pro.oeed toward them by quickly testing their ideas. In certain cases they discarded techniques which, in ~he authors' experie~tce, would have been valuable had they been tested in other s~tuations. Hence, they ,seemed les,s willing to experhnent than we had hoped. Medical stt~deats, on the other hand, seemed t~o be forever groping, redefining goals, being uncertain of evidence, and not being certain when it ~ a s a~o longer profitabl'e to pursue a sub-go,al. Judgments as to the meaning o~f .such behavior are complicated by the fact that the investigators believe that it is .often necessary to th'~k of an intermediate step as "provisional'" ,and pursue it to its illogical end before realizing that it adds little to achieving the defined goal. Wh~t we t~sually call "trial ~nd error" l e a r n ~ g ~.s ,az~.ticipa~ed, therefore. Mo,st likely, however, there are still other consider.atio~s, since there was ,a great difference between residents and students in the extent to which various intermediate goals were pursued. Other things being equal, it wa;s the over~all i~pre,s,sion that both students and residents pursued intermediate step,s--specific techn i q u e s - a s long as they were productive of new and/or "relevant"

infol~mation. This principle seemed to apply both with details of specific ,symptoms, ,and the larger "as soeia,tionM type" information often ,sought to a,ssess the general mentM-so~cial environment eontext of file patient. Elsewhere, one of the authors has written about the operation of cognitive thought patterns, which for the purpose of this paper may be filougl~t o~ as comprising a finite set of faots and intereonneat~m~s (rules for connecting facts) between these facts. ~ To the extent that the~se facts and intereonneetions represent one type of incidental learning, the eo.urse may be considered successful for both medical students and re:sidents. For it was our impression that the amount of as,able factual material both students a~d residents had available at the end of the (~our.se was much greater than in didactic eourse,s covering the same material. The re~sults may be looked at in still other ways. In reviewing the ~o,als and the results of file course, it seems clear that the instruetor.s' principle objective was to teach self-eo~rreeting i n f o f marion proee,ssing tec~.iques. To be sure, any hope of achieving such a.n objective in 16 hour~s ~s unrealistic. This attempt seemed worthwhile, however, even though it must be ~dmitted that it strongly refle.ets the investigators' belief that things which have traditionally been thought .os as "art," .such .as inte~wiewing, do have a purely teeh~icM .side. The fact that most o,f the .students consider it important that medicine contain an element of "art," where,as the residents were less concerned, may be a more irapor~ant point than we had orig'mMly realized. There was information feedba~ek from the shldents that we were atte~npting to "regiment" a "personM part of medi.cine" and that the co~rse might be objected to on these gro.u~&s alone. Residents, on the other ~and, saw interviewing primarily as a "tool." One other point which was and remain:s tro~bles~)me to interpret is the effect of sequencing. For example, would it have been wi.ser to use a sequence in which students first had some experience, then formulated so,me goals, and fm.Mly studied transcripts to as eerta~ if the goals had any applicability? Subsequent experienee has suggested that some p.rior clinical experi.ence would have been. worthwhile since students were really unaware of the variety of interview situations and thu.s had little extra-course information to go on.

~J0~

TEACHING COMPLEX OLllNI(JAL SKILLS

It is clear that these arguments fail to take into consideration individual differer~ces. AJad, although the idea of different types of learning as well as different sequences of learning designed for specific individuals is both aestheticMly pleasing and reasonable, the results suggest that it is profitable to question seriously the merit of designh~g teaching problems with this goal in mi~d. That is, h~complete as they are, oar data suggest t~at the level of training and values which exist within the prevailing social system are more influential in directing and determining interest than are considerations of indi~duality.

Additional Cansiderations In the space available we cannot possibly deal with the extensive body of theory which led us to select certain information for discussion. A number of ideas which appear to have pedagogic importance, but which did not receive full discussion, are briefly presented in the remainder of this paper. Each of these ideas raises a number of theoretical points which should be considered in any pedagogic theory of problem-solving ~struction. 1. The Displacemen~ Notion. Study of data which o%hers have created ~illustrates the use of the d~splacement notion. In the course described, the early use of transcripts, in preference to real interviews, represented an attempt to apply this notion. The objective of displacement is to free the student from self-~nposed requirements to ~chieve so that he may (1) be as objective as poslsible in his analysis ~of das and (2) lo,ok at other solutions to the same problems he is studying without undergoing the difficult and often frightenh~g experience of having his own work judged before he has developed his ,o,wn techniques and criteria for judgment, and mastered the material to the point that he may judge the wo.rk of others and their evaluation of his own. Displacement might be justified, theref~o,re, on the basis that it protects students from .suffering embarrassment at the beginning of a complex task where a vague knowledge .of what should be striven for often hinders and restrains the student instead .of assisting him. 2. Trc~nsfer of I,~itiative to the Student. The student must eventually take the initiative of analyzing teaching materiM as well as of ~onducting his own evaluation of his leaxning teelmiques. Both to encourage and force this sittmtion, it can be argued that the teacher should refrain as much as possible from any involve-

G. C. QUAI~TOI~ IVL T, MC QUII~E~ AI~D P. E. SIFI~EOS

~05

meat in problem solution until l~te in a given co,urse. By the teacher's relative nonparticipation the student will be freed from an authoritarian evaluation of his efforts and simultaneously be encouraged to exercise whatever natural initiative he possesses as his poin.t of departure. Ideally he would accept the alternative of establishing his own criteria for evaluation of his progress toward task completion. However, the results of this study suggest that the timing is important and may be .content specific. 3. Facing the Fact of Goal Co~nflict. Conflicts always exist as to the choice of methods and goals. Choice of one method and/or goal means others must be temporarily set aside. This conflict is probably unresolvable. Consequently, it would seem to be necessary for the student to comprehend that this choice to pursue certain objectives precludes the pursuit of other goals or use of o,ther metho,ds. 4. Rehearsal and Practice. For st~den,ts to develoo a broad rather than limited approach to understanding material under study, we wor argue that there should be s,o~ne rehearsal and practice in the nonstressful situation before they undertake actual practice. We attempted to institute this idea through the use of transcripts and the analysis ,of o~lers' mistakes. This would seem a reasenable way to prevent quickly learned and inefficient techniques from becoming set by the early confrontation o.f complex and stressful tasks. Through rehearsal and practice in ordering and evaluating data, the type of course described provides a situation where there is an opportunity to test a number of organizing approaohes to the data, and where rehearsal aaqd practice in a group setting introduces the other members o,f the group to the specific skills of several students. 5. Rules of Thumb vs. Unique Details. Generalizations do not always explain specific situatio,ns; empirical evidence does not always lead to generalizations. These axio~ns represent experience. Yet it is difficult to teach them in a viable form .simply by telling students that this is what .o.ccurs. But by requiring a general ~laSk to be so,lved where the s~udent must begin with a finite but extensive body of 4a~a, the difficulty of this pr.oblem is at least given meaning. As a student works to mal