Learning in Medical School

Learning in Medical School: A Model for the Clinical Professions

John I Balla
Margaret Gibson
Anne M Chang
Copyright Date: 1989
Pages: 240
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  • Book Info
    Learning in Medical School
    Book Description:

    The purpose of this book is to develop the beginnings of a suitable theoretical framework for medical education which could be taken as a model for education in the other clinical professions. It should therefore prove relevant to those who teach in nursing or other allied health professions, where two of the editors come from. All the contributors have an impressive record of achievement in educational research and a wide range of publications. The book is aimed at the expert, but the clear expository style of the authors will make this suitable reading for the relative novice in the field.

    eISBN: 978-988-220-198-9
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-vi)
  3. Preface
    (pp. vii-xii)
    John I Balla
  4. Acknowledgements
    (pp. xiii-xiv)
  5. Contributors and Symposium Participants
    (pp. xv-xviii)
    • Chapter 1 Changing Concepts in Clinical Education: The Case for a Theory
      (pp. 3-18)
      John I Balla

      It will be suggested in this chapter that while medical students are prepared with a solid foundation of science, clinical practice does not always reach its full potential as a rigorous scientific discipline. It will be argued that we need to change our perceptions of the practice of clinical medicine in a modern society. To do this, we shall describe a particular way of looking at the clinical process and will relate it to the education of medical students. It will be stressed how societal forces change our mode of practice and how some theories on student learning become relevant...

    • [Introduction]
      (pp. 19-20)

      In the first chapter of this section, Biggs responds to the question: “Based on modern theories of learning, what are the likely reasons for difficulties in the integration of knowledge?” and in answer to this, many themes are introduced that are central to this book. Learning and problem-solving in everyday life differ markedly from learning and problem-solving as carried out in schools and universities; this difference affects both the students’ motivation, and the nature and level of abstraction of what is learned. Professional faculties such as medicine need to integrate abstract knowledge with problem-solving in practical contexts. This chapter explores...

    • Chapter 2 Institutional Learning and the Integration of Knowledge
      (pp. 21-40)
      John B Biggs

      Institutional learning in schools and universities has characteristics that make it quite different from everyday learning (Resnick, 1987; Sternberg and Wagner, 1986). The nature of the learning process, as well as the content being learned, becomes institutionalised, which creates problems of two kinds: institution-related, which are associated with the logistics and managment of delivery and accreditation, and student-related, which often derive from the solutions to the managerial problems, and are associated with poor motivation and ineffective learning. Professional education, including medical education, has additional problems due to the fact that the learning delivered in the institution needs to relate back...

    • Chapter 3 The Role of Context in Elaborated Learning
      (pp. 41-58)
      Colin R Coles

      This chapter will examine the learning processes engaged in by those entering the health-care professions. It looks at what seems to be needed and at the conditions required for this to be generated, discussing how these might be provided educationally through the curriculum arrangement. Those curricula in which this occurs already are examined, and, out of this, is derived an educational theory on which to base future developments. This theory and its adoption, followed by what all of this says about student-learning research, are discussed. The chapter ends by posing some research questions this raises. The beginning, however, looks at...

    • [Introduction]
      (pp. 59-60)

      The next three chapters form a set and look at how doctors make decisions and how they think about this process. Elstein and Grant focus on different aspects and give different, but not always entirely contradictory perspectives.

      Elstein responds to the question: “Should we expect doctors to make decisions based on rational principles?" by examining the evidence that looks at this in real-life decision makers, and then asks the further question whether we are indeed rational. He sees the criterion for rationality as internal consistency. He demonstrates that decision makers do not obey the rules of a subjective expected utility...

    • Chapter 4 On the Psychology of Clinical Decision Making: What is a Rational Expectation?
      (pp. 61-80)
      Arthur S Elstein

      Upon responding to the question: “Should we expect doctors to make decisions based on rational principles?”, at first glance, the question seemed disarmingly simple, for it seemed inconceivable that anyone would answer: “No”. Upon further reflection, it became evident that it was a very complex question indeed, with multiple aspects: (1) “what was meant by ‘rational principles’?”, (2) “how should rational principles be tempered by virtues such as compassion and empathy and by moral or religious commitments?”, and (3) “since rational decision making is generally held in high esteem, at least in clinical contexts, and since the answer to the...

    • Chapter 5 Clinical Decision Making: Rational Principles, Clinical Intuition or Clinical Thinking?
      (pp. 81-102)
      Janet Grant

      This chapter is presented in three main parts, prior to the identification of a specific research proposal. It is arranged as follows:

      1. Clarifying terms: decisions, rational principles, intuition and thinking.

      2. The diagnostic thinking process.

      3. Improving diagnostic skill.

      The question that this section responds to is as follows:

      “ Based on our knowledge of how people make decisions, is it feasible or desirable to expect clinicians to base their decisions on rational principles, or should we continue to rely on clinical intuition?"

      Before we can discuss this question, it is necessary to clarify exactly what it means and to untangle some...

    • Chapter 6 Learning Clinical Decision Analysis
      (pp. 103-116)
      John I Balla, Arthur S Elstein and Caryn Christensen

      Over recent years there has been an increasing interest in clinical decision analysis (CDA). A recent review of the topic contained 261 references (Kassirer et al., 1987) and was necessarily selective. It will be argued that there is a need for a theory of clinical work (Dudley, 1982) and that CDA may come close to fulfilling this role. We shall not claim that CDA, and its logical foundation — expected utility theory — is perfect. It is not, it is complex, as are the decisions to which it is applied, and it sometimes leads to conclusions that are quite contrary...

    • [Introduction]
      (pp. 117-118)

      Laurillard looks at medical students’ problem-solving in response to the complex questions: “Would a deeper understanding of the processes of clinical reasoning be expected to lead to improved diagnostic and management skills? To what extent is the context of learning important from this point of view?” In answer, the first point she makes is that, unlike most other discipline areas, in medicine the articulation of the subject matter is currently an unresolved issue in the profession as a whole. Therefore, consideration of how to improve the teaching of problem-solving cannot even begin at the usual starting-point of an agreed knowledge...

    • Chapter 7 Understanding Medical Students’ Problem-solving
      (pp. 119-132)
      Diana Laurillard

      The process of teaching, in a didactic model of education at least, requires the prior articulation of the subject matter being taught. The teaching of medical problem-solving is interesting because, unlike most other discipline areas in medicine, the articulation of the subject matter is currently an unresolved issue in the profession as a whole. The tacit agreement about the nature of medical problem-solving that used to exist is now being challenged, and it is difficult to define the “received view” on what medical problem-solving is, or should be. Therefore, consideration of how to improve the teaching of problem-solving cannot even...

    • Chapter 8 What Does It Take to Improve Medical Students’ Learning?
      (pp. 133-148)
      Paul Ramsden

      Sir Arthur Conan Doyle, trained as a doctor at Edinburgh University, dedicated The Adventure of Sherlock Holmes to “my old teacher, Joseph Bell, MD etc. of 2, Melville Crescent Edinburgh”. It is said that the clinical reasoning techniques of Conan Doyle’s professor provided the idea for the methods of deduction used by Sherlock Holmes.

      It would appear that Conan Doyle and his professor were ahead of their time. Holmes operates on a model uncommonly like the modern view of how medical problem-solving should occur. He reasons imaginatively, encoding important features of cases in a way that captures the relations between...

    • Chapter 9 Improving the Assessment of Clinical Reasoning
      (pp. 149-166)
      Geofferey Masters

      In the practice of clinical medicine, the definition, clarification and management of patient problems are fundamental aspects of day-to-day routine. Within the environment of the hospital or clinic, the practising clinician is expected to observe patients, to diagnose underlying conditions and to institute and monitor appropriate management strategies. For these reasons, the definition and management of clinical problems are pervasive themes in the educational objectives of most medical schools (Norman et al., 1985).

      Despite the critical importance of clinical problem-solving to medical practice and despite a great deal of recent research into the problem-solving processes of practitioners, this is an...

    • Chapter 10 A Model for Learning in the Clinical Professions
      (pp. 167-176)
      John I Balla

      In previous sections of this book we applied educational theory to some of the problems identified in medical education. In this final chapter, we shall bring the various threads together to develop a model which could be used to study these issues with emphasis on clinical education. We offer the model in the belief that successful research and innovation in medical education needs such theoretical foundations. We hope that, by analogy, it may serve a purpose for developments in other clinical professions, where content and the structure of education may be similar, although constraints on the professions may differ.