Personal view or opinion piece
Open Access

Combining classroom and workplace teaching to deliver physical examination teaching: A theoretical approach

Adhnan Omar[1]

Institution: 1. Newcastle University
Corresponding Author: Dr Adhnan Omar ([email protected])
Categories: Students/Trainees, Teachers/Trainers (including Faculty Development), Teaching and Learning, Clinical Skills, Undergraduate/Graduate
Published Date: 10/12/2019

Abstract

Medical educators work to better prepare students for clinical work by constantly evolving medical curricula. The ‘integrated curriculum’ was designed to be repetitive but progressive with the aim to reduce disconnect between basic science and clinical practice. The problems arose when classroom teaching and clinical exposure happen as isolated events rather than being part of the same learning experience. This piece presents a theoretical overview of the benefits and drawbacks of combining classroom and workplace teaching to deliver physical examination teaching. The Adult learning theory proposes that this methods of teaching would promote their interest in meaningful learning. Furthermore, combining cognitivism and constructivism approaches to create and then build on schemata offers an effective way to transfer learning. There is however recognition of the limitations that primarily focus of the individuality of students with which teachers can struggle to respond.

 

Keywords: Integrated curriculum; learning theory; Classroom teaching; Workplace teaching

Introduction

Medical educators in their quest to better prepare students for clinical work are constantly evolving medical curricula (Brauer and Ferguson, 2015). An approach first described by Harden, Sowden and Dunn (1984), was to integrate classroom based learning with clinical exposure – labelled the ‘integrated curriculum’. The curriculum was designed to be repetitive but progressive with the aim to reduce disconnect between basic science and clinical practice; enhance knowledge retention; and to develop clinical skills (Neufeld, Woodward and MacLeod, 1989).

 

The main concern raised with this method is that classroom teaching and clinical exposure happen as isolated events rather than being part of the same learning experience (Dyrbye et al., 2011). The connection between the two is important as it enables students to learn the context in which they should apply their learning (Bransford, Brown and Cocking, 2000). Furthermore, studies show students are not often able to make these connection themselves, which if not facilitated by educators, hinder the transfer of learning (Yardley, Brosnan and Richardson, 2013). This highlights the need for better association between classroom learning and its clinical applications. This piece highlights the benefit of bringing the classroom to the workplace environment in the context of teaching clinical examination. This facilities classroom teaching on examination technique and theory to be followed immediately by relevant context-specific clinical correlation, in this case simulated patient practice.

Theoretical approach

There are a number of learning theories that can be applied to justify this teaching approach. The Knowles principles of adult learning proposes that adult learners interest in meaningful learning is correlated to their understanding of the topic relevance (Kaufman and Mann, 2010). Traditional medical education has often set students in a role as a child, concentrating on knowledge acquisition without appreciating its importance in the clinical context (Jolly, Rees and Coles, 1998). In medical education, as with the described approach here, to overcome the difficulty of merging basic sciences with clinical practice, teachers can apply an integrated approach.

 

In his book Taxonomy of Educational Objectives: the Classification of Educational Goals, Bloom et al.(1956) described three domains of learning, these were cognitive, psychomotor and affective. For medical education these domains can be considered as knowledge, skills and attitudes. Historically curricula have been set up in a pre-clinical and clinical phase. This meant that students developed their knowledge in classroom settings then later on gained skills in the clinical environment. Integration is favoured as it aims to combine the delivery of this information to increase the retention and ease of application of the learning (Fostaty-Young and Wilson, 2000).

                                                  

Finally, this style of integrated learning applies aspects of both the cognitivism and constructivism learning theories. The classroom teaching uses the cognitivism theory which is based on how information is received, organised, stored and retrieved. An assumption of cognitivism is that existing knowledge must be present in order to compare and process new information for learning. The existing knowledge structure is also known as a schema (McLeod, 2003).

 

Piaget supported this theory of learning involving the formation and development of schemata. Schema are the basic building blocks of the cognitive model that he defined as "a cohesive, repeatable action sequence possessing component actions that are tightly interconnected and governed by a core meaning" (Piaget and Cook, 1952).They represent a way of organising knowledge, as Wadsworth (2004) suggests that schemata act as 'index cards' in the brain, telling an individual how to react to incoming stimuli or information. When Piaget talked about development of a person's knowledge, he referred to the increase in number and complexity of the schemata a person has.

 

The subsequent simulation teaching applies the constructivist approach – whereby teachers cannot simply transmit knowledge to learners but rather they need to construct it in their own minds (Olusegun, 2015). The approach works on the premise that learning is the result of ‘mental construction’ where students learn by fitting information together within the context of what they already know, how the idea is taught and also by students beliefs and values (Driscoll, 2000). This means that constructivist learning is an active process, so information may be given, but understanding cannot. Constructivism requires a teacher to act as a facilitator to help students be active participants in their own learning and make connections between old and new knowledge (Tam, 2000).

 

Furthermore, David Kolb (1984) theorised that ‘learning is the process whereby knowledge is created through the transformation of experience’. This is famously represented by a four-stage learning cycle in which the learner can enter at any point but effective learning only occurs one all four stages are mastered. The simulation session fits both this and also the behaviourism learning theory where it states that learning involves responses to stimuli from the environment.

 

It is well noted that a major drawback to the integrated curriculum were some student perceptions of the teaching style. In medical schools where they have reformed the traditional curriculum to the newer style, students have been compared from both curriculum style. The perceptions of students taught in the previous curriculum were that students under the reformed curriculum had a pooper learning quality. This could undermine the self-confidence of the students studying the current curriculum. 

 

Another criticism is that schemas in the cognitive approach help to make learning more meaningful, but a learner is hugely disadvantaged when the schemas or prerequisite knowledge do not exist. To account for this, teachers need to ensure that teaching is appropriate for all skill levels and experiences which can be problematic. Likewise, constructivism learning is based on individual traits, which can again pose a delivery problem. Learners may each have different experiences within the learning process and teachers can struggle to respond to the multitude of student identities due to lack of resources available.

Conclusion

When designing this teaching approach each theoretical perceptive was considered to offer benefits and drawbacks - the context depends on the goals and learners. Since the learning environment is dynamic there needs to be a combinatory rather than a sole theoretical approach. 

Take Home Messages

  • An integrated curriculum is designed to be repetitive but progressive with the aim to reduce disconnect between basic science and clinical practice.
  • This introduction of classroom teaching to the workplace environment in the context of teaching clinical examination facilities theoretical teaching to be followed immediately by relevant context-specific clinical correlation.
  • Learners may each have different experiences within the learning process and teachers can struggle to respond to the multitude of student identities due to lack of resources available.

Notes On Contributors

Dr Adhnan Omar is a junior doctor currently working in the South Thames region with an interest in medical education and medical leadeship in the role of improving patient outcomes. ORCID ID: https://orcid.org/0000-0001-5667-0263

Acknowledgements

None.

Bibliography/References

Bloom, B., Engelhart, M., Furst, E., Hill, W., et al. (1956) Taxonomy of educational objectives: The classification of educational goals. Handbook I, Cognitive Domain. New York: Longman.

 

Bransford, J., Brown, A. and Cocking, R. (2000) How people learn: brain, mind, experience, and school. Washington DC: National Academy Press.

 

Brauer, D. G. and Ferguson, K. J. (2015) ‘The integrated curriculum in medical education: AMEE Guide No. 96.’, Medical Teacher. England, 37(4), pp. 312–322. https://doi.org/10.3109/0142159X.2014.970998

 

Driscoll, M. (2000) Psychology of Learning for Instruction. Boston: Allyn & Bacon.

 

Dyrbye, L. N., Starr, S. R., Thompson, G. B. and Lindor, K. D. (2011) ‘A model for integration of formal knowledge and clinical experience: the advanced doctoring course at Mayo Medical School.’, Academic Medicine: Journal of the Association of American Medical Colleges. United States, 86(9), pp. 1130–1136. https://doi.org/10.1097/ACM.0b013e31822519d4

 

Fostaty-Young, S. and Wilson, R. (2000) Assessment and learning: The ICE approach. Winnipeg, MB: Portage and Main.

 

Harden, R. M., Sowden, S. and Dunn, W. R. (1984) ‘Educational strategies in curriculum development: the SPICES model.’, Medical Education. England, 18(4), pp. 284–297. https://doi.org/10.1111/j.1365-2923.1984.tb01024.x

 

Jolly, B., Rees, L. and Coles, C. (no date) How students learn. The process of learning. in Medical education in the millenium. eds Jolly B, Rees L (Oxford University Press, Oxford). (1998) pp 63–82.

 

Kaufman, D. and Mann, K. (2010) Teaching and learning in medical education: How theory can inform practice. In: Swansick T, editor. Understanding medical education: Evidence, theory and practice. West Sussex, UK: Wiley-Blackwell. https://doi.org/10.1002/9781444320282.ch2

 

Kolb, D. (1984) Experiential learning: Experience as the source of learning and development (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall.

 

McLeod, G. (2003) ‘Learning theory and instructional design.’, Learning Matters, 2(3), pp. 35–43.

 

Neufeld, V. R., Woodward, C. A. and MacLeod, S. M. (1989) ‘The McMaster M.D. program: a case study of renewal in medical education’, Academic Medicine: Journal of the Association of American Medical Colleges, 64(8), p. 423—432. https://doi.org/10.1097/00001888-198908000-00001

 

Olusegun, S. (2015) ‘Constructivism Learning Theory: A Paradigm for Teaching and Learning’, IOSR Journal of Research & Method in Education, 5(6), pp. 66–70.

 

Piaget, J. and Cook, M. T. (1952) The origins of intelligence in children. New York, NY: International University Press. https://doi.org/10.1037/11494-000

 

Tam, M. (2000) ‘Constructivism, instructional design, and technology: implications for transforming distance learning.’, Journal of Education Technology and Society, 3(3), pp. 50–60.

 

Wadsworth, B. J. (2004) Piaget’s theory of cognitive and affective development: Foundations of constructivism. New York: Longman.

 

Yardley, S., Brosnan, C. and Richardson, J. (2013) ‘The consequences of authentic early experience for medical students: creation of  metis’, Medical Education. England, 47(1), pp. 109–119. https://doi.org/10.1111/j.1365-2923.2012.04287.x

Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

Ethical approval was waived as this study did not incur healthcare cost, use patient identifiable information nor impede upon patient care.

External Funding

This article has not had any External Funding

Reviews

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Ken Masters - (21/03/2020) Panel Member Icon
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An opinion piece on combining classroom and workplace teaching to deliver physical examination teaching.

The paper begins well by showing a central problem of the disjuncture between classroom-based basic science education and clinical exposure, and describes the idea of an integrated curriculum. From there on, though, the paper diverges and gives brief theoretical summaries, but often fails to bring the theory directly back to medical education and, most importantly, of supporting an integrated curriculum. For example, constructivism is a learning approach that is applied across a wide range of subjects, including outside the medical curriculum. So, constructivism could just as easily be applied in the split curriculum, and, correspondingly, there is nothing to suggest that the integrated curriculum automatically supports constructivism. So, the author has argued the value of constructivism, but has not demonstrated how this supports the concept of the integrated curriculum. Similarly with the other theories.

The paper is also rather undermined by the conclusion. In such a paper, the conclusion really should strongly present the core of the argument about how the theories support the idea that the integrated curriculum is the best possible approach.

Also, there are quite a few small punctuation and grammatical errors that the author should correct.

So, the paper is worth reading as presenting a few early ideas, but need to be strongly tightened to present a convincing argument.


Possible Conflict of Interest:

For transparency, I am an Associate Editor of MedEdPublish.

Margaret Bunting - (28/02/2020)
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Having read the abstract, I was very keen to read the full article; I teach educational theories at Masters Level and there is always room for literature that is applying medical educational theory to clinical practice. The abstract and the introduction present the case of combining classroom teaching of examination skills and suggesting this is followed by a case simulated patient practice. The downside of this article is that this teaching concept is not specifically referred to again. It would have been good to have a suggested breakdown of the learning objectives set for the classroom with a comparison of those for the simulated practice. For me, a gap within this article was that there was essentially no further detail on the ‘flipped lecture’ method of teaching examination skills. The section on theoretical approach would have benefited from the author’s interpretation of the term ‘integration’ and ‘integrated curriculum’. There are a number of interpretations within medical education and therefore do need some clarity when used. Simulation of physical examination would often be more associated with the behaviourist approach to learning and whilst this was mentioned in one sentence there wasn’t a clear rationale as to why it only was given a brief nod in that direction. I felt there were statements that would benefit from having a reference, such as the sentence “it is well noted that a major drawback to the integrated curriculum were some students perceptions of the teaching style”. There are a number of errors within the paragraph where this specific sentence comes from, to the extent that it affects the reader’s ability to understand the point the author is making. This article would have benefited from weaving in the authors idea of combining classroom and workplace teaching within the theoretical approach section.
Subha Ramani - (12/12/2019) Panel Member Icon
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I read the introduction with great interest as I wanted to see how classroom and clinical examination teaching can be integrated to improve clinical skills. It is a positive sign to see educators diving into educational theories and teaching and learning frameworks to justify educational strategies.
What I did not see was practical examples of how we should bring the classroom to the simulated or real clinical setting. I would have liked to have seen such an exemplar at the end of the discussion about various theories. One could wonder if all the theories introduced may be too many. The interface between cognitivism and constructivism, I can understand and one can certainly bring in Experiential learning. Adult learning theory seems redundant here and Bloom's taxonomy can be invoked when writing learning objectives. As a consequence, multiple theories are mentioned and none in depth. Moreover, the theories do not lead to a practical example.
I would encourage the author to narrow down learning theories and develop a curriculum or program that exemplifies integration and application of relevant theory.
There are several grammatical errors and punctuation errors that need to be corrected.
Good place to start.
Felix Silwimba - (11/12/2019)
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this is a good explanation of medical education theories. it has explicitly summarized trends in medical education. I recommend this article to all medical educators
Ian Wilson - (11/12/2019)
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It is good to see our younger colleagues thinking about medical education. this paper is one person's consideration of the linking of classroom and workplace education. the arguments presented would help deal with the problems that occur on transition from classroom to clinical setting.

It is good to see someone thinking about this, but dissapointing that there is no research to support the ideas presented. It is disappointing that there are some typos - e.g. facilities instead of facilitates (twice), Swansick instead of Swanick, plus others.

I strongly urge the author to take this thought piece andd extend it to clarification through research.