Best Evidence Medical Education in Psychiatry Training

INTRODUCTION

The late part of the last century saw the widespread growth of evidence-based medicine (EBM). The ideas behind EBM have been traced to ancient China, ¹ but only gained support in Western medicine in the late 1980s, and became known as EBM in the 1990s. ² In practical terms, however, inadequate dissemination, understanding and application of the principles of EBM hampered its utilisation by clinicians who feared EBM would lead to a loss of autonomy and constriction of their clinical practice. ³ The controversies and misconceptions surrounding EBM have probably subsequently contributed to the lack of progress towards an evidence-based culture in medical education. ⁴

The term Best Evidence Medical Education (BEME) was coined at the 1998 Association for Medical Education in Europe conference and was endorsed by representatives of institutions at the forefront of undergraduate medical education research and practice in Maastricht, Ottawa, Dundee and Newcastle. ⁵ Best Evidence Medical Education was based on the EBM paradigm of identifying and framing a question, developing a search strategy, evaluating the available evidence, implementing change, and finally evaluating the outcome of the change.

METHODS

The authors adopted the first three steps in the BEME paradigm to examine the evidence-base in medical education and psychiatry training. The relevant questions were: what is the most effective method of imparting the attitudes, skills and knowledge essential to prepare future psychiatrists for modern psychiatric practice?; what is the most effective method of optimising trainees' motivation to learn and their enjoyment of learning?; and what is the most effective method of fostering a commitment to self-directed, life-long learning?

The current available literature was reviewed by searching medical and education computer databases up to December 2001, using Psychlit, Psych-info, Ovid, Pubmed, Medline and AskERIC. A web search of evidence-based education was also conducted using the Altavista engine.

The references cited in the articles obtained were scanned for papers not yielded by the database and web searches.

THE LITERATURE REVIEWED

Theories of learning are currently divided into two major schools: directed learning and constructivist learning.

Directed learning is based on behaviourist learning theory, and more recently has incorporated the notion of information-processing from cognitive learning theory. ⁶ Directed learning is focused on the systematic, teacher-driven transmission of knowledge and skills using traditional classroom methods. The behavioural practices of reinforcement are supported by techniques to enhance attention and ensure encoding. Information processing in relation to learning involves three major elements. The first is prior knowledge activation: pre-existing knowledge is used to understand and structure new information, and the kind of structure in which it is available in long-term memory determines how new information is understood and in turn what is learned. The second element is encoding specificity: future retrieval of information is promoted when retrieval cues are coded together with the information. The third element is elaboration: elaboration of knowledge occurs through answering questions, taking notes, writing summaries, and teaching others, which facilitates understanding, processing, storing and retrieving information. ^7–9

Constructivist learning is based on an eclectic mix of ideas derived primarily from cognitive neuroscience including information processing theory. ¹⁰ The guiding principle is that learning is achieved best through relevant and meaningful activity in which the student is actively engaged, and to which the student brings his or her unique background, needs, interests and skills. Constructivists believe that cognitive development and social development are inextricably linked, based largely on the work of Vygotsky and Piaget, and that students should be encouraged and guided to explore and discover knowledge and skills, based on the work of Bruner. This learning process therefore involves posing problems to stimulate students to search for solutions, usually in small groups where information and resources are shared. ¹¹

The constructivist emphasis on small-group learning is supported by cooperative learning theory. Cooperative learning is defined in the literature as that which involves joint goals, shared resources, mutual rewards and complementary roles. It is said to occur in group situations, where individuals perceive that they can reach their learning goals only if the other group members do so too. A meta-analysis of studies looked at the effects of cooperative learning compared to ‘competitive learning’ (learning which involved goals or rewards that only one or a few members could achieve by outperforming the others). Cooperative learners exchanged ideas and corrected each other's errors more frequently and more effectively than competitive learners, and this was also associated with higher quality problem-solving. ¹²

The constructivist preference for learning in a small group does not, however, deny the importance of the individual. On the contrary, constructivist learning incorporates the notions of learning style theory that suggests that each individual has a unique set of abilities with which he or she learns. For example, four fundamental learning styles have been described: the concrete experiencer who favours laboratories, field work, observations, or trigger films; the reflective observer who uses logs, journals, and brain-storming; the abstract conceptualiser who is best suited to lectures, papers, and analogies; and the active experimenter who prefers simulations, case-studies, and homework. These learning styles form a fluid continuum and an individual may move through these styles at different times, but each individual tends to favour one overall. ¹³ Similarly, learning styles have been described in terms of multiple intelligences, suggesting that individuals show a preference for a select few. The multiple intelligences include verbal/linguistic intelligence (preferring words), logical/mathematical intelligence (preferring questions), visual/spatial intelligence (preferring images and pictures), musical/rhythmic intelligence (preferring music), body/kinaesthetic intelligence (preferring movement), interpersonal intelligence (preferring social activity), and intra-personal intelligence (preferring internal stimuli). Learning style preferences can potentially positively or negatively influence a student's performance and adjusting instructional design to suit is reported to be beneficial to students. ¹⁴

The constructivist focus on student-driven learning is supported by self-determination theory that is similar to the more popular notion of self-directed learning. ¹⁵ , ¹⁶ Self-determination theory focuses on issues of motivation and behaviour. It distinguishes between controlled and autonomous conditions that motivate learning. Controlled motivating conditions are said to be maladaptive and include external demands and contingencies, and introjected regulation about what one should do, accompanied by rewards or punishments. This leads to stress and anxiety, so learning is short-lived, and poorly incorporated into long-term memory and skills. Autonomous motivating conditions reflect what the learner finds interesting and important, and offer the learner a sense of volition and choice, promoting better conceptual understanding, better academic performance and a stronger sense of competence.

Two other theories sit somewhat outside the directed and constructivist schools. These are the theory of adult learning and the theory of transformative learning.

The four principles of adult learning ¹⁷ are: 1) with maturity, the individual's self-concept moves from one of total dependency to increasing self-directed-ness; 2) with maturity, the individual accumulates an expanding reservoir of experiences, providing an increasingly rich resource for learning; 3) with maturity, readiness to learn is decreasingly the product of biological development and academic pressure, and increasingly a developmental task required for the performance of evolving social roles; 4) children are conditioned to subject-centred orientation to learning, whereas adults tend towards problem-centred orientation. This theory of adult learning, also known as androgogy (as opposed to pedagogy), is said to have profoundly affected post-secondary, and particularly medical, education. At the time (the 1970s), cognitive psychology was in its infancy, and prior to this relatively ‘humanistic’ perspective, education was predominantly understood from a behavioural perspective. Androgogy was an attempt to distinguish the way adults learn from the way children do, and suggested that instruction for adults needs to focus more on process and less on content of learning. It identified educational strategies such as case studies, role-playing, simulation, and self-evaluation as most useful in working with adults.

Transformative learning theory is about how adults make sense of experiences, what influences the way they construe experiences and the dynamics of modifying meaning, that is, the process of making meaning of experience through reflection, critical reflection and critical self reflection The outcome is said to foster individuals who are more inclusive in perceptions, able to differentiate greater complexity, integrate different dimensions of experience and see other points of view. Eight principles or outcomes of transformative learning have been proposed: 1) increased autonomy, 2) increased independence, 3) the ability to separate one's feelings and opinions from those of others, 4) the ability to critically and respectfully examine the views of others, 5) the ability to set personal and professional goals, 6) the ability to see how one's actions affect the system in which one works, 7) the ability to balance and choose among conflicting priorities and at some point transcend self-interest, and 8) the ability to acknowledge one's role in constructing one's reality. Transformative learning is also seen in a developmental context as an essential component of the process of individuation, or self-actualisation. Knowledge and skills are the text that are rendered meaningful through the learner acting on them within particular life contexts. ¹⁸

Only one major development stands out in medical education in the last century: problem-based learning.

Problem-based learning (PBL) was developed as a means for students to integrate knowledge across subject boundaries and develop problem-solving skills. It was based on earlier models in medical education of experiential learning, discovery learning and ‘case-study learning’ whereby knowledge was understood through its application to a clinical case. ¹⁹ , ²⁰

Problem-based learning has been described as striving to provide a method by which students become capable in generalisable competencies such as being holistic, collaborative, reasoning critically, managing novel situations, and in providing a philosophy for adult learning conditions. ²¹

Others ²² described PBL as a process whereby individuals work in small groups on a clinical problem, generating learning objectives and research strategies, then using resources made available to explore the areas identified. They are supported by a tutor who is non-expert and facilitates the group process. Assumptions informing this process are that students want to solve problems, and the curriculum comprises problems that focus learning and are stimulating.

A proposed taxonomy for PBL includes: the acquisition of a rich body of deeply understood knowledge that is integrated from a wide variety of disciplines, structured in ways that facilitate recall and application to other problems and enmeshed with the problem-solving required to solve patient problems; the development of clinical problem-solving, self-directed learning, and team and interpersonal skills; and the development of an insatiable curiosity and desire to continually learn. ²³

The process of PBL has been described as consisting of seven steps. ²⁴ Step 1 is the clarification of terms and concepts not readily comprehensible. Step 2 is the definition of the problem, including reaching a consensus about which interrelated clinical phenomena should be explained, for example. Step 3 is an analysis of the problem, resulting in ideas and suppositions about the problems from individuals' opinions, knowledge, and ideas about processes and mechanisms - ‘brainstorming’. Step 4 involves drawing a systematic inventory of the explanations inferred from step 3, which will act as a summary and outline directions for further action. Step 5 is the formulation of learning objectives, prioritising key issues among many, and allocating distribution of tasks, and possible learning resources (literature, audiovisual aids, expert consultation, etc.). Step 6 is the collection of additional information outside the group. Step 7 then involves the synthesis and testing of newly acquired information. At this point, new questions will emerge and the process can begin again from step 4.

Three major reviews of the evidence relating to PBL have been undertaken, and ‘despite semantic uncertainty and different study designs, (these) contemporary reviews of two decades of literature were cautiously optimistic about the effectiveness of PBL’. ^25–27 One review ²⁵ concluded that ‘the graduate of PBL is not distinguishable from his or her traditional counterpart’. The other reviews concluded that PBL was superior to traditional methods in relation to clinical performance, with small but significant differences reported, particularly with psychiatry and preventive/community medicine subtests; student satisfaction, a consistent and clearly statistically significant finding; study behaviours, with PBL graduates more likely to study for understanding and research purposes rather than short-term recall, and showing greater independent library and resource utilisation - features which continued into residency; and faculty satisfaction. Additionally, subsequent professional characteristics showed graduates of PBL medical schools tended towards family medicine, collaborative (group) practices, and were more actively involved in teaching. ²⁶ , ²⁷

There is currently no published evidence specific to the field of education in postgraduate psychiatry training.

DISCUSSION

What is the most effective method of preparing future psychiatrists for modern psychiatric practice, of optimising their enjoyment and motivation to learn, and of fostering their commitment to life-long learning?

The evidence supports the use of both the directed and the constructivist approach to education and training. Directed learning is a traditional, well established approach to learning that offers the valuable elements of structure and expert guidance, and encourages the individual to fulfil his or her poten-tial. ^28,29 Constructivist learning combines cognitive and social approaches to learning and therefore simultaneously emphasises the individual's uniqueness and his or her importance in a group. It also emphasises the notion of supervised independence, which allows learning to be both guided and self-directed, and, most importantly, it emphasises the context of learning. ^30,31 In addition, problem-based learning as used in medical education has been shown to produce superior results with respect to student satisfaction, clinical performance, study behaviours and teaching staff satisfaction, and PBL is associated with the development of greater subsequent professional involvement in collaborative and group practice and in teaching. ^32–34

An eclectic approach that combines elements of the directed approach and the constructivist approach within a problem-based learning framework seems warranted. Such an approach to psychiatry training would have the flexibility to accommodate the trainee's needs to learn independently at times and collaboratively at others, and make some allowances for trainees' differing cognitive styles, professional interests and developmental stages. It would be relevant, stimulating, challenging and engaging, it would commence under careful, expert supervision, and would ultimately lead to independent learning and to a life-long commitment to the maintenance of professional standards.

The apprenticeship model that is currently popular in clinical psychiatry training seems to offer some of the right elements, assuming that the skills of the supervisor are reasonable, i.e. that he or she has an understanding of the principles and practice of adult education. Similarly, many of the academic teaching programs available to psychiatry trainees seem to employ both directed and constructivist teaching methods. However, psychiatry training could be strengthened significantly by a greater emphasis on problem-based learning and small-group learning in both the clinical and the academic arenas.

A problem-based learning approach to psychiatry training can be utilised in a clinical setting by the supervisor by focusing on the objectives of the clinical experience, by assisting the trainee to identify relevant clinical questions and research strategies to answer them, by fostering the development of the interpersonal skills required to work collaboratively in a multidisciplinary team, and by stimulating the trainee's interest in a variety of clinical problems.

The PBL approach to psychiatry training can, of course, also be utilised effectively in the academic setting. ³⁵

A small-group approach to learning in psychiatry training can be utilised in a clinical setting for supervision, journal clubs, case conferences and peer review, and in an academic setting for tutorials and study groups. If these activities are to be of educational value, the emphasis must be on constructively and collaboratively exploring the issues and questions raised in the group through a process of pooling and sharing the resources of the group. The opportunities for discussion and elaboration offered by small-group learning is most likely to develop the skills required to think systematically and to think critically36 and to facilitate the learner's ability to understand, integrate and apply new material. ³⁷

CONCLUSION

The emphasis in modern medical education is on a constructivist approach, dominated by problem-based learning and built around small-group activities. Postgraduate psychiatry training could be improved significantly by adopting the evidence-based advances that have been made in education and undergraduate medical education over the past three decades.