8 Identifying learners’ needs and self-assessment
Constructivism See main Glossary, p 338.
Learning agreements See personal learning plans
Learning Management Systems Systems that support and assist learners to plan, manage, customise, share, regulate, and evaluate their learning. These resources might include learning tools and guides, study guides, course management systems, and portfolios, among others. Currently, most learning management systems are computer-based and increasingly robust.
Learning Strategies See main Glossary, p 339.
Minute paper See main Glossary, p 339.
Personal learning plans These plans are formulated by learners, often in collaboration with teachers, and outline learners’ goals, learning activities, and strategies they plan to use to reach the goals, resources they will use, and how they will monitor their progress and evaluate their learning. They are also called learning contracts or learning agreements in some settings.
Self-efficacy See main Glossary, p 340.
Self-regulated learning See main Glossary, p 340.
This chapter considers how educators can help learners take responsibility for identifying and addressing their learning needs. It considers the topic from theoretical and empirical research perspectives as well as giving practical insights. Physicians must possess the skills we describe here if they are to be effective lifelong self-regulated learners. To help them discharge their responsibilities towards their own and others’ learning, we describe tools for self-identifying and addressing gaps in knowledge and skills, educational principles, and methods that support self-regulated learning, tips, and principles for helping faculty assume roles as effective facilitators in more active and small-group methodologies, and information on electronic tools that can help learners manage and enhance their learning. Finally, we present some conclusions and a consideration of the chapter’s implications.
One of the major responsibilities of medical practitioners is to maintain knowledge and skills through continuous learning. A physician’s motivation to learn should be driven by needs identified in the course of clinical practice; that is, day-to-day professional work including collaborations on teams and encounters with patients and colleagues. These provide an informal, opportunistic context for identifying personal learning needs (Grant, 2002). Despite its importance, there is evidence that physicians are not very effective at self-assessing their own learning needs (i.e. identifying ‘blind spots’ and gaps) (Bandara and Calvert, 2002; Davis et al, 2006; Eva and Regehr, 2005). Likewise, students enter medical school lacking skills to self-assess learning needs (Fitzgerald et al, 2003). By virtue of being in a learning phase, they lack the competence or knowledge to assess their own performance accurately within the domain of what they are learning (i.e. ‘How can I know what I do not know when I do not know what I do not know?’) (Eva and Cunningham, 2004).
As medical education becomes more learner-centred, approaches that shift responsibility for learning to students, including responsibility to identify and address learning needs, become more important. There is growing evidence that personal learning plans (PLPs) and portfolios – coupled with guidance, reflection, and feedback – can be effective tools for identifying (i.e. self-assessing) and addressing learning needs (Challis, 2000; Mathers et al, 1999). As a result, PLPs are becoming more common in medical education. Portfolios in particular have been under academic investigation as lifelong learning tools in medical practice for some time, particularly in the United Kingdom. Given changes in certification for physicians in the United States, they will likely become more common there as well in the near future. Tools like portfolios provide a structure for recording, reflecting on, and assessing learning needs. Thus, it makes sense to introduce them as early as possible so students become increasingly facile by the time they are autonomous medical practitioners.
Personal learning plans (PLPs), also called learning contracts or learning agreements, have been linked with ‘deep’ learning (Marton et al, 1984), adult learning principles (Knowles, 1986), self-assessment, self-regulated learning, and lifelong learning (Knowles, 1975; see Box 8.1).
Box 8.1 How learning plans help learners (Challis, 2000)
As with all learning, guidance and feedback from a mentor are key to developing a PLP and its ongoing implementation and adaptation. It is important to gauge and encourage motivation and self-confidence, particularly for learners who are accustomed to having their learning needs dictated and assessed by faculty (Challis, 1997). A critical underlying philosophy is that a PLP challenges students to assume responsibility for learning – including identifying learning needs or gaps, setting learning objectives, choosing resources, and self-assessing. This responsibility can be increased over time, as skills become sharper. Ultimately, the PLP should be designed to help students develop into motivated and skilled self-regulating learners throughout their professional lives (Anderson et al, 1996).
Portfolios, which are considered at greater length in Chapter 13, have become an increasingly popular tool in the context of student-centred learning. They are similar to PLPs in that they challenge students to take more responsibility for their own learning but they often also involve writing and reflection combined with collection and assessment of learning goals, resources, events, and outcomes. Portfolio-based learning has been shown to improve acquisition of factual knowledge (Elango et al, 2005) but, as important, its use fosters autonomy and self-assessment (Challis, 2000). Again, continuous guidance and feedback by a mentor are key. In assessing a portfolio, mentors should see evidence of completion of the self-regulated learning cycle: learning needs identified; strategies to meet needs customised to learning styles and activities; structured self-assessment and reflection on experience; and use of feedback and critical events to modify or reformulate learning objectives (Mathers et al, 1999). Principles of reflective learning are presented in Chapter 2.
The notion of being a reflective practitioner is not new – in fact there is a wealth of literature on the topic dating back to the early twentieth century (Dewey, 1933). Effective methods to help students become more reflective, however, have been more elusive; in part, that is due to a lack of appropriate skills on the part of instructors (McGrath and Higgins, 2005). While concrete, purposefully worded learning outcomes and time set aside specifically for reflection are a good start, these can be insufficient. Learners need to know how they will achieve their intended outcomes. Without facilitation and an appropriate environment, time set aside to reflect might lead to diffuse and disparate outcomes (Boud and Walker, 2001). Thoughtful writing with individualised feedback (Wald et al, 2009) and other forms of structured reflection such as reflective practice groups (Platzer et al, 1997) and critical incident analysis (Ghaye and Lillyman, 1997) have been shown to yield deep (as opposed to surface) learning (Mathers et al, 1999) and foster insight into personal accountability and responsibility.
There is relatively less attention in the literature to what instructors need to know in order to help learners acquire reflective skills. These include synthesis and evaluation (high-order skills on Bloom’s taxonomy of the cognitive domain) (Bloom, 1956), clinical reasoning, problem solving, and self-awareness (McGrath and Higgins, 2005). Boud and Walker (2001) argue that ritualised processes or pre-written sets of questions to be pondered and answered are more comfortable for facilitators but do not allow learners to construct their own meanings. Reflection is not solely a cognitive process – feelings are key elements of reflection and unique to individuals so learners must be able to express themselves intellectually and emotionally. Effective environments to promote reflection require respect, trust, boundaries, and appropriate understanding of the learning milieu (context), which influences instructors and learners in different ways (Boud and Walker, 2001).
Although there are established links between self-regulated, continuous medical education and the quality of care provided by physicians (Lowenthal, 1981; Westberg and Jason, 1994), there is evidence that physicians are not particularly effective at identifying gaps in their own knowledge and skills (Davis et al, 2006; Eva and Regehr, 2005). We know that good self-regulated learning (SRL) habits can be taught (Pintrich, 1995) and it therefore seems logical to help students develop such behaviours when they enter medical school. To achieve successful outcomes, however, SRL has to be intentionally integrated into a curriculum – meaning that it will require additional time and resources in the curriculum in order to ensure appropriate mentoring, monitoring, and feedback.
Integrating SRL into curricula has shorter-term benefits as well. Research has suggested that learners who are proactive tend to learn more and learn better than learners who expect instructors to transmit knowledge (Knowles, 1975); proactive learners are more persistent, resourceful, motivated, and confident (Pintrich, 1995; Zimmerman and Schunk, 2001). Developing SRL in learners can be fostered by creating learning environments that make learning processes explicit, offer opportunities for practicing self-regulation (Schunk and Zimmerman, 1994), set clear expectations for goal-setting, self-monitoring, and reflection, and provide specific and comprehensive feedback linked with learner self-assessment and achievement of learner-set goals (White and Gruppen, 2007).
A self-regulating learner takes initiative for diagnosing learning needs, formulating goals, identifying resources, implementing appropriate learning/studying activities and strategies, and evaluating progress and outcomes (Spencer and Jordan, 1999). To foster self-regulation, students must be actively involved in monitoring and regulating their performance in the context of strategies and resources they choose, and how these influence progress against goals (Nicol and MacFarlane-Dick, 2006). The more self-regulating learners become, the more effective they are at generating and using internal feedback (self-assessment) to measure progress against personal goals, and the more effective they are at interpreting external feedback in relation to their goals (Butler and Winne, 1995). Students must understand and assume ownership of goals to measure progress effectively and achieve them.
The instructor’s role is to provide formative feedback that centres on learner self-regulation. Feedback concerns how the student’s present state of learning relates to their goals, which must have some overlap with goals originally set by the instructor. Table 8.1 offers specific advice on effective feedback.
Table 8.1 Seven principles of good feedback practice that facilitate self-regulation (Nicol and MacFarlane-Dick, 2006)
There are several models or infrastructures through which educators can integrate SRL practices into curricula. Zimmerman’s groundbreaking work on self-regulated learning developed a three-step model comprising forethought (task analysis and self-motivation); performance/control (self-control and self-observation); and self-reflection (self-judgement and self-reaction) (Zimmerman, 2000). While many educators agree that all learners self-regulate to some degree (Winne, 1997), Zimmerman believed that what separates effective SRL from ineffective SRL is the quality and quantity of SRL processes. The model on which the seven principles above were developed (Nicol and MacFarlane-Dick, 2006) comprises a series of steps that begin with the instructor assigning a task. Subsequent steps include the learner drawing on prior knowledge and motivation to construct an interpretation of the task and its requirements, formulating personal learning goals, and using strategies and tactics that produce internally and externally observable outcomes. Internal feedback (self-monitoring; self-assessment) permeates almost all of the steps; external feedback is compared with the learner’s interpretation of the task, which is modified as needed to adjust future strategies and tactics (Nicol and MacFarlane-Dick, 2006).
White and Gruppen (2007) proposed a model adapted from Zimmerman’s work (2000) comprising four major phases: planning (institutional and personal learning goals, motivation, and self-efficacy); learning (expectations and methods, epistemology, learning styles, learning strategies); assessing (self-assessment, external feedback); and adjusting (reflection, adjustment). This model views SRL as dynamic and contextual, with both learners and instructors having roles and responsibilities – some separate and some overlapping. External feedback is built into all phases.
In an engineering schools study, students were encouraged to develop habits for self-regulated learning by practicing planning, time management, self-reflection, and self-motivation (Jowitt, 2008). They were provided with information about tools and techniques that included self-evaluation, organising and transforming, goal-setting and planning, information seeking, self-monitoring, environment structuring, self-consequences (e.g. rewards for good performance), rehearsing and memorising, seeking social assistance (e.g. study groups), and reviewing records (e.g. grades). Although definitions of SRL and models for it might vary somewhat, there are many more similarities than differences. In general, medical educators agree that SRL is important for practicing physicians, include it in medical schools’ goals for education, and commonly discuss it in literature on medical education.
If medical schools want their students to assume responsibility for learning, there are a few specific steps they can take. Intended learning outcomes of their curricula can include SRL skills and attitudes, which can be reinforced with opportunities for learning and practicing SRL, role modelling, and feedback pertaining to those outcomes. Learning SRL can be integrated across the educational programme rather than compressed into the clinical years. SRL can also be a structured activity which includes feedback. Increasing choices about and responsibility for learning will help students become more effective self-regulating learners (Hagen and Weinstein, 1991). When learners rely on others for their learning, they look for cues about what to learn and how to learn it; they focus on trying to figure out what teachers want from them and on what they will be assessed. This is poor preparation for independent, lifelong learning.
A key element of self-regulated learning is self-assessment. Learners need detailed formative and summative feedback about their progress so they can gauge their self-assessments and make adjustments in order to reach learning or mastery goals. Although scores on quizzes and examinations are sufficient to tell learners whether they are memorising or comprehending information and concepts correctly, such scores tend to focus on lower-order cognitive skills that do not help learners achieve the higher-order skills of analysis, synthesis, and evaluation. We know that most learners do not possess inherent self-assessment skills (Baker, 1984)and that poorer performers tend to overestimate their performance while better performers tend to underestimate it (Eva and Regehr, 2005; Kruger and Dunning, 1999). Sullivan and colleagues (1999) acknowledged that ‘In order for students to acquire lifelong learning skills, they must develop the ability to critically evaluate themselves’. Their study, similar to many medical school studies (e.g. Calhoun et al, 1984; Risucci et al, 1989), compared students’ assessments of their performance with peer and tutor evaluations of their performance. Students were less able to identify their strengths and weaknesses than peers and faculty, leading the authors to conclude that, ‘A possible explanation for these results is that students are not routinely taught self-evaluation skills in a traditional curriculum’. Self-regulated learning helps learners take responsibility for their own learning, change from a focus on external measures (e.g. faculty and grades) to a focus on learning, helps them monitor their own performance more effectively, and achieve at higher levels. Self-regulated learners can effectively use a broad array of measures – internal and external – to guide and enhance their own education in school, in residency, and in practice.
Learning objectives (or intended learning outcomes) should send a clear message to learners about the content (knowledge, skills, attitudes) faculty intend them to learn and how learning of it will be measured. Likewise, it is paramount that learners are clear on the pedagogic principles of the curriculum and the methods that will be used to deliver content. An inherent assumption of self-regulated learning is that both instructors and learners share accountability for learning – that is, both parties have explicit responsibilities. Two examples of educational principles that align with self-regulated learning and a joint (and in some ways also co-dependent) sense of responsibility are constructivism and adult learning (andragogy), topics that are also discussed in Chapter 2.
Constructivists believe that knowledge is developed within learners rather than transmitted by an instructor to a passive student. Learning occurs most effectively when the mind filters incoming information and connects that information to past experience and current need or relevance. Thus, learners find solutions by ‘playing’ with new information – revising, restructuring, and exploring new information as they place it in their own personal cognitive structures (Spigner-Littles and Chalon, 1999). Understanding and embracing constructivism in theory and principle is one thing; integrating it into the design of a curriculum, however, is another matter (Tenenbaum et al, 2001). Box 8.2 lists some elements of a constructivist approach.
Furthermore, instructors in a constructivist environment must have appropriate training and resources so they are prepared to create motivating conditions for students, take responsibility for creating problem situations for students to work through, foster acquisition and retrieval of prior knowledge, and create a social environment that emphasises the attitude of learning to learn (Phye, 1997). Instructors in constructivist settings need to learn how to guide and not tell, and to create and foster an environment in which students can make their own meaning rather than receive ‘pre-packaged’ meaning from teachers, not focus on one right answer but look for diversity in thought processes, modify previous notions of right and wrong, and loosen rigid standards and criteria (Airsian and Walsh, 1997). In such environments, students learn to think for themselves (instead of waiting for the teacher to tell them what to think), proceed with more autonomy and less direction from the teacher, express their own ideas in their own words, and revisit and revise knowledge constructions (Airsian and Walsh, 1997). The reward for integrating constructivism into a course or curriculum is that students learn to think more critically and creatively – they are able to analyse, predict, present theories, and engage in meaningful dialogue (Brooks, 1990). Constructivism lends itself extraordinarily well to SRL. SRL calls for students to assume increased responsibility for their own learning by creating personal goals that are challenging but achievable, looking inwardly for motivation to learn, experimenting with learning strategies to find which are most effective, comparing external feedback with self-assessment, and finally reflecting on performance and continuously and dynamically adjusting goals and plans (White and Gruppen, 2007).
The work of Malcolm Knowles focused on how adult learners differ from standard school-aged learners (Knowles, 1973). He was interested in how the development of individuals influenced their learning. He wrote about how earlier traditions of teaching and learning practiced by great teachers in ancient history – Confucius, Jesus, Socrates, Plato, and Aristotle, who primarily taught adults with methods such as dialogue and learning by doing – were lost with the fall of Rome. It became common for children to be educated from the seventh century onwards and pedagogy (from the same stem as paediatrics) was based on obedience and efficiency. Other educators and researchers have provided evidence that, as individuals mature, the need to be self-directing, use personal experiences as a context for learning, and organise learning around life problems increases steadily and rapidly (Bower and Hollister, 1967; Bruner, 1961; White, 1959). Ultimately, Knowles (1984) identified the following characteristics of adult learners, who
As with constructivism, instructors must align their teaching practices with adult learning principles to achieve desired outcomes. Guidance from research includes the following (Zemke and Zemke, 1984):
Connecting principles with educational methods is key to building a bridge of understanding and shared accountability between teachers and learners. Just as it is important for educators to explain principles that underlie their expectations and educational approaches, learners need to understand and embrace the principles as well, so they are prepared to meet their teachers’ expectations. As self-directed learners in training’, students should be expected to set their own goals, use experts and resources to help them achieve their goals, be willing to take responsibility for their own learning and productivity, be able to manage their own time and projects, and assess themselves and their peers (Grow, 1991).
Teachers can conceptualise, construct, and model specific learning activities that encourage ongoing cognitive growth and acquisition of complex reasoning skills. Approaches that foster development and provide opportunities for development of self-regulating habits tend to be those with progressively increased emphasis on learners’ participation and responsibility for their own and their peers’ learning. Active learning methods such as collaboration and opportunities for learners to discuss and analyse ill-structured problems and controversial issues help foster advanced cognitive skills (Baxter Magolda, 1999; King and Kitchener, 1994). Other methods include small group discussion, cooperative projects, simulations, case studies, and role-playing (Meyers and Jones, 1993). Use of active learning methods requires more attention from the instructor than more passive methods. For instance, small groups must be carefully composed and their discussions carefully crafted based on explicit principles and intended outcomes.
In choosing methods that align with principles and reinforce expectations, instructors can keep the following seven guidelines, developed by Chickering and Gamson (1987), in mind:
Finally, instructors should write clear and precise learning objectives that convey achievement expectations to students, but that also guide decisions about learning and assessment methods. Bloom’s taxonomies for cognition (1956) and affect/attitude (Krathwohl et al, 1973) and Simpson’s for psychomotor skills (Simpson, 1972) are excellent resources for writing learning objectives.
Many instructors, especially in professional education, are not formally trained as educators (Wilkerson and Irby, 1998). Their professional degrees certify them to practice, as a result of which they can provide a critical element of professional education by role modelling. Comprehensive professional education, however, also requires specific educational competencies that include designing learning modules, choosing and executing appropriate and innovative teaching/learning and assessment methods, scaffolding/sequencing presentation of new knowledge and skills, and evaluating the effectiveness of those educational elements.
Important links between active/collaborative learning methods (e.g. small group discussions, cooperative projects, case studies, role-playing) and self-regulation have been investigated (Bell and Kozlowski, 2008; DeRouin et al, 2004; Ivancic and Hesketh, 2000). There is agreement among researchers that SRL habits can (and should) be taught in formal educational settings (Pintrich, 1995) but, to be learnt effectively, they must be embedded or integrated into a curriculum (Cho, 2004). So, instructors have a critical role in learners’ SRL development – see Box 8.3. In many active learning environments, the instructor acts more as a facilitator than a lecturer, a role that is very different and in many ways more difficult. In discussions in which one of the goals is for students to tackle complex, ill-defined issues or problems (King and Kitchener, 1994), for instance, a facilitator needs to step away from the leading role and let students grapple with the problems or issues they are addressing.
Box 8.3 Teaching tips for facilitators in active learning environments
(adapted from Tulane University, 2009)
Effective questioning can promote effective learning (see Table 8.2). Planned carefully and posed thoughtfully, questions arouse curiosity, stimulate interest, clarify important concepts, role model and encourage thinking at more advanced cognitive levels, promote collaboration, confirm learners’ grasp of the material, and help identify which learners are having difficulty. Good questions are the backbone of productive (and enjoyable) group discussion. The most productive questions open up a variety of responses and invite students to think about and respond to the material at a high level.
Table 8.2 Tactics for effective questioning (after Davis, 1995)
| What to do | How to do it |
|---|---|
| Ask one question at a time | Keep questions brief and clear |
| Avoid yes/no questions | Ask why or how questions – let students work towards answers |
| Pose questions that lack a single right answer | Ask ‘Ill-structured’ questions – they have a number of equally-plausible responses; students can generate their own hypotheses |
| Ask focused questions | Avoid overly broad questions that can easily lead students off-topic |
| Avoid leading questions | Leading questions can limit open, relevant discussion around the topic; also, do not answer your own question |
| After asking a question, wait silently for an answer | Be patient. Waiting is a signal that you want thoughtful participation. If a prolonged silence continues, ask learners what it means |
| Search for consensus on correct responses | When one student immediately gives a correct response, ask others what they think; get them involved in the discussion |
| Ask questions that require students to demonstrate their understanding | Instead of asking ‘Do you understand how to take an appropriate family history?’ (a yes/no question) ask, ‘What are the key elements of an appropriate family history?’ or ‘What are the critical approaches to keep in mind when taking a family history?’ |
| Structure questions to encourage student-to-student interaction | Relate what one student says with what another subsequently says; find links and make them clear for the students. Think-pair-share: pose a question or problem and ask students to discuss in pairs |
| Use questions to change direction of discussion | Clarify perspectives: ‘In a few words, name the most important …’ |
| Move from specific to general: ‘If you were to generalise …’ | |
| Move from general to specific: ‘Can you give some specific examples?’ | |
| Acknowledge good points made previously: ‘John, would you agree with Mary on this point?’ | |
| Elicit or give closure: ‘Beth, what two themes recurred in today’s discussion?’ |
Bloom’s taxonomy in the domain of cognition (Table 8.3) provides a very useful tool for writing learning objectives, which can also be useful in designing learning activities – including types of questions that facilitate learning. The taxonomy begins at a low level of expected outcome (knowledge – the recall of memorised information) and progresses through to a much more complex level (evaluation – assessing evidence and defending decisions). The level of the question should match the complexity of intended learning.
Table 8.3 Bloom’s taxonomy with sample questions
| Knowledge (simplest) | Recall; repeat |
| Sample: List four major causes of pneumonia in immuno-compromised patients | |
| Comprehension | Interpret; describe |
| Sample: Explain the molecular basis of the polymerase chain reaction | |
| Application | Use facts, rules, principles |
| Sample: A 40-year-old patient has a persistent cough and a fever (39°C) for 3 days. A radiograph shows a right lower lobe lung infiltrate. Based on these findings, construct a differential diagnosis | |
| Analysis | Subdivide to component parts; reveal underlying structure |
| Sample: Compare and contrast the symptoms, pathophysiologic mechanisms, and complications between Crohn’s disease and ulcerative colitis | |
| Synthesis | Put together elements and hypothesise; predict |
| Sample: A 53-year-old patient with hypertension, peripheral oedema, and shortness of breath is diagnosed with cardiomyopathy. His ejection fraction is 22%. What would be your diagnostic and therapeutic plan? | |
| Evaluation (most complex) | Assess; justify |
| Sample: Defend why you would order a test for subtype influenza A in a 24-year-old pregnant woman and not a 57-year-old healthy man |
For more than a decade, leading educators and educational researchers have advised that a broader range of assessment tools is needed to connect assessment with learning. More open-ended performance tasks, the argument goes, help ensure that students are able to reason critically, solve complex problems, and apply knowledge in real-world contexts. That means expanding the assessment ‘toolbox’ to include observations, clinical interviews, reflective journals, projects, demonstrations, collections of student work, and student self-assessments. It also means that teachers ‘must engage in a systematic analysis of the available evidence’ (Shepard, 2000). A specific class of assessment methods, called Classroom Assessment Techniques (CATs), has been designed to involve teachers and students in continuous monitoring of student performance against course objectives (Haugen, 2005). CATs help students become more effective self-assessors and help faculty monitor links between effective (or ineffective) teaching and learning and make adjustments and improvements as part of a dynamic cycle. Without such monitoring, there can be significant gaps between what is taught and what is learnt. Instructors often assume that students are learning what they are teaching, only to be faced with disappointing evidence to the contrary when they grade tests, when it is too late to fix problems (Angelo and Cross, 1993). Also, as a result of practice with classroom assessment, faculty members become better teachers and improve their ability to help students become more effective self-assessing, self-regulating learners.
A growing number of educators are convinced that a learner-centred approach yields deeper and more cognitively advanced learning, which in turn makes knowledge more accessible throughout formal education and professional life (Shepard, 2000; Spencer and Jordan, 1999). This approach requires students to be actively involved in their own learning – taking increasing responsibility over time. However, managing learner-centred education can be complex for the learner and the institution. In the last few decades, as curricula have transitioned from teacher-centred learning to more and more student-centred learning, there has been a growing recognition that robust management tools can support and enhance learning. Many such tools have been developed and are in widespread use but continuous advances in computer technology – and continuously more facile learners – mean that there is still important work in progress.
A number of systems have been developed over the years to provide students with tools they can use to guide their learning. Below are just a few examples:
Study guides support learning by specifying learning outcomes, helping students develop their own personal goals and study plans, identifying appropriate learning resources and how they should be used, and providing students with self-assessment opportunities (Skelly and Quentin-Baxter, 1997). They are particularly useful in the context of discovery learning.
These environments are designed to help novice learners engage in new, complex processes such as investigation of scientific phenomena (Quintana et al, 2004). Using a learner-centred design, developers have created tools that support novices by breaking down complex processes into individual steps.
Currently, this tool is specific to one programme (pharmacy graduate education) but it is applicable across disciplines and educational levels. It helps students through the logical stepwise process of building a (written) research project. They complete one step (online), receive feedback from an experienced faculty member, and then revise that step before moving on to the next one.
Online course management systems (e.g. Moodle, Blackboard, TRIO) have changed the face of education. Both ‘home grown’ and commercial systems provide educational programmes with enormous flexibility for learning to take place outside the physical environment of classrooms (i.e. distance learning). Instructors can post announcements, syllabi, instructions, resources (e.g. book chapters, journal articles), assignments, and questions. Students can access these postings, submit assignments, engage in ‘chats’ (with faculty and classmates), take exams, and collaborate on assignments/projects. Course management systems, like tools and guides, can support learner-centred approaches to education; however, they are actually teacher-centred systems in that they help instructors manage the many elements of their courses. While students can access learning tools and instruments, they generally cannot customise the site to manage their own learning over time.
Portfolios are not new in the educational world, particularly in disciplines such as art, architecture, and interior design. Since they have gone online, ‘ePortfolio’ systems have gained ground in medical education as effective tools, especially for helping students assume responsibility for learning, reflection, self-assessment, and formative/summative assessment. Although some are created for personal use only, most that are used in formal educational contexts are open to scrutiny beyond individual learners. They are used as longer-term repositories that reflect longitudinal development, reflection, and achievement of outcomes. Learners may be asked to select the work most representative of their development and achievements – this self-assessment is then linked with formative or summative feedback from faculty – see Box 8.4 (Challis, 2000).
Box 8.4 Advantages of portfolios (Challis, 2000)
Despite the growing popularity of portfolios among educators, concerns linger about the effectiveness of them in virtual learning environments beyond formal educational structures (i.e. are they effective tools for lifelong learning?) (Larsen and Lofgreen, 2007). Medical students have expressed concern about the additional time-related burden of using portfolios, particularly in the clinical years and when portfolios are used as journals for longitudinal reflective writing (Elango et al, 2005). It is critical that learners understand the purpose of a portfolio and how to construct one that meets their goals and expectations (van Tartwijk et al, 2008). Articulating clear expectations and providing specific instructions might preclude some current concerns about portfolios.
An effective learner-centred learning management system (LMS) could help learners customise, manage, share, and regulate their learning, both in the shorter term (for instance, within a course, or within a degree programme) and the longer term (for instance, from the beginning of medical school, through postgraduate training, and into clinical practice). Such a system could be built on a logical model for self-regulated learning (SRL) (White and Gruppen, 2007). An appropriately robust LMS will ultimately provide individuals with a customisable, user-friendly, online system for
Ultimate LMS functionality would include creating, modifying, tagging, rating, sharing, and storing resources; chatting and collaborating with selected groups of others; journaling; and giving and receiving feedback to/from peers and faculty. Students would have a private space within the system, but would also be able to permit access at multiple levels (individual faculty and/or students, pairs or small groups of faculty and/or students, friends, potential residency directors or employers, etc.). The LMS is envisioned as a dynamic system of elements and activities associated with self-regulated learning that can be used by individuals at micro, macro, and mega levels, depending on status, activities, curriculum, and personal/professional interests (Forment et al, 2009).
There have historically been boundaries between and among outcomes that learners should achieve in medical school, in residency, and in professional practice. With changes in health care delivery, in what we know about effective education, in the vast and dynamic body of relevant information for medical practice, and in tools and technology that support education, these boundaries are fading. Advanced skills and habits that support effective learning can be acquired within the formal structures of education, when there are significant opportunities for modelling, practice, and feedback. Habits for self-regulated learning – so key to effective lifelong learning and high-quality health care – can be integrated into formal curricula, with specific outcomes articulated and appropriate tools, mechanisms, and methodologies available to support learner achievement. This chapter has presented some of the underlying theory and evidence related to self-regulated learning, along with suggestions for instruments, mentoring, feedback, principles, methodologies, and faculty development that support mastery of effective SRL. Expectations of SRL already exist in residency programmes in the form of required self-assessment and individual learning plans; their effectiveness is extremely limited – as is effectiveness of physician self-assessment – because there has been no formal and longitudinal cycle of practice–feedback–adjustment within the educational programmes, and no faculty development to support the cycle. Almost every medical school publishes a formal statement of goals that include some mention of self-assessment and lifelong learning, yet curricula have yet to indicate how and where they can be learnt. This chapter is intended to provide some level of guidance as to how to think about formal integration and assessment of self-regulated learning into curricula across the continuum of medical education.
Airsian P.W., Walsh M.E. Constructivist cautions. Phi Delta Kappan. 1997;78:444-449.
Anderson G., Boud D., Sampson J. Learning contracts: a practical guide. London: Kogan Page, 1996.
Angelo T., Cross P.K. Classroom assessment techniques: a handbook for college teachers. San Francisco, CA: Jossey-Bass; 1993.
Baker L. Children’s effective use of multiple standards for evaluating their comprehension. J Educ Psychol. 1984;76:588-597.
Bandara I., Calvert G. General practitioners: uncelebrated adult learners – a qualitative study. Educ Prim Care. 2002;13:370-378.
Baxter Magolda M.B. Creating contexts for learning and self-authorship: constructive-developmental pedagogy. Nashville, TN: Vanderbilt University Press, 1999.
Bell B.S., Kozlowski S.W.J. Active learning: effects of core training design elements on self-regulatory processes, learning and adaptability. J Appl Psychol. 2008;93(2):296-316.
Bloom B.S. Taxonomy of educational objectives, Handbook 1: the cognitive domain. New York, NY: David McKay, Co Inc, 1956.
Bloom B.S., Krathwohl D.R. Taxonomy of educational objectives: the classification of educational goals, by a committee of college and university examiners. Handbook 1: cognitive domain. New York: Longmans, 1956.
Boud D., Walker D. Promoting reflective learning in professional courses: the challenge of context. Supporting lifelong learning, vol 1. Oxon, UK:Routledge. 2001. Perspectives on learning
Bower E.M., Hollister W.G., editors. Behavioral science frontiers in education. New York: Wiley, 1967.
Brooks J.G. Teachers and students: constructivists forging new connections. Educ Leadersh. 1990;47:68-71.
Bruner J.S. The act of discovery. Harv Educ Rev. 1961;31:21-32.
Butler D.L., Winne P.H. Feedback and self-regulated learning: a theoretical synthesis. Rev Educ Res. 1995;65(3):245-281.
Calhoun J.G., Woolliscroft J.O., Hockman E.M. Evaluating medical student clinical skill performance: relationships among self, peer, and expert ratings. Proc Annu Conf Res Med Educ. 1984;23:205-210.
Challis M. Portfolio-based learning: continuing medical education for general practitioners – a mid-point evaluation. Med Educ. 1997;31:22-26.
Challis M. AMEE medical education guide No. 19: personal learning plans. Med Teach. 2000;22:225-236.
Chickering A.W., Gamson Z.F. Seven principles for good practice in undergraduate education. Wingspread J. 7(2), 1987.
Cho M.-H. The effects of design strategies for promoting students? self-regulated learning skills on student?s self-regulation and achievement in online environments. In Presented at the Association for Educational Communications and Technology. Chicago: Illinois; 2004.
Davis D., Thomson M. A systematic review of the effect of continuing medical education strategies. JAMA. 1995;274:700-705.
Davis D.A., Mazmanian P.E., Fordis M., et al. Accuracy of physician self-assessment compared with observed measures of competence. JAMA. 2006;296(9):1094-1103.
DeRouin R.E., Fritzsche B.A., Salas E. Optimizing e-learning: research-based guidelines for learner-controlled training, Human Resource Management. 2004;43:147-162.
Dewey J. How we think: a restatement of the relation of reflective thinking in the educative process. Boston, MA: University Press, 1933.
Elango S., Jutti R.C., Lee L.K. Portfolio as a learning tool: students’ perspective. Ann Acad Med Singap. 2005;34:511-514.
Eva K., Cunningham J. How can I know what I don’t know? Personalities. Adv Health Sci Educ. 2004;9:211-224.
Eva K., Regehr G. Self assessment in the health professions: a reformulation and research agenda. Acad Med. 2005;80(10):S46-S54.
Fitzgerald J.T., White C.B., Gruppen L.D. A longitudinal study of self-assessment accuracy. Med Educ. 2003;37(7):645-649.
Forment M.A., Guerrero M.J.C., Gonzalez M.A.C., Peñalvo F.J.C., Severance C. Lecture Notes in Computer Science, Volume 5736. Berlin: Springer. 2009:286-295.
Ghaye T., Lillyman S. Learning journals and critical incidents: reflective practice for health care professionals. Salisbury, UK: Mark Allen Publishing Limited, 1997.
Grant J. Learning needs assessment: assessing the need. BMJ. 2002;324:156-159.
Grow G. Teaching learners to be self-directed. Adult Educ Q. 1991;41:125-149.
Hagen A.S., Weinstein C.E. Achievement goals, self-regulated learning, and the role of the classroom context. In: Pintrich P.R., editor. Understanding self-regulated learning. San Francisco, CA: Jossey-Bass, 1991.
Haugen S., Becker D. Classroom assessment and accounting student performance. International Journal of Innovation and Learning. 2005;2(1):36-46.
Ivancic K., Hesketh B. Learning from errors in a driving simulation: Effects on driving skill and self-confidence. Ergonomics. 2000;43:1966-1984.
Jowitt W.A. Promoting and monitoring self-regulated learning techniques in engineering schools. 2008. Proceedings of the 2008 AaeE Conference
King P., Kitchener K.S. Developing reflective judgment: understanding and promoting intellectual growth and critical thinking in adolescents and adults. San Francisco: Jossey-Bass, 1994.
Knowles M. Self-directed learning: a guide for learners and teachers. New York, NY: Association Press, 1975.
Knowles M. Using learning contracts. San Francisco, CA: Jossey-Bass, 1986.
Knowles M.S. The adult learner: a neglected species. Houston, TX: Gulf Publishing, 1973.
Knowles M.S. Andragogy in action. Applying modern principles of adult education. San Francisco: Jossey-Bass, 1984.
Krathwohl D.R., Bloom B.S., Masia B.B. Taxonomy of educational objectives, the classification of educational goals. Handbook II: affective domain. New York: David McKay Co., Inc, 1973.
Kruger J., Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999;77(6):1121-1134.
Larsen L.J., Lofgreen L.B. PLE and e-portfolio as learning tools in the educational system. Proceedings of the World Conference on E-Learning in Corporate, Government, Health Care and Higher Education. 2007:2069-2076.
Lowenthal W. Continuing education for professionals: voluntary or mandatory? J High Educ. 1981;52(5):519-538.
McGrath D., Higgins A. Implementing and evaluating reflective practice group sessions. Nurse Educ Pract. 2005;6:175-181.
Marton F., Hounsell D., Entwistle N., editors. The experience of learning. Edinburgh, Scotland: Scottish Academic Press, 1984.
Mathers N.J., Challis M.C., Howe A.C., et al. Portfolios in continuing medical education – effective and efficient? Med Educ. 1999;33:521-530.
Meyers C., Jones T.B. Promoting active learning: strategies for the college classroom. San Francisco, CA: Jossey-Bass, 1993.
Nicol D.J., MacFarlane-Dick D. Formative assessment and self-regulated learning: a model and seven principles of good feedback practice. Stud High Educ. 2006;31(2):199-218.
Phye G.D. Handbooks of academic learning: construction of knowledge. San Diego: Academic Press, 1997.
Pintrich P.R. Understanding self-regulated learning. New directions for teaching and learning, No. 63. San Francisco, CA: Jossey-Bass, 1995.
Platzer H., Snelling J., Blake D. Promoting reflective practitioners in nursing: a review of theoretical models and research into the use of diaries and journals to facilitate reflection. Teach High Educ. 1997;2:103-121.
Quintana C., Reiser B., Davis E.A., et al. A scaffolding design framework for software to support science inquiry. Journal of the Learning Sciences. 2004;13(3):337-386.
Risucci D.A., Tortolani A.J., Ward R.J. Ratings of surgical residents by self, supervisors, and peers. Surg Gynecol Obstet. 1989;169:519-526.
Schunk D.H., Zimmerman B.J. Self-regulation of learning and performance: issues and educational applications. Mahwah, NJ: Lawrence Erlbaum, 1994.
Simpson E.J. The classification of educational objectives in the psychomotor domain. Washington, DC: Gryphon House, 1972.
Skelly G., Quentin-Baxter M. Implementation and management of on-line curriculum study guides: the challenges of organizational change. Proceedings of CTICM Computers in Medicine Conference, Bristol, CTICM. 1997:656-673.
Spencer J.A., Jordan R.K. Learner centered approaches in medical education. BMJ. 1999;318:1280-1283.
Spigner-Littles D.A., Chalon E. Constructivism: a paradigm for older learners. Educ Gerontol. 1999;25:203-210.
Sullivan M.E., Hitchcock M., Dunnington G.L. Peer and self assessment during problem-based tutorials. Am J Surg. 1999;177:266-269.
van Tartwijk, van Rijswijk M., Tuithof H., Drieesen E.W. Using an analogy in the introduction of a portfolio. Teaching and Teacher Education. 2008;24(4):927-938.
Tenenbaum G., Naidu S., Jegede O., et al. Constructivist pedagogy in conventional on-campus and distance learning practice: an exploratory investigation. Learn Instr. 2001;11(2001):87-111.
Wald H.S., Davis S.W., Reis S.P., et al. Reflecting on reflections: enhancement of medical education curriculum with structured field notes and guided feedback. Acad Med. 2009;84(7):830-837.
Westberg J., Jason H. Fostering learners’ reflection and self-assessment. Fam Med. 1994;26:278-282.
White C.B. Smoothing out transitions: how pedagogy influences medical students’ achievement of self-regulated learning goals. Adv Health Sci Educ. 2007;12(3):279-297.
White CB, Gruppen LD: Association for the Study of Medical Education: Self-regulated learning in medical education
White R.H. Motivation reconsidered: the concept of competence. Psychol Rev. 1959;66:297-333.
Wilkerson L., Irby D. Strategies for improving teaching practices: a comprehensive approach to faculty development. Acad Med. 1998;73(4):387-396.
Winne P. Experimenting to bootstrap self-regulated learning. J Educ Psychol. 1997;88:397-410.
Zemke R., Zemke S. Thirty things we know for sure about adult learning. Innov Abstr. 1984;6(8):57-60.
Zimmerman B.J. Attaining self-regulated learning: a social cognitive perspective. In: Boekaerts M., Pintrich P.R., Zeidner Moshe, editors. Handbook of self-regulation. San Diego, CA: Academic Press, 2000.
Zimmerman B.J., Schunk D.H. Self-regulated learning and academic achievement: theoretical perspectives. Mahwah, NJ: Lawrence Erlbaum, 2001.