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Content covering foundational educational theories (behaviorism, humanism, cognitivism, social cognitivism, and constructivism) used in higher education and professional learning.

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Kelly's Educational Theory Playlist - YouTube

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Kelly's Educational Theory Playlist - YouTube

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Playlist of educational theory videos on YouTube that I found helpful or inspiring

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Helpful videos related to educational theory

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Questions for continued personal and professional development as an educator

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Tools for Educators - Programs, Apps, & Tips

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Tools for Educators - Programs, Apps, & Tips

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Resources for educators, including programs, websites, apps, and more

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Resources and References: Nutrition Education

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Resources and References: Nutrition Education

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Content related to nutrition education, including dietetics & nutrition, health professionals, and the public

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Content related to assessment and evaluation of learning outcomes in learners across the spectrum of health care (undergraduate, graduate/post-grad, professional).

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Content related to development of learning objectives in higher education, as well as professional practice

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Clinical educator self-efficacy, self-evaluation and its relationship with student evaluations of clinical teaching

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Clinical educator self-efficacy, self-evaluation and its relationship with student evaluations of clinical teaching

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Vaughan B. (2020). Clinical educator self-efficacy, self-evaluation and its relationship with student evaluations of clinical teaching. BMC medical education, 20(1), 347. https://doi.org/10.1186/s12909-020-02278-z

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Clinical educator self-efficacy, self-evaluation and its relationship with student evaluations of clinical teaching - BMC Medical Education

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Background In a whole-of-system approach to evaluation of teaching across any degree, multiple sources of information can help develop an educators’ understanding of their teaching quality. In the health professions, student evaluations of clinical teaching are commonplace. However, self-evaluation…

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The relationship between assessment methods and self-directed learning readiness in medical education

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The relationship between assessment methods and self-directed learning readiness in medical education

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Monroe K. S. (2016). The relationship between assessment methods and self-directed learning readiness in medical education. International journal of medical education, 7, 75–80. https://doi.org/10.5116/ijme.56bd.b282

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Abstract

Objective: This research explored the assessment of self-directed learning readiness within the comprehensive evaluation of medical students' knowledge and skills and the extent to which several variables predicted participants' self-directed learning readiness prior to their graduation.

Methods: Five metrics for evaluating medical students were considered in a multiple regression analysis. Fourth-year medical students at a competitive US medical school received an informed consent and an online survey. Participants voluntarily completed a self-directed learning readiness scale that assessed four subsets of self-directed learning readiness and consented to the release of their academic records.

Results: The assortment of metrics considered in this study only vaguely captured students' self-directedness. The strongest predictors were faculty evaluations of students' performance on clerkship rotations. Specific clerkship grades were mildly predictive of three subscales. The Pediatrics clerkship modestly predicted critical self-evaluation (r=-.30, p=.01) and the Psychiatry clerkship mildly predicted learning self-efficacy (r =-.30, p=.01), while the Junior Surgery clerkship nominally correlated with participants' effective organization for learning (r=.21, p=.05). Other metrics examined did not contribute to predicting participants' readiness for self-directed learning.

Conclusions: Given individual differences among participants for the variables considered, no combination of students' grades and/or test scores overwhelmingly predicted their aptitude for self-directed learning. Considering the importance of fostering medical students' self-directed learning skills, schools need a reliable and pragmatic approach to measure them. This data analysis, however, offered no clear-cut way of documenting students' self-directed learning readiness based on the evaluation metrics included.

Keywords: assessment; evaluation; self-directed learning.

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Densen P. Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc. 2011;122:48-58. - PMC - PubMed

Brook RH. Continuing medical education: let the guessing begin. JAMA. 2010;303:359-360. doi: 10.1001/jama.2010.25. - DOI - PubMed

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national center for biotechnology information

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Academy of Nutrition and Dietetics: Revised 2018 Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Education of Nutrition and Dietetics Practitioners

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Academy of Nutrition and Dietetics: Revised 2018 Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Education of Nutrition and Dietetics Practitioners

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Anderson Girard, T., Russell, K., & Leyse-Wallace, R. (2018). Academy of Nutrition and Dietetics: Revised 2018 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Mental Health and Addictions. Journal of the Academy of Nutrition and Dietetics, 118(10), 1975–1986.e53. https://doi.org/10.1016/j.jand.2018.07.013

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Abstract

In 2016, there were 44.7 million adults affected by mental illness, and 20.1 million people aged 12 years or older affected by substance use disorder. More than 8.2 million Americans are afflicted with co-occurring disorders or dual diagnosis, such as both a mental illness and an addiction. Registered dietitian nutritionists (RDNs) have an important role in the treatment of this population, as optimizing nutrition status improves cognitive and emotional functioning. The Behavioral Health Nutrition Dietetic Practice Group, with guidance from the Academy of Nutrition and Dietetics Quality Management Committee, has developed Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs in Mental Health and Addictions for three levels of practice: competent, proficient, and expert. The SOP uses the Nutrition Care Process and clinical workflow elements for care of individuals with mental illness and/or addictions. The SOPP describes six domains that focus on professionalism: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Indicators outlined in the SOP and SOPP depict how these standards apply to practice. The SOP and SOPP are complementary resources for RDNs caring for individuals with, or specializing in, mental health and addictions and practicing in other mental health and addictions-related areas, including research. The SOP and SOPP are intended to be used by RDNs for self-evaluation to assure competent practice and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.

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 A Theory-Based Contextual Nutrition Education Manual Enhanced Nutrition Teaching Skill

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 A Theory-Based Contextual Nutrition Education Manual Enhanced Nutrition Teaching Skill

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Human Nutrition, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa

Background: A theory-based contextual nutrition education manual (NEM) may enhance effective teaching of nutrition in schools. School nutrition education should lead to the realization of such benefits as improved health, scholarly achievement leading to manpower development and consequently the nation's development. The purpose of the study was to develop a contextual NEM for teachers of Grade 5 and 6 learners in the Bronkhorstspruit district, South Africa, and to assess teachers' perception on the use of the manual for teaching nutrition.

Methods: This descriptive case study used an interpretivist paradigm. The study involved teachers ( N = 6) who taught nutrition in Life Skills (LS) and Natural Science and Technology (NST) in a randomly selected primary school in the Bronkhorstspruit district. Findings from a nutrition education needs assessment were integrated with the constructs of the Social cognitive theory (SCT) and the Meaningful learning model (MLM) and the existing curriculum of the Department of Basic Education (DoBE) to develop a contextual NEM. The manual was used by the teachers to teach nutrition to Grades 5 and 6 learners during the 2015 academic year as a pilot project. A focus group discussion (FDG) was conducted with teachers to gauge their perceptions of the usefulness of the NEM. Data were analyzed using the thematic approach of the framework method for qualitative research.

Results: Teachers described the NEM as rich in information, easy to use and perceived the supporting materials and activities as being effective. The goal setting activities contained in the NEM were deemed to be ineffective. Teachers felt that they did not have enough time to teach all the important things that the learners needed to know.

Conclusion: Teachers perceived the NEM as helpful toward improving their nutrition teaching skills.The NEM template may furthermore guide teachers in planning theory-based nutrition lessons.

Introduction

A nutrition education (NE) manual is a step by step guideline and plan for delivering nutrition lessons using theoretical concepts ( 1). The step by step guidelines for delivering nutrition messages can also be referred to as a curriculum, a lesson plan or an educational plan ( 2). Theory based, behaviorally oriented methods are known to be effective in NE ( 3). In the debate on the usefulness and barriers of theory application in nutrition interventions, Brug and colleagues argued that theories promoting behavior change and motivation are useful ( 4). Theories may bridge the gap between motivation for change and behavior change ( 5). Bridging the gap between motivation and behavior change is especially important in nutrition interventions. Nutrition education curriculum development and implementation based on behavioral theories such as social cognitive theory (SCT) and the meaningful learning model (MLM) has been successful ( 6, 7). Successful school NE curricula, incorporating SCT, capitalized on the influence of the school environment on learners' ability to learn new behaviors ( 6- 9). The MLM encourages active involvement of learners in the delivery of messages by ascertaining learners' prior knowledge, establishing and facilitating the use of new learning in real life situations ( 7, 10).

Nutrition education curricula are usually developed to address specific issues. For example, the Food and Agriculture Organization's (FAO) NE curriculum took into account that many developing countries do not offer NE in schools ( 1). In both developing and developed countries, NE curricula were developed to improve school children's attendance and attention in class, to develop healthy eating, and to promote healthy food behaviors ( 1, 11, 12).

Nutrition teaching is generally included as topics within subjects, focusing on increasing learners' knowledge of good nutrition, often neglecting behavior change ( 1, 13, 14). In South Africa, the Department of Basic Education (DoBE) emphasized behavioral outcomes in the curriculum but the did not include a behavioral component ( 15). Nutrition curricula without behavioral components may undermine the benefits of school NE ( 6, 16- 18). The literature on school NE in South Africa has documented several important issues. These concerns included a need for an educational strategy that fits into the school curriculum, unhealthy eating among learners, and a need for an effective approach for communicating nutrition messages to learners from limited resource settings ( 19, 20). Additionally, there is limited information in the literature regarding the details of the educational materials used in curriculum-based NE interventions; the integration of behavioral and learning theories is often not explained. Against this background, we developed a theory based contextual nutrition education manual (NEM) to promote healthy eating. We assessed if teachers who used the NEM deemed the resource as valuable. The manual was developed by enhancing the existing DoBE curriculum using SCT and MLM. To our knowledge, this is the first project to execute school NE with this approach in Africa.

Methods

Needs Assessment

The needs assessment revealed two categories of factors that may influence behavior:

Factors with the potential of promoting healthy eating:

* locally available foods in the community,

* foods served through the National School Nutrition Program (NSNP),

* healthy choices of foods in tuck shop,

* teachers' desire for training to teach nutrition,

* classroom nutrition messages.

Factors with the potential of hindering healthy eating:

* lack of teachers' nutrition knowledge in certain areas such as the energy content of food, sources of nutrients and composition of fats,

* unavailability of up to date instructional materials such as teachers' manuals, posters, learner's workbooks and hands-on materials,

* lack of nutrition training for the teachers,

* inappropriate methods of delivery of NE to learners,

* learners' inadequate nutrition knowledge,

* learners' resource-constrained environment,

* unhealthy choices of foods among the learners.

Development of the Manual

Table 1. Example of template for grade 5 nutrition topic-Healthy Eating for Children.

The manual included a picture book, learner's workbook, and posters. The NE materials were subjected to face and content validity by the officers of the DoBE and nutrition experts at the University of Pretoria. The DoBE officers recommended limiting the manual to essential concepts suited to the allotted 30 min lesson time. We shortened the manual to comply with the suggestions made by the DoBE officers.

Nutrition Education Manual and the Accompanying Materials

The NEM featured the nutrition topics for Grades 5 and 6, outlined in the DoBE's curriculum and delineated into sub-topics to make up a chapter. Each chapter consisted of a sub-topic plan with an outline and subtopic notes. The sub-topic plan provided teachers with guidelines on how to present nutrition messages to learners while accommodating the learners' resource-constrained situation. The sub-topic notes provided detailed information about the sub-topics and served as a resource when the teachers prepared for teaching the lessons.

We presented the sub-topic plan and outline in clear headings which described the pedagogy for implementing the lessons: objectives, lesson preparation, learners' prior knowledge, active participatory teaching and learning, problem-based small group discussion and self-regulatory learning. The self-regulatory learning consisted of two activities for learners. Firstly, the learners' goal setting exercises where learners made decisions concerning the nutrition messages they received and secondly the learner's worksheets where learners engaged in problem identification and problem-solving exercises. The instruction approach featured educational activities such as class demonstrations with food items, correct hand washing techniques, and learners' goal setting. Learners were encouraged to involve their parents by sharing their worksheet exercises and goals with families. The pedagogical outline of the NEM in one of the nutrition lessons is presented in Table 2.

Table 2. Pedagogical outline of the NE manual in a lesson "South African Food-Based Dietary Guidelines."

The picture book was a collection of pictures relevant to the learners' context to be used as a supplementary resource.

The learner's workbook was a collation of the learners' tasks and comprised goal setting exercises and worksheet activities that learners were to complete with parents or guardians at home. We structured the NEM in such a way that teachers had to encourage learners to set their goals. Teachers had to monitor learners' progress toward achieving their goals.

The posters were pictorial illustrations of nutrition concepts. Teachers could hang posters on classroom walls serving as constant reminders of nutrition messages.

Participants

The Gauteng DoBE selected three primary schools to participate in a broader study: "Schools as sites for social change" also an Institutional Research Theme (IRT) of the University of Pretoria. One of the three primary schools was randomly selected to pilot the developed NEM. The teachers ( n = 6) for LS and NST in Grades 5 and 6 in the selected school were purposively selected to participate in the study. Four teachers taught nutrition through LS and NST subjects to 177 6th Grade learners in five classes, and two teachers taught nutrition through LS to 173 5th Grade learners in five classes. All of the teachers consented to participate in the study.

Intervention

We trained the teachers to use the NEM in a 1 day workshop, which gave opportunities for familiarization and obtaining input from the teachers on the outline and practical implementation of the manual. During the workshop, we taught fundamental nutrition concepts to the teachers, addressing one of the needs identified in the needs assessment. After the workshop, teachers used the manual to teach nutrition topics in the DoBE curriculum for one academic year (2015). Each learner received a workbook to complete class and homework activities.

At the end of the academic year, a focus group discussion (FDG) with the teachers was conducted to obtain their perceptions of the use of the NE manual. The small sample of teachers necessitated a single FGD. A researcher and two research assistants conducted the FGD, which lasted 56 min. The assistants took notes and monitored the audio tape recording according to recommended procedures ( 24).

Assessment of Perceptions

We developed an interview guide of 12 questions to guide the discussion. Nutrition experts at the University of Pretoria assessed the face and content validity of the interview guide. Examples of the questions were "In your own opinion, how can the use of the manual in presenting nutrition messages help learners to adopt healthy eating?" and "What part(s) of the lesson did learners enjoy the most?"

Data Analysis

Data were analyzed using the thematic approach of the framework method which comprises data familiarization, thematic pattern identification, theme coding, charting and mapping ( 25, 26). The emerging themes were discussed in categories.

Results

The perceptions of teachers regarding the use of the NEM were described using selected quotes designated with the teachers' participating number (e.g., P2-participant 2). The teachers' views of the use of the NEM were discussed under three themes, namely the perceptions of the manual, the perceptions of the supporting materials and activities and recommendations for improvement.

Teachers' Perceptions of the Manual

The teachers described the manual as rich in information, well-outlined with nutrition concepts, adequately illustrated with colorful pictures and as easy to use. They explained that the cover page pictures illustrated healthy eating and were relevant to the learners' environment. The teachers remarked:

" It was easy to use the manual and to understand. The mere looking at the manual with the colorful pictures made it easy to use it to teach." -P2.

Teachers viewed that the teaching of nutrition using the NEM might influence learners' eating behaviors in two ways. Firstly, learners would benefit from nutrition knowledge in the future. Teachers explained that learners' low economic background might limit their capacity to effect behavioral change.

" It would help learners to know what they didn't know before. If they couldn't practice what they learned now because they couldn't afford the foods, they will be able to use the knowledge to benefit their lives in future." -P4.

Secondly, teachers felt that learners benefited from the practical demonstrations in which they participated in class. Learners could implement these practices in their homes, for example, the demonstration of effective hand washing.

Teachers felt that the NEM had more information relevant to the learners' situation compared to the DoBE recommended textbooks for nutrition topics.

" The manual was more practical, the foods mentioned in the manual were what the learners were familiar with which they also used in their homes." -P4.

Teachers' Perceptions of the Supporting Materials and Activities

During the FGD, we discussed the usefulness of the posters and picture book in teaching the nutrition lessons. We discussed the influence of goal setting on learners' eating behaviors, the influence of worksheet activities on learners' understanding, the influence of group discussions on learners' understanding and the parts of the lesson that the learners enjoyed the most.

Teachers viewed the posters and the picture book as valuable supplements to the manual because they helped to consolidate the nutrition messages, making teaching lively.

" The picture book was helpful because when we taught the lessons, we used the pictures in the picture book to show learners examples." -P2.

Teachers perceived the goal setting activities as exercises in which the learners had to make decisions beyond their control. Teachers explained that learners only ate what their parents provided, and some learners depended on foods served at school. Teachers, therefore, reasoned that the goal setting activities were unlikely to have an appreciable influence on the learners' eating behaviors.

" For learners to set their goals was difficult for them because they did not have a choice, it was what their parents gave that they would eat." -P5.

Teachers perceived the worksheet activities as being unable to influence learners' understanding. The workbooks contained too few non-writing activities such as crosswords or matching pictures with texts.

" The worksheets required more of writing which our learners did not like so much. Our learners like to cut and paste pictures and also drawing rather than writing."- P4.

The problem-based group discussions presented opportunities for learners to learn from each other while the classroom demonstrations and practical sessions gave opportunities for learners to work in groups.

" The group discussion helped them to learn because they had the opportunity to share ideas and learned from the ideas of the other members of the group." -P2.

Teachers mentioned that learners enjoyed the lessons about the consequences of a poor diet. Teachers reported that learners also enjoyed the practical sessions and demonstrations and that all the learners wanted to participate.

" The part of demonstrating effective washing of hands was very interesting for learners; they had said we thought when we wet our hands it was clean. They saw that wetting of hands was not clean at all when we did the demonstration." -P1.

Teachers' Recommendations for Improvement

Teachers recommended improvement in three themes, namely teachers' decision to continue using the manual, the strengths of the manual and suggestions for improvement.

Teachers mentioned that they would like to continue to use the manual to teach nutrition. They felt that the manual had a clear outline, attractive appearance and used simple language. The NEM was thus practical and easy to use. The content was in line with the existing curriculum, and the messages were implementable.

" If ever it was my choice, I would like that all the other aspects of NST be like this manual." -P3.

Teachers emphasized that the strengths of the NEM lay in the implementable messages and attractive presentation with illustrations.

" It was valuable in the sense that it taught learners what could practically be done." -P4.

The teachers suggested the following improvements to the manual: the learner's workbook should include more optional activities and should feature more hands-on activities.

Discussion

We developed a NEM that capitalized on the strengths of behavioral theories to facilitate improved nutrition knowledge and desirable behavior change. We selected SCT constructs, including the environment, behavioral capability, expectation, observational learning, and self-regulated learning. The MLM constructs included relevant prior knowledge and integration of new knowledge with prior knowledge.

Behavioral capability is about acquiring knowledge about an issue and developing the skills to perform the behaviors to address the issue. In this case, if we expect learners to adopt healthy eating behaviors, they need to know what healthy eating is and how to eat healthily ( 29). We integrated behavioral capability into the curriculum through interactive and question-answer methods of lesson delivery. We recommended that learners actively engage in classroom activities and interpret class experiences for making healthy food choices ( 1).

In the NEM, expectation concept was presented by emphasizing positive outcomes of healthful behaviors. Learners who can identify positive outcomes are more likely to adopt healthy eating behaviors in both the short and the long term. Knowing that healthy eating promotes brain function and good school performance is a powerful motivator for learners ( 30). Other motivators included in the NEM were good growth, healthy bones, healthy teeth and to be disease free.

Self-regulated learning was integrated through goal setting activities included in the learner's workbook. The workbook encouraged learners to attain their goals by committing to a line of action ( 29). The goal setting activities required learners to evaluate their knowledge, then write their goals and plan strategies on how to accomplish their eating goals.

The developed NEM featured curriculum structures such as objectives, group discussions, prior relevant knowledge and building on existing knowledge as reported in previous studies ( 7, 33).

Our NEM enhanced the nutrition topics outlined by the DoBE following the allotted time. This strategy corroborates the findings from previous studies that integrating school-based NE into the existing curriculum brings about desirable results ( 6, 35, 36). Also, supporting the developed NE manual with materials, i.e., the picture book, learner's workbook and the posters is consistent with the recommendations that school NE materials should comprise a teacher's manual and instructional materials ( 35).

The teachers described the manual as informative, well-illustrated with pictures and easy to use. In previous studies, teachers valued clear instructions and good arrangement as helpful teaching aids ( 37). The components of a NEM and ease of use are some of the factors that could motivate teachers in implementing NE programs ( 38, 39). In this study, teachers perceived that the NEM could influence learners eating behavior in two ways. Firstly, learners had learned valuable nutrition concepts and would be able to use this knowledge in the future. Teachers felt that learners' current resource-constrained situation limited their ability to make immediate behavioral changes. A constrained socio-economic background may hinder the success of school NE interventions ( 18, 40, 41). In resource-limited communities, NE curricula need to be carefully considered to have the desired outcomes. For example, if the supply of healthy food is limited, learners need to be taught how to grow seasonal crops or develop home gardens to improve food variety and household food security. McNulty reasoned that school NE should prepare learners for their role as future parents who need to take responsibility for their own nutritional well-being and that of their families ( 14). It may be frustrating for learners to learn about nutrition if they are unable to use the information in their resource-constrained situations. Furthermore, learners who drop out of school early to start a family may benefit from nutrition knowledge acquired during school NE ( 42).

Secondly, learners benefited from some of the classroom demonstrations such as effective hand washing. This lesson could also be applied at home.

Teachers indicated their willingness to continue using the NEM if given the opportunity. The reasons given emphasized the fact that teachers appreciated the manual's attractive appearance, simple language, practical orientation, and ease of use. In previous studies, teachers gave similar reasons when expressing their satisfaction with the educator's manual and the NE materials ( 39, 41).

The strengths of the NEM such as its integration in the existing curriculum and its well-structured pedagogy for use by teachers are valuable and contribute to the potential sustainability of the NEM. Teachers suggested that the learner's workbook should include more activities from which teachers could choose and that the learner's workbook should include more hands-on activities because learners tend to sustain knowledge after engaging in practical activities. Teachers recommended that supporting materials for school NE should include a variety of resources in different presentations to enhance effective teaching of nutrition in schools ( 35). Teachers suggested that posters could be improved through lamination, further revealing the teachers' desire to continue using the NEM.

This evaluation was limited to a single FGD with six teachers. Interviewing a larger number of teachers would have allowed for more FGDs and provided richer information. The findings of this study cannot be generalized to entire South Africa due to the small sample size and the contextual orientation of the NEM. However, as a pilot project, this study has provided direction to scaling up activities. Moreover, the NEM was based on the national curriculum which is used by all public primary schools in South Africa.

Conclusion

This study demonstrated the feasibility of developing a theory-based contextual NE manual based on an existing school curriculum. Teachers perceived the contextual NEM to be helpful for teaching nutrition to learners. While developing the NEM, we considered and used selected constructs of the SCT and the MLM to enhance the existing curriculum for use in resource-limited settings. We demonstrated that these theories improved the understanding of the concepts of nutrition in the context of the teachers' experiences.

Future studies could continue to implement the NEM to more schools, including all Grades. Teachers could use the nutrition lesson template to guide the planning of nutrition lessons suited to learners' specific needs. The theoretical template could be used to adapt the NEM to different settings with special attention to the prevailing situation of the target audience.

Ethics Statement

This study was carried out in accordance with the recommendations of the Gauteng Department of Education (Numbers: D2014/199; D2014/308A and D2015/374A). The protocol was approved by the Research Ethics Committee of the Faculty of Natural and Agricultural Sciences of the University of Pretoria (Number: EC130424-037). All participants provided written informed consent in accordance with the Declaration of Helsinki.

Author Contributions

UM and GG conceptualized the study. MK collected the data and wrote the first draft of the manuscript with contributions from UM and GG. All authors reviewed and approved the draft of the manuscript and ensured the accuracy and integrity of the work before submission to the journal.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

This work was supported by the University of Pretoria's Strategic Institutional Research Theme through the Institute for Food, Nutrition, and Wellbeing; the Nestle Nutrition Institute Africa; and the Association of African Universities. The authors gratefully acknowledge the Gauteng Department of Education (GDE) in granting the permission to conduct the study; and the principals, teachers, and learners for participating in the study.

References

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15. Department of Basic Education. Curriculum and Assessment Policy Statement (CAPS) - National Curriculum Statement (NCS) Grades 4 - 6 Natural Sciences and Technology. Republic of South Africa: Basic Education Department. (2011).

16. Bauer K, Liou D, Sokolik C. Nutrition Counseling, and Education Skill Development, 3rd Edn. Boston, MA: Cengage Learning (2012).

23. Department of Basic Education. Curriculum and Assessment Policy Statement (CAPS) - National Curriculum Statement (NCS) Grades 4 - 6: Life Skills. Republic of South Africa: Basic Education Department. (2011).

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A Theory-Based Contextual Nutrition Education Manual Enhanced Nutrition Teaching Skill

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Background: A theory-based contextual nutrition education manual (NEM) may enhance effective teaching of nutrition in schools. School nutrition education should lead to the realization of such benefits as improved health, scholarly achievement leading to manpower development and consequently the nation's development.

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Abstract

This study used an online-structured interview methodology to examine the impact of an intensive field experience in facilitating problem (PBL) and project-based learning (PjBL) on teachers' pedagogy. The purpose of the study was to determine to what extent the field experience had transformed their teaching. Data were collected in the form of online interviews with 36 participants who completed the gifted education licensure program at a regional state university in the southeast. The online interviews were followed up with telephone interviews with four of the participants. The resulting themes can be grouped under the major categories of teacher-related and student-related themes. This article will focus on the teacherrelated themes, the most important being the change in the teachers' pedagogy. The article will further discuss the obstacles that stood in the way of the teachers' successful implementation of PBL and PjBL.

Recommended Citation

Dole, S. , Bloom, L. , & Kowalske, K. (2016). Transforming Pedagogy: Changing Perspectives from Teacher-Centered to Learner-Centered. Interdisciplinary Journal of Problem-Based Learning, 10(1).
Available at: https://doi.org/10.7771/1541-5015.1538

DOWNLOADS

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This study used an online-structured interview methodology to examine the impact of an intensive field experience in facilitating problem (PBL) and project-based learning (PjBL) on teachers' pedagogy. The purpose of the study was to determine to what extent the field experience had transformed their teaching.

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Tips & tutorials for educators and learners

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Meaningful ways for teachers and students to collaborate online are more important than ever. That's why so many educators love Padlet, a digital bulletin board tool. It gives teachers, students, and even parents an easy way to share ideas, review work, and a whole lot more. Wondering what it's all about? Here's our guide to Padlet for teachers, including plenty of clever ways to use it with your students.

What is Padlet?

Think of Padlet as an online bulletin board, but with a lot of things a regular bulletin board could never do. Users can post text, images, videos, files, links ... basically anything digital. Others can see the postings, as well as comment or vote on them if the board owner allows. You can customize each Padlet by changing the background, layout, font, and color scheme.

One of the best things about Padlet for teachers is how very easy it is to use, even for young students. It works on computers and laptops, plus devices like Chromebooks, iPads, or smartphones. Perhaps most importantly, teachers can control whether contributions have students' names on them or are made anonymously. This empowers students who might otherwise feel too timid to share. You can also decide whether or not to allow comments or ratings and even require approval before posting or filter out profanity.

Is Padlet free?

Padlet's free version for all users allows you to create up to three Padlet boards at a time. You can erase and create new ones to stay under the limit. This is a good option for teachers who only plan to use it occasionally or who want to give it a try to see if it works for them.

If you decide you're willing to pay for an upgrade, there are two options. You can sign up for a Pro account, which offers unlimited Padlets and removes upload limits. Individual Pro accounts currently cost $8/month.

Padlet also offers Backpack for Schools, a bulk pricing plan that gives schools more privacy options, extra security, student portfolios, and more. Learn more about Backpack here.

15 Cool Ways to Use Padlet for Teachers

Ready to give it a try? There are so many ways to use Padlet for teachers and students. Here are some of the best ideas we've found to inspire you.

1. Remake existing Padlets as templates

If you come across a Padlet made by someone else that you really like, you can copy it to your own account and use it as a template. You can choose to copy the posts too, or just grab the layout to get you started. It's as simple as clicking the Remake button, then choosing what you want to copy over. The new Padlet will appear on your account, and you're ready to go! Want to make your own templates? Visit Guiding on the Side for a walk-through.

2. Collaborate and organize

Imagine you've asked your class to research a topic, with each student contributing several facts. In a hands-on classroom, you might have each student write their fact on a sticky note and add it to a whiteboard. Then, together with your class, you could organize those facts by moving the notes into columns. You can do the same with Padlet, but your "sticky notes" can contain photos, graphs, videos and audio, article links, and anything else that might be useful.

On the board above, students have contributed facts about E.T.A. Hoffman, author of The Nutcracker story, as well as information about the ballet. Here's the same board organized into columns, with posts sorted by subject. Learn how to change Padlet layouts here.

You can organize information in other ways, too, like timelines and flowcharts. The Techie Teacher has free graphic organizer Padlet templates you can re-make for your students here.

3. Get to know each other

Padlet is perfect for icebreaker activities. Ask students to share what they have in common or share an image of their favorite study space. You could even ask each student to create their own Padlet, sharing some of their favorite things. Learn how one teacher uses Padlet for a Selfie Icebreaker at Dr. Catlin Tucker.

4. Create a timeline

Padlet has a timeline feature built right in as one of their organizational options. How cool is that? Use it for history class, tracing scientific eras or evolutions, or even to map out the order of events in a book for English class. Wherever a timeline comes in handy, Padlet has you covered. Learn more about timelines here.

5. Get feedback with exit tickets

Exit tickets are a fantastic way to find out what your students learned in class and where they may still need some help. Lots of teachers have kids write their answers to a reflection question on a sticky note and post it by the door on the way out. If you're teaching online, or want to incorporate some technology, use Padlet instead.

6. Display student work

Teachers are no longer limited to displaying student work on a classroom bulletin board or in the hallway nearby. Since Padlets are easy to share, parents can drop in and see what their kids have been working on. See how The Techie Playground does it here.

7. Keep track of who needs help

One teacher likes to use Padlet to see who needs help during independent work. Kids simply add their name to the list to indicate they need a minute of the teacher's time. They can see how many kids are ahead of them, and no one is forgotten in the shuffle. Learn more at Stefbub's Classroom.

8. Hold a debate

Classroom discussion and debate can be difficult when you're teaching online. Even in person, there's rarely enough time for everyone's opinion to be heard. Try taking the debate online instead, like this Padlet from Teach Every Day. Post a question, then have students choose a side and gather resources about it. As students review the information posted by others, they can share their own thoughts and ask further questions. This is also an excellent way to help kids learn to have civil conversations online, even when they don't agree on the subject.

9. Have a scavenger hunt

Everyone loves a scavenger hunt! Set up a Padlet with columns, titling each with something your students need to find. Use a scavenger hunt for team building, or create a hunt that helps students learn more about a class subject. Make a field trip more meaningful (even a virtual one!) by asking kids to post pictures that meet certain criteria. Learning the alphabet with your littles? Have them take photos of items around them that start with each letter. There's so much you can do with this smart Padlet for teachers idea!

10. Set up a bookshelf

Use Padlet to make book recommendations or keep track of what students are reading. Recommendations by teachers or other students will help parents and kids find new reads to love. Ask kids to rate and comment on the books they're reading for class and include their own personal choices too.

11. Make a map

Padlet's map feature makes it a breeze to create a collaborative map for your students to use. Choose from a variety of styles, including satellite views. Add points to the map, along with information like links, photos, and more. Learn more about the map function from Free Technology For Teachers.

12. Conduct a writers' workshop

Writers' workshops help students develop their own skills and learn from others. One teacher has taken her writing workshops online, using Padlet to help her young writers see strong examples from their classmates while improving their own efforts. See how it's done at Mud and Ink Teaching.

13. Use Padlet Backchannel for discussions

Padlet's Backchannel feature makes it easy to have a discussion during another activity, like watching a film or listening to a presentation. It works just like a regular Padlet, but a text box at the bottom simplifies the process, allowing users to quickly type and send, just like in other chat programs. You can still add other items like links, images, or videos, too. Learn more about Backchannel from Richard Byrne on YouTube.

14. Assign lessons or homework

Use Padlet to keep all of your homework assignments for the week in one place, or lay out the daily lessons for a virtual classroom. You can link to videos, online games, and other resources, or create assignments directly in Padlet, like responding to reading questions. Students or parents can post questions to the assignments as needed, too. Learn how one teacher does it at Elementary Grapevine.

15. Take a poll

By enabling the voting feature, you can easily take a poll or survey for just about anything. Choose your next class reward, find out which book your students loved the most, or ask them which problem was the most difficult on last night's math homework. There are so many possibilities!

How do you use Padlet? Share in the comments!

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Padlet For Teachers: The Best Tips, Tricks, and Ideas For Your Classroom

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Wondering how to use this cool online bulletin board tool in your classroom? We've got everything you need to know about Padlet for teachers.

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Clark R. E. (2018). A History and Overview of the Behavioral Neuroscience of Learning and Memory. Current topics in behavioral neurosciences, 37, 1–11. https://doi.org/10.1007/7854_2017_482

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doi: 10.1007/7854_2017_37. Online ahead of print.

Affiliations

¹ Veterans Affairs San Diego Healthcare System, San Diego, CA, 92161, USA. reclark@ucsd.edu.

² Department of Psychiatry, University of California, La Jolla, San Diego, CA, 92093, USA. reclark@ucsd.edu.

doi: 10.1007/7854_2017_37. Online ahead of print.

Affiliations

¹ Veterans Affairs San Diego Healthcare System, San Diego, CA, 92161, USA. reclark@ucsd.edu.

² Department of Psychiatry, University of California, La Jolla, San Diego, CA, 92093, USA. reclark@ucsd.edu.

Abstract

Here, I provide a basic history of important milestones in the development of theories for how the brain accomplishes the phenomenon of learning and memory. Included are the ideas of Plato, René Descartes, Théodule Ribot, William James, Ivan Pavlov, John Watson, Karl Lashley, and others. The modern era of learning and memory research begins with the description of H.M. by Brenda Milner and the gradual discovery that the brain contains multiple learning and memory systems that are supported by anatomically discrete brain structures. Finally, a brief overview is provided for the chapters that are included in current topics in Behavioral Neuroscience-Learning and Memory.

Keywords: Brenda Milner; Descartes; H.M; Ivan Pavlov; John Watson; Karl Lashley; Plato; Ribot; William James.

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national center for biotechnology information

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A History and Overview of the Behavioral Neuroscience of Learning and Memory - PubMed

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Here, I provide a basic history of important milestones in the development of theories for how the brain accomplishes the phenomenon of learning and memory. Included are the ideas of Plato, René Descartes, Théodule Ribot, William James, Ivan Pavlov, John Watson, Karl Lashley, and others. The modern ...

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Clark K. R. (2018). Learning Theories: Behaviorism. Radiologic technology, 90(2), 172–175.

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Humanistic theory | Behavior | MCAT | Khan Academy

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Dennick R. (2016). Constructivism: reflections on twenty five years teaching the constructivist approach in medical education. International journal of medical education, 7, 200–205. https://doi.org/10.5116/ijme.5763.de11

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Introduction

There is no single overarching theoretical framework that accounts for how we learn in all situations. There are many theories of how we learn from our experiences and there are many theories of what experiences are. We know that we do learn and that we have knowledge but there is no consensus on the relationship between the mechanism by which our brains learn and the optimal way in which we should be taught. In other words there is no necessary connection between epistemology and pedagogy. We seem capable of learning from a wide variety of pedagogical processes and although there is empirical evidence that some ways of learning are more effective than others in specific situations no one pedagogical method dominates. However, reflecting on twenty five years as a medical educationalist I have come to the conclusion that there is one framework that makes more connections between different epistemological and pedagogical theories than others and that could have support from neuroscience. I wish to explore the connections between a variety of educational, communication and psychotherapeutic processes and try to show that constructivism holds the promise of providing some unity to the practice of education and learning.

The constructivist model

The constructivist theory of learning, whose philosophical origins are frequently ascribed to Kant and whose educational origins to Piaget, is based on the premise that the act of learning is based on a process which connects new knowledge to pre-existing knowledge. I do not intend to go into all the arguments surrounding this theory and to describe the variety of constructivist models that have been created. The reader is referred to the extensive literature on the subject.⁻ For the purposes of my argument it is simply necessary to acknowledge some basic assumptions underpinning the theory from which important connections to other educational theories can be made as well as to therapeutic practices, neuroscience and even the nature of scientific knowledge.

Possibly the most well-known articulation of the underlying assumption of constructivism is the famous quotation of Ausubel: "The most important factor influencing learning is what the learner already knows". In many years of teaching teachers how to teach I have found many people have an intuitive grasp of this fact and tailor their teaching to take account of the background knowledge of their students. Piaget expressed it differently by stressing that experience is constantly being 'assimilated' or filtered through pre-existing concepts. New knowledge is therefore interpreted by existing knowledge and then connected to existing knowledge. The implications of this conception are manifold and spread beyond conventional education into interpersonal communication and psychotherapy. In addition this phenomenon begs the question of how the process is conducted and manifested in the brains of individuals.

The statement of Ausubel automatically leads to a pedagogical intervention even if it is merely ascertaining the prior knowledge of a learner by asking questions. Piaget avoided suggesting detailed pedagogy but certain ways of teaching flow from his assumptions. He stressed that learning was fundamentally about interacting with the world in order to explore the 'rules of the game' and to discover the causal relationships between events. This leads to an active pedagogy involving exploration, experience and experimentation. Dewey aptly summarized this idea by saying that learners should be actors rather than spectators. Others have extended this concept to suggest that individals interact with the world in order to extract meaning from it and to construct a coherent and consistent cognitive model. Another way of saying this is that our brains are programmed to support our survival. From an evolutionary perspective organisms have evolved brains which create and internalize an increasingly complex and accurate model of the world. Based on our experience of interacting with the world we have each created our own unique model of reality. Nevertheless we are social beings and we cannot ignore the power of social interactivity that has influenced this process, a concept emphasised by the Russian psychologist Vygotsky. Other human beings influence the way in which we construct our models giving rise to the teacher and to the various social processes of pedagogy.

Model building in the individual, based on interactivity with the world, is the result of a cognitive process which involves the experience of the world being assimilated and filtered through prior knowledge as previously described. If sense or meaning can be attached to the experience then the experience fits with existing cognitive structures (Piaget's 'schemas'). However, if the experience does not make sense then a feeling of dissatisfaction or cognitive dissonance can ensue in which the individual will seek to reach some sort of mental equilibrium by exploration or questioning. At this point the individual may make use of the faculty of imagination to suggest or hypothesise why the experience is problematic. It is the existence of human imagination, the ability of each of us to interrogate our mental model, to speculate and to ask questions that is one of the hallmarks of our intelligence and our capacity to survive. Albert Einstein famously stated that 'imagination is more important than knowledge' since he realized that ultimately all knowledge is derived from an initial process of imagination that is subsequently tested against the world. As individuals we can simulate reality by asking ourselves 'what if?' questions. We can perform acts in our imagination before doing them in reality and risking having our genes deleted from the gene pool. Our imagined conjectures can be tested by seeking other experiences and by so doing we can resolve the dissonance and elaborate our learning and our mental model.

Constructivism and scientific reasoning

You may notice that what I have just described, as the individual attempts to construct a more meaningful and coherent mental model, is what is often called hypothetico-deductive reasoning. When confronted with experience hypotheses are created via inductive reasoning and human imagination. These hypotheses are then tested by exploration, further experience or deliberate manipulation of the world coupled to and processed by deductive reasoning. Hypotheses are then either rejected or supported, leading to the elaboration of knowledge. Hopefully the reader should now see that what the constructivist model of learning describes in the individual is what is commonly known as the 'scientific method'. Driver and many other constructivists have frequently asserted that the individual learner behaves like a scientist in seeking to make sense of the world.Indeed Glopnik has gone so far as to assert that even the baby in the cradle is a little scientist testing out hypotheses about reality.

In summary we assert that the constructivist model is built on the premise that the brain naturally attempts to extract meaning from the world by interpreting experience through existing knowledge and then building and elaborating new knowledge in a process identical to hypothetico-deductive reasoning or the scientific method.

Clinical diagnostic reasoning

Diagnostic reasoning is one of the key cognitive skills that doctors need to acquire and medical schools need to teach. It has many characteristics in common with scientific reasoning and hence is connected to the constructivist model. When a patient presents with a problem the doctor will begin a process of hypothesis formation aided by information derived from the patient's history and examination findings. Pattern recognition and 'gut feelings' are important here but very much depend on the range and quality of the mental models of illness presentation that they have built up. This initial phase can be seen as an inductive process in which sensory information is assimilated through the pre-existing knowledge of the clinician. The hypotheses, or differential diagnoses, next require testing to see which ones can be supported, falsified and eliminated by the acquisition of further evidence. This might involve more history taking and examination or the ordering of investigations such as blood tests or radiographs. The results obtained can be used to eliminate some hypotheses and can potentially lead to a final diagnosis of the problem. This phase of the process is characterized by deductive reasoning and the whole diagnostic process as hypothetico- deductive reasoning, which can hopefully be seen as identical to the scientific method as previously described.

Of course many things can go wrong in this process. Lack of background knowledge and experience will inhibit the assimilative inductive phase and reduce hypothesis formation from the imagination. Bias can influence the hypothesis testing phase by only looking for evidence to support a diagnosis rather than attempting to falsify one. Interpreting the results of investigations can also be influenced by a lack of background knowledge and experience. There are a myriad factors that affect the outcome of the diagnostic process and there are many ways of teaching this skill. Nevertheless it is important from a medical education perspective that students are made aware of the constructivist nature of the hypothetico-deductive process as the underlying engine of diagnostic reasoning.

Now that the constructivist framework has been described and its relationship to scientific method has been outlined it is useful to look at other theoretical models to see if there are any connections that can be discerned.

Students' theories

It is a remarkable and well evidenced observation that students learning science have their own mental constructs or 'theories' and will articulate them when asked to explain the phenomena they are exposed to. This can be explained by the constructivist model in that experiences will be filtered through limited prior knowledge followed by imaginative attempts to provide a plausible explanation. The student comes to school with years of personal experience of heat, light, gravity, forces, motion, solids, liquids, gases, energy, electricity, plants, animals and people. It is not surprising that strongly held theories about the nature of the physical, biological and social world have been elaborated by the student even before any scientific teaching is encountered.

Since the student is at the heart of learning good pedagogy suggests that it is essential that teachers make the effort to try to understand the student's point of view. Teachers should create learning situations that encourage students to bring out their ideas. It is here that the 'social constructivist' approaches described by Vygotsky become important. The individual develops conceptual understanding via the social sharing of meanings and intellectual debate. Thus as far as possible scientific and medical learning should be a group activity with opportunities to discuss ideas, make hypotheses and devise ways of testing them. The teacher should facilitate the developing conceptual understanding of students by providing examples of cognitive conflict as well as emphasising how well the 'scientific' concepts explain phenomena in comparison to the more contradictory theories of the students. Of course the aim of teaching is to replace the 'erroneous' beliefs of the student with the 'correct' evidence-based scientific ones. Problem based learning is an ideal way to create this teaching environment.

However, children become adults and although they may then be considered mature thinkers , ('logical operators' to use Piaget's terminology), nevertheless it is clear from many studies that they still have scientific misconceptions. Medical students can be considered to have broken through the immature phase of science education and clearly they have successfully learned the correct scientific theories and concepts required to get into medical school. Nevertheless, that doesn't mean they are immune from still having personal theories and erroneous beliefs that might get in the way of acquiring the received evidence-based wisdom provided by their teachers.

Lay theories

Adults, with little knowledge of science and medicine beyond an elementary education, will have 'lay beliefs' concerning the anatomy and physiology of the body and of the causation of illness, and medical students and practitioners will interact with patients holding such beliefs.⁻

Lay beliefs are therefore a component of the mental models that individuals have made and hence are part of the constructivist framework. Health care professionals need to be aware of lay theories when engaging with patients as they can have an important impact on health outcomes.

However, when we move into the area of lay beliefs we are entering sociological territory and the metaphor of construction is used in a radically different way. In Berger and Luckman's work 'The Social Construction of Reality' it is implied that reality itself is very much a social construction and that there is no single, coherent, real world. This 'Postmodern' viewpoint asserts that individuals experience reality as multifaceted and contradictory and rejects scientific 'objectivity'. This extreme view of constructivism can lead to a cognitive relativism that is a long way from the scientific approach.

Illness occurs within a culture that fundamentally shapes how that illness is experienced. Anthropologists have provided a rich source of examples of the way in which lay beliefs about illness are part of the social fabric of all societies. Many studies in contemporary society demonstrate the continuing existence of a wide range of health beliefs that are seen as causative factors in illness. It is tempting to suggest that these constellations of causal factors constitute 'theoretical frameworks' but they do not exhibit a high degree of consistency, order, stability and rationality and respondents often maintain and use contradictory models without recognising a logical inconsistency between them.

It may appear paradoxical that one of the claims of constructivism is that the brain uses a process of 'scientific' enquiry to try to make sense of the world but that individuals can then come up with and sustain 'non-scientific' beliefs or theories. Although the process may follow a scientific logic the final outcomes can clearly be totally unscientific and result from a lack of background knowledge, personal bias and an uncritical interpretation of evidence. Thomas Kuhn famously proposed that even scientists can be resistant to evidence that could lead to theory change and it sometimes takes a revolution to enable 'paradigm shifts' to take place. Individuals can be equally resistant to evidence that might change their belief systems and might need their own personal revolution.

Nevertheless the real and potential gulf between lay beliefs and medical knowledge is a major factor in the therapeutic effectiveness of the doctor-patient relationship. Doctors need to understand the constructions of their patients and need to speak to them using language they can understand. Eliciting the patient's ideas is an essential step in this process although this can be another source of confusion since what a lay person understands by a particular medical term maybe entirely different from the doctor's understanding.

In the medical field interpersonal communication or 'communication skills' is very important. The ability to listen to an individual, to ask them questions, to interpret what they are saying and to give them information and advice in a way that they can understand is a major feature of good medical practice which in one sense is educational. At the heart of it is an engagement with an individual that is analogous to the learner centred approach and hence is described as patient centred. As in constructivist pedagogy it involves finding out the background knowledge of the patient and then communicating with them and educating them in a way that they can understand. If constructivist pedagogy is used to establish prior knowledge it is also used in helping the patient to construct their understanding of their condition and to help the doctor to establish potentially new behaviours in the patient which will be of medical benefit. In many ways this is fundamentally associated with a teaching process and the Cambridge-Calgary method is a well established formulation of this method.

Experiential learning

The experiential learning theory developed by David Kolb cites Piaget as a precursor in addition to acknowledging the influence of the social factors on learning identified by Vygotsky. Therefore it comes with good constructivist credentials. However, Kolb's framework has been interpreted and misinterpreted by so many individuals over the years that it is sometimes difficult to see where constructivist concepts can be found within it. Because experiential or 'non-formal' learning frequently happens in a haphazard and unstructured way, with individuals having raw experiences in working environments, it is not always obvious that there is any pedagogy involved. But those 'concrete experiences' still have to be assimilated through pre-existing cognitive constructs. It is here that the social constructivist role of others becomes important, either as mentors who deliberately foster 'reflection' or merely fellow learners who can discuss and refine understanding. Kolb's 'abstract conceptualisations' become the mental models discussed earlier and 'active experimentation' becomes the deductive reasoning process associated with questioning and active learning.

Humanistic theories

In the field of education humanistic theories of learning have contributed ideas and practices that complement constructivist and behaviourist models of learning. In particular the humanistic theories of Rogers and Maslow emphasise the importance of acknowledging the individual and starting from their standpoint in either a therapeutic or educational process., This leads to human-centred or learner-centred approaches to education where the needs of the learner become the heart of the educational process. In addition one of the principles of adult learning, sometimes termed 'andragogy', is that the life experiences and background knowledge of adult learners becomes an important educational resource. With adult learners, therefore, we build on and respect their prior knowledge, which may have been acquired from their own personal needs. But as we have previously established starting from where the learner is and building on their knowledge is a fundamental tenet of the constructivist model. Thus we can establish a strong connection between constructivism and learner-centred approaches.

Personal construct theory and cognitive behavioural therapy

George Kelly's Personal Construct Theory is built on the premise that 'all men are scientists' and have constructed specific mental constructs and beliefs based on their experiences that make them what they are. It also posits that mistaken constructs can be created which can cause mental problems and inappropriate behaviour. Constructivist psychotherapy and Cognitive Behavioural Therapy are similarly based on the premise that individuals may have constructed inappropriate behaviours and beliefs. Therapy involves challenging these 'cognitive distortions' to normalize behaviour.

Neuroscience

Social constructivists often stress that as social beings our knowledge is disseminated amongst other human beings and also stored within physical locations such as libraries and the internet. But we cannot lose sight of the fact that learning and memory are ultimately processes that take place in individual human brains. Therefore what does the constructivist metaphor mean in terms of neural structure and processing? Is the construction of knowledge paralleled by the construction of neural structures and do the pedagogical processes suggested by the epistemology of constructivism enhance these constructions?

There is considerable evidence that our perceptions of reality and our own mental states are, in fact, constructions. Images projected onto the retina are analysed and processed by a variety of mechanisms in the brain and what we 'think' we see is largely a creation of mental processing. The central image on the fovea, scanned by unconsciously experienced saccadic eye movements, constitutes the centre of a perception whose peripheral elements are entirely 'filled in' by the brain. We do not therefore perceive reality as it actually is but we perceive a construct based on a probabilistic model of reality created by the brain. Our brains are constantly predicting what is out there in the world and by a series of 'top down' processes they fill in the sensory data we are receiving to create what Clark has called a 'controlled hallucination'.

Further illustrations of how the brain constructs our perceptions, thoughts and even feelings have been provided by the work of Ramachandran., Oliver Sacks has also written eloquently about how individuals who have tragically suffered from damage to specific regions of the brain can reconstruct their cognitions, often in strange and unusual ways. The key conception that derives from these studies and observations is that the brain actively 'fills in' gaps in perception, sensation and cognition with constructs that attempt to maintain some sort of mental cohesion, even if the results can sometimes be anomalous.

It has been argued that constructivism is underpinned by mainstream theories of cognitive neuroscience: it is how our brains work when we are learning. According to Quartz and Sejnowski the cerebral cortex has evolved to maximize its structure and function through constructive learning. In addition the importance of active learning methods, as recommended by constructivist pedagogy, is supported by studies of neurogenesis in the adult brain. Neurogenesis continually occurs in the dentate gyrus area of the hippocampus of the human brain, a region well known for its part in learning and memory. Furthermore it is now established from mouse models that activity in an enriched living environment stimulates neurogenesis and results in increased synaptic connectivity. The implication of these and other studies suggests that learning is a physically constructive process in the brain which is enhanced by active learning.

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Constructivism: reflections on twenty five years teaching the constructivist approach in medical education

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There is no single overarching theoretical framework that accounts for how we learn in all situations. There are many theories of how we learn from our experiences and there are many theories of what experiences are.

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Pedagogy, Andragogy, & Heutagogy - Medical Education (Undergraduate)

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Pedagogy, Andragogy, & Heutagogy - Medical Education (Undergraduate)

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Bansal, A., Jain, S., Sharma, L., Sharma, N., Jain, C., & Madaan, M. (2020). Students' perception regarding pedagogy, andragogy, and heutagogy as teaching-learning methods in undergraduate medical education. Journal of education and health promotion, 9, 301. https://doi.org/10.4103/jehp.jehp_221_20

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Students' perception regarding pedagogy, andragogy, and heutagogy as teaching-learning methods in undergraduate medical education

Alka Bansal ¹, Smita Jain ¹ Department of Pharmacology, SMS Medical College, Jaipur, Rajasthan, India
² Department of Mathematics, JECRC University, Jaipur, Rajasthan, India
², Lokendra Sharma ¹, Neha Sharma ¹, Charu Jain ¹, Moksh Madaan ¹

Date of Submission

13-Mar-2020

Date of Acceptance

11-Apr-2020

Date of Web Publication

26-Nov-2020

Correspondence Address:
Dr. Neha Sharma
SMS Medical College, Jaipur, Rajasthan
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jehp.jehp_221_20

INTRODUCTION: Medical education is tricky to imbibe and difficult to apply. Various teaching-learning (TL) methods have been tried from time to time to enhance the proficiency of students. The aim was to assess the students' perception toward three different TL methods (pedagogy, andragogy, and heutagogy) in medical education.
MATERIALS AND METHODS: A comparative experimentalquestionnaire-based study was done on population of second-year MBBS students of SMS Medical College, Jaipur, in October 2019. They were taught topic of anticancer drugs using pedagogy, andragogy, and heutagogy methods. Then, their opinion regarding these methods was collected and evaluated. The reliability of the questionnaire was ascertained by Cronbach's alpha value which turned out to be 0.89. The data collected were analyzed statistically using one-way Analysis of Variance (ANOVA) and Principal Component Analysis (PCA).
RESULTS: The results showed that all these methods differ significantly from each other as the P < 0.05 considering 5% as level of significance. PCA revealed that andragogy and heutagogy were found to be most effective in this study.
CONCLUSION: Competency-based andragogy and capability-based heutagogy are more effective TL methods than didactic lecture-based pedagogy for MBBS undergraduate students.

Keywords: Medical education, pedagogy, self-directed learning

How to cite this article:
Bansal A, Jain S, Sharma L, Sharma N, Jain C, Madaan M. Students' perception regarding pedagogy, andragogy, and heutagogy as teaching-learning methods in undergraduate medical education. J Edu Health Promot 2020;9:301

How to cite this URL:
Bansal A, Jain S, Sharma L, Sharma N, Jain C, Madaan M. Students' perception regarding pedagogy, andragogy, and heutagogy as teaching-learning methods in undergraduate medical education. J Edu Health Promot [serial online] 2020 [cited 2023 Mar 28];9:301. Available from: https://www.jehp.net//text.asp?2020/9/1/301/301514

Medical education has always been a challenging task as every patient is unique and dynamic. Learners here have to learn and perform in open, heterogeneous, dynamic, and uncertain environments.[1] Furthermore, the students at this stage are adults who have to study various multidisciplinary and interdependent subjects. Out of the bombardment of knowledge to them, it is very tricky to remember the imperative and still more difficult to apply them. Various TL methods have been tried from time to time to enhance the expertise in medicine.

Pedagogy is an oldest teacher centric form of learning where teacher decides what and how to teach and assess the learning.[2] In conventional terms, it is basically a lecture-based classroom TL method with its main focus on imparting knowledge without emphasizing its application. Subsequently, it was realized that after adolescence, students are mature enough to put forth their views and wish their participation and also to decide the curriculum and methods of learning. It paved the way for andragogy (adult learning), term given by Knowles in 1970.[3] Key features of andragogy are autonomous, self-directed, interactive learning, and learners are more motivated by internal than external drives. Students in andragogy are more interested in immediate implementation of knowledge gained and hence prefer problem-centric approach and expect respect and equal status.[3],[4]

Abela et al. 2009 have also described five main classes of learning - instrumental, self-directed, experiential, perspective transformation, and situated cognition. Andragogy is one of the popular theories of adult learning under self-directed learning.[5]

Heutagogy is a concept originally given by Hase and Kenyon at the turn of century and was revived by Blasche in 2012.[6],[7] Nowadays, in this era of digital technology, it is favored to acquire, renew, and upgrade knowledge and skills for long-term learning. Heutagogy is a student-centric self-determined learning based on humanistic theory guided by technology-based learning design. It lays distinct emphasis on learners to decide what to learn, and how to learn and on learning to create opportunities.[7],[8] For this, several "C" have been proposed like the curious learners cognize the problem and explore the knowledge and means to solve them using their own ways depending on their learning abilities. Finally, they connect, communicate, collaborate, and share their experience mostly using digital media (computers) that is why heutagogy has been called a "net-centric" theory and is a combination of experiential as well as transformative type according to Abela et al.[5],[7],[9],[10] It will help to make them creative, confident, and capable in addition to competent for the workplace. Heutagogy makes the students lifelong learners and the role of educator is limited to teach them "how to teach themselves."[11] Another main differential factor of heutagogy from other two approaches is the idea of "double-loop learning." Single-loop learning is used when the current goals, values, and strategies are sound, not questionable, and the emphasis is on techniques and their effectiveness. On the other hand, double-loop learning is used when strategy is reviewed and the emphasis is on learning and reviewing previous situations. Hence, double-loop learning allows learners to put together their own beliefs before trusting the theories in use and then reflect on the problem, and this is actually how the science grows.[12] Important differences between pedagogy, andragogy, and heutagogy are summarized in [Table 1].

As the students are the targets whatever be the methods used, this study was designed in an endeavor to get the perception of students regarding the different TL methods in terms of suitability as professionals, generating interest, and usefulness to understand the topic and subject.

Aim

The aim of the study was to study the perception of students regarding the pedagogy, andragogy, and heutagogy as TL methods in medical education at undergraduate level.

Research method

This was a comparative experimental study.

Population and sampling

The population of this study included all second-year MBBS students of SMS Medical college, Jaipur. Simple random sampling was used to select the participants. The inclusion criteria were being second-year MBBS student and students who gave consent for the study. The exclusion criteria students hadnot given consent to take part in the study and other than second-year MBBS students.

Research hypotheses

Null hypothesis (H ₀) = Mean response of all the four methods are same, i.e., all the teachinglearningTL methods do not differ significantly.

Research tool

Prevalidated questionnaire was validated by interdepartmental faculty of SMS Medical College and its reliability was checked by calculating Cronbach's alpha which was found to be good (0.89) for the study.

Ethical clearance

Prior ethical approval was obtained (No. 2683 MC/EC/2016 dated 30/9/16) from the institution.

Methodology

The present study is a questionnaire-based research where the perception of the second MBBS students was recorded for different instructional techniques used in learning at undergraduate level. These are classroom lecture-based pedagogy, problem-based self-directed andragogy, and keyboard technology-based heutagogy. After obtaining the required consent from second-year MBBS students, they were taught topic of anticancer drugs with these methods. Topic of anticancer drugs was selected as it is important, extensive, and thorny. A part of it was taught by didactic lecture-based pedagogy. For the second part, students were given a problem and were asked for self-directed learning. The role of teacher here was as a guide and facilitator where instead of discussing in detail they were briefed about the topic to be covered and resources available. As component of heutagogy part, students were asked to find, observe, and interact with the cancer patients when they go into the ward or community and also read and share texts and videos of the patients' and students' experience in a class group formed on mobile phones. We choose these three methods as pedagogy is practiced widely, andragogy is adopted in competency-based medical education, and heutagogy owing to the fact that hospitals, community, and digital platform are going to be their future workplace and learning from there will keep them conscious of the ground reality of problem, presentation, and facilities available.

Instrument

To collect the data regarding students' perception about pedagogy, andragogy, and heutagogy, a questionnaire was developed as no validated questionnaire could be found on Internet. The developed questionnaire was validated interdepartmentally and had 12 question items [Table 2].

The reliability of the questionnaire was determined using Cronbach's alpha coefficient. It turned out to be 0.89 which was good enough to go with the questionnaire. The students were required to select the most appropriate choice from the pedagogy, andragogy, and heutagogy and all methods are equal in their opinion. The questionnaire was shared through the Google Forms to the students. A total of 132 students took the questionnaire.

Data analysis

To analyze the data, we used Minitab 14 software (Pennsylvania, United States) and using this statistical software first, we evaluated the descriptive statistics such as frequency, percentage, mean, median, standard deviation, coefficient of variation, and third quartile for all four options (variables). Analytical test including Anderson-Darling normality test was done to indicate that populations had a normal distribution. One-way analysis of variance (ANOVA) and principal component analysis (PCA) were then done.

Descriptive statistics of four options are given in [Figure 1].

The descriptive study showed that the mean, standard deviation, and coefficient of variation are highest for the variable A. This concludes that option "A" is highly variate in all the questions.

Hypothesis (H ₀): We assumed that the mean response for all the four methods are the same, i.e., all the four TL methods do not differ significantly. For testing the above hypothesis, we used one-way ANOVA.

In One Way ANOVA table, the source of variations are Factor, Error and Total. For these three sources of variation, the degrees of freedom (df) are 3, 44 and 47 respectively. Sum of squares (SS) for Factor, Error and Total are 1768.2, 2342.3 and 4110.5, respectively. The mean sum of squares (MS) for factor is 589.4 and for Error is 53.2. The F value and P value for the factor are 11.07 and 0.00 respectively as shown below:

One-way ANOVA A, B, C, D.

Source DF SS MS F P.

Factor 3 1768.2 589.4 11.07 0.000.

Error 44 2342.3 53.2.

Total 47 4110.5.

Since P < 0.05 (5% level of significance), we reject the null hypothesis and conclude that the mean responses are different and all the four TL methods differ significantly.

To analyze the effectiveness of each variable, we performed PCA as depicted in [Table 3].

As shown in [Table 3], in PCA of options A, B, C, and D, the first principal component has variance (eigenvalue) 1.9677 and accounts for 49.2% of the total variance. The second principal component has variance 1.0896 and accounts for 27.2% of the data variability. Hence by PCA, we conclude that factor B (andragogy) and C (heutagogy) are most effective in this study.

Individual responses to various questions are summarized in [Figure 2].

Our study reports that students found heutagogy as most brain storming, practice oriented, and it made the learners more confident about their capability in comparison to other two. When learners are competent, they demonstrate the acquisition of knowledge and skills; skills can be repeated and knowledge retrieved. When learners are capable, skills and knowledge can be reproduced in unfamiliar and changing situation by their creativity. Capability is thus the continuum of one's own competence as capability alone is not possible without competency. Many educators in the professional fields also found heutagogy to be a plausible response to the critical issues that their learners come across in the actual workplace and have designed their learning environments accordingly to harp the maximum benefits.[13],[14],[15] For example, Bhoyrub et al. (2010) established that for nursing students, heutagogy is offered as an emerging and potentially highly congruent educational framework placed around practice-based learning.[13] We could not find similar study regarding the evaluation of pedagogy, andragogy, and heutagogy using students' perception despite extensive search; hence, we cannot compare with other studies. However, Wenger has emphasized the importance and influence of "Communities of Practice" to guide and encourage the learners to work together as a team with available resources to gain the required competencies.[16] Similarly, Greenhill et al. uphold that using clinical immersion models of clerkship rotations in hospital and community helps learners to gain insights in the areas of patient centeredness, systems thinking, clinical skepticism, and understanding diversity.[17] Kolb's experiential learning theory helps educators to create learning experiences in the professional curriculum and facilitate learning through discovery and critical thinking when possible. For this, the educators make the learners plan for and later reflect on the learning experience so that they are better prepared for the next time they are faced with the same problem or professional task, thereby improving the efficiency to perform.[18] Heutagogy method used in our study had combined the above three by experiencing through exposure in ward postings as well as in the community around them and then sharing and discussing their related views and experience through technology. The results of our study are in full accordance with these studies. In 2010, the UNESCO also recommended the following teaching strategies for the 21 st century: experiential learning, storytelling, values education, inquiry learning, appropriate assessment, future problem solving, outside classroom learning, and community problem solving.[19]

Pedagogy is educator centric method of teaching where teacher decides the curriculum, methods of learning, and assessment. It does not give students any sense of participation in their own learning. Andragogy is patient centric where instructors establish objectives and curriculum based on learner input and guide students along the learner path, while the responsibility for learning lies with the learner. Heutagogy is technology-based learner centric as they become aware of their favored learning style and can easily adapt new learning situations to their learning styles. For it, they become more creative thus making them lifelong learners with longest retention and it is reflected in their approach toward the problem. Our study also confirmed that heutagogy and andragogy allowed them to choose their own method of innate learning giving them feeling of maximum participation in their own learning and making the learning more effective and longer lasting. Moreover, extensive learning resources such as connectivity and collaboration in heutagogy also contribute to better learning. The same views are expressed in the previously published studies.[20],[21] In fact Wheeler 2011 in his study went as far as to say, "New technologies have also created a need for considering new pedagogical approaches, with andragogy, seemingly "outmoded in the light of recent rapid development in new teaching methods, learning resources, and digital media."[21] A project entitled "Digital learning now!" in the United States in December 2010 also stressed that "Digital learning has the potential to be a catalyst for transformational change in education." It allows students to learn in their own way at their own pace, and maximize their chances for success in school and beyond."[1],[22]

Students in our study found pedagogy to be the most easiest method to identify and stress on important topics with the help of teachers Still they found heutagogy followed by andragogy as the most effective method when directed to adult learners. These self-motivated and self-determined professional learners improve productivity by ensuring their participation and personalization, the "three Ps."[23],[24] A similar study which compared the pedagogy and andragogy learning orientation preferences reported that an integrated approach should be considered in classroom learning as well as in designing and developing an online learning application among undergraduate learners.[25]

Limitations

This study has been performed on only second-year MBBS students of one medical college only, so the results cannot be generalized to all learners across all disciplines.

Future implications

This study is first of its kind. This study could become the basis for comparison of different teachinglearning methods for future studies. More of such multicentric studies involving large population are warranted.

Pedagogy makes the learners conscious about the knowledge and skill required. Andragogy makes them competent to use skill in trained conditions, but heutagogy makes them capable to work in all circumstances using their creative, cognitive, communicative, collaborative, and digital skills. The study concluded that andragogy and heutagogy are more effective TL methods at the undergraduate level to produce the erudite, competent as well as capable professionals.

Acknowledgments

We would like to acknowledge our gratitude to all the students who sincerely participated in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

4.

Prakash R, Sharma N, Advani U. Learning process and how adults learn. Int J Acad Med 2019;5:75.
[Full text]

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Anshu ST, editor. Portfolios in learning & assessment. In: Principles of Assessment in Medical Education. 1 st ed. New Delhi Jaypee; 2012. p. 173-9.

19.

Mynbayeva A, Sadvakassova Z, Akshalova B. Pedagogy of the twenty- first century: Innovative teaching methods. In: New Pedagogical Challenges in the 21 st Century-Contributions of Research in Education. London, UK: Intech Open; 2017.

23.

Chacko TV. Emerging pedagogies for effective adult learning: From andragogy to heutagogy. Arch Med Health Sci 2018;6:278.
[Full text]

[Figure 1], [Figure 2]

[Table 1], [Table 2], [Table 3]

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Students' perception regarding pedagogy, andragogy, and heutagogy as teaching-learning methods in undergraduate medical education Bansal A, Jain S, Sharma L, Sharma N, Jain C, Madaan M - J Edu Health Promot

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Students' perception regarding pedagogy, andragogy, and heutagogy as teaching-learning methods in undergraduate medical education Alka Bansal 1, Smita Jain 1 Department of Pharmacology, SMS Medical College, Jaipur, Rajasthan, India 2 Department of Mathematics, JECRC University, Jaipur, Rajasthan, India 2, Lokendra Sharma 1, Neha Sharma 1, Charu Jain 1, Moksh Madaan 1 Date of Submission 13-Mar-2020 Date of Acceptance 11-Apr-2020 Date of Web Publication 26-Nov-2020 Correspondence Address:Dr. Neha SharmaSMS Medical College, Jaipur, Rajasthan India Source of Support: None, Conflict of Interest: None Check DOI: 10.4103/jehp.jehp_221_20 INTRODUCTION: Medical education is tricky to imbibe and difficult to apply.

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Kassam, A., Ruetalo, M., Topps, M., Mountjoy, M., Walton, M., Edwards, S., & Nickell, L. (2019). Key stakeholder opinions for a national learner education handover. BMC medical education, 19(1), 150. https://doi.org/10.1186/s12909-019-1598-7

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Abstract

Background

Sharing information about learners during training is seen as an important component supporting learner progression and relevant to patient safety. Shared information may cover topics from accommodation requirements to unprofessional behavior. The purpose of this study was to determine the views of key stakeholders on a proposed national information sharing process during the transition from undergraduate to postgraduate medical education in Canada, termed the Learner Education Handover (LEH).

Method

Key stakeholder groups including medical students, resident physicians, residency program directors, medical regulatory authority representatives, undergraduate medical education deans, student affairs leaders, postgraduate medical education deans participated in focus groups conducted via teleconference. Data were transcribed and coded independently by two coders, then analyzed for themes informed by principles of constructivist grounded theory.

Results

Sixty participants (33 males and 27 females) from 16 focus groups representing key stakeholder groups participated. Most recognized value in a national LEH that would facilitate a smooth learner transition from medical school to residency. Potential risks and benefits of the LEH were identified. Themes significant to the content, process and format of the LEH also emerged. Guiding principles of the LEH process were determined to include that it be learner-centered while supporting patient safety, resident wellness and professional behavior. The learner and representatives from their undergraduate medical education environment would each contribute to the LEH.

Conclusions

The LEH must advocate for the learner with respect for learner privacy, while promoting professionalism, patient safety and learner wellness.

Peer Review reports

Background

Current literature suggests that medical learners feel inadequately prepared for residency, particularly in terms of clinical experience, knowledge and skills [ 1, 2, 3]. Faculty are often able to pinpoint where improvements are needed to help ease the transition however these are heavily based on technical deficits that need improvement and no other competency domains [ 2, 4]. Recent studies have developed a model [ 5] for an educational handover or learner handover tool [ 6] whereby information about the learner is shared with faculty members. These studies however did not engage the learner during the handover process.

Sozener et al. identified that there may be a disconnect between how the medical school leadership write about the student to ensure a successful match and the actual sharing of information itself and " this concern could also lead to a healthy discussion within the medical school to reconcile potential differences between the two documents" (Dean's letter and information sharing/handover document) [ 6]. The Dean's letter is a document sent to a residency program by a medical school (undergraduate medical education) dean which describes a candidate in his/her final year of medical school. The Dean's letter can also be referred to as the Medical Student Performance Evaluation or Medical Student Performance Record (MSPE or MSPR) letter which accompanies medical student's residency application. This letter summarizes the student's medical school performance and provides a summary evaluation of the student's potential as a resident [ 7, 8].

There are differing viewpoints on information sharing about learners. On the one hand, it may help to develop better reporting tool for learners and direct teaching toward specific learner needs that may help to produce better physicians. This practice supports patient safety by ensuring that graduates have the required knowledge and skills for residency [ 9]. On the other hand, information sharing may lead to bias towards the student, potentially resulting in unfair advantages and disadvantages [ 10]. To date, there is no evidence demonstrating that information sharing has been either detrimental or useful in remediating struggling students in order to prepare them for their transition into residency [ 9, 11]. In the United States, only 14% of medical schools have written policies about sharing information yet 57% of clerkship directors design remediation plans for struggling students; it is unknown whether these plans focus on personal or non-academic needs of the learner [ 9, 11].

Two recent scoping reviews have been conducted to explore learner handovers. The first examined the influence of prior performance information on ratings of current performance for learner handovers [ 12]. Due to the scarcity of studies in the medical education literature, the review looked at literature across other disciplines such as psychology, business, sports, and education. When considering indirect prior performance information, the majority of studies supported an assimilation effect which means that in the context of a learner handover bias could be prevalent. Specifically, a faculty member's perception of the learner from prior performance information (e.g., formal learner handover, a learner dashboard, or learner reputation), is biased toward the previous performance information. This would cause significant concern in the medical education community and support the arguments of those opposed to learner handover. Of more concern is the suggestion that negative prior performance information may be more influential than positive prior performance information [ 12].

The second scoping review [ 13] examined existing scholarship on learner-centered [ 14] initiatives to facilitate the transition from medical school to residency. While a variety of learner-centered programs that focus on specific professional competencies have been implemented to ease the transition to residency, many do not engage learners as key stakeholders in program development. The existing literature highlights various gaps in approaches particularly with respect to addressing non-medical skills competencies, and focusing on individual learners needs. Novel and innovative programs, including learner handovers, may better support the transition needs of medical residents.

Given the impact of prior performance information and the lack of learner centered interventions that exist to help learners transition from medical school to residency, it is important to explore key stakeholder opinions about a learner handover.

An Association of Faculties of Medicine of Canada (AFMC) Working Group has proposed a model for information exchange termed the Learner Education Handover (LEH) similar to learner handovers proposed by others however with the unique feature of input from the learner [ 15]. This model refers to the sharing of relevant information to facilitate a smoother transition for the learner proceeding from undergraduate medical education (UME) to postgraduate medical education (PGME). An ideal LEH focuses on the transfer of relevant information related to academic progression including medical knowledge, academic vulnerability, learner accommodation requirements, professionalism challenges, and health, emotional and social issues. In the context of the LEH the term accommodation [ 16] refers an adaptation or adjustment to the learning environment, curriculum format, or equipment that would assist the learner with any disability or health concerns (both physical and mental) to thrive as a medical learner.

An assumption for the LEH is that basic competencies/standards (entrust able professional activities [ 17, 18, 19]) have been met in order to proceed to residency and residency matching occurs prior to the information exchange. The handover is focused on providing a more comprehensive understanding of the learners, to enable them and their programs to achieve a smoother, transparent, robust transition, enhancing safety for the learner, residency program and ultimately for patients.

Examples of the difficulties encountered during the transition from medical school to residency include physical and mental health issues such the need for special equipment, extra exam time, duty hour reductions during clinical clerkship, modified call hours, personal coping readiness and other adequate psychosocial supports. These may be remediated by a learner handover by allowing information to be shared about the learner prior to starting residency so that appropriate alterations can be made by PGME and if necessary, residency programs. This is because it would allow for an early system of alerting programs while providing a medium for learners to disclose any concerns before starting residency. Given the controversies that exist around information sharing between UME and PGME programs, and that there are various stakeholders involved in a LEH process however, the purpose of this study was to determine the perceptions of key stakeholders regarding a national LEH process for medical learners in Canada after they have been matched to their residency program.

Method

The AFMC LEH working group was comprised of student affairs leaders, medical students representing a national medical student organization, residents representing a national resident organization, postgraduate medical education deans, undergraduate medical education deans and a non-clinician medical education researcher. We decided to conduct a qualitative study as opposed to a quantitative study (survey) because we wanted to obtain insights from key stakeholders about the idea of a national LEH. We believed that conducting focus groups would help to uncover attitudes and allow for us to explore in depth the risks and benefits associated with a LEH. Most importantly, we wanted our participants to feel they had a "voice" in a national initiative.

Ethics board approval for this study was obtained from the University of Calgary Conjoint Health Research Ethics Board (CHREB) Ethics ID: REB15-1244. We developed the interview guide as a group. Given that the AFMC working LEH working group is comprised of key stakeholders themselves, the interview guide was developed over the course of several telephone meetings during which discussions were held about each question and edited accordingly. Working group members had the opportunity to comment on drafts of the interview guide between meetings via e-mail after liaising with members from the key stakeholder groups they represented. They would then bring their comments back to the working group. Of note, there was little overlap (n=2) between the members of the AFMC LEH working group and the actual participants of the focus groups.

The working group developed an interview guide on the proposed content, process and format of the LEH and stakeholder opinions were solicited about the use of the LEH. A caveat was that the LEH would be used for all Canadian medical graduates entering residency at all schools in Canada post residency program match.

A project administrator outside of the research team identified and contacted potential participants in stakeholder groups ensuring that all 17 medical schools from all provinces across Canada were included and a wide range of perspectives could be sought. Key stakeholders included medical students, senior and junior residents, program directors, student affairs leaders, UME Deans, PGME deans and Medical Regulatory Authority representatives from across Canada. Focus groups of 2-9 participants met, via teleconference, between April and August 2015 and were facilitated by author AK. In one case, an individual interview was held due to scheduling constraints. The interviewer used the interview guide developed by the working group for the focus groups and the one interview. They were audio recorded and transcribed verbatim. Focus groups were homogeneous with respect to key stakeholders to ensure there was no bias introduced by hierarchy, for example, residents and program directors. The facilitator ensured each participant had a chance to speak and voice their opinions about the LEH.

Recruitment was carried out with the assistance of administrative staff at the AFMC. Since the AFMC is comprised of all of the 17 faculties of medicine across Canada, e-mails were sent to the respective key stakeholder groups associated with each school. Additionally, recruitment of medical students and residents was carried out through the national organization representatives on the AFMC LEH working group. The recruitment of Medical Regulator Authorities which are based in each province was carried out in conjunction with a national organization that oversees the provincial bodies called the Federation of Medical Regulatory Authorities of Canada.

Focus group data were collected over the course of five months (April 2015 to August 2015) and concurrently transcribed. Data was first raw coded for broad themes by author AK and member checked the data with the working group key stakeholder representatives who took these themes to their respective groups. For example, the medical student representative on the working group who also represented a national medical school organization, took the themes back to the members of the national medical student organization.

Two authors (AK, MR) then independently analyzed the data. We approached each data analysis initially by line-by-line coding of transcripts and definitive concepts of the content, format and process of a LEH. A definitive concept refers precisely to what is common to text within a transcript, by the aid of a clear definition in terms of attributes [ 20]. Our interview guide informed such attributes.

We attempted to achieve theoretical saturation [ 21] within each homogenous group so as not to miss any new information from any one key stakeholder group. That is, the development of themes and the emerging theory in the analysis process during the initial raw coding took place as the criterion for additional data collection. This was driven by the notion of theoretical saturation. For instance, we held a focus group with postgraduate medical education deans but did not achieve theoretical saturation after the first focus group, so we held two other subsequent focus groups with postgraduate medical education deans. This was true for other key stakeholder groups as well.

We also attempted to achieve thematic saturation [ 21] during the data analysis phase with our definitive concepts of content, format and process. During this deductive approach, saturation was reached when the pre-determined codes by way of definitive concepts from the interview guide were represented in the data. This is similar to the idea of the themes being sufficiently supplied with examples in the data.

We maintained rigor and fostered reflexivity throughout the data analysis process through the use of memo writing as well as regularly scheduled telephone meetings between the coders. As non-clinical medical education researchers, we underwent an ongoing critique and critical reflection of our own biases and assumptions and how these have influenced all stages of the research process. We maintained dialogue and discussed divergent understandings when examining key stakeholder opinions of the LEH and provided a context in which we discussed our hidden beliefs and assumptions. For instance since both coders were based in different institutions in different provinces in Canada they brought their own unique experiences and biases when coding which were documented and discussed. We were also cognizant of their own bias towards supporting the LEH given our position in PGME Offices and connection with the AFMC (for author/coder AK and not author/coder MR). We also acknowledged our passion for the advocacy for learners and learner wellness as areas of research that we are involved in.

Data was coded the data using NVivo (QRS NUD*IST NVivo) qualitative software [ 22, 23]. We used a thematic analysis approach informed by principles of constructivist grounded theory [ 24] to analyze transcripts acquired during the interview, and focus groups. We used constructivist grounded theory, which is interpretivist [ 25] in nature. This means that the notion of a shared reality is interpreted by the researcher and that "...reality arises from the interactive process and its temporal, cultural, and structural contexts." [ 26] Constructivist grounded theory rejects the notion of an objective reality. Instead it postulates that reality, society and the self are socially constructed by developing shared understandings through social interaction with others (also known as social constructivism) [ 27]. We believe that this approach facilitates a researcher's understanding of how a shared reality is created and how meaning is developed through the social interactions with others within defined contexts, and for this study, engaging key stakeholders for their opinions on the LEH.

As the analysis progressed, the application of codes became more focused and connections between various concepts were identified. Axial codes were progressively developed throughout the analytical process, but were finalized during later stages of analysis. Throughout each phase of analysis, we implemented a quasi-constant comparative approach, in which both coding of transcripts and provisional framework development based on the content, format and process of a LEH occurred in a concurrent and iterative fashion [ 28]. During the final stage of analysis, we collapsed codes, which were found to be similar across both coders [ 29]. Discrepancies were discussed and a third author (LN) was asked to help reach a decision where discrepancies could not be resolved. We then deductively reapplied this framework to the data.

Results

Sixty key stakeholders were recruited and included: medical students ( n=8), junior and senior residents ( n=13), Program Directors ( n=8), Student Affairs Leaders ( n=8), UME Deans ( n=7), PGME Deans ( n=9), and Medical Regulatory Authority Representatives ( n=7). Table 1 shows the distribution of males and females across the key stakeholder categories. We do not report other demographic data such as location because this would allow participant identities to be compromised.

Table 1 Key Stakeholder Group and Gender Distribution

Overall, stakeholders endorsed value in a national LEH document that would support learner transition from medical school to residency. Pertinent themes emerged in the areas of content, process and format and are described below. Stakeholders identified that the LEH must be learner centered which was defined as having learner involvement in reviewing the information provided (content), ensuring that the information would be used appropriately and as needed (process), and that it would be different from the existing MSPE/Dean's Letter (format). Figure 1 shows the construct of an ideal LEH.

Themes of Content, Process and Format of the Learner Education Handover

Content of the LEH

Stakeholders reported that the LEH would be most useful if it included information on academic performance, professionalism lapses and special circumstances of training such as the need for an accommodation. There was no consensus whether the learner should have the ability to withhold consent over the release of information in the LEH. There was agreement that the process would apply to all learners (to normalize this as a routine process), and that the content be shared directly with the learner and reviewed by the learner when handover takes place. Most importantly medical students were in support of the idea of a LEH.

Medial students saw the utility of the LEH for learners that may require assistance in residency.

Yet there was also acknowledgement that while the LEH would be for all incoming learners for those without concerns, there would be little information handed over.

Key stakeholders also stated that the current information on prior performance is not of much value and specific information to help the learner would be beneficial.

There was also emphasis that the content of a LEH would have to be transparent to the learner.

Overall, key stakeholders believed the LEH would be of value as an early alert system.

Process for the implementation of the LEH

Stakeholders indicated that the process of the LEH should be learner-centered. Transfer of information from UME to PGME should involve the learner. There was general consensus that PGME would act as the gatekeeper for the information ensuring that key individuals in the respective programs would be informed only if there were learner deficits that could impact the learner and residency program. Further consideration as to how the information would be used appropriately also emerged. There was no consensus as to whether the LEH might become part of a future accreditation process.

There was discussion that the implementation process would require faculty development with respect to how to use the information.

Regarding the information sharing process, medical students were often hesitant about how the information would be shared.

There were also concerns as to how the information will be used once shared.

The process of information storage was also elaborated upon. Essentially PGME could hold the information and only relay it to program directors when necessary.

The importance of standardizing the process was also highlighted. This would need to occur before accreditation.

Some stakeholders believed that the LEH as an accreditation requirement would not be necessary or would require further buy-in before being considered as an accreditation standard.

Format of the LEH

Stakeholders agreed that the LEH should be different from a MSPR/Dean's letter and that the UME Dean would provide it. The LEH format of presentation was discussed including the idea of a learner-directed portfolio. It was agreed that alignment with the evolving approach to competency-based medical education and reference to the CanMEDS roles [ 18, 30] is important although the CanMEDS roles may not cover all aspects of the LEH. CanMEDS is an educational framework that describes the abilities physicians require to effectively meet the health care needs of the people they serve [ 18, 30].

Stakeholders believed the format of the LEH would benefit as a summative piece of information that goes beyond the MSPR.

There were concerns however with respect to the format the LEH would have with respect the information shared from UME.

Risks and benefits of the LEH

Potential risks and benefits to having an LEH emerged (Fig. 2).

Themes of Risks and Benefits of Learner Education Handover

An identified perceived risk to the LEH was the possibility that learners may be subjected to bias thereby being unable to start their residency free from previously resolved issues which key stakeholders referred to as a "clean slate" or a "fresh start". Other risks of the LEH identified were i) the potential lack of security resulting in the misuse of information, ii) the feasibility of the implementation of LEH and iii) whether there is adequate infrastructure in place for a standardized national initiative.

Stakeholders also reported several perceived benefits to having a LEH, resulting in an enhanced transition from UME to PGME. For example, information shared could improve patient safety through enhanced quality assurance, promote the development of expected professional behaviors, continuity of mentorship, resident wellness, and .prevention of relapses. The LEH could facilitate self-directed learning, supported by the individualized learning plan.

With respect to the residency program, a perceived benefit includes the use of a learner-centered transition plan. Respondents indicated that the LEH would also allow the program to be more adequately prepared for the learner. Quotes reflecting the risks and benefits can be found in Table 2.

Table 2 Key Stakeholder Opinions about the Risks and Benefits of a Learner Education Handover (LEH)

Discussion

This study is the first to engage medical education stakeholders in a discussion regarding the use of an LEH to share medical learner information between UME and PGME to ease the transition from medical school to residency. While the idea of a LEH was viewed positively, potential risks were identified related to bias, security and feasibility.

Our study provides preliminary insights into a national LEH process and whether it would be of value to learners to ease the transition from UME to PGME. Stakeholders reported that the LEH would be useful for both the learner and the program. Caveats with respect to the process would allow a learner-centered approach while focusing on patient safety, resident wellness and professional behavior. Both the learner and UME would complete documentation for the LEH. An identified risk is of potential bias towards the learner and the loss of the possibility of a "clean slate" when beginning residency. The most frequently recognized benefit to the process was enhanced program preparation for particular learner needs.

While the concept of a formalized LEH has support, the nature of its content, process and format warrants further investigation. With respect to content, key stakeholders agreed that an LEH would be most useful if both the learner and UME contribute content, which could include strengths of the learner to the residency program. The process for the LEH requires accountability with respect to the transfer and use of information as well as the acknowledgement that this process is ultimately to help the learner.

Timing of the handover must be after the residency match process so as to avoid any hesitation by learners in sharing their information for fear it may impact their residency program match. While it might be beneficial to have a LEH before the matching process, this would pose logistical problems since the Canadian matching process is independent of PGME programs in Universities. Furthermore, to ensure learner buy-in, a post-match LEH can be seen as more learner-centered. Regarding format, the LEH should also provide information that goes above and beyond the MSPR/Dean's letter that would help assist PGME and programs to tailor learning plans for incoming residents if there is a need. Furthermore, PGME would be the gate keeper for the LEH information and would only share it with programs on a "need to know" basis. Incorporating CanMEDS roles while helpful would not be sufficient for a national LEH. Other areas to be included are the wellness of the learner and the learner's preparedness for residency. The conceptual framework of the LEH warrants further key stakeholder input and investigation along with future beta and pilot testing of an LEH to ensure it provides functional information for residency programs while meeting learner needs.

Unlike the studies by Warm et al. [ 5] and Sozener et al. [ 6], we consulted key stakeholders regarding the content, process and format of a LEH. The results of this study demonstrate value in developing a handover tool specifically for information sharing purposes in addition to existing assessments. Another strength of our study included representation from stakeholders across the country, increasing the generalizability of our results and rigorous study methods to ensure that the LEH is based on key stakeholder input promoting support and buy-in for such an initiative. Our study also highlights the need for learner-centeredness for potential national level policy initiatives. As such a learner-centered LEH should consider a holistic learner approach by creating a conducive learning environment that is free of harassment, promotes a safe environment for students to ask questions, or voice opinions, supports the psychological and social characteristics of learners, embraces learner diversity and individual learning needs while recognizing learner strengths and activities in areas beyond those traditionally valued in future physicians [ 14]. These may include life experience and leadership attributes, which are not afforded the same level of influence as clinical knowledge when entering residency [ 31].

There are several limitations of this study. First, participant stakeholders who consented to participate in this study may be more positively inclined because they perceive their vested interest in the LEH and our results may not accurately represent key stakeholder groups more broadly. Second, while we had members from the key stakeholder representatives (for example, medical students and residents) on the LEH working group as proxies and vehicles for member checking our work with the LEH, this does not afford the same opportunities as member checking with the study actual participants. Third, the AFMC deemed the LEH as an important initiative for medical schools across Canada, and as such the working group and all stages of this study may have a biased lens in favour of an LEH given that the working group already sees value in the LEH. We tried to mitigate this by having an external coder during data analysis and by fostering reflexivity throughout the however other strategies could have also been used such as member checking with actual participants or conducting a mixed methods study. For example, we could have developed a survey on key stakeholder opinions of the LEH to obtain a broader range of responses followed by interviews conducted and analyzed by independent researchers who were not part of the AFMC. This may have also allowed for the triangulation of data from various sources. Last, we did not sample clinical educators/preceptors as part of our key stakeholder consultations. This would be useful given that information in the LEH could be shared with residency programs and as such the clinical educator/preceptors involved in the teaching and assessment of residents. We chose not to include clinical educator/preceptors for this study because we were exploring the concept for LEH and saw clinical educator/preceptors as important key stakeholders but further downstream in the implementation process of the LEH.

Concerns about bias with respect to previous performance information in a LEH were plentiful in our study data and seen as a major threat to the LEH being learner-centered by key stakeholders. Future studies should consider program director and clinical educator/preceptor perceptions of the LEH and previous performance information bias. Additionally further research needs to ensure that learner handovers function appropriately in medical education and ultimately help ease learner transition from medical school to residency.

Conclusions

Learner handovers are garnering much attention in the era of competency based medical education. However much of the learner education handover models that exist today focus on clinical performance without input from the learner. A new stakeholder-informed information sharing process termed called the Learner Education Handover (LEH) should be tested to ensure feasibility, utility and benefits. The LEH must be learner-centered, respecting learner privacy, while facilitating a smooth transition from undergraduate to post-graduate medical training, promoting learner wellness, professionalism, and performance.

Abbreviations

AFMC:

Association of Faculties of Medicine of Canada

CanMEDS:

Canadian medical education directions for specialists (framework)

CHREB:

Conjoint Health Research Ethics Board

LEH:

Learner Education Handover

MSPE:

Medical Student Performance Evaluation

MSPR:

Medical Student Performance Record

PGME:

Postgraduate Medical Education

UME:

Undergraduate Medical Education

References

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Acknowledgements

We would like to acknowledge Valerie Broadfoot and Matthew Raegele for their assistance in recruitment and organizing the focus groups.

Funding

This study was funded by the Association of the Faculties of Medicine of Canada (AFMC).

Availability of data and materials

We do not have ethics approval to make raw data from this study available for sharing.

Author information

Authors and Affiliations

1. Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

Aliya Kassam & Maureen Topps

2. University of Toronto, Toronto, Ontario, Canada

Mariela Ruetalo, Susan Edwards & Leslie Nickell

3. McMaster University, Hamilton, Ontario, Canada

Margo Mountjoy & Mark Walton

Contributions

All Authors meet the Vancouver guidelines for authorship. AK and LN designed the study. AK collected data, and AK, MR and LN analyzed the data. MT, MM and MW& SE made contribution to the data analysis, interpretation and final write up. All authors revised the manuscript and gave approval for the final version to be published, and are accountable for all aspects of the work.

Corresponding author

Correspondence to Aliya Kassam.

Ethics declarations

Ethics approval and consent to participate

The project was given ethical approval by the University of Calgary Conjoint Health Research Ethics Board (CHREB), Ethics ID: REB15-1244.

Participants volunteered to take part and actively consented. It was made clear that if they chose not to participate, it would involve no penalty or loss of benefits to which they were otherwise entitled.

Consent for publication

Participants gave consent for anonymous quotes to be published from the research.

Competing interests

All authors were AFMC LEH Working Group Members with the exception of author MR.

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Kassam, A., Ruetalo, M., Topps, M. et al. Key stakeholder opinions for a national learner education handover. BMC Med Educ 19, 150 (2019). https://doi.org/10.1186/s12909-019-1598-7
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Key stakeholder opinions for a national learner education handover - BMC Medical Education

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Background Sharing information about learners during training is seen as an important component supporting learner progression and relevant to patient safety. Shared information may cover topics from accommodation requirements to unprofessional behavior.

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Experiential Learning | Flipped Classrooms

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Experiential Learning | Flipped Classrooms

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Chen, F., Lui, A. M., & Martinelli, S. M. (2017). A systematic review of the effectiveness of flipped classrooms in medical education. Medical education, 51(6), 585–597. https://doi.org/10.1111/medu.13272

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A systematic review of the effectiveness of flipped classrooms in medical education

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Context
There are inconsistent claims made about the effectiveness of the flipped classroom (FC) in medical education; however, the quality of the empirical evidence used to back up these claims is ...

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Hatlevik, I., & Hovdenak, S. S. (2020). Promoting Students' Sense of Coherence in Medical Education Using Transformative Learning Activities. Advances in medical education and practice, 11, 807–816. https://doi.org/10.2147/AMEP.S266960

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Introduction

A major challenge for medical students is the application of theoretical knowledge to medical practice with actual patients, that is, students may experience a lack of coherence between knowledge and skills acquired in medical education and the competence demands of professional practice. To better understand how medical education can be improved to accommodate this challenge, it is important to obtain knowledge about the connection between teaching and student learning outcomes. Moreover, student evaluations can provide valuable information about the quality of the teaching and learning activities offered. This paper reports on a longitudinal qualitative study that examined medical students' evaluations of various learning opportunities offered on campus and at clinical placement sites in the medical program at the University of Tromsø - The Arctic University of Norway (UiT). During this six-year program, a gradual escalation of placement learning took place. Antonovsky's concept of coherence and transformative learning theory provide the theoretical framework for examining and discussing medical students' statements regarding their learning experience in UiT's medical program. Critical reflection and problem solving, which are central features of transformative learning, and other related concepts are used widely in health education literature and have been proposed as methods for professional knowledge acquisition. However, few studies have used a longitudinal design that investigates students' evaluations of transformative learning activities offered throughout the medical program. This paper aims to identify learning activities that promote transformative learning and reveal how these learning activities can lead to students' integration of theory and practice, thereby creating a sense of coherence in their medical education.

Theoretical Framework

Sense of Coherence

The theoretical knowledge content of a professional program, such as medicine, is chosen because various theories can illuminate challenges in professional practice and form the basis for action in specific situations. Moreover, scientific theoretical knowledge taught in a professional program provides a reliable basis for critically reflecting on and further developing professional practice. However, medical students do not always grasp the relevance of some aspects of the theoretical knowledge they are taught, such as chemistry and biochemistry, unless these concepts bear an explicit relation to medical education. In addition, students may experience difficulties in applying theoretical and practical knowledge to treat patients. Furthermore, students may have different preconceptions about what comprises good professional practice, and variations may exist in scholars' opinions and evidence that point in different directions regarding what comprises the best means of treating specific medical conditions. In other words, medical education is complex and contains conflicting situations that the students may interpret as a lack of coherence between theory and practice.

Antonovsky, a professor of medical sociology concerned with the relationship between health, stress, and coping, claims that facilitating a "sense of coherence" is important for supporting human health and well-being. He postulates that a sense of coherence may act as a health-promoting mastering mechanism to help human beings cope with complex, conflictual situations that can also be described as "creating order out of chaos." Antonovsky describes the concept "sense of coherence" as a global orientation that consists of the three core components: comprehensibility, manageability, and meaningfulness. Comprehensibility refers to having confidence in "that the stimuli deriving from one's internal and external environments in the course of living are structured, predictable and explicable". Manageability is about experiencing that "resources are available to one to meet the demands posed by these stimuli". Meaningfulness is about perceiving the demands one encounter "are challenges, worthy of investment and engagement".

Antonovsky suggests expanding how his sense-of-coherence concept can be applied to include an individual's competence development. With this in mind, we argue that Antonovsky's emphasis on a sense of coherence-with its core components of comprehensibility, manageability and meaningfulness-is a relevant contribution that can illuminate our findings because it indicates important motivating factors of human behaviour. In medical education, comprehensibility refers to the student's perception of educational content as understandable. Manageability is the student's confidence in his/her ability to develop skills or access the support and resources required to master educational and professional demands. Meaningfulness refers to the student's perception of educational content as relevant and useful for professional practice.

Making the educational content understandable, manageable, and meaningful for students is also highlighted in research on teaching and learning as important aspects of teaching quality. Ramsden emphasizes that some of the important properties of good teaching are the lecturers' ability to explain the material clearly, engage with students at their level of understanding, and make clear what has to be understood, at what level, and why. Bandura's concept of self-efficacy-believing that one will succeed in undertaking a task-elaborates on Antonovsky's point about the importance of manageability. According to Bandura, self-efficacy in a specific domain affects the thought processes, endurance, motivation, and emotions related to tasks in the same or similar domain, hence influencing the individual's effort and the results of their actions. Bandura also emphasizes the mastery of experiences and feedback from a significant other as influential sources for developing self-efficacy in a specific domain. Moreover, previous research has shown that self-efficacy in a specific domain is an influential, motivational driving force for the individual to continue with further engagement in that same domain. The importance of meaningfulness, the third core component in Antonovsky's sense-of-coherence concept, is also highlighted in the expectancy-value theory, which emphasizes the importance of believing that the learning content is important and useful or interesting, as well as calculating whether striving to learn the content is worth the effort and challenges it entails. Students' self-efficacy combined with the expected value of a task is crucial to their effort, endurance, and performance.

Based on Antonovsky's theory, we argue that experiencing a sense of coherence in medical education does not require an absence of conflicting situations and a lack of tension among various perspectives. Instead, creating coherence in medical education means that students must experience and perceive educational content as comprehensible and meaningful for professional practice and that demands in education and professional practice must be viewed as manageable. However, how the tensions that students experience (ie, diverging perspectives or a lack of understanding and perceived practical competence) are addressed and processed is important. There are many theories that explain how students learn and how to enhance student learning, and each has its own merits. We argue that transformative learning theory contributes with a particularly interesting theoretical framework for understanding and addressing the tensions that students experience. Transformative learning theory shows how experienced tensions and lack of understanding and ability to perform can be a source of learning and how this can facilitate students' professional competence development in professional education. Moreover, the theory of transformative learning offers a theoretical foundation for learning activities that integrates theory and practice and facilitates students' perceptions of coherence in medical education.

Transformative Learning

Transformative learning is an analytic metatheory that provides educators with a theoretical lens through which to view student learning. Facilitating transformative learning in medical education gives students a broad perspective and an expanded understanding of patients' conditions and professional conduct, thereby promoting a change in attitude and professional practice. Illeris emphasizes that when transformative learning takes place

we have to do with the processes that pave the way for what truly can measure up to the buzzword of competence development when changes in mind and behaviour are followed by more concrete changes in understanding and acting.

Transformative learning theory is founded on both humanist and constructivist assumptions; that is, humans are seen as free and autonomous beings that have potential for growth, development, and self-actualization, and experience is seen as socially constructed, and learning is seen as a process of creating meaning from experience. The concept of transformative learning was first created by Mezirow in 1978, and transformative learning theory has evolved over time and has been adapted to address criticism. Transformative learning differs from learning that only involves the acquisition of new knowledge and skill or elaboration of existing knowledge. However, learning that begins as the acquisition of new knowledge can become transformative if the learner's perspective, assumptions, or expectations undergoes a fundamental shift. Mezirow defines "transformative learning" as:

Learning that transforms problematic frames of reference -sets of fixed assumptions and expectations (habits of mind, meaning perspectives, mindsets)-to make them more inclusive, discriminating, open, reflective and emotionally able to change.

Furthermore, Mezirow ¹⁰ underlines that "such transformed frames of reference are better than others because they are more likely to generate beliefs and opinions that will prove more true or justified to guide action." Moreover, transformative learning involves "reflecting critically on the source, nature, and consequences of relevant assumptions-our own and those of others", and it may occur in both instrumental and communicative learning. Transformative learning in instrumental learning, which is often task oriented, uses empirical research methods to determine whether something is true, whereas transformative learning in communicative learning involves critical self-reflection and an understanding of others' arguments and experiences, arriving at strongly justified beliefs by participating in an informed continual discourse. Particularly in relation to communicative learning, transformative learning is metacognitive reasoning that applies critical thinking that involves becoming aware of, considering, and revising one's attitudes, assumptions, and preconceptions in light of new experiences and newly acquired theoretical knowledge that challenge existing ways of understanding and acting.

Transformative learning typically occurs after one experiences a disorienting dilemma, which is an insufficiency between previous understanding and practical experience, other people's interpretations, or newly acquired theoretical knowledge. This experience of inadequacy in prior understanding and tensions between different perspectives implies that students become uncertain and feel the need to solve this disorienting dilemma. Both in medical education and medical practice, a disorienting dilemma is a situation in which previous assumptions and preconceptions about a patient or a medical condition are tested and found to be inadequate regarding a full understanding of the symptoms, the patient's needs, and/or how to best communicate with the patient about his or her condition and further treatment. Thus, experiencing inadequate understanding may provide medical students with a starting point and motivate them to study further, thereby providing an opportunity to transition into a transformed and deeper understanding of the relationships between theoretical knowledge and practical challenges, as well as of the demands of professional practice.

While Mezirow emphasize critical reflection, dialogue, and experience as central to transformative learning, Taylor and Cranton additionally address the role of empathy and desire to change. They argue that empathy provides the learner with the ability to better understand and identify with the perspectives of others and the motivation to listen to others. Furthermore, empathy lessens the likelihood of prejudgment; increases the opportunity for identifying shared understanding; and facilitates critical reflection through the emotive valence of assumptions. In addition, they emphasize that for transformative learning to occur, the learner needs to be willing and able to engage in activities that have the potential to lead them to shifts in perspectives. One important question for the medical educator is therefore, how to facilitate transformative learning. In our study, we addressed this question by investigating medical students' experiences with learning opportunities at various learning sites, and elaborate on what, according to the students, characterizes learning activities that had a profound impact on their learning outcome and contributed to their understanding of the interplay between theoretical knowledge and professional practice and created a sense of coherence in their medical education.

Materials and Methods

The medical school in Tromsø was established in 1971 and is said to be at the forefront of medical education in Norway due to its principles of integration between medical theory and clinical practice. Thus, the interplay between theoretical knowledge on campus and practical cases or placement experiences has been the backbone of the medical program for many years. This paper highlights this process by focusing on students' perspectives on transformative learning activities and by asking what characterizes a learning process that seems to create a sense of coherence in medical education.

The current paper reports on a longitudinal qualitative study from 2012 through 2018 that complied with the Declaration of Helsinki and was approved by the Norwegian National Research Ethics Committees. Forty medical students were interviewed regarding their learning experiences at various learning sites. Each student was interviewed at the end of each academic year. The study was based on self-selection, and the sample was comprised of 16 male and 24 female students, accurately reflecting the gender breakdown of the entire medical student body. All students who volunteered took part in the study through the program for six years, and informed consent was obtained from the study participants prior to study commencement. This informed consent included permission to quote the participants. The interviews were conducted in accordance with the Personal Data Act and with the legal and ethical guidelines regulating research developed by the Norwegian National Research Ethics Committees. The interviews were conducted individually and lasted approximately 60 minutes.

As this study sought to understand the students' learning perspectives concerning their experiences in medical education, a semi-structured interview guide was chosen as the basic method for obtaining the presented qualitative data. We applied open-ended questions and designed the qualitative approach in order to get to know what, according to the students, seemed to be important about the theme under study. The interview guide also allowed the medical students to present their reflections and experiences, which is of great importance in qualitative research. For detailed information about the content of the interview guide, see .

In a qualitative approach, the researcher is the key instrument, and thus the researcher's role is demanding, especially when it comes to validity. Maxwell points out that researcher bias and reactivity as two threats that can influence the validity of a study. In our case, follow-up questions were used for clarification and further in-depth understanding. At the end of each interview, the researcher presented the interviewee with a short summary of the session and her understanding of the main points to avoid misunderstandings that could influence the study's validity. According to Maxwell, these strategies are important to strengthen validity in qualitative research. The same researcher conducted all the interviews to ensure consistency.

Each interview was recorded and transcribed verbatim. The transcribed text was read and reread to obtain an overall impression of the data. The themes concerning transformative learning, sense of coherence, and the impact of on-campus and placement learning were then identified and coded, balancing inductive and deductive coding, which can be referred to as an abductive research strategy, which is the process of generating social scientific accounts from the interviewee's account of his/her experiences. Abduction is a position in between induction and deduction that highlights the dialectic connection between empirical and theoretical perspectives. Thus, the abductive position contributes to the interpretation of the meaning of the data. In this process, inductive coding emerged from the collected empirical data, whereas deductive coding was derived from the applied theoretical framework-namely, Antonovsky's sense of coherence and transformative learning theory. In this case, the analysis was a synthesis of the data collected and the applied theoretical framework, which, according to Cohen et al, is a preferable process because it is the most faithful to the data. Additionally, during the process of writing this text, the authors extensively discussed the interplay between theory and the collected data to present a valid interpretation and analysis.

Findings

Our focus was on characteristics of transformative learning activities at the various learning sites, which, from the students' perspectives, seemed to impact their learning outcomes greatly. These learning activities are linking theoretical knowledge to professional practice, experiencing authentic placement situations with real patients, and discussing cases and critically reflecting on professional practice with experienced doctors. The various learning activities are elaborated upon below according to on-campus learning and placement learning (as practical clinical teaching, in the casualty ward, and as extensive practice in hospitals).

On-Campus Learning

On-campus learning includes lectures and problem-based seminars. Linking theoretical knowledge to professional experience and practical cases is, according to the students' statements, "a key characteristic of high-quality, on-campus teaching." Linking theoretical knowledge to professional practices is a transformative learning activity that may give students a broader perspective and a deeper understanding of a specific medical phenomenon. The students reported, however, that the lectures given in the auditorium differed qualitatively with respect to quality. According to one student, "A good lecturer relates theoretical knowledge to practical cases and their own practical experiences during the lecture." Another student said, "The main difference between a good and a bad lecturer is whether the lecturer uses examples from clinical practice." All the interviewed students agreed that the lecturers who were able to exemplify medical theory by means of patient cases were regarded as clever and inspiring teachers who motivated and stimulated the students in their learning processes. Thus, the theory became understandable and meaningful, which are two of the core components in sensing coherence. However, according to the students, not all lecturers related theoretical knowledge to practical cases. One student said, "Together, these doctors have over a hundred years of experience. So, why don't they share any of their experiences with us when they are lecturing?"

According to the students' statements, "problematizing," "discussing," and "reflecting on cases with a more experienced teacher," which is a typical transformative learning activity that provides students with alternative interpretations during the problem-based seminars, seemed to be beneficial in reassuring them that they were on the right track. One student said, "I am very happy with the seminars and cases. We immediately get to know whether we are right or not." Another student said, "A problem-based seminar is a very good way of learning, I think." The students reported that they appreciated this learning site because it gave them an even deeper understanding of the theory and cases presented-the first core component in developing a sense of coherence. The following quotation from a student is representative: "A good lecture, combined with a practical case and experiences, can really open up our learning. It is motivating and inspiring!" Additionally, the students reported that they ensured that they were well-prepared for every seminar in order to be able to participate in the discussions. One student expressed this notion by saying,

I am always very well prepared before attending a seminar. Thus, I feel that I can contribute to the discussions in a positive way. It makes me feel good, and I like it.

These findings indicate that students' study engagement is a prerequisite for taking full advantage of transformative learning activities in teaching lessons similar to those offered in the problem-based seminars.

Placement Learning as Practical Clinical Teaching

Practical clinical teaching (PCT) took place in different departments at the university hospital. PCT is longitudinal and occurs throughout the program after theoretical on-campus teaching courses have been completed. One principal point that all the students expressed was that PCT quality depended significantly on student access to patients. When the students had opportunities to meet patients, they claimed that they became more conscious of the problem, which is a typical characteristic of transformative learning. One student said,

In practical clinical teaching together with a patient and a mentor, I can experience the relevance of theory in clinical settings, which is very motivating for further reading.

The students also reported experiencing better concentration and a greater sense of responsibility because they had met with a real person suffering from an illness. One student said, "I have experienced that I concentrate in another way when examining a patient. I really do my very best in these situations." Elaborating on this notion, another student said,

There is a big difference if you have PCT with or without a patient. You are aware of your own behavior while talking with a patient, and you remember the case study better because you have a face to relate to.

These findings indicate that meeting a real patient gave the students a better understanding of the medical knowledge required to help different patients, which corresponds to the first and third core components in sensing coherence. The students also stressed the importance of having the opportunity to talk about the patient and a possible treatment with their mentors after the patient consultation. As one student said, "It is important that we discuss with the doctor afterwards about what the patient is suffering from, about the treatment and all that."

Placement Learning in the Casualty Ward

Teaching in the casualty ward took place twice a semester during the medical students' third or fourth years of study. The students were paired up and assigned an experienced doctor as a mentor. Each pair met an authentic patient, and neither the students nor the mentors knew beforehand what illness the patient had. One student examined the patient and proposed a course of treatment while the second student and their mentor observed. After the consultation, the three discussed the case and drew their conclusions. This typical transformative learning activity was reported to be an excellent learning situation because the students could test their medical knowledge, apply this knowledge to an authentic patient, discuss the chosen solution with the mentor, and receive immediate feedback. One student said,

I want to brag about the casualty ward. I learned a lot. Indeed, it was a steep learning curve. I examined the patient, drew a conclusion, and then discussed it with my mentor and fellow student. The discussion and feedback were very important.

Mastery experiences and immediate feedback from a significant other, in our case a mentor, is emphasized by Bandura as an influential source when it comes to believing that one will succeed in undertaking a task. One student expressed this notion by saying,

Here, you have the opportunity to try independently, and I think that is good for professional maturation. And you also have someone to discuss the case with, and that is also important.

The interviewed students viewed their experience in the casualty ward as a beneficial and well-organized learning arena where they were able to apply their medical knowledge in new and different settings, which was important for experiencing professional practice as being manageable (the second core component in sensing coherence). In these contexts, the students reported that their opportunity to test themselves as physicians in the making and gain experience enabled them to transform their theoretical knowledge into professional practice. One student said,

I am more able to relate theory to practice now. I feel more like a physician in the making compared to what I felt when I started this practice six months ago. I feel safer now.

Furthermore, they received constructive criticism and could have discussions with their mentors, which prepared them for their futures as medical doctors. One student said,

In these situations I felt more like a doctor than a medical student. I drew my conclusion, and I got immediate feedback, not being yelled at exactly, but criticized. This was important for my further development.

All the students were satisfied with the time and location of this practice; a possible explanation may be that the students had attained a minimum level of medical knowledge that they could apply in concrete cases. This interpretation is in line with findings from Vågan's study, which indicated that physicians in the making should reach a certain theoretical level before they start examining patients.

Placement Learning as Extensive Practice in Hospitals

During the fifth year of the medical program, students attend 26 weeks of extensive placement in hospitals. The students reported that this lengthy placement greatly helped their understanding of the interplay between theory and practice. The following quotation from a student is representative: "This was a very good period with a long-lasting practice where I had to connect theory to practical patient cases all the time." Participating in authentic patient cases resulted in typical transformative learning outcomes that were perceived and reflected on in a complex and problematizing way, and these experiences motivated the students to pursue further theoretical studies. One student expressed this notion by saying, "After a day in hospital I often went home to read and get further insight into patient cases. Meeting patients is very important for further motivation." Meeting patients in various situations required reflecting on and combining different forms of medical knowledge, testing their skills and previously acquired knowledge, and attempting to obtain a deeper and broader understanding of the individual patient's overall situation. In some cases, the students expressed their empathy with the patients; one of them said that she was "thinking about her mother and what to do if this had happened to her." Another student told about a patient case related to a similar situation in his family, and how he was concerned with finding a good solution for this specific illness. Thus, theoretical medical knowledge was transformed into concrete cases requiring practical solutions to care for the patients. These findings also indicate that empathy is not only a prerequisite for transformative learning to occur, an increased level of empathy towards patients is also a positive learning outcome. Furthermore, the students claimed that they underwent a "transformative process." One student said, "I entered the fifth year as a hard-working medical student and completed it as a doctor in the making, which I experienced as a steep learning curve." Moreover, the extensive, external placement experiences helped the students perceive future professional practice as manageable (the second core component in sensing coherence) because they realized their potential to cope with various medical cases. One student said, "This fifth year has been like a revelation. The pieces have started to fall into place. This practice has made me more fit for use." Additionally, the students stressed the importance of being invited to discuss cases with experienced doctors. One student expressed this by saying, "Having a good mentor to discuss with is worth its weight in gold." Concerning this typical transformative learning activity, the study revealed different practices. Broadly speaking, the students' experiences could be classified into two categories: the students as participants and the students as observers. Medical teachers who treated students as participants discussed patient cases with them, whereas, the medical teachers who treated students as observers left the students on their own to seek out information about what had happened to different patients. In the latter category, students only had fellow students and intern doctors to discuss patient cases with, which meant fewer opportunities to participate in facilitated transformative learning activities.

As for the sixth and final year of the program, the students' placement learning occurred in the university hospital where they worked with experienced doctors and attended lectures on medical topics. The students reported that the year "reinforced their experience," "further deepening" and "problematizing" their medical knowledge. They also emphasized that this final year greatly prepared them to become responsible physicians. One student elaborated on this notion by saying,

This has been the most important year for further professional development as a medical doctor. I have deepened my theoretical perspectives and related them to practical cases and patients, and I have been discussing with experienced mentors. I feel safer and more prepared to become a responsible medical doctor now.

Discussion

Our findings yielded three key features that characterize transformative learning activities that can foster students' sense of coherence in medical education: linking theoretical knowledge with professional practice, participating in authentic learning situations, and discussing and critically reflecting on cases and one's own placement experiences with experienced doctors. These transformative learning activities go beyond the acquisition of new knowledge and elaboration of existing knowledge by transforming the learner's understanding and assumptions regarding medical practice and their role as future professionals. One may argue that these transformative learning activities are fairly common in medical education; however, our findings show that even in a medical program that explicitly reports focusing on integrating theory and practice, a substantial number of the medical educators do not use these types of transformative learning activities. Furthermore, our findings indicate that the use of transformative learning activities presupposes thoughtful planning and facilitation by a medical educator. Moreover, an absence of these types of learning activities may indicate that the respective medical educator in charge of the lecture, seminar, or mentoring situation are not familiar with the benefits of transformative learning for student learning outcomes. Hence, our findings may have implications for practice, that is, a need for enhanced awareness among medical educators regarding the importance of knowing why and how to promote transformative learning.

Students highlighted linking theoretical knowledge to professional practice as a significant aspect of good teaching at both on-campus and placement learning sites because it made the theoretical content comprehensible and meaningful for their professional practice-the first and third core components of sensing coherence. Opportunities to discuss cases and practice with peers and lecturers on campus and with mentors at the placement site were emphasized as vital for learning. Having been given opportunities to discuss cases and practical experiences with peers, lecturers, and experienced doctors, the students received alternative perspectives and explanations-a central feature of transformative learning. Moreover, the findings indicate that authentic learning situations in which students meet actual patients, work with experienced doctors and examine, discuss, and put forth possible treatment scenarios for patients are essential for experiencing professional practice as manageable, which is the second core component of sensing coherence. The students stated that these types of learning opportunities helped them gain confidence that they would be able to handle similar situations as future physicians. Using Bandura's terminology, these situations enhanced their professional self-efficacy. This indicate that both first-hand experiences, that is students' own placement experiences, and second-hand experiences, that is practical cases or others experiences mediated by a lecturer, can be used by medical educators to make the educational content comprehensible and meaningful. Not unexpectedly, first-hand experiences are even more powerful than second-hand experiences, because discussing first-hand placement experiences with a medical educator contributes to the students' perceiving future professional practice as manageable. Hence, it is especially important in medical education to ensure that that students have mentors who invite them to discuss their placement experiences.

Additionally, the students reported that experiencing a lack of understanding and knowledge in these practice settings led to a desire to change and motivated them to study further. Therefore, our findings indicate that experiencing a lack of knowledge and competence in either case-based learning on campus or when meeting an actual patient in practice can contribute to experiencing tensions and what Mezirow terms a "disorienting dilemma." Thus, the need to acquire new skills, knowledge, and alternative perspectives and explanations emerges. The findings show that experiencing a disorienting dilemma motivated the students to discuss the case at hand and study further to broaden their knowledge and deepen their understanding of health-related phenomenon. Thus, providing students with opportunities to experience lack of understandings may be a way for medical educators to engage students in learning activities that have the potential to lead them to shifts in perspectives.

Furthermore, the findings show that the students experienced a progression in difficulty level regarding linking theoretical knowledge to professional practice. At the beginning of the medical program, cases and the lecturers' own medical practice were primarily used to illustrate and actualize theoretical knowledge. Later in the program, the students' own practical experiences were increasingly used as a basis for reflection and further study, and during the latter part of the program, when the students experienced extensive practice, they reported experiencing the pieces coming together and fully sensing coherence in their medical training. This sense of coherence enhanced their motivation to enter their final year of study and actually become physicians. In addition, the findings indicate that a sense of coherence between theory and practice is something that students must create, requiring effort in one's studies, a certain level of acquired medical knowledge, practical experience, and critical reflection. Thus, at the beginning of the medical program, the lecturers, in addition to linking theory to practical cases and facilitating critical reflection on professional practice, should communicate to the students that fully experiencing a sense of coherence is something that develops over time.

Finally, the findings underline the importance of facilitating a balance between various learning situations, such as acquiring new knowledge through participation in lectures, reading medical literature, participating in dialogue and critically reflecting on professional practice with experienced doctors, and practical training, which includes applying new insights in authentic or close-to-authentic practice situations. Mezirow emphasizes that transformative learning involves developing a specific kind of attitude that corresponds to engaging in these types of learning activities. For medical students, this attitude involves constantly testing their assumptions about a medical condition and how to best treat a patient against other professionals' understanding and scientific knowledge. This is an important attitude to develop, both in terms of being responsive to patients and in relation to the rapid development of the latest in medical knowledge. Moreover, this kind of attitude is essential for justifying physicians' professional autonomy and space for discretion.

Conclusion

This paper theoretically and empirically describes how transformative learning activities promote medical students' understanding of the interplay between theoretical knowledge and professional practice, thereby creating a sense of coherence in their medical education. This study contributes to the knowledge of some characteristics of good quality learning opportunities that can foster transformative learning, motivate students to partake in further theoretical studies, and give them a deeper understanding of professional practice, which is important knowledge for medical educators. The results indicate that linking theoretical knowledge to practical cases or placement experiences, having authentic placement experiences with real patients, and providing opportunities for discussing cases with experienced doctors help students perceive learning content as comprehensible and meaningful and makes educational demands manageable, which are the core components for sensing coherence in professional education. Based on the findings, we conclude that promoting transformative learning necessitates offering various types of learning activities that together provide a balance between acquiring and applying professional knowledge and critically reflecting on assumptions and professional practice. With critical reflection, students move beyond an individual viewpoint and learn how to deeply analyze a range of complex information and issues.

In spite of this knowledge, it is not a given that learning activities that may promote transformative learning are present in the teaching offered at various learning sites; therefore, we argue that an enhanced awareness of why and how to promote transformative learning is required among medical educators. Because this is a qualitative study, it is only possible to show our findings; thus, a need exists for more research in this field using both qualitative and quantitative approaches. However, within these limitations, the study offers valuable insight into how students perceive various learning opportunities offered on campus and at clinical placement sites.

Disclosure

The authors report no conflicts of interest for this work.

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Promoting Students' Sense of Coherence in Medical Education Usin | AMEP

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A major challenge for medical students is the application of theoretical knowledge to medical practice with actual patients, that is, students may experience a lack of coherence between knowledge and skills acquired in medical education and the competence demands of professional practice.

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Shirani Bidabadi, N., Nasr Isfahani, A., Rouhollahi, A., & Khalili, R. (2016). Effective Teaching Methods in Higher Education: Requirements and Barriers. Journal of advances in medical education & professionalism, 4(4), 170–178.

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Affiliations

¹ Psychology and Educational Sciences School, University of Isfahan, Isfahan, Iran.

² Department of English, Management and Information School, Isfahan University of Medical Science, Isfahan, Iran.

³ Quality Improvement in Clinical Education Research Center, Education Development Center, Shiraz University of Medical Sciences, Shiraz, Iran.

Free PMC article

Free PMC article

Affiliations

¹ Psychology and Educational Sciences School, University of Isfahan, Isfahan, Iran.

² Department of English, Management and Information School, Isfahan University of Medical Science, Isfahan, Iran.

³ Quality Improvement in Clinical Education Research Center, Education Development Center, Shiraz University of Medical Sciences, Shiraz, Iran.

Abstract

Introduction: Teaching is one of the main components in educational planning which is a key factor in conducting educational plans. Despite the importance of good teaching, the outcomes are far from ideal. The present qualitative study aimed to investigate effective teaching in higher education in Iran based on the experiences of best professors in the country and the best local professors of Isfahan University of Technology.

Methods: This qualitative content analysis study was conducted through purposeful sampling. Semi-structured interviews were conducted with ten faculty members (3 of them from the best professors in the country and 7 from the best local professors). Content analysis was performed by MAXQDA software. The codes, categories and themes were explored through an inductive process that began from semantic units or direct quotations to general themes.

Results: According to the results of this study, the best teaching approach is the mixed method (student-centered together with teacher-centered) plus educational planning and previous readiness. But whenever the teachers can teach using this method confront with some barriers and requirements; some of these requirements are prerequisite in professors' behavior and some of these are prerequisite in professors' outlook. Also, there are some major barriers, some of which are associated with the professors' operation and others are related to laws and regulations. Implications of these findings for teachers' preparation in education are discussed.

Conclusion: In the present study, it was illustrated that a good teaching method helps the students to question their preconceptions, and motivates them to learn, by putting them in a situation in which they come to see themselves as the authors of answers, as the agents of responsibility for change. But training through this method has some barriers and requirements. To have an effective teaching; the faculty members of the universities should be awarded of these barriers and requirements as a way to improve teaching quality. The nationally and locally recognized professors are good leaders in providing ideas, insight, and the best strategies to educators who are passionate for effective teaching in the higher education. Finally, it is supposed that there is an important role for nationally and locally recognized professors in higher education to become more involved in the regulation of teaching rules.

Keywords: Barriers; Higher Education; Qualitative research; Requirements; Teaching.

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national center for biotechnology information

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Effective Teaching Methods in Higher Education: Requirements and Barriers - PubMed

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In the present study, it was illustrated that a good teaching method helps the students to question their preconceptions, and motivates them to learn, by putting them in a situation in which they come to see themselves as the authors of answers, as the agents of responsibility for change.

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What can I do in my online classroom? This resource considers Weimer’s (2013) five key changes to practice within the context of the remote classroom.

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Assessment vs Evaluation in Higher Education

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Assessment vs Evaluation in Higher Education

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The terms assessment and evaluation are used in a variety of contexts within higher education, and often are used interchangeably. However they are quite different in how and when the review is implemented, the focus of the review, and what is done with the findings of the review. The table below compares assessment and evaluation.

Content: timing, primary purpose

Formative: ongoing, to improve learning

Summative: final, to gauge quality

Orientation: focus of measurement

Process-oriented: how learning is going

Product-oriented: what's been learned

Findings: uses thereof

Diagnostic: identify areas for improvement

Judgmental: arrive at an overall grade/score

Content adapted from: Angelo, T and Cross, K.P. 1993. Classroom assessment techniques a handbook for college teachers. Jossey-Bass A Wiley Imprint, San Francisco, CA. Pp 427.
Assessment encompasses everything from institutional level assessments to an assessment of student learning outcomes for an individual course. With regard to teaching and learning, assessment can be considered as the systematic collection and analysis of information to improve both endeavors.

Carnegie Melon University has created a great online resource about the assessment of teaching and learning. The website includes assessment basics, detailed descriptions of how to assess students' prior knowledge, learning, and performance, as well as your teaching, and department and program level assessment strategies.

This section of the website will focus assessment and evaluation in two areas:

Of Your Teaching including: formative mid-semester evaluations (PLUS/DELTA); student evaluation of teaching (SET); and strategies for better course evaluations and analyzing student feedback

Of Student Learning including: classroom assessment techniques, peer assessment and guidelines for student outcomes assessment at ISU

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The terms assessment and evaluation are used in a variety of contexts within higher education, and often are used interchangeably. However they are quite different in how and when the review is implemented, the focus of the review, and what is done with the findings of the review.

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A major source of stress for many is the pervasive feeling that there is never enough time. In response, many of us turn to time management. We try to squeeze hour-long meetings into half-hour sprints by being "more efficient" or we slot smaller tasks into gaps in our calendar to minimize unproductive time. And yet, paradoxically, time management often increases the stress we face instead of reducing it. As we become more efficient, we make room for even more tasks and feel even more pressure. When we are feeling overwhelmed, we are better served by attacking the root causes: the sheer volume of tasks, decisions, and distractions.

The Trap of Time Management

The move to remote work following the onset of the Covid-19 pandemic provided an interesting natural experiment that illustrates the paradox of time management. More than three-quarters of people report that working from home saves them time, typically related to commuting and business travel, and about half of remote workers report that they are more productive.

Despite these self-reported time savings and productivity gains, data from enterprise software firm Atlassian shows that the average workday has expanded by a full 30 minutes globally - the opposite of what we would expect with people using their time more productively. Compounding the issue, the additional 30 minutes of work has come mostly at the expense of what is typically leisure time in the evening.

Time management promises us that if we become more efficient, we can make space to accommodate all of our to-dos comfortably. And yet, time management is like digging a hole at the beach: the bigger the hole, the more water that rushes in to fill it. In a world of potentially infinite demands, freeing up an hour on your calendar is akin to setting off a signal flare announcing your capacity to jump on another project or take on an additional role.

This is not to say that time management has no value. Productivity is important. But in a world where burnout is running rampant, we also need strategies for eliminating volume instead of simply accommodating it. There are three things you can do to escape the trap.

1. Reduce the Volume of Tasks

To-dos represent an agreement: "I'll handle the budget update for next week's meeting," "I'll pick up something for dinner on the way home," or "I'll send you the updated PowerPoint deck later tonight."

As soon as an agreement is in place, it begins to create the pressure to deliver. If we have to break or renegotiate the agreement, we add the additional stress of a challenging conversation and the guilt of letting someone down. To reduce the pressure from task volume, hold the line upfront so you aren't forced to renegotiate later. How you hold the line depends on whether your pile of to-dos tends to grow from tasks you are assigned or from tasks that you choose to take on.

For tasks that are assigned to you, think in terms of priorities not time. When a superior asks you to do something, responding with "I don't have time for that" may feel too abrupt. Instead, consider asking: "Where would you like me to prioritize this against x, y, and z?" This accomplishes two things. First, the onus for prioritization is placed on the superior, not you. Second, it reframes the exchange from a binary choice to a collaborative discussion about what is most important.

For tasks you are considering adding on yourself, calendar-block first. We often overwhelm ourselves because we are overly optimistic about our capacity. We look at our calendar, see some daylight, and think, "Okay, I can probably get this done for Friday." And then Friday comes, and - lo and behold - we have to renegotiate.

The challenge is that your calendar usually only shows the claims on your time that involve synchronous work (tasks that you perform with other people at the same time that they do): meetings, phone calls, coffee chats, and so on. Your to-dos are a parallel list of agreements with other people for asynchronous work (tasks that you perform on your own and not in real time with others) that has a claim on your time. The solution? Merge your calendar and to-do list by blocking time on your calendar for each one of your to-dos. By getting a complete view of the commitments you've made, you can see your real capacity before you agree to take on more.

2. Replace Decisions with Principles

Our past year has been characterized by an endless parade of decisions: Do I send my kids to school? Can I visit my parents? Is it safe to return to the office? Continually facing decisions with important consequences and imperfect information can lead to what scientists call cognitive overload, in which the demands from the mental work we need to do outstrip our abilities to cope. Cognitive overload both increases the likelihood that you will make errors and contributes significantly to feeling overwhelmed.

You can begin to reduce your cognitive load by replacing decisions with absolute principles. For example, the science of weight-loss management tells us that it is much more effective to say, "I won't eat after 7 PM" than "I'll limit my snacking after 7 PM" The latter creates an infinite number of subsequent decisions: "Can I have this cup of yogurt? What about a piece of fruit?" The absolute principle of no food after 7 PM shuts the door once and for all. The decisions disappear.

Tim Ferriss, a successful author and podcaster, calls this "finding the one decision that removes 100 decisions." For Ferriss, this meant establishing a principle of reading no newly published books in 2020. After years of being deluged by eager authors and their publicists to read, review, or blurb dozens of new or upcoming books a week, this blanket principle freed him from hundreds of book-by-book decisions.

Steve Jobs famously decided to wear the same thing every day to remove the decision fatigue of choosing an outfit every morning. Jon Mackey, the managing director of the Canadian operations of executive search firm Heidrick & Struggles, set up the principle of no meetings on Fridays. After failing to protect time for deep work through individual decisions on which meetings to accept or reject, he created a day a week in which he can focus.

3. Use Structure, Not Will Power, to Minimize Distractions

Distractions sidetrack us from accomplishing our tasks and making our most important decisions. Distractions are a particularly corrosive contributor to feeling overwhelmed because they prevent us from feeling that we are making progress against the sources of the pressure.

When you try to use willpower to shut out distractions such as social media, you are pitting yourself against an army of our generation's greatest minds. They are focused relentlessly on how to exploit what Facebook's founding President Sean Parker calls "vulnerability in human psychology" to steal a slice of your attention. When it comes to distraction, structure beats willpower every time.

Several leaders I've worked with in business have established periods during the day in which they turn off their laptop's Wi-Fi to focus. Others have created standing 30-minute sessions during which their team can pop in to clear questions and get direction. This has dramatically reduced the number of people asking, "Can I grab you for five minutes?" throughout the day.

Former Deloitte CEO Cathy Engelbert eliminated scheduling back-to-back meetings. Instead, she had her assistant leave 10-minute gaps for what she called SMORs - small moments of reflection. This quick break to recover meant she wasn't distracted at the end of meetings by what was coming up next or carrying the prior meeting into the current one.

In all of these instances, the solution isn't to become more efficient to accommodate more tasks, more decisions, and more distractions. The imperative is clear: simplify. Reduce the number of tasks you take on, replace decisions with principles, and put structure in place to eliminate distractions.

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A major source of stress for many is the pervasive feeling that there is never enough time. In response, many of us turn to time management. We try to squeeze hour-long meetings into half-hour sprints by being "more efficient" or we slot smaller tasks into gaps in our calendar to minimize unproductive time.

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We may be slowly returning to our offices (more or less), but the strains of the pandemic are hardly over. As we enter a transitional stage after a year of trauma and strain, more than ever we need ways to refresh our energies, calm our anxieties, and nurse our well-being. One potentially powerful intervention is rarely talked about in the workplace: The cultivation of experiences of awe. Like gratitude and curiosity, awe can leave us feeling inspired and energized. It's another tool in your toolkit and it's now attracting increased attention due to more rigorous research.

As a physician and a psychologist, we have facilitated hundreds of resilience and well-being workshops both before and during Covid for the military, physicians, educators, law enforcement, and in the business world. Helping participants to explore, experience, and recall moments of awe is one of the key scientifically supported strategies we engage in during our workshops and it's been rewarding to see our participants benefit and bring what they've learned to their own organizations.

Awe and Its Benefits

University of Michigan psychologist Ethan Kross defines awe as "the wonder we feel when we encounter something powerful that we can't easily explain." Often the things which bring us awe have an element of vastness and complexity. Think of a starry night sky, an act of great kindness, or the beauty of something small and intricate. During your workday the colors of the leaves outside your office or an act of sacrifice by a colleague could prompt a similar feeling - especially if you are attuned to it. In the United States and China especially, experiences of awe are frequently related to the virtuous behavior of others: an act of dedication, skill, or courage.

Cultivating experiences of awe is especially important and helpful now as we renew our energy and make plans for a more hopeful future. That's because beyond physical effects like tingling and goosebumps and a lowered heart rate under stress, awe also affects us emotionally. One experimental group, when asked to draw pictures of themselves, literally drew themselves smaller in size after having an awe experience. Such an effect has been termed " unselfing." This shift has big benefits: As you tap into something larger and your sense of self shrinks, so too do your mental chatter and your worries. At the same time, your desire to connect with and help others increases. People who experience awe also report higher levels of overall life satisfaction and well-being.

Let's look more closely at the effects on stress and resilience. Experiences of awe are associated with lowered levels of reported stress and recent experimental research suggests that this may be a causal relationship: That awe can actively help reduce stress. Recent research using fMRI has also shown that experiences of awe, such as watching awe-inspiring videos (compared to neutral or pleasant videos) decreases activity in the brain's default mode network (DMN), which is associated with self-focus and rumination. The result is decreased mental chatter.

Awe's benefits extend beyond stress relief, however. Research has shown that experiencing something bigger than us helps us transcend our frame of reference by expanding our mental models and stimulating new ways of thinking. This can increase creativity and innovation, and facilitate scientific thinking and ethical decision making.

It also helps us build relationships. Though feeling awe frequently happens in solitude, it draws us out of ourselves and toward others and inspires pro-social behavior like generosity and compassion. Some scientists theorize that it has evolved to aid group cohesion and provide survival advantages. For work groups experiences of awe can lead to increased collaboration, team building, and social connection.

There are many ways you can cultivate experiences of awe during the course of your workday.

For Individuals

A simple and powerful way to experience awe if you can step away from your desk is to take an " awe walk." Take twenty minutes to wander and be curious and observe the everyday beauty around you, even in a familiar place like your yard or neighborhood. In our workshops, this instruction helps people to notice others, as well as places and things they might typically rush past - a bee flitting from flower to flower, for example. Afterwards our participants report feeling inspired, calmer, and better able to focus.

Even better, take an awe-seeking walk in a natural landscape. Research shows that walks in nature, compared to urban environments, have a greater positive effect on our mood and well-being. Nature is an immersive experience of growth and resilience; it can be a powerful source of wonder and awe. Nature's rhythms also remind us that we are a part of the natural world, and we too are enduring. A CEO of a Michigan technology company one of us (David) has collaborated with schedules frequent bike rides through a landscape of trees and water. Doing so, he feels a part of something larger than himself as well as a boost to his energy and resilience.

If you can't step away from your desk, take advantage of the wonders at your fingertips on the web. Several studies have shown that videos can stimulate awe. Perhaps you're inspired by award-winning documentaries such as , , or the recent Oscar winner My Octopus Teacher. Let Amanda Gorman's "The Hill We Climb" give you goosebumps. The harmony and complexity of music can also elevate and inspire awe. Create your own personal "awe playlist" of videos or music and when you're feeling stuck spend a few minutes being drawn into what you're seeing and hearing. You can also invite moments of awe by asking the simple question "What's beautiful here?"

Another option is to tune into news sites that spread good news - acts of kindness, generosity, and perseverance. Keep a file on your computer of stories of the goodness, benevolence, and decency of the human race. Tap it when you are feeling overwhelmed or depleted and want to be elevated. A simple story of one person making a difference can inspire others around the world.

For Managers and Teams

If you're a manager, you can leverage the power of awe to help your team with its energy and resilience and to provide empathy and emotional support. Encourage your team members to share their awe playlists and create opportunities to share experiences of awe by starting meetings with questions like "What took your breath away this week?" or "What made you glad you're on this planet?" (Contribute your own stories too, and share their impact on you.) In work one of us (Karen) has done with The Oklahoma City Thunder, leaders asked teams to bring personal photos that sparked awe and gratitude. At a team meeting, the photos were projected, and each person spoke about their photo and experience. Meanwhile the health system where David works offers voluntary noontime resilience webinars featuring awe. Individuals from disparate departments who've never met come together and share stories of awe in small group zoom rooms. The positive energy after each of these events is evident and elevating.

Managers should watch out for several potential missteps when creating awe experiences for their teams, however. First, what stimulates awe in one person can stimulate feelings of threat or danger in another - if someone with a fear of heights is forced to look at a vertiginous view, for example. Know your team well enough to understand where to draw the line. Secondly, as you encourage your teams to experience awe, keep in mind that it's an addition and not a subtraction: Adding experiences of awe does not eliminate grief or anxiety; nor does it mitigate the need for teams to talk openly about the challenges they face and the support they need from leadership. It's normal and healthy to experience a full range of emotions, especially in highly challenging times. It's imperative that managers offer as much compassion and understanding as they can muster. Finally, don't mistake intimidation for awe: We're not talking about developing a cult of power around yourself as a leader - a very different approach which can do more harm than good.

We spend much of our time at work trying to stake our claim and make our voices heard. It can feel counterintuitive to engage in something that might stimulate feelings of "smallness." But doing so through a positive experience of awe can, in the end, bring us that sense of grounding we're searching for, along with a multitude of benefits - such as energy, inspiration, and resilience - for ourselves and for our teams.

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Why You Need to Protect Your Sense of Wonder - Especially Now

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We may be slowly returning to our offices (more or less), but the strains of the pandemic are hardly over. As we enter a transitional stage after a year of trauma and strain, more than ever we need ways to refresh our energies, calm our anxieties, and nurse our well-being.

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As a grad student juggling work, school, and serving as co-president of my student organization, I often get asked, "how do you do it?" To be honest, I'm never quite sure how to answer, so I decided to really dig deep and figure out how I am able to survive grad school while still managing to get 7 hours of sleep a night and eat three meals a day. I came up with these five effective ways I manage grad school, and how you can too!

Step 1: Treat It Like a Job

One of the pitfalls many graduate students get trapped in is having large amounts of free time and not managing that time properly. Many students may also work a part time job (like me), but still have days where they only have one class. One of the things that has helped me the most to succeed is to treat graduate school like a job, and stick to a schedule. Even on the days I'm not working in the office 9-5, I keep to the same schedule. I wake up every morning at the same time, and head to school even if I don't have work or class. I use that time to get my readings and school work done, so that I am not stuck reading until 12 a.m. By keeping to a regular schedule, I avoid sleeping in and losing out on time I could be working.

I sit down at the beginning of the week and look at what I have coming up. Once I have blocked off time for work, school, and other meetings and events, I am able to see where I can schedule in study time. Organization helps to reduce my anxiety about the things I need to get done, and helps me set the pace for each week.

Step 3: Break It Down

If you are in the humanities, like I am, you probably have loads of reading for each class. I get assigned around 500 pages + of reading a week. Instead of saving all of my readings for the day or two before class, I try and do a little bit each day. If I know I have 200 pages to read, I'll read 50 pages over four days. This can be applied to other disciplines as well! By setting smaller goals, the task at hand seems (and is) more manageable.

I also keep my work easily accessible on my iPad so that I can do readings on my lunch break or on the subway. The cloud is your best friend! This also goes for tasks outside of school! Don't head to Trader Joe's after work at the busiest time and waste two hours grocery shopping. Know when the best time for laundry, grocery shopping, etc. is, so that you can maximize your time!

Step 5: Self Care

Last but certainly not least, self care is key!! If you aren't taking care of yourself, you will not have enough energy for any other part of your life. I make sure to plan one super fun thing at least every other week, which helps get my mind out of school and work mode. I've done things around the city like attending a taping of The Late Show with Stephen Colbert and Jimmy Kimmel Live, seen a broadway play, and had game nights with friends. I also make sure to give myself a little time at home to catch up on my favorite shows and have a cup of tea!

It's so easy to get caught up in the chaos of graduate school and forget to breathe, take it easy, and take some time for yourself.

There you have it! By following these five steps you can both survive and thrive through graduate school!

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Grad Student How-To: Time Management & Juggling It all

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As a grad student juggling work, school, and serving as co-president of my student organization, I often get asked, "how do you do it?" To be honest, I'm never quite sure how to answer, so I decided to really dig deep and figure out how I am able to survive grad school while still managing to get 7 hours of sleep a night and eat three meals a day.

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1. What is the goal of my PhD in "leadership and education" as a health science professional?

2. How will my current knowledge and skill overlap with my professional learning needs?

3. How do these needs overlap with my (newish) employer needs? Will they see my PhD as a benefit?

4. How are my current methods meeting my learner needs? How and why does it vary by learner type?

5. What motivates and demotivates me as a student? WHY?

6. What motivates and/or demotivates me as an educator? WHY?

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Bedenkov, A., Rajadhyaksha, V., Beekman, M., Moreno, C., Fong, P. C., Agustin, L., & Odell, S. (2020). Developing Medical Affairs Leaders Who Create the Future. Pharmaceutical medicine, 34(5), 301–307. https://doi.org/10.1007/s40290-020-00351-y

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The medical affairs function in the pharmaceutical industry is evolving and modifying as a result of several drivers of change.

This may include areas such as evidence generation, interaction with stakeholders and channels of communication.

This will influence the healthcare and pharmaceutical industry to a greater extent in the future.

Specific capabilities require focus among medical affairs professionals to prepare them for the future.

There is a need to develop specialised programmes for the medical leaders of tomorrow.

Historical Context of Medical Affairs

Medical affairs has developed as an integral part of the pharmaceutical industry over the last 50 years, evolving from a support function to a reliable strategic partner. The evolution of medical affairs can be divided into two distinct phases [ 1, 2].

Phase I: Scientific Support to the Commercial Department

Historically, this role involved the provision of scientific and medical information to healthcare providers and medical governing bodies by reviewing and approving promotional messages and materials in line with guidelines and regulations. Other pivotal responsibilities included within this phase were the development and delivery of training for sales representatives to enhance their understanding of products and therapy areas, conducting Phase IV clinical trials and supporting investigator-initiated trials.

Phase II: A Reliable Partner to the Organisation

The increasing complexities of drug development, discovery of new targets, emergence of personalised medicines, regulatory changes regarding the relationship between industry and physicians, and shifting expectations of different stakeholders have all contributed to the establishment of this phase. By partnering with medical societies to cascade the latest data, scientific communication with respected medical and scientific experts became an integral part of the responsibilities of this role. The emergence of medical science liaisons opened up opportunities for obtaining crucial medical insights and leveraging these to develop organisational strategies.

Over the last several years, the nature of new products has changed and the science underpinning the products has become more complex. To address this, medical affairs teams started to partner during launch preparation-this included raising awareness of the condition, setting up diagnostic facilities, building healthcare capabilities, and ensuring access to medicines. Additionally, collaborating with market access teams to develop evidence that supported access submissions, both in the pre-launch and post-launch phases, particularly in specialised care, became vital responsibilities. All of these responsibilities are the foundation and continuing basis of medical affairs, which are consistently evolving within the changing environment (Fig. 1).

Evolution of medical affairs function

Healthcare, Pharmaceutical Industry and Medical Affairs Environments in the Future

In 1963, Dennis Gabor, a Nobel laureate in physics-most notable for inventing holography-wrote in his book Inventing the Future: "The future cannot be predicted, but futures can be invented. It was man's ability to invent which has made human society what it is" [ 3]. Healthcare evolution is moving hand in hand with technological innovation that is driven by disruptive technologies (Fig. 2).

Healthcare, pharmaceutical industry and medical affairs environment in the future

Healthcare

Healthcare is finally being designed around people and patients, and the future will bring even more integration. Everything from diagnosis to drugs to devices will be custom designed to seamlessly integrate into a patient's daily life. Digital health technologies, such as wearables, will be at the forefront. Healthcare practice will be digitalised and decentralised; healthcare practitioners will have improved connectivity and miniaturised diagnostic technology to ensure accessibility and convenience for future medical consultations. Medical robots and artificial intelligence (AI) will create more efficient healthcare platforms, powered by the insights of data analytics. Genetic information will be readily available to physicians, facilitating tailored and personalised healthcare decisions for every patient. Technology will address privacy concerns. Healthcare services will be utilised continuously, leading to a subscription-based business model, as one option that focuses on high productivity and asset-light strategies [ 4]. Healthcare will be integrated and outcomes based.

The impending revolution predicted within the realm of healthcare has taken root in the current era. Richard Watson and the Tech Foresight team at Imperial College London suggested a table of disruptive technologies with a timeline (now, new, and distant future) specific to different industries. This consists of 100 potentially disruptive technologies capable of significant social, economic, or political upheaval. Some of these technologies, such as robotic companions, intention decoding algorithms, or delivery robots, are currently emerging. It is clear that most, if not all of them, irrespective of the industries they represent, will change the healthcare model and delivery. Hence, disruptors should promptly start integrating and executing these technologies [ 5, 6].

Despite the great strides in technology, human interaction will remain vital within the healthcare environment. This trust between humans will be crucial, especially when patients have to make life-altering decisions. There is no doubt that shared decision-making, where patients play a more central role in deciding on solutions based on all the data presented, will be critical. People will be inclined to engage in interactions with physicians to discuss data and information from various technologies (such as wearables on vital signs, household air quality monitors for allergens, sleep pattern analyses from smart mattresses, and stress level assessments from contact lenses) that have synchronised into a universal healthcare database.

With the rapid evolution of healthcare and technology, some jobs may cease to exist and new jobs, such as data-based medical diagnostics experts, genetics coaches, precision medicine compounding pharmacists, and health finances planners, will evolve in the future, warranting new approaches, capabilities, and training for the next-generation workforce [ 7, 8]. As a result, jobs within healthcare will require new leadership profiles, skills, and capabilities from medical affairs and the pharmaceutical industry.

Pharmaceutical Industry

To navigate developing healthcare trends, it is imperative that pharmaceutical industry change their model through partnerships-completing the transition from 'pill' to a 'platform' company-to holistically streamline and improve the patient experience. The model of the future would inherently connect awareness, prevention, early detection and diagnosis, and post-treatment well-being, while at the same time, to shape the future workforce it is important to focus on the following four areas: (1) patient-centricity that shifts its outlook from products to patients; (2) data analytics that effectively leverage omnichannel data to better identify, develop, and market new medicines; (3) social listening competencies that facilitate understanding of human behaviour; and (4) deep learning technologies with applications on range of devices that support understanding and effectively execute programmes on disease management and compliance to treatment [ 9, 10].

The pharmaceutical industry of the future will continue to develop new ways to diagnose, treat, and cure a wide range of diseases. With the increasing costs required to develop innovative medicines that have a competitive edge compared with their competitors, the ability to tailor treatments to patients, with high precision, will be imperative, not only to physicians but also to payers. Innovation will move at an increasingly high speed, making internalising new capabilities a luxury the industry cannot afford and forcing cross-industry collaboration to become the norm. Creative solutions to support precision medicine with new technologies, e.g. high-tech contact lenses, smart toilets, implantable sensors will need to be developed [ 9, 10]. Risk and compliance savviness will be a newly required capability as the willingness to take the right risks will be just as important as avoiding the wrong ones [ 11].

Medical Affairs

The future of medical affairs will be largely influenced by the healthcare space; however, the medical affairs function itself still has the potential to modify the pharmaceutical industry and healthcare. It is predicted that the following are three main areas where medical affairs will lead [ 12, 13, 14, 15].

Partnerships with a Broad Range of Internal and External Stakeholders, Incorporating Patient-Centric Healthcare

Medical affairs will partner with physicians, pharmacists, access providers, diagnostics groups, insurance providers, patients and patient advocacy groups, tech companies, and entrepreneurs, as well as the general community, to enhance patient-centric healthcare. Medical affairs professionals would build a network with these partners and create a sustainable ecosystem, where patient centricity and demonstration of the real value of medicines and treatment options are paramount. Medical teams would also develop sophisticated systems and tools to track and assess the impact of healthcare interventions. Additionally, medical affairs would play a role in enhancing the knowledge of patients and advocacy groups, thus helping them to gain a greater visibility and voice in decision making.

Embracing Innovation in Data Generation

Future medical affairs teams, through their thorough understanding of science and data capabilities, as well as their dialogue with stakeholders, will be well positioned to understand the generation of evidence required to support the entire product lifecycle, to optimise patient outcomes. In the era of digitalisation, medical affairs will be able to use data analytics and complex tools for creating big data, incorporating AI techniques, and building cloud-based platforms to enhance data collection, even in community settings and stand-alone clinics. The data collected will further help to improve understanding of healthcare issues, support the right decision making, and shape health policy in the long term. Furthermore, medical affairs will be responsible for taking ownership of evidence planning and generation in the digital age.

Demonstrating Value for Novel Treatment Options

With profound insights on healthcare professionals and patient needs, medical affairs will be one of the key stakeholders driving the organisational strategies to develop and deliver people-centric healthcare solutions. Medical affairs will play a key role in demonstrating clinical and economic value to make medicines an option for patients and will focus on key aspects of value that are more pertinent to a specific stakeholder, e.g. out-of-pocket for patients, reimbursement for payers. Medical teams will ensure a broad strategy to maximise benefits to physicians and patients, and ensure that cost effectiveness and comparative efficacy data are available at the launch of a product. Thus, the rapid evolution of medical affairs is transitioning to an integrated strategic role within the organisation, focused on improving patient experiences and outcomes [ 16].

Drivers of Change

Three main drivers of change may influence medical affairs. The first involves increased expectations from a broader set of stakeholders, including physicians, payers, patients, caregivers, and the community. An increased awareness and empowerment, the nature of new treatment modalities (particularly in specialty care), and the new models of healthcare delivery are central to this change. The second driver is the rapid advancement in technology and the interest of digital giants and start-up companies within the future healthcare ecosystem. An increasing number of stakeholders involved in a strong patient-oriented environment will also drastically change the capabilities required for medical affairs to successfully manoeuvre among a diverse group of both internal and external partners, while providing smart and practical, yet innovative, solutions that satisfy everyone's needs. Medical affairs will not only need to be good in the core functionalities but also savvy in the digital and innovation space, while having the capabilities to manage a wide range of new stakeholders. The third driver of change is the desire to change and meet patient needs in the future.

Medical Affairs-Capabilities, Skills, and Experiences Needed for the New Environment

With the emergence of additional stakeholders, the healthcare environment will involve more complexities. Large technology companies such as Google, Amazon, and Apple are entering the healthcare space and offering healthcare solutions directly to patients. Patients will thus gain increased access to their electronic healthcare records and be more empowered to make decisions [ 17].

In 2020, the COVID-19 pandemic provided an opportunity for the pharmaceutical industry to demonstrate its societal value in the race to bring new treatments and vaccines to patients globally. However, will this recent trend of a more positive perception expand the horizons of the pharmaceutical industry in terms of new opportunities for collaborating outside of the usual stakeholders? The medical team of the future will need to think about how to broaden its influence across the healthcare community and society as a whole. Some of the key capabilities that need to be developed are provided in Fig. 3.

The seven key capabilities for driving the future of medical affairs

Communications and Behavioural Change

Translating evidence into the right scientific narratives meeting the needs of all stakeholders to make the right choice when selecting the most appropriate medication remains a core capability of medical affairs. However, with the changing environment, the right choice would include the whole patient ecosystem, thus impacting the role of medical affairs and therefore the capabilities of its practitioners.

Business Leadership, Including Novel Leadership in Partnerships

Fostering stronger partnerships across the healthcare ecosystem, especially with government agencies, health authorities, start-ups, and technology companies, is key within the new environment. This means that medical affairs professionals need to have an intrinsic passion to collaborate with partners and need to take the role of the 'conductor of the orchestra': shape the project, execute in the best possible way, listen critically, and synergise with stakeholders to interpret concepts accurately. This will require excellent skills in team building, leadership, and application of emotional intelligence to execute and deliver a project seamlessly.

Knowledge Acquisition and Self-Development

Another critical capability for our future leaders is the ability to role model growth mindset, innovation, openness, and continuous learning. To be able to meet the needs of a constantly evolving healthcare system, medical leaders must be able to take current knowledge and adapt it for future use, both within and outside the medical arena.

Generating High-Quality Evidence from Real-World Insights (Health Economics, Payer, and Real-World Evidence)

Evidence generation has become an increasingly important part of medical affairs-filling the gaps that appear from early discussions with experts, payers, and patients on new medicines. Many companies are in the process of building this capability, but they need to escalate development due to the rapid evolution in data analytics, big data, and AI.

Data Science and Analytics Expertise

Robust capabilities in data analytics need to be built to ensure that medical affairs accelerate data generation and further help patients, physicians, and payers to make the right choice for the right medication. The medical leader of the future will need to learn how to work with data scientists who will build and drive medical insights, generate data using advanced digital methodologies, and provide the healthcare community as a whole with impactful medical insights (Fig. 3).

iStep Up to Leadership

To ensure that the right 'person' is recruited and developed within medical affairs (which encompasses the capabilities, skills and experience discussed within this article), an ecosystem of sustainable development interventions centred around our flagship development programme, iStep Up to Leadership, has been designed. These interventions not only look to develop the capabilities, skills, and experiences of the medical leadership community, but also to inspire and engage. This programme is specifically developed for medical affairs leaders who are potential candidates for a Medical Director role in the future and the entire programme has been designed to develop the future Medical Directors; hence this is a very specialised programme compared to other leadership programmes internally and possibly externally. Fundamentally, these activities aim to accelerate talent from across the international community so that future global medical leaders are created.

The development activity is planned around the 3E framework: Education, Experience, Exposure. Through collaboration with medical affairs leaders, human resources, local markets, and external organisations, the aim is to drive a culture of lifelong learning by providing knowledge acquisition opportunities and empowering employees to own their development through education and experience with stretch assignments and secondments, as well as exposure to senior leaders.

iStep Up to Leadership, a 1-year intervention, combines individual development with group experience to build sponsorship and networks across the organisation. The experience is bespoke to each individual leader, identifying, at the beginning of the programme through psychometric assessment and experience analysis, the specific capabilities and skills requiring focus for learning. Once the development needs are identified, individuals are assigned a programme mentor to guide them through their learning journey. The mentors are hand-picked from the most experienced international medical leaders; to ensure suitability, the mentors and mentees are matched based on the development needs of the participants, who are then exposed to a series of group and individual learning events. These include technical and leadership modules from external and internal experts, and interactive peer-sharing sessions, during which participants support each other's learning and development by sharing their own experiences, knowledge and best practices in areas including compliance, patient centricity, leading through change, and digital innovation. Finally, to provide a view on the future of medical affairs and its role therein, a partnership with a leading management consultancy has been established to produce the latest innovative medical techniques and industry insights, with the focus firmly on the future of healthcare.

iStep Up to Leadership provides access to knowledge, senior leaders, industry-leading experts, and most critically, each other, forming a community within which everyone can continue to learn and grow. Life-long learning, which not only involved adaptation to the changing environment but also anticipation of future changes in the healthcare ecosystem, allows for the development of best-in-class medical leaders for the future, who will, in turn, inspire the next generation.

Conclusions

To conclude, medical affairs has now become a strategic function within the pharmaceutical industry-evolving from a support to a partner to a leadership role. Current and evolving changes within the healthcare and pharmaceutical industries, often influenced by technological advances, affect the function and, possibly, structure of medical affairs. As medical affairs embraces the changing scenario, it needs to build in new technical, as well as leadership, capabilities. It is our responsibility to create that foundation in order for the next generation of medical affairs leaders to develop, thrive, and succeed, and propel medical affairs into the next evolutionary phase. It is obvious that medical affairs that is designed for the twentieth century will be eclipsed by the coming era of patient-centric healthcare.

Author information

Affiliations

1. AstraZeneca Medical, International Region, Horizon Place, 600 Capability Green, Luton, LU3 1LU, UK

Alexander Bedenkov, Viraj Rajadhyaksha, Maarten Beekman, Carmen Moreno, Pei-Chieh Fong & Lyra Agustin

2. AstraZeneca Human Resources, International Region, Cambridge, UK

Sarah Odell

Corresponding author

Correspondence to Viraj Rajadhyaksha.

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Funding

No funding has been received for this manuscript. The open access fee was paid by AstraZeneca.

Conflict of interest

All authors are permanent employees of AstraZeneca. The thoughts and statements expressed within this article are written in the capacity of medical affairs professionals and not as AstraZeneca employees. The opinions expressed in this article are those of the authors and not necessarily those of AstraZeneca.

Availability of Data and Material

Not applicable.

Ethics Approval

Not applicable.

Consent

Not applicable.

Code Availability

Not applicable.

Author Contributions

All authors have written the paper together with each one being given the responsibility to write a section and then discuss amongst the team to arrive to a final version. Everyone has read and approved the final version of the submitted paper.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.
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Bedenkov, A., Rajadhyaksha, V., Beekman, M. et al. Developing Medical Affairs Leaders Who Create the Future. Pharm Med 34, 301-307 (2020). https://doi.org/10.1007/s40290-020-00351-y
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# data[].attributes.attachment_link.title
Developing Medical Affairs Leaders Who Create the Future - Pharmaceutical Medicine

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Medical affairs has evolved over recent years from a support, to a partner, to a strategic leadership function. In the future, there will be significant changes in healthcare and pharmaceutical industries, and many of these will be due to technological advances and digitalisation.

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Daniel, M., Rencic, J., Durning, S. J., Holmboe, E., Santen, S. A., Lang, V., Ratcliffe, T., Gordon, D., Heist, B., Lubarsky, S., Estrada, C. A., Ballard, T., Artino, A. R., Jr, Sergio Da Silva, A., Cleary, T., Stojan, J., & Gruppen, L. D. (2019). Clinical Reasoning Assessment Methods: A Scoping Review and Practical Guidance. Academic medicine : journal of the Association of American Medical Colleges, 94(6), 902–912. https://doi.org/10.1097/ACM.0000000000002618

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Clinical Reasoning Assessment Methods: A Scoping Review and ... : Academic Medicine

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e practice. A scoping review was performed to explore the existing menu of CR assessments. Method Multiple databases were searched from their inception to 2016 following PRISMA guidelines. Articles of all study design types were included if they studied a CR assessment method. The articles were s…

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Medicine, Industry, & Continuing Education - Balance

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Medicine, Industry, & Continuing Education - Balance

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Kearney, P., Simoons, M., Ryden, L., Kirchhof, P., Pries, A., O'Morain, C., & Bax, J. J. (2019). The Medical Profession, Industry, and Continuing Medical Education: Finding the Balance That's Right for Patients. The American journal of medicine, 132(8), 921–925. https://doi.org/10.1016/j.amjmed.2019.02.026

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Abstract

Provision and participation in formal external continuing medical education (CME) is costly. Employer or state support of CME is the exception rather than the rule. The medical industry has supported both providers and consumers of educational activities, leading to concerns of commercial bias. Recent medical industry initiatives in Europe to improve the transparency of the relationship between industry and the profession, including the field of medical education, have had the paradoxical effect of the industry playing an increasingly direct role in the provision of physician education. Funding of medical professional society annual congresses has been directly and indirectly jeopardized. Acknowledging that there are areas of cooperation in the field of education between the medical profession and the medical industry from which both can benefit, we argue that medical education requires an objective approach that the primary fiduciary duty of medical industry companies precludes. Medical professional societies, as not-for-profit organizations whose core mission is the development and promotion of best practice, are best placed to guide and deliver medical education to their members.

Section snippets

Clinical Significance

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Maintaining knowledge and skills requires continuous and unbiased medical education.

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Accreditation systems have been devised to avoid bias in cases of industry support of continuing medical education (CME).

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Medical professional societies are central to provision of unbiased CME at international level.

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The collaboration between the medical professional societies and the medical industry in the field of education involves inevitable challenges as well as important opportunities.

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The future lies in

Role of Professional Medical Societies

Doctors seek knowledge in a wide variety of ways. Medical journals, medical websites, or other digital resources (social networks, dedicated blogs) and, to a lesser extent, textbooks are used for self-learning. Learning in practice, small group educational meetings, multidisciplinary discussions (both formal and informal), and interactive workshops, in particular, have been shown to be effective.6., 7. Large meetings including national and international symposia and specialty congresses remain

Role of the Medical Industry

The medical industry plays a key role in the development of novel technologies, devices, and medications, in close collaboration with clinical scientists and physicians. There is a regulatory requirement for the industry to ensure safe use of its pharmaceutical products ⁹ and devices. ¹⁰ These requirements mandate a certain level of training in the safe and effective use of products. Procedural training in the use of complex devices is frequently device specific and focused on correct application

Greater Industry Engagement in Education and its Impact

Some commentators view any industry involvement in medical education of physicians as unacceptable, ¹³ while others take a more nuanced and pragmatic view.14., 15. Concerns relating to the introduction of bias in physician education and wider concerns about the interaction of industry and medical professionals has led to regulation. This includes the Sunshine Act in the United States and "soft legislation" produced by the European Commission in 2012 when the List of Guiding Principles Promoting

Proposals for the Future of Continuing Medical Education

Development and delivery of CME by medical professional societies is an expensive undertaking. It is made possible by the input of volunteer professional members as developers, guideline writers, organizers, and faculty; by membership fees; and, to a significant degree, industry financial support. A small proportion of the funding of CME comes from statutory bodies, tax relief, or health care and academic institutions. Recent developments of diminishing financial sponsorship and a growing move

AcknowledgmenTS

The following collaborators are acknowledged for their contributions to the manuscript:

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Prof Gunhild Waldemar, MD, DMSc (Board member - Alliance for Biomedical Research in Europe)

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Michel Ballieu (Executive Director - Alliance for Biomedical Research in Europe)

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Prof Peter Hellings, MD, PhD (Secretary General - European Academy of Allergy and Clinical Immunology)

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Prof David B. Vodušek, MD, PhD, FEAN (Chair of Communication Committee - European Academy of Neurology)

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Eveline Sipido (EU Liaison officer -

European Commission
Study concerning the review and mapping of continuous professional development and lifelong learning for health professionals in the EU: Final Report

Union Européenne des Médecins Spécialistes-European Accreditation Council for CME (UEMS-EACCME)
EACCME criteria for the accreditation of live education events

Royal College of Physicians of Ireland
Industry sponsorship and support

Royal College of Physicians of Ireland
Guide to approval of events for continuing professional development (CPD)

Royal College of Physicians
Provide a CPD event

Continuing education meetings and workshops: effects on professional practice and health care outcomes

Cochrane Database Syst Rev

Helping European cardiologists keep up to date. PMLiVE 22nd June 2015

Regulation (EC) No 726/2004 of the European Parliament and of the Council of 31 March 2004 laying down Community procedures for the authorisation and supervision of medicinal products for human and veterinary use and establishing a European Medicines Agency (Consolidated version: June 5, 2013)

There are more references available in the full text version of this article.

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200 HIV-infected patients evaluated: 171 (86%) males with a median age of 48.1 (42.3-53.8) years and 10.6 (4.3-13.6) years of HAART exposure.

DCI was 889 (589-1308) mg/day and 79 (40%) patients had an optimal DCI. Framingham risk>20% was found in 13 (6.7%) patients and femoral OP was diagnosed in 12 (6%) pts.

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# data[].attributes.attachment_link.title
The Medical Profession, Industry, and Continuing Medical Education: Finding the Balance That's Right for Patients

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Provision and participation in formal external continuing medical education (CME) is costly. Employer or state support of CME is the exception rather than the rule. The medical industry has supported both providers and consumers of educational activities, leading to concerns of commercial bias.

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Continuing Ed - Healthcare Professionals

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Continuing Ed - Healthcare Professionals

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Bedenkov, A., Rajadhyaksha, V., Beekman, M., Moreno, C., Fong, P. C., Agustin, L., & Odell, S. (2020). Developing Medical Affairs Leaders Who Create the Future. Pharmaceutical medicine, 34(5), 301–307. https://doi.org/10.1007/s40290-020-00351-y

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The medical affairs function in the pharmaceutical industry is evolving and modifying as a result of several drivers of change.

This may include areas such as evidence generation, interaction with stakeholders and channels of communication.

This will influence the healthcare and pharmaceutical industry to a greater extent in the future.

Specific capabilities require focus among medical affairs professionals to prepare them for the future.

There is a need to develop specialised programmes for the medical leaders of tomorrow.

Historical Context of Medical Affairs

Medical affairs has developed as an integral part of the pharmaceutical industry over the last 50 years, evolving from a support function to a reliable strategic partner. The evolution of medical affairs can be divided into two distinct phases [ 1, 2].

Phase I: Scientific Support to the Commercial Department

Historically, this role involved the provision of scientific and medical information to healthcare providers and medical governing bodies by reviewing and approving promotional messages and materials in line with guidelines and regulations. Other pivotal responsibilities included within this phase were the development and delivery of training for sales representatives to enhance their understanding of products and therapy areas, conducting Phase IV clinical trials and supporting investigator-initiated trials.

Phase II: A Reliable Partner to the Organisation

The increasing complexities of drug development, discovery of new targets, emergence of personalised medicines, regulatory changes regarding the relationship between industry and physicians, and shifting expectations of different stakeholders have all contributed to the establishment of this phase. By partnering with medical societies to cascade the latest data, scientific communication with respected medical and scientific experts became an integral part of the responsibilities of this role. The emergence of medical science liaisons opened up opportunities for obtaining crucial medical insights and leveraging these to develop organisational strategies.

Over the last several years, the nature of new products has changed and the science underpinning the products has become more complex. To address this, medical affairs teams started to partner during launch preparation-this included raising awareness of the condition, setting up diagnostic facilities, building healthcare capabilities, and ensuring access to medicines. Additionally, collaborating with market access teams to develop evidence that supported access submissions, both in the pre-launch and post-launch phases, particularly in specialised care, became vital responsibilities. All of these responsibilities are the foundation and continuing basis of medical affairs, which are consistently evolving within the changing environment (Fig. 1).

Evolution of medical affairs function

Healthcare, Pharmaceutical Industry and Medical Affairs Environments in the Future

In 1963, Dennis Gabor, a Nobel laureate in physics-most notable for inventing holography-wrote in his book Inventing the Future: "The future cannot be predicted, but futures can be invented. It was man's ability to invent which has made human society what it is" [ 3]. Healthcare evolution is moving hand in hand with technological innovation that is driven by disruptive technologies (Fig. 2).

Healthcare, pharmaceutical industry and medical affairs environment in the future

Healthcare

Healthcare is finally being designed around people and patients, and the future will bring even more integration. Everything from diagnosis to drugs to devices will be custom designed to seamlessly integrate into a patient's daily life. Digital health technologies, such as wearables, will be at the forefront. Healthcare practice will be digitalised and decentralised; healthcare practitioners will have improved connectivity and miniaturised diagnostic technology to ensure accessibility and convenience for future medical consultations. Medical robots and artificial intelligence (AI) will create more efficient healthcare platforms, powered by the insights of data analytics. Genetic information will be readily available to physicians, facilitating tailored and personalised healthcare decisions for every patient. Technology will address privacy concerns. Healthcare services will be utilised continuously, leading to a subscription-based business model, as one option that focuses on high productivity and asset-light strategies [ 4]. Healthcare will be integrated and outcomes based.

The impending revolution predicted within the realm of healthcare has taken root in the current era. Richard Watson and the Tech Foresight team at Imperial College London suggested a table of disruptive technologies with a timeline (now, new, and distant future) specific to different industries. This consists of 100 potentially disruptive technologies capable of significant social, economic, or political upheaval. Some of these technologies, such as robotic companions, intention decoding algorithms, or delivery robots, are currently emerging. It is clear that most, if not all of them, irrespective of the industries they represent, will change the healthcare model and delivery. Hence, disruptors should promptly start integrating and executing these technologies [ 5, 6].

Despite the great strides in technology, human interaction will remain vital within the healthcare environment. This trust between humans will be crucial, especially when patients have to make life-altering decisions. There is no doubt that shared decision-making, where patients play a more central role in deciding on solutions based on all the data presented, will be critical. People will be inclined to engage in interactions with physicians to discuss data and information from various technologies (such as wearables on vital signs, household air quality monitors for allergens, sleep pattern analyses from smart mattresses, and stress level assessments from contact lenses) that have synchronised into a universal healthcare database.

With the rapid evolution of healthcare and technology, some jobs may cease to exist and new jobs, such as data-based medical diagnostics experts, genetics coaches, precision medicine compounding pharmacists, and health finances planners, will evolve in the future, warranting new approaches, capabilities, and training for the next-generation workforce [ 7, 8]. As a result, jobs within healthcare will require new leadership profiles, skills, and capabilities from medical affairs and the pharmaceutical industry.

Pharmaceutical Industry

To navigate developing healthcare trends, it is imperative that pharmaceutical industry change their model through partnerships-completing the transition from 'pill' to a 'platform' company-to holistically streamline and improve the patient experience. The model of the future would inherently connect awareness, prevention, early detection and diagnosis, and post-treatment well-being, while at the same time, to shape the future workforce it is important to focus on the following four areas: (1) patient-centricity that shifts its outlook from products to patients; (2) data analytics that effectively leverage omnichannel data to better identify, develop, and market new medicines; (3) social listening competencies that facilitate understanding of human behaviour; and (4) deep learning technologies with applications on range of devices that support understanding and effectively execute programmes on disease management and compliance to treatment [ 9, 10].

The pharmaceutical industry of the future will continue to develop new ways to diagnose, treat, and cure a wide range of diseases. With the increasing costs required to develop innovative medicines that have a competitive edge compared with their competitors, the ability to tailor treatments to patients, with high precision, will be imperative, not only to physicians but also to payers. Innovation will move at an increasingly high speed, making internalising new capabilities a luxury the industry cannot afford and forcing cross-industry collaboration to become the norm. Creative solutions to support precision medicine with new technologies, e.g. high-tech contact lenses, smart toilets, implantable sensors will need to be developed [ 9, 10]. Risk and compliance savviness will be a newly required capability as the willingness to take the right risks will be just as important as avoiding the wrong ones [ 11].

Medical Affairs

The future of medical affairs will be largely influenced by the healthcare space; however, the medical affairs function itself still has the potential to modify the pharmaceutical industry and healthcare. It is predicted that the following are three main areas where medical affairs will lead [ 12, 13, 14, 15].

Partnerships with a Broad Range of Internal and External Stakeholders, Incorporating Patient-Centric Healthcare

Medical affairs will partner with physicians, pharmacists, access providers, diagnostics groups, insurance providers, patients and patient advocacy groups, tech companies, and entrepreneurs, as well as the general community, to enhance patient-centric healthcare. Medical affairs professionals would build a network with these partners and create a sustainable ecosystem, where patient centricity and demonstration of the real value of medicines and treatment options are paramount. Medical teams would also develop sophisticated systems and tools to track and assess the impact of healthcare interventions. Additionally, medical affairs would play a role in enhancing the knowledge of patients and advocacy groups, thus helping them to gain a greater visibility and voice in decision making.

Embracing Innovation in Data Generation

Future medical affairs teams, through their thorough understanding of science and data capabilities, as well as their dialogue with stakeholders, will be well positioned to understand the generation of evidence required to support the entire product lifecycle, to optimise patient outcomes. In the era of digitalisation, medical affairs will be able to use data analytics and complex tools for creating big data, incorporating AI techniques, and building cloud-based platforms to enhance data collection, even in community settings and stand-alone clinics. The data collected will further help to improve understanding of healthcare issues, support the right decision making, and shape health policy in the long term. Furthermore, medical affairs will be responsible for taking ownership of evidence planning and generation in the digital age.

Demonstrating Value for Novel Treatment Options

With profound insights on healthcare professionals and patient needs, medical affairs will be one of the key stakeholders driving the organisational strategies to develop and deliver people-centric healthcare solutions. Medical affairs will play a key role in demonstrating clinical and economic value to make medicines an option for patients and will focus on key aspects of value that are more pertinent to a specific stakeholder, e.g. out-of-pocket for patients, reimbursement for payers. Medical teams will ensure a broad strategy to maximise benefits to physicians and patients, and ensure that cost effectiveness and comparative efficacy data are available at the launch of a product. Thus, the rapid evolution of medical affairs is transitioning to an integrated strategic role within the organisation, focused on improving patient experiences and outcomes [ 16].

Drivers of Change

Three main drivers of change may influence medical affairs. The first involves increased expectations from a broader set of stakeholders, including physicians, payers, patients, caregivers, and the community. An increased awareness and empowerment, the nature of new treatment modalities (particularly in specialty care), and the new models of healthcare delivery are central to this change. The second driver is the rapid advancement in technology and the interest of digital giants and start-up companies within the future healthcare ecosystem. An increasing number of stakeholders involved in a strong patient-oriented environment will also drastically change the capabilities required for medical affairs to successfully manoeuvre among a diverse group of both internal and external partners, while providing smart and practical, yet innovative, solutions that satisfy everyone's needs. Medical affairs will not only need to be good in the core functionalities but also savvy in the digital and innovation space, while having the capabilities to manage a wide range of new stakeholders. The third driver of change is the desire to change and meet patient needs in the future.

Medical Affairs-Capabilities, Skills, and Experiences Needed for the New Environment

With the emergence of additional stakeholders, the healthcare environment will involve more complexities. Large technology companies such as Google, Amazon, and Apple are entering the healthcare space and offering healthcare solutions directly to patients. Patients will thus gain increased access to their electronic healthcare records and be more empowered to make decisions [ 17].

In 2020, the COVID-19 pandemic provided an opportunity for the pharmaceutical industry to demonstrate its societal value in the race to bring new treatments and vaccines to patients globally. However, will this recent trend of a more positive perception expand the horizons of the pharmaceutical industry in terms of new opportunities for collaborating outside of the usual stakeholders? The medical team of the future will need to think about how to broaden its influence across the healthcare community and society as a whole. Some of the key capabilities that need to be developed are provided in Fig. 3.

The seven key capabilities for driving the future of medical affairs

Communications and Behavioural Change

Translating evidence into the right scientific narratives meeting the needs of all stakeholders to make the right choice when selecting the most appropriate medication remains a core capability of medical affairs. However, with the changing environment, the right choice would include the whole patient ecosystem, thus impacting the role of medical affairs and therefore the capabilities of its practitioners.

Business Leadership, Including Novel Leadership in Partnerships

Fostering stronger partnerships across the healthcare ecosystem, especially with government agencies, health authorities, start-ups, and technology companies, is key within the new environment. This means that medical affairs professionals need to have an intrinsic passion to collaborate with partners and need to take the role of the 'conductor of the orchestra': shape the project, execute in the best possible way, listen critically, and synergise with stakeholders to interpret concepts accurately. This will require excellent skills in team building, leadership, and application of emotional intelligence to execute and deliver a project seamlessly.

Knowledge Acquisition and Self-Development

Another critical capability for our future leaders is the ability to role model growth mindset, innovation, openness, and continuous learning. To be able to meet the needs of a constantly evolving healthcare system, medical leaders must be able to take current knowledge and adapt it for future use, both within and outside the medical arena.

Generating High-Quality Evidence from Real-World Insights (Health Economics, Payer, and Real-World Evidence)

Evidence generation has become an increasingly important part of medical affairs-filling the gaps that appear from early discussions with experts, payers, and patients on new medicines. Many companies are in the process of building this capability, but they need to escalate development due to the rapid evolution in data analytics, big data, and AI.

Data Science and Analytics Expertise

Robust capabilities in data analytics need to be built to ensure that medical affairs accelerate data generation and further help patients, physicians, and payers to make the right choice for the right medication. The medical leader of the future will need to learn how to work with data scientists who will build and drive medical insights, generate data using advanced digital methodologies, and provide the healthcare community as a whole with impactful medical insights (Fig. 3).

iStep Up to Leadership

To ensure that the right 'person' is recruited and developed within medical affairs (which encompasses the capabilities, skills and experience discussed within this article), an ecosystem of sustainable development interventions centred around our flagship development programme, iStep Up to Leadership, has been designed. These interventions not only look to develop the capabilities, skills, and experiences of the medical leadership community, but also to inspire and engage. This programme is specifically developed for medical affairs leaders who are potential candidates for a Medical Director role in the future and the entire programme has been designed to develop the future Medical Directors; hence this is a very specialised programme compared to other leadership programmes internally and possibly externally. Fundamentally, these activities aim to accelerate talent from across the international community so that future global medical leaders are created.

The development activity is planned around the 3E framework: Education, Experience, Exposure. Through collaboration with medical affairs leaders, human resources, local markets, and external organisations, the aim is to drive a culture of lifelong learning by providing knowledge acquisition opportunities and empowering employees to own their development through education and experience with stretch assignments and secondments, as well as exposure to senior leaders.

iStep Up to Leadership, a 1-year intervention, combines individual development with group experience to build sponsorship and networks across the organisation. The experience is bespoke to each individual leader, identifying, at the beginning of the programme through psychometric assessment and experience analysis, the specific capabilities and skills requiring focus for learning. Once the development needs are identified, individuals are assigned a programme mentor to guide them through their learning journey. The mentors are hand-picked from the most experienced international medical leaders; to ensure suitability, the mentors and mentees are matched based on the development needs of the participants, who are then exposed to a series of group and individual learning events. These include technical and leadership modules from external and internal experts, and interactive peer-sharing sessions, during which participants support each other's learning and development by sharing their own experiences, knowledge and best practices in areas including compliance, patient centricity, leading through change, and digital innovation. Finally, to provide a view on the future of medical affairs and its role therein, a partnership with a leading management consultancy has been established to produce the latest innovative medical techniques and industry insights, with the focus firmly on the future of healthcare.

iStep Up to Leadership provides access to knowledge, senior leaders, industry-leading experts, and most critically, each other, forming a community within which everyone can continue to learn and grow. Life-long learning, which not only involved adaptation to the changing environment but also anticipation of future changes in the healthcare ecosystem, allows for the development of best-in-class medical leaders for the future, who will, in turn, inspire the next generation.

Conclusions

To conclude, medical affairs has now become a strategic function within the pharmaceutical industry-evolving from a support to a partner to a leadership role. Current and evolving changes within the healthcare and pharmaceutical industries, often influenced by technological advances, affect the function and, possibly, structure of medical affairs. As medical affairs embraces the changing scenario, it needs to build in new technical, as well as leadership, capabilities. It is our responsibility to create that foundation in order for the next generation of medical affairs leaders to develop, thrive, and succeed, and propel medical affairs into the next evolutionary phase. It is obvious that medical affairs that is designed for the twentieth century will be eclipsed by the coming era of patient-centric healthcare.

Author information

Affiliations

1. AstraZeneca Medical, International Region, Horizon Place, 600 Capability Green, Luton, LU3 1LU, UK

Alexander Bedenkov, Viraj Rajadhyaksha, Maarten Beekman, Carmen Moreno, Pei-Chieh Fong & Lyra Agustin

2. AstraZeneca Human Resources, International Region, Cambridge, UK

Sarah Odell

Corresponding author

Correspondence to Viraj Rajadhyaksha.

Ethics declarations

Funding

No funding has been received for this manuscript. The open access fee was paid by AstraZeneca.

Conflict of interest

All authors are permanent employees of AstraZeneca. The thoughts and statements expressed within this article are written in the capacity of medical affairs professionals and not as AstraZeneca employees. The opinions expressed in this article are those of the authors and not necessarily those of AstraZeneca.

Availability of Data and Material

Not applicable.

Ethics Approval

Not applicable.

Consent

Not applicable.

Code Availability

Not applicable.

Author Contributions

All authors have written the paper together with each one being given the responsibility to write a section and then discuss amongst the team to arrive to a final version. Everyone has read and approved the final version of the submitted paper.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.
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About this article

Cite this article

Bedenkov, A., Rajadhyaksha, V., Beekman, M. et al. Developing Medical Affairs Leaders Who Create the Future. Pharm Med 34, 301-307 (2020). https://doi.org/10.1007/s40290-020-00351-y
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# data[].attributes.attachment_link.title
Developing Medical Affairs Leaders Who Create the Future - Pharmaceutical Medicine

# data[].attributes.attachment_link.description
Medical affairs has evolved over recent years from a support, to a partner, to a strategic leadership function. In the future, there will be significant changes in healthcare and pharmaceutical industries, and many of these will be due to technological advances and digitalisation.

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Nutrition Competencies - Health Education & Training

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Nutrition Competencies - Health Education & Training

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Kris-Etherton, P. M., Akabas, S. R., Douglas, P., Kohlmeier, M., Laur, C., Lenders, C. M., Levy, M. D., Nowson, C., Ray, S., Pratt, C. A., Seidner, D. L., & Saltzman, E. (2015). Nutrition competencies in health professionals' education and training: a new paradigm. Advances in nutrition (Bethesda, Md.), 6(1), 83–87. https://doi.org/10.3945/an.114.006734

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ABSTRACT

Most health care professionals are not adequately trained to address diet and nutrition-related issues with their patients, thus missing important opportunities to ameliorate chronic diseases and improve outcomes in acute illness. In this symposium, the speakers reviewed the status of nutrition education for health care professionals in the United States, United Kingdom, and Australia. Nutrition education is not required for educating and training physicians in many countries. Nutrition education for the spectrum of health care professionals is uncoordinated, which runs contrary to the current theme of interprofessional education. The central role of competencies in guiding medical education was emphasized and the urgent need to establish competencies in nutrition-related patient care was presented. The importance of additional strategies to improve nutrition education of health care professionals was highlighted. Public health legislation such as the Patient Protection and Affordable Care Act recognizes the role of nutrition, however, to capitalize on this increasing momentum, health care professionals must be trained to deliver needed services. Thus, there is a pressing need to garner support from stakeholders to achieve this goal. Promoting a research agenda that provides outcome-based evidence on individual and public health levels is needed to improve and sustain effective interprofessional nutrition education.

Nutrition practices have a powerful impact on the leading diet-related chronic diseases including heart disease, hypertension, type 2 diabetes, and certain cancers ( 1). Despite this, it is widely recognized that most health care professionals receive little nutrition training and are ill-equipped to assess their patients' diets and nutritional status as well as provide nutrition counseling ( 2- 4). Poor nutrition also has adverse effects on the clinical course of many acute illnesses and communicable diseases ( 5, 6). In this symposium, the state of nutrition efforts in the United States, United Kingdom, and Australia was reviewed by speakers who are leading the effort in these countries. The rationale for development of nutrition competencies and interprofessional nutrition education was discussed. Strategies to advance these goals from practical and policy perspectives, as well as the role of research in promoting nutrition education for health care professionals, were presented. This symposium complements the supplement published in the American Journal of Clinical Nutrition in May 2014 that focused on improving the nutrition education of health care professionals.

The goals of the presentations by Dr. Sharon Akabas and Dr. Douglas Seidner were the following: 1) to distinguish competency-based from structure-based (objectives) learning, 2) to review the competency framework developed by the Accreditation Council for Graduate Medical Education (ACGME) ¹⁵ and discuss how this can be applied to health care professional training, 3) to encourage the mapping of nutrition and physical activity competencies in existing curricula, 4) to provide examples of successful competency-based interprofessional education programs, and 5) to make recommendations for next steps in the development of fundamental milestones. There is a shift in the goals of the education process from what the student "knows" to a progressive process where the student learns the additional steps "knows how," "shows how," and "does," resulting in the ability to integrate this knowledge into day-to-day practice ( 7). This shift can promote improved nutrition assessment and integration of nutrition into patient care. This shift is accompanied by a core commitment to interprofessional education, which is one of 8 domains identified by the ACGME ( 8), and is an emphasis of prevention and chronic care models ( 9), which is a key aspect of the Patient Protection and Affordable Care Act. Practitioners are encouraged to work with other educators in their academic settings to identify milestones to assess nutrition and physical activity knowledge and skills with the goal to include these competencies in the accreditation process.

Dr. Martin Kohlmeier provided examples of the impact of appropriate nutrition education on health care outcomes and summarized the status of nutrition education in US medical schools. For example, when physicians provide nutrition guidance, their patients have fewer pregnancy complications and give birth to healthier children ( 10). Hospital stays and outcomes after expensive surgeries and other treatments are gaining attention because best nutrition practices save money. However, most physicians are not sufficiently prepared to deliver appropriate nutrition messages to their patients. Many ignore nutrition altogether because they lack the necessary training. Learning nutrition science and acquiring the necessary clinical skills take time. A national survey found that nutrition education at many medical schools is inadequate and not improving ( 4). Half of the accredited medical schools in the United States teach 17 h at most, and 9% require no nutrition education at all. About 10% of US medical schools indicate that they are able to provide ≥40 h of education within the 4-y curriculum.

Dr. Kohlmeier suggested that students will be better prepared if medical schools require a nutrition and behavior modification course as a prerequisite for admission.

Pending legislation suggests nutrition-themed continuing education for federal employees. A second bill proposes financial incentives for medical schools to improve nutrition training.

Dr. Kohlmeier cited a recent study that found that resident obstetricians who had just 1 h of online instruction implemented effective assessment and counseling tools with their pregnant patients ( 10). Before the training session, most of these residents rarely or never advised their patients about recommended weight gain, but 3 mo after the 1-h education session most of them did so. This is a promising start.

Dr. Carine Lenders provided an update of ongoing ASN nutrition education activities for health care professionals. ASN is committed to research, translation, and dissemination of nutrition research to improve public health and clinical practice worldwide and to promote education and training of clinicians in nutrition. The education activities of ASN are led by a Nutrition Education Committee that is comprised of 3 subcommittees: 1) the Nutrition Education in Health Professional Schools Committee, 2) the Learning Library Committee, and 3) the Mentoring Committee.

Since 2012, the charge of the Nutrition Education in Health Professional Schools Committee has been to develop strategies to advance nutrition education and training of students and faculty in medical and other health professional schools; to interact with other societies/groups engaged in medical nutrition education and certification [e.g., the National Heart, Lung, and Blood Institute; the American Association of Medical Colleges (AAMC)]; and to represent ASN at the Institute of Medicine's (IOM) Global Forum on Innovations in Health Professional Education. The Learning Library aims to increase nutrition education capacity via the development of web-based resources, whereas the Mentoring Committee works to develop a network of educators across the United States and award grants to medical students and physicians to facilitate nutrition education and training.

Competencies are a key aspect of any educational and training model for medical nutrition across disciplines. After discussions with collaborators from the AAMC, successful groups that have defined competencies also have the following common attributes: 1) they have primary stakeholders, 2) they have a compelling argument that focuses on need and urgency, 3) they share a defined vision and outcome as well as a comprehensive approach that includes working within the AAMC competency framework, 4) they obtain advice from certification groups (e.g., the Liaison Committee on Medical Education; the National Board of Medical Examiners), and 5) they are working to convince the US Congress that the topic is important.

ASN participates in initiatives with other health care professionals that foster innovation and advocacy. Within the last couple of years, ASN has partnered with colleagues from the IOM Global Forum on Innovations in Health Professional Education; the National Heart, Lung, and Blood Institute Working Group on Future Directions for Implementing Nutrition across the Continuum of Medical Education and Training, and for Practicing Physicians; the Global Capacity Building in Nutrition Science: Training Future Practitioners and Empowering Leaders, organized by the New York Academy of Sciences; and the Bipartisan Policy Forum on Teaching Nutrition and Physical Activity in Medical School: Training Doctors for Prevention-Oriented Care. ASN is also exploring ways to partner with other countries on medical nutrition education initiatives for health care professionals.

Funding is currently being sought to establish an ASN-led steering committee to advance medical nutrition education. A long-term effort involving multiple stakeholders, this center would centralize efforts to monitor and promote existing efforts and resources, develop needed tools, evaluate implementation, and disseminate findings.

The need for nutrition education for health care professionals is recognized worldwide. The symposium featured presentations about efforts in the United Kingdom and Australia.

Dr. Sumantra Ray, Pauline Douglas, and Celia Laur discussed the Need for Nutrition Education/Innovation Program (NNEdPro; www.nnedpro.org.uk), a practical application of introducing nutrition into competency-based medical education in a United Kingdom context. The NNEdPro Group was developed in 2008 to increase awareness among medical/health care professionals regarding the importance of clinical and public health nutrition. It is a virtual strategic partnership between physicians, dietitians, nutritionists, and other health care professionals. It is comprised of several partner organizations including the British Dietetic Association, the Society for Nutrition Education and Behavior, the Cambridge University Hospitals/School of Clinical Medicine, the University of Ulster, and the U.K. Medical Research Council Human Nutrition Research Unit in Cambridge, United Kingdom.

The NNEdPro Group has pursued a phased approach to the generation of evidence justifying the need for medical nutrition education and has evaluated the impact of innovation in educational delivery in medical students, junior physicians and latterly specialized physicians, and other health care professionals ( 11- 13). Evaluation methods have included examining pre- and post-training scores for changes to knowledge, attitudes, and practices, along with qualitative feedback and assessment of confidence vs. competence. As part of strengthening the platform upon which this work is based, NNEdPro has established a vertical curriculum strand within the University of Cambridge School of Clinical Medicine ( 13). In addition, these approaches to medical nutrition education have led to work geared at strengthening the nutrition evidence base in certain key areas of medical importance. Another innovative approach that has been used by the NNEdPro Group is the combination of nutrition training with change management (this denotes the systematic management of stepped changes that are required to bring about a shift in processes leading to improved outcomes) to provide both knowledge and the advocacy skills to translate such knowledge in practical settings ( 12). In the next phase of work, the group will build upon the local innovation that is having an unexpected global impact because of a number of parallels in medical nutrition education across countries and continents. This innovation and impact have led the group into some of the policy aspects of education, including the understanding that the need for nutrition education may also equate to the need for nutrition education regulation. The future direction for the NNEdPro Group includes expansion of teaching into other specialties including other health care professionals and other topics including hydration awareness. The group is also continuing to foster global partnerships to provide a unified voice for medical nutrition education.

Dr. Caryl Nowson discussed nutrition education for health care professionals in the context of Australian medical education. Australia currently has ∼3000 medical students graduating each year from 18 entry-level medical courses (configured as 6-y undergraduate courses and 4-y postgraduate courses). Course accreditation guidelines are that medical graduates should be able to apply nutrition knowledge in practice; however, there are no nutrition competencies formally integrated into Australian medical courses ( 14).

In 2013 Dr. Nowson and her team (a collaboration of 4 entry-level medical courses and the Dietitians Association of Australia) were awarded an Office for Learning and Teaching government grant (2013-2015). The aim of this project is to develop a web-based nutrition competency implementation toolkit ( http://wncit.weebly.com/) that will enable medical courses to effectively embed nutrition competencies within curricula and ensure that all medical graduates are "nutritionally competent." The toolkit is based on a nutrition competency framework of 4 knowledge-based and 5 skill-based competencies that incorporate learning outcomes. The toolkit will include an online curriculum mapping tool to map courses for nutrition competencies, a set of quality nutrition teaching exemplars (including a bank of multiple choice questions), a collation of web-based nutrition education resources, and an instruction manual. All components of the toolkit will be stringently evaluated and refined to develop quality modules.

The immediate challenges to effectively integrating nutrition into medical education are endorsement of the nutrition competency framework from the Australian Medical Council (which develops standards for medical education and training) and the Medical Deans Australia and New Zealand, Inc. (the peak body representing professional entry-level medical education, training, and research), effective dissemination of the web-based nutrition competency implementation toolkit to the key stakeholders, and general consensus on the level of practical nutrition skill levels appropriate for medical graduates.

In his presentation, Dr. Matthew Levy argued persuasively for the need for policy advocacy that is focused on nutrition education for health care professionals. As stated earlier, poor nutrition practices and physical inactivity are leading risk factors for many prevalent and costly chronic conditions; however, most health care professionals are not adequately trained to counsel patients on the components of a healthy lifestyle. In recent years, changes in the health care delivery and financing landscape, such as the passage of the Affordable Care Act, have led governmental agencies and nongovernmental organizations to increasingly develop policies and programs that support a public health focus on prevention and treatment of chronic diseases through better nutritional awareness, assessments, and counseling. Unfortunately, "[Health] professional education has not kept pace with [the health care delivery challenges] largely because of fragmented, outdated, and static curricula that produce ill-equipped graduates" ( 3). Some of the barriers to improving health professional education include the limited number of physician champions in health professional schools, limited penetration of nutrition into curricula because of competition for time, limited reimbursement for nutrition counseling as a separate visit, limited coordinating strategies across health care professional sectors, and some disagreement about what the appropriate role is of various providers in delivering such information ( 15). As noted in the recent article in the American Journal of Clinical Nutrition, health care professionals must seize this opportunity to improve the health of patients by advocating for the following: 1) realigning the training of health care professional students and residents by looking at outcomes-driven education and develop effective longitudinal, educational interprofessional strategies that align individual health with population health, 2) training all health care professionals in the nutrition and physical activity needs of our growing population and develop standard nutrition fellowship training programs, and 3) aligning incentives such as reimbursement and licensure to support increased focus on nutrition and physical activity in practice and motivate providers to want to change ( 16).

Dr. Charlotte Pratt presented the rationale for, and status of, research opportunities in the area of nutrition education for health care professionals. Many nutrition educators and health care professionals have called for research to evaluate the effectiveness of innovative teaching strategies, to test various approaches to implement curricular changes, and assess the effects of such approaches on patient and population health ( 2, 17, 18). As new knowledge in nutrition evolves, physicians and other health care professionals must be poised to incorporate the knowledge and skills in their professional practice. Research that evaluates new approaches for longitudinal incorporation of nutrition in medical training for medical students, residents, fellows, and other health care professionals through use of new technologies and training modules is needed. Research is also needed to evaluate nutrition education programs at all levels of medical education and for other health care professionals such as nurses, dentists, and pharmacists. A key research question would be does longitudinal integration of nutrition in the curriculum impact health care professionals' and/or patient health outcomes (e.g., diet, physical activity, and chronic disease risk)?

Interprofessional education has been promoted by the IOM and adopted by the AAMC, ACGME, and other professions ( 19, 20). Research is needed to examine how interprofessional nutrition education with multidisciplinary teams contributes to more coordinated care, better performance, and improved patient outcomes. A key research question would be whether such multidisciplinary teams better facilitate the integration of nutrition and physical activity into the medical school curriculum (e.g., cardiovascular curriculum) or change the eating habits, physical activity, or chronic disease risks of patients? The use of electronic medical records and monitoring devices provide opportunities for accomplishing such tasks.

Conclusion

There is growing recognition that health care professionals must be better trained in nutrition to provide optimal patient care and, thereby, contribute to improved population health ( 3). This will require a competency-based nutrition education approach for health care professionals that addresses clinical and public health nutrition for the prevention and treatment of many acute, communicable, and chronic diseases. There is an upsurge of interest in revamping medical nutrition activities for all health care professionals. It is essential that this momentum be maintained. Moreover, strategies must be identified that coordinate and grow this effort among interested stakeholders. It is impressive that there are ongoing global activities that address the need for nutrition education for health care professionals. Working together will be essential to improve nutrition knowledge of all health care professionals. It is evident that achieving this goal expediently is in the best interests of all concerned stakeholders. Furthermore, making progress toward improved patient care will achieve significant population health benefits. The authors acknowledge the ongoing activities that are directed toward improving medical nutrition education and the commitment of so many individuals who are pursuing this goal.

Acknowledgments

All authors read and approved the final manuscript.

References

Abbreviations

Author notes

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Nutrition Competencies in Health Professionals' Education and Training: A New Paradigm

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Most health care professionals are not adequately trained to address diet and nutrition-related issues with their patients, thus missing important opportunities to ameliorate chronic diseases and improve outcomes in acute illness. In this symposium, the speakers reviewed the status of nutrition education for health care professionals in the United States, United Kingdom, and Australia.

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Using Bloom's Revised Taxonomy in Assessment

These levels can be helpful in developing learning outcomes because certain verbs are particularly appropriate at each level and not appropriate at other levels (though some verbs are useful at multiple levels). A student might list presidents or proteins or participles to demonstrate that they remember something they learned, but generating a list does not demonstrate (for example) that the student is capable of evaluating the contribution of multiple presidents to American politics or explaining protein folding or distinguishing between active and passive participles.

Remember

Definition: retrieve, recall, or recognize relevant knowledge from long-term memory (e.g., recall dates of important events in U.S. history, remember the components of a bacterial cell). Appropriate learning outcome verbs for this level include: cite, define, describe, identify, label, list, match, name, outline, quote, recall, report, reproduce, retrieve, show, state, tabulate, and tell.

Understand

Definition: demonstrate comprehension through one or more forms of explanation (e.g., classify a mental illness, compare ritual practices in two different religions). Appropriate learning outcome verbs for this level include: abstract, arrange, articulate, associate, categorize, clarify, classify, compare, compute, conclude, contrast, defend, diagram, differentiate, discuss, distinguish, estimate, exemplify, explain, extend, extrapolate, generalize, give examples of, illustrate, infer, interpolate, interpret, match, outline, paraphrase, predict, rearrange, reorder, rephrase, represent, restate, summarize, transform, and translate.

Apply

Definition: use information or a skill in a new situation (e.g., use Newton's second law to solve a problem for which it is appropriate, carry out a multivariate statistical analysis using a data set not previously encountered). Appropriate learning outcome verbs for this level include: apply, calculate, carry out, classify, complete, compute, demonstrate, dramatize, employ, examine, execute, experiment, generalize, illustrate, implement, infer, interpret, manipulate, modify, operate, organize, outline, predict, solve, transfer, translate, and use.

Analyze

Definition: break material into its constituent parts and determine how the parts relate to one another and/or to an overall structure or purpose (e.g., analyze the relationship between different flora and fauna in an ecological setting; analyze the relationship between different characters in a play; analyze the relationship between different institutions in a society). Appropriate learning outcome verbs for this level include: analyze, arrange, break down, categorize, classify, compare, connect, contrast, deconstruct, detect, diagram, differentiate, discriminate, distinguish, divide, explain, identify, integrate, inventory, order, organize, relate, separate, and structure.

Evaluate

Definition: make judgments based on criteria and standards (e.g., detect inconsistencies or fallacies within a process or product, determine whether a scientist's conclusions follow from observed data, judge which of two methods is the way to solve a given problem, determine the quality of a product based on disciplinary criteria). Appropriate learning outcome verbs for this level include: appraise, apprise, argue, assess, compare, conclude, consider, contrast, convince, criticize, critique, decide, determine, discriminate, evaluate, grade, judge, justify, measure, rank, rate, recommend, review, score, select, standardize, support, test, and validate.

Create

Definitions: put elements together to form a new coherent or functional whole; reorganize elements into a new pattern or structure (design a new set for a theater production, write a thesis, develop an alternative hypothesis based on criteria, invent a product, compose a piece of music, write a play). Appropriate learning outcome verbs for this level include: arrange, assemble, build, collect, combine, compile, compose, constitute, construct, create, design, develop, devise, formulate, generate, hypothesize, integrate, invent, make, manage, modify, organize, perform, plan, prepare, produce, propose, rearrange, reconstruct, reorganize, revise, rewrite, specify, synthesize, and write.

Source: Anderson, Lorin W., and David R. Krathwohl, eds. 2001. A Taxonomy for Learning, Teaching, and Assessing: A Revision of Bloom's Taxonomy of Educational Objectives. New York: Addison Wesley Longman, Inc.

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Bloom’s Revised Taxonomy - Colorado College

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There are six levels of cognitive learning according to the revised version of Bloom’s Taxonomy. Each level is conceptually different. The six levels are remembering, understanding, applying, analyzing, evaluating, and creating.