Medical Student Preference in Teaching Methods and Educational Support

Abstract

Student learning styles and preferences have been a vogue of educational research. This brief communication reports the findings of a questionnaire that formed part of an investigation into supporting medical students with learning difficulties. There were 325 responses from students at medical schools in California (USA) and New Zealand. Responses confirmed theories that are known to underpin elements of education. Interestingly, there were conflicting views regarding the use of slides and handouts to support educational activities. Such conflicts highlight the complexity of reconciling pressures from special educational needs policy with institutional traditions and managerialist priorities.

Keywords:

• learning preferences
• teaching styles
• learner support

Background

One focus for educational research over the past few decades has been student preference for particular learning styles, and the effect that testing for and accommodating these has on outcome measures. Tension exists between accommodating for individual learning preferences and mass delivery of outcome-driven learning activity (Paul et al. 1994). Other factors contributing to differences in learning among trainee doctors include Specific Learning Difficulties (SpLD), which are increasingly disclosed by or identified among medical student cohorts (Shrewsbury 2011).

Introduction

When seeking to guide teaching methods, educators consider learning objectives, pressures from institutions/regulatory authorities, resource availability and learner factors such as level of study. Occasionally learner preferences and styles are considered, to add extra dimension to these guiding principles. However, in a review, Coffield et al. (2004) concluded that the majority of tools designed to assess learning style and preference are not helpful in practice. Guidance and pressure from regulators, along with legislation, further complicates educational activity development by recommending certain practices to support students with protected characteristics such as learning difficulties. Little is known about how students actually respond to supportive strategies, such as advance provision of resources. This paper briefly discusses findings from the analysis of a data set, which forms part of a wider investigation into learning differences and difficulties in medical education. Students from medical schools in the USA and New Zealand were administered a semi-structured online questionnaire, exploring perceptions of difficulties within their educational experience. The two medical schools shared similarly structured pre-clinical curricula, dominated by lectures with some tutorials and small-group skills sessions, followed by a clinical curriculum weighted towards clinical attachments. Data from 325 responses suggest, amongst other things, a dichotomy between providing adequate learner support and sufficient novel stimulus during teaching. We conclude by linking these emerging perceptions with suggestions to help drive excellence in medical education.

Methods

A 22 item semi-structured questionnaire was developed and piloted to ascertain students’ views about, and perceptions of, barriers to success in their learning. Questions were divided into three groups: demographics, their learning experience, and facilitation of their learning experience. Combinations of tick-box, Likert and free-text responses were used.

With ethical approval, the web-based questionnaire was distributed by email to all medical students enrolled at Auckland and UCLA medical schools. A reminder was sent to Auckland students one month later, but not to American students for administrative and legal reasons. The survey was closed six months after initial circulation, and responses were collated.

Results

Following the distribution of the questionnaire, 325 students (256 Auckland; 69 UCLA) gave complete responses to the questionnaire (response rates: 42% and 14% respectively). Average respondent age was 22.8 years, with 53% male, and 47% female.

Twenty-seven (8.6%) students had been required to re-sit an assessment. Of these 16 were written assessments, seven clinical examinations and one a communication assessment. Seventeen (5.2%) respondents reported having to re-sit an entire course year. Only five participants declared a SpLD diagnosis. Of these, three had dyslexia and two attention deficit hyperactivity disorder. Students who did not declare a diagnosis of a SpLD were asked if they felt they might have an undiagnosed SpLD – 15.5% said yes.

Students were invited (in free text) to feed back on what they felt could be done to improve their learning experience. A total of 132 free-text responses from 76 students were collected (excluding ‘no’ and ‘n/a’). Using an inductive approach to thematic analysis (Braun & Clarke 2006), the following themes were identified from the data: delivery; timing; resources; perceived expectations and educator qualities.

Delivery

Students perceived that didactic teaching methods contributed to barriers in learning medicine. Twenty-six responses indicated that lectures were not the preferred method of delivery. However, four responses suggested that when slides, projections and (interestingly) handouts are not used, lectures were perceived as “usually better”, with two students specifically asking for more “blackboard style teaching”. Twelve perceived that aspects of self-directed, problem-based and computer-aided learning were often under-productive as, commonly described for these three approaches, they were perceived to lack structure, personal meaning or significance. Rather, these activities were often regarded as exercises undertaken to satisfy arbitrary criteria. Additionally, respondents (n = 14) suggested that an increase in tutorial-style teaching, and earlier clinical exposure (n = 9), would improve the learning experience.

Timing

Eleven responses suggested that scheduling several teaching sessions in a series, and the length of individual activities, caused students difficulty. Concentration was believed to be limited, one specifying up to 15 minutes, another 20 minutes. One student requested “not more than two hours of straight lectures please”, reflecting the sentiments of two others. Additionally, one student commented that long stretches of lectures made childcare and breastfeeding difficult to manage. This highlights a challenge for some adult learners that can be overlooked in education. Students frequently cited being unable to keep up and make useful notes as causing anxiety. Fast-paced lectures were perceived as lower value and poorer quality. Several responses called for “better organisation” with three specifying that repetition and overlap causes some frustration related to perceived time-wasting.

Resources

Respondents suggested that irregularities in advance availability of lecture notes/handouts was a cause of frustration and anxiety, undermining efforts to prepare for sessions effectively. Likert-scale responses relating to availability and perceived usefulness of handouts show 13% of students felt that handouts were available all of the time, while 4% felt they were never available. When they were available, 23% (74) of the students felt handouts were very useful, 76% (235) felt they were satisfactory to moderately useful, and 5% felt that they were unsatisfactory. Fourteen students gave free-text responses suggesting that more consistent access to presentation slides/handouts would improve their learning experience. This conflicts with other responses which suggest that handouts, and the use of presentation slides, can be detrimental to the overall learning experience, allowing, for example, “. . . many lecturers to be lazy and bombard students with information”.

Perceived expectations

Twelve respondents suggested that students were expected to over-memorise “ridiculous amounts of information” – specifically lists of facts and names – at the expense of understanding concepts. One recalled how they were told, for exmaple, to “memorise an anatomy textbook”. These respondents also suggested that learning objectives, or course material, often did not appear to match the lecture content or what was assessed in related exams.

Educator qualities

Responses were quite explicit, citing qualities of educators not considered conducive to effective learning. Eight responses reported attributes of educators in terms such as “dry”, “un-engaging” or “dull”, and suggested that more variety, confidence and enthusiasm would benefit teaching. Ten respondents were critical of educators’ abilities to convey simplified explanations, use technology or cater for different teaching and learning style preferences. Sixteen responses suggested that use or misuse of resources and tools, for example projected presentations, could actually be deleterious to learning. One specifically called for medical schools to “. . . actually hire . . . people who [are] trained adult educators (not educational researchers)”. Relating to ability is competence, with three responses touching on competence to teach, and one specifically highlighting “cultural competence” as a factor that both individual educators and institutions should consider.

Discussion

It is well-established that being flexible and dynamic in teaching style meets the needs of more learners (Mohanna et al. 2007). Some responses from students echo existing knowledge, such as the attention span of learners relating to session duration. Other responses directly contradict what is recommended by guidance relating to student support, as illustrated in the contradiction of simultaneous preference for advanced availability of resources, and lectures without the use of slides/handouts.

The questionnaire was part of a project designed to investigate issues around inclusion and support of medical students with SpLD. However, a surprisingly small proportion of respondents (1.5%) disclosed a SpLD diagnosis. This doesn’t reflect UK data from The University and College Admissions Service (Shrewsbury 2011), or the Higher Education Statistics Agency (Gibson & Leinster 2011), and falls well below a representation of the general-population prevalence of ~6% (Miles 2004). This could be explained by numerous factors, for example international differences, poor publicity and/or awareness of the project, or poor organizational skills precluding completion of the questionnaire before the deadline. It could also reflect reticence to disclose a diagnosis of a disability associated with stigma. Unfortunately, no data were available to ascertain the actual number of students at each institution who had disclosed a diagnosis of a SpLD.

Learning differences and difficulties

The majority of responses were from students who did not declare themselves to have a SpLD, and therefore conclusions from this isolated data-set should not be taken to reflect an analysis of issues pertaining to special educational needs or support, but to the wider context of the student experience. However, the data highlight some interesting areas, with students calling for more variety in approaches to teaching and a mentor, or ‘buddy’ system to support learners. The complexities of learning difficulties and learning preferences would make a one-size-fits-all approach to supporting learners with difficulties impractical. Moreover, the pressures that drive decision-making in curriculum design and delivery demand efficiency most readily achieved through mass-methods, such as lectures. While being wary of panaceas; exploiting new technologies, principles of blended learning, and inverted classrooms (Lage et al. 2000) could offer opportunities for medical schools to better address the nuanced needs of individuals, including those with competing commitments, for example childcare and those with difficulties, for example SpLD. Such measures would require a solid foundation of appropriate tutorials and, where appropriate, one-to-one support (augmented perhaps by the proposed ‘buddy’ system).

Common sense and common practice

It was empirically demonstrated in 1976 that students’ attention in lectures can be realistically maintained for 15–20 minutes (Johnstone & Percival 1976). Cantillon (2003) develops this, suggesting ways of ‘breaking up’ a lecture and encouraging interaction. He proposes using questions and activities such as buzz groups, brainstorming and mini-assessments (e.g. quizzes). Whilst these may appear to be common sense, and are ingrained in many education textbooks, responses to this questionnaire would suggest that they are yet to be fully integrated into routine undergraduate lectures.

The handout paradox

There is legislative pressure on institutions to provide reasonable adjustments to students with disabilities. Here, pressure seems to have driven a global trend in advance publication and distribution of learning material, although the timeliness, contemporaneity and completeness of this is variable. It has been reported that the development of such guidelines can erode autonomy and professional practice of an educator, and can breed a certain amount of discontent (Riddell et al. 2007).

There is a further tension between the imperative for academics to provide learning materials and handouts in advance, detracting from maintenance of attention during teaching. Anecdotally, we are aware that another concern of educators is that advanced access to learning materials might influence learners’ attendance decisions. It is common practice for handouts to be distributed or resources to be published on virtual learning environments. It is believed that good quality handouts can help to reduce cognitive burden during lectures, and allow students to participate in learning more actively (Cantillon 2003). However, responses from students suggested that handouts and the use of slides detracted from the interactivity and overall session quality.

Does this handout paradox call into question the use of such tools? The sample of students here is too small (and non-representative in other respects) to answer. However, it highlights the complexity of the issue. It is arguably good practice to have such resources available in advance, especially for students with learning difficulties.

Conclusion

There is an intricate interplay between the preferences that learners have and the preferences, pressures and traditions that an individual educator or institution has and responds to. There is evidence to recommend good practices that appear to be ‘common sense’. However, results here tentatively suggest there is work to be done to incorporate these practices into routine educational activities.

As medical education becomes more commericalised, educators and institutions will need to respond to pressures applied by guidance and legislation, as well as student expectations. This will impact on the use and provision of supportive technologies, resources (e.g. handouts) and techniques used to augment and enhance the learning experience. Delivery and timing of educational activities should be aligned with global preferences and guided by theoretical evidence. These data suggest that lectures, which remain the mainstay of early medical education, should be avoided where possible. Where they cannot, they should be made more interactive, reflecting an awareness of the natural tendency for attention to wane after 15 minutes.

In planning learning activities, convergence with course learning outcomes must be planned, i.e. constructive alignment (Biggs & Tang 2011). This process should be transparent and accessible to students as a means of encouragement, allaying anxieties and avoiding potential mismatch between student effort and course expectation.

Perhaps most significantly, this work highlights the often conflicting nature of student learning preference. On the one hand students want handouts in advance of learning activities, on the other they feel they can detract from the quality of the session. Reconciling differing views and responding to the guidance from legislation and policy is a complex task, but is fundamental to future educational success.

Acknowledgements

This project was supported by supervision from Associate Professor Andy Wearn (Auckland) and Dr Lawrence ‘Hy’ Doyle (UCLA), who also contributed to the development of the project design.

Funding: This study was made possible with the generous support of an elective scholarship from the Sir Arthur Thompson Charitable Trust, University of Birmingham.

Ethical Approval: Full approval from institutional ethical committees was obtained (Human Participants Ethics Committee, New Zealand and Institutional Review Board, USA).