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Editorial |
1 From the Department of Radiology, Indiana University Medical Center, 702 Barnhill Dr, Rm 1053, Indianapolis, IN 46202-5200. From the 2003 RSNA scientific assembly. Received February 2, 2004; accepted February 6. Address correspondence to R.B.G. (e-mail: rbgunder@iupui.edu).
Index terms: Editorials • Education • Radiology and radiologists
If radiology educators are to perform at their best, it is vital that they operate with a sound understanding of how people learn. The ultimate goal of education is not for educators to teach well, but for learners to learn well. However, most medical educators, including radiologists, have little or no formal background in education (1) and have learned how to teach largely from watching other educators in action. The problem with this approach is that educators in fields such as radiology may find themselves years and even decades behind the latest developments in educational research and practice. So that the field of radiology can begin to take advantage of these developments, this article provides an overview of three of the most influential theories of human learning, the behaviorist, cognitivist, and constructivist theories. The goal in presenting these theories is not to argue that radiologists should choose one over another but rather to urge that all three have strengths that deserve consideration.
Educational Practice
Before learning theory is considered, it is necessary to say a few words about educational practice. Broadly speaking, education in radiology and every other field consists of three components. The first of these components is curriculum, which consists of what we intend our students to learn. There are two types of curriculum. The formal curriculum consists of written learning objectives, reading assignments, lectures, course syllabi, and so on. Of equal importance, though less attended to by educators, is the informal curriculum. In contrast to its formal counterpart, the informal curriculum represents the lessons learned outside formal channels, lessons such as how to consult with referring physicians or how to cope with errors. This knowledge is not official in the sense of being prescribed or even monitored, yet it permeates the experience of all students in any program, whether they are aware of it or not (2).
More generally, the informal curriculum refers to the expectations and beliefs held by both learners and faculty. These can be beliefs about each other’s roles, about what defines the domain (eg, the field of radiology), about how instruction should occur, and about what the learners will do after completing their course of instruction. All radiology educators need to recognize that the informal curriculum is every bit as important, and perhaps more important, than the formal curriculum. When the two components conflict, learners may conclude that it is more important to do what their superiors do than what they say, and the informal curriculum may prevail.
The second component of educational practice is instruction, or how we teach. Every educator knows that learners can be taught in many different ways. One way of teaching is through assigning readings. Another is through lectures. Still another is through computer-based instruction, simplistic examples of which could include reading an electronic textbook and listening to a recorded lecture linked to slides. Of course, the computer also offers educators much more sophisticated options. Many developers have created stand-alone or Web-delivered programmed instruction (3).
At the complex end of the technology spectrum is the idea of computer-supported exploratory learning environments (4). Such programs have yet to appear in the medical education literature except as theories (5). Through the apprenticeship model, learners learn by working side by side with more knowledgeable and experienced practitioners in the field. A relatively recently described form of this approach is the cognitive apprenticeship (6), which has found its way into health care education with promising results (7).
Consider also that instruction can be both planned and unplanned. In one case, an educator can plan to give a lecture on a particular topic at a particular time and place. In other settings, "just-in-time" learning delivered spontaneously during clinical practice can prove even more valuable (8). It is vital that educators be on the lookout for such "teachable moments."
The third component of educational practice is assessment, or how we can determine what the learner has learned. A similar term, evaluation, is often used in this context, although evaluation is generally understood to refer to a single instance of judgment or appraisal, while assessment refers to a more comprehensive program (9). Again, assessment may be both formal and informal. Formal assessment generally refers to written assessments that become part of the learner’s formal record, such as course grades, records of standardized test performance, and narrative performance appraisals submitted by faculty members. Informal assessment, which can be even more influential than formal assessment, includes such appraisals as oral feedback delivered to learners in the course of day-to-day activities. One potential problem that should concern educators is the perception by some learners that they receive little or no feedback, that feedback is not given in a timely fashion, or that the feedback provides no advice on how they could improve their performance (10). In any event, it is clear that assessment is an important factor in learning (11).
What curriculum, instruction, and assessment should be, and how they should fit together into a coherent educational whole, depends largely on the particular learning theory we are working with. Such theories speak to fundamental issues in education. What do we mean by knowledge? What do we mean by learning? Radiology educators need to appreciate the fact that different educators may understand even such basic notions as these in very different ways. A great deal hangs in the balance, for different views of the meaning of knowledge may promote very different approaches to what we teach, how we teach, and how we determine whether learners understand what we want them to.
Learning Theories
Let us turn first to the behaviorist theory of instruction. Behaviorism is traditionally associated with the 20th-century educational theorist B. F. Skinner (12), although its roots may extend as far back as the 17th-century British empiricist philosopher John Locke. Behaviorists regard knowledge from an external, objective point of view. They are not interested in the minds of learners, because they question whether it is even possible to know what goes on inside that "black box" at all. Instead, they focus on observable behavior and how learners’ response patterns change over time as they encounter different stimuli. Behaviorist educators frequently view learner responses as falling into one of two basic categories: right or wrong. Learners have either learned to respond correctly to a question or they have not. If they respond correctly, the educator has succeeded, while if they respond incorrectly, further instruction is administered until the correct answer becomes the fixed pattern of response.
By contrast, cognitive theorists are interested primarily in what goes on in the minds of learners. Cognitivists such as John Dewey and Jean Piaget (13) believed that it is possible to peer inside the "black box" of the learner’s mind and understand what is going on within. Against the behaviorists they would argue that it is exactly what goes on in a learner’s mind that is of utmost importance. Cognitive theory tends to focus on information patterns, how ideas and concepts fit together in the minds of learners, and how factors that alter those patterns enhance or detract from learners’ abilities to use what they know to solve problems. Cognitivists are less interested than behaviorists in whether learners’ responses to specific questions are right or wrong and more interested in how acquired knowledge transfers to new situations. A key concept in cognitive learning theory is that knowledge is processed on multiple levels (14). Merely memorizing information, such as a list of differential diagnoses, is a lower level of processing than generating an appropriate differential diagnosis for a lesion by using previously acquired knowledge.
Constructivists are less interested in how learners behave or in what is going on in the mind of the learner than in what happens between and among learners. The constructivist theory of learning, as put forward by such theorists as Lev Vygotsky, stresses that learning is a largely social process (15). It is not so much a matter of experts telling learners what they need to know as it is learners and educators negotiating understanding through practice in realistic situations (16). Constructivists tend to view learning in connection with a community of practice and knowledge as an integral part of the context in which learning develops (5). Ask any two radiologists what they mean by a concept such as "infiltrate" as applied to chest radiography and you may get different answers. However, put the two radiologists in conversation with one another, and you are likely to find that they have something rather similar in mind. At the end of their discussion, each may emerge with a different and perhaps deeper sense of the term’s meaning than he or she began with. Understanding comes as a product of interaction, and knowledge—in this case the meaning of the word infiltrate—is negotiable rather than fixed.
The three theories also differ in their views of what constitutes learning. The behaviorist focuses on the connections between stimuli and responses and on how educators can, by varying stimuli, evoke different response patterns in learners. A familiar, though somewhat simplistic, behaviorist model of learning is that of pigeons learning to press a bar that causes a pellet of food to be dropped into a dish.
By contrast, cognitive learning theory stresses the importance of information processing, whereby learners become active thinkers who connect new knowledge with prior experience. For example, different learners may emerge from a lecture with different perspectives on what they have seen and heard. Those perspectives may come from differences in prior knowledge that can be related to one learner’s cultural background or to another learner’s diligence in working through the assigned readings. One learner could have been highly interested in the subject while another spent the lecture time daydreaming. One may have highlighted sentences in the book while another effortfully connected concepts presented in lecture to ideas from a previous class. The learning achieved by each person in the lecture venue relates directly to the depth of effort expended to understand the presentation. We cannot necessarily assume that everyone who attends a lecture understands everything that was presented.
The constructivist, by contrast, focuses on educator-learner and learner-learner interactions to determine how meaning evolves through negotiation. Did the presenter ask questions of the learners? Did learners break into small groups and discuss what they heard? Was the presentation delivered by a "talking head" or more as a dialogue between the presenter and the audience? Were connections made in discussion to realistic situations in which the information that was presented might be used? From a constructivist point of view, it is impossible to abstract knowledge from the context in which learning takes place. Learners may gain different understandings of a concept from a lecture and from discussing it during actual clinical practice.
Curriculum, Instruction, and Assessment
Each of the three theories provides a different perspective on curriculum. From a behaviorist point of view, the curriculum is the set of facts, concepts, principles, and procedures that experts believe learners must know to master the domain. Such a curriculum might consist of a set of learning objectives that should be the focus of every learner. Short of a requirement for necessary prerequisite classes, no account is taken of differences in knowledge and experience that learners might bring to the encounter, and every learner is expected to emerge knowing the same things.
From a cognitive perspective, by contrast, a greater emphasis is placed on relating instruction to what learners already know. The curriculum places greater emphasis on the underlying, foundational concepts of a discipline, rather than simply on large collections of facts. Important concepts are revisited and elaborated throughout the time spent in the curriculum. Learners are expected to not regurgitate what they have been fed but rather to use concepts to solve novel problems.
From a constructivist point of view, the curriculum should consist primarily of working on the sorts of problems that learners are likely to encounter once they leave the instructional context. The focus is on exploration, with educators and learners working side by side to, for example, detect lesions, offer differential diagnoses, and make further recommendations for diagnostic work-up. There is no assumption that there is a fixed body of knowledge that every learner should acquire, and both educators and learners are encouraged to construct new knowledge as they work together.
Similar differences between the theories emerge in relation to instruction. From a behaviorist perspective, instruction consists primarily of presentation and practice. That is, the educator tells the learners what they need to know, and the learners practice their responses accordingly. When learners are tested, they are provided with feedback on their performance that they then use to modify later responses. From a cognitive perspective, there is more emphasis on looking at problems from multiple points of view—for example, through questioning. The goal is to encourage learners to rely on their understanding of fundamental concepts and to apply those concepts in solving complex problems. A behaviorist might simply expect a radiology learner to be able to recite the correct differential diagnosis for a particular imaging finding, while a cognitivist might expect the learner to use conceptual knowledge of pathophysiology to develop a differential diagnosis. A constructivist, by contrast, would stress the importance of getting learners involved as explorers of the domain. The role of the instructor is not so much to tell the learner what to look at, but rather to encourage exploration of the problem. For example, a medical student or resident might be asked to interview referring physicians and peruse a patient’s medical record to provide a richer cognitive background for interpreting results of a complex imaging examination.
Assessment techniques differ dramatically between the three approaches. A behaviorist approach is likely to stress objective, independent, and criterion-referenced assessment. An example of a behaviorist approach is a written examination in which students are presented with multiple-choice questions, the correct answers to which have already been determined by experts. Every student takes essentially the same examination, and every learner’s score can be easily compared with every other’s. By contrast, cognitive assessment techniques tend to emphasize depth over breadth, seeking to gain insight into how learners think rather than into merely what they know. An example of a cognitive approach to assessment is an examination in which examiners seek to gain a sense of how effectively candidates approach a problem rather than seeking to catalogue candidates’ knowledge base. In constructivist approaches, assessment and instruction are usually closely blended and occur simultaneously. Learners are confronted with complex and extended tasks that do not lend themselves to completion in a short, fixed period of time. An example of constructivist assessment is the ongoing interaction during a rotation between radiology faculty members and radiology residents in the reading room. Cases are reviewed as they appear spontaneously in practice, and no answer key is at hand for evaluating performance. Yet, over time, faculty members gain a sense of each resident’s strengths and weaknesses.
Conclusion
There has been a clear evolution of learning theories over time, and these are trends that radiology educators can benefit by exploring. For example, the state of the art of learning theory has moved from a teacher-directed model to a more learner-centered model. Learner initiative has come to be regarded as an essential ingredient in effective education, and newer instructional strategies increasingly aim to foster it. Likewise, a trend of playing down component skills and emphasizing component problems, focusing less on what every single learner should know and more on how learners approach complex situations, has emerged. There is a big difference between merely memorizing facts and routines and actually being able to function effectively as a clinical radiologist. Generally speaking, there has been a movement away from classrooms and toward contextual observation and practice. Some medical schools have implemented competency-based curricula and introduced competency-based examinations into their assessments (17). Instead of sitting at a desk and filling in ovals with a No. 2 pencil, students are actually being evaluated on their ability to take histories and perform physical examinations. Finally, there is less emphasis on what gets transmitted to the learners and more emphasis on what the learners actually acquire. Learning outcomes are now driving curriculum rather than vice versa.
What strategies can radiology educators employ to capitalize on newer learning theories? An overarching strategic objective is to make sure learners become actively engaged with the information they are expected to acquire. Educators should ask learners to put into use what they have learned, and they should do so early and often. For example, educators should ask frequent questions of learners, questions that ask the learners to discover answers for themselves rather than merely recite information (18). One line of questioning might concern predictions. Learners should generate hypotheses and be encouraged to test them. Residents studying a chest radiograph might be asked to predict the appearance on a chest radiograph obtained the next day in the same patient and to be able to explain the reasons for such an appearance. For example, does the resident think that a case of pulmonary edema represents congestive heart failure or acute respiratory distress syndrome? How can heart size and the presence of pleural effusions help sort this out? What is the typical clinical course of the two disorders in the first 24 hours? Learners should be challenged to back up their judgments with evidence, and they should be provided with feedback on how they are doing on the spot. Making mistakes is not forbidden, and learners should be encouraged to reflect on and learn from those mistakes they make. As long as patients are protected, mistakes provide some of the best learning opportunities.
In terms of assessment, a greater emphasis should be placed on learner progress as opposed to a learner’s absolute level of knowledge. We cannot always predict on the basis of what learners know today how much they will know a year from now, and it is the velocity of learning rather than the absolute quantity of knowledge that provides the best indicator of future performance. The educator’s goal is to develop learners, not to construct storehouses of knowledge. Also, it is important for educators to respect the subjective aspects of assessment. There is something intrinsically appealing to many educators about numeric scores that can be used to compare learners (8), yet many crucial aspects of learner performance are difficult or even impossible to quantify. Examples include eagerness to learn, professional demeanor, and rapport with other health professionals. Instead of attempting to quantify everything in their domain, educators should focus on becoming connoisseurs of learning who are able to provide reliable assessments of the qualitative aspects of radiology performance. Professional judgment is no more a dirty word in educational assessment than in the interpretation of diagnostic images.
The purpose of discussing these three learning theories is not to say that one is correct and the other two are wrong. Clearly, there are areas of overlap between behavioral, cognitive, and constructive theories. In these theories, learners and learning are viewed differently, yet each theory has something of value to offer the educational enterprise. The value of each theory hinges on the educational context being discussed, and changing the context will change the contributions each theory is capable of making. The best learning environments are those in which individuals are aware of all three perspectives.
FOOTNOTES
Authors stated no financial relationship to disclose.
REFERENCES
This article has been cited by other articles:
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  E. J. R. van Beek and D. E. Malone Evidence-based Practice in Radiology Education: Why and How Should We Teach It? Radiology, June 1, 2007; 243(3): 633 - 640. [Abstract] [Full Text] [PDF]
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 J. M. Winn and V. V. Grantham Using Personality Type to Improve Clinical Education Effectiveness J. Nucl. Med. Technol., December 1, 2005; 33(4): 210 - 213. [Abstract] [Full Text] [PDF]
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