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2013
2013; 35: 433–443
TWELVE TIPS
Enhancing learning approaches: Practical tips
for students and teachers
SAMY A. AZER
1
, ANTHONY P. S. GUERRERO
2
& ALLYN WALSH
3
1
King Saud University, Saudi Arabia,
2
University of Hawai, USA,
3
McMaster University, Canada
Abstract
Background: In an integrated curriculum such as problem-based learning (PBL), students need to develop a number of learning
skills and competencies. These cannot be achieved through memorization of factual knowledge but rather through the
development of a wide range of cognitive and noncognitive skills that enhance deep learning.
Aim: The aim of this article is to provide students and teachers with learning approaches and learning strategies that enhance deep
learning.
Methods: We reviewed current literature in this area, explored current theories of learning, and used our experience with medical
students in a number of universities to develop these tips.
Results: Incorporating the methods described, we have developed 12 tips and organized them under three themes. These tips are
(1) learn how to ask good questions, (2) use analogy, (3) construct mechanisms and concept maps, (4) join a peer-tutoring group,
(5) develop critical thinking skills, (6) use self-reflection, (7) use appropriate range of learning resources, (8) ask for feedback, (9)
apply knowledge learnt to new problems, (10) practice learning by using simulation, (11) learn by doing and service learning, and
(12) learn from patients.
Conclusions: Practicing each of these approaches by students and teachers and applying them in day-to-day learning/teaching
activities are recommended for optimum performance.
Introduction
In an integrated curriculum such as problem-based learning
(PBL), students are encouraged to use a wide range of learning
approaches that can enforce cognitive skills and the develop-
ment of competencies. This is particularly important in self-
directed learning and in meeting the learning outcomes
outlined in the curriculum. However, students might be new
to meaningful integrated learning. In most instances, they
come from educational systems that encourage rote learning
and teacher-centered approaches to learning. In such tradi-
tional systems, teachers deliver the contents in lectures and
students have to review what they were taught. The teacher
has to deliver the contents of his/her subject to the students,
and the students have to passively receive knowledge
transferred to them. This is not the case in an integrated
student-centered curriculum, where the students have to take
the lead in applying knowledge learnt, providing reasoning for
their actions, and demonstrating deep understanding of the
concepts discussed. These cognitive skills require from
students readjusting their learning approaches and developing
a number of approaches that serve this purpose (Azer 2008a;
McNamara 2010).
According to Biggs (1994), approaches to learning can be
defined as ‘‘ways in which students go about their academic
tasks, thereby affecting the nature of their learning out-
comes.’’ Students’ approaches to learning are viewed as
being responses to the learning environment. These
responses are dynamic and open to changes rather than
being fixed entities. They may change to a higher and more
sophisticated levels to match with the learner’s needs and
skills/competencies already developed. However, some
students might tend to adopt the same approach toward
different learning tasks. Changing learning approaches in
these students are related to their disposition to change or
their ability to adopt new learning approaches to their new
learning environment (Snelgrove & Slater 2003). The leading
work of Marton and Saljo (1976) has led to the identification
of levels for processing materials learnt by students that was
subsequently termed deep/superficial approaches to learning
dichotomy. A student using predominantly a superficial
learning approach tends to focus on factual knowledge and
memorization of fine details. On the other hand, a student
undertaking a deep learning approach tends to dig deeper
and examines the wide range of aspects related to what he/
she is learning. The subsequent work of Norton and Dickens
(1995) and Gibbs (1994) has shown that deep learning
approaches rather than superficial approaches tend to
promote academic success (See Figures 1 and 2). Deep
learning and the development of cognitive and noncognitive
skills aim to graduate students who are fit to join the medical/
health care workforce and able to provide safe practice and
high-quality care.
There is evidence from research that deep learning can be
taught and developed through training and practice. However,
Correspondence: Professor Samy A. Azer, Department of Medical Education, College of Medicine, King Saud University, P. O. Box 292, Riyadh
11461, Saudi Arabia. Tel: þ966542307075; fax: þ96614699174; email: azer2000@optusnet.com.au
ISSN 0142–159X print/ISSN 1466–187X online/13/060433–11 ß2013 Informa UK Ltd. 433
DOI: 10.3109/0142159X.2013.775413
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students will not move to adapt deep learning strategies unless
the assessment format aims at testing the understanding of
concepts and related cognitive and noncognitive components.
With these challenges in mind, we decided to write this article
to address students’ learning needs as well as present to
teachers and examiners a focused approach addressing
strategies for deep learning, the theoretical bases behind
them, and how to implement them.
To develop these tips, PubMed and MEDLINE were
researched using key words such as ‘‘Learning strategies,’’
‘‘deep learning,’’ ‘‘theories of learning,’’ ‘‘learning techniques,’’
‘‘analogy and learning,’’ ‘‘mechanisms and learning,’’ and
‘‘simulation and learning.’’ We also examined books and
resources developed by the Association of Medical Education
in Europe (AMEE) as well as explored our experience with
medical students in a number of universities to develop these
tips.
The 12 tips discussed in this article aim at enhancing skills
to explore a number of approaches that can enforce deep
learning. These tips are organized under three themes as
follows: Theme 1: apply specific techniques that foster deep
learning (Tips 1–6), Theme 2: master active learning (Tips 7
and 8), and Theme 3: practice learning beyond the classroom
(Tips 9–12). The article is useful to students and teachers
working with students to improve their learning approaches
(Box 1 summarizes these 12 tips).
Theme 1: Apply specific techniques that foster deep
learning
One student in a PBL group has just concluded his
presentation on the assigned learning issue:‘‘renal physiol-
ogy.’’ The remainder of the group members are overwhelmed
by the complexity of the material,copied from an abbreviated
‘‘review book,’’ and the next 20 minutes include uncomfor-
table silence and vague comments. The tutor is able to help the
students by first asking them a series of questions (Tip 1) that
probe the relationship between basic physiology and the
clinical findings of the vignette (which describes a patient
with acute tubular necrosis following an episode of septic
shock). The students engage in a thoughtful discussion, and
are able to laugh as they review humorous analogies for the
functional organization of a nephron (Tip 2). Following other
students’ learning issue presentations (on the mechanisms
and manifestations of shock, urinalysis 101, and microbiol-
ogy of gram-negative infections), the students are able to
synthesize all of the mechanisms in one master diagram (Tip
3) that explains the basis for all of the patient’s signs and
symptoms, and why the treatments were effective. While
constructing this diagram, they recognized the need to read
further about the pharmacology of certain antibiotics, and
resolved to explore this further in their peer-tutoring group (Tip
4), and they also acknowledged the limitations of the
references (including the review book) they used to research
Transfer of
knowledge to
students
Superficial
Learning
Learner’s brain
Figure 1. Superficial Learning: Leaning via transfer of knowledge to the learner’s brain without addressing the learner’s needs
and allowing the learner to interact with the knowledge addressed. (Modified from Azer SA. Kaohsiung J Med Sci 2009;25:
240–249).
S. A. Azer et al.
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their learning issues (Tip 5). Finally, at the end of the session,
they reflected on how they could have made their session more
efficient, and how they could have asked deep learning-type
questions earlier during the next session (Tip 6).
Deep learning, as reviewed by Heijne-Penninga and
colleagues (2010), involves active interest and engagement
in the subject and accomplishes understanding (including an
overview with outlines and structure), elaboration (including
critical appraisal and relating what is learned to other ideas),
and analysis (including finding the reasoning behind what is
said). According to Abraham and colleagues (2006), while
surface learning implies memorization of facts without a
genuine understanding of the subject, deep learning facilitates
recollection of factual details and drives lifelong learning. It
would seem ideal, therefore, if certain processes of small
group PBL that Visschers-Pleijers and colleagues (2006) have
found to be associated with effective discussions and deep
learning (including seeking explanations, integrating and
applying knowledge, and considering different perspectives)
could also be applied somehow to students’ learning. The next
seven tips are intended to promote deep learning.
Tip 1
Learn how to ask good questions
Questions are the keys for answers. Students need to learn
how to ask good questions to improve their deep learning.
Identify
Learning Needs
Plan their
Learning
Identify the
Resources they
Need
Search for
Answers from
these Resources
Ask Questions
Ask New
Questions
Look for
Relationships Look into the
Different Aspects
of an Issue
Construct New
Knowledge from
What They Learnt
Deep Learning
Apply Knowledge
Learnt to New
Situations.
Learner’s brain
Figure 2. Deep Learning: The learner here is central to the learning process. The design of teaching/learning material allows the
learner to think, ask questions, research issues, make decisions and construct new information from the resources he/she
researched. (Modified from Azer SA. Kaohsiung J Med Sci 2009;25:240–249).
Box 1. Summary of the 12 tips.
Theme 1: Apply specific techniques that foster deep learning
Tip 1: Learn how to ask good questions
Tip 2: Use analogy
Tip 3: Construct mechanisms and concept maps
Tip 4: Join a peer-tutoring group
Tip 5: Develop critical thinking skills
Tip 6: Use self-reflection
Theme 2: Master active learning
Tip 7: Use appropriate range of learning resources
Tip 8: Ask for feedback
Theme 3: Practice learning beyond the classroom
Tip 9: Apply knowledge learnt to new problems
Tip 10: Practice learning by using simulation
Tip 11: Learn by doing and service learning
Tip 12: Learn from patients
Learning approaches
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Although students are expected to know how to learn from a
text or how to research learning resources, students also need
to use strategic approaches that facilitate their research targets
and help them discover connections and relationships.
For example, students who usually use superficial or
shallow learning find it difficult to analyze knowledge learnt
or present new ideas. They usually find little value to reflect on
their learning. On the other hand, learners enforce deep
learning style when they raise questions, focus on under-
standing, look for relationships and conceptions, generate
hypotheses, construct complex mechanisms, provide reason-
ing and justification, and use evidence in making decisions.
This is usually fostered through asking good open-ended
questions as they research a learning resource.
Therefore, one of the elements of developing meaningful
understanding is to learn how to format good questions in
relation to what students want to learn (Graig et al. 2006;
Zhang et al. 2010). Identifying key questions and looking at
their depth, breadth, flow, and whether they address the basic
principles about what they really need to know is essential.
The more the learner is clear about what they need to know,
the more they are preparing themselves to undertake active
learning approaches. Refining these questions and putting
them in a logical sequence as students prepare their research
will help them to identify which resource to start with and
what they really want to know.
Why do students need to learn how to ask questions?
Asking good open-ended questions help students to:
.Make their research for a learning issue more focused.
.Evaluate the different aspects about a concept.
.Identify what they know, and what they did not know.
.Go deeper into an issue and develop a meaningful learning.
.Weigh supportive evidence for and against each hypothesis.
.Turn learning to a journey of discovery.
.Make a purpose for their learning.
How can questions reinforce deep understanding?
Questions can help in reinforcing deep understanding
when students aim at exploring a particular cognitive skill, for
example:
.Generating hypotheses: ‘‘What are the possible causes
for ...?’’
.Testing a hypothesis: ‘‘What if ...?’’ ...‘‘Are there relation-
ships between ...and ...?’’
.Reasoning: ‘‘How can I justify ...?’’
.Developing an enquiry plan: ‘‘What are my goals? What
approach should I take? What questions should I ask to
make a hypothesis less likely, more likely, or excluded?’’
.Interpreting findings: ‘‘How these findings are different from
normal? What do they mean?’’
.Examining a process: ‘‘What are the consequences of ...?
.Explaining: ‘‘How can we explain ...?’’
.Linking clinical changes with basic sciences: ‘‘What does
this relate to our knowledge about normal body ...?’’
.Critically evaluate: ‘‘What evidence do I have ...?’’
.Identifying key concepts learnt: ‘‘What is the take home
message?’’
.Identify learning needs: ‘‘What do I know?’’ ...‘‘What do I
need to know? How?’’
Tip 2
Use analogy
Analogies are used in science to explain difficult concepts,
establish relationships between components of a concept, and
enforce learning and application. Analogy involves a structural
alignment or mapping between domains, and aims at
providing learners with a familiar frame that they can use to
comprehend a more complex system. For example, Emil
Fisher’s famous lock-and-key analogy for the specificity of
enzyme action has provided scientific communities for over
100 years with a mental picture of molecular recognition
processes and deep understanding of the creative processes
involved in enzyme function (Lichtenthaler 1994). Johannes
Kepler used the analogy to develop scientific proposals and
raise important scientific concepts such as the earth and the
other planets move, rather than the sun. In one of his analogies
about planetary motions, he assumed that the planet
corresponds to the boat and the sun’s power to the river’s
current, referring to the role of sun in planetary function and
movement (Genter & MarKman 1997). A good number of
analogies have been described in the literature to facilitate
understanding of the cardiovascular system (Belloni 1999),
blood glucose control (Swain 1999), nerve conduction (Sircar
& Tandon 1996), and glycolysis regulation (Stavrianeas &
Silverstein 2005).
Why do students need to use analogy?
A well-constructed analogy:
.Allows learners to better understand the different compo-
nents of a difficult concept.
.Enables learners to take complicated issue/concept and
compare it to something simpler that listeners/readers are
familiar with and clearly understand.
.Covers three constraints: similarity, structure/function, and
purpose. A good analogy examines each of these
components and the similarity established between one
analog termed the source or base is more understood than
the second analog termed target. The illuminated simila-
rities provide the basis for analogical transfer, establish-
ment of relationships, and generation of inferences about
the target.
How can analogy help learners to explore meaningful
understanding?
By using analogy, learners can:
.Identify relationship between the familiar model and the
new information they are learning. The more this relation-
ship is well established, the more learners are able to
comprehend the function and structure of the new system
they are studying.
.Apply knowledge learnt in different real-life situations with
confidence (Busari 2000).
.Comprehend difficult concepts and how the different
components contribute to a particular function.
.Identify new questions in relation to the difficult concept
they are learning.
.Build on knowledge learnt and use the analogy in solving
similar problems.
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Tip 3
Construct mechanisms and concept maps
Learning is enhanced when the learners construct knowledge
learnt from several resources using their own sentences and
writing structure. They do not just summarize their findings or
put together pieces of information they collected, they rather
use innovative strategies to clearly present their new knowl-
edge in a meaningful way. Students might use originally
created flow diagrams, tables, labeled diagrams, mechanisms,
or a combination of more than one of these to construct their
new knowledge and present their research findings (Guerrero
2001; Azer 2005). A good approach is to construct the new
knowledge in a way that shows integration across disciplines,
logical flow, a balance between the big picture and fine details,
and enforces thinking processes as well as demonstrates deep
understanding. Therefore, in this process, the learner deliber-
ately seeks to organize his/her knowledge, incorporates new
knowledge learnt to what he/she possesses, and demonstrates
commitment to meaningful learning. The use of mechanisms
and concept mapping is a good example of construction of
knowledge, and integration of knowledge in an organized and
logical way (Guerrero 2001; Novak 2003). Construction of
mechanisms and concept maps requires a number of skills
from the learner, but their use in learning and in assessment
can strongly support meaningful learning.
Why do students need to learn how to use mechanisms and
concept maps?
Using mechanisms help students to:
.Identify areas that they do not know and need to understand.
.Construct knowledge and integrate knowledge from several
resources/disciplines.
.Explore disease pathogenesis and role of contributing
factors.
.Understand the processes involved in diseases, and
mechanisms by which medications work.
.Apply the principles learnt to delay the progress of a disease
(prevention).
How can mechanisms and concept maps reinforce deep
learning?
Mechanisms and concept maps can help in:
.Integrating knowledge from several disciplines.
.Identifying possible contributing factors.
.Ensuring logical sequence of a process/change.
.Ensuring that the problem is discussed at body system,
body organ, cellular, receptor, and molecular levels.
.Enabling learners to use mechanisms as a basis for their
prevention and management plan.
Tip 4
Join a peer-tutoring group
Several medical and health schools realized the value of peer-
teaching programs in improving students’ learning. The aim of
such programs is to enhance the development of learning
skills and interpersonal skills among undergraduate students.
While peer tutoring could make significant improvement on
learning of tutees, it also has benefits for the tutors. Such
programs have been evaluated and there is evidence that peer
teaching is appreciated by students and causes significant
changes on teaching and learning. For example, Sobral (2002)
found that acting as a peer tutor can be an appealing and
constructive educational opportunity to further students’
academic development. Peer tutors better understand the
learning needs of their fellow students than teachers do; since
they have recent similar learning experiences.
Why do students need peer teaching?
Peer teaching can:
.Help in developing a culture of learning in the college.
.Encourage active learning where students take a deep
learning approach.
.Enforce collaborative learning.
.Support students struggling with their learning.
.Provide a system of partnership in the learning process,
where the teaching and learning are owned by students.
.Enable students to develop transferable skills such as
communication, interpersonal skills, and time management.
How peer teaching can foster student’s learning?
Peer teaching can help in reinforcing deep understanding
by:
.Discovering gaps/inadequacies in their knowledge.
.Identifying misconceptions and correct them.
.Enhancing motivation to learning.
.Learning new skills.
.Using their time more effectively.
.Enhancing their learning skills, collaborative learning, and
discussion of difficult concepts.
.Improving their communication and interpersonal skills.
Tip 5
Develop critical thinking skills
Critical thinking is a purposeful process that involves self-
regulation, analysis, evaluation, interpretation, conceptual, and
methodological assessment as a learning approach. Recently,
critical thinking has been viewed beyond cognitive skills and it
is believed that it comprises two main components: cognitive
skills and affective domains of reasoning and attitude (Scheffer
& Rubenfeld 2000). This is because of complexity of processes
involved in critical thinking together with the oriental of mind
during critical thinking. Such views are supported by other
researchers (Simpson & Courtney 2002; Profetto-McGrath
2003).
What are the components of critical thinking?
According to Scheffer and Rubenfeld (2000), the two
components of critical thinking are cognitive skills and
affective dispositions, which are as follows:
.Cognitive skills: Discrimination, analyzing, predicting,
logical reasoning, information seeking, applying standards,
and transforming knowledge.
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.Affective dispositions: Intellectual integrity, open-minded-
ness, flexibility, contextual perspective, confidence, inquisi-
tiveness, reflection, creativity, and intuition.
Other researchers (such as Facione & Facione 1992)
identified interpretation, analysis, evaluation, inferences, expla-
nation, self-regulation for cognitive skills and truth seeking,
open-mindedness, inquisitiveness, and maturity for affective
disposition. While there might be some elements of connection
among these different domains, it is clear that these different
components/levels are integral in critical thinking development.
Why do students need to develop critical thinking skills?
Critical thinking skills enable students to:
.Develop their self-regulation, analysis, and interpretation
skills.
.Enhance their skills in cognitive and affective dispositions
discussed above.
How can students develop their critical thinking?
Critical thinking is a skill that can be developed by students
gradually as they keep practicing and working on it. So the
willingness of the learner to focus on such approach and work
on it is vital.
.Readjusting their learning approaches from memorization to
critical thinking.
.Continuous training and working on tasks that can reinforce
students’ critical thinking.
.Using learning resources that encourage learner’s skills such
as interpretation of findings, analysis, inferences, explana-
tion, and application of knowledge. These resources may
include computer-aided learning programs and interactive
e-cases.
.Receiving feedback on performance and working with
colleagues who share with you a passion about exploring
critical thinking in their learning.
.Understanding that such skills are part of continuous life-
long learning and continuous development.
Tip 6
Use self-reflection
Self-reflection is a metacognitive process that can occur at all
stages of an encounter: before, during, and after. It helps the
learner to understand both the self and the situation (Azer
2008b; Sandars 2009). Reflection is a process that can be
controlled and regulated by the learner with the purpose of
developing various training strategies and enhancing the
learning process. The awareness about the self and the
situation through reflection will enable the learner to recognize
underlying personal values and benefits that are represented
as professional attitudes and the development of self-efficacy.
The continuous practice of reflection along these lines will
help learners to develop a number of skills including planning,
practicing experiential learning, and changing their future
responses to align with the professional attitude. Although a
recent study by Lew and Schmidt (2011) found that self-
reflection has caused limited improvement in students’
academic performance, there is evidence that reflection can
help learners to:
.Become self-regulated and life-long learners.
.Review their group learning process and their own personal
input in their groups.
.Improve their learning as it is the case in experiential
learning (Kolb 1984). According to Kolb, there are four
phases: in the first phase, the learner has an experience; in
the second phase, the learner reflects, which in turn leads to
the third phase where the learner makes attempts to
understand their actions or reactions to the experience. This
usually leads to identification of learning needs and skills
that need to be acquired before facing a similar situation. In
phase four, the learner applies what he/she has learnt. This
four-phase cycle may be repeated several times with the
purpose of improving the learner’s performance.
.Relate new knowledge to prior understanding.
.Help them assess their own progress in learning and
critically analyze their achievements.
Theme 2: Master active learning
At a future meeting of this tutorial group, students resolve
to approach a clinical problem by consulting a wider array of
resources beyond just the abbreviated review book – in order
to insure up-to-date information and more specific answers to
their questions about the mechanisms underlying clinical
symptoms (Tip 7). More comfortable with the learning
environment and with admitting gaps in knowledge, the
students actively solicit feedback from the tutor and from each
other (Tip 8).
Active learning requires active participation of students in
different learning activities that have been carefully designed
in the curriculum (Gleason et al. 2011). The aim is to facilitate
student engagement, enhance relevance, and improve motiva-
tion for learning and self-directed learning. Therefore, active
learning necessitates making changes to the learning environ-
ment and shifting control from the teacher to the learner.
Tip 7
Use appropriate range of learning resources
Too often students rely in their learning on memorization of
factual knowledge and the use of mnemonics to retain
information, but these strategies are not sufficient for deep
understanding of difficult concepts. Students need to make use
of more effective learning strategies such as the use of a wide
range of learning resources to explore more aspects about
particular concepts or learning issues. Students can be tempted
by the efficiency of using a narrow selection of learning
resources. As medical schools have moved from prescribing
readings for students to expecting them to identify their own
learning resources, this has become a more problematic area.
Students need to identify resources that can help them learn
and meet their objectives: different resources will be helpful
for different needs. In addition, information and learning needs
change as students advance; it is important to have a realistic
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understanding of what resources are useful at what stage, and
for which purpose.
Moving beyond knowledge of basic concepts, students
begin to search out learning resources in the clinical realm –
textbooks in the clinical disciplines, published review papers,
and increasingly available Internet videos on medical topics
including procedures.
These learning resources may include e-case packages,
multimedia, journal articles, review papers, textbooks, educa-
tional Web sites, YouTube videos, museum, plastinated
specimen, bed-side teaching, outpatient clinic, rural services,
lecture notes, and so on. Some of these resources are already
embedded in the curriculum and the day-by-day teaching/
learning activities. What is more important to the learner is
how to get the best out of each of these learning resources,
and how to build links between these learning resources and
learning needs. Two areas of importance at this stage are to be
able to evaluate information, and to be able to apply
population-derived research to individual patients. Students
are often eager to use clinical resources before they have
grasped the fundamental concepts; for example, using
summary books, which have been prepared for final year
students or graduates preparing for exams can lead to
memorizing lists of differential diagnoses, or presenting signs
and symptoms to the detriment of developing conceptual
understanding. The use of a wide range of appropriate
learning resources could help students in:
.Self-testing and facilitating the process of long-term recall
through repeated testing (Larsen et al. 2009).
.Assessing their knowledge and what they already know and
exploring new aspects of interest to them.
.Engaging students more efficiently to expand their self-
directed learning and find more answers to their questions.
.Enabling students to compare and contrast between what
they learnt from a particular learning session and what they
have discussed in other learning resources. The new
knowledge could help students to construct concept
maps, integrate and synthesize information.
.Providing students with opportunities to explain important
processes/concepts orally and in writing.
.Allowing students to revisit what they were taught, organize,
relate new knowledge, and explain how topics fit together,
and how to relate fine details to a key scientific principle.
.Enabling students to self-regulate their learning: plan,
monitor, and evaluate their own learning (Sandars &
Cleary 2011). So some of their learning resources could
be designed in a way that allow them to develop their self-
directed learning, self-monitoring skills, and how to ask
good questions as they prepare for their learning. For
example, ‘‘What do I really know about this area?’’ ‘‘What
do I need to know?’’ ‘‘What learning resources should I
use?’’ ‘‘Do I need to do any further research?’’
Tip 8
Ask for feedback
Early on in medical training, students should be exposed to
feedback as a routine part of quality improvement and quality
control in our healing profession (Norcini 2010). Students may
appreciate learning that teams of professionals entrusted with
peoples’ lives (including airline pilots and well-functioning
surgical teams) must regularly debrief about how they are
functioning and to discuss areas where improvement may be
needed. Students may also benefit from imagining what
problems may arise if people in an airline cockpit or operating
room fail to give each other feedback in a way that jeopardizes
safety. It has been well shown that practice alone without
coaching and feedback does not lead to improvement in
performance and the development of expertise (Ericsson et al.
1993). ‘‘Feedback,’’ which is different from ‘‘evaluation,’’
involves the objective, nonjudgmental description of perfor-
mance, particularly in relation to the expected standard, and
should take place frequently in order to be meaningful and
effective in facilitating performance improvement. Feedback is
for the benefit of its receiver.
Understandably, ‘‘feedback’’ often generates some degree
of anxiety for students (as well as teachers). Students may
perceive a lack of time or inapproachability of teachers as
barriers to feedback (Milan et al. 2011). We suggest that, given
the importance of feedback, students should assume an active
role in engaging their teachers in the process of feedback,
through regularly asking for feedback and attending any
forums where the topic of feedback is discussed. We suggest
that, early in the course, students and teachers should engage
in a discussion that sets the stage for regular, expected
feedback. This discussion should address specifics, such as:
when will feedback occur (e.g., at the end of each session, at
the end of each week, etc.); how feedback will be recorded if
at all and what happens to any documentation of feedback;
and how to ask for or give feedback at any time that it may be
necessary. This discussion should help to build a relationship
between the student and teacher that enables honest commu-
nication to occur in both directions, for the benefit of the
learning environment and (ultimately) future patients.
Constructive feedback can also be used by teachers to
enhance active learning strategies. This is mainly through
fostering two-way communication, creating a healthy environ-
ment between teachers and learners, and promoting student’s
comprehension and meaningful learning.
Theme 3: Practice learning beyond the classroom
At another future meeting, the group revisits a case of
cardiogenic shock and because of their previous deep
learning, they are actively able to sketch a tentative
mechanism explaining how the patient’s left-sided heart
failure results in abnormalities on the urinalysis (Tip 9). In
the simulation lab that accompanies this case vignette, they
also review the mechanics of cardiopulmonary resuscitation
that were discussed in the problem-based case (Tip 10), and
in their community medicine and clinical skills preceptor-
ships, they are able to interview patients who have
experienced a myocardial infarction (Tips 11 and 12).
With deep learning and consolidation of learning around
real-life experiences, they were able to perform well in their
end-of-course exams.
Learning from standardized simulated patients and from
real patients adds important components to medical and health
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student learning. Also, recent technologies have changed the
face of learning and allowed learners to learn beyond the
classroom. Tablet computers facilitated mobile learning and
enabled learners to link with their peers, and work collabora-
tively from a distance. The Internet, Google, YouTube,
Facebook, and other Web 2 modalities provided students
with a range of learning resources that they can research at any
time and add to by sharing materials they have created. In
future, teleconferences may enable students from two
institutes in two different countries to debate issues, discuss
cases, and share their learning experiences.
Tip 9
Apply knowledge learnt to new problems
Learners might need to always think about what they are
doing. Are they just trying to remember factual knowledge or
are they using a number of cognitive skills to foster their
understanding by applying knowledge learnt.
Why do students need to apply knowledge learnt to new
problems?
Applying knowledge learnt helps students in:
.Integrating knowledge learnt from several disciplines.
.Exploring relationships.
.Practicing a number of cognitive skills such as comparing,
analyzing, evaluating, hypothesizing, looking for evidence,
linking basic sciences to clinical presentation, questioning,
examining possible contributing factors, studying pathogen-
esis, explaining, identifying gaps, referring to the literature,
researching several resources, interpreting findings, and
designing a management plan.
.Examining the significance of basic sciences in clinical
situations and real practices.
.Enhancing deep understanding.
.Discovering inadequacies or gaps in their understanding.
As future physicians, responsible for dealing with complex
problems, students must move beyond simply remembering
factual knowledge to applying, or transferring, this knowledge
to new situations. Deep learning involves the practice of a
number of cognitive skills. During the initial encounter of a
new problem, these skills include analyzing, hypothesizing,
looking for evidence, comparing, evaluating, questioning,
interpreting findings, and examining contributing factors; and
during the study of new knowledge, subsequently applied to
the problem, these skills include searching the literature,
studying pathogenesis, linking basic sciences to the clinical
presentation, explaining, designing a management plan, and
identifying further gaps in knowledge.
How can students develop their skills in applying knowl-
edge to new problems?
We recommend that specific process be routinely applied
in order to insure that knowledge is integrated and applied to
new problems in a manner that exercises these aforemen-
tioned cognitive skills. In a PBL curriculum, students may wish
to organize their initial discussion of a problem around ‘‘facts,’’
‘‘problems,’’ ‘‘hypotheses,’’ (generated from previous knowl-
edge of disease entities and mechanisms) ‘‘additional
information desired,’’ and ‘‘learning issues.’’ When applying
newly researched learning issues back to the original problem,
students may wish to use structured tools, such as case
diagrams (Guerrero 2001) to integrate knowledge; to specifi-
cally describe the mechanisms behind clinical symptoms and
treatment interventions; and to identify further gaps in
knowledge (leading to challenges in constructing parts of the
diagram).
Students should also be encouraged to review their
performance as they try to apply knowledge learnt to new
problems. They may ask themselves questions such as ‘‘What
did I learn from this experience?’’ ‘‘Why did I miss to provide
the correct answer?’’ ‘‘Did I miss understand the question?’’
‘‘Do I need to read and check my resources again in regard to
this particular area?’’ and ‘‘I do remember studying this part but
this case is not typical as the examples I studied. What did I
learn so far?’’ Such questions could enhance the learner’s
strategies and learning outcomes as he/she apply knowledge
learnt to solve new problems. In fact, applying knowledge
learnt by students to solve new problems is one of the key
elements for enhancing deep understanding and learning skills
in general (Metcalfe 2009).
Tip 10
Practice learning by using simulation
Simulation involves the replacement of live patient encounters
with either standardized patients or technological devices that
mimic a clinical situation and that may employ mannequins,
videogame technology, or full environment approaches
(similar to cockpit training for pilots). A recent review by
Okuda et al. (2009) concluded that learning through the use of
simulators may improve medical knowledge, comfort and
competency with procedures, teamwork and communication,
and (potentially) clinical outcomes. The effectiveness of
simulation derives from principles of adult learning, including
motivation to solve problems, building on previous experi-
ences, and active involvement in the learning process.
Simulation is an ideal way to accumulate the required practice
necessary to attain expertise, always bearing in mind the
importance that this practice requires coaching and feedback,
or deliberate practice (Ericsson et al. 1993).
Ideally, students can solidify deep learning through the use
of simulation. However, there may be limitations to the
optimal use of simulation resources in medical learning,
including limited availability (depending on institution) or
inconsistent access, particularly if students in a self-directed
curriculum (where there are other competing activities) must
take some of the initiative to access resources. Given the
potential benefits of simulation and the reality that simulation
will play a growing role in licensure and certification in
medical education (Levine et al. 2012), we strongly recom-
mend that students, early in their medical training, thoroughly
familiarize themselves with available resources (including
online resources, as they become more and more available)
and maintain discipline in regularly accessing resources that
are relevant to their curriculum.
S. A. Azer et al.
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Tip 11
Learn by doing and service learning
Students do not develop expertize just by being bright and
absorbing information like sponges. Rather, active engage-
ment and practice allows them to move along a path toward
mastery. Learning by doing is an educational theory describing
the utility of fostering skill development and the learning of
facts in the context in which those facts will be used (Schank
et al. 1999). However, in practical terms in medical education,
this concept refers to the notion of a learner involvement
during the learning process, rather than passive reception.
There is evidence from research that students could master
their learning skills when they engage themselves in activities
that are sufficiently difficult to promote mental effort, but not
so difficult that could inhibit their desire to learn (Snelgrove
2004). Therefore, students could work on tasks that require
them to fill in and listen to lectures, research resources, and
consult with others to complete these tasks. The tasks may be
prepared by faculty or embedded in computer learning
resources which are recommended as a learning resource.
Why do students need to learn by doing and service
learning?
Learning by doing and service learning have several
educational benefits including:
.Fostering responsibility, accountability, and caring for
others.
.Extending students’ learning from classroom learning to
community services.
.Enabling students to develop skills that are less likely
developed in traditional modes of learning. These skills
include contributing to public safety, environmental protec-
tion, and public education about common diseases and
healthy living habits.
.Enabling learners to experience the exact meaning of
learning and how service learning could add new dimen-
sions to their learning experience.
To complete these tasks, students will need to construct
information collected from multiple learning resources and
present their work to their small groups for further discussion.
The stimulus for students is to exert greater mental effort and
through a desirable level of task difficulty, students could make
their learning more memorable.
Learning should not solely in the classroom. Service learning
provides an excellent opportunity to students to learn by doing
as well as develop their skills, knowledge, attitude, and
professional values. Service learning also allows students to
meet identified needs in the community and establish links
between the community and academic/clinical learning.
Tip 12
Learn from patients
Finally, learning from patients provides students with a
number of educational opportunities that cannot be substi-
tuted by other teaching modes such as simulation, e-case
packages, paper-based cases, or clinical skill lab. The aim of
student interaction with patients is not just to learn how to take
a medical history, conduct a clinical examination, or make a
diagnosis, it is a unique opportunity to learn how to
communicate effectively with patients, become patient-
centered in approach, and build rapport with patients. The
importance of these skills is often ignored by students and less
emphasized in the day-to-day clinical teaching. Therefore,
learning from patients in bedside teaching and outpatient
clinics brings a number of teaching and learning opportunities
(Wang-Cheng et al. 1989; LaCombe 1997). These can be
summarized as follows:
.Allow students to gain first-hand experience of doctor–
patient relationships.
.Enhance the development of patient-centered care. The aim
is not just how to make a clinical diagnosis, but also how to
address the human impact of disease, understand illness,
and engage the patient to take control of their condition.
.Enhance students’ competence in taking a medical history
and examining real patients.
.Experience the reality of clinical practice and challenges
that could face doctors and patients on day-to-day practice
(e.g., this is completely different from experience with a
simulated).
How can students maximize their learning from patients?
Be helpful to patients and attend to their comfort. Do not
rush.
.Learn how to use nonverbal cues (both giving and
receiving) in your communication.
.Engage the patient in the discussion, convey empathy to the
patient’s concerns, and use open-ended questions.
.Avoid the use of medical jargon, use simple language and in
a direct manner.
.Be sincere, honest, and interested in talking to the patient
about their ideas, emotions, and expectations rather than
just asking them to listen to their hearts or take a medical
history.
.Ask permission from the patients before examining them.
Once you complete your examination, thank them, and
leave them to have some rest.
.Be sensitive to cultural and educational differences in the
way you communicate, build rapport, and express positive
attitude.
.Ask a colleague to give you feedback on your communica-
tion and approaches with patients.
.Reflect on your experiences with the patients: ‘‘What did
you learn?’’ ‘‘What type of challenges did you face?’’ ‘‘How
did you handle these challenges?’’ ‘‘What will you do
differently next time?’’ and ‘‘Why?’’ (Lew & Schmidt 2011).
Conclusions
We sincerely hope that these tips will provide students with
concrete tools to achieve deep learning through: a dissection
of information through questions, analogies, mechanistic
maps, group learning, and critical and reflective thinking;
active learning using a variety of resources and feedback and
debriefing; and application of learning beyond the classroom –
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to new problems, service learning settings in the community,
and ultimately, real-life patients.
Notes on contributors
SAMY A. AZER, MD, PhD (USyd), MEd (UNSW), FACG, MPH (UNSW), is a
Professor of Medical Education and the Chair of Curriculum Development
and Research Unit, College of Medicine, King Saud University. He was the
Professor of Medical Education and Chair of Medical Education Research
and Development Unit, Faculty of Medicine, Universiti Teknologi MARA,
Malaysia. Formerly, he was a Senior Lecturer in Medical Education at the
Faculty of Medicine, Dentistry and Health Sciences, the University of
Melbourne and the University of Sydney. Over the last few years, he has
conducted a number of training workshops to students on learning and
how to enhance their learning approaches. He is one of the Associate
Editors of BMC Medical Education and in the Editorial Board of
MedEdWorld, UK.
ANTHONY P. S. GUERRERO, MD, is Professor of Psychiatry and Clinical
Professor of Pediatrics at the University of Hawaii at Ma
¯noa John A. Burns
School of Medicine. He is currently the Interim Chair for the Department of
Psychiatry and the Director of the Child and Adolescent Psychiatry Division
and Residency Training Program. He was formerly the Associate Chair for
Education and Training and Director of Medical Student Education in the
Department of Psychiatry. He regularly tutors problem-based learning for
first-year medical students in their very first module. He is actively involved
in national and international problem-based learning initiatives in the
specialty of child and adolescent psychiatry.
ALLYN WALSH, MD, CCFP, FCFP, is the Chair of Student Affairs, and
Professor of Family Medicine, in the Michael G. DeGroote School of
Medicine, McMaster University, Canada. Formerly, she was the Assistant
Dean of the Program for Faculty Development of that institution, and has
written guides for tutors in PBL as well as programs for clinical teaching in
health sciences education. She regularly conducts workshops for teachers
and she teaches across the spectrum of medical education. She is actively
involved in Canadian and international initiatives geared to enhancing
medical education at all levels.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of the article
The work was supported by College of Medicine
Research Centre, Deanship of Scientific Research, King Saud
University, Riyadh, Saudi Arabia
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