Stephen H. Sheldon, DO
Ardis L. Olson, M.D.

With the definition of specific learning objectives in the general pediatric core curriculum, clerkship directors need to consider the student's role in self study.Some topics of learning might be best taught in formal didactic sessions, but other topics might be assigned to the student for independent work. The student also needs to develop clinical problem solving skills for common pediatric problems. The effectiveness and efficiency of independent learning methods influence both the approach to life-long learning and the astuteness of diagnostic skills.

Two different types of independent learning will be discussed: 1) Student self-directed learning, which is defined as learning where the student is responsible for independently determining what details to learn to answer the question or clinical problem, and 2) student self study which is a more limited concept, where the student is told specifically what to read independently to learn specific information. As an example, Problem Based Learning (PBL) is based on student self-directed learning. Each type of learning has a role in medical education but should be actively chosen as a learning method, not occur by default.

It is easy to assume that students in the clerkship understand how to learn independently in clinical settings. Many medical students have not really mastered independent learning. Thus, the transition to the clinical clerkship year, while exciting because of the patient contact, can befrustrating, confusing, andstressful. Two major factors seem to contribute to the development of these problems: 1) persistence of learning habits which may have been efficient in pre-clinical instruction, but become quite inefficient and ineffective in the clinical sciences; and 2) previous experiences where passive approaches to learning were rewarded.Indeed, student habits of formal learning have been shaped by experiences well before entry into medical school.A premium has been placed on grades, test scores, and the teacher directing the experience.

During early childhood development, as well as in adult education, another type of learning known as discovery learning is critical.Unfortunately, aside from the earliest years of education, discovery learning takes a back seat to traditional didactics.Discovery learning still continues in most informal education outside the classroom.It occurs during self-directed solutions to everyday problems.One continues to learn how to learn from day-to-day activities and to gain rewards which are internalized.This informal curriculum is written by situation and circumstance and the problems which need to be solved.The learner is motivated to seek the knowledgenecessary to solve these "life-skill" questions.The reward issolvinga problem skillfully and efficiently, not the grade or diploma.With time the reward system is internalized.Learning continues in this manner in parallel to formal medical school education with external rewards of grades and formal lectures continuing. Transition to the clinical years requires the student to make a sudden change from a teacher-centered, knowledge based curriculum to learning situations where limits of learning are no longer strictly defined by the teacher, but instead by patients' problems.Now knowledge is required tosolveclinical problems of diagnosis and treatment,and not just to answer questions on an examination or to obtain a grade in a course.

Student-centered, problem-based discovery learning is not unique to the clinical clerkship.In fact, most students are typically quite good at problem-solving and learning on the path to problem resolution.Foremost is an understanding of the processof learning through problem solving.Through behavior modification, habit development, and thought processing, new and different life-long learning styles emerge. The rapidly expanding knowledge base in medicine demands efficient continuing education (both formal and informal).Learning styles must be adapted so the busy practitioner/student can keep up-to-date on changing content and practices.

It is not easy for the medical student to develop internal rewards.Unfortunately, in most medical education systems conflicting messages are given to students by requiring grades in clinical courses and demanding performance for appropriate numbers on objective examinations.Significant difficulties are created for the student.Prior to the clinical years, students and teachers have gained comfort from obtaining acceptable grades.The assumption was that good grades translated into a guarantee that the student learned what the teacher thought necessary.However, educational success is measured during the clinical years in unfamiliar ways.New and less structured learning feedback systems require a significant degree of maturity on the part of the student.

One of the most important aspects of learning from solving clinical problems is the establishment of clear learning objectives in the domains of attitudes and professional conduct, skills and cognitive knowledge.Expectations must be provided to the student at the beginning of the learning experience.These objectives and goals also become the basis for formative and summative evaluations.Goals and objectives provide a format for continuous feedback and reinforcement as well as for self-evaluation. Using the curriculum as a map, the clerkship program can provide self-learning resources specific to these objectives that students can choose to utilize to meetobjectives (computer programs, reprints, audio or videotapes). In addition, checklistsand clinical experience logs may be used to help students meetnon-negotiable objectives. For example, one program uses aneonatal learning checklist¹.Students can also develop self-directed, negotiable objectives, thereby expanding learning which is now open-ended and only defined by the patients' problems, rather than artificially structured by the covers of a book or teacher's assignment list.

Every patient encounter is a learning experience for the student.Regardless of the problem or the frequency of presentation, something can be learned from every patient situation.The successful clinical student first establishes what he/she wants to learn from the encounter.These learning issues are guided by the goals and objectives for the clinical rotation.The objective may be broad-based and general (e.g., how to obtain a reproducible systems review in a school aged child), or may be very specifically focused (e.g., what immunizations are indicated in a 6 month old youngster).Basic science issues, clinical science issues, diagnostics and management issues may be addressed.During the patient encounter, the student can be taught to use the followingsteps of clinical problem-solving² which generate further specific learning issues:

Initial assessment : With the presentation of the patient complaint in the encounter, identification of the patient situation and perception of certain cues leads quickly,and oftenunconsciously, to the generation of initial hypotheses.This initiates the process and guides the direction of inquiry, making history-taking and performance of physical examinations diagnostically purposeful.

Problem formulation and development of a plan of inquiry : Specific inquiry tests initial hypotheses by first using searching questions. These arehistory items thatsupport or refute specific diagnostic entities hypothesized.Scanninghistory items complete the history by comprehensively searching for other significant information that may not be detected with searching questions. Scanning questions provides completeness and affords the student time to think.Both forms of inquiry involve aspects of the history of present illness, systems review, family history, social history, and past medical history.After the historical data is obtained problems are clarified and the hypothesis set is revised and prioritized.

Clinical exam : The physical examination isperformed next using clinical skills to continue to test and reorganize the remaining hypotheses.

Conclusions : Closure occurs with the student committing to afinal definition of problems and their differential diagnosis. Diagnostic and therapeutic plans are then formulated.

During the process, notes should be taken so that the student may "go to the books" later and learn what is necessary to better manage the patient's problem.New knowledge can then be applied back to the patient and future patient encounters.As an example, the student may generate the following learning issues from an encounter with a patient about to undergo a tonsillectomy and adenoidectomy:1) position of the tonsils and adenoids and adjacent structures; 2) function of lymphoid tissue; 3) mechanism of action of preoperative medication; or 4) indications and contraindications of tonsillectomy and adenoidectomy. In an ambulatory setting with numerous shorter encounters, the student may develop a learning list throughout the day to explore further and then discuss with his preceptor.

Understanding this learning process is extremely important for both teacher and learner in uncovering the steps in clinical problem-solving. Efforts should be made in exposing students to self-discovery learning prior to and during the clerkship. Various methods are available. The use of non-clinical problems can be helpful to separate medical content from process. Sherlock Holmes mystery stories have effectively been used as one method to teach the clinical reasoning processes³. Students also need the opportunities during the clerkship to verbalize their changing hypotheses and reasoning at each stage of inquiry rather than just giving the final differential diagnosis. These can occur in case seminars, attending discussions or problem-based learning seminars.

Within a student-centered problem-based curricular structure, lectures, conferences, and seminars are still vitally important. Didactic presentations provide a familiar and comfortable structure and can prioritize information, provide broad concepts and visual information as well as integrating clinical and basic science information. This background can be a resource to the student's discovery learning. Faculty and residents also have a major role in reinforcing independent learning. Is the student able to generate the questions to investigate further? If they are assigned to research a patient related topic, does anyone ever ask them what they learned? Discussion of the student's reading helps the student clarify the key concepts as well as encouraging further investigation. Similarly, the clerkship director needs to be sure there are opportunities to integrate the assigned clerkship readings into clinical care.

In conclusion, student self-directed learning is multi-faceted and involves more than assigning students to read textbooks and learn independently. Rather, independent learning includes: 1) the guidance of broader goals and objectives, 2) clinical problem-solving methods that help students define the questions and seek out the knowledge, and 3) broad clerkship support of clinical self-directed learning with both resources and faculty reinforcement.

REFERENCES

1. McCurdy FA, Weisman MC, Teaching newborn medicine to third-year students: use of a checklist. Arch. Pediatr. Adolesc. Med. 149: 49-52. 1995.
2. Barrows HS, Tamblyn RM. Problem Based Learning: An Approach to Medical Education. Springer,New York. 1980.
3. Sheldon SH, Noronha PA. Using classic mystery stories in teaching. Academic Medicine 65: 234-235. 1990.