Journal Club

Analyzing the concept of context in medical education. Koens F, Mann KV, Custers EJFM and Ten Cate OTJ. Medical Education 2005;39:1243-1249.

Reviewed by Starla Martinez, Northeastern Ohio University.

The issue and what is known about it so far:

In medical education circles we talk about the "context" of learning, and we generally mean either education that takes place in the classroom or in a clinical setting, with PBL being thought of as closer to the clinical setting than the traditional classroom. It has been suggested by PBL champions that students who learn basic science in a PBL setting are better able to apply their knowledge in a clinical setting compared to students taught in the traditional model.

What did the authors do?
These educators, from Utrecht, Holland, and from Halifax, Nova Scotia, first review what little information there is on context in medical education literature and discuss concepts such as same-context advantage (e.g. when a list of objects is memorized in a specific setting, the list will be easier to recall if the learner is in that same setting rather than another setting); independent versus interactive contexts; and the internal context of a learner (i.e. a learner's prior knowledge and experience informs how the learner responds to the current learning situation).

The authors then go on to identify three dimensions of context in medical education that have not previously been identified. They propose that these dimensions be considered when devising curricula or learning tasks. Two of their dimensions of context, the physical and the commitment/ motivation dimensions, are ones that are readily apparent to all of us when we give some thought to it, but the third I find a bit harder to see. The physical dimension is of course the physical environment in which learning takes place. The commitment/motivation dimension refers to a learner's desire to learn and willingness to put forth effort and depends not only on the learner but also on the perceived importance of the learning task (e.g. learning from standardized patient cases versus learning on the wards while caring for "real" patients.)

The third proposed dimension of context is the semantic/cognitive dimension, defined as "...where the knowledge of the learner and the information in the context, which can be used to perform the learning task, connect," and it includes the prior knowledge of the learner.

The discussion was particularly interesting and included ideas about the context in which basic science might best be learned. It also considered how being aware of these three dimensions might lead to studies that would answer some of the outstanding questions surrounding the issue of the best context for teaching basic science. One statement I found fascinating: "...it has also been suggested that PBL students are better able to apply their basic science knowledge to solving clinical problems. This may be true, but it is irrelevant if the application of basic science knowledge is seldom necessary in clinical practice." Wow! That is quite an important "if," don't you think?

Limitations and implications: The article is theoretical but not obscure and contains untested ideas, but it certainly made me think about context in our medical school and clerkship. It contains some very interesting ideas that required me to see medical education in a broader perspective, and it opens up new areas for research. I was most interested in the comments the authors made in regard to PBL in their discussion, but in actual fact I did not think the discussion related well to the body of the paper. In spite of that, I still found this a worthwhile article and recommend it to you when you want to exercise your powers of thought.

(Comment: I'm not sure I "got" the third context either. Certainly, we can be mindful of the fact that, on average, 85% of students who rotate through Pediatrics as clerks will NOT be either pediatricians or family physicians. Those 85% sometimes benefit from clarification of the importance of their Pediatrics experience as students. There may be some interesting studies on the effects of enhancing the "semantic/ cognitive dimension" for clerks, if only we knew what that was… Bruce Morgenstern)