Journal Club

Delva DM, Kirby J, Schultz K and Godwin M. "Assessing the Relationship of Learning Approaches to Workplace Climate in Clerkship and Residency" Acad Med 2004;79:1120-1126.

Reviewed by Leslie Fall, Dartmouth Medical School

While the goal of medical student education is to foster independent, self-directed, lifelong learning, little research has focused on the effect of the workplace on learning styles during the clinical training years. Previous work with pre-clinical medical students, nurses, and practicing physicians demonstrated that high workload is associated with a "surface/disorganized" learning style, while a supportive-receptive and choice-independent workplace is associated with "deep/organized" learning (see paper for definitions but it is safe to say that surface/disorganized is not a style we hope to promote). To further investigate, the authors surveyed all 532 medical students and 2,939 residents in the 5 medical schools in Ontario, Canada, using a modified, previously validated Approaches to Work Questionnaire, containing 30 questions about approaches to learning and 15 questions about perceptions of workplace climate. The combined response rate was 47.3% (student-only response rate not reported). The findings in this study were similar to those studies of other groups noted above. Of note, interns were most likely to adopt a surface-disorganized approach to learning, and medical students perceived less support in the workplace than did residents. Significant differences were noted among various specialties. (Pediatrics was not broken out specifically). The authors conclude by stating that these relationships may indicate that teachers may be able to positively affect learning and perceptions of a busy workload through specific modifications of the workplace. The authors raise interesting questions about the effect of one's intrinsic learning style on specialty choice, and the role of age and experience in modifying one's learning style in a given work environment.

The attempt to balance the service and educational components of clinical training has always been a difficult task for medical teachers. Not surprisingly, this study demonstrates a clear relationship between a high workload and adoption of ineffective learning styles, particularly for interns. I like their suggestion, however, that modification of the student and resident work environment (i.e. more learner choice, increased support by the teacher), may "lighten the load" of a busy service. Hmmm, sounds like a good point for faculty development!

(This wasn't an easy paper to read. Like Leslie, I wasn't surprised by the findings. I was stuck that it doesn't make a difference what the faculty see as "the workload." Learning styles are dependent on how the students/residents perceive the workload. So, regardless of our views of comparative workload (e.g. When I was a resident I didn't get to leave after 24/30 hours), our ability to promote a more effective learning style (and perhaps more efficient patient care style) depends on acknowledging learner perceptions and supporting learners through their perceived challenges. Have you been dismayed when students demand "Just tell me what's on the test?" Or ask for the answers to the vignettes - why should they spend time finding the answers when we(the faculty) know where they are? As I've aged, I've thought of this as a generational problem (those youngsters, you know and perhaps a sign of laziness). Now I have to consider that somehow the learning environment we have created is overtaxing and the students are doing what we all do - falling back to a superficial/disorganized approach. Perhaps its time to investigate the students' perspectives on workload and pilot some interventions that will help them move to the deeper/integrated learning styles we all hope to promote. Any ideas? Karen Marcdante)