MEDICAL EDUCATION

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Notes for Primary Care Teachers

SELF-DIRECTED LEARNING: WHAT IT IS, AND HOW TO PROMOTE IT

LEARNING WITH UNDERSTANDING

Learning comprises of both what is learned as well as how it is learned. It is important to note that ‘how’ one learns essentially determines whether or not ‘what’ is learned will become part of a learner’s collection of knowledge (‘long-term memory’) or is discarded soon after its use (‘short-term memory’).²

In the practice of medicine, some knowledge will need to be stored as long-term memory whereas information that is easily accessible need not be stored. However, students must learn appropriate information handling skills to access this at the point of care.

Let us take as an example of a patient in general practice. Azima, aged 22 years, attends the clinic seeking treatment for a prolonged fever of a two-week duration. For a successful consultation, the attending GP will need to derive the possible diagnosis and differential diagnoses as well as the required relevant investigations. This usually is from long-term memory. However once the diagnosis is confirmed, the GP may refer to a current drug formulary to verify the most effective drug of choice for Azima. This may be a drug that is used infrequently (short-term memory).

Sometimes the GP may have inadequate knowledge of an essential subject matter. For example, as in Azima’s case, the GP may have forgotten about less common infectious diseases which cause prolonged fevers. The GP should then take the opportunity to read on this topic from a relevant textbook or a review article as soon as possible. SDL is more effective when linked to a recently encountered patient problem.^{5, 17} Therefore, learning with understanding, i.e. deep learning, aids long-term retention of knowledge.

READING THE SELECTED SUBJECT EFFECTIVELY

The collection of medical information multiplies in large quantities each year. Learning to be selective is an essential skill. Students should have at least one current core text book as a reference for each of the major subjects that they are studying. As a general guide, students must refer to the course guidebook of the course for which they have signed up, e.g. dermatology in family practice, primary care orthopaedics, vocational training programmes, etc. Ideally, students should own a personal copy of relevant core texts.

Next, the student must be clear of the purpose of study so as to read effectively. The student should ask “Why am I reading this?” Is it for general interest or is the student in pursuit of specific information? If the student is aiming to do some essential reading, the following frequently-suggested SQR4 approach may be useful (Box 2).⁵

Box 2: The SQR4 Approach

THE SQR4 APPROACH

Take as an example a patient Linda, aged 43-years-old, in a general practice clinic who seeks advice about her risk of developing breast cancer. Linda’s mother was diagnosed with breast cancer and died from metastatic disease at the age of 56.

The student decides to read up on the genetics of breast cancer and factors that may affect the risk of developing this condition and choose to read a British Medical Journal review article titled ‘ABC of breast diseases: Breast cancer–epidemiology, risk factors, and genetics’ by McPherson K et al.⁹

The student can read and apply the SQR4 approach as follows:

1. Scan through the article to see what the sub-headings are.
2. Look for the summary and read it through, identifying the main points and discussions that have been covered.
3. Ask “What do I want to get from this reading?”
4. Read the introductory paragraphs. These would ‘set the scene’.
5. Then, read the sections and sub-sections, actively identifying the main ideas in each.
6. Link this to the patient i.e. Linda in this case. Ensure understanding regarding how the patient’s issues are related to the facts or thoughts in the chapter.
7. Summarise periodically. It is important to pause and list the main ideas in the section being read and check that the important points have not been missed out and that the ideas have been understood. Encourage note-making along the way.
8. Then review the whole topic when finished by scanning through the notes.
9. Relate what has been read to other areas of knowledge. For example, prior knowledge of genetic predisposition for instance in an earlier patient seen with a family history of colonic carcinoma will reinforce the repertoire of knowledge in this area of medical genetics.

In the above approach, there is an emphasis on relating the material in each section to other material. Research has shown that new material is more readily learned when this can be slotted into a framework of previously-acquired knowledge.⁴ So as one learns, one must relate the new information to earlier-learned facts (review point 9 above). When this is done, it reinforces the newly gained knowledge as this is built on what has already been learned.

Should students encounter a similar situation in the future, they will readily recall what they have learned – the student has now learned to integrate their learning. Consequently, learning during medical practice will be most effective if their reading is done around patients that have been seen day-to-day.

The use of personal learning plans and portfolio-based learning are methods that have been recommended to develop effective learning. These could aid deep-learning. Portfolio-based learning and assessment has already been addressed in this series. Another effective study technique used to improve factual recall of written material is mind-mapping. Some of these methods are described below.

PERSONAL LEARNING PLANS

A Personal Learning Plan (PLP) or learning contract is a description of what a student wants to learn about and how they will go about it. It encourages the student to identify what needs to be learned, why they need to learn it and how they are going to learn it. The PLP also identifies how they will know when they have learned it, the time frame they are going to learn it as well as identify how their intentions link to past and future learning.⁷

Basically, the PLP assists the student to document and put into motion, in a structured way, their plan to learn when they encounter an event or incident that made them think about what needs to be learned. An important aspect of a PLP is that the student is in control. The student identifies something that needs to be learned, then thinks how to do it and proceeds to do it. The student should then reflect on whether the process was useful and resulted in any change. To enhance this process, students should share their PLPs with their mentor (trainer) who can provide support, guidance and challenges when necessary. In Appendix 1, an example of a PLP template adapted from the Association for Medical Education in Europe (AMEE) Guide is given.