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University Dental Hospital of Manchester, UK
Correspondence: J. Sandler, Outpatients Suite 2, Royal Hospital, Calow, Chesterfield S44 5BL, UK. Email: JonSandler{at}AOL.com
Abstract
Developments in teaching and learning have implications for every orthodontist. This paper describes some of the theories of teaching and learning that have led to a quiet revolution in higher education. Developments have included the incorporation of self-directed and problem-based learning concepts, together with a more active and interactive role for the learner. The importance of these changes for orthodontic education is discussed.
Key words: Clinical photography, Gold Standard, Angle Society
Introduction
Traditionally medical and dental education has been delivered by a combination of didactic teaching and an apprenticeship to learn clinical skills. Dental students were required to memorize facts and demonstrate skills to reach an acceptable standard at terminal assessment. This style of teaching encouraged the learner to adopt a surface approach to learning where memorization was more important than understanding. The emphasis was on curriculum coverage and not on ensuring students had the skills needed for life-long learning and continuous professional development.1,
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Active learning, in contrast, is a process of engaging with the learning task at both the cognitive and the affective level, in an attempt to foster and develop learning skills for life. The emphasis in teaching style moves away from didactic lectures to small group, student-led interactive teaching. Central to adult learning is the notion of personal motivation, and one of the core skills of teaching is the ability to maintain, develop, and utilize this personal motivation.3 Much of current teaching practice is supported and encouraged by these ideas and the introduction of active learning in dental education requires an evolution, rather than a revolution. The aim of this paper is to provide an update on theories of teaching and learning.
How do we learn?
Learning has been defined as a relatively permanent change in behaviour of the learner.3 This can be demonstrated when students are able to show that they have gained insight, realization, facts, or new skills.4 There are a number of theories on how we learn and we will give a brief résumé of these:
Constructivism
Constructivism is a philosophy founded on the premise that by reflecting on our experiences we construct an understanding of the way our world works. A new experience or fact must be put in the context of that understanding; hence, our bewilderment when something challenges our construct:
Well I never knew that!
According to constructivism students must build on their prior learning and development occurs through problem-solving experiences shared with someone else, usually a teacher, but sometimes a peer. Constructivism also tells us that we learn by fitting in new understanding and knowledge by extending or supplanting old understanding and knowledge. Without changes or additions to pre-existing knowledge and understanding no learning will have occurred. 5
Ideas about student learning including ‘experiential learning’ and the use of ‘reflection’ are based in constructivism. Since students learn through interaction, curricula should be designed to emphasize interaction between students and the learning task.
Andragogy
Knowles6 developed the concept of andragogy ‘the art and science of helping adults learn’. Andragogy is considered to have five principles:
In the andragogical perspective the adult learner is self-directed and needs an active learning environment. Hence, the teacher is viewed as a facilitator of the teaching and learning process, and less as the sole source of information. A facilitator should act as a guide, but must ensure that the aims and objectives of the learning task are met.
These concepts are not without their critics who question the need for more longitudinal research to understand how periods of self-direction alternate with more traditional forms of educational participation in adults'; autobiographies as learners.7
Zone of proximal development
This was introduced by Vygotsky.8 The theory describes a students' ability to perform a task in the presence of the teacher that would not have been possible alone. As the student gains in confidence, experience, or knowledge, the teacher becomes more passive and eventually can withdraw. Vygotsky believed that what a student can do with teacher support today, he/she will be able to do alone tomorrow and he defines intelligence as the capacity to learn through instruction. This appears to accord with the old surgical adage of ‘see one, do one, teach one’. The zone of proximal development will, however, vary between individuals so teaching and learning environments need to provide a range of activities to allow students to influence their own learning. Students should be able to go at their own pace, within defined limits. Changes in the zone of proximal development can be seen during students’ progress through a postgraduate orthodontic programme. They change from being inexperienced and needing significant teacher support to being independent specialists at the completion of the programme.
Learning cycle
Using ideas from Piaget9 and Bruner,10 Kolb built on the constructivist theory to develop the idea of ‘experiential learning’. He believed ideas were not fixed but are formed and re-formed through ‘experience’. Kolb represented this idea as the Kolb learning cycle11 (Figure 1). He believed that our experiences are followed by a period of reflection, which leads to the formation of abstract ideas or concepts to solve our problems. This leads us to test our hypothesis with the result that new experiences are assimilated. This continuous process means educators need to focus on imparting learning skills, rather than facts.
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Reflective learning
Schon12 suggested students should become more adept at observing and learning through reflection on the artistry of their own profession. Reflection on practice between the student and teacher should occur. This has implications for learning through clinical practice, as there can be conflicts between clinical and educational needs. The students need a safe environment to apply knowledge in orthodontics and discuss the merits of alternative options, but the patient also needs to make satisfactory progress through treatment and feel they are in ‘safe hands’. It is important, therefore, to provide time for reflection where teachers’ and students’ interaction is not influenced by the presence of patients or parents.
Learning styles
Honey and Mumford13 described learning styles in a four-fold classification: activist, reflector, theorist, and pragmatist. Gaining an understanding of learning styles will help both students and teachers to accumulate knowledge more efficiently. They are a description of the attitudes and behaviours that determine a preferred way of learning for an individual:
Observational learning
Also called the social learning theory, observational learning occurs when an observer's behaviour changes after viewing the behaviour of a model. The observer will imitate the model's behaviour if the model possesses characteristics that the observer finds attractive or desirable, and the behaviour change is more likely if the model is rewarded in some way. Learning by observation involves four separate processes: attention, retention, production, and motivation.14 The implication for trainers in orthodontics is that their behaviour will have a highly significant influence on their trainees. This can be seen on clinic where, years later, we repeat ‘phrases’ used by our teachers.
How do we teach?
Kember15 synthesized a body of research to suggest two broad orientations of university teacher (Table 1). These two groups were teacher-centred/content-orientated and student-centred/learning-orientated. Ramsden2 simplified these conceptions as:
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Teaching as telling
The traditional didactic lecture is a representation of this perspective on teaching, where the teacher has the knowledge and the students are passive recipients of knowledge from the speaker. The focus is on the speaker who must be an ‘expert’ in the field in question and may take pride in the charismatic nature of his/her delivery. Lecturers who use this theory will attribute failure to learn as faults in the students as they conceptualize the relationship between what the teacher does and what the student learns as an intrinsically unproblematic one.2
Didactic teaching may have a role to play for large groups of learners, for revision of material, or presenting something new. Didactic teaching style can also be appropriate for comparing and contrasting different points of view or linking new material from a number of different sources.3
Teaching as organizing student activity
In this model teaching is no longer seen as transmission, but it is also about dealing with students activity to improve learning. The focus is still on the lecturer and their teaching techniques, and implies that improvement in the teaching technique would improve the learning outcome for the student. Sadly this is not always the case.
Teaching as making learning possible
In this model teaching is comprehended as a process of working cooperatively with learners to help them change their understanding. Teaching here involves finding out about student misunderstandings, intervening to change them, and creating a context of learning, which encourages the student to engage in application of new knowledge. Learning is a process of applying and changing the students' own ideas, it is something the student does, rather than something that is done to the student.2
Problem-based learning
In problem-based learning (PBL) the students are faced as a group with a problem, usually of a clinical nature. The group must identify the relevant learning objectives cued from the problem and then find the information needed to address these. The gaining of knowledge is more important than ‘solving’ the problem. The teacher is present as facilitator and must not supply the answers as would be the case in a traditional seminar. The role of the ‘teacher’ in PBL is much more difficult as they must guide the learners to ensure the learning objectives are met, but must not organize the learning, as this must come from the students themselves. In this form of teaching, the lecturer loses their traditional role as the source of all knowledge. If the group are functioning effectively it may seem that the facilitator is ‘not doing anything’.
Functions of teachers
Squires16 has identified 10 functions that teachers can do for learners that they may find difficult to do for themselves (Table 2). Teachers on didactic programmes must have good subject knowledge and be effective communicators. As active learning is introduced a range of new skills and understanding are required, in addition to this expertise as the teacher must also be able to encourage the learning process.
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The primary implication for teaching and learning in orthodontics is the development of active involvement for the learner. Encouraging students to find information for themselves, share this with the group, and reflect on the information that can be used to solve a problem is most likely to require deep level processing and thinking, and hence lead to knowledge that is retained in the long term.4
The implication of adopting active learning on an undergraduate orthodontic programme will vary between schools. Some schools have enthusiastically adopted PBL, yet it is ironic that a profession that demands adherence to scientific method swung so strongly in favour of PBL, despite evidence that the difference in learning outcomes in its favour were small indeed.17 Norman18 suggested graduates of PBL schools appear to have a comparable or slightly inferior knowledge base, but are primarily distinguished from their peers on didactic programmes as having a less jaundiced view of the undergraduate experience. Chadwick2 has described the adoption of active learning on an undergraduate orthodontic programme through a variety of teaching techniques, including problem-based learning, computer assisted learning (CAL), chair side clinical teaching, and a work book for students to complete at their own pace.
The theories of teaching and learning support some of the present teaching activity in postgraduate orthodontic education. Postgraduate students should build on their prior knowledge of orthodontics, but at the start of the programme they will need intensive support on clinic. Didactic teaching techniques can be useful to provide a framework on which postgraduate students should be encouraged to develop their own ideas. Short diagnostic tests using clinical records that students examine for a limited time and then must present to the group together with proposals for treatment is supported by theories of teaching and learning as are student led seminars. Orthodontic programmes will vary in their proportion of active, interactive, and didactic teaching and learning opportunities.
If the aim of active learning is to change learner behaviour and equip students with skills needed for life-long learning then adjustments to the teaching on orthodontic postgraduate programmes will not be enough on their own. It is a challenge to the specialty to adapt assessment strategies to ensure cognitive knowledge and clinical skills are tested, but the wider aspirations of student learning are not forgotten.19 Traditional assessments that have been found in many professional examinations, do little to encourage the range of behaviours and skills developed through active learning, which is unfortunate as learner behaviour is often driven by assessment.
Who should teach orthodontics?
It is clear from the discussion of teaching and learning presented above that being a subject expert does not automatically make that expert a good teacher. Without an understanding of the way adults learn and the concepts of teaching theory the expert will simply repeat the teaching process that they underwent themselves. This is particularly apparent in medical and dental education, where the didactic lecture with clinical slides is the standard format for much of the teaching given to both undergraduate and postgraduate students.
Help to equip specialists for a teaching role is available from a variety of sources. These range from university-based programmes for lecturers to higher education courses leading to a certificate or diploma to short courses such as the Training the Trainers course at the Royal College of Surgeons of England.3 In the same way as we would not consider a weekend course adequate to train an orthodontist, short courses, although a good starting point, cannot alone create a good teacher. The Training the Trainers course is a distillation of the teaching and learning theories outlined above, and these have been used to provide practical advice for the teacher to improve their own teaching style, but an understanding of learning and the importance of reflective practice take time to develop. Opportunities exist to undertake courses leading to certificates or diplomas, and membership of the Institute for Teaching and Learning (ILT). These enable the teacher to explore and reflect on teaching and learning theory, and how it should impact on course design and delivery. Reflective practice is crucial for the teacher to be able to recognize the strengths and weaknesses of the students' learning experience. These principles are equally important if orthodontic auxiliaries, undergraduate, and postgraduate students are to have appropriate learning environments.
Conclusions
References
1 Biggs J. Student Approaches to Learning and Studying. Haworth: Australian Council for Educational Research, 1987.
2 Ramsden P. Learning to Teach in Higher Education. London: Routledge, 1992.
3 Harris D, Peyton R, Walker M. Training the Trainers: learning and teaching. London: Raven Department of Education, 1996.
4 Chadwick SM, Bearn DR, Jack AC, O'Brien KD. Orthodontic undergraduate education: developments in a modern curriculum. Eur J Dent Educ 2002 (in press).
5 Fry H, Ketteridge S, Marshall S. A Handbook for Teaching and Learning in Higher Education: Enhancing Academic Practice. London: Kogan Page, 1999.
6 Knowles M. Andragogy in Action. Houston: Gulf Publishing Co., 1984.
7 Tuijnman AC (Ed), International Encyclopedia of Adult Education and Training. Oxford: Pergamon, 1995.
8 Vygotsky LS. Mind in Society: the development of higher psychological processes. Cambridge: Harvard University Press, 1978.
9 Piaget J. The Psychology of Intelligence. London: Routledge and Kegan Paul, 1950.
10 Bruner JS. Towards a Theory of Instruction. Cambridge: Harvard University Press, 1966.
11 Kolb DA. Experiential Learning. Englewood Cliffs: Prentice-Hall, 1984.
12 Schon D. Educating the Reflective Practitioner: toward a new design for teaching and learning in the professions. San Francisco: Jossey-Bass Publishers, 1987.
13 Honey P, Mumford A. The Manual of Learning Styles. Maidenhead: Peter Honey, 1982.
14 Bandura A. Social Foundations of Thought and Action: a social cognitive theory. Englewood Cliffs: Prentice Hall, 1986.
15 Kember D. A reconceptualisation of the research into university academics' conceptions of teaching. Learning and Instruction 1997; 7: 255–275.[CrossRef]
16 Squires G. New Model of Teaching and Training. Hull: Geof Squires, 1994.
17 Schmidt HG, Dauphinee DG, Patel VL. Comparing the effects of problem-based and conventional curriculum in an international sample. J Med Educ 1987; 62: 305–315.[Medline]
18 Norman GR, Schmidt HG. The psychological basis of problem-based learning: a review of the evidence. Acta Med 1992; 67: 557–565.
19 Bearn D, Chadwick SM, Sackville A. Orthodontic undergraduate education: assessment in a modern curriculum. Eur J Dent Educ 2002 (in press).
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