The Education Cycle

The notion that broad concepts of the process of learning can be described as a cycle is not new. Pattinson and Matthews⁵⁸ recently applied it to wilderness medicine while planning a mountain medicine curriculum. As depicted in Figure 105-3, the program director first makes an assessment of the needs of the learners; he or she gets to know the audience. Next is the often-underestimated task of establishing tailored and focused learning objectives. The educator then selects teaching methods and settings that best accomplish the objectives while meeting the needs and expectations of the learners. Finally, after the experience, the educator makes an assessment to ascertain whether learning has occurred. This final step may be the most difficult and least attended of all. These elements will be addressed later.

FIGURE 105-3 The education cycle.

Experience-Based Learning

Kolb’s model⁴¹ of learning is based on how individuals internalize and process learning experiences. Learners perform an action, referred to as a “concrete experience.” They then process the new information by “reflective observation.” Next they consider how the new information can be applied to their unique circumstances by “abstract conceptualization.” Having internalized the experience, they try it by “actively experimenting” with what they have learned to apply it in new and unique ways. This model is reflected in several of the teaching and assessment techniques discussed later, especially those that address concrete skills.

Education and the Human Organism

Setting the conditions for learning can be conceptualized by using Maslow’s famous explanation⁴⁸ of how humans address fundamental needs. Vella’s work^71,73 in popular education extends these ideas to the realm of education in the social context but still deals with the rudiments of human nature.

Unmet physiologic needs, such as warmth and hunger, tend to impair learning as the human organism prioritizes toward survival. Unfulfilled security needs, which Vella⁷¹ refers to as safety, distract from any process that does not pose an immediate threat. In adult education, safety issues may be subtle. Students who do not feel free to voice opinions or reveal a deficiency may be said to lack a safe learning environment. Identification with a group of learners addresses the need for belonging that is used by organized team sports and the military. The need for self-esteem may be met by recognition for academic achievement in front of one’s peers. Finally, the highest level of Maslow’s concept, self-actualization, is represented by satisfied expectations on the part of the learner. By expanding these concepts and directly addressing each in the classical hierarchical fashion, a program director can remove many obstacles to learning during the planning phase of the educational experience. A learning event that accounts for them will have a high likelihood of success and impact the student’s life well beyond the experience.

Learner Sophistication

Another powerful tool available to teachers is the identification of the level of understanding, or “sophistication,” of the learner. Neal Whitman proposed four levels that learners traverse as they acquire new knowledge and skills. Correctly matching teaching methods to these will improve the overall experience by saving time and increase the likelihood of fully meeting expectations.⁷⁵

Most people begin the education journey at the level of being “unconsciously incompetent” and do not know enough about the material to know what they do not know. After a time, they become “consciously incompetent” as they gain an appreciation for the amount and nature of the information they will have to master. Next they become “consciously competent,” in that they know how to perform the skill or can use the information but not yet with efficiency or at the level of mastery. The final stage, that of the teacher, is becoming “unconsciously competent.” At this level the learner becomes so practiced at the skill and the understanding is so well internalized that it can be performed to standard without consciously focusing on process. The learner simply knows what to do.

Principles of Androgogy

There have been numerous efforts to roll learning theories together into a concise package of tools for health care education. To this end, the work of Malcolm Knowles is widely read and often cited by education academics. He put structure to the concept of helping adults learn and called it “androgogy.” He suggested that through the principles of androgogy, adult learners are most successful when they are assisted in the process rather than directed through it.³⁹ Knowles made five basic assumptions about adult learners from which he derived his principles. They can be summarized as follows: (1) Adults tend to have internally and not externally focused motivations for learning; (2) The learning process should be related to solving real-life problems; (3) Existing knowledge and experience greatly influence learning; (4) Self-direction improves the learning experience; and (5) Adults learn best with problem-based rather than subject-based methods. Knowles’ seven principles of androgogy are summarized in Box 105-1.

Learner-Centered Education

Jane Vella has applied learning theory in unique ways to the social context across different cultures. She recognized that education lay at the heart of many social issues. The teacher’s message is often lost in the delivery because of avoidable cross-cultural and interpersonal obstacles. She maintains that the key to adult learning is clear dialogue between the teacher and learner.^71–72 Educators too often fail to establish productive dialogue and hence select ineffective teaching approaches. Vella suggested that traditional hierarchical teacher-student roles be discouraged. Teachers become facilitators. Barriers to dialogue are “addressed and eradicated.” She offered to popular education a paradigm that places the learner at the center of the educational universe. Her principles link theory to practical use in a way that enables learning in challenging circumstances. Vella’s principles are summarized in Box 105-2.

Learning-Oriented Teaching Model

Cate and associates⁹ recently published their notion of a model of teaching based on concepts from educational psychology. Their proposals are meant to influence all aspects of adult education, especially those of curriculum design, teaching techniques, and teacher assessment. An attractive feature is a method to “inventory” and match teaching and learning styles to improve outcomes. The authors build a model around what they identify as the “components of learning” and the “amount of guidance” that learners require to navigate the experience. Their premise is that, because education seeks to enable people to “function independently,” the process should foster self-regulation of learning. In the model, learners mature from “externally guided” learning through “shared guidance” to self-guided or “internally guided” learning. This applies to both cognitive (what to learn) and affective (why to learn) components of learning.

Putting It All Together

Theories and models are meaningless without practical application. Directly applying ideas from theorists with diverse backgrounds and agendas into the realm of wilderness medicine education is difficult. Kaufman³⁸ recently reviewed several adult education theories in the context of health care education. He examined them for key areas of commonality and offered simple principles to “guide” medical educators as they think about and plan educational experiences (Box 105-3). Wilderness medicine educators can easily adopt these.

Lecture

Lecture is the most often used educational technique. It offers several important advantages. Large amounts of information can be delivered in relatively short periods of time. Planning is generally easier for the lecture format. It requires little logistic support and only one teacher. It works well for highly technical information that the learner will most likely have to study again in order to internalize. Lectures can be easily enhanced with audiovisual aids. All of this adds up to a degree of efficiency that is highly attractive to the resource-limited educator. In one small but interesting study, Reed⁶² illustrated that, despite the availability of highly technical and resource-intensive teaching methods, a simple “low-cost, low-tech” lecture approach can offer rewards in terms of improved skill performance (Figure 105-4, online).

FIGURE 105-4 Despite limitations, lecture remains a valuable method of teaching because of the flexibility and efficiency it offers.

(Courtesy James R. Liffrig.)

The lecture technique has several equally important disadvantages. Learning is highly dependent on the delivery skill of the teacher. Because it is passive, many adult learners do not respond as well to this approach. It is generally accepted that levels of retention of material presented by pure lecture are lower than more active teaching techniques.⁶⁷ There is generally limited opportunity for hands-on applications and practice. Thus the usefulness is limited in some areas of wilderness medicine that are largely skills oriented. The more restricted the opportunity for student questioning and dialogue, the less effective this technique becomes. Students can often more effectively learn by themselves information to be presented by lecture. Brookfield⁸ discussed methods to enhance the lecture as a means to communicate information (Box 105-4).

Problem-Based Learning

A highly effective trend in health care education is the use of problem-based learning (PBL). PBL can take various forms, but generally learners are presented with a problem and are guided through a structured discussion that leads to a preestablished solution. This learner-centered approach has proven popular among students and demonstrates comparable outcomes when compared with other, more traditional formats. An interesting aspect to PBL is that student-led experiences tend to be more highly favored among participants than those facilitated by faculty, yet the outcomes remain at least comparable in terms of satisfaction and examination scores.^29,66

PBL offers great versatility to the curriculum planner. It can be used whether the focus is on acquiring pure fact-based knowledge or practical skills. It is most often applied in the small-group setting and therefore may pose logistic challenges in some space and resource-limited settings. It complements the strengths of small-group learning in that it reinforces communication and problem-solving skills, teamwork, individual responsibility for learning, and the need to share knowledge.⁷⁷ It tends to give the best results when it is structured and forces learners to use critical thinking skills. It fosters the process of analysis, organized problem solving, and decision making using group discussion to direct and reinforce learning. The general format for PBL is presented in Box 105-5.⁵

Case-Based Learning

Case-based learning (CBL) is a subtype of PBL that is extremely useful in wilderness medicine education. It makes use of several powerful aspects of theory to solidify learning. This method improves outcomes over pure lecture for certain types of material. Many of the skills-oriented topics in wilderness medicine can be easily presented through scenarios and cases. The teacher can easily modify case scenarios to suit various learner levels, styles, and objectives. It can be modified for learning experiences in the field setting because, if properly planned, it requires minimal logistic support.

This technique motivates the learner because it is directly relevant to the reasons for which they sought the experience. It offers an automatic sequence and information source for presentation, because cases flow in accordance with actual or simulated events. The teacher generally facilitates discussion and assists the students with understanding and methods to organize information. Clinical problem-solving styles can easily be demonstrated.

Scenarios and Role-Play

Scenario-based and role-play training is familiar to prehospital emergency care educators but less widely used in traditional medical education. It maximizes many of the strengths of newer approaches to adult education because it guides self-motivated students through a process of “discovery” of the information.⁴⁵ The main role for teachers in this format is to facilitate, not direct, the learning process.³⁰ Being an expert in the clinical details of each case is less important than understanding how to apply problem-based learning. This method is often scripted and makes use of actors, props, and moulage to simulate real-life situations. The logistics of carrying out this aggressive training technique may be prohibitive to some programs, but the investment is worth the effort in terms of improved outcomes and retention of knowledge by learners. Nearly all organizations that train prehospital wilderness medicine practitioners use some form of complex case- or scenario-based learning program. The use of role-play has benefits beyond the teaching and development of technical skills. One recent randomized controlled trial confirmed the utility of using role-play when teaching technical skills in the area of communication. The authors of this small study of 36 medical students randomized to learn a skill with and without role-playing concluded that, although there were no differences in technical performance between groups, the introduction of role-play as a training method enhanced the realism of technical skills training and led to better patient-physician communication⁵³ (Figure 105-5).

FIGURE 105-5 Wilderness medicine education provides many opportunities for scenario-based training using role-playing.

(Courtesy Fred Baty.)

Subject-Based Learning

The term subject-based learning (SBL) is a euphemism for traditional teacher-centered techniques of presenting information. The student in an SBL setting is the passive recipient of instruction rather than an active participant in the learning process. SBL methods typically present information by broad topic in a mainly lecture-based format. Health care curricula designed around SBL tend to be redundant, because broad topics may deal with the same or similar types of information. For example, a traditional medical school first-year basic science curriculum will have a series of lectures on pharmacology, biochemistry, pathology, and microanatomy. Each will incorporate specific material on diabetes presented by different departments. The student may have to wait a year to receive a session that focuses on diabetes that incorporates elements of pharmacology, biochemistry, pathology, and microanatomy.

Although SBL has a role, most health care educators have incorporated more learner-centered techniques, such as PBL, into their curricula. The main drawback of SBL is that by favoring efficient delivery and lengthy, complex curricula, it often fails to take advantage of features in adult learning theory that are known to lead to higher rates of retention and deeper learning.

Discussion

The technique of discussion is a versatile and highly effective teaching tool that is rooted in behavioral science. People learn better when the information is presented in ways that challenge them to process it in more than one way. Although not as efficient as lecture in terms of the quantity of information that can be delivered, it offers advantages to the wilderness medicine educator when teaching problem-solving skills and broad concepts that can be applied to many types of scenarios. Students readily internalize material because they have to intellectually manipulate it in various ways. The information is introduced, processed, and discussed. Students modify their own notions and then formulate solutions based on their new internal constructs of the problem. Learning is guided by the facilitator-teacher and reinforced by the group, which is all going through the same process and adopting a similar problem-solving skill set.

There are two basic modes of discussion-based learning.⁴³ The Socratic questioning method challenges students to identify the most important features of a specific problem and then reconstruct it using general principles that are the true focus of the discussion. Developmental discussion approaches the problem in parts. It keeps all students focused on one part at a time and takes advantage of the group setting to ensure that teaching points are addressed.

Teacher-facilitators may highlight the discussion with the powerful tools of analogy, discovery, and induction to stimulate learning and ensure retention.¹⁶ Analogy illustrates concepts by asking students to visualize using examples with which they are already familiar. The process of discovery leads students through a sequence of steps from the most basic to the more complex to guide them to the final goal of deeper understanding of the principal learning objective. Induction asks students to take general lessons from specific examples or experiences, make comparisons, and draw new conclusions relevant to the learning objective. These three techniques can be applied in any setting that involves learner interaction with the teacher.

Small-Group Learning

The selection of a teaching method is highly influenced by class size and quantity of information that must be learned. Large classes that must digest substantial amounts of information tend to push faculty into selecting passive modes of teaching. The traditional CME conference at which hundreds of attendees review highly technical material is an example of this. However, passive, lecture-based methods are not the most effective and often not the most efficient for all types of learning, especially in wilderness medicine. It is now widely accepted that skills-based learning presented in a small-group setting is a better way to teach practical skills⁴⁴ (Figure 105-6, online).

FIGURE 105-6 Education conducted in small groups may enhance learning in many areas of wilderness medicine because it is an active process in which all learners participate.

(Courtesy James R. Liffrig.)

The problems inherent in teaching large groups can often be overcome by adopting a combined approach. In this strategy, the information is delivered in parts to the entire group. Learners are then broken into small groups to conduct activities that allow them to discuss it, use it, and solidify learning. There is usually a more favorable teacher-to-learner ratio and greater self-direction of learning by the group.

Wilderness medicine offers ample opportunity to use the combined approach and the pure small-group venue for teaching. Both rely upon the process and mechanics of group experiences. The simple act of breaking a large group into smaller groups does not constitute small-group teaching. This method requires skill and experience with group processes on the part of the educator to avoid pitfalls that detract from learning. When done well, small-group learners take away solid lessons and the strong relationships that they had to build to get them. If done poorly, learners walk away dissatisfied with negative attitudes toward learning, the setting, and the discipline.

To understand group learning is to understand how the individuals within the group interact.

Bruce Tuckman’s original concept of the developmental sequence of small groups should greatly influence how teachers plan and conduct these activities.^26,36,69,70 The general strategy for teachers is to become familiar with the stages, recognize their manifestations, and use a planned approach that gradually releases control of the teaching process to the group as members become more able to direct their own learning.

Group members get acquainted and become oriented to the setting during the forming stage. Student anxiety may hinder learning as interpersonal dynamics take shape. Students tend to adopt a passive mode of learning. They respond best during this stage to a more directive teaching style with clearly defined expectations and structured events.

During the storming stage, the group’s identity begins to take shape among some members, while others continue to seek individual goals over those of the group. Dissent may be voiced about leader- or teacher-directed tasks. Teachers should demonstrate strong but patient leadership to move through this stage without alienating group members. They should openly encourage support for group-generated goals.

The group identity solidifies during the norming stage. Individual ownership of group goals and a greater affinity for teamwork are hallmarks. As they gain a sense of safety, members in their interactions with other participants display genuineness. Leadership tasks should be directed to group members. Learning activities, such as role-play and case discussions, become most useful.

During the performing stage, the teacher acts only as a resource for the group that has developed to a point of relative autonomy. The group is able to plan and conduct its own activities, as well as make self-assessments in an organized and productive fashion. Energy is spent on learning rather than on the interpersonal mechanics of the process.

The role of the teacher in a small-group setting should be oriented toward facilitation of learning rather than direct delivery of material. However, the teacher remains accountable and cannot take a completely hands-off approach and expect that objectives will be met. By attending to the details of process, the teacher ensures that the learners do not have to perform this task. The teacher creates the proper learning environment and keeps the process on track. Some common mistakes made by small-group “facilitators” include the following: the teacher presents a lecture; the teacher talks too much; students do not participate unless prompted or directly questioned; the students lack preparation for the session (e.g., prereading); there are overbearing, domineering students; and participants want to be provided a quick and simple solution to the problem rather than engage in the process of group discovery.³⁵

Despite not being part of the learner group, the teacher has great influence over the process and the outcomes. A poorly prepared teacher ignores the internal dynamics of the group and sets up the experience for failure. Some techniques available to avoid these problems include: agreed-upon rules for the conduct of sessions; clearly stated tasks and objectives; use of the rhetorical method of questioning to stimulate thinking; taking a lengthy pause after posing a question, allowing students to answer; not offering immediate solutions or guidance unless participants appear to be taking the wrong path; attending to body language and mannerisms of all participants, both when they are speaking and when they are listening; addressing the entire group, rather than a single student, with mannerisms and eye contact.³⁵

The general steps in preparing for and conducting small-group teaching are summarized as follows:

Small-group learning is a rewarding and highly effective method of teaching. It requires preparation and experience. The characteristics of small-group learning make it the teaching method of choice for many wilderness medicine educational activities, especially when combined with other techniques such as simulation, scenarios, and case presentations.

Distance Learning

Distance learning, traditionally provided via correspondence courses, has taken an entirely new direction. With proliferation of the Internet, more people than ever find it possible to further their education without physically entering the classroom. A little-used tool in wilderness medicine education is web-based distance learning. It has found widespread application in other academic areas such that health care educators have embraced many of the benefits of this rapidly evolving tool.

The advantages that the Internet offers to medical educators are many. Even courses that are not offered as complete web-based packages can be supported by limited Internet applications such as e-mail, distribution of materials, enrollment, needs assessments, and testing. To this can be added videoconferencing, discussion boards, live topic-specific chat rooms, and presentation of live events via video streaming. Nearly any software application that can be used on a home computer can be offered in some fashion over the Internet. With the advent of high-speed connectivity and constantly changing security programs, obstacles to efficiency and learner security have been minimized. Virtual learning environment software enables all of these applications to be managed efficiently while keeping the focus on the learner and not the technology.³²

The ability to hyperlink from any web page brings an entire world of web-based information to the learner with a few clicks. The speed and degree of access that modern learners have to information create implications for adult education that theorists never imagined.

For all of its attraction, the Internet is not a panacea for wilderness medicine education. There are two main disadvantages. First is the need for learners to posses sufficient computing power to allow for rapid and efficient downloading and presentation of course materials. This is made worse when they travel to remote locations. Perhaps the biggest drawback to web-based learning in wilderness medicine is its dependence on technology and the support that goes with it. Large organizations that offer this approach find it necessary to hire full-time support staff to provide a comprehensive and reliable product. Many wilderness medicine educators find it difficult to dedicate the resources necessary to bring it to full implementation. However, even small organizations find great usefulness in some applications.

For many wilderness medicine topics, passive approaches to learning, such as distance learning online, suffice to deliver information. It is up to the student to embrace the style and internalize the material. Basic science and clinical topics that can also be taught in lecture format with audiovisual aids work well when presented online. However, much of the body of wilderness medicine knowledge, especially that dealing with the prehospital phase of care, is largely experiential and requires direct interaction with other people.

There are numerous ways that education can be delivered online. The two broad categories are pure distance learning and the hybrid web-based course. In a completely web-based program, all course work, materials, sessions, and assessments are transmitted via the Internet; even assistance from teachers occurs by e-mail or live message applications. This method is a true virtual learning experience. Alternatively, many organizations offer hybrid online courses in which students use Internet applications as an additional tool to complete portions of the course but are required to participate in periodic face-to-face sessions.

Many health care practitioners involve themselves in wilderness medicine because of the fellowship with other uniquely qualified and experienced professionals. As web-based applications become more widely used in wilderness medicine, educators will be increasingly challenged to ensure that learners do not feel isolated from their wilderness medicine peers and role models. The learner, not the technology, must remain at the center of the effort. Internet applications must be selected for how they enhance the learning experience, not because they are high-tech and progressive.

Field Experiences

Medical schools and residencies are following the lead of commercial WPHEC programs and moving learners out of the classroom and into the field.⁴⁵ Rotations and electives that include field-training experiences of various lengths are now highly sought after. These have the effect of maintaining high levels of student interest and satisfaction. They offer direct relevance and immediate application of newly learned skills. When coupled with effective group process and feedback, the benefits of field training make this a powerful venue for skills-oriented education. These experiences are most often part of an overall curriculum that incorporates other techniques, such as lecture and problem-based learning, in a didactic setting (Figure 105-7).

FIGURE 105-7 Learning conducted in the field under genuine conditions is a vital component of any comprehensive wilderness medicine course. This method enhances skills development for individuals and teams and facilitates several aspects of the 360-degree summative evaluation of learners.

(Courtesy Fred Baty.)

Concerns include safety and security of participants as well as liability issues for the sponsoring organization. The logistic support package can be expensive and complex. The quality of the experience is greatly influenced by uncontrollable factors such as weather and climate. Proper screening and selection of participants are critical to success, especially in programs that are conducted in remote locations or in physically demanding environments. Multiple techniques, such as scenarios and hands-on practical exercise, can be applied simultaneously to maximize the learning experience. Field training affords an opportunity to introduce nonmedical skills such as leadership, wilderness survival, and land navigation.⁴⁵ This not only generates interest but also creates well-prepared learners and an overall lower level of risk.