Radiography (2005) 11, 61e65

REVIEW ARTICLE

Teaching medicine and allied disciplinesin the 21st centurydlessons from Irelandon the continuing need for reform

Tim McMahon)

The Centre for Teaching and Learning, Woodview, University College Dublin, Belfield,Dublin 4, Ireland

Accepted 25 May 2004

Abstract This article identifies the imperatives behind the need to move awayfrom teaching based on the transmission of a lot of facts to teaching that enablesstudents to become lifelong learners. It reminds us that the over-riding goal is aneducation process that maximizes the ability of teachers to teach well and of stu-dents to learn effectively. It argues that the necessary reform process can only besuccessful if the three components of an education programmedthe curriculum,teaching strategies and assessmentdare reformed simultaneously to ensure thateach is designed to produce more effective teaching and learning. It points tothe literature that tells us what we know about factors affecting student behaviourand, in particular, notes the crucial factor of student perception of the requirementof the assessment regime. It recommends that Biggs’ model of constructive align-ment is used as the organizing principle of continuing reform.ª 2004 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

KEYWORDSConstructive

alignment;Medical education;Lifelong learning;Assessment

Major changes in the way medicine (includingradiography) is taught at both the pre-qualificationand post-qualification state are inevitable. In Ire-land a Working Group on Undergraduate MedicalEducation and Training has been charged by theMinisters for Health and Children and for Educationand Science1 with examining current practice andrecommending changes that are in line with,among other things, the Medical Council’s Reviewof Medical Schools 2001.2

) Tel.: D353-1-716-2555.E-mail address: tim.mcmahon@ucd.ie.

As far as the 2001 review is concerned, visitorsto the Medical Council’s website who access thesummary of this document might well be takenaback by both the content and bluntness of thefifth recommendation that

Continued efforts are needed to reduce thefactual load in the curriculum3

The rationale for what, at first, might seem like anextraordinary statement can be found later on inthe text:

Medical education faces new challengesin incorporating the rapid scientific and

1078-8174/$ - see front matter ª 2004 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.radi.2004.05.005

62 T. McMahon

technological developments now occurring inmedicine. If anything, the pace of suchdevelopment will increase during the nextdecade. Rather than trying to impart all ofthis information to medical students, thechallenge for medical schools will increas-ingly be to equip students with the skills andattitudes needed to cope with rapid changeand lifelong learning3

This is a specific example of the argument putforward by Knowles as long ago as 19884 andmore recently, by, among others, Wagner5 andthe World Bank6 that the rate of change of tech-nology in advanced western societies is such thateducation in general, and higher education in par-ticular, can no longer be based on the transitionmodel where students become experts in a subject(or vocational) area by mastering a relatively sta-ble body of knowledge. Rather, what the WorldBank calls the ‘‘short shelf-life’’ of knowledgeand skills and the ‘‘acceleration of scientific andtechnological progress’’ requires Higher Educationproviders to place a

diminished emphasis on remembering count-less facts and basic data.6(p29)

and, instead, recognize

the growing importance of methodologicalknowledge and analytical skillsdthe skillsneeded for learning to think and to analyzeinformation autonomously.6(p29)

Nowhere is this more important than in science-based education programmes such as the study ofradiography where there is a constant need toadapt to new discoveries that require new skillsto apply new knowledge. In such disciplines,

The learning process now needs to be in-creasingly based on the capacity to find andaccess knowledge and to apply it in problem-solving. Learning to learn, learning to trans-form information into new knowledge, andlearning to translate new knowledge intoapplications become more important thanmemorizing specific information. In this newparadigm, primacy is given to analyticalskills; that is, to the ability to seek and findinformation, crystallize issues, formulatetestable hypotheses, marshal and evaluateevidence, and solve problems.6(p29,30)

This is the imperative that led to the MedicalCouncil’s call for a reduction in the factual loadof the curriculum. It is also the imperative that isleading to greater use of such techniques as

problem-based learning and the move towardsa systems-based approach in medical education.Such innovations must be welcomed. Unfortu-nately, there is evidence that things are not pro-gressing as fast as they should. In its most recentreview of medical training in Ireland, the MedicalCouncil found that in too many instances

Teaching methods are still disorganised withinsufficient interactive, student centred lear-ning.7(p14)

Further, the Council found that

In all schools there is still extensive relianceon the lecture as a teaching tool despite theinternational evidence on its educationallimitations.7(p14)

This suggests that, despite the many excellent ad-vances that have been made in Ireland in theteaching and learning of radiography and othermedical education programmes, there remains anurgent need to speed up the rate of reform.

The direction that reform should take, in orderto benefit both students and the wider profession,is clear. As the Medical Council says,

In modern medical education it is nowaccepted that learning in small groups isthe best method for the development ofprofessional attitudes, retention of knowl-edge and learning new skills.Lectures areunsuited to areas such as attitudinal de-velopment, acquisition of skills in medicine,problem identification, problem solving orprofessional development.7(p14)

The principles and practices of good teaching arewell documented elsewhere and these sources giveclear guidance on what reforms are likely to be ef-fective and why and how they are best imple-mented. For those unfamiliar with the literaturethe best place to start is probably Chapters 5 and6 of Biggs.8 In these chapters teachers will findwell-researched ideas on how to improve theirteaching. They will also find an explanation ofwhy things must change and what form new teach-ing and learning activities are likely to take. Forthose who prefer the instant availability providedby the internet, the website of the Centre forTeaching and Learning at UCD (http://www.ucd.ie/teaching/) is well worth a visit.

Knowing what is needed, however, is not thesame thing as being able to provide it immediately.There are a number of hindrances to educa-tional reform, not all of which are under the con-trol of the medical schools. The chief of these,at least in Ireland, is well-documented chronic

Lessons on need for reform 63

under-funding.2,7 Moving from information-givinglectures to interactive small group work is expen-sive and, as the Medical Council says,

The case must be made for adequate fund-ing.83% of current funding for medicaleducation comes from the fees of overseasstudents. The strategic implications of thissituation are potentially very serious andrequire an immediate response from govern-ment. A public debate on the place of medicaleducation in Irish society is needed to informhow government should respond; the case forinvestment in medical education must beclearly presented in this debate. The WorkingGroup on Medical Education has a substantialrole to play in this debate.7(p30)

The strategic implications of this situationalso require that those who teach and those wholearn in medical schools get involved in this publicdebate. This is just as important a developmentactivity as continuing the quality improve-ment process already underway in Irish medicaleducationda process that depends on the activeinvolvement of both teachers and learners anda process that can continue in tandem with thecampaign for more adequate funding.

Fortunately, educators do have, at least, a mea-sure of control over most of the other hindrancesto educational reform. The collation of the resultsof several studies put together by Ellis9 stronglysuggests that educational reform is unlikely to besuccessful unless all or most of the teaching staffare firmly committed to its implementation. Thesame source also identifies those factors likely topredispose teachers to supporting change, viz.,

1. Teachers must have confidence in their ownability to implement the new practices.

2. Teachers must believe that the change willimprove both their teaching and the learning oftheir students.

3. Teachers must believe that the benefits of thechange outweigh the costs.

4. Teachers must perceive that the change can beimplemented without too much disruption,that they will be able to experiment with orimprove on the change without undue risk tothemselves or their students and that they willreceive positive feedback from their students.

5. Teachers must believe that the change willbecome an established part of educationalprocesses and not turn out to be a passing fad.

Based on 20 years experience of curriculum andteaching development within universities, theauthor would conclude that these factors are often

absent from institutional change strategies andthat, consequently, many reforms proceed moreslowly than might be desirable because teachersperceive the change as presenting a risk both tothemselves and to their students.

These risks are most often perceived by teach-ers in one or a combination of the following:

� Teachers perceive a risk that delivering thecurriculum in the ‘‘new’’ way might failbecause of their own lack of the ‘‘new’’ skillsrequired.

� Teachers perceive a risk of adverse studentreaction to the point of disruption of classes.

� Teachers perceive a risk to the performancestandards of their students.

Similarly, students are often suspicious ofchange, for similar reasons. They often perceivechange as posing one or more of the followingrisks:

� The risk of having to do additional work with noadditional reward. This is perceived as beingunfair compared to the lot of previous stu-dents.

� The risk that the change will adversely affecttheir marks either because of increased work-load or because they are unfamiliar with therequirements of the ‘‘new’’ approach.

All of these risks can be, and very often are,real. It is not, therefore, unreasonable for teachersand students to be concerned about them. Thus itis important that those sponsoring or promotingchange adopt implementation strategies that takedue account of these concerns.

The skills that teachers need to implement inno-vative teaching and learning techniques appropri-ately can be, and are being, developed throughappropriate professional development pro-grammes of the kind now available in all Irish Uni-versities. As well as addressing the first set ofconcerns, these programmes also deal with howto bring learners into the change partnership: de-veloping such partnerships being essential not onlyto prevent student disaffection but also to enablestudents to maximize the learning gains that arethe reason for the changes in the first place. Bring-ing learners into the change partnership beginswith the golden rule of ensuring that studentsare fully informed as to what is changing, why itis changing and the implications for them of anysuch change. It continues with including them inthe rigorous evaluations necessary to ensure thatthings are changing for the better and by ensuringthat their concerns are seen to lead to action. Mostimportantly of all, students need to see that their

64 T. McMahon

support for new teaching and learning strategies ismore likely to lead to improved learning and im-proved marks than it is to lead to poorer learningand poorer marks. There is little doubt that theconcern for marks is higher than the concern foreffective learning.10 Teachers need to be assuredon this point as welldit being the third and, prob-ably, most important of their concerns.

How can we assure both teachers and learnersthat changes to teaching and learning activitiesare likely to lead to improved learning and im-proved marks?

In theory, at least, the answer is both straight-forward and simple. In practice, it requires a gooddeal of hard work on the part of teachers, manag-ers and administrators.

It is well established that the single most impor-tant factor in influencing what students learn, andhow they approach learning, is what they perceiveto be the main intentions behind the assessmentregimedin other words, they learn what theythink will be most rewarded with high marks andthey learn in the way they think is most likely tolead to the highest possible marks.10e15

Biggs calls this ‘‘backwash’’ which he defines ashappening

.when the assessment determines what andhow students learn more than the curriculumdoes.8(p140)

In other words, whatever we teach and howeverwe teach it, students will learn for the assessment.They would, as Biggs says,

.be foolish if they didn’t.8(p141)

Biggs notes that if the assessment regime doesnot properly reflect curriculum objectives thenthe result will be inappropriate surface learningof the kind that current reforms are attemptingto discourage. He then goes on to propose thateducators use the inevitability of ‘‘backwash’’ tosecure effective educational reform.

You can’t beat backwash, so join it. Studentswill always second-guess the assessment taskand then learnwhat they thinkwill meet thoserequirements. But if those assessment re-quirements mirror the curriculum, there is noproblem. Students will be learning what theyare supposed to be learning.8(p210)

This may seem obvious, even axiomatic; none-theless, the implication for educational reformdthat reforms to teaching practices and/or theorganization of the curriculum will not succeed inimproving learning unless assessment regimes arealigned with these reforms and students are

aware of this alignmentdall too often goesunrecognized.

Ellis indicates that successful educationalreform requires coordination of all three ‘‘compo-nents’’ of educational programmes, viz., curricu-lum, teaching (‘‘instruction’’) and assessment.He even draws a parallel between successful edu-cational change and successful teaching:

Successful educational change agents (uni-versity science and education faculty andschool administrators) design and conductreform projects that coordinate improve-ments to all program components. Effectiveteachers develop an overriding philosophythat guides their approach to curriculum,instruction, and assessment.9

Biggs goes one step further and proposes an educa-tional model that aligns the three components ina way that maximizes the opportunities for effec-tive teaching and leaning. He calls his model ‘‘con-structive alignment’’ and describes it thus:

Constructive alignment is a design for teach-ing calculated to encourage deep engage-ment. In constructing aligned teaching, it isfirst necessary to specify the desired level orlevels of understanding of the content inquestion. Stipulating the appropriate verbs ofunderstanding helps to do this. These verbsthen become the target activities that stu-dents need to perform, and therefore forteaching methods to encourage, and for theassessment tasks to address.8(p32) (emphasisin original).

The whole purpose of this ‘‘constructive align-ment’’ model is to prompt the kind of deep learn-ing necessary to ‘‘equip students with the skillsand attitudes needed to cope with rapid changeand lifelong learning’’ identified by both theMedical Council and the World Bank.

Conclusion

In the Republic of Ireland, both the Medical Coun-cil and the Medical Schools have recognized theneed to reform medical education in order to moveaway from a factually-heavy transmission model oflearning to one which emphasizes the primacy ofthe need for learners to be able to adapt torapid changes in knowledge, technology and prac-tice. As a consequence, reforms have been and arebeing instigated in all areas of medical education.The latest review of schools by the Medical

Lessons on need for reform 65

Council, however, found that the medical curri-culum was still dominated by the transition offacts through large lectures, suggesting thatreform might be progressing more slowly than isdesirable to meet the needs of current and futurestudentsdand, ultimately, current and futurepatients. The analysis presented above, suggeststhat this is probably largely due to the real and jus-tified concerns that teachers have over the impactof change on themselves and on their students.Just as the practice of medicine should be basedon rigorous and continuing research, so shouldthe teaching of medicine take full account of cur-rent research into how people learn. This researchidentifies the Biggs model of constructive align-ment as an appropriate organizing principle forcurriculum reform. The model enables teachersto ensure that changes to teaching activitiesare properly reflected in changes to assessmentregimesdthus removing the risk that ‘‘new’’ formsof teaching might cause students to perform lesswell in existing summative assessment processes.The model will only work, however, if the teachersresponsible for implementing changes to the waymedicine is taught have, or are able to develop,whatever new skills are required. Thus, it is essen-tial that proper professional development pro-grammes are an integral part of the changestrategy.

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