tertiary education has remained relatively unchanged for centuries, reflecting the need to deliver information to students through lectures, books, and laboratories where appropriate. The new technologies we now have remove the need for traditional teaching. In addition, we now understand much better how people actually learn. The combination of this understanding with new technologies is resulting in the most revolutionary time in education since the invention of the printing press.
It is a great privilege to be invited to give the 2015 Claude Bernard lecture. As a teacher, I discussed Claude Bernard's seminal insight on the constancy of the milieu intérieur (internal environment) in the introductory lecture to the Physiology course every year. Bernard is often quoted, and amongst his many memorable sayings “It is that which we do know which is a great hindrance to our learning that which we do not know” serves as a warning to all teachers.
The invitation to give this lecture caused me to reflect on how education is changing. Indeed, I believe that we are experiencing the most revolutionary time in education since the invention of the printing press. But to understand what is happening and why we do what we do, we need to understand the past.
I first studied physiology as a medical student almost 60 yr ago. How did we get our information then? There were no computers, no internet, no e-mail, no mobile phones. This must seem prehistoric to today's students. We had textbooks, but not the glossy ones we see today. In those days, new editions were infrequent and our textbooks were usually secondhand (or more!). Figure 1 shows a page from the textbook I used then: it was actually fourthhand, and every owner had embellished the text with their comments. We didn't have many handouts as these were not easily produced. There was no photocopying, and Gestetner stencil duplicators were used. As shown in Fig. 2, the copies were not especially attractive.
So, in the absence of up-to-date text books or handouts, we relied on lectures to provide us with “the facts.” We also had laboratories (Fig. 3) where most of the work was done on anesthetized animals or animal organs or tissues. We recorded changes in physiological variables on smoked drums, much as Karl Ludwig, who invented the kymograph in 1847, would have done. Indeed, any physiologist from the late 1800s would have recognized not only our equipment but also the experiments that we were performing. My experience then was very similar to those that Davenport (2) describes and illustrates.
And, of course, we had examinations. These took the form of essay questions, the aim being to reproduce, as accurately as possible, what we had been told in the lectures. One can debate how effective the learning actually was.
So, our education followed the pattern that had evolved in universities over centuries reflecting the resources available to both teachers and students.
My Teaching Experiences
I began teaching students physiology some 50 yr ago. And I can confidently say that I made every mistake possible over that time. This talk should really be titled “Misadventures in Education.” I began believing that everything I knew (or thought that I knew) should be conveyed to the students, thereby totally overloading and confusing them. I learned over the years that you can never make things too simple and removed more and more detail from my lectures every year! I also learned that it is difficult (impossible?) for students to really concentrate through a 50-min lecture. I found that students don't write down what you say. Indeed, I gave up using lectures as a way to convey “facts” when I found, looking at the notes one student had taken at the end of a lecture, that he had written the opposite to what I had actually said about a very important point. From that time on, I gave out detailed notes and spent the lecture time talking about the important concepts, not the details.
The biggest change over the years was in laboratories. When I started teaching, we were still in the smoked drum, kymograph, world (Fig. 4A) and stimulated tissues electrically using induction coils (Fig. 4B). At that time in our university, the only way to obtain new equipment was to get a new building. In the early 1970s, the government decided that we needed to produce more doctors and this necessitated a significant remodeling of the space physiology occupied, so much so that we were deemed to be getting a new building for equipment replacement purposes. So, we were able to reequip our laboratories with Tektronix storage oscilloscopes (Fig. 5A) and Grass polygraphs (Fig. 5B). (Incidentally, up to that time, this was the biggest single order that Grass had received for its equipment, and Mrs. Grass flew out to New Zealand personally to supervise the installation and setting up of the equipment.) Suddenly, we were in a new age! But, the experiments themselves didn't change; we just recorded the results in a more up-to-date way.
Some 10 yr later, the screens on the Tektronix storage oscilloscopes were starting to deteriorate. The oscilloscopes sat in a cupboard for 50 wk of the year, and it was hard to justify the cost of replacing them. Fortuitously, the 128K Apple Mac had just been released, my oldest son needed a project for his combined computer science/electronics MSc thesis, and, being able to move a mouse, I could actually use a Mac. So, he embarked on a project to replace the oscilloscopes with a computer-based data-acquisition system. He was also able to write a program so that the system could replace the Grass polygraphs as well. This was done solely for the Physiology Department, but other physiologists saw the system and wanted it, and so what became AD Instruments and PowerLab (originally MacLab; Fig. 6) was born.
You may note, in passing, how many knobs there are on the Grass recorders and Tektronix oscilloscopes. Anyone who has taught in a physiology laboratory knows that the first thing that happens when students get bored or frustrated is that they start turning the various knobs in an unpredictable way. Much time was spent by the demonstrators trying to get the signal back on the screen or in range on the paper. So when the MacLab was first developed, I insisted that there should be no knobs, with everything controlled in the software.
The major advance in equipping laboratories with computer-based data-acquisition systems came not from the change in equipment per se but from the ability to record physiological variables easily from the students themselves. This actually transformed the laboratories. The results are much more easily obtained, and students get really excited when they see their own ECGs, blood pressure tracings, or whatever.
Laboratory learning remains a controversial topic in physiology departments. At least for health science students, laboratories are relatively ineffective and unpopular if run in isolation from the rest of the teaching program and with experiments largely performed on animals. They are also unpopular if they are not part of the assessment procedures and if the students don't get meaningful (to them!) results.
But the understanding of basic biomedical sciences is greatly enhanced by “hands-on” experiences, and physiology laboratories are fully justified if we create a practical environment in which students see the relevance of their work to their career choices and obtain knowledge and learn skills that they cannot easily acquire elsewhere in the course. We need to define the objectives of the practical course. Many, if not all, of these should be unique to that course and not be more easily met through other activities in the course (e.g., lectures or tutorials). And we must give good, timely feedback to the students about the work that they perform during the practical and design our course assessments with components that recognize the value of the time spent in the laboratory.
But the most important thing that I learned during these years of teaching medical and other health science students was that the combination of lectures and laboratories, with some tutorials, that we were using just wasn't effective. We weren't teaching our health science students physiology in a way that they could see its importance to them in their future careers.
Things came to a head in 1988. We had a class of ∼200 first-year medical students (second year at the university). These were a selected group of high achievers, who had gained nothing but A passes in their first year at university and had probably never failed an exam in their lives. Yet we were failing ∼25% of the class in their Physiology course at the end of the year. Not surprisingly, physiology was the most unpopular subject in the program. But we thought that we taught well. We even had our own textbook, Lecture Notes on Human Physiology, published by Blackwells that was well received internationally.
Something had to be done! So we moved to a program of “active learning” with case-based teaching and tutorials and student study time built in. We kept lectures but made the time for the case-based teaching by reducing the laboratories from 20 to 10 min and linked each laboratory as far as possible to the case being discussed that fortnight. The cases were chosen to span all of the physiology taught in this year of the course. The examinations were now based on the understanding of the physiology that underlay the cases. The result: every student passed the examination, and physiology had become the most popular subject in the program. But the really important thing was that students had learned more detailed physiology than we had ever attempted to teach them. As an example, we included a case of cystic fibrosis. For years I had taught in lectures about channels, and I could see the student's eyes glaze over as I talked. But now, students were writing more about chloride channels that I would ever have dared to include in a lecture, and they did this by finding the information for themselves and understanding it!
Today, so much of what we used to do in teaching is now unnecessary. Students really don't need textbooks or even conventional lectures anymore. Anyone with a computer and internet connection can access more information than it would be possible in a lifetime to read or watch, let alone digest. We can now design and implement new programs unhindered by the requirements of the past. So what should guide us as we create the learning environment of the future?
To provide quality education what we deliver must be engaging and authentic. By engaging, we mean that students are involved in the learning process and not simply passive receptacles for the material. There must be “active learning”: a fact that has been known for a number of years. For example, “One must learn by doing the thing, for, though you think you know it, you have no certainty until you try” (Sophocles, Trachiniae 5th centry BCE). By authentic, we mean that what the students are learning has to seem relevant to them as individuals and members of society. Specifically, for future health professionals, they must relate what they are learning now to how they will use it in their future professional work, that is, the learning must be “contextual.”
We now understand better than ever before how people actually learn and we should design our materials to enhance that learning. We learn by taking information from the environment through our sensory inputs and memory into our working memory. Our working memory is very limited, and we must not overload it. We need to process the information there, rehearse it, and link it to knowlege we already have in long-term memory.
So, there are four fundamental steps that facilitate learning (1).
First, the learner must focus on key graphics and words; both are necessary to enhance learning. Graphics and sound are also a very effective combination.
Second, the learner must rehearse this information in working memory to organize it and integrate it with existing knowledge in long-term memory.
Third, to do this integration, the limited working memory that we all have must not be overloaded. We shouldn't try to make our material more ”entertaining“ by including extraneous material such as music, complicated animations, etc. (Think how entertained you are by a good science documentary on television with its scenery, music, images and animations and how little of the information you have retained when you think back after watching the 50-min program.)
Fourth, new knowledge stored in long-term memory must be able to be retrieved when needed in the future and so must be learned in context. As preclinical medical students, we were always asking why we were learning specific things, only to be told that we would find out one day. Which was true. We did find out, but by then couldn't recall what we had learned for we had learned it with no context.
The computer and the internet together have removed the need for all learning to be done in formal campus settings. Some see this as placing the traditional tertiary campus model at risk. I'm sure the campus will change, but I'm equally sure students will still wish to be there. For they don't come to the tertiary campus just to study. They are there to learn about life, have new experiences, and meet new people. And it is ironic that all this they do, not by sitting in a lecture hall and being talked at or by reading books, but by personal involvement: active learning.
So how do we use the computer and internet to facilitate learning? Not by simply producing electronic versions of text books or sticking PDFs on a learning management system or allowing students to watch a 50-min lecture as many times as they wish. These are just examples of passive learning transferred to the internet.
Platforms are now being developed to deliver active learning. In assessing these, there are a number of points to consider. First and foremost, the platform should enable instructors to create their own active learning material and to modify existing material. Instructors must have ownership of the courses in which they teach. No academic even likes what another academic writes; we are always changing words, sentences, and even paragraphs when we can! So surely no academic wants to deliver someone else's course. And students learn much better from material provided by someone they know personally than they do from material delivered by some stranger, however good that material is.
The content created in such an active learning platform should motivate the students, build on what they already know, make them demonstrate their current knowledge before they see the instructor's feedback, provide instant, quality feedback, provide repetition to rehearse the information they are learning, and provide contextual material.
In addition, the platform must allow students to learn at their own rate in their own time. Perhaps this is the greatest single advantage of putting material online. The platform must also allow the students to work together in groups. This is of prime importance, for group learning is a very effective way for students to learn while also acquiring and practicing a range of communication skills. As everyone who has ever taught knows, you don't really understand something until you try to teach it-and then not always even after that!
One major advance that online learning platforms facilitate is the identification of students who are having difficulties in the subject early on in a course. Powerful analytics allow instructors to rapidly identify students who are having problems so that remedial work can be instigated. They also allow us to improve the quality of our questions and other instructional material.
The key to all effective learning is student motivation. Without this, the best active learning system will fail to enhance learning. My belief is that for medical and allied health students, all our teaching should be built around people and their problems. In the past, I used paper cases for this purpose, but far better is the use of patient videos. Hearing and seeing a person talking about their breathlessness or chest pain or thirst and increased urine production leads immediately to a desire to understand the underlying physiology and its disturbance. For other physiology students, there are always questions from the world around them that can be used to motivate them. I used to tell my students “Physiology isn't in a book, it's you!” And if you think about and analyze what happens to you in different situations, you already know a lot of physiology.
A central question is how do we integrate the online learning into the whole course? For me, the hybrid or blended learning model makes the most sense. We can use online tutorials as a way to engage and inform students who then attend a “live” small-group tutorial session or a “flipped classroom” lecture session.
Another question is the place of laboratories within this new learning environment. New technologies are making it so much easier to provide laboratory experiences that encompass elements of self-design where students are encouraged to identify a question and obtain experimental data to answer it. This approach is far preferable to the traditional “cookbook” laboratory course, as it extends the active learning that is central to the laboratory experience.
For medical and allied health sciences, these laboratories can be linked to patient studies so that students obtain the same data on themselves as are obtained from the patient's investigations. Furthermore, there is no need for students to be in a conventional physiology laboratory to do this. Students can as easily perform the measurements in their small tutorial group in a study room. Linking the patient's results to their own in this way provides an ideal opportunity to connect physiology with pathophysiology.
So, given the enormous possibilities that now lie in front of us in tertiary education, why is it so difficult to implement change? Why do so many still cling to the conventional approach that developed from necessity over centuries? Some people just don't want to change, and we hear comments like “I've always taught this way–and it works!” and “I'm close to retirement so I leave change to my successor.” Others tell you they'd like to change but “we're underresourced,” “I don't have the time,” “my colleagues are opposed to the ideas,” “the students like the course the way it is,” “there is no time in the (overcrowded) curriculum for new initiatives,” “the Dean won't allow change,” “external examining boards require me to teach the way I do,” and many other excuses, some of which often do reflect the situation in the school in which the instructor works.
But, the good news is that, irrespective of the staff, the students coming now into the system are aware of how things could be done better. In the end, it is student opinion that will result in the changes that tertiary institutions must make to stay relevant and deliver the best learning environment for the students, who will create the better world that we all believe education can provide.
No conflicts of interest, financial or otherwise, are declared by the author(s).
A.D.C.M. conception and design of research; A.D.C.M. performed experiments; A.D.C.M. analyzed data; A.D.C.M. interpreted results of experiments; A.D.C.M. prepared figures; A.D.C.M. drafted manuscript; A.D.C.M. edited and revised manuscript; A.D.C.M. approved final version of manuscript.
- Copyright © 2016 The American Physiological Society