Authentic learning in anatomy: A primer on pragmatism.

Abstract

“Education is life itself.” —John Dewey (1859-1952) Authentic learning in medical education is an increasingly popular topic. We are seeing more presentations on “authentic learning” at medical education conferences (Harden, 2015; Manninen, 2015) and the presentations are often linked to competency-based education. More commonly, “authentic learning” is used to describe the type of learning that occurs when students get early clinical exposure to the health care environment with meaningful patient contact to enhance their learning (Yardley et al., 2013; Gonzalo et al., 2014). While this medical education buzz phrase may sound foreign, as anatomists “authentic learning” is something we do daily in the teaching and learning activities that occur in our anatomy classrooms and laboratories. In fact, we consider the “patient contact” our students have to be one of the earliest and most intimate educational/clinical exposures they have in medical school. Historically, in many traditional basic science courses including biochemistry, molecular biology, and anatomy, there used to be a palpable separation between “knowing” and “doing” (Resnick, 1987). Students who memorized anatomical facts could pass their examinations, but were often unable to access this knowledge to solve a clinical problem they encountered later during their clinical clerkships. Information acquired in the anatomy laboratory used to be a collection of stored facts. But now, we would argue that modern teaching strives to provide dynamic tools for real-life problem-solving (Bransford et al., 1990; Herrington and Oliver, 2000; Johnson et al., 2012). In general, “authentic learning” is learning that impacts a student's ability to navigate the clinical environment, solve complex problems, and make meaning of their efforts in the context of their personal lives and ethical practices (Lombardi, 2007). Teaching materials and student activities in the “authentic” classroom should be “real life” situations where the content learned and the skills obtained can be applied. The assumption underlying this approach is students will learn what is meaningful to them. Once learning has personal meaning, it is more motivating and more deeply processed (Chang et al., 2010). The concept of “authenticity” in education is not new. In 1866, William Ware, a professor for the School of Architecture at the Massachusetts Institute of Technology, presented an outline for his new course on “Instruction in Building and Architecture.” In this course, students designed projects aimed at addressing problems in the local community (Ware, 1866; Shaffer and Resnick, 1999). His major concern was how the traditional curriculum might cut students off “from a knowledge of practical details” necessary to function within their profession (Ware, 1866). Similarly, in his book Experience and Education, education philosopher John Dewey championed the notion that “freedom of observation and judgment exercised on behalf of [practical] purposes … are intrinsically worthwhile” (Dewey, 1938). Following the legacy established by Ware and Dewey, the modern pedagogical concept of “authentic learning” has been articulated by Herrington and Oliver (2000). “Authentic learning” brings together disparate disciplines and perspectives to work toward a common goal—an objective which mirrors the real-world of the active professional navigating their field (Lombardi, 2007; Herrington et al., 2014). Early exposure to “authentic learning” provides an opportunity to address professional identity formation alongside knowledge acquisition, a setting which requires a student to become familiar with the realities of clinical reasoning, where they learn not only content but team-forward behaviors (Yardley et al., 2013). Over the last 10 years, the hours available for anatomical education in United States medical schools have decreased (Drake et al., 2009, 2014). As such, anatomists have been forced to become selective in the material they present and adopt educational strategies that focus on the most clinically relevant information. This does not, however, mean that anatomy is watered down. In fact, in some ways, these changes have led to a more relevant and meaningful educational experience in the anatomical sciences. For example, as surgery becomes more robotic and minimally invasive, we have been forced to reorient ourselves and not only view anatomy from above, but change our perspective and think of anatomy from within. Anatomy courses provide essential background for many early patient-contact activities in medical school. For this reason, physical examination courses often run concurrently with anatomy. We are also seeing many anatomy courses starting to implement ultrasonography training (Pawlina and Drake, 2015a) as a practical extension of skills-based education with “high instrumental value.” Imagine how ultrasound might enhance student appreciation of “carpal tunnel syndrome.” Using ultrasound, students can clearly distinguish the median nerve from the surrounding tendons by wiggling certain fingers—the motion of the tendons clearly visible in contrast to the median nerve. More than just “exposing structures,” we observe students becoming deeply engaged in the clinical applications of anatomy with bedside ultrasound activities. The same can be said regarding other imaging modalities (X-rays, CTs, and MRIs), many of which are commonly taught concurrently with anatomy. All anatomy courses in the United States utilize human materials to teach anatomy, most commonly, human cadavers (Drake et al., 2009, 2014). During dissection, students explore the pathology that afflicted the life of their “first patient” and in many courses, such as our own, students practice preparing oral and/or written presentations to report on the possible cause of death of their cadaver. This allows them to practice the skills of building a differential diagnosis and defending their position using clinical evidence. “Authentic learning” is a vehicle for integrating multiple disciplines, perspectives, ways of working, habits of mind, and communities (Lombardi, 2007). Clinical faculty from different disciplines who visit gross anatomy laboratories can contribute to this integrative model by sharing clinical stories of their recent patient encounters. With a continual variety of input from multiple sources including: clinical data, cadaveric dissections, radiologic images, textbooks, atlases, multimedia programs, and model-based educational tools, when students are given a specific task, they will be less likely to view the challenge with a unilateral “what is the right answer” or “what I have to know to pass the test” approach. Instead, students who have “authentically learned” should be expected to arrive at a solution within the context of a team effort, approaching the problem from a variety of theoretical and practical perspectives based on their experience with multiple modalities - interpersonal and skill-based. Part of the challenge of “authentic learning” is learning to distinguish relevant from irrelevant information in this process (Lombardi, 2007). Clearly, teamwork, interprofessional learning, and reflection are key components of “authentic learning.” Teamwork allows students to collaborate on tasks, both within the dissection team huddled around the cadaver as well outside the classroom in the “real world” healthcare environment (Barrow, 2012). Teamwork exhibited in the anatomy laboratory should be considered a foreshadowing of performance on teams in the clerkships and as such, an eminently teachable opportunity to prevent unprofessional behavior that might arise in clinical situations. The ability to communicate and learn from those in other health professions (interprofessional education) is an important virtue that should be acquired early in one's medical career (Pawlina and Drake, 2015b). Examples of models facilitating these interprofessional skills were featured last year in this journal's Special Issue on Interprofessional Education in the Anatomical Sciences. Assessment methods for authentic learning is a field ripe for innovation (Oh et al., 2005; Ginsburg et al., 2010). Students need to be assessed in more active ways than the old “practicum” examinations—tours perusing labeled structures and answering identification questions. Many anatomy programs are exploring alternatives to the old practical tests. The objective structure practical examinations (OSPEs) are one method for evaluating students by a more three dimensional rubric. In OSPEs, students are graded not only for their knowledge but also for their acquired skills (Yaqinuddin et al., 2013; Smith and McManus, 2015). Many courses utilize real patients’ clinical scenarios to construct multiple-choice question (MCQ) written examinations. Alternatively, others use vignette-based short answer examinations in which students need to apply their knowledge to reason through the related anatomical basis underlying a patient's clinical chief complaint. There are some classrooms attempting to get at the “authentic learning” goals of teamwork by allowing students to contribute to the final grade of their teammates with reflection and peer-assessment (Lachman and Pawlina, 2015). We look forward to innovations to come in the assessment of “authentic learning” over the next decade of anatomical education. Anatomy provides a powerful framework for “authentic learning.” Any classroom should strive to meet the four pillars mentioned in this article, but teachers of anatomy have no excuse. Our material is real. Our lessons are transportable. But the onus is on us as educators to make sure that our methods are high in intrinsic and instrumental value. As the father of pragmatism, John Dewey, once said, “Education is not preparation for life; education is life itself.” Wojciech Pawlina, M.D.* Department of Anatomy, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota Richard L. Drake, Ph.D.* Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio