The Course Director at TUSM describes his perspective on “whole learning” as a compelling model for educating our students

Photo and Story by Annie Soisson

Ralph Aarons’ life is non-traditional, and he’s always looking for his next creative adventure. His home is filled with friends’ art and antiques. He is passionate about human and civil rights, and believes that one manifests who they are in what they do.

He lives with his family, six chickens, two gerbils, three dogs, three cats and two canaries and no, he is not at Cummings. He is a practicing neonatologist at the Elliot Hospital and has been a leader in the Problem Based Learning (PBL) program at Tufts Medical School for the last 12 years. His role as Course Director for the program during the last three years in addition to his work with I-Clickers has made him invaluable to Tufts.

A neonatologist whose pediatric beginnings in Denver, Colorado sparked his interest in becoming an educator, Aarons describes himself as “open to possibilities.” He spent time at Stanford where he was first exposed to the ICU, and was able to teach not just the technical side of medicine, but also the human side. It was at Stanford that he nurtured his belief that an “authority based model” of education is not the best learning model. The authority model is based on telling students what they are supposed to do, assuming they need to be protected until they are completely ready. Aarons counters that the sense of responsibility one feels when one is totally responsible for a patient creates a much more compelling desire to learn. He calls this teaching method “whole learning.”

An introduction to PBL

This model is the core philosophy of the Problem Based Learning Program (PBL) at Tufts University School of Medicine. While students in this program are not learning on live patients, they are learning by being presented with real patient situations, and working in small groups where learning how to take responsibility and how to communicate effectively with colleagues is as important as learning specific content and understanding well enough to teach that content to others.

PBL is not a new model according to Aarons. He notes that Howard Barrows and a group of visionary educators developed an entire medical school curriculum at McMaster University in Canada around problem based learning in 1969.In medical schools, it has had a sustained following, but many other disciplines outside of the health sciences have recently adopted this method for learning as well. PBL can be explained as “the learning that results from the process of working toward the understanding or resolution of a problem.” (Barrows, 1980)PBL is based on two key concepts: active engagement of the learner and feedback (through group and peer evaluation and self assessment.) One of the keys to the success of PBL is the establishment and development of a relationship between a “tutor” or facilitator and a small group of students. The role of the facilitator is not to serve as the content “expert”, but rather to ask guiding questions to move students from their patterns of “passive” learning from authority to “active” self-directed, collective learning. Facilitators must see themselves as responsible helping the students develop skills for exploration into unfamiliar domains, not merely to understand human biology, but also to integrate with it understanding of human behavior, human populations, and health care delivery systems, as they wrestle with true-to-life problems. This is clearly a model that can be used in many, if not most, disciplines.

While the premise seems simple, there is time and training required to implement it effectively. The ability to give constructive and balanced feedback can take some time to develop, and is best done in a climate of trust, which is part of the rationale for the team-based model in PBL. Students help direct their own learning by evaluating themselves, asking their peers for feedback, and responding to the guidance of their facilitator. Shifting the role of the professor and authority (expert in content) to that of learning facilitator (expert in process) is a“paradigm shift,” as Kuhn (1962) would describe it, for faculty and students. Though the logic of this process seems obvious to many, this model departs from traditional models and it takes a conscious effort to learn the skills to do it effectively.

Next Steps for the Medical School Curriculum

Aarons’ next challenge is to help integrate the PBL program into the medical school’s new curriculum. In medical schools, students typically have two full years of classroom education to prepare them to actively engage with patients, which is the predominant activity of the third and fourth years. In the fall of 2009, Tufts University Medical School will change this approach by adopting its revised curriculum, integrating basic science and clinical medicine more extensively and building many of the concepts of small group and active, problem based learning into coursework. For the first time at Tufts, first-year medical students will experience “integrated coursework.” The goal is to integrate problem-based and case-based approaches into all courses, not teach it as a separate program. Students will interact with patients through cases and simulated exercises from the beginning of the program and develop broad perspectives on health care –from insurance policies to community-based support programs, to understanding family dynamics and the economics of healthcare. This will hopefully engender the attitude of: “If I don’t know, I’ll find out.” This change in teaching is intended to foster greater empathy and wisdom, helping doctors to understand the bigger picture within which they are treating their patients. Barrows, H., Tamblyn, R., 1980.Problem-based learning: an approach to medical education.Medical Education.Volume 1. New York: Springer Publishing Company. Kuhn, T.S., 1962. The Structure of Scientific Revolutions, 1st. ed., Chicago: Univ. of Chicago Press.

For a great chapter describing PBL across the disciplines, click on this link: http://www.ntlf.com/html/pi/9812/pbl_1.htm National Teaching and Learning Forum, an online resource: Problem-Based Learning: An Introduction December 1998 Vol. 8 No. 1

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