Letters to the Editor

It was with interest that I read the commentary on curriculum development in the December 2002 Supplement (Starkey C. Curriculum development. J Athl Train. 2002;37[4 suppl]:S180–S181). The commentary highlights the paradigm shift that must occur in athletic training education as the educational expectations of faculty and students continue to move toward the professional educational standards of other health care professions, including medicine, physical therapy, and pharmacy. Unlike the dichotomies drawn between the roles of academic and clinical faculty or graduate and undergraduate learners, the professional expectations of entry-level athletic training education are the same regardless of whether the academic program is at the baccalaureate or master's degree level. Clinical faculty are an integral component of education in all health professions—and clinicians in other disciplines face challenges similar to those of clinical faculty in athletic training, including job responsibilities, time constraints, and expectations (eg, expectations of academe, which are research, service, and academics, versus expectations found in athletic departments or clinical practice). The challenge facing athletic training education programs is to take advantage of their clinicians' years of experience: a problem-based learning (PBL) curriculum allows the talents of clinicians and academicians to be utilized in the development of clinical cases forming the core of the PBL curriculum and as tutors.^1,2

In my manuscript,² I provided an athletic training example of an acute orthopaedic injury, the knowledge required to solve the problem, and the complexity of the knowledge links to highlight the integration of the basic sciences with the clinical application. The education and socialization of the athletic training student does not take place in a vacuum, nor is one group responsible for one area of student development (“one group provides knowledge and skills and the other group is responsible for the student's introduction and socialization into the profession”); rather, the student's professional development is the result of student-centered learning and a collaborative effort of all the faculty—both academic and clinical—with whom the student interacts. Learning must take place in the context of clinical practice, rather than independent of the clinical-reasoning process. Differences in theory and technique between academic and clinical staff are to be expected (and are healthy) and do not necessarily cause adversarial relationships between the two groups, as suggested in the commentary. In reality, students will experience diversity in assessment and management approaches; differences in opinion force students to constantly evaluate the information they receive. By their nature, clinical problems are “messy,” ill-defined, and often characterized by more than one approach to the solution.¹ The development of a PBL curriculum requires “real” clinical problems that have been carefully selected for their richness and depth of content; the reader is referred to the sample concept map² in my manuscript for an example. Concept mapping encourages students to organize and systematize their knowledge, identify knowledge gaps, and be explicit about relationships among ideas.³

The commentary highlights the misunderstandings that often occur when the term PBL is used without fully understanding the underlying cognitive educational theory of the instructional-design methods. The PBL method emphasizes designing a learning environment, rather than instructional sequences, in which the learners work together as they use a variety of tools and information resources in their guided pursuit of learning.³ Cognitive theory focuses on the way information is stored in the brain: learning involves creating new links between information and grouping of knowledge. This method moves away from the behaviorist theory of “traditional” instruction and focuses the attention on learning and the learner.³

The PBL approach is not restricted to adult learners, as implied by the commentary. In fact, this approach has been successfully employed in the K through 12 educational levels⁴ and in other disciplines (A. Kelson, personal communication, 2001); perhaps the “problem” has been too narrowly defined in the commentary. Problems are not always negative situations requiring a remedy; problems can also be the search for a better way to do something or a “goal where the correct path to the solution is not known.”⁵ The commentary draws the incorrect conclusion that “adult learning styles and PBL are overemphasized during the student's undergraduate education.”

The literature was misinterpreted in the commentary: rather than overemphasizing “adult learning styles” and PBL methods, the traditional methods are soundly criticized by both Parsell and Bligh⁶ and Donaldson et al.⁷ The traditional teaching methods of subject-based information (eg, lectures; shallow cases with one clear solution; nonadaptive, static, Internet-based environments that are ignorant of the individual knowledge state of the user^3,8) are increasingly recognized for their failure to prepare students for today's professional environment, in which value is placed on problem-solving skills, critical analysis, and decision-making skills.⁶

Subject-based information is transmitted to an audience of passive learners. At the undergraduate level, students find great difficulty understanding relationships among scientific concepts acquired in separately taught disciplines and relating them effectively to clinical practice. This situation is perpetuated by an examination and assessment system that stresses the need to memorize a large number of facts, forcing students to become dependent, rather than independent, learners. It is now widely accepted that this preparation is inadequate training for professional practice in a changing social and medical climate.⁶

Furthermore, the commentary implied that students' abilities to succeed with PBL are based on maturity, rather than on a well-designed, student-centered instructional curriculum. Students' abilities to understand the relationships are a function of an instructional design grounded in cognitive learning theory, not maturity. The commentary cited Donaldson et al⁷ in support of the “overemphasis of the importance of adult learning styles and problem-based learning.” However, a closer examination of the Donaldson et al⁷ paper reveals that the survey of 13 nontraditional undergraduate students (age greater than 27 years) demonstrated that the older undergraduate students recognized the difference between “making the grade” and “learning.” Learning was defined as having ownership of the material and being able to apply the learning to real-world problems—a hallmark of PBL. Paradoxically, the adult learners' success strategies included repetition and memorization of facts, cramming, and using mnemonic devices—all of which resulted in “good” test grades but did not focus on deeper understanding and improved retention through active learning. If information is retrieved in the same manner in which it is stored, memorization and cramming do not guarantee the student will be able to use the information to solve a problem. The older students focused exclusively on “success” in college as measured by success on testing, using assessment methods that are increasingly seen as inadequate in preparing tomorrow's professionals.⁷ This success is externally defined and imposed and is fundamentally different from the success that occurs when students own and internalize the learning in a meaningful way. Donaldson et al's interpretations are limited by the fact that the interviews were conducted only with nontraditional-aged students. There was no corresponding sample of traditional-aged undergraduate students to explore how their perceptions of learning differed from their older counterparts. Furthermore, students' perceptions of learning are likely also dependent on the learning environment (ie, traditional passive lecture versus active PBL). Therefore, the current lens through which we measure academic success may not be correct. Perhaps a new perspective and lens should be used to explore how educational policy must change to prepare today's student for tomorrow.

As the commentary correctly pointed out, aviation training consists in part of learning the basic technical skills associated with piloting an aircraft. However, reducing the problem of piloting an aircraft to “how to avoid crashing” is a far too narrow and simplistic definition of the problem. Although it is true that memorization and training aids are important to learn the basic behavior and discipline, the most difficult aspect of pilot training to learn is how to behave and think in a manner to minimize risk and the chance for fatal mistakes. The analogous training aids are as basic as learning the basic ankle-taping skills: unless these basics (anatomy, psychomotor skills) are mastered, the learning level should not be advanced (assessment, decision making, rehabilitation principles). In the same way, unless the pilot masters the basics of flight, he or she cannot understand the importance of sophisticated fluid dynamics or “fly-by-wire” technology. Without PBL training, the pilot of the United Airlines DC-10 that lost its number 2 engine over Iowa in the late 1980s would never been able to make the emergency landing. Perhaps with better education, training, and learned discipline, John F. Kennedy Jr might never have taken off for the last time. Piloting a small private plane is fundamentally different from piloting an Airbus A-340, in which leadership, decision-making skills, teamwork, discipline, and crew resource management are critical. The managerial and leadership skills of the pilot are as important as the technical skills. The aviation industry has already turned to PBL, computer simulations, and simulator training to develop these problem-solving skills and teamwork required to successfully manage a long-haul flight (J.D. Rodriguez, personal communication, 2003). In fact, this concept of crew resource management is so powerful that medicine has adopted this paradigm for surgical training. Similarly, on-field management of sports trauma contains those same principles used in crew resource management.² Memorizing checklists and rote knowledge is a very small, but important, part of solving dynamic problems encountered during flight; the problem-solving and decision-making skills are more crucial. The aviation example I used² also highlighted the diverse use of PBL in learning environments in one discipline ranging from K through 12 to the most advanced aviation education research using PBL. The reader is encouraged to return to the manuscript to view the interactive Web sites cited in this example.

Cognitive theorists and educators are correct in recognizing that today's students, be they schoolchildren or adults, must acquire the generic skills and personal characteristics of independent and self-directed learners in order to become life-long learners.^1,2,6,8 Learning is an active process of constructing, rather than acquiring, knowledge. Instruction is a process of supporting that construction, rather than communicating knowledge.⁹ Perhaps in modern society, where scientific advances outpace our ability to learn every single fact, we would be wise to remember the words of John Dewey, in the early 20th century, when he argued against an educational framework of memorization and recitation in order to meet the demands of the new industrial age, saying, “education is not a preparation for life, it is life itself.”⁹