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2007; 29: 280–282
POINT . . .COUNTERPOINT
Teaching Syndromes – A Response to LearningSyndromes
Comments on a paper by Robert Burns (2006) Learning syndromes afflicting beginning medicalstudents: identification and treatment – reflections after forty years of teaching*
MARCEL D’EON, CAROLINE KOSMAS & JAMIE MACMILLAN
University of Saskatchewan, Canada
The article, ‘‘Learning syndromes afflicting beginning medical
students: identification and treatment – reflections after forty
years of teaching,’’ (Burns 2006) seems to resonate with
teachers but completely misses the point. In a lighthearted way
the author seems to be laying blame for these syndromes at the
feet of the medical students. The point we would like to make
from our own experience of teaching, doing research,
conducting workshops, and attending and presenting at
conferences in medical education for almost 10 years (MD)
and as medical students (CK, JM) is that many of the
syndromes and conditions are in fact symptomatic of systemic
problems to which the medical students are merely reacting
and that the major responsibility for these learning syndromes
ought to fall at the feet of the faculty of the medical school.
The author provides an example that supports our thesis in the
‘Slip and Slide’ syndrome where the anatomy department
modified its testing program, which then created changes in
medical student study behaviour. It would do little good to tell
people who are sick from mining asbestos that they should
better look after themselves. There would clearly be a moral
imperative for the managers and supervisors to improve the
working conditions at the mine!
Medical students from all years often agonize over all kinds
of questions asked on examinations because the questions are
ambiguous, have more than one right answer, include
grammatical errors, or were not taught or included in the
objectives (if objectives were provided). We have observed
that course coordinators during examination reviews did not
know the answers to certain questions, that others admitted
that there were two good answers but refused to allow marks
for both, and that some picked from a question bank without
knowing what exactly was taught by a particular lecturer.
Questions that seem clear to an instructor with tens of years
of experience will likely seem complex to a student who is
trying to apply the information for the first time. Instead of
telling medical students not to agonize over every question,
we as medical educators need to write technically correct
multiple choice questions and pay more attention to student
assessment generally (Entwhistle 1992). One method we are
trying out at the University of Saskatchewan is an examination
audit whereby practicing clinicians and former graduates
systematically review exam questions for relevance and
quality.
Medical students, like many of us, may at times postpone
studying till what seems like the last moment. This is often a
good coping strategy since most tasks will expand to fill the
amount of time available. But they may be overwhelmed and
we think the larger issue is the total amount of content that we
expect them to learn in a finite amount of time. One estimate
pegs the rate of learning new facts and concepts in medical
school (based on a 40 hour work week) at about one every
two and a half minutes for the pre-clinical material and about
one every four and a half minutes for clinical skills and
knowledge, whereas the recommended rate is about one
every 12 minutes (Anderson & Graham 1980). Our own
estimates for some courses are similar. How can anyone learn
at that rate and be able to use and apply the material in a
proficient way?
The author laments the chorus of medical students who
only want to study relevant material fearing that we will turn
out mere technicians and trades people. There is more than
enough material that is relevant to clinical practice to fill four
years of study without including material that is only margin-
ally relevant (Jamshidi & Cook 2003). There is much wasted
effort in teaching irrelevant material to students when they will
promptly forget much of it within months and sometimes up to
50% within a year of the exam (D’Eon 2006). Instead of
teaching them with and about electron microscope images of
inflammation in first year let’s stick to what is authentically
relevant such as: On physical examination what does
inflammation look like? How does it behave? What are the
consequences? What do we do about it? To train physicians as
opposed to mere technicians we would explore the science
behind inflammation to the extent that it furthered one’s ability
to identify and manage inflammation in varied circumstances.
We should go deeper on some relevant content and avoid
other material entirely.
The author also introduces the importance of ‘pass the
exam’ relevance implying that students should compliantly
study the material as handed down by the teacher because it is
on the exam. This is often no more than an attempt at coercive
motivation when no rational and convincing explanation
Correspondence: Marcel D’Eon, Director, Educational Support and Development, College of Medicine, University of Saskatchewan, Saskatoon,
Canada. Email: marcel.deon@usask.ca
280 ISSN 0142–159X print/ISSN 1466–187X online/07/02-030280–3 � 2007 Informa UK Ltd.
DOI: 10.1080/01421590701252115
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for the utility of course content can be mustered
(Haylock & D’Eon 1999). We hardly see how passively
accepting the task of learning irrelevant material is going to
help medical students to become more self-directed or make
them want to learn for understanding! And though it is true that
many medical students have learned to memorize, they have
done so in response to our requirements that they achieve
high marks in prerequisite courses and then simply carry over
their successful ways into medical school, again, because we
value high marks. Many medical students, perhaps the
majority, would like to learn for understanding but, when
faced with an almost insurmountable quantity of course
content, revert to the ‘cram for the exam’ survival strategy,
which, unfortunately, we reward.
The medical student may be afflicted with numerous
learning ills but in our opinion they have been acquired due
to poor teaching and learning opportunities which thrive in
the institution. Let’s not blame the students; it offends and
confuses them and deflects the real responsibility so that
appropriate action will not be taken by those best in a position
to make important and necessary changes – the faculty.
References
Anderson J, Graham A. 1980. A problem in medical education: is there an
information overload? Medical Education 14:4–7.
Burns ER. 2006. Learning syndromes afflicting beginning medical students:
identification and treatment – reflections after forty years of teaching.
Medical Teacher 28:230–233.
D’Eon M. 2006. Knowledge loss of medical students on first year basic
science course at the University of Saskatchewan. BMC Medical
Education 6:5.
Entwhistle N. 1992. Influences on the quality of student learning –
implications for medical education. South African Medical Journal
81:596–606.
Haylock D, D’Eon MF. 1999. Helping low achievers succeed at mathematics
(Toronto, Canada, Trifolium Books, Inc.).
Jamshidi HR, Cook DA. 2003. Some thoughts on medical education in the
twenty-first century. Medical Teacher 25:229–238.
Response by Robert Burns
I appreciate Dr D’Eon’s (2007) interest and passion for the
points he raised however, many of these do not pertain to the
content of the ‘‘Syndromes’’ article (Burns 2006a). These
include: (1) technically correct exam questions, (2) exam
review/auditing, (3) learning objectives, (4) amount of content
to learn in a finite period of time, (5) course administration
inefficiencies, and (6) the broad issue of relevant vs. irrelevant
content.
D’Eon claims that I ‘‘completely missed the point . . . by [my]
laying blame for these syndromes at the feet of the medical
students . . . that the major responsibility for these learning
syndromes ought to fall at the feet of the faculty of the medical
school . . . due to poor teaching and learning opportunities
which thrive in the institution’’. ‘‘Syndromes’’ focused on the
learning problems beginning medical students had before they
interacted with medical school faculty. These problems were,
therefore, acquired in the students’ previous educational
experiences. ‘‘Syndromes’’ details how I attempted to help.
Much of this help was offered during orientation week before
medical school courses started. The hope was (is) that the
students would be able to approach their medical education
with more effective learning strategies and techniques.
Thereby becoming better learners while in medical school
and, importantly, afterwards as life-long learners responsible
for the modern care of their patients. There is a significant
difference between causing (D’Eon view) these syndromes vs.
diagnosing and treating them.
D’Eon recommends that ‘‘postponing studying . . . till the
last moment . . . is often a good coping strategy’’. This is the
‘‘Slip and Slide’’ syndrome wherein students ricochet from
exam to exam in a mode of crisis-based memorization.
Recommending the cram-for-exam approach is inappropriate,
especially since we are trying to educate students to be
life-long, self-motivated learners, not exam-motivated learners.
In an attempt to treat the ‘‘Slip & Slide’’ syndrome we clustered
major exams in currently running courses. This did, as D’Eon
states, ‘‘create changes in medical student study behavior’’,
however, these were for the better, not for the worse as he
assumes. Many of our students decreased/stopped using the
cram/memorize-for-exam method. With appropriate counsel-
ing they adopted more efficient learning strategies and tactics,
especially the use of understanding vs. rote memorization.
This initial treatment for the S & S syndrome evolved into a
new organ-based curriculum for the M1 and M2 years. Now
once every 3 weeks students are tested in a single all-day,
USMLE-Step 1 type examination covering content presented in
all concurrently running courses. This causes the students
to stay current in their studies. This process is not, as
D’Eon maintains, ‘‘coercive motivation when no rational and
convincing explanation for the utility of course content
can be mustered’’. Medical teachers have the responsibility
to: (1) identify the material they expect the students to learn
and (2) schedule exams in the best interest of student mastery
of that content. The problem of identifying content, especially
in the basic sciences, that is deemed relevant in a medical
education is under constant investigation (see Koens
et al. 2006).
Medical teachers also can help students learn basic science
content in a more efficient way by utilizing types of questions
that: (1) do not have a rote memorization route to the correct
answer and (2) have an obvious connection to clinical content
(Burns, 2006b). The latter is easy to do because most if not all
disease processes involve something defective happening in
the organelles, cells, tissues, organs and organ systems of the
Correspondence: Dr E Robert Burns, Department of Neurobiology and Developmental Sciences, College of Medicine – slot 510, University of
Arkansas for Medical Sciences, Little Rock, AR 75505, USA. Email: burnsbob@uams.edu
Point . . .Counterpoint
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human body. For example, ‘‘Chromosomal analysis of various
tissues taken from a female patient shows XO, XX and XXX.
Cells from every tissue type contain 44 autosomes. It is
assumed that a single abnormal division accounts for all of
these aberrations. Which of the following division processes
would account for this situation? A – meiotic anaphase
lagging, B – meiotic nondisjunction, C – mitotic anaphase
lagging, D – mitotic deletion, E – mitotic nondisjunction’’ (Burns
and Cave 2007). The student not only realizes the clinical
appropriateness of the question, but also has to think the
problem through using an understanding of the applicable
content because there is no memorized factoid to recall as an
answer.
The theme of a content connection between basic and
clinical science extends to the contribution electron micro-
scopy-based cell/tissue biology has made to medicine. D’Eon
states: ‘‘instead of teaching them with and about electron
microscope images of inflammation in the first year let’s stick
to what is authentically relevant such as: On physical exam
what does inflammation look like . . . .’’. It is worth recording
that electron microscopy content and images appear in
modern medical texts of Cell Biology, Histology,
Embryology, Pathology (some diagnoses even depend on
analysis by EM) and others. Electron micrograph-based
questions are on the US National Board of Medical
Examiners (NBME) Subject Specific (‘‘Shelf’’) Examination in
Cell Biology & Histology and on the USMLE Step 1. In addition
there are many diseases that are manifested by defects
in specific organelles, e.g. (1) the mitochondrial encephalo-
myopathies (Kearns-Sayre, MELAS and MERRF syndromes);
(2) Tay-Sachs and Pompe’s disease or type II glycogen storage
disease (lysosomal storage diseases); (3) Kartagener’s syn-
drome resulting from abnormal dynein arms in cilia leading
to a loss of ciliary movement and (4) in the widely read
New England Journal of Medicine, a review article entitled
‘‘Age-Related Macular Degeneration’’ by de Jong (2006)
presents a summary of the electron microscopic findings of
this disease process, i.e. ‘‘ . . . there are enlarged lipofuscin
granules, thickened Bruck’s membrane with increasing
porosity in its central elastic lamina . . . ’’. These authors,
organizations and clinical situations support the inclusion of
EM-based content on the normal and abnormal structure and
function of cells and their organelles as important in medical
education.
The ‘‘Syndromes’’ article has been recommended as
‘‘compulsory reading for course coordinators in all medical
schools and all new medical students’’ (Levison, 2006). Several
US medical and pharmacy schools have recommended it to
their students and faculty.
References
Burns ER. 2006a. Learning syndromes afflicting beginning medical students:
identification and treatment – reflections after forty years of teaching.
Medical Teacher 28:230–233.
Burns ER. 2006b. Clinical Histology. Clinical Anatomy 19:156–163.
Burns ER, Cave MD. 2007. Rapid Review: Histology and Cell Biology,
(question #25, p 247), second ed., Mosby, Inc. an affiliate of
Elsevier Inc.
D’Eon M, Kosmas C, MacMillan J. 2007. Teaching syndromes: A response to
learning syndromes by Burns-2006. Medical Teacher 29:280–281.
de Jong PTVM. 2006. Age-related macular degeneration. N Eng J Med
355:1474–1485.
Koens F, Custers EJFM, Ten Cate OTJ. 2006. Clinical and basic science
teachers’ opinions about the required depth of biomedical knowledge
for medical students. Medical Teacher 28:234.
Levison D. 2006. How not to learn and how to learn as a medical student.
Medical Teacher 28:209–238.
Point . . .Counterpoint
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