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

281

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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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