Related Article, p. 115
Interest in nephrology as a specialty has been declining in the last decade.
1
One posited explanation for this decline has been that nephrology encompasses highly
complicated topics that are poorly taught.
2
The standard lecture, a passive learning technique, is still used by many nephrology
training programs
3
to fulfill the Acreditation Council for Graduate Medical Education (ACGME) mandate
for regularly scheduled didactic sessions. However, there is limited evidence that
the lecture format is associated with improvements in knowledge retention
4
or scores on the in-training examination
5
or specialty board examinations.
6
Nephrology educators should look for alternative approaches to address this problem.
A wealth of educational research has shown that active learning provides deeper comprehension
and retention of content material compared with passive learning approaches.
7
Bonwell and Eison define active learning as anything that “involves students in doing
things and thinking about the things they are doing.”
8
(p 2)
Graffam
9
recognizes 3 key components in active learning: (1) intentional engagements, (2) purposeful
observations, and (3) critical reflection. Intentional engagements are purposeful
learning experiences in which trainees perform what we want them to learn (eg, fellow
examines a patient). Purposeful observations involve trainees watching and listening
to someone doing what we want them to learn (eg, fellow observes a renal attending
giving bad news to a patient). Critical reflection brings all components together,
in which the learner makes meaning out of their experience and information and brings
the learning process into his or her consciousness. Passive learning is a valid strategy
to disseminate basic knowledge to large groups, but in contrast to active learning,
passive learning fails to connect new information with prior experience. Data for
active learning implementation in nephrology education remains modest at best during
preclerkship years,
10
but it is largely unknown at the postgraduate level.
In this issue of Kidney Medicine, Renaud et al,
11
applying the theory of planned behavior as their frame of reference, performed a sequential
explanatory mixed-methods study (ie, analyzing both quantitative and qualitative data)
surveying and interviewing nephrology faculty at 6 government teaching hospitals in
Singapore with the purposes of exploring: (1) perceptions about active learning, (2)
perceptions of difficult teaching topics in nephrology, (3) relationship between the
basic notions of the theory of planned behavior and the extent of active learning
use to teach difficult topics in nephrology, and (4) factors affecting active learning
adoption.
The authors used the framework of the theory of planned behavior to try to correlate
certain factors to the actual behavior of using active learning. The theory of planned
behavior is a theory in social psychology developed by Ajzen in 1985 as an extension
of the theory of reasoned action developed by Ajzen and Fishbein
12
in 1975, which aims to predict future behavior based on people’s current beliefs.
The theory of planned behavior has been used to predict a wide range of behavioral
outcomes, such as smoking cessation, exercise, and condom use. The theory of planned
behavior proposes that a specific behavior is influenced by the intention to perform
that specific behavior.
Intention in this context is determined by 3 sets of beliefs: (1) attitude, (2) subjective
norm, and (3) perceived behavioral control. Attitude refers to the degree to which
a person (eg, a nephrology faculty) has a favorable or unfavorable assessment of the
behavior of interest (eg, using active learning). Subjective norm relates to a person’s
belief whether peers or people of importance in their network (eg, nephrology division
chief, fellowship director, faculty colleagues, and nephrology fellows) approve or
disapprove of the behavior. Perceived behavioral control refers to one’s perception
of the ease or difficulty performing the behavior of interest (eg, a nephrology faculty
contemplates how difficult it would be to integrate audience response system into
her hyponatremia lecture).
Nevertheless, the theory of planned behavior has been criticized, especially because
of its limited predicted validity.
13
Using linear regression, Renaud et al showed that favorable assessment of active learning
was the strongest predictor of the theory of planned behavior construct of attitude,
and attitude accounted for most of the variance in intention. Intention had only a
moderate influence on using active learning behavior. Similarly, within the construct
of subjective norm, nephrology faculty considered nephrology trainee approval of active
learning methods as the most influential.
Although there are multiple barriers for the implementation of active learning strategies
in nephrology education, teacher belief is probably one of the major hurdles.
14
With no andragogical background, most medical faculty believe that to be a good teacher
one only needs to be a subject expert.
15
However, faculty beliefs are susceptible to change with proper faculty development.
Nephrology faculty in this study were more likely to implement active learning in
their teaching if they have more than 5 years of teaching experience, have a leadership
role, or teach more than 1 difficult topic per year. It is likely that more experienced
faculty in leadership positions have received faculty development and feel more comfortable
using active learning in their teaching.
Another factor we need to consider for active learning implementation is the institutional
culture.
16
“Culture eats strategy for breakfast” is a famous quote attributed to Peter Drucker,
legendary management consultant and writer. Changing to active learning requires a
significant time investment, as well as enthusiasm, faculty development, and support
from administration. Selecting a few faculty members interested in education (ie,
faculty champions) can facilitate the transition to active learning by having them
show the way to others. Initial efforts should focus on junior faculty, who are more
susceptible to change. These junior faculty can then be used as “trainers” to work
with others. Using an incremental approach is likely to result in better outcomes.
Faculty champions can attend junior faculty teaching activities and give them constructive
feedback with suggestions on how to incorporate active learning. The trainers can
provide instructive materials and facilitate formal professional development (eg,
support their attendance at a seminar or workshop on teaching at their own institution
or other training options outside their institution, such as the Harvard Macy Institute
Program for Educators in Health Professions). Outside individual nephrology programs,
there are ample available opportunities to engage in active learning. For instance,
there is a large international nephrology community that has embraced active learning
through e-learning. Using social media, nephrologists across the globe have engaged
in games (eg, NephMadness), online journal clubs (eg, NephJC), and interactive learning
(eg, GlomCon), among others.
17
The idea of changing all the formal didactics to active learning activities might
seem overwhelming. Most nephrology faculty participants in this study used low-hanging-fruit
active learning strategies such as interactive lectures as their preferred teaching
methods. Interactive lectures are teaching sessions in which the instructor inserts
a break at least once per class. This provides the trainees the opportunity to participate
in an activity that lets them work directly with the material. Incorporating 3 to
4 multiple-choice questions in a lecture is a simple way to transform a traditional
lecture into an interactive lecture. There are also a number of other active learning
techniques that can be gradually incorporated into a nephrology curriculum but will
likely require some professional development. Interestingly, only a little more than
half the participants in this study reported using active learning to teach difficult
topics such as fluid, electrolyte, and acid-base disorders or hemodialysis adequacy.
These topics are likely considered difficult to teach because they require trainees’
solid understanding of basic science (eg, electrolyte physiology and urea kinetics).
Some of the comments gathered during the interview phase of this study corroborated
this idea as some faculty expressed concerns about using active learning in trainees
who lack a solid background knowledge and “the content is not there to apply,” tacitly
favoring passive learning instead. We would argue that a well-planned active learning
curriculum can incorporate these passive strategies, such as reviewing foundational
material before asking trainees to apply it to clinical case scenarios (eg, flipped
classroom).
We live in a time when faculty are pressured to meet increasing service and research
demands and generate more clinical income and research funding. With less and less
time allocated for teaching and other academic activities, it can be difficult to
motivate faculty to adopt active learning. Therefore, incentives should be provided
in the form of bonuses, administrative support, promotion opportunities, and institutional
recognition.
In conclusion, the results of the study by Renaud et al are difficult to extrapolate
to other educational environments but show that active learning is still not widely
implemented in nephrology education. The literature suggests that a few individual
US nephrology training programs have embraced active learning as part of their formal
curriculum.18, 19, 20 We believe this trend will continue to increase over the next
several years. However, a cultural shift inside individual programs is necessary to
achieve this goal. Professional development, finding faculty champions, gradual implementation,
and faculty incentives are key to transition to active learning.