The topic of anorexia nervosa and the ethic of forced feeding

Learning is a relatively enduring change in behaviour or the capacity to behave in a given way which results from practice (Chunk,2012). Over the years people have been trying to understand learning and the debates that have occurred through the ages reoccur today in a variety of viewpoints about the purpose of education and how to encourage learning(Hammond,2002). Every conceivable theory has been seriously put forward but theorising about learning remains an exercise in generalisation and can often be as controversial as it seeks to be empirical.

For the purpose of medical education, every teacher has his or her own method of teaching style and preferred methods of teaching and I would like to compare and contrast two teaching methods that have been used in my practice with reference to educational theories and discuss the impact upon teaching learning. Firstly I led the discussion to a small group of second year medical students on the topic of anorexia nervosa and the ethic of forced feeding. It was a compulsory session and I facilitated discussion among eight students.

Secondly I delivered a lecture to a larger group of GP trainees on the topic of Mental Capacity Act. Although this session was also deemed to be compulsory, a significant number of trainees did not attend due to clinical workload. Many common learning theories may be applied to explain the learning of the two groups and it is likely that more than one theory plays a role and that each learner regardless of the groups they belong will have their own personal constraints, experiences and preferences even though all the learners are adult to which Malcolm Knowles referred to “Andragogy”. (Knowles,1989)

Looking at the differential attendance rates between the two groups gives rise to the issue of time factors on learning. In fact many researchers have been concerned about the different kinds of educational time, namely instrumental time, time on task, academic learning time and dead time (Anderson,1981) .In Caroll’ model, the time needed for a given student to learn a given concept depends on five factors, one of which is “opportunity to learn” which may have been an issue for the GP trainees but not so much so for the medical students who are in full time education. ( Carroll,1963).

By emphasizing equality of opportunity it means not only giving appropriate opportunities to learn but also stretching all student’s potentialities as far as possible toward their upper limit. There are however other factors such as motivation and attitude that may also explain the differential attendance rates. Motivation has been described as a “person’s aroused desire for participation in a learning process”(Curzon,2004). Motivation is seen as need -related. Perhaps,the most well-known theory of motivation is Maslow’s Hierarchy of needs who considers self-actualisation as what drives people to learn.

(Mohanna et all,2004). So it is irrelevant whether the two sessions were compulsory but rather the internal motivation that is the determining factor in the attendance rate. The Humanistic theory of Maslow is supported by the student centred learning of Carl Roger who differentiate two types of learning namely cognitive (meaningless) and experiential (significant) learning which correspond to academic and applied knowledge respectively. However some contemporary researchers do not give support to the ordering of the needs within the hierarchy even if they agree with the existence of universal human needs.

(Tay and Diener, 2011). It is also worth noting the difficulty of testing the theory and the ordering and definition of needs. Similarly even though Malcolmes Knowles explain the motivation to learn ,its main drawback lies in the little significance he attaches to the context and the social mechanism of deriving meaning and knowledge. We now know that context and social factors are paramount in professional education. (Tayler and Hamdy, 2013) Maslow theory of motivation is nevertheless consistent with Deci and Ryan Self Determination Theory which give importance to three innate and psychological needs (Deci and Ryan,2000).

Competence which is the need to control the outcome and experience mastery, Relatedness which is the innate need to interact and Autonomy which is the innate drive to be the master of one owns life play an important role in the learning for both groups regardless of difference in level of prior knowledge that may exist among the second year medical students and the GP trainees group on anorexia nervous and mental capacity act respectively. It is interesting to note that the Humanistic theories described above give little importance to the impact of prior knowledge.

In some ways, this is supported by John Locke, in his Essay Concerning Human Understanding, sets out the case that the human mind at birth is a complete, but receptive, blank slate (scraped tablet or tabula rasa) upon which experience imprints knowledge. (Herrnstein & Murray, 1994). Over the years though, there have been further theories putting forward that give serious consideration to the importance of prior knowledge and these would be particularly relevant in the learning of the two groups.

One can expect that compared to the didactic nature of mental capacity lecture,the “critical reflection” putting forward by Jack Mezirow in the late 1900, would be more evident in the small group discussion where there are more opportunity for dialoguing with other students on the ethic of forced feeding in anorexia nervosa and considering if their underlying assumptions and beliefs on the topic are accurate.

His transformation learning theory utilises disorientating dilemmas which often occur in the context of small group discussion where students are forced to reconsider their beliefs and prior knowledge in a way that will fit new experience in the rest of their world view. (Howie and Bagnall,2013). There is some indication, though, that true transformation cannot occur until students get the opportunity to actively take steps that acknowledge their new belief for example in caring for a patient with anorexia nervosa who is rigidly adhering to their right to die and the ethic of forced feeding.

In relation to this, Jack Mezirow did not take into account the role of affective learning given that emotions can be difficult to manage in learners particularly where there is critical awareness and changing this can be problematic. Similarly some critics argue that his theory gives too much weight to critical reflection and this on its own does not necessarily lead to transformative learning. (Taylor, 1998). However one should be aware that concepts such as Leadership, ethics, and communications that are integral in medical training, requiring deep cognitive restructuring , are best seen in transformation learning.

(Kuechler and Stedham,2017). The role of prior knowledge on learning is well supported by one of the most influential theorist in developmental psychology. Piaget described the 4 stages of learning with the formal operational stage being the final stage of cognitive development which occurs from 11 to adulthood. Regardless of the type of teaching groups they belonged, both the second year medical students and the GP trainees, should be able to think abstractly and achieve skills such as inductive and deductive reasoning abilities.

They can make use of many strategies and resources for problem solving as they have developed complex thinking and hypothetical thinking skills and through hypothetical –deductive reasoning, they are able to identify the factors of a problem and deduce solutions. (Woolfolk,A, 2004). One can see how these thought processes described in Piaget formal operational stage would be more “flourishing” in the small group discussion of anorexia nervosa where they have the opportunity to explore many solutions to problems through group interaction and facilitation.

One of the major criticism of Piaget theory is that his work on cognitive development focused only on children and may not applied to adult learning. Moreover his stage of formal operations may never be reached by some significant proportion of individuals. (Kuhn 1979). His theory has also be described as “asocial “as he did not see the impact of the environment on knowledge acquisition. (Gross,2010). The integration of theory and practice is a challenge to students but the relevance of their professional knowledge can be achieved if the students are supported by a knowledgeable companion.

(Doel and Shardlow,2009) My role as a facilitator in the small group discussion on anorexia nervosa would be seen as beneficial to students according to Vygotsky as I was acting as a “more knowledgeable other ” with a better understanding or higher ability level than the second year medical students , with respect to a particular task, process, or concept. (Vigotsky,1978). Another interesting idea described by Vygotsky which is far more relevant to my small group teaching as opposed to my lecture on mental capacity act is the transitional area which he referred to the Zone of Proximal Development .

In this respect, Intrapersonal speech in discussion with me as a more experienced person would provide a vital platform to transit the second year medical students to the level of maturation that they are capable of. The concept of Scaffolding coined by Jerome Bruners ,who share the beliefs with Vygosky that social environment and social interactions are key elements of the learning process ,is also relevant here particularly in the small group discussion .

Bruner’s studies on learning led to his research and ultimate development of the famous scaffolding theory in education, which identifies the importance of providing students with enough support in the initial stages of learning a new subject. Being a more knowledgebale facilitator would have ensured that the second year medical students weren’t left to their own devices in understanding something. It is worth noting as well that Vigosky`s social contructivism theory is well supported by Bandura`s social learning theory as both share the view that learning is a socially active process .

It follows therefore that in both the lecture and the small group discussion that I faciliated ,the student`s learning would have been improved by me acting as a “good role model”. (Bandura,1977). It is important to  stress that a number of influential theorists for example Jerome Bruners and Jean Piaget  have focus their work on childhood cognitive development. Pershap a model more consistent with adult learning is the Bloom taxonomy which were put forward by a team of cognitive psychologist in 1958.

The pyramidal model  shows the hierchiarcal levels of learning with knowledge at the bottom and increasingly more complex and abstract mental levels, to the highest order which is classified as evaluation. Bloom taxonomy, if appreciated by medical teachers and students and correctly applied, should make meta-cognition of the diagnostic process routine. ( Nkanginieme, 2016). It is likely that the second year medical students being at an early stage of training would be mostly  at knowledge level with me being a facilitator helping them to “navigate” through comprehension, application, analysis, synthesis and finally the evaluation level.

Many of the GP trainees would have had clinical experience in mental capacity act and were therefore  likely “operating” at the higher mental levels such as analysis, synthesis and evaluation in their learning. Many critiques of the taxonomy’s cognitive domain agree with the existence of these six levels but argue against  the existence of a sequential, hierarchical link. (Paul,1993) Of vital significance in the learning of second year medical students and the GP trainees and in line with the contructivist view is the concept of reflection in action and reflection on action . (Munby 1989).

The dissonance between the prior knowledge and the concrete experience that was provided as the learning opportunity played a crucial role. In both group of teachings ,the learners compared what they were hearing and seeing with what they already knew and reflected upon the difference which allowed them to develop abstract concepts in order to make sense of new infromation. It was likely though some of the GP traniees would have had previous opportunities in dealing with clinical cases involving mental health capacity and as such enabling them to engage in reflection on action.

It is important to note that learning style also plays an important role in both type of teaching methods. The VARK acronym stands for visual ,aural ,read and kinaesthetic sensory modalities. (Flemming and Mills,1992). It is likely that the mental capacity act lecture would have targeted visual learners through the use of powerpoint slides ,while the anorexia nervosa session would have targeted the kinasthetic learners through group interaction. There is however no consistent evidence that identifying an individual student`s learning style produces better student outcomes (Dashler,2008).

Furthermore a study of first year medical students using the VARK inventory revealed that the majority of student prefered multiple modes of learning . Lujan,2006) So far it seems that some of the well known learning theories seem to be in favour of the small group discussion. Problem based learning is however not without its drawbacks. A particular problem that can arise is negative group dynamics. It was the social psychologist, Kurt Lewin,who  coins the term “group dynamics” in the early 1940s. He noticed that some people can take on distinct roles and behaviours while performing in a group.

“Group dynamics” describes the impacts of these roles and behaviours on other group members or on the group as a whole. ( Lewin,1944) Some of the most common problems that can occur are Weak Leadership, leading to a lack of direction,Excessive deference to authority ,leading to suppression of one’s own opinion,Blocking,leading to disruption in the flow of information, Group thinking,leading to failure to consider alternative solutions, Freeriding, also known “social loafing “,where the free riders limit their contribution and finally Evaluation apprehension resulting from fear of excessive judgement.

Some of these issues were noticeable during my small group discussion session but not present in the lecture. Furthermore lectures have been seen to be effective in modelling how professionals work through disciplinary questions or problems and present little risk to students It can also organised to meet the need of specific audiences and material not available elsewhere can be presented to students. ( Cashin,1985).

In relation to the various learning theories that have been developed over the years, it can be concluded that none of them on their own can fully explain adult learning but that each have their strength and any particular teaching method is more justified in presence of more than one learning theory. Indeed medical teaching is becoming of ever increasing importance to educators and more robust evidence of the best teaching methods are needed though further research founded on appropriate learning theories.