So one effort. Knowledge and action should not be separated [IO].

The view of Kant that theory has a distinctive place in all human activities and the Chinese concept of the essential unit! of knowing and doing is reflected in the psychology of William James. the educational philosophy of John Dewey and the sociological psychology of George Mead that underlies much of the content of modern behavioural science theory.

* Piaget would agree with this point. but would reverse the coin and contend that action IS the beginning of knowledge [I I].

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Less well known in the West, but equally influential. is the elaboration of these ideas in the writing’s of Mao. In an essay On Practice he asserts that truth is discovered through practice and through practice we develop and verify truth. Mao tersely summarizes this dialectical conception of knowledge: Starting from peripheral knowledge and activity we develop it into rational knowledge and then starting from rational knowledge actively develop practice so as to remold the subjective and objective world. Practice. knowledge, more practice. more knowledge; the cyclic repetition of this pattern to infinity. and with each cycle the elevation of the content of practice and knowledge to a higher level

[lOI. Many of those who have attempted to employ behavioural science theory to foster insight into the social psychological dimensions of their respective fields have not emphasized the inseparability of theory and practice and have consequently. overlooked its potential to help medical students think scientifically and integrate seemingly disparate areas of study. Theoretical

knowledge

Some academics are interested solely in the knowledge they have to communicate, which does not mean they deny its potential utility or insist that it is good in itself. Rather they confine themselves to one kind of communication and one phase of scientific activity. Others may have an interest beyond knowledge alone, and are concerned with the problems it can solve-that is they communicate knowledge with a view to its application. Both types of academic are necessary and complement one another’s activities. These two attitudes toward communication reflect major phases in theory construction. The first involves systematizing what is known and the second derives plans of action from the systematization. Theory requires in its first phase an abstract language, so that it may acquire the scope or provide a breadth that to the student may seem irrelevant. Then, too, many students get bogged down in learning the theoretical vocabulary. Both faith and an understanding of the nature of theory generation are required to carry the student through this vital phase to potential application. Theories are therefore intellectural tools for organizing experiences in such a way that generalizations can be made from one set of experiences to another. The value of a theory-an abstract scheme of concepts-lies in its overview and interrelation of experiences. As Popper states: Theories are nets cast to catch what we call the world: to rationalize. explain. and master it. We endeavour make this mesh finer and finer [12].

to

Popper’s theory of knowledge is a theory of reason that assigns the role to rational arguments of criticizing attempts to solve problems and a theory of experience that assigns to observations of the role providing tests which may help in the discovery of mistakes [13]. His thesis is that knowledge progresses by quesses. tentative solutions to problems and conjectures. These conjectures are controlled by criticism. attempted refutations which include critical tests.

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Criticism of conjectures bring out mistakes and clarify the difficulties involved in attempts to solve problems. Acquaintance with problems is thus increased and more mature solutions are made possible [ 131. In short, knowledge grows by correcting mistakes and theory serves as a guide to the discovery. organization. explanation. investigation. and criticism of observation. Conant similarly. but more succinctly. defines theory as: an interconnected oped as a result

series of concepts that have develof experimentation and observation and

are fruitful of more experimentation

and observation

[14].

These conceptual schemes put flesh on the skeleton of logic by growing from (a) unorganized everyday impressions based on implicit presumptions the current thoughtways of Zeitgcist. Kuhn has effectively argued that knowledge does not grow by accretion. Rather it proceeds by revolutionary process in which older theory is rejected or replaced by an incompatible new one. These changes have conslsted of a series of paradigms gaining ascendency. Kuhn defines a paradigm as:

an achievement that serves for a time to Imphcltlq * Several types of theorizing exist within the concept of paradigm outlined by Kuhn. One is general theory, a master conceptual scheme useful for deriving subsidiary theories. Another is middle range or substantive theory. a theory developed for a particular empirical or conceptual area of inquiry. The latter may be from general theory or it may be empirically grounded at strategic points in order to permit the development of more well-founded theories. The work of Glaser and Straus on death and dying may be seen as part of the process of generating and grounding a theory of status passage [ 181. Moreover. several forms of theory are implied in this discussion: (1) Meta Theory-theory about theory. The specification of the rules of theory construction. (2) Modeldescriptive analogies used to help organize and visualize that which cannot be observed. (3) Metaphor---% if” statements or the substitution of an object for another to suggest likeness between them. Further. theories can be classified according to their attending degree of logical rigor: (I) axiomatic (explicit postulates); (2) explanatory (how and why statements) (3) descriptive (how statement): and (4) formative (elementary organization of impressions).

the legitimate for succeeding

problems and methods of a research generations of practitioners [IT].*

define

tieId

The communication of the rclevencr of theor! to the practitioner can begin by providing an opportunity to gain a historical perspective of the growth of ideas. Placing the content of the students undergraduate areas of study is a useful pomt of departure. The unity and growth of science is depictable in the parallel inlluences of Newton in physics. Freud in psychology, and Comte in sociology during the nineteenth century. The twentieth century can be contrasted through the influence of Einstein in physics. Piaget in psychology, Mead in sociology. The works of these theorists have been part of the creation of a climate of opinion and the source of problems attended to at a given time. The aim of behavioural science theorv should, in addition to providing rrliable insights ;nto the social psychological factors involved in prevention and treatment. establish a commitment viewing the insights of systematic ideas as

Behavioural

science theory

relevent across disciplines to man’s understanding of health and illness. By understanding theories, having concepts readily at his disposal and becoming practiced in linking them to his observations, the student practitioner can draw on the systematic and verified aspects of a conceptual scheme to make sense out of his observations of those portions of the world of learning that immediately concern him. Moreover, in-depth awareness of theory stimulates open-ended thinking, the questioning of established applications. and a more rigorous self-evaluation.

Teaching theory can be defined as a worthwhile endeavour. but it occasions difficulties that often transcend the student clinician’s perspective. To generate theoretical sophistication requires more than audio-visual gadgetry and entertaining lectures. Vague generalities and irrelevant trivia can intrude. Theory can become irrelevant because of unimaginative presentation, minimal coverage in abbreviated programs. and outright depreciation by instructors. Academics, much like students, tend to be egocentric regarding their intellectual pursuits. Current theories can become more important than current problems. Championing and seeking converts to a particular perspective is an irrelevant enterprise in professional education. Nor should theory, divorced from practice, be an aim in itself. While nothing is as practical as good theory. nothing is perhaps as impractical as a bad theory. Theory. in some instance. can inhibit understanding by creating a simplified idealization. Often overconfidence in the capacity of a theory to generalize can result. Once the theory has been assimilated and legitimized it may define problems and be the focus of validating efforts regardless of its validity. As Gardner observed: Mmd forged manacles bind many a gifted scholar smotherIng his creative talent. by a growing commitment to his own previously stated doctrine [ 191.

For the reasons outlined theory and practice are inseparable. Multiple theoretical perspectives should be at the disposal of. and serve the aims of. both the academic and the practitioner. Several fallacies currently perpetuated in the employment of behavioural science theory in medical education inhibit this aim. The first involves the notion that the presentation of “rule of thumb” or the accumulated trial and error information of practitioners dealing with patients or groups is a valid use of a majority of student time. What appears useful ma! in fact be misleading trivia. Not unrelated. the second fallacy is the notion that behavioural science theor), must be simplified and popularized in order to have appeal to medical students. In a reaction against abstraction. behavioral science theory has often been presented in paraphrased form or derived from newspaper and mass media popularizations. These methods detract from behavioural science theor? and depreciate its potential. The existence of helpful practitioners should be achieved bv virtue or career choice and selection of degree candjdates. Still problematic. however. is the creition of practitioners competent in translating theor! into practice. putting

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to use scientific knowledge in solving some of the problems of his profession. The challenge of community health problems and the concept of the behavioural scientist physician will not be met by armchair speculation, unsupported impressionism, dogmatic opinion and blind acceptance of tradition. The shortening of a physician’s training period has necessitated more effective utilization of previous training and has meant placing greater responsibility on the student for his own training in an effort to emphasize learning by the student in contrast to teaching the faculty. Behavioural science theory role in this education process need not be minimized by watered down materials and “Mickey Mouse” programs. Several necessary ingredients, in the effective communication of the relevence are obvious. First. there is no substitute for good instruction. Second, there is no substitute for interested students. Determining what is a good teacher is made complicated by what is called the “art of practice”. One factor remaining unobserved in this area is the extent to which the teacher is a good model. That is, the good instructor -is also an interested student who shows continued effort in learning. The unfortunate tendency of some instructors to assume responsibility for student learning often occurs at the expense of their own learning. In brief. the scientist-scholar model is as important in medical education as in liberal arts. The often confusing vagueness of the aim of behavioural science in medical school curriculums is an additional impediment to its effective communication. The claim that it is necessary in order to understand the whole patient or social policy affecting medicine most likely implies an exploration in profound common sense. While a worthy endeavor in und&graduate study. this aim would probably appear to be an expensive use of scarce study time. If behavioural science theory can do more than this by enabling knowledge to become open to inspection and test, direction in its application is essential. Only recently has behavioural science begun to apply to itself some of its basic principles. In educational psychology a movement has been underway ,to increase instructional efficiency through the use of behavioural objectives [20]. Behavioural objectives are statements of specific terminal behaviours that can be observed and measured at the end of an instructional program. The mere delineation of behavioural objectives has not eliminated any major problems in general education. On the contrary it has dramatized the need for considering the differential learning styles and rates of students. To be effective, statements of educational objectives should be general, flexible and not tied to the relatively trivial outcomes that can be measured by the limited evaluation techniques currently available in education. The statement of educational objectives in medical education can be accomplished through the formulation of outcome competencies. Like behavioural objectives. outcome competencies are stated in terms of what students should be able to do at the end of a course. Unlike them however, they also include statements of what students should know. The following are outcome competencies used in a graduate course in Child Development. At the end of the

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course students will: (1) have demonstrated knowledge of concepts and research pertaining to child development. (2) be able to locate critical developments in childhood and early adolescence. (3) appreciate the implications of (or lack oft early experience to later life. (4) recognize and apply criteria for evaluating adaptational competencies. A number of benefits accrue from the development and use of these sort of statements: (1) Instructors are less likely to overlook components of teaching vital for students to obtain competency; (2) Outcome competencies provide a basis for program and student evaluation; (3) General outlining of these goals offers the possibility for individualizing study; (4) Such statements enable intermediate steps in learning to be clarified: (5) Students can use these statements as study guides; (6) Finally, they provide a visible rationale for the purpose of various areas of study. Outcome competencies are, thus. useful in eliminating confusion surrounding the relation of seemingly separate aspects of an instructional program. This compartmentalization has been an impediment to effective medical education. While outcome competencies may be helpful in overcoming this problem. structural features associated with professional and academic enterprises need to be dealt with. The activity of basic research and theory construction has traditionally had its own reward system and rarely interacted with the world of practical application. To integrate these separate realities the mutually meaningful collection, interpretation, creation and translation’of their findings is essential. One attempt to accomplish this aim is General Systems Theory. This conceptual scheme provides a multilevel framework of assertions applicable to all systems whether physical, biological or behavioural. This approach offers the possibility of achieving integration in medical education. Moreover, as a general framework for instruction, it enables students to integrate what appears to be distinct aspects of their education. The concept of system, defined as a set of elements standing in relation, can be a powerful means of bringing together such seemingly diverse areas as microbiology and political economy. The interdisciplinary theme of this perspective is represented in the characterization provided by its founder Ludwig von Bertalanffy: the aims of General Systems Theory can be indicated as follows: (a) There is a general tendency toward integration in the various sciences. natural and social. (b) Such integration seems to be centered in a general theory of systems. (c) Such theory may be an important means for aiming at exact theory in the non-physical fields of science. (d) Developing unifying principles running “vertically” through the universe of the individual sciences, this theory brings us nearer to the goal of the unity of science. (e) This can lead to as much needed integration scientific educatron [?I].

When behavioural science theory is seen as a unified part of medical education. its importance beyond mere liberal education becomes clear. The following strategies for communicating the relevance of theory and practice are in keeping with this approach and useful in all aspects of medical education.

VOLE

(I) Tmm rwchimq. Ideally. instructors in professional programs should be aware of the elIects of the practicum. conversant with the language accepted by the profession and theoretically sophisticated. Rather than expect a single individual to embody all these qualities. a team-teaching approach may be uttlized. Problems of status. logistics. and communication have complicated many experiments in team-teaching and have sometimes led to the creation of a hybrid instructor with presumably all the necessary ingredients to articulate the relation of theory and practice [22]. Unfortunately. this hypothettcal solution removes from team-teaching its potential for encouraging academics and practitioners to work together in an effort to resolve common issues and to improve communication. Team-teaching requires the pooling of available resources. Consider the possibility of a team composed of a social scientist and a general practitioner. co-presenting a course in child development for medical students. A rationale for health care planning and the appropriateness of certain treatments could be presented in the light of the physical. emotional. cognitive and social development characteristics of actual children. Team-teaching of this sort demands careful preliminary planning and considerable time to develop procedures. but the benefits to be derived are well worth the effort. (2) Biographicul study. Looking at the lives of major theorists-an intrinsically interesting enterprise for many--can reveal the way theory is generated and used with actual problems. If theory is presented only in the form of a “reconstructed logic”, the visibility of its correspondence with observation and experience diminishes. But. if viewed in the context of its creation and of the questions and subsequent research that provide its inception, the relation of theory to practice can be demonstrated. Moreover. this examination of “logic in use” facilitates appreciation of theory as the distilled experience of others. Freud’s life---his constant self-analysis. the struggle to win acceptance and his continuous modification of psychoanalytic theory -illustrates how biographical study can make real the close interrelationship of theory and practice, and at the same time depict theoretical problems as in fact a species of practical problems. (3) Theory explication. Explication is an attempt to make theories precise and clear by making explicit their assumption. concepts. propostttons, and related research. In this assignment. students can lay bare the logical framework of a theory and assess its potential for application. They learn how to cut through a theory’s verbiage and determine its strengths and weaknesses. A typical exercise would require the student to prepare an outline with such content as the following: (I) The author’s name. background. identity (2) His thesis or central idea; some its scope (3) List concepts a. defined. with the definitions b. undefined

professional indication

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Brhavioural science theory in medical education (4) Author’s assumptions-what he takes for granted without proof (5) Some elaboration of his core conceptions, such as a. man: active-passive b. man’s nature: good-bad c. man’s mind: blank state or primary categories d. society : nominal-real e. social reality: normative-interpretive (6) Propositions (empirical generalizations) (7) Representative supporting research (inferential and empirical) (8) Conclusions and implications (9) So what? (What does it mean to you?) The foregoing three strategies. employed in full year tutorials and/or discussion seminars, can effectively bridge the imaginary gap between theory and practice. Theory portrayed as the tentative embodiment of what is known in a field can thus be=made relevant to the student practitioner as a means of resolving problems with greater long term significance for practice than highly personalized methods or certain fads of technique. Implied in all of them is a discovery model of learning. Conceptual schemes have an almost limitless ability to explain phenomena. Mere explanation may be mtellectually satisfying to the academic. To the practitioner, theory becomes relevant only when the connection between conceptualization and experience is discovered and genuine understanding thus made possible. The aim of these strategies is to overcome the false dichotomy between theory and practice by demonstrating their inherent inseparability.

to incubate, they can be intimidating. The opportunity to “live with” a theory should be provided by both instructor and student. In summation, to view theory as a luxury beyond the concerns of applied pursuits is to misconstrue its nature. Attempts to provide theoretical education in professional programs must recognize the main features of the student practitioner’s perspective and present theory as a continuous process of creation that moves back and forth between abstract concepts and concrete experiences.

Two additional issues tend to confound attempts to make theory relevant. First, professional education has in many instances responded to manpower requirements or to the need for the economy by condensing professional programs. This shortening of courses has been at the expense of theoretical exposure. Students who will have a life time to practise should not be robbed of the opportunity to immerse themselves in the foundations on which practice is built. The consequences of program abbreviation will be far-reaching both for practitioners and their professions. The possible long term results can be likened to the different expectations of those technically trained and those liberally educated.* In the second place. formal education cannot do everything. Specifically. the application of theory to practice must ultimately be made b>; the student. Effort and time are necessary for the impact of ideas upon events to become evident. Unless time is allowed for these ideas

10

* An example of one outcome associated in part by nontheoretical training is the marked contrast between the roles of nurses with a two-year Diploma (technical) and nurses with a four-year Bachelor of Science degree (professional). One has a functionary role. while the other is rising to full membershlp m the health-care delivery team.

REFERENCES

I. Flexner. A. Medical Education in The United States and Canada. The Carnegie Foundation, New York.

1910. C. The Flexner report. Daedulus. Winter, 105. 1974. Kemper, T. D.. Kelver, M. and Fritz, H. B. Social science in schools of medicine. Milhank Mem. F. Q. XLIX (2), 244. 1971. Langsley. D. G., McDermott, J. and Enelow. A. (Editors) Mental Health Education in the New Medical Schools. Jossey-Bass. San Francisco, 1973. Frame. J. D. The prison of relevance. Teacher Education. Spring, 42, 1973. Warshay, L. H. Breadth of perspective. In Human Behauiour and Social Processes (Edited by Rose, A.) 148-178. Houghton-Mufflin, Boston, 1962.. Becker. H. Bovs in White. Universitv of Chicago Press. Chicago, 196i. Piaget, J. and lnhelder B. The Psychology of the Child. Basic Books, New York, 1969. Kant, I. On That Old Saw: That May Be Right In Theory But It Won’t Work In Practice. University of Pennsylvania Press, Philadelphia, 1974. Chan, W. A Source Book In Chinese Philosophy. Princeton University, Princeton, 1963. Piaget. J. Biology and Knowledge. University of Chicago, Chicago 1970. Popper. K. The Logic of ScientiJic Discovery. Harper & Row, New York, 1959. Popper, K. Conjectiues And Refutations. Harper, New York, 1965. Conant, J. C. Science and Common Sense. Yale, New Haven, 1951. Margenau. H. The Nature of Physical Reality. McGraw-Hill. New York, 1950. Kaplan, A. The Conducl of Inquiry. Chandler, San Francisco, 1964. Kuhn, T. The Structure of Scientific Revolutions. Uni-

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11 12. 13. 14. 15. 16. 17.

versity of Chicago. Chicago, 1970. 18. Glaser. B. and Strauss, A. The Discovery of Grounded Theory. Aldine, Chicago, 1967. 19. Gardner, J. W. SeIf-renew& The Individual and the innouatiue society. Harper & Row, New York. 1965. 20. Bloom, B.. Hastings, J. T. and Madaus. G. (Editors) Hand Book On Formative And Summative Evaluation of Student Learning. McGraw-Hill, New York, 1971. 21. Bertalanffy. L. Genera/ Systems Theory. Braziller. New

York, 1968. 22. Larsen, D. Behavioural science in the faculty of medicine. University of Alberta. Milbank Mem. F. Q. XLIX, (2) 219, 1971.