Evaluation of an Academic Reinforcement Program for Health Students Science G. Fuentes, Jr., John G. Bruhn, PhD, and Fernando M. Trevino, MPH Raymond
Denver, Colorado, and Galveston Texas
An Academic Reinforcement Program has been used for three years at the University of Texas Medical Branch to assist health science students with test taking, note taking, memorization, labeling, charting, and time-scheduling techniques. An evaluation indicated that the majority of students who have learned the techniques improved their academic grades with less expenditure of study time, learned to deal with some problems which affected their studies, and gained self-confidence through the encouragement and support of the staff who taught the techniques. There are numerous self-instructional books and techniques available to students to assist them in sharpening their basic skills, in reading,writing, vocabulary, mathematics, and test taking. Most of these resources are for high school and college students.'-4 It is often assumed that students who enter health professional schools have already perfected their study techniques. Most students who pursue a health career are academically qualified, highly motivated, and dedicated to their careers. They have usually maintained above average grades throughout their schooling. Although well qualified by all these criteria, students may encounter study problems in professional school. Some of these problems are unrealistic time scheduling, ineffective organization of material, inability to learn and retain large volumes of material, difficulty with examinations given in health professional schools (often with multiple multiple-
Mr. Fuentes is a doctoral student in the School of Professional Psychology at the University of Denver. Mr Trevino is a staff member of the Office of Special Programs in the Office of the Dean of Medicine and Dr. Bruhn is Associate Dean for Community Affairs, the University of Texas Medical Branch, Galveston. Requests for reprints should be addressed to Dr. John G. Bruhn, Office of the Dean of Medicine, University of Texas Medical Branch, Galveston, TX 77550.
choice questions), and setting priorities. Social or personal problems may also interfere with students' academic performance. Some students become discouraged with their potential as health practitioners when they find that they cannot earn grades as high as they earned during college. In an attempt to assist health professional students in mastering the study problems outlined above, Dr. Miriam S. Willey, Director of Medical Education at Howard University School of Medicine, and Mrs. Barbara M. Jarecky, Coordinator of Reading and Study Skills Program, University of Kentucky School of Dentistry, developed techniques for note taking, memorization, organizing material (bracketing, underlining, labeling, and charting), and for taking multiplechoice tests. These techniques have been taught to medical students at Kentucky, Howard, Tulane, Colorado, Texas at San Antonio, Galveston, and Houston, Virginia at Richmond, Georgia, South Carolina, and to students at the Michigan State \Osteopathic School, Texas College of Osteopathic Medicine, and University of Maryland Dental School. No publications are available to describe the techniques other than the workbook used in training sessions.5 No formal evaluation and follow-up of the students who have been taught the techniques has been published.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 2, 1979
Academic Reinforcement Program Background In 1975, the School of Medicine at The University of Texas Medical Branch (UTMB) at Galveston centralized its support services for nursing,. allied health, graduate, and medical students. These services included housing information, financial aid counseling, personal and marital counseling, legal services, academic reinforcement, and peer tutorials. The School of Medicine had established an Office of Special Programs (OSP), whose fulltime staff were engaged in liaison activities with premedical advisors in Texas colleges and universities, in the recruitment of minority students for medicine, and in teaching techniques of academic reinforcement to students on campus. The integration of the Office of Special Programs staff with the staff of the Student Counseling Service provided the nucleus for a support service for all students. The support services offered to students include the study techniques developed by Dr. Willey and Mrs. Jarecky. Mrs. Jarecky was invited to conduct a workshop in 1975 for four staff members of OSP to instruct them in the study techniques she and Dr. Willey had developed. Five days were required to train instructors in the techniques, allowing time for practice and questions. Following this workshop, the staff of OSP offered the study techniques to all health science students at UTMB, to be given in private sessions with individual students.* This service was called the Academic Reinforcement Program. The program of*ln 1977 selected faculty and staff in the School
of Allied Health Sciences were trained in the techniques by Mrs. Jarecky and, in 1978, faculty in the School of Nursing were trained. Thus, each professional school on our campus has a cadre of available academic reinforcement instructors.
179
fered assistance in note taking, memorization, test taking, organizing material (bracketing, underlining, labeling, and charting), time scheduling, and study contracts. The program was publicized in the campus newspaper, in announcements to classes, and by word of mouth. All students on campus were eligible to participate in the program. Priority was given to students in academic difficulty. Students who were preparing to take or re-take National Board Examinations or who wanted to enhance their academic performance also participated. The program was free of charge and students could participate for as long as the instructor and the student agreed the sessions were needed. The length, duration, and format of instruction were tailored to the needs of each student.
The Techniques The techniques of academic reinforcement can be taught individually or in small groups. They are most effectively taught in individual sessions. The techniques are also interrelated. For example, it is important for students to be able to organize material and take meaningful notes before they can effectively memorize material or take tests on the material. Therefore, in a sense, the techniques form a continuum of study skills which are formalized by time schedules and student commitments to practicing the techniques through study contracts.
Bracketing and Underlining It is essential that a student be able to identify key materials so that rereading is minimized. Bracketing and underlining are taught to the student in lieu of the "underline everything" approach which many students use. The student is taught how to underline the topics and subtopics in textbooks and to bracket the details corresponding to those topics and subtopics. This helps the student to distinguish the main themes or topics quickly, and then the details pertinent to each topic, when reviewing textbooks for examinations. This technique also provides the student with feedback about what he has already mastered and highlights information that he must analyze and learn further. Bracketing and underlining can also help the student discriminate important from unimportant material and improve reading comprehension. 180
Note Taking Learning to take notes in an indented form assists the student in analyzing and understanding information that is presented. The first step, analyzing information, is done by identifying the topic and the details about the topic, and the second step, understanding information, is done by organizing the elements of information to reflect the relationships that exist among them. A basic method for displaying organized information is the indented format. In this format, details are indented under the topics they describe. Details about details are again indented to show the relationships among them. Learning to take notes in the indented format usually requires that the student unlearn current note-taking methods, such as using large and small letters of the alphabet along with a numerical system in taking notes or taking notes in a paragraph form or in a series of phrases. Thus, the student needs to learn the process for identifying the topic and details (bracketing and underlining) before learning note taking in the indented format.
Labeling When there are a number of details about a topic they can be organized by clustering the details that seem to have something in common and then labeling each cluster of details. Labeling can be used in lecture notes as well as in identifying information in textbooks or handouts. It puts information into manageable units for learning. This process requires the learner to think about the information and, thus, furthers understanding and learning. Labels also, because they develop clusters of related information, aid in recall. Students can organize and label information in ways compatible with their own style of thinking. Labeling is a necessary step in organizing details and summarizing information for constructing charts.
Charting The student is taught to extract related information from textbooks and lectures, label it, and enter the material into a chart. Charting makes it easier for the student to prepare for multiplechoice questions which require comparison and contrast of information. For example, by charting, the student can easily identify the similarities and differences between several diseases with respect to their source of infec-
tion, mode of transmission, treatment, and prevention. Charting is an effective learning technique, because the student is actively arranging and rearranging and associating information in the process of constructing a chart.
Memorization The amount of effort spent memorizing information in comparison with understanding it varies from course to course. Course content that pertains to processes and systems usually requires more attention than course content that does not. For example, gross anatomy or microbiology requires greater effort toward memorizing than does physiology or biochemistry. The memorizing technique helps to identify information that needs to be memorized, to develop networks of associations to aid in information recall, and to provide a method for practicing memorization. The memorization technique is based on the premise that learning is facilitated once the information has been broken down into smaller units of information. Thus, information to be memorized is grouped into units of four or less according to some commonality (size, function, structure, location, unique characteristics, similar spelling, or sound of the items). The learning technique involves manipulating the information to be learned by regrouping, rewriting, rearranging. Thus, the student "actively" learns the material, and in the same process, increases comprehension.
Test Taking Most examinations administered to health science students consist of multiple multiple-choice questions, whereas their college examinations have been mainly short answers and essays. Thus, the health science student's performance is based upon recognition of items rather than recall of information. Unless a student is prepared for the recognition method of test taking, examinations will be unexpectedly difficult, because the recall method of studying does not allow retention of the many details needed to answer multiple multiple-choice questions. The test-taking technique attempts to teach the student to rely on recognition rather than on recall. The training sessions in test taking also help the student recognize maladaptive test-taking behavior such Continued on next page
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 2, 1979
Continued from preceding page
as reading only the beginning and end of questions, thus, eliminating and glossing over the middle of the questions which contain important information, or choosing an answer before all possible answers have been read. The habit of predetermining answers (because the student has "memorized" the pattern of answers in the list of multiple-choice questions) may also be recognized, as well as reading into the questions and answers information that does not exist or deleting information that is presented (this occurs most often when a student relies on recall and attempts to reconstruct the question to fit a preconceived answer). Finally, the student may learn the folly of changing answers as a part of a psychological game, "If I think that is the correct answer, then it must be wrong." Students may recognize that one or more of these behaviors is impairing their own effectiveness in test taking. The training in test-taking technique makes the student aware that a multiple multiple-choice examination is actually a true-false test. The question, plus any one of the possible answers, requires a true or false answer. Thus, each possible combination of questions and answers is confronted individually. In this way, the student is forced to make a decision on each item rather than mull over four or five items collectively. Lastly, the student is shown how to reconstruct negatively worded questions by converting them into positive language, which is more familiar to the student's usual learning patterns.
Time Scheduling One of the frequent complaints among health science students is the lack of time in which to learn the vast amount of information presented. Some students, on the one hand, seem to study all the time, with few breaks, in an effort to master all of the material. At the other extreme are students who wait until an examination is imminent and then study for hours in a "crash" attempt to learn. Students at either extreme exhaust themselves in learning for one examination, without really learning or retaining the material for any length of time. A program of time scheduling attempts to teach the student to plan study periods and free periods for one week at a time. Thus, the student learns to make best use of the time allotted to
a scheduled activity and to reduce the anxiety or worry about activities that are not scheduled during that time. For example, when the schedule calls for free time, the student can relax and enjoy whatever activity he is involved in and not feel guilty about not studying during that time. Also, when he is studying on scheduled time, he can relax and concentrate, knowing that there is a time for "getting away" from studying.
Study Contracts Once the techniques of academic reinforcement are learned, students need a commitment to practice them so they become "natural" ways of learning. To help the student in becoming comfortable with the new techniques, the student and instructor need to agree upon goals for a given time period, (for example, a weekend) and solidify this commitment in a written contract. If the goals and objectives are discussed, then the student and instructor can be realistic about mutual expectations and both will be able to discuss the results of the efforts to change behavior. The study contract helps students to learn, discuss problems openly, and establish realistic goals for themselves.
The Teaching-Learning Environment Students learned the academic reinforcement techniques from one of the OSP staff members. The instruction was conducted on an individual basis in a private office in an informal atmosphere. During the sessions, the instructors made a conscious effort to be empathetic with the students. Students were free to express their needs and concerns. The instructors were "active listeners. " In the initial session, the instructors attempted to evaluate the nature of the student's problem by use of open communication. Often, such an exchange revealed that academic performance was not the only problem and not necessarily the major problem that concerned the student. Other concerns included family, marital, and financial problems, feelings of isolation and loneliness, and adjustmeht to professional school. Since many of these problems were interrelated with academic problems, the staff dealt with these more personal issues as an integral part of the comprehensive academic reinforcement program. If major social or psychological problems
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 2, 1979
were identified, the students were referred to staff in the Student Counseling Service.
An Evaluation of Academic Reinforcement Techniques A questionnaire was sent to 75 of the first 78 students who had received individualized academic reinforcement (three could not be located). The majority of these students had learned the techniques nine months earlier. Completed questionnaires, which had been designed to allow students to return them anonymously, were received from 56 of the 75 students (a response rate of 75 percent). Areas covered in the questionnaire were why the students had availed themselves of the academic reinforcement program, which were the most helpful parts of the program, whether the students continued to use the techniques, and if so, which ones, whether the students could associate a change in academic grades with the use of the techniques, what other services, if any, were provided by the academic reinforcement staff, and how did the students first learn of the program. Of the 56 students who responded, 38 percent were first year medical students, 16 percent second year, and five percent fourth year. Five percent were first level nursing students, seven percent second level, four percent third level, and two percent fourth level. Sixteen percent were graduate students, four percent were allied health students, and three percent were students from nearby universities who had heard of the program.
Results The reason given most often by the students for choosing to be instructed in the academic reinforcement techniques was to improve their study habits. Other reasons included poor grades, recommendation by the Associate Dean for Student Affairs, and
curiosity. The majority of the students learned about the techniques from other students and the Associate Dean for Student Affairs. Eighty-six percent of the students had received no other academic help or personal counseling before their contact with the academic reinforcement staff. Sixty-three percent of the students said that all parts of the program were Continued on next page
181
Continued from preceding page
helpful. The segments that were identified as .most helpful, however, were test taking, note taking, memorization, and study contracts, in that order. Eighty-four percent of the students indicated that they continued to use all or some of the techniques, 11 percent discontinued using them, and five percent did not respond. Fifty-four percent stated that they had noticed an improvement in their grades with less study time, 16 percent said there was no change in their grades, and 30 percent did not respond. When asked, "What other services were provided by the staff other than academic reinforcement?" 80 percent of the students indicated that the encouragement and support of the staff was important. These students noted that the staff helped them in examining attitudes about school, with other problems which affected their studies, and in gaining confidence in themselves. Eleven percent of the students indicated that they only received instruction in the techniques of academic reinforcement. Fourteen students added that they would recommend the program to others. Only one student commented that the techniques were not helpful.
Discussion Although it is often assumed that preprofessional and professional students know how to study, studying is like any other behavior; study habits and techniques must be learned. Instruction in learning how to study could expedite the studying-learning process and allow students to spend their time more efficiently. These techniques are not remedial; they are tools to assist the students in doing a better job in their academic pursuits. Instructors in academic reinforcement programs need to be carefully selected and trained. An instructor who is not judgmental is extremely important, since the meanings of grades and study habits are unique to each individual and discussion of them may arouse sensitivity and emotionality. Learning new study techniques and approaches from staff members who are caring, supportive, and understanding is important in the student's receptivity to, and use of, academic reinforcement techniques. Instructors of academic reinforcement do not have to know course content to teach the techniques. However, the application can be most effective if faculty and peers, who are familiar with
course content, also know academic reinforcement techniques. Indeed, academic reinforcement techniques could assist the faculty in improving the organization of their lectures and tests. Not all students need, nor will all benefit from, academic reinforcement techniques. The results of this study indicate, however, that academic reinforcement is an important student support service which should be made available to all health science students and offered as an optional part of the
curriculum.
Acknowledgements This project was supported by Robert Wood Johnson Foundation Grant No. 2422 and NIH Health Professions Special Project Grant No.
06-D-000008-03.
Literature Cited 1. Ray9or A, Wallace J: Guide to
McGraw-Hill Basic Skills System. New York, McGraw-Hill, 1970 2. Carman RA, Adams WR: Study Skills: A Students' Guide for Survival. New York, John Wiley, 1972 3. Pauk W: How to Study in College, ed 2. Boston, Houghton Mifflin, 1974 4. Maddox H: How To Study. Greenwich, Conn, Fawcett, 1963 5. Willey MS, Jarecky BM: Analysis and Apnlication of Information. Privately printed,
Dental Health Problems of the Geriatric Population Clifton 0. Dummett, DDS Los Angeles, California
A topic seldom considered and even more rarely discussed among the dental components of the health professions is presented. The dentist's preoccupation with hosts of dental treatment problems has left little time for considering the perplexities of aging, critical illness, or dying or dead patient's relatives. Community dentistry has now forced upon our consciousness the fact that perhaps the subject is one which must not be avoided, if we are to fulfill completely our professional obligations to the public. Current estimates of the percentages of the American people who are over 65 years of age range between 10 and 11 percent of the entire population. Demographers predict that by the year 2000, one out of every eight persons Presented to the Section on Community Medicine of the 83rd Annual Convention and Scientific Assembly of the National Medical Association, Washington, DC, July 30-August 3, 1978. Requests for reprints should be addressed to Dr. Clifton 0. Dummett, PO Box 77006, Los Angeles, CA 90007.
182
will be at least 65 years of age, and by the year 2030, 17 percent of the US population will be "aged." Many of the disease processes which occur in the younger population also occur in the aged, but generally these occur with greater frequency, more severity, and probably run longer courses. This is especially the case with the so-called chronic diseases, of which many oral diseases are representative. As is the case with the vast body of
medical information, increasing dental knowledge confirms the fact that oral health problems of senior citizens vary from those of their juniors because of the fact that the reactions of the aging stomatic system to inevitable disease processes are plainly different. During these advanced periods of human development, the metabolic processes influence general tissue reactions, usually detrimentally, and Continued on next page
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 2, 1979
Denver, Colorado, and Galveston Texas
An Academic Reinforcement Program has been used for three years at the University of Texas Medical Branch to assist health science students with test taking, note taking, memorization, labeling, charting, and time-scheduling techniques. An evaluation indicated that the majority of students who have learned the techniques improved their academic grades with less expenditure of study time, learned to deal with some problems which affected their studies, and gained self-confidence through the encouragement and support of the staff who taught the techniques. There are numerous self-instructional books and techniques available to students to assist them in sharpening their basic skills, in reading,writing, vocabulary, mathematics, and test taking. Most of these resources are for high school and college students.'-4 It is often assumed that students who enter health professional schools have already perfected their study techniques. Most students who pursue a health career are academically qualified, highly motivated, and dedicated to their careers. They have usually maintained above average grades throughout their schooling. Although well qualified by all these criteria, students may encounter study problems in professional school. Some of these problems are unrealistic time scheduling, ineffective organization of material, inability to learn and retain large volumes of material, difficulty with examinations given in health professional schools (often with multiple multiple-
Mr. Fuentes is a doctoral student in the School of Professional Psychology at the University of Denver. Mr Trevino is a staff member of the Office of Special Programs in the Office of the Dean of Medicine and Dr. Bruhn is Associate Dean for Community Affairs, the University of Texas Medical Branch, Galveston. Requests for reprints should be addressed to Dr. John G. Bruhn, Office of the Dean of Medicine, University of Texas Medical Branch, Galveston, TX 77550.
choice questions), and setting priorities. Social or personal problems may also interfere with students' academic performance. Some students become discouraged with their potential as health practitioners when they find that they cannot earn grades as high as they earned during college. In an attempt to assist health professional students in mastering the study problems outlined above, Dr. Miriam S. Willey, Director of Medical Education at Howard University School of Medicine, and Mrs. Barbara M. Jarecky, Coordinator of Reading and Study Skills Program, University of Kentucky School of Dentistry, developed techniques for note taking, memorization, organizing material (bracketing, underlining, labeling, and charting), and for taking multiplechoice tests. These techniques have been taught to medical students at Kentucky, Howard, Tulane, Colorado, Texas at San Antonio, Galveston, and Houston, Virginia at Richmond, Georgia, South Carolina, and to students at the Michigan State \Osteopathic School, Texas College of Osteopathic Medicine, and University of Maryland Dental School. No publications are available to describe the techniques other than the workbook used in training sessions.5 No formal evaluation and follow-up of the students who have been taught the techniques has been published.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 2, 1979
Academic Reinforcement Program Background In 1975, the School of Medicine at The University of Texas Medical Branch (UTMB) at Galveston centralized its support services for nursing,. allied health, graduate, and medical students. These services included housing information, financial aid counseling, personal and marital counseling, legal services, academic reinforcement, and peer tutorials. The School of Medicine had established an Office of Special Programs (OSP), whose fulltime staff were engaged in liaison activities with premedical advisors in Texas colleges and universities, in the recruitment of minority students for medicine, and in teaching techniques of academic reinforcement to students on campus. The integration of the Office of Special Programs staff with the staff of the Student Counseling Service provided the nucleus for a support service for all students. The support services offered to students include the study techniques developed by Dr. Willey and Mrs. Jarecky. Mrs. Jarecky was invited to conduct a workshop in 1975 for four staff members of OSP to instruct them in the study techniques she and Dr. Willey had developed. Five days were required to train instructors in the techniques, allowing time for practice and questions. Following this workshop, the staff of OSP offered the study techniques to all health science students at UTMB, to be given in private sessions with individual students.* This service was called the Academic Reinforcement Program. The program of*ln 1977 selected faculty and staff in the School
of Allied Health Sciences were trained in the techniques by Mrs. Jarecky and, in 1978, faculty in the School of Nursing were trained. Thus, each professional school on our campus has a cadre of available academic reinforcement instructors.
179
fered assistance in note taking, memorization, test taking, organizing material (bracketing, underlining, labeling, and charting), time scheduling, and study contracts. The program was publicized in the campus newspaper, in announcements to classes, and by word of mouth. All students on campus were eligible to participate in the program. Priority was given to students in academic difficulty. Students who were preparing to take or re-take National Board Examinations or who wanted to enhance their academic performance also participated. The program was free of charge and students could participate for as long as the instructor and the student agreed the sessions were needed. The length, duration, and format of instruction were tailored to the needs of each student.
The Techniques The techniques of academic reinforcement can be taught individually or in small groups. They are most effectively taught in individual sessions. The techniques are also interrelated. For example, it is important for students to be able to organize material and take meaningful notes before they can effectively memorize material or take tests on the material. Therefore, in a sense, the techniques form a continuum of study skills which are formalized by time schedules and student commitments to practicing the techniques through study contracts.
Bracketing and Underlining It is essential that a student be able to identify key materials so that rereading is minimized. Bracketing and underlining are taught to the student in lieu of the "underline everything" approach which many students use. The student is taught how to underline the topics and subtopics in textbooks and to bracket the details corresponding to those topics and subtopics. This helps the student to distinguish the main themes or topics quickly, and then the details pertinent to each topic, when reviewing textbooks for examinations. This technique also provides the student with feedback about what he has already mastered and highlights information that he must analyze and learn further. Bracketing and underlining can also help the student discriminate important from unimportant material and improve reading comprehension. 180
Note Taking Learning to take notes in an indented form assists the student in analyzing and understanding information that is presented. The first step, analyzing information, is done by identifying the topic and the details about the topic, and the second step, understanding information, is done by organizing the elements of information to reflect the relationships that exist among them. A basic method for displaying organized information is the indented format. In this format, details are indented under the topics they describe. Details about details are again indented to show the relationships among them. Learning to take notes in the indented format usually requires that the student unlearn current note-taking methods, such as using large and small letters of the alphabet along with a numerical system in taking notes or taking notes in a paragraph form or in a series of phrases. Thus, the student needs to learn the process for identifying the topic and details (bracketing and underlining) before learning note taking in the indented format.
Labeling When there are a number of details about a topic they can be organized by clustering the details that seem to have something in common and then labeling each cluster of details. Labeling can be used in lecture notes as well as in identifying information in textbooks or handouts. It puts information into manageable units for learning. This process requires the learner to think about the information and, thus, furthers understanding and learning. Labels also, because they develop clusters of related information, aid in recall. Students can organize and label information in ways compatible with their own style of thinking. Labeling is a necessary step in organizing details and summarizing information for constructing charts.
Charting The student is taught to extract related information from textbooks and lectures, label it, and enter the material into a chart. Charting makes it easier for the student to prepare for multiplechoice questions which require comparison and contrast of information. For example, by charting, the student can easily identify the similarities and differences between several diseases with respect to their source of infec-
tion, mode of transmission, treatment, and prevention. Charting is an effective learning technique, because the student is actively arranging and rearranging and associating information in the process of constructing a chart.
Memorization The amount of effort spent memorizing information in comparison with understanding it varies from course to course. Course content that pertains to processes and systems usually requires more attention than course content that does not. For example, gross anatomy or microbiology requires greater effort toward memorizing than does physiology or biochemistry. The memorizing technique helps to identify information that needs to be memorized, to develop networks of associations to aid in information recall, and to provide a method for practicing memorization. The memorization technique is based on the premise that learning is facilitated once the information has been broken down into smaller units of information. Thus, information to be memorized is grouped into units of four or less according to some commonality (size, function, structure, location, unique characteristics, similar spelling, or sound of the items). The learning technique involves manipulating the information to be learned by regrouping, rewriting, rearranging. Thus, the student "actively" learns the material, and in the same process, increases comprehension.
Test Taking Most examinations administered to health science students consist of multiple multiple-choice questions, whereas their college examinations have been mainly short answers and essays. Thus, the health science student's performance is based upon recognition of items rather than recall of information. Unless a student is prepared for the recognition method of test taking, examinations will be unexpectedly difficult, because the recall method of studying does not allow retention of the many details needed to answer multiple multiple-choice questions. The test-taking technique attempts to teach the student to rely on recognition rather than on recall. The training sessions in test taking also help the student recognize maladaptive test-taking behavior such Continued on next page
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 2, 1979
Continued from preceding page
as reading only the beginning and end of questions, thus, eliminating and glossing over the middle of the questions which contain important information, or choosing an answer before all possible answers have been read. The habit of predetermining answers (because the student has "memorized" the pattern of answers in the list of multiple-choice questions) may also be recognized, as well as reading into the questions and answers information that does not exist or deleting information that is presented (this occurs most often when a student relies on recall and attempts to reconstruct the question to fit a preconceived answer). Finally, the student may learn the folly of changing answers as a part of a psychological game, "If I think that is the correct answer, then it must be wrong." Students may recognize that one or more of these behaviors is impairing their own effectiveness in test taking. The training in test-taking technique makes the student aware that a multiple multiple-choice examination is actually a true-false test. The question, plus any one of the possible answers, requires a true or false answer. Thus, each possible combination of questions and answers is confronted individually. In this way, the student is forced to make a decision on each item rather than mull over four or five items collectively. Lastly, the student is shown how to reconstruct negatively worded questions by converting them into positive language, which is more familiar to the student's usual learning patterns.
Time Scheduling One of the frequent complaints among health science students is the lack of time in which to learn the vast amount of information presented. Some students, on the one hand, seem to study all the time, with few breaks, in an effort to master all of the material. At the other extreme are students who wait until an examination is imminent and then study for hours in a "crash" attempt to learn. Students at either extreme exhaust themselves in learning for one examination, without really learning or retaining the material for any length of time. A program of time scheduling attempts to teach the student to plan study periods and free periods for one week at a time. Thus, the student learns to make best use of the time allotted to
a scheduled activity and to reduce the anxiety or worry about activities that are not scheduled during that time. For example, when the schedule calls for free time, the student can relax and enjoy whatever activity he is involved in and not feel guilty about not studying during that time. Also, when he is studying on scheduled time, he can relax and concentrate, knowing that there is a time for "getting away" from studying.
Study Contracts Once the techniques of academic reinforcement are learned, students need a commitment to practice them so they become "natural" ways of learning. To help the student in becoming comfortable with the new techniques, the student and instructor need to agree upon goals for a given time period, (for example, a weekend) and solidify this commitment in a written contract. If the goals and objectives are discussed, then the student and instructor can be realistic about mutual expectations and both will be able to discuss the results of the efforts to change behavior. The study contract helps students to learn, discuss problems openly, and establish realistic goals for themselves.
The Teaching-Learning Environment Students learned the academic reinforcement techniques from one of the OSP staff members. The instruction was conducted on an individual basis in a private office in an informal atmosphere. During the sessions, the instructors made a conscious effort to be empathetic with the students. Students were free to express their needs and concerns. The instructors were "active listeners. " In the initial session, the instructors attempted to evaluate the nature of the student's problem by use of open communication. Often, such an exchange revealed that academic performance was not the only problem and not necessarily the major problem that concerned the student. Other concerns included family, marital, and financial problems, feelings of isolation and loneliness, and adjustmeht to professional school. Since many of these problems were interrelated with academic problems, the staff dealt with these more personal issues as an integral part of the comprehensive academic reinforcement program. If major social or psychological problems
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 2, 1979
were identified, the students were referred to staff in the Student Counseling Service.
An Evaluation of Academic Reinforcement Techniques A questionnaire was sent to 75 of the first 78 students who had received individualized academic reinforcement (three could not be located). The majority of these students had learned the techniques nine months earlier. Completed questionnaires, which had been designed to allow students to return them anonymously, were received from 56 of the 75 students (a response rate of 75 percent). Areas covered in the questionnaire were why the students had availed themselves of the academic reinforcement program, which were the most helpful parts of the program, whether the students continued to use the techniques, and if so, which ones, whether the students could associate a change in academic grades with the use of the techniques, what other services, if any, were provided by the academic reinforcement staff, and how did the students first learn of the program. Of the 56 students who responded, 38 percent were first year medical students, 16 percent second year, and five percent fourth year. Five percent were first level nursing students, seven percent second level, four percent third level, and two percent fourth level. Sixteen percent were graduate students, four percent were allied health students, and three percent were students from nearby universities who had heard of the program.
Results The reason given most often by the students for choosing to be instructed in the academic reinforcement techniques was to improve their study habits. Other reasons included poor grades, recommendation by the Associate Dean for Student Affairs, and
curiosity. The majority of the students learned about the techniques from other students and the Associate Dean for Student Affairs. Eighty-six percent of the students had received no other academic help or personal counseling before their contact with the academic reinforcement staff. Sixty-three percent of the students said that all parts of the program were Continued on next page
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Continued from preceding page
helpful. The segments that were identified as .most helpful, however, were test taking, note taking, memorization, and study contracts, in that order. Eighty-four percent of the students indicated that they continued to use all or some of the techniques, 11 percent discontinued using them, and five percent did not respond. Fifty-four percent stated that they had noticed an improvement in their grades with less study time, 16 percent said there was no change in their grades, and 30 percent did not respond. When asked, "What other services were provided by the staff other than academic reinforcement?" 80 percent of the students indicated that the encouragement and support of the staff was important. These students noted that the staff helped them in examining attitudes about school, with other problems which affected their studies, and in gaining confidence in themselves. Eleven percent of the students indicated that they only received instruction in the techniques of academic reinforcement. Fourteen students added that they would recommend the program to others. Only one student commented that the techniques were not helpful.
Discussion Although it is often assumed that preprofessional and professional students know how to study, studying is like any other behavior; study habits and techniques must be learned. Instruction in learning how to study could expedite the studying-learning process and allow students to spend their time more efficiently. These techniques are not remedial; they are tools to assist the students in doing a better job in their academic pursuits. Instructors in academic reinforcement programs need to be carefully selected and trained. An instructor who is not judgmental is extremely important, since the meanings of grades and study habits are unique to each individual and discussion of them may arouse sensitivity and emotionality. Learning new study techniques and approaches from staff members who are caring, supportive, and understanding is important in the student's receptivity to, and use of, academic reinforcement techniques. Instructors of academic reinforcement do not have to know course content to teach the techniques. However, the application can be most effective if faculty and peers, who are familiar with
course content, also know academic reinforcement techniques. Indeed, academic reinforcement techniques could assist the faculty in improving the organization of their lectures and tests. Not all students need, nor will all benefit from, academic reinforcement techniques. The results of this study indicate, however, that academic reinforcement is an important student support service which should be made available to all health science students and offered as an optional part of the
curriculum.
Acknowledgements This project was supported by Robert Wood Johnson Foundation Grant No. 2422 and NIH Health Professions Special Project Grant No.
06-D-000008-03.
Literature Cited 1. Ray9or A, Wallace J: Guide to
McGraw-Hill Basic Skills System. New York, McGraw-Hill, 1970 2. Carman RA, Adams WR: Study Skills: A Students' Guide for Survival. New York, John Wiley, 1972 3. Pauk W: How to Study in College, ed 2. Boston, Houghton Mifflin, 1974 4. Maddox H: How To Study. Greenwich, Conn, Fawcett, 1963 5. Willey MS, Jarecky BM: Analysis and Apnlication of Information. Privately printed,
Dental Health Problems of the Geriatric Population Clifton 0. Dummett, DDS Los Angeles, California
A topic seldom considered and even more rarely discussed among the dental components of the health professions is presented. The dentist's preoccupation with hosts of dental treatment problems has left little time for considering the perplexities of aging, critical illness, or dying or dead patient's relatives. Community dentistry has now forced upon our consciousness the fact that perhaps the subject is one which must not be avoided, if we are to fulfill completely our professional obligations to the public. Current estimates of the percentages of the American people who are over 65 years of age range between 10 and 11 percent of the entire population. Demographers predict that by the year 2000, one out of every eight persons Presented to the Section on Community Medicine of the 83rd Annual Convention and Scientific Assembly of the National Medical Association, Washington, DC, July 30-August 3, 1978. Requests for reprints should be addressed to Dr. Clifton 0. Dummett, PO Box 77006, Los Angeles, CA 90007.
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will be at least 65 years of age, and by the year 2030, 17 percent of the US population will be "aged." Many of the disease processes which occur in the younger population also occur in the aged, but generally these occur with greater frequency, more severity, and probably run longer courses. This is especially the case with the so-called chronic diseases, of which many oral diseases are representative. As is the case with the vast body of
medical information, increasing dental knowledge confirms the fact that oral health problems of senior citizens vary from those of their juniors because of the fact that the reactions of the aging stomatic system to inevitable disease processes are plainly different. During these advanced periods of human development, the metabolic processes influence general tissue reactions, usually detrimentally, and Continued on next page
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 2, 1979
