ORIGINAL REPORTS
The Learning Styles of Orthopedic Residents, Faculty, and Applicants at an Academic Program Raveesh Daniel Richard, MD, Brian Francis Deegan, BS, and Joel Christian Klena, MD Department of Orthopaedic Surgery, Geisinger Health System, Danville, Pennsylvania BACKGROUND: To train surgeons effectively, it is important to understand how they are learning. The Kolb Learning Style Inventory (LSI) is based on the theory of experiential learning, which divides the learning cycle into 4 stages: active experimentation (AE), abstract conceptualization (AC), concrete experience, and reflective observation. The purpose of this investigation was to assess the learning styles of orthopedic residents, faculty, and applicants at an east-coast residency program. METHODS: A total of 90 Kolb LSI, Version 3.1 surveys, and demographic questionnaires were distributed to all residency applicants, residents, and faculty at an academic program. Data collected included age, sex, type of medical school (MD or DO), foreign medical graduate status, and either year since college graduation, postgraduate year level (residents only), or years since completion of residency (faculty only). Seventy-one completed Kolb LSI surveys (14 residents, 14 faculty members, and 43 applicants) were recorded and analyzed for statistical significance. RESULTS: The most prevalent learning style among all
participants was converging (53.5%), followed by accommodating (18.3%), diverging (18.3%), and assimilating (9.9%) (p ¼ 0.13). The applicant and resident groups demonstrated a high tendency toward AE followed by AC. The faculty group demonstrated a high tendency toward AC followed by AE. None of the 24 subjects who were 26 years or under had assimilating learning styles, in significant contrast to the 12% of 27- to 30-year-olds and 18% of 31 and older group (p o 0.01). CONCLUSIONS: The majority of applicants, residents, and faculty in the orthopedic residency program were “convergers.” The converging learning style involves problem solving and decision making, with the practical application of ideas and the use of hypothetical-deductive
Correspondence Inquiries to: Raveesh Daniel Richard, Department of Orthopaedic Surgery, Geisinger Health System, Danville, Pennsylvania 17822; e-mail: [email protected]
110
reasoning. Learning through AE decreased with age, whereas learning through AC increased. ( J Surg 71:110C 2014 Association of Program Directors in Surgery. 118. J Published by Elsevier Inc. All rights reserved.) KEY WORDS: learning styles, orthopedic surgery, resi-
dency, education, Kolb learning style inventory, residents, applicants COMPETENCIES: Medical
Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills
INTRODUCTION With work-hour restrictions and increased faculty workload, residency programs must optimize time for education. To educate surgeons effectively, it is important to understand how they learn. Learning is the process by which one acquires new skills and permanently changes behavior through cognitive and noncognitive (affective) experiences.1 Learning styles have been analyzed in numerous medical specialties.7,8,12-16 In addition to variation across specialties, there appears to be a difference in learning styles between junior and senior residents within the same specialty. An understanding of learning styles allows programs to potentially identify those incoming residents at risk of underperforming in surgical skill acquisition and makes academic teaching more effective.14 Such awareness can maximize the learning process for residents and students, allowing the learner to tailor his educational approach to that of the program or instructor. A popular and validated method of assessing learning is the Kolb Learning Style Inventory (LSI), which allows comparisons of learning styles across medical specialties and between training levels.2,3 It measures both an individual’s learning potential when placed in different environments and his learning style when challenged to acquire new material.9 This method is based on the theory of experiential learning, separating learners based on the y-axis of
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.05.011
information perception (learning by experience or thinking) and the x-axis of information processing (learning by doing or reflecting). Learning is thus divided into 4 stages: active experimentation (AE) (doing), abstract conceptualization (AC) (thinking), concrete experience (CE) (watching), and reflective observation (RO) (feeling).4 Ideal learning incorporates all 4 components, but individuals tend to have stronger preferences toward specific methods. Kolb established 4 categories of learning styles: diverging, assimilating, converging, and accommodating.5-7 “Convergers” utilize the strategies of AC and AE.5,8,9 Dominant learning styles within this group involve problem solving and decision making, with the practical application of ideas and the use of hypothetical-deductive reasoning.5,7,10 These individuals are relatively unemotional, preferring to deal with things rather than people, have narrow technical interests, and often are involved with engineering.1,7,11 “Accommodators” utilize the strategies of CE and AE.5,8,9 These learners tend to be action oriented and intimately involved with challenges, adapting quickly to varying situations by combining experience and doing.5,9,11 These individuals are viewed as risk-takers, relying on others for information, and are often found in action-oriented jobs such as marketing or sales.1,7,11 “Divergers” utilize the strategies of CE and RO.5,8,9 Observation is preferred over action, with brainstorming and the application of prior experience used to problem solve.5,9,10 These individuals enjoy working with groups, view concrete situations from multiple perspectives, are imaginative and emotional, and tend to be those who specialize in the liberal arts.1,7,8,11 “Assimilators” utilize the strategies of AC and RO.5,8,9 These learners place a heavy emphasis on logic and theory and are skilled at integrating large amounts of information to create smaller, succinct ideas.5,8-10 These individuals enjoy reading and lectures, are less interested in people and more concerned with abstract concepts, and are often found in the applied sciences and research departments.1,5,7,11 To our knowledge, there has been no previous study conducted in the United States where the learning styles of orthopedic applicants, residents, and faculty have been examined. We assessed the predominant learning styles of these 3 groups at an orthopedic residency program. Our hypothesis was that the converging and accommodating learning styles would be most prevalent among the orthopedic residency applicants, residents, and faculty members.
MATERIAL AND METHODS This study was prospectively conducted at an east-coast academic center after institutional review board (IRB) exemption status was obtained. Information sheets regarding the study, Kolb LSI surveys, and a demographic
questionnaire were distributed to all residency applicants on the day of their interview (n ¼ 60). Similarly, current orthopedic residents (n ¼ 14) and core orthopedic faculty (n ¼ 16) were given the same packet of information and surveys. The information sheet given to the participants in the study included material regarding the purpose of the study and assurances that the survey was voluntary and refusal to participate would not affect employment or chances of obtaining a residency position. A minimal amount of information regarding learning styles was given to limit any bias prior to completion of the Kolb LSI questionnaire. Demographic information collected included age, sex, type of medical school (MD or DO), foreign medical graduate (FMG) status, year since college graduation, postgraduate year level (residents only), and years since completion of residency (faculty only). All participants were given the opportunity to ask questions regarding the study. A total of 90 Kolb LSI surveys and demographic questionnaires were distributed among the applicants, residents, and faculty. The LSI consisted of 12 items composed of 4 different statements, each representing one of the 4 elements of the learning process. The total scores for each of the 4 elements of the learning process (AE, CE, RO, and AC) were compiled, ranging from 12 to 48. Using a Cartesian graph, AE minus RO was plotted on the x-axis (range, −36 to þ36), whereas AC minus CE was plotted on the y-axis (range, −36 to þ36) (Figs. 1-4). The Fisher exact test was used to determine whether the differences in the overall distribution of percentages observed (overall 4 learning style categories) were representative of significant differences between the subgroups (applicants, residents, and faculty) in the general population. Logistic regression was used to estimate the proportions and confidence intervals of each learning style, overall and within subgroups. The p-values reflect whether the proportions in each subgroup were significantly different from a baseline comparison subgroup. For group type, “residents” was used as the baseline comparison group, and for age group, “26 years and under” was used as the baseline comparison group (Table 3). p-values were also adjusted for the multiple comparisons made within each category.
RESULTS Seventy-one of the 90 surveys (78.9%) were correctly completed. Of 71 respondents, sixty-five (92%) were men, 66 (93%) had MD degrees, and there were 43 (61%) applicants, 14 (20%) residents, and 14 (20%) faculty. None of the respondents were FMGs. The mean age was 31 years (range, 23-64), mean time since graduation was 10 years (range, 4-43), and mean time since residency was 17 years (range, 3-33). The demographic data and Kolb
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29 27 25 23 21 19 17 15 13 11
A E
9
7
-25 -23 -21 -19 -17 -15 -13 -11 -9 -7 -5 -3 -1 1 3 5 3 5 7 9 11 13 15 17 19 21 23 25 27 29
Applicants 1
-1 -3 -5 -7 -9 -11 -13 -15 -17 -19 -21 -23 -25
R O
A C FIGURE 1. Learning style distribution of applicants.
LSI distribution for the participants are reported in Tables 1 and 2. Of the surveys distributed to the residency applicants, 43 of 60 (71.7%) were correctly completed. The remaining 17 surveys were either not returned or incorrectly completed. A summary of the residency applicant information is listed in Table 1. The most prevalent learning style among the residency applicants was converging (60.5%), followed by accommodating (20.9%), diverging (16.3%), and assimilating (2.3%). Applicants demonstrated a high tendency toward AE (mean ¼ 38.5) followed by AC (mean ¼ 31.9) (Fig. 1).
All resident surveys were returned and completed correctly for a 100% completion rate. A complete summary of the resident information is listed in Table 1. There were 2 fifthyear residents, 3 fourth-year residents, 3 third-year residents, 3 second-year residents, and 3 interns (mean postgraduate year level ¼ 2.9). The most prevalent learning style among the orthopedic residents was converging (50%), followed by assimilating (21.4%), accommodating (14.3%), and diverging (14.3%). Residents also demonstrated a high tendency toward AE (mean ¼ 37.9) followed by AC (mean ¼ 32.9) (Fig. 2).
TABLE 1. Demographics by Category Applicants Average age (y) Age range (y) Female (%, n) Male (%, n) DO medical school (%, n) MD medical school (%, n) FMG status (%, n) Average time since college graduation (y) Average time since residency graduation (y)† †
26.8 23-32 9.3% (n ¼ 90.7% (n ¼ 4.7% (n ¼ 95.3% (n ¼ 0 5.6 n/a
4) 39) 2) 41)
Residents 29.5 26-32 7.1% (n ¼ 92.9% (n ¼ 7.1% (n ¼ 92.9% (n ¼ 0 7.9 n/a
1) 13) 1) 13)
Faculty 48.9 29-64 6.3% (n ¼ 1) 93.8% (n ¼ 13) 12.5% (n ¼ 2) 87.5% (n ¼ 12) 0 27.4 16.9
Faculty only.
112
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9
C E -25 -23 -21 -19 -17 -15 -13 -11 -9 -7 -5 -3 -1 1 3 7 5 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 A C
1
-1
-3
-5
-7
-9 -11 -13 -15 -17 -19 -21 -23 -25
Residents R O
FIGURE 2. Learning style distribution of residents.
Fourteen of 16 (87.5%) faculty surveys were returned. A complete summary of the faculty information is listed in Table 1. The most prevalent learning style among the faculty members was converging (35.7%), followed by diverging (28.6%), assimilating (21.4%), and accommodating (14.3%). Faculty demonstrated the highest tendency toward AC (mean ¼ 34.1) followed by AE (mean ¼ 32.9) (Fig. 3).
Among all survey participants, the most prevalent learning style was converging (53.5%), followed by accommodating (18.3%), diverging (18.3%), and assimilating (9.9%) (Fig. 4 and Fig. 5). Estimates of proportions and 95% confidence intervals of applicants, residents, and faculty with each learning style, both overall and within each subgroup, are reported in Table 3.
TABLE 2. Distribution of Learning Style Categories (Overall, By Group Type, and By Age Range) All subjects, N (%) By group type Residents, N (%) Applicants, N (%) Faculty, N (%) By age range (y) 26 and under, N (%) 27-30, N (%) 31 and older, N (%)
Total, N
Accommodating
Assimilating
Converging
Diverging
p-value
71
13 (18%)
7 (10%)
38 (54%)
13 (18%)
– 0.13
14 43 14
2 (14%) 9 (21%) 2 (14%)
3 (21%) 1 (2%) 3 (21%)
7 (50%) 26 (60%) 5 (36%)
2 (14%) 7 (16%) 4 (29%)
24 25 22
5 (21%) 3 (12%) 7 (23%)
0 (0%) 3 (12%) 4 (18%)
15 (63%) 14 (56%) 9 (41%)
4 (17%) 5 (20%) 4 (18%)
0.39
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9
C E -25 -23 -21 -19 -17 -15 -13 -11 -9 -7 -5 -3 -1 1 3 7 5 3 5 7 9 11 13 15 17 19 21 23 25 27 29 A C
Faculty 1
-1
-3
-5
-7
-9 -11 -13 -15 -17 -19 -21 -23 -25 R O
FIGURE 3. Learning style distribution of faculty.
DISCUSSION An individual’s learning style is the process by which one attains, retains, and recalls information, thereby facilitating growth in knowledge and skills. Personality type, professional career, and educational specialization can also influence learning styles and account for up to 50% of the variance in learning.17 A relationship exists between learning style and specialty choice in medicine. This suggests that individuals of similar learning preferences are drawn to similar careers and that residency programs have a learning style distribution characteristic of that specialty.1,5,17 Individual learning styles have been shown to change during progression from medical school to residency and beyond.8,10,18 The selection of a learning style most likely takes place prior to the residency application process, allowing medical students to choose a specialty they most identify with based on a similar learning style.7 Evidence suggests that surgical trainees develop specific learning styles early in their career, and with the advent of work-hour 114
restrictions, increased emphasis must be placed on effective and efficient learning. Identifying and teaching to these specific learning styles could positively influence surgical education.5,7,10,19 Recent studies have demonstrated that the converging learning style, the predominant learning style among all 3 groups in our study, is also predominant among surgeons4,7,13,14 (Table 4). This is in contrast to earlier studies, which found that other learning styles predominate among surgeons.1,11,20 Among surgical trainees, the converging learning style has been shown to be most common, present in 44%-60% of individuals.8,17,21 A survey of 13 first-year orthopedic residents at a Canadian university found that 53.8% of these residents were “convergers.”5 The prevalence of the converging learning styles has also been demonstrated among fellows and faculty within surgical subspecialties.4,7,13,14 In contrast to surgeons, other medical specialties have been associated with learning styles different from converging. The majority of residents and faculty at an internal medicine residency program were found to be “assimilators.”15
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C -25 E -23 -21 -19 -17 -15 -13 -11 -9 -7 -5 -3 -1 Applicants
1 30 28 26 24 22 20 18 16 14 12 10 8
6
3 4 5
Residents 2
0
-2 -4 -6 -8 -10 -12 -14 -16 -18 -20 -22 -24 -26 -28 -30 Faculty
7
A E
R O
9 11 13 15 17 19 21 23 25 27 29 31 A C FIGURE 4. Learning style distribution of applicants, residents, and faculty combined.
Studies performed at different pediatric residency programs reported mixed findings of predominant learning styles among faculty and residents.12,22 Multiple factors influence performance; it is understood that learning style alone cannot predict academic accomplishment. Baker et al. dubbed surgeons the “human engineers” of medicine, and thus the predominance of the converging learning style is intuitive.1 Converging learners attain the highest average USMLE Step 1 and NBME scores and accommodating learners the lowest.4,23 Among all groups we studied, “accommodators” were the least prevalent among faculty and were tied for the least prevalent among residents. “Convergers” were also found to score higher on the American Medical Education Examination.17 This may be due to the implementation of AC, which helps these individuals perform better on multiple choice examinations.15,23 Similarly, “convergers” were more successful in problem-based learning courses in medical school.10
60.00% Overall percentage 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Converging Accomodating
Diverging
Assimilating
FIGURE 5. Distribution of learning styles among all participants.
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TABLE 3. Comparison of Learning Styles By Group Type and Age Range
All subjects, N (%) By group type Residents Applicants Faculty By age range (y) 26 and under 27-30 31 and older
Accommodating (%) [95% CI]
p
18 [11%-29%]
–
Assimilating (%) [95% CI] 10 [5%-19%]
p
Converging (%) [95% CI]
p
Diverging (%) [95% CI]
p
–
54 [42%-65%]
–
18 [11%-29%]
–
– 0.08 0.99
50 [26%-74%] 60 [45%-74%] 36 [16%-62%]
– 14 [4%-43%] – 0.66 16% [8%-30%] 0.93 0.63 29 [11%-56%] 0.54
63 [42%-79%] 56 [37%-74%] 41 [23%-62%]
– 0.78 0.27
14 [4%-43%] 21 [11%-36%] 14 [4%-43%]
– 21 [7%-49%] 0.75 2 [0%-15%] 0.99 21 [7%-49%]
21 [9%-41%] 12 [4%-31%] 23 [10%-44%]
– 0 [0.0%-0.2%] – 0.59 12 [4%-31%] o0.01 0.94 18 [7%-40%] o0.01
17 [6%-37%] 20 [9%-40%] 18 [7%-40%]
– 0.87 0.94
p-values reflect logistic regression testing of whether the proportion in one subgroup is significantly different from the first subgroup in that cell of the table (i.e., residents or 26 years and under).
Nevertheless, no correlation has been found between learning style and surgical standardized examinations.8 With advancing age, there is a decreased preference for learning by action and an increased preference for learning by reflection as measured by the (AE-RO) scale.5 The 2 learning styles that utilize AE (“accommodators” and “convergers”) show a decrease over time, whereas the 2 learning styles that utilize RO (“divergers” and “assimilators”) show an increase. Among the applicants, the AE-RO scale decreased when comparing the group younger than the mean age to the group older than mean age, falling from an average of 13.2 to 12.4 (Table 5). Among the residents, the AE-RO scale similarly decreased between the 2 groups, falling from an average of 11.9 to 9.4. Among the faculty, the AERO scale decreased from 4.8 to 3.7 when comparing the group younger than the mean age to the group that was above the mean age. Similarly, with advancing age, AC has been shown to increase.15 A corresponding increase in the percentage of “assimilators” occurs, because both RO and AC are employed. An unexpected finding in our study was that 21.4% of the residents were “assimilators,” more popular than the “accommodators” (14.3%), although this was not
significant because of a small sample size. However, none of the 24 subjects who were 26 years or under had assimilating learning styles, in significant contrast to the 12% of 27- to 30-year-olds and 18% of the 31 and older group (p o 0.01). The percentage of applicants studied who were “assimilators” (2%) was smaller than the percentages of either the residents or faculty “assimilators” (both at 21%), although this difference was not significant (p ¼ 0.08) (Table 3). Learning style compatibility between a resident and the training program has shown to be a predictor of resident performance and completion of the program.17 Residents with learning styles similar to their faculty also tend to be considered outstanding by those faculty members.1 As the converging style was most prevalent in our program, it is conceivable that faculty could structure learning and teaching to be more congruent with this learning style than others could. Those faculty members who are not “convergers” should recognize the difference in learning styles and direct their efforts toward the learning style of the majority of residents. Additionally, it has been demonstrated that over 90% of medical students with diverging learning styles change their learning style over time.10 If a
TABLE 4. Previous Surgical Studies with Converging as the Preferred Learning Style Author
Year
Caulley et al. Engels et al.
2012 2010
Orthopedics Surgery
Jack et al.
2010
Surgery
Laeeq et al. Mammen et al. Contessa et al.
2009 2007 2005
Otolaryngology Surgery Surgery
Drew et al. Lynch et al. Baker et al.
1999 1998 1985
Surgery
116
Department
Surgery
Level (s)
n
Preferred Learning Style
Percentage
Residents Faculty Residents Medical students Faculty Residents Medical students Residents Residents Faculty Residents Residents Medical students Residents
13 44 40 157 61 96 183 43 91 6 16 52 227 39
Converging Converging Converging Assimilating Converging Converging Converging Converging Converging Converging Converging Converging Converging Converging
54 48 60 40 34 47 53 56 57 67 44 60 45 46
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TABLE 5. Applicants, Residents, and Faculty Distributed by Mean Age Group Applicants
Residents
Faculty
Mean Age (y) 26.8
29.5
48.9
Completed
AE-RO Converging Accommodating Diverging Assimilating Scale
Below 23/43 (53.5%) 13 (50%) mean age Above 20/43 (46.5%) 13 (50%) mean age Below 6/14 (42.9%) 4 (57.1%) mean age Above 8/14 (57.1%) 3 (42.9%) mean age Below 8/14 (57.1%) 2 (40%) mean age Above 6/14 (42.9%) 3 (60%) mean age
resident changes his learning style, the converging learning style is usually adopted.8 This concept of teaching to the majority should not, however, be at the expense of the minority learning styles. Administering the Kolb LSI to incoming residents to identify those who may potentially be at risk for underperforming is not a novel concept.17 A potential drawback to this is increased homogeneity in the applicant pool.14 Increased work-hour restrictions, a growing need for peerto-peer teaching by residents, and elevated competition for orthopedic residency positions continue to exert pressure on surgical specialties to become less diverse with respect to learning styles. Those utilizing reflection and imagination are lost in exchange for those who are increasingly practical and action oriented. Conversely, such training environments may force trainees to adapt from a predominant single learning style into a more balanced learning style.13 It has been demonstrated that deliberate pairings of noncomplementary learning styles can stimulate learning.9,24 A more appropriate use of the Kolb LSI may be an annual assessment, which provides faculty and residents the opportunity to identify changes in learning styles and to improve teaching efficiency.4 To our knowledge, this is the first study to examine the learning styles of orthopedic applicants, residents, and faculty at an orthopedic surgery program. Our study represents a small sample size at one academic residency program, and thus, the results may not be generalizable across all programs. A nationwide survey could better determine the preferred learning style of orthopedic learners across a larger group of individuals. In addition, 92% of the respondents were men, and learning styles have been shown to differ between men and women.8 We recognize the possibility of nonrespondent bias, as individuals with converging and accommodating learning styles are more likely to respond to the surveys than the other learning styles. However, the likelihood of nonrespondent bias is low as we attained a relatively high overall response rate of 78.9%.
5 (55.6%)
4 (57.1%)
1 (100%)
13.2
4 (44.4%)
3 (42.9%)
0
12.4
0
1 (50%)
1 (33.3%)
11.9
2 (100%)
1 (50%)
2 (66.7%)
9.4
2 (100%)
3 (75%)
1 (33.3%)
4.8
0
1 (25%)
2 (66.7%)
3.7
The results of this study support prior studies of Kolb learning styles among surgical residency programs. By understanding an individual’s specific learning style, resident education can be tailored to maximize that individual’s education. Trainees who are not of the majority learning style in a given residency program may benefit from increased collaboration with faculty of a similar learning style to provide continual support throughout their education. Faculty mentors could be paired with trainees based on predilection of learning styles to foster efficient education. It has been suggested that those who learn with a converging learning style may benefit from independent learning over didactic lectures and brainstorming sessions.8 It has also been proposed that focusing and strengthening lesspreferred learning styles helps students expand the scope of their learning and become more versatile learners.24 Ideally, a surgical education should incorporate the preferences of all 4 LSI learning styles. In our orthopedic surgery residency program, where the majority is convergers and increasing demands are placed on protected resident educational time, we believe that increasing effective teaching is necessary to maintain current standards of excellence.
ACKNOWLEDGMENT We wish to acknowledge the help with statistical analysis provided by Jove Graham, PhD.
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16. Stratman EJ, Vogel CA, Reck SJ, Mukesh BN.
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Journal of Surgical Education Volume 71/Number 1 January/February 2014
The Learning Styles of Orthopedic Residents, Faculty, and Applicants at an Academic Program Raveesh Daniel Richard, MD, Brian Francis Deegan, BS, and Joel Christian Klena, MD Department of Orthopaedic Surgery, Geisinger Health System, Danville, Pennsylvania BACKGROUND: To train surgeons effectively, it is important to understand how they are learning. The Kolb Learning Style Inventory (LSI) is based on the theory of experiential learning, which divides the learning cycle into 4 stages: active experimentation (AE), abstract conceptualization (AC), concrete experience, and reflective observation. The purpose of this investigation was to assess the learning styles of orthopedic residents, faculty, and applicants at an east-coast residency program. METHODS: A total of 90 Kolb LSI, Version 3.1 surveys, and demographic questionnaires were distributed to all residency applicants, residents, and faculty at an academic program. Data collected included age, sex, type of medical school (MD or DO), foreign medical graduate status, and either year since college graduation, postgraduate year level (residents only), or years since completion of residency (faculty only). Seventy-one completed Kolb LSI surveys (14 residents, 14 faculty members, and 43 applicants) were recorded and analyzed for statistical significance. RESULTS: The most prevalent learning style among all
participants was converging (53.5%), followed by accommodating (18.3%), diverging (18.3%), and assimilating (9.9%) (p ¼ 0.13). The applicant and resident groups demonstrated a high tendency toward AE followed by AC. The faculty group demonstrated a high tendency toward AC followed by AE. None of the 24 subjects who were 26 years or under had assimilating learning styles, in significant contrast to the 12% of 27- to 30-year-olds and 18% of 31 and older group (p o 0.01). CONCLUSIONS: The majority of applicants, residents, and faculty in the orthopedic residency program were “convergers.” The converging learning style involves problem solving and decision making, with the practical application of ideas and the use of hypothetical-deductive
Correspondence Inquiries to: Raveesh Daniel Richard, Department of Orthopaedic Surgery, Geisinger Health System, Danville, Pennsylvania 17822; e-mail: [email protected]
110
reasoning. Learning through AE decreased with age, whereas learning through AC increased. ( J Surg 71:110C 2014 Association of Program Directors in Surgery. 118. J Published by Elsevier Inc. All rights reserved.) KEY WORDS: learning styles, orthopedic surgery, resi-
dency, education, Kolb learning style inventory, residents, applicants COMPETENCIES: Medical
Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills
INTRODUCTION With work-hour restrictions and increased faculty workload, residency programs must optimize time for education. To educate surgeons effectively, it is important to understand how they learn. Learning is the process by which one acquires new skills and permanently changes behavior through cognitive and noncognitive (affective) experiences.1 Learning styles have been analyzed in numerous medical specialties.7,8,12-16 In addition to variation across specialties, there appears to be a difference in learning styles between junior and senior residents within the same specialty. An understanding of learning styles allows programs to potentially identify those incoming residents at risk of underperforming in surgical skill acquisition and makes academic teaching more effective.14 Such awareness can maximize the learning process for residents and students, allowing the learner to tailor his educational approach to that of the program or instructor. A popular and validated method of assessing learning is the Kolb Learning Style Inventory (LSI), which allows comparisons of learning styles across medical specialties and between training levels.2,3 It measures both an individual’s learning potential when placed in different environments and his learning style when challenged to acquire new material.9 This method is based on the theory of experiential learning, separating learners based on the y-axis of
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.05.011
information perception (learning by experience or thinking) and the x-axis of information processing (learning by doing or reflecting). Learning is thus divided into 4 stages: active experimentation (AE) (doing), abstract conceptualization (AC) (thinking), concrete experience (CE) (watching), and reflective observation (RO) (feeling).4 Ideal learning incorporates all 4 components, but individuals tend to have stronger preferences toward specific methods. Kolb established 4 categories of learning styles: diverging, assimilating, converging, and accommodating.5-7 “Convergers” utilize the strategies of AC and AE.5,8,9 Dominant learning styles within this group involve problem solving and decision making, with the practical application of ideas and the use of hypothetical-deductive reasoning.5,7,10 These individuals are relatively unemotional, preferring to deal with things rather than people, have narrow technical interests, and often are involved with engineering.1,7,11 “Accommodators” utilize the strategies of CE and AE.5,8,9 These learners tend to be action oriented and intimately involved with challenges, adapting quickly to varying situations by combining experience and doing.5,9,11 These individuals are viewed as risk-takers, relying on others for information, and are often found in action-oriented jobs such as marketing or sales.1,7,11 “Divergers” utilize the strategies of CE and RO.5,8,9 Observation is preferred over action, with brainstorming and the application of prior experience used to problem solve.5,9,10 These individuals enjoy working with groups, view concrete situations from multiple perspectives, are imaginative and emotional, and tend to be those who specialize in the liberal arts.1,7,8,11 “Assimilators” utilize the strategies of AC and RO.5,8,9 These learners place a heavy emphasis on logic and theory and are skilled at integrating large amounts of information to create smaller, succinct ideas.5,8-10 These individuals enjoy reading and lectures, are less interested in people and more concerned with abstract concepts, and are often found in the applied sciences and research departments.1,5,7,11 To our knowledge, there has been no previous study conducted in the United States where the learning styles of orthopedic applicants, residents, and faculty have been examined. We assessed the predominant learning styles of these 3 groups at an orthopedic residency program. Our hypothesis was that the converging and accommodating learning styles would be most prevalent among the orthopedic residency applicants, residents, and faculty members.
MATERIAL AND METHODS This study was prospectively conducted at an east-coast academic center after institutional review board (IRB) exemption status was obtained. Information sheets regarding the study, Kolb LSI surveys, and a demographic
questionnaire were distributed to all residency applicants on the day of their interview (n ¼ 60). Similarly, current orthopedic residents (n ¼ 14) and core orthopedic faculty (n ¼ 16) were given the same packet of information and surveys. The information sheet given to the participants in the study included material regarding the purpose of the study and assurances that the survey was voluntary and refusal to participate would not affect employment or chances of obtaining a residency position. A minimal amount of information regarding learning styles was given to limit any bias prior to completion of the Kolb LSI questionnaire. Demographic information collected included age, sex, type of medical school (MD or DO), foreign medical graduate (FMG) status, year since college graduation, postgraduate year level (residents only), and years since completion of residency (faculty only). All participants were given the opportunity to ask questions regarding the study. A total of 90 Kolb LSI surveys and demographic questionnaires were distributed among the applicants, residents, and faculty. The LSI consisted of 12 items composed of 4 different statements, each representing one of the 4 elements of the learning process. The total scores for each of the 4 elements of the learning process (AE, CE, RO, and AC) were compiled, ranging from 12 to 48. Using a Cartesian graph, AE minus RO was plotted on the x-axis (range, −36 to þ36), whereas AC minus CE was plotted on the y-axis (range, −36 to þ36) (Figs. 1-4). The Fisher exact test was used to determine whether the differences in the overall distribution of percentages observed (overall 4 learning style categories) were representative of significant differences between the subgroups (applicants, residents, and faculty) in the general population. Logistic regression was used to estimate the proportions and confidence intervals of each learning style, overall and within subgroups. The p-values reflect whether the proportions in each subgroup were significantly different from a baseline comparison subgroup. For group type, “residents” was used as the baseline comparison group, and for age group, “26 years and under” was used as the baseline comparison group (Table 3). p-values were also adjusted for the multiple comparisons made within each category.
RESULTS Seventy-one of the 90 surveys (78.9%) were correctly completed. Of 71 respondents, sixty-five (92%) were men, 66 (93%) had MD degrees, and there were 43 (61%) applicants, 14 (20%) residents, and 14 (20%) faculty. None of the respondents were FMGs. The mean age was 31 years (range, 23-64), mean time since graduation was 10 years (range, 4-43), and mean time since residency was 17 years (range, 3-33). The demographic data and Kolb
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29 27 25 23 21 19 17 15 13 11
A E
9
7
-25 -23 -21 -19 -17 -15 -13 -11 -9 -7 -5 -3 -1 1 3 5 3 5 7 9 11 13 15 17 19 21 23 25 27 29
Applicants 1
-1 -3 -5 -7 -9 -11 -13 -15 -17 -19 -21 -23 -25
R O
A C FIGURE 1. Learning style distribution of applicants.
LSI distribution for the participants are reported in Tables 1 and 2. Of the surveys distributed to the residency applicants, 43 of 60 (71.7%) were correctly completed. The remaining 17 surveys were either not returned or incorrectly completed. A summary of the residency applicant information is listed in Table 1. The most prevalent learning style among the residency applicants was converging (60.5%), followed by accommodating (20.9%), diverging (16.3%), and assimilating (2.3%). Applicants demonstrated a high tendency toward AE (mean ¼ 38.5) followed by AC (mean ¼ 31.9) (Fig. 1).
All resident surveys were returned and completed correctly for a 100% completion rate. A complete summary of the resident information is listed in Table 1. There were 2 fifthyear residents, 3 fourth-year residents, 3 third-year residents, 3 second-year residents, and 3 interns (mean postgraduate year level ¼ 2.9). The most prevalent learning style among the orthopedic residents was converging (50%), followed by assimilating (21.4%), accommodating (14.3%), and diverging (14.3%). Residents also demonstrated a high tendency toward AE (mean ¼ 37.9) followed by AC (mean ¼ 32.9) (Fig. 2).
TABLE 1. Demographics by Category Applicants Average age (y) Age range (y) Female (%, n) Male (%, n) DO medical school (%, n) MD medical school (%, n) FMG status (%, n) Average time since college graduation (y) Average time since residency graduation (y)† †
26.8 23-32 9.3% (n ¼ 90.7% (n ¼ 4.7% (n ¼ 95.3% (n ¼ 0 5.6 n/a
4) 39) 2) 41)
Residents 29.5 26-32 7.1% (n ¼ 92.9% (n ¼ 7.1% (n ¼ 92.9% (n ¼ 0 7.9 n/a
1) 13) 1) 13)
Faculty 48.9 29-64 6.3% (n ¼ 1) 93.8% (n ¼ 13) 12.5% (n ¼ 2) 87.5% (n ¼ 12) 0 27.4 16.9
Faculty only.
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9
C E -25 -23 -21 -19 -17 -15 -13 -11 -9 -7 -5 -3 -1 1 3 7 5 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 A C
1
-1
-3
-5
-7
-9 -11 -13 -15 -17 -19 -21 -23 -25
Residents R O
FIGURE 2. Learning style distribution of residents.
Fourteen of 16 (87.5%) faculty surveys were returned. A complete summary of the faculty information is listed in Table 1. The most prevalent learning style among the faculty members was converging (35.7%), followed by diverging (28.6%), assimilating (21.4%), and accommodating (14.3%). Faculty demonstrated the highest tendency toward AC (mean ¼ 34.1) followed by AE (mean ¼ 32.9) (Fig. 3).
Among all survey participants, the most prevalent learning style was converging (53.5%), followed by accommodating (18.3%), diverging (18.3%), and assimilating (9.9%) (Fig. 4 and Fig. 5). Estimates of proportions and 95% confidence intervals of applicants, residents, and faculty with each learning style, both overall and within each subgroup, are reported in Table 3.
TABLE 2. Distribution of Learning Style Categories (Overall, By Group Type, and By Age Range) All subjects, N (%) By group type Residents, N (%) Applicants, N (%) Faculty, N (%) By age range (y) 26 and under, N (%) 27-30, N (%) 31 and older, N (%)
Total, N
Accommodating
Assimilating
Converging
Diverging
p-value
71
13 (18%)
7 (10%)
38 (54%)
13 (18%)
– 0.13
14 43 14
2 (14%) 9 (21%) 2 (14%)
3 (21%) 1 (2%) 3 (21%)
7 (50%) 26 (60%) 5 (36%)
2 (14%) 7 (16%) 4 (29%)
24 25 22
5 (21%) 3 (12%) 7 (23%)
0 (0%) 3 (12%) 4 (18%)
15 (63%) 14 (56%) 9 (41%)
4 (17%) 5 (20%) 4 (18%)
0.39
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9
C E -25 -23 -21 -19 -17 -15 -13 -11 -9 -7 -5 -3 -1 1 3 7 5 3 5 7 9 11 13 15 17 19 21 23 25 27 29 A C
Faculty 1
-1
-3
-5
-7
-9 -11 -13 -15 -17 -19 -21 -23 -25 R O
FIGURE 3. Learning style distribution of faculty.
DISCUSSION An individual’s learning style is the process by which one attains, retains, and recalls information, thereby facilitating growth in knowledge and skills. Personality type, professional career, and educational specialization can also influence learning styles and account for up to 50% of the variance in learning.17 A relationship exists between learning style and specialty choice in medicine. This suggests that individuals of similar learning preferences are drawn to similar careers and that residency programs have a learning style distribution characteristic of that specialty.1,5,17 Individual learning styles have been shown to change during progression from medical school to residency and beyond.8,10,18 The selection of a learning style most likely takes place prior to the residency application process, allowing medical students to choose a specialty they most identify with based on a similar learning style.7 Evidence suggests that surgical trainees develop specific learning styles early in their career, and with the advent of work-hour 114
restrictions, increased emphasis must be placed on effective and efficient learning. Identifying and teaching to these specific learning styles could positively influence surgical education.5,7,10,19 Recent studies have demonstrated that the converging learning style, the predominant learning style among all 3 groups in our study, is also predominant among surgeons4,7,13,14 (Table 4). This is in contrast to earlier studies, which found that other learning styles predominate among surgeons.1,11,20 Among surgical trainees, the converging learning style has been shown to be most common, present in 44%-60% of individuals.8,17,21 A survey of 13 first-year orthopedic residents at a Canadian university found that 53.8% of these residents were “convergers.”5 The prevalence of the converging learning styles has also been demonstrated among fellows and faculty within surgical subspecialties.4,7,13,14 In contrast to surgeons, other medical specialties have been associated with learning styles different from converging. The majority of residents and faculty at an internal medicine residency program were found to be “assimilators.”15
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C -25 E -23 -21 -19 -17 -15 -13 -11 -9 -7 -5 -3 -1 Applicants
1 30 28 26 24 22 20 18 16 14 12 10 8
6
3 4 5
Residents 2
0
-2 -4 -6 -8 -10 -12 -14 -16 -18 -20 -22 -24 -26 -28 -30 Faculty
7
A E
R O
9 11 13 15 17 19 21 23 25 27 29 31 A C FIGURE 4. Learning style distribution of applicants, residents, and faculty combined.
Studies performed at different pediatric residency programs reported mixed findings of predominant learning styles among faculty and residents.12,22 Multiple factors influence performance; it is understood that learning style alone cannot predict academic accomplishment. Baker et al. dubbed surgeons the “human engineers” of medicine, and thus the predominance of the converging learning style is intuitive.1 Converging learners attain the highest average USMLE Step 1 and NBME scores and accommodating learners the lowest.4,23 Among all groups we studied, “accommodators” were the least prevalent among faculty and were tied for the least prevalent among residents. “Convergers” were also found to score higher on the American Medical Education Examination.17 This may be due to the implementation of AC, which helps these individuals perform better on multiple choice examinations.15,23 Similarly, “convergers” were more successful in problem-based learning courses in medical school.10
60.00% Overall percentage 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Converging Accomodating
Diverging
Assimilating
FIGURE 5. Distribution of learning styles among all participants.
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TABLE 3. Comparison of Learning Styles By Group Type and Age Range
All subjects, N (%) By group type Residents Applicants Faculty By age range (y) 26 and under 27-30 31 and older
Accommodating (%) [95% CI]
p
18 [11%-29%]
–
Assimilating (%) [95% CI] 10 [5%-19%]
p
Converging (%) [95% CI]
p
Diverging (%) [95% CI]
p
–
54 [42%-65%]
–
18 [11%-29%]
–
– 0.08 0.99
50 [26%-74%] 60 [45%-74%] 36 [16%-62%]
– 14 [4%-43%] – 0.66 16% [8%-30%] 0.93 0.63 29 [11%-56%] 0.54
63 [42%-79%] 56 [37%-74%] 41 [23%-62%]
– 0.78 0.27
14 [4%-43%] 21 [11%-36%] 14 [4%-43%]
– 21 [7%-49%] 0.75 2 [0%-15%] 0.99 21 [7%-49%]
21 [9%-41%] 12 [4%-31%] 23 [10%-44%]
– 0 [0.0%-0.2%] – 0.59 12 [4%-31%] o0.01 0.94 18 [7%-40%] o0.01
17 [6%-37%] 20 [9%-40%] 18 [7%-40%]
– 0.87 0.94
p-values reflect logistic regression testing of whether the proportion in one subgroup is significantly different from the first subgroup in that cell of the table (i.e., residents or 26 years and under).
Nevertheless, no correlation has been found between learning style and surgical standardized examinations.8 With advancing age, there is a decreased preference for learning by action and an increased preference for learning by reflection as measured by the (AE-RO) scale.5 The 2 learning styles that utilize AE (“accommodators” and “convergers”) show a decrease over time, whereas the 2 learning styles that utilize RO (“divergers” and “assimilators”) show an increase. Among the applicants, the AE-RO scale decreased when comparing the group younger than the mean age to the group older than mean age, falling from an average of 13.2 to 12.4 (Table 5). Among the residents, the AE-RO scale similarly decreased between the 2 groups, falling from an average of 11.9 to 9.4. Among the faculty, the AERO scale decreased from 4.8 to 3.7 when comparing the group younger than the mean age to the group that was above the mean age. Similarly, with advancing age, AC has been shown to increase.15 A corresponding increase in the percentage of “assimilators” occurs, because both RO and AC are employed. An unexpected finding in our study was that 21.4% of the residents were “assimilators,” more popular than the “accommodators” (14.3%), although this was not
significant because of a small sample size. However, none of the 24 subjects who were 26 years or under had assimilating learning styles, in significant contrast to the 12% of 27- to 30-year-olds and 18% of the 31 and older group (p o 0.01). The percentage of applicants studied who were “assimilators” (2%) was smaller than the percentages of either the residents or faculty “assimilators” (both at 21%), although this difference was not significant (p ¼ 0.08) (Table 3). Learning style compatibility between a resident and the training program has shown to be a predictor of resident performance and completion of the program.17 Residents with learning styles similar to their faculty also tend to be considered outstanding by those faculty members.1 As the converging style was most prevalent in our program, it is conceivable that faculty could structure learning and teaching to be more congruent with this learning style than others could. Those faculty members who are not “convergers” should recognize the difference in learning styles and direct their efforts toward the learning style of the majority of residents. Additionally, it has been demonstrated that over 90% of medical students with diverging learning styles change their learning style over time.10 If a
TABLE 4. Previous Surgical Studies with Converging as the Preferred Learning Style Author
Year
Caulley et al. Engels et al.
2012 2010
Orthopedics Surgery
Jack et al.
2010
Surgery
Laeeq et al. Mammen et al. Contessa et al.
2009 2007 2005
Otolaryngology Surgery Surgery
Drew et al. Lynch et al. Baker et al.
1999 1998 1985
Surgery
116
Department
Surgery
Level (s)
n
Preferred Learning Style
Percentage
Residents Faculty Residents Medical students Faculty Residents Medical students Residents Residents Faculty Residents Residents Medical students Residents
13 44 40 157 61 96 183 43 91 6 16 52 227 39
Converging Converging Converging Assimilating Converging Converging Converging Converging Converging Converging Converging Converging Converging Converging
54 48 60 40 34 47 53 56 57 67 44 60 45 46
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TABLE 5. Applicants, Residents, and Faculty Distributed by Mean Age Group Applicants
Residents
Faculty
Mean Age (y) 26.8
29.5
48.9
Completed
AE-RO Converging Accommodating Diverging Assimilating Scale
Below 23/43 (53.5%) 13 (50%) mean age Above 20/43 (46.5%) 13 (50%) mean age Below 6/14 (42.9%) 4 (57.1%) mean age Above 8/14 (57.1%) 3 (42.9%) mean age Below 8/14 (57.1%) 2 (40%) mean age Above 6/14 (42.9%) 3 (60%) mean age
resident changes his learning style, the converging learning style is usually adopted.8 This concept of teaching to the majority should not, however, be at the expense of the minority learning styles. Administering the Kolb LSI to incoming residents to identify those who may potentially be at risk for underperforming is not a novel concept.17 A potential drawback to this is increased homogeneity in the applicant pool.14 Increased work-hour restrictions, a growing need for peerto-peer teaching by residents, and elevated competition for orthopedic residency positions continue to exert pressure on surgical specialties to become less diverse with respect to learning styles. Those utilizing reflection and imagination are lost in exchange for those who are increasingly practical and action oriented. Conversely, such training environments may force trainees to adapt from a predominant single learning style into a more balanced learning style.13 It has been demonstrated that deliberate pairings of noncomplementary learning styles can stimulate learning.9,24 A more appropriate use of the Kolb LSI may be an annual assessment, which provides faculty and residents the opportunity to identify changes in learning styles and to improve teaching efficiency.4 To our knowledge, this is the first study to examine the learning styles of orthopedic applicants, residents, and faculty at an orthopedic surgery program. Our study represents a small sample size at one academic residency program, and thus, the results may not be generalizable across all programs. A nationwide survey could better determine the preferred learning style of orthopedic learners across a larger group of individuals. In addition, 92% of the respondents were men, and learning styles have been shown to differ between men and women.8 We recognize the possibility of nonrespondent bias, as individuals with converging and accommodating learning styles are more likely to respond to the surveys than the other learning styles. However, the likelihood of nonrespondent bias is low as we attained a relatively high overall response rate of 78.9%.
5 (55.6%)
4 (57.1%)
1 (100%)
13.2
4 (44.4%)
3 (42.9%)
0
12.4
0
1 (50%)
1 (33.3%)
11.9
2 (100%)
1 (50%)
2 (66.7%)
9.4
2 (100%)
3 (75%)
1 (33.3%)
4.8
0
1 (25%)
2 (66.7%)
3.7
The results of this study support prior studies of Kolb learning styles among surgical residency programs. By understanding an individual’s specific learning style, resident education can be tailored to maximize that individual’s education. Trainees who are not of the majority learning style in a given residency program may benefit from increased collaboration with faculty of a similar learning style to provide continual support throughout their education. Faculty mentors could be paired with trainees based on predilection of learning styles to foster efficient education. It has been suggested that those who learn with a converging learning style may benefit from independent learning over didactic lectures and brainstorming sessions.8 It has also been proposed that focusing and strengthening lesspreferred learning styles helps students expand the scope of their learning and become more versatile learners.24 Ideally, a surgical education should incorporate the preferences of all 4 LSI learning styles. In our orthopedic surgery residency program, where the majority is convergers and increasing demands are placed on protected resident educational time, we believe that increasing effective teaching is necessary to maintain current standards of excellence.
ACKNOWLEDGMENT We wish to acknowledge the help with statistical analysis provided by Jove Graham, PhD.
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