HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Crawford, J. M. Articles by Licari, F. W. Search for Related Content PubMed PubMed Citation Articles by Crawford, J. M. Articles by Licari, F. W.

Curriculum Restructuring at a North American Dental School: Rationale for Change

Key words: learning, dental education

Submitted for publication 08/27/06; accepted 12/27/06

	Abstract

Top Abstract Rationale Conclusions References

 
The purpose of this article is to discuss how traditional dental school curricula are inconsistent with research in how learners learn. In the last ten years, there has been considerable discussion about the need for dental education reform, and innovative changes have occurred in the curricula of a number of U.S. dental schools. However, efforts in curriculum restructuring have been hindered by the lack of evidence that one specific curriculum design achieves outcomes superior to other designs. Moreover, there has been little discussion in the dental literature about how modern theories of learning can provide a sound rationale for change in dental education. Thus, it is important for those involved in curriculum reform to present the rationale for change based on the best available evidence. In this review, we summarize aspects of research on learning that seem applicable to dental education and outline ways in which curricula might be changed to become more consistent with the evidence.

Five years ago, the University of Illinois at Chicago (UIC) College of Dentistry clinical care model was a traditional discipline-based, faculty-centered one and was in the process of changing from a requirement-driven philosophy to one based on competency. At that time, the preclinical curriculum was also traditional in design and was heavily discipline-based, teacher-oriented, and delivered in sustained periods of fifty-minute lectures followed by three-hour "bench-top" laboratory sessions with little formative evaluation. A change in leadership at the college, with an awareness of the need for change in health professions education and the driving force of the Commission on Dental Accreditation (CODA), brought major changes in philosophy and practice. The clinical care program has evolved to a more comprehensive care model that is patient-centered and competency-driven. In addition, a computer-based patient record system (Axium^®) replaced a traditional paper record.

In 2003, the UIC College of Dentistry was awarded a Robert Wood Johnson Foundation grant to increase student awareness of the community issues in oral health care. As part of this grant, senior (D4) students currently spend sixty days at off-campus sites. The basic and behavioral sciences are still mainly taught in lectures, but now include other forms of learning such as small groups and have more emphasis on students’ metacognitive skills (learning how to learn). Prepatient care experiences are less focused on low-fidelity lab bench exercises, and students engage in patient care in the D1 year with a focus on reversible procedures targeted at disease prevention and treatment of mild periodontal diseases. Despite these significant changes, the college leadership thought that a review of the entire curriculum was necessary to determine how it could better fulfill its mission to produce competent dentists in the rapidly changing world of health care in the twenty-first century.

In 2004, the executive associate dean for academic affairs initiated a curriculum restructuring process by appointing a subcommittee of the curriculum committee charged with providing the college with a framework for a new predoctoral curriculum. Predicting that a dentist practicing in 2030 will need a different skill set from that acquired in the current curriculum, the subcommittee was charged with designing a predoctoral curriculum to ensure graduating students possess the following skill set:

1. self-evaluation
   
2. information gathering and assessment
   
3. problem solving
   
4. motor skills
   
5. ability to evolve with changing evidence
   

The subcommittee initially was made up of six faculty members from the Departments of Periodontics (JMC), Restorative Dentistry (AO), Pediatric Dentistry (IP), Oral Biology (MZ), and Oral Medicine and Diagnostic Sciences (PAP). One member was a department chair (IP) and one was an assistant dean (GWK). Subsequently, three other members joined the committee (KK, BJ, and GA) to facilitate the later stages in the design and implementation phases. The charge was received on March 4, 2004, and the deadline for submission of the report was June 1, 2005. The subcommittee met on a fairly regular, biweekly schedule for the fifteen-month period leading up to the submission of a plan for the curriculum framework.

In this article, we describe how the subcommittee established a rationale for curriculum change. The planned new curriculum will build on changes already implemented. The changes will profoundly affect what and how students learn in pre-patient care and will be focused on knowledge, skills, and behaviors that they will need to achieve competence in patient care activities. In a subsequent article, we will discuss the design of the new curriculum.

	Rationale

Top Abstract Rationale Conclusions References

 
In a very early meeting with the faculty, the subcommittee was asked, "What is the evidence that our curriculum needs to change?" This was a helpful reminder that it was incumbent on the group to determine and articulate a rationale for curriculum change. This article describes the evidence we have gathered to support curriculum change from a model that emphasized teaching to one that emphasizes learning; from one that emphasized the passive acquisition of information to one that actively engages students in the learning process; from one that presented information in unfocused contexts to one that uses contexts relevant to the practice of dentistry. As a consequence, the subcommittee read widely in the literature of adult learning and met with experts in education to develop a rationale for change. The subcommittee has also attempted to keep faculty informed of our progress and involved them heavily in the process of restructuring.

The Institute of Medicine report Dental Education at the Crossroads: Challenges and Change³ urged dental schools to develop a plan and timetable for curriculum reform. The report pointed out that traditional dental school curricula are crowded with redundant or marginally useful material and students do not have time to consolidate concepts or to develop critical thinking skills. The report concluded that the science base of oral health is not effectively related to clinical practice. To address these issues, the report recommended decreasing the number of lecture hours and increasing time spent in more active learning strategies such as small group discussions.

More than ten years ago, Tedesco⁴ reviewed the dental curricula in North American dental schools and provided a useful historical summary of changes that had taken place since the Gies report of 1926.⁵ More recently, Kassebaum et al.⁶ surveyed curriculum changes at U.S. and Canadian dental schools. They found that the curriculum in most U.S. dental schools had not changed very much in response to the evidence for change. They reported that the majority (77 percent) of dental schools were still organized along traditional discipline boundaries with less than 10 percent organized around interdisciplinary themes. An influential paper by Hendricson and Cohen⁷ presented a comprehensive argument for curriculum reform in dental education. They identified ten recommendations for a reform agenda that included significant reorganization and reorientation of the science education and dental clinics. They stressed the need to change from a model in which specific departments decide what students need to know to a model that follows a bottom-up plan, starting with this question: what knowledge, skills, and behaviors do students need to have to be able to function effectively as entry-level general dentists? This change is consistent with the movement in medical education away from an emphasis on educational process to one that emphasizes learning outcomes.^8,9 Bertolami¹⁰ has also argued for curriculum reform and points out a significant dilemma facing curriculum reformers: how does one prepare dental students to address current oral health care needs and also prepare students for the expected rapid changes in practice in the future?

The rationale for curriculum change can be illustrated by examining how the five principles of adult learning defined by Lindeman in 1926¹¹ (discussed in Knowles, Holton, and Swanson, 1998¹²) are at odds with a traditional dental school curriculum.

These principles are:

1. Adults are motivated to learn as they experience needs and interests that learning will satisfy.
   
2. Adults’ orientation to learning is life-centered.
   
3. Experience is the richest resource for adults’ learning.
   
4. Adults have a deep need to be self-directing.
   
5. Individual differences among people increase with age.
   

It should be pointed out that not all experts on education subscribe to the theory of adult learning. For example, Norman¹³ argues that adult learning theory does not have a rigorous experimental basis. He agrees that adult learning theory is useful in the sense that it has put the focus of education on the learner, but suggests that allowing learners to be completely self-directed "flies in the face of a lot of knowledge about human foibles and the nature of professions."

The first and second principles are not followed in a dental curriculum when the biomedical sciences are presented in a way that is often divorced from the context of the practice of dentistry. This system, often referred to as "2 + 2," is a legacy of the Flexner report on medical education.¹ Adams et al.¹⁴ have shown that accessing relevant information is facilitated by learning contexts that help students experience problems and then experience the usefulness of the information for solving those problems. Therefore, it should not be surprising that students have difficulty reorganizing information to make it useful for solving clinical problems. Rather, information should be learned and applied in similar environments: "the relevance and meaningfulness of any form of instruction may hinge upon the individual student’s perceptions of the purposes of the undertaking."¹⁵ Studies by Gick and Holyoak¹⁶ demonstrate clearly that access to knowledge in solving problems is facilitated by experiences that demonstrate the usefulness of the knowledge in solving problems. Most dental students’ life-centeredness is focused on the practice of dentistry. It is therefore appropriate to design the whole curriculum (not just the so-called clinical years) around the knowledge, skills, and behaviors that relate to the practice of dentistry.

The third principle is not followed when discipline-based or systems-based education presents information to students with little regard to their previous experience. Regehr and Norman¹⁷ emphasize the importance of embedding new information in relevant, pre-existing knowledge to make retrieval easier. Bransford et al.¹⁸ quote a study by Chi who demonstrated that non-chess-playing college students were much better at short-term recall of number strings than younger children who were chess enthusiasts. However, the young children were much better able to remember the positions of chess pieces on a chess board than college students. In other words, specific knowledge (in this example, the children’s experience of chess) plays an important part in memory. This is consistent with learning theories that argue that problem solving is not so much a generic process but one that is highly dependent on the availability of knowledge relevant to a specific problem.^19,20 Aamodt and Plaza²¹ call this "domain-dependent knowledge," which, they suggest, helps learners solve new problems (cases) when it is applied to their knowledge of previous similar problems or cases.

Bransford et al.²² also emphasize the need to learn knowledge in a context that is relevant to the problem for it to be accessible. They point out that students often learn diagnostic criteria from verbal or written descriptions of experts which have been filtered by the experts’ pattern recognition process. Students may then fail to recognize diagnostic criteria when they are presented with real clinical cases, which are unlikely to be as clear as the textbook descriptions. Other studies quoted by Bransford et al. show that the relationship between the knowledge and using the knowledge must be made explicit; this is termed "conditionalized knowledge"—knowledge that includes information about the conditions and constraints of its use. Brown et al.²³ use the term "blind training" for providing students with problem-solving strategies without helping them to understand why they were useful and when they might be used. In summary, students cannot be expected to solve problems related to patient care if the problems are presented independent of the clinical context.²⁴ Barr and Tagg²⁵ suggest that teaching in colleges frequently involves only rudimentary, stimulus- response relationships whose cues may be coded into the context of a particular course but are not rooted in the students’ everyday, functioning understanding.

Lindeman’s fourth principle is not followed because, in most traditional dental school curricula, students are not very actively engaged in the learning process. The "principal objective of medical schools should be to encourage each student to assume responsibility for his or her own learning."²⁶ A shift in emphasis from teaching to learning is needed; specifically, there needs to be recognition of the importance of the learner’s self-awareness during the learning process.¹⁸ Students must learn to be self-directed and to manage their learning effectively. They have to be aware of how they learn best and have to develop strategies to balance competing demands on their learning. They have to monitor information for meaning in the context of their learning. They have to be able to evaluate their own performance against established norms. These skills are examples of meta-cognition: "learning how to learn." Metacognition has been defined in various ways, but in the sense we mean, it is monitoring one’s progress as one learns and making changes and adapting strategies if you perceive that you are not doing well.²⁷

Learning does take time, and, in a variety of learning situations, the time needed is roughly proportional to the amount to be learned. Even talented individuals require a great deal of practice to develop expertise.²⁸ However, studies indicate that learning is facilitated if it is actively monitored and feedback about progress is included.²⁸ Bransford et al.¹⁸ state:

Issues of assessment also represent an important perspective for viewing the design of learning environments. Feedback is fundamental to learning, but feedback opportunities are often scarce in classrooms. Students may receive grades on tests and essays, but these are summative assessments that occur at the end of projects. What are needed are formative assessments, which provide students with opportunities to revise and improve the quality of their thinking and understanding. Assessments must reflect the learning goals that define various environments. If the goal is to enhance understanding and applicability of knowledge, it is not sufficient to provide assessments that focus primarily on memory for facts and formulas.

One way to enhance metacognitive skills is therefore to provide students with more formative assessments and provide them with environments and opportunities for reflection on learning.

Some learners do not acquire the tools to adapt to other types of problem solving; they are unable to transfer learning. It is argued by Harris et al.²⁹ that traditional teaching methods are not effective in developing the ability to transfer learning to different contexts (they call this "adaptive expertise"). Other methods of teaching and learning that focus on understanding, self-assessment, and reflection have been shown to increase the ability of learners to adapt to new conditions and perhaps become lifelong learners.^30,31

As Chickering and Ehrmann³² succinctly state, "Learning is not a spectator sport." Knowles et al.¹² remind us that pedagogy originated in medieval European monastic and cathedral schools and that the educational model has still not evolved significantly from the concepts developed in these early beginnings. In this pedagogical model, the teacher makes all decisions about what is to be learned, how it will be learned, when it will be learned, and if it has been learned. The student passively follows the teacher’s instructions. One way that students can be engaged more actively in the learning process is with small group activities. One of the seven principles for good practice in undergraduate education proposed by Chickering and Gamson³³ is "good practice develops reciprocity and cooperation among students." They add that good learning is collaborative and social, not competitive and isolated.

In analyses of more than 900 publications, using an extremely diverse number of outcome measures, Springer et al.³⁴ and Johnson et al.³⁵ concluded that learning in groups was superior to individual learning. Their findings suggested that various forms of small group learning were effective in promoting greater academic achievement and more favorable attitudes toward learning. Heller et al.³⁶ reported on an investigation of the effects of cooperative group learning on the problem-solving performance of college students in a large introductory physics course. They found that better solutions to problems emerged through collaboration than were achieved by even the best individuals working alone. Importantly, group learning improved the problem-solving performance of students at all ability levels. However, Colliver et al.³⁷ strongly disputed the conclusions of Springer et al. They criticized the design of some of the studies included by Springer et al. and the relevance of other studies to the conventional model of small group learning. Colliver et al. claimed that the evidence presented did not support the widespread implementation of small group learning in undergraduate science, mathematics, engineering, and technology courses.

The importance of active involvement in the learning process, problem solving, and the advantages of group learning logically led our group to explore the subject of problem-based learning (PBL). We spent considerable time evaluating the strengths and weaknesses of PBL and the feasibility of adopting a PBL curriculum at the UIC College of Dentistry. As defined by Hmelo-Silver,³⁸ PBL is a curriculum designed to provide students with guided experience in learning through solving complex, real world problems. Barrows and Kelson³⁹ define the goals of PBL as helping students:

1. construct an extensive and flexible knowledge base,
   
2. develop effective problem-solving skills,
   
3. develop self-directed, lifelong learning skills,
   
4. become effective collaborators, and
   
5. become intrinsically motivated to learn.
   

There is an abundance of literature examining the effectiveness of PBL in a variety of learning environments, particularly in predoctoral medical education. Reviewers of this literature have described the difficulties in formulating conclusions from the body of work. A major difficulty is the variety of pedagogies described under the rubric of PBL, which is practiced very differently in different institutions. Other difficulties include the complexity of the PBL process itself (small group discussions, case-based learning, ability of facilitators, etc). Some reviewers^40,41 have questioned the use of conventional outcomes to measure the effects of PBL because the presence of the multiple PBL components confounds the search for cause and effect relationships.

In a pilot systematic review of twelve studies on the effectiveness of PBL (mainly in predoctoral medical programs), Newman⁴² concluded that existing reviews of PBL do not provide robust evidence for its effectiveness. Colliver⁴³ stated bluntly in his review of PBL research that there is no conclusive evidence that PBL improves knowledge base and clinical performance. Norman and Schmidt⁴⁰ agreed with Colliver’s conclusions that research on PBL does not reveal dramatic differences in cognitive outcomes. However, Norman and Schmidt concluded that standard curriculum intervention studies (comparing a group of students trained by PBL to a traditionally trained group) could not be used as a methodology to evaluate PBL because it is impossible to maintain blinding in the study design, it is difficult to measure the outcome, and it is impossible to make the intervention uniform. Hmelo-Silver³⁸ examined the evidence whether PBL helps students in the five domains defined by Barrows and Kelson,³⁹ described above. She found some support that PBL is superior to traditional curricula in the first three domains, but insufficient research has been done in the last two domains. In a long-term follow-up of the New Pathway (NP) program at Harvard Medical School (primarily a PBL curriculum), Peters et al.⁴⁴ looked for differences between NP and traditional curriculum students in three domains—humanism, lifelong learning, and social learning—eight to nine years after graduation. They found significant differences in five of a total of twenty-two measures, all of which were in the humanism domain.

Hendricson and Cohen⁷ discuss some of the barriers that have prevented the more widespread adoption of PBL in dental education. They cite the focus of PBL on differential diagnosis compared with the focus of traditional dental school curricula on treatment; the density of the dental school curriculum, not allowing the time for problem solving that is at the heart of PBL; faculty concerns about the resources needed for PBL; and the unfamiliarity of dental school faculty with the PBL process.

In the traditional dental school curriculum, the fifth of Lindeman’s principles is not followed because students are expected to learn at the same rate and in the same way. Learners are individuals with respect to how they prefer to receive information. Barr and Tagg²⁵ state, "Our time-bound mentality has fooled us all into believing that schools can educate all of the people all of the time in a school year of 180 six-hour days. . . . If experience, research, and common sense teach nothing else, they confirm the truism that people learn at different rates, and in different ways with different subjects. But we have put the cart before the horse: our schools . . . are captives of clock and calendar. The boundaries of student growth are defined by schedules . . . instead of standards for students and learning." Barr and Tagg go on to say that learning and not teaching should be the focus of education. Many of their arguments for a paradigm shift in education are relevant to traditional dental curricula. They suggest that the rigid structure of tuition in years, semesters, and fifty-minute lectures is not the best learning environment for adults with a variety of talents and learning preferences. They also suggest that traditional lecture-based instruction fosters a competitive and individualistic atmosphere in which students must succeed or fail through their own efforts and that success is an individual accomplishment.

The Institute of Medicine report on dental education,³ as quoted above, suggested that dental curricula are crowded with redundant or marginally useful material. Educational theorists have argued that redundancy of material at the curriculum level and at the level of individual presentations (e.g., lectures) impedes learning. Whitehead⁴⁵ warned about the dangers of inert ideas: "ideas that are merely received into the mind without being utilized, or tested, or thrown into fresh combinations. . . . Education with inert ideas is not only useless: it is above all things harmful." Bordage⁴⁶ addressed the question of curriculum overload and reminds us that similar questions were asked about medical education more than a hundred years ago by Osler. Bordage argued for the presentation, early in the curriculum, of a limited number of disease prototypes to provide efficient and effective anchor points for future generalization of knowledge. He presented evidence that medical students’ rate of retention is inversely related to the number of disorders presented to them in courses. Russell et al.⁴⁷ studied the effect of adding varying amounts of "semi-related" information to clinical lectures and found a negative effect on the retention of basic information. The effect of redundancy was studied by Mayer et al.⁴⁸ in experiments with multimedia learning. They observed that students shown animations with on-screen text that summarized or duplicated information given by narration performed worse on tests of retention and transfer than students who received no on-screen text. The concept of "less is more" appears to be a valuable construct when planning a curriculum.

The literature on adult learning discussed above provides strong evidence that a curriculum should not be individual-focused, lock-stepped, teacher-centered, discipline-based, lecture-based, with performance evaluated summatively by recall of facts with little feedback. However, the literature gives little guidance for designing a curriculum that, in sum, will be superior to any other design. As a result, it seems prudent to build a curriculum with the following qualities:

1. flexibility,
   
2. multiple approaches to learning,
   
3. active student participation in the learning process,
   
4. collaborative learning in teams,
   
5. a focus on skills, knowledge, and behaviors that relate to patient care, and
   
6. clearly articulated learning objectives that are evaluated formatively (providing feedback) and summatively.
   

In this article, we have focused on the rationale for curriculum change and have not considered student and curriculum assessment. Evidence suggests that student assessment is a force that strongly influences how students learn.⁴⁹ Assessment strategies have, therefore, to be consistent with learning objectives; likewise, curriculum assessment has to be consistent with curriculum goals. We are currently in the process of designing a new curriculum that is based on the evidence of how adults learn described in this review. Details of the structure of the new curriculum and assessment tools will be the focus of a future publication.

	Conclusions

Top Abstract Rationale Conclusions References

 
Research on learning in the last three decades has provided insights into the structure of memory, problem solving, and metacognition. This body of work provides a strong argument for curriculum change and for changes in the way we teach. A dental curriculum, to be consistent with modern learning theory, must actively engage students and focus on the roles, responsibilities, and frequently performed tasks of dental practitioners. Students should learn collaboratively more than competitively. The curriculum should provide students with knowledge in the context that they will use it in their professional lives. Expectations of students in the form of learning outcomes should be clearly stated. The curriculum should be flexible and varied enough to accommodate different learning styles of students. The curriculum should provide students with repeated exposure to the knowledge, skills, and behaviors needed for competent dental practice. These attributes of practice should be introduced as relatively small numbers of key concepts and progressively built upon with increasing complexity through the curriculum. Lastly, the curriculum should provide ongoing formative evaluation so that students can reflect on what they have learned and assess their level of performance.

	Footnotes

 
Dr. Crawford is Professor, Department of Periodontics; Dr. Adami is Associate Professor, Department of Oral Medicine and Diagnostic Sciences; Dr. Johnson is Associate Professor and Director of Postdoctoral Endodontics, Department of Endodontics; Dr. Knight is Assistant Dean for Clinical Affairs; Dr. Knoernschild is Associate Professor, Department of Restorative Dentistry; Dr. Obrez is Associate Professor, Department of Restorative Dentistry; Dr. Patston is Associate Professor, Department of Oral Medicine and Diagnostic Sciences; Dr. Punwani is Professor and Head, Department of Pediatric Dentistry; Dr. Zaki is Professor Emeritus, Department of Oral Biology; and Dr. Licari is Executive Associate Dean for Academic Affairs—all at the University of Illinois at Chicago College of Dentistry. Direct correspondence and requests for reprints to Dr. John M. Crawford, Department of Periodontics, College of Dentistry, University of Illinois at Chicago, 801 South Paulina St., Chicago, IL 60612; 312-996-1266 phone; 312-996-0943 fax; jimmy{at}uic.edu.

	REFERENCES

Top Abstract Rationale Conclusions References

 

1. Flexner A. Medical education in the United States and Canada. Bulletin number 4. New York: The Carnegie Foundation, 1910.
2. Cushing H. The life of Sir William Osler, vol. 1. Oxford, UK: Clarendon Press, 1925:596–7.
3. Dental education at the crossroads: challenges and change. Washington, DC: National Academy Press, 1995.
4. Tedesco LA. Issues in dental curriculum development and change. J Dent Educ 1995; 59(1):97–146.[Abstract]
5. Gies WJ. Dental education in the United States and Canada. New York: The Carnegie Foundation for the Advancement of Teaching, 1926.
6. Kassebaum DK, Hendricson WD, Taft T, Haden NK. The dental curriculum at North American dental institutions in 2002–03: a survey of current structure, recent innovations, and planned future changes. J Dent Educ 2004; 68(9): 914–31.[Abstract/Free Full Text]
7. Hendricson WD, Cohen P. Oral health care in the 21^st century: implications for dental and medical education. Acad Med 2001; 76(12):1181–206.[Medline]
8. Harden RM. Developments in outcome-based research. Med Teach 2002; 24(2):117–20.[Medline]
9. Clark JD, Robertson LJ, Harden RM. Applying learning outcomes to dental education. Br Dent J 2004; 196(6): 357–9.[Medline]
10. Bertolami CN. Rationalizing the dental curriculum in light of current disease prevalence and patient demand for treatment: form vs. content. J Dent Educ 2001; 65(8):725–35.[Abstract]
11. Lindeman EC. The meaning of adult education. New York: New Republic, 1926.
12. Knowles MS, Holton EF III, Swanson RA. The adult learner. 5^th ed. Houston: Gulf Publishing Co., 1998.
13. Norman GR. The adult learner: a mythical species. Acad Med 1999; 74(8):886–9.[Medline]
14. Adams LT, et al. Facilitating access. Unpublished manuscript, Vanderbilt University. Quoted in Bransford et al., reference 22.
15. Harris KR, Alexander PA. Integrated, constructivist education: challenge and reality. Educ Psychol 1998; 10(2): 115–27.
16. Gick ML, Holyoak JK. Schema induction and analogical transfer. Cognit Psychol 1983; 15:1–38.
17. Regehr G, Norman GR. Issues in cognitive psychology: implications for professional education. Acad Med 1996; 71(9):988–1001.[Medline]
18. Bransford JD, Brown AL, Cocking RR. How people learn: brain, mind, experience, and school. Washington, D.C.: National Academy Press, 1999.
19. Schmidt HG, Norman GR, Boshuizen HPA. A cognitive perspective on medical expertise: theory and implications. Acad Med 1990; 65(10):611–21.[Medline]
20. Bordage G, Grant J, Marsden P. Quantitative assessment of diagnostic ability. Med Educ 1990; 24(5):413–25.[Medline]
21. Aamodt A, Plaza E. Case-based reasoning: foundational issues, methodological variations, and system approaches. AICom—Artificial Intelligence Communications 1994; 7:39–59.
22. Bransford J, Sherwood R, Vye N, Rieser J. Teaching thinking and problem solving. Res Foundations Am Psychol 1986; 41(10):1078–89.
23. Brown AL, Bransford JD, Ferrara RA, Campione JC. Learning, remembering and understanding. In: Flavell JH, Markman EM, eds. Carmichaels’s manual of child psychology, vol. 1. New York: Wiley, 1983:77–166.
24. Shatzer JH. Instructional methods. Acad Med 1998; 73(9): S38–45.[Medline]
25. Barr RB, Tagg J. From teaching to learning: a new paradigm for undergraduate education. Change Magazine 1995; 27(6):12–25.
26. Tosteson D. Quoted in: Garvin DA. Making the case. Harvard Magazine, September-October 2003. At: www.harvardmagazine.com/on-line/090322.html. Accessed: June 7, 2006.
27. Winn W, Snyder D Cognitive perspectives in psychology. In: Jonassen DH, ed. Handbook of research for educational communications and technology. New York: Simon and Schuster/MacMillan, 1996:112–42.
28. Ericsson KA, Krampe RT, Tesch-RomerC. The role of deliberate practice in the acquisition of expert performance. Psychol Rev 1993; 100(3):363–406.
29. Harris TR, Bransford JD, Brophy SP. Roles for learning sciences and learning technologies in biomedical engineering education: a review of recent advances. Ann Rev Biomed Eng 2002; 4:29–48.[Medline]
30. Palincsar AS, Brown AL. Reciprocal teaching of comprehension-fostering and comprehension-monitoring activities. Cognit Instr 1984; 1:117–75.
31. Scardamalia M, Bereiter C, Lamon M. The CSILE project: trying to bring the classroom into world 3. In: McGilly K, ed. Classroom lessons: integrating cognitive theory and classroom practice. Cambridge, MA: MIT Press/Bradford Books, 1994:201–28.
32. Chickering AW, Ehrmann SC. Implementing the seven principles: technology as a lever. AAHE bulletin, October 1996:3–6.
33. Gamson ZF. A brief history of the seven principles for good practice in undergraduate education. In: Chickering AW, Gamson ZF, eds. Applying the seven principles for good practice in undergraduate education. San Francisco: Jossey-Bass Inc., 1991:5–12.
34. Springer L, Stanne ME, Donovan S. Effects of small group learning on undergraduates in science, mathematics, engineering, and technology: a meta-analysis. Rev Educ Res 1999; 69(1):21–51.
35. Johnson DW, Johnson RT, Stanne MB. Cooperative learning methods: a meta-analysis. At: www.co-operation.org/pages/cl-methods.html. Accessed: June 29, 2005.
36. Heller P, Keith R, Anderson S. Teaching problem solving through cooperative grouping. Part 1: group versus individual problem solving. Am J Physics 1992; 60(7):627–36.
37. Colliver JA, Feltovich PJ, Verhulst SJ. Small group learning in medical education: a second look at the Springer, Stanne, and Donovan meta-analysis. Teach Learn Med 2003; 15(1):2–5.[Medline]
38. Hmelo-Silver CE. Problem-based learning: what and how do students learn? Educ Psychol Rev 2004; 16:235–66.
39. Barrows H, Kelson AC. Problem-based learning in secondary education and the problem-based learning institute. Monograph 1. Springfield, IL: Problem-Based Learning Institute, 1995.
40. Norman GR, Schmidt HG. Effectiveness of problem-based learning curricula: theory, practice, and paper darts. Med Educ 2000; 34(9):721–8.[Medline]
41. Albanese MA. Problem-based learning: why curricula are likely to show little effect on knowledge and clinical skills. Med Educ 2000; 34(9):729–38.[Medline]
42. Newman N. A pilot systematic review and meta-analysis on the effectiveness of problem-based learning. Teaching and Learning Research Briefing, Number 8, October 2004. At: www.tlrp.org/pub/research.html. Accessed: February 22, 2006.
43. Colliver JA. Effectiveness of problem-based learning curricula: research and theory. Acad Med 2000; 75(2): 259–66.[Medline]
44. Peters A, Greenberger-Rosovsky R, Crowder C, Block SD, Moore GT. Long-term outcomes of the new pathway program at Harvard Medical School: a randomized controlled trial. Acad Med 2000; 75(5):470–9.[Medline]
45. Whitehead AN. The aims of education and other essays. New York: The Free Press, 1967.
46. Bordage G. The curriculum: overloaded and too general? Med Educ 1987; 21(3):183–8.[Medline]
47. Russell IJ, Hendricson WD, Herbert RJ. Effects of lecture information density on medical student achievement. J Med Educ 1984; 59(11):881–9.[Medline]
48. Mayer RE, Heiser J, Lonn S. Cognitive constraints on multimedia learning: when presenting more material results in less learning. J Educ Psychol 2001; 93(1):187–98.
49. Cohen-Schotanus J. Student assessment and examination rules. Med Teach 1999; 21(3):318–21.

This article has been cited by other articles:

				E. F. Rossomando and M. Moura The Role of Science and Technology in Shaping the Dental Curriculum J Dent Educ., January 1, 2008; 72(1): 19 - 25. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Crawford, J. M. Articles by Licari, F. W. Search for Related Content PubMed PubMed Citation Articles by Crawford, J. M. Articles by Licari, F. W.