Abstract
The authors describe an intensive graduate program involving compressed classroom preparation followed by a period of experiential activities designed to reinforce and enhance the knowledge base. Beginning with a brief review of the andragogical issues, they describe methods undertaken to track learning styles via the Kolb Learning Styles Inventory (Version 3.1) among a cohort from matriculation to 2 months post-graduation when the individuals were in practice. Finally, the outcome of the study and potential implications of each finding are described.
“Students are expected to perform to the level of their education and continuously enhance performance through expansion of the knowledge and refinement of skills.”
Education for the Physician Assistant (PA) undergoes continuous modification to meet the expanding challenges of modern medicine. In early years, individuals with extensive health care experience were accepted into programs granting a certificate upon completion. Since that time, both curriculum and requirements have evolved.
Focused on primary care, PA education programs reflect the complexities of 21st-century medical specialties and admit individuals with a variety of life and career experiences. Recent data from the Physician Assistant Education Association (PAEA, 2014) reveal that typical students entering PA education are college graduates with an average GPA of 3.5, upper percentile scores on the GRE, and mastery of prerequisite math and science coursework, as well as required health care hours (Carter & Strand, 2000; Jones, 2007).
Programs are 24 to 27 months long, requiring around 115 credit hours leading to a master’s degree. Within this time, curriculum is divided into classroom and clinical experience phases taught on a medical school model (Wingate University, 2014). The first year is usually 12 months of full-day classroom education mirroring topics covered in the first two years of medical school. Classroom hours include laboratory and workgroup activities to reinforce concepts and develop medical skills.
The second year involves supervised clinical experiences where students often gain knowledge and experience side by side with medical students and residents. The sequence of required rotations, each of several weeks’ duration, is in core areas of medicine as stipulated by the Accreditation Review Commission on Education of the Physician Assistant (ARC-PA; 2010). Elective clinical experiences are also provided where the student can determine the specialty area.
When students begin the program, paradigm shifts are necessary. The student must move from familiar educational approaches to synthesizing and applying new information from multiple topic areas. Throughout the entire period of education, students internalize vast knowledge and build interpersonal and technical capabilities requisite for medical practice. Many students appear to have self-knowledge with personalized and successful approaches to learning. However, studies reveal that medical students and others in intensive learning environments use adaptive learning styles during their education (Bitran, Zúñiga, Pedrals, Padilla, & Mena, 2013).
Throughout the program, there is often participation in activities such as simulated patient encounters, skills demonstration, and oral examinations, evaluating both knowledge and performance. These experiences provide opportunities for students to give and receive feedback and interact with faculty. As students progress in the program, advanced knowledge application is expected where aspects of situations are considered and action from a reasoned position. This expectation is based on findings of Teunissen and Westerman (2011) in that, even if students entered clinical experiences assuming that they would be taught by others, some will recognize a learning environment’s experiential focus and become more self-directed.
Theoretical Framework
Experiential learning theory suggests a benefit if we acquire information, reflect upon it in the context under which it was acquired, and interpret this information into individualized meaning and actions (D. A. Kolb, Boyatzis, & Mainemelis, 2000). We believe that PA education fits this model as information is presented in a topical context, discussed and simulated to allow reflection and internalization, and followed by opportunities to integrate the knowledge and apply it in a variety of supervised clinical experiences. We also believe that the self-regulation theory of Schunk and Zimmerman (2003) enhances the internalization and integration components of experiential learning among PA students, in that the students strongly desire competency and independence, reflecting and undertaking personal behavioral and intellectual changes to reach their goals.
Kolb hypothesized that reflective modifications in response to experiences can be identified and measured, leading to development of the Learning Styles Inventory (LSI; D. A. Kolb, 1984; D. A. Kolb, Rubin, & McIntyre, 1971). The establishment of learning styles led to an existing, yet controversial, concept in education that to maximize learning, it is essential to understand that students have multiple learning styles that need consideration when designing educational experiences (Dekker, Lee, Howard-Jones, & Jolles, 2012; Pashler, McDaniel, Rohrer, & Bjork, 2008). In PA education, there is an absence of research into learning styles from matriculation to graduation and licensure. The authors intend to address this gap in this, and follow-up studies.
Our research question is whether learning styles change during PA education in concert with changing level of knowledge and experience and whether these changes persist outside of the academic setting. To address this, we evaluated learning styles in a PA education program, employing a learning style assessment with a history of use in similar areas of education.
Literature Review
As previously detailed, experiential learning theory implies benefit through acquiring, reflecting upon, and subsequently interpreting information into individualized meaning and actions (D. A. Kolb et al., 2000). In his 1971 learning styles theory, Kolb maintains that the effective learner uses four antithetical modes: concrete experience (CE), reflective observation (RO), abstract conceptualization (AC), and active experimentation (AE). This acknowledges that learning is a process where the material is learned to yield understanding of information that is useful to the learner. In Kolb’s view, CE and RO refer to ways of acquiring information or experiences, and AC and AE refer to ways of processing it (D. A. Kolb et al., 1971; Nulty & Barrett, 1996). Characteristics of these modes are delineated in Table 1.
Characteristics of Kolb’s Learning Modes.
Adapted from A. Kolb, Kolb, and Hay Group (2005).
Kolb’s LSI is a forced-choice instrument using short phrases to identify students’ preferred modes of learning without segregating the students into defined groups. Once the learning preferences have been scored, they are paired to determine the learner’s preference for action or reflection compared with abstraction or concreteness. The inventory has undergone at least five revisions and generation of comparative norms since introduction (D. A. Kolb, 1981, 1984, 1993; D. A. Kolb et al., 2000).
Criticisms of the Kolb inventory exist. Tennant (2006) posited that the Kolb Model was used in learning situations where it did not fully apply, such as situations incongruent with experiential education. Anderson (1988) questioned whether the Kolb inventory adequately accounts for cultural differences. We acknowledge the criticisms but believe that historical use of Kolb’s inventory in multiple areas made it appropriate for this study.
Based on pairings of Kolb’s learning modes, graphical analysis is used to define the learner’s preferred style: diverging, assimilating, converging, or accommodating. A student who is considered a diverger is imaginative and reflective, considering connections between situations and all possibilities before taking action. The assimilator uses abstract and reflective thinking to define situations, and then considers possibilities for logical action. The converger also uses abstract thinking and logic to define situations but is action-oriented, making decisions quickly. The accommodator is willing to take a risk but remains practical yet flexible in approach, learning from experiences (Felder & Brent, 2005).
Educators have long held interest in using research-driven methods to teach students based on individual learning styles (De Bello as cited in Cassidy, 2004). As a result, instructors in many fields have used the Kolb LSI and similar instruments to delineate learner characteristics for instructional purposes (Dekker et al., 2012; Pashler et al., 2008). Researchers have similarly applied learning style assessment to populations at different levels of academic standing (Hauer, Straub, & Wolf, 2005; Richard, Deegan, & Klena, 2014). However, providing instruction to students based on the prevalent learning style is controversial, with some researchers encouraging incorporation of all four styles to accommodate all learners (Armstrong & Parsa-Parsi, 2005).
Pertinent to our question, Engels and de Gara (2010) demonstrated migration of learning style from assimilating for medical students on a surgery experience to converging and accommodating among the surgical residents and faculty. The strongest alterations of learning style occurred during the transition from supervised actions as a student to independent actions as a resident, with further changes as residents progressed in the program (Engels & de Gara, 2010).
The role of curriculum type in shaping learning style has also been assessed and discarded. Gurpinar, Bati, and Tetik (2011) reported LSI administration to medical students in their first and second year to determine learning style change over time and in relation to different curriculum methods such as integrated curriculum, problem based learning, or a hybrid of the two. Their data revealed some variation in preferred styles between first and second year but the method of instruction did not exert a significant effect (Gurpinar et al., 2011).
Method
The current study was designed as a non-experimental prospective cohort study, conducted using the Kolb Learning Styles Inventory (Version 3.1). Consent to use the Kolb LSI was obtained from the copyright holder, Hay Group, Inc. (D. A. Kolb, 1993). The choice of non-experimental format was made on the basis of data being collected in an uncontrolled setting without intervention or change in the existing program. The Kolb inventory uses closed-ended responses with discrete categories, necessitating a quantitative approach. In addition, trends in the cohort’s learning style were investigated rather than shifts of individuals (Creswell, 2012), again indicating a quantitative approach.
Participants
Following approval by the University Institutional Review Board, 22 students entering the Physician Assistant class of 2011 cohort were recruited for the project. However, only 21 students participated in the study as one student withdrew from the program. Informed consent was obtained prior to participation, and participants were advised that they could withdraw without penalty at any time. Students in this cohort have undergraduate degrees in a wide range of disciplines, including sciences, liberal arts, and business.
Data Collection
The initial survey was distributed on paper and collected using an anonymous drop-box. Subsequent surveys were collected using an Internet-based survey engine without obtaining participant IP addresses. Surveys were administered when all students were present, at the initiation of the program and repeated at 5-month intervals, corresponding to the initial, middle, and end of each year of the program. A terminal survey was administered at 2 months post-graduation, when all individuals were in practice. There was 100% completion of the LSI at each encounter.
Data Analysis
Data were downloaded from the survey engine into a spreadsheet and verified to ensure accuracy. Data files were secured and, to limit potential bias, were not analyzed until participants graduated and the post-graduate survey had been collected. To analyze the responses, the researchers again verified data and averaged responses across the cohort as a whole. Interpretation was carried out using the Kolb LSI grid as mentioned below (Figure 1).
Relative quadrant distribution of predominant learning style by inventory iteration.
Findings
The initial group score for the cohort indicated an indeterminate style preference with a slight skew toward the converging quadrant of the LSI Grid (A. Kolb, Kolb, & Hay Group, 2005). Convergers tend to be technically oriented, less emotional, and evaluate relevancy of an issue prior to seeking details (D. A. Kolb, Osland, & Rubin, 1995). Importantly, the skew was slight, reflecting a group with distribution of styles without a group preference. By the end of the first classroom semester, the LSI indicated that students were predominately using the converger style.
Later periods in the classroom year reveal that the majority of students shift to the accommodating mode, looking for significance of an issue and then considering what they can do and what others have done in similar situations to yield the necessary outcomes. At the beginning of the clinical experience year, the cohort preference revealed a majority shift to the diverger style with focus on questioning and analyzing a situation while favoring collaboration with others to gain information needed to address the problem. The diverger style was maintained by the students through the entire clinical experience year and was present at 2 months after graduation. Variation of learning styles associated with program phases is depicted in Table 2.
Kolb Learning Styles Inventory Stages by Stage of the Physician Assistant Education Program.
Note. Intervals between administrations of the LSI corresponded to divisions in each year, with August being the initiation point for each phase of the program. AC = abstract conceptualization; CE = concrete experience; AE = active experimentation; RO = reflective observation; LSI = Learning Styles Inventory.
Discussion of Findings
In the first year, evaluation of the students progresses, through introduction of clinical scenarios, from recall and explanatory approaches to diagnostic accuracy and therapeutic decision making. The significance of preference for the converger scale is progression to greater reliance on the “how” of a situation, followed by generation of a hypothesis, a major element in medical education and practice. The preference for accommodating later in the classroom year may reflect maturing of students who desire application of their new skills while also gleaning information from faculty.
As they begin the clinical year, students develop and apply knowledge through supervised clinical experiences. At this point, they reveal a preference for the diverger style, analyzing situations and collaborating with their preceptor and others to resolve issues. Maintenance of the diverger style continues through the clinical year as students face challenging situations where the patient’s condition fits with multiple possibilities. These situations require careful consideration and consultation with specialists or preceptors, corresponding to the preceptors’ expectation of more involvement in patient evaluation and management. Of note is that, when the students graduate and begin their professional career, they sustain diverger style, indicating continued reliance on analytical thought and consultation.
The concept of individual learning styles and their significance has long been a subject of discussion, with much written on both sides of the fence (Felder, 2010). Our study did not evaluate individual effects and did not segregate participants based on age, gender, undergraduate major, or other parameters. Efforts focused on evaluation of the impact of a structured and intensive curriculum on the predominant learning style within a group of highly motivated individuals. Figure 1 depicts the distribution of styles following each administration of the LSI.
Our findings support the assumption that learning styles can vary in a dynamic manner and that within populations, there can be substantial change in predominant styles based on intellectual need or stressors present for the group (Bitran et al., 2013; Gurpinar et al., 2011). For example, movement from accommodator style to diverger style in our participants during the clinical year coincided with students accepting the need to leave academic comfort zones, grow and eventually stand alone, fully analyzing and acting upon situations with preceptor guidance.
The shift in styles observed in our study cohort supports the assertions of Kolb that learning style can change by situation (D. A. Kolb et al., 2000) and raises the question of a relationship between style and perceived self-efficacy at the point of change in activities. In clinical rotations, students are expected to perform to the level of their education and continuously enhance performance through expansion of the knowledge and refinement of skills (ARC-PA, 2010; Jones, 2007).
These data may reflect factors not strictly curriculum based, including realization by participants that deliberative skill and precision are highly valued (Contessa, Ciardiello, & Perlman, 2005). We believe that progression of styles, ending in widespread adoption of the diverger style, relates to the core curriculum, as PA education is constructed to develop analytical and collaborative problem solving in a primary care setting even though all students do not enter primary care (PAEA, 2014). Although some graduates in this cohort entered specialty practice, our data indicate that they did not adopt the learning styles prevalent in specialty physicians, where many specialists maintain converger style but most primary care physicians maintain accommodator or diverger styles (Contessa et al., 2005; Engels & de Gara, 2010; Mammen et al., 2007; Plovnick, 1975; Whitney & Caplan, 1978).
In reviewing our study, we recognize the limitation of a small number of participants (n = 21) and the absence of longitudinal data after the students are in clinical practice. Some authors reported a higher rate of AC traits among men taking the Kolb LSI, paired with a higher rate of CE traits among women also taking the Kolb LSI (McCabe, 2014; Severiens & Dam, 1997). Although the gender distribution among students in the study population is predominantly female, as are most of today’s Physician Assistant programs (PAEA, 2014), our study did not reveal an effect on learning style preference that could be attributed to gender.
Implications for Research and Practice
We understand how individuals developing curriculum are drawn to the ideal of having activities and material for a class crafted to address the predominant learning style (Dekker et al., 2012; Pashler et al., 2008). In our study, there were no interventions or modifications of curriculum, yet the shift in predominant style to diverger occurred in alignment with program stages and persisted into early clinical practice. This provides a path for further research to determine the distribution and stability of this characteristic in Physician Assistants in the years post-graduation. Despite finding a predominant style, our data reveal that other learning styles exist among the students, supporting incorporation of methods that connect with all learners. However, a question is left of whether adding some emphasis on the dominant learning style would improve academic outcomes in adult learners.
Footnotes
Conflict of Interest
The author(s) declared no potential conflicts of interest with respect to the authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Author Biographies
David A. Compton, MD, MPH, is an associate professor and associate director of the Wingate University Physician Assistant program.
Cynthia M. Compton, PhD, is an associate professor and capstone advisor for the educational leadership program in the School of Graduate Education at Wingate University.