The new framework
Although many beliefs described in the original Samuelowicz and Bain framework were also applicable in a medical education context, our data gave rise to new insights and allowed for refinements. The necessary adaptations in belief orientations and dimensions, including their constituent beliefs, will be described below.
The new framework (Table 1) is comprised of six belief orientations, set out as columns, and nine belief dimensions set out as rows, representing qualitatively distinct aspects of beliefs about teaching, learning, and knowledge. Within each dimension three or four different beliefs can be distinguished. To facilitate the descriptions, beliefs have been categorised as A (teaching-centred), A/b (teaching-centred but with learning-centred aspects), B/a (learning-centred but with teaching-centred aspects), and B (learning-centred). Each of the orientations is thus defined as a unique pattern of beliefs within nine belief dimensions.
Table 1
New framework of belief orientations defined by their constituent belief dimensions and beliefs
Dimensions | Teaching- centred orientations | Learning- centred orientations |
| | I. Imparting information | II. Transmitting structured knowledge | III. Providing and facilitating understanding | IV. Helping student develop expertise | V. Sharing the responsibility for developing expertise | VI. Negotiating meaning |
1 | Desired learning outcomes | Recall of atomised information | A | Reproductive understanding | A/b | Reproductive understanding | A/b | Change in ways of thinking | B | Change in ways of thinking | B | Change in ways of thinking | B |
2 | Expected use of knowledge | Within subject | A | Within subject for future use | A/b | Within subject for future use | A/b | Interpretation of reality | B | Interpretation of reality | B | Interpretation of reality | B |
3 | Responsibility for transforming knowledge | Teacher | A | Teacher | A | Teacher shows how knowledge can be used | A/b | Teacher helps student | B/a | Students & teacher | B | Students & teacher | B |
4 | Nature of knowledge | Externally constructed, focus on information/ structured knowledge | A | Externally constructed, focus on information/ structured knowledge | A | Externally constructed, teacher shows how knowledge can be used in reality | A/b | Personalised, focus on learning from reality | B | Personalised, focus on learning from reality | B | Personalised, focus on learning from reality | B |
5 | Students' existing conceptions | Not taken into account | A | Not taken into account | A | Not taken into account | A | Used as basis for developing expertise | B/a | Used as basis for developing expertise | B/a | Used to negotiate meaning | B |
6 | Teacher- student interaction | Not stressed | A | Reciprocal to maintain students' attention | A/b | Reciprocal to clarify understanding | B/a | Reciprocal to clarify understanding | B/a | Reciprocal to negotiate meaning | B | Reciprocal to negotiate meaning | B |
7 | Creation of a conducive learning environment | Not stressed | A | Not stressed | A | Stressed, to make the students feel at ease | A/b | Stressed, to help individual student | B/a | Stressed, to allow each individual student to learn | B | Stressed, to allow each individual student to learn | B |
8 | Professional development | Not stressed | A | Not stressed | A | Certain competencies stressed | A/b | Stressed, teacher helps student in their professional development | B/a | Stressed, teacher fosters professional development of student | B | Stressed, teacher fosters professional development of student | B |
9 | Students' motivation | Teacher tries to transmit motivation to students. | A | Teacher tries to transmit motivation to students | A | Teacher is aware of students’ intrinsic motivation | A/b | Teacher is aware of individual differences in students’ motivation | B/a | Teacher is aware of individual differences in students’ motivation | B/a | Teacher fosters intrinsic motivation of the individual student to enhance the learning | B |
Additional file 1: Samuelowicz & Bain Framework [14] |
<Please insert Table 1 about here>
Belief orientations in the new framework
The six distinct belief orientations have been ordered from left to right according to the degree of learning-centredness and have been numbered I to VI. The original framework’s seventh, most learning-centred orientation, labelled ‘Encouraging knowledge creation’ was not observed in our data. Central to this orientation is the belief that students should be in control of the learning content. We changed the label of Orientation V from ‘Preventing misunderstandings’ to ‘Sharing the responsibility for developing expertise’. This better summarised the pattern of beliefs, due to a change in belief related to the dimension ‘Students existing conceptions’ (Dimension 5).
As in the original framework, the medical educators’ focus in Orientations I to III was on the content and its transmission; hence, we conclude that these orientations are teaching-centred. In Orientations IV to VI the focus of the educators was on student learning and development, so we conclude these represent learning-centred belief orientations. The two belief orientations on either side of the teaching-centred versus learning-centred ‘divide,’ Orientations III and IV, share just one belief. In the original framework these two orientations shared two common beliefs. All other adjacent belief orientations share three to seven beliefs. In the original framework the other adjacent belief orientations shared six to eight beliefs.
Belief dimensions and their constituent beliefs in the new framework
One of the original dimensions, ‘Control of content’ disappeared in the new framework because none of the participants expressed that the control of content was to be determined by the student. However, we distilled a new dimension from our data, ‘Creation of a conducive learning environment’ (Dimension 7). We discovered that many of the participants believed this to be an important responsibility of the educator to enhance the learning of the student. Apart from two dimensions (Dimension 1 and 2), all dimensions had to be adjusted or refined. Within the dimension ‘Responsibility for transforming knowledge’ (Dimension 3), we made minor changes to the description of beliefs to better fit the content of our findings. The dimension ‘Students’ existing conceptions’ (Dimension 5) needed an adjustment: whereas in the original framework under belief orientation IV students’ existing conceptions were not taken into account, we found that our participants holding an Orientation IV believed these conceptions should be used as a basis for developing expertise.
Interviewer: ‘What do the students bring to the learning process?’
Participant: ‘Knowledge, and experience. (…) Indeed, you should – and maybe that’s the most difficult or challenging – make use of where the student is at this moment and take the next step further to learn new things.’ (Dimension 5 B/a; L01)
We labelled this fragment a learning-centred belief with teaching-centred aspects (D 5B/a), because this participant, unlike participants with teaching-centred belief orientations (I to III), realises that students are not ‘empty vessels’ but come to a teaching session with their own knowledge and experience. The educator sees it as their responsibility to use and build on these and, together with the students, to further develop knowledge constructs.
We uncovered the same belief (D5 B/a), using students’ existing conceptions as a basis for developing expertise, for the participants holding an Orientation V, which was also incongruent with the original framework. In the original framework, educators with an Orientation V believed that they should prevent common misunderstandings by pointing them out to students and explaining why the established view is more suitable. Thus, in comparison to the original framework, the emphasis in our findings is less on correcting misconceptions and more on activating (pre-)conceptions to develop expertise.
In the most learning-centred belief within this dimension (labelled D5B), participants emphasised that they themselves also learn from the conceptions that students present. To these educators, learning encompasses a two-way exchange of conceptions to negotiate meaning. We changed the label accordingly in our new framework.
The dimension ‘Teacher-student interaction’ (Dimension 6) contains two learning-centred beliefs (B/a and B) which differ in the purpose of the interaction: clarifying understanding (D6 B/a) and negotiating meaning (D6B), respectively. In the original framework the distinction between the two beliefs lay between Orientation III and IV; based on our findings the distinction was placed between Orientations IV and V in the new framework.
Finally, three of the original dimensions needed to be fine-tuned: the dimensions ‘Nature of knowledge’ (Dimension 4), ‘Professional development’ (Dimension 8), and ‘Students’ motivation’ (Dimension 9). In the original framework these dimensions consisted of two dichotomous beliefs, while in our data more than two constituent beliefs could be extracted within these dimensions. These refinements resulted in a sharper demarcation between the orientations. Below we describe the newly emerged beliefs within these dimensions, including those within the new dimension ‘Creation of a conducive learning environment’.
Dimension 4: Nature of knowledge
Some educators viewed knowledge as externally constructed, described as a ‘database’, as necessary ‘tools’ of factual knowledge, coming from outside sources like books or literature, and not linked to the reality of patient care (coded as D4A).
Interviewer: ‘What is knowledge in your discipline?’
Participant: ‘Information about disease, identification, prognosis, treatment of disease.’ (D4A; S03)
We uncovered a further distinction between the view of ‘knowledge being externally constructed’. Some participants viewed knowledge as consisting of facts only, while others emphasised that this knowledge, even though externally constructed, should be related to patient care by the educator. They believed that the educator should explain how the ‘factual knowledge’ can be used (D4A/b):
First of all you have basic factual knowledge… I would say the next step is understanding why it is like that, so a sort of reflection on the knowledge and why it is important to possess this knowledge … that you have to make a kind of doctor’s reflection on it... like when the patient comes with this or that pain or this or that complaint, what is behind it (in basic knowledge),... the focus lies for me on the first steps:… that’s how it is and that’s how you need to look at it. (D4A/b; L12)
Participants with a learning-centred belief orientation described knowledge as personalised, ‘dynamic’ and as ‘change’, coming from experience and exposure to the professional reality or to professional role models, with a focus on its application. In this view, competencies such as collaboration, communication, and clinical reasoning are seen as elements of knowledge to be learned, and they become relevant learning goals (coded as D4B).
Well, it [knowledge in the discipline, ed.] is a lot of different things; there is some factual knowledge, there is also knowledge about aspects of what it means to be a human being, and a human being who is suffering, and a human being who has a disease and all the implications of that. That’s not really factual knowledge; it’s experiential knowledge in some ways, that is a little difficult to identify specifically. It’s more amorphous. (D4B; S02)
Dimension 7: Creation of a conducive learning environment
Educators within the most teaching-centred belief orientations did not stress the importance of creating a conducive learning environment or formulated this in a negative way. For example, they described giving room to ask questions, which theoretically would promote learning, and then talked about the ‘stupidity’ of a question (D7A). Within the most learning-centred orientations educators explained that they created a positive, personal relationship with individual students to enable them to learn; the focus is on the learning process (D7B):
I think it’s just really willingness to make the learning fun. You know the students, they like teachers who allow them to learn something new. If teachers just are trying to be nice and popular, they see through that. (D7B; S02)
In the teaching-centred orientation with learning-centred aspects (Orientation III) the aim of the educator when creating a conducive learning environment is to make students feel at ease (D7A/b), with a focus on the group of students as a whole; in the learning-centred orientation with teaching aspects (Orientation IV), the aim is to help students in their understanding with a focus on the person of the individual student (D7B/a):
‘To create an atmosphere in which students feel at ease … to freely ask me questions.’ (D7A/b; L12)
‘I know them as an individual, I care about them and they have a safe place where they can respond.’ (D7B/a; S12)
The main difference between D7B/a and D7B is the focus of the educator, which is on the person of the student (D7B/a) or on the learning process (D7B), respectively.
Dimension 8: Professional development
Professional development within a medical context can be described as the development from the role of a student to that of a doctor. In the teaching-centred belief orientations the focus of the teaching is on the academic discipline and less on the professional development of the student. Thus, although some educators recognised the relevance of certain professional competencies, the teaching of these competencies was not primarily aimed at the development of students. The educators with a belief Orientation I or II believed that students acquired some awareness of these competencies by the educator telling students about them (D8A).
What I always do is that now and again in the small group is I bring in general knowledge about our healthcare and the market forces … I always try to bring in a few examples. Because I find that students should have a broader helicopter view of healthcare. (D8A; L05)
The educators with belief Orientation III were aware that a variety of professional competencies such as clinical reasoning, collaboration, communication, and professional attitude are important. For these educators, a small group is an appropriate environment to learn these competencies, or they believe some of these competencies can be demonstrated by being a role model (D8A/b).
…I think that it’s important to work together in small groups; co-operation between students is important … that is important for doctors because they work in teams. So learning to work together, and learning to accept the roles that other people play, because there are often people who take the lead and there are people who hang back. That’s all part of it. (D8A/b; L12)
In the learning-centred belief orientations the focus of the teaching is on the development of the student. Educators within Orientation V and VI described the student’s professional development as an educator’s responsibility and emphasised the importance of fostering the learning or development of the students (D8B). Most participants holding this belief refer to multiple physician roles. In addition to being a clinical expert, the professional physician should also be a communicator, collaborator, leader, health advocate, and scholar (showing qualities such as critical thinking and lifelong learning) [37].
that if one runs a small group successfully to where people don’t see that they necessarily must be the mirror image of each other but they capitalize on each other’s strengths, then they actually can begin to be learning what they are going to do for a lifetime. So the power of the small group is the power of the professional behaviour that you hope continues forever; especially around team-work and respect – the whole… (D8B; S05)
Educators within Orientation IV believed that they had an important role in the professional development of students, but were less outspoken about their responsibility in this process (D8B/a).
For the student, I think that what you especially want is that he really participates [in a workgroup]. Maybe it is also something that develops. It would of course be fantastic if after four years, students could take on the role of teacher. One of the things is of course teamwork in the hospital or another place where you work later; so these are skills which are totally essential. (D8B/a; L01)
Dimension 9: Students’ motivation
In the two most teaching-centred orientations (l and ll), educators focused on their own interests or enthusiasm, and believed that, consistent with their belief in transmitting knowledge, they also have to transmit their own motivation to the students (D9A):
I think [teaching] is trying to transmit information in a way that fosters interest in the audience. I think your goal ought to be to generate some excitement, to be excited about what you are teaching and to be an effective communicator so you can share your excitement, your passion, and generate some enthusiasm in the audience. (D9A; S07)
In Orientation III, educators described their awareness of students’ intrinsic motivation (D9A/b), acknowledging, for example, the enthusiasm of students. In Orientation IV educators were aware of the individual differences in students’ intrinsic motivation (D9B/a). These educators used phrases like wanting to learn about what the student is interested in, recognising where the student ‘wants to get’.
If you consider that intrinsic motivation is most important, then those students who are intrinsically motivated will find their way themselves with a bit of help… I go along with what I think interests them. (D9A/b; L10)
try to find something about what’s their driver, what makes them tick, what makes them excited, what makes them feel like it’s worth coming to class. And for some it’s problem-solving, for some it’s knowing something no one else knows…, different reasons, and not assuming that all [reasons] have to be the same. (D9B/a; S12)
In the most learning-centred orientation (Vl), educators described their responsibility to find out what makes the learning of the individual student exciting, to invest in the person of the student and his/her passion, and to foster the motivation and interest of the student with the goal of enhancing the learning (D9B):
What I know about adult learning is that they do best when they are focused on what is important to them, and so if they have identified their own specific learning objective, and we as the facilitator-teacher help them with that, then that is reinforcing and motivating and that sort of thing. (D9B; S11)
Results of quality strategies
Comparison of the classification of the independent research-assistant with that of the authors resulted in a high inter-rater reliability of 0.85 (Cohen’s Kappa). For the two transcripts, out of a total of 18 interview transcripts that were rated differently, final consensus was reached. This result validates the framework, supporting that it is not dependent on the perspective of a single educational researcher.
Comparison of the three sets of groups of participants generated the following results: The belief orientations of educators at SUSM were significantly more learning-centred than the belief orientations of LUMC educators (p = 0.015). Additionally, those teaching clinical topics proved to have a more learning-centred belief orientation compared to those teaching basic science topics (p = 0.029) (see Table 2).
Table 2
Belief orientation of medical educators specified by faculty, teaching topic and educational role
| Belief orientation | p value* |
I | II | III | IV | V | VI |
Faculty | LUMC | 1 | 3 | 5 | 4 | 0 | 0 | 0.015 |
SUSM | 0 | 4 | 0 | 1 | 2 | 6 |
Teaching topic/ educational role | Basic Science | 0 | 7 | 2 | 0 | 0 | 1 | 0.029 |
Clinician | 1 | 0 | 2 | 3 | 1 | 3 |
Administrator | 0 | 0 | 1 | 2 | 1 | 2 | |
*p values are based on comparisons using Chi-squared test for trend. Data with p values below 0.05 are shown in bold
The three administrators holding a belief Orientation III or IV (see Table 2) are from the LUMC, while the three administrators holding a belief Orientation V or VI are from SUSM. These data imply that none of the educators shows a more learning-centred orientation than the administrators from that medical school, namely a belief Orientation IV for the LUMC, and a belief Orientation VI for the SUSM. The number of administrators is too small to quantify this relationship, but the findings are in line with the hypothesis that the belief orientations of administrators in educational leadership positions influence the belief orientations of the educators at their respective medical schools.
These comparisons showed that the new framework can distinguish between the belief orientations of different groups of medical educators.
As a final quality strategy we provide a thick description of two maximally contrasting belief orientations (Orientations I and VI). Only one educator in our study displayed an Orientation I; he is a clinician from LUMC. Of the six educators who displayed an Orientation VI we selected the basic science educator to illustrate how a teacher with a learning-centred belief orientation teaches basic science topics. His educational beliefs contrasted with the beliefs of the other basic science educators. This educator worked at SUSM.
Dr A: teaching-centred orientation I: Imparting information
In the narrative of Dr A, the spotlight is on the teacher, who puts a lot of effort into his teaching. What highlights Dr A’s belief about teaching is his desire to ‘transfer knowledge’, which he sees as a tool, and is first introduced from ‘hardware’, such as books or electronic information. He emphasises the importance of memorising factual knowledge, as this is a prerequisite for clinical reasoning. ‘You can look everything up, but I don’t think it works like that in practice’. In his teaching he expects students to be well prepared and checks this by asking questions, for example, about anatomy. Students should be ‘committed, diligent, and well-behaved’. He is worried about the attitude and lack of motivation that he observes in some students. He aims to make students take responsibility for working hard by being provocative. For example, he presents a patient case with a bad outcome due to a medical error. Next to the importance of knowledge transfer, teaching to him means providing students with tips and tricks about how to drill the facts. He wants to be a role model, hoping that by demonstrating his own level of knowledge the students will be motivated: ‘(…) what you show then is that you know a lot. It would be very nice if that is motivating for the students. To ensure that you know a great deal about a certain subject.’ A good teacher to him is someone who determines his own teaching goals and achieves them. When asked about what students bring to the learning process, he responds that he is often disappointed that students are so unresponsive. Yet he tries to convey his own motivation on the subject and in this way generate enthusiasm among the students.
Dr B: learning-centred orientation VI: Negotiating meaning
In the narrative of Dr B students are the main characters, and the focus is on their learning process. He has several aims which he hopes to achieve through his teaching. First that ‘they learn the material’ which is integrated into patient presentations, as ‘they should be able to apply the material to patient care’. Second, he wants ‘to introduce students to the idea of how they can learn in the future’. Therefore he spends a significant part of his course analysing medical articles so that students can read medical literature and understand its implications for patient care. Third, he aims to teach students to be sceptical and critical and ‘to understand that the literature, the professor, or commonly accepted wisdom can be wrong. So they get a lot of credit for pointing out that I’m wrong.’ His assessments reflect the importance of being able to apply what they have learned: ‘The idea is they have to be able to apply what they learn in the class to the patients and also to be able to extract information from the journal articles that they can apply. […] If they try to memorise the course notes and take our final exam they won’t do very well, because we ask for synthesis in our final exam.’ Dr B sees teaching as ‘an alliance, a collaboration between the student and the teacher to learn’. Knowledge for him is not only about the basic science material, but also about taking care of patients. He emphasizes that a lot of reciprocal teaching occurs in his small group setting, and that by splitting the group up into pairs the teaching is ‘completely interactive’. He is clear that creating a supportive learning environment is a prerequisite for the learning to occur. Thus he emphasises the importance of continuity in the learning process, with the same teacher over a longer period of time. ‘They have to learn to trust me, that I won’t make fun of them.’ He puts effort into trying to make the learning fun, for example by using a competition or games. He sees it as his responsibility to figure out how to engage the students: ‘They come predisposed to learning and the reason is they have a very high incentive to learn because they are really concerned about preparing themselves to take care of patients in the near future and so they have a tremendous incentive to learn. But they’re always demanding to know if it is meaningful or relevant.’
The narratives as well as the results of the other implemented quality strategies provide support for the utility of the new framework.