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medical education in review

Concept maps in medical education: an analytical

literature review
Barbara J Daley1 & Dario M Torre2

OBJECTIVES As the medical profession con- on the uses of concept mapping in medical
tinues to change, so do the educational methods education.
by which medical students are taught. Various
authors have acknowledged the need for alter- RESULTS The 35 studies reviewed here indi-
native teaching and learning strategies that will cate that concept maps function in four main
enable medical students to retain vast amounts ways: (i) by promoting meaningful learning;
of information, integrate critical thinking (ii) by providing an additional resource for
skills and solve a range of complex clinical learning; (iii) by enabling instructors to provide
problems. Previous research has indicated that feedback to students, and (iv) by conducting
concept maps may be one such teaching and assessment of learning and performance.
learning strategy. This article aims to: (i) review
the current research on concept maps as a CONCLUSIONS This review provides ideas for
potential pedagogical approach to medical medical school faculty staff on the use of con-
student learning, and (ii) discuss implications cept maps in teaching and learning. Strategies
for medical student teaching and learning, as such as fostering critical thinking and clinical
well as directions for future research. reasoning, incorporating concept mapping
within problem-based learning, and using con-
METHODS The literature included in this cept mapping in group and collaborative
review was obtained by searching library data- learning are identified. New developments in
bases including ACADEMIC SEARCH, ERIC, medical education include the use of serial
EBSCOHost, PsychINFO, PsychARTICLES, concept maps, concept maps as a methodology
PubMed MEDLINE, CINAHL and EMBASE. to assist learners with lower cognitive compe-
This literature review is a summary of both tence, and the combination of group concept
conceptual and empirically published literature maps with structured feedback.

Medical Education 2010: 44: 440448


Department of Administrative Leadership, School of Education, Correspondence: Professor, Dr Barbara J Daley, Department of
University of Wisconsin Milwaukee, Milwaukee, Wisconsin, USA Administrative Leadership, School of Education, University of
Department of Medicine, University of Pittsburgh, Pittsburgh, Wisconsin Milwaukee, PO Box 413, Milwaukee, Wisconsin 53201,
Pennsylvania, USA USA. Tel: 00 1 414 229 4311; Fax: 00 1 414 229 5300;

440 Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 440448
Concept maps in medical education: an analytical review

set of concept meanings embedded in a framework of

propositions. In this view, we think and learn with
concepts by linking new concepts to what we already
According to Shulman,1 the signature pedagogies of the
know.6 In addition, concepts are stored hierarchically
professions are not eternal and unchanging. Even
and differentiated as learning grows. Learning with
though they seem remarkably stable at any one point
concept maps means that the learner is making an
in time, they are always subject to change as condi-
intentional effort to link, differentiate and relate
tions in the practice of the profession itself and in the
concepts to one another.3,7
institutions that provide professional service or care
undergo larger societal change. Thus, changes in the
Theoretical framework
practice of medical education lead to many questions.
Is medical education preparing future practitioners
Ausubel and his co-authors believe that during the
for the inevitable changes in health care delivery? Are
process of thinking and learning with concepts, an
medical students learning in ways that will facilitate
individual uses three processes: subsumption, pro-
their future clinical practice? Are there more effective
gressive differentiation and integrative reconcilia-
educational strategies that can be used in the devel-
tion.5,8 In subsumption, lower-order concepts are
opment of medical practitioners? The rapid changes
subsumed under higher-order concepts.9 In progres-
in the science of medicine and the need for future
sive differentiation, concepts are broken down into
practitioners to remain competent as the medical
finer and finer components. In this way, progressive
environment evolves mean that todays medical stu-
differentiation is similar to the process of analysis.
dents must learn in meaningful and integrated ways.
Finally, integrative reconciliation occurs when the
Meaningful learning, the ability to understand and
learner attempts to reconcile and link concepts on
relate relevant medical concepts by linking them to
the left side of the map with those on the right.10,11
prior knowledge, is of great formative value to
This is similar to the process of synthesis.
medical students. Furthermore, critical thinking,
clinical reasoning and clinical problem solving are of
Figure 1, a concept map of a concept map, depicts
significant importance in the education of future
these three processes. It shows how lower-order
doctors. Despite attempts to foster new ways of
concepts are subsumed under higher-order concepts,
learning, mainly in graduate medical education,2 the
how concepts are differentiated, and how concepts
creation of new teaching tools has been limited by
are horizontally reconciled.
difficulties in developing, delivering and assessing
such strategies in undergraduate medical curricula.
Creating concept maps
With that in mind, this article will review the current
research on concept maps as a potential pedagogical
To create a concept map, the learner engages in an
approach to medical student learning. Implications
active process that includes the following steps.
for medical student teaching and learning are
Firstly, the learner identifies the most general
outlined, along with directions for future research in
concepts and places them at the top of the map.
medical education.
Secondly, the learner identifies more specific con-
cepts that relate to the general concepts in some way.
Thirdly, the learner ties together the general and
specific concepts with linking words that make sense
to him or her. Finally, the learner actively looks for
Before proceeding to the analysis of literature on
cross-linkages that tie concepts from one side of the
concept maps, it is helpful to review the definition
map to concepts on the other. Concept maps can
of concept maps, the theoretical framework support-
be created by hand with paper and pencil, or they can
ing their use, the steps needed to create them and
be created using one of many computer-based soft-
some of the challenges involved in using maps.
ware programs, for example CMAP Tools (see http://
Challenges in using concept maps
The concept map, a graphic tool for organising and
representing knowledge, was developed by Novak and Concept maps are often considered a new way of
Gowin3 and is based on Ausubels4,5 assimilation learning by both students and faculty staff, and as
theory of learning. Novak and Gowin3 describe a such it takes time for both to understand and
concept map as a schematic device for representing a incorporate mapping as a learning strategy. Student

Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 440448 441
B J Daley & D M Torre

Figure 1 A concept map showing the key features of concept maps. Concept maps tend to be read from the top downward.
(Novak JD, Canas AJ. The Theory Underlying Concept Maps and How to Construct Them. Technical Report, Florida Institute for
Human and Machine Cognition 2006.12 Reprinted with permission)

resistance is sometimes seen during the initial stages

of incorporating concept mapping into the medical
school curriculum. This resistance is usually related
In this study, we chose to investigate concept maps
to the time it takes to create maps. It may also be
over other learning strategies for two reasons. Firstly,
related to the students inability to understand how
there is a growing body of literature in this area and,
constructing maps and learning meaningfully will
secondly, the maps may be a learning strategy to assist
assist them in scoring well on standardised tests.2,3
medical students in learning clinical reasoning, crit-
ical thinking and clinical decision making. The
Another challenge in using maps involves helping
literature included in this review was obtained by
faculty understand that maps are designed to imple-
searching a variety of library databases for the years
ment the concept of meaningful learning. This
19892009. The databases included ACADEMIC
means that the faculty members focus shifts from
teaching content to helping the student create and
understand the meaning of the concepts within the
EMBASE. The key terms used in the search were
context of his or her medical practice. As students
concept mapping, meaningful learning, educa-
develop an understanding of meaning, their maps
tion, medical education, assessment and learning
will incorporate not only the content of the curric-
outcomes. The references of all retrieved articles
ulum, but also their experiences in clinical practice.
were scanned to identify additional articles. Over 350
This implies that as the students learning grows, the
articles were found in this search.
maps they create will change over time. Teaching staff
may see this as unreliability in the maps, when in
Because the purpose of this literature review was to
reality the idiosyncratic nature of the maps demon-
inform medical education, articles and studies were
strates how the students learning has grown and
included if they were perspective articles that de-
changed over time. This is analogous to the process
scribed the use of concept maps in medical or health
that takes place in the development of expertise. As
professions education curricula, courses or pro-
doctors develop their level of expertise, their under-
grammes, or if they were research articles in which the
standing of particular topics grows and deepens. If
participants were medical or health professions stu-
one asks two experts to develop maps on the same
dents. Health professions students included under-
topic, it is likely that these maps will look different
graduate and graduate nursing students,
because they reflect the cognitive structures of
undergraduate science students, dentistry students
different people, as well as the varied clinical expe-
and veterinary students. In addition, both quantitative
riences of those experts. As such, concept mapping is
and qualitative studies were included, as well as studies
a learning strategy that requires adjustment on the
in either basic or clinical sciences. Before any research
part of both students and teaching staff.

442 Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 440448
Concept maps in medical education: an analytical review

article was included in this review, its study design, thinking abilities within their disciplines. Ertmer and
sample and methodology were assessed. Reliable and Nour20 indicate that this type of meaningful learning
valid studies were included as these articles were was also achieved using concept maps online. As
identified as providing insight into the effectiveness indicated in Table S1, these studies have established
and applicability of concept mapping in medical the effectiveness of concept mapping in promoting
education. Articles about the use of concept maps in learning and yet the vast majority of them are limited
patient education and understanding patient knowl- by, for instance, their use of small samples of conve-
edge structures were excluded from this review. nience, descriptions of single educational pro-
grammes and their limited generalisability.
Table S1 briefly describes the purpose and findings
of the 35 articles1347 selected for this review. Of the Despite these limitations a number of interesting
studies and articles included here, 19 refer to the findings are apparent in this review. Firstly, concept
medical profession,2,911,15,16,19,21,30,32,33,35,37,3941,43,46 maps are being integrated into the delivery of
two of which relate to basic sciences,27,38 13 refer to problem-based learning (PBL) approaches in medi-
the nursing profession,13,14,17,2226,28,29,31,42,44 two to cal and health professions education. Hsu25 reports
the veterinary profession,18,20 and one to the dental the successful use of concept maps within the
profession.34 To analyse these articles, researchers discussion component of PBL. Her results indicate
reviewed each manuscript to identify the themes that the experimental group had significantly higher
discussed and the findings presented. Following this proposition and hierarchy scores for their concept
review, researchers were able to reduce the initial maps compared with the control group.25 Rendas
themes to four categories in which concept maps et al.37 describe similar findings and report that their
were used in medical education. results appear to indicate the use of concept maps
stimulated meaningful learning within a PBL course.
They go on to state: PBL and concept mapping
RESULTS proved to be complementary tools because the
method of information gathering, hypothesis gener-
The studies reviewed here indicate that concept maps ation, and identification of learning issues allowed for
function in four main ways within medical education: the exposure of a broad range of knowledge needs
that were visualised in the concept maps.37
1 by promoting meaningful learning;
2 by providing an additional resource for learning; Secondly, concept maps are being used in medical
3 by enabling instructors to provide feedback to and health professions education to foster the devel-
students, and opment of group and collaborative learning. For
4 by conducting assessment of learning and per- example, Kinchin and Hay27 performed a qualitative
formance. study that identified three major patterns or struc-
tures when analysing students concept maps. These
Each of these functions is explained in further detail. patterns or structures (spoke, chain and net) were
identified as indicators of different developmental
Promoting meaningful learning understanding. Kinchin and Hay28 went on to
expand this work and study concept mapping in
Concept maps have been successfully used in educa- collaborative learning. They placed students in
tion for over 25 years45 and a growing body of groups of three and asked them to produce a
literature indicates that their use in medical education consensus concept map on the topic of pathogenic
is increasing. The vast majority of articles in this review microbes. Findings indicated that students who were
indicate that concept maps foster the development of in triads of individuals with very different knowledge
meaningful learning, critical thinking and problem structures showed greater improvements in their
solving in the learner.13,1720,22,24,26,37,40,42,46 As indi- learning than students who were in groups with more
cated in these studies, meaningful learning occurs similar knowledge structures. These findings are
when the student links new knowledge with previous similar to those of Boxtel et al.,11 who found signif-
knowledge, thereby creating more integrated cogni- icant learning gains when concept mapping was used
tive knowledge structures. The studies indicate that as a group task.
through the use of concept maps, students were able
to integrate basic and clinical science information, Thirdly, recent research has examined if and how
move from linear thinking patterns to more inte- students with specific learning styles benefit from the
grated holistic patterns, and demonstrate critical use of concept maps. Studies by both Kostovich

Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 440448 443
B J Daley & D M Torre

et al.29 and Laight30 indicate that learning style within a curriculum and as a resource for knowledge
does not play a role in ability to perform well on elicitation and curriculum development. However,
concept maps. These researchers indicate that there is still a great need for additional research as
concept maps can function well across groups of the vast majority of articles in this area tend to be
learners with multiple and varied learning styles. descriptive in nature.

Finally, two studies have raised interesting and new As a resource for learning, concept maps allow
issues within the field of medical education that will students to demonstrate their mastery of the concepts
need additional research and exploration. In one of associated with a particular body of knowledge.
the studies, All and Huycke14 used serial concept Concept mapping is a creative activity that fosters
maps in graduate education to demonstrate the reflection on ones own understanding.6 According to
evolution of a students thinking over time. All and Pinto and Zeitz,9 concept maps can facilitate students
Huycke14 define a serial concept map as a series of understanding of the organisation and integration of
evolving maps created about a single concept over a important concepts. Torre et al.40 note that students
specified time period. Serial concept maps have reported: the concept maps allowed for creativity
provided a way to intermittently monitor student by developing a system of thinking that included
progress, to clarify faulty conceptual relationships, pattern recognition, the ability to think broadly on
and to foster the connections between theoretical topics, and finally, allowed for knowledge integration.
information and clinical practice. In addition, new
work by Gonzalez et al.21 provides interesting infor- Laight30 designed a study to explore students
mation on the use of concept maps in medical attitudes towards concept maps as an additional
education. These authors divided their students into learning resource. Pre-prepared concept maps were
two groups: a control group, which attended a integrated into traditional instructional methods.
traditional course in physiology, and an intervention Questionnaires asked whether the concept maps were
group, which constructed concept maps related to useful and allowed for other comments. A significant
cardiovascular physiology and used them to solve majority of students reported that pre-prepared
problems related to this subject.21 Both groups of concept maps were useful to their learning. Students
students were tested using two types of examination: a reported being motivated to think more deeply and
problem-solving examination and a multiple-choice noted that they gained in understanding of concep-
examination. Findings indicate that the group using tual inter-relationships. Therefore, according to
concept maps performed significantly better on the Laight30, pre-prepared concept maps may offer
problem-solving examination. Their performance on alternative and innovative learning and teaching
the multiple-choice examination was similar to that of opportunities and methods in large classes.
the traditional group. These findings by Gonzalez
et al.21 seem to uphold those of Roberts,38 who found Patrick et al.36 and Weiss and Levison41 both describe
no significant change in concept map scores over concept maps as a resource for learning and curric-
time but did find significant correlations between ulum development. Patrick et al.36 explain how con-
map scores and practical assignment scores. They also cept maps can assist in the development of
appear to corroborate those of West et al.,2 who curriculum databases in medical schools, specifically
indicate that assessments with concept maps may be to support the development of PBL curricula. Weiss
measuring different cognitive domains from assess- and Levison,41 by contrast, describe using concept
ments with more standard tests. Even more interest- maps as a blueprint for the development of curricular
ing in the Gonzalez et al.21 study is the finding that goals and objectives. Weiss and Levison also indicate
using concept maps in problem solving had the most that the maps can serve to assist with the integration
impact on students who came into the study with the of curricular themes across and among departments
lowest cognitive competence. This finding will need and disciplines, and describe how the maps assisted in
additional research, but it is important nonetheless as the development of a womens health medical edu-
it may indicate that concept mapping represents a cation collaboration.41
method by which teaching staff can assist medical
students who are struggling to learn and perform. One of the most innovative ways in which concept
maps function as a resource for learning is articulated
Providing a resource for learning by Castro et al.15 and Willemsen et al.43 These authors
indicate that concept maps can function in the
The literature in this review reports that concept development of knowledge models. Castro
maps function as a resource for student learning et al.15describe how they used concept maps to begin

444 Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 440448
Concept maps in medical education: an analytical review

building a knowledge ontology within the nutrige- and shared meaning-making processes deepen. This
nomics community. Willemsen et al.43 observe that, study demonstrates how the discussion of concept
within clinical genomics research, one of the main maps in a group, combined with feedback on the
challenges is the acquisition and integration of data, maps provided by the instructor, fosters students
information, and expert knowledge for specific bio- learning and performance.
medical domains and diseases. They created 155
concept maps linked together in a knowledge model Assessment of learning and performance
that allows for the visualisation of vast amounts of
information.43 These ontologies and knowledge Concept maps have been used in a variety of studies
models have the potential to provide highly inte- as an assessment tool to identify student clinical
grated and organised knowledge frameworks that can performance, understand student thinking and rea-
be applied to medical student learning and clinical soning processes, and compare student maps with
performance. expert maps. Williams44 notes that concept maps
can be used to assess learning rather than just as an
Providing feedback end process of learning. However, according to
Roberts,38 because maps can vary greatly in style, a
In relation to feedback, concept mapping can assist scoring method which suits the particular type of map
students in clarifying a topic, and teachers can use must be chosen. The studies in this literature review
maps to provide feedback and identify student indicate researchers are working on methods by
misunderstandings.38 According to Kinchin and which assessment activities and scores can be linked
Hay,27 concept maps are seen as a tool for commu- to the development of concept maps.
nication between student and teacher which reveals
the students constructions of connections. Daley et al.17 used concept maps as both a learning
and an assessment strategy. Over the course of a
Edmondson and Smith18 performed a qualitative study semester in a clinical setting, 54 students created
that analysed students responses to the integration of three concept maps depicting relationships among
concept maps as a teaching and learning tool. Almost the clients, pathophysiologic factors, pharmacologic
one-half of the students agreed that creating a concept factors, and therapeutic nursing interventions. These
map was an effective learning device. As a teaching maps were used in post-conferences as discussion
method, the concept map provided the teacher with an tools to foster links between theoretical course
understanding of the students errors, thereby allow- material and clients for which the students were
ing the teacher to provide feedback and clarify both providing care.17 Results indicate a statistically
content and performance. significant change between the first and last concept
map scores of the semester. Hicks-Moore and
Morse and Jutras35 provide us with an ever-greater Pastirik23 also conducted a study to assess the level of
understanding of the role that feedback can play in critical thinking with concept maps. Their results
teaching and learning with concept maps. In their indicate that critical thinking, as measured by the
study, students in a cell biology course were divided Holistic Critical Thinking Scoring Rubric, was
into three groups. The control group did not enhanced by developing maps in the clinical setting.23
construct concept maps; the second group con-
structed maps individually, and the third group Concept mapping was also used in a pre-test post-test
created maps individually and then discussed them in study carried out by West et al.2 Like Daley et al.,17 West
teams that provided both peer and instructor feed- et al.2 found that concept mapping assessment (CMA)
back. Results from this study indicate that concept scores improved after course instruction; however,
maps without feedback had no significant effect on CMA scores did not correlate with final course or
student performance, whereas concept maps with standardised test scores. According to West et al.,2 the
feedback produced a measurable increase in student absence of a positive correlation suggests that CMA
problem solving performance and a decrease in measures a different knowledge characteristic than do
failure rates.35 This finding is important because it multiple-choice examinations; therefore, CMA has
confirms one of the theoretical premises of concept the potential to evaluate how students or residents
mapping. Novak and Gowin3 believe that a major organise and use knowledge in a way that traditional
purpose of concept mapping is to foster the devel- tests cannot. West et al.10 expanded on this work by
opment of shared meaning between the instructor studying both a structural scoring method and a
and the student. As instructors and students discuss, relational scoring method. Structural scoring is based
think about and revise concept maps, their learning on the maps organisation of hierarchical structure,

Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 440448 445
B J Daley & D M Torre

concept links and cross-links. Structural scoring assigns education as a teaching, learning and assessment
points for each valid component in four categories. strategy. Despite the limitations of each individual
Relational scoring is based on the quality or impor- research article cited here, there is a growing body of
tance of each component, with no regard to the overall evidence on the effectiveness of mapping as a method
structure of the map. West et al.10 found that structural to promote meaningful learning, as a resource for
scores increased significantly, particularly with more learning, as a methodology for providing student
experienced residents, yet relational scores were not feedback, and as an assessment strategy in medical
significantly different. education. The research cited in this review demon-
strates that concept maps can assist in medical
McGaghie et al.32 conducted a quantitative study that student learning. The reviewers could find no studies
used Pathfinder scaling to evaluate concept maps for that indicate detrimental effects of using this strategy
internal consistency, studentinstructor similarity, in medical education. Additionally, for teaching staff
and correlational relationships to final examination in medical schools, this review provides ideas on how
results. Although descriptive analysis did not show a to use concept maps to foster critical thinking and
correlation between studentinstructor concept clinical reasoning in medical students, how to incor-
map similarity scores and scores on examinations, porate concept mapping within PBL approaches, and
student scores were internally consistent and the how to use concept mapping in group and collabo-
similarity of student maps with instructor maps rative learning. New developments in medical and
increased significantly following instruction. health professions education include the use of serial
McGaghie et al. also report on three additional studies concept maps, concept maps as a methodology to
that attempted to compare concept maps developed assist learners with lower cognitive competence, and
by faculty experts with maps prepared by medical enhancing the use of concept maps in group settings
students. Findings indicate that after a 3-week unit in by providing specific feedback to students.
pulmonary physiology, student and expert maps were
more similar.33 However, as a side note, McGaghie Nonetheless, specific research on the validity of
et al. report a wide variety in the maps of experts.33 mapping within the medical school curriculum
remains necessary. This review includes a preliminary
Most recently, the understanding of CMAs has moved analysis of the different ways in which maps can be
to the development of rubrics and multiple scoring used in assessments and a number of proposed scoring
systems. For example, Moni and Moni34 developed an formulas for concept maps, both quantitative and
assessment rubric for concept maps in a dentistry qualitative. However, for maps to be used widely within
programme. The rubric was based on the content, medical education, the area of assessment and scoring
logic and presentation of the maps. Students reported needs to be developed much further. How can we
that they viewed the rubric positively, but, more use concept maps to assess and document learning
importantly, the researchers were able to identify two and change in meaning and understanding for learn-
distinct patterns in the ways students used the rubric to ers? Can a simplified scoring method that clearly
facilitate map construction and learning.34 DAntoni documents learning outcomes be developed? Further
et al.16 adapted the CMA scoring system developed by research is also needed into how concept mapping as
West et al.2 and found that the depth of the map can be an assessment tool correlates with standardised
assessed based on concept links, cross-links, hierar- assessments within medical education. Validity and
chies, examples, pictures and colours. Finally, Srini- reliability testing of concept mapping compared with
vasan et al.39 developed a study to test the reliability of other measures of learning is also needed.
CMAs. They created four scoring systems and found
that the scoring systems that focused on the quality of Additionally, longitudinal studies on the use of
the map, on the quality and importance of concepts, concept mapping in medical education are virtually
and a hybrid system had similar reliability and were non-existent. Longitudinal research is needed to
overall more reliable than the scoring system that determine if concept maps can play a role in assisting
focused on the structure of the map alone. medical students as they make the transition to
practising doctors. This type of research would need
to focus on how thinking and learning patterns
IMPLICATIONS FOR MEDICAL EDUCATION AND develop and change over the course of a doctors
FUTURE RESEARCH career. It is this type of longitudinal work that may
have implications for understanding how concept
Based on this literature review, it appears that the maps can assist in developing clinical reasoning
concept map has a potential role to play in medical processes in doctors.

446 Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 440448
Concept maps in medical education: an analytical review

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CmapTools 2006-01. Pensacola, FL: Institute for
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Acknowledgements: none. an associate degree nursing programme. J Nurs Educ
Funding: none. 2006;45 (9):35664.
14 All AC, Huycke LI. Serial concept maps: tools for
Conflicts of interest: none.
concept analysis. J Nurs Educ 2007;46 (5):21724.
Ethical approval: not applicable.
15 Castro AG, Rocca-Serra P, Stevens R, Taylor C, Nashar
K, Ragan MA, Sansone SA. The use of concept maps
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assessment rubric for a group concept map in physi- education.
ology. Adv Physiol Educ 2008;31 (1):4754.
35 Morse D, Jutras F. Implementing concept-based learn-
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Educ 2008;7 (2):24353.
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36 Patrick T, Worth E, Hardin L. Using concept maps
material) should be directed to the corresponding author
on the world-wide web to access a curriculum data-
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