Medical Education 1986,20,267-273

The approaches to learning of students in a traditional and

in an innovative problem-based medical school

D. I. NEWBLEt & R. M. CLARKE$

t Department .f Medicine, University o f Adelaide, South Australia and $Faculty of Medicine,

University ofhiewcastle, New South Wales

Summary. The way in which students Introduction

approach their learning is dependent on a
The way in which students approach their
variety of factors including the characteristics
learning, and the implications this may have for
of the departments and teaching to which they
medical education, have been discussed in some
are exposed. These factors appear to influence
detail in a recent review (Newble & Entwistle
whether the students adopt a surface, deep or
1986). A brief summary may be helpful here. It
strategic approach.
seems that all students have a preferred learning
In order to explore further the relationship
style largely dependent on their personality
between educational context and approach to
traits. They also have distinctive approaches to
learning, a comparison was made between
learning which are influenced by an array of
students attending a traditional medical school
characteristics of the department and the
and those attending a problem-based medical
teaching to which the students are exposed.
school. The results showed marked differences,
The result is that students can be observed to
with the problem-based school being higher on
use one of three broad approaches to learning
deep approach and lower on surface approach
which are now generally called surface, deep
than the traditional school.
and strategic (or achieving). Each is characte-
This study provides one of the first pieces of
rized by features relating to the students’
evidence of a difference between students in the
motivation and intention toward the subject
two types of medical school which can be
being studied.
directly attributed to the educational environ-
Students adopting a surface approach are pre-
ment. Students in the problem-based school
dominantly motivated by a concern to com-
appear to have an approach to learning which
plete the course or by a fear of failure. They
more closely approximates the aims of most
intend to fulfil assessment requirements by the
medical schools. The results provide support
reproduction of factual material. The process
for the philosophies and strategies of the
they use to achieve this is rote learning and the
problem-based schools.
outcome is, at best, a knowledge of factual
information and a superficial level of under-
Key words: *Learning; Students, medical/ standing. In contrast, students adopting a deep
* psychol; * Education, medical undergraduate; approach are motivated by an interest in the
Problem-solving; Curriculum; Australia subject matter and/or by its vocational rele-
vance. Their intention is to reach an under-
Correspondence: Dr D. I. Newble, Department of standing. The process of achieving this varies
Medicine, The Queen Elizabeth Hospital, Woodville, between individual students and also in a
South Australia 5 0 1 I , Australia. general way between students in different
268 D . 1. Newble G. R. M . Clarke
academic disciplines. Science-based students
tend to use a process called operation learning
which involves a logical step-by-step approach
and a cautious acceptance of generalizations
only when based on sound evidence. Arts-
based students are more likely to use comprehen-
sion learning, a process in which a broad focus is
adopted where the initial focus is on the outline
of ideas and their interconnections. The most
effective learners have been shown to be those
able to use each process where appropriate-the
so-called versatile learner. The outcome of the
versatile approach is understanding based on a
knowledge of broad principles supported by
relevant facts. The inappropriate reliance on
one or other of these two processes has been
called a learning pathology. Students who
almost exclusively use operation learning with-
out developing useful interrelations between
ideas are said to show improvidence. Such stu-
dents may be difficult to distinguish from
students using the surface approach. Students
who predominantly utilize comprehension
learning, and thus are too ready to accept
generalizations without seeking supporting evi-
dence, are said to show globetrotting. Neither
approach leads to a fully successful outcome.
Students demonstrating the strategic approach
may be seen to use processes which, at any
point in time, may be similar to those used by
both the surface and deep learner. The fun-
damental difference lies in their motivation and
intention. Such students are motivated by the
need to achieve high marks and to compete
with others. Their intention is to be successful
by whatever means necessary. The outcome is
a variable level of understanding which de-
pends on what is required by the course and
methods of assessment.
The attributes that we would hope for in a
university student are those embodied in the
deep approach. Disturbingly, the little evidence
we have suggests that not only are these
attributes unlikely to be achieved by some
students but they might be actively inhibited
by our curriculum structures and our teaching
and examining methods. One recent study
investigated the learning behaviour of students
in two medical schools, one with a traditional
curriculum and one with an objectives-based
mastery curriculum (Vu & Galofre 1983). De-
spite the curriculum difference, most students
in both schools did not have a well-planned
study system and were not motivated to search
actively beyond that which they were in-
structed to do.
In order to explore further the relationship
between educational context and approaches to
learning we have conducted a study which
compares the approaches adopted by mcdical
students in the University of Adelaide and the
University of Newcastle, New South Wales.
The former is a traditional school admitting
most students directly from school on the basis
of matriculation results. It has a 6-year curricu-
lum divided into a preclinical and a clinical
component (Cox 1971). The teaching is, as
might be expected in such a school, heavily
dependent on lectures supported by tutorials
and ward work in the clinical years. Assess-
ment is largely based on end-of-course ex-
aminations with a predominance of objective-
type tests. Clinical assessment includes ward
ratings and an objective structured clinical
examination (Newble & Elmslie 1981). In con-
trast, the University of Newcastle is an innova-
tive school (Engel & Clarke 1979). Students
may be admitted by two routes. The first is
previous academic achievement based on
school matriculation scores or a tertiary equiva-
lent. The second is by multiple criteria where a
lower level of academic achievement is a
threshold criterion and selection within this
group is based on written tests and a structured
interview designed to assess appropriate intel-
lectual and personal attributes. About half
Newcastle entrants are admitted straight from
school. The rest have had some post-secondary
life experience or education, or may be gradu-
ates. The school has a $-year problem-based
curriculum in which students learn by con-
fronting selected clinical problems which rc-
quire them to acquire the relevant basic and
clinical skills. Students work predominantly in
small groups and much time is spent in indi-
vidual study. Achievement is assessed annually
using a range of instruments; prominant is thc
so-called ‘modified essay question’, which is
used to measure diagnostic and/or management
skills and to test the ability to apply thc
underpinning basic sciences (Feletti et al. 1983).
Clinical skills are assessed by observation of
 Student learning in traditional a n d problem-based medical schools 269

patient interviews and examinations, and clinic-
al problem-solving skills by oral examination.
The ability to evaluate research papers critically
is also tested annually.
O n the basis of the literature w e have briefly
reviewed it might be expected that the Adelaide
curriculum would tend to support o r induce a
surface approach or, at best, a strategic one. O n
the other hand, the curriculum, teaching
methods and forms of assessment at Newcastle
would be expected to encourage the deep
approach. As the educational strategy used at
Newcastle is largely designed to remedy the
problems perceived in conventional medical
schools, a failure to demonstrate a significant
difference between the two institutions would
seriously undermine the philosophical and edu-
cational justification of the innovative problem-
based approach.
Methods
As yet, no instrument has been specifically
designed to measure the approaches to learning
of medical students. We have chosen to use the
Lancaster Approaches to Studying Inventory
(LI), which is a general inventory culminating
from the work of Entwistle and his group
(Entwistle & Ramsden 1983). This inventory
has undergone many modifications and the
final version incorporates most of the concepts
we have discussed.
The LI is a 64-item self-report questionnaire.
These items are grouped into 16 subscales
which are themselves combined to form thrce
major factors: reproducing orientation, mean-
ing orientation and strategic Orientation. I t also
includes a grouping of subscales related to
styles and pathologies of learning. The repro-
ducing orientation factor includes the features
we have described as surface approach. The
meaning orientation factor contains the features
which are almost identical to those w e have
called the deep approach. The achieving orienta-
tion factor similarly includes the features we
have described as the strategic approach. The
actual subscales included under each factor, and
their definitions, are shown in Fig. I (Ramsden
& Entwistle 1981). It is important to remember
that there is a possibility of confusing the
terminology w e have used for the approaches
and the terminology of some of the orientation
subscales. The concepts we have described as
surface, deep and strategic are more compre-

Subscale
Meaning orientation
Deep approach
Interrelating ideas
Use of evidence
Intrinsic motivation
Reproducing orientation
Surface approach
Syllabus boundness
Fear of failure
Extrinsic motivation
Arhievinl orientation
Strategic approach
Disorganized study methods
Negative attitudes to studying
Achievement motivation
Styles and pathologies
Comprehension leaming
Globetrotting
Operation learning
Improvidence
Meaning
Active questioning in learning
Relating to other parts of the course
Relating evidence to conclusions
Interest in learning for learning’s sake
Preoccupation with memorization
Relying on staff to define learning tasks
Pessimism and anxiety about academic outcomes
Interest in courses for the qualifications they offer
Awareness of implications of academic demands made by staff
Unable to work regularly and effectively
Lack of interest and application
Competitive and confident
Readiness to map out subject area and think divergently
Over-ready to jump to conclusions
Emphasis on facts and logical analysis
Over-cautious reliance on details

Figure I . Meanings of the subscales in the Lancaster Approaches to Studying Inventory (from
Ramsden & Entwistle 1981).
270 D . I. Newble G R . M . Clarke

6o r N N

1
P<O.OOI
1
0 I 2 3 516
Year of study

Figure 2. Comparison of mean scores of Adelaide (A) and Newcastle (N) students on Meaning
Orientation.

hensive than those described for the subscales
of the same name in the LI. O n the other hand,
the concepts we have described are not exactly
represented by the reproducing, meaning and
strategic orientations. Nevertheless, for the
purposes of this study, we shall assume that the
concepts of surface, deep and strategic
approach are broadly represented in the inven-
tory by the reproducing, meaning and strategic
orientations respectively.
The LI was administered in Adelaide and
Newcastle to first-, third- and final-year (Ade-
laide, sixth year; Newcastle, fifth year) stu-
dents, approximately two-thirds of the way
through each year. It was also administered to
another cohort of third-year Adelaide students
approximately half-way through the year, a
few weeks prior to their final preclinical ex-
aminations.
Comparisons were made between equivalent
Adelaide and Newcastle student groups using
Student’s t-test.
Results
In Adelaide the LI was completed by 87% of
first-year students (n=97), 89% of pre-
examination third-year students (n=94), 98%
of clinical third-year students (n=104) and 91%
of the final-year group (n=43). The relative

45r A A

N
I I 1 _-I
0 I 2 3 5/6
Year of study
Figure 3. Comparison of mean scores of Adelaide (A) and Newcastle (N) students on
Reproducing Orientation.
 Student learning in traditional and problem-based mediral schools
Table I. Comparisons of Adelaide and Newcastle students
Year I Year I
All Direct
students entrants Year 3 Year 516
t P t P t P t P
Meaning orientation 4.45 0.001 2.67 0.01 435 0.00I 1.35 NS
Deep approach 2.05 0.05 2.36 0.02 3.21 0.01 0 NS
Interrelating ideas 3.23 0.01 2.38 0.02 3.43 0.00I 0 NS
Use of evidence 3.57 0.001 1.40 0.05 2.26 0.05 0 NS
Intrinsic motivation 4.79 0.001 2.93 0.01 463 0.001 2.60 0.05
Reproducing orientation 5.03 0.001 3.60 0.001 3.20 0.01 2.70 0.0 I
Surface approach 3.06 0.01 2.25 0.05 3.43 0.001 2.49 0.02
S yllabus-boundness 487 0.001 3.03 0.01 4.10 0.001 436 0.001
Fear of failure 0.62 NS 0.74 NS 1.13 NS 0 NS
Extrinsic motivation 5.3 3 0.001 3.88 0.001 1.89 NS 0.59 NS
Achieving orientation 41.2 0.001 2.30 0.05 1.13 NS 2.80 0.01
Strategic approach 1.95 NS 1.58 NS I69 NS 2.43 0-02
Disorganized study methods 1.63 NS 0.87 NS 0.63 NS 2.19 0.05
Negative attitudes 3.45 0.001 1.90 NS 0.43 NS 0 NS
Achievement motivation 1.58 NS 0.76 NS 0.61 NS 1.98 0.05
Styles and pathologies - - - - - - - -
Comprehension learning 1.65 NS 1.54 NS I .02 NS I .07 NS
Globetrotting 0 NS 0.94 NS 2.04 0.05 0.59 NS
Operation learning 3.02 0.01 3.48 0.001 3.12 0.0I 2.17 0.05
Improvidence 2.08 0.05 1.00 NS 2.84 0.01 1.92 NS

smallness of the final-year group is due to the
fact that the investigators only had access to
that half of the class which, at the time, was
undertaking student internships in medicine
and surgery. However, the results represent a
91% return from an unselected sample. In
Newcastle, the LI was completed by 95% of
the first-year students (n=63), 81% of third-
year students (n=46) and 76% of final-year
students (n=44).
The results of comparisons made between
the Adelaide and Newcastle students are shown
in Figs 2 and 3 and Table I . Table I also
contains comparisons between Newcastle first-
year students admitted without previous terti-
ary study and Adelaide first-year students.
Newcastle students rate themselves higher on
meaning orientation than Adelaide students in
all years, these differences being highly signifi-
cantly different in years I and 3 (Fig. 2). The
scores for the two final-year groups are not
significantly different. The scores for Adelaide
students rise for each year and the changes
between first-, third- and sixth-year groups
were significant when tested with a one-way
analysis of variance followed by Duncan's
post-hoc multiple-range tests. Newcastle stu-
dents scored consistently higher on all four
subscales contributing to meaning orientation,
with significant differences in most subscales
between first- and third-year groups.
Similar results, but in the opposite direction,
were found for reproducing orientation. Ade-
laide students scored themselves higher in all
years than Newcastle students and these differ-
ences were significant (Fig. 3). It is interesting
to note that the highest score was found in the
pre-examination third-year Adelaide group.
The group tested a few weeks after this ex-
amination, at the time they had just started
their clinical course and when there was no
immediate threat of examinations, produced a
score which was the lowest of all Adelaide
groups. The subscales contributing most to
these differences were surface approach and
syllabus boundness. Fear of failure subscales
were almost identical in all years with a rising
trend with seniority. Extrinsic motivation was
significantly higher in Adelaide first-year stu-
dents but later years showed no significant
differences.
O n achievement orientation there were no
272 D . I. Newble fi R . M . Clarke
significant differences between Adelaide stu-
dents and their Newcastle counterparts.
Among the subscales in this orientation, only
negative attitudes to studying stands out as a
highly significant discriminator and only in the
first year. In both schools there is an upward
trend in this subscale with seniority.
The group of subscales dealing with styles
and pathologies showed that Adelaide students
rated themselves significantly higher than
Newcastle students on operation learning, and
to a lesser extent on the associated pathology of
improvidence.
Because of the possibility that first-year dif-
ferences might have been due to the differences
in selection criteria, a comparison between
direct entrants in both schools was made. This
showed results that were almost identical to
those obtained from the total group.
Discussion
The results of this study show marked differ-
ences between the responses of students in the
two schools. While it must be pointed out that
these results are based on a self-report question-
naire, which asks students to reflect on their
approaches to studying and is not a direct
measure of the approaches they actually use, it
would be impossible to explain away the
findings simply in terms of the nature of the
instrument. Overall it appears that the
approaches to learning apparently used by
Newcastle students are very much those which
would be thought desirable by all medical
schools. They are very high on deep approach
and very low on surface approach. These
desirable attributes, as expressed both in the
main orientations and in the subscales of the LI,
are more evident than in Adelaide medical
students and indeed than in any other group of
students tested previously in other institutions,
The same attributes were seen in students who
had been admitted using the same criteria as
those used to admit students of the Adelaide
school so the selection process itself is unlikely
to have contributed significantly to the
observed differences. Adelaide students, on the
other hand, have less desirable attributes. They
rate themselves highly on surface approach.
While initially scoring low on deep approach
there is an increase in scores in later years.
Whether this is due to a positive effect of the
institution or a maturational and developmental
effect cannot be determined. The fact that such
an increase did not occur in the conventional
European school in the study described below
does give some hope that the former might be
the case.
These results have been replicated in a Euro-
pean study which compared another problem-
based school with a conventional school and
with Southampton Medical School (Coles
1985). It thus appears that the observed differ-
ences in approaches to learning are most likely
to reflect contrasts in the educational environ-
ment. It is impossible to say which components
of the environment are the most influential as
there are substantial differences between the
innovative and conventional schools in the
areas of curriculum, teaching methods, assess-
ment and staff-student relationships, and all are
likely to contribute in some way (Harden et al.
1984). If the findings in these two studies are
confirmed using other techniques then convcn-
tional schools may have to consider making
substantial changes. However, it is unlikely
that an established school will ever be able to
introduce the degree of innovation which was
possible for the problem-based schools, all of
which were new institutions. The sort of
changes which might be possible, and would
arguably improve the situation, include a sub-
stantial reduction in didactic teaching and
work-load, an increase in independent learning
activities and a change of examination methods
away from multiple-choice questions.
In conclusion, this study is one of the first to
provide evidence that shows a difference be-
tween students at a traditional school and an
innovative problem-based school. It also shows
that the students in the problem-based school
appear to have an approach to studying that
closely approximates the aims of most medical
schools. O n the other hand, the approach
adopted by students at the conventional school
is far from the ideal. The results provide strong
support for the philosophies and educational
strategies of the problem-based schools. In
addition, the idea of investigating the way in
which students approach their learning is pro-
 Student learning in traditional and problem-based medical schools
viding fundamental and new insights into a
hitherto-ignored component of the educational
equation. The methodology being developed
may allow us to monitor much more effective-
ly the outcome of our educational endeavours
and interventions.
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Received 4 June 1985; editorial comments to authors
19 November 1985; accepted f o r publication 2 0
December 1985