Authors: James Hoffman, MD; Ricciardo Bianchi, PhD; Muhammad Durrani, DO
Editor: Michael Gottlieb, MD

A Case

John is a medical student on a rotation in the Emergency Department. On a busy Friday evening shift in the Emergency Department, John asks Dr. Smith if he can see a new patient with a chief complaint of “shortness of breath.”

“Of course,” Dr. Smith replies, and John goes to assess the patient.

Dr. Smith is then handed the patient’s ECG, which shows an antero-lateral ST-Elevation Myocardial Infarction (STEMI). The team begins to mobilize and the interventional cardiologist is paged.

Both Dr. Smith and John note that the patient is short of breath with peripheral edema and his blood pressure is low. Dr. Smith shows John the patient’s ECG and discusses with the patient what is currently going on and that it appears the patient needs to undergo emergent cardiac catheterization. After stabilization and resuscitation of the patient, the patient is transferred to the catheterization suite for percutaneous coronary intervention.

After Dr. Smith and John return to their workspace, Dr. Smith asks “Do you have any questions about the case we just saw?”

John admits that he has not seen a STEMI patient before and is confused about how the patient’s symptoms of shortness of breath and hypotension fit.

In an effort to simplify the concept for John, Dr. Smith confidently and clearly states that “the antero-lateral STEMI caused a large area of infarct in the left ventricle and this led to cardiogenic shock.”

John is confused and tells Dr. Smith that he still does not understand what exactly happened and is also struggling with the concept of cardiogenic shock as he has never taken care of a patient with it before.

It is nearing the end of Dr. Smith’s shift and she is frustrated that she cannot convey this seemingly simple concept to John. Dr. Smith prints out a review article on cardiogenic shock from the American Heart Association and asks John to read it while she finishes up her shift.

John senses Dr. Smith’s frustration and says that he will look it over and thanks her for her time.

Both of them are left frustrated and wondering how the situation could have gone better.

Background

Educational psychology, the study of the social, emotional, and cognitive processes that occur in learners, has come a long way in the past 70 years.¹ The development of behaviorism in the 1950s considered learning in the form of conditioning, with a focus on observable and measurable external factors. However, this theory did not account for cognitive processes and the internal factors influencing the learner. This led to a shift in education theory towards a focus on cognitive processes and constructivist ideas. David Ausubel, an American psychologist, contributed greatly to this field by developing one of the most profound educational theories, Meaningful Learning Theory, first published in 1963.²

Ausubel advocated that the most important factor in learning is that which the learner already knows. “Meaningful learning occurs when the learner interprets, relates, and incorporates new information with existing knowledge and applies the new information to solve novel problems”.³ External factors, such as one’s learning environment, were still considered significant, but the emphasis was primarily on internal factors and the individual learner. Previously, classroom teaching was primarily paternalistic in nature with the teacher serving as the foundation and relaying information to learners. With meaningful learning, the teacher primarily functions as a facilitator, helping learners to experience and absorb new information. This is accomplished by creating an environment in which learners are encouraged as well as permitted to experiment with concepts and act freely. The learner serves as the foundation in this situation. 

Meaningful learning encourages teachers to use tools such as advance organizers to assist in the process of learning. These tools can be used prior to a learning experience to prepare the learner’s mind and activate specific prior knowledge that will be needed to understand and interpret the new information. An example can be a chart, graph, or an experiment.⁴ This involves active learning techniques, where the tools can stimulate learners to make meaningful connections between preexisting and new knowledge.⁵ Advance organizers are capable of serving this function because they are at a higher level of abstraction or generality than the information that follows, and they are based on what the learner already knows.⁵

In relating new information to old, the information is incorporated into a framework that makes sense of an overall concept. “The interaction of new knowledge with the existing ideas allows, through its cognitive activity, the learner to develop new meanings, which are unique to them.”⁶ To achieve this, a learner must be willing to learn as well. Only then will it be deemed interesting and meaningful so they can substantiate and understand the information. As new information is cognitively integrated within a framework of longstanding concepts and information, the learner is more readily able to assimilate and develop new meaning, while constantly reinforcing it each time it is applied.

Modern takes on this Theory

In its original presentation, Ausubel’s Meaningful Learning Theory focused on the acquisition and retention of verbal knowledge in classroom settings where groups of young learners were presented with subject-specific information by teachers.² Over the years, this theory has increasingly impacted learners of different ages in various learning environments. In his second monograph, Ausubel underlined that “the acquisition and retention of knowledge are [not] necessarily restricted to the formal instructional contexts of schools and universities, where designated teachers and pupils interact in stereotypical ways mostly for this purpose.”⁸ Actually, the acquisition and retention of knowledge are pervasive and lifelong activities essential for the competent performance, efficient management, and improvement of daily work tasks”.⁸

Ausubel also noted that the “promise of the cognitive approach to school (subject-matter) learning and to the acquisition, retention, and organization of knowledge in the learner’s cognitive structure has been amply fulfilled since the publication of ‘The Psychology of Meaningful Verbal Learning’ in 1963.”⁸ However, the effects of meaningful learning and its application to instructional methods still remained to be investigated at higher levels of education.

As changes from passive and teacher-centered learning in large classrooms to active and student-centered learning in small groups have been increasingly adopted, the principles of the Meaningful Learning Theory have provided the foundation for new instructional methods. The emphasis on subsumption of new knowledge into the learner’s existing cognitive structure brings the focus on individual learners, emphasized in the self-directed learning modalities. The requirement for the learner to process the acquisition of new knowledge engages active learning, which is a prerequisite of adult learning theories. The achievement of meaningful learning ensures that the educational experience has practical applications for the learner and promotes their personal growth, which is the basis for goal-directed and competency-based learning.

In recent years, an effective strategy to achieve meaningful learning has emerged with the use of concept mapping.⁷ Concept maps are visual constructs of interconnected elements (concepts) that result from the processing of instructional material and relevant ideas by the learner. Concept mapping reflects the learner’s cognitive structure assimilating new knowledge. Studies support the effective application of concept maps in medical student learning.

Gonzalez et al.³ had students learn a cardiovascular module of a medical physiology course by constructing concept maps related to cardiovascular physiology. The learning was supported by ‘mediators’ (i.e., faculty who assisted students with the cognitive process rather than with subject content). These students performed significantly better on problemOther Examples of Where this Theory Might Apply

Other examples of where this theory might apply in both the classroom & clinical setting

Meaningful learning trains the learner to actively find ways to connect the new information gained from experience to current knowledge, thereby reorganizing and expanding the learner’s knowledge and skills. This educational approach is currently being utilized in many medical education programs to integrate basic and clinical sciences, to develop clinical reasoning, and to promote interprofessional learning. One example includes the integration of basic and clinical sciences by promoting the collaboration of first- and fourth-year medical students during clinical grand rounds presentations, with a faculty member guiding them through concept maps.¹⁰ In this interesting application of the Meaningful Learning Theory, the advanced modifiers initially laid down by the faculty facilitator were adapted during the discussion towards the cognitive constructs of the students who explicitly guided the refinement and completion of the concept maps. Focus groups revealed that students appreciated the integrated learning of basic science and clinical medicine concepts, as well as the clinical reasoning thought processes.

In a methodological study on the construction and validation of an American Heart Association Basic Life Support course for distance learning, the authors provided a concrete example of direct application of Ausubel’s theory for health professional education.¹¹ Using Bloom’s taxonomy, cognitive educational objectives were defined, as per American Heart Association recommendations, to guide the course material development, the teaching-learning process, and the assessment. Three conditions of Ausubel’s theory were built into the course to enable meaningful learning: (1) to tap into pre-existing knowledge of the learner, cases that the learners were familiar with were proposed; (2) to ensure the explicit predisposition of the learners to learn, objectives were targeted to the needs of the learners; and (3) to supply new and structured knowledge, content material was presented in a systematic and logical sequence.

Limitations of this Theory

Central to Ausubel’s theory is the idea that selective anchoring of new material to existing cognitive structures is necessary for meaningful learning to occur. Yet the conditions that govern this selective anchoring also exposes inherent limitations to Ausubel’s theory. Specifically, Ausubel’s assertion that meaningful learning can only occur when a learner is conscientiously willing to learn highlights limitations that may arise when the intention and goals of the learner and teacher are not congruent with meaningful learning. For example, if the learner simply wants to store content for an upcoming examination, learning becomes mechanical instead of meaningful. Similarly, if the goal of the learner or teacher is to do well on an examination that rewards rote memorization, it may be more advantageous to the learner to justify mechanical learning in the short term.

Another limitation arises from the need for content to be meaningful from a psychological perspective to the learner. Each learner encompasses a unique outlook and has varied experiences that constitute their cognitive structure. Thus, if a learner cannot perceive or integrate the content being presented into their cognitive structure, teaching may become meaningless.

Lastly, Ausubel’s theory necessitates that ample time be available to allow for anchoring and reinforcement of content. Depending on the educational system or constraints upon an individual and the teacher, the lack of ample time may steer the learner to mechanical learning instead of meaningful learning.

Returning to the case…

A few days later, John is on shift again with Dr. Smith. Dr. Smith comes over and asks, “Hi John, did that review article on cardiogenic shock help you to better understand the patient we saw together?”

John admits that the review article was very complicated, and he was unable to understand it.

Dr. Smith nods and gestures for John to sit. “I’ve been thinking more about the patient we saw together and how to better teach you about cardiogenic shock.”

Dr. Smith asks John about his background and any previous jobs he had held. John says that his family owns a plumbing business and he helped with jobs growing up. Dr. Smith says she wants to use John’s plumbing background to try and explain cardiogenic shock and the patient’s presentation to John (condition 1: material has significance to the learner).

John remarks that he knows about different plumbing systems, pumps, tanks, and pipes (condition 2: learner possesses relevant cognitive structures to anchor new information).

John is excited and highly motivated to prove to Dr. Smith that he can grasp this material (condition 3: intrinsic motivation for meaningful learning).

Dr. Smith begins by searching the internet for visual representations of different plumbing systems that utilize pumps, tanks, and pipes and shows this to John (graphical advance organizer). She remarks that she wants to use John’s knowledge of plumbing systems to teach him about the patient they encountered (comparative advance organizer).

Dr. Smith tells John that there are systems of pumps, tanks, and pipes in our body just as there are in the field of plumbing (derivative subsumption). John knows the concepts of pumps, tanks, and pipes and now considers how these are also present in the human body.

Dr. Smith then discusses how the body’s pump, tank, and pipes move blood similar to how sewage and water are moved through pipes (correlative subsumption). John realizes that he must alter his concept of pumps, tanks, and pipes as they relate to plumbing to now include the possibility of blood flowing through them.

Dr. Smith tells John to think of the body’s system of pipes, tank, and pump as interconnected and states that this is how the circulatory system of the body works. She tells John that the tank represents the inferior vena cava bringing blood to the pump, which is represented by the heart. And lastly, John is told that the heart pumps blood through the pipes which can be thought of as the aorta and arteries of the body (superordinate learning). Although John has a working knowledge of plumbing and different pumps, tanks, and pipes, he is now able to grasp the concept of circulation through his previous experience.

Lastly, Dr. Smith tells John that, similar to plumbing, the body’s pipes can become clogged from different materials. Dr. Smith relates to John the concept of atherosclerosis and plaque rupture.

References

1. Bailey JH, Rutledge B. The educational psychology of clinical training. Am J Med Sci. 2017;353(2):96-100.
2. Ausubel DP. The psychology of meaningful verbal learning. New York: Grune & Stratton; 1963.
3. Gonzalez HL, Palencia AP, Umana LA, et al. Mediated learning experience and concept maps: a pedagogical tool for achieving meaningful learning in medical physiology students. Adv Physiol Educ. 2008;32:312-316.
4. Getha-Eby TJ, Beery T, Xu Y, O’Brien BA. Meaningful learning: Theoretical support for concept-based teaching. J Nurs Educ. 2014;53(9):494-500.
5. Ausubel DP. The use of advance organizers in the learning and retention of meaningful verbal material. J Educ Psychol. 1960;51:267-272.
6. Sousa ATO, Formiga NS, Oliveira SHS, et al. Using the theory of meaningful learning in nursing education. Rev Bras Enferm. 2015;68(4):626-635.
7. Novak JD, Gowin DB. Learning How to Learn. Cambridge University Press; 1984.
8. Ausubel DP. The Acquisition and Retention of Knowledge – A Cognitive View. Springer Netherlands; 2000.
9. Tian Z, Zhang K, Zhang T, et al.. Application of Ausubel cognitive assimilation theory in teaching/learning medical biochemistry and molecular biology. Biochem Mol Biol Educ. 2020;48(3):202-219.
10. Richards J, Schwartzstein R, Irish J, et al. Clinical physiology grand rounds. Clin Teach. 2013;10:88-93.
11. Costa IKF, Tibúrcio MP, Melo GSM, et al. Construction and validation of a distance Basic Life Support Course. Rev Bras Enferm. 2018;71(suppl 6):2698-2705.
12. Novak JD. Meaningful learning: The essential factor for conceptual change in limited or inappropriate propositional hierarchies leading to empowerment of learners. Sci Educ. 2002;86:548-571.
13. Ausubel DP. Educational psychology: a cognitive view, Ausubel DP. Holt, Rinehart, and Winston, New York; 1968.