November 2006 Volume 2
Article 5.
PDF File

Article Title
Teaching English to Students of Medicine: A Student-Centered Approach

Authors
Ahmad Sabouri Kashani, Soraya Soheili, & Zinat Nadia Hatmi
Tehran University of Medical Sciences (TUMS), Iran kashani45@yahoo.com

Bio Data
Zinat Nadia Hatmi, MD, is an associate professor at the Department of Community Medicine in Tehran University of Medical Sciences (TUMS). She is an epidemiologist who successfully passed a fellowship on cardiovascular disease. She is also interested in evidence-based medical practice and medical education (EBM). She is actively involved in staff-enablement workshops offered at the Educational Development Center (EDC) of TUMS.

Soraya Soheili is an assistant professor at (TUMS) Department of Community Medicine. She received her PhD in Health management and she is interested in demographic research with health management orientation. She is also very keen on Education. At the present, she is in charge of the teacher training unit at EDC.

Ahmad Sabouri Kashani is an assistant professor in charge of curriculum unit at EDC. His primary interest, however, has been testing, measurement, and evaluation. He produced the first standardized English tests at TUMS language center which he founded in 1992 and headed for 6 years. He has a PhD in TEFL, an MA in TEFL and another MA in general linguistics. He has had language education experience with children at Nursery, Primary school, High school, college level students, and armed forces. He has trained English teachers for about 30 years. His other interests are human psychology, philosophy, ethnography, politics and translation.

Abstract

The purpose of this study was to compare the achievement levels of the majority of the applicants to our medical school at Tehran University of Medical Sciences (TUMS) in the academic year 2002-2003 with that of a smaller group of the same population. The former group received instruction based on the established syllabus, but for the latter group a new student-centered approach to teaching English was designed. Participants were screened and then grouped into homogeneous classes on the basis of their English language proficiency levels. After receiving instruction based on the newly-developed student-centered approach for five consecutive semesters, they sat for the National Comprehensive Exam of Basic Sciences. Performance of the two groups on the English subtest of this exam was then correlated. Students covering the university established syllabus, it was observed, did better on the English subtest. Careful monitoring of the university Language Center’s educational program seemed to be an effective mechanism to motivate students to do their best.
                                                             

Key words: student-centered curriculum development, student-centeredness, ESP, medical English,   evaluation and wash-back effect.

Introduction

            Paying a visit to TESL-EJ Forum on “Student-Centered Learning: What does it really mean?” we found the concept of student-centeredness rather controversial (cf. TESL-EJ Forum, 2001). In this forum, David Ross, from Houston Community College, finds the essence of student-centeredness in the change in the role of the teacher as a facilitator of students’ learning and no more as a resourceful authority. Lola Katz, the cross cultural communication consultant from Israel, emphasizes the appropriateness of the tasks and activities to the level and learning style of the learners and their knowledge, at all times, of the reasons for what they are doing. Casy Peltier from George Mason University Language Institute, however, claims that younger students rarely know what is good for their language development, thus limits student-centeredness to older ones. Jim Williams, academic coordinator from Pacific Rim Language Institute, sees student-centeredness primarily as a process of customizing and constantly updating traditional policies and tried-and-true applications. John Harbord from Central European University in Hungary sums up the gist of student-centeredness as teachers’ professional judgment to decide what is the best they can do while they may sometimes make concessions regarding the students’ demands only not to give them the impression that they have been totally ignored. According to Anthea Tillyer, from City University of New York, there is so much disagreement on the meaning and implementation of the student-centered classroom. To her, what really matters is the fact that learning and the needs of the learners should determine our teaching objectives. Finally, Bill Snyder declares that a student-centered educational program is not one in which the students run the show or one in which their every whim is catered to. Rather, it is one run for the benefit of them, where the focus of all participants is on helping students acquire what is needed based on a consideration of all viewpoints. Therefore, in this perspective, the views of students are taken into account, but they are balanced against others’ perceptions. Snyder continues to say that ignoring student’s wants, even when they do not contribute to their primary objectives, may lead to resentment and lack of motivation. It is only when the students are not considered or included in the process, and not informed about why they are doing what they are doing that curricular decision-making becomes administrative fiat.

            Faced with such discrepancies, we may find it useful to have a closer look at some of the concepts contributing to the development of a student-centered educational approach to teaching English as a foreign language. After all, Lea et al. (2003) suggest many institutions and educators claim to practice student-centered education, but in reality they do not.

Student-Centered Education

            The notion of student-centeredness may have been derived from the concept of child-centered education supported by the work of the prominent Swiss psychologist, Jean Piaget, who believed that the teacher should not interfere with the process of maturation, but act as a guide (see Lavatelli, 1973). Similar emphasis on the learner may be found in “Democracy and Education” by John Dewey, the American major leader in “progressive movement” in education. Dewey (1916) sought social change through child-centered education. His pragmatism, in fact, includes many elements of student-centeredness. Another concept which seems to have influenced the notion was “individual differences.” Even as far back as 1916, the subject seemed a major focus of concern in the realm of foreign language teaching (see Deihl, 1916). This concern was, of course, not peculiar to foreign language classrooms. In fact, in the 24th yearbook of the national Society for the study of Education (1925) a part is devoted to “applying the schools to individual differences” (cf. Whipple, 1925).
            In 1973, Gerald Logan introduces the idea of the “open classroom” as a type of classroom management closely associated with individualized learning which provides the conditions that allow much individual freedom of choice in the learning process. Logan believes that two premises are involved in this “open” approach to learning:
(1) Students become more responsible by exercising responsibility in ever-increasing degree.
(2) Desirable forms of behavior are much more likely to result.
The teacher should make sure, however, that learning tasks are “clear” and “realistic” and that the student gets all the assistance s/he needs. Learners should not waste a great deal of time waiting to be evaluated in order to go on to the next assignment and the program should be as interesting as possible to the students (see Logan, 1973).

            Moffet and Wagner (1992) note that a student-centered curriculum teaches each learner to select and sequence his own activities and materials (individualization), arranges for students to center on and teach each other (interaction); and interweaves all symbolized and symbolizing subjects so that the student can effectively synthesize knowledge structures in his own mind (integration). Race (1995), nonetheless, claims that open learning is mostly based on learner-centered learning materials which are meant to be studied alone.

            McCombs and Whisler (1997) believe learning will be heightened when individuals are in respectful and caring relations with others who see their potential, genuinely appreciate their unique talents and accept them as individuals. They consider learning an active, volitional, and internally mediated process of discovering and constructing meaning from information and experience filtered through the learners’ unique perceptions, thoughts, and feelings and facilitated by social interactions and communication with others in flexible, diverse, and adaptive instructional settings. To them, learner-centered learning is a perspective that couples a focus on individual learners (their heredity, experiences, perspectives, backgrounds, talents, interests, capacities, and needs) with a focus on learning (the best available knowledge about learning and how it occurs). It is the teaching practice that is most effective in cultivating the highest levels of motivation, learning and achievement for all learners.  

            Burnard (1999), sums up Rogers’ ideas of student-centered classroom as a learning situation where students might not only choose what to study, but how and why that topic might be an interesting one to study. Reflecting the viewpoint that knowledge is constructed by students, and that the lecturer is a facilitator of learning rather than a presenter of information, Burnard emphasizes the concept of students having a “choice” in their learning. Yet, McCombs believes that a “learner-centered” perspective contends that education must concern itself with how to provide the most supportive learning context for diverse students— a context created primarily when teachers value and understand individual student’s needs.

            Calder (2000) claims that in mid-1980s, such authorities as Lewis, Rumple, Scriven, Robinson and Carr attempted to disentangle what was meant by the term “open” learning. He continues that the term “flexible” learning bears a distinct resemblance to the concept of open learning by virtue of extended access to learning through the removal of barriers, and a philosophy of learner-centered provision where learner choice is the key. The same thoughts about open learning as a student-centered approach and active removal of all study barriers have widely emerged in the literature on educational science.

            In so far as assessment in a student-centered classroom is concerned, there seems to be more formative assessment which emphasizes feedback to students and enhance their learning, which does not necessarily add to the end of the course mark. So we come across diaries, logbooks, journals, portfolios, projects, group work, profiles, peer assessments learning contracts, and negotiated assessment in the literature, all of which might be considered as essential activities contributing to Black’s (1999) concern of helping students take responsibility for their own learning; therefore, self-assessment is often emphasized in this strategy. Knight (2002) considers contracts as goals set by the student, depending on their learning gaps, which are, in turn, negotiated with the lecturer. Black (1999) and Knight (2002) both show how the students would like to be assessed in order to demonstrate that they have reached the goals, hence adding ‘choice’ in what to study as well as ‘choice' in how the student will be assessed. This very concept of negotiation addresses a dramatic change in relationship between teacher and student. In this way the student can suggest self-assessment grades and negotiate self-assessment or peer-assessment goals.

            Carol Bliss (2006), on the other hand, emphasizes the importance of sociability and human connections. She holds that authentic connection in a student-centered classroom will remove fears of failure, ridicule, family problems, the feeling of outcomes not fitting in identity issues which can prevent students from deeper learning. In a similar line, E. R. Melander (2002), Professor Emeritus at Pennsylvania State University, maintains that student-centered education becomes focused on coaching the student toward the development of attitudes, skills, and behaviors as a learner, decision maker, and community participant, with success measured in terms of learner outcomes. He also holds that the syllabus and learning resources should guide the student’s discovery, understanding, and decision-making abilities regarding learning and development in the formal curriculum. In the long run, this approach  should shape the student’s own capacities for self-assessing learning strengths and development needs identifying opportunities for learning growth and development, planning learning and development strategies, deciding on learning and development actions, reflecting on learning and development experiences, and initiating adjustments in learning and development strategies.

The Study

            It is clear then that there is a great deal of controversy surrounding whether student-centeredness is an orientation towards learning centered or customer service, i.e., learner centered. However, student-centeredness seems to be the main basic principle of open and flexible courses, i.e., taking into consideration the fact that there is no standard student; that all students are individuals with individual needs, student-centeredness can be increased with individualization, which can mean, for example, taking into consideration different learning styles and personal life situations: work, family, hobbies and accessibility. This, in turn, can mean the opportunity to participate in the activities regardless of age, status of employment, engagements of everyday life, economical resources or previous studies or without certainty of regularity of studies. Other criteria could be the educational background, study methods, contents, evaluation, and support services.

            Very much in this line, this study first set out to explore the achievement levels of the English language knowledge of the majority of the applicants to TUMS medical school in the academic year 2002-2003 who received instruction based on the established syllabus. Secondly, an attempt was made to compare the performance levels of this large group of students with that of a smaller group of the same population who received instruction based on a newly-developed student-centered approach to teaching English, i.e., the students did not follow a particular textbook, they ignored the established criteria for English courses at the School of Medicine, they did not take any objective tests, and they negotiated their final grades on the final essay-type tests with their young tutors who were specially trained for the project.

Method

            The participants consisted of 107 medical students out of the total applicants (219) to the medical school in September 2002 who had been able to successfully cover all their courses for the basic science section of the medical curriculum in five semesters. In March 2005, they sat for the National Comprehensive Examination of Basic Sciences— a local nation-wide exam administered by the Ministry of Health as a prerequisite for the next stage on Iranian medical curriculum. The initial performance of the participants on a screening English proficiency test administered in September 2002 clearly demonstrated that they had to start their English program at three different levels of P1 (a beginner's level of English), P2 (an elementary level), and I+ (a pre-intermediate level of English knowledge or above).  This test is a 34-item reading comprehension test measuring the students’ ability to read English texts as short as 10 words up to simple passages comprising 150 words. Since 1995 it has been successfully administered to applicants to place them in rather homogeneous learning groups for their English courses (Mean= 25.48; Range= 2-34; SD= 6.83; r = 0.93).

            Furthermore, these 107 students belonged to two different groups on the basis of their English syllabus. Group I (N = 49) had received a student-centered English program. The university language center was instructed to provide these students with any services they demanded to the best of its ability but was not allowed to monitor them in any way lest it might cause unnecessary stress! Their teaching-learning materials consisted of clippings and extracts from different books or internet duplicated at the language center and distributed as handouts for each session. Games and computer instructions on preparing PowerPoint slides for English lectures were two significant activities throughout a period of two and half years. The teaching texts were general English in the first phase, but later texts on medical topics aiming at public reader (general English with a medical veneer) were also offered.

            Group II (N = 58), never the less, had followed the established university English syllabus, Reading and thinking in English Series, Book I and Book II,  by John Moore et al. (1986) published by Oxford University Press for the beginners and elementary levels complemented by some extracts from Interactions I by Elaine Kirn and Pamela Hartmann (2002) published by McGrawHill. Some exercises on English sounds and stress patterns produced at TUMS Language Center, and A.A. Hill’s (1980) Steps to Understanding Passages were also presented later. |

            As for the I+ level students, Reading and Thinking in English, Book III by Moore et al. (1986), and Interactions II by Elaine Kirn and Pamela Hartmann (2002) for general English courses, and Medical English by James Vaughan (1989)  for EMP Course I, and Medical English by Tahririan (1997) for EMP Course II were used.

            The performances of both groups of students on two tests (a) the English subtest of the National Comprehensive Examination for Medical students (NCME) and (b) the early screening English proficiency test administered at the time of their admission was then matched to explore the differences.

Results and Discussion

            Table 1 below shows the number of students who were divided into beginners-elementary and intermediate or higher proficiency levels in the two groups. In Group II, there were two levels: Beginners/lower-elementary level consisted of 22 students with a mean of 21.04 on the screening test, being placed at the beginner's level, and pre-intermediate and intermediate students consisted of 36 students with a mean of 30.36.
            In Group I, 26 students with a significantly higher mean of 24.50 were placed at the elementary level of English and 22 students at the intermediate level with a mean of 30.32.

It should be noted here that the results for one student who was transferred from the Elementary to the Intermediate level merely on the student's request were not included in the data pool as the poor performance of this student was primarily the result of violations of the screening test results not the syllabus and its inclusion could thus confound the results of this experimentation.
            Figure 1 below compares the performance of students in the two groups on the English subtest of the National Comprehensive Exam of March 2005 and the screening test of September 2002.

Finally, Table 2 below presents the correlation indices at p<.01 level of significance in most cases and p<.05 in the case of Medical English 2 in order to demonstrate the degree of go-togetherness between the results of I+ level students’ performance on the screening test and on the English subtest of the comprehensive exam, and the achievement test scores for Group II on the established course

Figure 1 above clearly indicates that those 26 elementary level students in Group I with a mean of -0.4970 started their studies at a significantly higher level of English proficiency as compared with the lower mean of -1.1893 on the standard score (Z distribution) gained by the 22 beginners in Group II. Yet, their lower Z score of -.6265 on NCME at the end of the fifth semester compared with the higher mean score of -.2508 for Group II is quite revealing. It seems to us that students at the lower end of the proficiency continuum would benefit more from the established curriculum with its regular monitoring and objective evaluation system but would be obviously harmed in a costly, though lenient, student-centered approach employing younger facilitators and/or teachers.

            However, the performance of the two groups at I+ level (an intermediate level of English proficiency) showed no significant differences between the mean scores of 0.67 for the 22 students in Group I and 0.68 for the 36 students in Group II. A difference of 0.2 in the mean scores on English subtest of the National Comprehensive Examination of Basic Science (NCME) also proved insignificant. It appears then that these students, being interested in English language and enjoying a fairly good knowledge of it, seem to be mature enough to take responsibility for their learning and, being so, they might benefit from any English program regardless of how well-structured such programs might be.

            Yet, considering the fact that Group I enjoyed a special budget which could buy the better ones various motivating rewards on different occasions or buy everybody pastry and fruit to be served in class sessions every now and then, and enabled their tutors, who were paid for the extra hours they spent, to bring about a friendly and relaxed atmosphere, and considering the fact that this Group used two well-equipped classrooms especially designed for EFL teaching and had no stress for exams, one might then suggest a study of cost-effectiveness to find out what was gained for the extra budget allocated to Group I. Table I clearly shows that the mean scores for intermediate students in groups I&II on both the standardized screening test (30.32 and 30.36 respectively) and the English subtest of National Comprehensive Examination of Basic Sciences (10.54 and 10.08) were insignificant. While intermediate student in Group I showed no better achievement than their counterparts in Group II, the elementary students in Group I were practically harmed (see Fig.1).

            To us, there also seems to be a misconception about the notion of student-centeredness. The student-centered approach places students, it appears, in the center of the learning process and expects them to be active participants in their learning process both in and out of the classroom. Students set the pace and use their own preferred learning strategies. This means that they are more intrinsically than extrinsically oriented. Learning is more individualized than standardized and students are more open to new ideas. They take responsibility for their own actions and accept related consequences. However, taking responsibility and following this pace, it seems to us, requires some maturity on the side of the students; otherwise, it may drive some of the sociability out of the learning process if care is not taken to emphasize the importance of peers.

            Stevenson and Sander (2002) found that first year medical students somehow rejected the value of student-centered learning methods. Very much in line with this, this study also showed that our novice Iranian English learners at the school of medicine not only failed to make much out of this approach but they were actually harmed. A student-centered approach requires the learner to accept responsibility for their learning, but taking responsibility can be expected from only mature learners. Furthermore, student-centeredness may be in contrast with limited resources available in developing countries and, despite Edwards’ (2001) claim that it reduces “waste in human and educational resources” our study seems to prove the opposite. In addition, as a teaching-learning approach, student-centeredness, as we experienced it here in our context, does not allow program developers to substitute a certain category of student’s self-evaluation for a standardized evaluation system. Neither a formative evaluation system could be substituted for a summative evaluation of achievement or proficiency judgments. In our Iranian version of student-centeredness, Black’s (1999) concern of helping students take responsibility for their own learning through formative assessment, or Knight’s (2002) idea of negotiation aiming at promoting self-learning, self-assessment and self-assessing development needs and learning strengths were seemingly misinterpreted to approximate a state which might be a version of student lawlessness.

            Finally, there is also some concern here for the washback effect of such measures which could be equally damaging to the students, teachers and, in the long run, to the whole educational system., That is to say, the mean scores for the students on the English courses which were based on essay type questions and teacher-students negotiations ranged from 16.84 to 19.04 (out of 20), whereas the average mean scores for the students on the established course ranged from 11.7 to 13.03. This apparently shows that students in Group I have highly overestimated themselves. While this internal evaluation shows a rise of more than 25% in the abilities of Group I over Group II, external evaluations; i.e., the screening and the NCME results proved the reverse.

In order to get some idea about the subjective evaluation system practiced by the tutors in Group I in comparison with the standardized objective tests for the established course, correlations were calculated between final scores on the three English courses which the students at this level had passed, namely, general English, Medical English I and Medical English II with the students’ performance on the standardized screening test of September 2002 on the one hand, and the English test presented to them by the Ministry of Health in March 2005 on the other. While the mean scores for the I+ level in the student-centered group ranged from 17.1 to 18.68 on a scale of 20, and that of their counterparts on the established syllable ranged from 12 to 13.71, we found significant correlations between both the screening test and NCME results at p<.01 for general English and Medical English I and at p<.05 for Medical English II for the latter group. The absence of significant correlations between the students’ final course scores and their scores on either the screening test or the NCME run by the Ministry of Health for the former (see Table 2 above) may manifest the unreasonable subjectivity of evaluation on this project. This may also indicate that the established syllabus made use of a solid evaluation system distinct from the subjective evaluation for Group I.

            However, considering the importance of Grade Point Average for the students of medicine and the way it affects their future lives, the washback effect of an unreliable evaluation system would leave certain issues about such experimentations at stake. Therefore, it should be pointed out here that what student-centeredness may present to the field of evaluation is a more active part on the student’s side, in order not to do the evaluation, but to accept responsibility for providing the evaluator(s) with more detailed and comprehensive evidence to enhance precision in evaluation. Portfolio is, therefore, a good example. While experts on evaluation of students’ performance emphasize that evaluation should be carefully done by adopting multiple-sources of information which leads to positive wash-back effect (see Brown and Hudson, 1998) there is no room for such misconceptions that objective tests cause stress, therefore, they are not good tools for measuring student’s achievement. Such pretexts led to the rejection of objective tests and substitution of subjective essay-type exams and student-teacher negotiation (read bargaining) for course final scores. The proponents of such ideas forget that tension and stress are integral parts of any education and evaluation system. In fact, the brilliant performance of elementary students in Group II on the English subtest of NCME, who were evaluated by standardized objective tests with a low range of scores and high risks of failure which would practically lead to repeating the course, and suffering its consequences, compared with the poor performance of their counterparts on the student-centered group, who were assured there would be no failure and all were rated ‘good’ on their course final essay-type exams may lead us to claim that tension caused by objective tests in a well-developed evaluation system is a kind of stress which may be called eustress which can contribute to further learning and should be differentiated from tension that distresses the learners; a claim obviously calling for further research.

Concluding remarks

Black, P. (1999). Assessment, learning theories and testing systems. In P. Murphy (ed.), Learners, learning and assessment. London: Open University Press, (pp. 118 -134).

Bliss C. (2006).  Integrating meaning and purpose: The student-centered college classroom. Journal of College and Character, Vol.7, No.1.

Brown J. D. and Hudson T. (1998). The alternatives in language assessment. TESOL Quarterly, 32(4). 653-673.

Burnard, P. (1999). Carol Rogers and postmodernism: Challenges in nursing and health services. Nursing and Health Sciences, 1, 241-247.

Calder, J. (2000). Beauty lies in the eye of the beholder. International Review of Research in Open and Distance Learning, 1, 1.

Deihl, J. D. (1916). Individual differences and note-book work in modern foreign languages. The Modern Language Journal, 1, 52-59.

Dewey, J. (1916). Democracy and education: An introduction to philosophy of education. New York: Free Press.

Edwards R. (2001). Meeting individual learner needs: Power, subject, subjection. In C. Paechter, M. Preedy, D. Scott and J. Soler (eds.), Knowledge, power, and learning.  London: Sage Publications.

Hill, A.A. (1980). Steps to understanding. Oxford: Oxford University Press.

Ioannidis J. P. A. (2005). Contradicted and initially stronger effects in highly cited clinical research. JAMA, 294, 218-228.

Kirn, E. and Hartmann, P. (2002). Interactions I. U.S.: McGraw-Hill/Contemporary.
 
Kirn, E. and Hartmann, P. (2002). Interactions II. U.S.: McGraw-Hill/Contemporary.

Knight, P. (2002). Learning contracts in assessment for learning in higher education. Birmingham: SEDA series.

Kunihiku M, Nobutaro B, Shunichi F, Takuro S, Hiroshi K, Seigo N, Naoki N, Toshio F,  and Tsuguya F. (2004). Poor English skills as a barrier for Japanese health care professionals in learning and practicing EBM. Medical Education, 38, 1204.

Lavatelli, C. (1973). Piaget's theory applied to an early childhood curriculum. Boston: American Science and Engineering, Inc.

Lea S. J. D., Stephenson D., and Troy J. (2003). Higher education students’ attitudes to student-centered learning: Beyond ‘educational bulimia’. Studies in Higher Education, 28(3), 321-334.

Logan, G. E. (1973). Individualized foreign language learning: An organic process. Rowley: Newburry House Publishers.

McComb, B. L. and Whisler, J. S. (1997). The learner-centered classroom and school. SanFrancisco: Jossey-Bass.

McCombs B. (2001). What do we know about learners and learning? The learner-centered framework: Bringing the educational system into balance. Educational Horizons.

Melander ER. (2002). The meaning of “student-centered” advising: Challenges to the advising learning community. The Mentor, Nov. 27, 2002,WWW.psu.edu/edu/dus/mentor/.

Moffett, J and Wagner, BJ. (1992). Student-centered language arts, K-12. Portsmouth, NH: Boyonton/Cook Publishers Heinemann.

Moore, J., D. B. de Salgado, L. F. de Knight, A. E. de Tamayo, & T. Mune´var (1986). Reading and thinking in English II. Oxford: Oxford University Press.

Moore, J., D. B. de Salgado, L. F. de Knight, A. E. de Tamayo, & T. Mune´var (1986). Reading and thinking in English III. Oxford: Oxford University Press.

Moore, J., D. B. de Salgado, L. F. de Knight, A. E. de Tamayo, & T. Mune´var (1986). Reading and thinking in English IV. Oxford: Oxford University Press.
        
Race, P. (1995). The open learning handbook: Promoting quality in designing and delivering flexible learning. 2nd edition. London: Kogan Page.

Stevenson K and Sander P. (2002). Medical students are from Mars- business and psychology students are from Venus- University teachers are from Pluto? Medical Teacher, 24(1), 27-31.

Tahririan, M. H. (1997). English for the students of medicine III, Tehran: SAMT (the Center for Studying and Compiling University Textbooks in Humanities).

Whipple, G. M. (1925). Adapting the schools to individual differences. 24th  yearbook [Part II], National Society for the study of education. Bloomington, Ill.: Public School Publishing Committee.