Web Based

Article
Learning and Cognitive Styles in Web-Based Learning: Theory, Evidence, and Application
David A. Cook, MD
Abstract
Cognitive and learning styles (CLS) have long been investigated as a basis to adapt instruction and enhance learning. Web-based learning (WBL) can reach large, heterogenous audiences, and adaptation to CLS may increase its effectiveness. Adaptation is only useful if some learners (with a defined trait) do better with one method and other learners (with a complementary trait) do better with another method (aptitudetreatment interaction). A comprehensive search of health professions education literature found 12 articles on CLS in computer-assisted learning and WBL. Because so few reports were found, research from nonmedical education was also included. Among all the reports, four CLS predominated. Each CLS construct was used to predict relationships between CLS and WBL. Evidence was then reviewed to support or refute these predictions. The wholistanalytic construct shows consistent aptitudetreatment interactions consonant with predictions (wholists need structure, a broad-beforedeep approach, and social interaction, while analytics need less structure and a deep-before-broad approach). Limited evidence for the activereflective construct suggests aptitudetreatment interaction, with active learners doing better with interactive learning and reflective learners doing better with methods to promote reflection. As predicted, no consistent interaction between the concrete abstract construct and computer format was found, but one study suggests that there is interaction with instructional method. Contrary to predictions, no interaction was found for the verbal imager construct. Teachers developing WBL activities should consider assessing and adapting to accommodate learners defined by the wholistanalytic and activereflective constructs. Other adaptations should be considered experimental. Further WBL research could clarify the feasibility and effectiveness of assessing and adapting to CLS.
Acad Med. 2005; 80:266 278.
Cognitive and learning styles (CLS)
have been a topic of research and discussion in medical education for decades. Uses either suggested or demonstrated of these learner characteristics have dealt with nearly every aspect of the education process.1 With the development and implementation of innovative educational technologies, assessment and use of CLS may find new and even more important roles. Web-based (WB) learning makes adaptation to the individual learner more feasible than in the past, and research in this field may be more productive than prior research in CLS. In fact, adapting WB environments to specific CLSreplicating the actions of an effective teacher who adapts instruction to meet the needs of individual learners in face-to-face (FTF) teachingmay be necessary to maximize the benefit from WB learning.2 Such adaptation is particularly important given the large and often
heterogenous body of learners a WB course may reach.3 In considering adaptations based on CLS, the concept of aptitudetreatment interaction4 is critical. An interaction occurs when a learner attribute predicts a different outcome depending on the teaching method. For example, interaction is present if group 1 (with attribute 1) learns better with method A than method B, while group 2 learns better with method B than method A. Adapting the method so that group 1 gets method A and group 2 receives method B would enhance learning. If the teaching method improves performance without interaction (e.g., both groups do better with method B), this implies that all learners (regardless of attribute) will benefit, and adaptation is thus unnecessary. In this review, I discuss the theory and evidence underlying potential applications of CLS to WB learning, with a focus on aptitudetreatment interactions. For each CLS, I will predict relationships to WB learning based on the theory or definition of the construct or dimension (I have used these terms interchangeably), examine the literature for evidence to support or refute these predictions, and
summarize the theory and evidence to propose applications of CLS to WB learning.
Definitions
Dr. Cook is assistant professor of medicine, Mayo Clinic College of Medicine, Rochester, Minnesota. Correspondence should be addressed to Dr. Cook, Baldwin 4-A, Division of General Internal Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, e-mail: cook.david33@mayo.edu.
Web-based learning WB learning is a subset of computerassisted learning (CAL), in which instruction is accomplished primarily or solely using the Internet or a local intranet using hypertext-based information.5,6 Although it has much in common with other CAL modalities, WB learning is unique in at least three respects. First, it allows near-instantaneous communication and access to resources between distant sites. Second, the information constituting the course itself resides in a central location, which facilitates content updates and course modifications. Third, the programs are relatively technologyindependent, and will usually function and have a similar appearance regardless of the local computer configuration. Other features commonly found in WB learning, such as hypertext links and multimedia, are also found in other forms of CAL. Because of these common features, many studies of non-WB CAL are relevant to the present discussion.
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Article
Although WB learning is often discussed as a unitary construct,79 this is not the case. The common thread in WB learning is the use of hypertext and the Internet, but this leaves room for wide variation in configuration, instructional method, and presentation. Indeed, these details often form the basis of proposed adaptations. Many reports fail to adequately describe these distinctions (as Tables 1 and 2 illustrate), even though this information is essential for interpretation and application of research. WB learning environments can be divided broadly into discussion-based and Web-page-based configurations. Discussion-based learning parallels the configuration of a small-group learning session. Learners communicate with each other while the instructor provides guidance, learning activities, and resources as appropriate. Compared to FTF groups, WB interactions are different:10,11 discussion is often asynchronous (with lapses in time between communications), and although it is a group process, the learner works alone. Page-based learning parallels the configuration of a lecture, as the learner attends a Web page that delivers content and activities prepared by the instructor. Neither configuration is inherently better or worse than the other. Rather, just as small-group learning and lectures each have a role in FTF teaching, discussion-based and page-based configurations have strengths and weaknesses that make each appropriate in different circumstances. Elements of both configurations are often incorporated into a single course. Instructional method is a critical but often overlooked aspect of WB learning.12,13 Just as in FTF teaching, WB instructional methods (e.g., case-based learning, self-assessment questions, group projects, simulation) play an important role in the success of the learning activity.14 Although discussion-based and page-based configurations are methods of instruction, their distinction as a separate level of variation is supported both conceptually (configuration is frequently defined before instructional methods are selected in both WB and FTF instruction) and logistically (discussion-based learning requires different planning than pagebased WB learning).14 The third level of variation is presentation. Nearly all WB environments
(whether page-based or discussionbased) are primarily text, but most employ enhancements such as multimedia (e.g., pictures, sound, or video), interaction between learner and page (hyperlinks to other resources, interactive models and games), or high simulation fidelity. A site consisting only of text will likely have a different effect on learning than a site enhanced by activities and multimedia, and this may be affected by (interact with) CLS. Web site structure and navigation are other important factors in presentation.15 Cognitive and learning styles Curry16 proposed a tripartite model of cognitive and learning style in 1983 that continues to provide structure to these diverse constructs. The first (outer) layer is instructional format preference, an affinity for various modes of information delivery or access17 such as environmental (presence of sound or light) and social (alone or with peers) conditions. These preferences are easily altered and thus relatively unstable. The middle layer is learning styleconscious and intentional strategies that individuals employ to achieve well-defined ends . . . most often observed as individually consistent orientations to learning and studying.17 These attributes are more stable and resistant to outside influence. The inner core is cognitive stylea students pattern of perception, memory, thinking, and judgment.17 These characteristics are stable and may in fact be lifelong attributes, relevant to both learning and nonlearning contexts. In this article, I will be concerned only with the latter (inner) two types of style. Multiple labels have been proposed for constructs of cognitive and learning styles, and many are redundant.1,18,19 I have attempted a reconciliation, outlined in Table 3, that groups constructs with similar definitions under a single label. Once a construct has been defined in this article one label will be consistently used to refer to all constructs represented by that definition regardless of the specific model or instrument.
Literature Review
aided learning, Internet, Web, or online. In ERIC the results were limited to postsecondary education, two-year colleges, and graduate education. Abstracts were reviewed, and articles presenting original data regarding CAL and CLS were selected for further review. Bibliographies were reviewed for additional citations. Unpublished abstracts and dissertations were excluded. The 16 articles involving learners in health professions education are summarized in Table 1. Of these 16, four articles assessing only learning preferences or qualitative observations were excluded from further discussion, leaving 12 studies of CLS. Because of the small number of studies identified among the health professions, the search was extended to include other fields of adult education (Table 2). However, the review was not exhaustive beyond health professions education. Four constructs of CLS dominated the studies reviewed, and are described below. For each style, relationships to WB learning were predicted based on the construct definition. Evidence was then sought to support or refute these predictions. Marked heterogeneity of learners, settings, interventions, and research methods precluded pooling of results for meta-analysis.
Findings
The wholistanalytic dimension In 1991, Riding and Cheema18 reviewed the literature on cognitive styles and concluded that most of the numerous labels were redundant. They proposed that all cognitive styles could be unified into two dimensions: the wholist (i.e., wholeist)analytic dimension and the verbal imager dimension. Rayner19 repeated this work and arrived at similar conclusions. The wholistanalytic dimension characterizes the manner in which an individual perceives the worldas a unified whole, or as a collection of individual parts. Because these are patterns of perception and thinking17 each constitutes a cognitive style. When perceiving information, individuals who are wholists will see a balanced view of the whole, while analytics will separate it out into its parts.20 In social situations, the wholist sees the group as a whole, while the analytic sees the group as a collection of individuals. Wholists benefit from structure, guidance, feedback, extrinsic motivation,
Medline and ERIC were searched using the terms learning style, cognitive style, or learning preference, and computer-assisted instruction, computer-aided instruction, computer-assisted learning, computer-
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Table 1
Studies of Cognitive and Learning Styles and Preferences, and of ComputerAssisted and Web-Based Learning, in Health Professions Education
Author and year
Abouserie and Moss, 1992
25
No., type of participants

79 first-year medical students
Study design*
Observational (no control, single time point)
Inventory
GEFT
Educational intervention(s)
CAL (self-study tutorial with questions)
Outcomes
Results
Attitude toward No difference in achievement or attitude CAL; course toward CAL among learners with achievement different cognitive styles. score ................................................................................................................................................................................................................................................................................................................... Billings and Cobb, 199276 22 undergraduate nursing Observational (no PEPS CAL (multimedia Post-test (ten items); No correlation between learning students control, single time interactive videodisc) attitude toward preference and achievement. Correlation point) CAL77 (r 0.44) between comfort with computers and achievement. ................................................................................................................................................................................................................................................................................................................... Brudenell and Carpenter, 40 undergraduate nursing Pre-experimental (no LSI CAL (details not reported) Attitude toward All learners had more negative attitudes 199058 students control; pre/post CAL77 toward CAL after the CAL intervention attitudes) than before. Attitudes of abstractreflective learners were more negative than those of others. ................................................................................................................................................................................................................................................................................................................... DiBartola et al., 200160 56 undergraduate health Pre-experimental LSI Distance WBL (discussionCourse grade Concretereflective learners in the WBL science students (controlled, static based with text lecture) group had higher grades (no statistical groups) vs. face-to-face class test reported) than concretereflective learners in the face-to-face group. It also appeared that concretereflective had higher grades than others in the WBL group. ................................................................................................................................................................................................................................................................................................................... 41 Effken and Doyle, 2001 18 undergraduate nursing Experimental VVQ Visually intensive CAL Performance on CAL Highly visual learners initially had higher students (controlled, simulation (three displays assessment (no. scores on one performance domain randomized of varying degrees of problems solved, (economy) using the most visually crossover) abstraction) time, accuracy, abstract display than less visual learners, economy of therapy) but this difference did not persist. Limited because almost all participants were visual learners. ................................................................................................................................................................................................................................................................................................................... Engleberg et al., 200161 137 second-year medical Pre-experimental (no LSI Combination of CAL (case- Pre/post rating of Prior to the course, most concrete students control; pre/post based and interactive), enthusiasm learners favored small-group learning and assessment of small group, lecture, and for/usefulness of CAL, while reflective learners favored attitudes) textbook each learning lecture. At the end of the course the modality differential preferences for CAL and lecture were no longer present, and the preference for small-group learning had decreased. ................................................................................................................................................................................................................................................................................................................... Fleming et al., 200364 33 dental hygiene students Experimental LSI WBL (page-based, text and Post-test score (test No significant difference between (controlled, images) vs. conventional items varied learning styles. randomized slides between formats), crossover) format preference ................................................................................................................................................................................................................................................................................................................... Kirchhoff et al., 197956 100 undergraduate nursing Pre-experimental (no LSI CAL (highly interactive text Pre/post-test (two In multivariate regression, high active and students control; pre/post and graphics) tests, 15 items each, high abstract scores predicted higher test achievement) alternated as pre scores. and post-test) ................................................................................................................................................................................................................................................................................................................... Lehmann et al., 199978 Approximately 120 medical Pre-experimental Naturalistic CAL (histology atlas) vs. Ethnographer Qualitative differences: The most students (controlled, static observation microscope (two-by-two observations interactive learning pattern was between groups) factorial) two students using CAL and a microscope. The most passive pattern was a single learner with CAL. Overall, CAL was more passive than microscope. ................................................................................................................................................................................................................................................................................................................... Lieberman et al., 200279 58 medical students (third Experimental PLSI CAL (highly interactive text Post-test The face-to-face group had slightly and fourth year) and (controlled, and graphics) vs. face-tohigher test scores. Learning preference physicians in postgraduate randomized face (discovery vs. receptive) had no training crossover) effect. ................................................................................................................................................................................................................................................................................................................... Lowdermilk et al., 199159 64 undergraduate nursing Experimental (noLSI CAL simulations (details Score on CAL No significant difference between students intervention control, not reported) vs. no simulation learning styles. randomized) intervention ................................................................................................................................................................................................................................................................................................................... Lynch et al., 200162 180 third-year medical Pre-experimental (no LPI CAL (interactive text and Pre, post, and sixNo correlation between learning style students control; pre/post graphics) month follow-up and test scores or attitudes toward CAL. achievement) post-test (seven items); attitude toward computers and CAL (Table continues)
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Article
Table 1
(Continued)
Author and year
Miller, 199880

23 undergraduate allied health students
Study design*
Quasi-experimental (controlled, crossover)
Inventory
PEPS
Lecture vs. programmed learning (PLS) CAL vs. PLS paper
Outcomes
Post-test; format preference
Results
Among learners preferring the paper PLS, those preferring a quiet environment did better. Among learners preferring face-to-face and CAL, those preferring more light did better. ................................................................................................................................................................................................................................................................................................................... Steele et al., 200263 151 third-year Observational (no LPI CAL (see Lynch 2001) Attitude toward See results of Lynch et al., 2001.62 medical students control, single time computers and CAL; point) interview ................................................................................................................................................................................................................................................................................................................... Thompson, 198757 18 physical therapist Experimental LSI CAL (details not reported) Pre, post, and six-week No significant correlation between assistant students (controlled, vs. paper follow-up post-test learning style and attitude toward CAL randomized) (seven items); attitude or test scores. toward computers and CAL ................................................................................................................................................................................................................................................................................................................... Yoder, 199470 58 undergraduate Experimental Modified LSI Interactive vs. linear Post-test Reflective learners did better with nursing students (controlled, (noninteractive) CAL noninteractive CAL, while active randomized) learners did better with interactive CAL.
* Study design uses terminology defined by Bland et al.81 GEFT, Group Embedded Figures Test82, PEPS, Dunn, Dunn, and Price Productivity Environment Preference Survey83, LSI, Kolb Learning Style Inventory (multiple versions)47; LPI, Rezler Learning Preference Inventory53; PLSI, Stone Preferred Learning Style Index79; VVQ, Verbal-Visualizer Questionnaire.40 CAL, computer-assisted learning (non Web-based; CAL is page-based unless otherwise noted); WBL, Web-based learning. Does not assess a cognitive or learning style, and thus not discussed in Findings.
and social activity in their learning,2,21 while analytics need less of each of these. This construct subsumes most of the previously defined cognitive styles18,19,22 including field dependence/independence, impulsive/reflective, leveler/sharpener, diverger/converger, and holist/serialist. Some authors have argued that field independence is an ability (i.e., more field independence is better) rather than a style,19 but this argument has not been specifically extended to the wholistanalytic construct. Nonetheless, wholist analytic appears to be the only construct for which suggestions to improve learning consistently involve mismatching (e.g., providing structure for wholists) rather than matching (e.g., using images for visual learners). As part of their Index of Learning Styles,23 Felder and Silverman24 proposed
*Discussing a learning style along with a cognitive style may seem inappropriate. Extrapolating the learning style (a more narrowly defined and less stable construct) to make inferences about the cognitive style (which is more stable and holds implications for both learning and nonlearning contexts) is certainly inappropriate. However, in a specific learning setting a learners cognitive style will likely have effects similar to an analogous learning style. Thus, when a cognitive style and learning style have congruent definitions, and both are applied to a learning context, I will discuss the two as a single construct.
the sequential global dimension of learning style (defined in terms of orientation to learning) that shares many features with the wholist-analytic dimension.* Sequential learners follow a linear (analytic) process, while global learners learn in fits and starts . . . until suddenly they get it. 24 WB learning environments often lack a clear structure especially those using extensive hyperlinksand require internal motivation. In addition, page-based learning can be socially isolating. In these contexts, analytics (who can provide their own structure and require less external motivation and social support) should have an advantage over wholists. In settings with explicit guidance or structure, external motivation, and social interaction, wholists have the advantage.21 The social nature of discussion-based WB learning should initially favor the wholist, but as discussion threads become long and complex the analytic (who can extract salient themes from the milieu) would be favored. The only study25 in health professions education to assess the styles defined by the wholistanalytic dimension in connection with WB learning or CAL found
no influence of style on achievement or attitude toward CAL tutorials. There are, however, many studies in other fields. Research evaluating instructional methods has found interaction between wholistanalytic styles and depth of studying, use of overviews, and structuring of information. Analytics studied material in greater depth than wholists,26,27 while wholists used an overview more often than analytics did.27 Wholists did better in a page-based WB environment that provided a broad overview before pursuing topics in detail, while analytics did better when exploring in detail first.28 Another study showed a similar trend,29 but a third study30 failed to confirm this. Wholists showed a trend toward improved performance when using a tool that made information structure explicit, while analytics did better when information was less structured31; however, another study found no interaction between style and a tool to facilitate structuring of knowledge.32 An adaptive WB system33 targeting all of these strategies at once was more effective than the control WB intervention. Contrary to my predictions, a structured, independentlearning CD-ROM favored analytics and an unstructured WB format with group discussion board favored wholists,34 but differences in motivation
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Article
Table 2
Selected Studies of Cognitive and Learning Styles, and of Computer-Assisted and Web-Based Learning, in Non-Health Professions Education
Author and year
Aragon et al., 2000
84

38 postgraduate students
Study design*
Pre-experimental (controlled, static groups)
Inventory
LSI
WBL (details not reported) and face-to-face courses
Outcomes
Combination of performance indicators on class assignments
Results
Face-to-face learners showed stronger reflective and abstract traits while WB learners showed more active traits. There was no significant correlation between performance and learning style for the WBL group. Abstract learners in the faceto-face group did worse than others. ................................................................................................................................................................................................................................................................................................................... Bostrum et al., 199065 Total of 229 participants: Four studies reported. LSI CAL (part of a group Post-test (all); no. In general, abstract learners did better undergraduate students in Studies 13: workshop); studies 13 tasks completed than concrete learners. For study 3 (the studies 1 and 3, full-time experimental compared abstract and (studies 1, 3, 4); largest), abstract learners did better when employees in studies 2 (controlled, concrete methods; study 4 time to complete using the abstract method, and concrete and 4 randomized) compared application to task (studies 1, 2) learners did better with the concrete Study 4: prejob-related problems and method. In study 1, there was a experimental generic problems nonsignificant trend suggesting (controlled, static interaction with the activereflective groups) dimension, with active learners doing better when using the abstract method and reflective learners doing better with the concrete method. ................................................................................................................................................................................................................................................................................................................... 69 Clariana, 1997 Total of 94 participants: Three studies, all LSI CAL (details not reported) Post-test used to Compared to preintervention LSI scores, secondary education observational (no stratify learning style there was a shift from abstract to students in study 1, adult control; pre/post analysis concrete and reflective to active remedial education students learning style following the CAL intervention. Those in study 2, undergraduate assessment) with higher test scores showed greater students in study 3 shift in learning style. ................................................................................................................................................................................................................................................................................................................... Cunningham-Atkins, et al., 118 undergraduate students Observational (no CSA WBL (discussion-based) No. messages No overall difference in participation 200445 control, single time written; course (number of postings), but among those point) completion who completed the course imagers had higher participation than verbalizers. Verbalizers dropped out more than Imagers. ................................................................................................................................................................................................................................................................................................................... Ford and Chen, 200027 65 postgraduate students Pre-experimental (no CSA WBL (page-based, Pre/post-test (20 Cognitive style did not affect score control; pre/post hypertext and images) items); navigation change (pre- to post-test) but compared achievement) pattern; time to analytics, wholists used a map overview more often, used the index and back/forward buttons less often, spent less time studying deeper material, and used a random approach (confirming the hypothesis). ................................................................................................................................................................................................................................................................................................................... Ford and Chen, 200128 73 postgraduate students Quasi-experimental CSA WBL (page-based, Pre/post-test (20 Matched (analytic: deep learning then (controlled; pre/post hypertext) matched vs. items) broad; wholist: broad then deep) learners achievement) mismatched to cognitive had higher post-test scores than style mismatched. However, when stratified by gender, the influence of cognitive style was only significant for men. ................................................................................................................................................................................................................................................................................................................... 85 Ghinea and Chen, 2003 132 undergraduate students Experimental CSA 12 WBL video clips (varied Post-test; format Wholists preferred and did better with (controlled, in multimedia preference video clips in which audiovisual randomized content/format and quality) information predominated, while crossover) analytics preferred and did better with clips with high textual information. Both groups did worse with highly dynamic clips, but wholists did relatively worse than analytics. ................................................................................................................................................................................................................................................................................................................... Graff, 200330 50 undergraduate students Experimental CSA WBL (page-based, Post-test (short Analytics using the long page had higher (controlled, hypertext; two-by-two answer and essay) essay scores than analytics using the randomized) factorial: short vs. long short page, and vice versa for wholists Web page and overview vs. (confirming the hypothesis). Verbalizers none) essay scores were higher than imagers. Imagers using the short page had higher short-answer scores than verbalists using the short page (partially confirming the hypothesis). The overview did not affect scores. (Table continues)
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Article
Table 2
(Continued)
Author and year
Graff, 200311

50 undergraduate students
Study design*
Educational Inventory intervention(s)
Outcomes
Results
Observational (no CSA WB tasks (search, Post-test No significant relationship between control, single time discussion, and quiz) (combination of cognitive style and test score for any of point) assessments) the interventions. ................................................................................................................................................................................................................................................................................................................... Hart, 199566 100 undergraduate students Observational (no LSI WBL (page-based, Attitude toward No relationship between learning style control, single time hypertext) specific elements of and attitudes or preferences. point) CAL ................................................................................................................................................................................................................................................................................................................... Hsu et al., 199432 40 undergraduate students Experimental GEFT CAL (hypermedia; Short essay graded Analytics had higher recall scores. (controlled, questions to guide learning for critical events Analytics and those who did not receive randomized) vs. no questions) (recall) and cognitive the guidance questions had higher complexity; cognitive complexity scores, but there navigation pattern was no interaction. ................................................................................................................................................................................................................................................................................................................... John and Boucouvalas, 50 undergraduate students Experimental CSA CAL (five hypermedia Efficiency (post-test Of 20 comparisons, the only significant (p 200144 and university staff (controlled, variations: audio vs. video score divided by .02) finding was that verbalizers did randomized vs text vs. image vs. text time to answer) better with audioverbalizer tasks than crossover) image, each with four imagers. Matching and mismatching tasks targeting a different cognitive style otherwise had no effect. cognitive style) ................................................................................................................................................................................................................................................................................................................... Jonassen and Wang, 199331 112 undergraduate students Quasi-experimental GEFT CALThree levels of Post-test (content Trend (p .07) toward interaction on (controlled semantic structuring: no recall and recall scores, with higher scores for experiment, groups explicit structuring vs. conceptual analytics than wholists when information systematically explicit pop-up window interrelationships) was unstructured (no structure or assigned) vs. generative pop-up generative) but worse when information was structured (explicit). Analytics remembered the semantic structure better than wholists. ................................................................................................................................................................................................................................................................................................................... Jordanov, 200172 139 undergraduate students Pre-experimental (no LSI WBL (online repository and LSI adapted to assess Learning style at the end of the course control; pre/post discussion board; part of learning style during was no different than learning style at learning style face-to-face course) WBL activities the start. The adapted LSI scores showed assessment) (midway through a shift toward active for WBL activities the course) relative to the standard LSI, but no change for abstractconcrete. ................................................................................................................................................................................................................................................................................................................... Kini, 199443 192 undergraduate students Pre-experimental GEFT, VVQ CAL (text vs. text Post-test (21 items) No interaction between cognitive style (controlled animation) and test score. experiment, method of group assignment not stated) ................................................................................................................................................................................................................................................................................................................... Liegle and Janicki, 200171 58 undergraduate students Observational (no LSI WBL (page-based hypertext Post-test; navigation Trends (p .1): active learners used control, single time with narrative, pattern more hyperlinks than reflective learners. point) demonstration, and Active learners who used hyperlinks had learning activity) higher scores than those who did not, while reflective learners who used hyperlinks had lower scores than those who did not. Did not report on abstract concrete styles. ................................................................................................................................................................................................................................................................................................................... Liu and Reed, 199426 63 undergraduate students Observational (no GEFT CAL (video with hyperlinks) Frequency of use; Wholists used the CAL intervention more control, single time use of specific CAL often than analytics and used more video point) elements options, while analytics accessed detailed information and used hyperlinks and the index more often. ................................................................................................................................................................................................................................................................................................................... Melara, 199668 40 undergraduate students Experimental LSI CAL (hypertext: hierarchical Post-test (ten items); Neither learning style nor hypertext (controlled, vs network structure) time structure affected test score, but the randomized) learners using the network structure spent less time. ................................................................................................................................................................................................................................................................................................................... Montgomery, 199542 143 undergraduate students Observational (no ILS CAL (multimedia) Perceived Active learners liked movies and a control, single time effectiveness cartoon figure that guided learning. point) Concrete learners liked demonstrations. Imagers liked movies. ................................................................................................................................................................................................................................................................................................................... Packard et al., 199786 102 postgraduate students Etiologic HPT CAL (text only vs. text Post-test Aptitudetreatment interaction present observational static image vs. text for text format and the wholistanalytic (controlled, groups animation) dimension (details of results and analysis systematically not reported). assigned) (Table continues)
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Article
Table 2
(Continued )
Author and year
Parkinson and Redmond, 200235

47 undergraduate students
Study design*
Experimental (controlled, randomized)
Educational Inventory intervention(s)

GEFT, CSA
Outcomes
Results
Text vs. CD-ROM Post-test Analytics had higher test scores than (intermediate hyperlinks/ wholists overall and for the text and WBL multimedia) vs. WBL (pageformats. Verbalizers using the WBL based, many hyperlinks/ format had higher scores than imagers, multimedia; also had extra while imagers using the CD-ROM had information) higher scores than verbalizers. ................................................................................................................................................................................................................................................................................................................... Pillay, 199829 134 undergraduate students Etiologic CSA Face-to-face lecture Post-test Format differences included advance observational followed by CAL (four organizer vs. none, text vs. diagram, and (controlled, group formats targeting each paragraphs vs. bulleted text. Trend (NS) assignment based on cognitive style) toward higher test scores and less time cognitive style) learning when learners cognitive styles matched the CAL design than when mismatched. Wholistverbalizers did significantly better than all other groups. ................................................................................................................................................................................................................................................................................................................... Reed et al., 200037 18 postgraduate students Observational (no GEFT, LSI CAL (hypertext and Navigation pattern; Wholists followed more links (both control, single time multimedia) time linearfollowing the intended path point) and nonlinear) and spent more time on task than analytics. No difference for LSI styles. ................................................................................................................................................................................................................................................................................................................... Rourke and Lysynchuck, 40 undergraduate students Quasi-experimental LSI WBL (page-based; Immediate and one- For WBL format, concrete-reflective 200067 (controlled, crossover) complex, abstract week follow-up learners had the highest test scores and hypertext) vs. paper (screen post-test (different concreteactive the lowest. For the paper snapshot of WBL) tests, 40 items each) format, abstractactive learners had the highest scores and concreteactive the lowest. ................................................................................................................................................................................................................................................................................................................... 87 Shih and Gamon, 2001 74 undergraduate students Observational (no GEFT WBL distance learning Course grade; No correlation between cognitive style control, single time (details not specified) motivation; attitude and outcomes. point) toward WBL ................................................................................................................................................................................................................................................................................................................... Shih and Gamon, 200288 74 undergraduate students Observational (no GEFT WBL (see Shih 2001) Course grade; No correlation between cognitive style control, single time learning preferences and outcomes. point) ................................................................................................................................................................................................................................................................................................................... Summerville, 199936 177 undergraduate students Experimental GEFT CAL (hypertext); two-byPost-test Matched (analytics: unstructured; (controlled, two factorial: matched vs. wholists: structured) and unmatched randomized) mismatched to cognitive learners had similar grades. Learner style and aware vs. awareness of cognitive style prior to unaware of cognitive style intervention did not affect grade. However, mismatched learners aware of their cognitive style were more frustrated with the learning environment. ................................................................................................................................................................................................................................................................................................................... Triantafillou et al., 200433 66 undergraduate students Pre-experimental GEFT WBL (page-based, Pre/post-test (ten Learners using the adaptive system had (controlled, selfhypertext; system adapting short-answer items); significantly higher post-test scores, selected groups, to cognitive style vs. satisfaction regardless of cognitive style, than those pre/post traditional WB) using the traditional WBL method. achievement) Wholists and analytics had similar posttest scores overall, but wholists using the adaptive system had greater learning gains (pre- to post-test) than wholists using the traditional method or analytics. ................................................................................................................................................................................................................................................................................................................... Workman, 200434 174 undergraduate students Pre-experimental STSI CAL (CD-ROM: structured; Post-test; perceived For CAL, analytics had higher test scores (controlled, static animation with selfeffectiveness than wholists while activereflective group) assessment questions) vs. styles made no difference. For WBL WBL (unstructured; format, wholist and active learners had hypertext with group higher test scores than analytic and discussion board) reflective learners. Wholists had higher test scores in the WBL format while analytics had higher scores using CAL. Wholist active learners felt the WBL format was more effective while reflective learners favored CAL.
* Study design uses terminology defined by Bland et al.81 LSI, Kolb Learning Style Inventory (multiple versions)47; CSA, Cognitive Styles Analysis20; GEFT, Group Embedded Figures Test82; VVQ, Verbal-Visualizer Questionnaire40; ILS, Index of Learning Styles23; HPT, Hidden patterns test (source unknown); STSI, Sternberg Thinking Style Inventory.89 CAL, computer-assisted learning (non Web-based; CAL is page-based unless otherwise noted); WBL, Web-based learning. Confirmed through personal communication with author, November 2004.
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Table 3
Parallel Constructs among Several Models and Inventories of Cognitive and Learning Styles* Inventory CSA (cognitive style) WholistAnalytic How learners perceive and process information: as a unified whole (wholist) vs. a collection of parts (analytic) VerbalizerImager How learners process and represent information and focus their attention: words, external focus (verbalizers) vs. pictures, internal focus (imagers) ConcreteAbstract ActiveReflective
...................................................................................................................................................................................................................................................................................................................
GEFT (cognitive style)
...................................................................................................................................................................................................................................................................................................................
Learner frame of reference: external, guided by whole environment (field dependent) vs. internal, able to extract salient clues (field independent) How learners progress to understanding: large jumps, holistically (global) vs. logical, small steps (sequential)
ILS (learning style)
...................................................................................................................................................................................................................................................................................................................
Modality of information learners prefer to perceive: written or spoken words (verbal) vs. pictures and diagrams (visual)
Type of information learners prefer to perceive: facts, data, sights, and sounds (sensing) vs. memories, ideas, and theories (intuitive) Preference for learning tangible, specific tasks (concrete) or learning theories and generating hypotheses (abstract)
How learners prefer to process information: activity and discussion (active) vs. introspection and thinking (reflective)
LPI (learning style)
...................................................................................................................................................................................................................................................................................................................
LSI (learning style)
How learners acquire information: experientially (concrete experience) vs. conceptually (abstract conceptualization) How learners prefer to perceive and process information: facts (sensing) or ideas and possibilities (intuition)
...................................................................................................................................................................................................................................................................................................................
How learners process information: doing (active experimentation) vs. watching and thinking (reflective observation)
MBTI (cognitive style)
...................................................................................................................................................................................................................................................................................................................
How learners direct their energy: words and action (extravert) or thought (introvert)
STSI (learning style)
Boundaries in mental structures: thin, shades of grey (high global) vs. thick, black-and-white (low global) Learners process information sequentially, in words (verbal) vs. parallel, pictorial (visual)
...................................................................................................................................................................................................................................................................................................................
Learner uses external sources, prefers collaboration (low internal) vs. introspective, selfdirected (high internal)
VVQ (cognitive style)
* Note that the parallels drawn here are approximate. Definitions are similar, but in most instances are not precisely the same. Also, the methods used to assess these styles vary widely from instrument to instrument. Labels within cells (in italics) are the terms the constructs author used, while the labels that are the column headings are used throughout this article to refer to these constructs. ILS, Index of Learning Styles23; LSI, Kolb Learning Style Inventory (multiple versions)47; CSA, Cognitive Styles Analysis20; MBTI, Myers-Briggs Type Inventory55; LPI, Rezler Learning Preference Inventory53; GEFT, Group Embedded Figures Test82; VVQ, Verbal-Visualizer Questionnaire40; STSI, Sternberg Thinking Style Inventory.89 Only the constructs from this model/instrument that parallel those of other models are included in this table.
and social interaction between the two formats could account for these observations. Looking at presentation, studies have found differences in navigation patterns, with wholists following a more direct path through the CAL or WB environment,26,27 achieving higher test scores using a broad-before-deep site structure,28 and doing better with short Web pages.30 Furthermore, analytics had
higher test scores than wholists when using a WB environment with many hyperlinks, while there was no difference between styles when using a less complex CD-ROM.35 In contrast, one study36 failed to find significant interaction between style and hypertext structure, and wholists followed more hyperlinks in another study.37 Overall, the evidence appears to support the theory-based predictions. Analytics
perform better in CAL or WB learning environments that are less structured or encourage studying in depth before presenting an overview. Wholists do better in environments that provide structure and a global perspective, and may benefit more from social interaction. The verbalimager dimension Riding and Cheema18 also proposed a verbalimager (verbalvisual) dimension
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of cognitive style. The verbalizer learns best from words (speech and written text), while the imager learns best from pictures, demonstrations, and displays. Imagers are also better at keeping track of their location in space. Riding20 suggests that this construct has social implications, with verbalizers better at communication and imagers more focused on a world internal to the individual. Imagers are also more likely to continue with tasks they find boring while verbalizers require stimulating presentations.38 Felder and Silverman24,39 proposed a similar visualverbal dimension of learning style. Kirby et al.40 described a visual verbal construct as well. Verbal learners should learn better than imagers in most WB learning settings since text is the dominant form of information in both page-based and discussion-based configurations. However, imagers should do better in multimedia-rich environments and in complex WB environments where they will remember their location in cyberspace. Evidence does not support these predictions. The sole study41 in health professions education assessing verbalimager styles failed to find a persistent difference in performance among participants using a visually intensive CAL environment. This study was limited by a skewed population (nearly all the learners were imagers). Some studies in nonhealth professions have supported the predictions made above by showing that imagers prefer images42 and better remember their location in a complex WB learning environment,30 verbalizers do better on essays,30 and wholist verbalizers do better overall in CAL.29 However, several studies have failed to demonstrate significant findings,11,43,44 and others report counterintuitive results. For example, one study35 found that verbalizers performed better using a multimedia-rich WB environment than using a CD-ROM that had less multimedia, while imagers did better using the less-visual CD-ROM. Another study45 found that imagers posted more messages to a WB discussion board than verbalizers did, and that fewer verbalizers completed the discussion-based course. The evidence is mixedshowing supportive, neutral, and counterintuitive results. Although this issue merits further study, it is possible that the verbalim-
ager dimension does not play a significant role in WB learning and CAL. The concreteabstract dimension Kolb proposed an experiential learning theory in which knowledge is created through the transformation of experience.46 In this model, information must first be grasped, or acquired, and then transformed, or processed. Learners continually choose how they will acquire new information (concretely, through the senses, or abstractly, by analyzing) and transform it (reflectively, by watching and thinking, or actively, by doing). The preferred choice along each of these two dimensions (acquisition and transformation) constitutes a style (for example, a learner may prefer abstract acquisition and reflective processing). Because these styles are defined in terms of individually consistent orientations to learning,17 they are learning styles. Kolb47 developed the Learning Style Inventory to assess these styles. Although Kolbs model and inventory have been criticized,48 50 others have defended them.51 The model and inventory continue to be generally accepted, and the Learning Style Inventory is one of the most widely used measures of CLS.52 The first dimensioninformation acquisition has the poles of abstract conceptualization and concrete experience. The concrete learner learns best from specific examples or experiences, and relates well to other people.47 The abstract learner prefers a conceptual, analytical, systematic approach to learning, and works better with theories and ideas. Rezler53 defined a parallel dimension in the Learning Preference Inventory. Jung54 defined a similar construct in terms of psychological types (patterns of perception,. . . thinking, and judgment,17 and thus cognitive styles according to Curry): the sensingintuitive dimension, assessed by the Myers-Briggs Type Indicator.55 Sensors prefer what is real (facts, data, and experimentation), while intuitors look for patterns and meaning (principles and theories). Felder and Silverman24 proposed a parallel dimension of learning style. In their definition, they note that Intuitors are more comfortable with symbols. Since words are symbols, translating them into what they represent comes naturally to intuitors and is a struggle for sensors.24 Thus, there may be some overlap of this
definition with the verbal-imager construct above. Differences in instructional method should show interaction with concrete abstract styles. For example, case-based learning or interactive demonstrations would favor concrete learners, while using data to introduce a principle or basic mechanisms to explain a disease would favor abstract learners. On the other hand, it seems unlikely that WB configuration or presentation will interact with concreteabstract styles. Concrete learners may do better with the interpersonal interactions of discussion-based learning, but this would be offset by the extensive use of words (abstract symbols). One possible exception is that concrete learners may do better in a multimedia-rich environment, in which the media represent vicarious experiences. When comparing WB to noncomputer interventions, the impact of the concreteabstract dimension is hard to predict, as effects would likely depend more on variation in instructional method than on properties of the media formats. Of nine reports in health professions education examining the concreteabstract dimension,56 64 none compared different CAL or WB instructional methods. One study56 found that abstract learners using interactive text and graphics had higher test scores than did concrete learners, but another with similar instructional methods found no difference.62 Test scores did not differ by style for a WB text/image tutorial64 or for a series of CAL simulations.59 Course grades were higher (no statistical test reported) for concrete reflective learners (divergers) in a distance-learning WB course than for divergers in the FTF classroom setting.60 Looking outside of health professions education, instructional methods matching abstract or concrete style demonstrated improved outcomes compared to methods that mismatched style.65 On the other hand, studies of hypertext-rich CAL and WB learning37,66,67 found no significant difference in outcomes between concrete and abstract learners, although there was no comparison with another CAL format. A comparison of two navigation formats68 found no difference between concrete and abstract learners outcomes. One author69 reported that learning styles were more concrete following CAL compared to preinterven-
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tion, but the CAL interventions are not described and the findings have not been duplicated. In summary, these findings agree with the prediction that concreteabstract learning styles would not interact with CAL or WB learning configurations or presentations. However, one report65 suggests that matching styles in this dimension with instructional method may be effective. The activereflective dimension The second dimension of Kolbs model offers the choice between active experimentation and reflective observation. Active learners prefer practical application of information they have received, and are willing to take risks as they influence situations and people.47 Reflective learners, on the other hand, internalize information observing before passing judgment, examining from different perspectives, and looking for meaning as they create new knowledge. Felder and Silverman24 defined their active-reflective construct using Kolbs construct. Both Felder and Silverman24 and Kolb52 note substantial similarity between this dimension and the extravert and introvert personality types defined by Jung54 and assessed by the Myers-Briggs Type Indicator. The extravert focuses attention and energy outward to activity and people, while the introvert focuses attention inward to his or her ideas and experiences.55 Most WB learning would seem to favor reflective learners. The asynchronous and independent nature of WB environments allows the learner to proceed without haste, promoting reflection but possibly boring the active learner. Activities in page-based learning, such as moving from page to page or pursuing hyperlinks, may not fully compensate for this. Discussion-based learning is inherently highly reflective. An exception to the pattern favoring reflective learners would be instructional methods using highly interactive games and models, which may meet the needs of the active learner but fail to allow adequate time for reflection. It is thus expected that reflective learners will prefer and do better with WB learning compared to active learners except when interactive features are prominent. Of eight studies in health professions education examining the active-reflective dimension,56 61,64,70 only one compared different CAL or WB interventions. This
study70 found an interaction between instructional method and style, confirming the authors hypothesis that reflective learners would learn better with linear CAL while active learners would learn better using an interactive program. In other research, active learners did better than those with any other learning style when using interactive CAL,56 but test scores did not differ by style for a WB text/image tutorial64 or for a series of poorly defined CAL simulations.59 Results from studies outside of health professions education are similar. One report65 comparing instructional methods found a trend suggesting interaction consistent with the above predictions. Another study34 hypothesized that active learners would do better than reflective learners when using a highly interactive WB format, while reflective learners would outperform active learners when using a minimally interactive CD-ROM. The results partially confirmed this hypothesis, as active learners did better with the WB format, but performance using the CD-ROM did not vary whether the learner had an active or a reflective style. Reflective learners had higher test scores than active learners using a complex, abstract WB intervention.67 However, another study found that active learners used hyperlinks more than reflective learners, and obtained higher test scores when they did.71 Furthermore, two studies suggest that learners assume a more active learning style with CAL69 or WB learning.72 A study comparing linear and nonlinear navigation formats68 and two studies37,66 using hypertext-rich CAL and WB learning found no difference in performance between active and reflective learners. Thus, the prediction that reflective learners would do better than active learners in most WB environments is not supported by the literature. This likely results from a paucity of evidence and varying degrees of active and reflective learning among existing studies. Alternatively, it could be due to faulty reasoning in the prediction, or a flaw in the active-reflective construct itself. Further research could clarify this issue. Limited evidence does suggest an interaction between instructional method and learning style, in that active learners do better than reflective learners with interactive WB learning and CAL, while reflective learners do better with methods that promote reflection.
Discussion
In summary, the theory and evidence presented above suggest that matching learners to specific WB formats, based on whether they have a wholist or an analytic style, has strong support in both theory and the literature as a means to improve performance. Specifically, analytics tend to do better with less structure, longer Web pages, and a deep before broad approach. Conversely, wholists do better with more structure, shorter Web pages, a broad before deep approach, and social interaction. This aptitude treatment interaction suggests that WB learning could be significantly enhanced by adapting presentation and instructional methods to styles in the wholist analytic dimension. The wholistanalytic dimension has received little attention in medical education research. Evidence neither supports nor clearly contradicts the predictions made from the theory of the verbalimager construct. Whether this is due to inadequate research or a faulty construct, or whether these styles are simply not relevant to WB learning, remains to be seen. At this point, adaptations to specifically target the verbalimager dimension are not justified. Regarding the concreteabstract dimension, both theory and limited evidence agree that adaptations targeting specific instructional methods will have more impact on learning than changes to the configuration or presentation of a WB learning tool. Such adaptations have not received much study in WB learning or CAL, but have been the subject of research in FTF teaching. Adaptations based on FTF evidence would likely be effective, but further research should confirm their merit. For the activereflective dimension, theory and limited evidence suggest that active learners do better than reflective learners with interactive WB learning and CAL, while reflective learners do better with methods that promote reflection. This does not imply that reflective learners do not require learning activities, but rather that reflective and active learners may benefit from different activities. This analysis is limited by the paucity of reports, small sample sizes, and heterogeneity of study populations, interventions, CLS models, and outcomes. Many studies
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suffered from methodological deficiencies, incompletely defined interventions, and (especially those in health professions) the absence of a clear hypothesis. It is also important to point out that although this article considered CLS constructs with similar definitions as a single dimension (see Table 3), this assumption should be viewed with caution until empirically verified. This study illustrates that it is not sufficient to simply define an intervention as Web based when conducting and reporting research. Instructional methods, configurations, and details of presentation vary widely and are critically important. It is also notable that nearly all of the significant findings involved specific modifications of the CAL environment rather than comparison of CAL to a noncomputer format. Among health professions education, both studies41,70 comparing distinct CAL interventions found significant differences among CLS, while only one60 of the four studies comparing CAL to another media format found a difference. Most of the controlled studies in nonhealth professions education compared two CAL formats, and nearly all of these found significant differences among CLS. The pitfalls of comparing CAL to noncomputer media have been described7375 and appear to hold true for CLS research. Future research could use CLS theory and existing evidence to develop and test hypotheses regarding the role of CLS in WB instructional design. Experimental studies comparing interventions should seek to confirm predicted aptitudetreatment interactions, and might consider matching and mismatching learners based on CLS. Changes in interventions should focus on variations of WB design configuration, presentation, and instructional methodrather than comparisons with noncomputer or no intervention. In addition, studies should further evaluate the theoretical basis of CLS, attempt to consolidate the numerous CLS models, and verify the validity of CLS assessments.
Summary
analytic dimension and, to a lesser extent, the activereflective dimension. Limited evidence suggests interaction between concreteabstract styles and instructional method, but confirmation is needed. Research in CLS is limited by deficiencies in study design and a multiplicity of models.17 Yet the findings described above offer hope that, at least for WB learning, investigation and application may be productive. Further WB learning research could clarify the feasibility and effectiveness of assessing and adapting to CLS.
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Teaching and Learning Moments Earls Story

A brief snowstorm in April left a thin layer of ice on the ground. After helping her ten-year-old son Earl, who is severely autistic, get his coat on, Earls mom went outside to sprinkle ice-melt on the driveway so he wouldnt slip walking to the bus. In her haste to ensure the sidewalk was ice-free for Earl, Earls mom had accidentally left the hot plate on and while she was outside, Earl tried to turn it off. Somehow Earls jacket caught fire and the searing pain emanating from his left arm confused him. He desperately tried to run away from the flames that danced up to his shoulder, melting the jacket into his flesh. Hearing Earls frightful shrieks, his mom ran after him as he headed towards his bedroom. His mom finally smothered the flames with a comforter. I first met Earl two weeks after he was admitted to the hospital for burns covering 35% of his body. I was consulted for my expertise and personal experience concerning autism. I noted that the skin grafted from uninjured sites of his body onto the debrided areas was healing well. Earls burns, although healing, were not considered accidental by child protective services. The charge of neglect was raised due to his moms past use of drugs. Unfortunately, the guilt and stress from Earls accident caused her to lapse in her battle with substance abuse. Therefore Earls placement back into his familys home was in question. Earls hospitalization further complicated matters. His mom had no transportation, two older children to care for, and lived two hours away from the burn center. She was threatened with removal of all her children if she did not keep multiple appointments with her caseworker, psychiatrist, and drug rehabilitation program. Making a daily hospital visit was just not plausible. For any child this would be devastating, but for a child with autism, who requires sameness and structure, his life had stopped. After discussing Earls case with his special education teacher and pediatrician, it seemed that Earls mom had taken impeccable care of him while overcoming the obstacles of substance abuse and being a single parent. Earl was nonverbal and difficult to control, but his mom patiently and lovingly looked after him. She would cook special pureed meals, organize his clothes by the days of the week, and use special hand and facial signals to express happiness or sadness. One month passed and Earl refused to eat. He had been fed throughout his hospital stay artificially by a nasogastric tube from his nose to his stomach. I reasoned with his mom that Earl might require surgery if he didnt start eating normally. His moms eyes glistened with tears as she realized she had the chance to protect her child from unneeded surgery. It would be a fitting end to this story to say that Earls mom reentered his life and is now nurturing him back to health, but the cruel irony is that child protective services felt that Earls mom was unfit to care for her child. A mother, who drifted into a depressive and sometimes self-medicated state from the guilt of her child being burned accidentally, was now ready to help her son heal and recover her sanity. Yet the bureaucratic system saw only an uneducated, neglectful, and drug-addicted mother grasping at straws. As I formulated a letter to the state office to reverse Earls predicament, I remembered a quote by Laurence J. Peter, Bureaucracy defends the status quo long past the time when the quo has lost its status.
The name has been changed to protect the confidentiality of this individual. John W. Harrington, MD
Dr. Harrington is an assistant professor of pediatrics at New York Medical College, Valhalla, NY.
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Cognitive and learning styles (CLS)

summarize the theory and evidence to propose applications of CLS to WB learning.

Academic Medicine, Vol. 80, No. 3 / March 2005

Academic Medicine, Vol. 80, No. 3 / March 2005

No., type of participants

Academic Medicine, Vol. 80, No. 3 / March 2005

No., type of participants

Academic Medicine, Vol. 80, No. 3 / March 2005

No., type of participants

Academic Medicine, Vol. 80, No. 3 / March 2005

No., type of participants

Educational Inventory intervention(s)

Academic Medicine, Vol. 80, No. 3 / March 2005

No., type of participants

Educational Inventory intervention(s)

Academic Medicine, Vol. 80, No. 3 / March 2005

GEFT (cognitive style)

ILS (learning style)

LPI (learning style)

LSI (learning style)

MBTI (cognitive style)

STSI (learning style)

VVQ (cognitive style)

Academic Medicine, Vol. 80, No. 3 / March 2005

Academic Medicine, Vol. 80, No. 3 / March 2005

Academic Medicine, Vol. 80, No. 3 / March 2005

Note: References 76 89 are cited in Table 1 and Table 2 only.

Academic Medicine, Vol. 80, No. 3 / March 2005

Academic Medicine, Vol. 80, No. 3 / March 2005

Teaching and Learning Moments Earls Story

Academic Medicine, Vol. 80, No. 3 / March 2005

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