The Importance of Identifying Learning Styles in Medical Education

– Learning Styles ABSTRACT Learning is a complex construct that involves several factors, mainly the interaction between teachers and students in the process of teaching and learning. Understanding how students learn and which factors influence academic performance is essential information for lesson planning and evaluation, in addition to allowing a better use of students’ learning potential and outcomes. The ability to constructively modify one’s behavior depends on how well we combine our experiences, reflections, conceptualizations, and planning to make improvements. This seems particularly relevant in medical education, where students are expected to retain, recall, and apply vast amounts of information assimilated throughout their training period. Over the years, there has being a gradual shift in medical education from a passive learning approach to an active learning approach. To support the learning environment, educators need to be aware of the different learning styles of their students to effectively tailor instructional strategies and methods to cater to students’ learning needs. However, the space for reflection on the process of teaching is still incipient in higher-education institutions in Brazil. The present article proposes a critical review of the importance of identifying students’ learning styles in undergraduate medical education. Different models exist for assessing learning styles. Different styles can coexist in equilibrium (multimodal style) or predominate (unimodal style) in the same individual. Assessing students’ learning styles can be a useful tool in education, once it is possible to analyze with what kind of learning students can better develop themselves, improving their knowledge and influencing positively in the process of learning. Over the last century, medical education experienced challenges to improve the learning process and curricular reform. Also, this has resulted in crucial changes in the field of medical education, with a shift from a teacher centered and subject based teaching to the use of interactive, problem based, student centered learning.


The Importance of Identifying Learning Styles in Medical Education
A Importância da Identificação dos Estilos de Aprendizagem na Educação Médica

ABSTRACT
Learning is a complex construct that involves several factors, mainly the interaction between teachers and students in the process of teaching and learning.Understanding how students learn and which factors influence academic performance is essential information for lesson planning and evaluation, in addition to allowing a better use of students' learning potential and outcomes.The ability to constructively modify one's behavior depends on how well we combine our experiences, reflections, conceptualizations, and planning to make improvements.This seems particularly relevant in medical education, where students are expected to retain, recall, and apply vast amounts of information assimilated throughout their training period.Over the years, there has being a gradual shift in medical education from a passive learning approach to an active learning approach.To support the learning environment, educators need to be aware of the different learning styles of their students to effectively tailor instructional strategies and methods to cater to students' learning needs.However, the space for reflection on the process of teaching is still incipient in higher-education institutions in Brazil.

INTRODUCTION
Learning is a complex construct involving many factors, including the interaction between teachers and students.When students learn new content, they go through a cycle that involves recognition, assimilation, experience and, finally, the capacity of socializing the acquired knowledge 1 .One of the major challenges people face in life is to learn about themselves and about the people with whom they relate.One way to meet this challenge is to identify learning styles 2 .Such a difficulty is greater for educators, who sometimes ignore the different ways of acquiring knowledge and the resulting essential characteristics of their students 3,4 .The present article proposes a critical review of the importance of identifying the learning style in undergraduate medical education.

CURRENT EDUCATIONAL MODEL
The school we know is based on the prevailing educational model in our country, that of homogeneous education.At first sight, this view may seem adequate, but reflection indicates that linear education does not reach everyone equally and fairly.On the contrary, we struggle all the time to adapt to a learning model that often does not fit students' needs.By trying to develop strategies to deal with this difficulty, we learn to live with failure and with the labels imposed by evaluation 2 .
In order to understand the teaching-learning process in higher education, it is necessary to understand that university students are the concrete subjects of learning.They are part of a specific culture, are involved in social relations and private life situations, and are emotionally involved in the subjective process meaning-making, thus bringing into this context their history and their individual needs.In order to stimulate the creative process, learner's involvement is necessary, so that the process represents a moment of the subject's realization, leading them to have emotionally and personally motivated experiences 5 .
In medical schools, we often find a scenario where the educational process is carried out by physicians without any 191 pedagogical skill to play the role of teachers, believing in the premise that professional expertise is enough to practice teaching.This context supports a teaching process centered around the teacher, fragmented and detached from students' real needs.Good teachers, far from being an abstraction, are an ongoing construct of the entire faculty committed with a vocational training that goes beyond mere learning procedures and techniques.They think, organize, and delineate pedagogical interventions centered around the complex dimension network that permeates their social role 6 .

LEARNING STYLES
Understanding how students learn and which factors influence academic performance is essential information for lesson planning and evaluation, in addition to allowing a better use of students' learning potential and outcomes.Learning style can be defined as how the individual learns 7 .
In an age when students are at the center of their learning, it is necessary to provide the subsidies for students to develop, in addition to expertise and skills, techniques to make learning a meaningful experience.Each student uses different methods to assimilate knowledge.In this sense, the process of learning and teaching becomes a challenge in academic education 8 .
Since the Classical Age there is a concern about the way people learn: both Plato and Aristotle registered their theories on the subject and expressed their appreciation for self-learning, as many of their works were written with the intent to be used by their disciples 9 .
Carl Jung developed the idea of the existence of psychological types, i.e., the different ways people perceive the outside world (perception) and internalize what was perceived (processing), incorporating the knowledge into their individuality.In recent decades, researchers have developed tools to asses learning preferences, and these tools have been validated in different languages 10 .
It is generally agreed that different individuals have different styles of learning.However, there are common features to many individuals.The different styles can coexist in equilibrium (multimodal style) or predominate (unimodal style) in the same individual.Different authors distinctly denominate the learning style categories.The Honey-Alonso Learning Styles questionnaire (QHAEA) by Portillo 8 is the result of the translation and adaptation into the academic context of the Learning Styles Questionnaire (LSQ) by Honey and adapted by Alonso, from English into Spanish, called C.H.A.E.A (Cuestionario de Honey y de estilos de Aprendizaje).The questionnaire consists of 81 social and academic questions divided into four groups: active, reflexive, theoretical and pragmatic.
A profile can change due to intrinsic factors, such as motivation and maturity, but is also influenced by extrinsic factors, such as the educational project and the choice of the teaching methodology by the faculty 4 .Kolb's model (Kolb's Cycle) works with a tool for individual identification of a learning style.Based on the recognition of each individual's learning skills, the model identifies four styles: the accommodating, the converging, the assimilating, and the diverging styles, which characterize the individual's way of learning, each with their own characteristics 11 .
The Vark evaluation tool was described by Fleming in 2001.It is a sensory model, and the acronym Vark stands for Visual (V), Aural (A), Read/Write (R) and Kinesthetic (K).Fleming defines the learning style as the characteristics of an individual and the ways used to acquire, organize and think about information.The Vark inventory provides a score for each of the four modes of perception that can coexist in individuals.Fleming reports that 51% of those who answered the tool have multiple styles, 27% have two styles, and the others, a single learning style 12 .
This tool is available at www.vark-learn.comand can be freely used in academic settings with the author's permission.The questionnaire was translated and validated into Portuguese and consists of 16 multiple-choice questions.Since the questionnaire allows to tick more than one answer, the combination of results reflects a unimodal, bimodal or multimodal learning style.Students with multiple ways to capture and process knowledge can be more flexible and adaptable to different teaching and learning resources.In courses where the skills and knowledge should be integrated into practice scenarios, this ability can provide an advantage during the knowledge internalization process 13 .

THE IMPACT OF THE EDUCATION PROJECT ON LEARNING STYLES
The development of student-centered teaching and learning processes was described by Harden in 1984, in opposition to the then current Flexnerian model 14 .The trends of the Spices model can be summarized in the table below 15 .The change to the student-centered educational process and based on problem-solving also impacted the understanding that effective learning must be contextualized.Traditional models of medical education that separated, temporally or geographically, the biomedical disciplines from clinical practice are prevalent in curriculum matrices characterized by fragmentation and theoretical and practical dissociation.Integrated approaches predict modules where there is horizontal integration of knowledge and skills of many disciplines grouped around a theme or health problem 16 .

Table 1 Trends for curriculum development in medical education
The results of a study carried out in India about learning styles in first-year undergraduate medical students using the Vark questionnaire showed that 61% of the students have a multimodal style, suggesting that a single teaching approach may not work for most of them 17 .

DISCUSSION
Considering the several possibilities found in medical education, the authors propose strategies that can positively affect the formation of medical professionals in a higher education setting.

The systemic view
The space for reflection on the teaching learning process is still incipient in Brazil's higher-education institutions.Teachers, immersed in specific activities, underestimate their influence on the curriculum design and pedagogical structure of an undergraduate program.However, there seems to be a clear understanding that individual approaches can have an impact in aiding curriculum designing at any level.The performance of pedagogical approach in the classroom is often the common thread between the structural faculty and the students.Teachers perform the interface between students' needs and the educational objectives proposed by the educational institution 6 .We understand that teachers, when combining professional and pedagogical technical qualifications, contribute to students' formation, thus creating a strong program with good performance ratings.

The teacher as learning facilitator
Education requires focus on the subject to be taught, on the understanding of its need for health practice, and on the ability to activate student learning.Concerning the latter, the use of appropriate teaching practices depends on the understanding of students as subjects.
Educational practices become effective when undergraduate course managers and the faculty understand their role as well as the impact of recognizing how students learn in the academic process.However, that does not mean categorizing students without contributing to teachers' planning of appropriate and varied teaching strategies.Therefore, identifying learning styles is a tool to be explored and debated in the educational scenario to influence the learning process8.
As for teachers, their role is to find solutions to the different individual needs, such as diversifying pedagogical strategies according to the predominant learning styles in different groups of students, which is only possible by having proper teacher training to develop alternatives to expository classes.Another possibility is to identify the learning styles of students with insufficient academic performance and design a recovery program based on the knowledge of how they learn.

Students at the center of the teaching-learning process
Learning becomes a challenge also for the students, as they actively participate in the construction of new pedagogical models.By elucidating the usual process of teaching, one creates space for the identification of alternative ways, allowing students to have a conscious and meaningful learning experience, improving the acquired knowledge and the program they chose.It is known that by alternating forms of assessment, self-assessment, and psychoeducational assessment, one can foster growth, selfknowledge, and extensive learning ability18.The use of active teaching methodologies such as problem-based learning (PBL), Peer instruction and FlipClass provide a more active posture of students, making them responsible for their own learning19.
Evaluating students' learning styles, allowing them to recognize how to improve their own learning, would serve to guide their studies and the search for different tools better suited to their own thought process.Learning autonomy also depends on learners' self-knowledge.
We are experiencing a decade of intense and rapid changes.Forms of interpersonal communication are undergoing constant adaptive changes to the needs of individuals and society.In education, these behavioral changes also exhibit their features throughout generations.The educational model associated with an orthodox curricular structure does not meet the current needs of higher education.The teacher-student dichotomy needs to be reviewed and rediscovered through the ' learning styles in undergraduate medical education.Different models exist for assessing learning styles.Different styles can coexist in equilibrium (multimodal style) or predominate (unimodal style) in the same individual.Assessing students' learning styles can be a useful tool in education, once it is possible to analyze with what kind of learning students can better develop themselves, improving their knowledge and influencing positively in the process of learning.Over the last century, medical education experienced challenges to improve the learning process and curricular reform.Also, this has resulted in crucial changes in the field of medical education, with a shift from a teacher centered and subject based teaching to the use of interactive, problem based, student centered learning.