The Liaison Committee on Medical Education (LCME) recently adopted Standard MS-31-A, which states that medical schools must document that they provide a supportive learning environment for their students.1 Evidence from undergraduate medical education suggests that developing learning communities is one approach for enhancing the learning environment and thereby improving student satisfaction, retention, and performance.2 The number of medical schools adopting learning communities has grown substantially in recent years.3 To shed light on the types of learning communities currently in place in medical educational settings, we surveyed all U.S. and Canadian medical schools and colleges both to identify those that report incorporating a learning community and to document the purpose, structure, function, benefits, and challenges of those communities.
Traditionally, the term learning community has referred to many qualitatively different interventions in the settings where they are implemented, especially undergraduate postsecondary education.2 Although learning communities usually have a common purpose, that is, “to maximize student learning,” each interprets who the students are, what learning entails, and what maximize means, differently.
While scholarly investigations of the varieties of learning communities in medical education settings are just beginning, reviews of learning community descriptions in the higher education literature can serve as a basis for investigating the key features of these communities in medical education.
What Is a Learning Community in Traditional Educational Settings?
Generically defined, a learning community is an intentional community for students and/or faculty designed to enhance and maximize student learning.2 By restructuring traditional academic and/or social components of the student environment, leaders of schools with learning communities intend to foster among students a higher level of student engagement and intellectual interaction with peers, faculty, curriculum, and/or their own individual intellectual development.4 The term learning community encompasses a broad range of intervention models that vary in purpose, structure, activities, and size depending on the context, culture, and needs of a particular environment.5
Learning communities have been widely adopted in various educational settings, ranging from K–12 to undergraduate and professional (including medical) education environments and in professional settings including businesses and corporations. However, the primary scholarship regarding learning communities is based on undergraduate education where more than 500 institutions currently use some approach to learning communities.6
Despite the common aforementioned goal of maximizing student learning, learning community initiatives and approaches vary significantly. Common objectives of learning communities include providing academic support, enhancing social or student service support, and delivering curriculum5 (all described below).
Creating an intentional community, that is, sorting students into small subsections or groups as they participate in an academic program, is the most common approach to establishing a learning community.5 The smaller subsections or groups serve as an organizational framework for students' academic experiences. Students either select into or are selected into a subgroup in an effort to encourage a smaller, group atmosphere with a more intimate and comfortable environment. Organizational mechanisms frequently include dividing students on the basis of curricular needs or interests, career interests, residential living areas, or similar backgrounds such as gender or minority status. These smaller subgroups, or learning communities, are then used for two major purposes—to create support systems and/or to deliver curriculum.5
Learning communities can promote a community of inclusion that aids students in feeling more connected to their learning environment, institution, peers, and/or faculty. The learning community often aims to promote a more personal setting “that is used to build a sense of group identity, cohesiveness, and uniqueness.”7 This inclusive community can be a social, academic, or student service support network that provides students with a familiar, safe space in which they can interact with peers and faculty.
An important characteristic of some learning communities is connecting students with one another for academic support purposes. Consequently, academic support-driven learning communities provide formal and informal academic support networks such as peer tutoring, study groups, academic advising, supplemental learning activities, and career mentoring. Additionally, faculty–student relationships may develop through this type of learning community environment creating additional mechanisms for student academic support.
Through interactions within learning communities, students may identify with their specific community and the individuals in it. Learning communities foster social engagement among students by creating a comfortable space for interaction. Often, as a way to increase student interaction, the learning community serves as the starting point for social gatherings and meetings. There is extensive literature on undergraduate (baccalaureate) student socialization and the importance of positive relationships with peers and faculty members.6,8–14
Student service support.
Learning communities are often used to eliminate the challenges students face coordinating needs such as financial aid, housing, and registration by providing a setting for community-based delivery of student service support. The learning community serves as the central location, either physically or through a facilitator, for students to coordinate their student service needs; for example, students within a particular community may receive advice about financial aid from a staff member who is also assigned to that community.
Curricular learning communities, as they are commonly referred to, use learning communities to deliver curricula. Educational scholarship related to undergraduate (baccalaureate) education focuses much of its efforts on these types of learning communities. Curricular learning communities may require that curricular content from different disciplines be paired—or that classes from different schools be team-taught. These curricular learning communities may also implement collaborative learning strategies, and they frequently emphasize an intellectually complex learning environment using integrative curriculum delivery that requires students to integrate diverse concepts through varying curricula, disciplines, and/or interactive pedagogies with peers and faculty. For example, communities may include students who are all majoring in a particular field, such as engineering, who work with others in their communities on major class projects. Curriculum integration, interdisciplinary approaches, and integrative learning strategies within a community environment aim to encourage deep learning (i.e., learning that goes beyond memorizing and reproducing knowledge received), which, rooted in learning theory and cognitive development, encourages students to be comfortable with intellectual complexity.6
Despite being an influential movement with many practitioners in undergraduate (baccalaureate) education, limited evaluations and few scholarly assessments demonstrate evidence of learning communities' impact. The preliminary evidence suggests that some types of learning community models do have positive effects on students and faculty within undergraduate education. The strongest, most conclusive evidence suggests that well-designed undergraduate learning communities that both emphasize collaborative learning and entail intensive faculty involvement result in improved academic performance, retention, and student satisfaction.2,15,16 Additional, less conclusive results from studies of learning communities demonstrate outcomes including improved quality of student learning, enhanced academic skills, higher self-esteem, increased involvement with the institution, deeper engagement in learning, greater intellectual richness, greater intellectual empowerment, and improved connectedness between social and academic student life.2
In June 2006, following approval by the University of Iowa's institutional review board, we sent e-mails to academic deans of all U.S. and Canadian medical schools in existence at the time of the survey (N = 124), asking them to respond to a survey about learning communities. The survey, which was developed based on existing literature, was pilot-tested with colleagues. The e-mail provided a link to a Web-based survey, which requested responses even if the school did not have learning communities in order to obtain an accurate census of all schools.
We sent an e-mail reminder in July 2006. Later that fall, we called nonresponding schools that we knew (through interactions at the original Learning Communities Institute and follow-up meetings held in conjunction with the Association of American Medical Colleges annual meeting) to have learning communities, and we encouraged them to participate in the study. In June and July 2007, we made follow-up phone calls to the remaining nonresponders. We offered respondents the option of providing identifying information for themselves and for their schools. One respondent declined and those results are not included in this paper.
So that respondents would understand how we defined and identified learning communities, the survey included the following statement: As we have broadly defined them, learning communities (also referred to as colleges, societies, CELLS, and houses), are intentionally developed groups that aim to enhance students' medical school experience and to maximize learning. Respondents were asked, “As defined above, does your medical school have one or more learning communities for students?” Respondents who answered “No” were then asked whether they were considering developing learning communities and were sent to the section about faculty learning communities.
The survey then asked when the student communities were established and requested the term used to describe the communities. Respondents then reviewed a list of 12 primary goals for learning communities and checked all the goals that applied to their communities (related to academic support, social support, student services support, or delivery of curriculum). The next question provided a list of 16 characteristics pertaining to communities (e.g., whether participation is voluntary, whether students from all four years are included in each community), and again respondents checked all those that applied. Respondents then indicated which of eight activities related to curriculum and student support were relevant for their communities (checking all that applied). Next, respondents identified through a yes/no question whether they collected evaluation data, and if so, they specified which types of evaluation data their schools collected with regard to learning communities. Finally, respondents answered open-ended questions regarding (1) why learning communities were important for their medical schools and for medical education, and (2) what issues and challenges learning communities needed to overcome. We downloaded responses into a spreadsheet and imported them into SAS (Statistical Analysis Software, Cary, North Carolina). We used factor analysis to identify themes for communities.
Fifty-nine schools responded to the Web-based survey. E-mail or phone contact with another 30 schools resulted in a total response rate of 72% (89/124). The following results reflect the answers of respondents from the 18 schools that said they have student learning communities. Another 13 schools indicated that they were considering developing student learning communities.
The first learning communities were established at the University of Missouri at Kansas City in 1971, followed by the University of Oklahoma in 1975 (see Figure 1). The University of Kentucky and Harvard both established learning communities in the 1980s. Northwestern University, the University of Kansas, East Tennessee State University, and the University of Iowa began their communities in the 1990s. The remaining schools started their communities in 2000 or more recently.
The most common term used for these entities is “college” (University of California–Los Angeles, Northwestern University, University of Washington, Temple University, University of California–San Francisco, and Johns Hopkins University). “Society” is a term used by several schools (University of Kansas, University of Texas Medical Branch, Harvard University, University of Kentucky, and Case Western Reserve University). Other terms include “learning community” (University of Alabama, Florida State University, University of Iowa), “house” (University of Wisconsin), “rural sites” (East Tennessee State University), “modules” (University of Oklahoma), and “docent units” (University of Missouri–Kansas City).
Goals, characteristics, learning topics, curriculum-delivery forms, and themes of learning communities
Table 1 lists the primary goals of intentionally developed student learning communities in U.S. and Canadian medical schools, and Table 2 shows the structural characteristics of these communities. Table 3 shows the curriculum topics that learning communities cover and the methods by which communities deliver these topics. Table 4 shows which student support activities are most common in U.S. and Canadian medical school learning communities.
Twelve schools (67%) indicated that they collect evaluation data, generally related to clinical performance (if that was a goal of the communities). Other evaluation data collected by schools measured satisfaction with the learning environment or with the communities themselves. Some schools gathered evaluation data on mentors. In addition, some schools collected data regarding participation, leadership, and connections among students.17
To further analyze the themes related to communities in different schools, items related to functions or goals were collapsed into five general categories: student support, curriculum, service learning, leadership, and interdisciplinary (i.e., interprofessional) education (List 1). We created subscales based on these themes. Table 5 shows the number of activities or purposes related to each theme for each school. Student support is an important theme of learning communities for most schools. One third of the schools (n = 6) incorporated 10 or all 11 of the student support elements, and eight additional schools incorporated at least six student support elements. Using learning communities to deliver curriculum seems to be less common, as only five schools checked the majority of the curriculum items, and six schools checked three or fewer. The themes of service and leadership seem to be related, because 10 schools included elements of both in their learning communities, and five schools incorporated neither, whereas only three schools incorporated one but not the other. In terms of incorporating interprofessional education (IPE) into learning communities, only three schools incorporated both items, whereas half of the schools had no interdisciplinary component and five had just one.
Finally, respondents answered two open-ended questions about their student learning communities. Responses to the first open-ended question, “In what ways are student communities important for your medical school and for medical education?” fell into four general categories. The first category related to support for students. Representative comments are:
We have found that the new college system has helped us to identify students who need additional support earlier (even within [the] first year), compared to our previous experience, as some students may not have been identified until the third year on clinical rotations.
[Learning communities] personalize the environment and provide social support.
The second category concerned creating a positive learning environment and creating opportunities for connecting with other students and faculty. For example,
the primary benefit of our system is the ability to create much more intimate learning communities within a fairly large class size (170), and facilitate the development of meaningful relationships with faculty, especially early on.
[Communities help] create a culture of collaboration and community, and decrease emphasis on competition.
[They] allow students to relate more one-on-one with faculty in the preclinical years and allow students from all four years to interact with each other.
A third general category of responses to this question concerned the benefits related to the curriculum:
[Learning communities] provide a potential mechanism for tying the formal curriculum to the informal curriculum, filling “gaps” in the formal curriculum.
[They are] helpful in creating and delivering clinical skills and professionalism training.
A final category of responses concerned the importance of learning communities for supporting community service.
[Learning communities provide a] mechanism to engage students in healthy social and community service activities.
Responses to the second open-ended question, “Based on your experiences, what medical education issues and challenges do student communities have to overcome?” were grouped into four general categories. The first addressed problems related to engagement of faculty and students.
[There is a] perception by some faculty that communities are “just social” and learning only takes place in formal curriculum.
Since it's voluntary, some students never participate.
[Some students experience a] sense of exclusivity; students aren't sure they want to participate.
[A major challenge is that learning communities are] perceived as irrelevant and not very useful.
A second category was related to resources, including time, space, and funding.
[Learning communities have] space requirements in an existing building not designed for such groups.
Logistics and time for the community to function [present challenges].
Investing in faculty and supporting faculty who oversee learning communities is a big issue.
Finding the time in an already tight schedule [is challenging].
A third category also related to resources, but specifically addressed the issue of faculty participation.
Our biggest challenge has been identifying enough clinical faculty to participate and assure that they are given the appropriate time to contribute to the program.
The biggest challenge for us will be to find the requisite number of mentors with the time to devote to this activity for a class of 240 students.
A final category of challenges concerned the relationship of communities to the curriculum and the ongoing evaluation of the communities themselves.
Fragmentation of learning goals, lack of integration of explicit and hidden curricula [make evaluation difficult].
Continued assessment of goals and outcomes [is a significant challenge].
[We face difficulty in] integration of community activities within [the] existing curriculum.
Discussion and Conclusions
Learning communities in medical education have emerged in response to challenges specific to medical education such as student burnout18 and the need for curriculum reform that is responsive to evolving understandings of knowledge and how medical students learn.19 Learning communities vary significantly across institutions, and they may be designed for academic support, general student support, social activities, or curriculum purposes, or any combination of these.2 Creating a supportive learning environment is a high priority for many medical schools, especially in light of the new LCME requirement mandating that schools document their efforts in this regard.1 As class sizes increase, learning communities can serve as a potential solution to creating such an environment.
Medical school learning communities aim to support students academically and socially. These communities seek to allow students to be fully engaged in their learning, feel supported, and leave medical school with the appropriate tools. Although outcomes such as improved retention, improved academic achievement, and improved mental health have yet to be demonstrated, learning communities have the potential to influence such outcomes positively.
Many learning communities are being used to deliver curricula in areas such as professionalism, humanities, and cultural competence. One reason may be that such topics require personal interaction that cannot be accomplished in a large lecture hall. Further, these topics may be addressed most effectively in interactions among students and faculty who have developed a sense of trust with one another through longer-term interactions that are made possible by learning communities.
In addition, medical schools use learning communities to deliver curricula in ways that train medical students to use more complex intellectual processes, for example, through collaborative learning or problem-based approaches. Although peer-learning or group approaches can be implemented without learning communities, such structures have the potential to build long-term relationships among students and between faculty and students that could enhance the effectiveness of such approaches.
The different structural characteristics suggest that medical schools are, in fact, adapting their learning communities to local needs, as suggested by prior research.5 Although they have a common purpose (to build academic and social support networks), their structures vary substantially, demonstrating the adaptability of learning communities to different medical schools' needs and environments.
The majority of schools focus on student support and enhancing the learning environment (e.g., through improved communication between students and faculty). There is less uniformity, however, regarding curricular purposes, service, or leadership. For example, while the purposes pertaining to student support were most common, fewer than half of the schools identified three of the four purposes related to curriculum delivery. One possible explanation for this difference may be that existing structures are more effective in meeting needs related to curriculum delivery, whereas learning communities are more effective than existing structures for meeting student support needs. Finally, although learning communities would be a logical mechanism for incorporating IPE, the adoption of IPE in U.S. and Canadian medical schools is a relatively recent phenomenon, and its influence may not be apparent in this study.20
Those interested in implementing learning communities face potential challenges. For example, faculty and students may be skeptical about the value of learning communities. This may be legitimate, and it is incumbent on developers of learning communities to establish evidence of their value. Lack of coordination, time, and facilities may also impede progress. Although this survey did not ask about the costs for developing and maintaining learning communities, other sources suggest that the costs for doing so may be substantial.3
This study documents the approaches taken by schools to develop learning communities, shows the diverse nature of learning communities as designed and implemented in the medical school environment, and provides a resource for schools that are considering developing their own learning communities by cataloguing other schools' experiences. Next steps should include evaluating the impact of learning communities based on their intended purpose(s). The results of this study must be considered within its limits; for example, schools with learning communities may differ from other schools in undetermined ways, so whether the findings will generalize to other institutions is unknown. In addition, because the number of schools that have learning communities is relatively small, drawing conclusions about what might be appropriate for a school considering learning communities is not possible at this stage in the development of learning communities in medical schools. Finally, as the landscape for medical education is changing rapidly, factors that were not considered when the study was conducted in 2006 may influence the generalizability of the results.
The findings of this survey raise many interesting questions for further research. For example, what impact do the structural characteristics of a learning community have on the community's success? How does requiring participation affect students' perceptions and satisfaction compared with communities in which participation is voluntary? How does the method for selecting students into communities (e.g., by self-selection, assignment by theme or interest, or random selection) influence the community's functioning and vitality? Is it critically important that the physical environment support the formation of group identity within a community? Can learning communities successfully integrate students from different disciplines and health professions around common curricular themes? Only by generating collaborative multisite research to answer questions such as these can we learn more about what functions learning communities are able to serve and what arrangements are best suited to fostering their goals.
The authors thank the organizers of the first Learning Communities Institute, held at the University of Iowa Carver College of Medicine in September 2005, for initiating discussion about collaborative efforts among institutions with learning communities, thereby setting the stage for this project.