The paper emphasises the potential of the autonomy-oriented approach as a scientific basis for the development of innovative training practices in medical universities of Russia. Based on a review of research, theory, and current teaching practices in Professor V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, the paper considers both theoretical and practical aspects of the autonomy-oriented approach implementation in higher medical education. The benefits of the autonomy-oriented approach for both undergraduate and postgraduate medical students are demonstrated from the perspective of the Self-Determination Theory. Our findings indicate that the autonomy-oriented approach in higher medical education is associated with a more “personalised” teaching style through supporting students’ self-determination, engagement and autonomy. The summative evaluation of the results of the study with participation of 54 medical students and 33 medical university teachers suggests that the use of the autonomy-oriented approach in higher medical education leads to effective implementation of creative, innovative, contextual and problem-based training techniques as well as students’ and teachers’ personal and professional self-development.
The current Russian system of higher medical education is undergoing a variety of progressive changes. Among these, of special note is implementation of new methods and forms of training organisation (workshops, case-studies, video-conferences, academic exchanges, counselling, various types of distance learning courses and networking cooperation, etc.). Nevertheless, this system remains insufficient in view of some factors.
First, despite the presence of positive educational initiatives in contemporary Russian theory and practice of higher medical education, there is lack of a holistic and comprehensive approach to teachers’ and students’ personal and professional development problem;
Second, most of training courses are organised on the basis of the formal approach and are oriented toward formal transition (using traditional forms and methods of training) of a certain volume of information to students but not toward achievement and development of students’ competences and their professional growth;
Third, the present level of knowledge, the student’s personal potential are not always considered when medical training is organised;
Fourth, there are many university teachers who are not ready to face the modern challenges of higher medical education, completely rethink traditional study goals and strategies of teaching in order to provide optimal challenges for students, ensure a diversity of learning experiences, built in accordance with the possibilities and the needs of all student categories, making students feel competent, supporting their autonomy [1, 2] and internationalising the content of higher education . Fifth, despite proclaimed transformation of the whole healthcare system from one-size-fits-all approach into a subject-oriented one , in the current situation of basic values revision scientific achievements in the practice of healthcare often lead to the dehumanisation of medicine and, consequently, medical education . Accordingly, it is vital to find relevant scientific basis for new training practices to develop future doctors’ humanistic and values-based attitude to patients and their health.
Another concern regarding contemporary medical education is the problem of medical students’ readiness for self-directed lifelong learning which is reported to be an integral part of medical professionalism .
To make higher medical education more responsive to the changes taking place in the medical community, it is critical to completely rethink traditional study goals and strategies and follow the ideas of a humanistic education model, based on student-centred approach and “transformational pedagogy” [7, 8]. Prioritising innovative, proactive and creative human nature, this model puts emphasis on interests of the students with consideration for their personal experience, inclinations, abilities, and ensures practice-based and personality-oriented implementation of new educational technology  to develop future doctors’ humanistic qualities and their professional autonomy .
Therefore, an acute necessity is emerging today to develop scientifically grounded personality-oriented training practices that may be used in higher medical education. Following the presented statements, the aim of this article is to explore the autonomy-oriented approach as a scientific basis for the development of innovative training practices in medical universities of Russia.
Taking into account that teaching is suggested to be an important factor influencing students’ motivation and performance [11, 12, 13] and teacher’s personal qualities are reported to be more important in motivating students than the teaching methods and classroom management practices [14, 15], we studied the potential of students and teachers’ autonomy in the context of higher education [16, 17, 18] using analytical and descriptive methods of the literature review. Modern approaches and technologies for organisation of student-centred training in higher education have been explored as well [7, 8, 19]. The study problem required a more detailed exploration of R. Ryan & E. Deci’s self-determination theory (SDT), in which self-determination is considered as feeling and realisation of freedom in person’s choice of behaviour and existence in the world independently from external environment and innerpersonal processes effects .
In addition to psychological and pedagogical theory studying, this research included analysis of modern higher medical education practice, which was conducted within the framework of open discussions in pedagogical conference workshops and round-table discussions with participation of the university faculty (10 teachers of medical English – members of the Linguistic Centre of Professor V.F. Voino-Yasenetsky Krasnoyarsk State Medical University (KrasSMU) and medical students – members of the KrasSMU Centre for Intercultural Communication (54 medical students, including 44 first- and second-year students and 10 postgraduates) in 2013-2017.
The practical aspects of the autonomy-oriented approach were also investigated through applying the ideas of autonomy-oriented education to the introduction of the “School of the young teacher” course for 23 young medical university teachers (2015-2016) and advanced training programme for 10 teachers of Medical English – members of the KrasSMU Linguistic Centre (2016-2017).
Our research results make it possible to suggest that the autonomy-oriented approach in higher education represents a methodological approach to the training process organisation that fosters both students’ and teachers’ autonomy through supporting their personal involvement into the training process as well as their personal responsibility for its results.
In view of this, the choice of the autonomy-oriented approach as a scientific basis for the development of innovative training practices in medical universities is first of all determined by the content of the “autonomy” notion.
Autonomy in healthcare practice is reported to allow junior doctors to feel ready for more senior, unsupervised roles, to work more in difficult scenarios involving team leadership and risk acceptance . Autonomy in the educational context is associated with creation of a new, subject-oriented type of education , growth of one’s independence, personal empowerment, ability to make decisions and choices [22, 23]. A lot of modern conceptions of autonomy in education emphasise teachers’ or/and students’ capacity to take control of their own activities through planning, making choices and taking responsible decisions. As it was revealed, perceived autonomy represents a high-level competence, which allows teachers and students to take control of their activities and to develop as self-determined and socially responsible educational actors.
Autonomy is associated with a set of personal characteristics, including intrinsic motivation to professional achievement and personal and professional development, internal locus of control, responsibility, creativity, ability to set goals make decisions and to make choices, ambiguity tolerance and critical mindfulness. Within the framework of medical education, it makes processes of learning and teaching inner-directed, and, consequently, desirable and enjoyable both for students and teachers .
In terms of theory, implementation of the autonomy-oriented approach is based on personalisation of the educational process within the framework of personality-oriented paradigm of higher education. Such personalisation requires the use of novel educational techniques in students’ training as well as in advanced training for teachers. These new techniques should be aimed at formation of students and teachers’ personal attitude towards the educational process and based on the mechanisms of dialogue, reflexivity and cooperation, providing educational actors’ personal involvement into the training process and their personal responsibility for its results. Applying the ideas outlined above to teaching practice at a medical university and based on the literature review, we specified the core characteristics of the autonomy-oriented approach compared to the traditional approach to teaching in Table 1.
Characteristics of the traditional and the autonomy-oriented teaching
|TRADITIONAL TEACHING||AUTONOMY-ORIENTED TEACHING|
|Theorised syllabus||Practice-oriented syllabus|
|Overview of some language phenomena||Emphasis on profession, interdisciplinarity: and on students' ability to apply new knowledge to their actual contexts of learning|
|Emphasis on transmission of information to the audience||Emphasis on students' involvement into the educational process, their active participation in making sense of a new practice using their own metacognitive skills to create their multi-dimensional awareness of the educational context Teacher functioning as a facilitator Provided opportunity for experiential, collaborative learning|
|Beaming down of a generic course content Adherence to a fixed curriculum||Provided opportunity to select what students would like to learn. Critical review and use of students' personal experience|
|Emphasis with new learning on quantitative techniques equipment of students||Emphasis on both qualitative innovational self-development of learners and their creativity|
|Token approach to teaching||Teaching as a stimulus for students' lifelong personal and professional development Provided opportunities for students to coach one another and work together to analyse new learning techniques|
|Summative evaluation of students by teachers||Multi-dimensional evaluation (fostering self-evaluation and peer-evaluation practices)|
|Use of old (or new) methods that may be not relevant for the students and may not relate to their specific demands||Relevant content, reflecting actual challenges faced by students in their learning (professional) activity|
|Non-problematic, non-diversified content Providing basic knowledge||Content construction on the basis of interdisciplinary problems topical in the in the broad context of a medical profession|
Analysing the revealed characteristics of the autonomy-oriented approach within the modern educational context allowed us to assume that using the autonomy-oriented approach in medical universities can stimulate certain changes in both teachers and students. The most important of these changes is the transformation of their external locus of control into the internal one.
To achieve this transformation, the following conditions are to be provided in the university educational environment:
Ensuring teachers’ and students’ awareness and a deep understanding of the educational process characteristics based on maximal accessibility of information about aims, goals, processes, methods of learning outcomes evaluation, etc.;
Providing opportunities for students’ and teachers’ personal and professional development by means of organisation of their access to a wide range of data resources;
Empowering teachers and students to actively participate and succeed in different aspects of educational, scientific and other types of activity and thus stimulating their responsibility (in contrast to accountability) for educational outcomes;
Organisation of an effective system of feedback between the administration of the university, the teaching staff, and the students;
Providing both students and teachers with opportunities for making choices of forms and types of activities, as well as opportunities for self-expression and creative work, including their participation in the development of the university educational environment;
Supporting teachers’ and students’ self-esteem and stimulating their positive professional competition by means of a rating (portfolio) system implementation;
Stimulation of interaction between teachers and students both inside the university educational environment and outside of it and their involvement in innovative activities.
The autonomy-oriented approach to the organisation of training in medical universities was seen as beneficial by all the study participants who emphasised the great value of students’ and teachers’ autonomy support in the educational setting of medical universities.
The summative evaluation of the study results suggests that the autonomy-oriented approach to the organisation of training in medical universities is potentially valuable in a number of ways.
First, it involves creation of autonomy-oriented informational-educational environment that comprises intellectual, cultural, methodological, technological resources and communication technology tools providing access to a wide range of educational resources and allowing for innovative and creative activity.
Second, it allows both teachers and students to take ownership of their sustainable personal and professional development  as well as to stay current in their fields through constant reevaluation of their own experience and reflective development in and beyond the university educational environment.
Our overall findings, based on the literature review results and the results of the practical part of our investigation, allowed us to prove our theoretical ideas concerning the benefits of the autonomy-oriented approach for the development of innovative training practices in medical universities of Russia.
Creation of the described complex of conditions will make it possible to implement the autonomy-oriented approach through stimulating recognition by teachers and students of their own leading role in the development of university educational environment as well as their personal responsibility and volition to overcome difficulties and develop their abilities and potential. These changes in turn will provide the transformations of teachers’ and students’ external locus of control into the internal one.
Providing an autonomous type of teacher’s behaviour, this approach will ensure teachers’ support of students’ autonomy, teachers’ role as facilitators and coordinators of the students’ discovery and creative learning. This will allow teachers to stimulate medical students’ intrinsic motivation to learn through making them know why to learn (demonstrating connections between learning and emotions or the practical application of knowledge and encouraging their initiative and curiosity), how to learn, and creating a relevant feedback system during training.
The autonomy-oriented approach makes both students and teachers active, reflective and critical educational environment actors who try to understand, rather than memorise the educational content. This benefit of the autonomy-oriented approach makes it close to the ideas of social constructivist philosophy and constructivism-based teaching [26, 27] and emphasises its holistic character.
The conducted research made it possible to draw the conclusion that application of the autonomy-oriented approach to the process of training in a medical school allows for transition from formal training to self-determined continuous personal and professional development of both students and teachers. Consequently, this makes higher education system responsive to the changes taking place in the modern Russian society and contributing to an accelerating paradigm shift toward personalised medicine.
Practical relevance of the study has been ensured through specifying the autonomy-oriented approach in higher education and defining a set of conditions, which are suggested to guide the implementation of this approach within the university educational environment. Outlining the characteristics of autonomy-oriented teaching in a medical university setting, the study allows for possible application of the autonomy-oriented approach in other educational contexts.
Several important study limitations need to be considered. First, this study used self-reported data, which may pose concerns around social desirability bias. However, various forms of training and communication allowed the study participants to respond using the full range of response options, yielding evidence against social desirability bias.
Second, the analysis of autonomy-oriented approach application in medical education presented in this paper is largely qualitative and is limited to the results of literature review as well as teaching and discussion practices among a small sample size of the study participants inside the university educational environment of KrasSMU. Studies targeting the broader higher medical education community might be able to provide quantitative analytics that could be used to reveal other possible aspects of autonomy-oriented approach implementation and its benefits for innovative development of higher medical education.
Conflict of interest
Conflict of interest statement: The author has no conflicts of interest to disclose.
Rogers CR. Freedom to Learn for the 80’s. Columbus, OH: Charles E. Merrill Publishing Company; 1983.
Brewer EW, Burgess DN. Professor’s role in motivating students to attend class [Internet]. J Ind Teach Educ. 2005;42(3):23–47. Available at: https://ir.library.illinoisstate.edu/jste/vol42/iss3/3
Reinders H, White C. 20 years of autonomy and technology: how far have we come and where to next? [Internet]. Language Learning & Technology. 2016;20(2):143–54. Available from: http://llt.msu.edu/issues/june2016/reinderswhite.pdf
Temiz T. Problem solving, creativity and constructivist-based teaching practice of preservice mathematics teachers [Internet]. Journal of Educational and Instructional Studies in the World. 2013;3(1). Available from: http://www.wjeis.org/FileUpload/ds217232/File/20_tugba_temiz.pdf
Marandi SS, Sadaghian S. A Shift into Autonomous Education [Internet]. Journal of English Language Teaching and Learning. 2016;17:75–92. Available from: http://elt.tabrizu.ac.ir/article_4961_d6d88774bfbc2866cf2b97f58c8e2038.pdf
Little D. Learning as dialogue: The dependence of learner autonomy on teacher autonomy [Internet]. System. 1995;23(2):175–81. Available from: http://eprints.teachingandlearning.ie/2753/1/Little%201995.pdf
Gavrilyuk OA. Autonomy as a core value of lifelong learning. Journal of Siberian Federal University. Humanities & Social Science. 2015;8(11):2283–90. https://doi.org/10.17516/1997-1370-2015-8-11-2283-2290