Archives of Medicine and Health Sciences

: 2019  |  Volume : 7  |  Issue : 2  |  Page : 267--272

Utility of concept mapping as a tool to enhance metacognitive teaching and learning of complex concepts in undergraduate medical education

Aye Aye Khine1, Anthonio Oladele Adefuye2, Jamiu Busari3,  
1 Division of Chemical Pathology, Faculty of Medicine and Health Sciences, National Health Laboratory Services, Stellenbosch University, Cape Town; Division Health Sciences Education, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
2 Division Health Sciences Education, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
3 Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands

Correspondence Address:
Dr. Anthonio Oladele Adefuye
Division Health Sciences Education, Faculty of Health Sciences, University of the Free State, PO Box: 339, Bloemfontein 9301
South Africa


The inherent complexity in the nature of medical practice necessitates that medical practitioners have to be equipped with a sound foundation in their knowledge as well as in their ability to think, act, reflect, evaluate, and synthesize thoughts at the metacognitive level. Furthermore, medical students are required to learn meaningfully and become lifelong learners. Prior study has shown that medical students struggle to learn and understand complex concepts in the curriculum. Metacognitive skillfulness has been reported to influence the achievement of deeper understanding and promote transition from a dependent learning state to that of self-directed learner. Concept mapping (CM) is an example of such a metacognitive strategy that can promote meaningful learning through advanced critical thinking and improved reasoning in students. We believe that CM is an effective educational strategy that can be used to teach complex concepts in medical education and provide a proposal on how to effectively incorporate CM into a teaching curriculum for medical students.

How to cite this article:
Khine AA, Adefuye AO, Busari J. Utility of concept mapping as a tool to enhance metacognitive teaching and learning of complex concepts in undergraduate medical education.Arch Med Health Sci 2019;7:267-272

How to cite this URL:
Khine AA, Adefuye AO, Busari J. Utility of concept mapping as a tool to enhance metacognitive teaching and learning of complex concepts in undergraduate medical education. Arch Med Health Sci [serial online] 2019 [cited 2020 Jun 4 ];7:267-272
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Globally, the undergraduate medical education curriculum has been transformed from content-based to outcome-based education (OBE) models.[1],[2] With this transition, medical curricula have been re-designed with much emphasis on the alignment of learning objectives to learning outcomes, which can be translated to competencies. The inherent complexity in the nature of medical practice and health care delivery, together with the ever-changing needs of the patients, necessitates that medical practitioners have to be equipped with a sound foundation in their knowledge and ability to think, act, reflect, evaluate, and synthesize thoughts at a higher-order cognitive (metacognitive) level. Furthermore, medical students are required to learn meaningfully and become lifelong learners.[3] Prior studies have shown that medical students struggle to learn and understand complex concepts in the curriculum.[4] Metacognitive skillfulness has been reported to influence the achievement of deeper understanding[5] and promote transition from a dependent learning state to that of self-directed learner.[6]

The notion of metacognition arose in the context of information processing studies in the 1970s[7] and has been described by Flavell as “one's knowledge concerning one's own cognitive processes and products or anything related to them.”[8] In 1990, Baird gave the following succinct definition that “metacognition refers to the knowledge, awareness, and control of one's own learning.”[9] Metacognitive theory integrates one's knowledge about cognition and regulation, and three types of metacognitive theories have been distinguished. These theories have been described as (1) tacit, explicit, but informal, (2) explicit, and (3) formal.[10] Metacognitive skills are thought to play a significant role in many types of cognitive activity, for example, in the verbal communication of information, verbal comprehension, reading comprehension, writing, perception, attention, memory, and problem-solving skills.[11] Although metacognitive skills develop slowly, it has been asserted that it is possible to enhance metacognition via classroom instructions.[12],[13] Concept mapping (CM) has been identified as a valuable way of achieving this by the promotion of meaningful learning as a metacognitive strategy.[14]

 Concept Mapping and the Concept-Based Curriculum

Gunstone reiterates that all learners are metacognitive and that any pedagogical goal should be to enhance metacognition.[15] He suggests that enhanced metacognition is a learning outcome in itself, which could have a critical impact on the achievement of content-based learning outcomes.[15] Over the years, several attempts have been made to teach metacognitive skills. Often called “study skills” programs, these approaches rest on the assumption that students are able to transfer these skills from one context to another.[7] Although the success and the efficacy of these programs in the context of higher education are limited, greater success has been achieved with metacognitive development in integrated contexts. For example, the use of metacognitive strategies such as concept-mapping, peer discussions, and an emphasis on qualitative reasoning has been shown to engender moves to deep approaches to learning (meaningful learning).[16]

Concept maps (CMs) were introduced by Novak and Gowin as a way of assessing children's understanding of science with graphical tools to organize and represent knowledge.[17] CMs have typically been used in reading activities to aid students' comprehension of texts or to examine students' critical thinking ability by asking them to construct their own concepts to address specific questions.[18] CMs demonstrate how a student understands a complex topic where critical points of the whole picture and their relationships are demonstrated in a simple concept diagram or schematic representation.

 The Concept-Based Curriculum Model Versus Outcome-Based Education Curriculum Model

The OBE model is a performance-based model and offers a powerful way of changing and managing medical education.[19] However, OBE-based curriculum design has been critiqued for its sole focus on learning or exit-level outcomes and discouraging higher cognitive achievement (e.g., conceptual development).[19],[20] According to Posner et al., a fundamental activity in the learning process is conceptual change, which involves the learner capturing new conceptions, restructuring existing conceptions, or exchanging one conception for another.[21] These activities are reflective of constructivist view of learning (constructivism) and are also entrenched in the notion of metacognition (metacognitive theory) since teaching for conceptual change is considered explicitly metacognitive.[22]

Conceptualization is the way one understands and internalizes the new knowledge and applies it in the relevant context. In this notion, conceptualization seems better suited than attaining exit-level outcomes to reflect continuous learning of knowledge and skills as the contexts change in one's life and practice of work. This has led to the concept-based curriculum model.[20] Concept-based curriculum and instruction is a three-dimensional design model that frames factual content and skills with disciplinary concepts, generalizations, and principles.[23] Traditional outcome-based curriculum models, however, refer to what students must know and be able to do (knowledge and application) but fail to highlight construction of concepts and adaptation as a third expectation. A concept-based curriculum model by design includes the importance of stimulating critical thinking in its conceptual dimension. The model differentiates between what students must know factually, understand conceptually, and are able to do, strategize, adjust, and collaborate.[20] The original idealists of this curricula model predict that concept mapping will emerge as one of the approaches of learning and teaching in the concept-based curriculum.[20]

 Cm and the Teaching Curriculum

There is extensive evidence that drawing a CM requires students to engage in higher cognitive functions.[24] In a study aimed at exploring students' journey toward conceptual understanding during an undergraduate medical course, Weurlander et al. reported that the visual and tactile experiences during practical course were important for students to make meaning of the theoretical knowledge.[4] Similarly, it is believed that the visual and tactile experiences when drawing a CM can foster meaningful understanding of theoretical knowledge. Based on this premise, we believe that CM is an effective educational strategy to teach complex concepts in the undergraduate medical curriculum to students.

 Case Study: Chemical Pathology as a Subject Model

The focus of undergraduate teaching of chemical pathology is to enable medical graduates aptly apply knowledge of the normal (human physiology), the abnormal (pathology), and medical biochemistry to rationally select and interpret laboratory tests for diagnostic and monitoring purposes. This process requires a broad knowledge of the factors that may affect test results and a solid foundation in how to manage the decision-making process and effective use of biochemical investigations.[25] To achieve this, trainees have to develop higher-order cognitive (metacognitive) skills during their training, meaning that they also have to engage in deep cognitive learning rather than rote learning. In addition, textbooks in clinical biochemistry/chemical pathology use pathways and linkages in explaining concepts and applications in disease processes, and it has been observed that students with rote-learning habits have shown to struggle in understanding complex concepts in the subject (personal experience from more than 10 years in teaching the discipline-AAK).

Using chemical pathology as a case study, we shall describe how CM can be incorporated into a teaching curriculum as an educational strategy and also provide an illustration of how it can enhance metacognitive teaching and learning of complex concept in undergraduate medical education. We shall describe this approach with the aid of the following the steps:

Step 1: Designing a focus question or task on a topic in chemical pathology and use CM to address the learning objectives [Figure 1]Step 2: Design a clinical scenario related to the topic in Step 1 and use CM to foster problem-solving skills [Figure 2]Step 3: Identify the alignment of learning outcomes with the revised Bloom's taxonomy [Table 1].{Figure 1}{Figure 2}{Table 1}

Step 1: Focus question or task in chemical pathology on chronic kidney disease

Focus question

Using a concept map, explain the various clinical presentations observed in chronic kidney disease and elucidate the various laboratory tests that can be helpful to confirm a diagnosis of renal pathology. Include the following learning objectives or pointers in your map: normal kidney functions; metabolic or biochemical changes seen in renal dysfunction; how patient present clinically; and laboratory tests appropriate to confirm renal dysfunction.

In chemical pathology, how kidneys function is one basic element in the topic of chronic kidney disease. Students are to describe the various physiological function of the kidney (factual knowledge) and conceptualize how each function is impaired in renal pathology (conceptual knowledge). Each pathophysiology concept then leads to how patient will present clinically and what laboratory tests should be requested to confirm the impression of a possible or type of renal pathology (procedural knowledge). Students can sketch out concepts first and attempt to connect the concepts as prepositions and then link the prepositions and this would form a first or initial map.[26] They can then add more concepts or layers as they continue reading the material and engage with the learning objectives given by the facilitator. Improvements on the first map can be taken as second map, and when compared with the copy of the first and second map, students can realize their own development in cognition. Students can self-evaluate their maps to ensure all learning objectives are covered and relationships are identified and shown. Student's map or maps can be compared to the facilitator's map [Figure 1] or can be evaluated by a criterion rubric. Students may realize gaps in their maps and are allowed to improve on it. These reflect metacognitive knowledge.

After reviewing the map, a clinical case scenario should be given to assess students' cognitive level in problem-solving.

Step 2: Clinical case scenario

Clinical scenario

A 68-year-old female patient with a long-standing history of diabetes presents at a medical outpatient clinic with progressive tiredness, bone pain, headache, and frequency in urination, especially at night (nocturia). On examination, her blood pressure was 160/95 mmHg and pallor was evident. Her face was puffy and swellings under the eyes were observed. Her skin was dry.


What is the most likely diagnosis in this patient and why?What caused this condition in this patient and how?Explain the patient's signs and symptoms using pathophysiology in this diseaseWhat laboratory tests would you request to confirm this?What abnormalities do you predict in the tests?

Students are to evaluate this information and synthesize a concept on what could be wrong with this patient, formulate which laboratory tests that should be selected to confirm the suspected condition, and forecast what abnormalities can be expected in these tests. Then, the actual test results are given to the students on which they are to interrogate and assess their own answers/decisions so far – the reflection phase. The facilitator then explains how the final diagnosis was made in this case and students are to reflect on their performance. Students may revisit their maps to add or improve on the concepts or linkages after acquiring more knowledge from solving the case. To demonstrate a higher order of meta-cognitive learning, students' can be asked to critique each laboratory test on how it adds value to the final diagnosis and monitoring of the patient, limitations of the tests, possible interference, and what precautions are there to take when interpreting results.

When constructing their concept maps, students may draw a flowchart for the case linking key findings in the history and clinical examination to which laboratory tests to be done and select the tests in a cost-effective manner, i.e., start with the least expensive test that can provide the most important information as a first-line test. Further, developing the concept map, students can show predictions of the laboratory results and develop idea of how to interpret each result to reach clinical decisions. Boxes can be added to show benefits and limitations, factors that may preclude the accuracy of the results, and how to avoid them. [Figure 2] is the concept map drawn by the authors to address the questions asked in the clinical case scenario.

Step 3: Concept mapping and the cognitive domain in the revised Bloom's taxonomy

Taxonomy in learning refers to the hierarchical arrangement of assessment tasks and learning objectives aligned to the level of cognition.[27] The Bloom's taxonomy of learning is composed of two dimensions: domain and level. A domain is a realm of human experience in which learning can occur.[28] The domains in the Bloom's taxonomy of learning includes cognitive, psychomotor, affective, interpersonal, and perceptual domains.[28],[29],[30] The cognitive domain focuses on an individual's intellectual abilities, and it is categorized into two main dimensions, namely process and knowledge.[28],[29] The cognitive process dimension consists of the following levels: remember, understand, apply, analyze, evaluate, and create (listed from lowest to highest). The cognitive knowledge dimension is concerned with the types of knowledge, and it includes factual knowledge, conceptual knowledge, procedural knowledge, and metacognitive knowledge (listed from concrete to abstract).[28],[29],[30] All domains of knowledge (or “skills”) can be represented in concept maps.[31] [Table 1] shows the alignment of the concept mapping for the chronic kidney disease topic and the clinical case scenario with the revised Bloom's taxonomy.


Medical undergraduates are required to learn and attain deeper understanding of complex concepts during their training. To achieve this, students need to develop higher-order cognitive (metacognitive) skills such as constructive analysis and synthesis of concepts in the learned subject. Arguably, one of the tasks where higher-order cognitive function can be developed is cognitive visualization, which is making “thinking” visible (visible thinking). An example of a technique for doing this is the use of concept maps (CMs), which displays conceptual knowledge by an arrangement of labeled boxes depicting concepts and the relationships between those concepts by lines and arrows.[32] There is extensive evidence that drawing a concept map requires students to engage in higher cognitive functions, to engender meaningful learning and deeper understanding of learned subject, and to promote transition from a dependent learning state to that of self-directed learner.[24]

We believe that the use of CM as a pedagogical tool in teaching and learning complex concepts in undergraduate medical education will enable higher-order cognitive development and foster meaningful learning. It will also assist medical students to advance their skills in critical thinking and qualitative reasoning.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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