Medical education as an instance of situated learning Tim Dornan, Pim Teunissen, Preeti Shah.

Medical education as an instance of situated learning

Tim Dornan, Pim Teunissen, Preeti Shah

Outline

• Introductions,• Current trends in medical education,• Situated learning in the medical education

literature,• Two models that instantiate situated

learning within medicine:– Experience Based Learning (ExBL),– Teunissen’s Framework for Understanding

Learning (FUL).

Introductions

Stages of medical education

• Access education,• ‘Undergraduate education’; UG or PG

entry; theory followed by more or less workbased learning in the workplace,

• Postgraduate education; workbased with a more or less explicit instructional component,

• Continuing education/development; variably workbased vs instructional.

MMS: Some facts and figures

• Five major academic or NHS sites,• Staff:

• 27 academic staff, including 1 visiting chair,• 8 doctoral students; 10 medical student

researchers; 7 doctors in training,• 10 contract research staff, • Various affiliates.

• Embedded in:• Primary and secondary care,• UGE, PGE, and CPD.

TeachingEducationresearch

Clinical practice Administration

Communication education

MMSERG

Admission, progression, and achievement

UMAP

Emotional learning

Cultural integration

ReflectiveLearning

Personal & professional development

Cohort studies

Assessment

Technology enhanced enquiry learning

Workplacelearning

Problem/case based

learning

Programmatic research

• Conducting theory-based research,

• Judicious selection of research topics rather than isolated, disjointed research,

• Followed by long-term systematic investigations,

• A series of studies that build and test theories from multiple perspectives.

Bordage 2007

Current trends in medical education

Slowly moving from an individual perspective to a collective

perspective

Ottawa conference 2008

Collective competence– Rethinking the discourse of competence in

the context of teamwork; Lorelei Lingard– Implications for the assessment of doctors;

Paul Hager

Lingard 2008

Individual Cognition

Our dominant learning

theories (adult learning,

reflective learning,

experiential learning) take

the learner as ‘active

agent’ at the centre of the

activity of learning

Bleakley 2006

Collectivist discourse

Competence is

a constantly evolving set

of multiple,

interconnected behaviors

achieved through

participation and

enacted in time and

space

Lingard 2008

Social Learning Theory

The competence of a community emerges through social interaction, shared experience, development of tacit knowledge, and innovation in response to situated needs.

Lave and Wenger 1991; Eraut 2000; Mittendorf 2006

Hager 2008

Under the influence of the mind-as-container metaphor, knowledge is treated as consisting of objects contained in individual minds, something like the contents of mental filing cabinets.”

Bereiter 2002, p. 179

Hager 2008

Crucial assumptions of ‘common-sense’ story shapethinking about learning and assessment in educationalsystems and policy documentsAssumptions such as:• ‘What is learnt is an independent thing or substance’,• ‘Learning is a kind of thing inside of learners’,• ‘Application as movement of a thing (learning) from• place to place’,• ‘Learning as a thing independent of both the learner and

the contexts in which it is acquired and applied’.

Hager 2008

Participation metaphor• Learning through participation in human

practices,• What is learnt is a complex social construction

that subsumes the individual learner,• Learning is no longer independent of the learner,• Learning is inherently contextual; both learning

and the learner evolve as contexts change,• Communal learning important, i.e. learning by

teams or organisations that is not reducible to individual learning.

Hager 2008

Conclusions• Recognise multi-facetted nature of learning,• Learning as a process of becoming, involving

both individuals and groups,• Individual not always the right unit of analysis,• Team work and group practice as hot issues in

medical practice,• What structures facilitate and value both

individual and group learning?

Situated learning theory in the medical education literature

Reviews

Many publications; eg

• Wooliscroft – UG medical education,

• Mann and Kaufman – How theory can inform practice,

• Swanwick – Informal PG learning; ‘From Cognitivism to Culturism’,

• Bleakley – ‘The message from teamworking’.

Four SL research programmes

• Lyon – Sydney, Au. Two papers exploring UG medical students’ learning in operating theatres,

• Sheehan and Wilkinson - Christchurch NZ. Two papers developing a model of workbased PG learning through participation,

• Teunissen et al – Amsterdam and Maastricht, NL. Three papers using multiple theoretical perspectives to understanding PG learning through participation,

• Dornan et al – Manchester, Maastricht, Dalhousie, UK/NL/Ca. Five papers exploring UG workplace learning.

Situated learning within MMS groupUnderstanding contexts, processes, and

outcomes within COPs to strengthen them• Lown, Carroll, Braidman and others; Medical students’ personal and

professional development within a COP,• Sanders, Vaughan, Wass; Cultural integration into a COP,• Pearson, Warren, Lown, Bundy; Emotional learning within COP,• Smithies, Capelli, Boggis and others; How a COP can define ILOs, • Graham, Dornan; Closing the loop between learners’ experiences of

community and teachers’ construction of community,• Shah, Dexter, Dornan; Mapping learning processes within COP in

order to reify and strengthen them,• Woolley, Isba; On-line case discussion within COP,• Regan, Braidman; Facilitated on-line learning within COP,• Shacklady, Smithson; Transitions along developmental trajectories,• Illingworth, Hart and others; Transferring competence within COP,• ExBL ..

Model 1: Undergraduate medical education – in the workplace but

not necessarily workbasedExperience based learning

The 19th century and earlier

The likely youth .. destined for a medical career .. was indentured to some reputable practitioner to whom his service was successively menial, pharmaceutical, and professional

He ran his master’s errands washed the bottles, mixed the drugs, spread the plasters, and finally, as the stipulated term drew towards its close, actually took part in the daily practice of his preceptor – bleeding his patients, pulling their teeth, and obeying a hurried summons in the night.

Abraham Flexner 1910

An academical system without the personal influence of teachers upon pupils, is an Arctic winter; it will create an ice-bound, petrified, cast-iron University, and nothing else

Sir William Osler 1906

Why is situated learning attractive?

• “Our original intention .. was to rescue the idea of apprenticeship”,

• “Learning .. concerns the whole person acting in the world”,

• “LPP does not take intentional instruction to be in itself the source or cause of learning”,

• “LPP is an analytical perspective”,

Lave and Wenger 1991

Why is situated learning attractive?

• “Newcomers (need) broad access to arenas of mature practice”,

• “Deeper sense of the value of participation .. lies in becoming part of the community”,

• Tension between self-replicating social community and one in a constant state of “learning, transformation, and change”,

Lave and Wenger 1991

The practicality of theory

A perspective is not a recipe; it does not tell you just what to do. Rather, it acts as a guide about what to pay attention to, what difficulties to expect, and how to approach problems

Wenger 1998

Expectations of a theory

1. Predict which approaches will be effective,

2. Create a framework for evaluating current practice,

3. Create a framework for new, untested theories,

4. Promote consistency in practice.

Mann 2004 quoting Laidley and Braddock

“Make a difference”

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The Experience based learning (ExBL) model


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Participation



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Student

Participation

Doctor

Patient


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Student

Participation

Doctor

Patient

Passive observerActive observer

Actor in rehearsalActor in performance


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Student

Participation

Doctor

Patient

Passive observerActive observer


Stu

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Doctor

Student Patient

Participation as:Passive observerActive observer



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Participation


Process Challenge


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Participation


Process Challenge

Affective

Pedagogic

Organisational

Context Support


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Interacting positively with students:

Making them welcomeHaving a warm team climate

Drawing students into the teamEncouraging reticent students

Stopping students being “spare wheels”

Not belittlingSharing


Affective support


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Participation


Process Challenge

Affective

Pedagogic

Organisational

Context Support


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nt Making participation possibleFamiliarity with the curriculum

Answering questions despite PBL!Suggesting objectives

Not letting “risk” stand in the way“Teaching” knowledge and skills

Creating tasks


Pedagogic support


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Participation


Process Challenge

Affective

Pedagogic

Organisational

Context Support


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Making placements workCurriculum structure &

sequence Placements that maximise

participationContinuity of attachment

Group sizePlacement timetable


Organisational support


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Supported participation


Process Challenge

Context Support

Affective

Pedagogic

Organisational


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Process Challenge

Context Support

Affective

Pedagogic

Organisational

Realpatientlearning


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Real patient learning

Experiencing .. reality

•“Why we’re here”

•“Best way to learn”

•“Seeing things for real”

•“Medicine in action

rather than theory”

•“Linking"

Gaining ..

•Positive feelings

and identity

•Cognitive structuring

and strengthening

•Reality

•(Social) competence


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Process Challenge

Context Support

Affective

Pedagogic

Organisational

Realpatientlearning

Practicallearning


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Acquiring skillsApplying knowledge

Learning to learn


Practical learning


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nt Learning to learnHow to manage time

How to behave in workplacesWhat to expect from clinical staff

How to handle difficult situationsHow to make sensible choices

How to learn reflectively


Practical learning


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Process Challenge

Context Support

Affective

Pedagogic

Organisational

Realpatientlearning

Practicallearning

Emotionallearning


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State of mind: Developing a sense of identity

Building confidenceSustaining motivation

Feeling rewarded


Emotional learning


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Process Challenge

Context Support

Outcome Practical and emotional (real

patient) learning

Affective

Pedagogic

Organisational

Realpatientlearning

Practicallearning

Emotionallearning


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Process Challenge

Context Support

Outcome Practical and emotional (real

patient) learning

Affective

Pedagogic

Organisational

Realpatientlearning

Practicallearning

Emotionallearning


Model 2: Postgraduate medical education – workbased

Perspectives on learning

Blueprints of a building

Towards a conceptual framework

• Research on learning in PME

• Insights from various disciplines

– Legitimate peripheral participation– Communities of Practice– Cognitive Load Theory– Social psychology

Model 2: Workbased postgraduate medical education

From activity to social practices and culture

Individual understanding

Discussion …

Medical education as an instance of situated learning Tim Dornan, Pim Teunissen, Preeti Shah.

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