Medical education as an instance of situated learning

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Medical education as an instance of situated
learning

• Tim Dornan, Pim Teunissen, Preeti Shah

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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),
• Teunissens Framework for Understanding Learning
  (FUL).

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Introductions
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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.

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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.

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Teaching
Education research
Clinical practice
Administration
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Admission, progression, and achievement
Cohort studies
Assessment
UMAP
MMSERG
Communication education
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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
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Current trends in medical education

• Slowly moving from an individual perspective to a
  collective perspective

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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

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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

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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

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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

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Hager 2008

• Crucial assumptions of common-sense story shape
• thinking about learning and assessment in
  educational
• systems and policy documents
• Assumptions 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.

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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.

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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?

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Situated learning theory in the medical education
literature
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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.

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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.

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Situated learning within MMS group

• Understanding 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 ..

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Model 1 Undergraduate medical education in the
workplace but not necessarily workbased

• Experience based learning

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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 masters 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

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• 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

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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
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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
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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
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Expectations of a theory

• Predict which approaches will be effective,
• Create a framework for evaluating current
  practice,
• Create a framework for new, untested theories,
• Promote consistency in practice.

Mann 2004 quoting Laidley and Braddock
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The Experience based learning (ExBL) model
Medical school entrant
Make a difference
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The Experience based learning (ExBL) model
Participation
Medical school entrant
Make a difference
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The Experience based learning (ExBL) model
Doctor
Student
Medical school entrant
Make a difference
Patient
Participation
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The Experience based learning (ExBL) model
Doctor
Passive observer Active observer Actor in
rehearsal Actor in performance
Student
Medical school entrant
Make a difference
Patient
Participation
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The Experience based learning (ExBL) model
Doctor
Passive observer Active observer Actor in
rehearsal Actor in performance
Student
Case complexity
Student seniority
Medical school entrant
Make a difference
Patient
Participation
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Doctor
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The Experience based learning (ExBL) model
Participation
Medical school entrant
Make a difference
Process Challenge
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The Experience based learning (ExBL) model
Affective
Participation
Pedagogic
Medical school entrant
Make a difference
Organisational
Process Challenge
Context Support
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The Experience based learning (ExBL) model
Interacting positively with studentsMaking
them welcome Having a warm team climate Drawing
students into the team Encouraging reticent
students Stopping students being spare
wheels Not belittling Sharing
Make a difference
Medical school entrant
Affective support
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The Experience based learning (ExBL) model
Affective
Participation
Pedagogic
Medical school entrant
Make a difference
Organisational
Process Challenge
Context Support
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The Experience based learning (ExBL) model
Making participation possible Familiarity with
the curriculum Answering questions despite
PBL! Suggesting objectives Not letting risk
stand in the way Teaching knowledge and
skills Creating tasks
Make a difference
Medical school entrant
Pedagogic support
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The Experience based learning (ExBL) model
Affective
Participation
Pedagogic
Medical school entrant
Make a difference
Organisational
Process Challenge
Context Support
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The Experience based learning (ExBL) model
Making placements work Curriculum structure
sequence Placements that maximise
participation Continuity of attachment Group
size Placement timetable
Make a difference
Medical school entrant
Organisational support
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The Experience based learning (ExBL) model
Affective
Supported participation
Pedagogic
Medical school entrant
Make a difference
Organisational
Process Challenge
Context Support
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The Experience based learning (ExBL) model
Affective
Supported participation
Pedagogic
Real patient learning
Medical school entrant
Make a difference
Organisational
Process Challenge
Context Support
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The Experience based learning (ExBL) model

• Experiencing ..
• reality
• Why were 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

Make a difference
Medical school entrant
Real patient learning
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The Experience based learning (ExBL) model
Affective
Supported participation
Pedagogic
Real patient learning
Medical school entrant
Make a difference
Practical learning
Organisational
Process Challenge
Context Support
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The Experience based learning (ExBL) model
Acquiring skills Applying knowledge Learning to
learn
Make a difference
Medical school entrant
Practical learning
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The Experience based learning (ExBL) model
Learning to learn How to manage time How to
behave in workplaces What to expect from clinical
staff How to handle difficult situations How to
make sensible choices How to learn reflectively
Make a difference
Medical school entrant
Practical learning
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The Experience based learning (ExBL) model
Affective
Emotional learning
Supported participation
Pedagogic
Real patient learning
Medical school entrant
Make a difference
Practical learning
Organisational
Process Challenge
Context Support
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The Experience based learning (ExBL) model
State of mind Developing a sense of
identity Building confidence Sustaining
motivation Feeling rewarded
Make a difference
Medical school entrant
Emotional learning
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The Experience based learning (ExBL) model
Affective
Emotional learning
Supported participation
Pedagogic
Real patient learning
Medical school entrant
Make a difference
Practical learning
Organisational
Outcome Practical and emotional (real patient)
learning
Process Challenge
Context Support
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The Experience based learning (ExBL) model
Affective
Emotional learning
Supported participation
Pedagogic
Real patient learning
Medical school entrant
Make a difference
Practical learning
Organisational
Outcome Practical and emotional (real patient)
learning
Process Challenge
Context Support
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The Experience based learning (ExBL) model
Affective
Emotional learning
Supported participation
Pedagogic
Real patient learning
Medical school entrant
Make a difference
Practical learning
Organisational
Outcome Practical and emotional (real patient)
learning
Process Challenge
Context Support
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Model 2 Postgraduate medical education
workbased
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Perspectives on learning
Blueprints of a building
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Towards a conceptual framework

• Research on learning in PME
• Insights from various disciplines
• Legitimate peripheral participation
• Communities of Practice
• Cognitive Load Theory
• Social psychology

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Model 2 Workbased postgraduate medical education
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From activity to social practices and culture
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Individual understanding
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Discussion