Medical education as an instance of situated learning

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

2. 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).

3. Introductions

4. 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.

5. 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.

6. Teaching Education research Clinical practice Administration

7. Technology enhanced enquiry learning Problem/ case based learning Workplace learning Personal & professional development Reflective Learning Cultural integration Emotional learning Admission, progression, and achievement Cohort studies Assessment UMAP MMSERG Communication education

8. 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

9. Current trends in medical education Slowly moving from an individual perspective to a collective perspective

10. 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

11. 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

12. 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

13. 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

14. 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’.

15. 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.

16. 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?

17. Situated learning theory in the medical education literature

18. 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’.

19. 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.

20. 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 ..

21. Model 1: Undergraduate medical education – in the workplace but not necessarily workbased Experience based learning

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. The Experience based learning (ExBL) model Medical school entrant “Make a difference”

29. The Experience based learning (ExBL) model Participation Medical school entrant “Make a difference”

30. The Experience based learning (ExBL) model Doctor Student Medical school entrant “Make a difference” Patient Participation

31. 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

32. 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

33. Participation as: Passive observer Active observer Actor in rehearsal Actor in performance Student Patient Doctor

34. The Experience based learning (ExBL) model Participation Medical school entrant “Make a difference” Process Challenge

35. The Experience based learning (ExBL) model Affective Participation Pedagogic Medical school entrant “Make a difference” Organisational Context Support Process Challenge

36. The Experience based learning (ExBL) model Interacting positively with students:Making 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

37. The Experience based learning (ExBL) model Affective Participation Pedagogic Medical school entrant “Make a difference” Organisational Context Support Process Challenge

38. 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

39. The Experience based learning (ExBL) model Affective Participation Pedagogic Medical school entrant “Make a difference” Organisational Context Support Process Challenge

40. 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

41. The Experience based learning (ExBL) model Affective Supported participation Pedagogic Medical school entrant “Make a difference” Organisational Context Support Process Challenge

42. The Experience based learning (ExBL) model Affective Supported participation Pedagogic Real patient learning Medical school entrant “Make a difference” Organisational Context Support Process Challenge

43. The Experience based learning (ExBL) model • 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 “Make a difference” Medical school entrant Real patient learning

44. The Experience based learning (ExBL) model Affective Supported participation Pedagogic Real patient learning Medical school entrant “Make a difference” Practical learning Organisational Context Support Process Challenge

45. The Experience based learning (ExBL) model Acquiring skills Applying knowledge Learning to learn “Make a difference” Medical school entrant Practical learning

46. 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

47. The Experience based learning (ExBL) model Affective Emotional learning Supported participation Pedagogic Real patient learning Medical school entrant “Make a difference” Practical learning Organisational Context Support Process Challenge

48. 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

49. 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 Context Support Process Challenge

50. 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 Context Support Process Challenge