LEARNING

Dear Colleague,

I would recommend reading the attachment dealing with the above I got from Nancy Redfern.
Regards,
Shaz.
<<Education - basic concepts.doc>>

The Challenge of Delivering Professional Medical Education. 

How we learn 

Professional education is a mixture of learning from books and lectures (academic context), practical clinical experience (practical context) and learning to connect the two from discussions on lists or in meetings (organisational context)¹.   Educators should guide trainees in acquiring the relevant range and depth of academic knowledge, learning to apply this to practical clinical situations and to use necessary specialist language.  By the time they finish training, trainees must have developed good professional judgment – practical wisdom, about what can and should be achieved.  

Knowledge is said to be context specific¹; learning acquired in one context has to be transformed (or re-learned) to make it useful in a different situation.  Transferring ideas from one context to another takes time and effort and there are no guarantees that trainees will be able to do this. Someone who is good at passing exams (academic context) may find it difficult to apply to apply this clinically (practice context).  In an 'off the job' course, there is so much to cover that little time is spent on each topic.  Trainees are left to work out the practical implications of an idea, and how to incorporate it into their clinical practice.  Some learning occurs when they come across a concept in a lecture or book, but more happens when the idea is used in supervised clinical practice³.   Thus, trainees need sufficient variety of experience to ensure they become proficient in handling the routine and quick to recognise and manage the unexpected or unusual.   

Using theoretical knowledge in practice involves four processes; replication, application, interpretation and association². Replication and application are only used in the early phases of trying to master something new.  Learning a new technique or changing the way one manages a clinical situation, ideally needs five components, theoretical input, demonstration of skills or behaviour, practice in simulated settings with structured feedback, practice in clinical settings and structured and open-ended feedback about performance³.  Although this structure is followed for some training, (e.g. ALS courses), much experience is acquired in a less organised way, on teaching lists, where learning is as much opportunistic as planned.  Teaching ward rounds/outpatients/list etc are mostly used to discuss interpretation and association of ideas about practical management of the patient, rather than for mastering new techniques by watching, experimenting, reviewing performance and assimilating new practices.   

Added to this, practical "know-how" is usually personal. We all have individual preferences and each trainer's interpretation is different, exposing the trainee to a variety of experience.  Practical knowledge is usually private, routines learned through experience and not things we talk about. Asked why s/he does something in a particular way, the experienced practitioner will often reply 'I don't know, I just do.' It is difficult to deconstruct and re-assemble professional know-how we use implicitly, and transform it from practical knowledge to something we can talk about (organisational context).   So practical knowledge is difficult to teach, learn and assess.   

Eraut¹ divides practical knowledge into 6 categories.  These can be useful in identifying in more detail what the trainee might find difficult, and providing a language to discuss what one observes. 

Eraut;s categories are

1. Knowledge about people,
• acquiring accurate information – remembering the typical as well as the unusual
• knowing how different people might react
• making accurate authentic judgements about people
2. Situational knowledge

• reading a situation,
• getting on with people,
• recognising and adapting to prevalent norms

      3. Knowledge of practice

• knowing policies and practices and using them appropriately
• applying academic knowledge

      4. Conceptual knowledge

• the individual's set of academic and practical concepts used to analyse and discuss practical clinical problems; remembered as lists or complex frameworks.

(e.g.  The concept of what constitutes a good doctor, formed early in our career, which we tend unwittingly to emulate, sometimes even in inappropriate circumstances.)

      5. Process knowledge

• how to do things

      6. Control knowledge – (akin to emotional intelligence (Goleman))

• Self-awareness & sensitivity
• Self-management e.g. prioritisation, delegation
• The ability to reflect and self-evaluate - Knowing one's strengths & weaknesses
• The gap between what one says and what one does

 

Understanding each other 

To get the most from a practical teaching session such as a clinic, ward round, or list, both expert and learner need interpersonal and communication skills. Egan⁴ describes these as the skills of the explainer (getting the messages across), of the understander (capturing fully the messages of others), and of the conversation manager (turn taking, connecting and mutual influencing).  Each needs to explore what is in the other person's mind and integrate new ideas by making connections with what is already known, (assimilating it into current frameworks), or by making changes to frameworks (accommodating the learner's frameworks) to better fit newly acquired information⁷. A trainee has to explain what s/he already knows, how it is structured, and how they see the new idea.  The trainer has to explain the new idea and explore how the trainee sees this fitting into or changing his/her existing understanding, and any misunderstandings.  

Both should be open to the other's ideas and to changing their own because of what they hear. Unless the trainee is completely bewildered, s/he will tend to go along with what is said -so as not to seem foolish.  The trainee reports back what s/he thinks the trainer wants to hear – i.e. that he or she is following the discussion, and thus the trainer gains a false impression of the trainee's understanding.  The trainer, too, may think he understands the concept, but find his grasp rather weaker under the scrutiny of the trainee's questions³. So barriers exist for both trainer and trainee in relating to each others' ideas. 

Then there is the matter of willingness to learn.  The trainee comes with a set of conceptual frameworks – his or her personal interpretation of how academic ideas relate to his/her work.  Learning involves abandoning some of these practices and routines and understanding, accepting and internalising new ideas.  This is a daunting prospect; changing practice involves deskilling, the possibility of looking foolish, potential risk to patients, information overload, mental strain and no certainty that the new way will be more functional than the old.  It is no surprise that some trainees are cautious about change, perhaps appearing to adopt new practices when working with consultants but reverting to old habits when working alone.  

References

1 Eraut M  (1994) Developing Professional Knowledge & Competence London The Falmer Press  

2 Broudy  HS, Smith BO and Burnett J. (1964)  Democracy and excellence in American Secondary Education.  Chicago Rand McNally 

3 Joyce BR & Showers B (1980 )  Improving in-service training; the messages of research  Educational Leadership 37 pp 379-85 

4 Egan G  (2002)  The Skilled Helper  California. Brookes Cole  
 

Nancy Redfern

Sept 06