Clinical training doesn’t necessarily result in learning
The difficulty and challenges to learn in clinical settings
Jerome Groopman, the author of How Doctors Think, explains that learning medicine was catch-as-catch-can. He compares residents observing attendings (or senior physicians who teach) to medieval apprentices observing master craftsmen. He writes, “somehow the novices were supposed to assimilate their elder’s approach to diagnosis and treatment.”
How we learn
People learn a wide range of tasks. They learn habits, both good and bad. They learn skills such as operating a forklift or a smartphone. They learn theories, beliefs, and even emotions. Sometimes learning is deliberate while other times it’s unconscious.
Learning involves a change in behavior, but it is more than that. Merriam-et al. define learning this way:
Learning is a process that brings together cognitive, emotional, and environmental influences and experiences for acquiring, enhancing, or making changes in one’s knowledge, skills, values, and worldviews.
Larkin reminds us that while incidental learning can occur with any experience, not all experiences have intentional learning goals. Larkin uses the label intentional learning to refer to cognitive activities that have learning as the goal.
Learning in a clinical setting
Clinical training has a unique instructional system. Medical facilities tend to pay learners as employees who work under the auspices of a clinical expert. The clinical expert happens to be their instructor. At times, it’s unclear when the new professionals function as employees and when as learners.
Consider Dr. Samantha Jones, a cardiologist attending. Dr. Jones manages the quality care of patients and the instruction of residents. Often, Dr. Jones focuses exclusively on a patient’s presenting problem but leaves residents to figure out on their own what they learn by observing how she works with the patient. At other times, Dr. Jones critiques the residents’ knowledge and observations to make explicit what the residents should learn from a specific case.
Residents may fail to appropriately learn due to a lack of information. They may not even reflect upon one of Dr. Jones’s cases from a learning perspective. As expressed in the opening, learning habitually is catch-as-catch-can.
The instructor’s dilemma
In Most Effective and Responsible Clinical Training Techniques in Medicine, I discuss various clinical dilemmas. One dilemma I don’t discuss is the instructor’s dilemma. Instructors struggle with two competing directives: focus on quality patient care and focus on quality instruction.
Focus more on quality patient care at the expense of instruction
When instructors emphasize quality patient care and de-emphasize instruction, they treat learners as employees who assist instructors with patient care. Instructors give minimal training and may unconsciously expect learners to figure out on their own cognitive processes and mindset needed to become experts. If learners can’t figure this out, then some instructors might conclude that the learners picked the wrong specialty and shouldn’t become this type of clinical specialist.
Focus more on instruction at the expense of quality patient care
Sadly, the other extreme of this dilemma happens as well. James A. Farmer Jr., an educational consultant to the American Academy of Orthopaedic Surgery (AAOS) and my graduate-school mentor, shared with me a story about Dr. Johnson (not his real name), an orthopaedic attending. Dr. Johnson wanted to humble Dr. Omar, a brilliant but overconfident and arrogant resident. He told the resident to lead a surgical procedure. While the resident hadn’t practiced this particular procedure before, he had assisted Dr. Johnson once. Dr. Johnson knew that the resident would encounter a complication, but he allowed Dr. Omar to proceed without warning. When the procedure went wrong and caused damage to the patient, Dr. Johnson took over, scolded Dr. Omar for his technical incompetence, and then showed the resident what he should have done. Even though the resident learned from the experience, Dr. Johnson did this at the expense of the patient’s health. Farmer calls unethical lessons like this guided shaming.
Dilemma resolution: syntonic and dystonic
Resolving the instructor’s dilemma requires doing both extremes. Quality patient care must be primary, or what I call the syntonic choice of a dilemma, and quality instruction must be secondary, or what I call the dystonic. To do both effectively, instructors need to be trained on effective instructional techniques and continuously develop their instructional capabilities. Doing so not only improves the quality of instruction for learners, but instructors will inadvertently discover that they become better at providing quality care for their patients.
Leveraging the clinical specialist and the instructor mindsets
Effective instructors have the mindset of an expert clinical specialist and the instructor mindset. Part of the instructor mindset is to consider every clinical experience as an opportunity for learners to develop new knowledge or to practice a procedure or skillset.
For Nesher (1989), all instruction is “goal-directed, intentional, and conscious activity and therefore amendable to rational analysis and critical consideration” (187). Instructors accomplish learning goals by guiding, shaping, and supporting novice learning until the instructor’s efforts are no longer needed (Brown and Palincsar, 1989). The more instructors intentionally instruction, the more likely learners will successfully accomplish their clinical training.
Prior experience awareness
Instructors need to recognize that when learners begin a clinical training program, they don’t start as empty vessels: their experiences and speculation contribute to preconceived and naive understanding about what the clinical specialist’s mindset is. Resnick summarizes this succinctly:
People do not come as empty vessels to learning. In almost any domain, even beginners carry with them ideas of how things work and frameworks for interpreting new information…People are sometimes unaware of having them but, nevertheless, use them as framework for interpreting situations and acting in them.
For example, while I’m not a sports-medicine expert, I have a naive sense of what’s involved in providing patient care for sports injuries. If I want to become a sports-medicine specialist, I’d have to either give up or change my naive beliefs.
Instructors need to be aware of where learners are developmentally (in becoming a type of specialist) and anticipate misconceptions that they could have about the clinical specialty and what they need to develop to become a clinical expert.
Three components of an instructional theory
In “On the Nature of Competence,” Gelman and Greeno (1989) describe Glaser’s three components needed for a theory of instruction. Before working with learners, clinical instructors need a theory about:
- The knowledge, skills, and mindset needed for learners to become a clinical specialist.
- The knowledge, skills, and mindset that learners have when starting clinical training
- The instructional process and techniques needed to transition learners from their initial state to the desired state of clinical specialty expertise
The third bullet point includes having instructors consider the instructional environment and related constraints that affect how learners develop their specialty expertise.
References
The following bullet list references are sourced from Knowing, Learning, and Instruction: Essays in Honor of Robert Glaser (Psychology of Education and Instruction Series) (Ed L. B. Resnick). Hillside NJ: Lawrence Erlbaum Associates, Inc.,1989.
- Brown, A. L., and A. S. Palincsarin. “Guided, Cooperative Learning and Individual Knowledge Acquisition” 393–451.
- Gelman, R. and J. G. Greeno. “On the Nature of Competence: Principles for Understanding in a Domain” 125–186.
- Larkin, J. H. “What Kind of Knowledge Transfers?” 283–305.
- Nesher, P. “Microworlds in Mathematical Education: A Pedagogical Realism” 187–215.
- Resnick, L. B. “Introduction” 1–24.
Groopman, Jerome. How Doctors Think. Boston: Houghton Mifflin Company, 2008.
Merriam, S. B., R. S. Caffarella, and L. M. Baumgartner. Learning in Adulthood: A Comprehensive Guide. San Francisco: Jossey-Bass, 2007.
Notations
- This is an excerpt from the second edition introduction of my book, Most Effective and Responsible Clinical Training Techniques in Medicine.
- For the last image in this blog, I purchased the usage rights from Shutterstock. Please do not use these images without purchasing usage rights.
About the author
Gary is a Leadership Author, Researcher, Consultant, and Podcast Guest. His latest book, What the Heck Is Leadership and Why Should I Care?, is available in paperback, eBook, and audiobook. You can learn more about Gary and his other books at https://www.garyadepaul.com.
