Clinical training doesn’t necessarily result in learning

The difficulty and challenges to learn in clinical settings

Quote: My generation was never explicitly taught how to think as clinicians…Rarely did an attending explain mental steps…
Quote: My generation was never explicitly taught how to think as clinicians…Rarely did an attending explain mental steps…

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 definition shown in image but written below this image
Learning definition shown in image but written below this image

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.

The instructor’s dilemma

Image of a working helping another worker learn how to use equipment
Image of a working helping another worker learn how to use equipment

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

Image for post
Image for post

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.

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 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 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.

  • 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.


  • 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

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Gary is a speaker, author, researcher, and leadership futurist.

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