Medicine As a Community of Practice: Implications for Medical Education Richard L

Perspective

Medicine as a Community of Practice: Implications for Medical Education Richard L. Cruess, MD, Sylvia R. Cruess, MD, and Yvonne Steinert, PhD

Abstract The presence of a variety of independent Having communities of practice as the medical education’s complexity. An learning theories makes it difficult theoretical basis of medical education initial step is to acknowledge the for medical educators to construct a does not diminish the value of other potential of communities of practice as comprehensive theoretical framework learning theories. Communities of practice the foundational theory. Educational for medical education, resulting in can serve as the foundational theory, and initiatives that could result from this numerous and often unrelated curricular, other theories can provide a theoretical approach include adding communities instructional, and assessment practices. basis for the multiple educational activities of practice to the cognitive base; Linked with an understanding of identity that take place within the community, thus actively engaging students in joining formation, the concept of communities of helping create an integrated theoretical the community; creating a welcoming practice could provide such a framework, approach. community; expanding the emphasis emphasizing the social nature of learning. on explicitly addressing role modeling, Individuals wish to join the community, Communities of practice can guide mentoring, experiential learning, and moving from legitimate peripheral to full the development of interventions reflection; providing faculty development participation, acquiring the identity of to make medical education more to support the program; and recognizing community members and accepting the effective and can help both learners the necessity to chart progress toward and educators better cope with 2017 community’s norms. membership in the community.

Over half a century ago, Merton1 The presence of many theories that that apply to defined specific educational pointed out the dual nature of medical are often competing rather than activities, communities of practice is a education, whose aims are to provide complementary can pose problems for robust and broad social learning theory those wishing to become physicians with medical educators, as it is difficult to that has the capacity to encompass the knowledge and skills necessary for the integrate them into a coherent approach the multifaceted nature of medicine’s practice of medicine and a professional to curricular design. Because of this, it knowledge base, including its foundations identity so that they come to “think, act, has been suggested that action should in biomedical science, the nature of the and feel like physicians.” Realizing these be taken to identify and reflect on the identity of a physician, and its rich mix of aims is a task of considerable complexity, many available theories, placing “them tacit and explicit knowledge. and a host of educational theories have within a conceptual framework that can been proposed to help understand the build a coherent body of evidence and, Communities of Practice process and assist in its organization.2–4 eventually, a better understanding of Despite a diligent search, we have been learning itself.”4 The theory unable to identify any attempt to bring Constructivism, a theory developed these theories together into a coherent Most of the educational theories that have in the latter half of the 20th century, whole or to explore their relationship to been invoked to help understand and proposes that individuals construct 2 each other. Although Kaufman and Mann guide the course of medical education new knowledge from experience and suggested that situated learning theory apply to specific educational strategies or reflect on that experience.2,4 As a part of could relate “to several other conceptions activities that take place within the broad this movement, social learning theories of learning, both long-standing and construct of the medical curriculum2–4 emerged that propose that learning more recent,” they did not propose it as a and, as such, are not capable of serving is a social activity that takes place in foundational theory for curricular design. as the basis of a conceptual framework. It communities and is heavily influenced by is not our intention to review the many history and culture.5–7 Various terms have Please see the end of this article for information theories available. Instead, we propose been used for these theories, including about the authors. an approach built around the theory of communities of learners8 and knowledge- communities of practice, since we believe 9 Correspondence should be addressed to Richard building communities. As a part of this 10 L. Cruess, Centre for Medical Education, McGill that medicine is, and has always been, movement, Lave and Wenger introduced University, 1110 Pine Ave. West, Montreal, Quebec, a community of practice. The theory the term community of practice in 1991.5 H3A 1A3; telephone: (514) 398-7331; e-mail: of communities of practice, originally They emphasized that while the concept [email protected]. elaborated by Lave and Wenger,5 was new, Wenger, in a later article,10 Acad Med. 2018;93:185–191. can help by providing the basis for a stated that such communities had existed First published online July 25, 2017 more integrated, comprehensive, and “since man lived in caves.” Linking doi: 10.1097/ACM.0000000000001826 Copyright © 2017 by the Association of American coherent theoretical approach to medical communities of practice to the theory Medical Colleges education. Unlike most learning theories of situated learning, Lave and Wenger

proposed a theory that emphasizes the well as the organizational structure of a particularly strong influence on the social nature of learning. Initially the the community. While some negotiation identity of its members.23 concept was developed in the world of of noncore items is possible, failure business and management, and much of to accept those deemed essential can Practice. Practice refers to the specific its literature is still derived from these result in marginalization or actual knowledge and skills that the community fields. Of interest, while Wenger10 clearly exclusion of an aspiring member.10,16 shares and develops, consisting of a set of indicates that the professions constitute a Achieving competence within the “frameworks, ideas, tools, information, community of practice, the first reference domain is essential, with the standards styles, language, stories, and documents linking the concept to medicine and being determined by the community.20 that the community members share.”10 medical education appeared in 2002.11 According to the theory, learning is a According to Wenger,10 in medicine, The theory has since received significant social rather than an individual activity, practice consists of clinical care, attention in the domain of medical and much of it occurs at the unconscious educational practices, and research. education. Our literature review, using level, resulting in the acquisition of a The word practice encompasses a social PubMed and Scopus linking communities large body of tacit knowledge.4,6,17,18 The environment in which both work and of practice and medical education, found learning is “situated” in the community, learning take place. 137 articles on the subject between 2000 and the content is given authenticity and 2016. It is worth noting that the term because it is acquired in the same context When these three elements are present, is used in reference to medical education in which it is applied.5,17,18,21 Learner Wenger believes that an ideal knowledge at the undergraduate, postgraduate, and participation—sometimes designated as structure is created “that can assume continuing professional development coparticipation19 with members of the responsibility for developing and sharing levels.2,4,12 community—is essential, as it allows knowledge,” a situation that certainly each individual to recreate meaning, applies to medicine. The knowledge Definitions are important, and the transforming knowledge from the base consists of a mixture of explicit one proposed by Barab et al13 seems abstract and theoretical into something and tacit knowledge that is acquired by appropriate for medicine: A community personal and unique. those wishing to join the community of of practice is practice.4,6 The community is responsible There are three essential elements to a for the creation and maintenance of a persistent, sustaining social network community of practice, all of which are the knowledge base, which is constantly of individuals who share and develop an being revised, in part through the process overlapping knowledge base, set of beliefs, characteristic of medicine as a profession: 18 values, history and experiences focused domain, community, and practice. of negotiation that takes place as new 5,10,12 on a common practice and/or mutual members achieve full participation. enterprise. Domain. Snyder and Wenger18 state The dynamic interplay between teachers that there must be a domain with clear and learners within the community The transition from viewing medicine boundaries that creates “common has an impact on the relevance and as a community that has long been ground and a sense of common identity.” the vitality of the knowledge base by characterized by collegiality14 and This affirms the purpose and value of renewing it as it is recreated by individual morality15 to the concept of medicine the community to both members and learners.10 as a community of practice in which society. The domain of medicine is the learning takes place has inherent logic. prevention and treatment of human Criticisms of the theory The cultural, structural, and behavioral disease and the promotion of the public There have been those both within24,25 aspects of a collegial profession as well as good.15 and outside of medicine6,17,26,27 who have its moral base become part of the norms pointed out the limitations and inherent of practice.16 Community. The presence of a tensions of communities of practice as a community creates the social fabric theory underlying educational practices. The concept is clear.4–6,10–12,17–21 An within which learning occurs, and The most telling of these support individual wishes to join a group engaged membership in the community must Bourdieu’s28 observation that social in a common activity—in this case the be seen as a desirable objective. For the structures tend to reproduce themselves, practice of medicine—by learning how to community to flourish, leadership is perpetuating existing hierarchies, power carry out the activities in which the group required and mutual trust and respect structures, and inequities. One observer is engaged. In doing so, the individual are essential elements, as is pride in the has referred to “self-deluding and self- becomes a member of the group by purpose and accomplishments of the reinforcing social behavior” that can take moving from legitimate peripheral community.18,20 place within communities of practice.29 participation to full membership in the group. The individual’s early membership Medicine consists of many communities Without question, these are valid is viewed as legitimate because he or she of practice, and physicians generally comments on the behavior of the has been accepted as a novice member belong to more than one.20,21 Clearly, a medical profession, whether it is referred of the community. Inherent in the physician is a part of a global medical to as a community of practice or not. move is the gradual acquisition of the community,22 but there are national and Historically, the profession has been required knowledge and skills, along regional groupings and organizations exclusionary, with women and virtually with the identity shared by members of to which physicians belong and give all categories of minorities having the group.5,16–18,20 This identity entails the allegiance.18,20 A physician’s specialty difficulty accessing the community.30–32 acceptance of core norms and values as is a community of practice that exerts Medicine has established and continues

to establish clear boundaries around important aspects of “who they are.”15,33,37 guide educational initiatives aimed at the community that determine both As this has been recognized, widespread improvement. Experiential learning is inclusion and exclusion31,33 and has a agreement has emerged that learners also fundamental to medical education, well-established internal hierarchical must be permitted to preserve and leading to the acquisition of both explicit structure and power relationships.31,33 further develop their personal identities and tacit knowledge. Kolb’s40 experiential as they become professionals.15,33,35 learning theory, along with Eraut’s41 Without in any way diminishing analysis of tacit learning, provide a basis the significance of the perceived for understanding a central part of the shortcomings of communities of Communities of Practice and educational activity that takes place practice, it should be pointed out that the Other Learning Theories within communities of practice. Both behavior patterns mentioned above are Proposing that communities of practice can be readily accommodated within the characteristic of most social structures,9,28 can be adopted as the theoretical base of theoretical approach of communities of including the medical profession,31 and medical education does not in any way practice, as they have the capacity both to that they existed long before Lave and affect the validity or usefulness of other explain and also to guide the actions of Wenger invoked the term communities theories. It is our belief that communities learners and teachers. of practice. Thus, leveling this criticism of practice can serve as the foundational at communities of practice as an theory and that other learning theories educational theory is appropriate in both provide the theoretical base for the Implications for Curricular Design generic and specific terms. multiple educational activities that take Communities of practice in medicine place within a community of practice. In have always existed,5 and physicians However, it is not possible to envisage this way, learning theories can be used have been educated for millennia, any enterprise as complex as the in their proper context, contributing to during which time a host of educational medical profession without boundaries, the creation of an integrated theoretical strategies have been developed and hierarchies, or power structures.6 It is approach to medical education. In implemented. Adapting modern the nature and impact of these essential suggesting this, we expand on the work medical education based on the theory elements that sometimes deserve criticism of Kaufman and Mann2 in their review of communities of practice will not and attention, not their existence. Those of learning theories in medicine in which necessarily result in radical curricular designing educational interventions using they proposed that an advantage of change. However, a major advantage of communities of practice as a theoretical situated learning theory is its ability to such a shift is that it would emphasize the framework must be aware of the potential relate to and incorporate other learning social nature of learning and would be negative impacts of the community on theories. We believe their approach to robust enough to serve as a framework the individual and community and take be correct but that, as situated learning around which both traditional and action to minimize them. takes place within a community of new educational strategies, with their practice rather than the reverse,5,20,29 it is theoretical underpinnings, could be Some of these limitations have been communities of practice that should be structured throughout the continuum of addressed directly. Despite persistent the organizing theory. medical education. Moreover, reorienting inequities, the medical profession relevant activities around communities is now more inclusive of women An example of a theory that can be of practice has the potential to establish and minorities15,30 and has more integrated into communities of practice clearer educational objectives and better understanding of the impact of is workplace learning. Learning and work align strategies with objectives. different cultures on the value systems converge as learners in medicine proceed of its communities of practice.34 The through the educational continuum, Learning in medicine occurs in a presence of medicine’s hierarchies and moving from the classroom to the curriculum that includes formal internal power structures has been both workplace of the practicing physician— components and experiences centered in recognized and questioned.30–32,35 the medical ward, the operating the medical workplace. Experiential, or room, the clinic, or the doctor’s office. informal, learning2–4,6,38,41 predominates An additional criticism stems from the Billett’s19,38 theory of workplace learning, as learners progress from laypersons to tension that arises between the imperative which he places within communities of professionals and from the periphery to impose the norms and standards of the practice, contributes to and strengthens to the center of the community. community and the desire of individuals the theoretical power of communities of While there are frequent references in to maintain important aspects of their practice. medical education to the impact of own identities as they move toward the informal curriculum,42 it must be full participation.33,35 It has long been Other learning theories can be helpful stressed that “workplace experiences recognized that tension is an inevitable in understanding the many aspects of are not ‘informal’”38 or “ad hoc,”41 even consequence of major changes in identity. medical education that take place within though, as in all areas of the curriculum, Erikson36 believed that an individual must the learning community.2–4,12 Mentors and unplanned and ad hoc experiences actually suppress a portion of his or her role models have long been understood can occur. Workplace experiences identity to achieve change, while others to be fundamental to the transformation are solidly grounded in the nature of suggest that “identity dissonance” can of an individual from a member of the medical practices, and these practices result.33 Medicine’s power relationships lay public to a skilled professional.6,39 shape the conduct of both the work and and hierarchical structure can make Bandura’s7 social cognitive theory helps the learning that take place.20 Formal it difficult for individuals to maintain to explain this complex activity and can knowledge is transmitted, but because of

the social nature of the learning, much within the community, and they Participation “provides the constitutive knowledge transfer is informal, leading to contribute to a sense of continuity. These texture of the experience of identity.”19 If the acquisition of both explicit and tacit activities include the acquisition of the learning is perceived to be a social activity, knowledge.19,41 knowledge, skills, and values necessary it does not occur without participation for the practice of medicine and the in the community.19,49 The voluntary act Reorienting a curriculum so that it development of a professional identity. of becoming a peripheral participant has a theoretical base grounded in is a necessary first step in engagement. communities of practice can involve Make communities of practice an Participation, or coparticipation,19 with different interventions. These include explicit part of the curriculum fellow learners and more senior members recognizing that medicine constitutes a If something is to be taught, learned, of the community in the many activities community of practice and making the and assessed, the educational objectives within the community deepens the sense concept an explicit part of the cognitive must be clear and the subject must be of engagement.41 base that is taught. Activities that have defined.40 This is also related to the traditionally been used to encourage the guiding principles of intentionality Educational activities designed to incorporation of the values and norms and alignment. We and others have promote engagement should create of the community can be reoriented recommended16,45,46 that the support a balance between transmitting to become congruent with the theory. of individuals as they develop their explicit knowledge about the nature of Finally, new activities necessary for professional identities become an communities of practice and activities in curricular renewal can be developed. objective of medical education addressed which the knowledge learned is used in authentic contexts.29,52 The following recommendations for explicitly in the curriculum. Inherent in the initiation or reorienting of specific this recommendation is the necessity to formally teach the nature of professional Create and maintain a welcoming curricular activities are based on community experience gained within the medical identity and an explication of the process profession,2–4,12,16,43–46 our personal of socialization. We have termed this Medicine’s community of practice has 44 experience,43,44 and information the “cognitive base.” To this base we not been created intentionally. According drawn from the literature on learning now add the concept that medicine to theory, it emerged as a result of theories.5,6,8,10,17–21,38,47–50 is a community of practice and that the activities taking place within the professional identity occurs in this community.53 Learning in communities,6 Acknowledge medicine as a community context. Learners should understand the as well as workplace learning,48 is of practice nature of the journey from peripheral encouraged by “fostering access to and participation to full participation if they Lave and Wenger’s work on communities membership in the target community are to be truly engaged in a process of 53 of practice, including the acquisition and of practice.” As a further extension of a professional identity, and Billett’s collective learning. of the principle of intentionality, this goal elaboration of the concept of workplace should be pursued explicitly with both Engage students in the journey from faculty and students. learning, stress the importance of peripheral to full participation intentionality, alignment, and continuity 5 as foundational elements in curricular As a part of the movement to support In their original article, Lave and Wenger design.6,48,50 All of these require formal professional identity formation, engaging pointed out the dynamic nature of the acknowledgment that medicine is a students in joining the community and in composition of a community of practice community of practice. By clearly the development of their own identities and the relationships between individuals recognizing this, the intent of the helps them to better understand their and groups within the community. faculty becomes evident to both learners personal journeys from laypersons to The composition of a community is in and faculty members. Intentionality professionals.12,15,33,44,46 Participation, constant flux as new individuals join it, and alignment are clearly linked. which has always been implicit, becomes others move from junior to senior status, Intentionality dictates that curricular formalized, requiring conscious and “old timers” leave. Teaching is not design should be based on objectives action on the part of the learner.40 based on traditional dyadic relationships that are congruent with the theory. The norms on which a professional but instead on an ever-changing “richly Alignment suggests that educational identity is constructed are determined diverse field of essential actors” who strategies should be aimed at assisting by the community of practice5,19 and populate the health care system and its learners as they move to full participation by society through an ongoing process learning environments.5 While individual in the community of practice and the of social negotiation.51 Moving from effort on the part of the learner is acquisition of a professional identity. legitimate peripheral participation to required, the community, including Continuity is provided by the nature full participation describes the move fellow learners and established members, of the “practice” within medicine’s from “outsider” to “insider,”31 and has a powerful impact on learning and “domain”20 and by the presence within understanding this can assist students identity formation.33 The community the community of individuals at all and their mentors in following the constantly recreates itself, and its future levels of experience from novice to learners’ progress. is dependent on its knowledge base being expert. In addition, the activities that transferred to another generation. occur throughout the continuum Engagement and participation are also of medical education constitute the foundational elements of communities The limitations of the theory of principal aim of the work and learning of practice6,17 and workplace learning.47,48 communities of practice and the negative

impact of some aspects of medicine’s means,4,5,7,55–58 leading to the transfer of Reflection. Reflection, whether instigated behavior as a community29–32 must be both explicit and tacit knowledge. The by role models or following a variety of acknowledged and must lead to action impact on learners is enhanced when experiences, is described as the process if the community is to be welcoming. explicit objectives are established55,57 and by which we examine our experiences in The community must be inclusive of when they are accompanied by guided order to learn from them.56,60 Reflection all involved in the enterprise and be reflection on their experiences.55–57 requires individuals to assume the welcoming to those at the periphery, perspective of an external observer,61 who represent its future. Particular Role models and mentors. Role models examining their own progress toward attention should be paid to those who and mentors have a central role in participation in the community. In have traditionally been excluded from transferring both explicit and tacit the process, they have an opportunity medicine’s community because of gender, knowledge to learners.4,6,7,39,42,55,56 For this to make explicit many aspects of both sexual orientation, socioeconomic status, reason, conscious action should be taken communities of practice and identity or other factors.30–33 In addition, learners so that a proper balance between formal formation.61 In addition to learning must be permitted to participate in the instruction and experience in authentic from their own personal experiences, development of their own professional situations is established.29 Role models individuals can become aware of their identities while maintaining their own and mentors must be aware of and own “location” in the journey toward personal sense of “self.”33,35 transmit, in a formal fashion, knowledge full participation in their community of about the nature of communities of practice.19 Deeper reflection is stimulated Learners’ engagement and participation practice and their norms, and should by complex problems and issues55 should be actively supported throughout actively support the acquisition of that give learners an opportunity to their educational experiences. This can a professional identity within the understand their own personal beliefs be accomplished in several ways. The community.15,58 Their fundamental role in and values and integrate them into learning environment is fundamental the transmission of tacit knowledge must their professional identities.58 Finally, if and should be respectful, welcoming, and be both recognized and supported. learning is regarded as a social activity, supportive.6,33 Addressing the negative reflection is best done within small aspects of the informal curriculum The sharing of tacit knowledge requires groups55,61 rather than as a solitary as defined by Hafferty and Hafler42 experiences that include joint activities activity.12 It is important to establish becomes doubly important, as a flawed and physical proximity between situations where collaborative learning learning environment inhibits learning teacher and learner or between learners can take place, stressing collective 5,19,20,49,50 and diminishes the sense of belonging functioning within the group. problem solving.29,53 Shared reflection of all involved.33 Access for all learners The process of socialization is dependent offers the learner the opportunity for on these work activities,33 as is learning to activities appropriate to their level 19 multiple perspectives and sources of must be assured, along with guidance in the workplace. Tacit knowledge can information.55 from “experts”39 who are responsible be converted to explicit knowledge—or for providing the contextual framework reified—prior to its transfer. Again, Educational interventions should within which learning takes place. conscious decisions must be made as to include activities that ensure that faculty which curricular material will remain members, role models, and mentors are tacit and which will be made explicit and Finally, purposely structured social aware of and communicate the nature comprehensible to others.18,41 events, both within and outside of of communities of practice and identity the workplace, can foster a sense of Experiential learning. Experiential formation. Access for all learners to a belonging, as can the rituals that have learning, or learning by doing, is a range of authentic activities should be long been associated with the medical concept that can be traced to Aristotle.59 made available, including the allocation 15,33,49,54 profession. It is noteworthy that Inextricably linked to reflection,4,55,56 it of responsibility appropriate to their 19 such activities have an influence on all is essential to the acquisition of both level. Importantly, both scheduled time members of the community from novice the knowledge and skills as well as the and informal opportunities to reflect after 15,33 to senior. professional identity of a physician.5,15,33 role modeling and workplace experiences Kolb’s40 model of experiential learning must be present at regular intervals in the Explicitly address the major factors 55,56 proposes that each individual goes curriculum. influencing professional identity through a cycle that begins with formation Provide faculty development a new experience and proceeds to While many factors can have an reflection, conceptualization, and active It is now well understood that major influence on the journey from peripheral experimentation. The curriculum curricular change is dependent for its participation to full membership must ensure that learners have access success on faculty development,62 and in a community of practice and the to authentic experiences so that this introducing the concept of communities acquisition of a professional identity, cycle of learning can occur.19,38 Through of practice requires particular attention. there is general agreement that role reflection, much that has been tacit in modeling and experiential learning, the past will be made explicit. However, Experience gained in faculty development both of which require reflection for there is a limit to the amount of tacit for professionalism can serve as a guide,62 their maximum impact, are the most knowledge that can be made explicit,41,60 as can early efforts in faculty development powerful.2,4,5,7,15,41 Each exerts its influence and the impact of tacit knowledge is for professional identity formation.63,64 through conscious and unconscious substantial.12 It has been found that the subject

must be addressed explicitly for faculty doing so are available.68 Positive feedback References and defined in easily understandable about progress is an important factor in 1 Merton RK. Some preliminaries to a terms.63,64 Faculty should know the the development of a professional identity, sociology of medical education. In: Merton concepts, be familiar with the vocabulary, engendering a feeling of confidence RK, Reader LG, Kendall PL, eds. The Student and be given an opportunity to and a sense of belonging.12,15,33,53,54 Of Physician: Introductory Studies in the Sociology of Medical Education. Cambridge, participate in planning major curricular equal importance is the identification MA: Harvard University Press; 1957:3–79. interventions. Of particular importance of individuals whose move from the 2 Kaufman DM, Mann KV. 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