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

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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 Academic Medicine, Vol. 93, No. 2 / February 2018 185 Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited. Perspective 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
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