Teaching and l earning in m edical e ducation: h ow t heory c an i nform p ractice David M Kaufman and Karen V Mann KEY MESSAGES • Understanding theory can enhance the use of effective • Learning is enhanced when it is relevant, teaching and learning strategies. particularly to the solution and understanding • The learner is an active contributor in the learning of real - life problems and practice. process. • Individuals ’ past experience and knowledge are critical • Learners interact actively with the curriculum, to how they learn. patients and teachers in a complex, changing • Learning has an emotional aspect to it that is often environment. under - recognised and can infl uence the learning • The entire context of learning is important, rather than signifi cantly. any single variable, and includes interactions of all the • Individual learners are capable of self - regulation, that variables. is, setting goals, planning strategies and monitoring • Values, attitudes and the culture of the profession are their progress. often learned implicitly and without explicit teaching • The ability to refl ect on one ’s practice (performance) is or awareness of learning. critical to lifelong, self - directed learning. Introduction • adult learning principles (3) • social cognitive theory (4) How can educational theory inform our practice? • refl ective practice (5) Several writers have described a gap between theory • transformative learning (6) and practice. Indeed, this perception has led practi- • self - directed learning (7) tioners in many professions to conclude that theory is • experiential learning (8) in an ivory tower, not useful or relevant to those in • situated learning (9) practice. Educators are no exception. (1) However, as • learning in communities of practice. (10) professional practice is better understood, it is clear We selected these because we believe them to be par- that theory has the potential both to inform practice ticularly useful in the context of the issues facing and to be informed by it. medical education today. We will describe each theo- Our purpose in this chapter is to describe eight retical formulation, highlighting its major constructs, selected approaches to education theory and explore and present implications of the theory for educational their implications for the practice of medical educa- practice, followed by a specifi c example drawn from tion. We use the term ‘ theory ’ in a general sense, that medical education. We will conclude with a considera- is, as a set of assumptions and ideas that help to explain tion of the connections and commonalities among the some phenomenon. Knowles (2) put this succinctly eight theories, so that readers may make these connec- more than 25 years ago, defi ning a theory as: ‘ a com- tions within their own practice. prehensive, coherent, and internally consistent system of ideas about a set of phenomena ’ . Each of the theoretical approaches we describe is Adult Learning Principles consistent with Knowles ’ defi nition. The eight theo- retical approaches discussed are: The purpose of adult education has been the subject of a number of typologies.(11 – 15) Generally, these accord with a list proposed by Darkenwald and Merriam, (15) Understanding Medical Education: Evidence, Theory and Practice namely: Edited by Tim Swanwick © 2010 The Association for the Study of • cultivation of the intellect Medical Education. ISBN: 978-1-405-19680-2 • individual self - actualisation 16 Teaching and learning in medical education 17 • personal and social improvement BOX 2.1 Andragogical assumptions (3,23) • social transformation • organisational effectiveness. 1 As a person matures, their self - concept moves from A number of theoretical frameworks have developed that of a dependent personality towards one of a around these functions, which Merriam (16) has self - directing human being. Adults are capable of grouped into three categories. The fi rst category is determining their own learning needs, and of fi nding based on adult learning characteristics , in which the the means to meet them. best - known framework is ‘ andragogy ’ . (3) Also in 2 An adult accumulates a growing reservoir of this group is Cross ’ (17) ‘ Characteristics of Adults experience, which is a rich resource for learning. This as Learners ’ model, based on differences between experience can be brought to bear on new learning, adults and children across personal and situational and enhance the new learning signifi cantly. It can also characteristics. provide an effective context for the acquisition of new The second category emphasises the adult ’ s life situ- knowledge and skills. ation . Two theories have been proposed in this cate- 3 The readiness of an adult to lean is closely related to gory, Knox ’ s Profi ciency Theory (18) and McClusky ’ s the developmental tasks of their social role. Adults Theory of Margin. (19) The third category focuses on value learning that integrates with the demands changes in consciousness . Several models in this cate- placed on them in their everyday life. gory emphasise refl ection upon experience and envi- 4 There is a change in time perspective as people ronment. Mezirow ’ s Perspective Transformation (20) mature, from future application of knowledge to (discussed later) and Freire ’ s Theory of immediacy of application. Thus an adult is more Conscientization (21) are the best - developed models in problem centred than subject centred in learning. this category. Generally, adults value learning that can be applied Merriam and Caffarella (22) have provided an excel- to authentic problems that they encounter in everyday lent summary of the various theory - building efforts in life. adult learning. They conclude that no single theory 5 Adults are more motivated to learn by internal factors fares well when judged by the criteria of comprehen- rather than external ones. The internal desire to siveness (i.e. includes all types of learning), practicality succeed, the satisfaction of learning and the presence and universality of its application. They also assert of personal goals have a greater effect on maintaining that a phenomenon as complex as adult learning will [italics added] motivation than external incentives probably never be adequately explained by a single and rewards. theory. Although these theoretical frameworks provide implications for practice, few have actually been applied widely in adult education practice. Knowles ’ (3) andragogy is the exception. The remainder of this criticism led Knowles to later modify his model by section focuses on and andragogy, its implications for describing andragogy and pedagogy as a continuum, practice and an example of its use in undergraduate and suggesting that the use of both teaching methods medical education. is appropriate at different times in different situations, regardless of the learner ’ s age. (23) Andragogy It is widely accepted that andragogy is not really a Malcolm Knowles (3) fi rst introduced the term ‘ andra- theory of how adults learn, the assumptions being gogy ’ to North America, defi ning it as ‘ the art and merely descriptions of the adult learner. (28) science of helping adults learn ’ . Knowles did not Furthermore, even the assumptions have been ques- present andragogy as an empirically based theory, but tioned as prescriptions for practice. simply as a set of four assumptions, (3) to which a fi fth Others argue that andragogy may in time become was later added ( see Box 2.1 ).( 23) a theory, but through empirical studies of the Andragogy has its roots in humanistic psychology assumptions. At least, andragogy captures general through the work of Maslow (24) and Rogers. (25) The characteristics of adult learners and offers guidelines core basis of andragogy is that the attainment of adult- for planning instruction with learners who tend hood is marked by adults coming to view themselves to be at least somewhat independent and self - directed as self - directed individuals. Knowles ’ ‘ model of (29) . assumptions ’ has given adult education a ‘ badge of identity ’ that distinguishes the fi eld from other areas Implications for e ducational p ractice of education, for example, childhood schooling. (26) There are several implications for practice that can be Bard (27) has asserted that andragogy ‘ probably more derived from the theories of adult learning which have than any other force, has changed the role of the at their heart the fact that an adult ’ s life situation is learner in adult education and in human resource quite different from that of a child. Merriam and development ’ (p. xi). However, it has also caused enor- Caffarella (22) discuss these differences in three areas: mous controversy, debate and criticism. The early context, learner and learning process. 18 Chapter 2 Context BOX 2.2 Principles of adult learning(23) Children are dependent on others for their well - being, while adults have assumed responsibility for manag- 1 An effective learning climate should be established. ing their own lives. Typically, being a learner is only Learners should be comfortable, both physically and one of several roles played concurrently by adults. emotionally. They should feel safe and free to express Additionally, the principles that have guided themselves without judgement or ridicule. approaches to teaching children, and which have been 2 Learners should be involved in mutual planning of applied to learners of all ages, have focused on gener- methods and curricular directions. Involvement will alised learning