HOW CAN LEARNING BE MADE MORE EFFECTIVE IN MEDICAL EDUCATION?
Contemporary practices and practical approaches have been designed to enhance the effectiveness of learning.
The thesis of the present chapter is that effective learning is already within the grasp of contemporary medical educators. The assumption is that how we think about learning affects what we do to enhance it. Accomplishing effective learning requires learners and teachers to diminish the gap between actual day-to-day practices in medical education and what is known, understood and believed about the underlying assumptions of those practices. Three themes are explored and discussed to promote more effective learning:
1 the importance of a continuous co-evolution between practice and theory (theory, in this context, refers to the underlying assumptions and beliefs that inform how we understand the world);
2 the implications of understanding learning as a complex adaptive process;
3 the necessity of matching the continuum of dimensions (number of factors involved that make a difference) among tasks, situations, conditions and pedagogy.
Three case studies are incorporated to illustrate these three themes at work in effective relationships between practice and theory and in the match of dimensions of tasks and teaching across different orders of magnitude: student–teacher–curriculum; patient and physician; and between two different institutions. Learning as a complex adaptive process is woven throughout the discussions.
Several ideas and concepts are presented that may be new to the reader and may involve new and perhaps unfamiliar terminology related to learning that challenges contemporary thinking about the importance of understanding the nature of learning as it relates to becoming a physician. This chapter intentionally seeks to disturb the status quo of some areas of medical education, to promote rethinking and to extend our understanding of the essential nature of interdependence and, in so doing, take medical education to an expanding frontier of effective learning practices. Sometimes it is necessary to see the familiar from different perspectives to realign practices and adapt understanding to changing circumstances.
Practice and theory: a praxis for learning
Innovative and effective educational practices and theories emerge complete and fully as an integrated whole. After a while, practice and theory begin to separate, to move further apart in time and space. They begin to age, to lose their sensitivity to variability, and their interdependence with each other diminishes as they are repeated, passed on from teacher to teacher, from school to school, and from generation to generation. Practice disconnected from its underlying assumptions and theory tends to metamorphose into habits, steps and procedures without the benefit of the insight, curiosity and understanding that made them interdependent and attractive as innovations in the first place. Problem-based learning is an example of a strong initial practice in medical education that, over time, became more and more disconnected from its underlying theory, promoting a decline in the understanding about its use and adaptability by practitioners (Schmidt 1993; Moust et al. 2005). As practice can lose its relationship to theory, so too can theory become an ineffective abstraction without practice. The challenge of achieving more effective learning is to reunify, strengthen and enhance the nature of the relationship between practice and theory across the spectrum of medical education and professional practice; to restore the coherence of learning practices that are respectful of variability and, at the same time, true and useful in that they promote action that remains fit for function.
Practice informed by theory and theory in practice is known as praxis. The word praxis comes from Greek and Latin roots meaning ‘doing’: ‘where patterns of learning emerge as individuals take action based on theories they hold about the world. Their theories about how the world works change as their experiences give them new insights’ (Teaching-Learning Collaborative 2011) and as they learn individually and collectively. Praxis is an educational experience in which both practice and theory co-evolve as an interdependent pair; they are complementary (Kelso and Engestrom 2006; Sullivan and Rosin 2008; Teaching-Learning Collaborative 2011; Eoyang 2012; Patterson et al. 2013).
A useful description of praxis comes from the Human Systems Dynamics Institute (2011) Teaching and Learning Collaborative. At any given moment, the capacity of the learner lies at the intersection between ongoing practice (activities and actions that make up their day-to-day life) and learners’ underlying assumptions, knowledge and beliefs that inform how they see the world. Learners come to new challenges in either place; i.e. if they are asked to do something they don’t know how to do, for example a new clinical skill (a practice challenge), or if they encounter a theory or idea that is new to them, for example the concept of the social determinants of health (theory/understanding challenge). Learners try something new; they change what they are doing and/or how they are thinking about what they are doing. They think about what will work and try it out – testing both their new skill and the underlying assumptions that are informing the trial. Then they see how it works. The trial and test help them know whether the new way of acting or the new way of seeing the world is more or less effective than where they stood before the trial. That answer informs their next step. If the new ‘theory’ provides better insight and generates more effective action, they continue to use those new ideas as they plan next steps. If not, they abandon the ideas or try to adapt them to fit what they experienced. They continue the cycle of observing, testing and reflecting around new ideas and new skills until eventually a higher level of performance or action emerges as their way of ‘doing’ – it becomes their praxis (adapted from the Human Systems Dynamics Institute 2011).
That practice and theory should be inseparable and embodied in teaching and learning may seem obvious and the vast majority of medical schools will surely claim to aspire to it. If you could visit all the medical schools in the world and observe how, and under what conditions, learning is actually occurring, chances are you would find it to be fragmented, overly stressful and distant from the practical realities and necessities of local and regional health needs. The learning process and environment would appear to be dominated by transmission and repetition with little time for understanding; and by an imbalance favouring the description and the naming of things more than an exploration of underlying assumptions, knowledge and beliefs. At the same time, you would find a variety of innovative learning practices in play: organ system modules, small-group problem-based and team-based learning (TBL), longitudinal clerkship experiences, entrustable professional activities, progress testing, formative assessment, simulation, assessment in authentic settings, community-oriented education, ethics and professionalism, social responsibility, permanent education, distance education, online ‘learning’ and complementary medicine, to name a few.
Concepts and theories of learning vary from transmission, behaviourism and cognitivism to constructivism and constructionism. Newer ideas expanding our understanding of the dynamics of interactions involved in learning are gaining traction: cultural historical activity theory, complex adaptive systems and adaptive action (Doll 1993; Davis et al. 2008; Engestrom 2008; Daniels et al. 2010; Bleakley et al. 2011; Dornan et al. 2011; Dent and Harden 2013; Eoyang and Holladay 2013; Swanwick 2014).
Nevertheless, medical education practices remain largely disconnected from each other and from explanations based on underlying assumptions and theory. The two seem to exist as parallel lines that may rarely meet, if at all. Bits and pieces of methods are added together in an ‘educational alchemy’ in the hopes that something effective happens. In contrast, understanding that emerges from praxis promotes learning and coherence. Coherence refers to the degree to which patterns of praxis present across the whole of any given education programme are similar, without losing the richness of difference at the same time (Eoyang and Holladay 2013). The increased attention to outcomes and outcome-based medical education reflects recognition of the need for a sustainable praxis (Harden et al. 1999; Smith 2009).
Some might attribute the absence of coherence as a norm to the massively entangled socio-economic and political realities of healthcare, health professions education and the systems in which they are embedded; to the autonomy given to the professions by society; and to an incomplete understanding of the similarities and differences between the medical expertise necessary for patient and healthcare and the educational expertise necessary for a praxis of teaching, assessing, learning, planning, leading and evaluating across the full spectrum of medical education. Add to this the fluidity of global travel and high-speed communication and collectively we may have invented comparative medical education, lived by many, recognised by few. It becomes important to consider that learning practices together with ‘learning theories have histories and are culturally grounded’ (Bleakley et al. 2011: 46).
Learning as a complex adaptive process: for whom and for what?
Learning is essential for life. We learn all the time, in different places, under different circumstances and in different ways. Learning in medical education embraces much more than medical students, residents and fellows because they interact and are co-embedded in the lives of teachers, patients, healthcare professionals, administrators, policy makers, institutions, healthcare systems and societies. All of them are co-evolving as they adapt to continuously changing circumstances. There are many definitions of and perceptions about learning. A clear and useful definition is:
Learning is the social process through which ideas (experiences, knowledge, perceptions, and movements, etc.) interact so that system-wide patterns emerge, and those patterns (concepts principles, hypotheses, new questions, etc.) influence subsequent thought and action.
This is consistent with the thesis that learning is situated not as an experience specific to education in a school or institution, but rather instead as part of the day-to-day life of the learner (Dewey 1910): ‘education in order to accomplish its ends both for the individual learner and for society must be based upon experience – which is always the actual life-experience of some individual’ (Dewey 1938: 89).
The present chapter posits that human thought and learning are complex adaptive processes (Kelso 1995, Tschacher and Dauwalder 2003; Edelman 2006; Friedenberg 2009). Complex adaptive systems consist of many interdependent, semi-autonomous agents (e.g. students, teachers, patients, clinics, laboratories, libraries, groups, committees) held together by physical, cultural and conceptual boundaries. Local interaction of agents has system-wide effects that, in turn, affect local agents. For example, a student may discuss a patient issue with her preceptor or tutor and arrive at an understanding of a particular practice and its related concepts, which in turn changes the way she thinks about many other related situations. Many non-linear, short-feedback loops exist, i.e. a small change in a single event or activity can make a big difference and a big change in policy can make little or no difference. Members of a complex adaptive system (CAS), i.e. people, things and the environment, act interdependently; what one does effects the other and the response of the other affects the one, i.e. they co-evolve. Co-evolution is characteristic of highly effective groups and teamwork (Arrow and Henry 2010; Voogt and Roblin 2010; Bleakley et al. 2011; Hofstadter and Sander 2013; Mennin 2013; Patterson et al. 2013). Complex self-organising systems follow simple rules and are sensitive to small changes in local condition. Well-known properties of the nervous and immune systems and relationship-centred care are examples (Suchman et al. 2011; Patterson et al. 2013; Sturmberg and Martin 2013).
Accepting the premise that learning and thought are complex, emergent phenomena (Patterson et al. 2013), it becomes important to examine the dynamics of the interrelationships that determine the conditions of and for learning (Bruner 1960; Doll 1993; Kelso and Engestrom 2006; Davis et al. 2008; Patterson et al. 2013). Learning emerges from the internal dynamics among thoughts, perceptions and past history without the need for external direction, hence the idea of self-organisation (Prigogine and Stengers 1996; Cilliers 1998). Effective learning is learning that is fit for purpose, i.e. learning that is emergent and makes a useful difference.
Promoting more effective learning requires attention to perceiving, understanding and influencing how we set the conditions for learning (Patterson et al. 2013). This is not a new idea and has been expressed in the medical education literature as critical thinking, deep, significant, meaningful learning (Mann et al. 2011) and deliberate practice (Ericsson 2004). Similar ideas are part of relationship-centred care (Suchman 2006) and entrustable professional activity (ten Cate et al. 2004; ten Cate 2005; ten Cate and Scheele 2007). Praxis, as practical reasoning informed by theory, is the new agenda for higher education, including the health professions (Sullivan and Rosin 2008; Cooke et al. 2010).
Three case studies create a framework of praxis with examples of what works in action followed by discussion of concepts, principles and theories related to and embedded in them. The Primary Care Curriculum (PCC) experiment in medical education (1979–94), from the University of New Mexico School of Medicine, illustrates an innovative approach to learning organised around praxis, expressed as a core set of values that informed the actions and choices of participants (implicit simple rules). It was relationship-centred and inquiry-based across multiple authentic settings for learning.
Case study 15.1 The Primary Care Curriculum at the University of New Mexico School of Medicine
The state of New Mexico in the USA is geographically large and sparsely populated with a high proportion of medically underserved and culturally diverse citizens. Access to healthcare services is, and has been, a major challenge. Responding to a request from the state government to address these challenges, the University of New Mexico School of Medicine, with the support of the WK Kellogg Foundation, created in 1979 an experimental, community-oriented, small-group, problem-based, student-centred parallel curriculum track, the PCC. Twenty students learned in PCC and 53 students learned in the parallel traditional curriculum track during the first 2 years of medical school (from 1979 to 1994), after which time students learned together during their final years of study (4-year curriculum) (Kaufman 1985).
Students began learning in a fully integrated curriculum from the first day, working in small-group problem-based tutorials, learning core clinical skills and the relevant sciences basic to medicine. They accepted significant responsibility for their own learning based on questions they developed during their exploration of clinical cases and early clinical and community experiences. Students found this to be highly motivating and rewarding (Kaufman et al. 1989), learning by understanding rather than memorisation (Regan-Smith et al. 1994).
Learning was fully self- and group-directed, without summative grades or formal lectures. Formative assessments, like the curriculum itself, approximated what students would be doing for the remainder of their professional lives, i.e. seeing patients, communicating, acquiring information about the patient’s problems, conducting relevant inquiries such as screening history and physical examinations, writing their findings, ordering laboratory and or imaging studies, defining and refining their understanding of the patient’s problem(s) based on new information, developing and pursuing learning questions, presenting their approach to the patient’s problem to professors, explaining their reasoning and discussing the relevant sciences basic to medicine. This approach was very empowering for students and teachers.
Students were prepared for their clinical experiences early in the first semester and during the second semester with a full-time 16-week longitudinal immersion in a rural primary care setting. Living in a rural community, working in the office of a primary care physician and interacting with their preceptor and patients proved to be one of the most powerful learning experiences in their 4 years of medical school. To help keep both practical and theoretical issues in perspective, faculty members did ‘circuit rides’, visiting the community and interacting with the student and preceptor once each month during the community attachment. They observed and discussed the student’s performance with the preceptor, discussed with students how their relationship with their preceptor was developing, observed students during a patient encounter, observed how they were defining and studying learning questions and derived experiences with patients and community, and how they were getting to know the community (Voorhees et al. 1985). Students designed, completed and presented a community project.
Students returned to the medical school for a second year of study eager and ready to learn – to extend their experiences in the community. An important lesson for students was the value of taking more and more responsibility for their own learning. They continued to learn self- and peer-assessment skills in small-group tutorials. Students arriving for their third-year clinical rotations were already familiar with this form of assessment.
Another unique aspect of PCC was early role modelling. Students learned clinical skills from their peers who were 1 year ahead of them and teamed with a clinician and a basic scientist. Clinical skills were integral to problem-based tutorials, the sciences basic to medicine and to half-day per week clinical attachments with primary care physicians. The PCC culture embodied authentic human relationships among students, teachers, patients and communities.
What stands out the most is the students’ curiosity and motivation to learn and to keep learning. The culture of learning was grounded in inquiry, the need to know, learning in practice and practice for understanding. They learned to recognise uncertainty as an invitation to inquiry. The programme had a lasting impact on everyone it touched and reached far beyond the borders of New Mexico.
Practice with understanding, simple rules
The PCC programme was designed and conducted to be fit for function, i.e. relevant to the healthcare needs of students and the citizens of New Mexico. Students were expected to explain their thinking, choices and practices to build habits of praxis. The designers of PCC were aware that the life history of the learner, and groups of learners, through which their instrumentality was formed (Royson 2002) framed how, and the extent to which, they were predisposed to learn from their interactions with other learners, teachers, patients, objects and the environments they co-habited (Royson 2002; Kelso and Engestrom 2006).
A palpable culture of learning infused students and teachers in PCC. In retrospect, PCC had implicit simple rules: shared values and beliefs that informed the individual actions of a diverse group of people working and learning together as a coordinated whole (Patterson et al. 2013). These broad guidelines became PCC’s identity as they functioned across multiple levels for students, teachers, preceptors, community, the medical school and the university. The implicit simple rules guided participants’ choices and expectations, shaped how they treated one another and influenced their professional identity and practices. They provided ‘coherence among the parts that gives rise to the whole’ (Kelso 1995: 252). Coherence of learning derived from implicit simple rules that occurred in diverse environments, activities and tasks encountered by PCC students in communities and classrooms. Early and sustained authentic learning experiences were motivating and effective in promoting readiness to learn (Voorhees et al. 1985) and implicit simple rules guided choices and decisions at the individual level, leading to system-wide patterns and changes (Eoyang and Holladay 2013; Patterson et al. 2013). Three examples of implicit simple rules (Eoyang and Holladay 2013: 99) in PCC were:
1 ‘Teach and learn in every interaction’. This simple rule perfused experiences in problem-based tutorials for teachers and students, formative assessments, peer teaching, preceptor–student interactions, student–patient interactions, circuit rider (medical school faculty) visits to students and preceptors in the community, and community–medical school relationships all the way up to the state government. The quality of inquiry and the thoughtfulness of the questions asked informed both teachers and students about their continued learning.
2 ‘Give and get value for value’ was evident in the way students exchanged ideas, and discussed and elaborated on learning questions developed collaboratively at the frontiers of their understanding; in the regular self, peer and teacher feedback sessions; and in the formative assessments with standardised patients. Interpersonal relationships were highly valued. Teachers in PCC treated students the way they wanted them to treat their patients and each other.
3 ‘Attend to the whole, the part and the greater whole’ refers to seeing the similarities and differences in what was being learned at different levels and orders of magnitude. Problem-based cases embraced multiple levels and scales of biological, social, policy and ethical issues. Authentic early clinical and community experiences functioned as the whole into which relevant aspects of basic clinical skills and principles of sciences basic to medicine were woven. The greater whole was New Mexico’s public health system, policies and practices. Learning was enhanced and sustainable when students saw the whole, the part and the greater whole; when they learned to zoom in and out of different perspectives, levels and dimensions of a patient’s problem.
Learning: matching dimensions, praxis and causality in medical education
Learning at all levels of professional life is grounded in observation, sense making and action. It involves working with a continuous flow of information, collecting and sorting through data and looking for patterns. Patterns are fundamental to thinking and to the ability to recognise and adapt to situations (Kelso 1995; Eoyang and Holladay 2013). They are essential for learning, caring, diagnosing and treating health problems and issues (Groopman 2007; Hofstadter and Sander 2013). Enhancing learning requires an awareness and sensitivity to matching the dimensions of the tasks and challenges learners face with the dimensions of the surrounding environment, with the dimension of the approach taken by the teacher and practitioner, and with the learner’s predisposition to learn. The learner’s predisposition to learn is critical because if students, patients and practitioners are not curious, not ready or interested in learning, the school, curriculum, diagnosis and treatment may not matter. The best we have to offer may not be good enough.
The case study of Mrs B and Dr Sweeney involves a mature practitioner dealing with certainty, uncertainty and human relationships as the doctor struggles to match dimensions of attention and communication with Mrs B. The take-home messages from this case are generalisable to learners and practitioners at all levels.
Case study 15.2 Jack’s dead and the boys have gone
Some years ago our practice nurse asked me to see Mrs B, an 85-year-old widow, who, as I recall, at the time of consultation had been registered as a patient with me for about 15 years. I knew her well. Her husband, a pleasant chap who had been a builder, had died 5 years previously. Mrs B was pretty much estranged from her two grown sons, who were recurrent petty criminals, both serving prison sentences at the time of the consultation. Box 15.1 shows the conditions from which Mrs B suffered, and Box 15.2 shows her test results, which the nurse wanted me to review with her.
Diabetes
Hypertension
Osteoarthritis
Macular degeneration
Hallus valgus
Box 15.2 Mrs B’s test results
Glycosylated haemoglobin 9.7%
Blood pressure 180/96 mmHg
Total cholesterol 8.0 mmol/l
Body mass index 29 kg/m2
When we met, at the practice nurse’s request, I rehearsed the abundant evidence supporting interventions to lower blood pressure, to improve the control of her diabetes and reduce her lipid levels. I remember even thinking where the references for this all lay (with a résumé in clinical evidence). I confess to feeling just a shade confident as I explained the abnormalities and how we could ‘help’ to reduce her risk. After a few moments I stopped – resting my case, as a barrister might say.
Mrs B remained silent for a moment or two. Then she said, ‘Well, Jack’s dead and the boys have gone’. . . . At the simplest level, one can say that the consultation, at the point when Mrs B made this contribution, moved from being doctor-centred to patient-centred. It moved, one could say, from the biomedical domain to the biographical domain, or from clinical, evidence-based medicine to a consultation predicated on narrative-based evidence. But the shift was profound. When the consultation moved from its biomedical phase, it shed its parameters of P-values, absolute risk and numbers needed to treat. These were replaced by the parameters of the biographical phase of the consultation led by Mrs B. Here despair, hopelessness, regret, guilt perhaps, and defeat were the parameters. Physical parameters had been replaced by metaphysical ones – two intellectual worlds seem to have collided. . . . It is clear that when Mrs B offered her contribution, the consultation took off in another direction. Up until that point, a fairly straightforward consultation was proceeding, drawing on scientific evidence gleaned from good clinical trials, many of them randomised and controlled, in the great tradition of scientific medicine. The remainder of the consultation, led by Mrs B, had nothing to do with that way of thinking and arose from her lived experience. Yet in that context Mrs B’s narrative evidence had more impact on the outcome of the interaction between Mrs B and myself than the clinical evidence-based observations with which I led the consultation. There were, one could argue, two ways of explaining things which were competing for influence – two explanatory models which at first sight did not seem to overlap much. At a deeper level, there were two types of knowledge jostling to influence. Two different types of viewing and making sense of the world were at stake.
Indeed, there are at least two explanatory models are at play in this case. One is best practice and evidence-based medicine that rely on certainty, reproducibility and a linear additive logic of causality. Given this problem plus that problem, this pattern of data plus that pattern of data, the best-evidence literature says treat this way. Dr Sweeney’s initial view of the pattern of Mrs B’s problems was best practice; her problems were known, her lab values given and useful literature available to guide his decisions and advice. When the answer is known, best practice prevails.
The second explanatory model came into play at the speed of thought when Mrs B said, ‘Jack is dead and the boys are gone.’ The number of factors at play increased dramatically to a high degree of uncertainty about the appropriate course of action. The consultation became complex, uncertain and unpredictable. Linear and additive logic was no longer fit for function as causality was now emergent and non-linear. Dr Sweeney and Mrs B had to collaborate to find a solution to try and then together see and learn what would happen.
What is significant is Dr Sweeney’s shift from linear best practice based on biological data to non-linear adaptive action (Eoyang and Holladay 2013) based on biographical data during his relationship with Mrs B. Moving from moderate to high dimensionality, switching from linear to non-linear thinking requires a lot of experience. We teach, and students learn, the linear (certain and known) aspects of healthcare very well, especially in the early phases of medical education. We’re not as good with teaching the non-linear (uncertain and unpredictable) aspects of healthcare, nor are we comfortable with non-linear emergent causality because uncertainty means not knowing and medical students are taught to know and to act with certainty. Students learn early in medical education to avoid admitting they ‘don’t know’. Patients too are uncomfortable with uncertainty and want specific answers. Studying and learning to become a physician require a healthy tolerance for uncertainty because every day brings something new to be learned.
Many teachers and learners try to linearise non-linear complex situations so that they think they can know what to do and to avoid appearing not to know something. Not knowing is culturally uncomfortable in the practice of medicine and in medical education. When there is no correct or known answer, when what worked in the past is no longer effective, the strategy is to formulate questions that focus inquiry and lead to action that is fit for function. Learning to recognise and differentiate between certainty and uncertainty and to match the dimensionality of teaching with the conditions of the tasks at hand enhances the effectiveness of inquiry, learning, patient care and the health system.
Praxis at an international level
The felt need of Singapore to develop basic medical research capabilities and to invest in the development of a new medical school to support that goal is explored in the next case study. International institutional collaboration between the National University of Singapore and Duke University in the USA illustrates how praxis can be fit for function between institutions and countries.
Case study 15.3 Addressing the educational needs for the 21st century – the Duke-National University of Singapore experience
In 2000, Singapore’s strategic mission was to develop a biomedical research hub in Southeast Asia. Singapore noted a lack of local researchers who could fill research roles in this industry, lead research initiatives and bridge the gap between the practice of medicine and the latest research findings. To fill this gap, Singapore chose to partner with the Duke School of Medicine to establish the first US-style postgraduate medical school in the area. Duke was chosen because of its success in biomedical research and its unique medical school curriculum, with a third year dedicated to research. The education team that came to Singapore to set up the new school had an opportunity to explore ways to improve traditional medical educational strategies, keeping in mind the need to deliver the Duke content while honouring local context and working within limited existing faculty resources. TBL (Michaelsen et al. 2002; Parmelee et al. 2012) was chosen as the educational strategy to deliver and enhance the Duke-National University of Singapore (Duke-NUS) pre-clinical science curriculum while ensuring appropriate Singapore context with local faculty.
We had 17 months to recruit and train faculty in TBL, recruit students and develop the TBL modules. We created over 70 TBL modules in the first year to address the core Duke curriculum. Duke provided videos of core content which helped to keep our two schools’ curricula aligned. Duke-NUS faculty developed the TBL tests and application questions. In the first year, we administered the same assessments to both Duke and Duke-NUS students to ensure they were learning the basic science foundation needed to perform well on the United States Medical Licensing Examination (USMLE), Step 1 (Kamei et al. 2012). We enhanced the TBL structure by engaging students in crafting team questions and facilitating in-class discussions. Further engaging students with the content helped students to pursue a deeper understanding and develop important lifelong learning skills (Duke-NUS 2011).
This strategy is now well integrated into our programme, well received by students and faculty, and has achieved the desired outcomes. Our success has motivated the Duke School of Medicine to take on the difficult task of introducing TBL into its pre-clinical curriculum. Changes in education are always difficult, and our success was helped by:
• an administration willing to provide the opportunity to develop a new learning paradigm (TBL);
• an office of education that provided comprehensive support to faculty to learn effective TBL design and implementation, mentoring in the development of quality TBL material and the provision of all-inclusive administrative support in preparation of materials, assessments and in-class implementation;
• faculty willing to be student-centric and step out of their comfort zone in teaching;
• students tolerant of early mistakes in our implementation of TBL and willing to take charge of their own learning.
The Duke-NUS case study illustrates awareness at the national level of the need to bring the practice of medicine closer to research-based inquiry. Praxis was evident in the development of a curriculum valuing inquiry with understanding. They thought about how TBL fit with their needs, modified it based on their understanding of the underlying assumptions and worked to use both theory and practice to improve their curriculum over a period of years. The video in the case study illustrates how the culture of practice and understanding perfused learning and was complementary to the development of the Duke-NUS partnership. The learning relationship within Duke Medical School and Duke-NUS was held together (bounded) by shared interests and values, setting the conditions for self-organisation such that the Duke-NUS programme remained fit for function as it evolved. The relationship between the two schools followed an implicit simple rule, give and get value for value; Duke Medical School learned about TBL from Duke-NUS and Duke-NUS learned about the relationship of inquiry-based learning to research and practice.
We can begin to improve learning effectiveness when we move away from the concept of learning as content acquisition, input–process–output, ‘banking of information’ and storage and retrieval models of cognition. Models of learning that embrace uncertainty, that recognise the complex adaptive nature of thinking and its interdependence with the learner’s life history, are more appropriate (Davis et al. 2008; Friedenberg 2009; Doll and Trueit 2010; Mennin 2010; Suchman et al. 2011). Inquiry-based medical education is fit for function in all dimensions (low to high) of practice and understanding. It enables learners to perceive the patterns of data and information, and to answer the question, what is going on?; to understand the meaning and significance of the patterns of information observed, i.e. to answer the question, so what does this mean for me, for the patient, for the group?; and to take action to influence the conditions that influence the emerging patterns, i.e. to ask the question, now what will we do? What? So what? and Now what? constitute adaptive action as three very important questions that shape inquiry-based learning (Eoyang and Holladay 2013).
Learning is always a complex adaptive process, the essence of which is experiential and uncertain. Praxis is action that combines practice and theory. The three case studies illustrate a similar pattern of praxis that enhanced learning for students, teachers, curriculum, medical school and the state of New Mexico; in a doctor–patient relationship between Mrs B and Dr Sweeney; and for an international collaboration between the Duke-NUS and the Duke Medical School. The praxis patterns are those of practice with understanding, ‘patterns that connect’ (Bateson 2002: 7), through ‘similarities, differences, and connections that have meaning across space and time’ (Eoyang and Holladay 2013: 43).
Standing in inquiry in which there is a match among the dimensions of activities, tasks and conditions (low, moderate and high) promotes the emergence of learning, i.e. new patterns of thought and ideas that are fit for function. When learners are curious, when they examine and question the assumptions about what they see and do at the edge of certainty and uncertainty, at the intersection of the familiar and novel, rich and generative learning emerges. Practice, together with an understanding of underlying assumptions, knowledge and beliefs that inform how we see the world, enhances learning in medical education.
Take-home messages
• More effective learning is readily accessible by combining practice and theory (praxis) in what we already know and do.
• More effective learning is more about praxis and less about needing more methods, techniques and tools for medical education.
• Situations, tasks and conditions of learning can be understood along a continuum of low to high dimensionality depending on the number of factors involved that make a difference.
• Learning is always a complex, adaptive process regardless of the dimensionality involved in the situation.
• More effective learning occurs by matching the dimensions of the tasks and challenges for learning with the dimensions of the environment and teaching approaches, and matching the predisposition of students, patients and practitioners to learn.
• Coherence in medical education exists when the patterns of practice and understanding are similar across the whole of the curriculum while preserving the richness of differences among individuals and groups.
• Implicit and explicit simple rules preserve individual choice and lead to system-wide changes that enhance learning.
Acknowledgements
The author thanks Regina Petroni Mennin, Glenda Eoyang and Royce Holladay for critical commentary and thought-provoking challenges during the composition of this chapter.
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