69

Introduction

The past two decades have seen significant changesin medical education at all levels of the continuum.First, our understanding of learning and teach-ing, and of the dynamic relationship betweenthem, has significantly advanced. Second, wehave begun to shift our activities from those thatemphasize teaching to those that emphasize learn-ing and to consider how we, as educators, canbest facilitate optimal learning. Lastly, there havebeen widespread national and international effortsto improve the content and process of medicaleducation, challenging us to consider how we canbest prepare and support learners for the practiceof medicine over a lifetime of learning.

The meaning of “curriculum” also has evolved.In undergraduate, graduate, and continuing edu-cation, we have traditionally viewed the curricu-lum as that which is written, including our goalsand educational content. On closer analysis, we canidentify at least three aspects of any curriculumexperienced by our learners. These include theformal curriculum, which is included in statedcourse objectives, learning activities, and evalu-ations. This curriculum is formally offered, and itis stated and endorsed. A second element is theinformal curriculum, which, although not usuallystated formally, includes important learning out-comes that we assume will be achieved, for exam-ple, presentation skills at rounds or criteria for refer-rals to consultants or other health professionals.More recently described is the hidden curricu-lum, which carries the “real” messages about howthe system works and the values that arise fromand reflect the organizational structure and culture.This curriculum is an “unscripted, predominantlyad hoc and highly interpersonal form of teachingand learning that takes place between and among

The Journal of Continuing Education in the Health Professions, Volume 22, pp. 69–76. Printed in the U.S.A. Copyright © 2002 The Alliancefor Continuing Medical Education, the Society for Academic Continuing Medical Education, and the Council on CME, Association forHospital Medical Education. All rights reserved.

Theoretical Foundations

Thinking about Learning: Implications for Principle-BasedProfessional Education

Karen V. Mann, PhD

Abstract

The understanding of teaching and learning in medical education has increased to improvemedical education at all levels. Selected approaches to understanding learning provide a basisfor eliciting principles that may inform and guide educational practice. In this article, theseapproaches are discussed from two perspectives: the cognitive and the environmental.

The cognitive perspective includes activation of prior knowledge, elaboration of newlearning, learning in context, transfer of learning, and organization of knowledge. The envi-ronmental perspective includes the dynamic interaction of learners with their environment,observational learning, incentives and rewards in the environment, goal setting and self-mon-itoring, self-efficacy, and situated learning.

Implications are presented for facilitation of effective learning and support of the learn-ing environment throughout the continuum of medical education.

Key Words: Curriculum, learning, medical education, continuing education, teaching, theories of learning, principle-based education

Dr. Mann: Division of Medical Education, Faculty ofMedicine, Dalhousie University, Halifax, NS.

Reprint requests: Karen V. Mann, PhD, Division ofMedical Education, Faculty of Medicine, DalhousieUniversity, 5849 University Avenue, Clinical ResearchCentre, Room C-112, Halifax, NS B3H 4H7.

faculty and students.”1 Although these concepts ofcurriculum have been described mainly in relationto undergraduate medical education, it is clearthat they also pertain to graduate and continuingmedical education (CME) learners. For example,continuing education programs have clearly statedobjectives that comprise the formal curriculum.Much informal learning occurs also in the dis-cussions that occur over coffee or in small groups.2

Lastly, the hidden curriculum messages might beseen in the program plan, where the time allocatedor program placement may transmit a messageabout the value placed on particular content.

There are many theoretical and conceptualapproaches to learning.3 Each of them can help usto understand aspects of the phenomenon; ourchallenge as educators is to consider each and todraw from them important underlying principlesthat can reliably inform our educational practice.

The objectives of this article are to considerselected approaches to understanding learning thatare relevant to medical education and to exploretheir implications for teaching and learning.

Thinking about learning across the medicaleducation continuum presents several questions,including: What kind of learning do we wish to pro-mote? What kind of teaching and learning activ-ities are likely to be effective to accomplish thatlearning? What do we want our learning experi-ences to achieve, both formally and informally?

Although we may not have actively reflectedon it, each of us has some fundamental under-standing about knowledge and learning. We havebeliefs about how knowledge is created and aboutwhether knowledge is objective (i.e., a truth to belearned or discovered) or subjective (i.e., per-ceived and constructed differently by us as indi-viduals). Further, we have values that we attachto these beliefs. We also hold beliefs about learn-ing and what we consider learning to be. Differ-ent beliefs about learning range from those thatview learning as an increase in knowledge and thedevelopment of skills to those that view it as a morecomplex process that transforms our way of think-ing and of viewing ourselves and the world.4

We each also hold beliefs about teaching,which arise from and reflect our beliefs aboutknowledge and learning and which contribute todiffering perspectives on teaching and how eachof us sees the teacher’s role and responsibilities.Together these beliefs about knowledge, learning,and teaching influence our individual approachesto teaching.4 Pratt et al. described these very clearlyin a recent article in this journal.5

Our teaching approaches, sometimes calledour “practical theories of teaching,” are alsodeveloped from a variety of sources,6 includingour personal teaching experience and our formalknowledge about teaching. Our ethical valuesand beliefs also powerfully affect our individualteaching practice.

Whatever our individual history, values,beliefs, and assumptions about what makes forgood teaching and learning, as educators, we sharea desire to help our learners acquire, maintain, ordevelop the knowledge, skills, and attitudes thatthey need in the context of their everyday work.Accordingly, some consideration of learning prin-ciples may be helpful.

In selecting those principles that will frame andguide our educational practice, it is helpful toconsider learning from two perspectives. The firstperspective is the cognitive perspective, whichexamines the processes occurring in the learner’sthinking and memory. The second is a social andenvironmental perspective, which considers learn-ing as it is affected by the environment and thelearner’s interaction in that environment. Eachperspective contains several distinct theories,which are not described fully here. However, ineach perspective, some major concepts can helpus to think about teaching and learning.

Cognitive Perspective

The principles drawn from cognitive theories oflearning actively inform medical education. Althoughnot limited to any particular educational method,these principles are clearly seen in medical educa-tion that involves problem-based learning.7–10

70

Thinking about Learning

Five principles are briefly explained as follows:

1. Activation of prior knowledge. Existing or“prior” knowledge is a critical basis for learn-ing. New learning happens most effectivelywhen it is connected to prior knowledge. Forconnections to be most effective, prior knowl-edge must be activated. This can happenthrough such activities as discussion, review,questioning, and reflective exercises, amongothers.

2. Elaboration of new knowledge. Elaborationof new knowledge is the process of workingwith it, discussing it, and connecting it withwhat is already known. This can happen veryeffectively in discussion, such as occurs inproblem-based learning groups, in seminars,and through note taking and study.Elaboration also happens when knowledgeis used in new situations and applied to rel-evant problems, either in the formaleducational setting or through direct experi-ence. In the case of continuing education,elaboration may frequently happen in thecontext of everyday practice.

3. Learning in context. Learning that occurs ina relevant situation or “context” facilitatesits storage in memory in a form that can bereadily retrieved and applied. Physicians’memory for the details of individual clini-cal cases exemplifies this principle. All ofthe aspects of the case are linked in memoryand can be recalled as an integrated whole.It follows, then, that the context in whichlearning occurs should be as close as possi-ble to the potential situation(s) in which itwill be applied. This concept is also referredto as encoding specificity. Examples of thismay be seen in the use of clinical problemsas the basis for problem-based learning inundergraduate and CME, as well as learn-ing that occurs in clinical and practicesettings.

4. Transfer of knowledge. Learning in contexthas very positive benefits; however, it alsohas limitations. Our learning becomes quitecontext specific, and we must actively workat being able to transfer that learning to newsituations. Undergraduate medical learnersadapting their knowledge from the class-room-based preclinical years to the clinicallybased years 3 and 4 exemplify this princi-ple. Transfer is facilitated by activities suchas considering how various aspects of a par-ticular problem might vary. Combining thetwo principles of learning in context and thespecificity of learning, we can see that learn-ers must see many clinical examples thatthey can compare and store for future use.Transfer of knowledge is not a concern lim-ited to medical students but must beconsidered also in faculty development ini-tiatives and formal CME programs. In facultydevelopment programs, faculty are helpedto acquire relevant knowledge and skills thathelp them as teachers; however, we attendless to the application of those skills andknowledge to teaching problems in the realsetting. Similarly, reported outcomes of someformal CME programs indicate that thedesired changes in practice are not observed.In part, the explanation may lie in the lackof attention to transferring what is learnedand linking it to practice.

5. Organization of clinical knowledge. The roleour knowledge base plays in problem solv-ing is increasingly understood. Priorknowledge, although necessary, is not suf-ficient, and neither are problem-solving skillssufficient on their own. Existing knowledgemust be organized in a way that is accessi-ble and usable. A well-organized knowledgebase is rich and elaborately interconnectedand is stored efficiently. We have all workedwith learners, from novice to expert, andobserved differences in the way in whichthey frame and solve problems. Bordage11,12

71

Mann

and others have described how teachers canhelp learners to build a working knowledgebase, as well as how problems with a knowl-edge base can be diagnosed and addressed.12

Most of this work has focused on under-graduate learners; however, recent work byCharlin and colleagues explored how physi-cians form “scripts,” which are essential intheir framing of clinical problems, and relatedthat to knowledge organization.13

Social and Environmental Perspective

Several theories view learning as an interactiveprocess, in which the learner is always in a dynamicinteraction with the learning environment.3,14,15

We may think of the learning environment as theclassroom, the clinical setting (office or healthcare institution), and the milieu of the institutionas a whole. Six principles are helpful to consider:

1. Individuals are constantly interacting dynam-ically with their environment. The belief thatwhat we teach is transmitted unchanged tolearners and will, in turn, be reflected exactlyin their behavior is challenged here. Learnersare constantly interacting with their teachers,colleagues, other health care professionals,and patients. Both learners and those withwhom they interact are affected by thoseexchanges and contacts so that the learningenvironment is continually changing.Moreover, as noted in the reference to the“hidden” curriculum, learners also perceiveand react to less obvious influences in theenvironment. In the context of continuingeducation, the physician is interacting withthe environment as well and learning frominteractions with colleagues and from theresults of practice interventions.

2. Learning occurs through observation.Fortunately, we need not experience every-thing first hand in order to learn. In fact, inlearning by observation or vicariously, wecan observe not only the actions of others

but also the effects of those actions, whetherthey are rewarded, and whether they areeffective or ineffective. This is the basic prin-ciple that underlies the notion of rolemodeling and its powerful effects on howlearners think and act. We have much to learnabout this complex phenomenon. However,we know that learning through observationoccurs whether or not the model intends it.Teachers are unconsciously role modelingall of the time. They model their skills andtheir attitudes. In CME, participants learnnot only from teachers but also from col-leagues’actions and from the actions of thosewho may be “educationally influential.”16,17

3. Learners see incentives and rewards in theenvironment. Our environment gives very pow-erful messages about which actions andoutcomes are valued and which are not. Someincentives are overt: efficient work may leadto more discretionary time or greater satis-faction; demonstrated skill will bring respectfrom colleagues and patients. Sometimes, how-ever, rewards in the environment are notcongruent with the kinds of learning and behav-ior we want learners to develop. The “hiddencurriculum” also plays a role here, givingstrong messages, often more powerful thanthe stated ones, about values and rewards. Forexample, although emphasis is placed oncommunication, patient-centered relationships,and preventive care, the rewards that resultfrom performing those actions may be eclipsedby rewards that accompany other activitiesmore valued by the health care system.

4. Learners can set goals and work towardthem. Abasic precept of learning theory holdsthat people are inherently self-directed andwill set goals and rewards for themselves,as well as monitor their own progress towardthose goals and rewards. A large volume ofresearch supports individuals’ goal-settingabilities and strategies, as well as their effec-tiveness.15 In a profession for which lifelong

72

Thinking about Learning

and self-directed learning have becomewatchwords, this is an extremely importantconcept as it has implications for both learnermotivation and for the support we provideto all levels of learners in developing andusing this capacity.

5. Perceptions of self-efficacy are key to devel-oping competency and autonomy. Self-efficacyis the perception one holds about one’s abil-ity to carry out a specific task or type of task.15

Generally, these perceptions are quite taskspecific and amenable to change. Experienceis the most powerful source of self-efficacyperceptions, but learners also make these judg-ments based on their observations of others’abilities, as well as their own feelings (e.g.,anxiety) and the encouragement of others.Self-efficacy appears in the kinds of goalspeople will set for themselves, how difficultthose goals are, and how long they will per-sist to achieve the goals.

Another approach to development ofautonomy and motivation is described as“self-determination” theory,18 whichdescribes how learners can be helped todevelop autonomous motivation, which willequip them for lifelong learning. Both con-cepts of self-efficacy and self-determinationhighlight the importance of competence andpersonal judgments of ability in motivatinglearners to continually assess their needs andset new goals based on their self-assessments.This principle has implications right acrossthe continuum.

6. Knowledge is constructed in the environmentand is situated there. This principle draws onboth the cognitive and social/environmentalapproaches to learning and is particularly rel-evant to clinical learning. Much clinicallearning occurs through apprenticeship. Whenlearners enter an apprenticeship environment,they learn not only content knowledge butalso processes, interactions, and approachesto practical problems in that environment.

These aspects of learning are not all separate;in fact, they are connected to the “situation”in what we call “situated learning.” Situatedlearning is also a social process; it occurs ininteraction with other participants — in thecase of medical learners, in a healthcare–related setting. Part of the learning occursthrough interaction with the people in theenvironment, through “talking about” and“listening to talk” about the framing and solu-tion of practice problems. Learners graduallybecome increasingly involved and skilled asthey learn and move from peripheral partic-ipation in the learning setting to more centralinvolvement, which includes more responsi-bility.4,19 Situated learning is very relevant incontinuing education. Our learners/partici-pants are continually interacting in theprofessional community, where they learn“from talk” and “to talk” with their colleagues.

No discussion of learning would be completewithout considering adult learning and its under-lying principles.13,19,20 We talk frequently abouttreating our learners as adult learners, yet we oftenstruggle with defining what an adult learner isand how that definition applies to our learners.These issues are much less controversial in the con-tinuing education setting. The principles of adultlearning are embedded in both the cognitive andsocial/environmental approaches presented above.Adult learners are individuals who have a partic-ular problem of interest. They draw heavily on theirexisting knowledge and previous experience, andthey want to acquire knowledge and skills that arerelevant to their educational needs and to the solu-tion of authentic problems. Self-assessment ofprogress is also an assumed principle of adultlearning. However, to date, the evidence of oureffectiveness at self-assessment is inconclusive.21

The ability to reliably assess our own performanceis, at a minimum, a skill that must be facilitatedand developed. Perhaps most important is theunderlying philosophy of adult learning thatrespects learners as individuals who possess theability to participate in defining, planning, and

73

Mann

evaluating their own learning and thus to be ongo-ing learners across their practice lifetime.

Implications for Teaching and Learning

To this point, this article has highlighted selectedconcepts and principles of learning that can informour practice as educators. To consider their use-fulness further, we need to ask two additionalquestions: What is implied by the above principlesas we think about the task of educating physi-cians at all levels? How do they help us to thinkabout learning and teaching and learning activi-ties that will promote effective learning?

Several implications are suggested below;however, this list is not exhaustive. The implica-tions may be seen both at the individual learnerlevel and at the environment or system level.

Learners need to:

1. be exposed to authentic tasks, such as thosethey will encounter, or are encountering, inpractice. This will promote learning in con-text and situated learning and will provideknowledge that is relevant and stored in auseful way for future use and learning.

2. engage actively in learning, not just watch orlisten. Active participation promotes work-ing with knowledge and adapting it for usein clinical tasks and will build feelings of self-efficacy and independence in our learners.

3. elaborate the new knowledge they are gain-ing. Opportunities to discuss their learningwill assist learners to understand and makeconnections among their knowledge. It willalso help teachers to see how learners aredeveloping and to assist where necessary. Formore advanced learners and those in prac-tice, the opportunity to discuss learning withcolleagues will support elaboration and inte-gration of new learning.

4. receive opportunities to learn “from talk”and “to talk.” In addition to thinking aloud

themselves, learners need to hear teachersthink aloud in order to understand their think-ing and approaches.

5. have opportunities to apply their learning inpractice so that they can keep building ontheir knowledge and developing increasinglycomplex skills and knowledge. This appliesto learners at all levels and helps to linkformal learning with practice. In CME, com-mitment to change strategies have been usedwith some success to help learners identifyhow their learning may be applied.22

6. develop the ability to learn from their prac-tice and to reflect on their learning. Learnerscan use reflection to ask themselves specificquestions. For example, “How does what Ilearned about ‘X’ condition relate to what Iknow about other similar conditions?” “Whatgeneralization(s) can I make from this expe-rience for the future?” “What did I do well?”“What do I need to learn next?” It is impor-tant to note that, to be most effective, reflectionshould include both the cognitive and theaffective aspects of learning. Severalapproaches to encourage reflection as part ofpractice and learning have been described.23

The learning that results from reflection maybe enhanced when reflecting is shared as withanother colleague or a practice group.24

More generally, there are implications at thesystem and environmental levels of planning.These include the following:

1. The importance of role models. Faculty andcolleagues are constant role models, con-sciously or not, of all kinds of behavior, values,and attitudes. As educators, it behooves us toconsider how our formal programs and thefaculty within them model values and beliefs,in addition to the content expertise they share.It also reminds us of the importance of “edu-cational influentials” and how they mightaffect their colleagues’ practice.

74

Thinking about Learning

2. The importance of the assessment system.Assessment has a consistently powerful effecton learning; the assessment system gives theloudest messages about what is valued.Assessment of competence among practic-ing physicians is emerging as an essentialelement of both improvement and account-ability. Many countries and regulatoryorganizations are exploring, developing, andimplementing approaches to revalidation andrecertification. The challenge is to developsystems of assessment that will monitor andreward continuing education activities thatwill lead to effective learning and practiceimprovement.

3. Feedback is essential. It helps learners toknow their progress, set goals, develop auton-omy, and improve toward mastery of skills.For learners in continuing education, oureducational role may include assisting ourlearners to identify appropriate sources offeedback, for example, using audits of theirpractice or choosing outcomes to measure.

4. The importance of clear expectations.Learners will set goals and work towardthem. It is important to build on that processby facilitating the setting of clear expecta-tions. Even early in their medical education,learners may benefit from involvement insetting these expectations. This experiencewill be useful to them as continuing learn-ers as they set their own goals andexpectations.

5. Learners need opportunities to make deci-sions, especially while still in their formaleducation. They need to make decisionsabout their learning, as well as about thepatient problems they are learning to manage.This will help to build confidence and com-petence in making choices and in monitoringtheir outcomes. For most practicing physi-cians, confidence and competence about a

range of patient problems exist. However,as educators, we may be able to support themin making decisions about their learning.

6. Learners at early stages need opportunitiesto assume increasing responsibility. Learningfrom experience and gradually assumingmore responsibility will build a sense of self-efficacy and autonomy. It will also graduallyinvolve them in the professional communityas responsible members. This principleapplies at all levels of education; in the earlystages of any learning, some guidance andopportunities for practice will enhance thequality of learning.

Summary and Conclusion

In this article, selected learning theories provideda basis from which to draw principles that caninform our educational practice. Such an activityis destined to underestimate the complexity ofeach individual approach. Yet, it allows building

75

Mann

Lessons for Practice

• Recognize the value of selected princi-ples when making instructional designdecisions

• Assure early exposure to tasks such asthose encountered in practice

• Promote the adaptation of knowledgefor use in clinical tasks

• Elaborate new knowledge throughdiscussion among learners

• Create opportunities to reflect uponpractice and learning

• Recognize the importance of rolemodels, the assessment system, clearexpectations, and feedback

of a framework that can help us as we examine ourexisting assumptions and beliefs about teachingand learning, and it can serve as a structure to guidedevelopment, use, and evaluation of our educa-tional programs and practice. By selecting prin-ciples to inform our practice as educators, we canenhance the effectiveness of educational experi-ences and facilitate the optimal learning that bothwe and our learners desire.

References

1. Hafferty FW. Beyond curriculum reform: con-fronting medicine’s hidden curriculum. AcadMed 1998; 73:403–407.

2. Tipping J, Donahue J, Hanna E. Value ofunstructured time (breaks) during formal con-tinuing medical education events. J ContinEduc Health Prof 2001; 21:90–96.

3. Merriam SB, Caffarella R. Learning in adult-hood. 2nd Ed. San Francisco: Jossey-Bass, 1999.

4. Pratt DD, and associates. Five perspectives onteaching in adult and higher education.Malabar, FL: Krieger, 1998.

5. Pratt DD, Arseneau R, Collins JB.Reconsidering “good teaching” across thecontinuum of medical education. J ContinEduc Health Prof 2001; 21(2):70–81.

6. Handal G, Lauvas P. Promoting reflectiveteaching: supervision in action. Milton Keynes,UK: The Society for Research into HigherEducation and Open University Press, 1987.

7. Schmidt H. Foundations of problem-basedlearning: some explanatory notes. Med Educ1993; 27:422–432.

8. Regehr G, Norman G. Issues in cognitive psy-chology: implications for professional educa-tion. Acad Med 1996; 71:988–1001.

9. Norman G, Schmidt H. The psychologicalbasis of problem-based learning. Acad Med1992; 67:557–565.

10. Coles C. Is problem-based learning the onlyway? In: Boud D, Feletti G, eds. The chal-lenge of problem-based learning. 2nd Ed.London: Kogan Page, 1998:313–325.

11. Bordage G. Elaborated knowledge: a key tosuccessful diagnostic thinking. Acad Med1994; 69:883–885.

12. Bordage G. Why did I miss the diagnosis?Some cognitive explanations and educationalimplications. Acad Med 1999; 74(Suppl8):138–143.

13. Charlin B, Roy L, Brallovsky CA, Goulet F,van der Vleuten C. The script concordancetest: a tool to assess the reflective clinician.Teach Learn Med 2002; 12(4):189–195.

14. Kaufman D, Mann KV, Jennett P. Teachingand learning in medical education: how theory can inform practice. Edinburgh:Association for the Study of MedicalEducation, 2000.

15. Bandura A. Social foundations of thought andaction: a social cognitive theory. EnglewoodCliffs, NJ: Lawrence Erlbaum, 1986.

16. Stross JK. The educationally influential physi-cian. J Contin Educ Health Prof 1996;16:167–172.

17. Kaufman DM, Hodder I, Ryan K. A study ofthe educationally influential physician. JContin Educ Health Prof 1999; 19:152–162.

18. Williams GC, Saizow RB, Ryan RM. Theimportance of self-determination theory formedical education. Acad Med 1999;74(9):992–995.

19. Lave J, Wenger E. Situated learning: legiti-mate peripheral participation. Cambridge, UK:Cambridge University Press; 1991.

20. Merriam SB. Updating our knowledge of adultlearning. J Contin Educ Health Prof1996;16:136–143.

21. Norman GR. The adult learner: a mythicalspecies. Acad Med 1999;74(8):886–889.

22. Mazmanian PE, Mazmanian PM.Commitment to change: theoretical founda-tions, methods, and outcomes. J Contin EducHealth Prof 1999;19:200–207.

23. Schön DA. Educating the reflective practitioner.San Francisco, CA: Jossey Bass, 1987.

24. Moon J. Reflection in learning and professionaldevelopment. London, UK: Kogan Page, 1999.

76

Thinking about Learning