Malta Medical Journal Volume 21 Issue 01 March 2009 11 Jürgen Abela Review Article Adult learning theories and medical education: a review Abstract Adult learning theories describe ways in which adults assimilate knowledge, skills and attitudes. One popular theory adult learning is highlighted, particularly since andragogy fails is put forward as an alternative concept. Using the three recognised domains of knowledge, skills and attitudes, ways of applying these theoretical concepts in medical education are subsequently discussed. Introduction In the past, there has been an assumption that if a person knows very well the subject, then, he will be able to teach it. However the complexity involved in practising medicine must be tackled with appropriate educational strategies in the training and education of undergraduate and postgraduate students. In fact, training teachers in educational techniques translates in better student learning outcomes.1 the broader context of adult learning theories. Ways on how to apply educational theories will be put forward, with the ultimate aim being to foster medical competence. Adult learning theories Given that in the medical context most education involves learning, experiential learning, perspective transformation and situated cognition.2 Of these, self-directed learning particularly focuses on the individual learner as primary focus. Prominent amongst these self-directed theories is andragogy. andra – meaning “man”; agogos to describe the educational theory of the Greek philosopher Plato. He used it to refer to the normal process by which adults engage in continuing education. In the 20th century, various respected intellectuals, such as John Dewey, Eduard Lindeman, and Martha Anderson pursued theories of andragogy, but were the work of Malcolm Knowles who championed this theory and further elaborated the concept.3 Andragogy assumes that adults: • are independent and self directing, • have (various degrees of) experience • integrate learning to the demand of their everyday life • are more interested in immediate problem centred approaches and • are motivated more by internal than external drives. Keywords Jürgen Abela MSc, MRCGP Department of Primary Health Care, Floriana jurgena@maltanet.net12 Malta Medical Journal Volume 21 Issue 01 March 2009 Another characteristic deemed to be relevant to adult learning environments, is the importance of mutual respect between teacher and learner and also amongst the learners themselves. Respect is important since it is a catalyst for a safe educational environment.4 adult learning, despite being an important component of adult learning skills.5,6 steps in Kolb’s Learning Cycle.7 In addition, the importance of be an important difference between adult learning (andragogy) be seen to enhance adult learning by increasing motivation to learn.8 Motivation is another important pillar on which adult describing motivation: • content theories: these describe what motivates people, and • process theories: these describe how people are motivated.9 One of the most popular of the content theories is Maslow’s Hierarchy of Needs.10 needs, such as physical needs and security culminating in self- environment cannot be overstated in the successful progression of the learner through the hierarchy of needs as described by However, Maslow’s model may be seen to be too rigid. In various needs simultaneously throughout his learning trajectory. It can thus be seen to be inadequate. A more appealing content theory is the one put forward by Clayton Alderfer, who describes and summarises motivation in three needs, ERG:9 • Existence – this is more or less equivalent to Maslow’s safety and physical well being steps • Relatedness – stresses the importance of interpersonal and social relationships • Growth – intrinsic individual desire for personal growth Process theories of motivation, on the other hand, are based on the idea that certain behaviours are produced by particular that motivation depends on two perceptions:11 1. an expectation that an outcome will bring the desired rewards 2. the required performance is within the capability of the person. In andragogy, Knowles states that adult learners are self (intrinsically) motivated.3 He fails to mention extrinsic motivation and especially, the role of the teacher as major source of motivation. In fact, as Peyton9 points out, most adult learners require the motivation provided by teachers for effective learning to take place. Not all adult learners are equally intrinsically motivated, and this further highlights the inadequacy of andragogy with respect to motivation. In fact, there necessarily arises the need of a mix of learning strategies, ranging from teacher-directed to student-directed learning.13 be a “match” (Figure 2) between the learner and the teaching styles used.14 But how does one strike a “match” between learner stage and teacher style? relationship is to carry out a needs-assessment of the student/trainees involved. Without such needs assessment, teaching would be tantamount to treatment without a diagnosis. For would be dependent on the teacher to show them how to take a history, during the subsequent years, the learning strategies should deal with examination skills, going on further along the months to discussing the differential diagnosis and treatment hopefully be matched by the progression of the learning stages Physiological Needs Safety Needs Security, Protection Social Needs Sense of belonging, Love Esteem Needs Self-esteem, recognition, status Self Actualisation Figure 1: Maslow’s Hierarchy of Needs Malta Medical Journal Volume 21 Issue 01 March 2009 13 Figure 2: Matching learner stages to style14Match Match Match Match Salesperson, motivator Facilitator Delegator Dependent Learner Interested Learner Involved Learner Self-directed Learner Learner Stages Teacher Styles Match Near Match Mismatch Authority, expert Severe Mismatch Key: coupled with the learner getting more involved (motivated) in with a variety of tools: and facilitate in-depth search on certain topics in addition to allowing for personal development. should always act as a background for any discussion on topics. • Use of the trainees’ experiences to discuss issues in practice, especially at postgraduate level. end of life. • Problem based learning. • Open discussions on “hot topics” such as medico-legal litigation. seems more appropriate.12 Crucial to this theory are the structures and mechanisms through which adults assimilate and understand called frames of reference are the meaning which people give to experiences and the structures used to arrive to such meaning. It genetic make-up and cultural assimilation of the particular adult. the assumptions which make up each frame of reference. In line with the motivating role of the teacher in adult on their own and others’ assumptions.12 Methods that may be particularly useful in this situation include critical incident analysis, small group work to formulate ideas on particular certainly there is the need of more research along this line.15 Inner Apprentice.16 in 1992, to describe the learning process of trainees. Neighbour Apprentice i.e. the unconscious learning mechanism that is intrinsically self-educating, provided the right information is provided in the right place and at the right time. Given such favourable learning climate, the inner apprentice (trainee) acquires knowledge (learns) by moving from cognitive dissonance to cognitive resonance through stages of “kairos.” Kairos in Greek means the right time of action, and by analogy, during points of “kairos” the trainee can most clearly recognise the nub mutative information eventually leads to changes in the frames of reference to achieve cognitive resonance. Going through the theories of adult learning, one runs the risk of losing track of what they stand for – to enhance adult learning and facilitate effective teaching. In other words, competence, whatever speciality, by the trainee. Indeed, achieving medical competence should be (and usually is) one of the ultimate motivations of any medical educational setup. education, may at times actually lead to incompetence.17 Medical 14 Malta Medical Journal Volume 21 Issue 01 March 2009 knowledge, technical skills, clinical reasoning, emotions, values and the community being served.”18 Medical education, including its theoretical basis, should effectively address all of these issues to produce competent application in practice of theoretical concepts, using the fact that medical education is based on three interrelated domains, which are knowledge, skills and attitudes.19 Knowledge can be “…a background of facts and interactions between facts that should lead to an understanding of the material being learned”20 interesting way to picture knowledge (and the lack of it) in learners is by the using the concept of JoHari Windows (JW) put forward by Joseph Luft and Harry Ingham (hence: Joseph & Harry = JoHari)21 improve the self-awareness between individuals and teams. It is sometimes called a disclosure/feedback model of self awareness. good use of it is to map out the trainee’s knowledge, which is understanding and management of knowledge (Figure 3). the Blind Spot since it refers to knowledge not known to the type lecturing, where new information is provided. Area 3 is called the Facade Area, and refers to what the person knows of both areas 2 and 3, and possibly area 4 is augmented with Skills are very much the panacea of medical institutions. Until recently the adage used to be “see one, do one, teach in the medical profession but at the same time creates undue tension in the learner and also may inhibit exploration of various aspects of the studied skill for example when things go wrongs or possible complications which arise during or after the particular procedure. In addition, certain skills such as communication skills do not lend themselves readily to this format. A practical example in the case of surgery would be Figure 3: The Johari Window21Malta Medical Journal Volume 21 Issue 01 March 2009 15 practical skill involves setting the scene correctly, using a sterile environment, preparing the skin, using the necessary instruments appropriately, removing the cyst with the capsule, suturing the wound ending by submitting the sample for histological assessment. However, in addition, to this, it is important to discuss the complications and their management, besides stressing the importance of providing proper information to enable the patient to make an informed consent. George & Doto offer an interesting skill-teaching framework:22 1. Overview: introduction to why the skill is needed and its relevance in the area of practice of the learner. Basic concepts on the skill. 2. Demonstration without comment: allows the learner to observe a whole picture of required skill. 3. Demonstration with comment: allows fragmentation of the skill into more manageable portions. 4. Verbalisation: learner talks through the skill. 5. Practice: the learner executes the skill. supplemented by positive feedback and encouragement from the trainer. George & Doto go further and describe reasons which may prevent the acquisition of the required skill such as inadequate demonstration/description, imprinting of previous wrong mind when teaching a skill. guidelines of desired medical conduct the attitudes of the medical professional are highly regarded.23 However, it is generally felt that in medical curricula this aspect is not given respond in a consistently favourable or unfavourable manner with respect to a given object.”19 In the undergraduate scenario, certain specialties, more than others, are useful in passing on particular attitudes. General practice and palliative care, for example, through their philosophies of holistic assessment and “total care” respectively, are suitable to pass on attitudes related to managing the patient and family.24,25 In fact, “incorporating palliative care into medical training not only improves the quality of palliative care, but also contributes to the moral quality of the doctors being trained.”19 On the other hand, surgical based specialties, will be more examples highlight the importance of exposing undergraduates to a mix of specialties, away from the traditional setup, to aid the development of appropriate attitudes. Another relevant way of passing on appropriate attitudes is teaching in the clinical environment (also known as On the Job different clinical scenarios.26 Such issues may include ethical questions and dealing with one’s own feelings when faced with a sick patient. Certainly, a traditional lecture will not be able to on behalf of the teacher is paramount. In addition, time pressures during a busy ward round or outpatient session. However, the trainees will have the opportunity of seeing the teacher interact with the patient, and also with adequate planning there can be 27 Feedback, in such situations and indeed in all situations should be given along Pendleton’s’ rules, thereby not undermining the standing of the student or trainee.28 By being allowed time and space to explore one’s own thoughts, the related to attitudes can be changed and modelled accordingly. Conclusion Addressing all of the above issues in a systematic way can be an arduous task, even for the most dedicated of trainers! However, the educational cycle is a useful concept for planning teaching activities. It consists of four steps:7 1. Assessing the needs of the learner 2. Setting educational objectives 3. Choosing and using a variety of methods 4. Assessing that learning occurred. In conclusion, andragogy is a popular theory used in medical educational. However, adult learning goes beyond that described Learning, though in its infant stages, seems to be particularly more awareness of the role of the teacher in acting as a catalyst for motivation. In addition, less traditional methods of teaching, Malta Medical Journal Volume 21 Issue 01 March 2009 17 encouraged. Any learning activity, should ideally address the knowledge, skills and attitudes necessary to become competent in what is being taught, or at least act as a building block towards to plan activities. References 1. Gibbs G, Coffe the Approach to Learning of their Students. Active Learning in Higher Education. 2004;5:87-100. education. 1999;82:19-32. 3. Knowles A. Andragogy in Action; Applying modern principles of adult learning. San Francisco: Jossey-Bass; 1984. Milton Keynes: Open University Press; 1986. 5. Walker M, Harris D. Principles of Adult Learning. In: Peyton Guildford: Manticore Europe Limited; 1998. p. 21-41. 6. Cantillon P, Hutchinson L, Wood D editors. ABC of Learning and health professionals. Oxford: Radcliffe Medical Press Ltd.; 2000. for Primary Care. 2001;12:249-57. Guildford: Manticore Europe Limited; 1998. p. 41-57. 10. Maslow AH. Motivation and Personality. New York: Harper and Row; 1970. 11. Vroom VH. Work and Motivation. New York: Wiley; 1964. directions in adult and continuing education. 1997;74:5-12. 13. Merriam SB. Andragogy and Self-Directed Learning: Pillars of Adult Learning. New Direction for Adult and Continuing Education. 2001;89:3-13. 14. Newman P, Peile E. Valuing Leraners’ experience and supporting further growth: edicational models to help experienced adult learners in medicine. British Medical Journal. 2002;325:200-2. 1992. 17. Hodges B. Medical Education and the maintenance of Competence. JAMA. 2002;287:226-35. 19. Olthuis G, Dekkers W. Medical education, palliative care and moral attitude: Some objectives and future perspectives. Med Educ. 2003;37:928-33. 20. Peyton J, Allery L. Setting Objectives. In: Peyton J, editor. Manticore Europe Limited; 1998. p. 57-69. 21. Chapman A. Ingham and Luft’s Johari Window Model Diagrams and examples. 2006; Available at: http://www.businessballs. com/johariwindowmodel.htm. Accessed: 5 November 2007. 1. Orienting learner Assess learner before clinical encounters, orient to the clinical site and preceptor style and expectations 2. Prioritising learning needs Before clerkship/clinic session, assess, prioritise, and tailor learner’s experience. 3. Problem-orientated learning (e.g., well-child visits). 4. Priming immediately before entering the patient’s room. 5. Pattern recognition presumptive diagnosis rather than detailed case presentation. presence this presentation 7. Limiting teaching points Focus on 1 to 2 key concepts/principles per teaching interaction. Learner observes preceptor actions complimented by preceptor explanations. Allows preceptor to assess learner to guide subsequent teaching of higher/lowerorder concepts. 10. Feedback Ongoing provision of information designed to guide learners’ performance beginning with concrete experience, learner self-assessment, abstraction of experience to general concept, then testing validity of concept (Kolb). Connects new elements to existing knowledge for both learner and teacher Table 1: Types of ambulatory teaching methods18 Malta Medical Journal Volume 21 Issue 01 March 2009 clinical skills. Fam Med. 2001;33:577-8. 23. Royal College of General Practitioners. Good Medical Practice for General Practitioners. First ed. Glasgow: Bell and Bain Ltd; 2002. Radcliffe Publishing; 2005. Journal. 1996;313:1599-601. In: Cantillon P, Hutchinson L, Wood D, editors. ABC of Learning p. 25-8. literature. Pediatrics. 2000;105:231-7. An approach to teaching and learning. Oxford: Oxford Medical Publications; 1984.