Learning Theories
There are three recognized classic learning theories: behaviorism, cognitive learning, and constructivism [1]. Each of these theories influences curriculum design, teaching, and evaluation. Most educators use elements from each theory in any given situation rather than strictly adhering to one style.
Behaviorism is the learning theory commonly associated with the Pavlovian response: a subject performs a behavior and receives a positive result, and the behavior is reinforced. If the result is negative then the behavior is discouraged and eventually eliminated. The behaviorist does not focus on the thought processes of the learner, but only on the response to a stimulus.
The cognitive learning theory is the opposite of behaviorism. It focuses on the learner’s thought processes instead of a response to a stimulus. The interest is in how the learner integrates new information and applies it to new situations.
In constructivism, the learner builds, or constructs, new ideas based on existing knowledge. Constructivism focuses on how students interact and learn from each other as well as from their educators.
Learning as a Child
Pedagogy refers to the learning style of children. Its literal translation from Greek is “to lead the child.” This is a teacher-centered style of learning. Because children are not thought to have sufficient experience to know what they need to learn, these decisions are made for them by their educators. Instructors decide on what material to teach and how to teach it. Young students generally have little choice as to the content of their curriculum. Decisions and information flow cent percent from the instructor to the student.
Aspects of the pedagogical style also apply to some adult learning situations. For example, during the preclinical years of medical school, adult students have little choice regarding content. However, unlike secondary school students, adults have chosen this curriculum because of their motivation to become physicians. The curriculum is a means to an identifiable end, providing motivation.
Learning as an Adult
As the study of learning advanced, adult learning enthusiasts recognized that children and adults receive and process new information differently. This recognition suggested that adults should be taught differently, prompting radical changes in adult education in many institutions. In the mid-1950s, Malcolm Knowles began publishing his work on adult education, which, at the time, was an underexplored subject. He popularized the term andragogy, which he defined as “the art and science of helping adults learn.” He observed that adults need to be involved in their education rather than being “led” to it. Childhood learning is teacher centered; adult learning is student centered. More on his theories is presented later in the chapter.
Pedagogical learning is based on discrete subjects: math, history, and spelling; or anatomy, cell biology, and pharmacology. This is appropriate for building lower levels of cognition, for the development of a foundation of knowledge. However, applying very basic knowledge, acquired in a pedagogical style, to real-world problems is more difficult.
Adult learning is more problem centered—an approach in which the learner pulls multiple bits of basic information from multiple, discrete subjects to solve a problem. Problem-centered learning is very relevant in the ED. For example, the ED physician, faced with a woman with right lower quadrant abdominal pain, simultaneously gives attention to all systems that may cause pain in this region. “Is this gastrointestinal (appendicitis, gastroenteritis), gynecologic (ectopic pregnancy, ovarian torsion, pelvic inflammatory disease), genitourinary (ureterolithiasis, pyelonephritis), vascular (aortic dissection), or something else (shingles)?” The clinician combines basic knowledge of these different systems and conditions with clinical experience to narrow the diagnostic possibilities and begin the appropriate evaluation.
Learning as an Adult—Malcolm Knowles’ Theories and the Arguments Against Them
Much of adult learning theory stems from five assumptions about adult learners that were developed by Knowles (Table 1.1). The assumptions reflect that adults are self-directed learners who seek information independently. They reconcile new information with their existing knowledge base and seek to apply it immediately to a known problem. It is important to note that these assumptions have not been validated.
Table 1.1 Malcolm Knowles’ assumptions about adult learning.
| Adults are self-directed and autonomous |
| Adults have life experiences that need to be respected |
| Adults want to learn tasks related to everyday life |
| Adults are problem centered and seek to apply learned material immediately |
| Adults are motivated by internal drives rather than external factors |
Adapted from [2] Kaufman DM. Applying educational theory in practice. BMJ 2003; 326: 213–216, with permission from BMJ Publishing Group Ltd.
Before embracing Knowles’ theories blindly, one must note the many criticisms of his work. A commonly cited criticism was the inadequate data used for the formulation of the assumptions is a commonly cited criticism [3–6]. This vacuum is of particular concern in today’s culture of evidence-based practice.
Norman [3] questions at what point a student transitions from a child learning to an adult learning style. It is not likely an age-based phenomenon, as chronologic and mental ages are not always congruent. He suggests that the transition is not effected by an internal condition of the learner, but rather by a change in learning style, needed to meet a new pressure or situation.
Some suggest that the motivation for adult learning is rarely exclusively internal and that it often stems from external forces [4, 6]. Adults might acknowledge only their conscious internal motivation, neglecting a subconscious external motivation. For example, physicians must receive continuing medical education (CME) to maintain their certification. A physician may satisfy an internal drive to learn more about dental emergencies by attending a lecture on this topic at a conference; the external motivation of receiving CME credits is also satisfied.
The assumption that all adult learning is self-directed is also debatable [3, 6]. Self-direction is a quality of a mature learner. A young learner may possess this quality, while a chronologically older student may not. In addition, before delving into any self-directed learning, students must do self-assessments to identify their weaknesses. Young students often perform inadequate self-assessments. The drive to learn is fed partly by success. Consequently, students are more likely to study topics with which they are familiar, feeding the hunger for success rather than focusing on weak areas. Adult learners facing new subjects may need a little “pedagogical guidance” from instructors.
Another criticism of Knowles’ work is that he did not comment on the use of reflection in learning [6]. In reflection, the learner considers the new material, integrating it with preexisting knowledge and resolving conflicts between new and old information. The learner can consider how to approach a task the next time, based on successes and mistakes from the first experience. Taking time to reflect on a newly learned topic ingrains the material into one’s mind.
Educating Adults
Adults are experienced learners who derive part of their identity from life experiences. Adult learning is enhanced when educators demonstrate respect for adults and their experiences. Any dismissal of the learner’s experience is perceived as a rejection of himself or herself [7]. With the learners’ cadre of life experiences come habits that are well established and difficult to break [7]. Despite their motivation to learn, adults are generally resistant to changing their habits. Educators must balance respect for the learners’ experiences with needed modifications of problem habits. A poor balance risks alienating the learners.
Dependence on the teacher within a pedagogical structure is counterintuitive to adult learners. Adult learners seek to solve problems on their own using their previous experience. Instructors of adult students are seen as facilitators, not teachers. Facilitators are guides who do not merely hand out information but who help students to develop their own questions and to find their own answers. This develops student self-reliance and skills that will be useful in solving future problems. Knowles and others developed recommendations for these facilitators of adult students [2, 8], detailed with examples in the following section.
Adult Learning in the Emergency Department
The ED is a rich, problem-based, learning environment. Most emergency medicine (EM) physicians are “action-oriented” people who say, “I learn best by doing” or “I learn on my feet.” The ED provides the ideal setting for such learning. The educational moments are “live”; they are “now.” Skilled educators exploit these attributes of the ED, incorporating principles of adult education to create rich learning experiences for young clinicians.
However, the ED is not a comfortable learning environment. Constant distractions are normal. Time is limited and precious, creating a significant barrier to education in the ED. Faculty members are under increasing pressure to see more patients and improve documentation, limiting the time available for teaching. The balancing of time between patient care and teaching is simply another form of ED triage. Not all cases need to include an educational moment, nor must every aspect of each case be dissected to provide thorough teaching. Educators must choose their moments, as exemplified in the following sections.
Set the Environment
Two environments can be optimized for learning: the physical and the interpersonal. The physical environment of the ED is a constant assault on all the senses, resulting in an array of distractions that is unparalleled in the world of education. Patients and providers are constantly on the move. Noise emanates from all directions. The lighting is harsh. The department is never big enough—patients overflow from rooms into hallway beds or large rooms with chairs and staff members compete for computer and counter space. Supplies run short, textbooks are old, and interruptions are frequent. New learners in the ED also face sheer intimidation. Despite these inordinate challenges, learners must focus on quality, one-at-a-time patient care. It would seem impossible to make the learner to also focus on educational moments, one at a time. Teachers in the ED must choose their moments among the distractions. To the extent possible, distractions should be minimized: spaces away from the main center of the department can be used and nurses should be notified that interruptions should be minimized unless they are truly emergent. It is important to “read” your learner to see if he or she is ready for such a moment. If a student is too distracted with a current situation, you cannot effectively teach. Save the pearl for later.
Interpersonal or relationship setting is the most important piece in the entire educational endeavor. As noted earlier, adults have years of experience for which they expect, and deserve, respect. Establishing an open and respectful relationship with the adult learner is the most important first step in providing adult education. It is this relationship that encourages learners to come to their teachers; it makes the teachers approachable. Learning will not occur if the students do not want to approach or hear from the teacher. In the teaching ED, physicians-in-training must discuss their cases with a supervising physician; thus, it seems that the learners have no choice but to come to the teachers. However, if the learners do not have a good relationship with the teacher, they will modify their presentations in ways to minimize exposure to the instructors. When faculty members try to teach in the setting of poor relationships, learners will be minimally receptive. Tension can worsen with each encounter. Various reviews have described the characteristics of good teaching faculty (Table 1.2). It should be noted that they are all based on the establishment of an open and respectful relationship with the learners.
Table 1.2 Characteristics of effective teachers. [9–14].
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