Maria Mylopoulos

Cognitive metaphors of expertise and knowledge: prospects and limitations for medical education.

Context  Many approaches to the study of expertise in medical education have their roots most strongly established in the traditional cognitive psychology literature. As such, they take a common approach to the construction of expertise and frame their questions in a common way. This paper reflects on a few of the paradigmatic assumptions that have ‘come along for the ride’ with the traditional cognitive approach, and explores what might have been left out as a consequence.

Cognition before curriculum: rethinking the integration of basic science and clinical learning.

Purpose Integrating basic science and clinical concepts in the undergraduate medical curriculum is an important challenge for medical education. The health professions education literature includes a variety of educational strategies for integrating basic science and clinical concepts at multiple levels of the curriculum. To date, assessment of this literature has been limited. Method In this critical narrative review, the authors analyzed literature published in the last 30 years (1982–2012) using a previously published integration framework. They included studies that documented approaches to integration at the level of programs, courses, or teaching sessions and that aimed to improve learning outcomes. The authors evaluated these studies for evidence of successful integration and to identify factors that contribute to integration. Results Several strategies at the program and course level are well described but poorly evaluated. Multiple factors contribute to successful learning, so identifying how interventions at these levels result in successful integration is difficult. Evidence from session-level interventions and experimental studies suggests that integration can be achieved if learning interventions attempt to link basic and clinical science in a causal relationship. These interventions attend to how learners connect different domains of knowledge and suggest that successful integration requires learners to build cognitive associations between basic and clinical science. Conclusions One way of understanding the integration of basic and clinical science is as a cognitive activity occurring within learners. This perspective suggests that learner-centered, content-focused, and session-level-oriented strategies can achieve cognitive integration.

How student models of expertise and innovation impact the development of adaptive expertise in medicine.

Objectives  The ability to innovate new solutions in response to daily workplace challenges is an important component of adaptive expertise. Exploring how to optimally develop this skill is therefore of paramount importance to education researchers. This is certainly no less true in health care, where optimal patient care is contingent on the continuous efforts of doctors and other health care workers to provide the best care to their patients through the development and incorporation of new knowledge. Medical education programmes must therefore foster the skills and attitudes necessary to engage future doctors in the systematic development of innovative problem solving. The aim of this paper is to describe the perceptions and experiences of medical students in their third and fourth years of training, and to explore their understanding of their development as adaptive experts.

Doctors’ perspectives on their innovations in daily practice: implications for knowledge building in health care

Context  When individuals adapt their practice in order to solve novel or unexpected problems of practice, they are creating new knowledge. This form of innovation development is understood as a core competency of adaptive expertise and the basis for knowledge building community practice. However, little is known about the ways in which this knowledge, produced through daily, innovative problem solving, is developed, identified and shared by health care professionals.

Putting the expert together again

Medical Education 2011:45: 920–926

Renowned physicians' perceptions of expert diagnostic practice.

Purpose To further the development of a substantive theory of expert diagnostic practice, the authors explored the ways in which exceptional physicians, nominated by their peers, conceptualized their own diagnostic expertise specifically and diagnostic excellence generally. Method In this grounded theory, interview-based study, physicians at six North American research sites were nominated by their peers as exceptional diagnosticians and exceptional professionals and invited to participate in the study. A saturation sample included 34 participants, 20 exceptional diagnosticians, and 14 exceptional professionals. Using a constant comparative approach, the authors conducted one-on-one interviews with participants, transcribed the audiotapes of those interviews, and analyzed them for emergent themes. They developed a stable thematic structure and applied it to the entire data set. Results Four interconnected themes emerged that inform the community’s understanding of how physicians conceptualize expert diagnostic practice: (1) possession of extensive knowledge built through purposeful, continuous engagement in clinical practice, (2) possession of the skills to effectively gather patient stories, (3) reflective integration of that knowledge and those patient stories during diagnosis, and (4) continuous learning through clinical practice. Conclusions Exploring these results within the context of current discourses in medical education brings to the forefront two key features of physicians’ construction of diagnostic excellence: (1) the integrated nature of the medical competencies that underpin the diagnostic process and (2) the optimally adaptive nature of the diagnostic process. These findings can inform the development of practical and effective pedagogical strategies to guide trainees, clinicians, and medical educators who strive for excellence.

Preparing medical students for future learning using basic science instruction

The construct of ‘preparation for future learning’ (PFL) is understood as the ability to learn new information from available resources, relate new learning to past experiences and demonstrate innovation and flexibility in problem solving. Preparation for future learning has been proposed as a key competence of adaptive expertise. There is a need for educators to ensure that opportunities are provided for students to develop PFL ability and that assessments accurately measure the development of this form of competence. The objective of this research was to compare the relative impacts of basic science instruction and clinically focused instruction on performance on a PFL assessment (PFLA).

Having our cake and eating it too: seeking the best of both worlds in expertise research

Context  Education researchers in a variety of disciplines have attempted to use their understanding of expert processes to inform learning across the continuum from school learning to lifelong learning. In medical education, this has led to models of expertise that aim to understand accurate and efficient clinical reasoning. More recently, researchers outside medicine have begun to develop models of ‘adaptive expertise’. As these additional constructions of expertise are introduced into health professions education, there is considerable potential to enhance research in medical expertise by providing opportunities for us to identify our implicit assumptions and reflect on the ways in which our theoretical lenses bias our perceptions of what it means to be an expert.

Informal self-regulated learning on a surgical rotation: uncovering student experiences in context

The ability to guide one’s own learning is an essential skill for the health professional. The apprenticeship model of undergraduate education offers an opportunity to engage in self-regulated learning as students work to set goals, evaluate the available opportunities and seek out those with the greatest potential for learning. A close examination of how students navigate their clinical rotations could therefore foster greater understanding of how students learn to guide their own learning. The study presented here aimed to examine undergraduate medical students’ day-to-day learning strategies in order to better understand the process of informal self-regulated learning in practice. As a secondary objective, we sought to provide a forum for students to share and critically reflect on their own self-regulated learning strategies. A series of focus groups were conducted with medical students on a surgical rotation. Participants were asked to discuss issues relating to the strategies and behaviours that they had implemented in order to maximize their educational experience. Three distinct approaches to informal self-regulated learning were identified: Participants articulated tendencies to acquiesce to a perceived lack of learning opportunities choose from available learning opportunities and create their own learning opportunities. The results are interpreted through the lens of self-regulated learning theory and implications for medical education are discussed.

Preparation for future learning: a missing competency in health professions education?

Evidence suggests that clinicians may not be learning effectively from all facets of their practice, potentially because their training has not fully prepared them to do so. To address this gap, we argue that there is a need to identify systems of instruction and assessment that enhance clinicians’ ‘preparation for future learning’. Preparation for future learning (PFL) is understood to be the capacity to learn new information, to use resources effectively and innovatively, and to invent new strategies for learning and problem solving in practice.